Posts Tagged ‘anti-cancer therapeutics’

37th Annual J.P. Morgan HEALTHCARE CONFERENCE: News at #JPM2019 for Jan. 8, 2019: Deals and Announcements

Reporter: Stephen J. Williams, Ph.D.


JP Morgan Healthcare Conference Update: FDA, bluebird, Moderna and the Price of Coffee

Researcher holding test tube up behind circle of animated research icons

Tuesday, January 8, was another busy day in San Francisco for the JP Morgan Healthcare Conference. One interesting sideline was the idea that the current government shutdown could complicate some deals. Kent Thiry, chief executive officer of dialysis provider DaVita, who is working on the sale of its medical group to UnitedHealth Group this quarter, said, “We couldn’t guarantee that even if the government wasn’t shut down, but we and the buyer are both working toward that goal with the same intensity if not more.”

And in a slightly amusing bit of synchrony, U.S.Food and Drug Administration (FDA)Commissioner Scott Gottlieb’s keynote address that was delivered by way of video conference from Washington, D.C., had his audio cut out in the middle of the presentation. Gottlieb was talking about teen nicotine use and continued talking, unaware that his audio had shut off for 30 seconds. When it reconnected, the sound quality was reportedly poor.

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bluebird bio’s chief executive officer, Nick Leschlygave an update of his company’s pipeline, with a particular emphasis on a proposed payment model for its upcoming LentiGlobin, a gene therapy being evaluated for transfusion-dependent ß-thalassemia (TDT). The gene therapy is expected to be approved in Europe this year and in the U.S. in 2020. Although the price hasn’t been set, figures up to $2.1 million per treatment have been floated. Bluebird is proposing a five-year payment program, a pledge to not raise prices above CPI, and no costs after the payment period.

Eli Lilly’s chief executive officer David Ricks, just days after acquiring Loxo Oncologyoffered up projections for this year, noting that 45 percent of its revenue will be created by drugs launched in 2015. Those include Trulicity, Taltz and Verzenio. The company also expects to launch two new molecular entities this year—nasal glucagons, a rescue medicine for high blood sugar (hyperglycemia), and Lasmiditan, a rescue drug for migraine headaches.

CNBC’s Jim Cramer interviewed Allergan chief executive officer Brent Saunders, in particular discussing the fact the company’s shares traded in 2015 for $331.15 but were now trading for $145.60. Cramer noted that the company’s internal fundamentals were strong, with multiple pipeline assets and a strong leadership team. Some of the stock problems are related to what Saunders said were “unforced errors,” including intellectual property rights to Restasis, its dry-eye drug, and Allergan’s dubious scheme to protect those patents by transferring the rights to the Saint Regis Mohawk Tribe in New York. On the positive side, the company’s medical aesthetics portfolio, dominated by Botox, is very strong and the overall market is expected to double.

One of the big areas of conversation is so-called “flyover tech.” Biopharma startups are dominant in Boston and in San Francisco, but suddenly venture capital investors have realized there’s a lot going on in between. New York City-based Radian Capital, for example, invests exclusively in markets outside major U.S. cities.

“At Radian, we partner with entrepreneurs who have built their businesses with a focus on strong economics rather than growth at all costs,” Aly Lovett, partner at Radian, told The Observer. “Historically, given the amount of money required to stand up a product, the software knowledge base, and coastal access to capital, health start-ups were concentrated in a handful of cities. As those dynamics have inverted and as the quality of living becomes a more important factor in attracting talent, we’re not seeing a significant increase in the number of amazing companies being built outside of the Bay Area.”

“Flyover companies” mentioned include Bind in Minneapolis, Minnesota; Solera Health in Phoenix, Arizona; ClearDATA in Austin, Texas; Healthe, in Eden Prairie, Minnesota; HistoSonics in Ann Arbor, Michigan; and many others.

Only a month after its record-breaking IPO, Moderna Therapeutics’ chief executive officer Stephane Bancelspent time both updating the company’s clinical pipeline and justifying the company’s value despite the stock dropping off 26 percent since the IPO. Although one clinical program, a Zika vaccine, mRNA-1325, has been abandoned, the company has three new drugs coming into the clinic: mRNA-2752 for solid tumors or lymphoma; mRNA-4157, a Personalized Cancer Vaccine with Merck; and mRNA-5671, a KRAS cancer vaccine. The company also submitted an IND amendment to the FDA to add an ovarian cancer cohort to its mRNA-2416 program.

One interesting bit of trivia, supplied on Twitter by Rasu Shrestha, chief innovation officer for the University of Pittsburgh Medical Center, this year at the conference, 33 female chief executive officers were presenting corporate updates … compared to 19 men named Michael. Well, it’s a start.

And for another bit of trivia, Elisabeth Bik, of Microbiome Digest, tweeted, “San Francisco prices are so out of control that one hotel is charging the equivalent of $21.25 for a cup of coffee during a JPMorgan conference.”

