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Archive for the ‘Regenerative Biology and Medicine’ Category

Scientist at Lankenau Institute for Medical Research Leads Study Demonstrating Drug-Induced Tissue Regeneration

Reporter: Aviva Lev-Ari, PhD, RN

(WYNNEWOOD, PA) – A study led by Ellen Heber-Katz, PhD, of the Lankenau Institute for Medical Research (LIMR), part of Main Line Health (MLH), shows that a primordial form of energy production that still exists in mammals can be harnessed to achieve spontaneous tissue regeneration in mice, without the need for added stem cells. The study findings were reported in the June 3, 2015, issue of Science Translational Medicine, a peer-reviewed journal of the American Association for the Advancement of Science. Key collaborators in the study, which was supported by grants from the National Institutes of Health, included Yong Zhang, PhD (LIMR), Iossif Strehin, PhD (Allergan), and Phillip Messersmith, PhD (University of California, Berkeley).

Heber-Katz notes that unlike other approaches to tissue regeneration, their group found that it was possible to achieve healthy tissue regrowth in a mouse model in situ, without the use of stem cells.

“Our experiment shows the possibility of taking mature cells and, with addition of HIF-1a, causing dedifferentiation to a highly immature state where the cells can proliferate, followed by redifferentiation upon withdrawal of HIF-1a,” says Heber-Katz. “Many researchers in the field see tissue regeneration as a very complex set of events, but some of us look at it more as a process that needs to be turned on and allowed to go to completion. This is what is so exciting about what we saw with drug-induced stabilization of HIF-1a.”

Heber-Katz and her collaborators plan to move ahead to modify the drug delivery system to achieve an ideal formulation, which they will use to investigate regrowth potential in many types of tissues.

“This remarkable work has vast importance in medicine and surgery and spotlights the diverse and important scientific investigations underway at LIMR,” says George Prendergast, PhD, President and CEO of LIMR. “We are committed to the quest to discover therapies that make healthy tissue regeneration a possibility in humans.”

REFERENCE
Zhang Y, Strehin I, Bedelbaeva K, Gourevitch D, Clark L, Leferovich J, Messersmith PB, Heber-Katz E. Drug-induced regeneration in adult mice. Sci Transl Med. 2015;290.

SOURCE

http://www.mainlinehealth.org/wtn/Page.asp?PageID=WTN001668&elq=0d54473cb38a47049bc33b8393fe50b2&elqCampaignId=6&elqaid=12979&elqat=1&elqTrackId=d028a3280aa5439f9fefc5285b34a947

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Allogeneic Stem Cell Transplantation

Writer and Curator: Larry H. Bernstein, MD, FCAP

This article has the following structure:

9.3.1  Cell based immunotherapy

9.3.2  Photodynamic therapy (PDT)

9.3.3  Small molecules targeted therapy drugs; Tyrosine kinase inhibitors; imatinib (Gleevec/Glivec) and gefitinib (Iressa).

9.3.4 Graft versus Host Disease

9.3.5 Aspergillus Complicating Allogeneic Transplantation

Introduction

9.3.1 Allogeneic Stem Cell Treatment

http://www.lls.org/treatment/types-of-treatment/stem-cell-transplantation/allogeneic-stem-cell-transplantation

Allogeneic stem cell transplantation involves transferring the stem cells from a healthy person (the donor) to your body after high-intensity chemotherapy or radiation.

Allogeneic stem cell transplantation is used to cure some patients who:

  • Are at high risk of relapse
  • Don’t respond fully to treatment
  • Relapse after prior successful treatment

Allogeneic stem cell transplantation can be a high-risk procedure. The high-conditioning regimens are meant to severely or completely impair your ability to make stem cells and you will likely experience side effects during the days you receive high-dose conditioning radiation or chemotherapy. The goals of high-conditioning therapy are to:

treat the remaining cancer cells intensively, thereby making a cancer recurrence less likely
inactivate the immune system to reduce the chance of stem cell graft rejection
enable donor cells to travel to the marrow (engraftment), produce blood cells and bring about graft versus tumor effect

Possible Adverse Effects

The immune system and the blood system are closely linked and can’t be separated from each other. Because of this, allogeneic transplantation means that not only the donor’s blood system but also his or her immune system is transferred. As a result, these adverse effects are possible:

  • Immune rejection of the donated stem cells by the recipient (host-versus-graft effect)
  • Immune reaction by the donor cells against the recipient’s tissues (graft-versus-host disease [GVHD])

The immune reaction, or GVHD, is treated by administering drugs to the patient after the transplant that reduce the ability of the donated immune cells to attack and injure the patient’s tissues. See Graft Versus Host Disease.

Allogeneic stem cell transplants for patients who are older or have overall poor health are relatively uncommon. This is because the pre-transplant conditioning therapy is generally not well tolerated by such patients, especially those with poorly functioning internal organs. However, reduced intensity allogeneic stem cell transplants may be an appropriate treatment for some older or sicker patients.

T-Lymphocyte Depletion

One goal of allogeneic stem cell transplant is to cause the T lymphocytes in the donor’s blood or marrow to take hold (engraft) and grow in the patient’s marrow. Sometimes the T lymphocytes attack the cancer cells. When this happens, it’s called graft versus tumor (GVT) effect (also called graft versus cancer effect). The attack makes it less likely that the disease will return. This effect is more common in myeloid leukemias than it is in other blood cancers.

Unfortunately, T lymphocytes are the same cells that cause graft versus host disease (GVHD). Because of this serious and sometimes life-threatening side effect, doctors in certain cases want to decrease the number of T lymphocytes to be infused with the stem cells. This procedure, called T-lymphocyte depletion, is currently being studied by researchers. The technique involves treating the stem cells collected for transplant with agents that reduce the number of T lymphocytes.

The aim of T-lymphocyte depletion is to lessen GVHD’s incidence and severity. However, it can also cause increased rates of graft rejection, a decreased GVT effect and a slower immune recovery. Doctors must be careful about the number of T lymphocytes removed when using this technique.

Stem Cell Selection

Stem cell selection is another technique being studied in clinical trials that can reduce the number of T lymphocytes that a patient receives. Because of specific features on the outer coat of stem cells, doctors can selectively remove stem cells from a cell mixture. This technique produces a large number of stem cells and fewer other cells, including T lymphocytes.

9.3.2 Defining Characteristics of  Stem Cells

http://stemcells.nih.gov/info/basics/pages/basics1.aspx

Stem cells have the remarkable potential to develop into many different cell types in the body during early life and growth. In addition, in many tissues they serve as a sort of internal repair system, dividing essentially without limit to replenish other cells as long as the person or animal is still alive. When a stem cell divides, each new cell has the potential either to remain a stem cell or become another type of cell with a more specialized function, such as a muscle cell, a red blood cell, or a brain cell.

Stem cells are distinguished from other cell types by two important characteristics. First, they are unspecialized cells capable of renewing themselves through cell division, sometimes after long periods of inactivity. Second, under certain physiologic or experimental conditions, they can be induced to become tissue- or organ-specific cells with special functions. In some organs, such as the gut and bone marrow, stem cells regularly divide to repair and replace worn out or damaged tissues. In other organs, however, such as the pancreas and the heart, stem cells only divide under special conditions.

Until recently, scientists primarily worked with two kinds of stem cells from animals and humans: embryonic stem cells and non-embryonic “somatic” or “adult” stem cells. The functions and characteristics of these cells will be explained in this document. Scientists discovered ways to derive embryonic stem cells from early mouse embryos more than 30 years ago, in 1981. The detailed study of the biology of mouse stem cells led to the discovery, in 1998, of a method to derive stem cells from human embryos and grow the cells in the laboratory. These cells are called human embryonic stem cells. The embryos used in these studies were created for reproductive purposes through in vitro fertilization procedures.

When they were no longer needed for that purpose, they were donated for research with the informed consent of the donor. In 2006, researchers made another breakthrough by identifying conditions that would allow some specialized adult cells to be “reprogrammed” genetically to assume a stem cell-like state. This new type of stem cell is called induced pluripotent stem cells (iPSCs).

Stem cells differ from other kinds of cells in the body. All stem cells—regardless of their source—have three general properties: they are capable of dividing and renewing themselves for long periods; they are unspecialized; and they can give rise to specialized cell types.

Stem cells are capable of dividing and renewing themselves for long periods. Unlike muscle cells, blood cells, or nerve cells—which do not normally replicate themselves—stem cells may replicate many times, or proliferate. A starting population of stem cells that proliferates for many months in the laboratory can yield millions of cells. If the resulting cells continue to be unspecialized, like the parent stem cells, the cells are said to be capable of long-term self-renewal.

Scientists are trying to understand two fundamental properties of stem cells that relate to their long-term self-renewal:

  1. Why can embryonic stem cells proliferate for a year or more in the laboratory without differentiating, but most adult stem cells cannot; and
  2. What are the factors in living organisms that normally regulate stem cell proliferation and self-renewal?

Discovering the answers to these questions may make it possible to understand how cell proliferation is regulated during normal embryonic development or during the abnormal cell division that leads to cancer.

Stem cells are unspecialized. One of the fundamental properties of a stem cell is that it does not have any tissue-specific structures that allow it to perform specialized functions. For example, a stem cell cannot work with its neighbors to pump blood through the body (like a heart muscle cell), and it cannot carry oxygen molecules through the bloodstream (like a red blood cell). However, unspecialized stem cells can give rise to specialized cells, including heart muscle cells, blood cells, or nerve cells.

Stem cells can give rise to specialized cells. When unspecialized stem cells give rise to specialized cells, the process is called differentiation. While differentiating, the cell usually goes through several stages, becoming more specialized at each step. Scientists are just beginning to understand the signals inside and outside cells that trigger each step of the differentiation process. The internal signals are controlled by a cell’s genes, which are interspersed across long strands of DNA and carry coded instructions for all cellular structures and functions. The external signals for cell differentiation include chemicals secreted by other cells, physical contact with neighboring cells, and certain molecules in the microenvironment. The interaction of signals during differentiation causes the cell’s DNA to acquire epigenetic marks that restrict DNA expression in the cell and can be passed on through cell division.

Adult stem cells typically generate the cell types of the tissue in which they reside. For example, a blood-forming adult stem cell in the bone marrow normally gives rise to the many types of blood cells. It is generally accepted that a blood-forming cell in the bone marrow—which is called a hematopoietic stem cell—cannot give rise to the cells of a very different tissue, such as nerve cells in the brain.

Through years of experimentation, scientists have established some basic protocols or “recipes” for the directed differentiation of embryonic stem cells into some specific cell types (Figure 1). (For additional examples of directed differentiation of embryonic stem cells, refer to the NIH stem cell report available at

http://stemcells.nih.gov/info/scireport/pages/2006report.aspx.)

stem cell differentiation figure1_sm

stem cell differentiation figure1_sm

http://stemcells.nih.gov/StaticResources/images/figure1_sm.jpg

9.3.3 Types of Stem Cell Transplants for Treating Cancer

http://www.cancer.org/treatment/treatmentsandsideeffects/treatmenttypes/bonemarrowandperipheralbloodstemcelltransplant/stem-cell-transplant-types-of-transplant

In a typical stem cell transplant for cancer very high doses of chemo are used, often along with radiation therapy, to try to destroy all the cancer cells. This treatment also kills the stem cells in the bone marrow. Soon after treatment, stem cells are given to replace those that were destroyed. These stem cells are given into a vein, much like a blood transfusion. Over time they settle in the bone marrow and begin to grow and make healthy blood cells. This process is called engraftment.

There are 3 basic types of transplants. They are named based on who gives the stem cells.

  • Autologous (aw-tahl-uh-gus)—the cells come from you
  • Allogeneic (al-o-jen-NEE-ick or al-o-jen-NAY-ick)—the cells come from a matched related or unrelated donor
  • Syngeneic (sin-jen-NEE-ick or sin-jen-NAY-ick)—the cells come from your identical twin or triplet
hematopoietic stem cell transplant

hematopoietic stem cell transplant

Autologous stem cell transplants

These stem cells come from you alone. In this type of transplant, your stem cells are taken before you get cancer treatment that destroys them. Your stem cells are removed, or harvested, from either your bone marrow or your blood and then frozen. To find out more about that process, please see the section “What’s it like to donate stem cells?” After you get high doses of chemo and/or radiation the stem cells are thawed and given back to you.

One advantage of autologous stem cell transplant is that you are getting your own cells back. When you donate your own stem cells you don’t have to worry about the graft attacking your body (graft-versus-host disease) or about getting a new infection from another person. But there can still be graft failure, and autologous transplants can’t produce the “graft-versus-cancer” effect.

This kind of transplant is mainly used to treat certain leukemias, lymphomas, and multiple myeloma. It’s sometimes used for other cancers, like testicular cancer and neuroblastoma, and certain cancers in children.

Getting rid of cancer cells in autologous transplants

A possible disadvantage of an autologous transplant is that cancer cells may be picked up along with the stem cells and then put back into your body later. Another disadvantage is that your immune system is still the same as before when your stem cells engraft. The cancer cells were able to grow despite your immune cells before, and may be able to do so again. The need to remove cancer cells from transplants or transplant patients and the best way to do it is being researched.

Doing 2 autologous transplants in a row is known as a tandem transplant or a double autologous transplant. In this type of transplant, the patient gets 2 courses of high-dose chemo, each followed by a transplant of their own stem cells. All of the stem cells needed are collected before the first high-dose chemo treatment, and half of them are used for each transplant. Most often both courses of chemo are given within 6 months, with the second one given after the patient recovers from the first one.

Allogeneic stem cell transplants

In the most common type of allogeneic transplant, the stem cells come from a donor whose tissue type closely matches the patient’s. (This is discussed later under “HLA matching” in the section called “ Donor matching for allogeneic transplant.”) The best donor is a close family member, usually a brother or sister. If you do not have a good match in your family, a donor might be found in the general public through a national registry. This is sometimes called a MUD (matched unrelated donortransplant. Transplants with a MUD are usually riskier than those with a relative who is a good match.

Blood taken from the placenta and umbilical cord of newborns is a newer source of stem cells for allogeneic transplant. Called cord blood, this small volume of blood has a high number of stem cells that tend to multiply quickly. But the number of stem cells in a unit of cord blood is often too low for large adults, so this source of stem cells is limited to small adults and children. Doctors are now looking at different ways to use cord blood for transplant in larger adults, such as using cord blood from 2 donors.

Pros of allogeneic stem cell transplant: The donor stem cells make their own immune cells, which could help destroy any cancer cells that remain after high-dose treatment. This is called the graft-versus-cancer effect. Other advantages are that the donor can often be asked to donate more stem cells or even white blood cells if needed, and stem cells from healthy donors are free of cancer cells.

Cons to allogeneic stem cell transplants: The transplant, also known as the graft, might not take — that is, the donor cells could die or be destroyed by the patient’s body before settling in the bone marrow. Another risk is that the immune cells from the donor may not just attack the cancer cells – they could attack healthy cells in the patient’s body. This is called graft-versus-host disease (described in the section called “Problems that may come up shortly after transplant”). There is also a very small risk of certain infections from the donor cells, even though donors are tested before they donate. A higher risk comes from infections you have had, and which your immune system has under control. These infections often surface after allogeneic transplant because your immune system is held in check (suppressed) by medicines called immunosuppressive drugs. These infections can cause serious problems and even death.

Allogeneic transplant is most often used to treat certain types of leukemia, lymphomas, multiple myeloma,myelodysplastic syndrome, and other bone marrow disorders such as aplastic anemia.

Mini transplants (non-myeloablative transplants)

For some people, age or certain health conditions make it more risky to wipe out all of their bone marrow before a transplant. For those people, doctors can use a type of allogeneic transplant that’s sometimes called a mini-transplant. Compared with a standard allogeneic transplant, this one uses less chemo and/or radiation to get the patient ready for the transplant. Your doctor might refer to it as a non-myeloablative transplant or mention reduced-intensity conditioning (RIC). The idea here is to kill some of the cancer cells along with some of the bone marrow, and suppress the immune system just enough to allow donor stem cells to settle in the bone marrow.

Unlike the standard allogeneic transplant, cells from both the donor and the patient exist together in the patient’s body for some time after a mini-transplant. But slowly, over the course of months, the donor cells take over the bone marrow and replace the patient’s own bone marrow cells. These new cells can then develop an immune response to the cancer and help kill off the patient’s cancer cells — the graft-versus-cancer effect.

Syngeneic stem cell transplants – for those with an identical sibling

This is a special kind of allogeneic transplant that can only be used when the recipient has an identical sibling (twin or triplet) who can donate — someone who will have the same tissue type. An advantage of syngeneic stem cell transplant is that graft-versus-host disease will not be a problem. There are no cancer cells in the transplant, either, as there would be in an autologous transplant.

A disadvantage is that because the new immune system is so much like the recipient’s immune system, there is no graft-versus-cancer effect, either. Every effort must be made to destroy all the cancer cells before the transplant is done to help keep the cancer from relapsing (coming back).

9.3.4 Graft versus Host Disease

http://bethematch.org/For-Patients-and-Families/Life-after-transplant/Graft-versus-host-disease–GVHD-/

Graft-versus-host disease(GVHD) occurs because of differences between the cells of your body and the donated cells and is a common side effect of an allogeneic bone marrow transplant.

An allogeneic transplant uses blood cells from a family member, unrelated donor or cord blood unit. GVHD can affect many different parts of the body including the skin, eyes, mouth, stomach, and intestines.

There are two types of GVHD:

  • Acute GVHD: Develops in the first 100 days or so after transplant but can occur later. This primarily affects the skin, stomach, intestines, and liver.
  • Chronic GVHD: Usually develops 3-6 months after transplant, but signs can appear earlier or later. If you have had or currently have acute GVHD, you are more likely to have chronic GVHD.

The severity of acute and chronic GVHD can range from mild to life-threatening.

Doctors often see mild GVHD as a good thing after an allogeneic transplant when the transplant was done for a blood cancer. It is a sign that the donor’s immune system is working to destroy any remaining cancer cells. Patients who experience some GVHD have a lower risk of the cancer returning after transplant than patients who do not develop GVHD. If the transplant was to treat a disease other than cancer disease, like aplastic anemia, then the doctor may want to treat even mild GVHD.

Graft-versus-Host Disease

JLM FerraraJE LevineP Reddy, and E Holler
Lancet. 2009 May 2; 373(9674): 1550–1561.
http://dx.doi.org:/10.1016/S0140-6736(09)60237-3

The number of allogeneic hematopoietic cell transplantations (HCT) continues to increase with more than 25,000 allogeneic transplantations performed annually. The graft-versus-leukemia / tumor (GVL) effect during allogeneic HCT effectively eradicates many hematological malignancies.1 The development of novel strategies that use donor leukocyte infusions, non-myeloablative conditioning and umbilical cord blood (UCB) transplantation have helped expand the indications for allogeneic HCT over the last several years, especially among older patients.2 Improvements in infectious prophylaxis, immunosuppressive medications, supportive care and DNA-based tissue typing have also contributed to improved outcomes after allogeneic HCT.1 Yet the major complication of allogeneic HCT, graft-versus-host disease (GVHD), remains lethal and limits the use of this important therapy.2 Given current trends, the number of transplants from unrelated donors is expected to double within the next five years, significantly increasing the population of patients with GVHD. In this seminar we review advances made in identifying the genetic risk factors and pathophysiology of this major HCT complication, as well as its prevention, diagnosis and treatment.

Etiology and Clinical Features

Fifty years ago Billingham formulated three requirements for the development of GVHD: the graft must contain immunologically competent cells; the recipient must express tissue antigens that are not present in the transplant donor; and the recipient must be incapable of mounting an effective response to eliminate the transplanted cells.3 We know now that the immunologically competent cells are T cells, and that GVHD can develop in various clinical settings when tissues containing T cells (blood products, bone marrow, and solid organs) are transferred from one person to another who is not able to eliminate those cells.45 Patients, whose immune systems are suppressed, and who receive white blood cells from another individual, are at particularly high risk for GVHD.

GVHD occurs when donor T cells respond to genetically defined proteins on host cells. The most important proteins are Human Leukocyte Antigens (HLA)267, which are highly polymorphic and are encoded by the major histocompatibility complex (MHC). Class I HLA (A, B, and C) proteins are expressed on almost all nucleated cells of the body at varying densities. Class II proteins (DR, DQ, and DP) are primarily expressed on hematopoietic cells (B cells, dendritic cells, monocytes), but their expression can be induced on many other cell types following inflammation or injury. High-resolution DNA typing of HLA genes with polymerase chain reaction (PCR)-based techniques have now largely replaced earlier methods. The incidence of acute GVHD is directly related to the degree of mismatch between HLA proteins89 and thus ideally, donors and recipients are matched at HLA-A, -B, -C, and -DRB1, (“8/8 matches”), but mismatches may be tolerated for UCB grafts (see below).1012

Non-HLA Genetics

Despite HLA identity between a patient and donor, approximately 40% of patients receiving HLA-identical grafts develop acute GVHD due to genetic differences that lie outside the HLA loci, or “minor” histocompatibility antigens (HA). Some minor HAs, such as HY and HA-3, are expressed on all tissues and are targets for both GVHD and GVL.13 Other minor HAs, such as HA-1 and HA-2, are expressed most abundantly on hematopoietic cells (including leukemic cells) and may therefore induce a greater GVL effect with less GVHD.1314

Polymorphisms in both donors and recipients for cytokines that are involved in the classical `cytokine storm’ of GVHD (discussed below) have been implicated as risk factors for GVHD.15 Tumor Necrosis Factor (TNF)-α, Interleukin 10 (IL-10), Interferon-γ (IFNγ) variants have correlated with GVHD in some, but not all, studies.1618 Genetic polymorphisms of proteins involved in innate immunity, such as nucleotide oligomerization domain 2 and Keratin 18 receptors, have also been associated with GVHD.1922 Future strategies to identify the best possible transplant donor will probably incorporate both HLA and non-HLA genetic factors.

Clinical Features of Acute GVHD

Based on an early Seattle experience, acute GVHD was defined to occur prior to day 100, whereas chronic GVHD occurred after that time.2325 This definition is far from satisfactory, and a recent National Institutes of Health classification includes late-onset acute GVHD (after day 100) and an overlap syndrome with features of both acute and chronic GVHD.26 Late-onset acute GVHD and the overlap syndrome occur with greater frequency after reduced-intensity conditioning (RIC), an increasingly widespread technique (see below). As shown in Table 1, the clinical manifestations of acute GVHD occur in the skin, gastrointestinal tract and liver.27 In a comprehensive review, Martin et al found that at the onset of acute GVHD, 81% of patients had skin involvement, 54% had GI involvement, and 50% had liver involvement.23 Recent data suggest that lungs might also be targets of experimental GVHD.28

Acute GVHD Symptoms

Table 1

Pathophysiology of Acute GVHD

Two important principles are important to consider regarding the pathophysiology of acute GVHD. First, acute GVHD reflects exaggerated but normal inflammatory mechanisms mediated by donor lymphocytes infused into the recipient where they function appropriately, given the foreign environment they encounter. Second, the recipient tissues that stimulate donor lymphocytes have usually been damaged by underlying disease, prior infections, and the transplant conditioning regimen.29 As a result, these tissues produce molecules (sometimes referred to as “danger” signals) that promote the activation and proliferation of donor immune cells.4245 Mouse models havebeen central to our identification and understanding of the pathophysiologic mechanisms of GVHD, and canine models have been critical to the development of clinically useful strategies for GVHD prophylaxis and treatment and to the development of donor leukocyte infusions.364647 Based largely on these experimental models, the development of acute GVHD can be conceptualized in three sequential steps or phases: (1) activation of the APCs; (2) donor T cell activation, proliferation, differentiation and migration; and (3) target tissue destruction (Figure 3).

Figure 3

GVHD Pathophysiology

In Phase I, the recipient conditioning regimen damages host tissues and causes release of inflammatory cytokines such as TNFα, IL-1 and IL-6. Increased levels of these cytokines leads to activation of host antigen presenting cells (APCs). In Phase II, host APCs activate mature donor cells. The subsequent proliferation and differentiation of these activated T cells produces additional effectors that mediate the tissue damage, including Cytotoxic T Lymphocytes, Natural Killer (NK) cells, TNFα and IL-1. Lipopolysaccharide (LPS) that has leaked through the damaged intestinal mucosa triggers additional TNFα production. TNFα can damage tissue directly by inducing necrosis and apoptosis in the skin and GI tract through either TNF receptors or the Fas pathway. TNFα plays a direct role in intestinal GVHD damage which further amplifies damage in the skin, liver and lung in a “cytokine storm.”

GVHD pathophysiology nihms-115970-f0003

GVHD pathophysiology nihms-115970-f0003

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2735047/bin/nihms-115970-f0003.jpg

Phase I: Activation of Antigen Presenting Cells (APCs)

The first step involves the activation of APCs by the underlying disease and the HCT conditioning regimen. Damaged host tissues respond by producing “danger” signals, including proinflammatory cytokines (e.g., TNF-α), chemokines, and increased expression of adhesion molecules, MHC antigens and costimulatory molecules on host APCs.424850 A recent report demonstrated that at one week after HCT, increased levels of TNF-α receptor I, a surrogate marker for TNF-α, strongly correlated with the later development of GVHD.51 Damage to the GI tract from the conditioning is particularly important because it allows for systemic translocation of additional inflammatory stimuli such as microbial products including lipopolysaccaride (LPS) or other pathogen-associated molecular patterns that further enhance the activation of host APCs.49 The secondary lymphoid tissue in the GI tract is likely the initial site of interaction between activated APCs and donor T cells.52 These observations have led an important clinical strategy to reduce acute GVHD by reducing the intensity of the conditioning regimen. Experimental GVHD can also be reduced by manipulating distinct subsets of APCs.53,54 In addition, non-hematopoietic stem cells, such as mesenchymal stem cells or stromal cells, can reduce allogeneic T cell responses, although the mechanism for such inhibition remains unclear.2

The concept that enhanced activation of host APCs increases the risk for acute GVHD unifies a number of seemingly disparate clinical associations with that risk, such as advanced stages of malignancy, more intense transplant conditioning regimens and histories of viral infections. APCs detect infections by recognizing conserved molecular patterns that are unique to microbes, called pathogen-associated molecular patterns (PAMPs). Among the classes of receptors that recognize such patterns, the Toll-like receptors (TLR) are the best characterized.55 For example, TLR4 recognizes LPS55 and mice with mutant TLR4 receptors that do not respond to LPS cause less GVHD when used as donors.56 Other TLRs that recognize viral DNA or RNA also activate APCs and may enhance GVHD, providing a potential mechanistic basis for increased GVHD associated with viral infections such as cytomegalovirus (CMV).57

Phase II: Donor T Cell Activation

The core of the GVH reaction is Step 2, where donor T cells proliferate and differentiate in response to host APCs. The “danger” signals generated in Phase I augment this activation at least in part by increasing the expression of costimulatory molecules.58 Blockade of co-stimulatory pathways to prevent GVHD is successful in animal models, but this approach has not yet been tested in large clinical trials.2

In mouse models, where genetic differences between donor and recipient strains can be tightly controlled, CD4+ cells induce acute GVHD to MHC class II differences, and CD8+ cells induce acute GVHD to MHC class I differences.5961 In the majority of HLA-identical HCTs, both CD4+ and CD8+ subsets respond to minor histocompatibility antigens and can cause GVHD in HLA-identical HCT.

Regulatory T cells can suppress the proliferation of conventional T cells and prevent GVHD in animal models when added to donor grafts containing conventional T cells.62 In mice, the Foxp3 protein functions as a master switch in the development of regulatory T cells, which normally constitute 5% of the CD4+ T cell population.62 Regulatory T cells secrete anti-inflammatory cytokines IL-10 and Transforming Growth Factor(TGF)-β and can also act through contact-dependent inhibition of APCs.62 It is likely that the use of regulatory T cells in clinical acute GVHD will require improved techniques to identify and expand them.

Natural Killer T cell (NKT) 1.1+ subsets of both the host and donors that have been shown to modulate acute GVHD.63 Host NKT cells have been shown to suppress acute GVHD in an IL-4 dependent manner.64 A recent clinical trial of total lymphoid irradiation used as conditioning significantly reduced GVHD and enhanced host NKT cell function.65 By contrast, donor NKT cells can reduce GVHD and enhance perforin mediated GVL in an experimental model.66

Activation of immune cells results in rapid intracellular biochemical cascades that induce transcription of genes for many proteins including cytokines and their receptors. Th1 cytokines (IFN-γ, IL-2 and TNF-α) are produced in large amounts during acute GVHD. IL-2 production by donor T cells remains the principal target of many current clinical therapeutic and prophylactic approaches to GVHD, such as cyclosporine, tacrolimus and monoclonal antibodies (mAbs) directed against IL-2 and its receptor.9 But emerging data indicate an important role for IL-2 in the generation and maintenance of CD4+ CD25+ T regs, suggesting that prolonged interference with IL-2 may have an unintended consequence of preventing the development of long term tolerance after allogeneic HCT.67 IFN-γ has multiple functions and can either amplify or reduce GVHD.68,69 IFN-γ may amplify GVHD by increasing the expression of molecules such as chemokines receptors, MHC proteins, and adhesion molecules; it also increases the sensitivity of monocytes and macrophages to stimuli such as LPS and accelerates intracellular cascades in response to these stimuli.70Early polarization of donor T cells so that they secrete less IFN-γ and more IL-4 can also attenuate experimental acute GVHD.71 IFN-γ may amplify GVHD by directly damaging epithelium in the GI tract and skin and inducing immnosuppression through the induction of nitric oxide.72 By contrast, IFN-γ may suppress GVHD by hastening the apoptosis of activated donor T cells.6973. This complexity means the manipulation of IFN-γ may have diverse effects in vivo, making it a challenging target with respect to therapeutic intervention. IL-10 plays a key role in suppression of immune responses, and clinical data suggest it may regulate acute GVHD.17 TGF-β, another suppressive cytokine can suppress acute GVHD but exacerbate chronic GVHD.74 Thus the timing and duration of the secretion of any given cytokine may determine the specific effects of that cytokine on GVHD severity.

Phase III: Cellular and Inflammatory Effector Phase

The effector phase of this process is a complex cascade of both cellular mediators such as cytotoxic T lymphocytes(CTLs) and NK cells and soluble inflammatory mediators such as TNF-α, IFN-γ, IL-1 and nitric oxide.229 These soluble and cellular mediators synergize to amplify local tissue injury and further promote inflammation and target tissue destruction.

Cellular Effectors

The cellular effectors of acute GVHD are primarily CTLs and NK cells.49 CTLs that preferentially use the Fas/FasL pathway of target lysis and appear to predominate in GVHD liver damage (hepatocytes express large amounts of Fas) whereas GVHD CTLs that use the perforin /granzyme pathways are more important in the GI tract and skin.275 Chemokines direct the migration of donor T cells from lymphoid tissues to the target organs where they cause damage. Macrophage inflammatory protein-1alpha (MIP-1α) and other chemokines such as CCL2-5, CXCL2, CXCL9-11, CCL17 and CCL27 are over-expressed and enhance the homing of cellular effectors to target organs during experimental GVHD.76Expression of integrins, such as α4β7 and its ligand MadCAM-1, are also important for homing of donor T cells to Peyer’s patches during intestinal GVHD.527778

Prevention of GVHD

Based on the evidence from animal models regarding the central role of T cells in initiating GVHD, numerous clinical studies evaluating T cell depletion (TCD) as prophylaxis for GVHD were performed in the 1980’s and 1990’s. There were three principal TCD strategies: (1) negative selection of T cells ex vivo, (2) positive selection of CD34+ stem cells ex vivo; and (3) anti-T cell antibodies in vivo.83Most strategies showed a significant limitation in both acute and chronic GVHD.8488 Unfortunately, the lower incidence of severe GVHD was offset by high rates of graft failure, relapse of malignancy, infections, and Epstein-Barr virus-associated lymphoproliferative disorders. Negative selection purging strategies using various anti-T cell antibodies achieved similar long-term results regardless of the breadth of antibody specificity.8993 One large registry study demonstrated that purging strategies using antibodies with broad specificities produced inferior leukemia-free survival than standard immunosuppression in patients receiving unrelated donor transplants.94 Several studies have investigated partial T cell depletion, either by eliminating specific T cell subsets (e.g., CD8+) or by titrating the dose of T cells present in the inoculum.9597 None of these approaches, however, has convincingly demonstrated an optimal strategy that improves long-term survival.

Alemtuzumab is a monoclonal antibody that binds CD52, a protein expressed on a broad spectrum of leukocytes including lymphocytes, monocytes, and dendritic cells. Its use in GVHD prophylaxis in a Phase II trial decreased the incidence of acute and chronic GVHD following reduced intensity transplant.98 In two prospective studies, patients who received alemtuzumab rather than methotrexate showed significantly lower rates of acute and chronic GVHD,99 but experienced more infectious complications and higher rates of relapse, so that there was no overall survival benefit. Alemtuzumab may also contribute to graft failure when used with minimal intensity conditioning regimens.100

An alternative strategy to TCD attempted to induce anergy in donor T cells by ex vivo antibody blockade of co-stimulatory pathways prior to transplantation. A small study using this approach in haploidentical HCT recipients was quite encouraging, but has not yet been replicated.101 Thus the focus of most prevention strategies remains pharmacological manipulation of T cells after transplant.

Administration of anti-T cell antibodies in vivo as GVHD prophylaxis has also been extensively tested. The best studied drugs are anti-thymocyte globulin (ATG) or antilymphocyte globulin (ALG) preparations. These sera, which have high titers of polyclonal antibodies, are made by immunizing animals (horses or rabbits) to thymocytes or lymphocytes, respectively. A complicating factor in determining the role of these polyclonal sera in transplantation is the observation that even different brands of the same class of sera exert different biologic effects.102 However, the side effects of ATG/ALG infusions are common across different preparations and include fever, chills, headache, thrombocytopenia (from cross-reactivity to platelets), and, infrequently, anaphylaxis. In retrospective studies, rabbit ATG reduced the incidence of GVHD in related donor HSCT recipients without appearing to improve survival.103104 In recipients of unrelated donor HSCT, addition of ALG to standard GVHD prophylaxis effectively prevented severe GVHD, but did not result in improved survival because of increased infections.105 In a long term follow-up study, however, pretransplant ATG provided significant protection against extensive chronic GVHD and chronic lung dysfunction.106

The primary pharmacologic strategy to prevent GVHD is the inhibition of the cytoplasmic enzyme, calcineurin, that is critical for in the activation of T cells. The calcineurin inhibitors, cyclosporine and tacrolimus, have similar mechanisms of action, clinical effectiveness and toxicity profiles, including hypomagnesemia, hyperkalemia, hypertension, and nephrotoxicity.9107 Serious side effects include transplant-associated thrombotic microangiopathy (TAM) and neurotoxicity that can lead to premature discontinuation. Although clinically similar to thrombotic thrombocytopenic purpura, TAM does not reliably respond to therapeutic plasmapheresis, carries a high mortality rate, and removal of the offending agent does not always result in improvement.108 Posterior reversible encephalopathy syndrome includes mental status changes, seizures, neurological deficits and characteristic magnetic resonance imaging findings; this syndrome has been seen in 1-2% of HCT recipients receiving and calcineurin inhibitors.109 Side effects of these drugs decrease as the dose is tapered, usually two to four months after HCT.

Calcineurin inhibitors are often administered in combination with other immunosuppressants, such as methotrexate, which is given at low doses in the early post-transplant period.9107 The toxicities of methotrexate (neutropenia and mucositis) have led some investigators to replace it with mycophenolate mofetil (MMF). In one prospective randomized trial, patients who received MMF as part of GVHD prophylaxis experienced significantly less severe mucositis and more rapid neutrophil engraftment than those who received methotrexate.110 The incidence and severity of acute GVHD was similar between the two groups, but the study closed early due to superiority of the MMF arm with respect to reduced mucositis and the speed of hematopoietic engraftment. A desire for faster neutrophil engraftment has led to the use of MMF in UCB blood transplants where graft failure is a major concern.111 MMF is also often used after RIC regimens for similar reasons.112113

Sirolimus is an immunosuppressant that is structurally similar to tacrolimus but does not inhibit calcineurin. In a small Phase II trial, it showed excellent efficacy in combination with tacrolimus;114 the drug damages endothelial cells, however, and it may enhance TAM that is associated with calcineurin inhibitors.115 The combination of tacrolimus and sirolimus is currently being compared in a large randomized multi-center trial.

RIC regimens attempt to suppress the host immune system sufficiently so that donor T cells can engraft and then ablate the lympho-hematopoietic compartment of the recipient. The term “non-myeloablative” is therefore somewhat misleading. RIC regimens produce less tissue damage and lower levels of the inflammatory cytokines that are important in the initiation of GVHD pathophysiology; this effect may explain the reduced incidence of severe GVHD following RIC compared to the full intensity conditioning used in historical controls.98116 The onset of acute GVHD may be delayed after RIC until after day 100, however, and it may present simultaneously with elements of chronic GVHD (“overlap syndrome”).116120

Treatment of Acute GVHD

GVHD generally first develops in the second month after HCT, during continued treatment with calcineurin-based prophylaxis.23121 Steroids, with their potent antilymphocyte and anti-inflammatory activity, are the gold standard for treatment of GVHD. Many centers treat mild GVHD of the skin (Grade I) with topical steroids alone, but for more severe skin GVHD and any degree of visceral GVHD involvement, high-dose systemic steroids are usually initiated. Steroid therapy results in complete remission in less than half of the patients,122 and more severe GVHD is less likely to respond to treatment.123124 In a prospective randomized study, the addition of ATG to steroids as primary therapy did not increase the response rate.124 In a retrospective study, the use of ATG in patients who showed early signs of steroid-resistance was beneficial,122 but not all studies show such benefit and ATG is not standardly used because of increased infection risks.106125126.

An increasingly common treatment for GVHD is extracorporeal photopheresis (ECP). During ECP, the patient’s white blood cells are collected by apheresis, incubated with the DNA-intercalating agent, 8-methoxypsoralen, exposed to ultraviolet light (UVA), and returned to the patient. ECP is known to induce cellular apoptosis, which has strong anti-inflammatory effects in a number of systems, including prevention of rejection of solid organ grafts.127 Animal studies show that ECP reverses acute GVHD by increasing the number of regulatory T cells.128 A Phase II clinical study of steroid-dependent or steroid refractory GVHD showed resolution of GVHD in a large majority of patients, with 50% long-term survival in this very high risk group.129 Randomized multi-center studies of this approach are needed to determine its place in the management of acute GVHD.

Another interesting strategy to treat GVHD is the blockade of the inflammatory cytokine TNF-α. TNF-α can activate APCs, recruit effector cells and cause direct tissue damage.130 In animal models, TNF-α plays a central role in GVHD of the GI tract, which is central to the “cytokine storm” and plasma levels of TNFR I (a surrogate marker for TNF-α) rise in patients before the clinical manifestations of GVHD appear. 51 A recent Phase II trial of etanercept, a solubilized TNFR II, showed significant efficacy when added to systemic steroids as primary therapy for acute GVHD. Seventy percent of patients had complete resolution of all GVHD symptoms within one month, with 80% complete responses in the GI tract and the skin. The authors also showed that plasma levels of TNFR I were a significant biomarker for clinical GVHD.131

Treatment of Chronic GVHD

In contrast to acute GVHD, the pathophysiology of chronic GVHD remains poorly understood, and it is treated with a variety of immunosuppressive agents. The response of chronic GVHD to treatment is unpredictable, and mixed responses in different organs can occur in the same patient. Confounding variables such as infection and co-morbidities also make responses hard to measure. The use of corticosteroids (with or without a calcineurin inhibitor) is the standard of care, but a randomized trial of more than 300 patients with chronic GVHD found no difference between cyclosporine plus prednisone versus prednisone alone.132 Chronic immunosuppressants, especially those containing steroids, are highly toxic and result in infectious deaths. Many second line therapies have been studied, but none has achieved widespread acceptance. As mentioned above, ECP shows some promise, with significant response rates in high-risk patients. The best responses were observed in skin, liver, oral mucosa, eye, and lung.133 This observation is particularly relevant because lung GVHD has the potential to be a particularly devastating complication necessitating lung transplant as the only therapeutic option.134135

Essential Supportive Care in GVHD Patients

Meticulous supportive care is critical for patients with both acute and chronic GVHD because of the extended duration of immunosuppressive treatments and because the multiple medications required may have synergistic toxicities. Such care includes extensive infectious prophylaxis, early interventions in cases of suspected infections, and prophylaxis against non-infectious side effects of medications (See Table 3). These complications often require rapid responses to prevent serious or irreversible damage, and are best handled in close collaboration between the primary physician and the transplant specialist.

Table 3

Recommendations for Supportive Care

All patients should receive at least fluconazole as prophylaxis against fungal infections. Invasive molds, especially aspergillus, are common in patients with prolonged steroid use.136 Prophylaxis with voriconazole or posaconazole should be considered for these patients. Usual sites of infection are the lungs, sinuses, brain, skin,137 and serial galactomannan assays may aid in the early detection.138 Candida can cause lesions in the lung and spleen, which may need screening with ultrasonography. Pneumocystis is another opportunistic infection that should receive cotrimoxazol (bactrim) prophylaxis.139

Viral infections are frequent in these patients with GVHD. Cytomegalovirus causes interstitial pneumonia and gastritis. Patients who are at risk should have their blood monitored several times monthly. Techniques that directly detect virus should be performed, such as CMV PCR or pp65 antigen, and evidence of increased viral load should prompt preemptive treatment with ganciclovir or foscarnet prior to clinical manifestations of disease. Shingles is not uncommon and acyclovir prophylaxis may be beneficial.140 Patients and caregivers should receive vaccinations against influenza, and treatment with neuraminidase inhibitors is recommended in the event of influenza infection.141142

Patients with GVHD often have IgG2 and IgG4 subclass deficiencies despite normal lgG levels, making them susceptible to infections with encapsulated organisms. Treatment of severe hypogammaglobulinemia with intravenous immunoglobulin is standard in many centers,143 but the level that triggers replacement varies considerably among transplant specialists. There is little supporting evidence for the routine use of intravenous immunoglobulin as prophylaxis144 but patients should receive routine prophylaxis (penicillin or its equivalent) due to the increased risk of streptococcal sepsis.145 Pneumococcal conjugate and hemophilus influenza vaccine may provide additional protection and are also recommended for all patients, including those with chronic GVHD.139146147 The sites of any indwelling catheters should be assessed regularly and early treatment of a suspected infection initiated. Early signs or symptoms of septic shock such as shaking chills or low blood pressure requires prompt evaluation with chest X-ray and/or CT scan, blood culture and broad spectrum antibiotics because shock may progress rapidly in these patients.

9.3.5 Aspergillus Complicating Allogeneic Transplantation

Aspergillus infections in allogeneic stem cell transplant recipients: have we made any progress?

E Jantunen, V-J Anttila and T Ruutu
BMT 2002; 30(12):925-929
http://www.nature.com/bmt/journal/v30/n12/full/1703738a.html
http://dx.doi.org:/10.1038/sj.bmt.1703738

Invasive aspergillosis (IA) is common in allogeneic SCT recipients, with an incidence of 4-10%. The majority of these infections are diagnosed several months after SCT and they are frequently associated with GVHD. The diagnosis is difficult and often delayed. Established IA is notoriously difficult to treat with a death rate of 80-90%. This review summarises recent data on this problem to assess whether there has been any progress. Effective prophylactic measures are still lacking. Severe immunosuppression is the main obstacle to the success of therapy. Recent and ongoing developments in diagnostic measures and new antifungal agents may improve treatment results to some extent, but Aspergillus infections still remain a formidable problem in allogeneic transplantation. Further studies in this field will focus on the role of various cytokines and combinations of antifungal agents.

Summary

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Ulcer-causing Helicobacter bacteria induce stomach stem cell to grow

Reporter: Aviva Lev-Ari, PhD, RN

 

 

 

 

 

The ulcer-causing bacterium Helicobacter pylori can directly interact with stomach stem cells, causing the cells to divide more rapidly, according to a new study by researchers at the Stanford University School of Medicine.

The increased cell division was observed in mice, but the findings could explain why H. pylori is a risk factor for gastric cancer in humans, the researchers said.

They used 3-D microscopy to identified colonies of the bacteria deep within human stomach glands, where stem cells and precursor cells that replenish the stomach’s lining reside.

One of every two people has H. pylori in their stomachs. It’s one of the few organisms capable of surviving the harsh acidic environment. While the majority of people remain asymptomatic, in about 15 percent of those infected the bacteria causes painful ulcers, and in another 1 percent the bacteria contribute to stomach cancer, the third-most lethal cancer worldwide.

Although the infection can be successfully treated with antibiotics, those who develop cancer are often unaware of their condition until the tumor is large enough to interfere with stomach functions. “The bacteria will be brewing for many years, and when the cancer starts to cause symptoms it may be too late,” said Manuel Amieva, MD, PhD, associate professor of pediatrics and of microbiology and immunology.

 

The researchers came up with the idea of sampling stomach tissues removed during weight-loss surgery. These samples came from healthy stomachs, in which H. pylori was not actively causing ulcers or cancer. After identifying tissue infected with particular strains of H. pylori, they used confocal microscopy to reconstruct 3-D images of the glands from four stomachs with H. pylori. All four showed colonies of the spiral-shaped bacteria clustered about two-thirds of the way into the gland, where fast-dividing precursor cells reside.

 

Unexpectedly, the researchers found a smaller number of bacterial colonies at the base of the glands, where the stem cells reside. When they went back to their mouse models, they discovered about 30 percent of the glands colonized by H. pylori had bacteria at the base of the glands.

H. pylori affects stem cells.

 

This unanticipated finding shed light on how H. pylori could influence cells to turn cancerous. Cancer is thought to develop slowly as the cell acquires mutations in the DNA that override cellular controls and increase cell proliferation. Even though H. pylori had been shown to manipulate cellular controls, the mature stomach’s epithelial cells don’t live long enough to acquire mutations.

Source: ekaweb02.eurekalert.org

See on Scoop.itCardiovascular Disease: PHARMACO-THERAPY

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How stem cells can fix a broken heart with just one jab – Daily Mail

Reporter: Aviva Lev-Ari, PhD, RN

 

 

 

 

 

 

 

It is hoped that the procedure could improve the quality of life for patients suffering from heart failure, which affects 900,000 people in the UK.

Source: www.dailymail.co.uk

See on Scoop.itCardiovascular Disease: PHARMACO-THERAPY

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Wnt/β-catenin Signaling

Writer and Curator: Larry H. Bernstein, MD, FCAP 

 

7.10 Wnt/β-catenin signaling

7.10.1 Wnt signaling and hepatocarcinogenesis. The hepatoblastoma model

7.10.2 The Wnt.β-catenin pathway in ovarian cancer : a review.

7.10.3 Wnt Signaling in the Niche Enforces Hematopoietic Stem Cell Quiescence and Is Necessary to Preserve Self-Renewal In Vivo

7.10.4 Wnt.β-Catenin Signaling in Development and Disease

7.10.5 Wnt.β-Catenin Signaling. Components, Mechanisms, and Diseases

7.10.6 Wnt.β-Catenin Signaling. Turning the Switch

7.10.7 Wnt–β-catenin signaling

7.10.8 Extracellular modulators of Wnt signaling

7.10.9 FOXO3a modulates WNT.β-catenin signaling and suppresses epithelial-to-mesenchymal transition in prostate cancer cells

7.10.1 Wnt signalinbg pathway in liver cancer

7.10.1.1 Wnt signaling and hepatocarcinogenesis. The hepatoblastoma model

Armengol C1Cairo SFabre MBuendia MA.
Int J Biochem Cell Biol. 2011 Feb; 43(2):265-70.
http://dx.doi.org:/10.1016/j.biocel.2009.07.012

The Wnt/β-catenin pathway plays a key role in liver development, regeneration and tumorigenesis. Among human cancers tightly linked to abnormal Wnt/β-catenin signaling, hepatoblastoma (HB) presents with the highest rate (50-90%) of β-catenin mutations. HB is the most common malignant tumor of the liver in childhood. This embryonic tumor differs from hepatocellular carcinoma by the absence of viral etiology and underlying liver disease, and by distinctive morphological patterns evoking hepatoblasts, the bipotent precursors of hepatocytes and cholangiocytes. Recent studies of the molecular pathogenesis of hepatoblastoma have led to identify two major tumor subclasses resembling early and late phases of prenatal liver development and presenting distinctive chromosomal alterations. It has been shown that the molecular signature of Wnt/β-catenin signaling in hepatoblastoma is mainly imposed by liver context, but differs according to developmental stage. Finally, the differentiation stage of tumor cells strongly influences their invasive and metastatic properties, therefore affecting clinical behavior.

7.10.1.2 Targeting the Wnt/β-Catenin Signaling Pathway in Liver Cancer Stem Cells and Hepatocellular Carcinoma Cell Lines with FH535

Roberto Gedaly ,Roberto Galuppo, Michael F. Daily, Malay Shah, Erin Maynard, et al.
PLoS ONE 2014; 9(6): e99272.     http://dx.doi.org:/10.1371/journal.pone.0099272

Activation of the Wnt/β-catenin pathway has been observed in at least 1/3 of hepatocellular carcinomas (HCC), and a significant number of these have mutations in the β-catenin gene. Therefore, effective inhibition of this pathway could provide a novel method to treat HCC. The purposed of this study was to determine whether FH535, which was previously shown to block the β-catenin pathway, could inhibit β-catenin activation of target genes and inhibit proliferation of Liver Cancer Stem Cells (LCSC) and HCC cell lines. Using β-catenin responsive reporter genes, our data indicates that FH535 can inhibit target gene activation by endogenous and exogenously expressed β-catenin, including the constitutively active form of β-catenin that contains a Serine37Alanine mutation. Our data also indicate that proliferation of LCSC and HCC lines is inhibited by FH535 in a dose-dependent manner, and that this correlates with a decrease in the percentage of cells in S phase. Finally, we also show that expression of two well-characterized targets of β-catenin, Cyclin D1 and Survivin, is reduced by FH535. Taken together, this data indicates that FH535 has potential therapeutic value in treatment of liver cancer. Importantly, these results suggest that this therapy may be effective at several levels by targeting both HCC and LCSC.

Hepatocellular carcinoma (HCC), the most common liver cancer, is the fifth most common cancer and the third highest cause of cancer-related mortality worldwide [1][2]. The alarming rise in HCC incidence in Europe and North America in recent years is related mainly to hepatitis C virus infection, although other factors such as excessive alcohol consumption and obesity also contribute to this increase [3]. The etiology of HCC is complex and involves numerous genetic and epigenetic alterations and the disruption of various signaling pathways including the Wnt/β-catenin, Ras/Raf/MAPK, PI3K/AKT/mTOR, HGF/c-MET, IGF, VEGF and PDGF pathways. Among these, the Wnt/β-catenin pathway is considered among the most difficult to inhibit [4]. Currently, few chemical agents targeting the Wnt/β-catenin pathway are available or under investigation [5].

Activation of the canonical Wnt/β-catenin pathway involves the binding of Wnt proteins to cell surface Frizzled receptors and LRP5/6 co-receptors. In the absence of Wnt proteins, much of the cellular β-catenin is bound to E-cadherin on the cell membrane. Cytosolic β-catenin is constitutively phosphorylated at specific serine residues by an enzymatic complex that includes adenomatous polyposis coli (APC), Axin, and the kinases glycogen synthase kinase-3β (GSK-3β) and casein kinase I, marking it for ubiquitin-mediated proteolysis. Under these conditions, the TCF/LEF transcription factors are bound to their cognate DNA recognition elements along with members of the Groucho family of co-repressors, insuring the transcriptional silencing of β-catenin target genes. Engagement of Wnt proteins with the Frizzled receptor activates the Dishevelled protein, resulting in the dissociation of the cytosolic destructive complex and inhibition of GSK-3β. This leads to the stabilization and accumulation of cytoplasmic β-catenin, which then enters the nucleus, binds TCF/LEF proteins and leads to the subsequent dissociation of groucho co-repressors, recruitment of the coactivator p300 and activation of β-catenin target genes [6][9]. Many of the β-catenin targets, including Cyclin D1, c-myc and Survivin, promote cell cycle progression and inhibit apoptosis [10][12]. Consistent with this data, activation of the Wnt/β-catenin pathway is seen in a variety of cancers, including HCC. Aberrant activation of the Wnt/β-catenin pathway has been observed in at least 1/3 of HCC, and roughly 20% of HCCs have mutations in the β-catenin gene. More than 50% of HCC tumors display nuclear accumulation of β-catenin indicating that other factors may be involved such as aberrant methylation of the tumor suppressors APC and E-cadherin, inactivation of casein kinase and GSK-3β, or increased secretion of Wnt ligants [4][5].

There has been increasing interest in the role of liver cancer stem cells (LCSC) in tumorigenesis, tumor progression, invasion and metastases. The cancer stem cell theory suggests that a tumor is comprised of a heterogeneous population of cells that form a distinct cellular hierarchy. Recent studies have provided convincing evidence that these cells do exist in solid tumors of many types including, brain, breast, colorectal, liver, pancreas and prostate cancers. In 2006, two different groups isolated a CD133+ subpopulation from HCC cell lines and described higher proliferative and tumorigenic potential, consistent with stem cell properties. CD44 was also found as an important marker used in combination with other stem cell markers to better define the surface phenotype of LCSC. It has been demonstrated that CD133+ and CD90+ cells co-expressing CD44+ are more aggressive than those expressing CD133 or CD90 alone [13][14].

The chemical agents used to target Wnt-/β-catenin pathway are at the membrane, cytosol and transcription factor levels [5]. The small molecular agent FH535 is a dual inhibitor of peroxisome proliferator-activated receptor (PPAR) and β-catenin/TCF/LEF. FH535 has been shown to inhibit proliferation of HCC and hepatoblastoma cell lines and its specificity on inhibition of β-catenin/TCF/LEF activity was illustrated in hepatoblastoma cell line HepG2 [15].

The aim of this study was to determine if FH535 can inhibit the activation of β-catenin-regulated genes by endogenous and ectopically expressed β-catenin in the HCC cell lines Huh7, Hep3B and PLC and liver cancer stem cells (LCSC). The specificity of FH535 on inhibition of β-catenin via TCF/LEF activation was assayed in dual luciferase reporter transfected in LCSC and in HCC cells. Proliferation, cell cycle, and other targeted genes and proteins were assayed.

FH535 inhibits transcriptional activation mediated by wild-type and constitutively active β-catenin

FH535 has been shown to block signaling through endogenous β-catenin in several cell lines, including the hepatoblastoma cell line HepG2 [15]. To further explore this regulation and to test whether FH535 could block ectopic β-catenin, co-transfections with β-catenin expression vectors and the TCF4-dependent luciferase reporter vector TOPFlash were performed in the human HCC cell lines Huh7 and Hep3B (Fig. 1). In both cell lines, co-transfected wild-type β-catenin expression vector increased luciferase activity from TOPFlash nearly 15-fold compared to cells co-transfected with the empty vector (E.V.) control. This β-catenin-dependent increase was inhibited by FH535 in a dose-dependent manner. β-catenin is often mutated in various cancers, including HCC. One natural mutation changes the serine at position 37; this altered form of β-catenin is resistant to degradation by the APC complex and thus has higher stability. To test whether this form of activated form of β-catenin could also be blocked by FH535, an expression vector for βCatS37A, in which the serine at position 37 has been changed to an alanine, was co-transfected with TOPFlash. As expected, βCatS37A-mediated transactivation of TOPFlash was significantly higher than transactivation by wild-type β-catenin. However, in both cell lines, βCatS37A-mediated transactivation was significantly inhibited by FH535. As controls, cells were also co-transfected with FOPFlash, which is identical to TOPFlash except that the TCF4 sites have been mutated and therefore no longer responsive to β-catenin; FOPFlash was not activated by wild-type β-catenin or βCatS37A as shown in Figure 1.

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Figure 1. FH535 inhibits β-catenin dependent transcriptional activation in HCC cell lines.

Huh7 (Panel A) and Hep3B (Panel B) HCC cells were transfected with the luciferase reporter genes TOPFlash (left panels), which contains three TCF binding sites, or E3-pGL3 (right panels), which contains the AFP enhancer element E3 that has a highly conserved TCF site. Cells were additionally co-transfected with an expression vector that contained no insert (empty vector control, E.V.), wild-type β-catenin (β-catenin), or a constitutively active form of β-catenin (βcatS37A). Renilla luciferase was used to control for variations in transfection efficiency. Six hours after the addition of DNA, cells were treated with DMSO alone (no treatment) or increasing amounts of FH535. After 48 hours, luciferase levels were determined; firefly luciferase was normalized to renilla. In both cell lines, FH535 inhibited β-catenin-dependent activation of target genes. *P<0.05. The experiment was done twice with similar results.

doi:10.1371/journal.pone.0099272.g001

TOPFlash contains three consensus TCF4 binding motifs that confer responsiveness to β-catenin. To test whether FH535 could also block β-catenin-mediated transactivation of a TCF4 motif in the context of a natural regulatory region, co-transfections were performed with E3-pGL3. E3 is a ~340 bp fragment that contains alpha-fetoprotein (AFP) enhancer element E3, one of three enhancers that control hepatic expression of the mouse AFP gene. E3 contains binding sites for multiple factors, including Foxa/HNF6, C/EBP, orphan nuclear receptors, and TCF4 [26][27]. We recently showed that this enhancer is regulated by β-catenin in cells and transgenic mice [21]. E3-pGL3 was transactivated by β-catenin and to a greater extent by βCatS37A (Fig. 1). However, this transactivation by both wild-type and S37A forms of β-catenin was blocked by FH535 in a dose-dependent manner.

3.2 FH535 inhibits β-catenin-mediated transcriptional activation in LCSC

Previous studies have shown that β-catenin signaling is elevated in EpCAM positive cells with LCSC properties [28]. We previously described that CD133+, CD44+, CD24+ LCSC aggressively form tumors when small numbers of these cells are injected into nude mice [29]. To test the ability of FH535 to inhibit β-catenin in these LCSCs, transient transfections were performed with TOPFlash. As controls, TOPFlash was also transfected into the HCC cell lines Huh7 and PLC (Fig. 2). In all three populations, untreated cells exhibited low luciferase levels. When treated with the GSK-3β inhibitor LiCl, which leads to endogenous β-catenin activation[30], TOPFlash activity increased dramatically. FH535 effectively blocked LiCl-mediated activation of TOPFlash in a dose-dependent manner. Interestingly, this inhibition was more robust in LCSC than in either HCC cell line. As a control, transfections were also performed with FOPFlash, which is no longer responsive to β-catenin. As expected, luciferase activity in FOPFlash-transfected cells was neither increased by LiCl nor inhibited by FH535.

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Figure 2. FH535 inhibits TOPFlash activation in LCSC and HCC cell lines.

LCSC (left panel), Huh7 (middle panel) and HPLC (right panel) cells were co-transfected with TOPFlash or FOPFlash luciferase reporter genes along with renilla luciferase. After 6 hours, cells were left untreated (no treatment) or treated with LiCl alone or LiCl with increasing amounts of FH535. LiCl is a known activator of β-catenin. After an additional 36 hours, cells were harvested and luciferase levels were determined; firefly luciferase was normalized to renilla. TOPFlash activity was highly induced in all three cell populations; this activation was inhibited by FH535. The negative control FOPFlash showed minimal response to LiCl or FH535. TOPFlash inhibition by FH535 was more robust in LCSC than in either HCC cell line. * P<0.003, # P<0.001. The experiment was done twice with similar results.

doi:10.1371/journal.pone.0099272.g002

3.3 FH535 inhibits proliferation of LCSC and HCC cell lines

Numerous studies have demonstrated that β-catenin plays an important role in proliferation during normal development and in cellular transformation in many tissues, including the liver. Liver development is impaired in the absence of β-catenin, and mutations that activate the β-catenin pathway are found in about 1/3 of HCC [4][5]. Furthermore, the growth of adult liver progenitor stem cells (oval cells) can be inhibited by blocking the β-catenin pathway. Since our data indicated that FH535 can block β-catenin-mediated transcriptional activation, we also tested whether proliferation of LCSC and HCC cell lines was affected by this compound. LCSC were cultured in the presence of 10% or 1% serum and with between 5 µM and 30 µM FH535 for 72 hours, and cell proliferation was monitored by 3H-thymidine incorporation (Figs. 3A and 3B, respectively). Proliferation decreased with increasing amounts of FH535, with a more dramatic reduction observed in cells grown in the presence of lower serum; the concentration of FH535 to cause a 50% inhibition of cell grown (IC50) was 13.8 µM for cells grown in 10% serum and 5.1 µM for cells grown in 1% serum. This inhibition was more potent than that seen with XAV939 (IC50 = 55 µM), which inhibits tankyrase, thus stabilizing axin and promoting β-catenin degradation (Fig. 3C) [31]. FH535 also blocked proliferation of HCC cells at concentrations that were similar to that seen with LCSC (IC50 of 10.9 µM, 9.25 µM and 6.6 µM for Huh7, PLC and Hep3B, respectively; Fig.3D). To confirm that FH535 indeed inhibited cell proliferation and did not lead to increased cell death, FH535 and 3H-thymidine were added simultaneously to Huh7 cells, which were then cultured for 18 h. In this scenario, we observed a significant inhibition of proliferation at 2.5, 5, 10 and 15 µM of FH535 treatment as compared to control (p<0.05, n = 6), with FH535 at 15 µM causing a 41% inhibition (Figure S3). This data indicates that FH535 is inhibiting cell proliferation rather than increasing cell death.

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Figure 3. FH535 inhibits proliferation of LCSC and HCC cell lines.

Cells were seeded in 96-well plates in 0.2 ml of media as described below for 72 hours, followed by the addition of 3H-thymidine at 1 µCi/well for 4 hours. Incorporation of 3H-thymidine was determined by scintillation counting. In panels A, B and D, the final concentration of DMSO in each well was 0.05%; in panel C, the final DMSO concentration in each well was 0.1%. (A) LCSCs were plated at 1000 cells/well in DMEM with 10% FBS along with DMSO alone or with increasing amounts of FH535. (B). LCSCs were plated at 5000 cells/well in DMEM with 1% FBS with DMSO alone or with increasing concentrations of FH535. (C). LCSCs were plated in DMEM with 10% FBS at 1000 cells/well with DMSO alone or increasing concentrations of XAV939. (D). Huh7, Hep3B and PLC cells were plated in DMEM with 10% FBS at 1000, 2500, and 5000 cells/well, respectively, with DMSO alone or increasing concentrations of FH535. Pvalues are for all the three cell lines treated with FH535 are compared to controls. The experiment was done twice with similar results.

doi:10.1371/journal.pone.0099272.g003

3.4 FH535 induces cell cycle arrest in the HCC cell line Huh7 and in LCSC

The ability of FH535 to inhibit cell proliferation prompted us to investigate the cell cycle distribution following treatment. Huh7 cells were synchronized by growth in 0.1% FBS for 24 hours and then cultured in the presence of 10% FBS and with no FH535 or FH535 at 7.5 µM and 15 µM. After 24 hours, cells were harvested and DNA content was analyzed by propidium iodide staining. In the presence of FH535, there was a statistically significant increase in the number of cells in G0/G1 and a corresponding decreased in the percentage of cells in S phase compared to cells grown in the absence of FH535 (Fig. 4A). The number of cells in G2 was not significantly altered by FH535. In addition, there was no sub-G1 peak detected by flow cytometry, indicating that FH535 was not promoting apoptosis at the concentrations being use (see Figure S4). We also did cell cycle analysis in LCSC after FH535 treatment and found FH535 at 15 µM significantly caused G1 phase arrest in LCSC (P = 0.012). FH535 also significantly reduced G2/M phase in the LCSC after 24 h of 7.5 µM and 15 µM FH535 treatment (P = 0.038 and P<0.001 respectively), no significant S phase inhibition was observed in LCSC (p = 0.446) (Fig. 4B.). Our data are similar to previously published results and reflects β-catenin regulation of cell cycle is different in different cell types [32][33]. Cell cycle regulators (cyclins, CDKs and regulators) can vary in different cell types, which could lead to different responses after FH535 treatment. This may worth exploring in our future study.

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Figure 4. FH535 alters cell cycle progression in Huh7 and LCSC cells.

A. Huh7 cells were cultured in DMEM +10%FBS for 24 h. The cells were washed with serum free DMEM 3 times, then cultured in DMEM +0.1% FBS for 24 h for cell synchronization. Cells were then cultured in DMEM+10% FBS along with different concentrations of FH535 for 24 h. The cells were harvested and stained with propidium iodide (PI) and analyzed by flow cytometry according to the GenScript protocol (Piscataway, NJ, USA). Treatment with FH535 increased the percentage of cells in G1 and decreased the percentage of cells in S phase. The experiment was done twice with similar results. B. LCSC cells were cultured in CelProgen complete LCSC culture medium for 24 h. Cells were then washed with serum free CelProgen medium 3 times and cultured in CelProgen Medium +0.1% FBS for 24 h for synchronization of the cells. The cells were then returned to CelProgen Complete Medium +10% FBS with different concentrations of FH535 for 24 h. Cell cycle was assayed as per Huh7 described above.

doi:10.1371/journal.pone.0099272.g004

3.5 Expression of β-catenin target genes cyclin D1 and Survivin is inhibited by FH535

β-catenin controls cell proliferation and survival by regulating the expression of numerous targets genes. Two well-established targets are the genes encoding Survivin (Birc5) and Cyclin D1 (CcnD1). Survivin is an anti-apoptotic protein that also regulates progression through mitosis [34]; Cyclin D1 controls proliferation by activating the G1 kinases cdk4 and cdk6 [35]. Survivin and Cyclin D1 transcription are regulated through TCF elements in their promoter regions [36]. To test whether FH535 inhibits expression of these two β-catenin target genes, real-time RT-PCR was performed with LCSC and HCC cells that were treated with increasing amounts of FH535. Cyclin D1 and Survivin mRNA levels were reduced by FH535 in all three cell populations in a dose-dependent manner (Fig. 5). To confirm that this reduction in mRNA levels also led to lower protein levels, western analysis was performed using whole cell extracts from Huh7 cells. Both Cyclin D1 and Survivin protein levels were reduced in a dose-dependent manner, with the greatest reduction seen in the presence of 10 µM FH535 (Fig. 6.). Densitometric analysis indicated that FH535 at 5 and 10 µM inhibited Cyclin D1 28% and 64% respectively; FH535 at 5 and 10 µM inhibited surviving 24% and 48% respectively (Fig. 6).

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Figure 5. FH535 reduces cyclin D1 and survivin mRNA levels in LCSC and in HCC cell lines.

LCSCs, Huh7 and Hep3B cells were treated with DMSO alone or increasing concentrations of FH535 for 38-time PCR for expression of Cyclin D1 (Panel A) or Survivin (Panel B). In both cases, mRNA levels were plotted relative to β2-microglobulin. The experiment was done twice with similar results.

doi:10.1371/journal.pone.0099272.g005

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Figure 6. FH535 reduces cyclin D1 and Survivin protein levels in Huh7 cells.

Huh7 cells were treated with DMSO alone or increasing amounts of FH535 for 38-PAGE, and transferred for Western analysis with antibodies against Cyclin D1, Survivin, and β-actin. The top of shows the western blot image; the bottom graph shows densitometric analysis of the western data. This densitometric analysis indicated that FH535 at 5 and 10 µM inhibited Cyclin D1 protein levels 28% and 64% respectively; FH535 at 5 and 10 µM inhibited Survivin protein levels 24% and 48% respectively. The experiment was done twice with similar results.

doi:10.1371/journal.pone.0099272.g006

Discussion

In recent years, numerous signaling pathways have been implicated in hepatic carcinogenesis. The β-catenin pathway is essential in stem cells for self-renewal and maintenance of stem cell properties. Disruption of this balance results in both genetic and epigenetic changes, found in many cancers, including colon cancer and HCC [4]. In this study, we used FH535 as an inhibitor of the β-catenin pathway. This compound has been used previously to inhibit β-catenin expression in cells from colon and lung as well as in cells from hepatoblastoma and HCC [15]. In this report, the authors concluded that FH535 was toxic to a number of cell lines, including Huh7. However, their assays could not distinguish between toxicity and reduced cell proliferation. Our data indicates that FH535 does indeed inhibit cell proliferation; we did not directly measure toxicity.

FH535 inhibition of LCSC proliferation is of interest due to its potential therapeutic effect in chemo-resistant HCC. Our group and others have focused on strategies to inhibit the proliferation of LCSC and differences in resistance patterns with non-liver cancer stem cell lines in vitro and in vivo.

Despite numerous efforts, the etiology of HCC tumorigenesis, whether transformed cells originate from mature hepatocytes or stem/progenitor cells remains unclear. Stem cells are defined by their potential for self-renewal and by their ability to proliferate and differentiate into diverse cell types [37]. In recent years, studies have provided convincing evidence that these cells do exist in solid tumors of many types including, brain, breast, colorectal, liver, pancreas and prostate cancers [27]. In this study we have used LCSC that are 64.4%, 83.2%, 96.4% and 96.9% positive, respectively, for CD133, CD44, CD24 and Aldehyde A1 as determined by flow cytometry. These cells have been previously profiled not only by checking the LCSC markers but also by evaluating their tumorigenic potential using low cell numbers (using 2000 LCSCs instead of 100,000 HCC cells to generate tumors) and studying resistance to several drugs. We previously found that these LCSC have intermediate to high resistance to drugs compare to non- liver cancer stem cell lines using different inhibitors.

In this study, we found that FH535, LCSC inhibition of proliferation was affected by FBS concentration in the culture medium, suggesting that the PPAR pathway may be involved in LCSC proliferation as found in the human cancer cell line HCT116 [15]. This could be explained by a variety of fatty acids and their derivatives present in the FBS that are natural agonists to PPAR. It is possible the PPAR agonists suppress the inhibitory effects of FH535 in cell culture. Indeed, in HCT116 cells, FH535 inhibition of β-catein/TCF-dependent luciferase reporter genes was five times stronger in serum-free medium than in media containing 10% FBS. The ability of FH535 to inhibit tumor growth was dramatically increased when 10% FBS was replaced with 10% BSA [15]. Lysophosphatidic acid was found to be an effective PPAR agonist that could reverse FH535 induced inhibition of HCT116 growth [15]. However, the potential function of PPAR in LCSC is beyond the scope of this study and needs further investigation. Recently, FH535 was found to be the most potent drug among several other Wnt/β-catenin inhibitors on human biliary tract cancer cells cultured in serum-free medium [38]. Our study found that FH535 is much more potent than XAV939 in 10%FBS DMEM. This may be related to the PPAR inhibition potential of FH535. Our study found that FH535 inhibited HCC cell lines Huh7, Hep3B and PLC proliferation, indicating that Wnt/β-catenin signaling plays an important role not only in LCSC but also in HCC.