Other posts on the JP Morgan 2019 Healthcare Conference on this Open Access Journal include:

#JPM19 Conference: Lilly Announces Agreement To Acquire Loxo Oncology

36th Annual J.P. Morgan HEALTHCARE CONFERENCE January 8 – 11, 2018

37th Annual J.P. Morgan HEALTHCARE CONFERENCE: #JPM2019 for Jan. 8, 2019; Opening Videos, Novartis expands Cell Therapies, January 7 – 10, 2019, Westin St. Francis Hotel | San Francisco, California


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A Curated History of the Science Behind the Ovarian Cancer β-Blocker Trial

Curator: Stephen J. Williams, Ph.D.


This post is a follow-up on the two reports found in this Open Access Journal


in order to explain some of the background which went into the development of these reports.

A recent paper by Anil Sood’s group at MD Anderson in Journal of Cancer: Clinical impact of selective and nonselective beta-blockers on survival in patients with ovarian cancer describes a retrospective pathologic evaluation of ovaries from patients taking various beta blockers for currently approved indications.

The history of this finding is quite interesting and, as I remember in a talk given by Dr. Sood in mid-2000’s, a microarray conducted by his lab had showed overexpression of the β2-AR (β2 adrenergic receptor in ovarian cancer cells relative to normal epithelium. At the time it appeared an interesting result however most of the cancer (and ovarian cancer) field were concentrating on the tyrosine kinase signaling pathways as potential therapeutic targets, as much promising translational research in this area was in focus at the time. As a result of this finding and noticing that sustained β-adrenergic stimulation can promote ovarian cancer cell growth (Sood, 2006), Dr. Sood’s group have been studying the effects of β-adrenergic signaling om ovarian cancer. In addition it has been shown that propanalol can block VEGF signaling and norepinephrine increased MMP2 and MMP9 expression, an effect mediated by the β2-AR.

The above re-post of a Scoop-IT describes promising results of a clinical trial for use of selective beta blockers in ovarian cancer.   As to date, there have been many clinical trials initiated in ovarian cancer and most have not met with success for example the following posts:

Good and Bad News Reported for Ovarian Cancer Therapy

a follow-up curation on the problems encountered with the PARP-inhibitor olaparib

enough is enough: Treat ‘Each Patient as an Individual’

which contains an interview with Dr. Maurie Markman (Vice President, Patient Oncology Services, and National Director for Medical Oncology, Cancer Treatment Centers of America) and Dr. Kathy D. Miller, Indiana University School of Medicine) and discusses how each patient’s ovarian cancer is genetically unique and needs to be treated as such

Therefore the mainstay therapy is still carboplatin plus a taxane (Taxotere, Abraxane). The results of this clinical trial show a 5 month improvement in survival, which for a deadly disease like ovarian cancer is a significant improvement.

First below is a SUMMARY of the paper’s methodology and findings.


  • Four participating institutions collected retrospective patient data and pathology reports from 1425 patients diagnosed with epithelial ovarian cancer (EOC)
  • Medical records were evaluated for use of both selective and nonselective β-blockers
  • β-blockers were used for various indications however most common indication was treatment for hypertension (71% had used β1 selective blockers while rest of patients taking β blockers were given nonselective blockers for a host of other indications)
  • most patients had stage III/IV disease and in general older (median age 63 years)
  • The authors looked at overall survival (OS) however progression free survival PFS) was not calculated


  • Hypertension was associated with decreased survival (40.1 monts versus 47.4 months for normotensive patients)
  • Overall Survival for patients on any β blockers was 47.8 months versus 42.0 months for nonusers
  • Patients receiving nonselective β blockers has an OS of 94.9 months versus 38 months for EOC patients receiving β1-selective blockers
  • No effect of diabetes mellitus on survival

Authors Note on Limitations of Study:

  • Retrospective in nature
  • Lack of documentation of dosage, trade-name and duration of β-blocker use
  • Important to stratify patients on selectivity of β-blocker since Eskander et. al. found no difference of Progression Free Survival and non-selective β-blocker
  • Several β adrenergic receptor polymorphisms may exist and no downstream biomarker evaluated to determine effect on signaling; could it be a noncanonical effect?

The goal of this brief, added curation is to paint a historical picture, and highlight the scientific findings which led up to the rationale behind this clinical trial.

How the βeta Adrenergic Receptor (βAR) Became a Target for Ovarian Cancer


A. βAR and its signaling over-expressed in ovarian cancer

Role of mitogen-activated protein kinase/extracellular signal-regulated kinase cascade in gonadotropin-releasing hormone-induced growth inhibition of a human ovarian cancer cell line.

Kimura A, Ohmichi M, Kurachi H, Ikegami H, Hayakawa J, Tasaka K, Kanda Y, Nishio Y, Jikihara H, Matsuura N, Murata Y.

Cancer Res. 1999 Oct 15;59(20):5133-42.

Cyclic AMP induces integrin-mediated cell adhesion through Epac and Rap1 upon stimulation of the beta 2-adrenergic receptor.

Rangarajan S, Enserink JM, Kuiperij HB, de Rooij J, Price LS, Schwede F, Bos JL.