FH535 inhibition of LCSC and HCC proliferation was illustrated by its ability to inhibit β-catenin/TCF/LEF-dependent luciferase reporter activity. To our knowledge, this is the first report on the ability of FH535 to inhibit β-catenin/TCF/LEF activity in LCSC and in HCC cell lines. Previously, Handeli and Simon reported that FH535 inhibits β-catenin/TCF/LEF activity in the HepG2 cell line, which was mistakenly labeled as HCC by these authors [15]. For over thirty years this cell line was considered HCC by numerous investigators. Lopez et al., who initially isolated these cells, recently concluded that HepG2 cells should in fact be considered a hepatoblastoma cell line [39]. Further studies will be needed to investigate how FH535 inhibition of β-catenin influences LCSCs and HCCs. As shown here, cyclin D1 and Survivin expression are inhibited by FH535. Survivin is an anti-apoptotic protein that also regulates progression through mitosis [26], whereas Cyclin D1 controls proliferation by activating the G1 kinases [35]. Real-time RT-PCR and Western analysis confirmed that the expression of these target genes was evident at the mRNA and protein level. Our preliminary data indicate that FH535 treatment does not alter CD133, CD13 and EPCAM expression in LCSC and HCC cell lines (data not shown). Further analysis of these and other stem cell markers are warranted.

In conclusion, our data show that FH535 is a potent inhibitor of the Wnt/β-catenin pathway in LCSCs and HCC cell lines. Whether its ability to inhibit PPAR also affects the growth of LCSCs and HCC cells will require further investigation. Further studies will also be needed to investigate the in vivo efficacy and toxicity of FH535 on HCC xenografts in an animal model. The role of combination therapy using FH535 with other anti-HCC drugs and the possibility of finding cross-talk of Wnt/β-catenin pathway with other signaling pathways should be investigated.

7.10.1.3 Wnt signaling in hepatocellular carcinoma: analysis of mutation and expression of beta-catenin, T-cell factor-4 and glycogen synthase kinase 3-beta genes.

Hepatocellular carcinoma (HCC) is a common killer cancer in the world. Recently, abnormal activation of the Wnt pathway has been found to be involved in the carcinogenesis of several human cancers including HCC. The goal of the present study was to investigate the mechanism of inappropriate activation of the Wnt pathway in hepatocarcinogenesis. We analyzed the alterations of three key components of the Wnt pathway: beta-catenin, glycogen synthase kinase (GSK)-3beta and T-cell factor (Tcf)-4 in 34 HCC and paracancerous normal liver by immunohistochemistry, polymerase chain reaction (PCR)-single-strand conformation polymorphism (SSCP), direct sequencing, and quantitative real-time reverse transcription (RT)-PCR. We found that 61.8% (21/34) of all HCC examined showed an abnormal beta-catenin protein accumulation in the cytoplasm or nuclei. The RT-PCR-SSCP and direct sequencing showed that beta-catenin exon 3 mutations existed in 44.1% (15/34) of the HCC. No mutations of GSK-3beta or Tcf-4 were detected in HCC. Moreover, messenger RNA of beta-catenin and Tcf-4, but not GSK-3beta, was found to be overexpressed in HCC. On analyzing the relationship between alterations of beta-catenin or Tcf-4 and C-myc or Cyclin D1 expression, we found that mutations of beta-catenin, as well as overexpression of beta-catenin or the Tcf-4 gene were independently correlated with C-myc gene overexpression in HCC. Our present findings strongly suggest that mutations of beta-catenin, as well as overexpression of beta-catenin and the Tcf-4 gene, independently activate the Wnt pathway in HCC, with the target gene most likely to be C-myc.
7.10.1.4 Wnt signaling and cancer
Genes & Dev. 2000. 14:1837-1851
http://dx.doi.org:/10.1101/gad.14.15.1837

The regulation of cell growth and survival can be subverted by a variety of genetic defects that alter transcriptional programs normally responsible for controlling cell number. High throughput analysis of these gene expression patterns should ultimately lead to the identification of minimal expression profiles that will serve as common denominators in assigning a cancer to a given category. In the course of defining the common denominators, though, we should not be too surprised to find that cancers within a single category may nevertheless exhibit seemingly disparate genetic defects. The wnt pathway has already provided an outstanding example of this. We now know of three regulatory genes in this pathway that are mutated in primary human cancers and several others that promote experimental cancers in rodents (Fig. 1). In all of these cases the common denominator is the activation of gene transcription by β-catenin. The resulting gene expression profile should provide us with a signature common to those cancers carrying defects in the wnt pathway. In this review, the wnt pathway will be covered from the perspective of cancer, with emphasis placed on molecular defects known to promote neoplastic transformation in humans and in animal models.

Figure 1.

Oncogenes and tumor suppressors in the wnt signaling pathway. Lines ending with arrows or bars indicate activating or inhibitory effects, respectively. Green and red indicate proto-oncogenic and tumor suppressive activity, respectively, in human cancer or transgenic animals. Definition of the genes and the basis for their activities are described in the text.

The wnt signaling mechanism

The model illustrated in Figure 2 is a proposed mechanism for wnt signaling and is based on the following literature. Signaling is initiated by the secreted wnt proteins, which bind to a class of seven-pass transmembrane receptors encoded by the frizzled genes (Bhanot et al. 1996; Yang-Snyder et al. 1996; He et al. 1997). Activation of the receptor leads to the phosphorylation of the dishevelled protein which, through its association with axin, prevents glycogen synthase kinase 3β (GSK3β) from phosphorylating critical substrates (Itoh et al. 1998; Kishida et al. 1999; Lee et al. 1999; Peters et al. 1999; Smalley et al. 1999). In vertebrates, the inactivation of GSK3β might result from its interaction with Frat-1 (Thomas et al. 1999; Yost et al. 1998; Li et al. 1999a; Salic et al. 2000). The GSK3β substrates include the negative regulators axin and APC, as well as β-catenin itself (Rubinfeld et al. 1996; Yost et al. 1996; Yamamoto et al. 1999). Unphosphorylated β-catenin escapes recognition by β-TRCP, a component of an E3 ubiquitin ligase, and translocates to the nucleus where it engages transcription factors such as TCF and LEF (Behrens et al. 1996; Molenaar et al. 1996;Hart et al. 1999). Additional components in the pathway include casein kinases I and II, both of which have been proposed to phosphorylate dishevelled (Sakanaka et al. 1999; Willert et al. 1997; Peters et al. 1999). The serine/threonine phosphatase PP2A associates with axin and APC, although its functional role in the pathway remains obscure (Hsu et al. 1999; Seeling et al. 1999). Also obscure is the manner by which the wnt receptors communicate with dishevelled.

Figure 2.

Proposed mechanism for the transmission of wnt signals. In the absence of wnt –wnt) GSK3β phosphorylates APC and axin, increasing their binding affinities for β-catenin, which too is phosphorylated by GSK3β, marking it for destruction. In the presence of wnt (+wnt) FRAT prevents GSK3β from phosphorylating its substrates, and β-catenin is stabilized. Casein kinase1ε (CK1ε) binds to and phosphorylates dishevelled (dvl) modulating the FRAT1/GSK3β interaction. RGS, PDZ, and DIX are protein interaction domains.

 Receptors, ligands, and related proteins

The proto-oncogenic effects of wnt were discovered over 18 years ago inciting intense investigation into the role of wnt genes in human cancer (Nusse and Varmus 1982). The subsequent discovery of wingless, the fly homolog of wnt-1, paved the way for assembling a signaling pathway subsequently found to contain cancer causing genes (Cabrera et al. 1987; Rijsewijk et al. 1987). Although wnt was the prototypical oncogene in this pathway, no formal proof for its involvement in human cancer has ever been documented. There have been numerous reports on the overexpression, and sometimes underexpression, of wnt genes in human cancers, but mRNA expression levels are merely correlative. More compelling evidence, such as amplification, rearrangement, or mutation of genes encoding wnt ligands or receptors has not been forthcoming. In lieu of these sorts of findings, we are left to speculate on the consequences of epigenetic events implicating these genes in human cancer. In doing so we can use animal and cell culture models to guide our interpretation.

The wnt ligands, of which there are at least 16 members in vertebrates, are secreted glycoproteins that can be loosely categorized according to their ability to promote neoplastic transformation (for review, seeWodarz and Nusse 1998). For example, the activation of wnt-1, wnt-3, or wnt-10b by retroviral insertion in the mammary gland will promote tumor formation in mice (Lee et al. 1995; Nusse and Varmus 1982; Roelink et al. 1990). Oncogenic potential can also be assessed in cultured mammalian cells, such as C57MG and CH310T1/2, where expression of the proto-oncogenic wnts results in morphological transformation (Bradbury et al. 1994; Wong et al. 1994). These cells are transformed by wnt-1, wnt-2, wnt3a but not by wnt-4, wnt-5a, and wnt-6. The transforming wnt genes also promote the accumulation of β-catenin in some cultured mammalian cells (Shimizu et al. 1997). Some aspects of the wnt cancer pathway are also recapitulated inXenopusdevelopment, where injection of transforming wnts into early embryos results in duplication of the dorsal axis (Wodarz and Nusse 1998). A caveat here is that the lack of specific receptors for certain wnts might also explain their inactivity in some of these assays (He et al. 1997). Nevertheless, identifying those wnts capable of neoplastic transformation will aid the interpretation of epigenetic evidence implicating wnts in cancer. For example, expression of thewnt-16 gene is activated by the E2A–Pbx1 fusion product in acute lymphoblastoid leukemia (McWhirter et al. 1999), but the oncogenic potential of wnt-16 is unknown.

As might be expected from the plethora of wnt genes, there are also numerous wnt receptors. At least 11 vertebrate frizzled genes have been identified, but how they differ in function and ligand specificity is far from clear. The analysis of mere binding specificity may not be sufficient to sort out the appropriate combinations of functional receptor-ligand interactions. Wnt-3a and wnt-5a both bind to Human frizzled 1 (Hfz1), yet only wnt-3a mediates TCF-dependent transcription (Gazit et al. 1999). This suggests that the activation of TCF/LEF-dependent transcription is a good correlate to neoplastic transformation. Implementation of this assay, along with a second assay involving the translocation of PKC to the cell membrane, resulted in the categorization of murine wnt receptors into two exclusive groups (Sheldahl et al. 1999). Human FzE3 fell into the TCF/LEF activation group, consistent with previous work showing that its overexpression resulted in nuclear localization of β-catenin (Tanaka et al. 1998). This receptor was also expressed in numerous human esophageal cancers, but not in matched normal tissue (Tanaka et al. 1998).

In addition to the frizzled receptors, there exists a family of secreted proteins bearing homology to the extracellular cysteine-rich domain of frizzled. The so-called secreted frizzled-related proteins (sFRP) bind to the wnt ligands, thereby exerting antagonistic activity when overexpressed in wnt signaling assays (Leyns et al. 1997; Wang et al. 1997). The vertebrate sFRPs, like the frizzled proteins, exhibit functional specificity with respect to the various wnts. InXenopus assays, the prototypical frizzled related protein frzb, now known as sFRP-3, inhibited wnt-1 and wnt-8, but not wnt-5a (Leyns et al. 1997; Lin et al. 1997; Wang et al. 1997). Assays in mammalian cells showed that FrzA, now termed sFRP-1, inhibited wnt-1-induced accumulation of β-catenin (Dennis et al. 1999;Melkonyan et al. 1997). Again, binding specificity may not relate to functional specificity, as wnt-5a associated with sFRP-3 but was unable to inhibit its activity (Lin et al. 1997). Even the significance of specific functional interactions might be suspect based on recent titration experiments with purified soluble sFRP-1. At low concentrations sFRP-1 enhanced signaling activity by soluble wingless protein, whereas at higher concentrations it was inhibitory (Uren et al. 2000). The authors proposed high and low states of binding affinity that involved the carboxy-terminal heparin binding domain and the amino-terminal cysteine-rich domain of sFRP-1, respectively. Binding to the cysteine-rich domain might confer inhibition while binding to the carboxy-terminal region could facilitate presentation of active ligand to receptor. The potential for some sFRPs to activate wnt signaling is consistent with a previous study in which sFRP-2, then known as SARP-1, increased the intracellular concentration of β-catenin and conferred anti-apoptotic properties to cultured MCF-7 cells (Melkonyan et al. 1997). Functional studies are further complicated by the binding of a sFRP to the putative human receptor frizzled-6, underscoring additional possible modes of regulation (Bafico et al. 1999). The sFRPs have not been directly linked to cancer, but one could speculate that the anti-apoptotic activity observed with the SARP-1 could contribute to tumor progression. Alternatively, the identification of sFRP-2 as a target of the hedgehog signaling pathway might be relevant to human basal cell cancers (Lee et al. 2000). Additional structurally distinct secreted inhibitors of wnt signaling include the recently discovered dickopft-1 and wif-1 proteins (Fedi et al. 1999; Glinka et al. 1998;Hsieh et al. 1999).

GSK3β

The serine/threonine kinase GSK3β binds to and phosphorylates several proteins in the wnt pathway and is instrumental to the down regulation of β-catenin (Dominguez et al. 1995; He et al. 1995; Hedgepeth et al. 1999b; Ikeda et al. 1998;Itoh et al. 1998;Li et al. 1999a; Nakamura et al. 1998b; Rubinfeld et al. 1996;Yamamoto et al. 1999; Yost et al. 1996). As a negative regulator of wnt signaling, GSK3β would qualify as a potential tumor suppressor. However, mutations or deletions in the gene coding for GSK3β were not been detect ed in a survey of colorectal tumors (Sparks et al. 1998). Perhaps GSK3β can compensate for the loss of GSK3β and the biallelic inactivation of both these genes is unlikely in tumor progression. Alternatively, the utilization of GSK3β by pathways independent of wnt could make its overall ablation incompatible with cell viability. Nevertheless, inactivation of GSK3β can still be achieved by a means other than genetic ablation and can occur in a manner that uniquely affects wnt signaling. This mode of inactivation involves the association of GSK3β with Frat-1. Frat-1 was identified by insertional mutagenesis in a screen for genes that enhanced the progression of transplanted T-cell lymphomas in mice (Jonkers et al. 1997). Subsequent transgenic expression of Frat-1 alone did not induce spontaneous lymphomas, but greatly enhanced lymphomagenesis initiated either by leukemia virus M-MuLV or expression of the Pim1 oncogene (Jonkers et al. 1999). A connection to GSK3β was realized by the discovery of the Frat-1 Xenopushomolog GBP, a GSK3β binding protein inhibitory to wnt signaling when expressed in Xenopus embryos (Yost et al. 1998). Frat-1 is also antagonistic to wnt signaling in mammalian cells, presumably because it competes with axin for binding to GSK3β (Li et al. 1999a; Thomas et al. 1999). GBP also inhibited the phosphorylation and degradation of β-catenin in vitro when added to Xenopusextracts (Salic et al. 2000). Although Frat-1 contributes to cancer progression in a transgenic mouse model, its contribution to human cancer has not been documented.

Dishevelled

The genetic analysis of dishevelled in developmental systems has defined it as a positive mediator of wnt signaling positioned downstream of the receptor and upstream of β-catenin (Noordermeer et al. 1994). Overexpression or constitutive activation of dishevelled would be expected to promote neoplastic transformation, but its involvement in human cancers has not been reported. This might reflect the dual function of dishevelled, one that transduces wnt signals for the stabilization of β-catenin and a second that relays signals for the activation of jun kinases (Li et al. 1999b; Moriguchi et al. 1999). Although these two functions are housed in physically separable regions of the protein, dysregulation of one function, without impacting the other, could place severe constraints on selection for potential oncogenic mutations. A possible connection of dishevelled to cancer is through casein kinase II, which binds to and phosphorylates dishevelled and also promotes the formation of lymphomas when expressed in transgenic mice (Seldin and Leder 1995; Song et al. 2000; Willert et al. 1997).

β-catenin

Mutations in the β-catenin gene (CTNNb1) affecting the amino-terminal region of the protein make it refractory to regulation by APC (Morin et al. 1997; Rubinfeld et al. 1997). These mutations affect specific serine and threonine residues, and amino acids adjacent to them, that are essential for the targeted degradation of β-catenin (for review, see Polakis 1999). The mutations abrogate the phosphorylation dependent interaction of β-catenin with β-TRCP, a component of an E3 ubiquitin ligase that makes direct contact with amino terminal sequence in β-catenin (Hart et al. 1999). This regulatory sequence in β-catenin is mutated in a wide variety of human cancers as well as in chemically and genetically induced animal tumors. Importantly, β-catenin mutations in tumors are exclusive to those that inactivate APC. This is particularly apparent in colorectal cancer where the vast majority of these tumors contain APC mutations and the overall frequency of β-catenin mutations is quite low (Samowitz et al. 1999; Sparks et al. 1998;Kitaeva et al. 1997) (Table 1). When colorectal tumors lacking APC mutations were analyzed separately, the likelihood of finding a CTNNb1 mutation was greatly increased (Iwao et al. 1998; Sparks et al. 1998). The exclusivity of CTNNb1 and APC mutations in colorectal cancer was also evident from the analysis of replication error-positive tumors identified by microsatellite instability. Both the hereditary and sporadic forms of replication error-positive colorectal cancers had a relatively high frequency of β-catenin mutations, whereas APC mutations were relatively rare (Mirabelli-Primdahl et al. 1999; Miyaki et al. 1999) (Table 1). Interestingly, this correlation between microsatellite instability andCTNNb1 mutations was not apparent in endometrial cancers (Mirabelli-Primdahl et al. 1999).

Table 1. 
Beta-catenin mutations in human cancers
Aggressive fibromatosis, otherwise known as desmoid tumor, is a locally invasive fibrocytic growth that occurs with increased incidence in patients with familial adenomatous polyposis coli (FAP). FAP individuals carry APC mutations in their germline and present with multiple intestinal adenomas at an early age. Desmoids also occur sporadically and, with the exception of colorectal cancer, represent a rare example of biallelic inactivation of APC in individuals without a pre-existing germline mutation in APC (Alman et al. 1997). Not surprisingly, mutations inCTNNb1 have also been detected in sporadic desmoid tumors (Shitoh et al. 1999;Tejpar et al. 1999). The β-catenin mutations were found in over half of the 42 desmoids analyzed, while inactivating mutations in APC were detected in nine and, again, there was no overlap between APC and β-catenin mutations (Tejpar et al. 1999). The β-catenin mutations were all of the missense variety and were confined to codons 41 and 45. Some of the desmoids lacked mutations in either β-catenin or APC, but all displayed increased expression of β-catenin, implying that yet unidentified defects in β-catenin regulation exist in some of these tumors.

There appears to be a low probability of accruing biallelic inactivating mutations in APC in most sporadic cancers, despite increased cancer incidence at numerous extracolonic sites in FAP patients. This suggests that the stabilization of β-catenin can promote cancer in many tissue types, but the biallelic inactivation of APC is an unlikely means to this end. Components in the wnt pathway other than APC, such as β-catenin, might make easier targets for oncogenic mutations. Indeed, several mutations in CTNNb1 were recently identified in gastric cancers, which occur with increased incidence in FAP patients (Park et al. 1999). In this study, 27% of intestinal type gastric cancers harbored mutations in β-catenin. Hepatoblastoma also occurs with increased incidence in FAP individuals (Hughes and Michels 1992;Giardiello et al. 1996; Cetta et al. 1997), but biallelic inactivation of APC is uncommon in the sporadic forms of these tumors. In three separate studies, mutations in β-catenin were identified at high frequency in hepatoblastoma, while no APC mutations were found (Koch et al. 1999; Jeng et al. 2000; Wei et al. 2000). Hepatoblastoma is also associated with Beckwidth–Wiedemann syndrome (BWS), however, a direct link between wnt signaling and the genetic defects underlying BWS are unlikely as a tumor from one of these patients also contained a somatic mutation in β-catenin (Wei et al. 2000). By contrast, a subset of patients with Turcot’s syndrome harbor germline mutations in APC and are at increased risk of medulloblastoma (Hamilton et al. 1995; Lasser et al. 1994). Although inactivating mutations in APC have not been detected in the sporadic forms of medulloblastoma, CTNNb1mutations were found in a small percentage (Zurawel et al. 1998).

Hepatocellular carcinoma (HCC) has become one of the most common tumors harboring mutations in the wnt pathway. Based on five separate studies, the frequency of CTNNb1 mutations in hepatocellular carcinoma (HCC) was ∼20% overall and perhaps higher still for HCCs associated with hepatitis C virus (de La Coste et al. 1998; Miyoshi et al. 1998;Huang et al. 1999; Legoix et al. 1999; Van Nhieu et al. 1999) (Table1). Preliminary data indicated a poorer prognosis associated with nuclear accumulation of β-catenin in HCC and histological data indicated enhanced nuclear staining in the invasive and intravascular compartments of the tumors (Huang et al. 1999; Van Nhieu et al. 1999). In one of these studies an inverse correlation between β-catenin mutations and loss of heterozygosity in the genome was noted (Legoix et al. 1999). This suggests that chromosomal instability and mutations inCTNNb1 represent alternative modes of tumor progression in HCC.

It is noteworthy that c-myc and cyclin D genes are amplified in a subset of HCCs and both these genes are downstream targets of β-catenin (He et al. 1998; Nishida et al. 1994; Peng et al. 1993;Shtutman et al. 1999; Tetsu and McCormick 1999). It would be of interest to determine whether any overlap exists between their amplification and CTNNb1mutations in HCC. Animal models of HCC have provided some clues toward understanding the relationship between these genes in cancer. HCCs induced by transgenic expression of SV40 T antigen in murine liver did not contain mutations in CTNNb1 (Umeda 2000). As T antigen activates cyclin D kinase by sequestration of Rb, the activation of the cyclin D gene by mutant β-catenin may no longer be required. By contrast, activating mutations inCTNNb1 were identified in half of the HCCs generated by transgenic expression of c-myc in murine liver (de La Coste et al. 1998). This animal model suggests that β-catenin mutations occur as a second “hit” in HCC tumor progression in cooperation with a distinct cancer pathway initiated by c-myc. That CTNNb1mutations can occur subsequent to other oncogenic defects is also evident from their occurrence in Wilm’s tumor. Mutations in β-catenin were detected in 15% of these pediatric kidney cancers and in two of these cases they were concomitant with mutations in the Wilm’s tumor gene WT1 (Koesters et al. 1999). One of these cases was associated with Denys-Drash syndrome, a familial disorder attributable to germline mutations in WT1.

It makes sense that extracolonic tumors associated with FAP, such as desmoids, medulloblastoma, and HCC, would contain CTNNb1mutations in their sporadic forms. Thyroid cancers also occur with increased incidence in FAP and, not surprisingly, a high frequency ofCTNNb1 mutations was recently reported for anaplastic thyroid cancers (Cetta et al. 2000; Garcia-Rostan et al. 1999). Although many of these mutations affected amino acids known to influence the regulation of β-catenin, many of them affected residues for which the consequence of their mutation is unknown (Garcia-Rostan et al. 1999). In particular, the substitution K49R was detected nine times. This mutation was frequently detected in the context of independentCTNNb1 mutations in the same thyroid tumor, and up to four independent CTNNb1 mutations were found in some tumors. The occurrence of multiple independent CTNNb1 mutations was also noted in some HCCs and might reflect the multifocal origin of some cancers (Huang et al. 1999; Legoix et al. 1999; Van Nhieu et al. 1999). In one HCC study, examination of different tumor areas from the same patient revealed distinct CTTNb1 mutations in two independent cases (Huang et al. 1999).

Some cancers, such as endometrial ovarian tumors, do not occur with increased incidence in patients with FAP, yet they contain activating mutations in CTNNb1(Palacios and Gamallo 1998; Gamallo et al. 1999; Wright et al. 1999). Perhaps inactivation of the remaining wild-type APC allele in FAP individuals is unlikely in this tissue, or the expression of an alternative APC gene compensates for its loss. The CTNNb1 mutations associated with ovarian cancer appeared to be confined to the endometrioid subtype. In this tissue, cancers with activated β-catenin signaling were reported to be less aggressive than their nonactivated counterparts. In one report, a more favorable prognosis was associated with cancers exhibiting enhanced nuclear staining of β-catenin and another indicated higher frequency ofCTNNb1 mutations in lower grade tumors (Palacios and Gamallo 1998; Wright et al. 1999). A similar inverse correlation between tumor grade and occurrence ofCTNNb1 mutations was also reported for uterine endometrial cancers (Fukuchi et al. 1998). The overlap between mutations in CTNNb1 and other gene defects in ovarian cancers has not been explored in detail, although one study noted coexisting mutations in the PTEN tumor suppressor andCTNNb1 in endometrioid tumors (Wright et al. 1999).

Additional types of cancers with CTNNb1 mutations, albeit at low frequency, include melanoma and prostate. Although only one of sixty-five melanomas contained detectable mutations, nuclear localization of the protein was seen in one-third (Rimm et al. 1999). Thus, additional mechanisms for β-catenin activation likely occur in these tumors. Possibly the highest percentage ofCTNNb1mutations occurs in a common skin tumor known as pilomatricomas (Chan et al. 1999). That these tumors might contain CTNNb1 mutations was surmised from the genesis of similar tumors in transgenic mice expressing mutant β-catenin in the skin (Gat et al. 1998). The tumors appeared to originate from the hair follicle, which is consistent with the lack of hair in mice homozygous for mutations in LEF, a transcription factor responsive to β-catenin (van Genderen et al. 1994).

Axin

Axin was originally identified as an inhibitor of wnt signaling inXenopus embryos and was subsequently shown to bind directly to APC, β-catenin, GSK3β and dishevelled (for review, see Peifer and Polakis 2000). A plethora of in vitro and in vivo studies inXenopus, Drosophila, and cultured mammalian cells has demonstrated that axin is central to the down regulation of β-catenin (Zeng et al. 1997; Behrens et al. 1998; Hart et al. 1998;Ikeda et al. 1998; Nakamura et al. 1998a; Sakanaka et al. 1998; Fagotto et al. 1999; Hedgepeth et al. 1999a; Li et al. 1999a; Willert et al. 1999a; Farr et al. 2000). It is not entirely clear how axin functions, but it has been proposed to facilitate the phosphorylation of β-catenin and APC by GSK3β (Hart et al. 1998; Ikeda et al. 1998). Thus axin would be viewed as a tumor suppressor based on its ability to downregulate signaling, and this has now been verified by documentation of its biallelic inactivation in human hepatocellular cancers and cell lines (Satoh et al. 2000). Importantly, these mutations were identified in those HCCs that lacked activating mutations inCTNNb1. All of the mutations were predicted to truncate the axin protein in a manner that eliminated the β-catenin binding sites. Axin, which should now be regarded as a tumor suppressor, constitutes the third genetic defect in the wnt pathway that contributes to human cancer. There also exists a close homolog of axin termed conductin, which exhibits of all the binding and regulatory functions of axin (Behrens et al. 1998). That this apparent redundancy did not suppress axin mutations in HCC suggests conductin is either not functionally equivalent to axin or not expressed at levels sufficient to compensate for its loss in HCCs.

PP2A

The dependence upon serine/threonine kinases for the regulation of β-catenin implies that phosphatases are also involved. Indeed, the rapid dephosphorylation of the axin protein is a consequence of wnt signaling and has been proposed to both destabilize axin and reduce its affinity for β-catenin (Willert et al. 1999b;Yamamoto et al. 1999). Although axin binds directly to the PP2A catalytic subunit, the phosphatase affecting axin in response to wnt signaling has not been identified (Hsu et al. 1999). If PP2A is this phosphatase, it would be viewed as proto-oncogenic because it downregulates the tumor suppressor axin. On the contrary, expression of the PP2A regulatory subunit B56 in human colon cancer cells results in the downregulation of β-catenin, consistent with a tumor suppressive function in the wnt pathway (Seeling et al. 1999). Moreover, the beta isoform of the PP2A A subunit is deleted in some human colon tumors, again implying tumor suppression (Wang et al. 1998). Also, disruption of twins, aDrosophila gene coding for a PP2A subunit, complemented the overexpression and underexpression of the β-catenin homolog armadillo, in a manner consistent with negative regulation of wnt signaling (Greaves et al. 1999). By all accounts, PP2A plays a role in wnt signaling, but its potential role as proto-oncogene or tumor suppressor might be dependent upon the precise nature of the defect.

APC

Genetic analysis of FAP families led to the identification of theAPC gene, and subsequent studies demonstrating an interaction with β-catenin placed it tentatively in the wnt pathway (Groden et al. 1991; Kinzler et al. 1991; Munemitsu et al. 1995; Rubinfeld et al. 1993; Su et al. 1993). Experiments in Drosophilaultimately revealed that genetic ablation of APC indeed resulted in upregulation of β-catenin signaling (Ahmed et al. 1998). In some systems, such as Xenopus andCaenorhabditis elegans, a positive role for APC in the wnt pathway has been proposed, but the former study suffers from potential overexpression artifacts and the latter from a lack of relatedness to the vertebrate APC protein (Rocheleau et al. 1997; Vleminckx et al. 1997). In any case, APC is a tumor suppressor in human cancers and its mutation relates strongly to the regulation of β-catenin. The spectrum of APC mutations, which typically truncate the protein, suggest selection against β-catenin regulatory domains, albeit not necessarily against β-catenin binding (for review, see Polakis 1999). The selective pressure might be directed against the presence of Axin binding sites, of which there are three, dispersed across the central region of the APC protein (Behrens et al. 1998). The presence of axin binding sites are critical to APC in the regulation of β-catenin levels and signaling in cultured cells (Kawahara et al. 2000). Moreover, mice lacking wild-type APC but expressing a truncated mutant APC retaining a single axin binding site are viable and do not develop intestinal neoplasia (Smits et al. 1999). This has not been the case for mice with more extensive truncations in APC (Oshima et al. 1995a; Su et al. 1992). Also, milder forms of colorectal polyposis, as well as familial infiltrative fibromatosis (desmoid tumors), have been associated with germline mutations in the 3′ region of the APC open reading frame. These mutations predict truncated proteins that retain only one or two of the three axin binding sites in APC (Walon et al. 1997; Kartheuser et al. 1999; Scott et al. 1996;van der Luijt et al. 1996). A recent study has also demonstrated that the expression of just the central region of APC, which contains all of the axin and β-catenin binding sites, was sufficient to elicit cellular growth suppression (Shih et al. 2000). This effect is consistent with previous work showing that a like fragment of APC was sufficient to downregulate β-catenin levels in cancer cells (Munemitsu et al. 1995).

Although both copies of the APC gene are typically inactivated in colorectal cancers, it remains possible that a mutant truncated APC could contribute to cancer progression. This was tested by transgenic expression of two different APC mutants in a wild-type intestinal background (Oshima et al. 1995b). This did not result in cancer-prone mice, despite high levels of expression of mutant proteins and, therefore, argues against a dominant negative effect by these particular mutants. However, it does not rule out an additive contribution to tumor progression by mutant APC protein in a background lacking wildtype APC. In fact, genetic evidence argues in favor of selection for a somewhat specific mutant APC protein. The mutation cluster region (MCR) in APC, roughly defined by codons 1250–1500, is not only consistent with selection against specific sequence, but also retention of an APC molecule that extends into the MCR (Fig.3.). A correlation between the presence of a germline mutation in the MCR and the severity of polyposis has been noted (Ficari et al. 2000; Nagase et al. 1992; Wu et al. 1998). The enhanced severity of polyposis suggests there should also be selective pressure for somatic mutations in the MCR, which indeed appears to be the case (Miyoshi et al. 1992). Selective pressure for an MCR mutant has also been proposed based on the occurrence of somatic mutations in the MCR relative to the position of the germline mutation in FAP (Lamlum et al. 1999). Tumors from FAP patients with a germline MCR mutation exhibited frequent inactivation of the remaining APC allele by LOH, while those without a germline MCR mutation had frequent somatic mutations in the MCR (Fig. 3). Therefore, a germline mutation in the MCR could relieve the constraint for a subsequent somatic MCR mutation, thereby increasing the likelihood of polyposis. This implies that a truncated MCR APC mutant has an interfering or gain of function property that enhances tumor progression beyond simple loss of APC function. An interfering function would probably not involve interaction with wild-type APC, as recently suggested, because the MCR mutant is still selected for in the absence of a wild-type APC gene copy (Dihlmann et al. 1999). Finally, some of the germline mutations in APC do not disrupt the open reading frame yet correlate with increased risk of colorectal cancer (Frayling et al. 1998; Gryfe et al. 1999; Laken et al. 1997). These mutations have been proposed to increase the occurrence of subsequent truncating mutations by enhancing the mutational susceptibility of the affected nucleotide tract.

Figure 3.

Mutations in APC. A compilation of germline and somatic mutations in APC illustrates selection for mutations in the mutation cluster region (MCR). MCR mutations result in truncated proteins retaining β-catenin binding but not regulatory activity. Somatic MCR mutations are more frequently selected for in FAP patients with germline mutations outside of the MCR.

Transcription factors

Prior to discussing the potential role for LEF/TCF transcription factors in cancer, it is important to outline the mechanism by which they have been proposed to operate. Although LEF/TCFs bind directly to DNA through their HMG domains, they are incapable of independently activating gene transcription (Eastman and Grosschedl 1999; Roose and Clevers 1999). This has best been illustrated for LEF, which through its binding to the cofactor ALY, makes indirect contacts with a second transcription factor AML (Bruhn et al. 1997). The TCFs do not contain the ALY binding site, but like LEF they cannot activate test genes comprised of multimerized TCF/LEF binding sites and a minimal promotor sequence. However, these reporter genes are activated on coexpression of TCF with β-catenin, suggesting that β-catenin supplies additional cofactors required for transcriptional activation (Molenaar et al. 1996). This activity was localized to the carboxy-terminal region of the Drosophila β-catenin armadillo, which when fused directly to TCF resulted in β-catenin independent transcriptional activation (van de Wetering et al. 1997).

The simple interpretation is that the TCF/LEF-β-catenin complex comprises a bipartite positive acting transcription factor in the wnt pathway. This interpretation agrees well with developmental studies in which the manipulation of LEF/TCF function results in phenotypes consistent with the genetic manipulation of wnt/β-catenin signaling (Behrens et al. 1996; Brunner et al. 1997; Huber et al. 1996; van de Wetering et al. 1997). For example, a zygotic homozygous null mutation inDrosophila LEF results in a loss of naked cuticle in the larval epidermis, a phenotype typical of loss of function wingless mutations (Brunner et al. 1997). Moreover, the formation of excess naked cuticle by ectopic expression of armadillo in wild-type embryos does not occur in the LEF null mutants. Exactly how β-catenin contributes to transcriptional activation is unclear, but might involve additional proteins that bridge the TCF/β-catenin complex to the basal transcriptional machinery. The bridging function might be fulfilled by Pontin 52, a TATA-binding protein that was reported to bind to β-catenin (Bauer et al. 1998). Also, a mutant form of β-catenin incapable of binding LEF squelched LEF-dependent reporter gene activation, presumably by titration of an essential cofactor (Prieve and Waterman 1999). Finally, the carboxy-terminal region of armadillo binds to the Zinc finger protein teashirt, a homeotic gene essential for a subset of wingless signaling outputs in Drosophila (Gallet et al. 1999).

The simple model of positive transcriptional activation by the TCF-β-catenin complex is not in accord with all experiments. Mutation of the TCF/LEF binding sites in the promotors of the wingless responsive gene ultrabithorax and the Wnt-responsive Xenopus gene Siamois enhanced their activities under conditions where the wingless/β-catenin signal input was weak (Brannon et al. 1999; Riese et al. 1997). The mammalian cyclin D gene was recently identified as a wnt target and, again, mutation of the corresponding TCF binding sites enhanced its basal activity (Tetsu and McCormick 1999). These results suggest TCF represses transcription of its target genes in unstimulated cells and the binding of β-catenin promotes derepression. Derepression cannot fully account for signaling activity, however, as mutations in the TCF binding sites compromise target gene activation under conditions of active wnt signaling (Brannon et al. 1999; Riese et al. 1997). Repression of gene expression by TCF is consistent with its direct physical interaction with at least three different gene products, the Groucho/TLE and CtBP corepressors, and the CREB binding protein CBP (Brannon et al. 1999;Cavallo et al. 1998; Levanon et al. 1998; Roose et al. 1998; Waltzer and Bienz 1998).

The groucho/TLE proteins bind to the central region of TCF/LEF at a site distinct from that of β-catenin binding and inhibit gene activation of TCF target genes (Levanon et al. 1998; Roose et al. 1998). By contrast, CtBP binds to two independent sites in the carboxy-terminal region of Xtcf-3, which when mutated abrogated the repressor function of this region of Xtcf-3 (Brannon et al. 1999). The binding sites for CtBP are not present in LEF, which might explain the ability of LEF, but not Xtcf-3, to induce axis duplication in Xenopus embryos. Finally, the Drosophila CREB binding protein CBP was reported to bind to the HMG domain of dTCF (Waltzer and Bienz 1998). Loss-of-function CBP mutants displayed some features of wingless over expression and also suppressed phenotypes resulting from loss of the β-catenin homolog armadillo. The genetics imply suppression of wingless by CBP, which is somewhat paradoxical when considering the role of CBP acetyltransferase activity in chromatin remodeling and gene activation. However, it was shown that CBP acetylates a lysine proximal to the armadillo binding site in TCF, thereby reducing its affinity for armadillo. Repression of β-catenin/TCF signaling by CBP does not occur in all settings, though, as two recent studies demonstrated activation ofXenopus TCF target genes by CBP (Hecht et al. 2000;Takemaru and Moon 2000). CBP directly associated with carboxy-terminal sequence in β-catenin and overexpression of E1A, which also directly binds CBP, reduced β-catenin dependent transactivation.

Does the activation of TCF/LEF target genes by β-catenin cause cancer? Good evidence to this effect was provided by the expression of a chimeric protein consisting of the LEF DNA binding sequence fused to the transcriptional activation domain of either VP16 or the estrogen receptor (Aoki et al. 1999). Expression of these constructs in chicken embryo fibroblasts resulted in their neoplastic transformation. The proliferative potential of TCF was also apparent from the phenotype resulting from homozygous disruption of TCF-4 in the germline of mice. These animals were incapable of maintaining a proliferative stem cell compartment in the small intestine and died shortly after birth (Korinek et al. 1998). Whether the TCF/LEF genes are directly activated by mutations in cancer is unclear, but mutations in TCF-4 have been detected in a subset of colorectal tumors (Duval et al. 1999). The mutations all occur as single base deletions in an (A)9 nucleotide repeat within the 3′ coding region of the gene. These deletions generate frame shifts predicted to effect the proportion of the long and short forms of TCF that normally result from alternative mRNA splicing. The mutations were also found in cancer cell lines, all of which possessed mutations in either APC or β-catenin. This indicates that the TCF mutations do not substitute for APC/β-catenin mutations but could act in an additive manner.

An additional mechanism by which TCFs could contribute to cancer was gleaned from the phenotype of mice homozygous for mutations in TCF-1 (Roose et al. 1999). Fifteen percent of these animals developed adenomatous intestinal polyps by one year of age, implicating TCF-1 as a tumor suppressor. The major isoforms of TCF-1 do not contain a β-catenin binding site and could therefore act in a dominant negative manner in wnt signaling. Crossing TCF-1 null mice with cancer-prone ApcMin/+ mice resulted in offspring with ten times the number of intestinal polyps relative to ApcMin/+ littermates. This experimental model suggests that the genetic ablation of TCF-1 could modify, or even independently contribute to cancer progression in humans. Additional potential mechanisms for cancer would include the inactivation of corepressors such as CtBP and TLE/groucho.

Cross talk

Defects leading to activation of the wnt pathway could also occur in signaling systems that are seemingly unrelated to wnt signaling. One potential mode of cross talk includes the kinase TAK1, which can substitute for MAPK kinase kinase in the yeast pheromone pathway. TAK1 (TGF-β activatedkinase) is activated by TGF-β in mammalian cells and has also been implicated in interleukin-1 activation of NFκB (Ninomiya-Tsuji et al. 1999; Yamaguchi et al. 1995). In c. elegans, the TAK1 homolog MOM-4 negatively regulates the TCF homolog POP-1 by activating another kinase LIT-1, which then phosphorylates POP-1 (Meneghini et al. 1999;Shin et al. 1999). LIT-1 is thought to gain access to POP-1 through its direct binding to the β-catenin homolog WRM-1 (Shin et al. 1999). Parallel interactions have been demonstrated for the mammalian counterparts of these proteins where the phosphorylation of TCF, by the LIT-1 homolog NLK, reduces its DNA binding affinity (Ishitani et al. 1999). Thus a MAPK-like signaling system might downregulate the wnt-1 pathway. A second opportunity for cross talk with wnt signaling was realized by a physical interaction between the β-catenin-TCF complex and SMAD4, a mediator of TGF-β signaling (Nishita et al. 2000). This interaction was proposed to be synergistic with respect to the activation of theXenopus wnt target gene twin. How this relates to cancer is somewhat puzzling when considering that TGF-β signaling is typically compromised by genetic and epigenetic defects during tumor progression.

An additional mode of cross regulation was recently revealed by the discovery that retinoids inhibit β-catenin dependent gene transcription (Easwaran et al. 1999). β-catenin associated with a retinoic acid receptor (RAR) and cooperated with retinoids to enhance activation of a retinoic acid responsive promotor. Moreover, the identification of RAR-γ as a target of wnt signaling inXenopus also points to an interaction between these signaling systems (McGrew et al. 1999). Signaling by β-catenin was also reported to be repressed by expression of sox3 and sox17 transcription factors, which associated directly with β-catenin (Zorn et al. 1999). Although inhibition of β-catenin signaling was clearly demonstrated, it is also possible that β-catenin drives gene activation independent of LEF/TCF, through its association with the sox proteins. Finally, the activation of the WISP genes by β-catenin is highly dependent upon the presence of a CREB binding site in the WISP promotor (Xu et al. 2000). This implies that cAMP-dependent protein kinase A feeds into wnt signaling and might cooperate with the activation of some wnt target genes. The binding of CBP to β-catenin is particularly relevant with respect to this proposal (Hecht et al. 2000; Takemaru and Moon 2000).

Conclusion

It is apparent that wnt signaling causes cancer and that tumor promotion by this pathway can proceed through a number of different genetic defects. Additional mechanisms by which defects in the regulation of wnt signaling contribute to tumor progression probably remain undiscovered. The manifestation of cancer by aberrant wnt signaling most likely results from inappropriate gene activation mediated by stabilized β-catenin. Target genes need not contain TCF/LEF binding sites in their promotors, though, as new potential modes of gene activation by β-catenin are becoming apparent. Several target genes of β-catenin signaling have now been identified and some of their functions are consistent with control of cellular growth, differentiation, and survival. For an excellent summary of wnt target genes, and a wealth of information on wnt signaling in general, I refer the reader to the Wnt Home Page posted by the Nusse lab (http://www.stanford.edu/rnusse/wntwindow.html).

7.10.2 The Wnt.β-catenin pathway in ovarian cancer : a review.

Arend RC1Londoño-Joshi AIStraughn JM JrBuchsbaum DJ.
Gynecol Oncol. 2013 Dec; 131(3):772-9.
http://dx.doi.org:/10.1016/j.ygyno.2013.09.034.

Objective: Ovarian cancer is the deadliest gynecologic malignancy and the fifth leading cause of death from cancer in women in the U.S. Since overall survival remains poor, there is a need for new therapeutic paradigms. This paper will review the Wnt/β-catenin pathway as it relates to epithelial ovarian cancer, specifically its role in chemoresistance and its potential role as a target for chemosensitization. Methods: A PubMed search was performed for articles published pertaining to Wnt/β-catenin pathway specific to ovarian cancer. Wnt/β-catenin signaling pathways play an active role in cancer stem cells (CSCs) and carcinogenesis of all ovarian cancer subtypes. Studies also have shown that ovarian CSCs are involved in chemoresistance, metastasis, and tumor recurrence. Results: Wnt/β-catenin target genes regulate cell proliferation and apoptosis, thereby mediating cancer initiation and progression. The Wnt/β-catenin pathway is one of the major signaling pathways thought to be involved in epithelial-to-mesenchymal transition (EMT). Alterations affecting Wnt pathway proteins on the cell membrane, in the cytoplasm, and in the nucleus have been shown to play important roles in the tumorigenesis of ovarian cancer. Conclusions: Wnt signaling is activated in epithelial ovarian cancer. Given the role of the Wnt/β-catenin pathway in carcinogenesis, more pre-clinical studies are warranted to further investigate other Wnt inhibitors in ovarian cancer. The Wnt pathway should also be investigated as a potential target in the development of new drugs for ovarian cancer as a single agent and in combination with chemotherapy or other targeted agents.

Introduction
Ovarian cancer is the deadliest gynecologic malignancy and the fifth leading cause of death from cancer in women in the U.S. In 2013, there will be an estimated 22,240 newly diagnosed cases of ovarian cancer and an estimated 14,030 deaths in the United States [1].A major contributor to the high mortality rate is the fact that 70% of women with ovarian cancer initially present with metastases throughout the peritoneal cavity. Over the last two decades, advances in chemotherapy have improved the overall survival in patients with advanced stage ovarian cancer [2]. These advances include the introduction of taxane/platinum-based chemotherapy, intraperitoneal delivery of chemotherapy,dose-dense chemotherapy, and the availability of novel agents such as bevacizumab [3,4].Since overall survival remains poor, there is a need for new therapeutic paradigms. Further research is needed to understand how molecular pathways contribute to the development of metastasis, recurrence, and resistance of ovarian cancer to chemotherapeutic agents. Studies have shown that ovarian cancer stem cells (CSCs) are also involved in chemoresistance, metastasis, and tumor recurrence [5]. CSCs area subpopulation of cancer cells that possess characteristics associated with normal stem cells and are able to generate tumors through the stem cell processes of self-renewal and differentiation.These cells are proposed to persist in tumors as a distinct population that cause recurrence and metastasis by giving rise to new tumors. Recently, chemoresistance has been reported to be associated with acquiring epithelial to mesenchymal transition (EMT) in ovarian cancer cells [6].CancercellsundergoingEMT are unique in that they have stem-like properties that enable cancer cell dissemination and metastasis formation [7]. Major signaling pathways involved in EMT include TGF-β, Wnt/ β-catenin, Notch, Hedgehog, and others [8]. Endometrioid ovarian carcinomas often harbor mutations in the β-catenin gene, but mutations in the Wnt/β-catenin pathway are rare in serous, clear cell, and mucinous ovarian carcinomas [9]. There is emerging data that suggests that despite not having mutations, the Wnt/β-catenin pathway plays a role in carcinogenesis of all ovarian cancer subtypes [10–12]. It has been suggested that the Wnt/β-catenin target genes can be divided into two groups: a “stemness/proliferation group” that is active early in tumor progression and an “EMT/ dissemination group” that is expressed in late stage tumors. The Wnt/ β-catenin pathway has been shown to be a therapeutic molecular target for CSCs[13].Wnt/β-catenin target genes regulate cell proliferation and apoptosis,thereby mediating cancer initiation and progression [14,15]. Given the role of the Wnt/β-catenin pathway in carcinogenesis, we will review the Wnt/β-catenin pathway as it relates to epithelial ovarian cancer, specifically its role in chemoresistance and its potential role as a target for chemosensitization.

Historical perspective of Wnt signaling in the ovary

In the late 1990s, the importance of the Wnt pathways in the embryonic development of the ovary was established. Wnt-4, a Wnt ligand, demonstrated a critical role in embryonic ovarian development [16]. Wnt-7a was shown to affect sex-specific differentiation of the reproductive tract [17]. In 2002, Ricken et al. reported that components of the Wnt signaling pathways are expressed in the immature rat ovary, and that their expression is localized to specific ovarian compartments [18]. This study reported the expression of three different Wnt transcripts (Wnt-2b, Wnt-5a, Wnt-11) that were common to five ovarian cancer cell lines derived from histologically varied human ovarian carcinomas.These results raised the possibility that aberrant Wnt expression may be involved in ovarian tumorigenesis in humans. Prior to this study, alterations in Wnt expression had been described in a variety of female human tumors, including breast and endometrial cancer, but this was the first study to suggest its involvement in ovarian cancer. When β-catenin gene mutations were initially discovered in ovarian cancer, they were thought to be limited to the endometrioid subtype [19]. A study by Wu et al. carried out a comprehensive molecular analysis of 45 tumor specimens of primary ovarian endometrioid adenocarcinomas and two ovarian endometrioid adenocarcinomaderived cell lines. They found Wnt/β-catenin pathway defects in both the cell lines and in nearly half of the primary ovarian endometrioid adenocarcinomas analyzed. β-catenin deregulation was most often attributable to a mutation of the β-catenin gene (CTNNB1) itself, although less frequently β-catenin deregulation may have resulted from inactive mutations in the APC, AXIN1, orAXIN2 genes [20]. Depending on the study, a wide range (3–59%) of serous ovarian cancers have also been reported to stain positive for cytoplasmic and nuclear β-catenin by immunohistochemistry even in the absence of mutations in APC, Axin or β-catenin, which are more common in the endometrioid subtype [21–23]. More recent data have shown that although gene mutations in the Wnt/β-catenin pathway are relatively uncommon in ovarian cancer in general, especially in serous ovarian cancer,components of the pathway are still important in the molecular events that lead to ovarian cancer development [12]. There are three main Wnt signaling pathways: the canonical Wnt/β-catenin pathway, the non-canonical planar cell polarity pathway, and the non-canonical Wnt–Ca2+ pathway. These pathways belong to one of two categories: canonical or non-canonical. The difference between these two categories is the presence or absence of β-catenin. The canonical Wnt/β-catenin pathway involves this protein and the non-canonical pathway operates independently of it.

Components of the Wnt signaling pathway

Non-canonical Wnt signaling pathways

Wnt proteins, which serve as ligands for the Wnt pathway, consist of 19 cysteine-rich glycoproteins. They bind to the Frizzled (Fzd) transmembrane receptor, one of the main receptors of the Wnt pathways [24]. When Wnt binds to Fzd, it can activate one of the three distinct intracellular signaling pathways. While the canonical Wnt/β-catenin signaling pathway leads to the accumulation and stabilization of cytosolic, unphosphorylated (“free”) β-catenin, the non-canonical pathways promote an increase in intracellular calcium or mediate cell polarity. In all three pathways, a Wnt ligand binds to Fzd receptor and promotes recruitment of Dishevelled (Dsh) protein (Figs. 1 and 2). In the planar cell polarity non-canonical pathway, this complex binds to the Dsh-associated activator of morphogenesis (Daam1). This cascade of events leads to the activation of Rac and RhoA GTPases which mediate cell polarity (Fig. 1). In the Wnt-Ca2+ noncanonical pathway, the Wnt/Fzd/Dsh complex binds with a G protein (Ror 1/2) as shown in Fig. 1, which leads to activation of calmodulindependent kinase II, protein kinase C and the phosphatase calcineurin. This binding promotes the increase in intracellular calcium levels which then mediates other signaling pathways. The Wnt pathways are critical to embryonic development of a variety of organs including the ovaries. Activation of Wnt signaling occurs via the canonical Wnt/β-catenin pathway and the non-canonical cell polarity pathway and the Wnt/ Ca2+ pathway; however, as it relates to oncology research the Wnt/β-catenin canonical pathwayis the mostrelevant [25].

Canonical (Wnt/β-catenin) signaling pathway

In the canonicalWnt/β-catenin pathway, the pathway is “off” when either there is no Wnt ligand, no receptor, or the receptor is being blocked (Fig. 2A). Dikkopf family (DKK1–4) binds directly to one of the transmembrane receptors (Fzd, LRP5/6) and blocks Wnt from binding. Wnt-inhibitory factor (WIF-1) and the family of secreted Fzd receptor proteins (SFRP1-5) bind to Wnt itself and prevent them from binding to the receptors. If the Wnt ligand does not bind to the receptors, β-catenin is degraded by a destruction complex that is comprised of Axin, adenomatous polyposis coli (APC), and glycogen synthase kinase 3β (GSK3β). β-Catenin is phosphorylated by the kinases casein kinase 1 (CK1) and GSK3β, followed by ubiquitination and proteasomal degradation by the 26S proteasome. Low cytoplasmic levels of β-catenin allow for the recruitment of the corepressor Groucho to lymphoid enhanced factor–T-cell factor (TCF/LEF) transcription factors,which blocks the target genes from being activated and ensures transcriptional repression (Fig. 2A). Activation of the canonical Wnt pathway involves the stabilization of β-catenin through the binding of Wn tligands to cell surface receptors including Fzd family receptors and low-density lipoprotein receptor (LDLR)-related proteins: LRP5 and LRP6. When the Wnt pathway is “on”, cytosolic β-catenin is stabilized (Fig. 2B). LRP6/LRP5 is phosphorylated by the kinases CK1 and GSK3β. Dsh molecules are recruited to the plasma membrane to interact with Fzd. Interaction of Axin with phosphorylated LRP6/LRP5 and Dsh leads to inactivation of the destruction complex and degradation of β-catenin is inhibited. βCatenin accumulates in the cytoplasm and enters the nucleus and activates Wnt target genes by binding to the transcriptional factors of the TCF/LEF family by displacing Groucho and interacting with coactivators such as B-cell lymphoma 9/Legles (BCL9/LGS) and Pygopus (Pygo) to promote transcription of target genes [26]. TCF/LEF, BCL9/ LGS, and Pygo all bind with β-catenin in the nucleus to form a transcriptional activation complex (Fig. 2B). β-Catenin promotes transcription of genes related to proliferation and survival. Some of the key downstream proteins and genes that are activated with the binding of β-catenin to the transcriptional factors of the canonical pathway include c-MYC (MYC), Cyclin D1 (CCND1), Survivin (BIRC5), Axin2 (AXIN2), and matrix metalloproteinases (MMPs). There have been over 100 target genes identified as regulated by the Wnt pathway and 23 of them have been shown to be overexpressed in ovarian cancer [27].

Regulation of the Wnt pathway

The remainder of the review will focus on the canonical Wnt/ β-catenin pathway, because the Wnt/β-catenin pathway has been the most well described in the literature as it relates to cancer research and specifically ovarian cancer. It is regulated at multiple levels: gene mutations, extracellular inhibitors, and intranuclear transcription cofactors. These all contribute to the diverse mechanisms that are involved in the Wnt pathway.When there is no Wnt ligand, a destruction complex regulates β-catenin levels. Specifically, CK1 and unphosphorylated GSK3β phosphorylate β-catenin and target the protein for ubiquitination and proteasomal degradation. Phosphorylation of GSK3β by protein kinases (A, B, and C), Akt/PI3K, and MAPK inhibits its ability to phosphorylate and target β-catenin for degradation. The majority of ovarian cancers have an activation of PI3K (phosphoinositide 3-kinase) by gene amplification, which can potentially phosphorylate GSK3β, impeding the phosphorylation of β-catenin and resulting in cellular differentiation, division, and survival [28,29].

Alterations of the Wnt pathway in ovarian cancer

Membranous factors

The first event in the activation of the Wnt pathway is the binding of a Wnt ligand to Fzd and LRP6/LRP5. Two subtypes of the Fzd receptor are increased in epithelial ovarian cancer, Fzd1 and Fzd5. A higher number of malignant ovarian specimens stained positive for both receptors than normal ovary and the Fzd5-positive tumors had a worse 6-year survival than those that were Fzd5-negative [30]. During metastatic spread of epithelial ovarian cancer, there is adhesion of cancer cells to submesothelial interstitial collagens. When β1 integrin mediated anchoring to the mesothelium and submesothelial matrix occurs, it facilitates the formation of metastatic tumor sites on other peritoneal organs. The engagement of collagen-binding β1 integrins have been shown to upregulate LRP6, WNT5A, MMP9, PTGS2 (COX2), PLAUR (uPAR), VIM (vimentin), SNAII (Snail) at the mRNA level [31]. This suggests tha tmetastatic spread of ovarian cancer is likely facilitated by the upregulation of LRP6 and targeting LRP6 may be an effective strategy for treating ovarian cancer.

There are several proteins that act as antagonists to the Wnt pathway. These proteins include: the Dikkopf family (DKK1–4), Wnt inhibitory factor (WIF-1) and the family of secreted Fzd receptor proteins (SFRP1-5)(Fig.2A). SFRPs bind directly to the Wnt ligand or Fzd receptor and inhibit Wnt from binding to Fzd and activating the pathway. Loss of SFRP4 expression correlates with a more aggressive ovarian cancer phenotype and the level of SFRP4 is directly related to prognosis [32]. Investigators have studied the re-expression of SFRP4 in epithelial ovarian cancer cell lines, and found that re-expression inhibited the Wnt/ β-catenin signaling pathway, thereby inhibiting cell migration and EMT. These proteins provide important potential therapeutic targets by either re-expression, if their expression is lost,or potentially upregulated.

Cytoplasmic and nuclear factors

Endometrioid ovarian carcinomas often have mutations in the βcatenin gene. Table 1 summarizes the studies that show β-catenin mutations in human ovarian cancer, from 16% to 54% in endometrioid cancers and 14% in mucinous cancers. Despite no reported mutations in the CTNNB1 gene in serous and clear cell cancers, nuclear β-catenin has been observed in serous and clear cell ovarian cancer [21]. Lee et al. showed a statistically significant correlation between nuclear β-catenin expression and high-grade serous ovarian cancer [23]. The protooncogene, frequently rearranged in advanced T-cell lymphomas-1 (FRAT1), which inhibits phosphorylation of β-catenin, was found to be overexpressed in serous ovarian cancer and was strongly correlated with the accumulation of cytoplasmic β-catenin, leading to an increase in nuclear β-catenin [21]. Pygo, oneof the co-activators that binds to β-catenin is a necessary component of tumor cell growth and is widely expressed in ovarian cancer, both in cell lines and in primary tumor tissue [33]. RNA expression of BCL9/LGS, also a co-activator,is common in both epithelial ovarian cancer and normal ovaries. Upregulation of these co-activators is further evidence that the Wnt pathway plays a pivotal role in the tumorigenesis of ovarian cancer.

Intercellular interactions

Cells undergoing EMT are known to lose E-cadherin and gain vimentin expression, resulting in tumor cell invasion and metastasis [34]. Epithelial ovarian cancer cells also undergo a mesenchymal to epithelial transition (MET) because the normal ovarian surface epithelium is mesenchymally derived. This dynamic process has been termed EMP (epithelial to mesenchymal plasticity). It is thought that both transitions are equally important for metastasis formation and that the “metastable” state is actually when the cells transition between the two states [34]. Metastatic epithelial ovarian cancer cells adhere to the interstitial collagen of the peritoneal cavity via integrins. Cell–matrix and cell– cell adhesions are paramount to this process and are mediated by integrins and E-cadherins. Integrin engagement has been linked to increased internalization of E-cadherin [31]. In epithelial cancer, the MET component dominates, unlike other epithelial cell-derived cancers where the EMT component dominates; therefore, E-cadherin expression is increased with malignant transformation in ovarian cancer [31]. E-cadherin-based adherens junctions are stabilized by β-catenin, and the loss of stability in the junctions may cause an increase in cytoplasmic and/or nuclear β-catenin. Integrins have also been suggested to inhibit GSK3β, elevate levels of nuclear β-catenin, and increase β-catenin-regulated promoter activation. Burkhalter et al.
showed that an inhibitor of β-catenin and TCF-4, a member of the TCF/LEF transcription factor family, reduced cellular invasion [31]. Most of the regulation of the Wnt pathway ultimately leads to an accumulation or depletion of β-catenin in the nucleus, or affects the binding of nuclear β-catenin to TCF/LEF, which determines whether apoptosis can occur. It is important to note that the transcriptional regulatory activity of β-catenin is also controlled by factors other than Wnt signaling. One example of Wnt-independent regulation of β-catenin is through E-cadherin expression, which selectively depletes the transcriptionally active pool of β-catenin [35]. This is especially significant as epithelial ovarian cancer cells are known to undergo MET which causes an increase in E-cadherin.

Extracellular factors

Not only have membranous and intercellular components of theWnt pathway been found to be upregulated in epithelial ovarian cancer, but extracellular activators also are upregulated. These factors specifically include Wnt-1,Wnt-2b,Wnt-5a, and Wnt-11 [30]. Ricken et al. reported the possibility that Wnt-5a could be involved in ovarian carcinogenesis [18]. This study used RT-PCR on RNA from five ovarian cancer cell lines and confirmed the expression of transcripts for Wnt-2b, Wnt-5a and Wnt-11. Filho et al. showed that upregulation of Wnt-1 and Wnt-5a, detected by immunohistochemistry in patient samples, portended a significantly lower survival than ovarian cancer patient samples that did not have an upregulation of Wnt-1 and Wnt-5a [30].

Gene expression

Kumar et al. analyzed 1500 miRNAs to identify which ones were potentially different between A2780 (parental ovarian cancer cell line) and A2780.cp70 (cisplatin resistant cell line) and found changes in 11 miRNAs [36]. The microRNA data was validated by quantitative realtime PCR for these 11 miRNAs. Ingenuity Pathway Analysis (IPA) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analysis were performed for the 11 miRNAs and their targets to identify the pathways involved in cisplatin resistance. Not only was Wnt signaling one of the pathways identified, but so were MAPK and mTOR signaling pathways which both cross-talk with the Wnt pathway by causing the phosphorylation of GSK3β, blocking its ability to phosphorylate βcatenin to allow it to be ubiquitinated. Four gene expression datasets: Moffitt Cancer Center (MCC), Total Cancer Care (TCC), the Cancer Genome Atlas(TCGA),andMDAnderson (MDA) were analyzed, and only four pathways were noted to be differentially expressed between normal ovarian surface epithelium and ovarian cancer. One of these pathways is the “Cytoskeleton remodeling/TGF–Wnt pathway” [37]. The“Cytoskeleton remodeling/TGF/WNT” pathway was previously described as a common pathway created by the crosstalk between the TGF-β pathway and the Wnt pathway that is involved in cytoskeleton remodeling: cell–cell adhesion and cell–matrix adhesion [38]. This pathway has been associated with metastasis in various cancer types and is critical for cancer cell migration and invasion. The same group at H. Lee Mof fitt Cancer Center found that six common molecular signaling pathways were associated with chemoresistance and survival in ovarian cancer that included the TGF– Wnt pathway and specifically Wnt pathway activated by Wnt-2, one of the 19 Wnt ligands [39]. In addition, this group also used the same novel computer analysis technique to identify genes and molecular signaling pathways associated with cancer cell proliferation. Genes and pathways associated with cancer cell proliferation and survival were analyzed against the NCI 60 cell line-drug screening database to identify agents predicted to have pathway- and gene-specific activity. They identified 81 existing agents that could potentially be repurposed to target the TGF-Wnt pathway that are currently the focus of in vitro functional analyses [40].

Non-canonical pathways

Fig. 1. Non-canonical Wnt signaling pathways. In the planar cell polarity pathway Wnt–Frizzled complex binds to the Dsh-associated activator of morphogenesis (Daam1). This cascade of events leads to the activation of Rac and RhoA GTPases which mediate cell polarity. In the Wnt–Ca2+ pathway, the Wnt/Fzd/Dsh complex binds with a G protein, which leads to activation of calmodulin-dependent kinase II (CaMKII), protein kinase C (PKC), and the phosphatase calcineurin. This binding promotes the increase in intracellular calcium levels which stimulates other signaling pathways.

Fig.2.The canonical Wnt signaling pathway. (A)In the absence of Wnt ligand, β-catenin is degraded through interactions with Axin, APC and GSK3β “destruction complex”. β-Cateninis phosphorylated by the kinases CK1 (casein kinase 1) and GSK3β (glycogen synthase kinase 3β), followed by ubiquitylation and proteasomal degradation. Low cytoplasmic levels of βcatenin allow for the recruitment of the corepressor Groucho to LEF (lymphoid enhanced factor)–TCF (T-cell factor) transcription factors which ensures transcriptional repression. Dikkopf (DKK) family proteins, the Wnt-inhibitory factor (WIF), and the family of secreted Frizzled receptor proteins (SFRPs) all act as antagonists to the Wnt pathway. SFRP binds directly to the Wnt ligand or th eFrizzled receptor to inhibit Wnt binding to Frizzled. (B) In the presence of Wnt ligands, Wnt proteins bind to Frizzled/LRP6/LRP5 receptor complex at the cell surface. LRP6/LRP5 is phosphorylated by the kinases casein kinase 1 (CK1) and glycogen synthase kinase 3β (GSK3β). Dishevelled (Dsh) molecules are recruited to the plasma membrane to interact with Frizzled. Interaction of Axin with phosphorylated LRP6/LRP5 and Dsh leads to inactivation of the destruction complex. Degradation of β-catenin is inhibited. β-Catenin accumulates inthe cytoplasm and nucleus. β-Catenin forms a transcriptionally active complex with TCF/LEF by displacing Groucho and interacting with co-activators suchasBCL9/LGS (B-cell lymphoma 9/Legless) and Pygo (Pygopus) to promote transcription of target genes (Axin, CyclinD1, Survivin). β-Catenin is also a coactivator of CREB binding protein (CBP) which is the binding protein of the cAMP response element-binding protein (CREB). β-Catenin/CBP binds to Wnt-responsive element (WRE) and activates transcription. This leads to cell proliferation, survival, and self-renewal.

Potential therapeutic targets of the Wnt pathway in ovarian cancer

Identification of the specific membranous, intracellular, and extracellular components of the Wnt pathway gives insight to potential targets for therapy. There currently are several small molecules that have recently entered into phase I clinical trials that target the Wnt pathway (Table 2). In order for the Wnt protein to be secreted by the cell to act as a ligand it must first undergo fatty acyl modification. Once it undergoes palmiteolyation it is shepherded through the secretory pathway by Wntless chaperone protein. PORCN is the founding member of a 16-gene family with acyltransferase activity and Porcupine (Porcn) is the acyltransferase enzyme that adds the fatty acid to Wnt which is a crucial step in the secretion of the Wnt ligand. Without Porcn to catalyze this modification, the Wnt protein remains trapped inside the cell. Currently being studied in a phase 1 trial is the small molecule, LGK974 (Novartis Pharmaceuticals) that inhibits Porcn(NCT01352203) [41]. Drugs that specifically target the Wnt signaling pathway in the nucleus include the small molecule inhibitor, PRI-724, which specifically blocks the recruitment of β-catenin with its coactivator CBP which is the binding protein of the cAMP response element-binding protein CREB. βCatenin/CBP binds to Wnt-responsive element (WRE) and activates transcription; therefore, PRI-724 prevents activated transcription by aberrant Wnt signaling. This drug is being studied in solid tumors and myeloid malignancies (NCT01606579) [41]. Other pathways may cross-talk with the Wnt pathway. In Wnt signaling, Axin is a key scaffolding protein of the destruction complex of β-catenin, and Poly (ADP ribose) polymerases (PARPs) promote the ribosylation of Axin, thereby causing it to become degraded and no longer facilitate β-catenin destruction. If PARP is inhibited, Axin is stabilized, which allows it to degrade β-catenin [42]. There are several PARP inhibitors that are currently being used in clinical trials for ovarian cancer. In addition, preclinical studies have been carried out with XAV939, which is a small-molecule PARP inhibitor that targets tankyrases, a specific type of PARP. Huang et al. used a chemical genetic screen to identify the small molecule, XAV939, which selectively inhibits β-catenin mediated transcription. XAV939 was shown to stimulate β-catenin degradation by stabilizing Axin. They used a quantitative chemical proteomic approach to show that XAV939 stabilizes Axin by inhibiting tankyrase1 and tankyrase2.They showed that both tankyrase isoforms 1 and 2 stimulate Axin degradation through the ubiquitin–proteasome pathway [43]. JW55 (Tocris Bioscience) is a selective tankyrase 1 and 2 inhibitor which has been shown to inhibit the growth of cancer. JW55 inhibits the canonical Wnt signaling pathway in colon carcinoma cells that contained mutations either in the APC locus or in anallele of β-catenin [44]. Frizzled, oneof themembrane receptors that activates thepathway upon Wnt ligand binding, has been reported to be overexpressed in ovarian cancer. There are two drugs that specifically target the Fzd receptorthatarebeingevaluatedinclinicaltrials.OMP-18R5(OncoMed Pharmaceuticals/Bayer) is one of the Wnt-targeted compounds that is in clinical development (NCT01345201) [41]. It is a monoclonal antibody that targets Fzd receptors and blocks their association with Wnt ligands. This drug is being used in combination with the standard chemotherapy for breast, lung, pancreas, and colon cancer. Another drug, OMP-54F28, binds to and sequesters the Wnt ligand and is a fusion protein of the Fzd8 ligand-binding domain with the Fc region of a human immunoglobulin (OncoMed Pharmaceuticals/Bayer) (NCT01352203) [41]. There has been a growing trend in oncology to evaluate“repurposed” drugs which are drugs that have been used in the past for other purposes and are now being screened for their function as anticancer drugs. Several drugs have been shown to work through the Wnt pathway including the FDA-approved anti-helminth compound, niclosamide, non-steroidalanti-inflammatory drugs(NSAIDS), and two antipsychotic drugs: lithium and valproic acid. NSAIDS have been shown to cause degradation of TCF and inhibit Wnt target genes such as COX2. Although they do not target the Wnt pathway directly, they could be a potential anti-Wnt agent. Niclosamide inhibitsWnt/β-catenin pathway activation. In colorectal cancer, it was shown to downregulate Dvl2, a member of the Dsh protein family, which in turn decreased downstreamβ-catenin signaling [45]. Recently, niclosamide has been reported to target not only Wnt/β-catenin but also other signaling pathways involved in CSC maintenance such as NF-κB, Notch, ROS, mTORC1, and Stat3 [46,47]. Niclosamide has also been reported to inhibit Wnt/β-catenin signaling by inducing degradation of the Wnt surface receptor, LRP6 [48]. Our laboratory has seen an increase expression of LRP6 in ovarian cancer patients. Yo et al. identified a subset of chemoresistant ovarian tumor cells that fulfilled the definition of CSCs and subjected these cells to high-throughput drug screening using more than 1200 clinically approved drugs. Sixty-one potential compounds were identified on preliminary screening and after more stringent screening, niclosamide was found to be the best drug to selectively target ovarian CSCs both in vitro and in vivo [49].