J Cell Biol. 2003 Feb 17;160(4):487-93. Epub 2003 Feb 10.

B. Mechanistic Link Between Chronic Stress From Excess Adrenergic Stimulation and Angiogenesis and Metastasis

Stress-related mediators stimulate vascular endothelial growth factor secretion by two ovarian cancer cell lines.

Lutgendorf SK, Cole S, Costanzo E, Bradley S, Coffin J, Jabbari S, Rainwater K, Ritchie JM, Yang M, Sood AK.

Clin Cancer Res. 2003 Oct 1;9(12):4514-21.PMID:

Norepinephrine up-regulates the expression of vascular endothelial growth factor, matrix metalloproteinase (MMP)-2, and MMP-9 in nasopharyngeal carcinoma tumor cells.

Yang EV, Sood AK, Chen M, Li Y, Eubank TD, Marsh CB, Jewell S, Flavahan NA, Morrison C, Yeh PE, Lemeshow S, Glaser R.

Cancer Res. 2006 Nov 1;66(21):10357-64.

VEGF is differentially regulated in multiple myeloma-derived cell lines by norepinephrine.

Yang EV, Donovan EL, Benson DM, Glaser R.

Brain Behav Immun. 2008 Mar;22(3):318-23. Epub 2007 Nov 5.

Chronic stress promotes tumor growth and angiogenesis in a mouse model of ovarian carcinoma.

Thaker PH, Han LY, Kamat AA, Arevalo JM, Takahashi R, Lu C, Jennings NB, Armaiz-Pena G, Bankson JA, Ravoori M, Merritt WM, Lin YG, Mangala LS, Kim TJ, Coleman RL, Landen CN, Li Y, Felix E, Sanguino AM, Newman RA, Lloyd M, Gershenson DM, Kundra V, Lopez-Berestein G, Lutgendorf SK, Cole SW, Sood AK.

Nat Med. 2006 Aug;12(8):939-44. Epub 2006 Jul 23.

Norepinephrine up-regulates the expression of vascular endothelial growth factor, matrix metalloproteinase (MMP)-2, and MMP-9 in nasopharyngeal carcinoma tumor cells.

Yang EV, Sood AK, Chen M, Li Y, Eubank TD, Marsh CB, Jewell S, Flavahan NA, Morrison C, Yeh PE, Lemeshow S, Glaser R.

Cancer Res. 2006 Nov 1;66(21):10357-64.

C. In Vivo Studies Confirm In Vitro Findings That Chronic Stress Via Adrenergic overstimulation Increases Ovarian Cancer Growth

Chronic stress promotes tumor growth and angiogenesis in a mouse model of ovarian carcinoma.

Thaker PH, Han LY, Kamat AA, Arevalo JM, Takahashi R, Lu C, Jennings NB, Armaiz-Pena G, Bankson JA, Ravoori M, Merritt WM, Lin YG, Mangala LS, Kim TJ, Coleman RL, Landen CN, Li Y, Felix E, Sanguino AM, Newman RA, Lloyd M, Gershenson DM, Kundra V, Lopez-Berestein G, Lutgendorf SK, Cole SW, Sood AK.

Nat Med. 2006 Aug;12(8):939-44. Epub 2006 Jul 23.

Stress hormone-mediated invasion of ovarian cancer cells.

Sood AK, Bhatty R, Kamat AA, Landen CN, Han L, Thaker PH, Li Y, Gershenson DM, Lutgendorf S, Cole SW.

Clin Cancer Res. 2006 Jan 15;12(2):369-75.

The neuroendocrine impact of chronic stress on cancer.

Thaker PH, Lutgendorf SK, Sood AK.

Cell Cycle. 2007 Feb 15;6(4):430-3. Epub 2007 Feb 9. Review.

Surgical stress promotes tumor growth in ovarian carcinoma.

Lee JW, Shahzad MM, Lin YG, Armaiz-Pena G, Mangala LS, Han HD, Kim HS, Nam EJ, Jennings NB, Halder J, Nick AM, Stone RL, Lu C, Lutgendorf SK, Cole SW, Lokshin AE, Sood AK.

Clin Cancer Res. 2009 Apr 15;15(8):2695-702. doi: 10.1158/1078-0432.CCR-08-2966. Epub 2009 Apr 7.

Sood group wanted to mimic the surgical stress after laparoscopic surgery to see if surgical stress would promote the growth of micrometasteses remaining after surgical tumor removal. Propranolol completely blocked the effects of surgical stress on tumor growth, indicating a critical role for beta-adrenergic receptor signaling in mediating the effects of surgical stress on tumor growth. In the HeyA8 and SKOV3ip1 models, surgery significantly increased microvessel density (CD31) and vascular endothelial growth factor expression, which were blocked by propranolol treatment. Tumor growth after surgery was decreased in a mouse null for βAR. Levels of cytokines G-CSF, IL-1a, IL-6, and IL-15were increased after surgery

Stress effects on FosB- and interleukin-8 (IL8)-driven ovarian cancer growth and metastasis J Biol Chem. 2010 Nov 12;285(46):35462-70. doi: 10.1074/jbc.M110.109579. Epub 2010 Sep 8.