Wnt/β-catenin pathway and CSC

TheWnt/β-catenin pathway is an important pathway in cell survival and has been implicated in the mechanism of chemoresistance of ovarian CSCs. CSCs are a subpopulation of tumor cells that possess characteristics associated with normal stem cells and have the ability to self-renew and differentiate. Wnt/β-catenin signaling plays an important role in the transcription of multidrug resistance genes such as ABCB1/MDR-1 [50]. Chemoresistance, which can be a result of the inhibition of apoptosis, has been reported to be associated with acquiring EMT in ovarian cancer cells [51,52]. Ovarian cancer cells undergoing EMT have stem-like properties that enable cancer cell dissemination and metastasis formation. A recent study done at Georgia Institute of Technology confirmed that metastasizing ovarian cancer cells taken from patients have a different molecular structure from primary tumor cells and display genetic signatures consistent with EMT [53]. The Wnt/ β-catenin pathway is one of the major signaling pathways thought to be involved in EMT and thus has been shown to play an integral role in metastasis.

Conclusions
Alterations affectingWnt pathway proteins on the cel lmembrane, in the cytoplasm, and in the nucleus have been shown to play important roles in the tumorigenesis of ovarian cancer. Pre-clinical studies have shown an upregulation of 5 of the 19 known Wnt ligands in ovarian cancer, which leads to increased activity of the Wnt pathway. Fzd is one of the membrane receptors that activates the pathway upon Wnt ligand binding. It has been reported to be overexpressed in ovarian cancer. Our laboratory has also seen an upregulation of LRP6 detected by immunohistochemistry (unpublished data). In ovarian cancer, an increase in nuclear β-catenin has been shown to be the result of an upregulation in the β-catenin gene itself and also mutations in the proteins necessary to degrade cytoplasmic β-catenin such as Axin2 and APC. The β-catenin destruction complex consists of Axin2, APC, and GSK3β, which must not be phosphorylated in order to cause βcatenin degradation. GSK3β is frequently phosphorylated in ovarian cancer through other pathways, such as PI3K, inhibiting its ability to degrade β-catenin. Upregulation of co-activators of β-catenin also contributes to the increase in transcription of the target genes. As many as 23 different target genes that lead to cell proliferation and survival, which is a result of nuclear β-catenin build-up, have been shown to be overexpressed in ovariancancer. Wntsignalingis activated in epithelial ovarian cancer, both directly through ligand activated upregulation of the pathway and through a ligand independent increase in nuclear β-catenin through cross-talk with other pathways. Recently, Yo et al. reported that niclosamide, which has been shown to have anti-Wnt activity inhibits growth in ovariantumor-initiatingcells[49].Morepre-clinicalstudies,specifically animal studies and mechanistic studies, are warranted to further investigate other Wnt inhibitors in ovarian cancer. The Wnt pathway is very complex, and further studies with targeted agents need to be done to see if inhibition of a single component of the pathway will be clinically useful. This paper supports the fact that the Wnt pathway shows promise as an effective target for anti-cancer therapy in ovarian cancer. As more efficacy data is collected from the phase 1 studies with Wnt inhibitors LGK974, OMP-54F28, OMP-18R5, and PRI724: NCT01352203, NCT01608867, NCT01345201, and NCT01606579 (www.clinicaltrials.gov), they should be considered as potential agents in the treatment of ovarian cancer. Given the fact that the Wnt pathway is involved in so many biological pathways, results from these studies will be important to determine if effective Wnt pathway inhibition will be excessively toxic to patients. Future directions for investigating the Wnt pathway in ovarian cancer should include genetic sequencing of ovarian cancer patients with the aim of targeting those patients who specifically have upregulation of Wnt pathway target genes. More quantitative data is needed to specifically look at the mechanisms of these drugs in patients by performing qPCR on tissue obtained before and after treatment. The Wnt pathway should be investigated as a potential target in the development of new drugs for ovarian cancer as a single agent and in combination with chemotherapy or other targeted agents.

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7.10.3 Wnt Signaling in the Niche Enforces Hematopoietic Stem Cell Quiescence and Is Necessary to Preserve Self-Renewal In Vivo

Fleming HE1Janzen VLo Celso CGuo JLeahy KMKronenberg HMScadden DT.
Cell Stem Cell. 2008 Mar 6; 2(3):274-83
http://dx.doi.org/10.1016%2Fj.stem.2008.01.003

Wingless (Wnt) is a potent morphogen demonstrated in multiple cell lineages to promote the expansion and maintenance of stem and progenitor cell populations. Pharmacologic modification of Wnt signaling has been shown to increase hematopoietic stem cells (HSC). We explored the impact of Wnt signaling in vivo, specifically within the context of the HSC niche. Using an osteoblast-specific promoter to drive the expression of a pan-inhibitor of canonical Wnt signaling, Dickkopf1 (Dkk1), we noted changes in trabecular bone and in HSC. Wnt signaling was inhibited in HSC and the cells exhibited reduced p21Cip1 expression, increased cell cycling and a progressive decline in regenerative function after transplantation. This effect was microenvironment-determined, but irreversible if the cells were transferred to a normal host. Wnt pathway activation in the niche is required to preserve the reconstituting function of endogenous hematopoietic stem cells.

The regulation of hematopoietic stem cell function is a complex and balanced process that requires coordinated input from inherent HSC programs and moderating signals provided by the surrounding microenvironment. Together, these signals permit the maintenance of the stem cell pool for the life of the organism, while also allowing for sufficient steady-state and injury-responsive blood cell production. These somewhat dichotomous aspects of HSC function require mechanisms that both preserve a quiescent population of stem cells and also promote their activation, expansion, differentiation and circulation under appropriate conditions (Akala and Clarke, 2006Scadden, 2006). The morphogen family of signaling molecules has been identified as a prominent player in the function of numerous stem cell types, including the hematopoietic lineage. The wingless (Wnt) pathway has been studied extensively in the context of hematopoiesis, and the combined impact of multiple family members binding to a range of receptors leads to activation of canonical and non-canonical signaling pathways (Nemeth and Bodine, 2007). Canonical signals are mediated by TCF/LEF transcription factor activity (Daniels and Weis, 2005), and are considered to be largely dependent on the accumulation of nuclear β- (and/or γ-) catenin (Nemeth and Bodine, 2007).Wnt signals have been implicated in mammalian hematopoiesis by studies not intended to assess normal physiology in which Wnt activation had a strong expansive effect on reconstituting HSCs and multipotent progenitors (Baba et al, 2006Murdoch et al, 2003Reya et al, 2003Trowbridge et al, 2006). With enforced, persistent Wnt activation, however, engineered mice developed hematopoietic failure with impaired differentiation of HSC (Kirstetter et al, 2006Scheller et al, 2006). In contrast, deletion of members of the Wnt / β-catenin cascade under homeostatic conditions had little to no effect on blood cell production by HSCs (Cobas et al, 2004Jeannet et al, 2007Koch et al, 2007), raising the question of what physiological role, if any, Wnt signaling has on this cell type. Some of the variation observed may reflect differing influences exerted by canonical versus non-canonical Wnt signals, particularly given a recent report indicating that Wnt5a can modulate canonical signals mediated by Wnt3a (Nemeth et al, 2007). Wnt signals are also regulated by a host of soluble inhibitors that may interact directly with Wnt ligands, such as the frizzled-related proteins (sFRP) or by preventing Wnt binding to its receptors (Kawano and Kypta, 2003). The Dickkopf (Dkk) family of Wnt inhibitors falls into this latter category, by binding the Wnt coreceptor LRP5/6 in combination with a Kremen receptor, and leading to internalization of the complex (Mao et al, 2001Mao et al, 2002). In order to specifically examine the impact of Wnt activation in an in vivomicroenvironment that has been shown to regulate HSC number and function, we utilized mice engineered to overexpress the Wnt inhibitor, Dkk1, under control of the osteoblast specific 2.3kb fraction of the collagen1α promoter. This promoter has been previously shown to direct transgene expression to osteoblastic cells, resulting in changes in the number and function of HSCs (Calvi et al, 2001Calvi et al, 2003)

We noted very little overt phenotype in the hematopoietic compartment of the Dkk1 tg mice at steady-state, and confirmed that transgene expression did not extend to the primitive hematopoietic fraction itself. Clear alterations of bone morphology were observed, however, including a 20% decrease in trabecular bone (manuscript in preparation). Despite the absence of a steady-state hematopoetic phenotype, TCF/LEF activity was specifically reduced within the HSC-containing fraction of Dkk1 transgenic mice, and stem cell function was altered under specific conditions. For example, a highly significant defect in the maintenance of reconstitution potential of HSC was observed, either in settings of serial transplant, or following secondary transplantation of wildtype donor cells previously used to reconstitute Dkk1 tg hosts. In agreement with the functional data, HSC populations had a marked reduction of cells within the G0 fraction of the cell cycle, and displayed enhanced sensitivity to 5-fluorouracil treatment. Wnt signals therefore appear to participate in mediating HSC quiescence in vivo, a result that was largely unpredicted from previous studies, although recent analysis of Hmgb3 mutant mice also supports this conclusion (Nemeth et al., 2006). Our results highlight the importance of studying the impact of a signaling pathway over long-term experiments, and in a physiologic context when seeking to resolve the effects of manipulations on HSC function. In that context, Wnt signaling plays an unanticipated role in maintaining HSC quiescence, which may underlie its requirement in preserving the self-renewing capability of HSC.

Osteoblast expression of Dkk1 does not affect blood or marrow primitive hematopoietic cell populations at steady state

The Wnt inhibitor, Dkk1, has been shown to play an important role in bone formation during development (Niehrs, 2006), and is normally expressed by osteoblasts (Grotewold et al., 1999MacDonald et al., 2004), hence may have regulatory roles as part of the endosteal HSC niche. To examine the impact of Wnt inhibition on hematopoietic stem cells localized to the periendosteal region, Dkk1 was overexpressed within osteoblastic lineage cells under the control of the truncated 2.3kb collagen 1α promoter (manuscript in preparation). Resulting Col1α2.3-Dkk1 transgenic (Dkk1 tg) mice were backcrossed for at least 5 generations to the C57Bl/6 background and examined for bone and blood phenotypic alterations. No significant differences in peripheral white or red blood cell counts were observed (figure S1a). Bone marrow (BM) and spleen cellularity were also unchanged when Dkk1 tg mice and their littermates were compared, although a slight but not significant trend towards reduced body weight and BM cellularity was apparent in transgenic mice (figure S1b and data not shown). In contrast, significant alterations in bone morphology were observed, as is reported elsewhere (manuscript in preparation, and (Li et al, 2006)) Of note, trabecular bone volume was reduced by approximately 20%, whereas cortical bone was unaffected in Dkk1 tg mice (data not shown). Trabecular bone has been shown by us and others to affect HSC number and function (Adams et al, 2007Calvi et al, 2003Jung et al, 2007Zhang et al, 2003). A panel of antibodies using 7 different flurochromes was used for multiparametric analysis of primitive precursors within the BM of Dkk1 tg mice and their littermates, including populations of LT-HSC, ST-HSC, CMP, GMP, MEP and CLP (figure 1a,c). Subpopulations containing primitive HSCs were not significantly altered at steady-state (figure 1b). However, additional cell surface markers revealed a slight but significant increase in the population containing phenotypically-defined common lymphoid progenitors (figure 1d). The calculated absolute cell numbers based on these frequencies indicated a similar pattern of results (figure S2). Despite the elevation of early lymphoid progenitors in the BM of Dkk1 tg mice, no significant changes were observed in the relative proportion of early B lineage progenitor subsets in the BM (data not shown).

Seven color FACS analysis of primitive populations in wt and Dkk1-tg BM nihms-240191-f0001

Seven color FACS analysis of primitive populations in wt and Dkk1-tg BM nihms-240191-f0001

Seven color FACS analysis of primitive populations in wt and Dkk1-tg BM

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Figure 1 Seven color FACS analysis of primitive populations in wt and Dkk1-tg BM

BM from Dkk1 tg and littermates was assayed by multiparameter FACS for relative proportion of primitive HSC populations. BM was stained with antibodies against Lineage markers, cKit, Sca-1, CD34, Flk2, CD16/32 and CD127 and gated as shown in panels (A) and (C). At least 10 mice per genotype were compared, over at least three separate experiments. The proportion of BM corresponding to the HSC-containing LK+S+ fraction (A, blue gate) is shown in (B, left axis), and is sub-sectioned according to CD34 and Flk2 expression to yield phenotypic assessments of LT-HSC and ST-HSC fractions (B, right axis). More differentiated progenitors gated in the LK+S− population (A, left, green gate) were sub-sectioned based on CD16/32 and CD34 expression to compare CMP, GMP and MEP progenitors as shown in (C, left panel). Frequencies of each population, from the same samples quantified for HSC frequency in (B) are shown in (D, left axis). The CLP fraction, gated on LKloSlo in (A, red gate), and gated further on CD127+ cells in (C, right panel) are quantified in (D, right axis). Significance was determined by a Student’s 2-tailed T-test. Error bars indicate the SE of the mean.

Dkk1-tg HSCs exhibit impaired Wnt signaling in a non-cell autonomous manner

To confirm that the transgenic expression of Dkk1 leads to the inhibition of Wnt/βcatenin signaling in the Dkk1 tg mice, HSC-containing populations were isolated from Dkk1 transgenic mice that had been intercrossed with the Topgal reporter strain. In these Topgal mice (DasGupta and Fuchs, 1999), multiple TCF/LEF binding sites have been inserted to control the expression of the reporter gene, β-galactosidase. Reporter activity using this construct has been shown to correlate with canonical Wnt signaling. Of note, TCF/LEF transcription has recently been shown to proceed even with the combined loss of β-catenin and γ-catenin, suggesting that canonical Wnt signals can be transduced by alternate intermediates (Jeannet et al, 2007). Reporter activity was examined within the LK+S+ (Lineage-cKit+Sca1+), HSC-containing population, and the LK+S− population which is devoid of LT-HSC potential. When the Wnt reporter activity detected in each of these populations was compared, a dramatic reduction (>100 fold reduction) in β-catenin activation was observed in the HSC-containing LK+S+ population isolated from Dkk1 tg mice (figure 2a). A more modest reduction (<5 fold reduction) was observed in the less-actively signaling LK+S− fraction. This finding indicates that despite the unchanged frequency of phenotypically-defined HSC-containing populations in unmanipulated Dkk1 tg animals, there is evidence that these cells are molecularly altered by osteoblast expression of the Wnt inhibitor. These data provide evidence for direct inhibition of Wnt signaling in the HSC population in addition to any effects that might be mediated by decreased trabecular bone mass. Wnt signaling is regulated, in part, via a negative feedback loop by TCF/LEF-dependent transcription of endogenous Dkk1 (Niida et al, 2004). Consistent with the decrease in Topgal reporter activity, expression of endogenous Dkk1 was also inhibited in the LK+S+ population of Dkk1 tg mice (figure 2b). Using primers specific for the Dkk1 tg, and in comparison its expression in wt and Dkk1 tg tibea, sorted LK+S+ cells do not express the Dkk1 transgene (figure 2c). Together, these results confirm that Dkk1 tg mice inhibit Wnt signaling specifically within the HSC compartment in a non-cell autonomous manner.

Assessment of canonical Wnt signal activity in HSC-containing populations of Dkk1-tg mice nihms-240191-f0002

Assessment of canonical Wnt signal activity in HSC-containing populations of Dkk1-tg mice nihms-240191-f0002

Assessment of canonical Wnt signal activity in HSC-containing populations of Dkk1-tg mice

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Figure 2 Assessment of canonical Wnt signal activity in HSC-containing populations of Dkk1-tg mice

Functional impact of the Dkk1 transgene on BM reconstitution

Analysis of stem/progenitor activity cannot rely exclusively on the quantitation of precursors according to phenotypically-defined parameters. Using functional measures, we detected a consistent defect in multilineage and myeloid colony formation on a per cell basis in BM isolated from Dkk1 transgenic mice (figure 3a). This result was despite the absence of significant alteration of myeloid and more primitive progenitors by immunophenotype, possibly reflecting the elevated lymphoid fraction, whose progeny are not read out under these culture conditions. In vitro methods such as the CFU assay offer an entry-level analysis of hematopoietic activity, however functional reconstitution in vivo more accurately examines true HSC function (Purton and Scadden, 2007). Therefore, in order to better assess the functional capacity of HSCs isolated from the Dkk1 transgenic environment, BM was transplanted from wt or Dkk1 tg littermates with an equivalent dose of competing marrow from congenic donor mice into lethally irradiated recipients. Donor marrow was isolated from a single wt or transgenic mouse to assess any individual-to-individual variation. Following six months of engraftment, no significant changes in reconstitution were observed across the groups of recipients receiving BM isolated from individual wt or Dkk1 tg environments, although a range of reconstitution capacity was apparent in both groups (figure S3a). Using a limiting dilution assay to determine the frequency of repopulating cells present in BM isolated from individual Dkk1-expressing animals revealed a two-fold elevation in the number of functional reconstituting HSCs (Figure 3b). These transplant results indicate that cells isolated from the Dkk1-epressing niche are capable of reconstituting irradiated recipients, and appear to be present at a higher frequency when Wnt has been inhibited in this location. An important additional parameter to test when investigating HSC function is their longevity, or ability to respond to repeated rounds of expansion stress. To assay the longevity of HSCs isolated from Dkk1 tg mice, noncompetitive serial transplants were performed. As expected from the previous transplant experiments, Dkk1 tg BM was able to completely reconstitute wt irradiated recipients (data not shown).

Functional assessment of HSCs isolated from Dkk1-tg mice

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Figure 3 Functional assessment of HSCs isolated from Dkk1-tg mice

(A) BM from 8 pairs of wt and Dkk1-tg mice was plated in methylcellulose with growth factors (SCF, IL-3, IL-6, Epo) and scored for CFU-C (combined scoring for BFU-E, CFU-GM and CFU-GEMM colonies) after 12 days. All live colonies of more than 30 cells were counted for each of three wells plated per sample. Data are shown as mean colonies per well for each of 8 mice studied over three individual experiments. Significance was determined using a two-tailed Student’s T test. (B) Limiting dilution experiments were performed using three doses of test marrow (CD45.1) transplanted with 5×105 competing cells (CD45.2) into groups of at least 9 recipients (CD45.2) per dose. Test marrow was isolated from two wt and two Dkk1-tg mice, and the Dkk1-tg donors shown here were transplanted into separate groups of irradiated recipients. Data points are plotted as the percent of recipients per group that did not exhibit at least 1% multi-lineage PB engraftment at 6 months (percent unreconstituted). LT-HSC frequency and significance were determined using Poisson statistics: wt, 1 in 63,00 (circles) vs tg, 1 in 31,500 or 1: 37,000 (squares); p<0.02. Similar results were obtained in an independent assessment of two Dkk1-tg donors. (C) Non-competitive serial transplants were initiated by transplanting 1×106 whole BM pooled from three wt or Dkk1-tg donors (CD45.1) into each of 10 irradiated recipients (CD45.2). Secondary and tertiary transplants were performed after 14 weeks of engraftment by pooling BM from 3-4 reconstituted recipients to transplant 1×106 whole BM into new groups of 10 irradiated CD45.2 recipients. The Kaplan-Meier survival graph depicts the survival of tertiary recipients, mice receiving BM from Dkk1-tg mice (solid line) or wt controls (dashed line). Similar results were obtained in an independent assessment of 2 wt and 2 Dkk1-tg mice. (D) Prior to transplant into tertiary recipients, BM from 5 secondary recipients of both genotypes was assayed by FACS for the frequency of LT-HSCs (LK+S+CD34loFlk2−). Error bars indicated SD of the mean, and significance was determined by a two-tailed T test

Effect of temporary exposure to endosteal Dkk1 on HSC function

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Figure 4 Transplant analysis of HSC function following residence in a Dkk1-tg environment

Wnt-inhibited HSC-containing populations are less quiescent

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Figure 5 Examination of cell cycle status of primitive BM in wt and Dkk1-tg mice

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Figure 6 Gene expression by quantitative PCR of sorted primitive populations

Understanding the role of specific signals in the varied regulatory functions of HSC activities is crucial for designing and developing therapeutic interventions involving these cells. The impact of the Wnt family on the expansion and regulation of hematopoietic cells has been examined in a variety of studies. However, the physiologic effects of this pathway remain somewhat ill-defined with often contradicting results. Some have demonstrated that Wnt cascade activation promotes the proliferation of HSCs and their progeny while maintaining at least short-term functional activity (Baba et al, 2006Murdoch et al, 2003Reya et al, 2003;Trowbridge et al, 2006). Others, employing persistent genetic activation of the pathway, have also demonstrated an increase in proliferation of cells with an HSC immunophenotype, but with marked impairment of HSC differentiation resulting in animal death (Kirstetter et al, 2006Scheller et al, 2006). However, induced deletion of β-catenin, the primary downstream mediator of the Wnt cascade resulted in no apparent impact on HSC activity, even in a reconstitution assay that required expansion of β-catenin null transplanted HSCs (Cobas et al, 2004). Furthermore, recent combined deletions of both β-catenin and its homologue, γ-catenin, also maintain HSC function under steady-state and primary reconstitution conditions (Jeannet et al, 2007Koch et al, 2007).All of these studies have either assayed Wnt activity in broad over- or under-stimulation settings, and the manipulations have been performed on the HSCs themselves, or broadly applied to recipient animals. The context in which morphogens are present is highly relevant to their effect and not previously studied for Wnt effects on hematopoiesis (Trowbridge et al., 2006). Indeed, Wnt ligands can modulate signaling initiated by other Wnt family members, underscoring the concept that context, and different signaling intermediates may have a strong impact on functional outcome (Nemeth et al, 2007).

In the present study, we have established a system that permits the analysis of localized Wnt inhibition, offering the opportunity to assay the impact of chronic or temporary exposure to this inhibited environment. In particular, we have directed expression of the Wnt inhibitor, Dkk1, to a cell population that has been previously demonstrated to exert a regulatory function over HSC activity, and which normally express Dkk-1, albeit at lower levels (Grotewold et al,1999MacDonald et al, 2004). It should be noted that while an increasing number of reports suggest that phenotypically-identified HSCs inhabit additional physical locations within the bone marrow environment (Hooper et al, 2007Scadden, 2006), the promoter used in our study has proven to functionally impact the number and activity of HSCs when used to direct modifying signal expression to a population of osteoblastic cells. Given that expression of Dkk1 also results in alterations to bone morphology itself, there is likely to be a dual effect of Dkk1: one altering the niche architecture and the other affecting Wnt signaling in stem/progenitor cells. Our studies demonstrated an effect of Dkk1 overexpression by non-HSCs on Wnt signaling in hematopoietic stem/progenitors, suggesting that this is at least a contributing factor to the phenotype observed. This observation that TCF/LEF reporter activity is reduced, as is expression of endogenous Dkk1, itself a Wnt signaling target (Niida et al, 2004) in BM cells of the transgenic mice indicates altered canonical Wnt signaling. It does not rule out that Dkk1 may exert additional Wnt-independent functions. The results presented here also indicate that the reduced longevity of HSCs does not require constant exposure to exogenous Dkk1, given that we were unable to detect Dkk1 tg expression within populations of primitive hematopoietic cells, and therefore the functional impact on transplanted cells is observed in a Dkk tg-free environment. It is important to note that transplantation of whole BM populations is generally not effective at engrafting non-hematopoietic cells (Koc et al, 1999).

Wnt mediates HSC quiescence and maintains reconstitution function in vivo

The results presented here establish a role for Wnt, in the maintenance of a quiescent fraction of functional HSCs in BM. This was associated with evidence of increased stem cells on limit dilution transplant analysis. However the ability of the same cells to function after serial rounds of transplantation was drastically reduced. The ability of stem cells to persist under the stress conditions of transplantation requires self-renewal capability that is compromised after Dkk1 exposure

The studies of inducible deletion of β- and γ-catenin noted that they were dispensable for HSC function, however did not include sequential transplants out to the extent where we observed our most dramatic phenotype (Cobas et al, 2004Jeannet et al, 2007Koch et al, 2007) Alternatively, it is possible that Dkk1 interferes with HSC function through a process that does not depend on β- or γ-catenin signaling (Jeannet et al, 2007Niehrs, 2006).

Our results emphasize the importance of studying pathways within the context of other signals present in the natural microenvironment, and underscore the potential for unanticipated functional roles. It is clear that different combinations of signals may have a range of effects depending on the context in which they are received. Indeed, we observed an impact of Wnt-inhibition on the activation of the Notch target, Hes-1, raising the possibility that Notch and Wnt coordinate in vivo to maintain quiescence of HSCs, rather than participating in expansive and/or self-renewal functions (Duncan et al, 2005). Notably, elevated Hes-1 and p21 expression have recently been shown to correlate with the maintenance of quiescence and repopulating function of primitive HSCs (Yu et al, 2006). We noted a highly specific impact of the Dkk1 tg on the stem cell enriched LK+S+ fraction in Wnt-dependent pathway activation and inhibition and the Notch target, Hes-1, or the cell cycle regulator, p21 expression.

The effects of Dkk1 on cell cycling were unanticipated given previous reports of constitutively active β-catenin inducing increased stem/progenitor cell proliferation (Kirstetter et al, 2006Scheller et al, 2006). However, others found that with deletion of the chromatin binding protein, Hmgb3, Wnt signaling was increased, yet stem cells more readily returned to quiescence after 5-FU challenge than controls. (Nemeth et al, 2006) Both increased and decreased activation of the pathway may therefore alter HSC cycling kinetics. This may again be due to the context differences observed with a microenvironmentally-provided signal in the current study contrasted with cell autonomous activation of the pathway in the prior reports. Alternatively, it may be an example of the complex effects of morphogens, which have dose-dependent actions (Delaney et al, 2005Kielman et al, 2002MacDonald et al, 2004). It may be that there is a bi-phasic response of cell cycling to the Wnt pathway and that proper control of stem cell quiescence requires a fine-tuned modulation of intermediate Wnt signaling intensity. This has implications for the potential use of Wnts as mediators of stem cell expansion ex vivo and for interruption of this pathway as an anti-leukemic intervention.

In sum, niche related expression of Dkk1 reveals a role for Wnt signaling in the physiologic regulation of the hematopoietic compartment, altering stem cell cycling and longevity following repeated expansion, or self-renewal. The phenotype observed was sufficiently distinct from what cell-autonomous modifications of the pathway would have predicted to argue for niche specific modeling of exogenous factors’ effects on stem cells. This may be particularly true for members of the locally acting morphogen group of cell modifiers.

7.10.4 Wnt.β-Catenin Signaling in Development and Disease

Clevers H1.
Cell. 2006 Nov 3; 127(3):469-80.
http://dx.doi.org/10.1016/j.cell.2006.10.018

A remarkable interdisciplinary effort has unraveled the WNT (Wingless and INT-1) signal transduction cascade over the last two decades. Wnt genes encode small secreted proteins that are found in all animal genomes. Wnt signaling is involved in virtually every aspect of embryonic development and also controls homeostatic self-renewal in a number of adult tissues. Germline mutations in the Wnt pathway cause several hereditary diseases, and somatic mutations are associated with cancer of the intestine and a variety of other tissues.

The mouse wnt1 gene, originally named Int-1, was identified in 1982 by Nusse and Varmus as a preferential integration site for the Mouse Mammary Tumor Virus in virally induced breast tumors ( Nusse and Varmus, 1982). When sequenced, the Wnt1 proto-oncogene was seen to encode a secreted protein that is cysteine rich. Subsequently, Drosophila wingless (wg), which controls segment polarity during larval development ( Nüsslein-Volhard and Wieschaus, 1980), was shown to be a fly homolog of Wnt1 ( Rijsewijk et al., 1987). Segmentation of the epidermis of wg mutant fly embryos is severely impaired as evidenced by abnormalities in the overlying ventral cuticle. In contrast to the wild-type cuticle, which exhibits alternating denticle and naked belts, the wg cuticle is completely covered with denticles. Fly embryos carrying mutations in the porcupinedishevelled, and armadillo genes display similar cuticle abnormalities to wgmutant embryos, whereas mutations in shaggy/zeste-white 3 cause the opposite phenotype, a naked cuticle. Epistatic analysis of cuticle structure in double mutants indicated that these genes constituted the core of a new signal transduction cascade ( Siegfried et al., 1992Noordermeer et al., 1994 and Peifer et al., 1994).

In 1989, McMahon and Moon (McMahon and Moon, 1989) observed a duplication of the body axis inXenopus following injection of mouse Wnt1 mRNA into ventral blastomeres of embryos at the 4-cell stage. This observation supported the notion that Wnt signaling was shared between vertebrates and invertebrates and, moreover, provided a rapid and convenient assay to study components of the Wnt pathway in vertebrates. Axis duplication was also induced by Dishevelled (Dsh), β-catenin (the vertebrate homolog of armadillo), and a dominant-negative version of glycogen synthase kinase 3 (GSK3), the vertebrate homolog of shaggy/zeste-white 3 ( Dominguez et al., 1995Guger and Gumbiner, 1995 and He et al., 1995). Although long elusive, the specific Wnt signal that triggers axis induction in Xenopus was identified as Wnt11 by Heasman and colleagues last year ( Tao et al., 2005).

The combined observations made in Drosophila and Xenopus delineated a highly conserved signaling pathway, activated by secreted Wnt proteins. Independent of these studies, the adenomatous polyposis coli (APC) gene was discovered in a hereditary cancer syndrome termed familial adenomatous polyposis (FAP) ( Kinzler et al., 1991 and Nishisho et al., 1991). Soon after, the large cytoplasmic APC protein was found to interact with β-catenin ( Rubinfeld et al., 1993 and Su et al., 1993). This observation provided the first connection between the Wnt pathway and human cancer.

Genome sequencing has since revealed that mammalian species have roughly 20 secreted Wnt proteins, which can be divided into 12 conserved Wnt subfamilies. Of these, only 6 subfamilies have counterparts in ecdysozoan animals such as Drosophila and Caenorhabditis. In contrast, at least 11 of the Wnt subfamilies occur in the genome of a cnidarian (the sea anemone Nematostella vectensis). This finding suggests that some Wnt subfamilies were lost during the evolution of the ecdysozoan lineage but more importantly reveals that a complex inventory of Wnt factors was present in multicellular animals well before the Cambrian explosion (550 million years ago). Thus, comparative genomic analysis underscores the crucial role that Wnt genes play in organismal patterning throughout the animal kingdom ( Kusserow et al., 2005).

Currently, three different pathways are believed to be activated upon Wnt receptor activation: the canonical Wnt/β-catenin cascade, the noncanonical planar cell polarity (PCP) pathway, and the Wnt/Ca2+ pathway. Of these three, the canonical pathway is best understood and is the primary subject of this review. For recent comprehensive overviews on the other Wnt signaling pathways, the reader is referred to Katoh (2005) and Kohn and Moon (2005). This review discusses how Wnt proteins are produced and secreted and how they activate the canonical Wnt signaling pathway in recipient cells. Further, the review examines the roles of the canonical Wnt pathway in development, tissue self-renewal, and cancer.

Wnt Protein Secretion

Wnt proteins are characterized by a high number of conserved cysteine residues. Although Wnt proteins carry an N-terminal signal peptide and are secreted, they are relatively insoluble. This insolubility has been attributed to a particular protein modification, cysteine palmitoylation, which is essential for Wnt function (Willert et al., 2003). Hofmann (2000) reported that a Drosophila gene required in the Wnt-secreting cell, termed porcupine, displays homology to acyl-transferases, enzymes that acylate a variety of substrates in the endoplasmic reticulum. Thus, porcupine and its worm homolog mom-1 are believed to encode the enzyme that is responsible for Wnt palmitoylation ( Zhai et al., 2004).

Recently, Banziger et al. (2006) and Bartscherer et al. (2006) uncovered in Drosophila another conserved gene that is essential for Wnt secretion, named wntless (wls) and evenness interrupted (evi), respectively. The gene encodes a seven-pass transmembrane protein that is conserved from worms (mom-3) to man (hWLS). In the absence of Wls/evi, Wnts are retained inside the cell that produces them. The Wntless protein resides primarily in the Golgi apparatus, where it colocalizes and physically interacts with Wnts. A genetic screen in C. elegans revealed that the retromer, a multiprotein complex involved in intracellular trafficking and conserved from yeast to man, is also essential for Wnt secretion and for the generation of a Wnt gradient ( Coudreuse et al., 2006). An attractive hypothesis is that the retromer complex is involved in recycling a Wnt cargo receptor (such as Wntless) between the default secretory pathway and a compartment dedicated to Wnt secretion (see Figure 1).

wnt-secretion

wnt-secretion

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Figure 1. Wnt Secretion

To be secreted, Wnt proteins in the endoplasmic reticulum (ER) need to be palmitoylated by the action of Porcupine. Wnt proteins also require Wntless (Wls/Evi) in order to be routed to the outside of the cell. Loading onto lipoprotein particles may occur in a dedicated endo/exocytic compartment. The retromer complex may shuttle Wls between the Golgi and the endo/exocytic compartment.

Wnt is thought to act as a morphogen (that is, a long-range signal whose activity is concentration dependent) (reviewed in Logan and Nusse, 2004). However, it is unclear how these long-range gradients are generated. It is conceivable that the palmitoyl moiety constrains movement away from membranes or lipid particles. Thus, Wnts may be tethered to intercellular transport vesicles or lipoprotein particles (Panakova et al., 2005). Alternatively, Wnts may be transported by cytonemes, which are long, thin filopodial processes. Additionally, studies in Drosophila suggest a role for extracellular heparan sulfate proteoglycans (HSPG) in the transport or stabilization of Wnt proteins. For instance, flies carrying mutations in Dally, a GPI-anchored HSPG, or in genes encoding enzymes that modify HSPGs resemblewingless mutants (reviewed in Lin, 2004).

Receptors, Agonists, and Antagonists for Wnt

Wnts bind Frizzled (Fz) proteins, which are seven-pass transmembrane receptors with an extracellular N-terminal cysteine-rich domain (CRD) (Bhanot et al., 1996). The Wnt-Fz interaction appears promiscuous, in that a single Wnt can bind multiple Frizzled proteins (e.g., Bhanot et al., 1996) and vice versa. In binding Wnt, Fzs cooperate with a single-pass transmembrane molecule of the LRP family known as Arrow inDrosophila ( Wehrli et al., 2000) and LRP5 and -6 in vertebrates ( Pinson et al., 2000 and Tamai et al., 2000). The transport of Arrow/LRP5/6 to the cell surface is dependent on a chaperone called Boca inDrosophila and Mesd in mice ( Culi and Mann, 2003 and Hsieh et al., 2003). And consistent with a role of the Boca/Mesd chaperone in the transport of Arrow/LRP5/6 transport, mutations in Boca and Mesdresemble loss of Arrow/LRP5/6. Although it has not been formally demonstrated that Wnt molecules form trimeric complexes with LRP5/6 and Frizzled, surface expression of both receptors is required to initiate the Wnt signal.

Derailed, a transmembrane tyrosine kinase receptor from the RYK subfamily, is an unusual Wnt receptor.Drosophila Wnt5 controls axon guidance in the central nervous system. Embryos lacking Dwnt-5 resemble those lacking Derailed, that is, they generate aberrant neuronal projections across the midline ( Yoshikawa et al., 2003). Derailed binds DWnt-5 through its extracellular WIF (Wnt inhibitory factor) domain. Signaling events downstream of this alternative Wnt receptor remain unclear. Somewhat unexpectedly, the Derailed kinase domain may be dispensable for signaling. Lu et al. (2004) propose that, unlike the Drosophila Ryk homolog Derailed, mammalian Ryk functions as a coreceptor along with Fz. Mammalian Ryk binds Dishevelled to activate the canonical Wnt/β-catenin signaling pathway. Another tyrosine kinase receptor, Ror2, harbors a Wnt binding CRD motif. Wnt5a can engage Ror2 to inhibit the canonical Wnt signaling pathway, although paradoxically Wnt5a can also activate the canonical pathway by directly engaging Fz4 (Mikels and Nusse, 2006) and Fz5 ( He et al., 1997).

At least two types of proteins that are unrelated to Wnt factors activate the Frizzled/LRP receptors. One of these factors is the cysteine-knot protein Norrin, which is mutated in Norrie disease, a developmental disorder characterized by vascular abnormalities in the eye and blindness. Norrin binds with high affinity to Frizzled-4 and activates the canonical signaling pathway in an LRP5/6-dependent fashion (Xu et al., 2004). Other factors that activate the canonical Wnt signaling pathway are R-spondins, which are thrombospondin domain-containing proteins. In Xenopus, R-spondin-2 is a Wnt agonist that synergizes with Wnts to activate β-catenin ( Kazanskaya et al., 2004). Human R-spondin-1 has been found to strongly promote the proliferation of intestinal crypt cells, a process which involves the stabilization of β-catenin (Kim et al., 2005). Indeed, studies in cultured cells demonstrate that R-spondins can physically interact with the extracellular domains of LRP6 and Fzd8 and activate Wnt reporter genes ( Nam et al., 2006).

The secreted Dickkopf (Dkk) proteins inhibit Wnt signaling by direct binding to LRP5/6 (Glinka et al., 1998). Through this interaction, Dkk1 crosslinks LRP6 to another class of transmembrane molecules, the Kremens (Mao et al., 2002), thus promoting the internalization and inactivation of LRP6. An unrelated secreted Wnt inhibitor, Wise, also acts by binding to LRP (Itasaki et al., 2003), as does the WISE family member SOST (Li et al., 2005 and Semenov et al., 2005).

Soluble Frizzled-Related Proteins (SFRPs) resemble the ligand-binding CRD domain of the Frizzled family of Wnt receptors (Hoang et al., 1996). WIF proteins are secreted molecules with similarity to the extracellular portion of the Derailed/RYK class of transmembrane Wnt receptors (Hsieh et al., 1999). SFRPs and WIFs are believed to function as extracellular Wnt inhibitors (reviewed in Logan and Nusse, 2004) but, depending on context, may also promote signaling by Wnt stabilization or by facilitating Wnt secretion or transport.

Canonical Wnt Signaling

Once bound by their cognate ligands, the Fz/LRP coreceptor complex activates the canonical signaling pathway (Figure 2). Fz can physically interact with Dsh, a cytoplasmic protein that functions upstream of β-catenin and the kinase GSK-3. Wnt signaling controls phosphorylation of Dsh (reviewed in Wallingford and Habas, 2005). However, it remains unclear whether the binding of Wnt to Fz regulates a direct Fz-Dsh interaction, nor is it known how Dsh phosphorylation is controlled or how phosphorylated Dsh functions in Wnt signal transduction.

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canonical-wnt-signaling

Figure 2. Canonical Wnt Signaling

(Left panel) When Wnt receptor complexes are not bound by ligand, the serine/threonine kinases, CK1 and GSK3α/β, phosphorylate β-catenin. Phosphorylated β-catenin is recognized by the F box/WD repeat protein β-TrCP, a component of a dedicated E3 ubiquitin ligase complex. Following ubiquitination, β-catenin is targeted for rapid destruction by the proteasome. In the nucleus, the binding of Groucho to TCF (T cell factor) inhibits the transcription of Wnt target genes. (Right panel) Once bound by Wnt, the Frizzled(Fz)/LRP coreceptor complex activates the canonical signaling pathway. Fz interacts with Dsh, a cytoplasmic protein that functions upstream of β-catenin and the kinase GSK3β. Wnt signaling controls phosphorylation of Dishevelled (Dsh). Wnts are thought to induce the phosphorylation of LRP by GSK3β and casein kinase I-γ (CK1γ), thus regulating the docking of Axin. The recruitment of Axin away from the destruction complex leads to the stabilization of β-catenin. In the nucleus, β-catenin displaces Groucho from Tcf/Lef to promote the transcription of Wnt target genes.

Recent studies have indicated that the coreceptor LRP5/6 interacts with Axin through five phosphorylated PPP(S/T)P repeats in the cytoplasmic tail of LRP (Davidson et al., 2005 and Zeng et al., 2005). Wnts are thought to induce the phosphorylation of the cytoplasmic tail of LRP, thus regulating the docking of Axin. GSK3 phosphorylates the PPP(S/T)P motif, whereas caseine kinase I-γ (CK1γ) phosphorylates multiple motifs close to the GSK3 sites. CK1γ is unique within the CK1 family in that it is anchored in the membrane through C-terminal palmitoylation. Both kinases are essential for signal initiation. It remains presently debated whether Wnt controls GSK3-mediated phosphorylation of LRP5/6 (Zeng et al., 2005) or whether CK1γ is the kinase regulated by Wnt (Davidson et al., 2005). When bound to their respective membrane receptors, Dsh and Axin may cooperatively mediate downstream activation events by heterodimerization through their respective DIX (Dishevelled-Axin) domains.

The Cytoplasmic Destruction Complex

The central player in the canonical Wnt cascade is β-catenin, a cytoplasmic protein whose stability is regulated by the destruction complex. The tumor suppressor protein Axin acts as the scaffold of this complex as it directly interacts with all other components—β-catenin, the tumor suppressor protein APC, and the two kinase families (CK1α, -δ, -ɛ and GSK3α and -β [reviewed in Price, 2006]). When WNT receptor complexes are not engaged, CK1 and GSK3α/β sequentially phosphorylate β-catenin at a series of highly conserved Ser/Thr residues near its N terminus (Figure 2). Phosphorylated β-catenin is then recognized by the F box/WD repeat protein β-TrCP, a component of a dedicated E3 ubiquitin ligase complex. As a consequence, β-catenin is ubiquitinated and targeted for rapid destruction by the proteasome (Aberle et al., 1997). Note that the CK1 and GSK3 kinases perform paradoxical roles in the Wnt pathway. At the level of the LRP coreceptor they act as agonists, whereas in the destruction complex they act as antagonists

Although genetic observations imply an essential role for APC in the destruction complex, there is no consensus on its specific molecular activity. APC has a series of 15 and 20 amino acid repeats with which it interacts with β-catenin. Three Axin-binding motifs are interspersed between these β-catenin-binding motifs. Increasing the expression of Axin in cancer cells that lack APC restores the activity of the destruction complex, implying that APC is only essential when Axin levels are limiting. Quantitatively, Axin indeed appears to be the limiting factor (Lee et al., 2003) and may be the key scaffolding molecule that promotes the rapid assembly and disassembly of the destruction complex.

Given that CK1, Dsh, β-TrCP, and GSK3 participate in other signaling pathways, low levels of Axin may insulate the Wnt pathway from changes in the abundance or activity of these signaling components. It has been proposed that APC is required for efficient shuttling and loading/unloading of β-catenin onto the cytoplasmic destruction complex. Both APC and Axin can themselves be phosphorylated by their associated kinases, which changes their affinity for other components of the destruction complex. Our understanding of the relevance of these phosphorylation events in the regulation of Wnt signaling remains incomplete. For a comprehensive discussion of the kinases in the Wnt pathway, the reader is referred to a recent review (Price, 2006)

β-catenin plays a second role in simple epithelia, that is, as a component of adherens junctions. It is an essential binding partner for the cytoplasmic tail of various cadherins, such as E-cadherin (Peifer et al., 1992). Unlike the signaling pool of β-catenin, the pool that is bound to the adherens junction is highly stable. It is currently unclear whether the adhesive and signaling properties of β-catenin are interconnected. In a likely scenario, newly synthesized β-catenin first saturates the pool that is part of the adhesion junction, which never becomes available for signaling. “Excess,” free cytoplasmic β-catenin protein is then efficiently degraded by the APC complex. It is only this second, highly unstable pool that is subject to regulation by Wnt signals. In support of this model, these two functions of β-catenin are separately performed by two different β-catenin homologs in C. elegans ( Korswagen et al., 2000).

Upon receptor activation by WNT ligands, the intrinsic kinase activity of the APC complex for β-catenin is inhibited. It is unclear how this occurs, but it likely involves the Wnt-induced recruitment of Axin to the phosphorylated tail of LRP and/or to Fz-bound Dsh. As a consequence, stable, nonphosphorylated β-catenin accumulates and translocates into the nucleus, where it binds to the N terminus of LEF/TCF (lymphoid enhancer factor/T cell factor) transcription factors (Behrens et al., 1996Molenaar et al., 1996 and van de Wetering et al., 1997).

It has been suggested that protein phosphatases may regulate β-catenin stability as antagonists of the serine kinases (reviewed in Price, 2006). For example, heterotrimeric PP2A is required for the elevation of β-catenin levels that is dependent on Wnt. Moroever, PP2A can bind Axin and APC, suggesting that it might function to dephosphorylate GSK3 substrates. If and how PP2A activity is regulated by Wnt signals remains to be resolved.

Crystallographic studies are starting to provide insights into the structure of the destruction complex. The central region of β-catenin (to which most partners bind) was the first component of the pathway to be crystallized. It consists of 12 armadillo repeats, which adopt a superhelical shape with a basic groove running along its length. Subsequently, structural interactions of Axin, APC, E-cadherin, and TCF with β-catenin have been visualized (Choi et al., 2006, and references therein). APC, E-cadherin, and TCF bind the central part of the basic groove in a mutually exclusive fashion. Despite very limited conservation of primary sequence in the respective interaction domains, the modes of binding are structurally very similar. Axin utilizes a helix that occupies the groove formed by the third and fourth armadillo repeats of β-catenin. Axin binding precludes the simultaneous interaction with other β-catenin partners in this region. Based on this observation, it is suggested that a key function of APC is to remove phosphorylated β-catenin from the active site of the complex (Xing et al., 2003). In a further study, the structure of Axin bound to APC (Spink et al., 2000) was solved. These studies form stepping stones to a better understanding of the dynamics of the destruction complex. Unfortunately, biochemical studies of the destruction complex in its different activation states are sorely lacking.

Nuclear Events

Upon stabilization by Wnt signals, β-catenin enters the nucleus to reprogram the responding cell (Figure 3). There is no consensus on the mechanism by which β-catenin travels between the cytoplasm and the nucleus. In many cases, cells that undergo Wnt signaling may actually display an overall rise in β-catenin protein without a clear nuclear preference. β-catenin’s nuclear import is independent of the Nuclear Localization Signal/importin machinery. β-catenin itself is a close relative of importin/karyopherins and directly interacts with nuclear pore components. Two proteins, Tcf and Pygopus are proposed to anchor β-catenin in the nucleus, although β-catenin can still localize to the nucleus in the absence of either of the two (reviewed in Staedeli et al., 2006). β-catenin can also be actively transported back to the cytoplasm, by either an intrinsic export signal or as cargo of Axin (Cong and Varmus, 2004) or APC (Rosin-Arbesfeld et al., 2000) that shuttle between cytoplasm and nucleus.

transactivation-of-wnt-target-genes

transactivation-of-wnt-target-genes

Transactivation of Wnt Target Genes

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Figure 3. Transactivation of Wnt Target Genes

The β-catenin/Tcf complex interacts with a variety of chromatin-remodeling complexes to activate transcription of Wnt target genes. The recruitment of β-catenin to Tcf target genes affects local chromatin in several ways. Bcl9 acts as a bridge between Pygopus and the N terminus of β-catenin. Evidence suggests that this trimeric complex is involved in nuclear import/retention of β-catenin (Townsley et al., 2004), but it may also be involved in the ability of β-catenin to activate transcription (Hoffmans et al., 2005). The C terminus of β-catenin also binds to coactivators such as the histone acetylase CBP, Hyrax, and Brg-1 (a component of the SWI/SNF chromatin-remodeling complex).

Whereas the fly and worm genomes both encode a single Tcf protein, the vertebrate genome harbors fourTcf/Lef genes. Tcf factors bind their cognate motif in an unusual fashion, i.e., in the minor groove of the DNA helix, while inducing a dramatic bend of over 90°. Tcf target sites are highly conserved between the four vertebrate Tcf/Lef proteins and Drosophila Tcf. These sites resemble AGATCAAAGG ( van de Wetering et al., 1997). Wnt/TCF reporter plasmids such as pTOPflash ( Korinek et al., 1997), widely used to measure Wnt pathway activation, consist of concatamers of 3–10 of these binding motifs cloned upstream of a minimal promoter. The four vertebrate TCF/LEF differ dramatically in their embryonic and adult expression domains, yet they are highly similar biochemically, explaining the extensive redundancy unveiled in double knockout experiments (as in Galceran et al., 1999).

In the absence of Wnt signals, Tcf acts as a transcriptional repressor by forming a complex with Groucho/Grg/TLE proteins (Cavallo et al., 1998 and Roose et al., 1998). The interaction of β-catenin with the N terminus of Tcf (Behrens et al., 1996Molenaar et al., 1996 and van de Wetering et al., 1997) transiently converts it into an activator, translating the Wnt signal into the transient transcription of Tcf target genes. To accomplish this, β-catenin physically displaces Groucho from Tcf/Lef (Daniels and Weis, 2005). The recruitment of β-catenin to Tcf target genes affects local chromatin in several ways. Its C terminus is a potent transcriptional activator in transient reporter gene assays (van de Wetering et al., 1997). It binds coactivators such as the histone acetylase CBP and Brg-1, a component of the SWI/SNF chromatin remodeling complex (reviewed in Staedeli et al., 2006). A recent study implies that the human and fly homologs of yeast Cdc37 (Parafibromin and Hyrax, respectively) also interact with the C-terminal transactivation domain of β-catenin to activate target gene transcription (Mosimann et al., 2006). Cdc37 is a component of the PAF complex. In yeast the PAF complex directly interacts with RNA polymerase II to regulate transcription initiation and elongation.

Two dedicated, nuclear partners of the TCF/β-catenin complex, Legless/Bcl9 and Pygopus, were recently found in genetic screens in Drosophila ( Kramps et al., 2002Parker et al., 2002 and Thompson et al., 2002). Mutations in these genes result in phenotypes similar to wingless, and overexpression of both genes promotes TCF/β-catenin activity in mammalian cells ( Thompson et al., 2002). Bcl9 bridges Pygopus to the N terminus of β-catenin. The formation of this trimeric complex has been implicated in nuclear import/retention of β-catenin ( Townsley et al., 2004) but may also directly contribute to the ability of β-catenin to transactivate transcription ( Hoffmans et al., 2005). Although most if not all Wnt signaling events in Drosophila appear to be dependent on Bcl9 and Pygopus, it is currently unclear if this holds true in vertebrate development.

Tcf itself can be regulated by phosphorylation. The MAP kinase-related protein kinase NLK/Nemo (Ishitani et al., 1999) phosphorylates Tcf, thereby decreasing the DNA-binding affinity of the β-catenin/Tcf complex and inhibiting transcriptional regulation of Wnt target genes. In C. elegans, LIT-1/NLK-dependent phosphorylation results in PAR-5/14-3-3- and CRM-1-dependent nuclear export of POP-1/Tcf ( Meneghini et al., 1999 and Lo et al., 2004). And lastly, a recent study utilizing chromatin immunoprecipitations suggests that APC, independent of its role in the cytoplasmic destruction complex, acts on chromatin to facilitate CtBP-mediated repression of Wnt target genes in normal, but not in colorectal cancer cells ( Sierra et al., 2006).

Wnt Target Genes

Loss of components of the Wnt pathway can produce dramatic phenotypes that affect a wide variety of organs and tissues. A popular view equates Wnt signaling with maintenance or activation of stem cells (Reya and Clevers, 2005). It should be realized, however, that Wnt signals ultimately activate transcriptional programs and that there is no intrinsic restriction in the type of biological event that may be controlled by these programs. Thus, Wnt signals may promote cell proliferation and tissue expansion but also control fate determination or terminal differentiation of postmitotic cells. Sometimes, these disparate events, proliferation and terminal differentiation, can be activated by Wnt in different cell types within the same structure, such as the hair follicle or the intestinal crypt (Reya and Clevers, 2005).

Numerous Tcf target genes have been identified in diverse biological systems. These studies tend to focus on target genes involved in cancer, as exemplified by the wide interest in the Wnt target genes cMyc and Cyclin D1. For a comprehensive, updated overview of Tcf target genes, the reader is referred to the Wnt homepage (http://www.stanford.edu/∼rnusse/wntwindow.html). The Wnt pathway has distinct transcriptional outputs, which are determined by the developmental identity of the responding cell, rather than by the nature of the signal. In other words, the majority of Wnt target genes appear to be cell type specific. It is not clear whether “universal” Wnt/Tcf target genes exist. The best current candidates in vertebrates are Axin2/conductin (Jho et al., 2002) and SP5 (Weidinger et al., 2005). As noted (Logan and Nusse, 2004), Wnt signaling is autoregulated at many levels. The expression of a variety of positive and negative regulators of the pathway, such as Frizzleds, LRP and HSPG, Axin2, and TCF/Lef are all controlled by the β-catenin/TCF complex.

Wnt Signaling in Self-Renewing Tissues in Adult Mammals

Wnt signaling not only features in many developmental processes; in some self-renewing tissues in mammals it remains essential throughout life. It is this aspect of Wnt signaling that is intricately connected to the development of disease. The examples discussed below illustrate how the Wnt pathway is involved in adult tissue self-renewal. Mutations in the Wnt pathway tip the homoeostatic balance in these tissues to cause pathological conditions such as disturbances in skeletal bone mass or cancer.

Gut

Figure 4. Self-Renewing Tissues in the Adult Mammal

Current evidence indicates that the Wnt cascade is the dominant force in controlling cell fate along the crypt-villus axis. In neonatal mice lacking Tcf4, the differentiated villus epithelium appears unaffected, but the crypt progenitor compartment is entirely absent (Korinek et al., 1998). This implies that physiological Wnt signaling is required for the establishment of this progenitor compartment.

Hair Follicle

Multipotent epidermal stem cells reside in the bulge region of the hair follicle (Figure 4). Bulge stem cells can generate all hair lineages but also the sebocytes and even the stem cells of the interfollicular epidermis (Alonso and Fuchs, 2003). To form a hair, cells migrate downward from the bulge through the outer root sheath. At the base of the hair, the cells enter a transit-amplifying compartment termed the germinative matrix where they undergo terminal differentiation in the precortex compartment of the hair.

Hematopoietic System

Hematopoietic stem cells (HSCs) are the best studied stem cells in mammals. A number of studies have implicated the Wnt signaling pathway as an important regulator of hematopoietic stem and progenitor cells. HSCs themselves as well as the bone marrow microenvironment can produce Wnt proteins. Indeed, Tcf reporters are active in HSCs in their native microenvironment.

Bone

In postnatal and adult life, osteoblasts produce bone matrix, whereas osteoclasts resorb the matrix. Bone density is determined by the relative activities of these two cell types. Gain-of-function mutations in the human LRP5 gene occur in bone diseases, indicating that canonical Wnt signaling may regulate bone mass. This observation has motivated genetic studies in mouse models, which generally confirm the importance of this signaling pathway in bone homeostasis, primarily as a positive regulator of the osteoblast lineage. Similar to humans carrying the gain-of-function LRP5G171V mutation, transgenic mice expressing this allele in osteoblasts display increased bone density and elevated numbers of active osteoblasts (reviewed in Hartmann, 2006).

Wnt Signaling in Cancer

Colon Cancer

The APC gene was among the first tumor suppressors to be cloned. A germline APC mutation is the genetic cause of a hereditary cancer syndrome termed Familiar Adenomatous Polyposis (FAP) (Kinzler et al., 1991 and Nishisho et al., 1991). FAP patients inherit one defective APC allele and as a consequence develop large numbers of colon adenomas, or polyps, in early adulthood. Polyps are benign, clonal outgrowths of epithelial cells in which the second APC allele is inactivated. Inevitably, some of these polyps progress into malignant adenocarcinoma. Loss of both APC alleles occurs in the large majority of sporadic colorectal cancers (Kinzler and Vogelstein, 1996). Mutational inactivation of APC leads to the inappropriate stabilization of β-catenin (Rubinfeld et al., 1996Figure 4). Indeed, Tcf reporter constructs, normally transcribed only upon Wnt signaling, are inappropriately transcribed in APC mutant cancer cells through the action of constitutive complexes between β-catenin and the intestinal TCF family member Tcf4 (Korinek et al., 1997). In rare cases of colorectal cancer where APC is not mutated, Axin2 is mutant (Liu et al., 2000), or activating (oncogenic) point mutations in β-catenin remove its N-terminal Ser/Thr destruction motif (Morin et al., 1997). Of note, patients with hereditary Axin2 mutations display a predisposition to colon cancer (Lammi et al., 2004).

In intestinal epithelial cells in which APC is mutated, the constitutive β-catenin/Tcf4 complex activates a genetic program in crypt stem/progenitor cells (van de Wetering et al., 2002). In the crypt, the Wnt signaling gradient drives expression of this genetic program to maintain progenitor cell proliferation. The Wnt gradient also controls expression of the EphB/EphrinB sorting receptors and ligands (Battle et al., 2002). The resulting EphB/EphrinB countergradients establish crypt-villus boundaries as well as position the Paneth cells at the bottom of the crypt. Several EphB genes are initially upregulated as Wnt/Tcf4 target genes in early adenomas, but their expression is lost upon cancer progression (Batlle et al., 2005) apparently as the result of a selection process. Activating Wnt pathway mutations are not restricted to cancer of the intestine. Loss-of-function mutations in Axin have also been found in hepatocellular carcinomas, whereas oncogenic β-catenin mutations occur in a wide variety of solid tumors (reviewed inReya and Clevers, 2005).

Several animal models exist for FAP. Dove and colleagues first described the multiple intestinal neoplasia(min) mouse, which carries a stop codon in APC (Apcmin). Unlike FAP patients, Apcmin mice develop adenomas predominantly in the small intestine ( Su et al., 1992). Several additional Apc knockout models have been generated in mice. Invariably, these mice develop neoplastic lesions but they may differ in tumor incidence and tissue type in which tumors first appear. In a recent elegant study, the Wnt cascade was mutationally activated in adult mice by conditional deletion of Apc ( Sansom et al., 2004). Within days, villi were entirely populated by crypt-like cells, demonstrating the direct link between active Wnt signaling and the proliferation of crypt progenitors, which when unrestrained results in cancer. Zebrafish that are mutant in Apc resemble the mouse models in that heterozygous mutants develop adenomas in organs of endodermal origin including the intestine. These fish may prove useful for genetic screens for genes that modify cancer risk ( Haramis et al., 2006).

Hair Follicle Tumors

Leukemia

Drawing from the parallels between self-renewal and cancer in the gut and hair follicle, the effects of Wnt pathway components on hematopoietic progenitors predict that Wnt deregulation may contribute to hematological malignancies. Indeed, a recent report suggests that leukemic growth of both myeloid and lymphoid lineages is dependent on Wnt signaling. Granulocyte-macrophage progenitors from Chronic Myelogenous Leukemia patients and blast crisis cells from patients resistant to therapy display active Wnt signaling as demonstrated by Tcf reporter activity and the accumulation of nuclear β-catenin (Jamieson et al., 2004).

Over the last 20 years, a detailed outline of the canonical Wnt pathway has emerged. Although it is likely that most core components of the pathway have now been identified, much remains to be learned about the biochemical events that connect these components. Many of the gaps in our knowledge are due to the notorious difficulties in the production of purified Wnt proteins. Few good Wnt antibodies exist and, 25 years after the cloning of Wnt1, its structure remains unknown. The routing and the coincident posttranslational modifications of Wnt proteins in the secreting cell are incompletely understood. And the rules that dictate the movement of Wnt proteins between cells remain uncertain. However, a procedure to produce soluble Wnt has recently been developed (Willert et al., 2003), which creates avenues to address many of these issues.

The components of the destruction complex have been long known, yet the biochemistry of its activity has remained elusive. APC is an essential component of the destruction complex, but what is its biochemical activity? How relevant is Dsh for the coupling of Wnt receptors to the destruction complex? And what mechanism inhibits the phosphorylation of β-catenin by the destruction complex when a Wnt signal is being transduced?

In addition, a multitude of proposed pathway components, not discussed here, may activate, modify, or inhibit Wnt signaling or may be involved in crosstalk to other pathways. An updated, comprehensive list of these putative components and interactions appears on http://www.stanford.edu/∼rnusse/wntwindow.html. Often based on single studies, these candidate components remain to be independently confirmed.

Wnt signaling ultimately controls developmental fates through the transcription of cell type-specific programs of Tcf target genes. Recent developments in array-based technology allow detailed analysis of the nuclear transcriptional response to Wnt signals. With these technologies, it is expected that the dissection of the gene programs in various developmental or pathological events will provide a wealth of insight into the biology of these processes.

7.10.5 Wnt.β-Catenin Signaling. Components, Mechanisms, and Diseases

MacDonald BT1Tamai KHe X.
Dev Cell. 2009 Jul; 17(1):9-26
http://dx.doi.org/10.1016%2Fj.devcel.2009.06.016

Signaling by the Wnt family of secreted glycolipoproteins via the transcription co-activator β-catenin controls embryonic development and adult homeostasis. Here we review recent progresses in this so-called canonical Wnt signaling pathway. We discuss Wnt ligands, agonists and antagonists and their interactions with Wnt receptors. We also dissect critical events that regulate β-catenin stability from Wnt receptors to the cytoplasmic β-catenin destruction complex, and nuclear machinery that mediates β-catenin-dependent transcription. Finally we highlight some key aspects of Wnt/β-catenin signaling in human diseases including congenital malformations, cancer and osteoporosis and potential therapeutic implications.

Signaling by the Wnt family of secreted glycolipoproteins is one of the fundamental mechanisms that direct cell proliferation, cell polarity and cell fate determination during embryonic development and tissue homeostasis (Logan and Nusse, 2004). As a result, mutations in the Wnt pathway are often linked to human birth defects, cancer and other diseases (Clevers, 2006). A critical and most studied Wnt pathway is canonical Wnt signaling, which functions by regulating the amount of the transcriptional co-activator β-catenin that controls key developmental gene expression programs. This review focuses on our current understanding of Wnt/β-catenin signaling, drawing mainly from genetic, developmental and biochemical analyses in Drosophila, Xenopus, mice and humans. For more comprehensive and historic perspective we refer readers to earlier reviews (Clevers, 2006Logan and Nusse, 2004) and the Wnt homepage (www.stanford.edu/~rnusse/wntwindow.html). The nematode Caenorhabditis elegans exhibits similar but also divergent Wnt/β-catenin pathways, which are covered elsewhere (Mizumoto and Sawa, 2007) and in the accompanying review (Kimble 2009). Wnt also activates a number of non-canonical signaling pathways that are independent of β-catenin and have been recently reviewed (Seifert and Mlodzik, 2007Wang and Nathans, 2007).

The central logic of Wnt/β-catenin signaling has emerged from two decades of studies (Figure 1). In the absence of Wnt, cytoplasmic β-catenin protein is constantly degraded by the action of the Axin complex, which is composed of the scaffolding protein Axin, the tumor suppressor adenomatous polyposis coli gene product (APC), casein kinase 1 (CK1), and glycogen synthase kinase 3 (GSK3). CK1 and GSK3 sequentially phosphorylate the amino terminal region of β-catenin, resulting in β-catenin recognition by β-Trcp, an E3 ubiquitin ligase subunit, and subsequent β-catenin ubiquitination and proteasomal degradation (He et al., 2004). This continual elimination of β-catenin prevents β-catenin from reaching the nucleus, and Wnt target genes are thereby repressed by the DNA-bound T cell factor/lymphoid enhancer factor (TCF/LEF) family of proteins (Figure 1a). The Wnt/β-catenin pathway is activated when a Wnt ligand binds to a seven-pass transmembrane Frizzled (Fz) receptor and its co-receptor, low-density lipoprotein receptor related protein 6 (LRP6) or its close relative LRP5. The formation of a likely Wnt-Fz-LRP6 complex together with the recruitment of the scaffolding protein Dishevelled (Dvl) results in LRP6 phosphorylation and activation and the recruitment of the Axin complex to the receptors. These events lead to inhibition of Axin-mediated β-catenin phosphorylation and thereby to the stabilization of β-catenin, which accumulates and travels to the nucleus to form complexes with TCF/LEF and activates Wnt target gene expression (Figure 1b).

Overview of Wnt.β-catenin signaling nihms196288f1

Overview of Wnt.β-catenin signaling nihms196288f1

Overview of Wnt/β-catenin signaling
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Figure 1 Overview of Wnt/β-catenin signaling

Wnt ligands and biogenesis

Wnts are conserved in all metazoan animals. In mammals, complexity and specificity in Wnt signaling are in part achieved through 19 Wnt ligands, which are cysteine rich proteins of approxiamately 350-400 amino acids that contain an N-terminal signal peptide for secretion. Murine Wnt3a represents the first purified and biochemically characterized Wnt protein (Willert et al., 2003) owing to its relatively efficient secretion (in contrast to most other Wnt proteins). In addition to N-linked glycosylation, which is required for Wnt3a secretion (Komekado et al., 2007), Wnt3a undergoes two types of lipid modifications that likely account for the hydrophobicity and poor solubility of Wnt proteins (Hausmann et al., 2007). The first reported lipididation was the addition of palmitate to cysteine 77 (Willert et al., 2003). Its mutation had minimal effect on Wnt3a secretion but diminished the ability of Wnt3a to activate β-catenin signaling (Galli et al., 2007;Komekado et al., 2007Willert et al., 2003). The second identified lipididation was a palmitoleoyl attached to serine 209, and its mutation resulted in Wnt3a accumulation in the endoplasmic reticulum (ER) and failure in secretion (Takada et al., 2006).

Drosophila Wingless (Wg) is the Wnt molecule most investigated in vivo (Hausmann et al., 2007). These studies plus work in nematodes have identified genes that regulate Wnt biogenesis and secretion. Porcupine (Porc) encodes a multipass transmembrane ER protein that contains an O-acyl transferase domain suggesting a role in Wg lipid modification (Hausmann et al., 2007). Porc deficiency results in Wg and Wnt3a accumulation in the ER and diminished Wnt3a palmitoleoylation at serine 209 (Takada et al., 2006), suggesting that Porc is responsible for this particular lipidation. Whether Porc or a distinct acyltransferase is involved in Wnt3a palmitoylation at cysteine 77 remains unknown.

Two additional proteins/protein complexes were identified for Wg/Wnt secretion: Wntless (Wls), also known as Evenness interrupted (Evi) or Sprinter (Srt), in Drosophila and the retromer complex in nematodes (Hausmann et al., 2007). Wls is a multipass transmembrane protein that localizes to the Golgi, endocytic compartments and the plasma membrane, and is essential for Wg secretion. The retromer complex, which is composed of five subunits, was defined first in yeast. It mediates membrane protein trafficking between endosomes and the Golgi apparatus (Hausmann et al., 2007). Several groups recently reported that the retromer complex is required for retrieval/recycling of Wls from the endosome to the Golgi (Belenkaya et al., 2008Franch-Marro et al., 2008bPan et al., 2008aPort et al., 2008Yang et al., 2008), likely mediated by direct interaction between Wls and the retromer Vps35 subunit. Loss of retromer function causes Wls to be degraded in the lysosomes and results in reduction of Wls and thus Wnt secretion. These studies led to an emerging picture of Wnt biogenesis (Figure 2). Wnt is glycosylated and lipid modified by Porc in the ER, and is escorted by Wls from the Golgi to the plasma membrane for secretion. Wls is recycled by endocytosis and trafficked back to Golgi by the retromer. Note that porcwls and retromer mutants largely phenocopywg/wnt mutants in flies and worms, attesting their dedicated roles in Wnt biogenesis.

Wnt biogenesis and secretion nihms196288f2

Wnt biogenesis and secretion nihms196288f2

Wnt biogenesis and secretion

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Figure 2  Wnt biogenesis and secretion

Wnt extracellular distribution and movement

Wnt proteins can function as morphogens that are capable of both short and long range signaling, as best demonstrated for Wg. Wg lipidation raises the issue of its diffusion and distribution through the aqueous extracellular space. Indeed purified Wnt3a exhibits increased activity via artificial liposomal packaging (Morrell et al., 2008). Two distinct Wg secretory pathways for short and long range signaling have been speculated but not fully substantiated. Wg may form multimers to bury lipid modifications inside (Katanaev et al., 2008), or bind to lipoprotein particles, which may be involved in Wg long range signaling (Panakova et al., 2005) (Figure 2). The membrane microdomain protein reggie-1/flotillin-2 specifically promotes Wg long-range secretion (Katanaev et al., 2008). The Wg receptors (see below) and heparan sulfate proteoglycans (HSPGs) such as Dally and Dally-like protein have important roles in the Wg morphogen concentration via regulating Wg degradation, diffusion, endocytosis/transcytosis, and may function in Wg signaling as potential low-affinity co-receptors (Lin, 2004). Note that reggie-1/flotillin-2, lipoprotein particles, Dally and Dally-like protein are important analogously for secreted Hedgehog morphogen, which is also lipid modified (Katanaev et al., 2008Lin, 2004Panakova et al., 2005).

Wnt receptors: Frizzled and LRP5/6

Two distinct receptor families are critical for Wnt/β-catenin signaling (Figure 3): the Frizzled (Fz or Fzd) seven-pass transmembrane receptors (Logan and Nusse, 2004) and the LDL receptor-related proteins 5 and 6 (LRP5 and LRP6) (He et al., 2004). The Wnt-receptor relationship is best illustrated for Wg, which binds toDrosophila Fz2 (Dfz2) and Dfz1 with high affinity (1-10 nM) and requires either Fz in a redundant manner (Logan and Nusse, 2004). Wg reception also absolutely depends on Arrow, the LRP5/6 homolog (He et al., 2004). The mammalian genome harbors 10 Fz genes, most of which have variable capacities to activate β-catenin signaling when co-overexpressed with Wnt and LRP5/6 (e.g., Binnerts et al., 2007) and functional redundancy among Fz members is likely prevalent (Logan and Nusse, 2004). Between the two LRPs, LRP6 plays a more dominant role and is essential for embryogenesis whereas LRP5 is dispensable for embryogenesis but critical for adult bone homeostasis. Nonetheless LRP5 and LRP6 are partially redundant as their functions together are required for mouse gastrulation (He et al., 2004). Most data, including Wnt binding to LRP5/6 and Wnt1-Fz8-LRP6 complex formation in vitro and observations that engineered Fz-LRP5/6 proximity is sufficient to activate β-catenin signaling (Cong et al., 2004Holmen et al., 2005;Tolwinski et al., 2003), support the model that Wnt induces the formation of Fz-LRP5/6 complex (He et al., 2004) (Figure 1). But unambiguous demonstration of this receptor complex in vivo is lacking. It is noteworthy that Wnt3a palmitoylation (at cysteine 77) is important for binding to both Fz and LRP6 (Cong et al., 2004Komekado et al., 2007), explaining in part the importance of this lipid modification

Secreted Wnt antagonists and agonists nihms196288f3

Secreted Wnt antagonists and agonists nihms196288f3

Secreted Wnt antagonists and agonists
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Figure 3 Secreted Wnt antagonists and agonists

A particular Wnt may activate β-catenin and/or non-canonical pathways depending on the receptor complement (van Amerongen et al., 2008). Fz function is involved in β-catenin and non-canonical pathways. The Fz-LRP5/6 co-receptor model stipulates that a Wnt-Fz pair capable of recruiting LRP5/6 activates the β-catenin pathway, consistent with the specific requirement of LRP5/6 in Wnt/β-catenin signaling (He et al., 2004). However some evidence suggests that LRP6 antagonizes non-canonical Wnt signaling in vivo, possibly via competing for Wnt ligands (Bryja et al., 2009) or an unknown mechanism (Tahinci et al., 2007). Other Wnt receptors exist such as Ryk and ROR2, which are not required for, but in some cases may antagonize, Wnt/β-catenin signaling (van Amerongen et al., 2008).