Shahzad MM1, Arevalo JM, Armaiz-Pena GN, Lu C, Stone RL, Moreno-Smith M, Nishimura M, Lee JW, Jennings NB, Bottsford-Miller J, Vivas-Mejia P, Lutgendorf SK, Lopez-Berestein G, Bar-Eli M, Cole SW, Sood AK.

Free PMC Article


A growing number of studies indicate that chronic stress can accelerate tumor growth due to sustained sympathetic nervous system activation. Our recent findings suggest that chronic stress is associated with increased IL8 levels. Here, we examined the molecular and biological significance of IL8 in stress-induced tumor growth. Norepinephrine (NE) treatment of ovarian cancer cells resulted in a 250-300% increase in IL8 protein and 240-320% increase in its mRNA levels. Epinephrine treatment resulted in similar increases. Moreover, NE treatment resulted in a 3.5-4-fold increase in IL8 promoter activity. These effects were blocked by propranolol. Promoter deletion analyses suggested that AP1 transcription factors might mediate catecholamine-stimulated up-regulation of IL8. siRNA inhibition studies identified FosB as the pivotal component responsible for IL8 regulation by NE. In vivo chronic stress resulted in increased tumor growth (by 221 and 235%; p < 0.01) in orthotopic xenograft models involving SKOV3ip1 and HeyA8 ovarian carcinoma cells. This enhanced tumor growth was completely blocked by IL8 or FosB gene silencing using 1,2-dioleoyl-sn-glycero-3-phosphatidylcholine nanoliposomes. IL8 and FosB silencing reduced microvessel density (based on CD31 staining) by 2.5- and 3.5-fold, respectively (p < 0.001). Our findings indicate that neurobehavioral stress leads to FosB-driven increases in IL8, which is associated with increased tumor growth and metastases. These findings may have implications for ovarian cancer management.

Dopamine blocks stress-mediated ovarian carcinoma growth.

Moreno-Smith M, Lu C, Shahzad MM, Pena GN, Allen JK, Stone RL, Mangala LS, Han HD, Kim HS, Farley D, Berestein GL, Cole SW, Lutgendorf SK, Sood AK.

Clin Cancer Res. 2011 Jun 1;17(11):3649-59. doi: 10.1158/1078-0432.CCR-10-2441. Epub 2011 Apr 29.

D. Additional mechanisms iincluding JAK/STAT modulation, prostaglandin synthesis, AKT, and Slug implicated in Stress (norepinephrine) induced increase in Ovarian Tumor Growth

Sustained adrenergic signaling leads to increased metastasis in ovarian cancer via increased PGE2 synthesis.

Nagaraja AS, Dorniak PL, Sadaoui NC, Kang Y, Lin T, Armaiz-Pena G, Wu SY, Rupaimoole R, Allen JK, Gharpure KM, Pradeep S, Zand B, Previs RA, Hansen JM, Ivan C, Rodriguez-Aguayo C, Yang P, Lopez-Berestein G, Lutgendorf SK, Cole SW, Sood AK.

Oncogene. 2015 Aug 10. doi: 10.1038/onc.2015.302. [Epub ahead of print]

The antihypertension drug doxazosin suppresses JAK/STATs phosphorylation and enhances the effects of IFN-α/γ-induced apoptosis.

Park MS, Kim BR, Kang S, Kim DY, Rho SB.

Genes Cancer. 2014 Nov;5(11-12):470-9.

hTERT mediates norepinephrine-induced Slug expression and ovarian cancer aggressiveness.

Choi MJ, Cho KH, Lee S, Bae YJ, Jeong KJ, Rha SY, Choi EJ, Park JH, Kim JM, Lee JS, Mills GB, Lee HY.

Oncogene. 2015 Jun;34(26):3402-12. doi: 10.1038/onc.2014.270. Epub 2014 Aug 25.

The antihypertension drug doxazosin inhibits tumor growth and angiogenesis by decreasing VEGFR-2/Akt/mTOR signaling and VEGF and HIF-1α expression.

Park MS, Kim BR, Dong SM, Lee SH, Kim DY, Rho SB.

Oncotarget. 2014 Jul 15;5(13):4935-44.

Meeting Abstracts on the Subject

From 2007 AACR Meeting

Neuroendocrine Modulation of Signal Transducer and Activator of Transcription-3 in Ovarian Cancer

  1. Requests for reprints:
    Anil K. Sood, Departments of Gynecologic Oncology and Cancer Biology, The University of Texas M. D. Anderson Cancer Center, 1155 Herman Pressler, CPB6.3244, Unit 1362, Houston, TX 77230-1439. Phone: 713-745-5266; Fax: 713-792-7586; E-mail:


There is growing evidence that chronic stress and other behavioral conditions are associated with cancer pathogenesis and progression, but the mechanisms involved in this association are poorly understood. We examined the effects of two mediators of stress, norepinephrine and epinephrine, on the activation of signal transducer and activator of transcription-3 (STAT3), a transcription factor that contributes to many promalignant pathways. Exposure of ovarian cancer cell lines to increasing concentrations of norepinephrine or epinephrine showed that both independently increased levels of phosphorylated STAT3 in a dose-dependent fashion. Immunolocalization and ELISA of nuclear extracts confirmed increased nuclear STAT3 in response to norepinephrine. Activation of STAT3 was inhibited by blockade of the β1- and β2-adrenergic receptors with propranolol, and by blocking protein kinase A with KT5720, but not with the α receptor blockers prazosin (α1) and/or yohimbine (α2). Catecholamine-mediated STAT3 activation was not inhibited by pretreatment with an anti–interleukin 6 (IL-6) antibody or with small interfering RNA (siRNA)–mediated decrease in IL-6 or gp130. Regarding the effects of STAT3 activation, exposure to norepinephrine resulted in an increase in invasion and matrix metalloproteinase (MMP-2 and MMP-9) production. These effects were completely blocked by STAT3-targeting siRNA. In mice, treatment with liposome-incorporated siRNA directed against STAT3 significantly reduced isoproterenol-stimulated tumor growth. These studies show IL-6–independent activation of STAT3 by norepinephrine and epinephrine, proceeding through the β1/β2-adrenergic receptors and protein kinase A, resulting in increased matrix metalloproteinase production, invasion, and in vivo tumor growth, which can be ameliorated by the down-regulation of STAT3. [Cancer Res 2007;67(21):10389–96]

From 2009 AACR Meeting

Abstract #2506: Functional \#946;2 adrenergic receptors (ADRB2) on human ovarian tumors portend worse clinical outcome


Objective: Stress hormones such as catecholamines can augment tumor metastasis and angiogenesis; however, the prevalence and clinical significance of adrenergic receptors in human ovarian cancer is unknown and is the focus of the current study. Methods: After IRB approval, paraffin-embedded samples from 137 patients with invasive epithelial ovarian carcinoma were examined for \#946;1- and \#946;2-adrenergic receptor (ADRB1 and ADRB2, respectively) expression. Correlations with clinical outcomes were determined using parametric and non-parametric tests. Survival analyses were performed using the Kaplan-Meier method. Expression of ADRB1 and -2 was examined by quantitative RT-PCR in 15 freshly extracted human ovarian carcinoma cells. Human ovarian carcinoma cells then underwent time-variable adrenergic stimulation, and tumorigenic and angiogenic cytokine levels were examined by ELISA. Results: Sixty-six percent of the tumors had high expression of ADRB1; 80% of specimens highly expressed ADRB2. Univariate analyses demonstrated that high ADRB1 expression was associated with serous histology (p=0.03) and the presence of ascites (p=0.03), while high expression of ADRB2 was associated with advanced stage (p=0.008). Moreover, high ADRB2 expression was associated with the lower overall survival (2.2 vs. 6.5 years; p<0.001). In multivariate analysis, controlling for FIGO stage, grade, cytoreduction, age, and ADRB expression, only FIGO stage, cytoreduction status, age, and ADRB status retained statistical significance in predicting overall survival. In tumor cells freshly isolated from human ovarian cancers, 75% of samples had high expression of ADRB2 while most lacked ADRB1 compared to normal surface epithelium. Stimulation of the freshly isolated ADRB2-positive human ovarian cancer cells with norepinephrine resulted in increased levels of cAMP and increased angiogenic cytokines IL-6 and VEGF. Conclusions: ADRB2 are frequently found on human ovarian tumors and are strongly associated with poor clinical outcome. These findings support a direct mechanism by which stress hormones modulate ovarian cancer growth and metastasis as well as provide a basis for therapeutic targeting.

And from the 2015 AACR Meeting:

Abstract 3368: Sustained adrenergic signaling activates pro-inflammatory prostaglandin network in ovarian carcinoma

  1. Archana S. Nagaraja1,

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA


Purpose: Catecholamine mediated stress effects are known to induce production of various pro-inflammatory cytokines. However, the mechanism and functional effect of adrenergic signaling in driving inflammation via pro-inflammatory metabolites is currently unknown. Here we address the functional and biological consequences of adrenergic-induced Cox2/PGE2 axis activation in ovarian cancer metastasis.

Methods: We first analyzed global metabolic changes in tumors isolated from patients with known Center for Epidemiologic Studies Depression Scale (CES-D; depressive) scores and tumoral norepinephrine (NE) levels. Beta-adrenergic receptor (ADRB) positive cells (Skov3 and HeyA8) were used to study gene and protein levels of PTGS2 (cyclooxygenase2), PTGES (prostaglandin E synthase) and metabolite PGE2 in vitro and in vivo. To study tumor-specific effects on catecholamine-derived expression of PTGS2, we used a novel DOPC delivery system of PTGS2 siRNA.