Wnt antagonists and agonists

Several secreted protein families antagonize or modulate Wnt/β-catenin signaling (Figure 3). sFRPs (secreted Frizzled related proteins), and WIF (Wnt inhibitory protein) bind to Wnt, and in the case of sFRPs, also to Fz (Figure 3), and thereby function as Wnt antagonists for both β-catenin and non-canonical signaling (Bovolenta et al., 2008). Loss-of-function studies in mice have revealed significant redundancy for the sFRP genes (Satoh et al., 2008). The Wnt-binding property suggests that sFRPs and WIF may also regulate Wnt stability and diffusion/distribution extracellularly beyond just Wnt inhibitors. Some sFRPs have been shown to have Wnt-independent activity such as regulators of extracellular proteinases (Bovolenta et al., 2008).

Two distinct classes of Wnt inhibitors are the Dickkopf (Dkk) family and the Wise/SOST family (Figure 3). Dkk proteins, exemplified by Dkk1, are LRP5/6 ligands/antagonists and are considered specific inhibitors for Wnt/β-catenin signaling. Although two different models for Dkk1 action have been proposed (Mao et al., 2002Semenov et al., 2001), recent biochemical and genetic studies (Ellwanger et al., 2008Semenov et al., 2008Wang et al., 2008) have argued against the model that Dkk1 inhibits Wnt signaling via inducing LRP6 internalization/degradation through transmembrane Kremen (Krm) proteins (Mao et al., 2002). Dkk1 disruption of Wnt-induced Fz-LRP6 complex remains a more likely mechanism (Semenov et al., 2001), with Krm playing a minor modulatory role in specific tissues (Ellwanger et al., 2008). Wise and SOST constitute another family of LRP5/6 ligands/antagonists (Itasaki et al., 2003Li et al., 2005Semenov et al., 2005). Like Dkk1, SOST is able to disrupt Wnt-induced Fz-LRP6 complex in vitro (Semenov et al., 2005). Both Dkk1 and SOST are strongly implicated in human diseases (see below).

Shisa proteins represent a distinct family of Wnt antagonists (Figure 3), which trap Fz proteins in the ER and prevent Fz from reaching the cell surface, thereby inhibiting Wnt signaling cell-autonomously (Yamamoto et al., 2005). Shisa proteins also antagonize FGF (fibroblast growth factor) signaling by trapping FGF receptors in the ER. Other Wnt antagonists with multivalent activities exist. Xenopus Cerberus binds to and inhibits Wnt as well as Nodal and BMP (bone morphogenetic protein) (Piccolo et al., 1999), and IGFBP-4 (Insulin-like growth-factor-binding protein-4) antagonizes Wnt signaling via binding to both Fz and LRP6, in addition to modulating IGF signaling (Zhu et al., 2008).

Norrin and R-spondin (Rspo) proteins are two families of agonists for Wnt/β-catenin signaling (Figure 3). Norrin is a specific ligand for Fz4 and acts through Fz4 and LRP5/6 during retinal vascularization (Xu et al., 2004). Rspo proteins exhibit synergy with Wnt, Fz and LRP6 (Kazanskaya et al., 2004Kim et al., 2005;Nam et al., 2006Wei et al., 2007), and show genetic interaction with LRP6 during embryogenesis (Bell et al., 2008), but their mechanism of action is controversial. Results that Rspo binds to both Fz and LRP6 (Nam et al., 2006), to LRP6 primarily (Wei et al., 2007), or to neither (Kazanskaya et al., 2004) have been reported. Another model suggests that Rspo is a ligand for Krm and antagonizes Dkk/Krm-mediated LRP6 internalization (Binnerts et al., 2007), but this seems unlikely given that Krm1 and Krm2 double knockout mice are viable and do not exhibit Rspo mutant phenotypes, and Rspo activates β-catenin signaling in cells lacking both Krm genes (Bell et al., 2008Ellwanger et al., 2008). Rspo genes are often co-expressed with and depend on Wnt for expression (Kazanskaya et al., 2004), and may represent a means of positive feedback that reinforces Wnt signaling. Mutations in Norrin and Rspo genes cause distinct hereditary diseases (see below).

Wnt signaling

Wnt-off state: β-catenin phosphorylation/degradation by the Axin complex

Cytosolic β-catenin phosphorylation/degradation and its regulation by Wnt are the essence of Wnt signaling (Figure 1). The scaffolding protein Axin uses separate domains to interact with GSK3, CK1α, and β-catenin and coordinates sequential phosphorylation of β-catenin at serine 45 by CK1α and then at threonine 41, serine 37 and serine 33 by GSK3 (Kimelman and Xu, 2006). β-catenin phosphorylation at serine 33 and 37 creates a binding site for the E3 ubiquitin ligase β-Trcp, leading to β-catenin ubiquitination and degradation (Figure 4). Mutations of β-catenin at and surrounding these serine and threonine residues are frequently found in cancers, generating mutant β-catenin that escapes phosphorylation and degradation (Table 1). Axin also contains an RGS (regulator of G protein signaling) domain that interacts with APC, a large multifunctional scaffolding protein that itself binds β-catenin. These core Axin complex components (Kimelman and Xu, 2006) share a common goal of ensuring β-catenin phosphorylation and degradation. Indeed both APC and Axin are tumor suppressor genes, and APC mutations are particularly prevalent in colorectal cancer (Table 1).

Regulation of Axin complex assembly for β-catenin degradation
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Figure 4 Regulation of Axin complex assembly for β-catenin degradation

Table 1 Human diseases associated with mutations of the Wnt signaling components

Several aspects of the Axin complex deserve further discussion. (i) In addition to β-catenin, GSK3 and CK1 also phosphorylate Axin and APC, leading to increased association of Axin and APC with β-catenin and thus enhanced β-catenin phosphorylation/degradation (Huang and He, 2008Kimelman and Xu, 2006) (Figure 4). (ii) Two abundant serine/threonine phosphatases, PP1 and PP2A, both of which associate with Axin and/or APC, counteract the action of GSK3 and/or CK1 in the Axin complex. Thus PP1 dephosphorylates Axin and promotes the disassembly of the Axin complex (Luo et al., 2007), whereas PP2A dephosphorylates β-catenin (Su et al., 2008), each resulting in reduced β-catenin degradation (Figure 4). One should note that PP2A may have multiple and opposing roles in the Wnt pathway depending on the particular associated regulatory subunits and substrates (Kimelman and Xu, 2006). (iii) The assembly of the Axin complex appears to be multivalent and robust. In fly embryos that are null for Axin, expression, at physiological levels, of Axin mutants lacking either the APC-, GSK3-, or β-catenin-binding domain restores a significant degree of normal patterning, implying a quasi-functional Axin complex assembly via multivalent interactions; furthermore, some of these Axin deletion mutants can complement each other and restore fly viability, possibly via Axin dimerization or multimerization (Peterson-Nedry et al., 2008). Indeed Axin has multiple potential dimerization domains (Luo et al., 2005) and the Axin DIX domain may form multimeric polymers (Schwarz-Romond et al., 2007a). (iv) Axin concentration is exceedingly low compared to other components in Xenopus oocytes, indicating that Axin is rate limiting for the complex assembly. This feature may ensure that changes in the Axin protein level will not fluctuate the availability of GSK3 (or other components) for non-Wnt functions, thereby further insulating Wnt and other signaling events (Lee et al., 2003). It is unknown, however, whether the drastic difference between the concentration of Axin versus the other components applies universally, and whether different cells employ quantitative differences in the ratio of Axin and other components to shape their unique Wnt response kinetics (such as the speed and level of β-catenin accumulation). Indeed in Drosophila photoreceptors, APC appears to be present at minimal levels such that a 50% reduction alters the graded Wg response (Benchabane et al., 2008).

Other proteins such as WTX (Wilms tumor gene on the X chromosome) may have roles in β-catenin degradation. Loss of WTX and activating β-catenin mutations seem to have non-overlapping occurrence in Wilms tumor (a pediatric kidney cancer) (Rivera et al., 2007). WTX binds to β-catenin, Axin, APC and β-Trcp to promote β-catenin ubiquitination, although its biochemical role remains unknown (Major et al., 2007). Another Axin-binding protein Diversin can facilitate β-catenin degradation via recruiting CK1ε to phosphorylate β-catenin (Schwarz-Romond et al., 2002).

APC function and APC-Axin cross regulation

The biochemical nature of APC has been enigmatic. A recent study suggested that APC protectsβ-catenin from dephosphorylation by PP2A thereby enhancing β-catenin phosphorylation/degradation (Su et al., 2008) (Figure 4), consistent with the observation that Axin overexpression causes β-catenin degradation even in cells lacking APC function (Behrens et al., 1998). Surprisingly APC (upon phosphorylation by CK1/GSK3) and Axin bind to and compete for the same β-catenin interaction interface, leading to a proposal that APC acts as a “ratchet” to remove phosphorylated β-catenin from Axin for ubiquitination and for making Axin available for a further round of β-catenin phosphorylation (Kimelman and Xu, 2006Xing et al., 2003). A different model was proposed based on differential β-catenin binding affinity by unphosphorylated versus phosphorylated APC (Ha et al., 2004). APC has also been shown to promote β-catenin nuclear export and to act as a chromatin-associated suppressor for β-catenin target genes, thus functioning in the nucleus (see below).

Another paradoxical observation is that APC has a positive function in physiological and ectopic Wg/Wnt signaling through the promotion of Axin degradation (Lee et al., 2003Takacs et al., 2008) (Figure 4). One model suggests that this represents a fail-safe mechanism to buffer dramatic β-catenin fluctuations when APC levels vary (Lee et al., 2003). Thus a decrease in the APC level results in higher Axin amounts, compensating for β-catenin degradation. APC-mediated Axin degradation depends on the APC amino terminal domain that is not involved inβ-catenin degradation (Takacs et al., 2008). It is intriguing that colon cancer cells are rarely null for APC but rather retain the amino terminal half, and may have hijacked a part of this fail-safe regulation for tumorigenesis. Conversely Axin can also facilitate APC degradation upon overexpression (Choi et al., 2004), constituting perhaps the other side of the Axin-APC regulation circuit (Figure 4). Mechanisms for Axin and APC degradation, which are proteosome-dependent, have not been characterized.

Wnt-on state

Activation of Wnt receptors

Wnt signaling requires both Fz and LRP6 (or LRP5), likely through a Wnt-induced Fz-LRP6 complex (Figure 1). Wnt-induced LRP6 phosphorylation is a key event in receptor activation (Tamai et al., 2004). LRP6, LRP5 and Arrow each have five reiterated PPPSPxS motifs (P, proline; S, serine or threonine, x, a variable residue), which are essential for LRP6 function and are each transferrable to a heterologous receptor to result in constitutive β-catenin signaling (MacDonald et al., 2008Tamai et al., 2004Zeng et al., 2005). These dually phosphorylated PPPSPxS motifs are docking sites for the Axin complex (Davidson et al., 2005;Tamai et al., 2004Zeng et al., 2005), thereby recruiting Axin to LRP6 upon Wnt stimulation (Mao et al., 2001) (Figure 5).

Models of Wnt receptor activation nihms196288f5

Models of Wnt receptor activation nihms196288f5

Models of Wnt receptor activation

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Figure 5 Models of Wnt receptor activation

The kinases responsible for PPPSPxS phosphorylation have been identified unexpectedly as GSK3 and CK1 (Davidson et al., 2005Zeng et al., 2005). Although one study argued that only CK1 phosphorylation is Wnt-induced (Davidson et al., 2005), most available data support that Wnt induces PPPSP phosphorylation (Binnerts et al., 2007Khan et al., 2007Pan et al., 2008bWei et al., 2007), which is carried out by GSK3 and primes xS phosphorylation by CK1, thereby leading to dually induced phosphorylation (Zeng et al., 2005) (Figure 5). Although potential involvement of additional kinases cannot be ruled out, experiments in GSK3α/β null cells indicate that GSK3 accounts for most, if not all, PPPSP phosphorylation (Zeng et al., 2008Zeng et al., 2005). As in β-catenin phosphorylation, Axin-bound GSK3 appears to mediate LRP6 phosphorylation (Zeng et al., 2008). Thus PPPSPxS phosphorylation exhibits a mirror image of β-catenin phosphorylation in sequential order, in priming requirement, and importantly in functionality, but apparently by the same Axin-GSK3 complex (Huang and He, 2008) (Figure 5). This unusual mechanism, using the same kinase complex for both positive and negative regulation, is reminiscent of another morphogenetic pathway, Hedgehog signaling in Drosophila (Price, 2006), and implies a simple view that Wnt signaling regulates the two opposing activities of the Axin-GSK3 complex. One caveat is that GSK3 is genetically defined as a negative regulator of β-catenin signaling. The positive requirement of GSK3 in LRP6 activation is demonstrated when a membrane-tethered GSK3 inhibitory peptide blocks Wnt signaling (Zeng et al., 2008).

Fz function is required for Wnt-induced LRP6 phosphorylation, and forced Fz-LRP6 association is sufficient to trigger LRP6 phosphorylation (Zeng et al., 2008). Fz function is usually linked to Dsh/Dvl (Wallingford and Habas, 2005), a cytoplasmic scaffolding protein that may directly interact with Fz (Wong et al., 2003). Indeed Fz-Dvl interaction and Dvl function are critical for Wnt-induced LRP6 phosphorylation (Bilic et al., 2007Zeng et al., 2008). As Dvl interacts with Axin (Wallingford and Habas, 2005), and is required for Axin recruitment to the plasma membrane during Wg signaling (Cliffe et al., 2003) or in Fz overexpression (Zeng et al., 2008), one model stipulates that Fz-Dvl recruitment of the Axin-GSK3 complex initiates LRP6 phosphorylation by GSK3 (Zeng et al., 2008) (Figure 5).

Several features of Wnt receptor activation deserve further discussion. (i) The observation that Axin is required for LRP6 phosphorylation, and phosphorylated LRP6 in turn recruits Axin suggests a positive feed-forward loop, potentially amplifying and ensuring the phosphorylation of all five PPPSPxS motifs (Figure 5). Indeed the phosphorylation of these motifs relies on the presence of one another, and LRP6 activity is particularly sensitive to the PPPSPxS copy number (MacDonald et al., 2008Wolf et al., 2008). This may explain the distinct roles of Fz and LRP6/Arrow in the “initiation” (which requires both Fz and Arrow) and “amplification” (which requires Arrow only) during Wg signaling (Baig-Lewis et al., 2007) (Figure 5a). (ii) Wnt-induced clustering of Fz-LRP6 receptor has been reported that critically depend on Dvl, Axin and GSK3 for formation (see below) (Bilic et al., 2007Schwarz-Romond et al., 2007a). Although unambiguous evidence for such aggregation under physiological conditions without overexpression remains to be shown, this “signalsome” model (Figure 5b) and the “initiation-amplification” model (Figure 5a) together provide a spatial and temporal framework for understanding Wnt receptor activation. (iii) Wnt also induces LRP6 phosphorylation by CK1γ outside the PPPSPxS motifs, in particular in a conserved S/T cluster amino-terminal to the first PPPSPxS motif (Davidson et al., 2005). This region upon phosphorylation binds to GSK3 (Piao et al., 2008), potentially accounting for observed LRP6-GSK3 interaction (Mi et al., 2006Zeng et al., 2005). The significance of this S/T cluster to LRP6 function has not been investigated in the intact receptor, but these results imply multiple interaction interfaces among LRP6, Axin and GSK3. (iv) Wnt may also “activate” Fz, which is structurally related to G-protein coupled receptors (GPCRs). Some genetic and pharmacological evidence suggests that trimeric G proteins, specifically the Gαo and Gαq, are required downstream of Fz and probably upstream of Dvl in Wnt/β-catenin signaling (Katanaev et al., 2005Liu et al., 2001Liu et al., 2005). Whether G proteins are involved in Wnt/Fz/Dvl-regulated LRP6 phosphorylation is unknown.

Dvl is involved in Wnt/β-catenin and other Wnt/Fz-dependent pathways and has numerous putative binding partners (Wallingford and Habas, 2005). For example CK1ε (or CK1δ) binds to Dvl and is a potent activator of β-catenin signaling, possibly via phosphorylating Dvl, LRP6 and/or the Axin complex (Price, 2006) (Figure 5). PP2A also associates with Dvl but has a positive or negative influence on Wnt signaling depending on the associated regulatory subunit (Kimelman and Xu, 2006). In addition Dvl is subjected to proteasomal degradation via distinct ubiquitination pathways (Angers et al., 2006Simons et al., 2005). Some of these Dvl regulation events have been suggested to switch Dvl between β-catenin and non-canonical pathways. Despite these progresses, the mechanism by which Dvl acts in Wnt/β-catenin signaling remains enigmatic. Two recent findings suggest potential new insights. (i) Polymerization/aggregation of Dvl (and Axin). Fz-Dvl and Dvl-Axin interactions are relatively weak (Schwarz-Romond et al., 2007bWong et al., 2003). However Dvl and Axin each harbor a homologous DIX domain that exhibit dynamic polymerization (Schwarz-Romond et al., 2007a). This unusual property is proposed to allow Dvl and Axin to form large aggregates that facilitate weak but dynamic protein interactions (Figure 5b). Indeed Wnt-induced receptor clustering requires an intact Dvl DIX domain (Bilic et al., 2007Schwarz-Romond et al., 2007a). It is unclear whether Wnt regulates DIX-dependent polymerization, and perhaps in a related manner, Fz-Dvl or Dvl-Axin interaction. (ii) Dvl stimulation of phosphatidylinositol 4,5-bisphosphate [PtdIns (4,5)P2 or PIP2] production by sequential actions of phosphatidylinositol 4-kinase type II (PI4KIIα) and phosphatidylinositol-4-phosphate 5-kinase type I (PIP5KI) (Pan et al., 2008b). Wnt induces Dvl, via the DIX domain, to bind to and activate PIP5K, and the resulting PIP2 production is suggested to promote LRP6 clustering and phosphorylation, although the underlying mechanism remains unclear (Figure 5c). Given that PIP2 has pleiotropic functions in cells including receptor endocytosis (see below), other potential mechanisms for PIP2 in LRP6 phosphorylation remain to be explored. Nonetheless Dvl DIX polymerization and stimulation of PIP2 may act in concert to ensure LRP6 clustering/phosphorylation/activation.

Other regulatory events at or proximal to Wnt receptors

A cytoplasmic protein in vertebrates, referred to as Caprin-2, binds to LRP6 and facilitates LRP6 phosphorylation by GSK3 (Ding et al., 2008). Caprin-2 has an oligomerization domain that may enhance LRP6 aggregation, and Caprin-2 additionally may also associate with both GSK3 and Axin and promote LRP6-Axin-GSK3 complex formation (Ding et al., 2008). Besides the requirement of Dvl, recruitment of Axin to the receptor complex may involve a giant protein (600 kD), Macf1 (microtubule actin cross-linking factor 1) (Chen et al., 2006). Macf1 is a member of the spectraplakin family of proteins that link the cytoskeleton to junctional proteins. Defective gastrulation in Macf1−/− mouse embryos phenotypically resembles Lrp5/6−/− double knockout mutants. On Wnt stimulation Macf1 associates with the Axin complex (including APC) in the cytosol and with LRP6 and the Axin complex (but not APC) in the membrane fraction (Chen et al., 2006), and may shuttle Axin to LRP6 (Figure 5). This Macf1 function may be vertebrate-specific as Drosophila Macf1 (shortstop) mutants do not exhibit wg-related phenotypes. …

Inhibition of β-catenin phosphorylation

How receptor activation leads to inhibition of β-catenin phosphorylation remains uncertain, and available data suggest possible parallel mechanisms. In the LRP6-centric view, as constitutively activated forms of LRP6 fully activate β-catenin signaling in an apparently Fz and Dvl-independent manner (He et al., 2004), LRP6 represents the key output whereas Fz and Dvl act upstream to control LRP6 activation. On the other hand, Dsh overexpression in Drosophila or recombinant Dvl in Xenopus egg extracts can activate β-catenin signaling presumably in the absence of Arrow/LRP6 (Salic et al., 2000Wehrli et al., 2000), and so does a GPCR-Fz chimeric protein in response to the GPCR ligand (Liu et al., 2001). These results argue that Fz/Dvl may activate β-catenin signaling independent of LRP6. The fact that nematodes have a related Wnt/β-catenin pathway (Kimble 2009) but have no LRP6 homolog may be consistent with this notion. Perhaps inDrosophila and vertebrates Wnt signaling components exist under sub-optimal levels and the two parallel branches need to operate together to counteract efficient β-catenin phosphorylation/degradation, whereas over-activation of either branch is sufficient to stabilize β-catenin. …

β-catenin nuclear function

β-catenin nuclear/cytoplasmic shuttling and retention

β-catenin stabilization results in its higher nuclear levels, but how β-catenin is shuttled to and retained in the nucleus is not well understood (Henderson and Fagotto, 2002Stadeli et al., 2006). Earlier studies suggested that β-catenin enters the nucleus in an NLS (nuclear localization signal)- and importin-independent fashion by interacting directly with nuclear pore proteins (Henderson and Fagotto, 2002). β-catenin also exits the nucleus via export involving APC (Henderson and Fagotto, 2002), Axin (Cong and Varmus, 2004), and RanBP3 (Ran binding protein 3), which binds to β-catenin in a Ran-GTP dependent manner (Hendriksen et al., 2005). Live cell imaging suggests that while Axin and APC can enrich β-catenin in the cytoplasm and TCF and β-catenin co-activators (BCL9 and Pygopus, see below) increase nuclear β-catenin, they do not accelerate the export or import rate of β-catenin, thereby arguing for their roles in β-catenin retention rather than shuttling (Krieghoff et al., 2006). Thus β-catenin nuclear and cytoplasmic partitioning is likely the dynamic sum of both shuttling and retention between the two compartments via multiple mechanisms. ….

TCF/LEF

The TCF/LEF family of DNA-bound transcription factors is the main partner for β-catenin in gene regulation (Arce et al., 2006Hoppler and Kavanagh, 2007). TCF represses gene expression by interacting with the repressor Groucho (TLE1 in human), which promotes histone deacetylation and chromatin compaction; Wnt-induced β-catenin stabilization and nuclear accumulation leads TCF to complex with β-catenin, which appears to displace Groucho (Daniels and Weis, 2005) and recruits other co-activators for gene activation (Figure 1). While a single TCF gene is found in Drosophila and worm, four TCF genes, TCF1, LEF1, TCF3 and TCF4, exist in mammals. Alternative splicing and promoter usage produce a large number of TCF variants with distinct properties (Arce et al., 2006Hoppler and Kavanagh, 2007). TCF proteins are HMG (high mobility group) DNA-binding factors, and upon binding to a DNA consensus sequence referred to as the Wnt responsive element (WRE), CCTTTGWW (W represents either T or A), they cause significant DNA bending that may alter local chromatin structure. A genome-wide analysis in colon cancer cells suggests that TCF4/β-catenin target genes are frequently “decorated” with multiple WREs, most of which are located at large distances from transcription start sites (Hatzis et al., 2008). Some TCF1 and TCF4 splicing variants harbor a second DNA-binding domain called C-clamp, which recognizes an additional GC element downstream of the typical WRE, allowing regulation of different sets of target genes (Atcha et al., 2007). These similarities and differences, combined with overlapping and unique expression patterns, underlie in part distinct and sometimes redundant functions of vertebrate/mammalian TCF genes. ….

Three major strategies exist to regulate TCF/β-catenin transcription. (i) Alternative promoter usage in TCF-1 and LEF-1 genes produces dnTCF-1/dnLEF-1, which lack the amino-terminal β-catenin-binding domain and thus act as the endogenous dominant negative TCF/LEF (Arce et al., 2006Hoppler and Kavanagh, 2007). Indeed the TCF-1 locus acts as an intestinal tumor suppressor primarily due to the production of dnTCF-1, which antagonizes TCF-4 in stem cell renewal. (ii) Nuclear antagonists Chibby and ICAT bind to β-catenin and disrupt β-catenin/TCF and β-catenin/co-activator interactions and promote β-catenin nuclear export (Li et al., 2008Tago et al., 2000). Besides these devoted inhibitors, many DNA-binding transcription factors interact with β-catenin or TCF and antagonize TCF/β-catenin-dependent transcription (Supplemental Table 1). For example, KLF4 inhibition of β-catenin transcriptional activation is important for intestinal homeostasis and tumor suppression (Zhang et al., 2006). (iii) Post-translational modifications of TCF/LEF exist including phosphorylation, acetylation, sumoylation, and ubiquitination/degradation (Arce et al., 2006Hoppler and Kavanagh, 2007). For instance, TCF-3 phosphorylation by CK1ε and LEF-1 phosphorylation by CK2 enhances their binding to β-catenin and diminishes LEF-1 binding to Groucho/TLE, whereas LEF-1 and TCF-4 phosphorylation by NLK (Nemo-like kinase) leads to less LEF/TCF/β-catenin complex binding to DNA and to LEF-1/TCF-4 degradation. LEF-1 and TCF-4 sumoylation (by the SUMO ligase PIASy) represses LEF-1 activity by targeting it to nuclear bodies but enhances TCF-4/β-catenin transcription, while CBP-mediated acetylation of TCF results in decreased TCF/β-catenin-binding in Drosophila and increased TCF nuclear retention in nematodes, both leading to transcriptional repression. These diverse modifications are often specific to individual TCF/LEF proteins, conferring differential regulation.

β-catenin associated co-activators

A plethora of β-catenin associated co-activators have been identified. These multi-protein complexes include BCL9 and Pygopus (Pygo), Mediator (for transcription initiation), p300/CBP and TRRAP/TIP60 histone acetyltransferases (HATs), MLL1/2 histone methyltransferases (HMTs), the SWI/SNF family of ATPases for chromatin remodeling, and the PAF1 complex for transcription elongation and histone modifications (Mosimann et al., 2009Willert and Jones, 2006) (Figure 6). While the central Arm-repeats of β-catenin associate with TCF, and the amino-terminal Arm-repeat binds to BCL9, most of the co-activator complexes interact with the β-catenin carboxyl terminal portion (Figure 6), creating a dazzling interplay between β-catenin and the transcriptional apparatus and the chromatin. Indeed TCF/β-catenin binding to WREs leads to histone acetylation in a CBP-dependent manner over a significant genomic distance (30 kb), suggesting that local TCF/β-catenin recruitment results in widespread chromatin modifications (Parker et al., 2008). …

Nuclear TCF.β-catenin co-activator complexes  nihms196288f6

Nuclear TCF.β-catenin co-activator complexes nihms196288f6

Nuclear TCF/β-catenin co-activator complexes

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2861485/bin/nihms196288f6.gif

Figure 6  Nuclear TCF/β-catenin co-activator complexes

…..

Unlike most co-activators that have general roles in transcription, BCL9 and Pygo in Drosophila are specifically required for β-catenin-dependent transcription and their biochemical functions proposed provide a glimpse of the complexity of TCF/β-catenin-coactivator interactions (Mosimann et al., 2009). (i) BCL9 and Pygo function as a “chain of activators” (Hoffmans et al., 2005). β-catenin binding to BCL9 recruits Pygo, which also interacts with Mediator (Carrera et al., 2008) (Figure 6); (ii) Pygo is constitutively nuclear and may have a role in recruiting/retaining BCL9/β-catenin in the nucleus upon Wg/Wnt signaling (Brembeck et al., 2004Townsley et al., 2004); (iii) Pygo also co-occupies chromatin loci with and via TCF in the absence of Wg signaling (despite a lack of direct TCF-Pygo interaction), and may help capture BCL9/β-catenin for TCF at the onset of Wg signaling (de la Roche and Bienz, 2007); (iv) Pygo has a PHD (plant homology domain) that binds preferentially to dimethylated H3K4 upon interaction with BCL9 (Fiedler et al., 2008). This “histone code” recognition leads to the speculation that Pygo/BCL9 act during the transition from gene silencing to Wnt-induced transcription by participating in histone methylation changes. Alternatively Pygo/BCL9-binding to dimethylated H3K4 may provide a separate β-catenin anchor on chromatin, thereby freeing TCF for interaction with Groucho to pause/terminate transcription (Mosimann et al., 2009); (v) Pygo function is not required when Groucho activity is absent, suggesting that Pygo acts as an anti-repressor (Mieszczanek et al., 2008). Therefore either a single biochemical mechanism of Pygo underlies these diverse observations, or multiple functional properties of Pygo participate in β-catenin signaling. …

Nuclear functions of “cytoplasmic” Wnt signaling components

APC also acts directly on chromatin/WREs to antagonize β-catenin-mediated gene activation via promoting the exchange of co-activators with co-repressors in a stepwise and oscillating manner, as such exchange does not occur in APC mutant cancer cells (Sierra et al., 2006). How APC is recruited to chromatin is a mystery but is unlikely due to β-catenin/TCF, because APC and TCF bind to β-catenin in a mutually exclusive manner. GSK3 and β-Trcp also appear to be associated with the WRE in a cyclic fashion that synchronizes with APC but is opposite to that of β-catenin/co-activators, suggesting that they may have negative roles in TCF/β-catenin-mediated transcription (Sierra et al., 2006). Some studies have also suggested that Dvl is observed in the nucleus (Itoh et al., 2005Torres and Nelson, 2000) and that nuclear Dvl is a component of the TCF/β-catenin complex and facilitates TCF/β-catenin interaction in conjunction with the c-Jun transcription factor (Gan et al., 2008). …

β-catenin-mediated repression and other transcriptional events

Wnt signaling, via the TCF/β-catenin complex, also represses transcription. Note that this is distinct from TCF-mediated repression in the absence of β-catenin. One mechanism is competitive repression, through which TCF/β-catenin displaces or inhibits other DNA-binding transcription activators (Kahler and Westendorf, 2003Piepenburg et al., 2000). Another mechanism is direct repression via TCF/β-catenin binding to the canonical WREs by recruiting co-repressors (Jamora et al., 2003Theisen et al., 2007). A third mechanism is revealed by a novel TCF binding element, AGAWAW, which specifically mediates TCF/β-catenin repression in Drosophila (Blauwkamp et al., 2008). There is evidence that β-catenin is capable of recruiting co-repressors including Groucho/TLE and histone deacetylases (Olson et al., 2006), but the mechanism by which β-catenin recruits co-activators versus co-repressors is unknown. The involvement of co-factors (Theisen et al., 2007) or distinct TCF/β-catenin configurations offers potential explanations. A less understood aspect of β-catenin signaling is that many DNA-binding transcription factors, in addition to TCF/LEF, interact with β-catenin to either activate or repress transcription (Supplemental Table 1b). These β-catenin partners in principle expand significantly the gene expression programs that are regulated by Wnt/β-catenin signaling, but further substantiation of their roles in mediating Wnt signaling is required.

Wnt/β-catenin target genes and Wnt pathway self-regulation

As Wnt/β-catenin signaling regulates proliferation, fate specification and differentiation in numerous developmental stages and adult tissue homeostasis, Wnt target genes are diverse (Vlad et al., 2008) and cell- and context-specific (Logan and Nusse, 2004). An emerging feature is that Wnt signaling components including Fz, LRP6, Axin2, TCF/LEF, Naked (a Dvl antagonist), Dkk1, and Rspo, are often regulated positively or negatively by TCF/β-catenin (Chamorro et al., 2005Kazanskaya et al., 2004Khan et al., 2007Logan and Nusse, 2004). Wnt induction of Axin2, Dkk1 and Naked and suppression of Fz and LRP6 constitute negative feedback loops that dampen Wnt signaling, and the suppression of Fz and LRP6 also enhances Wg/Wnt gradient formation over longer distances (Logan and Nusse, 2004). On the contrary, Wnt induction of Rspo and TCF/LEF genes constitute positive feed-forward circuits that reinforce Wnt signaling, a feature that has been exploited during colon carcinogenesis (Arce et al., 2006Hoppler and Kavanagh, 2007). These various Wnt pathway self-regulatory loops are mostly utilized in a cell-specific manner, affording additional complexity in the control of amplitude and duration of Wnt responses. …

Wnt/β-catenin signaling in diseases and potential therapeutics

Give the critical roles of Wnt/β-catenin signaling in development and homeostasis it is no surprise that mutations of the Wnt pathway components are associated with many hereditary disorders, cancer and other diseases (Table 1). …

LRP5 activity correlates with bone mass likely via regulation of osteoblast (bone forming cell) proliferation, whereas SOST and DKK1, which are specifically expressed in osteocytes, negatively regulates bone mass by antagonizing LRP5. …

Association of deregulated Wnt/β-catenin signaling with cancer has been well documented, particularly with colorectal cancer (Polakis, 2007) (Table 1). Constitutively activated β-catenin signaling, due to APC deficiency or β-catenin mutations that prevent its degradation, leads to excessive stem cell renewal/proliferation that predisposes cells to tumorigenesis. Indeed APC deletion or β-catenin activation in stem cells is essential for intestinal neoplasia (Fuchs, 2009). Blocking β-catenin signaling for cancer treatment has thus generated significant interests. Indeed the beneficial effect of non-steroidal anti-inflammatory drugs (NSAIDS) in colorectal cancer prevention and therapy has been attributed partially to the perturbation of TCF/β-catenin signaling through the ability of NSAIDS to inhibit Prostaglandin E2 production, which enhances TCF/β-catenin-dependent transcription (Castellone et al., 2005Shao et al., 2005). Small molecules that disrupt TCF/β-catenin (Lepourcelet et al., 2004) or β-catenin/co-activator (CBP) interaction (Emami et al., 2004) and thereby block TCF/β-catenin signaling have been described. The task of disrupting TCF/β-catenin interaction specifically, however, is a difficult one since β-catenin interacts with TCF and other binding partners such as APC, Axin and E-cadherin via the same or overlapping interface (Barker and Clevers, 2006). Another potential therapeutic target is the kinase CDK8, which, as a Mediator subunit, is often amplified in and is required for β-catenin-dependent transcription and proliferation of colon cancer cells (Firestein et al., 2008Morris et al., 2008). A new class of small molecules that inhibits β-catenin signaling has recently be identified (Chen et al., 2009), which via an unknown mechanism stabilizes the Axin protein, thereby promoting β-catenin degradation even in cancer cells that lack APC function. As discussed above, since Axin protein levels are the rate-limiting step for β-catenin degradation, manipulation of Axin stabilization represents a promising therapeutic strategy.

Many cancers that do not harbor mutations in the Wnt pathway nonetheless rely on autocrine Wnt signaling for proliferation or survival (Barker and Clevers, 2006). In fact APC mutant colon cancer cells maintain their dependence on Wnt and epigenetically silence the expression of secreted Wnt antagonists (He et al., 2005;Suzuki et al., 2004). Therefore targeting Wnt signaling upstream of TCF/β-catenin is also an important therapeutic option. Reagents against Wnt proteins such as antibodies (He et al., 2005) or a secreted Fz extracellular domain (DeAlmeida et al., 2007), which act outside the cancer cells to block Wnt-receptor interaction, show promise in certain experimental settings, as do small molecule and peptide inhibitors that antagonize Fz-Dvl interaction (Shan et al., 2005Zhang et al., 2009). Small molecules have also been identified that inhibit Porcupine and thus prevent Wnt lipidation and secretion (Chen et al., 2009). We will likely see additional molecular and chemical agents that can interfere with different steps of Wnt/β-catenin signaling, whose complexity presents many potential therapeutic targets. The challenge will be ensuring that these agents target cancer cells without damaging normal tissue homeostasis.

Since the discovery of the Wnt-1 gene 27 years ago (Nusse and Varmus, 1982), Wnt/β-catenin signaling has cemented its role as a key regulatory system in biology. Studies of different animal models and human diseases have established a complex Wnt signaling network far beyond a linear pathway, with many components having multiple distinct roles and acting in different cellular compartments, and many modulators feeding into and cross-regulating within this network. The patterns of dynamic and kinetic protein phosphorylation/modification and complex assembly/disassembly are beginning to emerge. Challenges and excitement both lie ahead. (i) Novel regulators will likely continue to be identified using classical genetic, molecular, modern genomic and proteomic approaches. (ii) New analytical and imaging technologies should enable us to dissect and visualize the dynamic signaling events in vivo and to shed light on the cell biological aspects of Wnt signaling, including where, when and how signaling occurs inside the cell. (iii) Although we have obtained significant structural information on individual domains and protein interaction interfaces, atomic structures of protein complexes such as the Axin complex and ligand-receptor complexes remain daunting challenges. (iv) Additional specific small molecular inhibitors or activators with defined targets and mechanisms would provide not only leads for therapeutics but also research tools to manipulate the Wnt pathway in precise temporal and spatial manners. (v) Integration of vast amounts of information into quantitative models will allow us to predict the behavior and to study the robustness and evolvability of Wnt signaling in various biological contexts. (vi) The Wnt responsive transcriptome remains a gold mine for digging into Wnt-regulated biology. Unfolding examples include Wnt regulation of intestinal and hair follicle development/homeostasis, which has provided significant insights into stem cell biology and cancer pathogenesis (Clevers, 2006Fuchs, 2009). As β-catenin is a co-activator for other transcription factors in addition to TCF/LEF, comparative analyses of Wnt responsive transcription programs that depend on TCF/LEF versus others will likely uncover further complexity of Wnt-regulated gene expression. (vii) β-catenin and APC are also key components in the E-cadherin cell adhesion complex and the microtubule network, but how Wnt/β-catenin signaling interacts with these cellular structures remains poorly understood. In addition, the involvement of the primary cilium, a centrosome- and microtubule-based protrusive organelle in vertebrate cells, in Wnt/β-catenin versus non-canonical Wnt signaling remains an intriguing but debated topic (Gerdes et al., 2009).

Since the discovery of the Wnt-1 gene 27 years ago (Nusse and Varmus, 1982), Wnt/β-catenin signaling has cemented its role as a key regulatory system in biology. Studies of different animal models and human diseases have established a complex Wnt signaling network far beyond a linear pathway, with many components having multiple distinct roles and acting in different cellular compartments, and many modulators feeding into and cross-regulating within this network. The patterns of dynamic and kinetic protein phosphorylation/modification and complex assembly/disassembly are beginning to emerge. Challenges and excitement both lie ahead. (i) Novel regulators will likely continue to be identified using classical genetic, molecular, modern genomic and proteomic approaches. (ii) New analytical and imaging technologies should enable us to dissect and visualize the dynamic signaling events in vivo and to shed light on the cell biological aspects of Wnt signaling, including where, when and how signaling occurs inside the cell. (iii) Although we have obtained significant structural information on individual domains and protein interaction interfaces, atomic structures of protein complexes such as the Axin complex and ligand-receptor complexes remain daunting challenges. (iv) Additional specific small molecular inhibitors or activators with defined targets and mechanisms would provide not only leads for therapeutics but also research tools to manipulate the Wnt pathway in precise temporal and spatial manners. (v) Integration of vast amounts of information into quantitative models will allow us to predict the behavior and to study the robustness and evolvability of Wnt signaling in various biological contexts. (vi) The Wnt responsive transcriptome remains a gold mine for digging into Wnt-regulated biology. Unfolding examples include Wnt regulation of intestinal and hair follicle development/homeostasis, which has provided significant insights into stem cell biology and cancer pathogenesis (Clevers, 2006Fuchs, 2009). As β-catenin is a co-activator for other transcription factors in addition to TCF/LEF, comparative analyses of Wnt responsive transcription programs that depend on TCF/LEF versus others will likely uncover further complexity of Wnt-regulated gene expression. (vii) β-catenin and APC are also key components in the E-cadherin cell adhesion complex and the microtubule network, but how Wnt/β-catenin signaling interacts with these cellular structures remains poorly understood. In addition, the involvement of the primary cilium, a centrosome- and microtubule-based protrusive organelle in vertebrate cells, in Wnt/β-catenin versus non-canonical Wnt signaling remains an intriguing but debated topic (Gerdes et al., 2009).

Finally the study of Wnt signaling in human diseases, and in stem cell biology and regeneration holds promises for translational medicine. In addition to cancer and osteoporosis, both of which will likely see Wnt signaling-based therapeutics moving into clinical trials or even clinics in the near future, potential links between neurological diseases (De Ferrari and Moon, 2006) and a Schizophrenia susceptibility gene product (Mao et al., 2009) to Wnt/β-catenin signaling offer new hopes for the treatment of neurological and psychiatric disorders. Manipulation of Wnt signaling for stem cell regulation also offers exciting opportunities for regenerative medicine (Clevers, 2006Fuchs, 2009Goessling et al., 2009Willert et al., 2003). A better understanding of Wnt/β-catenin signaling will have broad impact on biology and medicine.

7.10.6 Wnt.β-Catenin Signaling. Turning the Switch

Cadigan KM1.
Dev Cell. 2008 Mar; 14(3):322-3
http://dx.doi.org/10.1016/j.devcel.2008.02.006

The regulation of many targets of the Wnt/β-catenin signaling pathway is thought to occur through a transcriptional switch that is achieved by β-catenin binding to TCF transcription factors. Recent work indicates that β-catenin’s intrinsic affinity for TCF is not sufficient for the switch to occur.

The Wnt/β-catenin signaling pathway plays many crucial roles in specifying cell fates during animal development and in regenerating adult tissues. In addition, this pathway is linked to several pathological states, most notably colorectal cancer. Many of the transcriptional responses to Wnt/β-catenin signaling are mediated by the TCF/LEF-1 (TCF) family of transcription factors. Several TCFs are known to repress Wnt targets in the absence of signaling, but upon pathway activation, β-catenin enters the nucleus and binds to TCF on the target chromatin, creating a transcriptional activation complex. Is β-catenin’s intrinsic affinity for TCF sufficient to switch TCF from the repression to the activation state? Two recent papers shed some light on this question. One reports that two previously characterized co-repressor subunits bind to β-catenin and are required to stabilize the β-catenin-TCF interaction. The other suggests that this interaction may be regulated by ubiquitination of APC, a well-known negative regulator of the Wnt/β-catenin pathway.

The first report from Li and Wang (2008) concerns Transducin β-like protein 1 (TBL1) and TBL1-related protein (TBLR1). These proteins are components of the SMRT-nuclear receptor corepressor (N-CoR) complex, where they have been shown to recruit E3 ubiquitin ligases to facilitate the replacement of corepressors with coactivators (Perissi et al., 2004). Similarly, the Drosophila homolog of TBL1, known as Ebi, facilitates proteosomal degradation of the fly N-CoR homolog SMRTER ( Tsuda et al., 2002). In addition, TBL1 binds to the E3 ubiquitin ligase components Siah-1 and Skp1 to promote β-catenin degradation ( Matsuzawa and Reed, 2001). Despite the extensive connections between TBL1, TBLR1, and proteosomal degradation, Li and Wang (2008) found no evidence for these proteins influencing β-catenin turnover in their system. In addition, the proteosome does not appear to contribute to the function of TBL1 and TBLR1 in promoting Wnt/β-catenin signaling.

Using siRNA, Li and Wang found that TBL1 and TBLR1 are required for activation of several targets by Wnt signaling in cell culture. Both proteins interact with β-catenin in coimmunoprecipitation assays. When TBL1 or TBLR1 are depleted, the pathway still promotes nuclear accumulation of β-catenin, but its recruitment to Wnt response element (WRE) chromatin is dramatically reduced. Conversely, TBL1 and TBLR1 are recruited to several WREs in a Wnt- and β-catenin-dependent manner. Thus, binding of β-catenin, TBL1, and TBLR1 to WREs is mutally dependent. Interestingly, TBL1 (but not TBLR1) can be immunoprecipitated by TCF4, and TBL1 is present at some WREs even in the absence of Wnt stimulation. This suggests a model where interactions between TBL1, TCFs, and β-catenin reinforce the complex on WREs, which is required for subsequent recruitment of transcriptional coactivators necessary to activate target gene expression (see Figure 1).

 role-of-tbl1-tblr1-and-trabid-in-tcf-ceb2-catenin-gene-regulation


role-of-tbl1-tblr1-and-trabid-in-tcf-ceb2-catenin-gene-regulation

Role of TBL1-TBLR1 and Trabid in TCF-β-Catenin Gene Regulation

http://ars.els-cdn.com/content/image/1-s2.0-S1534580708000762-gr1.jpg

Figure 1. Speculative Model on the Role of TBL1-TBLR1 and Trabid in TCF-β-Catenin Gene Regulation

In the absence of signaling (top panel), a TCF-corepressor complex silences target gene expression. When Wnt signaling causes nuclear accumulation of β-catenin (bottom panel), TBL1 and TBLR1 help recruit β-catenin to TCF at target loci, which nucleates a complex of transcriptional coactivators. APC can inhibit the TCF-β-catenin complex, and Trabid’s positive role in the pathway can be explained by its ability to regulate the ubiquitination state of APC.

This report extends the importance of TBL1 and TBLR1 in Wnt/β-catenin gene regulation in two important ways. First, the key findings were reproduced in Drosophila cell culture. Second, the authors demonstrate that depletion of TBL1 or TBLR1 greatly reduced activation of Wnt targets in a well-characterized colorectal cell line lacking functional APC. This decrease in target gene activation had a striking effect on the ability of these cells to grow on soft agar. In addition, the invasive nature of head and squamous cell carcinoma cells transfected with β-catenin was greatly curtailed by TBL1 or TBLR1 knockdown, as was the growth of these cells into tumors in nude mice. These results clearly demonstrate both the evolutionary conservation of these factors in the pathway and suggest that strategies to interfere with their function might have great therapeutic value.

While most reports (and reviews) focus on the TCF transcriptional switch from the “OFF” to the “ON” state, it is also interesting to consider how the switch works in reverse. For example, a colorectal cell line lacking functional APC can be stably transfected with an inducible full-length APC gene. Without induction, β-catenin is bound to WREs and Wnt target expression is high. Upon induction of APC, Jones and coworkers found that β-catenin and coactivators are rapidly replaced by corepressors at the WRE (Sierra et al., 2006). Interestingly, APC transiently occupies the WRE during this switch. A recent report from Bienz and coworkers (Tran et al., 2008) suggests that ubiquitination of APC may influence its ability to regulate the TCF-β-catenin complex.

This group identified an APC-interacting protein they call Trabid, which contains three tandem Npl4 zinc (NZF) fingers and an ovarian tumor (OTU) domain. They demonstrated that the OTU domain contains a deubiquitylating (DUB) activity that shows marked preference for K63-linked ubiquitin chains. When Trabid is depleted from cells by siRNA, activation of several Wnt targets is reduced, and rescue experiments indicate that both the NZF and OTU domains are required for Trabid’s positive role in Wnt signaling. Epitasis analysis indicates that Trabid is required downstream of β-catenin stabilization but is dispensible for TCF fusion proteins containing transactivation domains. This suggests that Trabid may influence the formation or dynamics of TCF-β-catenin complexes.

7.10.7 Wnt–β-catenin signaling

Tetsu Akiyama
Cyokine & GF Rev Dec 1, 2000; 11(4):273–282
http://dx.doi.org/10.1016/S1359-6101(00)00011-3

The Wnt/Wingless signaling transduction pathway plays an important role in both embryonic development and tumorigenesis. β-Catenin, a key component of the Wnt signaling pathway, interacts with the TCF/LEF family of transcription factors and activates transcription of Wnt target genes. Recent studies have revealed that a number of proteins such as, the tumor suppressor APC and Axin are involved in the regulation of the Wnt signaling pathway. Furthermore, mutations in APC or β-catenin have been found to be responsible for the genesis of human cancers.

7.10.8 Extracellular modulators of Wnt signaling

Boudin E1Fijalkowski IPiters EVan Hul W.
Semin Arthritis Rheum. 2013 Oct; 43(2):220-40
http://dx.doi.org:/10.1016/j.semarthrit.2013.01.004

Objectives: The Wnt signaling pathway is a key pathway in various processes, including bone metabolism. In this review, current knowledge of all extracellular modulators of the canonical Wnt signaling in bone metabolism is summarized and discussed. Methods: The PubMed database was searched using the following keywords: canonical Wnt signaling, β-catenin bone metabolism, BMD, osteoblast, osteoporosis, Wnt, LRPs, Frizzleds, sFRPs, sclerostin or SOST, dickkopfs, Wif1, R-spondins, glypicans, SOST-dc1 and kremen, all separately as well as in different combinations.
Results: Canonical Wnt signaling is considered to be one of the major pathways regulating bone formation. Consequently, a large number of studies were performed to elucidate the role of numerous proteins in canonical Wnt signaling and bone metabolism. These studies led to the identification of novel modulators of the pathway like the R-spondin and glypican protein families. Furthermore novel insights are gained in the regulatory role of the different Wnt proteins. Finally, due to its function in bone formation, the pathway is an interesting target for the development of therapeutics for osteoporosis and other bone diseases. In this review, we discuss the promising results of the Wnt modulators sclerostin, Dkk1 and sFRP1 as targets for osteoporosis treatment.
Conclusion: The increasing number of studies into the exact function of all proteins in the canonical Wnt pathway in general and in bone metabolism already led to novel insights in the regulation of the canonical Wnt pathway. In this review we covered the current knowledge of all extracellular modulators of canonical Wnt signaling.

Fig 1. Activators and inhibitors of the Wnt/b-catenin signaling pathway.
(a) Lipid-modified Wnt protein (green; palmitoleoyl group is shown in red) binds to Frizzled CRD, LRP6 b-propellers 1–2 and/or 3–4, and triggers downstream signaling. CRD of Wnt receptor Frizzled8
is shown in light blue, four b propellers of  co-receptor LRP6 are shown in dark blue. Hinge region between b-propellers 1–2 and 3–4 is shown as a blue dot. Dimeric signaling activator Norrin (monomers
shown in magenta and grey) binds specifically to Frizzled4 (grey) and LRP6 b-propellers 1–2. Dotted lines represent interactions between molecules where crystal structures of the complexes are absent.
(b) Extracellular inhibitors bind to Wnt co-receptor LRP6 or Wnt and prevent them from triggering signalling. Both Sclerostin and Dickkopf  (Dkk) contain an Asn-X-Ile motif (peptide shown as
connected yellow spheres) recognized by LRP6 b-propeller 1.  The C-terminal domain of Dkk1 (red) binds to LRP6 b-propeller 3.  WIF1 (pink; WIF1-bound DPPC, light blue) and secreted Frizzled
related protein 3 (sFRP3 CRD, teal) prevent signaling by binding to Wnts. WIF1 binds to HS chains of HSPGs (grey). Sclerostin (as well as other activators and inhibitors) bind to HS-mimic, heparin.
Signaling inhibitor 5T4/Wnt-activated inhibitory factor 1 (WAIF1, purple) acts via unknown binding partners.

Fig 2. Atomic details of Wnt recognition and signaling inhibition.
(a) Zoom-in view of the palmitoleoyl binding site in the CRD of Frizzled8. Molecules are colored as in Figure 1. The Ser187-linked palmitoleoyl group is shown as connected red spheres. Frizzled8 CRD
residues forming the hydrophobic groove are shown as sticks (carbon, blue; oxygen, red) and numbered. Boundaries of the lipid-binding groove are marked with grey lines.
(b) WIF domain of WIF-1 forms a hydrophobic pocket which accommodates DPPC (carbon, grey; oxygen, red; phosphorus, orange; nitrogen, blue). The head group of DPPC is exposed to the solvent
and located proximal to the putative Wnt3a binding site.
(c) The first b propeller of LRP6 recognizes an evolutionarily conserved tripeptide motif Asn-X-Ile (X, variable amino acid) present in two inhibitors of  Wnt signaling, Dickkopf1 and Sclerostin. A peptide
derived from human Sclerostin (residues Leu115–Arg121) is shown as sticks (carbon, yellow; oxygen, red; nitrogen, blue).

Regulation of Wnt signaling by R-spondin and its receptors.

(a) Transmembrane ubiquitin (Ub, shown in grey) E3 ligases ZNRF3 (brown) and RNF43 (red) ubiquitinylate Frizzled thus promoting its endocytosis and inhibition of
Wnt signalling. Cytoplasmic regions of both ligases contain RING domains required for ubiquitinylation. The extracellular domains of ZNRF3 form weak dimers in
solution (protomers are shown in brown and grey, respectively; [36]).
(b) R-spondin 1 (RSPO1, green) forms a ternary complex with RNF43 and LGR5 (blue) [35]. Endocytosis of RNF43 and ZNRF3 in complex with RSPOs and LGRs
4–6 prevents ubiquitinylation of Frizzled and promotes Wnt signaling. Dotted lines represent interactions between molecules where crystal structures of complexes
are not determined.

Conclusions and future perspectives

Tremendous progress has been made in structural studies of  Wnt signaling receptors and modulators during the past five years. A series of structures of the Wnt co-receptor LRP6, agonists and
antagonists, and, remarkably, the first crystal structure of a Wnt family member, Wnt8, in complex with the Frizzled8 CRD, provide invaluable insights into the basic mechanisms of Wnt
signaling activation and regulation. In 2012, a novel mechanism of Wnt signaling regulation was discovered which centers on the interactions of the ZNRF3/RNF43 E3 ubiquitin ligases,
the R-spondins and LGR4/5/6.

7.10.9 FOXO3a modulates WNT.β-catenin signaling and suppresses epithelial-to-mesenchymal transition in prostate cancer cells

Liu H1Yin J1Wang H2Jiang G3Deng M1Zhang G2Bu X2Cai S4Du J5He Z6.
Cell Signal. 2015 Mar; 27(3):510-8
http://dx.doi.org:/10.1016/j.cellsig.2015.01.001

Highlights

  • FOXO3a inhibits β-catenin expression through transactivating miR-34b/c.
  • FOXO3a direct binds to β-catenin.
  • FOXO3a inhibits β-catenin/TCF transcriptional activity.
  • FOXO3a inhibit EMT in prostate cancer cells.
  • β-catenin as a regulator of FOXO3a-mediated suppression of EMT.

Emerging evidence has revealed a negative correlation between Forkhead box-O (FOXO) expression and prostate cancer grade and spread, indicating its role as a suppressor of prostate cancer metastasis. However, there is still incomplete understanding about the role of FOXO transcription factors in prostate cancer progression. In this investigation, we demonstrate that FOXO3a significantly inhibits the expression β-catenin in prostate cancer cells. The mechanism of inhibiting β-catenin expression involves the FOXO3a-mediated transactivated microRNA-34b/c, which consequently suppressed β-catenin mRNA expression by targeting the untranslated regions (UTRs) of β-catenin. Additionally, FOXO3a can directly bind to β-catenin, and competes with TCF for interaction with β-catenin, thereby inhibiting β-catenin/TCF transcriptional activity and reducing the expression of β-catenin target genes. Furthermore, prostate cancer cells expressing FOXO3a shRNAs display mesenchymal characteristics, including enhanced cell migration and differential regulation of the EMT markers, whereas knockdown of β-catenin results in reversal of shFOXO3a-mediated EMT phenotypic changes. Collectively, these observations demonstrated that FOXO3a inhibits malignant phenotypes that are dependent on β-catenin-dependent modulation of EMT-related genes, and provided fresh insight into the mechanisms by which a FOXO3a-miR-34b/c axis restrains canonical β-catenin signaling cascades in prostate cancer cell.

Fig.1. FOXO3a activation correlates with downregulation of β-catenin expression in prostate cancer cells. (A) PC3 and DU145 cells were treated with LY294002 for 48h, and Western blot was performed to assess p-FOXO3a, total FOXO3a, and β-catenin expression compared with that of the control cells.(B,C) The PC3 and DU145 cells were transfected with FOXO3a overexpressing and si-FOXO3a knockdown vectors; the mRNA expression (B) and protein expression (C) of β-catenin were assessed by real-time RT-PCR and Western blot, respectively. (D) PC3 cells were transfected with FOXO3a overexpressing vector, immunofluorescence images from PC3 cells stained for FOXO3aand β-catenin. DNA is stained with 4,6-diamidino2-phenylindole (DAPI, blue).Data were presentedasmeans± SDof three independent experiments. *Significant difference from control values with P b 0.05.

Fig.2.FOXO3a inhibits β-catenin expression by modulating miR-34 expression. (A) The miR-34b/c promoter contains consensus FOXO binding sites. miR-34b and miR-34c are encoded by one primary transcript (BC021736). Putative FOXO binding sites were identified at positions−1518,−1512,−1223,and−185 relative to the transcription start site.(B)FOXO3abinds to the BC021736 promoter in vivo. PC3 cells were infected with pCMV-FOXO3a. DNA-bound proteins were crosslinked to chromatin, and FOXO3a was immunoprecipitated with an antibody directed against FOXO3a. Rabbit IgG immune serum was used as IP control. Immunoprecipitated DNA-fragments were amplified by PCR with primers specific for theputative FOXO3 a consensus binding sites(−1518/12,−1223,−185) or a control region.Data are plotted aspercentage ofinput DNA ± SD. (C, D)The PC3 cells were transfectedwith FOXO3a overexpressing(C)andsi-FOXO3aknockdownvectors(D),themRNAexpressionofmiR-34wereassessedbyreal-timeRT-PCR.(E)RealtimeRT-PCRanalysesofβ-cateninmRNAexpression levelswereperformedinPC3 cells 48h after transfectionwith control,miR-34b, ormiR-34cmimics. (F)ThePC3 cells were transfected with pCMV-FOXO3a, anti-miR-34c, pCMVFOXO3a and anti-miR-34c, respectively; or shFOXO3a, miR-34c mimics, shFOXO3a and miR-34c mimics, respectively, the protein expression of FOXO3a and β-catenin were analyzed by Western blot. Data were presented as means± SD of three independent experiments. *Significant difference from control valueswith P < 0.05.

Fig.3. FOXO3a binds to β-catenin, reduces binding of β-Catenin to TCF, and inhibits β-Catenin/TCF-dependent transcription. (A) Total protein extracts of PC3 and DU145 cells were subjected to IP using FOXO3a antibody or control IgG, followed by IB with β-cateninantibody (upper panels). Reciprocal IP was done using β-catenin antibody or control IgG, followed by IB with the FOXO3a antibody (lower panels). (B) Lysates of PC3 cells that stably express FOXO3a or a control vector were subjected to IPusing FOXO3a antibodies, followed by IB with β-catenin antibody.(C) Lysates of PC3 cells that stably express FOXO3a or a control vector were subjected to IP using TCF4 antibodies, followed by IB with β-catenin antibody. Reciprocal IP was done using β-catenin antibody or control IgG, followed by IB with the TCF4 antibody. (D) TOP flash and FOP flash firefly luciferase expression vectors were co-transfected with control, pCMV-FOXO3a, and pCMV-β-catenin plasmid in PC3 cells, and TOP flash activity was measured. (E) PC3 cells were transfected with pCMV-FOXO3a plasmid, or FOXO3 as hRNA, the differential expression of potential β-catenin target genes are shown in the heat map.Data were presented as means±SD of three independent experiments.**Significant difference from control values with P<b 0.01

http://ars.els-cdn.com/content/image/1-s2.0-S0898656815000030-fx1.sml

Aurelian Udristioiu

Aurelian

Aurelian Udristioiu

Lab Director at Emergency County Hospital Targu Jiu

Some studies showed that patients with cancer make
antibodies against p53 proteins, but the frequency and
magnitude of this response is still under debate (Vojtesek
et al., 1995). However, a large number of patients with
cancer did produce p53-reactive T cells (Van der Burg et
al., 2001).
The results from these studies served as a good
reason to attempt the vaccination of patients using p53-
derived peptides, and a several clinical trials are currently
in progress. The most advanced work used a long
synthetic peptide mixture derived from p53 (p53-SLP; ISA
Pharmaceuticals, Bilthoven, the Netherlands) (Speetjens
et al., 2009; Shangary et al., 2008; Van der Burg et al.,
* The vaccine is delivered in the adjuvant setting
and induces T helper type cells.

UPDATE 10/10/2021

WNT/β-catenin pathway activation correlates with immune exclusion across human cancers

Source: Luke JJ, Bao R, Sweis RF, Spranger S, Gajewski TF. WNT/β-catenin Pathway Activation Correlates with Immune Exclusion across Human Cancers. Clin Cancer Res. 2019;25(10):3074-3083. doi:10.1158/1078-0432.CCR-18-1942

Abstract

Background:

The T cell-inflamed phenotype correlates with efficacy of immune-checkpoint blockade while non-T cell-inflamed tumors infrequently benefit. Tumor-intrinsic WNT/β-catenin signaling mediates immune exclusion in melanoma, but association with the non-T cell-inflamed tumor microenvironment in other tumor types is not well understood.

Methods:

Using The Cancer Genome Atlas (TCGA), a T cell-inflamed gene expression signature segregated samples within tumor types. Activation of WNT/β-catenin signaling was inferred using three approaches: somatic mutations or somatic copy number alterations (SCNAs) in β-catenin signaling elements including CTNNB1, APC, APC2, AXIN1, AXIN2; pathway prediction from RNAseq gene expression; and inverse correlation of β-catenin protein levels with the T cell-inflamed gene expression signature.

Results:

Across TCGA, 3137/9244 (33.9%) tumors were non-T cell-inflamed while 3161/9244 (34.2%) were T cell-inflamed. Non-T cell-inflamed tumors demonstrated significantly lower expression of T cell inflammation genes relative to matched normal tissue, arguing for loss of a natural immune phenotype. Mutations of β-catenin signaling molecules in non-T cell-inflamed tumors were enriched three-fold relative to T cell-inflamed tumors. Across 31 tumors, 28 (90%) demonstrated activated β-catenin signaling in the non-T cell-inflamed subset by at least one method. This included target molecule expression from somatic mutations and/or SCNAs of β-catenin signaling elements (19 tumors, 61%), pathway analysis (14 tumors, 45%), and increased β-catenin protein levels (20 tumors, 65%).

Conclusions:

Activation of tumor-intrinsic WNT/β-catenin signaling is enriched in non-T cell-inflamed tumors. These data provide a strong rationale for development of pharmacologic inhibitors of this pathway with the aim of restoring immune cell infiltration and augmenting immunotherapy.

Introduction

Immunotherapies targeting immune checkpoints have contributed to a marked improvement in treatment outcomes in patients with advanced cancer. In melanoma, anti-cytotoxic T lymphocyte antigen 4 (CTLA-4) and anti-programmed death 1 (PD-1) antibodies have demonstrated robust response rates with years of durability in some patients(,) and improvement in overall survival(,). Significant clinical activity of PD-1-targeting agents has led to FDA approval in multiple additional cancer entities. Despite this broad activity, only a subset of patients benefits from treatment within each cancer subtype, and molecular mechanisms to explain primary resistance in these patients remain incompletely understood.

High expression of specific immune cell genes in the tumor microenvironment, described as the T cell-inflamed phenotype, has been observed to correlate with response to multiple immunotherapies including therapeutic vaccines and checkpoint blocking antibodies(,). Conversely, the non-T cell inflamed tumor microenvironment appears to closely associate with lack of clinical benefit to immunotherapy, particularly with anti-PD-1 antibodies(,). Categorization of tumors using transcriptional profiles marking the T cell-inflamed gene expression signature is advantageous as it can define biologically relevant patient sub-populations and set a framework in which to investigate hypothetical mechanisms for primary immunotherapy resistance.

Although multiple molecular mechanisms could theoretically disfavor a T cell-inflamed microenvironment, several lines of investigation have indicated that specific oncogenic molecular aberrations can be sufficient to drive this immune exclusion phenotype in some cases. Tumor cell-intrinsic WNT/β-catenin signaling in melanoma was the first somatic alteration associated with the non-T cell-inflamed tumor microenvironment in patients, and was demonstrated to be causal using a genetically-engineered mouse model(). The mechanism of this effect appears to be through transcriptional repression of key chemokine genes that leads to lack of Batf3-lineage dendritic cell recruitment and subsequent failure to prime and recruit CD8+ T cells(,). This effect is dominant in the tumor microenvironment and leads to loss of therapeutic efficacy of checkpoint blockade, tumor antigen vaccination, and adoptive T cell transfer immunotherapy approaches preclinically(,). While the above studies of tumor-intrinsic WNT/β-catenin signaling have been evaluated in the context of melanoma, the impact of this pathway in driving the non-T cell-inflamed tumor microenvironment in other tumor types are increasingly being recognized. In syngeneic murine models of B16F10 melanoma, 4T1 mammary carcinoma, Neuro2A neuroblastoma, and Renca renal adenocarcinoma, blocking β-catenin pathway signaling via RNA interference resulted in influx of CD8+ T cells and increase in interferon-γ-associated gene targets(). Subsequent combination with immunotherapy yielded complete regressions in the majority of treated animals. More broadly, roles for WNT/β-catenin signaling impacting on the immune system via development and function, active immune exclusion by tumor cells and cancer immunosurveillance are being recognized and accepted across cancer types().

To investigate the influence of WNT/β-catenin signaling across cancers, we performed an integrative analysis of The Cancer Genome Atlas (TCGA) separating individual tumors by T cell-inflamed status and identifying β-catenin pathway activation on three levels. We find that most tumor types within TCGA are enriched for activation of WNT/β-catenin signaling in non-T cell-inflamed tumors. These observations suggest pharmacologic targeting of this pathway could have broad implications for improving immunotherapy efficacy.

Editors note:  Although the majority of mutations in the WNT signaling pathway in cancer have been in the APC gene, this study, although bioinformatic in nature, shows good correlate between other pathway mutations and immune infiltrate. It is interesting to also note that tumor utational burden is the approved biomarker for immune checkpoint inhibitor efficacy.

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Neonatal Pathophysiology

Neonatal Pathophysiology

Writer and Curator: Larry H. Bernstein, MD, FCAP 

 

Introduction

This curation deals with a large and specialized branch of medicine that grew since the mid 20th century in concert with the developments in genetics and as a result of a growing population, with large urban populations, increasing problems of premature deliveries.  The problems of prematurity grew very preterm to very low birth weight babies with special problems.  While there were nurseries, the need for intensive care nurseries became evident in the 1960s, and the need for perinatal care of pregnant mothers also grew as a result of metabolic problems of the mother, intrauterine positioning of the fetus, and increasing numbers of teen age pregnancies as well as nutritional problems of the mother.  There was also a period when the manufacturers of nutritional products displaced the customary use of breast feeding, which was consequential.  This discussion is quite comprehensive, as it involves a consideration of the heart, the lungs, the brain, and the liver, to a large extent, and also the kidneys and skeletal development.

It is possible to outline, with a proportionate emphasis based on frequency and severity, this as follows:

  1. Genetic and metabolic diseases
  2. Nervous system
  3. Cardiovascular
  4. Pulmonary
  5. Skeletal – bone and muscle
  6. Hematological
  7. Liver
  8. Esophagus, stomach, and intestines
  9. Kidneys
  10. Immune system

Fetal Development

Gestation is the period of time between conception and birth when a baby grows and develops inside the mother’s womb. Because it’s impossible to know exactly when conception occurs, gestational age is measured from the first day of the mother’s last menstrual cycle to the current date. It is measured in weeks. A normal gestation lasts anywhere from 37 to 41 weeks.

Week 5 is the start of the “embryonic period.” This is when all the baby’s major systems and structures develop. The embryo’s cells multiply and start to take on specific functions. This is called differentiation. Blood cells, kidney cells, and nerve cells all develop. The embryo grows rapidly, and the baby’s external features begin to form.

Week 6-9:   Brain forms into five different areas. Some cranial nerves are visible. Eyes and ears begin to form. Tissue grows that will the baby’s spine and other bones. Baby’s heart continues to grow and now beats at a regular rhythm. Blood pumps through the main vessels. Your baby’s brain continues to grow. The lungs start to form. Limbs look like paddles. Essential organs begin to grow.

Weeks 11-18: Limbs extended. Baby makes sucking motion. Movement of limbs. Liver and pancreas produce secretions. Muscle and bones developing.

Week 19-21: Baby can hear. Mom feels baby – and quickening.

http://www.nlm.nih.gov/medlineplus/ency/article/002398.htm

fetal-development

fetal-development

https://polination.files.wordpress.com/2014/02/abortion-new-research-into-fetal-development.jpg

Inherited Metabolic Disorders

The original cause of most genetic metabolic disorders is a gene mutation that occurred many, many generations ago. The gene mutation is passed along through the generations, ensuring its preservation.

Each inherited metabolic disorder is quite rare in the general population. Considered all together, inherited metabolic disorders may affect about 1 in 1,000 to 2,500 newborns. In certain ethnic populations, such as Ashkenazi Jews (Jews of central and eastern European ancestry), the rate of inherited metabolic disorders is higher.

Hundreds of inherited metabolic disorders have been identified, and new ones continue to be discovered. Some of the more common and important genetic metabolic disorders include:

Lysosomal storage disorders : Lysosomes are spaces inside cells that break down waste products of metabolism. Various enzyme deficiencies inside lysosomes can result in buildup of toxic substances, causing metabolic disorders including:

  • Hurler syndrome (abnormal bone structure and developmental delay)
  • Niemann-Pick disease (babies develop liver enlargement, difficulty feeding, and nerve damage)
  • Tay-Sachs disease (progressive weakness in a months-old child, progressing to severe nerve damage; the child usually lives only until age 4 or 5)
  • Gauchers disease and others

Galactosemia: Impaired breakdown of the sugar galactose leads to jaundice, vomiting, and liver enlargement after breast or formula feeding by a newborn.

Maple syrup urine disease: Deficiency of an enzyme called BCKD causes buildup of amino acids in the body. Nerve damage results, and the urine smells like syrup.