Results: Our results revealed that levels of PGs were significantly increased in patients with high depressive scores (>16). PGE2 was upregulated by 2.38 fold when compared to the low CES-D scores. A similar trend was also observed with other pro-inflammatory eicosanoids, such as 6-keto prostaglandin F1 Alpha (2.03), prostaglandin A2 (1.39) and prostaglandin E1 (1.39). Exposure to NE resulted in increased PTGS2 and PTGES (prostaglandin E2 synthase) gene expression and protein levels in Skov3 and HeyA8. PGE2 ELISA confirmed that upon treatment with NE, PGE2 levels were increased in conditioned medium from Skov3 and HeyA8 cells. Treatment with a broad ADRB agonist (isoproterenol) or ADRB2 specific agonist (terbutaline) led to increases in expression of PTGS2 and PTGES as well as PGE2 levels in supernatant. Conversely, treatment with a broad antagonist (propranolol) or an ADRB2 specific antagonist (butoxamine) in the presence of NE abrogated gene expression changes of PTGS2 and PTGES. ChIP analysis showed enrichment of Nf-kB binding to the promoter region of PTGS2 and PTGES by 2.4 and 4.0 fold respectively when Skov3ip1 cells were treated with NE. Silencing PTGS2 resulted in significantly decreased migration (40%) and invasion (25%) of Skov3 cells in the presence of NE. Importantly, in the Skov3-ip1 restraint stress orthotopic model, silencing PTGS2 abrogated stress mediated effects and decreased tumor burden by 70% compared to control siRNA with restraint stress.

Conclusion Increased adrenergic stimulation results in a pro-inflammatory milieu mediated by prostaglandins that drives tumor progression and metastasis in ovarian cancer.

Citation Format: Archana S. Nagaraja, Piotr Dorniak, Nouara Sadaoui, Guillermo Armaiz-Pena, Behrouz Zand, Sherry Y. Wu, Julie K. Allen, Rajesha Rupaimoole, Cristian Rodriguez-Aguayo, Sunila Pradeep, Lin Tan, Rebecca A. Previs, Jean M. Hansen, Peiying Yang, Garbiel Lopez-Berestein, Susan K. Lutgendorf, Steve Cole, Anil K. Sood. Sustained adrenergic signaling activates pro-inflammatory prostaglandin network in ovarian carcinoma. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3368. doi:10.1158/1538-7445.AM2015-3368

Other Article in This Open Access Journal on Ovarian Cancer Include

Beta-Blockers help in better survival in ovarian cancer

Ovarian Cancer Survival Increased 5 Months Overall With Beta Blockers – Study – The Speaker

Model mimicking clinical profile of patients with ovarian cancer @ Yale School of Medicine

Preclinical study identifies ‘master’ proto-oncogene that regulates stress-induced ovarian cancer metastasis | MD Anderson Cancer Center

Beta-Blockers help in better survival in ovarian cancer

Role of Primary Cilia in Ovarian Cancer

Dasatinib in Combination With Other Drugs for Advanced, Recurrent Ovarian Cancer


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Cancer Stem Cells as a Mechanism of Resistance


Curator: Stephen J. Williams, Ph.D.

The cancer stem-cell hypothesis proposes the existence of a subset of cells within a heterogeneous tumor cell population that have stem-cell like properties [1], and may be essential for the progression and metastases of epithelial malignancies, by providing a reservoir of cells that self-renew and differentiate into the bulk of the tumor [2]. The stem-cell hypothesis implies that similar genetic regulatory pathways might define critical stem-cell like functions, such as self-renewal and pluripotency, in both normal and cancer stem-cells. Indeed, cancer stem-cells have been identified in many tumor types, such as breast [3], pancreas [4] and ovarian [5], based on screening with cellular markers typically found in normal stem-cells such as CD44, ALDH1, and CD133 (reviewed in [2]). A number of studies have suggested that the expression of these stem-cell markers is correlated with poor prognosis [6-9]. The ability to identify and isolate these populations may have a significant impact on design of individualized therapies.

Great general posts and good review on this site about Cancer Stem Cells, their markers, and ability to target them with chemotherapy can be seen here.

In Focus: Identity of Cancer Stem Cells

In Focus: Targeting of Cancer Stem Cells

Stem Cells and Cancer


However, there has been growing acknowledgement of the ability of cancer stem cell populations to resist the cytotoxic effects of most chemotherapeutic agents, including cisplatin, topoisomerase inhibitors, DNA damaging agents, and even tyrosine kinase inhibitors (TKI). Indeed, some feel that intrinsic resistance to cytotoxic drugs may be a biological feature of cancer stem cells.


Acquired resistance: a resistance to a particular drug which results following continued exposure to said drug. Can take days (in cases of some TKIs) or months to develop. Acquired resistant cells lines are developed by exposure to increasing drug concentration over a time period (either intermittent exposure or continuous exposure)

Intrinsic resistance: a pre-existing resistance usually termed refractory where cancer cells THAT HAVE NOT BEEN EXPOSED to drug, do not respond to initial drug exposure. Can be seen experimentally in panels of unrelated cancer cells lines isolated from untreated patients which show no cytotoxicity to drug exposure in vitro.

Below is one of the first reports which described the drug resistant phenotype of cancer stem cells in an in vivo (mouse) model of breast cancer with videos.

Cancer Res. 2008 May 1;68(9):3243-50. doi: 10.1158/0008-5472.CAN-07-5480.

Cancer stem cells contribute to cisplatin resistance in Brca1/p53-mediated mouse mammary tumors.

Shafee N1, Smith CR, Wei S, Kim Y, Mills GB, Hortobagyi GN, Stanbridge EJ, Lee EY.

Author information


The majority of BRCA1-associated breast cancers are basal cell-like, which is associated with a poor outcome. Using a spontaneous mouse mammary tumor model, we show that platinum compounds, which generate DNA breaks during the repair process, are more effective than doxorubicin in Brca1/p53-mutated tumors. At 0.5 mg/kg of daily cisplatin treatment, 80% primary tumors (n = 8) show complete pathologic response. At greater dosages, 100% show complete response (n = 19). However, after 2 to 3 months of complete remission following platinum treatment, tumors relapse and become refractory to successive rounds of treatment. Approximately 3.8% to 8.0% (mean, 5.9%) of tumor cells express the normal mammary stem cell markers, CD29(hi)24(med), and these cells are tumorigenic, whereas CD29(med)24(-/lo) and CD29(med)24(hi) cells have diminished tumorigenicity or are nontumorigenic, respectively. In partially platinum-responsive primary transplants, 6.6% to 11.0% (mean, 8.8%) tumor cells are CD29(hi)24(med); these populations significantly increase to 16.5% to 29.2% (mean, 22.8%; P < 0.05) in platinum-refractory secondary tumor transplants. Further, refractory tumor cells have greater colony-forming ability than the primary transplant-derived cells in the presence of cisplatin. Expression of a normal stem cell marker, Nanog, is decreased in the CD29(hi)24(med) populations in the secondary transplants. Top2A expression is also down-regulated in secondary drug-resistant tumor populations and, in one case, was accompanied by genomic deletion of Top2A. These studies identify distinct cancer cell populations for therapeutic targeting in breast cancer and implicate clonal evolution and expansion of cancer stem-like cells as a potential cause of chemoresistance.

Please Watch Videos


Below is a curation of talks and abstracts from the 2015 Annual AACR Meeting in Philadelphia, PA.

The Talk by Dr. Cheresh is an example of this school of thought; that inducing cancer cell stemness can result in development of drug resistance, in this case to a TKI. (For a press release on this finding see here.)

SY27-04: Induction of cancer stemness and drug resistance by EGFR blockade
Tuesday, Apr 21, 2015, 12:00 PM -12:15 PM
David A. Cheresh. UCSD Moores Cancer Center, La Jolla, CA

Presentation Title: Induction of cancer stemness and drug resistance by EGFR blockade
Presentation Time: Tuesday, Apr 21, 2015, 12:00 PM -12:15 PM
Abstract Body: Tumor drug resistance is often accompanied by genetic and biological changes in the tumor cell population reflecting the acquisition of a stem-like state. However, it is not clear whether cancer therapies select for the growth of drug resistance cancer stem cells and/or directly induce the reprograming of tumor cells to a cancer stem-like, drug resistance state. We provide evidence that breast, pancreas and lung carcinomas in the presence of prolonged exposure to EGFR inhibitors undergo an epigenetic reprogramming resulting in a drug resistant stem-like tumor population expressing the cell surface marker CD61 (b3 integrin). In fact, CD61 in the context of KRAS, is necessary and sufficient to account for drug resistance, tumor initiation, self-renewal and expression of the pluripotent genes Oct 4 and Nanog. Once expressed, CD61 in the unligated state recruits KRAS to the plasma membrane leading to the activation of RalB, TBK1 and c-Rel driving both stemness and EGFR inhibitor resistance. Pharmacological targeting this pathway with drugs such as bortezomib or revlimid not only reverses stemness but resensitizes these epithelial tumors to EGFR inhibition. This epigenetic pathway can also be initiated by range of cellular stresses found within the tumor microenvironment such as hypoxia, nutrient deprivation, low pH, and oxidative stress. In normal tissues CD61 is induced during tissue remodeling and repair. For example, CD61 was found to be critical for mammary gland remodeling during pregnancy and as a mediator of pathological neovascularization. Together these findings reveal a stress-induced epigenetic pathway characterized by the upregulation of CD61 that promotes the remodeling of normal tissues but in tumors contributes to EGFR inhibitor resistance and tumor progression.