Phenylketonuria (PKU): Deficiency of the enzyme PAH results in high levels of phenylalanine in the blood. Mental retardation results if the condition is not recognized.

Glycogen storage diseases: Problems with sugar storage lead to low blood sugar levels, muscle pain, and weakness.

Metal metabolism disorders: Levels of trace metals in the blood are controlled by special proteins. Inherited metabolic disorders can result in protein malfunction and toxic accumulation of metal in the body:

Wilson disease (toxic copper levels accumulate in the liver, brain, and other organs)

Hemochromatosis (the intestines absorb excessive iron, which builds up in the liver, pancreas, joints, and heart, causing damage)

Organic acidemias: methylmalonic acidemia and propionic acidemia.

Urea cycle disorders: ornithine transcarbamylase deficiency and citrullinemia

Hemoglobinopathies – thalassemias, sickle cell disease

Red cell enzyme disorders – glucose-6-phosphate dehydrogenase, pyruvate kinase

This list is by no means complete.

http://www.webmd.com/a-to-z-guides/inherited-metabolic-disorder-types-and-treatments

New variations in the galactose-1-phosphate uridyltransferase (GALT) gene

Clinical and molecular spectra in galactosemic patients from neonatal screening in northeastern Italy: Structural and functional characterization of new variations in the galactose-1-phosphate uridyltransferase (GALT) gene

E Viggiano, A Marabotti, AP Burlina, C Cazzorla, MR D’Apice, et al.
Gene 559 (2015) 112–118
http://dx.doi.org/10.1016/j.gene.2015.01.013
Galactosemia (OMIM 230400) is a rare autosomal recessive inherited disorder caused by deficiency of galactose-1-phosphate uridyltransferase (GALT; OMIM 606999) activity. The incidence of galactosemia is 1 in 30,000–60,000, with a prevalence of 1 in 47,000 in the white population. Neonates with galactosemia can present acute symptoms, such as severe hepatic and renal failure, cataract and sepsis after milk introduction. Dietary restriction of galactose determines the clinical improvement in these patients. However, despite early diagnosis by neonatal screening and dietary treatment, a high percentage of patients develop long-term complications such as cognitive disability, speech problems, neurological and/or movement disorders and, in females, ovarian dysfunction.

With the benefit of early diagnosis by neonatal screening and early therapy, the acute presentation of classical galactosemia can be prevented. The objectives of the current study were to report our experience with a group of galactosemic patients identified through the neonatal screening programs in northeastern Italy during the last 30 years.

No neonatal deaths due to galactosemia complications occurred after the introduction of the neonatal screening program. However, despite the early diagnosis and dietary treatment, the patients with classical galactosemia showed one or more long-term complications.

A total of 18 different variations in the GALT gene were found in the patient cohort: 12 missense, 2 frameshift, 1 nonsense, 1 deletion, 1 silent variation, and 1 intronic. Six (p.R33P, p.G83V, p.P244S, p.L267R, p.L267V, p.E271D) were new variations. The most common variation was p.Q188R (12 alleles, 31.5%), followed by p.K285N (6 alleles, 15.7%) and p.N314D (6 alleles, 15.7%). The other variations comprised 1 or 2 alleles. In the patients carrying a new mutation, the biochemical analysis of GALT activity in erythrocytes showed an activity of < 1%. In silico analysis (SIFT, PolyPhen-2 and the computational analysis on the static protein structure) showed potentially damaging effects of the six new variations on the GALT protein, thus expanding the genetic spectrum of GALT variations in Italy. The study emphasizes the difficulty in establishing a genotype–phenotype correlation in classical galactosemia and underlines the importance of molecular diagnostic testing prior to making any treatment.

Diagnosis and Management of Hereditary Hemochromatosis

Reena J. Salgia, Kimberly Brown
Clin Liver Dis 19 (2015) 187–198
http://dx.doi.org/10.1016/j.cld.2014.09.011

Hereditary hemochromatosis (HH) is a diagnosis most commonly made in patients with elevated iron indices (transferrin saturation and ferritin), and HFE genetic mutation testing showing C282Y homozygosity.

The HFE mutation is believed to result in clinical iron overload through altering hepcidin levels resulting in increased iron absorption.

The most common clinical complications of HH include cirrhosis, diabetes, nonischemic cardiomyopathy, and hepatocellular carcinoma.

Liver biopsy should be performed in patients with HH if the liver enzymes are elevated or serum ferritin is greater than 1000 mg/L. This is useful to determine the degree of iron overload and stage the fibrosis.

Treatment of HH with clinical iron overload involves a combination of phlebotomy and/or chelation therapy. Liver transplantation should be considered for patients with HH-related decompensated cirrhosis.

Health economic evaluation of plasma oxysterol screening in the diagnosis of Niemann–Pick Type C disease among intellectually disabled using discrete event simulation

CDM van Karnebeek, Tima Mohammadi, Nicole Tsaod, Graham Sinclair, et al.
Molecular Genetics and Metabolism 114 (2015) 226–232
http://dx.doi.org/10.1016/j.ymgme.2014.07.004

Background: Recently a less invasive method of screening and diagnosing Niemann–Pick C (NP-C) disease has emerged. This approach involves the use of a metabolic screening test (oxysterol assay) instead of the current practice of clinical assessment of patients suspected of NP-C (review of medical history, family history and clinical examination for the signs and symptoms). Our objective is to compare costs and outcomes of plasma oxysterol screening versus current practice in diagnosis of NP-C disease among intellectually disabled (ID) patients using decision-analytic methods.
Methods: A discrete event simulation model was conducted to follow ID patients through the diagnosis and treatment of NP-C, forecast the costs and effectiveness for a cohort of ID patients and compare the outcomes and costs in two different arms of the model: plasma oxysterol screening and routine diagnosis procedure (anno 2013) over 5 years of follow up. Data from published sources and clinical trials were used in simulation model. Unit costs and quality-adjusted life-years (QALYs) were discounted at a 3% annual rate in the base case analysis. Deterministic and probabilistic sensitivity analyses were conducted.
Results: The outcomes of the base case model showed that using plasma oxysterol screening for diagnosis of NP-C disease among ID patients is a dominant strategy. It would result in lower total cost and would slightly improve patients’ quality of life. The average amount of cost saving was $3642 CAD and the incremental QALYs per each individual ID patient in oxysterol screening arm versus current practice of diagnosis NP-C was 0.0022 QALYs. Results of sensitivity analysis demonstrated robustness of the outcomes over the wide range of changes in model inputs.
Conclusion: Whilst acknowledging the limitations of this study, we conclude that screening ID children and adolescents with oxysterol tests compared to current practice for the diagnosis of NP-C is a dominant strategy with clinical and economic benefits. The less costly, more sensitive and specific oxysterol test has potential to save costs to the healthcare system while improving patients’ quality of life and may be considered as a routine tool in the NP-C diagnosis armamentarium for ID. Further research is needed to elucidate its effectiveness in patients presenting characteristics other than ID in childhood and adolescence.

Neurological and Behavioral Disorders

Estrogen receptor signaling during vertebrate development

Maria Bondesson, Ruixin Hao, Chin-Yo Lin, Cecilia Williams, Jan-Åke Gustafsson
Biochimica et Biophysica Acta 1849 (2015) 142–151
http://dx.doi.org/10.1016/j.bbagrm.2014.06.005

Estrogen receptors are expressed and their cognate ligands produced in all vertebrates, indicative of important and conserved functions. Through evolution estrogen has been involved in controlling reproduction, affectingboth the development of reproductive organs and reproductive behavior. This review broadly describes the synthesis of estrogens and the expression patterns of aromatase and the estrogen receptors, in relation to estrogen functions in the developing fetus and child. We focus on the role of estrogens for the development of reproductive tissues, as well as non-reproductive effects on the developing brain. We collate data from human, rodent, bird and fish studies and highlight common and species-specific effects of estrogen signaling on fetal development. Morphological malformations originating from perturbed estrogen signaling in estrogen receptor and aromatase knockout mice are discussed, as well as the clinical manifestations of rare estrogen receptor alpha and aromatase gene mutations in humans. This article is part of a Special Issue entitled: Nuclear receptors in animal development.

 

Memory function and hippocampal volumes in preterm born very-low-birth-weight (VLBW) young adults

Synne Aanes, Knut Jørgen Bjuland, Jon Skranes, Gro C.C. Løhaugen
NeuroImage 105 (2015) 76–83
http://dx.doi.org/10.1016/j.neuroimage.2014.10.023

The hippocampi are regarded as core structures for learning and memory functions, which is important for daily functioning and educational achievements. Previous studies have linked reduction in hippocampal volume to working memory problems in very low birth weight (VLBW; ≤1500 g) children and reduced general cognitive ability in VLBW adolescents. However, the relationship between memory function and hippocampal volume has not been described in VLBW subjects reaching adulthood. The aim of the study was to investigate memory function and hippocampal volume in VLBW young adults, both in relation to perinatal risk factors and compared to term born controls, and to look for structure–function relationships. Using Wechsler Memory Scale-III and MRI, we included 42 non-disabled VLBW and 61 control individuals at age 19–20 years, and related our findings to perinatal risk factors in the VLBW-group. The VLBW young adults achieved lower scores on several subtests of the Wechsler Memory Scale-III, resulting in lower results in the immediate memory indices (visual and auditory), the working memory index, and in the visual delayed and general memory delayed indices, but not in the auditory delayed and auditory recognition delayed indices. The VLBW group had smaller absolute and relative hippocampal volumes than the controls. In the VLBW group inferior memory function, especially for the working memory index, was related to smaller hippocampal volume, and both correlated with lower birth weight and more days in the neonatal intensive care unit (NICU). Our results may indicate a structural–functional relationship in the VLBW group due to aberrant hippocampal development and functioning after preterm birth.

The relation of infant attachment to attachment and cognitive and behavioural outcomes in early childhood

Yan-hua Ding, Xiu Xua, Zheng-yan Wang, Hui-rong Li, Wei-ping Wang
Early Human Development 90 (2014) 459–464
http://dx.doi.org/10.1016/j.earlhumdev.2014.06.004

Background: In China, research on the relation of mother–infant attachment to children’s development is scarce.
Aims: This study sought to investigate the relation of mother–infant attachment to attachment, cognitive and behavioral development in young children.                                                                                                                            Study design: This study used a longitudinal study design.
Subjects: The subjects included healthy infants (n=160) aged 12 to 18 months.
Outcome measures: Ainsworth’s “Strange Situation Procedure” was used to evaluate mother–infant attachment types. The attachment Q-set (AQS) was used to evaluate the attachment between young children and their mothers. The Bayley scale of infant development-second edition (BSID-II) was used to evaluate cognitive developmental level in early childhood. Achenbach’s child behavior checklist (CBCL) for 2- to 3-year-oldswas used to investigate behavioral problems.
Results: In total, 118 young children (73.8%) completed the follow-up; 89.7% of infants with secure attachment and 85.0% of infants with insecure attachment still demonstrated this type of attachment in early childhood (κ = 0.738, p b 0.05). Infants with insecure attachment collectively exhibited a significantly lower mental development index (MDI) in early childhood than did infants with secure attachment, especially the resistant type. In addition, resistant infants were reported to have greater social withdrawal, sleep problems and aggressive behavior in early childhood.
Conclusion: There is a high consistency in attachment development from infancy to early childhood. Secure mother–infant attachment predicts a better cognitive and behavioral outcome; whereas insecure attachment, especially the resistant attachment, may lead to a lower cognitive level and greater behavioral problems in early childhood.

representations of the HPA axis

representations of the HPA axis

representations of limbic stress-integrative pathways from the prefrontal cortex, amygdala and hippocampus

representations of limbic stress-integrative pathways from the prefrontal cortex, amygdala and hippocampus

Fetal programming of schizophrenia: Select mechanisms

Monojit Debnatha, Ganesan Venkatasubramanian, Michael Berk
Neuroscience and Biobehavioral Reviews 49 (2015) 90–104
http://dx.doi.org/10.1016/j.neubiorev.2014.12.003

Mounting evidence indicates that schizophrenia is associated with adverse intrauterine experiences. An adverse or suboptimal fetal environment can cause irreversible changes in brain that can subsequently exert long-lasting effects through resetting a diverse array of biological systems including endocrine, immune and nervous. It is evident from animal and imaging studies that subtle variations in the intrauterine environment can cause recognizable differences in brain structure and cognitive functions in the offspring. A wide variety of environmental factors may play a role in precipitating the emergent developmental dysregulation and the consequent evolution of psychiatric traits in early adulthood by inducing inflammatory, oxidative and nitrosative stress (IO&NS) pathways, mitochondrial dysfunction, apoptosis, and epigenetic dysregulation. However, the precise mechanisms behind such relationships and the specificity of the risk factors for schizophrenia remain exploratory. Considering the paucity of knowledge on fetal programming of schizophrenia, it is timely to consolidate the recent advances in the field and put forward an integrated overview of the mechanisms associated with fetal origin of schizophrenia.

NMDA receptor dysfunction in autism spectrum disorders

Eun-Jae Lee, Su Yeon Choi and Eunjoon Kim
Current Opinion in Pharmacology 2015, 20:8–13
http://dx.doi.org/10.1016/j.coph.2014.10.007

Autism spectrum disorders (ASDs) represent neurodevelopmental disorders characterized by two core symptoms;

(1)  impaired social interaction and communication, and
(2)  restricted and repetitive behaviors, interests, and activities.

ASDs affect ~ 1% of the population, and are considered to be highly genetic in nature. A large number (~600) of ASD-related genetic variations have been identified (sfari.org), and target gene functions are apparently quite diverse. However, some fall onto common pathways, including synaptic function and chromosome remodeling, suggesting that core mechanisms may exist.

Abnormalities and imbalances in neuronal excitatory and inhibitory synapses have been implicated in diverse neuropsychiatric disorders including autism spectrum disorders (ASDs). Increasing evidence indicates that dysfunction of NMDA receptors (NMDARs) at excitatory synapses is associated with ASDs. In support of this, human ASD-associated genetic variations are found in genes encoding NMDAR subunits. Pharmacological enhancement or suppression of NMDAR function ameliorates ASD symptoms in humans. Animal models of ASD display bidirectional NMDAR dysfunction, and correcting this deficit rescues ASD-like behaviors. These findings suggest that deviation of NMDAR function in either direction contributes to the development of ASDs, and that correcting NMDAR dysfunction has therapeutic potential for ASDs.

Among known synaptic proteins implicated in ASD are metabotropic glutamate receptors (mGluRs). Functional enhancement and suppression of mGluR5 are associated with fragile X syndrome and tuberous sclerosis, respectively, which share autism as a common phenotype. More recently, ionotropic glutamate receptors, namely NMDA receptors (NMDARs) and AMPA receptors (AMPARs), have also been implicated in ASDs. In this review, we will focus on NMDA receptors and summarize evidence supporting the hypothesis that NMDAR dysfunction contributes to ASDs, and, by extension, that correcting NMDAR dysfunction has therapeutic potential for ASDs. ASD-related human NMDAR genetic variants.

Chemokines roles within the hippocampus

Chemokines roles within the hippocampus

IL-1 mediates stress-induced activation of the HPA axis

IL-1 mediates stress-induced activation of the HPA axis

A systemic model of the beneficial role of immune processes in behavioral and neural plasticity

A systemic model of the beneficial role of immune processes in behavioral and neural plasticity

Three Classes of Glutamate Receptors

Three Classes of Glutamate Receptors

Clinical studies on ASDs have identified genetic variants of NMDAR subunit genes. Specifically, de novo mutations have been identified in the GRIN2B gene, encoding the GluN2B subunit. In addition, SNP analyses have linked both GRIN2A (GluN2A subunit) and GRIN2B with ASDs. Because assembled NMDARs contain four subunits, each with distinct properties, ASD-related GRIN2A/ GRIN2B variants likely alter the functional properties of NMDARs and/or NMDAR-dependent plasticity.

Pharmacological modulation of NMDAR function can improve ASD symptoms. D-cycloserine (DCS), an NMDAR agonist, significantly ameliorates social withdrawal and repetitive behavior in individuals with ASD. These results suggest that reduced NMDAR function may contribute to the development of ASDs in humans.

We can divide animal studies into two groups. The first group consists of animals in which NMDAR modulators were shown to normalize both NMDAR dysfunction and ASD-like behaviors, establishing strong association between NMDARs and ASD phenotypes (Fig.). In the second group, NMDAR modulators were shown to rescue ASD-like behaviors, but NMDAR dysfunction and its correction have not been demonstrated.

ASD models with data showing rescue of both NMDAR dysfunction and ASD like behaviors Mice lacking neuroligin-1, an excitatory postsynaptic adhesion molecule, show reduced NMDAR function in the hippocampus and striatum, as evidenced by a decrease in NMDA/AMPA ratio and long-term potentiation (LTP). Neuroligin-1 is thought to enhance synaptic NMDAR function, by directly interacting with and promoting synaptic localization of NMDARs.

Fig not shown.

Bidirectional NMDAR dysfunction in animal models of ASD. Animal models of ASD with bidirectional NMDAR dysfunction can be positioned on either side of an NMDAR function curve. Model animals were divided into two groups.

Group 1: NMDAR modulators normalize both NMDAR dysfunction and ASD-like behaviors (green).

Group 2: NMDAR modulators rescue ASD-like behaviors, but NMDAR dysfunction and its rescue have not been demonstrated (orange). Note that Group 2 animals are tentatively placed on the left-hand side of the slope based on the observed DCS rescue of their ASD-like phenotypes, but the directions of their NMDAR dysfunctions remain to be experimentally determined.

ASD models with data showing rescue of ASD-like behaviors but no demonstrated NMDAR dysfunction

Tbr1 is a transcriptional regulator, one of whose targets is the gene encoding the GluN2B subunit of NMDARs. Mice haploinsufficient for Tbr1 (Tbr1+/-) show structural abnormalities in the amygdala and limited GluN2B induction upon behavioral stimulation. Both systemic injection and local amygdalar infusion of DCS rescue social deficits and impaired associative memory in Tbr1+/- mice. However, reduced NMDAR function and its DCS-dependent correction have not been demonstrated.

Spatial working memory and attention skills are predicted by maternal stress during pregnancy

André Plamondon, Emis Akbari, Leslie Atkinson, Meir Steiner
Early Human Development 91 (2015) 23–29
http://dx.doi.org/10.1016/j.earlhumdev.2014.11.004

Introduction: Experimental evidence in rodents shows that maternal stress during pregnancy (MSDP) negatively impacts spatial learning and memory in the offspring. We aim to investigate the association between MSDP (i.e., life events) and spatial working memory, as well as attention skills (attention shifting and attention focusing), in humans. The moderating roles of child sex, maternal anxiety during pregnancy and postnatal care are also investigated.  Methods: Participants were 236mother–child dyads that were followed from the second trimester of pregnancy until 4 years postpartum. Measurements included questionnaires and independent observations.
Results: MSDP was negatively associated with attention shifting at 18monthswhen concurrent maternal anxiety was low. MSDP was associated with poorer spatial working memory at 4 years of age, but only for boys who experienced poorer postnatal care.
Conclusion: Consistent with results observed in rodents, MSDP was found to be associated with spatial working memory and attention skills. These results point to postnatal care and maternal anxiety during pregnancy as potential targets for interventions that aim to buffer children from the detrimental effects of MSDP.

Acute and massive bleeding from placenta previa and infants’ brain damage

Ken Furuta, Shuichi Tokunaga, Seishi Furukawa, Hiroshi Sameshima
Early Human Development 90 (2014) 455–458
http://dx.doi.org/10.1016/j.earlhumdev.2014.06.002

Background: Among the causes of third trimester bleeding, the impact of placenta previa on cerebral palsy is not well known.
Aims: To clarify the effect ofmaternal bleeding fromplacenta previa on cerebral palsy, and in particular when and how it occurs.
Study design: A descriptive study.
Subjects: Sixty infants born to mothers with placenta previa in our regional population-based study of 160,000 deliveries from 1998 to 2012. Premature deliveries occurring atb26 weeks of gestation and placenta accrete were excluded.
Outcome measures: Prevalence of cystic periventricular leukomalacia (PVL) and cerebral palsy (CP).
Results: Five infants had PVL and 4 of these infants developed CP (1/40,000 deliveries). Acute and massive bleeding (>500 g) within 8 h) occurred at around 30–31 weeks of gestation, and was severe enough to deliver the fetus. None of the 5 infants with PVL underwent antenatal corticosteroid treatment, and 1 infant had mild neonatal hypocapnia with a PaCO2 < 25 mm Hg. However, none of the 5 PVL infants showed umbilical arterial academia with pH < 7.2, an abnormal fetal heart rate monitoring pattern, or neonatal hypotension.
Conclusions: Our descriptive study showed that acute and massive bleeding from placenta previa at around 30 weeks of gestation may be a risk factor for CP, and requires careful neonatal follow-up. The underlying process connecting massive placental bleeding and PVL requires further investigation.

Impact of bilirubin-induced neurologic dysfunction on neurodevelopmental outcomes

Courtney J. Wusthoff, Irene M. Loe
Seminars in Fetal & Neonatal Medicine 20 (2015) 52e57
http://dx.doi.org/10.1016/j.siny.2014.12.003

Extreme neonatal hyperbilirubinemia has long been known to cause the clinical syndrome of kernicterus, or chronic bilirubin encephalopathy (CBE). Kernicterus most usually is characterized by choreoathetoid cerebral palsy (CP), impaired upward gaze, and sensorineural hearing loss, whereas cognition is relatively spared. The chronic condition of kernicterus may be, but is not always, preceded in the acute stage by acute bilirubin encephalopathy (ABE). This acute neonatal condition is also due to hyperbilirubinemia, and is characterized by lethargy and abnormal behavior, evolving to frank neonatal encephalopathy, opisthotonus, and seizures. Less completely defined is the syndrome of bilirubin-induced neurologic dysfunction (BIND).

Bilirubin-induced neurologic dysfunction (BIND) is the constellation of neurologic sequelae following milder degrees of neonatal hyperbilirubinemia than are associated with kernicterus. Clinically, BIND may manifest after the neonatal period as developmental delay, cognitive impairment, disordered executive function, and behavioral and psychiatric disorders. However, there is controversy regarding the relative contribution of neonatal hyperbilirubinemia versus other risk factors to the development of later neurodevelopmental disorders in children with BIND. In this review, we focus on the empiric data from the past 25 years regarding neurodevelopmental outcomes and BIND, including specific effects on developmental delay, cognition, speech and language development, executive function, and the neurobehavioral disorders, such as attention deficit/hyperactivity disorder and autism.

As noted in a technical report by the American Academy of Pediatrics Subcommittee on Hyperbilirubinemia, “it is apparent that the use of a single total serum bilirubin level to predict long-term outcomes is inadequate and will lead to conflicting results”. As described above, this has certainly been the case in research to date. To clarify how hyperbilirubinemia influences neurodevelopmental outcome, more sophisticated consideration is needed both of how to assess bilirubin exposure leading to neurotoxicity, and of those comorbid conditions which may lower the threshold for brain injury.

For example, premature infants are known to be especially susceptible to bilirubin neurotoxicity, with kernicterus reported following TB levels far lower than the threshold expected in term neonates. Similarly, among extremely preterm neonates, BBC is proportional to gestational age, meaning that the most premature infants have the highest UB, even for similar TB levels. Thus, future studies must be adequately powered to examine preterm infants separately from term infants, and should consider not just peak TB, but also BBC, as independent variables in neonates with hyperbilirubinemia. Similarly, an analysis by the NICHD NRN found that, among ELBW infants, higher UB levels were associated with a higher risk of death or NDI. However, increased TB levels were only associated with death or NDI in unstable infants. Again, UB or BBC appeared to be more useful than TB.

Are the neuromotor disabilities of bilirubin-induced neurologic dysfunction disorders related to the cerebellum and its connections?

Jon F. Watchko, Michael J. Painter, Ashok Panigrahy
Seminars in Fetal & Neonatal Medicine 20 (2015) 47e51
http://dx.doi.org/10.1016/j.siny.2014.12.004

Investigators have hypothesized a range of subcortical neuropathology in the genesis of bilirubin induced neurologic dysfunction (BIND). The current review builds on this speculation with a specific focus on the cerebellum and its connections in the development of the subtle neuromotor disabilities of BIND. The focus on the cerebellum derives from the following observations:
(i) the cerebellum is vulnerable to bilirubin-induced injury; perhaps the most vulnerable region within the central nervous system;
(ii) infants with cerebellar injury exhibit a neuromotor phenotype similar to BIND; and                                                       (iii) the cerebellum has extensive bidirectional circuitry projections to motor and non-motor regions of the brain-stem and cerebral cortex that impact a variety of neurobehaviors.
Future study using advanced magnetic resonance neuroimaging techniques have the potential to shed new insights into bilirubin’s effect on neural network topology via both structural and functional brain connectivity measurements.

Bilirubin-induced neurologic damage is most often thought of in terms of severe adverse neuromotor (dystonia with or without athetosis) and auditory (hearing impairment or deafness) sequelae. Observed together, they comprise the classic neurodevelopmental phenotype of chronic bilirubin encephalopathy or kernicterus, and may also be seen individually as motor or auditory predominant subtypes. These injuries reflect both a predilection of bilirubin toxicity for neurons (relative to glial cells) and the regional topography of bilirubin-induced neuronal damage characterized by prominent involvement of the globus pallidus, subthalamic nucleus, VIII cranial nerve, and cochlear nucleus.

It is also asserted that bilirubin neurotoxicity may be associated with other less severe neurodevelopmental disabilities, a condition termed “subtle kernicterus” or “bilirubin-induced neurologic dysfunction” (BIND). BIND is defined by a constellation of “subtle neurodevelopmental disabilities without the classical findings of kernicterus that, after careful evaluation and exclusion of other possible etiologies, appear to be due to bilirubin neurotoxicity”. These purportedly include:

(i) mild-to-moderate disorders of movement (e.g., incoordination, clumsiness, gait abnormalities, disturbances in static and dynamic balance, impaired fine motor skills, and ataxia);                                                                                             (ii) disturbances in muscle tone; and
(iii) altered sensorimotor integration. Isolated disturbances of central auditory processing are also included in the spectrum of BIND.

  • Cerebellar vulnerability to bilirubin-induced injury
  • Cerebellar injury phenotypes and BIND
  • Cerebellar projections
Transverse section of cerebellum and brainstem

Transverse section of cerebellum and brainstem

Transverse section of cerebellum and brain-stem from a 34 gestational-week premature kernicteric infant formalin-fixed for two weeks. Yellow staining is evident in the cerebellar dentate nuclei (upper arrow) and vestibular nuclei at the pontomedullary junction (lower arrowhead). Photo is courtesy of Mahmdouha Ahdab-Barmada and reprinted with permission from Taylor-Francis Group (Ahdab Barmada M. The neuropathology of kernicterus: definitions and debate. In: Maisel MJ, Watchko JF editors. Neonatal jaundice. Amsterdam: Harwood Academic Publishers; 2000. p. 75e88

Whether cerebellar injury is primal or an integral part of disturbed neural circuitry in bilirubin-induced CNS damage is unclear. Movement disorders, however, are increasingly recognized to arise from abnormalities of neuronal circuitry rather than localized, circumscribed lesions. The cerebellum has extensive bidirectional circuitry projections to an array of brainstem nuclei and the cerebral cortex that modulate and refine motor activities. In this regard, the cerebellum is characteristically subdivided into three lobes based on neuroanatomic and phylogenetic criteria as well as by their primary afferent and efferent connections. They include:
(i) flocculonodular lobe (archicerebellum);
(ii) anterior lobe (paleocerebellum); and
(iii) posterior lobe (neocerebellum).

The archicerebellum, the oldest division phylogenically, receives extensive input from the vestibular system and is therefore also known as the vestibulocerebellum and is important for equilibrium control. The paleocerebellum, also a primitive region, receives extensive somatosensory input from the spinal cord, including the anterior and posterior spinocerebellar pathways that convey unconscious proprioception, and is therefore also known as the spinocerebellum. The neocerebellum is the most recently evolved region, receives most of the input from the cerebral cortex, and is thus termed the cerebrocerebellum. This area has greatly expanded in association with the extensive development of the cerebral cortex in mammals and especially primates. To cause serious longstanding dysfunction, cerebellar injury must typically involve the deep cerebellar nuclei and their projections.

Schematic of the bidirectional connectivity between the cerebellum and other

Schematic of the bidirectional connectivity between the cerebellum and other

Schematic of the bidirectional connectivity between the cerebellum and other brain regions including the cerebral cortex. Most cerebro-cerebellar afferent projections pass through the basal (anterior or ventral) pontine nuclei and intermediate cerebellar peduncle, whereas most cerebello-cerebral efferent projections pass through the dentate and ventrolateral thalamic nuclei. DCN, deep cerebellar nuclei; RN, red nucleus; ATN, anterior thalamic nucleus; PFC, prefrontal cortex; MC, motor cortex; PC, parietal cortex; TC, temporal cortex; STN, subthalamic nucleus; APN, anterior pontine nuclei. Reprinted under the terms of the Creative Commons Attribution License from D’Angelo E, Casali S. Seeking a unified framework for cerebellar function and dysfunction: from circuit to cognition. Front Neural Circuits 2013; 6:116.

Given the vulnerability of the cerebellum to bilirubin-induced injury, cerebellar involvement should also be evident in classic kernicterus, contributing to neuromotor deficits observed therein. It is of interest, therefore, that cerebellar damage may play a role in the genesis of bilirubin-induced dystonia, a prominent neuromotor feature of chronic bilirubin encephalopathy in preterm and term neonates alike. This complex movement disorder is characterized by involuntary sustained muscle contractions that result in abnormal position and posture. Moreover, dystonia that is brief in duration results in chorea, and, if brief and repetitive, leads to athetosis ‒ conditions also classically observed in kernicterus. Recent evidence suggests that dystonic movements may depend on disruption of both basal ganglia and cerebellar neuronal networks, rather than isolated dysfunction of only one motor system.

Dystonia is also a prominent feature in Gunn rat pups and neonatal Ugt1‒/‒-deficient mice both robust models of kernicterus. The former is used as an experimental model of dystonia. Although these models show basal ganglia injury, the sine qua non of bilirubin-induced murine neuropathology is cerebellar damage and resultant cerebellar hypoplasia.

Studies are needed to define more precisely the motor network abnormalities in kernicterus and BIND. Magnetic resonance imaging (MRI) has been widely used in evaluating infants at risk for bilirubin-induced brain injury using conventional structural T1-and T2-weighted imaging. Infants with chronic bilirubin encephalopathy often demonstrate abnormal bilateral, symmetric, high-signal intensity on T2-weighted MRI of the globus pallidus and subthalamic nucleus, consistent with the neuropathology of kernicterus. Early postnatal MRI of at-risk infants, although frequently showing increased T1-signal in these regions, may give false-positive findings due to the presence of myelin in these structures.

Diffusion tensor imaging and tractography could be used to delineate long-term changes involving specific white matter pathways, further elucidating the neural basis of long-term disability in infants and children with chronic bilirubin encephalopathy and BIND. It will be equally valuable to use blood oxygen level-dependent (BOLD) “resting state” functional MRI to study intrinsic connectivity in order to identify vulnerable brain networks in neonates with kernicterus and BIND. Structural networks of the CNS (connectome) and functional network topology can be characterized in infants with kernicterus and BIND to determine disease-related pattern(s) with respect to both long- and short-range connectivity. These findings have the potential to shed novel insights into the pathogenesis of these disorders and their impact on complex anatomical connections and resultant functional deficits.

Audiologic impairment associated with bilirubin-induced neurologic damage

Cristen Olds, John S. Oghalai
Seminars in Fetal & Neonatal Medicine 20 (2015) 42e46
http://dx.doi.org/10.1016/j.siny.2014.12.006

Hyperbilirubinemia affects up to 84% of term and late preterm infants in the first week of life. The elevation of total serum/plasma bilirubin (TB) levels is generally mild, transitory, and, for most children, inconsequential. However, a subset of infants experiences lifelong neurological sequelae. Although the prevalence of classic kernicterus has fallen steadily in the USA in recent years, the incidence of jaundice in term and premature infants has increased, and kernicterus remains a significant problem in the global arena. Bilirubin-induced neurologic dysfunction (BIND) is a spectrum of neurological injury due to acute or sustained exposure of the central nervous system(CNS) to bilirubin. The BIND spectrum includes kernicterus, acute bilirubin encephalopathy, and isolated neural pathway dysfunction.

Animal studies have shown that unconjugated bilirubin passively diffuses across cell membranes and the blood‒brain barrier (BBB), and bilirubin not removed by organic anion efflux pumps accumulates within the cytoplasm and becomes toxic. Exposure of neurons to bilirubin results in increased oxidative stress and decreased neuronal proliferation and presynaptic neuro-degeneration at central glutaminergic synapses. Furthermore, bilirubin administration results in smaller spiral ganglion cell bodies, with decreased cellular density and selective loss of large cranial nerve VIII myelinated fibers. When exposed to bilirubin, neuronal supporting cells have been found to secrete inflammatory markers, which contribute to increased BBB permeability and bilirubin loading.

The jaundiced Gunn rat is the classic animal model of bilirubin toxicity. It is homozygous for a premature stop codon within the gene for UDP-glucuronosyltransferase family 1 (UGT1). The resultant gene product has reduced bilirubin-conjugating activity, leading to a state of hyperbilirubinemia. Studies with this rat model have led to the concept that impaired calcium homeostasis is an important mechanism of neuronal toxicity, with reduced expression of calcium-binding proteins in affected cells being a sensitive index of bilirubin-induced neurotoxicity. Similarly, application of bilirubin to cultured auditory neurons from brainstem cochlear nuclei results in hyperexcitability and excitotoxicity.

The auditory pathway and normal auditory brainstem response (ABR).

The auditory pathway and normal auditory brainstem response (ABR).

The auditory pathway and normal auditory brain-stem response (ABR). The ipsilateral (green) and contralateral (blue) auditory pathways are shown, with structures that are known to be affected by hyperbilirubinemia highlighted in red. Roman numerals in parentheses indicate corresponding waves in the normal human ABR (inset). Illustration adapted from the “Ear Anatomy” series by Robert Jackler and Christine Gralapp, with permission.

Bilirubin-induced neurologic dysfunction (BIND)

Vinod K. Bhutani, Ronald Wong
Seminars in Fetal & Neonatal Medicine 20 (2015) 1
http://dx.doi.org/10.1016/j.siny.2014.12.010

Beyond the traditional recognized areas of fulminant injury to the globus pallidus as seen in infants with kernicterus, other vulnerable areas include the cerebellum, hippocampus, and subthalamic nuclear bodies as well as certain cranial nerves. The hippocampus is a brain region that is particularly affected by age related morphological changes. It is generally assumed that a loss in hippocampal volume results in functional deficits that contribute to age-related cognitive deficits. Lower grey matter volumes within the limbic-striato-thalamic circuitry are common to other etiological mechanisms of subtle neurologic injury. Lower grey matter volumes in the amygdala, caudate, frontal and medial gyrus are found in schizophrenia and in the putamen in autism. Thus, in terms of brain volumetrics, schizophrenia and autism spectrum disorders have a clear degree of overlap that may reflect shared etiological mechanisms. Overlap with injuries observed in infants with BIND raises the question about how these lesions are arrived at in the context of the impact of common etiologies.

Stress-induced perinatal and transgenerational epigenetic programming of brain development and mental health

Olena Babenko, Igor Kovalchuk, Gerlinde A.S. Metz
Neuroscience and Biobehavioral Reviews 48 (2015) 70–91
http://dx.doi.org/10.1016/j.neubiorev.2014.11.013

Research efforts during the past decades have provided intriguing evidence suggesting that stressful experiences during pregnancy exert long-term consequences on the future mental wellbeing of both the mother and her baby. Recent human epidemiological and animal studies indicate that stressful experiences in utero or during early life may increase the risk of neurological and psychiatric disorders, arguably via altered epigenetic regulation. Epigenetic mechanisms, such as miRNA expression, DNA methylation, and histone modifications are prone to changes in response to stressful experiences and hostile environmental factors. Altered epigenetic regulation may potentially influence fetal endocrine programming and brain development across several generations. Only recently, however, more attention has been paid to possible transgenerational effects of stress. In this review we discuss the evidence of transgenerational epigenetic inheritance of stress exposure in human studies and animal models. We highlight the complex interplay between prenatal stress exposure, associated changes in miRNA expression and DNA methylation in placenta and brain and possible links to greater risks of schizophrenia, attention deficit hyperactivity disorder, autism, anxiety- or depression-related disorders later in life. Based on existing evidence, we propose that prenatal stress, through the generation of epigenetic alterations, becomes one of the most powerful influences on mental health in later life. The consideration of ancestral and prenatal stress effects on lifetime health trajectories is critical for improving strategies that support healthy development and successful aging.

Sensitive time-windows for susceptibility in neurodevelopmental disorders

Rhiannon M. Meredith, Julia Dawitz and Ioannis Kramvis
Trends in Neurosciences, June 2012; 35(6): 335-344
http://dx.doi.org:/10.1016/j.tins.2012.03.005

Many neurodevelopmental disorders (NDDs) are characterized by age-dependent symptom onset and regression, particularly during early postnatal periods of life. The neurobiological mechanisms preceding and underlying these developmental cognitive and behavioral impairments are, however, not clearly understood. Recent evidence using animal models for monogenic NDDs demonstrates the existence of time-regulated windows of neuronal and synaptic impairments. We propose that these developmentally-dependent impairments can be unified into a key concept: namely, time-restricted windows for impaired synaptic phenotypes exist in NDDs, akin to critical periods during normal sensory development in the brain. Existence of sensitive time-windows has significant implications for our understanding of early brain development underlying NDDs and may indicate vulnerable periods when the brain is more susceptible to current therapeutic treatments.

Fig (not shown)

Misregulated mechanisms underlying spine morphology in NDDs. Several proteins implicated in monogenic NDDs (highlighted in red) are linked to the regulation of the synaptic cytoskeleton via F-actin through different Rho-mediated signaling pathways (highlighted in green). Mutations in OPHN1, TSC1/2, FMRP, p21-activated kinase (PAK) are directly linked to human NDDs of intellectual disability. For instance, point mutations in OPHN1 and a PAK isoform are linked to non-syndromic mental retardation, whereas mutations or altered expression of TSC1/2 and FMRP are linked to TSC and FXS, respectively. Cytoplasmic interacting protein (CYFIP) and LIM-domain kinase 1 (LIMK1) are known to interact with FMRP and PAK, respectively [105]. LIMK1 is one of many dysregulated proteins contributing to the NDD Williams syndrome. Mouse models are available for all highlighted (red) proteins and reveal specific synaptic and behavioral deficits. Local protein synthesis in synapses, dendrites and glia is also regulated by proteins such as TSC1/2 and the FMRP/CYFIP complex. Abbreviations: 4EBP, 4E binding protein; eIF4E, eukaryotic translation initiation factor 4E.

Fig (not shown)

Sensitive time-windows, synaptic phenotypes and NDD gene targets. Sensitive time-windows exist in neural circuits, during which gene targets implicated in NDDs are normally expressed. Misregulation of these genes can affect multiple synaptic phenotypes during a restricted developmental period. The effect upon synaptic phenotypes is dependent upon the temporal expression of these NDD genes and their targets. (a) Expression outside a critical period of development will have no effect upon synaptic phenotypes. (b,c) A temporal expression pattern that overlaps with the onset (b) or closure (c) of a known critical period can alter the synaptic phenotype during that developmental time-window.

Outstanding questions

(1) Can treatment at early presymptomatic stages in animal models for NDDs prevent or ease the later synaptic, neuronal, and behavioral impairments?

(2) Are all sensory critical periods equally misregulated in mouse models for a specific NDD? Are there different susceptibilities for auditory, visual and somatosensory neurocircuits that reflect the degree of impairments observed in patients?

(3) If one critical period is missed or delayed during formation of a layer-specific connection in a network, does the network overcome this misregulated connectivity or plasticity window?

(4) In monogenic NDDs, does the severity of misregulating one particular time-window for synaptic establishment during development correlate with the importance of that gene for that synaptic circuit?

(5) Why do critical periods close in brain development?

(6) What underlies the regression of some altered synaptic phenotypes in Fmr1-KO mice?

(7) Can the concept of susceptible time-windows be applied to other NDDs, including schizophrenia and Tourette’s syndrome?

Cardiovascular

Cardiac output monitoring in newborns

Willem-Pieter de Boode
Early Human Development 86 (2010) 143–148
http://dx.doi.org:/10.1016/j.earlhumdev.2010.01.032

There is an increased interest in methods of objective cardiac output measurement in critically ill patients. Several techniques are available for measurement of cardiac output in children, although this remains very complex in newborns. Cardiac output monitoring could provide essential information to guide hemodynamic management. An overview is given of various methods of cardiac output monitoring with advantages and major limitations of each technology together with a short explanation of the basic principles.

Fick principle

According to the Fick principle the volume of blood flow in a given period equals the amount of substance entering the blood stream in the same period divided by the difference in concentrations of the substrate upstream respectively downstream to the point of entry in the circulation. This substance can be oxygen (O2-Fick) or carbon dioxide (CO2-FICK), so cardiac output can be calculated by dividing measured pulmonary oxygen uptake by the arteriovenous oxygen concentration difference. The direct O2-Fick method is regarded as gold standard in cardiac output monitoring in a research setting, despite its limitations. When the Fick principle is applied for carbon dioxide (CO2 Fick), the pulmonary carbon dioxide exchange is divided by the venoarterial CO2 concentration difference to calculate cardiac output.

In the modified CO2 Fick method pulmonary CO2 exchange is measured at the endotracheal tube. Measurement of total CO2 concentration in blood is more complex and simultaneous sampling of arterial and central venous blood is required. However, frequent blood sampling will result in an unacceptable blood loss in the neonatal population.

Blood flow can be calculated if the change in concentration of a known quantity of injected indicator is measured in time distal to the point of injection, so an indicator dilution curve can be obtained. Cardiac output can then be calculated with the use of the Stewart–Hamilton equation. Several indicators are used, such as indocyanine green, Evans blue and brilliant red in dye dilution, cold solutions in thermodilution, lithium in lithium dilution, and isotonic saline in ultrasound dilution.

Cardiovascular adaptation to extra uterine life

Alice Lawford, Robert MR Tulloh
Paediatrics And Child Health 2014; 25(1): 1-6.

The adaptation to extra uterine life is of interest because of its complexity and the ability to cause significant health concerns. In this article we describe the normal changes that occur and the commoner abnormalities that are due to failure of normal development and the effect of congenital cardiac disease. Abnormal development may occur as a result of problems with the mother, or with the fetus before birth. After birth it is essential to determine whether there is an underlying abnormality of the fetal pulmonary or cardiac development and to determine the best course of management of pulmonary hypertension or congenital cardiac disease. Causes of underdevelopment, maldevelopment and maladaptation are described as are the causes of critical congenital heart disease. The methods of diagnosis and management are described to allow the neonatologist to successfully manage such newborns.

Fetal vascular structures that exist to direct blood flow

Fetal structure Function
Arterial duct Connects pulmonary artery to the aorta and shunts blood right to left; diverting flow away from fetal lungs
Foramen ovale Opening between the two atria thatdirects blood flow returning to right

atrium through the septal wall into the left atrium bypassing lungs

Ductus venosus Receives oxygenated blood fromumbilical vein and directs it to the

inferior vena cava and right atrium

Umbilical arteries Carrying deoxygenated blood fromthe fetus to the placenta
Umbilical vein Carrying oxygenated blood from theplacenta to the fetus

Maternal causes of congenital heart disease

Maternal disorders rubella, SLE, diabetes mellitus
Maternal drug use Warfarin, alcohol
Chromosomal abnormality Down, Edward, Patau, Turner, William, Noonan

 

Fetal and Neonatal Circulation  The fetal circulation is specifically adapted to efficiently exchange gases, nutrients, and wastes through placental circulation. Upon birth, the shunts (foramen ovale, ductus arteriosus, and ductus venosus) close and the placental circulation is disrupted, producing the series circulation of blood through the lungs, left atrium, left ventricle, systemic circulation, right heart, and back to the lungs.

Clinical monitoring of systemic hemodynamics in critically ill newborns

Willem-Pieter de Boode
Early Human Development 86 (2010) 137–141
http://dx.doi.org:/10.1016/j.earlhumdev.2010.01.031

Circulatory failure is a major cause of mortality and morbidity in critically ill newborn infants. Since objective measurement of systemic blood flow remains very challenging, neonatal hemodynamics is usually assessed by the interpretation of various clinical and biochemical parameters. An overview is given about the predictive value of the most used indicators of circulatory failure, which are blood pressure, heart rate, urine output, capillary refill time, serum lactate concentration, central–peripheral temperature difference, pH, standard base excess, central venous oxygen saturation and color.

Key guidelines

➢ The clinical assessment of cardiac output by the interpretation of indirect parameters of systemic blood flow is inaccurate, irrespective of the level of experience of the clinician

➢ Using blood pressure to diagnose low systemic blood flow will consequently mean that too many patients will potentially be undertreated or overtreated, both with substantial risk of adverse effects and iatrogenic damage.

➢ Combining different clinical hemodynamic parameters enhances the predictive value in the detection of circulatory failure, although accuracy is still limited.

➢ Variation in time (trend monitoring) might possibly be more informative than individual, static values of clinical and biochemical parameters to evaluate the adequacy of neonatal circulation.

Monitoring oxygen saturation and heart rate in the early neonatal period

J.A. Dawson, C.J. Morley
Seminars in Fetal & Neonatal Medicine 15 (2010) 203e207
http://dx.doi.org:/10.1016/j.siny.2010.03.004

Pulse oximetry is commonly used to assist clinicians in assessment and management of newly born infants in the delivery room (DR). In many DRs, pulse oximetry is now the standard of care for managing high risk infants, enabling immediate and dynamic assessment of oxygenation and heart rate. However, there is little evidence that using pulse oximetry in the DR improves short and long term outcomes. We review the current literature on using pulse oximetry to measure oxygen saturation and heart rate and how to apply current evidence to management in the DR.

Practice points

  • Understand how SpO2 changes in the first minutes after birth.
  • Apply a sensor to an infant’s right wrist as soon as possible after birth.
  • Attach sensor to infant then to oximeter cable.
  • Use two second averaging and maximum sensitivity.

Using pulse oximetry assists clinicians:

  1. Assess changes in HR in real time during transition.
  2. Assess oxygenation and titrate the administration of oxygen to maintain oxygenation within the appropriate range for SpO2 during the first minutes after birth.

Research directions

  • What are the appropriate centiles to target during the minutes after birth to prevent hypoxia and hyperoxia: 25th to 75th, or 10th to 90th, or just the 50th (median)?
  • Can the inspired oxygen be titrated against the SpO2 to keep the SpO2 in the ‘normal range’?
  • Does the use of centile charts in the DR for HR and oxygen saturation reduce the rate of hyperoxia when infants are treated with oxygen.
  • Does the use of pulse oximetry immediately after birth improve short term outcomes, e.g. efficacy of immediate respiratory support, intubation rates in the DR, percentage of inspired oxygen, rate of use of adrenalin or chest compressions, duration of hypoxia/hyperoxia and bradycardia.
  • Does the use of pulse oximetry in the DR improve short term respiratory and long term neurodevelopmental outcomes for preterm infants, e.g. rate of intubation, use of surfactant, and duration of ventilation, continuous positive airway pressure, or supplemental oxygen?
  • Can all modern pulse oximeters be used effectively in the DR or do some have a longer delay before giving an accurate signal and more movement artefact?
  • Would a longer averaging time result in more stable data?

Peripheral haemodynamics in newborns: Best practice guidelines

Michael Weindling, Fauzia Paize
Early Human Development 86 (2010) 159–165
http://dx.doi.org:/10.1016/j.earlhumdev.2010.01.033

Peripheral hemodynamics refers to blood flow, which determines oxygen and nutrient delivery to the tissues. Peripheral blood flow is affected by vascular resistance and blood pressure, which in turn varies with cardiac function. Arterial oxygen content depends on the blood hemoglobin concentration (Hb) and arterial pO2; tissue oxygen delivery depends on the position of the oxygen-dissociation curve, which is determined by temperature and the amount of adult or fetal hemoglobin. Methods available to study tissue perfusion include near-infrared spectroscopy, Doppler flowmetry, orthogonal polarization spectral imaging and the peripheral perfusion index. Cardiac function, blood gases, Hb, and peripheral temperature all affect blood flow and oxygen extraction. Blood pressure appears to be less important. Other factors likely to play a role are the administration of vasoactive medications and ventilation strategies, which affect blood gases and cardiac output by changing the intrathoracic pressure.

graphic

NIRS with partial venous occlusion to measure venous oxygen saturation

NIRS with partial venous occlusion to measure venous oxygen saturation

NIRS with partial venous occlusion to measure venous oxygen saturation. Taken from Yoxall and Weindling

Schematic representation of the biphasic relationship between oxygen delivery and oxygen consumption in tissue

Schematic representation of the biphasic relationship between oxygen delivery and oxygen consumption in tissue

graphic

Schematic representation of the biphasic relationship between oxygen delivery and oxygen consumption in tissue.  (a) oxygen delivery (DO2). (b) As DO2 decreases, VO2 is dependent on DO2. The slope of the line indicates the FOE, which in this case is about 0.50. (c) The slope of the line indicates the FOE in the normal situation where oxygenation is DO2 independent, usually < 0.35

The oxygen-dissociation curve

The oxygen-dissociation curve

graphic

The oxygen-dissociation curve

Considerable information about the response of the peripheral circulation has been obtained using NIRS with venous occlusion. Although these measurements were validated against blood co-oximetry in human adults and infants, they can only be made intermittently by a trained operator and are thus not appropriate for general clinical use. Further research is needed to find other better measures of peripheral perfusion and oxygenation which may be easily and continuously monitored, and which could be useful in a clinical setting.

Peripheral oxygenation and management in the perinatal period

Michael Weindling
Seminars in Fetal & Neonatal Medicine 15 (2010) 208e215
http://dx.doi.org:/10.1016/j.siny.2010.03.005

The mechanisms for the adequate provision of oxygen to the peripheral tissues are complex. They involve control of the microcirculation and peripheral blood flow, the position of the oxygen dissociation curve including the proportion of fetal and adult hemoglobin, blood gases and viscosity. Systemic blood pressure appears to have little effect, at least in the non-shocked state. The adequate delivery of oxygen (DO2) depends on consumption (VO2), which is variable. The balance between VO2 and DO2 is given by fractional oxygen extraction (FOE ¼ VO2/DO2). FOE varies from organ to organ and with levels of activity. Measurements of FOE for the whole body produce a range of about 0.15-0.33, i.e. the body consumes 15-33% of oxygen transported.

Fig (not shown)

Biphasic relationship between oxygen delivery (DO2) and oxygen consumption (VO2) in tissue. Dotted lines show fractional oxygen extraction (FOE). ‘A’ indicates the normal situation when VO2 is independent ofDO2 and FOE is about 0.30. AsDO2 decreases in the direction of the arrow, VO2 remains independent of DO2 until the critical point is reached at ‘B’; in this illustration, FOE is about 0.50. The slope of the dotted line indicates the FOE (¼ VO2/DO2), which increases progressively as DO2 decreases.

Relationship between haemoglobin F fraction (HbF) and peripheral fractional oxygen extraction

Relationship between haemoglobin F fraction (HbF) and peripheral fractional oxygen extraction

Graphic
(A)Relationship between haemoglobin F fraction (HbF) and peripheral fractional oxygen extraction in anaemic and control infants. (From Wardle et al.)  (B) HbF synthesis and concentration. (From Bard and Widness.) (C) Oxygen dissociation curve.

Peripheral fractional oxygen extraction in babies

Peripheral fractional oxygen extraction in babies

graphic

Peripheral fractional oxygen extraction in babies with asymptomatic or symptomatic anemia compared to controls. Bars represent the median for each group. (From Wardle et al.)

Practice points

  • Peripheral tissue DO2 is complex: cardiac function, blood gases, Hb concentration and the proportion of HbF, and peripheral temperature all play a part in determining blood flow and oxygen extraction in the sick, preterm infant. Blood pressure appears to be less important.
  • Other factors likely to play a role are the administration of vasoactive medications and ventilation strategies, which affect blood gases and cardiac output by changing intrathoracic pressure.
  • Central blood pressure is a poor surrogate measurement for the adequacy of DO2 to the periphery. Direct measurement, using NIRS, laser Doppler flowmetry or other means, may give more useful information.
  • Reasons for total hemoglobin concentration (Hb) being a relatively poor indicator of the adequacy of the provision of oxygen to the tissues:
  1. Hb is only indirectly related to red blood cell volume, which may be a better indicator of the body’s oxygen delivering capacity.
  2. Hb-dependent oxygen availability depends on the position of the oxygen-hemoglobin dissociation curve.
  3. An individual’s oxygen requirements vary with time and from organ to organ. This means that DO2 also needs to vary.
  4. It is possible to compensate for a low Hb by increasing cardiac output and ventilation, and so the ability to compensate for anemia depends on an individual’s cardio-respiratory reserve as well as Hb.
  5. The normal decrease of Hb during the first few weeks of life in both full-term and preterm babies usually occurs without symptoms or signs of anemia or clinical consequences.

The relationship between VO2 and DO2 is complex and various factors need to be taken into account, including the position of the oxygen dissociation curve, determined by the proportion of HbA and HbF, temperature and pH. Furthermore, diffusion of oxygen from capillaries to the cell depends on the oxygen tension gradient between erythrocytes and the mitochondria, which depends on microcirculatory conditions, e.g. capillary PO2, distance of the cell from the capillary (characterized by intercapillary distances) and the surface area of open capillaries. The latter can change rapidly, for example, in septic shock where arteriovenous shunting occurs associated with tissue hypoxia in spite of high DO2 and a low FOE.

Changes in local temperature deserve particular consideration. When the blood pressure is low, there may be peripheral vasoconstriction with decreased local perfusion and DO2. However, the fall in local tissue temperature would also be expected to be associated with a decreased metabolic rate and a consequent decrease in VO2. Thus a decreased DO2 may still be appropriate for tissue needs.

Pulmonary

Accurate Measurements of Oxygen Saturation in Neonates: Paired Arterial and Venous Blood Analyses

Shyang-Yun Pamela K. Shiao
Newborn and Infant Nurs Rev,  2005; 5(4): 170–178
http://dx.doi.org:/10.1053/j.nainr.2005.09.001

Oxygen saturation (So2) measurements (functional measurement, So2; and fractional measurement, oxyhemoglobin [Hbo2]) and monitoring are commonly investigated as a method of assessing oxygenation in neonates. Differences exist between the So2 and Hbo2 when blood tests are performed, and clinical monitors indicate So2 values. Oxyhemoglobin will decrease with the increased levels of carbon monoxide hemoglobin (Hbco) and methemo-globin (MetHb), and it is the most accurate measurements of oxygen (O2) association of hemoglobin (Hb). Pulse oximeter (for pulse oximetry saturation [Spo2] measurement) is commonly used in neonates. However, it will not detect the changes of Hb variations in the blood for accurate So2 measurements. Thus, the measurements from clinical oximeters should be used with caution. In neonates, fetal hemoglobin (HbF) accounts for most of the circulating Hb in their blood. Fetal hemoglobin has a high O2 affinity, thus releases less O2 to the body tissues, presenting a left-shifted Hbo2 dissociation curve.5,6 To date, however, limited data are available with HbF correction, for accurate arterial and venous (AV) So2 measurements (arterial oxygen saturation [Sao2] and venous oxygen saturation [Svo2]) in neonates, using paired AV blood samples.

In a study of critically ill adult patients, increased pulmonary CO production and elevation in arterial Hbco but not venous Hbco were documented by inflammatory stimuli inducing pulmonary heme oxygenase–1. In normal adults, venous Hbco level might be slightly higher than or equal to arterial Hbco because of production of CO by enzyme heme oxygenase–2, which is predominantly produced in the liver and spleen. However, hypoxia or pulmonary inflammation could induce heme oxygenase–1 to increase endogenous CO, thus elevating pulmonary arterial and systemic arterial Hbco levels in adults. Both endogenous and exogenous CO can suppress proliferation of pulmonary smooth muscles, a significant consideration for the prevention of chronic lung diseases in newborns. Despite these considerations, a later study in healthy adults indicated that the AV differences in Hbco were from technical artifacts and perhaps from inadequate control of different instruments. Thus, further studies are needed to provide more definitive answers for the AV differences of Hbco for adults and neonates with acute and chronic lung diseases.

Methemoglobin is an indicator of Hb oxidation and is essential for accurate measurement of Hbo2, So2, and oxygenation status. No evidence exists to show the AV MetHb difference, although this difference was elucidated with the potential changes of MetHb with different O2 levels.  Methemoglobin can be increased with nitric oxide (NO) therapy, used in respiratory distress syndrome (RDS) to reduce pulmonary hypertension and during heart surgery. Nitric oxide, in vitro, is an oxidant of Hb, with increased O2 during ischemia reperfusion. In hypoxemic conditions in vivo, nitrohemoglobin is a product generated by vessel responsiveness to nitrovasodilators. Nitro-hemoglobin can be spontaneously reversible in vivo, requiring no chemical agents or reductase. However, when O2 levels were increased experimentally in vitro following acidic conditions (pH 6.5) to simulate reperfusion conditions, MetHb levels were increased for the hemolysates (broken red cells). Nitrite-induced oxidation of Hb was associated with an increase in red blood cell membrane rigidity, thus contributing to Hb breakdown. A newer in vitro study of whole blood cells, however, concluded that MetHb formation is not dependent on increased O2 levels. Additional studies are needed to examine in vivo reperfusion of O2 and MetHb effects.

Purpose: The aim of this study was to examine the accuracy of arterial oxygen saturation (Sao2) and venous oxygen saturation (Svo2) with paired arterial and venous (AV) blood in relation to pulse oximetry saturation (Spo2) and oxyhemoglobin (Hbo2) with fetal hemoglobin determination, and their Hbo2 dissociation curves. Method: Twelve preterm neonates with gestational ages ranging from 27 to 34 weeks at birth, who had umbilical AV lines inserted, were investigated. Analyses were performed with 37 pairs of AV blood samples by using a blood volume safety protocol. Results: The mean differences between Sao2 and Svo2, and AV Hbo2 were both 6 percent (F6.9 and F6.7 percent, respectively), with higher Svo2 than those reported for adults. Biases were 2.1 – 0.49 for Sao2, 2.0 – 0.44 for Svo2, and 3.1 – 0.45 for Spo2, compared against Hbo2. With left-shifted Hbo2 dissociation curves in neonates, for the critical values of oxygen tension values between 50 and 75 millimeters of mercury, Hbo2 ranged from 92 to 93.4 percent; Sao2 ranged from 94.5 to 95.7 percent; and Spo2 ranged from 93.7 to 96.3 percent (compared to 85–94 percent in healthy adults). Conclusions: In neonates, both left-shifted Hbo2 dissociation curve and lower AV differences of oxygen saturation measurements indicated low flow of oxygen to the body tissues. These findings demonstrate the importance of accurate assessment of oxygenation statues in neonates.

In these neonates, the mean AV blood differences for both So2 and Hbo2 were about 6 percent, which was much lower than those reported for healthy adults (23 percent) for O2 supply and demand. In addition, with very high levels of HbF releasing less O2 to the body tissue, the results of blood analyses are worrisome for these critically ill neonates for low systemic oxygen states.  O’Connor and Hall determined AV So2 in neonates without HbF determination. Much of the AV So2 difference is dependent on Svo2 measurement. The ranges of Svo2 spanned for 35 percent, and the ranges of Sao2 spanned 6 percent in these neonates. The greater intervals for Svo2 measurements contribute to greater sensitivity for the measurements (than Sao2 measurements) in responding to nursing care and changes of O2 demand. Thus, Svo2 measurement is essential for better assessment of oxygenation status in neonates.

The findings of this study on AV differences of So2 were limited with very small number of paired AV blood samples. However, critically ill neonates need accurate assessment of oxygenation status because of HbF, which releases less O2 to the tissues. Decreased differences of AV So2 measurements added further possibilities of lower flow of O2 to the body tissues and demonstrated the greater need to accurately assess the proper oxygenation in the neonates. The findings of this study continued to clarify the accuracy of So2 measurements for neonates. Additional studies are needed to examine So2 levels in neonates to further validate these findings by using larger sample sizes.

Neonatal ventilation strategies and long-term respiratory outcomes

Sandeep Shetty, Anne Greenough
Early Human Development 90 (2014) 735–739
http://dx.doi.org/10.1016/j.earlhumdev.2014.08.020

Long-term respiratory morbidity is common, particularly in those born very prematurely and who have developed bronchopulmonary dysplasia (BPD), but it does occur in those without BPD and in infants born at term. A variety of neonatal strategies have been developed, all with short-term advantages, but meta-analyses of randomized controlled trials (RCTs) have demonstrated that only volume-targeted ventilation and prophylactic high-frequency oscillatory ventilation (HFOV) may reduce BPD. Few RCTs have incorporated long-term follow-up, but one has demonstrated that prophylactic HFOV improves respiratory and functional outcomes at school age, despite not reducing BPD. Results from other neonatal interventions have demonstrated that any impact on BPD may not translate into changes in long-term outcomes. All future neonatal  ventilation RCTs should have long-term outcomes rather than BPD as their primary outcome if they are to impact on clinical practice.

A Model Analysis of Arterial Oxygen Desaturation during Apnea in Preterm Infants

Scott A. Sands, BA Edwards, VJ Kelly, MR Davidson, MH Wilkinson, PJ Berger
PLoS Comput Biol 5(12): e1000588
http://dx.doi.org:/10.1371/journal.pcbi.1000588

Rapid arterial O2 desaturation during apnea in the preterm infant has obvious clinical implications but to date no adequate explanation for why it exists. Understanding the factors influencing the rate of arterial O2 desaturation during apnea (_SSaO2 ) is complicated by the non-linear O2 dissociation curve, falling pulmonary O2 uptake, and by the fact that O2 desaturation is biphasic, exhibiting a rapid phase (stage 1) followed by a slower phase when severe desaturation develops (stage 2). Using a mathematical model incorporating pulmonary uptake dynamics, we found that elevated metabolic O2 consumption accelerates _SSaO2 throughout the entire desaturation process. By contrast, the remaining factors have a restricted temporal influence: low pre-apneic alveolar PO2 causes an early onset of desaturation, but thereafter has little impact; reduced lung volume, hemoglobin content or cardiac output, accelerates _SSaO2 during stage 1, and finally, total blood O2 capacity (blood volume and hemoglobin content) alone determines _SSaO2 during stage 2. Preterm infants with elevated metabolic rate, respiratory depression, low lung volume, impaired cardiac reserve, anemia, or hypovolemia, are at risk for rapid and profound apneic hypoxemia. Our insights provide a basic physiological framework that may guide clinical interpretation and design of interventions for preventing sudden apneic hypoxemia.

A novel approach to study oxidative stress in neonatal respiratory distress syndrome

Reena Negi, D Pande, K Karki, A Kumar, RS Khanna, HD Khanna
BBA Clinical 3 (2015) 65–69
http://dx.doi.org/10.1016/j.bbacli.2014.12.001

Oxidative stress is an imbalance between the systemic manifestation of reactive oxygen species and a biological system’s ability to readily detoxify the reactive intermediates or to repair the resulting damage. It is a physiological event in the fetal-to-neonatal transition, which is actually a great stress to the fetus. These physiological changes and processes greatly increase the production of free radicals, which must be controlled by the antioxidant defense system, the maturation of which follows the course of the gestation. This could lead to several functional alterations with important repercussions for the infants. Adequately mature and healthy infants are able to tolerate this drastic change in the oxygen concentration. A problem occurs when the intrauterine development is incomplete or abnormal. Preterm or intrauterine growth retarded (IUGR) and low birth weight neonates are typically of this kind. An oxidant/antioxidant imbalance in infants is implicated in the pathogenesis of the major complications of prematurity including respiratory distress syndrome (RDS), necrotizing enterocolitis (NEC), chronic lung disease, retinopathy of prematurity and intraventricular hemorrhage (IVH).

Background: Respiratory distress syndrome of the neonate (neonatal RDS) is still an important problem in treatment of preterm infants. It is accompanied by inflammatory processes with free radical generation and oxidative stress. The aim of study was to determine the role of oxidative stress in the development of neonatal RDS. Methods: Markers of oxidative stress and antioxidant activity in umbilical cord blood were studied in infants with neonatal respiratory distress syndrome with reference to healthy newborns. Results: Status of markers of oxidative stress (malondialdehyde, protein carbonyl and 8-hydroxy-2-deoxy guanosine) showed a significant increase with depleted levels of total antioxidant capacity in neonatal RDS when compared to healthy newborns. Conclusion: The study provides convincing evidence of oxidative damage and diminished antioxidant defenses in newborns with RDS. Neonatal RDS is characterized by damage of lipid, protein and DNA, which indicates the augmentation of oxidative stress. General significance: The identification of the potential biomarker of oxidative stress consists of a promising strategy to study the pathophysiology of neonatal RDS.

Neonatal respiratory distress syndrome represents the major lung complications of newborn babies. Preterm neonates suffer from respiratory distress syndrome (RDS) due to immature lungs and require assisted ventilation with high concentrations of oxygen. The pathogenesis of this disorder is based on the rapid formation of the oxygen reactive species, which surpasses the detoxification capacity of antioxidative defense system. The high chemical reactivity of free radical leads to damage to a variety of cellular macro molecules including proteins, lipids and nucleic acid. This results in cell injury and may induce respiratory cell death.

Malondialdehyde (MDA) is one of the final products of polyunsaturated fatty acids peroxidation. The present study showed increased concentration of MDA in neonates with respiratory disorders than that of control in consonance with the reported study.

Anemia, Apnea of Prematurity, and Blood Transfusions

Kelley Zagol, Douglas E. Lake, Brooke Vergales, Marion E. Moorman, et al
J Pediatr 2012;161:417-21
http://dx.doi.org:/10.1016/j.jpeds.2012.02.044

The etiology of apnea of prematurity is multifactorial; however, decreased oxygen carrying capacity may play a role. The respiratory neuronal network in neonates is immature, particularly in those born preterm, as demonstrated by their paradoxical response to hypoxemia. Although adults increase the minute ventilation in response to hypoxemia, newborns have a brief increase in ventilation followed by periodic breathing, respiratory depression, and occasionally cessation of respiratory effort. This phenomenon may be exacerbated by anemia in preterm newborns, where a decreased oxygen carrying capacity may result in decreased oxygen delivery to the central nervous system, a decreased efferent output of the respiratory neuronal network, and an increase in apnea.

Objective Compare the frequency and severity of apneic events in very low birth weight (VLBW) infants before and after blood transfusions using continuous electronic waveform analysis. Study design We continuously collected waveform, heart rate, and oxygen saturation data from patients in all 45 neonatal intensive care unit beds at the University of Virginia for 120 weeks. Central apneas were detected using continuous computer processing of chest impedance, electrocardiographic, and oximetry signals. Apnea was defined as respiratory pauses of >10, >20, and >30 seconds when accompanied by bradycardia (<100 beats per minute) and hypoxemia (<80% oxyhemoglobin saturation as detected by pulse oximetry). Times of packed red blood cell transfusions were determined from bedside charts. Two cohorts were analyzed. In the transfusion cohort, waveforms were analyzed for 3 days before and after the transfusion for all VLBW infants who received a blood transfusion while also breathing spontaneously. Mean apnea rates for the previous 12 hours were quantified and differences for 12 hours before and after transfusion were compared. In the hematocrit cohort, 1453 hematocrit values from all VLBW infants admitted and breathing spontaneously during the time period were retrieved, and the association of hematocrit and apnea in the next 12 hours was tested using logistic regression. Results Sixty-seven infants had 110 blood transfusions during times when complete monitoring data were available. Transfusion was associated with fewer computer-detected apneic events (P < .01). Probability of future apnea occurring within 12 hours increased with decreasing hematocrit values (P < .001). Conclusions Blood transfusions are associated with decreased apnea in VLBW infants, and apneas are less frequent at higher hematocrits.

Bronchopulmonary dysplasia: The earliest and perhaps the longest lasting obstructive lung disease in humans

Silvia Carraro, M Filippone, L Da Dalt, V Ferraro, M Maretti, S Bressan, et al.
Early Human Development 89 (2013) S3–S5
http://dx.doi.org/10.1016/j.earlhumdev.2013.07.015

Bronchopulmonary dysplasia (BPD) is one of the most important sequelae of premature birth and the most common form of chronic lung disease of infancy, an umbrella term for a number of different diseases that evolve as a consequence of a neonatal respiratory disorder. BPD is defined as the need for supplemental oxygen for at least 28 days after birth, and its severity is graded according to the respiratory support required at 36 post-menstrual weeks.

BPD was initially described as a chronic respiratory disease occurring in premature infants exposed to mechanical ventilation and oxygen supplementation. This respiratory disease (later named “old BPD”) occurred in relatively large premature newborn and, from a pathological standpoint, it was characterized by intense airway inflammation, disruption of normal pulmonary structures and lung fibrosis.

Bronchopulmonary dysplasia (BPD) is one of the most important sequelae of premature birth and the most common form of chronic lung disease of infancy. From a clinical standpoint BPD subjects are characterized by recurrent respiratory symptoms, which are very frequent during the first years of life and, although becoming less severe as children grow up, they remain more common than in term-born controls throughout childhood, adolescence and into adulthood. From a functional point of view BPD subjects show a significant airflow limitation that persists during adolescence and adulthood and they may experience an earlier and steeper decline in lung function during adulthood. Interestingly, patients born prematurely but not developing BPD usually fare better, but they too have airflow limitations during childhood and later on, suggesting that also prematurity per se has life-long detrimental effects on pulmonary function. For the time being, little is known about the presence and nature of pathological mechanisms underlying the clinical and functional picture presented by BPD survivors. Nonetheless, recent data suggest the presence of persistent neutrophilic airway inflammation and oxidative stress and it has been suggested that BPD may be sustained in the long term by inflammatory pathogenic mechanisms similar to those underlying COPD. This hypothesis is intriguing but more pathological data are needed.  A better understanding of these pathogenetic mechanisms, in fact, may be able to orient the development of novel targeted therapies or prevention strategies to improve the overall respiratory health of BPD patients.

We have a limited understanding of the presence and nature of pathological mechanisms in the lung of BPD survivors. The possible role of asthma-like inflammation has been investigated because BPD subjects often present with recurrent wheezing and other symptoms resembling asthma during their childhood and adolescence. But BPD subjects have normal or lower than normal exhaled nitric oxide levels and exhaled air temperatures, whereas they are higher than normal in asthmatic patients.

Of all obstructive lung diseases in humans, BPD has the earliest onset and is possibly the longest lasting. Given its frequent association with other conditions related to preterm birth (e.g. growth retardation, pulmonary hypertension, neurodevelopmental delay, hearing defects, and retinopathy of prematurity), it often warrants a multidisciplinary management.

Effects of Sustained Lung Inflation, a lung recruitment maneuver in primary acute respiratory distress syndrome, in respiratory and cerebral outcomes in preterm infants

Chiara Grasso, Pietro Sciacca, Valentina Giacchi, Caterina Carpinato, et al.
Early Human Development 91 (2015) 71–75
http://dx.doi.org/10.1016/j.earlhumdev.2014.12.002

Background: Sustained Lung Inflation (SLI) is a maneuver of lung recruitment in preterm newborns at birth that can facilitate the achieving of larger inflation volumes, leading to the clearance of lung fluid and formation of functional residual capacity (FRC). Aim: To investigate if Sustained Lung Inflation (SLI) reduces the need of invasive procedures and iatrogenic risks. Study design: 78 newborns (gestational age ≤ 34 weeks, weighing ≤ 2000 g) who didn’t breathe adequately at birth and needed to receive SLI in addition to other resuscitation maneuvers (2010 guidelines). Subjects: 78 preterm infants born one after the other in our department of Neonatology of Catania University from 2010 to 2012. Outcome measures: The need of intubation and surfactant, the ventilation required, radiological signs, the incidence of intraventricular hemorrhage (IVH), periventricular leukomalacia, retinopathy in prematurity from III to IV plus grades, bronchopulmonary dysplasia, patent ductus arteriosus, pneumothorax and necrotizing enterocolitis. Results: In the SLI group infants needed less intubation in the delivery room (6% vs 21%; p b 0.01), less invasive mechanical ventilation (14% vs 55%; p ≤ 0.001) and shorter duration of ventilation (9.1 days vs 13.8 days; p ≤ 0.001). There wasn’t any difference for nasal continuous positive airway pressure (82% vs 77%; p = 0.43); but there was less surfactant administration (54% vs 85%; p ≤ 0.001) and more infants received INSURE (40% vs 29%; p=0.17). We didn’t found any differences in the outcomes, except for more mild intraventricular hemorrhage in the SLI group (23% vs 14%; p = 0.15; OR= 1.83). Conclusion: SLI is easier to perform even with a single operator, it reduces the necessity of more complicated maneuvers and surfactant without statistically evident adverse effects.

Long-term respiratory consequences of premature birth at less than 32 weeks of gestation

Anne Greenough
Early Human Development 89 (2013) S25–S27
http://dx.doi.org/10.1016/j.earlhumdev.2013.07.004

Chronic respiratory morbidity is a common adverse outcome of very premature birth, particularly in infants who had developed bronchopulmonary dysplasia (BPD). Prematurely born infants who had BPD may require supplementary oxygen at home for many months and affected infants have increased healthcare utilization until school age. Chest radiograph abnormalities are common; computed tomography of the chest gives predictive information in children with ongoing respiratory problems. Readmission to hospital is common, particularly for those who have BPD and suffer respiratory syncytial virus lower respiratory infections (RSV LRTIs). Recurrent respiratory symptoms requiring treatment are common and are associated with evidence of airways obstruction and gas trapping. Pulmonary function improves with increasing age, but children with BPD may have ongoing airflow limitation. Lung function abnormalities may be more severe in those who had RSV LRTIs, although this may partly be explained by worse premorbid lung function. Worryingly, lung function may deteriorate during the first year. Longitudinal studies are required to determine if there is catch up growth.

Long-term pulmonary outcomes of patients with bronchopulmonary dysplasia

Anita Bhandari and Sharon McGrath-Morrow
Seminars in Perinatology 37 (2013)132–137
http://dx.doi.org/10.1053/j.semperi.2013.01.010

Bronchopulmonary dysplasia (BPD) is the commonest cause of chronic lung disease in infancy. The incidence of BPD has remained unchanged despite many advances in neonatal care. BPD starts in the neonatal period but its effects can persist long term. Premature infants with BPD have a greater incidence of hospitalization, and continue to have a greater respiratory morbidity and need for respiratory medications, compared to those without BPD. Lung function abnormalities, especially small airway abnormalities, often persist. Even in the absence of clinical symptoms, BPD survivors have persistent radiological abnormalities and presence of emphysema has been reported on chest computed tomography scans. Concern regarding their exercise tolerance remains. Long-term effects of BPD are still unknown, but given reports of a more rapid decline in lung function and their susceptibility to develop chronic obstructive pulmonary disease phenotype with aging, it is imperative that lung function of survivors of BPD be closely monitored.

Neonatal ventilation strategies and long-term respiratory outcomes

Sandeep Shetty, Anne Greenough
Early Human Development 90 (2014) 735–739
http://dx.doi.org/10.1016/j.earlhumdev.2014.08.020

Long-term respiratory morbidity is common, particularly in those born very prematurely and who have developed bronchopulmonary dysplasia (BPD), but it does occur in those without BPD and in infants born at term. A variety of neonatal strategies have been developed, all with short-term advantages, but meta-analyses of randomized controlled trials (RCTs) have demonstrated that only volume-targeted ventilation and prophylactic high-frequency oscillatory ventilation (HFOV) may reduce BPD. Few RCTs have incorporated long-term follow-up, but one has demonstrated that prophylactic HFOV improves respiratory and functional outcomes at school age, despite not reducing BPD. Results from other neonatal interventions have demonstrated that any impact on BPD may not translate into changes in long-term outcomes. All future neonatal ventilation RCTs should have long-term outcomes rather than BPD as their primary outcome if they are to impact on clinical practice.

Prediction of neonatal respiratory distress syndrome in term pregnancies by assessment of fetal lung volume and pulmonary artery resistance index

Mohamed Laban, GM Mansour, MSE Elsafty, AS Hassanin, SS EzzElarab
International Journal of Gynecology and Obstetrics 128 (2015) 246–250
http://dx.doi.org/10.1016/j.ijgo.2014.09.018

Objective: To develop reference cutoff values for mean fetal lung volume (FLV) and pulmonary artery resistance index (PA-RI) for prediction of neonatal respiratory distress syndrome (RDS) in low-risk term pregnancies. Methods: As part of a cross-sectional study, women aged 20–35 years were enrolled and admitted to a tertiary hospital in Cairo, Egypt, for elective repeat cesarean at 37–40 weeks of pregnancy between January 1, 2012, and July 31, 2013. FLV was calculated by virtual organ computer-aided analysis, and PA-RI was measured by Doppler ultrasonography before delivery. Results: A total of 80 women were enrolled. Neonatal RDS developed in 11 (13.8%) of the 80 newborns. Compared with neonates with RDS, healthy neonates had significantly higher FLVs (P b 0.001) and lower PA-RIs (P b 0.001). Neonatal RDS is less likely with FLV of at least 32 cm3 or PA-RI less than or equal to 0.74. Combining these two measures improved the accuracy of prediction. Conclusion: The use of either FLV or PA-RI predicted neonatal RDS. The predictive value increased when these two measures were combined

Pulmonary surfactant - a front line of lung host defense, 2003 JCI0318650.f2

Pulmonary surfactant – a front line of lung host defense, 2003 JCI0318650.f2

Pulmonary hypertension in bronchopulmonary dysplasia

Sara K.Berkelhamer, Karen K.Mestan, and Robin H. Steinhorn
Seminars In  Perinatology 37 (2013)124–131
http://dx.doi.org/10.1053/j.semperi.2013.01.009

Pulmonary hypertension (PH) is a common complication of neonatal respiratory diseases, including bronchopulmonary dysplasia (BPD), and recent studies have increased aware- ness that PH worsens the clinical course, morbidity and mortality of BPD. Recent evidence indicates that up to 18% of all extremely low-birth-weight infants will develop some degree of PH during their hospitalization, and the incidence rises to 25–40% of the infants with established BPD. Risk factors are not yet well understood, but new evidence shows that fetal growth restriction is a significant predictor of PH. Echocardiography remains the primary method for evaluation of BPD-associated PH, and the development of standardized screening timelines and techniques for identification of infants with BPD-associated PH remains an important ongoing topic of investigation. The use of pulmonary vasodilator medications, such as nitric oxide, sildenafil, and others, in the BPD population is steadily growing, but additional studies are needed regarding their long-term safety and efficacy.
An update on pharmacologic approaches to bronchopulmonary dysplasia

Sailaja Ghanta, Kristen Tropea Leeman, and Helen Christou
Seminars In Perinatology 37 (2013)115–123
http://dx.doi.org/10.1053/j.semperi.2013.01.008

Bronchopulmonary dysplasia (BPD) is the most prevalent long-term morbidity in surviving extremely preterm infants and is linked to increased risk of reactive airways disease, pulmonary hypertension, post-neonatal mortality, and adverse neurodevelopmental outcomes. BPD affects approximately 20% of premature newborns, and up to 60% of premature infants born before completing 26 weeks of gestation. It is characterized by the need for assisted ventilation and/or supplemental oxygen at 36 weeks postmenstrual age. Approaches to prevention and treatment of BPD have evolved with improved understanding of its pathogenesis. This review will focus on recent advancements and detail current research in pharmacotherapy for BPD. The evidence for both current and potential future experimental therapies will be reviewed in detail. As our understanding of the complex and multifactorial pathophysiology of BPD changes, research into these current and future approaches must continue to evolve.

Methylxanthines
Diuretics and bronchodilators
Corticosteroids
Macrolide antibiotics
Recombinant human Clara cell 10-kilodalton protein(rhCC10)
Vitamin A
Surfactant
Leukotriene receptor antagonist
Pulmonary vasodilators

Skeletal and Muscle

Skeletal Stem Cells in Space and Time

Moustapha Kassem and Paolo Bianco
Cell  Jan 15, 2015; 160: 17-19
http://dx.doi.org/10.1016/j.cell.2014.12.034

The nature, biological characteristics, and contribution to organ physiology of skeletal stem cells are not completely determined. Chan et al. and Worthley et al. demonstrate that a stem cell for skeletal tissues, and a system of more restricted, downstream progenitors, can be identified in mice and demonstrate its role in skeletal tissue maintenance and regeneration.

The groundbreaking concept that bone, cartilage, marrow adipocytes, and hematopoiesis-supporting stroma could originate from a common progenitor and putative stem cell was surprising at the time when it was formulated (Owen and Friedenstein, 1988). The putative stem cell, nonhematopoietic in nature, would be found in the postnatal bone marrow stroma, generate tissues previously thought of as foreign to each other, and support the turnover of tissues and organs that self-renew at a much slower rate compared to other tissues associated with stem cells (blood, epithelia). This concept also connected bone and bone marrow as parts of a single-organ system, implying their functional interplay. For many years, the evidence underpinning the concept has been incomplete.

While multipotency of stromal progenitors has been demonstrated by in vivo transplantation experiments, self-renewal, the defining property of a stem cell, has not been easily demonstrated until recently in humans (Sacchetti et al., 2007) and mice (Mendez-Ferrer et al., 2010). Meanwhile, a confusing and plethoric terminology has been introduced into the literature, which diverted and confounded the search for a skeletal stem cell and its physiological significance (Bianco et al., 2013).

Two studies in this issue of Cell (Chan et al., 2015; Worthley et al., 2015), using a combination of rigorous single-cell analyses and lineage tracing technologies, mark significant steps toward rectifying the course of skeletal stem cell discovery by making several important points, within and beyond skeletal physiology.

First, a stem cell for skeletal tissues, and a system of more restricted, downstream progenitors can in fact be identified and linked to defined phenotype(s) in the mouse. The system is framed conceptually, and approached experimentally, similar to the hematopoietic system.

Second, based on its assayable functions and potential, the stem cell at the top of the hierarchy is defined as a skeletal stem cell (SSC). As noted earlier (Sacchetti et al., 2007) (Bianco et al., 2013), this term clarifies, well beyond semantics, that the range of tissues that the self-renewing stromal progenitor (originally referred to as an ‘‘osteogenic’’ or ‘‘stromal’’ stem cell) (Owen and Friedenstein, 1988) can actually generate in vivo, overlaps with the range of tissues that make up the skeleton.

Third, these cells are spatially restricted, local residents of the bone/bone marrow organ. The systemic circulation is not a sizable contributor to their recruitment to locally deployed functions.

Fourth, a native skeletogenic potential is inherent to the system of progenitor/ stem cells found in the skeleton, and internally regulated by bone morphogenetic protein (BMP) signaling. This is reflected in the expression of regulators and antagonists of BMP signaling within the system, highlighting potential feedback mechanisms modulating expansion or quiescence of specific cell compartments.

Fifth, in cells isolated from other tissues, an assayable skeletogenic potential is not inherent: it can only be induced de novo by BMP reprogramming. These two studies (Chan et al., 2015, Worthley et al., 2015) corroborate the classical concept of ‘‘determined’’ and ‘‘inducible’’ skeletal progenitors (Owen and Friedenstein, 1988): the former residing in the skeleton, the latter found in nonskeletal tissues; the former capable of generating skeletal tissues, in vivo and spontaneously, the latter requiring reprogramming signals in order to acquire a skeletogenic capacity; the former operating in physiological bone formation, the latter in unwanted, ectopic bone formation in diseases such as fibrodysplasia ossificans progressiva.

To optimize our ability to obtain specific skeletal tissues for medical application, the study by Chan et al. offers a glimpse of another facet of the biology of SSC lineages and progenitors. Chan et al. show that a homogeneous cell population inherently committed to chondrogenesis can alter its output to generate bone if cotransplanted with multipotent progenitors. Conversely, osteogenic cells can be shifted to a chondrogenic fate by blockade of vascular endothelial growth factor receptor, consistent with the avascular and hypoxic milieu of cartilage. This has two important implications:

  • commitment is flexible in the system;
  • the choir is as important as the soloist and can modulate the solo tune.

Reversibility and population behavior thus emerge as two features that may be characteristic, albeit not unique, of the stromal system, resonating with conceptually comparable evidence in the human system.

The two studies by Chan et al. and Worthely et al. emphasize the relevance not only of their new data, but also of a proper concept of a skeletal stem cell per se, for proper clinical use. Confusion arising from improper conceptualization of skeletal stem cells has markedly limited clinical development of skeletal stem cell biology.

Gremlin 1 Identifies a Skeletal Stem Cell with Bone, Cartilage, and Reticular Stromal Potential

Daniel L. Worthley, Michael Churchill, Jocelyn T. Compton, Yagnesh Tailor, et al.
Cell, Jan 15, 2015; 160: 269–284
http://dx.doi.org/10.1016/j.cell.2014.11.042

The stem cells that maintain and repair the postnatal skeleton remain undefined. One model suggests that perisinusoidal mesenchymal stem cells (MSCs) give rise to osteoblasts, chondrocytes, marrow stromal cells, and adipocytes, although the existence of these cells has not been proven through fate-mapping experiments. We demonstrate here that expression of the bone morphogenetic protein (BMP) antagonist gremlin 1 defines a population of osteochondroreticular (OCR) stem cells in the bone marrow. OCR stem cells self-renew and generate osteoblasts, chondrocytes, and reticular marrow stromal cells, but not adipocytes. OCR stem cells are concentrated within the metaphysis of long bones not in the perisinusoidal space and are needed for bone development, bone remodeling, and fracture repair. Grem1 expression also identifies intestinal reticular stem cells (iRSCs) that are cells of origin for the periepithelial intestinal mesenchymal sheath. Grem1 expression identifies distinct connective tissue stem cells in both the bone (OCR stem cells) and the intestine (iRSCs).

Identification and Specification of the Mouse Skeletal Stem Cell

Charles K.F. Chan, Eun Young Seo, James Y. Chen, David Lo, A McArdle, et al.
Cell, Jan 15, 2015; 160: 285–298
http://dx.doi.org/10.1016/j.cell.2014.12.002

How are skeletal tissues derived from skeletal stem cells? Here, we map bone, cartilage, and stromal development from a population of highly pure, postnatal skeletal stem cells (mouse skeletal stem cells, mSSCs) to their downstream progenitors of bone, cartilage, and stromal tissue. We then investigated the transcriptome of the stem/progenitor cells for unique gene-expression patterns that would indicate potential regulators of mSSC lineage commitment. We demonstrate that mSSC niche factors can be potent inducers of osteogenesis, and several specific combinations of recombinant mSSC niche factors can activate mSSC genetic programs in situ, even in nonskeletal tissues, resulting in de novo formation of cartilage or bone and bone marrow stroma. Inducing mSSC formation with soluble factors and subsequently regulating the mSSC niche to specify its differentiation toward bone, cartilage, or stromal cells could represent a paradigm shift in the therapeutic regeneration of skeletal tissues.

Bone mesenchymal development

Bone mesenchymal development

Bone mesenchymal development

The bone-remodeling cycle

The bone-remodeling cycle

Nuclear receptor modulation – Role of coregulators in selective estrogen receptor modulator (SERM) actions

Qin Feng, Bert W. O’Malley
Steroids 90 (2014) 39–43
http://dx.doi.org/10.1016/j.steroids.2014.06.008

Selective estrogen receptor modulators (SERMs) are a class of small-molecule chemical compounds that bind to estrogen receptor (ER) ligand binding domain (LBD) with high affinity and selectively modulate ER transcriptional activity in a cell- and tissue-dependent manner. The prototype of SERMs is tamoxifen, which has agonist activity in bone, but has antagonist activity in breast. Tamoxifen can reduce the risk of breast cancer and, at same time, prevent osteoporosis in postmenopausal women. Tamoxifen is widely prescribed for treatment and prevention of breast cancer. Mechanistically the activity of SERMs is determined by the selective recruitment of coactivators and corepressors in different cell types and tissues. Therefore, understanding the coregulator function is the key to understanding the tissue selective activity of SERMs.

Hematopoietic

Hematopoietic Stem Cell Arrival Triggers Dynamic Remodeling of the Perivascular Niche

Owen J. Tamplin, Ellen M. Durand, Logan A. Carr, Sarah J. Childs, et al.
Cell, Jan 15, 2015; 160: 241–252
http://dx.doi.org/10.1016/j.cell.2014.12.032

Hematopoietic stem and progenitor cells (HSPCs) can reconstitute and sustain the entire blood system. We generated a highly specific transgenic reporter of HSPCs in zebrafish. This allowed us to perform high resolution live imaging on endogenous HSPCs not currently possible in mammalian bone marrow. Using this system, we have uncovered distinct interactions between single HSPCs and their niche. When an HSPC arrives in the perivascular niche, a group of endothelial cells remodel to form a surrounding pocket. This structure appears conserved in mouse fetal liver. Correlative light and electron microscopy revealed that endothelial cells surround a single HSPC attached to a single mesenchymal stromal cell. Live imaging showed that mesenchymal stromal cells anchor HSPCs and orient their divisions. A chemical genetic screen found that the compound lycorine promotes HSPC-niche interactions during development and ultimately expands the stem cell pool into adulthood. Our studies provide evidence for dynamic niche interactions upon stem cell colonization.

Neonatal anemia

Sanjay Aher, Kedar Malwatkar, Sandeep Kadam
Seminars in Fetal & Neonatal Medicine (2008) 13, 239e247
http://dx.doi.org:/10.1016/j.siny.2008.02.009

Neonatal anemia and the need for red blood cell (RBC) transfusions are very common in neonatal intensive care units. Neonatal anemia can be due to blood loss, decreased RBC production, or increased destruction of erythrocytes. Physiologic anemia of the newborn and anemia of prematurity are the two most common causes of anemia in neonates. Phlebotomy losses result in much of the anemia seen in extremely low birthweight infants (ELBW). Accepting a lower threshold level for transfusion in ELBW infants can prevent these infants being exposed to multiple donors.

Management of anemia in the newborn

Naomi L.C. Luban
Early Human Development (2008) 84, 493–498
http://dx.doi.org:/10.1016/j.earlhumdev.2008.06.007

Red blood cell (RBC) transfusions are administered to neonates and premature infants using poorly defined indications that may result in unintentional adverse consequences. Blood products are often manipulated to limit potential adverse events, and meet the unique needs of neonates with specific diagnoses. Selection of RBCs for small volume (5–20 mL/kg) transfusions and for massive transfusion, defined as extracorporeal bypass and exchange transfusions, are of particular concern to neonatologists. Mechanisms and therapeutic treatments to avoid transfusion are another area of significant investigation. RBCs collected in anticoagulant additive solutions and administered in small aliquots to neonates over the shelf life of the product can decrease donor exposure and has supplanted the use of fresh RBCs where each transfusion resulted in a donor exposure. The safety of this practice has been documented and procedures established to aid transfusion services in ensuring that these products are available. Less well established are the indications for transfusion in this population; hemoglobin or hematocrit alone are insufficient indications unless clinical criteria (e.g. oxygen desaturation, apnea and bradycardia, poor weight gain) also augment the justification to transfuse. Comorbidities increase oxygen consumption demands in these infants and include bronchopulmonary dysplasia, rapid growth and cardiac dysfunction. Noninvasive methods or assays have been developed to measure tissue oxygenation; however, a true measure of peripheral oxygen offloading is needed to improve transfusion practice and determine the value of recombinant products that stimulate erythropoiesis. The development of such noninvasive methods is especially important since randomized, controlled clinical trials to support specific practices are often lacking, due at least in part, to the difficulty of performing such studies in tiny infants.
The Effect of Blood Transfusion on the Hemoglobin Oxygen Dissociation Curve of Very Early Preterm Infants During the First Week of Life

Virginie De HaUeux, Anita Truttmann, Carmen Gagnon, and Harry Bard
Seminars in Perinatology, 2002; 26(6): 411-415
http://dx.doi.org:/10.1053/sper.2002.37313

This study was conducted during the first week of life to determine the changes in Ps0 (PO2 required to achieve a saturation of 50% at pH 7.4 and 37~ and the proportions of fetal hemoglobin (I-IbF) and adult hemoglobin (HbA) prior to and after transfusion in very early preterm infants. Eleven infants with a gestational age <–27 weeks have been included in study. The hemoglobin dissociation curve and the Ps0 was determined by Hemox-analyser. Liquid chromatography was also performed to determine the proportions of HbF and HbA. The mean gestational age of the 11 infants was 25.1 weeks (-+1 weeks) and their mean birth weight was 736 g (-+125 g). They received 26.9 mL/kg of packed red cells. The mean Ps0 prior and after transfusion was 18.5 +- 0.8 and 21.0 + 1 mm Hg (P = .0003) while the mean percentage of HbF was 92.9 -+ 1.1 and 42.6 -+ 5.7%, respectively. The data of this study show a decrease of hemoglobin oxygen affinity as a result of blood transfusion in very early preterm infants prone to O 2 toxicity. The shift in HbO 2 curve after transfusion should be taken into consideration when oxygen therapy is being regulated for these infants.

Effect of neonatal hemoglobin concentration on long-term outcome of infants affected by fetomaternal hemorrhage

Mizuho Kadooka, H Katob, A Kato, S Ibara, H Minakami, Yuko Maruyama
Early Human Development 90 (2014) 431–434
http://dx.doi.org/10.1016/j.earlhumdev.2014.05.010

Background: Fetomaternal hemorrhage (FMH) can cause severe morbidity. However, perinatal risk factors for long-term poor outcome due to FMH have not been extensively studied.                                                                                 Aims: To determine which FMH infants are likely to have neurological sequelae.
Study design: A single-center retrospective observational study. Perinatal factors, including demographic characteristics, Kleihauer–Betke test, blood gas analysis, and neonatal blood hemoglobin concentration ([Hb]), were analyzed in association with long-term outcomes.
Subjects: All 18 neonates referred to a Neonatal Intensive Care Unit of Kagoshima City Hospital and diagnosed with FMH during a 15-year study period. All had a neonatal [Hb] b7.5 g/dL and 15 of 17 neonates tested had Kleihauer–Betke test result N4.0%.
Outcome measures: Poor long-term outcome was defined as any of the following determined at 12 month old or more: cerebral palsy, mental retardation, attention deficit/hyperactivity disorder, and epilepsy.
Results: Nine of the 18 neonates exhibited poor outcomes. Among demographic characteristics and blood variables compared between two groups with poor and favorable outcomes, significant differences were observed in [Hb] (3.6 ± 1.4 vs. 5.4 ± 1.1 g/dL, P = 0.01), pH (7.09 ± 0.11 vs. 7.25 ± 0.13, P = 0.02) and base deficits (17.5 ± 5.4 vs. 10.4 ± 6.0 mmol/L, P = 0.02) in neonatal blood, and a number of infants with [Hb] ≤ 4.5 g/dL (78%[7/9] vs. 22%[2/9], P= 0.03), respectively. The base deficit in neonatal arterial blood increased significantly with decreasing neonatal [Hb].
Conclusions: Severe anemia causing severe base deficit is associated with neurological sequelae in FMH infants

Clinical and hematological presentation among Indian patients with common hemoglobin variants

Khushnooma Italia, Dipti Upadhye, Pooja Dabke, Harshada Kangane, et al.
Clinica Chimica Acta 431 (2014) 46–51
http://dx.doi.org/10.1016/j.cca.2014.01.028

Background: Co-inheritance of structural hemoglobin variants like HbS, HbD Punjab and HbE can lead to a variable clinical presentation and only few cases have been described so far in the Indian population.
Methods: We present the varied clinical and hematological presentation of 22 cases (HbSD Punjab disease-15, HbSE disease-4, HbD Punjab E disease-3) referred to us for diagnosis.
Results: Two of the 15 HbSDPunjab disease patients had moderate crisis, one presented with mild hemolytic anemia; however, the other 12 patients had a severe clinical presentation with frequent blood transfusion requirements, vaso occlusive crisis, avascular necrosis of the femur and febrile illness. The 4 HbSE disease patients had a mild to moderate presentation. Two of the 3 HbD Punjab E patients were asymptomatic with one patient’s sibling having a mild presentation. The hemoglobin levels of the HbSD Punjab disease patients ranged from 2.3 to 8.5 g/dl and MCV from 76.3 to 111.6 fl. The hemoglobin levels of the HbD Punjab E and HbSE patients ranged from 10.8 to 11.9 and 9.8 to 10.0 g/dl whereas MCV ranged from 67.1 to 78.2 and 74.5 to 76.0 fl respectively.
Conclusions: HbSD Punjab disease patients should be identified during newborn screening programs and managed in a way similar to sickle cell disease. Couple at risk of having HbSD Punjab disease children may be given the option of prenatal diagnosis in subsequent pregnancies.

Sickle cell anemia is the most common hemoglobinopathy seen across the world. It is caused by a point mutation in the 6th codon of the beta (β) globin gene leading to the substitution of the amino acid glutamic acid to valine. The sickle gene is frequently seen in Africa, some Mediterranean countries, India, Middle East—Saudi Arabia and North America. In India the prevalence of hemoglobin S (HbS) carriers varies from 2 to 40% among different population groups and HbS is mainly seen among the scheduled tribe, scheduled caste and other backward class populations in the western, central and parts of eastern and southern India. Sickle cell anemia has a variable clinical presentation in India with the most severe clinical presentation seen in central India whereas patients in the western region show a mild to moderate clinical presentation.

Hemoglobin D Punjab (HbD Punjab) (also known as HbD Los-Angeles, HbD Portugal, HbD North Carolina, D Oak Ridge and D Chicago) is another hemoglobin variant due to a point mutation in codon 121 of the β globin gene resulting in the substitution of the amino acid glutamic acid to glycine. It is a widely distributed hemoglobin with a relatively low prevalence of 0.86% in the Indo-Pak subcontinent, 1–3% in north-western India, 1–3% in the Black population in the Caribbean and North America and has also been reported among the English. It accounts for 55.6% of all the Hb variants seen in the Xenjiang province of China.

Hemoglobin E (HbE) is the most common abnormal hemoglobin in Southeast Asia. In India, the frequency ranges from 4% to 51% in the north eastern region and 3% to 4% in West Bengal in the east. The HbE mutation (β26 GAG→AAG) creates an alternative splice site and the βE chain is insufficiently synthesized, hence the phenotype of this disorder is that of a mild form of β thalassemia.

Though these 3 structural variants are prevalent in different regions of India, their interaction is increasingly seen in all states of the country due to migration of people to different regions for a better livelihood. There are very few reports on interaction of these commonly seen Hb variants and the phenotypic–genotypic presentation of these cases is important for genetic counseling and management.

HbF of patients with HbSD Punjab disease with variable clinical severity. The HbF values of 4 patients are not included as they were post blood transfusion

The genotypes of the patients were confirmed by restriction enzyme digestion and ARMS (Fig). Patients 1 to 15 were characterized as compound heterozygous for HbS and HbD Punjab whereas patients 16 to 19 were characterized as compound heterozygous for HbS and HbE. Patient nos. 20 to 22 were characterized as compound heterozygous for HbE and HbD Punjab.

Molecular characterization of HbS and HbDPunjab by restriction enzyme digestion and of HbE by ARMS.

Molecular characterization of HbS and HbDPunjab by restriction enzyme digestion and of HbE by ARMS.

Molecular characterization of HbS and HbDPunjab by restriction enzyme digestion and of HbE by ARMS.

The 3 common β globin gene variants of hemoglobin, HbS, HbE and HbD Punjab are commonly seen in India, with HbS having a high prevalence in the central belt and some parts of western, eastern and southern India, HbE in the eastern and north eastern region whereas HbD is mostly seen in the north western part of India. These hemoglobin variants have been reported in different population groups. However, with migration and intermixing of the different populations from different geographic regions, occasional cases of HbSD Punjab and HbSE are being reported. There are several HbD variants like HbD Punjab, HbD Iran, HbD Ibadan. However, of these only HbD Punjab interacts with HbS to form a clinically significant condition as the glutamine residue facilitates polymerization of HbS. HbD Iran and HbD Ibadan are non-interacting and produce benign conditions like the sickle cell trait. The first case of HbSD Punjab disease was a brother and sister considered to have atypical sickle cell disease in 1934. This family was further reinvestigated and reported as the first case of HbD Los Angeles which has the same mutation as the HbD Punjab. Serjeant et al. reported HbD Punjab in an English parent in 6 out of 11 HbSD-Punjab disease cases. This has been suggested to be due to the stationing of nearly 50,000 British troops on the Indian continent for a period of 200 y and the introduction into Britain of their Anglo-Indian children.

HbSD Punjab disease shows a similar pattern to HbS homozygous on alkaline hemoglobin electrophoresis but can be differentiated on acid agar gel electrophoresis and on HPLC. In HbSD Punjab disease cases, the peripheral blood films show anisocytosis, poikilocytosis, target cells and irreversibly sickled cells. Values of HbF and HbA2 are similar to those in sickle homozygous cases. HbSD Punjab disease is characterized by a moderately severe hemolytic anemia.

Twenty-one cases of HbSDPunjab were reported by Serjeant of which 16 were reported by different workers among patients originating from Caucasian, Spanish, Australian, Irish, English, Portuguese, Black, American, Venezuelan, Caribbean, Mexican, Turkish and Jamaican backgrounds. Yavarian et al. 2009 reported a multi centric origin of HbD Punjab which in combination with HbS results in sickle cell disease. Patel et al. 2010 have also reported 12 cases of HbSD Punjab from the Orissa state of eastern India. Majority of these cases were symptomatic, presenting with chronic hemolytic anemia and frequent painful crises.

HbF levels >20% were seen in 4 out of our 11 clinically severe patients of HbSD-Punjab disease with the mean HbF levels of 16.8% in 8 clinically severe patients, while 3 clinically severe patients were post transfused. However, the 3 patients with a mild to moderate clinical presentation showed a mean HbF level of 8.6%. This is in contrast to the relatively milder clinical presentation associated with high HbF seen in patients with sickle cell anemia. This was also reported by Adekile et al. 2010 in 5 cases of HbS-DLos Angeles where high HbF did not ameliorate the severe clinical presentation seen in these patients.

These 15 cases of HbSDPunjab disease give us an overall idea of the severe clinical presentation of the disease in different regions of India. However the HbDPunjabE cases were milder or asymptomatic and the HbSE cases were moderately symptomatic. Since most of the cases of HbSDPunjab disease were clinically severe, it is important to pick up these cases during newborn screening and enroll them into a comprehensive care program with the other sickle cell disease patients with introduction of therapeutic interventions such as penicillin prophylaxis if required and pneumococcal immunization. In fact, 2 of our cases (No. 6 and 7) were identified during newborn screening for sickle cell disorders. The parents can be given information on home care and educated to detect symptoms that may lead to serious medical emergencies. The parents of these patients as well as the couples who are at risk of having a child with HbSDPunjab disease could also be counseled about the option of prenatal diagnosis in subsequent pregnancies. It is thus important to document the clinical and hematological presentation of compound heterozygotes with these common β globin chain variants.

Common Hematologic Problems in the Newborn Nursery

Jon F. Watchko
Pediatr Clin N Am – (2015) xxx-xxx
http://dx.doi.org/10.1016/j.pcl.2014.11.011

Common RBC disorders include hemolytic disease of the newborn, anemia, and polycythemia. Another clinically relevant hematologic issue in neonates to be covered herein is thrombocytopenia. Disorders of white blood cells will not be reviewed.

KEY POINTS

(1)               Early clinical jaundice or rapidly developing hyperbilirubinemia are often signs of hemolysis, the differential diagnosis of which commonly includes immune-mediated disorders, red-cell enzyme deficiencies, and red-cell membrane defects.

(2)             Knowledge of the maternal blood type and antibody screen is critical in identifying non-ABO alloantibodies in the maternal serum that may pose a risk for severe hemolytic disease in the newborn.

(3)             Moderate to severe thrombocytopenia in an otherwise well-appearing newborn strongly suggests immune-mediated (alloimmune or autoimmune) thrombocytopenia.

Hemolytic conditions in the neonate

1. Immune-mediated (positive direct Coombs test)  a. Rhesus blood group: Anti-D, -c, -C, -e, -E, CW, and several others

  b. Non-Rhesus blood groups: Kell, Duffy, Kidd, Xg, Lewis, MNS, and others

  c. ABO blood group: Anti-A, -B

2. Red blood cell (RBC) enzyme defects

  a. Glucose-6-phosphate dehydrogenase (G6PD) deficiency

  b. Pyruvate kinase deficiency

  c. Others

3. RBC membrane defects

  a. Hereditary spherocytosis

  b. Elliptocytosis

  c. Stomatocytosis

  d. Pyknocytosis

  e. Others

4. Hemoglobinopathies

  a. alpha-thalassemia

  b. gamma-thalassemia

Standard maternal antibody screeningAlloantibody                                 Blood Group

D, C, c, E, e, f, CW, V                     Rhesus

K, k, Kpa, Jsa                                  Kell

Fya, Fyb                                          Duffy

Jka, Jkb                                           Kidd

Xga                                                  Xg

Lea, Leb                                          Lewis

S, s, M, N                                        MNS

P1                                                    P

Lub                                                  Lutheran

Non-ABO alloantibodies reported to cause moderate to severe hemolytic disease of the newbornWithin Rh system: Anti-D, -c, -C, -Cw, -Cx, -e, -E, -Ew, -ce, -Ces, -Rh29, -Rh32, -Rh42, -f, -G, -Goa, -Bea, -Evans, -Rh17, -Hro, -Hr, -Tar, -Sec, -JAL, -STEM

Outside Rh system:  Anti-LW, -K, -k, -Kpa, -Kpb, -Jka, -Jsa, -Jsb, -Ku, -K11, -K22, -Fya, -M, -N, -S, -s, -U, -PP1 pk, -Dib, -Far, -MUT, -En3, -Hut, -Hil, -Vel, -MAM, -JONES, -HJK, -REIT

 

Red Blood Cell Enzymopathies

G6PD9 and pyruvate kinase (PK) deficiency are the 2 most common red-cell enzyme disorders associated with marked neonatal hyperbilirubinemia. Of these, G6PD deficiency is the more frequently encountered and it remains an important cause of kernicterus worldwide, including the United States, Canada, and the United Kingdom, the prevalence in Western countries a reflection in part of immigration patterns and intermarriage. The risk of kernicterus in G6PD deficiency also relates to the potential for unexpected rapidly developing extreme hyperbilirubinemia in this disorder associated with acute severe hemolysis.

Red Blood Cell Membrane Defects

Establishing a diagnosis of RBC membrane defects is classically based on the development of Coombs-negative hyperbilirubinemia, a positive family history, and abnormal RBC smear, albeit it is often difficult because newborns normally exhibit a marked variation in red-cell membrane size and shape. Spherocytes, however, are not often seen on RBC smears of hematologically normal newborns and this morphologic abnormality, when prominent, may yield a diagnosis of hereditary spherocytosis (HS) in the immediate neonatal period. Given that approximately 75% of families affected with hereditary spherocytosis manifest an autosomal dominant phenotype, a positive family history can often be elicited and provide further support for this diagnosis. More recently, Christensen and Henry highlighted the use of an elevated mean corpuscular hemoglobin concentration (MCHC) (>36.0 g/dL) and/or elevated ratio of MCHC to mean corpuscular volume, the latter they term the “neonatal HS index” (>0.36, likely >0.40) as screening tools for HS. An index of greater than 0.36 had 97% sensitivity, greater than 99% specificity, and greater than 99% negative predictive value for identifying HS in neonates. Christensen and colleagues also provided a concise update of morphologic RBC features that may be helpful in diagnosing this and other underlying hemolytic conditions in newborns.

The diagnosis of HS can be confirmed using the incubated osmotic fragility test when coupled with fetal red-cell controls or eosin-5-maleimide flow cytometry. One must rule out symptomatic ABO hemolytic disease by performing a direct Coombs test, as infants so affected also may manifest prominent micro-spherocytosis. Moreover, HS and symptomatic ABO hemolytic disease can occur in the same infant and result in severe hyperbilirubinemia and anemia.  Of other red-cell membrane defects, only hereditary elliptocytosis,  stomato-cytosis, and infantile pyknocytosis have been reported to exhibit significant hemolysis in the newborn period. Hereditary elliptocytosis and stomatocytosis are both rare. Infantile pyknocytosis, a transient red-cell membrane abnormality manifesting itself during the first few months of life, is more common.

Risk factors for bilirubin neurotoxicityIsoimmune hemolytic disease

G6PD deficiency

Asphyxia

Sepsis

Acidosis

Albumin less than 3.0 g/dL
Data from Maisels MJ, Bhutani VK, Bogen D, et al. Hyperbilirubinemia in the newborn infant > or 535 weeks’ gestation: an update with clarifications. Pediatrics 2009; 124:1193–8.

Polycythemia

Polycythemia (venous hematocrit 65%) in seen in infants across a range of conditions associated with active erythropoiesis or passive transfusion.76,77 They include, among others, placental insufficiency, the infant of a diabetic mother, recipient in twin-twin transfusion syndrome, and several aneuploidies, including trisomy. The clinical concern related to polycythemia is the risk for microcirculatory complications of hyperviscosity. However, determining which polycythemic infants are hyperviscous and when to intervene is a challenge.

 

 

Liver

Metabolic disorders presenting as liver disease

Germaine Pierre, Efstathia Chronopoulou
Paediatrics and Child Health 2013; 23(12): 509-514
The liver is a highly metabolically active organ and many inherited metabolic disorders have hepatic manifestations. The clinical presentation in these patients cannot usually be distinguished from liver disease due to acquired causes like infection, drugs or hematological disorders. Manifestations include acute and chronic liver failure, cholestasis and hepatomegaly. Metabolic causes of acute liver failure in childhood can be as high as 35%. Certain disorders like citrin deficiency and Niemann-Pick C disease may present in infancy with self-limiting cholestasis before presenting in later childhood or adulthood with irreversible disease. This article reviews important details from the history and clinical examination when evaluating the pediatric patient with suspected metabolic disease, the specialist and genetic tests when investigating, and also discusses specific disorders, their clinical course and treatment. The role of liver transplantation is also briefly discussed. Increased awareness of this group of disorders is important as in many cases, early diagnosis leads to early intervention with improved outcome. Diagnosis also allows genetic counselling and future family planning.

Adult liver disorders caused by inborn errors of metabolism: Review and update

Sirisak Chanprasert, Fernando Scaglia
Molecular Genetics and Metabolism 114 (2015) 1–10
http://dx.doi.org/10.1016/j.ymgme.2014.10.011

Inborn errors of metabolism (IEMs) are a group of genetic diseases that have protean clinical manifestations and can involve several organ systems. The age of onset is highly variable but IEMs afflict mostly the pediatric population. However, in the past decades, the advancement in management and new therapeutic approaches have led to the improvement in IEM patient care. As a result, many patients with IEMs are surviving into adulthood and developing their own set of complications. In addition, some IEMs will present in adulthood. It is important for internists to have the knowledge and be familiar with these conditions because it is predicted that more and more adult patients with IEMs will need continuity of care in the near future. The review will focus on Wilson disease, alpha-1 antitrypsin deficiency, citrin deficiency, and HFE-associated hemochromatosis which are typically found in the adult population. Clinical manifestations and pathophysiology, particularly those that relate to hepatic disease as well as diagnosis and management will be discussed in detail.

Inborn errors of metabolism (IEMs) are a group of genetic diseases characterized by abnormal processing of biochemical reactions, resulting in accumulation of toxic substances that could interfere with normal organ functions, and failure to synthesize essential compounds. IEMs are individually rare, but collectively numerous. The clinical presentations cover a broad spectrum and can involve almost any organ system. The age of onset is highly variable but IEMs afflict mostly the pediatric population.

Wilson disease is an autosomal recessive genetic disorder of copper metabolism. It is characterized by an abnormal accumulation of inorganic copper in various tissues, most notably in the liver and the brain, especially in the basal ganglia. The disease was first described in 1912 by Kinnier Wilson, and affects between 1 in 30,000 and 1 in 100,000 individuals. Clinical features are variable and depend on the extent  and the severity of copper deposition. Typically, patients tend to develop hepatic disease at a younger age than the neuropsychiatric manifestations. Individuals withWilson disease eventually succumb to complications of end stage liver disease or become debilitated from neurological problems, if they are left untreated.

The clinical presentations of Wilson disease are varied affecting many organ systems. However, the overwhelming majority of cases display hepatic and neurologic symptoms. In general, patients with hepatic disease present between the first and second decades of life although patients as young as 3 years old or over 50 years old have also been reported. The most common modes of presentations are acute self-limited hepatitis and chronic active hepatitis that are indistinguishable from other hepatic disorders although liver aminotransferases are generally much lower than in autoimmune or viral hepatitis. Acute fulminant hepatic failure is less common but is observed in approximately 3% of all cases of acute liver failure. Symptoms of acute liver failure include jaundice, coagulopathy, and hepatic encephalopathy. Cirrhosis can develop over time and may be clinically silent. Hepatocellular carcinoma (HCC) is rarely associated with Wilson disease, but may occur in the setting of cirrhosis and chronic inflammation.

Copper is an essential element, and is required for the proper functioning of various proteins and enzymes. The total body content of copper in a healthy adult individual is approximately 70–100 mg, while the daily requirements are estimated to be between 1 and 5 mg. Absorption occurs in the small intestine. Copper is taken up to the hepatocytes via the copper transporter hTR1. Once inside the cell, copper is bound to various proteins including metallothionein and glutathione, however, it is the metal chaperone, ATOX1 that helps direct copper to the ATP7B protein for intracellular transport and excretion. At the steady state, copper will be bound to ATP7B and is then incorporated to ceruloplasmin and secreted into the systemic circulation. When the cellular copper concentration arises, ATP7B protein will be redistributed from the trans-Golgi network to the prelysosomal vesicles facilitating copper excretion into the bile. The molecular defects in ATP7B lead to a reduction of copper excretion. Excess copper is accumulated in the liver causing tissue injury. The rate of accumulation of copper varies among individuals, and it may depend on other factors such as alcohol consumption, or viral hepatitis infections. If the liver damage is not severe, patients will accumulate copper in various tissues including the brain, the kidney, the eyes, and the musculoskeletal system leading to clinical disease. A failure of copper to incorporate into ceruloplasmin leads to secretion of the unsteady protein that has a shorter half-life, resulting in the reduced concentrations of ceruloplasmin seen in most patients with Wilson disease.

Wilson disease used to be a progressive fatal condition during the first half of the 20th century because there was no effective treatment available at that time. Penicillamine was the first pharmacologic agent introduced in 1956 for treating this condition. Penicillamine is a sulfhydryl-bearing amino acid cysteine doubly substituted with methyl groups. This drug acts as a chelating agent that promotes the urinary excretion of copper. It is rapidly absorbed in the gastrointestinal track, and over 80% of circulating penicillamine is excreted via the kidneys. Although it is very effective, approximately 10%–50% of Wilson disease patients with neuropsychiatric presentations may experience worsening of their symptoms, and often times the worsening symptoms may not be reversible.

Alpha1-antitrypsin deficiency

Alpha1-antitrypsin deficiency (AATD) is one of the most common genetic liver diseases in children and adults, affecting 1 in 2000 to 1 in 3000 live births worldwide. It is transmitted in an autosomal co-dominant fashion with variable expressivity. Alpha1 antitrypsin (A1AT) is a member of the serine protease inhibitor (SERPIN) family. Its function is to counteract the proteolytic effect of neutrophil elastase and other neutrophil proteases. Mutations in the SERPINA1, the gene encoding A1AT, result in changes in the protein structure with the PiZZ phenotype being the most common cause of liver and lung disease-associated AATDs. Although, it classically causes early onset chronic obstructive pulmonary disease (COPD) in adults, liver disease characterized by chronic inflammation, hepatic fibrosis, and cirrhosis is not uncommon in the adult population. Decreased plasma concentration of A1AT predisposes lung tissue to be more susceptible to injury from protease enzymes. However, the underlying mechanism of liver injury is different, and is believed to be caused by accumulation of polymerized mutant A1AT in the hepatocyte endoplasmic reticulum (ER). Currently, there is no specific treatment for liver disease-associated AATD, but A1AT augmentation therapy is available for patients affected with pulmonary involvement.

A1AT is a single-chain, 52-kDa polypeptide of approximately 394 amino acids [56]. It is synthesized in the liver, circulates in the plasma, and functions as an inhibitor of neutrophil elastase and other proteases such as cathepsin G, and proteinase 3. A1AT has a globular shape composed of two central β sheets surrounded by a small β sheet and nine α helices. The pathophysiology underlying liver disease is thought to be a toxic gain-of-function mutation associated with the PiZZ phenotypes. This hypothesis has been supported by the fact that null alleles which produce no detectable plasma A1AT, are not associated with liver disease. In addition, the transgenic mouse model of AATD PiZZ developed periodic acid-Schiff-positive diastase-resistant intrahepatic globule early in life similar to AATD patients. The PiZZ phenotype results in the blockade of the final processing of A1AT in the liver, as only 15% of the A1AT reaches the circulation whereas 85% of non-secreted protein is accumulated in the hepatocytes.

Citrin deficiency

Citrin deficiency is a relatively newly-defined autosomal recessive disease. It encompasses two different sub-groups of patients, neonatal intrahepatic cholestasis caused by citrin deficiency (NICCD), and adult onset citrullinemia type 2 (CTLN 2).

AGC2 exports aspartate out of the mitochondrial matrix in exchange for glutamate and a proton. Thus, this protein has an important role in ureagenesis and gluconeogenesis. In CTLN2, a defect in this protein is believed to limit the supply of aspartate for the formation of argininosuccinate in the cytosol resulting in impairment of ureagenesis. Interestingly, the mouse model of citrin deficiency (Ctrn−/−) fails to develop symptoms of CTLN2 suggesting that the mitochondrial aspartate is not the only source of ureagenesis. However, it should be noted that the rodent liver expresses higher glycerol-phosphate shuttle activity than the human counterpart. With the intact glycerol-phosphate dehydrogenase, it can compensate for the deficiency of AGC2, as demonstrated by the AGC2 and glycerol-phosphate dehydrogenase double knock-out mice that exhibit similar features to those observed in human CTLN2.

HFE-associated hemochromatosis

HFE-associated hemochromatosis is an inborn error of iron metabolism characterized by excessive iron storage resulting in tissue and organ damage. It is the most common autosomal recessive disorder in the Caucasian population, affecting 0.3%–0.5% of individuals of Northern European descent. The term “hemochromatosis” was coined in 1889 by the German pathologist Friedrich Daniel Von Recklinghausen, who described it as bronze stain of organs caused by a blood borne pigment.

The classic clinical triad of cirrhosis, diabetes, and bronze skin pigmentation is rarely observed nowadays given the early recognition, diagnosis, and treatment of this condition. The most common presenting symptoms are nonspecific including weakness, lethargy, and arthralgia.

The liver is a major site of iron storage in healthy individuals and as such it is the organ that is universally affected in HFE-associated hemochromatosis. Elevation of liver aminotransferases indicative of hepatocyte injury is the most common mode of presentation and it can be indistinguishable from other causes of hepatitis. Approximately 15%–40% of patients with HFE-associated hemochromatosis have other liver conditions, including chronic viral hepatitis B or C infection, nonalcoholic fatty liver disease, and alcoholic liver disease.

 

The liver in haemochromatosis

Rune J. Ulvik
Journal of Trace Elements in Medicine and Biology xxx (2014) xxx–xxx
http://dx.doi.org/10.1016/j.jtemb.2014.08.005

The review deals with genetic, regulatory and clinical aspects of iron homeostasis and hereditary hemochromatosis. Hemochromatosis was first described in the second half of the 19th century as a clinical entity characterized by excessive iron overload in the liver. Later, increased absorption of iron from the diet was identified as the pathophysiological hallmark. In the 1970s genetic evidence emerged supporting the apparent inheritable feature of the disease. And finally in 1996 a new “hemochromato-sis gene” called HFE was described which was mutated in about 85% of the patients. From the year2000 onward remarkable progress was made in revealing the complex molecular regulation of iron trafficking in the human body and its disturbance in hemochromatosis. The discovery of hepcidin and ferroportin and their interaction in regulating the release of iron from enterocytes and macrophages to plasma were important milestones. The discovery of new, rare variants of non-HFE-hemochromatosis was explained by mutations in the multicomponent signal transduction pathway controlling hepcidin transcription. Inhibited transcription induced by the altered function of mutated gene products, results in low plasma levels of hepcidin which facilitate entry of iron from enterocytes into plasma. In time this leads to progressive accumulation of iron and subsequently development of disease in the liver and other parenchymatous organs. Being the major site of excess iron storage and hepcidin synthesis the liver is a cornerstone in maintaining normal systemic iron homeostasis. Its central pathophysiological role in HFE-hemochromatosis with downgraded hepcidin synthesis, was recently shown by the finding that liver transplantation normalized the hepcidin levels in plasma and there was no sign of iron accumulation in the new liver.

Gastrointestinal

Decoding the enigma of necrotizing enterocolitis in premature infants

Roberto Murgas TorrazzaNan Li, Josef Neu
Pathophysiology 21 (2014) 21–27
http://dx.doi.org/10.1016/j.pathophys.2013.11.011

Necrotizing enterocolitis (NEC) is an enigmatic disease that affects primarily premature infants. It often occurs suddenly and when it occurs, treatment attempts at treatment often fail and results in death. If the infant survives, there is a significant risk of long term sequelae including neurodevelopmental delays. The pathophysiology of NEC is poorly understood and thus prevention has been difficult. In this review, we will provide an overview of why progress may be slow in our understanding of this disease, provide a brief review diagnosis, treatment and some of the current concepts about the pathophysiology of this disease.

Necrotizing enterocolitis (NEC) has been reported since special care units began to house preterm infants .With the advent of modern neonatal intensive care approximately 40 years ago, the occurrence and recognition of the disease markedly increased. It is currently the most common and deadly gastro-intestinal illness seen in preterm infants. Despite major efforts to better understand, treat and prevent this devastating disease, little if any progress has been made during these 4 decades. Underlying this lack of progress is the fact that what is termed “NEC” is likely more than one disease, or mimicked by other diseases, each with a different etiopathogenesis.

Human gut microbiome

Human gut microbiome

Term or near term infants with “NEC” when compared to matched controls usually have occurrence of their disease in the first week after birth, have a significantly higher frequency of prolonged rupture of membranes, chorio-amnionitis, Apgar score <7 at 1 and 5 min, respiratory problems, congenital heart disease, hypoglycemia, and exchange transfusions. When a “NEC” like illness presents in term or near term infants, it should be noted that these are likely to be distinct in pathogenesis than the most common form of NEC and should be differentiated as such.

The infants who suffer primary ischemic necrosis are term or near term infants (although this can occur in preterms) who have concomitant congenital heart disease, often related to poor left ventricular output or obstruction. Other factors that have been associated with primary ischemia are maternal cocaine use, hyperviscosity caused by polycythemia or a severe antecedent hypoxic–ischemic event. Whether the dis-ease entity that results from this should be termed NEC can be debated on historical grounds, but the etiology is clearly different from the NEC seen in most preterm infants.

The pathogenesis of NEC is uncertain, and the etiology seems to be multifactorial. The “classic” form of NEC is highly associated with prematurity; intestinal barrier immaturity, immature immune response, and an immature regulation of intestinal blood flow (Fig.). Although genetics appears to play a role, the environment, especially a dysbiotic intestinal microbiota acting in concert with host immaturities predisposes the preterm infant to disruption of the intestinal epithelia, increased permeability of tight junctions, and release of inflammatory mediators that leads to intestinal mucosa injury and therefore development of necrotizing enterocolitis.

NEC is a multifactorial disease

NEC is a multifactorial disease

What causes NEC? NEC is a multifactorial disease with an interaction of several etiophathologies

It is clear from this review that there are several entities that have been described as NEC. What is also clear is that despite having some overlap in the final parts of the pathophysiologic cascade that lead to necrosis, the disease that is most commonly seen in the preterm infant is likely to have an origin that differs markedly from that seen in term infants with congenital heart disease or severe hypoxic–ischemic injury. Thus, epidemiologic studies will need to differentiate these entities, if the aim is to dissect common features that are most highly associated with development of the disease. At this juncture, we areleft with more of a population based preventative approach, where the use of human milk, evidence based feeding guide-lines, considerations for microbial therapy once these are proved safe and effective and approved as such by regulatory authorities, and perhaps even measures that prevent prematurity will have a major impact on this devastating disease.

Influenced by the microbiota, intestinal epithelial cells (IECs) elaborate cytokines

Influenced by the microbiota, intestinal epithelial cells (IECs) elaborate cytokines

Influenced by the microbiota, intestinal epithelial cells (IECs) elaborate cytokines, including thymic stromal lymphoprotein (TSLP), transforming growthfactor (TGF), and interleukin-10 (IL-10), that can influence pro-inflammatory cytokine production by dendritic cells (DC) and macrophages present in the laminapropria (GALT) and Peyer’s patches. Signals from commensal organisms may influence tissue-specific functions, resulting in T-cell expansion and regulation of the numbers of Th-1,
Th-2, and Th-3 cells. Also modulated by the microbiota, other IEC derived factors, including APRIL (a proliferation-inducing ligand),B-cell activating factor (BAFF), secretory leukocyte peptidase inhibitor (SLPI), prostaglandin E2(PGE2), and other metabolites, directly regulate functions ofboth antigen presenting cells and lymphocytes in the intestinal ecosystem. NK: natural killer cell; LN: lymph node; DC: dendritic cells.Modified from R. Sharma, C. Young, M. Mshvildadze, J. Neu, Intestinal microbiota does it play a role in diseases of the neonate? NeoReviews 10 (4) (2009)e166, with permission

Cross-talk between monocyte.macrophage cells and T.NK lymphocytes

Cross-talk between monocyte.macrophage cells and T.NK lymphocytes

Current Issues in the Management of Necrotizing Enterocolitis

Marion C. W. Henry and R. Lawrence Moss
Seminars in Perinatology, 2004; 28(3): 221-233
http://dx.doi.org:/10.1053/j.semperi.2004.03.010

Necrotizing enterocolitis is almost exclusively a disease of prematurity, with 90% of all cases occurring in premature infants and 90% of those infants weighing less than 2000 g. Prematurity is the only risk factor for necrotizing enterocolitis consistently identified in case control studies and the disease is rare in countries where prematurity is uncommon such as Japan and Sweden. When necrotizing enterocolitis does occur in full-term infants, it appears to by a somewhat different disease, typically associated with some predisposing condition.

NEC occurs in one to three in 1,000 live births and most commonly affects babies born between 30-32 weeks. It is most often diagnosed during the second week of life and occurs more often in previously fed infants. The mortality from NEC has been cited as 10% to 50% of all NEC cases. Surgical mortality has decreased over the last several decades from 70% to between 20 and 50%. The incremental cost per case of acute hospital care is estimated at $74 to 186 thousand compared to age matched controls, not including additional costs of long term care for the infants’ with lifelong morbidity. Survivors may develop short bowel syndrome, recurrent bouts of catheter-related sepsis, malabsorption, malnutrition, and TPN induced liver failure.

Although extensive research concerning the pathophysiology of necrotizing enterocolitis has occurred, a complete understanding has not been fully elucidated. The classic histologic finding is coagulation necrosis; present in over 90% of specimens. This finding suggests the importance of ischemia in the pathogenesis of NEC. Inflammation and bacterial overgrowth also are present. These findings support the assumptions by Kosloske that NEC occurs by the interaction of 3 events:

  • intestinal ischemia,
  • colonization by pathogenic bacteria and
  • excess protein substrate in the intestinal lumen.

Additionally, the immunologic immaturity of the neonatal gut has been implicated in the development of NEC. Reparative tissue changes including epithelial regeneration, formation of granulation tissue and fibrosis, and mixed areas of acute and chronic inflammatory changes suggest that the pathogenesis of NEC may involve a chronic process of injury and repair.

Premature newborns born prior to the 32nd week of gestational age may have compromised intestinal peristalsis and decreased motility. These motility problems may lead to poor clearance of bacteria, and subsequent bacterial overgrowth. Premature infants also have an immature intestinal tract in terms of immunologic immunity.

There are fewer functional B lymphocytes present and the ability to produce sufficient secretory IgA is reduced. Pepsin, gastric acid and mucus are also not produced as well in prematurity. All of these factors may contribute to the limited proliferation of intestinal flora and the decreased binding of these flora to mucosal cells (Fig).

Role of nitric oxide in the pathogenesis of NEC

Role of nitric oxide in the pathogenesis of NEC

Role of nitric oxide in the pathogenesis of NEC.

Characteristics of the immature gut leading to increased risk of necrotizing enterocolitis

Characteristics of the immature gut leading to increased risk of necrotizing enterocolitis

Characteristics of the immature gut leading to increased risk of necrotizing enterocolitis.

As understanding of the pathophysiology of necrotizing enterocolitis continues to evolve, a unifying concept is emerging. Initially, there is likely a subclinical insult leading to NEC. This may arise from a brief episode of hypoxia or infection. With colonization of the intestines, bacteria bind to the injured mucosa eliciting an inflammatory response which leads to further inflammation.

Intestinal Microbiota Development in Preterm Neonates and Effect of Perinatal Antibiotics

Silvia Arboleya, Borja Sanchez,, Christian Milani, Sabrina Duranti, et al.
Pediatr 2014;-:—).  http://dx.doi.org/10.1016/j.jpeds.2014.09.041

Objectives Assess the establishment of the intestinal microbiota in very low birth-weight preterm infants and to evaluate the impact of perinatal factors, such as delivery mode and perinatal antibiotics.
Study design We used 16S ribosomal RNA gene sequence-based microbiota analysis and quantitative polymerase chain reaction to evaluate the establishment of the intestinal microbiota. We also evaluated factors affecting the microbiota, during the first 3 months of life in preterm infants (n = 27) compared with full-term babies (n = 13).
Results Immaturity affects the microbiota as indicated by a reduced percentage of the family Bacteroidaceae during the first months of life and by a higher initial percentage of Lactobacillaceae in preterm infants compared with full term infants. Perinatal antibiotics, including intrapartum antimicrobial prophylaxis, affects the gut microbiota, as indicated by increased Enterobacteriaceae family organisms in the infants.

Human gut microbiome

Human gut microbiome

Conclusions Prematurity and perinatal antibiotic administration strongly affect the initial establishment of microbiota with potential consequences for later health.

Ischemia and necrotizing enterocolitis: where, when, and how

Philip T. Nowicki
Seminars in Pediatric Surgery (2005) 14, 152-158
http://dx.doi.org:/10.1053/j.sempedsurg.2005.05.003

While it is accepted that ischemia contributes to the pathogenesis of necrotizing enterocolitis (NEC), three important questions regarding this role subsist. First, where within the intestinal circulation does the vascular pathophysiology occur? It is most likely that this event begins within the intramural microcirculation, particularly the small arteries that pierce the gut wall and the submucosal arteriolar plexus insofar as these represent the principal sites of resistance regulation in the gut. Mucosal damage might also disrupt the integrity or function of downstream villous arterioles leading to damage thereto; thereafter, noxious stimuli might ascend into the submucosal vessels via downstream venules and lymphatics. Second, when during the course of pathogenesis does ischemia occur? Ischemia is unlikely to the sole initiating factor of NEC; instead, it is more likely that ischemia is triggered by other events, such as inflammation at the mucosal surface. In this context, it is likely that ischemia plays a secondary, albeit critical role in disease extension. Third, how does the ischemia occur? Regulation of vascular resistance within newborn intestine is principally determined by a balance between the endothelial production of the vasoconstrictor peptide endothelin-1 (ET-1) and endothelial production of the vasodilator free radical nitric oxide (NO). Under normal conditions, the balance heavily favors NO-induced vasodilation, leading to a low resting resistance and high rate of flow. However, factors that disrupt endothelial cell function, eg, ischemia-reperfusion, sustained low-flow perfusion, or proinflammatory mediators, alter the ET-1:NO balance in favor of constriction. The unique ET-1–NO interaction thereafter might facilitate rapid extension of this constriction, generating a viscous cascade wherein ischemia rapidly extends into larger portions of the intestine.

Schematic representation of the intestinal microcirculation

Schematic representation of the intestinal microcirculation

Schematic representation of the intestinal microcirculation. Small mesenteric arteries pierce the muscularis layers and terminate in the submucosa where they give rise to 1A (1st order) arterioles. 2A (2nd order) arterioles arise from the 1A. Although not shown here, these 2A arterioles connect merge with several 1A arterioles, thus generating an arteriolar plexus, or manifold that serves to pressurize the terminal downstream microvasculature. 3A (3rd order) arterioles arise from the 2A and proceed to the mucosa, giving off a 4A branch just before descent into the mucosa. This 4A vessel travels to the muscularis layers. Each 3A vessel becomes the single arteriole perfusing each villus.

Collectively, these studies indicate that disruption of endothelial cell function has the potential to disrupt the normal balance between NO and ET-1 within the newborn intestinal circulation, and that such an event can generate significant ischemia. In this context, it is important to note that NO and ET-1 each regulate the expression and activity of the other. An increased [NO] within the microvascular environment reduces ET-1 expression and compromises ligand binding to the ETA receptor (thus decreasing its contractile efficacy), while ET-1 compromises eNOS expression. Thus, factors that upset the balance between NO and ET-1 will have an immediate and direct effect on vascular tone, but also exert an additional indirect effect by extenuating the disruption of balance between these two factors.

It is not difficult to construct a hypothesis that links the perturbations of I/R and sustained low-flow perfusion with an initial inflammatory insult. Initiation of an inflammatory process at the mucosal–luminal interface could have a direct impact on villus and mucosal 3A arterioles, damaging arteriolar integrity and disrupting villus hemodynamics. Ascent of proinflammatory mediators to the submucosal 1A–2A arteriolar plexus could occur via draining venules and lymphatics, generating damage to vascular effector systems therein; these mediators might include cytokines and platelet activating factor, as these elements have been recovered from human infants with NEC. This event, coupled with a generalized loss of 3A flow throughout a large portion of the mucosal surface, could compromise flow rate within the submucosal arteriolar plexus.

Necrotizing enterocolitis: An update

Loren Berman, R. Lawrence Moss
Seminars in Fetal & Neonatal Medicine 16 (2011) 145e150
http://dx.doi.org:/10.1016/j.siny.2011.02.002

Necrotizing enterocolitis (NEC) is a leading cause of death among patients in the neonatal intensive care unit, carrying a mortality rate of 15e30%. Its pathogenesis is multifactorial and involves an over reactive response of the immune system to an insult. This leads to increased intestinal permeability, bacterial translocation, and sepsis. There are many inflammatory mediators involved in this process, but thus far none has been shown to be a suitable target for preventive or therapeutic measures. NEC usually occurs in the second week of life after the initiation of enteral feeds, and the diagnosis is made based on physical examination findings, laboratory studies, and abdominal radiographs. Neonates with NEC are followed with serial abdominal examinations and radiographs, and may require surgery or primary peritoneal drainage for perforation or necrosis. Many survivors are plagued with long term complications including short bowel syndrome, abnormal growth, and neurodevelopmental delay. Several evidence-based strategies exist that may decrease the incidence of NEC including promotion of human breast milk feeding, careful feeding advancement, and prophylactic probiotic administration in at-risk patients. Prevention is likely to have the greatest impact on decreasing mortality and morbidity related to NEC, as little progress has been made with regard to improving outcomes for neonates once the disease process is underway.

Immune Deficiencies

Primary immunodeficiencies: A rapidly evolving story

Nima Parvaneh, Jean-Laurent Casanova,  LD Notarangelo, ME Conley
J Allergy Clin Immunol 2013;131:314-23.
http://dx.doi.org/10.1016/j.jaci.2012.11.051

The characterization of primary immunodeficiencies (PIDs) in human subjects is crucial for a better understanding of the biology of the immune response. New achievements in this field have been possible in light of collaborative studies; attention paid to new phenotypes, infectious and otherwise; improved immunologic techniques; and use of exome sequencing technology. The International Union of Immunological Societies Expert Committee on PIDs recently reported on the updated classification of PIDs. However, new PIDs are being discovered at an ever-increasing rate. A series of 19 novel primary defects of immunity that have been discovered after release of the International Union of Immunological Societies report are discussed here. These new findings highlight the molecular pathways that are associated with clinical phenotypes and suggest potential therapies for affected patients.

Combined Immunodeficiencies

  • T-cell receptor a gene mutation: T-cell receptor ab1 T-cell depletion

T cells comprise 2 distinct lineages that express either ab or gd T-cell receptor (TCR) complexes that perform different tasks in immune responses. During T-cell maturation, the precise order and efficacy of TCR gene rearrangements determine the fate of the cells. Productive β-chain gene rearrangement produces a pre-TCR on the cell surface in association with pre-Tα invariant peptide (β-selection). Pre-TCR signals promote α-chain recombination and transition to a double-positive stage (CD41CD81). This is the prerequisite for central tolerance achieved through positive and negative selection of thymocytes.

  • Ras homolog gene family member H deficiency: Loss of naive T cells and persistent human papilloma virus infections
  • MST1 deficiency: Loss of naive T cells

New insight into the role of MST1 as a critical regulator of T-cell homing and function was provided by the characterization of 8 patients from 4 unrelated families who had homozygous nonsense mutations in STK4, the gene encoding MST1. MST1 was originally identified as an ubiquitously expressed kinase with structural homology to yeast Ste. MST1 is the mammalian homolog of the Drosophila Hippo protein, controlling cell growth, apoptosis, and tumorigenesis. It has both proapoptotic and antiapoptotic functions.

  • Lymphocyte-specific protein tyrosine kinase deficiency: T-cell deficiency with CD41 lymphopenia

Defects in pre-TCR– and TCR-mediated signaling lead to aberrant T-cell development and function (Fig). One of the earliest biochemical events occurring after engagement of the (pre)-TCR is the activation of lymphocyte-specific protein tyrosine kinase (LCK), a member of the SRC family of protein tyrosine kinases. This kinase then phosphorylates immunoreceptor tyrosine-based activation motifs of intracellular domains of CD3 subunits. Phosphorylated immunoreceptor tyrosine-based activation motifs recruit z-chain associated protein kinase of 70 kDa, which, after being phosphorylated by LCK, is responsible for activation of critical downstream events. Major consequences include activation of the membrane-associated enzyme phospholipase Cg1, activation of the mitogen-activated protein kinase, nuclear translocation of nuclear factor kB (NFkB), and Ca21/Mg21 mobilization. Through these pathways, LCK controls T-cell development and activation. In mice lacking LCK, T-cell development in the thymus is profoundly blocked at an early double-negative stage.

TCR signaling

TCR signaling

TCR signaling. Multiple signal transduction pathways are stimulated through the TCR. These pathways collectively activate transcription factors that organize T-cell survival, proliferation, differentiation, homeostasis, and migration. Mutant molecules in patients with TCR-related defects are indicated in red.

  • Uncoordinated 119 deficiency: Idiopathic CD41 lymphopenia

Idiopathic CD41 lymphopenia (ICL) is a very heterogeneous clinical entity that is defined, by default, by persistent CD41 T-cell lymphopenia (<300 cells/mL or <20% of total T cells) in the absence of HIV infection or any other known cause of immunodeficiency.

Well-Defined Syndromes with Immunodeficiency

  • Wiskott-Aldrich syndrome protein–interacting protein deficiency: Wiskott-Aldrich syndrome-like phenotype

In hematopoietic cells Wiskott-Aldrich syndrome protein (WASP) is stabilized through forming a complex with WASP interacting protein (WIP).

  • Phospholipase Cg2 gain-of-function mutations: Cold urticaria, immunodeficiency, and autoimmunity/autoinflammatory

This is a unique phenotype, sharing features of antibody deficiency, autoinflammatory diseases, and immune dysregulatory disorders, making its classification difficult. Two recent studies validated the pleiotropy of genetic alterations in the same gene.

Predominantly Antibody Defects

  • Defect in the p85a subunit of phosphoinositide 3-kinase: Agammaglobulinemia and absent B cells
  • CD21 deficiency: Hypogammaglobulinemia
  • LPS-responsive beige-like anchor deficiency:
  • Hypogammaglobulinemia with autoimmunity and

early colitis

Defects Of Immune Dysregulation

  • Pallidin deficiency: Hermansky-Pudlak syndrome type 9
  • CD27 deficiency: Immune dysregulation and
  • persistent EBV infection

Congenital Defects Of Phagocyte Number, Function, Or Both

  • Interferon-stimulated gene 15 deficiency: Mendelian susceptibility to mycobacterial diseases

Defects In Innate Immunity

  • NKX2-5 deficiency: Isolated congenital asplenia
  • Toll/IL-1 receptor domain–containing adaptor inducing IFN-b and TANK-binding kinase 1 deficiencies: Herpes simplex encephalitis
  • Minichromosome maintenance complex component 4 deficiency: NK cell deficiency associated with growth retardation and adrenal insufficiency

Autoinflammatory Disorders

  • A disintegrin and metalloproteinase 17 deficiency: Inflammatory skin and bowel disease

 

Cross-talk between monocyte.macrophage cells and T.NK lymphocytes

Cross-talk between monocyte.macrophage cells and T.NK lymphocytes

Cross-talk between monocyte/macrophage cells and T/NK lymphocytes. Genes in the IL-12/IFN-g pathway are particularly important for protection against mycobacterial disease. IRF8 is an IFN-g–inducible transcription factor required for the induction of various target genes, including IL-12. The NF-kB essential modulator (NEMO) mutations in the LZ domain impair CD40-NEMO–dependent pathways. Some gp91phox mutations specifically abolish the respiratory burst in monocyte-derived macrophages. ISG15 is secreted by neutrophils and potentiates IFN-g production by NK/T cells. Genetic defects that preclude monocyte development (eg, GATA2) can also predispose to mycobacterial infections (not shown). Mutant molecules in patients with unusual susceptibility to infection are indicated in red.

The field of PIDs is advancing at full speed in 2 directions. New genetic causes of known PIDs are being discovered (eg, CD21 and TRIF). Moreover, new phenotypes qualify as PIDs with the identification of a first genetic cause (eg, generalized pustular psoriasis). Recent findings contribute fundamental knowledge about immune system biology and its perturbation in disease. They are also of considerable clinical benefit for the patients and their families. A priority is to further translate these new discoveries into improved diagnostic methods and more effective therapeutic strategies, promoting the well-being of patients with PIDs.

Primary immunodeficiencies

Luigi D. Notarangelo
J Allergy Clin Immunol 2010; 125(2): S182-194
http://dx.doi.org:/10.1016/j.jaci.2009.07.053

In the last years, advances in molecular genetics and immunology have resulted in the identification of a growing number of genes causing primary immunodeficiencies (PIDs) in human subjects and a better understanding of the pathophysiology of these disorders. Characterization of the molecular mechanisms of PIDs has also facilitated the development of novel diagnostic assays based on analysis of the expression of the protein encoded by the PID-specific gene. Pilot newborn screening programs for the identification of infants with severe combined immunodeficiency have been initiated. Finally, significant advances have been made in the treatment of PIDs based on the use of subcutaneous immunoglobulins, hematopoietic cell transplantation from unrelated donors and cord blood, and gene therapy. In this review we will discuss the pathogenesis, diagnosis, and treatment of PIDs, with special attention to recent advances in the field.

 

 

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Graft-versus-Host Disease

Writer and Curator: Larry H. Bernstein, MD, FCAP 

 

Introduction

This piece is a follow up to the article on allogeneic transfusion reactions, which extends into transplantation and transplantation outcomes for hematological diseases, both malignant and nonmalignant. The safety of transfusions in Western countries has improved substantially, and the causes for transfusion mishaps has been reduced to unexpected infectious sources, uncommon immune incompatibilities, and errors in processing the blood products.  The greatest risk is incurred in platelet transfusions because of the short shelf-life of the product, and the time needed for testing prior to release.  This portion of the review is concerned with Graft-versus-Host Disease, which is unique to transfusion and transplanting of blood. In other transplantation, there is graft failure because of host versus graft incompatibility or complications.  The reverse order applies to blood.  In this case, on the contrary, the transfused or grafted donor tissue becomes a pursuer after the recipients hematopoietic cells.

Peter Brian Medawar: Father of Transplantation

Thomas E. Starzl, M.D., PH.D., F.A.C.S.
J Am Coll Surg. 1995 Mar; 180(3): 332–336

Most of the surgical specialities can be tracked to the creative vision of a surgeon. Transplantation is an exception. Here, the father of the field is succinctly defined in the dictionary as: “Peter Brian Medawar: a Brazilian born British Zoologist who at the age of 45 shared a 1960 Nobel Prize for his work on acquired immunologic tolerance”. Medawar was mysteriously overwhelming to many colleagues and observers, even when he was young. He was the son of a Lebanese father and an English mother—tall, athletic, abnormally handsome, hypnotically articulate in public, and politely cordial in his personal relations. In September 1969, at the age of 54, he had the first of a series of strokes. These crippled him physically but not in spirit. Although I saw Medawar often professionally and privately over a 22 year period, before and after he was disabled, this sporadic exposure was not enough to understand him. My sense is that no one did, except perhaps Jean, his wife for nearly 50 years.

Medawar’s dazzling personality before and great courage after his strokes was inspirational, but his fame was based on the unique achievement in 1953 captured by the terse dictionary mention of “acquired immunologic tolerance.” The roots leading to this accomplishment had fed on the blood of war. More than 12 years earlier, the recently wed zoologist Medawar—24 years of age and fresh from graduate studies at Oxford University—was assigned to
the service of the British surgeon, Dr. Thomas Gibson, to determine if skin allografts could be used to treat casualties from the Battle of Britain. First,
in human studies with Gibson, and then with simple and logical rabbit experiments, Medawar showed that rejection of the skin was an immunologic phenomenon. This later was shown  to be analogous to the cell-mediated delayed hypersensitivity that confers immunity to diseases such as tuberculosis. The principal evidence in the early studies was that repetitive grafts from the same donor were rejected more rapidly with each successive attempt —the sensitization and donor specificity confirming an earlier clinical observations by Emil Holman of Stanford in skin-grafted burn victims. Once it was established that rejection was an immune reaction, strategies began to evolve to weaken the recipient immune system. By 1953, total body irradiation and adrenal cortical steroids had been shown to delay skin rejection. However, this immunosuppressive effect was either minor if the animals survived, or lethal to the recipient if the grafts were spared.

Bombshell

In the resulting atmosphere of nihilism about clinical applications, a three and one-half page article by Billingham, Brent, and Medawar in the October 3, 1953 issue of Nature describing acquired tolerance, came as a blinding beacon of hope. The three men had learned that donor splenocytes could be engrafted by their intravenous infusion into immunologically immature mice in utero or perinatally. When these inoculated recipients matured, they could accept skin and other tissues from the donor (but from no other) mouse strain. The immune system of the recipients had been populated by the immunocytes of the donor, meaning that they were now chimeras. The race was on to convert this principle to humans. However, the dark side of their accomplishment soon was revealed by the two younger members of Medawar’s team, Billingham and Brent and by the Dane, Simonsen. The engrafted donor cells could turn the tables and reject the defenseless recipient unless the tissue match was a good one. This was the dreaded graft versus host disease (GVHD) in which transplanted donor cells attacked the recipient skin, gastrointestinal tract, lungs, liver, and the bone marrow itself. Medawar’s dream of 1953 was suddenly a nightmare. Or was it?

On the contrary, the work took a straight line to clinical application, after the demonstration by Prehn and Main that similar tolerance could be induced in adult mice rendered immunologically defenseless by total body irradiation before splenocyte (or later bone marrow) infusion. The recipient conditioning, known as cytoablation, also could be accomplished with myelotoxic drugs. However, as Billingham, Brent, and Medawar had predicted, donor specific tolerance could be induced in humans without GVHD only if there was a good tissue (HLA) match. In 1968, 15 years after the epic Billingham, Brent and Medawar publication, Robert Good and Fritz Bach reported the first two successful human bone marrow transplants. Both recipients of well matched bone marrow from blood relatives are still alive. This was a triumph in which the principal clinicians were internists, as summarized 25 years later in the acceptance speech by the 1990 Nobel Laureate Donnall Thomas.

The growth of bone marrow and whole organ transplantation

The growth of bone marrow and whole organ transplantation

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2681237/bin/nihms-87975-f0001.gif

The growth of bone marrow (right) and whole organ transplantation (left) from the seed planted by Peter Medawar during World War II. GVHD, Graft versus host disease.

Immunological Tolerance: Medawar Nobel Acceptance Lecture

“Immunological tolerance” may be described as a state of indifference or non-reactivity towards a substance that would normally be expected to excite an immunological response. The term first came to be used in the context of tissue transplantation immunity, i.e. of the form of immunity that usually prohibits the grafting of tissues between individuals of different genetic make-up; and it was used to refer only to a non-reactivity caused by exposing animals to antigenic stimuli before they were old enough to undertake an immunological response. For example, if living cells from a mouse of strain CBA are injected into an adult mouse of strain A, the CBA cells will be destroyed by an immunological process, and the A-line mouse that received them will destroy any later graft of the same origin with the speed to be expected of an animal immunologically forearmed. But if the CBA cells are injected into a foetal or newborn A-line mouse, they are accepted; more than that, the A-line mouse, when it grows up, will accept any later graft from a CBA donor as if it were its own. I shall begin by using the term “immunological tolerance” in the rather restricted sense that is illustrated by this experiment, and shall discuss its more general usage later on.

The experiment I have just described can be thought of as an artificial reproduction of an astonishing natural curiosity, the phenomenon of red-cell chimerism in certain dizygotic twins. The blood systems of twin cattle before birth are not sharply distinct from each other, as they are in most other twins; instead, the blood systems make anastomoses with each other, with the effect that the twins can indulge in a prolonged exchange of blood before birth. In 1945, R.D. Owen2 made the remarkable discovery that most twin cattle are born with, and may retain throughout life, a stable mixture – not necessarily a fifty-fifty mixture – of each other’s red cells; it followed, then, that the twin cattle must have exchanged red-cell precursors and not merely red cells in their mutual transfusion before birth. This is the first example of the phenomenon we came to call immunological tolerance; the red cells could not have “adapted” themselves to their strange environment, because they were in fact identified as native or foreign by those very antigenie properties which, had an adaptation occurred, must necessarily have been transformed. A few years later R.E. Billingham and I3, with the help of three members of the scientific staff of the Agricultural Research Council, showed that most dizygotic cattle twins would accept skin grafts from each other, and that this mutual tolerance was specific, for skin transplanted from third parties was cast off in the expected fashion.

Some properties of the tolerant state

The main points that emerged from our analysis of the tolerant state were these. In the first place, tolerance must be due to an alteration of the host, not to an antigenic adaptation of the grafted cells, for grafts newly transplanted in adult life have no opportunity to adapt themselves, and the descendants of the cells injected into foetal or newborn animals can be shown by N.A. Mitcbison’s methods to retain their antigenic power10. Once established, the state of tolerance is systemic; if one part of the body will tolerate a foreign graft, so will another; we found no evidence that a tolerated graft builds up a privileged position for itself within its own lymphatic territory. The stimulus that is responsible for instating tolerance is an antigenic stimulus – one which, had it been applied to older animals, would have caused them to become sensitive or immune. A plural stimulus can induce plural tolerance; the donor will usually contain several important antigens that are lacking in the recipient, and long-lasting tolerance must imply tolerance of them all. The state of tolerance is specific in the sense that it will discriminate between one individual and another, for an animal made tolerant of grafts from one individual will not accept grafts from a second individual unrelated to the first; but it will not discriminate between one tissue and another from the same donor.

Tolerance and auto-immunity: 50 years after Burnet.

Martini A1, Burgio GR
Eur J Pediatr. 1999 Oct;158(10):769-75.

Fifty years ago Sir F. Macfarlane Burnet published his first fundamental contribution to the theory of immune tolerance he perfected 10 years later. Since then an impressive amount of new information on the function of the immune system has been gathered. As any original meaningful theory, Burnet’s hypothesis on the development of immune tolerance has undergone extensive modifications to take into account all these new findings. An improved understanding of the mechanisms of tolerance has led to new possibilities for the treatment of auto-immune diseases.

Clonal Selection
http://en.wikipedia.org/wiki/Clonal_selection

Clonal selection theory is a scientific theory in immunology that explains the functions of cells (lymphocytes) of the immune system in response to specific antigens invading the body. The concept was introduced by an Australian doctor Frank Macfarlane Burnet in 1957 in an attempt to explain the formation of a diversity of antibodies during initiation of the immune response. The theory has become a widely accepted model for how the immune system responds to infection and how certain types of B and T lymphocytes are selected for destruction of specific antigens.

The theory states that in a pre-existing group of lymphocytes (specifically B cells), a specific antigen only activates (i.e. selection) its counter-specific cell so that particular cell is induced to multiply (producing its clones) for antibody production. In short the theory is an explanation of the mechanism for the generation of diversity of antibody specificity. The first experimental evidence came in 1958, when Gustav Nossal and Joshua Lederberg showed that one B cell always produces only one antibody. The idea turned out to be the foundation of molecular immunology, especially in adaptive immunity.

The fundamental contribution of Robert A. Good to the discovery of the crucial role of thymus in mammalian immunity

Domenico Ribatti
Immunology. 2006 Nov; 119(3): 291–295.
http://dx.doi.org:/10.1111/j.1365-2567.2006.02484.x

Robert Alan Good was a pioneer in the field of immunodeficiency diseases. He and his colleagues defined the cellular basis and functional consequences of many of the inherited immunodeficiency diseases. His was one of the groups that discovered the pivotal role of the thymus in the immune system development and defined the separate development of the thymus-dependent and bursa-dependent lymphoid cell lineages and their responsibilities in cell-mediated and humoral immunity.  Keywords: bursa of Fabricius, history of medicine, immunology, thymus

Robert Alan Good (May 21, 1922 – June 13, 2003) was an American physician who performed the first successful human bone marrow transplant

Robert A. Good began his intellectual and experimental queries related to the thymus in 1952 at the University of Minnesota, initially with pediatric patients. However, his interest in the plasma cell, antibodies and the immune response began in 1944, while still in Medical School at the University of Minnesota in Minneapolis, with his first publication appearing in 1945.

Idiopathic Acquired Agammaglobulinemia Associated with Thymoma (1953)

  • a markedly deficient ability to produce antibodies and significant deficits of all or most of the cell-mediated immunities
  • in no instance did removal of the thymic tumour restore immunological function or correct the protein deficit

Good syndrome: thymoma with immunodeficiency

  • increased susceptibility to bacterial infections by encapsulated organisms and opportunistic viral and fungal infections
  • immunodeficiencies, leukopenia, lymphopenia and eosinophylopenia
  • severely hypogammaglobulinemic rather than agammaglobulinemic

Good and others found that the patients lacked all of the subsequently described immunoglobulins. These patients were found not to have plasma cells or germinal centers in their hematopoietic and lymphoid tissues. They possessed circulating lymphocytes in normal numbers.

Speculation on the reason for immunological failure following neonatal thymectomy has centered on the thymus as a source of cells or humoral factors essential to normal lymphoid development and immunological maturation.

The bursa of Fabricius and the thymus are ‘central lymphoid organs’ in the chicken, essential to the ontogenetic development of adaptive immunity in that species. Studies by Papermaster and co-workers in Good’s laboratory34,35 indicated that bursectomy in the newly hatched chicks did not completely abolish immunological potential in the adult animal but rather produced a striking quantitative reduction insufficient to eliminate the homograft reaction. The failure of thymectomy in newly hatched chicks to alter the immunological potential of the maturing animal probably only reflected the participation of the bursa of Fabricius in the development of full immunological capacity.

Bursectomized and irradiated birds were completely devoid of germinal centers, plasma cells and the capacity to make antibodies yet they had perfectly normal development of thymocytes and lymphocytes elsewhere in the body that mediated cellular immune reactions. On the other hand, thymectomized and irradiated animals were deficient in lymphocytes that mediated cellular immunity as assessed by skin graft rejection, delayed-type hypersensitivity and graft versus host assays, but they still produced germinal centers, plasma cells and circulating immunoglobulins.

 

Graft vs Host Disease

Graft-versus-host disease (GVHD) is a complication that can occur after a stem cell or bone marrow transplant. With GVHD, the newly transplanted donor cells attack the transplant recipient’s body.

Graft-versus-host disease (GVHD) is a common complication following an allogeneic tissue transplant. It is commonly associated with stem cell or bone marrow transplant but the term also applies to other forms of tissue graft. Immune cells (white blood cells) in the tissue (the graft) recognize the recipient (the host) as “foreign“. The transplanted immune cells then attack the host’s body cells. GVHD can also occur after a blood transfusion if the blood products used have not been irradiated or treated with an approved pathogen reduction system.

http://en.wikipedia.org/wiki/Graft-versus-host_disease

Causes

GVHD may occur after a bone marrow or stem cell transplant in which someone receives bone marrow tissue or cells from a donor. This type of transplant is called allogeneic. The new, transplanted cells regard the recipient’s body as foreign. When this happens, the newly transplanted cells attack the recipient’s body.

GVHD does not occur when someone receives his or her own cells during a transplant. This type of transplant is called autologous.

Before a transplant, tissue and cells from possible donors are checked to see how closely they match the person having the transplant. GVHD is less likely to occur, or symptoms will be milder, when the match is close. The chance of GVHD is:

  • Around 30 – 40% when the donor and recipient are related
  • Around 60 – 80% when the donor and recipient are not related

There are two types of GVHD: acute and chronic. Symptoms in both acute and chronic GVHD range from mild to severe.

  • Acute GVHD usually happens within the first 6 months after a transplant.
  • Chronic GVHD usually starts more than 3 months after a transplant, and can last a lifetime.

Bone marrow transplant

A bone marrow transplant is a procedure to replace damaged or destroyed bone marrow with healthy bone marrow stem cells.  Stem cells are immature cells in the bone marrow that give rise to all of your blood cells.

There are three kinds of bone marrow transplants:

  • Autologous bone marrow transplant: The term auto means self. Stem cells are removed from you before you receive high-dose chemotherapy or radiation treatment. The stem cells are stored in a freezer (cryopreservation). After high-dose chemotherapy or radiation treatments, your stems cells are put back in your body to make (regenerate) normal blood cells. This is called a rescue transplant.
  • Allogeneic bone marrow transplant: The term allo means other. Stem cells are removed from another person, called a donor. Most times, the donor’s genes must at least partly match your genes. Special blood tests are done to see if a donor is a good match for you. A brother or sister is most likely to be a good match. Sometimes parents, children, and other relatives are good matches. Donors who are not related to you may be found through national bone marrow registries.
  • Umbilical cord blood transplant: This is a type of allogeneic transplant. Stem cells are removed from a newborn baby’s umbilical cord right after birth. The stem cells are frozen and stored until they are needed for a transplant. Umbilical cord blood cells are very immature so there is less of a need for matching. But blood counts take much longer to recover.

Before the transplant, chemotherapy, radiation, or both may be given. This may be done in two ways:

  • Ablative (myeloablative) treatment: High-dose chemotherapy, radiation, or both are given to kill any cancer cells. This also kills all healthy bone marrow that remains, and allows new stem cells to grow in the bone marrow.
  • Reduced intensity treatment, also called a mini transplant: Patients receive lower doses of chemotherapy and radiation before a transplant. This allows older patients, and those with other health problems to have a transplant.

Histocompatibility antigen:

  • A histocompatibility antigen blood test looks at proteins called human leukocyte antigens (HLAs). These are found on the surface of almost all cells in the human body. HLAs are found in large amounts on the surface of white blood cells. They help the immune system tell the difference between body tissue and substances that are not from your own body.

http://www.nlm.nih.gov/medlineplus/ency/article/001309.htm

Induction of transplantation tolerance in haploidenical transplantation under reduced intensity conditioning: The role of ex-vivo generated donor CD8+ T cells with central memory phenotype

Eran Ophir, Y Eidelstein, E Bachar-Lustig, D Hagin, N Or-Geva, A Lask, , Y Reisner
Best Practice & Research Clinical Haematology 24 (2011) 393–401
http://dx.doi.org:/10.1016/j.beha.2011.05.007

Haploidentical hematopoietic stem cell transplantation (HSCT) offers the advantage of readily available family member donors for nearly all patients. A ‘megadose’ of purified CD34þ hematopoietic stem cells is used to overcome the host’s residual immunity surviving the myeloablative conditioning, while avoiding severe GVHD. However, the number of CD34+ cells that can be harvested is insufficient for overcoming the large numbers of host T cells remaining after reduced intensity conditioning (RIC). Therefore, combining a ‘megadose’ of CD34+ HSCT with other tolerizing cells could potentially support and promote successful engraftment of haploidentical purified stem cell transplantation under a safer RIC. One approach to address this challenge
could be afforded by using Donor CD8 T cells directed against 3rd-party stimulators, bearing an ex-vivo induced central memory phenotype (Tcm). These Tcm cells, depleted of GVH reactivity, were shown to be highly
efficient in overcoming host T cells mediated rejection and in promoting
fully mismatched bone-marrow (BM) engraftment, in HSCT murine models.
This is likely due to the marked lymph node homing of the Tcm, their strong proliferative capacity and prolonged persistence in BM transplant recipients. Thus, combining anti 3rd-party Tcm cell therapy with a ‘megadose’ of purified CD34+ stem cells, could offer a safer RIC protocol for attaining hematopoietic chimerism in patients with hematological diseases and as a platform for organ transplantation or cell therapy in cancer patients.

Induction of tolerance in organ recipients by hematopoietic stem cell transplantation

Eran Ophir, Yair Reisner
International Immunopharmacology 9 (2009) 694–700
http://dx.doi.org:/10.1016/j.intimp.2008.12.009

The use of hematopoietic stem cell transplantation (HSCT) for the establishment of mixed chimerism represents a viable and attractive approach for generating tolerance in transplantation biology, as it generally leads to durable immune tolerance, enabling the subsequent engraftment of organ transplants without the need for a deleterious continuous immunosuppressive therapy. However, in order to apply HSCT to patients in a manner that enables long term survival, transplant-related mortality must be minimized by eliminating the risk for graft-versus-host-disease (GVHD) and by reducing the toxicity of the conditioning protocol. T-cell depleted bone marrow transplants (TDBMT) have been shown to adequately eliminate GVHD. However, even in leukemia patients undergoing supralethal conditioning, mismatched TDBMT are vigorously rejected. This barrier can be overcome through the modulatory activity of CD34 cells, which are endowed with veto activity, by the use of megadose stem cell transplants. In mice, megadoses of Sca+linhematopoietic stem cells can induce mixed chimerism following sub-lethal conditioning. Nevertheless, the number of human CD34 cells that can be harvested is not likely to be sufficient to overcome rejection under reduced intensity conditioning (RIC), which might be acceptable in recipients of organ transplantation. To address this challenge, we investigated a novel source of veto cells, namely anti 3rd-party cytotoxic T cells (CTLs) which are depleted of GVH reactivity, combined with megadoses of purified stem cells and a RIC protocol. This approach might provide a safer modality for the induction of durable chimerism.

Intrinsic unresponsiveness of Mertk/B cells to chronic graft-versus-host disease is associated with unmodulated CD1d expression

Wen-Hai Shao, Y Zhen, FD Finkelman, RA Eisenberg, PL Cohen
Journal of Autoimmunity 39 (2012) 412e419
http://dx.doi.org/10.1016/j.jaut.2012.07.001

Activation and migration of marginal zone B (MZB) cells into follicular (FO) regions of the spleen has been proposed as one of the mechanisms that regulate the development of autoreactive B cells. The mer receptor tyrosine kinase (Mertk) mediates apoptotic cell clearance and regulates activation and cytokine secretion. In the well-studied class II chronic GVH model of bm12 cells into B6 hosts, we observed that Mertk deficient B6 mice did not generate autoantibodies in response to this allogeneic stimulus. We posited that Mertk is important in MHC-II-mediated B cell signaling. In the present study, we show that B cells from Mertk-/- mice but not WT B6 mice exhibited decreased calcium mobilization and tyrosine phosphorylation when stimulated by MHC-II cross-linking. The finding that Mertk was important for class II signaling in B cells was further supported by the preponderance of a-allotype autoantibodies in cGVH in RAG-KO mice reconstituted with a mixture of bone marrow from Mertk-/-mice (b-allotype) and C20 mice (a-allotype). MZB cells from Mertk-/-  mice were unable to down regulate surface CD1d expression and subsequent inclusion in the MZ, associated with significantly lower germinal center responses compared to MZB cells from WT. Moreover, Mertk-/- mice treated with an anti-CD1d down regulating antibody responded significantly to bm12 cells, while no response was observed in Mertk-/- mice treated with control antibodies. Taken together, these findings extend the role of Mertk to include CD1d down regulation on MZB cells, a potential mechanism limiting B cell activation in cGVH.

Galectin-9 ameliorates acute GVH disease through the induction of T-cell apoptosis

Kazuki Sakai, Eri Kawata, Eishi Ashihara, Yoko Nakagawa, et al.
Eur. J. Immunol. 2011. 41: 67–75 http://dx.doi.org:/10.1002/eji.200939931

Galectins comprise a family of animal lectins that differ in their affinity for β-galactosides. Galectin-9 (Gal-9) is a tandem-repeat-type galectin that was recently shown to function as a ligand for T-cell immunoglobin domain and mucin domain-3 (Tim-3) expressed on terminally differentiated CD41 Th1 cells. Gal-9 modulates immune reactions, including the induction of apoptosis in Th1 cells. In this study, we investigated the effects of Gal-9 in murine models of acute GVH disease (aGVHD). First, we demonstrated that recombinant human Gal-9 inhibit MLR in a dose-dependent manner, involving both Ca21 influx and apoptosis in T cells. Next, we revealed that recombinant human Gal-9 significantly inhibit the progression of aGVHD in murine BM transplantation models. In conclusion, Gal-9 ameliorates aGVHD, possibly by inducing T-cell apoptosis, suggesting that gal-9 may be an attractive candidate for the treatment of aGVHD.

 

GVHD Prevention: An Ounce Is Better Than a Pound

Pavan Reddy, Gerard Socie, Corey Cutler, Daniel Weisdorf
Biol Blood Marrow Transplant 18:S17-S26, 2012  http://dx.doi.org:/10.1016/j.bbmt.2011.10.034

The pathophysiology of acute graft-versus-host disease (aGVHD) is known to involve donor T cells responding to host histoincompatible allo-antigens presented by the host antigen presenting cells (APCs) and the subsequent induction of pro-inflammatory cytokines and cellular effectors that cause target organ damage. In a more general sense, GVHD can be considered as an immune response against foreign antigens that has gone awry. Similar to all immune responses, GVHD, can be understood as a process that consists of (A) triggers, (B) sensors, (C) mediators, and (D) effectors of GVHD.

Like all immune responses, certain triggers are critical for induction of acute graft-versus-host disease (aGVHD). These include: (1) Disparities between histocompatibility antigens: antigen disparity can be at the level of major histocompatibility complex (MHC), that is, MHC mismatched or at the level of minor histocompatibility antigens (miHA), that is, MHC matched but miHA mismatched. The severity of aGVHD is directly related to the degree of M HC mismatch. In bone marrow transplants (BMT) that are MHC matched but miHA disparate, donor T cells still recognize MHC-peptide derived from the products of recipient polymorphic genes, the miHAs.

Damage induced by conditioning regimens and underlying diseases: under most circumstances, the initiation of an adaptive immune response is triggered by the innate immune response. The innate immune system is triggered by certain exogenous and endogenous molecules. This is likely the case in the induction of aGVHD. Pattern recognition receptors such as Toll-like receptors (TLR), nucleotide-binding oligomerization domain containing 2 (NOD2) play an essential role in innate immunity and in initiating the cellular signaling pathways that activate cytokine secretion, such as NF-kB. Some of their ligands, such as lipopolysaccharide, CpG, and MDP2, which is recognized by TLR-4, TLR-9, and NOD2, respectively, are released by the preparative regimens and contribute to the induction and enhancement of allo-T cell responses. In this way, the conditioning regimens amplify the secretion of proinflammatory cytokines like interleukin (IL)-1, tumor necrosis factor (TNF)-α,  IL-6, and other interferon family members in a process described as a ‘‘cytokine storm.’’

The triggers that initiate an immune response have to be sensed and presented. APCs might be considered the sensors for aGVHD. The APCs sense the DAMPs, present the MHC disparate or miHA disparate protein, and provide the critical secondary (costimulatory) and tertiary (cytokine) signals for activation of the alloreactive T cells, the mediators of aGVHD. APCs sense allo-disparity through MHC and peptide complexes. Dendritic cells (DCs) are the most potent APCs and the primary sensors of allo-disparity.

APCs provide the critical costimulation signals for turning on the aGVHD process. The interaction between the MHC/allopeptide complex on APCs and the T cell receptor of donor T cells along with the signal via T cell costimulatory molecules and their ligands on APCs is required to achieve T cell activation, proliferation, differentiation, and survival and the in vivo blockade of positive costimulatory molecules (such as CD28, ICOS, CD40, CD30, etc.), or inhibitory signals (such as PD-1 and CTLA-4) mitigate or exacerbate aGVHD, respectively.

Evidence suggests that alloreactive donor T cells consist of several subsets with different stimuli responsiveness, activation thresholds, and effector functions.

The allo-antigen composition of the host determines which donor T cells subsets differentiate and proliferate. As mentioned previously, in the majority of HLA-matched HCT, aGVHD may be induced by either or both CD41 and CD81 subsets responses to miHAs. The repertoire and immunodominance of the GVHD-associated peptides presented by MHC class I and class II molecules has not been defined. Donor naive CD62L1 T cells are the primary alloreactive T cells that drive the GVHD reaction while the donor effector memory CD62L2 T cells do not. Interestingly, donor regulatory T cells (Tregs) expressing CD62L are also critical to the regulation of GVHD. We now know that it is possible to modulate the alloreactivity of na€ıve T cells by inducing anergy with costimulation blockade, deletion via cytokine modulation, or mixed chimerism. Donor effector memory T cells that are nonalloreactive do not induce GVHD, yet are able to transfer functional memory. In contrast, memory T cells that are alloreactive can cause severe GVHD.

The effector phase that leads to GVHD target organ damage is a complex cascade that involves cytolytic cellular effectors such as CD8 cytotoxic T lymphocytes (CTLs), CD4 T cells, natural killer cells, and inflammatory molecules such as IL-1β, TNF-α, IFN-ϒ, IL-6, and reactive oxygen species. The cellular effectors require cell-cell contact to kill the cells of the target tissues via activation of perforin granzyme, Fas-FasL (CD95-CD95L), or TNFR TRAIL pathways. Other CTLs killing mechanisms such as TWEAK, and LTβ/LIGHT pathways have also been implicated in GVHD. It is important to note that
CTL pathways are essential for GVL effects as well.

All of the above aspects of the biology of aGVHD have been summarized in the mold of a normal immune response. Although this allows for accessing the biology of GVHD, it is important to note that GVHD is a complicated systemic process with as yet still many unknowns and is not a simplified, linear, or cyclical process.

Kinetics of CD4+ and CD8+ T-cell subsets in graft-versus-host reaction (GVHR) in ginbuna crucian carp Carassius auratus langsdorfii

Yasuhiro Shibasakia, H Todaa, Isao kobayashib, T Moritomoa, T Nakanishia
Developmental and Comparative Immunology 34 (2010) 1075–1081
http://dx.doi.org:/10.1016/j.dci.2010.05.009

We have previously demonstrated the presence of graft-versus-host reaction (GVHR) in fish employing a model system of clonal triploid ginbuna and tetraploid ginbuna-goldfish hybrids. To elucidate the role of CD8+ T cells in the induction of GVHR, we investigate the kinetics of CD4+ and CD8+ T-cell subsets in GVHR along with the pathological changes associated with GVH disease (GVHD) in ginbuna. GVHR was not induced with a leukocyte fraction lacking CD8+ T cells separated by magnetic cell sorting. Ploidy and immunofluorescence analysis revealed that CD4+ and CD8+  T cells from sensitized donors greatly

increased in the host trunk kidney, constituting more than 80% of total cells 1–2 weeks after donor cell injection, while those from non-sensitized donors constituted less than 50% of cells present. The increase of CD4+ T cells was greater and more rapid than that of CD8+ T cells. The number of donor CD4+ and CD8+ T cells was highest in trunk kidney followed by spleen. Increases in donor CD4+ and CD8+ T cells were also found in liver and PBL, although the percentages were not as high. Pathologic changes similar to those in human and murine acute GVHD were observed in the lymphoid organs as well as target organs such as skin, liver and intestine, including the destruction of cells and tissues and massive leukocyte infiltration. The pathologic changes became more severe with the increase of CD8+ T cells. These results suggest that donor-derived CD8+ T cells play essential roles for the induction of acute GVHR/D in teleosts as in mammals.

Fludarabine and Exposure-Targeted Busulfan Compares Favorably with Busulfan/Cyclophosphamide-Based Regimens in Pediatric Hematopoietic
Cell Transplantation: Maintaining Efficacy with Less Toxicity

I.H. Bartelink, E.M.L. van Reij, C.E. Gerhardt, E.M. van Maarseveen, et al
Biol Blood Marrow Transplant 20 (2014) 345e353
http://dx.doi.org/10.1016/j.bbmt.2013.11.027

Busulfan (Bu) is used as a myeloablative agent in conditioning regimens before allogeneic hematopoietic cell transplantation (allo-HCT). In line with strategies explored in adults, patient outcomes may be optimized by replacing cyclophosphamide (Cy) with or without melphalan (Mel) with fludarabine (Flu). We compared outcomes in 2 consecutive cohorts of HCT recipients with a nonmalignant HCT indication, a myeloid malignancy, or a lymphoid malignancy with a contraindication for total body irradiation (TBI). Between 2009 and 2012, 64 children received Flu + Bu at a target dose of 80-95 mg-h/L, and between 2005 and 2008, 50 children received Bu targeted to 74-80 mg-h/L þ Cy. In the latter group, Mel was added for patients with myeloid malignancy (n = 12). Possible confounding effects of calendar time were studied in 69 patients receiving a myeloablative dose of TBI between 2005 and 2012. Estimated 2-year survival and event-free survival were 82% and 78%, respectively, in the FluBu arm and 78% and 72%, respectively, in the BuCy (Mel) arm (P,  not significant). Compared with the BuCy (Mel) arm, less toxicity was noted in the FluBu arm, with lower rates of acute (noninfectious) lung injury (16% versus 36%; P < .007), veno-occlusive disease (3% versus 28%; P < .003), chronic graft-versus-host disease (9% versus 26%; P < .047), adenovirus infection (3% versus 32%; P < .001), and human herpesvirus 6 infection reactivation (21% versus 44%; P < .005). Furthermore, the median duration of neutropenia was shorter in the FluBu arm (11 days versus 22 days; P < .001), and the patients in this arm required fewer transfusions. Our data indicate that Flu (160 mg/m2) with targeted myeloablative Bu (90 mg-h/L) is less toxic than and equally effective
as BuCy (Mel) in patients with similar indications for allo-HCT.

Fibrotic and Sclerotic Manifestations of Chronic Graft-versus-Host Disease

Carrie L. Kitko, Eric S. White, Kristin Baird
Biol Blood Marrow Transplant 18:S46-S52, 2012
http://dx.doi.org:/10.1016/j.bbmt.2011.10.021

Chronic graft-versus-host disease (cGVHD) is a common cause of morbidity
and mortality following allogeneic stem cell transplantation (HCT), with approximately 50% to 60% of long-term HCT survivors developing one or more manifestations of the disorder. Although acute GVHD is typically limited to skin, liver, and gastrointestinal involvement, virtually every organ is at risk for the development of cGVHD. Although the pathophysiology of cGVHD remains poorly understood, some of the most severe organ manifestations are linked by end-organ fibrosis. In particular, fibrotic cutaneous and bronchiolar changes, resulting in scleroderma-like changes and bronchiolitis obliterans syndrome (BOS), respectively, are two of the most devastating outcomes for these patients. Both sclerotic GVHD (ScGVHD) and BOS have been reported in 5% to 15% of patients with cGVHD.

Many of the manifestations of cGVHD share clinical characteristics seen in nontransplant conditions, including systemic sclerosis or pulmonary fibrosis. Thus, understanding the pathophysiology underlying these related conditions may help identify potential mechanisms and ultimately new therapeutic options for patients with cGVHD.

Tyrosine kinase inhibitors (TKIs) have been shown to inhibit two different profibrotic pathways (transforming growth factor β [TGF-β] and platelet-derived growth factor [PDGF]) in various mouse models of fibrotic disease and offer a possible novel treatment approach for cGVHD patients suffering from severe sclerosis. Likewise, overexpression of TNF-α has been shown to induce fibrogenesis in experimental hepatocellular disease and has been linked with human scleroderma-associated interstitial pulmonary fibrosis and profibrotic responses in human osteoarthritic hip joint fibroblasts. The use of TNF antagonists has been examined in some clinical situations associated with fibrosis, suggesting they may also be of some benefit to patients with cGVHD; however, this must first be prospectively tested.

Table. Proposed Modifications to NIH BOS Clinical Definition

  • Absence of infection (no change)
  • Another cGVHD manifestation in another organ (no change)
  • FEV1 <75% predicted (no change) or >10% decline from pre-HCT value (modification)
  • Signs of Obstruction
  • FEV1/SVC ratio <0.7 (modification), or
  • RV >120% predicted (no change), or
  • RV/TLC >120% (modification), and
  • HRCT with evidence of air trapping (no change)

SVC indicates slow vital capacity; RV, residual volume; TLC, total lung capacity; HRCT, high-resolution computed tomography

Figure (not shown)
Effect of etanercept on survival in post-HCT patients with subacute lung injury. (A) Overall 5-year survival by pulmonary function testing defect. Patients with an obstructive defect (solid line) had a 5-year survival of 67% compared with 44% in those with a restrictive lung defect (dashed line) (P 5 .19). (B) Overall 5-year survival by response to therapy. Patients who responded to etanercept therapy (solid line) had a 5-year survival of 90% compared with 55% in patients who failed to respond (dashed line) (P 5.07). (Figures reprinted with permission, Biol Blood and Marrow Trans).

Extensive, sclerotic skin changes with superficial or deep subcutaneous or fascial involvement are seen in approximately 4% to 13% of patients with cGVHD and can be a life-threatening manifestation. ScGVHD of the skin includes several cutaneous presentations characterized by inflammation and progressive fibrosis of the dermis and subcutaneous tissues. These changes can resemble morphea, systemic sclerosis, or eosinophilic fasciitis and may or may not occur in the setting of concurrent overlying epidermal GVHD. When severe, ScGVHD can result in contractures, severe wasting, and chest wall restriction.

Development of clinical trials for patients with cGVHD is difficult because of the complexity and heterogeneity of disease, variable approaches to treatment, and the lack of standardized assessments of disease. In particular, the study of ScGVHD lacks universally accepted measures of disease burden and response. Investigators have used several measures to assess ScGVHD involvement including body surface area, magnetic resonance imaging, ultrasound, and range-of-motion measurements. Additionally, investigators have tried to apply the Rodnan score, the standardmeasure for skin involvement in scleroderma. Thus far, none of these measures has proven
to be completely reliable in the setting of ScGVHD, and it is likely that multiple measures will need to be integrated into the assessment of ScGVHD.

Imatinib mesylate (Gleevec in the US; Glivec in Europe, Australia, and Latin America, marketed by Novartis) is a TKI that has biological activity against both PDGF and TGF-β signaling pathways. Both cytokines have been implicated in the pathogenesis of several fibrosing diseases, including hepatic, renal, and lung, as well as in scleroderma, a disease that closely resembles ScGVHD. In addition, stimulatory antibodies specific for the PDGF receptor (PDGFR) were identified in a series of 39 patients with extensive cGVHD with higher levels detected in those patients with skin involvement. Similar stimulatory antibodies targeting PDGFR have been reported in patients with scleroderma, suggesting an important therapeutic target for these fibrosing conditions. Imatinib mesylate has particularly potent activity against PDGF and is FDA approved in the United States for the treatment of several disorders associated with aberrant PDGFR signaling. The side effect profile of the drug is well established in non-HCT patients, which is helpful in the setting of a therapy for allogenic HCT patients, many of whom have multiorgan system symptoms and possible dysfunction and who will require ongoing immunosuppressive therapy.

Through the efforts of the Chronic GVHD Consortium, led by Stephanie Lee at the Fred Hutchinson Cancer Research Center, there is a multicenter, ongoing prospective evaluation of the NIH diagnostic and assessment tools. This effort has already resulted in several publications that have further refined essential criteria for cGVHD evaluation, including organ-specific manifestations such as BOS and ScGVHD. Currently, the Consortium is conducting a multicenter prospective clinical trial of fluticasone propionate, azithromycin, and montelukast for the treatment of BOS (ClinicalTrials.gov NCT01307462); a separate trial of imatinib versus rituximab for treatment of ScGVHD is also enrolling subjects (ClinicalTrials.gov NCT01309997).

Although cGVHD remains a significant problem for many long-term survivors of HCT, critical advances in cGVHD research and treatment can be achieved by cooperative group efforts such as those put forth by the Chronic GVHD Consortium and the Clinical Trials Network.

Hematopoietic stem cell transplantation (HSCT): An approach to autoimmunity

Carmen Alaez, Mariana Loyola, Andrea Murguıa, Hilario Flores, et al.
Autoimmunity Reviews 5 (2006) 167– 179
http://dx.doi.org:/10.1016/j.autrev.2005.06.003

HSCT provides the opportunity to replace a damaged tissue. It is the most important treatment for high risk hematologic malignant and nonmalignant disorders. An important challenge in the identification of matched donors/patients is the HLA diversity. The Mexican Bone Marrow Registry (DONORMO) has nowadays N5000 donors. The prevalent alleles are Amerindian, Mediterranean (Semitic and Spanish genes) and African. In theory, it is possible to find 11% of 6/6 A–B–DR low resolution matches for 70% of patients with Mexican ancestry. We contributed with 39 unrelated, cord blood and autologous HSCT for patients with malignant, genetic and autoimmune disorders. Overall disease survival was 50% (2–7 years) depending on the initial diagnosis, conditioning, disease evolution or other factors. Clinical studies using autologous and unrelated HSC are performed on patients with refractory autoimmune diseases producing mixed results: mainly, T1D, RA, MS, SLE. Improvement has been observed in skin damage and quality of life in SLE and systemic sclerosis. Disease stabilization in 2/3 of MS patients. However, in RA and T1D, initial benefits have been followed by eventual relapse. With growing clinical experience and protocol improvement, treatment-related mortality is decreasing. Proof efficacy will be achieved by comparing HSCT with standard therapy in autoimmunity.

Monoclonal Antibody-Mediated Targeting of CD123, IL-3 Receptor α Chain, Eliminates Human Acute Myeloid Leukemic Stem Cells

Liqing Jin, Erwin M. Lee, Hayley S. Ramshaw, Samantha J. Busfield, et al.
Cell: Stem Cell 5, 31–42, July 2, 2009
http://dx.doi.org:/10.1016/j.stem.2009.04.018

Leukemia stem cells (LSCs) initiate and sustain the acute myeloid leukemia (AML) clonal hierarchy and possess biological properties rendering them resistant to conventional chemotherapy. The poor survival of AML patients raises expectations that LSC-targeted therapies might achieve durable remissions. We report that an anti-interleukin-3 (IL-3) receptor α chain (CD123)-neutralizing antibody (7G3) targeted AML-LSCs, impairing homing
to bone marrow (BM) and activating innate immunity of nonobese diabetic/ severe-combined immunodeficient (NOD/SCID) mice. 7G3 treatment profoundly reduced AML-LSC engraftment and improved mouse survival.
Mice with preestablished disease showed reduced AML burden in the BM
and periphery and impaired secondary transplantation upon treatment, establishing that AMLLSCs were directly targeted. 7G3 inhibited IL-3-mediated intracellular signaling of isolated AML CD34+ CD38[1] cells in vitro and reduced their survival. These results provide clear validation for therapeutic monoclonal antibody (mAb) targeting of AML-LSCs and for translation of in vivo preclinical research findings toward a clinical application.

Many Days at Home during Neutropenia after Allogeneic Hematopoietic Stem Cell Transplantation Correlates with Low Incidence of Acute Graft-versus-Host Disease

Olle Ringdén, Mats Remberger, Katarina Holmberg, Charlotta Edeskog, et al.
Biol Blood Marrow Transplant 19 (2013) 314e320
http://dx.doi.org/10.1016/j.bbmt.2012.10.011

Patients are isolated in the hospital during the neutropenic phase after allogeneic hematopoietic stem cell transplantation. We challenged this by allowing patients to be treated at home. A nurse from the unit visited and checked the patient. One hundred forty-six patients treated at home were compared with matched hospital control subjects. Oral intake was intensified from September 2006 and improved (P < .002). We compared 4 groups: home care and control subjects before and after September 2006. The cumulative incidence of acute graft-versus-host disease (GVHD) of grades II to IV was 15% in the “old” home care group, which was significantly lower than that of 32% to 44% in the other groups (P <.03). Transplantation-related mortality, chronic GVHD, and relapse were similar in the groups. The “new” home care patients spent fewer days at home (P < .002). In multivariate analysis, GVHD of grades 0 to I was associated with home care (hazard ratio [HR], 2.46; P <.02) and with days spent at home (HR, .92; P < .005) but not with oral nutrition (HR, .98; P = .13). Five year survival was 61% in the home care group as compared with 49% in the control subjects (P < .07). Home care is safe. Home care and many days spent at home were correlated with a low risk of acute GVHD.

Impact on Outcomes of Human Leukocyte Antigen Matching by Allele-Level Typing in Adults with Acute Myeloid Leukemia Undergoing Umbilical Cord Blood Transplantation

Jaime Sanz, Francisco J. Jaramillo, Dolores Planelles, Pau Montesinos, et al.
Biol Blood Marrow Transplant 20 (2014) 106e110
http://dx.doi.org/10.1016/j.bbmt.2013.10.016

This retrospective study analyzed the impact of directional donor-recipient human leukocyte antigen (HLA) disparity using allele-level typing at HLA-A, -B, -C, and -DRB1 in 79 adults with acute myeloid leukemia (AML) who received single-unit umbilical cord blood (UCB) transplant at a single institution. With extended high resolution HLA typing, the donor-recipient compatibility ranged from 2/8 to 8/8. HLA disparity showed no negative impact on nonrelapse mortality (NRM), graft-versus-host (GVH) disease or engraftment. Considering disparities in the GVH direction, the 5-year cumulative incidence of relapse was 44% and 22% for patients receiving an UCB unit matched > 6/8 and < 6/8, respectively (P <.04). In multivariable analysis, a higher HLA disparity in the GVH direction using extended high-resolution typing (Risk ratio [RR] 2.8; 95% confidence interval [CI], 1.5 to 5.1; P ¼.0009) and first complete remission at time of transplantation (RR 2.1; 95% CI, 1.2 to 3.8; P < .01) were the only variables significantly associated with an improved disease-free survival. In conclusion, we found that in adults with AML undergoing single-unit UCBT, an increased number of HLA disparities at allele-level typing improved disease-free survival by decreasing the relapse rate without a negative effect on NRM.

HLA mismatch direction in cord blood transplantation: impact on outcome and implications for cord blood unit selection
Cladd E. Stevens, C Carrier, C Carpenter, D Sung, and A Scaradavou

Blood. 2011; 118(14):3969-3978
http://dx.doi.org:/10.1182/blood-2010-11-317271

Donor-recipient human leukocyte antigen mismatch level affects the outcome of unrelated cord blood (CB) transplantation. To identify possible “permissive” mismatches, we examined the relationship between  direction of human leukocyte antigen mismatch (“vector”) and transplantation outcomes in 1202 recipients of single CB units from the New York Blood Center National Cord Blood Program treated in United States Centers from 1993-2006. Altogether, 98 donor/patient pairs had only unidirectional mismatches: 58 in the graft-versus-host (GVH) direction only (GVH-O) and 40 in the host-versus-graft or rejection direction only (R-O). Engraftment was faster in patients with GVH-O mismatches compared with those with 1 bidirectional mismatch (hazard ratio [HR] = 1.6, P < .003). In addition, patients with hematologic malignancies given GVH-O grafts had lower transplantation-related mortality (HR = 0.5, P < .062), overall mortality (HR = 0.5, P < .019), and treatment failure (HR = 0.5, P < .016), resulting in outcomes similar to those of matched CB grafts. In contrast, R-O mismatches had slower engraftment, higher graft failure, and higher relapse rates (HR = 2.4, P < .010). Based on our findings, CB search algorithms should be modified to identify unidirectional mismatches. We recommend that transplant centers give priority to GVH-O-mismatched units over other mismatches and avoid selecting R-O mismatches, if possible.

Mutation of the NPM1 gene contributes to the development of donor cell–derived acute myeloid leukemia after unrelated cord blood transplantation
for acute lymphoblastic leukemia

G Rodríguez-Macías, C Martínez-Laperche, J Gayoso, V Noriega, .., Ismael Buño
Human Pathology (2013) 44, 1696–1699
http://dx.doi.org/10.1016/j.humpath.2013.01.001

Donor cell leukemia (DCL) is a rare but severe complication after allogeneic stem cell transplantation. Its true incidence is unknown because of a lack of correct recognition and reporting, although improvements in molecular analysis of donor-host chimerism are contributing to a better diagnosis of this complication. The mechanisms of leukemogenesis are unclear, and multiple factors can contribute to the development of DCL. In recent years, cord blood has emerged as an alternative source of hematopoietic progenitor cells, and at least 12 cases of DCL have been reported after unrelated cord blood transplantation. We report a new case of DCL after unrelated cord blood transplantation in a 44-year-old woman diagnosed as having acute lymphoblastic leukemia with t(1;19) that developed acute myeloid leukemia with normal karyotype and nucleophosmin (NPM1) mutation in donor cells. To our knowledge, this is the first report of NPM1 mutation contributing to DCL development.

Graft-versus-leukemia in the bone marrow
Blood, 23 JAN 2014; 123(4)
http://imagebank.hematology.org.

63-year-old female with relapsed acute myeloid leukemia (AML) after allogeneic stem cell transplantation reached CR2 after re-induction therapy followed by consolidation with donor lymphocyte infusions: 3 x 107/kg and 3 x 108/kg after 1 and 2.5 months, respectively. No signs of graft-versus-host disease were observed at this time. At 5 months follow-up, her blood count deteriorated: hemoglobin: 6.9 mmol/L, thrombocytes: 58 x 109/L and leukocytes: 1.37 x 109/L. Bone marrow aspirate was not evaluable. Bone marrow trephine biopsy showed relapse AML with hypercellularity in the H&E staining (340 objective lens, panel A) and 20% CD341 blast cells without any signs of maturation (panel B). Also, a high number of CD3 positive T cells (panel C) was noted, intermingling with the CD34 positive blasts, both staining positively with CD43 (panel D). Only supportive care was given. However, normalization of the blood count was observed in the following months and she developed graft-versus-host disease of the lung, which was treated with ciclosporin and prednisone. A bone marrow aspirate performed 3 months after relapse showed a third remission with 0.8% myeloid blasts. In retrospect, one could therefore consider the picture of the bone marrow trephine biopsy at the second relapse as graft-versus-leukemia in the bone marrow.

GVL- panel A

GVL- panel A

GVL - panel B

GVL – panel B

GVL - panel C

GVL – panel C

GVL - panel D

Long-Term Outcomes of Alemtuzumab-Based Reduced-Intensity Conditioned Hematopoietic Stem Cell Transplantation for Myelodysplastic Syndrome and Acute Myelogenous Leukemia Secondary to Myelodysplastic Syndrome

Victoria T. Potter, Pramila Krishnamurthy, Linda D. Barber, ZiYi Lim, et al.
Biol Blood Marrow Transplant 20 (2014) 111e117
http://dx.doi.org/10.1016/j.bbmt.2013.10.021

Allogeneic hematopoietic stem cell transplantation (HSCT) with reduced-intensity conditioning (RIC) offers a potential cure for patients with myelodysplastic syndrome (MDS) who are ineligible for standard-intensity regimens. Previously published data from our institution suggest excellent outcomes at 1 yr using a uniform fludarabine, busulfan, and alemtuzumab-based regimen. Here we report long-term follow-up of 192 patients with MDS and acute myelogenous leukemia (AML) secondary to MDS (MDS-AML) transplanted with this protocol, using sibling (n = 45) or matched unrelated (n = 147) donors. The median age of the cohort was 57 yr (range, 21 to 72 yr), and median follow-up was 4.5 yr (range, 0.1 to 10.6 yr). The 5-yr overall survival (OS), event-free survival, and nonrelapse mortality were 44%, 33%, and 26% respectively. The incidence of de novo chronic graft-versus-host disease (GVHD) was low at 19%, illustrating the efficacy of alemtuzumab for GVHD prophylaxis. Conversely, the 5-yr relapse rate was 51%. For younger patients (age <50 yr), the 5-yr OS and relapse rates were 58% and 39%, respectively. On multivariate analysis, advanced age predicted significantly worse outcomes, with patients age >60 yr having a 5-yr OS of 15% and relapse rate of 66%. Patients receiving preemptive donor lymphocyte infusions had an impressive 5-yr OS of 67%, suggesting that this protocol may lend itself to the incorporation of immunotherapeutic strategies. Overall, these data demonstrate good 5-yr OS for patients with MDS and MDS-AML undergoing alemtuzumab-based RIC-HSCT. The low rate of chronic GVHD is encouraging, and comparative studies with other RIC protocols are warranted.

Natural killer cell activity influences outcome after T cell depleted stem cell transplantation from matched unrelated and haploidentical donors

Peter Lang, Matthias Pfeiffer,  Heiko-Manuel Teltschik, Patrick Schlegel, et al.
Best Practice & Research Clinical Haematology 24 (2011) 403–411
http://dx.doi.org:/10.1016/j.beha.2011.04.009

Lytic activity and recovery of natural killer (NK) cells was monitored in pediatric patients with leukemias (ALL, AML, CML, JMML) and myelodysplastic syndromes after transplantation of T cell depleted stem cells from matched unrelated (n = 18) and mismatched related (haploidentical, n = 29) donors. CD34+ selection with magnetic microbeads resulted in 8 x 103/kg residual T cells. No post-transplant immune suppression was given. NK cells recovered rapidly after transplantation (300 CD56+/mL at day 30, median), whereas T cell recovery was delayed (median: 12 CD3+/mL at day 90). NK activity was measured as specific lysis of K 562 targets several times (mean: 3 assays per patient). Four temporal patterns of lytic activity could be differentiated: consistently low, consistently high, decreasing and increasing activity. Patients with consistently high or increasing activity had significantly lower relapse probability than patients with consistently low or decreasing levels (0.18 vs 0.73 at 2 years, p < 0.05). The subgroup of patients with ALL showed similar results (0.75 vs 0.14 at 2 years, p < 0.05). Speed of T cell recovery had no influence. These data suggest that both achieving and maintaining a high level of NK activity may contribute to prevent relapse. Since NK activity could be markedly increased by in vitro stimulation with Interleukin 2 (IL-2), in vivo administration should be considered.

Graft-versus-host disease: Pathogenesis and clinical manifestations of graft-versus-host disease

Sharon R. Hymes, Amin M. Alousi,  and Edward W. Cowen
J Am Acad Dermatol  2012; 66: 515.e1-18.

  • Graft-versus-host disease is the primary cause of morbidity and nonerelapse related mortality in patients who undergo allogeneic hematopoietic cell transplantation.
  • Acute graft-versus-host disease manifests as a skin exanthem, liver dysfunction, and gastrointestinal involvement.
  • Chronic graft-versus-host disease of the skin is remarkably variable in its clinical presentation.
  • Chronic graft-versus-host disease is a multisystem disorder that may affect nearly any organ; the most common sites are the skin, oral mucosa, and eyes.

Key points

  • Allogeneic transplantation is in widespread use for hematologic malignancies, but is also increasingly used for marrow failure syndromes, immunodeficiencies, and other life-threatening conditions
  • Graft-versus-host disease is the primary cause of morbidity and nonerelapse related mortality after allogeneic hematopoietic cell transplantation
  • Minimizing graft-versus-host disease without losing the graft-versus-tumor effect is an area of active research
  • The skin is the most common organ affected in patients with graft-versus-host disease

Outcomes of Thalassemia Patients Undergoing Hematopoietic Stem Cell Transplantation by Using a Standard Myeloablative versus a Novel Reduced-Toxicity Conditioning Regimen According to a New Risk Stratification

Usanarat Anurathapan, S Pakakasama, P Mekjaruskul, N Sirachainan, et al.
Biol Blood Marrow Transplant 20 (2014) 2056e2075
http://dx.doi.org/10.1016/j.bbmt.2014.07.016

Improving outcomes among class 3 thalassemia patients receiving allogeneic hematopoietic stem cell transplantations (HSCT) remains a challenge. Before HSCT, patients who were > 7 years old and had a liver size > 5 cm constitute what the Center for International Blood and Marrow Transplant Research defined as a very high risk subset of a conventional high-risk class 3 group (here referred to as class 3 HR). We performed HSCT in 98 patients with related and unrelated donor stem cells. Seventy-six of the patients with age < 10 years received the more conventional myeloablative conditioning (MAC) regimen (cyclophos-phamide, busulfan,  + fludarabine); the remaining 22 patients with age > 10 years and hepatomegaly (class 3 HR), and in several instances additional comorbidity problems, underwent HSCT with a novel reduced-toxicity conditioning (RTC) regimen (fludarabine and busulfan). We then compared the outcomes between these 2 groups (MAC versus RTC). Event-free survival (86% versus 90%) and overall survival (95% versus 90%) were not significantly different between the respective groups; however, there was a higher incidence of serious treatment-related complications in the MAC group, and although we experienced 6 graft failures in the MAC group (8%), there were none in the RTC group. Based on these results, we suggest that (1) class 3HRthalassemia patients can safely receive HSCT with our novel RTC regimen and achieve the same excellent outcome as low/standard-risk thalassemia patients who received the standard MAC regimen, and further, (2) that this novel RTC approach should be tested in the low/standard-risk patient population.

Pharmacological Immunosuppression Reduces But Does Not Eliminate the Need for Total-Body Irradiation in Nonmyeloablative Conditioning Regimens for Hematopoietic Cell Transplantation

Marco Mielcarek, Beverly Torok-Storb, Rainer Storb
Biol Blood Marrow Transplant 17: 1255-1260 (2011)
http://dx.doi.org:/10.1016/j.bbmt.2011.01.003

In the dog leukocyte antigen (DLA)-identical hematopoietic cell transplantation (HCT) model, stable marrow engraftment can be achieved with total-body irradiation (TBI) of 200 cGy when used in combination with postgrafting immunosuppression. The TBI dose can be reduced to 100 cGy without compromising engraftment rates if granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood mononuclear cells (G-PBMC) are infused with the marrow. T cell-depleting the G-PBMC product abrogates this effect. These results were interpreted to suggest that the additional T cells provided with G-PBMC facilitated engraftment by overcoming host resistance.We therefore hypothesized that the TBI dose may be further reduced to 50 cGy by augmenting immunosupression either by (1) tolerizing or killing recipient T cells, or (2) enhancing the graft-versus-host (GVH) activity of donor T cells. To test the first hypothesis, recipient T cells were activated before HCT by repetitive donor-specific PBMC infusions followed by administration of methotrexate (MTX) (n 5 5), CTLA4-Ig (n = 4), denileukin diftitox (Ontak; n = 4), CTLA4-Ig 1 MTX (n = 8), or 5c8 antibody (anti-CD154) 1 MTX (n = 3). To test the second hypothesis, recipient dendritic cells were expanded in vivo by infusion of Flt3 ligand given either pre-HCT (n = 4) or pre- and post-HCT (n = 5) to augment GVH reactions. Although all dogs showed initial allogeneic engraftment, sustained engraftment was seen in only 6 of 42 dogs (14% of all dogs treated in 9 experimental groups). Hence, unless more innovative pharmacotherapy can be developed that more forcefully shifts the immunologic balance in favor of the donor, noncytotoxic immunosuppressive drug therapy as the sole component of HCT preparative regimens may not suffice to ensure sustained engraftment.

Pretransplant Immunosuppression followed by Reduced-Toxicity Conditioning and Stem Cell Transplantation in High-Risk Thalassemia: A Safe Approach to Disease Control

Usanarat Anurathapan, S Pakakasama, P Rujkijyanont, N Sirachainan, et al.
Biol Blood Marrow Transplant 19 (2013) 1254e1270
http://dx.doi.org/10.1016/j.bbmt.2013.04.023

Patients with class 3 thalassemia with high-risk features for adverse events after high-dose chemotherapy with hematopoietic stem cell transplantation (HSCT) are difficult to treat, tending to either suffer serious toxicity or fail to establish stable graft function. We performed HSCT in 18 such patients age 7 years and hepatomegaly using a novel approach with pretransplant immunosuppression followed by a myeloablative reduced-toxicity conditioning regimen (fludarabine and i.v. busulfan [Flu-IV Bu]) and then HSCT. The median patient age was 14 years (range, 10 to 18 years). Before the Flu-IV Bu þ antithymocyte globulin conditioning regimen, all patients received 1 to 2 cycles of pretransplant immunosuppression with fludarabine and dexamethasone. Thirteen patients received a related donor graft, and 5 received an unrelated donor graft. An initial prompt engraftment of donor cells with full donor chimerism was observed in all 18 patients, but 2 patients developed secondary mixed chimerism that necessitated withdrawal of immunosuppression to achieve full donor chimerism. Two patients (11%) had acute grade III-IV graft-versus-host disease, and 5 patients had limited chronic graft-versus-host disease. The only treatment-related mortality was from infection, and with a median follow-up of 42 months (range, 4 to 75), the 5-year overall survival and thalassemia-free survival were 89%. We conclude that this novel sequential immunoablative pretransplant-ation conditioning program is safe and effective for patients with high-risk class 3 thalassemia exhibiting additional comorbidities.

Profiling antibodies to class II HLA in transplant patient sera

Curtis McMurtrey, D Lowe, R Buchli, S Daga, D Royer, A Humphrey, et al.
Human Immunology 75 (2014) 261–270
http://dx.doi.org/10.1016/j.humimm.2013.11.015

Immunizing events including pregnancy, transfusions, and transplantation promote strong alloantibody responses to HLA. Such alloantibodies to HLA preclude organ transplantation, foster hyperacute rejection, and contribute to chronic transplant failure. Diagnostic antibody-screening assays detect alloreactive antibodies, yet key attributes including antibody concentration and isotype remain largely unexplored. The goal here was to provide a detailed profile of allogeneic antibodies to class II HLA. Methodologically, alloantibodies were purified from sensitized patient sera using an HLA-DR11 immunoaffinity column and subsequently categorized. Antibodies to DR11 were found to fix complement, exist at a median serum concentration of 2.3 lg/mL, consist of all isotypes, and isotypes IgG2, IgM, and IgE were elevated. Because multimeric isotypes can confound diagnostic determinations of antibody concentration, IgM and IgA isotypes were removed and DR11-IgG tested alone. Despite removal of multimeric isotypes, patient-to patient antibody concentra-tions did not correlate with MFI values. In conclusion, allogeneic antibody responses to DR11 are comprised of all antibody isotypes at differing proportions, these combined isotypes fix complement at nominal serum concentrations, and enhancements other than the removal of IgM and IgA multimeric isotypes may be required if MFI is to be used as a means of determining anti-HLA serum antibody concentrations in diagnostic clinical assays.

Reduced-intensity conditioning and HLA-matched hemopoietic stem-cell transplantation in patients with chronic granulomatous disease: a prospective multicenter study

Tayfun Güngör, P Teira, M Slatter, G Stussi, P Stepensky, D Moshous, et al.
Lancet 2014; 383: 436–48
http://dx.doi.org/10.1016/S0140-6736(13)62069-3

Background In chronic granulomatous disease allogeneic hemopoietic stem-cell transplantation (HSCT) in adolescents and young adults and patients with high-risk disease is complicated by graft-failure, graft-versus-host disease (GVHD), and transplant-related mortality. We examined the effect of a reduced-intensity conditioning regimen designed to enhance myeloid engraftment and reduce organ toxicity in these patients.       Methods This prospective study was done at 16 centers in ten countries worldwide. Patients aged 0–40 years with chronic granulomatous disease were assessed and enrolled at the discretion of individual centers. Reduced-intensity conditioning consisted of high-dose fludarabine (30 mg/m² [infants <9 kg 1∙2 mg/kg]; one dose per day on days –8 to –3), serotherapy (anti-thymocyte globulin [10 mg/kg, one dose per day on days –4 to –1; or thymoglobulin 2·5 mg/kg, one dose per day on days –5 to –3]; or low-dose alemtuzumab [<1 mg/kg on days –8 to –6]), and low-dose (50–72% of myeloablative dose) or targeted busulfan administration (recommended cumulative area under the curve: 45–65 mg/L × h). Busulfan was administered mainly intravenously and exceptionally orally from days –5 to –3. Intravenous busulfan was dosed according to weight-based recommendations and was administered in most centers (ten) twice daily over 4 h. Unmanipulated bone marrow or peripheral blood stem cells from HLA-matched related donors or HLA-9/10 or HLA-10/10 matched unrelated-donors were infused. The primary endpoints were overall survival and event-free survival (EFS), probabilities of overall survival and EFS at 2 years, incidence of acute and chronic GVHD, achievement of at least 90% myeloid donor chimerism, and incidence of graft failure after at least 6 months of follow-up. Findings 56 patients (median age 12∙7 years; IQR 6·8–17·3) with chronic granulomatous disease were enrolled from June 15, 2003, to Dec 15, 2012. 42 patients (75%) had high-risk features (ie, intractable infections and autoinflammation), 25 (45%) were adolescents and young adults (age 14–39 years). 21 HLA-matched related-donor and 35 HLA-matched unrelated-donor transplants were done. Median time to engraftment was 19 days (IQR 16–22) for neutrophils and 21 days (IQR 16–25) for platelets. At median follow-up of 21 months (IQR 13–35) overall survival was 93% (52 of 56) and EFS was 89% (50 of 56). The 2-year probability of overall survival was 96% (95% CI 86∙46–99∙09) and of EFS was 91% (79∙78–96∙17). Graft-failure occurred in 5% (three of 56) of patients. The cumulative incidence of acute GVHD of grade III–IV was 4% (two of 56) and of chronic graft-versus-host disease was 7% (four of 56). Stable (≥90%) myeloid donor chimerism was documented in 52 (93%) surviving patients. Interpretation This reduced-intensity conditioning regimen is safe and efficacious in high-risk patients with chronic granulomatous disease.

Refinement of the Definition of Permissible HLA-DPB1 Mismatches with Predicted Indirectly ReCognizable HLA-DPB1 Epitopes

Kirsten A. Thus, MTA Ruizendaal, TA de Hoop, Eric Borst, et al.
Biol Blood Marrow Transplant 20 (2014) 1705e1710
http://dx.doi.org/10.1016/j.bbmt.2014.06.026

Hematopoietic stem cell transplantation with HLA-DPB1emismatched donors leads to an increased risk of acute graft-versus-host disease (GVHD). Studies have indicated a prognostic value for classifying HLA-DPB1 mismatches based on T cell epitope (TCE) groups. The aim of this study was to determine the contribution of indirect recognition of HLA-DPe derived epitopes, as determined with the Predicted Indirectly ReCognizable HLA Epitopes (PIRCHE) method. We therefore conducted a retrospective single-center analysis on 80 patients transplanted with a 10/10 matched unrelated donor that was HLA-DPB1 mismatched. HLADPB1 mismatches that were classified as GVH nonpermissive by the TCE algorithm correlated to higher numbers of HLA class I as well as HLA class II presented PIRCHE (PIRCHE-I and -II) compared with permissive or host-versus-graft nonpermissive mismatches. Patients with acute GVHD grades II to IV presented significantly higher numbers of PIRCHE-I compared with patients without acute GVHD (P < .05). Patients were divided into 2 groups based on the presence or absence of PIRCHE. Patients with PIRCHE-I or -II have an increased hazard of acute GVHD when compared with patients without PIRCHE-I or -II (hazard ratio [HR], 3.19; 95% confidence interval [CI], 1.10 to 9.19; P <.05; and HR, 4.07; 95% CI, .97 to 17.19; P < .06, respectively). Patients classified as having an HLA-DPB1 permissive mismatch by the TCE model had an increased risk of acute GVHD when comparing presence of PIRCHE-I with absence of PIRCHE-I (HR, 2.96; 95% CI, .84 to 10.39; P < .09). We therefore conclude that the data presented in this study describe an attractive and feasible possibility to better select permissible HLA-DPB1 mismatches by including both a direct and an indirect recognition model.

Treosulfan-Thiotepa-FludarabineeBased Conditioning Regimen for
Allogeneic Transplantation in Patients with Thalassemia Major: A
Single-Center Experience from North India

Dharma Choudhary, SK Sharma, N Gupta,…, Satyendra Katewa
Biol Blood Marrow Transplant 19 (2013) 492e503
http://dx.doi.org/10.1016/j.bbmt.2012.11.007

Hematopoietic stem cell transplantation (HSCT) is the definite treatment
for patients with thalassemia major. A busulfan (Bu) and cyclophosphamide
(Cy)ebased regimen has been the standard myeloablative chemotherapy,
but it is associated with higher treatment-related toxicity, particularly in
patients classified as high risk by the Pesaro criteria. Treosulfan-based
conditioning regimens have been found to be equally effective and less
toxic. Consequently, we analyzed the safety and efficacy of treosulfan/
thiotepa/fludarabine (treo/thio/flu)-based conditioning regimens for
allogeneic HSCT in patients with thalassemia major between February
2010 and September 2012. We compared those results retrospectively
with results in patients who underwent previous HSCT with a Bu/Cy/
antithymocyte globulin (ATG)ebased conditioning regimen. A treo/thio/
flu-based conditioning regimen was used in 28 consecutive patients with
thalassemia major. The median patient age was 9.7 years (range, 2-18
years), and the mean CD34+ stem cell dose was 6.18 x 106/kg. Neutrophil
and platelet engraftment occurred at a median of 15 days (range, 12-23
days) and 21 days (range, 14-34 days), respectively. Three patients
developed veno-occlusive disease, 4 patients developed acute graft
versus-host disease (GVHD), and 2 patients had chronic GVHD. Treatment-
related mortality (TRM) was 21.4%. Two patients experienced secondary
graft rejection. We compared these results with results in patients who
underwent previous HSCT using a Bu/Cy/ATG-based conditioning regimen.
Twelve patients were treated with this protocol, at a median age of 7.2
years (range, 2-11 years). One patient had moderate veno-occlusive disease,
2 patients developed acute GVHD, 2 patients had chronic GVHD, and 2
patients experienced graft rejection. There was no TRM in this group. We
found no significant differences between the 2 groups (treo/thio/flu vs Bu/
Cy/ATG) in terms of the incidence of acute GVHD, chronic GVHD, TRM,
and graft failure, although a trend toward higher TRM was seen with the
treo/thio/flu regimen.

Graft-versus-Host Disease
James L.M. Ferrara, John E. Levine, Pavan Reddy, and Ernst Holler
Lancet. 2009 May 2; 373(9674): 1550–1561
http:dx.doi.org:/10.1016/S0140-6736(09)60237-3

The number of allogeneic hematopoietic cell transplantations (HCT)
continues to increase with more than 25,000 allogeneic transplantations
performed annually. The graft-versus leukemia/ tumor (GVL) effect during
allogeneic HCT effectively eradicates many hematological malignancies.
The development of novel strategies that use donor leukocyte infusions,
non-myeloablative conditioning and umbilical cord blood (UCB)
transplantation have helped expand the indications for allogeneic HCT
over the last several years, especially among older patients. Improvements
in infectious prophylaxis, immunosuppressive medications, supportive care
and DNA-based tissue typing have also contributed to improved outcomes
after allogeneic HCT. Yet the major complication of allogeneic HCT, graft-
versus-host disease (GVHD), remains lethal and limits the use of this
important therapy. Given current trends, the number of transplants from
unrelated donors is expected to double within the next five years,
significantly increasing the population of patients with GVHD. In this
seminar we review advances made in identifying the genetic risk
factors and pathophysiology of this major HCT complication, as well
as its prevention, diagnosis and treatment.

Non-HLA Genetics—Despite HLA identity between a patient and donor,
approximately 40% of patients receiving HLA-identical grafts develop
acute GVHD due to genetic differences that lie outside the HLA loci,
or “minor” histocompatibility antigens (HA). Some minor HAs, such as HY
and HA-3, are expressed on all tissues and are targets for both GVHD
and GVL. Other minor HAs, such as HA-1 and HA-2, are expressed most
abundantly on hematopoietic cells (including leukemic cells) and may
therefore induce a greater GVL effect with less GVHD. Polymorphisms
in both donors and recipients for cytokines that are involved in the
classical `cytokine storm’ of GVHD have been implicated as risk factors
for GVHD. Tumor Necrosis Factor (TNF)-α, Interleukin 10 (IL-10),
Interferon-γ (IFNγ) variants have correlated with GVHD in some, but
not all, studies. Genetic polymorphisms of proteins involved in innate
immunity, such as nucleotide oligomerization domain 2 and Keratin 18
receptors, have also been associated with GVHD.

Future strategies to identify the best possible transplant donor will
probably incorporate both HLA and non-HLA genetic factors. Skin is most
commonly affected and is usually the first organ involved, often coinciding
with engraftment of donor cells. The characteristic maculopapular rash is
pruritic and can spread throughout the body, sparing the scalp. In severe
cases the skin may blister and ulcerate. Apoptosis at the base of epidermal
rete pegs is a characteristic pathologic finding. Other features include
dyskeratosis, exocytosis of lymphocytes, satellite lymphocytes adjacent
to dyskeratotic epidermal keratinocytes, and a perivascular lymphocytic
infiltration in the dermis.

Gastrointestinal tract involvement of acute GVHD usually presents as
diarrhea but may also include vomiting, anorexia, and/or abdominal pain
when severe. The diarrhea of GVHD is secretory and often voluminous
(greater than two liters per day). Bleeding, which carries a poor prognosis,
occurs as a result of mucosal ulceration but patchy involvement of the
mucosa often leads to a normal appearance on endoscopy.

The incidence of the severity of acute GVHD is determined by the extent
of involvement of  three principal target organs. The overall grades are
classified as I (mild), II (moderate), III (severe) and IV (very severe). Severe
GVHD carries a poor prognosis, with 25% long term survival for grade III and
5% for grade IV. The incidence of acute GVHD is directly related to the
degree of mismatch between HLA proteins and ranges from 35-45% in
recipients of full matched sibling donor grafts to 60-80% in recipients of
one-antigen HLA mismatched unrelated donor grafts. The same degree
of mismatch causes less GVHD using UCB grafts and incidence of acute
GVHD is lower following the transplant of partially matched UCB units
and ranges from 35-65%.

Two important principles are important to consider regarding the
pathophysiology of acute GVHD. First, acute GVHD reflects exaggerated
but normal inflammatory mechanisms mediated by donor lymphocytes infused
into the recipient where they function appropriately, given the foreign
environment they encounter. Second, the recipient tissues that stimulate
donor lymphocytes have usually been damaged by underlying disease,
prior infections, and the transplant conditioning regimen. As
a result, these tissues produce molecules (sometimes referred to as
“danger” signals) that promote the activation and proliferation of donor
immune cells.  Based largely on experimental models, the development
of acute GVHD can be conceptualized in three sequential steps or phases:
(1) activation of the APCs; (2) donor T cell activation, proliferation,
differentiation and migration; and (3) target tissue destruction.

Alemtuzumab is a monoclonal antibody that binds CD52, a protein
expressed on a broad spectrum of leukocytes including lymphocytes,
monocytes, and dendritic cells. Its use in GVHD prophylaxis in a
Phase II trial decreased the incidence of acute and chronic GVHD
following reduced intensity transplant.98 In two prospective studies,
patients who received alemtuzumab rather than methotrexate showed
significantly lower rates of acute and chronic GVHD, but experienced
more infectious complications and higher rates of relapse, so that there
was no overall survival benefit. Alemtuzumab may also contribute to
graft failure when used with minimal intensity conditioning regimens.

An alternative strategy to TCD attempted to induce anergy in donor
T cells by ex vivo antibody blockade of co-stimulatory pathways prior
to transplantation. A small study using this approach in haploidentical
HCT recipients was quite encouraging, but has not yet been replicated.
Thus the focus of most prevention strategies remains  pharmacological
manipulation of T cells after transplant.

Administration of anti-T cell antibodies in vivo as GVHD prophylaxis
has also been extensively tested. The best studied drugs are anti-
thymocyte globulin (ATG) or antilymphocyte globulin (ALG) preparations.
These sera, which have high titers of polyclonal antibodies, are made
by immunizing animals (horses or rabbits) to thymocytes or lymphocytes,
respectively. A complicating factor in determining the role of these
polyclonal sera in transplantation is the observation that even different
brands of the same class of sera exert different biologic effects. However,
the side effects of ATG/ALG infusions are common across different
preparations and include fever, chills, headache, thrombocytopenia
(from cross-reactivity to platelets), and, infrequently, anaphylaxis. In
retrospective studies, rabbit ATG reduced the incidence of GVHD in
related donor HSCT recipients without appearing to improve survival.
In recipients of unrelated donor HSCT, addition of ALG to standard
GVHD prophylaxis effectively prevented severe GVHD, but did not
result in improved survival because of increased infections. In a long
term follow-up study, however, pretransplant ATG provided significant
protection against extensive chronic GVHD and chronic lung dysfunction.

As allogeneic transplantation becomes an increasingly attractive therapeutic
option, the need for novel approaches to GVHD has accelerated. The
number of patients receiving transplants from unrelated donors is
expected to double in the next five years, significantly increasing
the population of patients with GVHD. The advent of RIC regimens
has reduced transplant-related mortality and lengthened the period
during which acute GVHD may develop (many new cases present up
to day 200) and the need for close monitoring of patients in this period
has increased. Patients have often returned to the care of their primary
hematologists by this time, increasing the need for these physicians to
collaborate with transplant specialists in the management of GVHD and
its complications.

Identification of biomarkers for GVHD with diagnostic (and possibly
prognostic) significance may eventually make the treatment of GVHD
preemptive rather than prophylactic. The use of cellular component therapy,
such as regulatory T cells that have been expanded ex vivo. will also
enter clinical trials in the near future, but the extensive infrastructure
required for such cellular approaches will likely limit their use initially.

Immunomodulatory Effects of Palifermin (Recombinant Human
Keratinocyte Growth Factor) in 
an SLE-Like Model of Chronic
Graft-Versus-Host Disease

C. A. Ellison, Y. V. Lissitsyn, I. Gheorghiu & J. G. Gartner
Scandinavian Journal of Immunology 2011; 75, 69–76
http://dx.doi.org:/10.1111/j.1365-3083.2011.02628.x

Keratinocyte growth factor (KGF) promotes epithelial cell proliferation
and survival. Recombinant human KGF, also known as palifermin, protects
epithelial cells from injury induced by chemicals, irradiation and acute murine
graft versus-host disease (GVHD). Findings from our studies and others
have shown that palifermin also has immunomodulatory properties. In a
model of acute GVHD, we showed that it shifts the immune response
from one in which Th1 cytokines dominate to mixed Th1 and Th2 cytokine
profile. Using the DBA⁄ 2 fi (C57BL ⁄ 6 · DBA⁄ 2)F1-hybrid model of chronic,
systemic lupus erythematosus-like GVHD, we showed that palifermin
treatment is associated with higher levels of Th2 cytokines, the production
of anti-nuclear antibodies, cryoglobulinemia and the development of more
severe pathological changes in the kidney. The aim of our current study
was to gain a better understanding of the immunobiology of KGF by
further characterizing the palifermin-mediated effects in this model of
chronic GVHD. Because the pathological changes we observed resemble
those seen in thymic stromal lymphopoietin (TSLP) transgenic mice, we
had originally hypothesized that palifermin might augment TSLP levels.
Surprisingly, we did not observe an increase in thymic

TSLP mRNA expression in palifermin-treated recipients. We did, however,
observe some differences in the percentages of CD4+CD25+Foxp3+
regulatory T cells in the spleen at some time points in palifermin-treated
recipients. Most importantly, we found that TGFβ levels were higher in
palifermin-treated recipients early in the GVH reaction, raising the
possibility that KGF might indirectly induce the development of fibrosis
and glomerulonephritis through a pathway involving TGFβ.

Keratinocyte growth factor (KGF) is an epithelial cell growth factor that is
produced by both mesenchymal cells and intraepithelial cdT cells. It is
also known as fibroblast growth factor 7. Its receptor, (KGFR⁄FGF7R), an
alternatively spliced form of FGFR2 ⁄ bek, is found on epithelial cells in
the intestine, mammary glands, ovaries and urinary tract, and on
hepatocytes, keratinocytes and alveolar type II cells. Previously, it
was shown that recombinant human KGF, also known as palifermin,
can protect the lung, bladder or intestine from chemical- or irradiation-
induced injury. This has been attributed to the ability of KGF to reduce
oxidative damage and enhance DNA repair.

Our own studies have provided a better understanding of the immuno-
biological properties of KGF in pathologically distinct models of systemic
disease driven by intense immunological and inflammatory responses.
The acute GVHD that develops in the C57BL ⁄ 6 fi (C57BL ⁄ 6 · DBA⁄ 2)F1-
hybrid model is characterized by the activation of alloreactive donor T cells,
the production of Th1 cytokines and tissue injury in the skin, gastrointestinal
tract, liver, thymus and lung, where epithelia are present. Injury to the
intestinal mucosa permits the translocation of endotoxin into the system,
which, if untreated, leads to the development of endotoxemic shock. We
showed that palifermin treatment protects recipients from epithelial
cell injury, endotoxemia and morbidity in GVH mice. Palifermin also
shifts the immune response away from one that is predominated by Th1
cytokines towards a profile of mixed Th1 and Th2 cytokines, with a
preponderance of Th2 cytokines. The DBA⁄ 2 fi (C57BL ⁄ 6 · DBA⁄ 2)F1-
hybrid model of chronic GVHD is characterized by pathological changes
resembling those seen in systemic lupus erythematosus (SLE). Using this
model, we showed that palifermin treatment augments the production of Th2
cytokines such as IL-4, IL-5 and IL-13 and obviates IFN-c production. Both
untreated and palifermin-treated recipients developed pathological changes
in the kidney, but these changes were more severe in palifermin-treated
recipients. Some of the changes that developed in the palifermin-treated
recipients resemble those seen in thymic stromal lymphopoietin (TSLP)
transgenic mice. These similarities include the presence of ANA in the
sera, the development of cryoglobulinemia and the development of
glomerulonephritis featuring the deposition of immune complexes
consisting of IgG, IgA, IgM and C3 in the mesangium and the glomerular
capillaries. This led us to hypothesize that treating the recipient mice with
palifermin might induce TSLP expression in this model.

In this study, we were interested in determining whether palifermin
treatment was indeed associated with increased TSLP expression.
We were also interested in knowing whether palifermin treatment
changes the percentage of CD4+CD25+FoxP3+ cells in the spleen,
because palifermin treatment has been associated with increased
percentages of CD4+CD25+FoxP3+ cells in other studies including
our own. Lastly, we wished to study the effect of palifermin treatment
on TGFb levels, because this cytokine is known to play a pivotal role
in the development of glomerulonephritis.

We studied the histopathological changes to confirm that the pathological
changes seen in the kidney in this study were the same as those reported
by us previously.We examined kidney sections from both untreated and
palifermin-treated recipients. In these experiments, we were able to
reproduce findings from an earlier study that showed that palifermin-
treated recipients mice in this model of chronic GVHD develop a severe,
extracapillary proliferative glomerular nephritis characterized by epithelial
crescents and hyaline thrombi. These changes were associated with higher
levels of protein in the urine and the development of ascites, presumably
related to the development of nephrotic syndrome, as a consequence
of glomerular injury.

Pathological changes in the kidney

Pathological changes in the kidney. (A) shows a section from a BDF1-hybrid control
mouse that did not receive a graft. (B) shows increased epithelial cellularity within a
glomerulus from an untreated recipient with chronic graft-versus-host disease, on
day 50. No crescents were observed in sections from this group of recipients.
(C and D) show examples of pathological changes observed in kidneys from
palifermin-treated recipients on day 50. Arrows indicate examples of crescentic
glomerulonephritis and the development of protein casts within tubular lumena.
(E and F) show examples of the hyaline thrombi (arrows) seen in the glomeruli
in kidney sections from palifermin-treated recipients on day 50. All sections
were stained with haematoxylin and eosin except for that shown in (F), which
was stained with Masson Trichrome. The concentration of protein measured in
the urine is shown in the lower left corner of each photomicrograph. Original
magnification: ·200 (B–E) and ·400 (A and F).

TGFβ is a highly pleiotropic cytokine with three isoforms, TGFβ1, TGFβ2 and
TGFβ3 . Nearly, all cells have receptors for at least one of these isoforms,
but cells of the immune system primarily express TGFβ1. This cytokine
was implicated in the development of experimental glomerulonephritis in
experiments in which rats were treated with antiserum directed against
TGFβ1. The ability of palifermin to induce TGFβ release and reverse
limited airflow was demonstrated in a mouse model of emphysema. The
authors further showed that palifermin induced the release of TGFβ1
from primary cultures of mouse alveolar type 2 cells. Our results show
that palifermin treatment is associated with a rise in splenic TGFβ levels
during the first month of the GVH reaction. It is possible that by inducing
TGFβ production shortly after transplantation, palifermin treatment is able
to promote the development of the severe, crescentic glomerulonephritis
that we observed at later time points. As such, our findings raise the
possibility that endogenous KGF might play a role in the development
of glomerulonephritis and ⁄ or other autoimmune phenomena associated
with chronic GVHD and ⁄ or SLE.

T cells, murine chronic graft-versus-host disease and autoimmunity

Robert A. Eisenberg, Charles S. Via
Journal of Autoimmunity 39 (2012) 240e247
http://dx.doi.org:/10.1016/j.jaut.2012.05.017

The chronic graft-versus-host disease (cGVHD) in mice is characterized by
the production of autoantibodies and immunopathology characteristic of
systemic lupus erythematosus (lupus). The basic pathogenesis involves
the cognate recognition of foreign MHC class II of host B cells by alloreactive
CD4 T cells from the donor. CD4 T cells of the host are also necessary for
the full maturation of host B cells before the transfer of donor T cells.
CD8 T cells play critical roles as well. Donor CD8 T cells that are highly
cytotoxic can ablate or prevent the lupus syndrome, in part by killing
recipient B cells. Host CD8 T cells can reciprocally downregulate donor
CD8 T cells, and thus prevent them from suppressing the autoimmune
process. Thus, when the donor inoculum contains both CD4 T cells and
CD8 T cells, the resultant syndrome depends on the balance of activities
of these various cell populations. For example, in one cGVHD model
(DBA/2 (C57BL/6xDBA/2)F1, the disease is more severe in females, as
it is in several of the spontaneous mouse models of lupus, as well as in
human disease. The mechanism of this female skewing of disease
appears to depend on the relative inability of CD8 cells of the female host
to downregulate the donor CD4 T cells that drive the autoantibody response.
In general, then, the abnormal CD4 T cell help and the modulating roles
of CD8 T cells seen in cGVHD parallel the participation of T cells in
genetic lupus in mice and human lupus, although these spontaneous
syndromes are presumably not driven by overt alloreactivity.

Systemic lupus erythematosus (SLE) is characterized by a spectrum of auto-
antibodies that targets multiple normal cellular components, particularly
nucleic acids or proteins that are physiologically bound to nucleic acids.
Although SLE is highly diverse in its manifestations, a common theme
is the loss of B cell tolerance to these cellular autoantigens. More than
for any other human condition, several spontaneously arising mouse
models for SLE have been described, beginning with the New Zealand
strains in 1959. These models are largely genetic. In some cases, an
individual gene such as fas or Yaa plays a major role in driving the loss
of tolerance. However, in general the genetic contribution is complex and
involves multiple loci, which are not yet fully defined.

Despite extensive investigations, the failures in immunoregulation that
underlie the genetic SLE models remain poorly understood. It is not known
for sure which B cell tolerance checkpoints are breached in a given model,
and why. The autoantibody response to DNA, Sm, and other autoantigens
resembles the normal response to exogenous antigens: it involves clonal
expansion, somatic mutation, and a pattern of isotype use characteristic of
a T-cell dependent immunization. Thus the cellular dynamics of the response
may be basically normal. Yet the B-cell repertoire is abnormally autoreactive.

In this review we wish to focus more on the role of the T cell in SLE. As
stated above, the loss of B cell tolerance in SLE does appear in general
to require the participation of T cells. Multiple T cells abnormalities have
been described in human and in murine SLE, although in most cases it is
not clear if these are primary or secondary manifestations. Nevertheless,
it is striking how difficult it has been to demonstrate definitively the specificity
of the T cells that provide help for autoantibody production.

The key cellular mechanism in the cGVHD that results in the loss of B cell
tolerance and the production of the autoantibodies typical of SLE is the
cognate interaction of CD4 T cells with an MHC class II determinant on
the B cell surface. A variety of protocols have achieved this interaction.
In general, either the donor/recipient strains are paired in such away
that they only differ at the MHC class II loci, or the CD4 cells are isolated
free of CD8 cells that would recognize MHC class I. If the allorecognition
involves both CD4 T cell interaction with MHC II and CD8 interaction with
MHC I, an acute GVHD occurs, which is immunosuppressive, rather than
immunostimulatory. The DBA/2 (C57BL/6 DBA/2)F1 (B6D2F1) and the
BALB/c (BALB/c A/J)F1 models are exceptions to this rule. The former
has been investigated extensively for a deficiency in CD8 cytotoxic
lymphocytes.

The MHC class II recognition may be at either the I-A or the I-E locus.
However, the autoantibody specificities seen and the degree of immuno-
pathology differ depending on the locus targeted. In one set of experiments,
F1 mice were bred between either B6 or coisogenic bm12 mice and
B10.A(2R) or B10.A(4R) MHC recombinant congenics. The MHC class II
of B6 is I-Ab, while that of bm12 is I-Abm12. These two alleles differ by
only three amino acids, which is sufficient for a full strength MLR (mixed
lymphocyte reaction) between the two strains. Otherwise B6 and bm12
are identical. B10.A(2R) and B10.A(4R) differ only by the expression of
I-E in the former strain, but not in the latter strain. Thus, donor/recipient
combinations could be employed that provided for allogeneic differs only
at I-A, only at I-E, or at both loci.

Results from Busser et al. delineate requirements for this MHC class II
recognition. Utilizing several transgenic mouse strains that express a
more or less constricted CD4 autoreactive repertoire, they showed that
a diverse repertoire was essential to the production of SLE autoantibodies
by MHC II recognition. On the other hand, the non-specific, early polyclonal
B cell activation phase of cGVHD occurred even with a limited CD4 repertoire.

Figure not shown. Chronic GVHD in bm12 C57BL/6 mice. The MHC of the
bm12 donor differs from the MHC of the C57BL/6 recipient just in three
amino acids in the I-A class II molecule. Thus donor CD4 T cells recognize
MHC IIþ B cells as foreign. Donor CD8 T cells see only self MHC I. All T
cells do not express MHC II. Polyclonal activation and specific lupus
autoantibody responses ensue..

Lupus can result from unchecked CD4 T cell cognate help to a polyclonal
population of B cells. CD8 T cells can downregulate this CD4 driven B-cell
hyperactivity through CD8 CTL effectors and can maintain remission,
possibly through memory CD8 T cells. Whether CD8 CTL actually prevent
lupus in normals and fail in lupus prone individuals is not known; however,
data from the P F1 model suggest that therapeutic induction of CD8 CTL
and possibly long term memory cells may be beneficial in preventing or
limiting disease expression. The potential major role played by either
IFNa and IL-21 in both lupus expression and CD8 CTL function remains
to be further defined, but already these cytokines are being targeted in
human or murine lupus.

It is not surprising that the T cells have been shown to have diverse roles in
the autoimmune cGVHD in mice. Donor CD4 T cells drive the host B cell
activation, while host CD4 T cells are required to mature these B cells prior
to their encounter with donor T cells. Donor CD4 T cells also help activate
donor CD8 T cells, which in turn can downregulate or even ablate the
autoimmune response. Donor CD4 T cells license host DC cells, which in
turn can interact with donor CD8 T cells. Host CD8 T cells can suppress
the activity of donor CD8 T cells, and thereby favor the development of
the lupus syndrome. Although the precise mechanisms of T cell participation
in spontaneous lupus are still being defined, it seems reasonable to probe
these syndromes in humans and in mice for T cell mechanism that have
been shown to participate in cGVHD, CD4-B cell interactions almost
certainly are central to the pathogenesis of spontaneous lupus, and they
have been a target of investigation for several decades. If we understood
the peptide specificity of the alloreactive CD4 T cells that drive the formation
of the characteristic lupus autoantibodies, we would have a much clearer
idea where to look for such epitopes in spontaneous disease. Much less
is known about the other T cell activities defined in cGVHD, particularly
those that involve CD8 T cells. This area should invite further detailed
investigation. For example, the striking role of CD8 T cells in the stronger
female disease in the DBA BDF1 model clearly demands that similar
mechanisms be sought for in spontaneous disease.

Understanding Chronic GVHD from Different Angles

Bruce Blazar, Eric S. White, Daniel Couriel
Biol Blood Marrow Transplant 18:S184-S188, 2012
http://dx.doi.org:/10.1016/j.bbmt.2011.10.025

Whereas acute graft-versus-host disease (aGVHD) rates have decreased
with more intensive GVHD preventive agents and use of single and double
umbilical cord blood units as a source of donor cells in adult recipients,
significant chronic GVHD (cGVHD) rates unexpectedly have remained high.
Moreover, granulocyte colony stimulating factor mobilized peripheral blood
stem cell grafts have been associated with an increased overall risk of
cGVHD. As such, cGVHD has emerged as a primary cause of morbidity
and mortality following allogeneic hematopoietic stem cell transplantation.
Progress in developing cGVHD interventional strategies has been hampered
by variable onset and clinical and pathological manifestations of cGVHD, now
better defined by the National Institutes of Health (NIH) consensus conference,
and a dearth of preclinical models that closely mimic the conditions in which
cGVHD is generated and manifested. Although the exact causes of cGVHD
remain unknown, higher antibody levels have been associated with auto-
immunity and implicated in cGVHD. Newly diagnosed patients with
extensive cGVHD had elevated soluble B cell activating factor levels and
anti-double-strand DNA antibodies were found, which was associated with
higher circulating levels of pregerminal center (GC) B cells and post-GC
plasmablasts. B cells from cGVHD patients were hyperresponsive to Toll-like
receptor-9 signaling and have up-regulated CD86 levels.

By using a Cy and low doses of donor T cells, aGVHD was avoided and
cGVHD with BO favored. Histologic changes were similar to the findings in
human cGVHD with peribronchiolar and perivascular cuffing and infiltration
of the airway epithelium. The liver had inflammation and lymphocytic
infiltration, along with collagen deposition. The parotid and submandibular
salivary glands displayed lymphocytic infiltrates in both the bone marrow
and cGVHD groups, likely because of transplantation conditioning.

Treatment of steroid refractory cGVHD patients with rituximab, a B cell–
depleting anti-CD20 monoclonal antibody, has shown a beneficial role in
resolution of the autoimmune disorders such as systemic lupus erythmatosus
and rheumatoid arthritis, andcGVHD, with overall response rates of 29%
to 36% for oral, hepatic, gastrointestinal, and lung cGVHD, and 60% for
cutaneous cGVHD in aggregate data from multiple trials. Thus, we recently
undertook studies to identify the presence of CD41 T helper cells and B2201
B cells in the airways of mice that had BO, tissue-specific antibodies from sera,
and alloantibody deposition in the lung and liver of cGVHD recipients. cGVHD
development was associated with IgG2c deposition in the lung and liver,
abrogated if the donor bone marrow was deficient in mature B cells or
incapable of producing antihost reactive IgG. Robust GC formation was
seen in mice with cGVHD. Alleviation of symptoms in mice that received
B cell–deficient bone marrow confirms the requirement of B cells for lung
dysfunction and inflammation and fibrosis in the lung and liver.

Given a role for IgG antibodies, allo- or auto-Ab binding to the cGVHD organs
could enable tissue destruction or the pathology could be defined by the
specific function of these secreted antibodies. Pathogenic antibody production
therefore is likely to be an important inducer of cGVHD, and targeting this
specific function of the B cells is an attractive strategy for cGVHD. Because
GC B cells display lower susceptibility to rituximab-mediated clearance, probably
because they reside in a nonoptimal environment for antibody-based depletion,
our observation that GC B cells are critical to the development of cGVHD
suggests that agents that are more effective at disrupting the GC might be
more clinically useful. Treatment with LTbR-Ig, a fusion protein that blocks
interactions between LTbR and its ligands, had a direct effect on the
symptoms of cGVHD, at least in part by blocking GC formation and suggest
that LTbR-Ig could be a potential clinical interventional strategy for prevention
and therapy of cGVHD.

Fibrosis is the end result of a number of inflammatory and other injurious events,
resulting in replacement of normal tissue with a dense extracellular matrix (ECM)
scar composed primarily of collagens. While some degree of tissue fibrosis is
considered protective (e.g. in the setting of cutaneous wound healing),
exaggerated or unrelenting ECM deposition with replacement of the normal
tissue architecture is considered pathologic. Fibroproliferative disorders as
a class involving multiple organs (e.g. cGVHD following hematopoietic stem
cell transplant [affecting up to 30% of recipients surviving more than 100 days,
scleroderma [estimated to affect 70,000 in the US], idiopathic pulmonary fibrosis
[estimated to affect 200,000 in the US], hepatic cirrhosis [estimated to affect
up to 400,000 in the US], and renal fibrosis due to diabetic nephropathy and
other causes [estimated to affect over 400,000 in the US]) are a major cause
of morbidity and mortality. Combined, these disorders alone are conservatively
estimated to affect approximately 1 in 300 persons in the United States. When
coupled with a host of other disorders in which tissue fibrosis contributes to
morbidity (e.g. fibroproliferative acute respiratory distress syndrome,
hypersensitivity pneumonitis, solid organ transplant rejection), that estimate
is likely to be much greater.

Wound healing occurs by a highly orchestrated, complex process that has
been well defined. In general, wound repair occurs in 4 stages which overlap
considerably: clotting/coagulation, inflammation, fibroproliferation, and tissue
remodeling. The initial injury leads to a local disruption of epithelial and
endothelial barriers resulting in the elaboration of inflammatory mediators and
extravasation of cells and plasma proteins that serve to achieve hemostasis
and provide a provisional fibrin-rich matrix for the influx of inflammatory and
other reparative cells. Simultaneously, platelet degranulation provides a local
“boost” of vasodilators, growth factors, and ECM proteins that aid in the wound
healing response. Inflammatory cell influx occurs next, with polymorphonuclear
leukocytes (PMNs) arriving first. Following PMN degranulation, mononuclear
cells (macrophages and lymphocytes) arrive next and, along with PMN derived
products, sterilize and remove foreign materials from the wound. This process
also results in the elaboration of cytokines and chemokines designed to
augment the inflammatory response, to promote angiogenesis (allowing for
enhanced nutrient and oxygen delivery to the wound bed), and to recruit
fibroblasts to the wound bed. Fibroblast recruitment and transdifferentiation to
myofibroblasts (or recruitment of already-differentiated myofibroblasts or
fibroblast precursors; this point is still controversial) marks the fibroproliferative
stage, with the result being the elaboration of ECM proteins (collagens,
fibronectins) to repair the tissue defect.

Vorinostat plus tacrolimus and mycophenolate to prevent graft-versus-host
disease after related-donor reduced-intensity conditioning allogeneic
hemopoietic 
stem-cell transplantation: a phase 1/2 trial

Sung Won Choi, T Braun, L Chang, JLM Ferrara, A Pawarode, et al.
Lancet Oncol 2014; 15: 87–95
http://dx.doi.org/10.1016/S1470-2045(13)70512-6

Background Acute graft-versus-host disease (GVHD) remains a barrier to more
widespread application of allogeneic hemopoietic stem-cell transplantation.
Vorinostat is an inhibitor of histone deacetylases and was shown to attenuate
GVHD in preclinical models. We aimed to study the safety and activity of
vorinostat, in combination with standard immunoprophylaxis, for prevention of
GVHD in patients undergoing related-donor reduced-intensity conditioning
hemopoietic stem-cell transplantation. Methods Between March 31, 2009,
and Feb 8, 2013, we did a prospective, single-arm, phase 1/2 study at two
centers in the USA. We recruited adults (aged ≥18 years) with high-risk
hematological malignant diseases who were candidates for reduced-intensity
conditioning hemopoietic stem-cell transplantation and had an available 8/8
or 7/8 HLA matched related donor. All patients received a conditioning regimen
of fl udarabine (40 mg/m² daily for 4 days) and busulfan (3·2 mg/kg daily for
2 days) and GVHD immunoprophylaxis of mycophenolate mofetil (1 g three
times a day, days 0–28) and tacrolimus (0·03 mg/kg a day, titrated to a goal
level of 8–12 ng/mL, starting day –3 until day 180). Vorinostat (either 100 mg
or 200 mg, twice a day) was initiated 10 days before haemopoietic stem-cell
transplantation until day 100. The primary endpoint was the cumulative
incidence of grade 2–4 acute GVHD by day 100. This trial is registered with
ClinicalTrials.gov, number NCT00810602.
Findings 50 patients were assessable for both toxic effects and response;
eight additional patients were included in the analysis of toxic effects. All
patients engrafted neutrophils and platelets at expected times after
hemopoietic stem-cell transplantation. The cumulative incidence of grade
2–4 acute GVHD by day 100 was 22% (95% CI 13–36). The most common
non-hematological adverse events included electrolyte disturbances (n=15),
hyperglycemia (11), infections (six), mucositis (four), and increased activity
of liver enzymes (three). Non-symptomatic thrombocytopenia after
engraftment was the most common hematological grade 3–4 adverse
event (nine) but was transient and all cases resolved swiftly.
Interpretation Administration of vorinostat in combination with standard
GVHD prophylaxis after related-donor reduced-intensity conditioning
hemopoietic stem-cell transplantation is safe and is associated with a
lower than expected incidence of severe acute GVHD. Future studies
are needed to assess the effect of vorinostat for prevention of GVHD in
broader settings of hemopoietic stem-cell transplantation.

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Summary to Metabolomics

Summary to Metabolomics

Author and Curator: Larry H. Bernstein, MD, FCAP 

This concludes a long step-by-step journey into rediscovering biological processes from the genome as a framework to the remodeled and reconstituted cell through a number of posttranscription and posttranslation processes that modify the proteome and determine the metabolome.  The remodeling process continues over a lifetime. The process requires a balance between nutrient intake, energy utilization for work in the lean body mass, energy reserves, endocrine, paracrine and autocrine mechanisms, and autophagy.  It is true when we look at this in its full scope – What a creature is man?

http://masspec.scripps.edu/metabo_science/recommended_readings.php
 Recommended Readings and Historical Perspectives

Metabolomics is the scientific study of chemical processes involving metabolites. Specifically, metabolomics is the “systematic study of the unique chemical fingerprints that specific cellular processes leave behind”, the study of their small-molecule metabolite profiles.[1] The metabolome represents the collection of all metabolites in a biological cell, tissue, organ or organism, which are the end products of cellular processes.[2] mRNA gene expression data and proteomic analyses reveal the set of gene products being produced in the cell, data that represents one aspect of cellular function. Conversely, metabolic profiling can give an instantaneous snapshot of the physiology of that cell. One of the challenges of systems biology and functional genomics is to integrate proteomic, transcriptomic, and metabolomic information to provide a better understanding of cellular biology.

The term “metabolic profile” was introduced by Horning, et al. in 1971 after they demonstrated that gas chromatography-mass spectrometry (GC-MS) could be used to measure compounds present in human urine and tissue extracts. The Horning group, along with that of Linus Pauling and Arthur B. Robinson led the development of GC-MS methods to monitor the metabolites present in urine through the 1970s.

Concurrently, NMR spectroscopy, which was discovered in the 1940s, was also undergoing rapid advances. In 1974, Seeley et al. demonstrated the utility of using NMR to detect metabolites in unmodified biological samples.This first study on muscle highlighted the value of NMR in that it was determined that 90% of cellular ATP is complexed with magnesium. As sensitivity has improved with the evolution of higher magnetic field strengths and magic angle spinning, NMR continues to be a leading analytical tool to investigate metabolism. Efforts to utilize NMR for metabolomics have been influenced by the laboratory of Dr. Jeremy Nicholson at Birkbeck College, University of London and later at Imperial College London. In 1984, Nicholson showed 1H NMR spectroscopy could potentially be used to diagnose diabetes mellitus, and later pioneered the application of pattern recognition methods to NMR spectroscopic data.

In 2005, the first metabolomics web database, METLIN, for characterizing human metabolites was developed in the Siuzdak laboratory at The Scripps Research Institute and contained over 10,000 metabolites and tandem mass spectral data. As of September 2012, METLIN contains over 60,000 metabolites as well as the largest repository of tandem mass spectrometry data in metabolomics.

On 23 January 2007, the Human Metabolome Project, led by Dr. David Wishart of the University of Alberta, Canada, completed the first draft of the human metabolome, consisting of a database of approximately 2500 metabolites, 1200 drugs and 3500 food components. Similar projects have been underway in several plant species, most notably Medicago truncatula and Arabidopsis thaliana for several years.

As late as mid-2010, metabolomics was still considered an “emerging field”. Further, it was noted that further progress in the field depended in large part, through addressing otherwise “irresolvable technical challenges”, by technical evolution of mass spectrometry instrumentation.

Metabolome refers to the complete set of small-molecule metabolites (such as metabolic intermediates, hormones and other signaling molecules, and secondary metabolites) to be found within a biological sample, such as a single organism. The word was coined in analogy with transcriptomics and proteomics; like the transcriptome and the proteome, the metabolome is dynamic, changing from second to second. Although the metabolome can be defined readily enough, it is not currently possible to analyse the entire range of metabolites by a single analytical method. The first metabolite database(called METLIN) for searching m/z values from mass spectrometry data was developed by scientists at The Scripps Research Institute in 2005. In January 2007, scientists at the University of Alberta and the University of Calgary completed the first draft of the human metabolome. They catalogued approximately 2500 metabolites, 1200 drugs and 3500 food components that can be found in the human body, as reported in the literature. This information, available at the Human Metabolome Database (www.hmdb.ca) and based on analysis of information available in the current scientific literature, is far from complete.

Each type of cell and tissue has a unique metabolic ‘fingerprint’ that can elucidate organ or tissue-specific information, while the study of biofluids can give more generalized though less specialized information. Commonly used biofluids are urine and plasma, as they can be obtained non-invasively or relatively non-invasively, respectively. The ease of collection facilitates high temporal resolution, and because they are always at dynamic equilibrium with the body, they can describe the host as a whole.

Metabolites are the intermediates and products of metabolism. Within the context of metabolomics, a metabolite is usually defined as any molecule less than 1 kDa in size.
A primary metabolite is directly involved in the normal growth, development, and reproduction. A secondary metabolite is not directly involved in those processes.  By contrast, in human-based metabolomics, it is more common to describe metabolites as being either endogenous (produced by the host organism) or exogenous. Metabolites of foreign substances such as drugs are termed xenometabolites. The metabolome forms a large network of metabolic reactions, where outputs from one enzymatic chemical reaction are inputs to other chemical reactions.

Metabonomics is defined as “the quantitative measurement of the dynamic multiparametric metabolic response of living systems to pathophysiological stimuli or genetic modification”. The word origin is from the Greek μεταβολή meaning change and nomos meaning a rule set or set of laws. This approach was pioneered by Jeremy Nicholson at Imperial College London and has been used in toxicology, disease diagnosis and a number of other fields. Historically, the metabonomics approach was one of the first methods to apply the scope of systems biology to studies of metabolism.

There is a growing consensus that ‘metabolomics’ places a greater emphasis on metabolic profiling at a cellular or organ level and is primarily concerned with normal endogenous metabolism. ‘Metabonomics’ extends metabolic profiling to include information about perturbations of metabolism caused by environmental factors (including diet and toxins), disease processes, and the involvement of extragenomic influences, such as gut microflora. This is not a trivial difference; metabolomic studies should, by definition, exclude metabolic contributions from extragenomic sources, because these are external to the system being studied.

Toxicity assessment/toxicology. Metabolic profiling (especially of urine or blood plasma samples) detects the physiological changes caused by toxic insult of a chemical (or mixture of chemicals).

Functional genomics. Metabolomics can be an excellent tool for determining the phenotype caused by a genetic manipulation, such as gene deletion or insertion. Sometimes this can be a sufficient goal in itself—for instance, to detect any phenotypic changes in a genetically-modified plant intended for human or animal consumption. More exciting is the prospect of predicting the function of unknown genes by comparison with the metabolic perturbations caused by deletion/insertion of known genes.

Nutrigenomics is a generalised term which links genomics, transcriptomics, proteomics and metabolomics to human nutrition. In general a metabolome in a given body fluid is influenced by endogenous factors such as age, sex, body composition and genetics as well as underlying pathologies. The large bowel microflora are also a very significant potential confounder of metabolic profiles and could be classified as either an endogenous or exogenous factor. The main exogenous factors are diet and drugs. Diet can then be broken down to nutrients and non- nutrients.

http://en.wikipedia.org/wiki/Metabolomics

Jose Eduardo des Salles Roselino

The problem with genomics was it was set as explanation for everything. In fact, when something is genetic in nature the genomic reasoning works fine. However, this means whenever an inborn error is found and only in this case the genomic knowledge afterwards may indicate what is wrong and not the completely way to put biology upside down by reading everything in the DNA genetic as well as non-genetic problems.

Coordination of the transcriptome and metabolome by the circadian clock PNAS 2012

Coordination of the transcriptome and metabolome by the circadian clock PNAS 2012

analysis of metabolomic data and differential metabolic regulation for fetal lungs, and maternal blood plasma

conformational changes leading to substrate efflux.img

conformational changes leading to substrate efflux.img

The cellular response is defined by a network of chemogenomic response signatures.

The cellular response is defined by a network of chemogenomic response signatures.

Dynamic Construct of the –Omics

Dynamic Construct of the –Omics

 genome cartoon

genome cartoon

central dogma phenotype

central dogma phenotype

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Introduction to Proteomics

Author and Curator: Larry H. Bernstein, MD, FCAP  

 

We have had a considerable extended discussion of preoteins and peptides, protein sinthesis, amino acid incorporation into protein, and metabolism of carbohydrates and lipids.  It is also clear that the historic practice of medicine, and the classification of biological systems has been highly dependent on the observations related to the observed phenotypical traits and disturbances of normal function that could be measured by traditional metabolic pathways for over a century.

What did we gain from the genomic revolution?

  1. Traceability of protein expression to a basic coded message
  2. The possibility of tracing disturbed cellular function to mutation related loss-of-function
  3. The ability to trace generational traits over long periods of time
  4. The promise of regenerating the enterprise of pharmacology and pharmaceutical intervention based on the silencing of or readjustment of regulated metabolic pathways to bring an adaptive rebalancing favoring extended life

What can we expect as we progress further as a result of the last two decades?

  1. There is a huge amount of information, as well as missing information that is necessary for adequately tackling the mastery of the life processes.
  2. There is a complex web of knowledge that goes beyond the genome and the one-gene one-enzyme, and the DNA-RNA-protein hypotheses that can only be realized by more full disclosure of the many metabolic control circuits involved in cellular homeostasis and adaptive control.
  3. The ability to come to disclosure and understanding of this cellular balancing will require the comprehensive exploration of the proteome and the active role of proteins and peptides in the functioning of all cells, and the organism.
  4. Proteomics will open up the discovery of new approaches to diagnostics and pharmaceutical discovery.

What about proteins?  What can proteins do? What can’t they do!

  • Enzymes are proteins that make sure that chemical reactions in your body take place up to a million times faster than they would without enzymes.
  • Antibodies are proteins that help your immune system to fight disease.
  • When you get an injury, the bleeding stops because of blood clots, thanks to the proteins fibrinogen and thrombin.
  • Transport! Some proteins carry vitamins ot hormones from one place to another, or form tunnels (pores) in cell membranes that will let only specific molecules (or ions) through. Hemoglobin, a protein in your blood, carries oxygen from your lungs to your cells.
  • Strength and support! Other proteins like collagen and keratin are strong and tough and make up your skin, hair, and fingernails. Collagen also supports your cells and organs so they don’t slosh around.
  • Motion! The proteins myosin and actin make up much of your muscle tissue. They work together so your muscles can move you around. Some bacteria have cilia and flagella made out of proteins. The bacteria can whip these around to move from place to place.

http://www.pslc.ws/macrog/kidsmac/protein.htm

Proteins (/ˈprˌtnz/ or /ˈprti.ɨnz/) are large biological molecules, or macromolecules,

Proteins perform a vast array of functions within living organisms, including

  1. catalyzing metabolic reactions,
  2. replicating DNA,
  3. responding to stimuli, and
  4. transporting molecules from one location to another.

Proteins differ from one another primarily in

  1. their sequence of amino acids,
  2. which is dictated by the nucleotide sequence of their genes, and
  3. which usually results in folding of the protein into

A linear chain of amino acid residues is called a polypeptide. A protein contains at least one long polypeptide. Short polypeptides, containing less than about 20-30 residues, are rarely considered to be proteins and are commonly called peptides, or sometimes oligopeptides. The individual amino acid residues are bonded together by peptide bonds and adjacent amino acid residues. The sequence of amino acid residues in a protein is defined by

In general, the genetic code specifies 20 standard amino acids; however, in certain organisms the genetic code can include selenocysteine and—in certain archaeapyrrolysine. Shortly after or even during synthesis,

  • the residues in a protein are often chemically modified by posttranslational modification,
  • which alters the physical and chemical properties, folding, stability, activity, and ultimately, the function of the proteins.

http://en.wikipedia.org/wiki/Protein

Posttranslational modification (PTM) is a step in protein biosynthesis. Proteins created by ribosomes translating mRNA into polypeptide chains may undergo PTM (such as folding, cutting and other processes) before becoming the mature protein product.  After translation, the posttranslational modification of amino acids extends the range of functions of the protein by attaching it to other biochemical functional groups (such as acetate, phosphate, various lipids and carbohydrates), changing the chemical nature of an amino acid (e.g. citrullination), or making structural changes (e.g. formation of disulfide bridges).

Also, enzymes may remove amino acids from the amino end of the protein, or cut the peptide chain in the middle. For instance, the peptide hormone insulin is cut twice after disulfide bonds are formed, and a propeptide is removed from the middle of the chain; the resulting protein consists of two polypeptide chains connected by disulfide bonds. Also, most nascent polypeptides start with the amino acid methionine because the “start” n mRNA also codes for this amino acid. This amino acid is usually taken off during post-translational modification. Other modifications, like phosphorylation, are part of common mechanisms for controlling the behavior of a protein, for instance activating or inactivating an enzyme.

posttranslational modification of insulin

posttranslational modification of insulin

Posttranslational modification of insulin. At the top, the ribosome translates a mRNA sequence into a protein, insulin, and passes the protein through the endoplasmic reticulum, where it is cut, folded and held in shape by disulfide (-S-S-) bonds. Then the protein passes through the golgi apparatus, where it is packaged into a vesicle. In the vesicle, more parts are cut off, and it turns into mature insulin.

Genetic Code mapped

Genetic Code mapped

The genetic code diagram showing the amino acid residues as target of modification.

PTMs involving addition of cofactors for enhanced enzymatic activity

http://en.wikipedia.org/wiki/Posttranslational_modification

Sometimes proteins have non-peptide groups attached, which can be called prosthetic groups or cofactors.  Examples of cofactors include metal ions like iron and zinc. Proteins can also work together to achieve a particular function, and they often associate to form stable protein complexes.

cofactor-examples

cofactor-examples

Coenzymes are molecules that work at the active site of an enzyme and aid in recognizing, attracting, or repulsing a substrate or product. Many are derived from vitamins. The substrate is the molecule upon which an enzyme catalyzes a reaction transforming A to B by removal or addition of a hydrogen, or a hydroxyl group, or a methyl group, and so forth. This is  how an alcohol or an aldehyde is produced. Such a reaction is critical is carbohydrate metabolism for producing two 3-carbon sugars from a 6-carbon sugar. Coenzymes shuttle chemical groups from one enzyme to another enzyme. They may bind loosely to enzymes, while another group of cofactors do not.

Prosthetic groups are cofactors that bind tightly to proteins or enzymes. As if holding on for dear life, they are not easily removed. They can be organic or metal ions and are often attached to proteins by a covalent bond. The same cofactors can bind multiple different types of enzymes and may bind some enzymes loosely, as a coenzyme, and others tightly, as a prosthetic group. Some cofactors may always tightly bind their enzymes. It’s important to note, though, that these prosthetic groups can also bind to proteins other than enzymes.  A holoenzyme is an enzyme with any metal ions or coenzymes attached to it that is now ready to catalyze a reaction.

prosthetic-groups

prosthetic-groups

http://education-portal.com/academy/lesson/coenzymes-cofactors-prosthetic-groups-function-and-interactions.html#lesson

Around the world, millions of people don’t get enough protein. Protein malnutrition leads to the condition known as kwashiorkor. Lack of protein can cause growth failure, loss of muscle mass, decreased immunity, weakening of the heart and respiratory system, and death.

All Protein Isn’t Alike

Protein is built from building blocks called amino acids. Our bodies make amino acids in two different ways: Either from scratch, or by modifying others. A few amino acids (known as the essential amino acids) must come from food.

  • Animal sources of protein tend to deliver all the amino acids we need.
  • Other protein sources, such as fruits, vegetables, grains, nuts and seeds, lack one or more essential amino acids.

Vegetarians need to be aware of this. People who don’t eat meat, fish, poultry, eggs, or dairy products need to eat a variety of protein-containing foods each day in order to get all the amino acids needed to make new protein.

http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/protein/
Molecular Biologists Guide to Proteomics

PR. Graves and TA.J. Haystead*
Microbiol Mol Biol Rev. Mar 2002; 66(1): 39–63  PMC120780
http://dx.doi.org:/10.1128/MMBR.66.1.39-63.2002

The emergence of proteomics, the large-scale analysis of proteins, has been inspired by the realization that

  • the final product of a gene is inherently more complex and
  • closer to function than the gene itself.

Shortfalls in the ability of bioinformatics to predict

  • both the existence and function of genes have also illustrated
  • the need for protein analysis.

Moreover, only through the study of proteins can posttranslational modifications be determined,

  • which can profoundly affect protein function.

Proteomics has been enabled by

  • the accumulation of both DNA and protein sequence databases,
  • improvements in mass spectrometry, and
  • the development of computer algorithms for database searching.

In this review, we describe why proteomics is important,

  • how it is conducted, and
  • how it can be applied to complement other existing technologies.

We conclude that currently, the most practical application of proteomics is

  • the analysis of target proteins as opposed to entire proteomes.

This type of proteomics, referred to as functional proteomics, is always

  • driven by a specific biological question.

In this way, protein identification and characterization has a meaningful outcome. We discuss some of the advantages

  • of a functional proteomics approach and

provide examples of how different methodologies can be utilized to address a wide variety of biological problems.

Entry of our laboratory into proteomics 5 years ago was driven by a need to define a complex mixture of proteins (∼36 proteins) we had affinity isolated that bound specifically to the catalytic subunit of protein phosphatase 1 (PP-1, a serine/threonine protein phosphatase that regulates multiple dephosphorylation events in cells). We were faced with the task of trying to understand the significance of these proteins, and the only obvious way to begin to do this was to identify them by sequencing. Since the majority of intact eukaryotic proteins are not immediately accessible to Edman sequencing

  • due to posttranslational N-terminal modifications,
  • we invented mixed-peptide sequencing.

This method enables internal peptide sequence information to be derived from proteins

  • electroblotted onto hydrophobic membranes.

Using the mixed-peptide sequencing strategy, we identified all 36 proteins in about a week. The mixture contained at least two known PP-1 regulatory subunits, but most were novel proteins of unknown function. Herein lies the lesson of proteomics. Identifying long lists of potentially interesting proteins often generates more questions than it seeks to answer.

Despite learning this obvious lesson, our early sequencing experiences were an epiphany that has subsequently altered our whole scientific strategy for probing protein function in cells. The sequencing of the 36 proteins has opened new avenues to further explore the functions of PP-1 in intact cells. Because of increased sensitivity, our approaches now routinely use state-of-the-art mass spectrometry (MS) techniques. However, rather than using proteomics to simply characterize large numbers of proteins in complex mixtures, we see the real application of this technology as a tool to enhance the power of existing approaches currently used by the modern molecular biologist such as classical yeast and mouse genetics, tissue culture, protein expression systems, and site-directed mutagenesis.

Importantly, the one message we would want the reader to take away from reading this review is that one should always let the biological question in mind drive the application of proteomics rather than simply engaging in an orgy of protein sequencing. From our experiences, we believe that if the appropriate controls are performed, proteomics is an extremely powerful approach for addressing important physiological questions. One should always design experiments to define a selected number of relevant proteins in the mixture of interest. Examples of such experiments that we routinely perform include defining early phosphorylation events in complex protein mixtures after hormone treatment of intact cells or comparing patterns of protein derived from a stimulated versus nonstimulated cell in an affinity pull-down experiment. Only the proteins that were specifically phosphorylated or bound in response to the stimulus are sequenced in the complex mixtures. Sequencing proteins that are regulated then has a meaningful outcome and directs all subsequent biological investigation.

The term “proteomics” was first coined in 1995 and was defined as the large-scale characterization of the entire protein complement of a cell line, tissue, or organism. Today, two definitions of proteomics are encountered. The first is the more classical definition, restricting the large-scale analysis of gene products to studies involving only proteins. The second and more inclusive definition combines protein studies with analyses that have a genetic readout such as mRNA analysis, genomics, and the yeast two-hybrid analysis. However, the goal of proteomics remains the same, i.e., to obtain a more global and integrated view of biology by studying all the proteins of a cell rather than each one individually.

Using the more inclusive definition of proteomics, many different areas of study are now grouped under the rubric of proteomics (Fig. (Fig.1).1). These include protein-protein interaction studies, protein modifications, protein function, and protein localization studies to name a few. The aim of proteomics is not only to identify all the proteins in a cell but also to create a complete three-dimensional (3-D) map of the cell indicating where proteins are located. These ambitious goals will certainly require the involvement of a large number of different disciplines such as molecular biology, biochemistry, and bioinformatics. It is likely that in bioinformatics alone, more powerful computers will have to be devised to organize the immense amount of information generated from these endeavors.

Types of proteomics and their applications to biology

Types of proteomics and their applications to biology

In the quest to characterize the proteome of a given cell or organism, it should be remembered that the proteome is dynamic. The proteome of a cell will reflect the immediate environment in which it is studied. In response to internal or external cues, proteins can be modified by posttranslational modifications, undergo translocations within the cell, or be synthesized or degraded. Thus, examination of the proteome of a cell is like taking a “snapshot” of the protein environment at any given time. Considering all the possibilities, it is likely that any given genome can potentially give rise to an infinite number of proteomes.

The first major technology to emerge for the identification of proteins was the sequencing of proteins by Edman degradation. A major breakthrough was the development of microsequencing techniques for electroblotted proteins. This technique was used for the identification of proteins from 2-D gels to create the first 2-D databases.  One of the most important developments in protein identification has been the development of MS technology. In the last decade, the sensitivity of analysis and accuracy of results for protein identification by MS have increased by several orders of magnitude. It is now estimated that proteins in the femtomolar range can be identified in gels. Because MS is more sensitive, can tolerate protein mixtures, and is amenable to high-throughput operations, it has essentially replaced Edman sequencing as the protein identification tool of choice.

The growth of proteomics is a direct result of advances made in large-scale nucleotide sequencing of expressed sequence tags and genomic DNA. Without this information, proteins could not be identified even with the improvements made in MS. Protein identification (by MS or Edman sequencing) relies on the presence of some form of database for the given organism. The majority of DNA and protein sequence information has accumulated within the last 5 to 10 years. In 1995, the first complete genome of an organism was sequenced, that of Haemophilus influenzae. At the time of this writing, the sequencing of the genomes of 45 microorganisms has been completed and that of 170 more is under way (http://www.tiger.org/tdb/mdb/mdbcomplete.html). To date, five eukaryotic genomes have been completed: Arabidopsis thaliana, Saccharomyces cerevisiae, Schizosaccharomyces pombe, Caenorhabditis elegans, and Drosophila melanogaster. In addition, the rice, mouse, and human genomes are near completion.

One of the first applications of proteomics will be to identify the total number of genes in a given genome. This “functional annotation” of a genome is necessary because

  • it is still difficult to predict genes accurately from genomic data. One problem is that
  • the exon-intron structure of most genes cannot be accurately predicted by bioinformatics.

To achieve this goal, genomic information will have to be integrated with

  • data obtained from protein studies to confirm the existence of a particular gene.

The analysis of mRNA is

  • not a direct reflection of the protein content in the cell.

Many studies have shown a poor correlation

  • between mRNA and protein expression levels.

The formation of mRNA is only the first step in a long sequence of events resulting in the synthesis of a protein (Fig. (Fig.2).2).

  1. mRNA is subject to posttranscriptional control in the form of alternative splicing, polyadenylation, and mRNA editing. Many different protein isoforms can be generated from a single gene at this step.
  2. mRNA then can be subject to regulation at the level of protein translation. Proteins, having been formed, are subject to posttranslational modification. It is estimated that up to 200 different types of posttranslational protein modification exist. Proteins can also be regulated by proteolysis and compartmentalization. It is clear that the tenet of “one gene, one protein” is an oversimplification.
Mechanisms by which a single gene can give rise to multiple gene products

Mechanisms by which a single gene can give rise to multiple gene products

Mechanisms by which a single gene can give rise to multiple gene products. Multiple protein isoforms can be generated by RNA processing when RNA is alternatively spliced or edited to form mature mRNA. mRNA, in turn, can be regulated by stability and efficiency
One of the most important applications of proteomics will be the characterization of posttranslational protein modifications. Proteins are known to be modified posttranslationally in response to a variety of intracellular and extracellular signals. For example, protein phosphorylation is an important signaling mechanism and disregulation of protein kinases or phosphatases can result in oncogenesis. By using a proteomics approach, changes in the modifications of many proteins expressed by a cell can be analyzed simultaneously.
Of fundamental importance in biology is the understanding of protein-protein interactions. The process of cell growth, programmed cell death, and the decision to proceed through the cell cycle are all regulated by signal transduction through protein complexes. Proteomics aims to develop a complete 3-D map of all protein interactions in the cell. One step toward this goal was recently completed for the microorganism Helicobacter pylori. Using the yeast two-hybrid method to detect protein interactions, 1,200 connections were identified between H. pylori proteins covering 46.6% of the genome. A comprehensive two-hybrid analysis has also been performed on all the proteins from the yeast S. cerevisiae.
mixed peptide sequencing with MS

mixed peptide sequencing with MS

The process of mixed-peptide sequencing involves separation of a complex protein mixture by polyacrylamide gel electrophoresis (1-D or 2-D) and then transfer of the proteins to an inert membrane by electroblotting (Fig. (Fig.4).4). The proteins of interest are visualized on the membrane surface, excised, and fragmented chemically at methionine (by CNBr) or tryptophan (by skatole) into several large peptide fragments.
FASTF and FASTS search programs

FASTF and FASTS search programs

The mixed-sequence data are fed into the FASTF or TFASTF algorithms, which sort and match the data against protein (FASTF) and DNA (TFASTF) databases to unambiguously identify the protein. The FASTF and TFASTF programs were written in collaboration with William Pearson (Department of Biochemistry, University of Virginia). Because minimal sample handling is involved, mixed-peptide sequencing can be a sensitive approach for identifying proteins in polyacrylamide gels at the 0.1- to 1-pmol level.  A recent variation of T/FASTF has been devised for MS (101) (Fig. (Fig.5B).5B). The T/FASTF/S programs are available at http://fasta.bioch.virginia.edu/ (Table (Table11).

triple quadrupole MS

triple quadrupole MS

Triple-quadrupole mass spectrometers are most commonly used to obtain amino acid sequences. In the first stage of analysis, the machine is operated in MS scan mode and all ions above a certain m/z ratio are transmitted to the third quadrupole for mass analysis (Fig. (Fig.6)6) (82, 173). In the second stage, the mass spectrometer is operated in MS/MS mode and a particular peptide ion is selectively passed into the collision chamber. Inside the collision chamber, peptide ions are fragmented by interactions with an inert gas by a process known as collision-induced dissociation or collisionally activated dissociation. The peptide ion fragments are then resolved on the basis of their m/z ratio by the third quadrupole (Fig. (Fig.6).6). Since two different mass spectra are obtained in this analysis, it is referred to as tandem mass spectrometry (MS/MS). MS/MS is used to obtain the amino acid sequence of peptides by generating a series of peptides that differ in mass by a single amino acid.

The largest application of proteomics continues to be protein expression profiling. Through the use of two-dimensional gels or novel techniques such as ICAT, the expression levels of proteins or changes in their level of modification between two different samples can be compared and the proteins can be identified. This approach can facilitate the dissection of signaling mechanisms or identify disease-specific proteins.

Cancer cells are good candidates for proteomics studies because they can be compared to their non-transformed counterparts. Analysis of differentially expressed proteins in normal versus cancer cells can

(i) identify novel tumor cell biomarkers that can be used for diagnosis,

(ii) provide clues to mechanisms of cancer development, and

(iii) identify novel targets for therapeutic intervention. Protein expression profiling has been used in the study of breast, esophageal, bladder and prostate cancer. From these studies, tumor-specific proteins were identified and 2-D protein expression databases were generated. Many of these 2-D protein databases are now available on the World Wide Web.

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Introduction to Subcellular Structure

Author and Curator: Larry H. Bernstein, MD, FCAP  

 

 

The following chapter of the metabolism/transcriptomics/proteomics/metabolomics series deals with the subcellular structure of the cell.  This would have to include the cytoskeleton, which has a key role in substrate and ion efflux and influx, and in cell movement mediated by tubulins.  It has been extensively covered already.  Much of the contributions here are concerned with the mitochondrion, which is also covered in metabolic pathways.  The ribosome is the organelle that we have discussed with respect to the transcription and translation of the genetic code through mRNA and tRNA, and the therapeutic implications of SiRNA as well as the chromatin regulation of lncRNA.

We have also encountered the mitochondrion and the lysosome in the discussion of apoptosis and autophagy, maintaining the balance between cell regeneration and cell death.

I here list the organelles:

  1. Nucleus
  2. Centrosome
  3. Nuclear Membrane
  4. Ribososome
  5. Endoplasmic Reticulum
  6. Mitochondria
  7. Lysosome
  8. Cytoskeleton
  9. Golgi apparatus
  10. Cytoplasm
cell_organelle_quiz

cell_organelle_quiz

http://www.youtube.com/watch?feature=player_embedded&v=JufLDxmCwB0

http://www.youtube.com/watch?feature=player_embedded&v=FFrKN7hJm64

Golgi Apparatus

Found within the cytoplasm of both plant and animal cells, the Golgi is composed of stacks of membrane-bound structures known as cisternae (singular: cisterna). An individual stack is sometimes called a dictyosome (from Greek dictyon: net + soma: body), especially in plant cells. A mammalian cell typically contains 40 to 100 stacks. Between four and eight cisternae are usually present in a stack; however, in some protists as many as sixty have been observed. Each cisterna comprises a flat, membrane-enclosed disc that includes special Golgi enzymes which modify or help to modify cargo proteins that travel through it.

The cisternae stack has four functional regions: the cis-Golgi network, medial-Golgi, endo-Golgi, and trans-Golgi network. Vesicles from the endoplasmic reticulum (via the vesicular-tubular clusters) fuse with the network and subsequently progress through the stack to the trans-Golgi network, where they are packaged and sent to their destination.

The Golgi apparatus is integral in modifying, sorting, and packaging these macromolecules for cell secretion (exocytosis) or use within the cell. It primarily modifies proteins delivered from the rough endoplasmic reticulum, but is also involved in the transport of lipids around the cell, and the creation of lysosomes.  Enzymes within the cisternae are able to modify the proteins by addition of carbohydrates (glycosylation) and phosphates (phosphorylation). In order to do so, the Golgi imports substances such as nucleotide sugars from the cytosol. These modifications may also form a signal sequence which determines the final destination of the protein. For example, the Golgi apparatus adds a mannose-6-phosphate label to proteins destined for lysosomes.

The Golgi plays an important role in the synthesis of proteoglycans, which are molecules present in the extracellular matrix of animals. It is also a major site of carbohydrate synthesis. This includes the production of glycosaminoglycans (GAGs), long unbranched polysaccharides which the Golgi then attaches to a protein synthesised in the endoplasmic reticulum to form proteoglycans. Enzymes in the Golgi polymerize several of these GAGs via a xylose link onto the core protein. Another task of the Golgi involves the sulfation of certain molecules passing through its lumen via sulfotranferases that gain their sulfur molecule from a donor called PAPS. This process occurs on the GAGs of proteoglycans as well as on the core protein. Sulfation is generally performed in the trans-Golgi network. The level of sulfation is very important to the proteoglycans’ signalling abilities, as well as giving the proteoglycan its overall negative charge.

The phosphorylation of molecules requires that ATP is imported into the lumen of the Golgi and utilised by resident kinases such as casein kinase 1 and casein kinase 2. One molecule that is phosphorylated in the Golgi is apolipoprotein, which forms a molecule known as VLDL that is found in plasma. It is thought that the phosphorylation of these molecules labels them for secretion into the blood.

The Golgi has a putative role in apoptosis, with several Bcl-2 family members localised there, as well as to the mitochondria. A newly characterized protein, GAAP (Golgi anti-apoptotic protein), almost exclusively resides in the Golgi and protects cells from apoptosis by an as-yet undefined mechanism.

The vesicles that leave the rough endoplasmic reticulum are transported to the cis face of the Golgi apparatus, where they fuse with the Golgi membrane and empty their contents into the lumen. Once inside the lumen, the molecules are modified, then sorted for transport to their next destinations. The Golgi apparatus tends to be larger and more numerous in cells that synthesize and secrete large amounts of substances; for example, the plasma B cells and the antibody-secreting cells of the immune system have prominent Golgi complexes.

Those proteins destined for areas of the cell other than either the endoplasmic reticulum or Golgi apparatus are moved towards the trans face, to a complex network of membranes and associated vesicles known as the trans-Golgi network (TGN). This area of the Golgi is the point at which proteins are sorted and shipped to their intended destinations by their placement into one of at least three different types of vesicles, depending upon the molecular marker they carry.

Nucleus_ER_golgi

Nucleus_ER_golgi

Diagram of secretory process from endoplasmic reticulum (orange) to Golgi apparatus (pink). 1. Nuclear membrane; 2. Nuclear pore; 3. Rough endoplasmic reticulum (RER); 4. Smooth endoplasmic reticulum (SER); 5. Ribosome attached to RER; 6. Macromolecules; 7. Transport vesicles; 8. Golgi apparatus; 9. Cis face of Golgi apparatus; 10. Trans face of Golgi apparatus; 11. Cisternae of the Golgi Apparatus

Exocytotic vesicles

After packaging, the vesicles bud off and immediately move towards the plasma membrane, where they fuse and release the contents into the extracellular space in a process known as constitutive secretion. (Antibody release by activated plasma B cells)

Secretory vesicles

After packaging, the vesicles bud off and are stored in the cell until a signal is given for their release. When the appropriate signal is received they move towards the membrane and fuse to release their contents. This process is known as regulated secretion. (Neurotransmitter release from neurons)

Lysosomal vesicles

Vesicle contains proteins and ribosomes destined for the lysosome, an organelle of degradation containing many acid hydrolases, or to lysosome-like storage organelles. These proteins include both digestive enzymes and membrane proteins. The vesicle first fuses with the late endosome, and the contents are then transferred to the lysosome via unknown mechanisms.

http://en.wikipedia.org/wiki/Golgi_apparatus

Lysosome (derived from the Greek words lysis, meaning “to loosen”, and soma, “body”) is a membrane-bound cell organelle found in animal cells (they are absent in red blood cells). They are structurally and chemically spherical vesicles containing hydrolytic enzymes, which are capable of breaking down virtually all kinds of biomolecules, including proteins, nucleic acids, carbohydrates, lipids, and cellular debris.  Lysosomes are responsible for cellular homeostasis for their involvements in secretion, plasma membrane repair, cell signalling and energy metabolism, which are related to health and diseases. Depending on their functional activity their sizes can be very different, as the biggest ones can be more than 10 times bigger than the smallest ones. They were discovered and named by Belgian biologist Christian de Duve, who eventually received the Nobel Prize in Physiology or Medicine in 1974.

Enzymes of the lysosomes are synthesised in the rough endoplasmic reticulum. The enzymes are released from Golgi apparatus in small vesicles which ultimately fuse with acidic vesicles called endosomes, thus becoming full lysosomes. In the process the enzymes are specifically tagged with mannose 6-phosphate to differentiate them from other enzymes. Lysosomes are interlinked with three intracellular processes namely phagocytosis, endocytosis and autophagy. Extracellular materials such as microorganisms taken up by phagocytosis, macromolecules by endocytosis, and unwanted cell organelles are fused with lysosomes in which they are broken down to their basic molecules. Thus lysosomes are the recycling units of a cell.

http://en.wikipedia.org/wiki/Lysosome

The endoplasmic reticulum (ER) is a type of organelle in the cells of eukaryotic organisms that forms an interconnected network of flattened, membrane-enclosed sacs or tubes known as cisternae. The membranes of the ER are continuous with the outer membrane of the nuclear envelope. Endoplasmic reticulum occurs in most types of eukaryotic cells, including the most primitive Giardia, but is absent from red blood cells and spermatozoa. There are two types of endoplasmic reticulum, rough endoplasmic reticulum (RER) and smooth endoplasmic reticulum (SER). The outer (cytosolic) face of the rough endoplasmic reticulum is studded with ribosomes that are the sites of protein synthesis. The rough endoplasmic reticulum is especially prominent in cells such as hepatocytes where active smooth endoplasmic reticulum lacks ribosomes and functions in lipid metabolism, carbohydrate metabolism, and detoxification and is especially abundant in mammalian liver and gonad cells. The lacey membranes of the endoplasmic reticulum were first seen in 1945 by Keith R. Porter, Albert Claude, Brody Meskers and Ernest F. Fullam, using electron microscopy.

http://en.wikipedia.org/wiki/Endoplasmic_reticulum

endoplasmic_reticulum

endoplasmic_reticulum

https://2cslacardano.wikispaces.com/file/view/Cell7.png/338811858/408×313/Cell7.png

Cytoskeleton

The Effects of Actomyosin Tension on Nuclear Pore Transport
Rachel Sammons
Undergraduate Honors Thesis
Spring 2011

The cytoskeleton maintains cellular structure and tension through a force balance with the nucleus, where actomyosin is anchored to the nuclear envelope by nesprin integral proteins. It is hypothesized that the presence or absence of this tension alters the transport of molecules through the nuclear pore complex. We tested the effects of cytoskeletal tension on nuclear transport in human umbilical vein endothelial cells (HUVECs) by performing fluorescence recovery after photo-bleaching (FRAP) experiments on the nuclei to monitor the passive transport of the molecules through nuclear pores.

Using myosin inhibitors, as well as siRNA transfections to reduce the expression of nesprin-1, we altered the nucleo-cytoskeletal force balance and monitored the effect of each on the nuclear pore. FRAP data was fit to a diffusion model by assuming pseudo-steady state inside the nuclear pore, perfect mixing within both the cytoplasm and the nucleus, and no intracellular binding of the fluorescent probes. From these results and a model from the current literature relating diffusion rate constants to nuclear pore radii, we were able to determine that changing cytoskeletal tension alters nuclear pore size and passive transport.

nuclear pores in nuclear envelope

nuclear pores in nuclear envelope

image of nuclear pores on the external surface of the nuclear envelope

nuclear envelope and FG filaments

nuclear envelope and FG filaments

nuclear envelope and FG filaments

Figure 1: The structure and location of the nuclear pore, shown by (a) AFM image of nuclear pores on the external surface of the nuclear envelope[5] and (b) computer model cross-section. The nuclear envelope is shown in cyan, and FG filaments in blue can be seen throughout the channel. The nuclear basket extends into the nucleoplasm.

Fusion-pore expansion during syncytium formation is restricted by an actin network

A Chen, E Leikina, K Melikov, B Podbilewicz, MM. Kozlov and LV. Chernomordik,*
J Cell Sci 1 Nov 2008;121: 3619-3628. http://dx.doi.org:/10.1242/​jcs.032169

Effects of actin-modifying agents indicate that the actin cortex slows down pore expansion. We propose that the growth of the strongly bent fusion-pore rim is restricted by a dynamic resistance of the actin network and driven by membrane-bending proteins that are involved in the generation of highly curved intracellular membrane compartments.

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