Selected Abstracts

  1. Abstract 1
  2. Molecular and Cellular Biology – Poster Presentations – Proffered Abstracts – Poster Presentations – Cell Death Mechanisms: Abstract 4: ABT-263 is effective in a subset of non-small cell lung cancer cell lines
    • Aoi Kuroda,
    • Keiko Ohgino,
    • Hiroyuki Yasuda,
    • Junko Hamamoto,
    • Daisuke Arai,
    • Kota Ishioka,
    • Tetsuo Tani,
    • Shigenari Nukaga,
    • Ichiro Kawada,
    • Katsuhiko Naoki,
    • Kenzo Soejima,
    • and Tomoko Betsuyaku

Cancer Res August 1, 2015 75:4; doi:10.1158/1538-7445.AM2015-4

  1. Abstract 2
  2. Molecular and Cellular Biology – Poster Presentations – Proffered Abstracts – Poster Presentations – Cell Death Mechanisms: Abstract 6: Quantitative assessment of BCL-2:BIM complexes as a pharmacodynamic marker for venetoclax (ABT-199)
    • Sha Jin,
    • Paul Tapang,
    • Donald J. Osterling,
    • Wenqing Gao,
    • Daniel H. Albert,
    • Andrew J. Souers,
    • Joel D. Leverson,
    • Darren C. Phillips,
    • and Jun Chen

Cancer Res August 1, 2015 75:6; doi:10.1158/1538-7445.AM2015-6

  1. Molecular and Cellular Biology – Poster Presentations – Proffered Abstracts – Poster Presentations – Cell Death Mechanisms: Abstract 24: The phosphorylation of p53 at serine 46 is essential to induce cell death through palmdelphin in response to DNA damage
    • Nurmaa Khund Dashzeveg and
    • Kiyotsugu Yoshida

Cancer Res August 1, 2015 75:24; doi:10.1158/1538-7445.AM2015-24

  1. Abstract 5
  2. Molecular and Cellular Biology – Poster Presentations – Proffered Abstracts – Poster Presentations – Cell Signaling in Cancer 1: Abstract 48: Identification of a novel binding protein playing a critical role in HER2 activation in lung cancer cells
    • Tomoaki Ohtsuka,
    • Masakiyo Sakaguchi,
    • Katsuyoshi Takata,
    • Shinsuke Hashida,
    • Mototsugu Watanabe,
    • Ken Suzawa,
    • Yuho Maki,
    • Hiromasa Yamamoto,
    • Junichi Soh,
    • Hiroaki Asano,
    • Kazunori Tsukuda,
    • Shinichiro Miyoshi,
    • and Shinichi Toyooka

Cancer Res August 1, 2015 75:48; doi:10.1158/1538-7445.AM2015-48

  1. Abstract 1 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Cell Death Mechanisms

Abstract 4: ABT-263 is effective in a subset of non-small cell lung cancer cell lines

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA


ABT-263 (Navitoclax) is one of the BH3 mimetics targeting anti-apoptotic B-cell lymphoma-2 (Bcl-2) family proteins such as Bcl-2, Bcl-XL, and Bcl-w, thereby inducing apoptosis. It has been reported that the response to ABT-263 is associated with expressions of myeloid cell leukemia-1 (Mcl-1), an anti-apoptotic protein. Given its effectiveness as a single agent in preclinical studies, ABT-263 is currently being evaluated in clinical trials for small cell lung cancer (SCLC) and leukemia. However, the efficacy of ABT-263 in non-small cell lung cancer (NSCLC) has not been fully evaluated. We examined the effect of ABT-263 on cell proliferation of NSCLC cell lines and investigated the underlying mechanisms.


The following 9 NSCLC cell lines were examined: SK-LU-1, A549, H358, Calu3, H3122, H1975, H460, H441, and BID007. The effects of ABT-263 in NSCLC cell lines were evaluated by MTS assay. Apoptosis was examined by flowcytometry using staining for annexin V and propidium iodide (PI), and also western blotting for cleaved PARP. Quantitative RT-PCR was carried out to assess the mRNA expression levels of anti-apoptotic genes and pro-apoptotic genes. Immunoprecipitation and western blotting were performed to compare the levels of anti-apoptotic and pro-apoptotic proteins between the sensitive and resistant cell lines. In addition, knockdown of Mcl-1 was performed by siRNA.


By screening 9 NSCLC cell lines using MTS assay, we found Calu3 and BID007were sensitive to ABT-263. We also confirmed that apoptosis was induced only in the ABT-263 sensitive lines but not in the ABT-263 resistant cell lines after ABT-263 treatment. However, the expression levels of Bcl-2 family proteins, including Mcl-1, did not differ significantly among the ABT-263 sensitive and resistant cell lines. Unlike the results in previous reports regarding SCLC, Mcl-1 was not decreased in the sensitive cell lines. The ABT-263 resistant cell lines became sensitive to ABT-263 after knockdown of Mcl-1 by siRNA, while the ABT-263 sensitive cell lines maintained the same sensitivity.


We found that Calu3 and BID007 were sensitive to ABT-263. In the sensitive NSCLC cell lines, ABT-263 induces apoptosis irrespective of Mcl-1 expression levels.

Citation Format: Aoi Kuroda, Keiko Ohgino, Hiroyuki Yasuda, Junko Hamamoto, Daisuke Arai, Kota Ishioka, Tetsuo Tani, Shigenari Nukaga, Ichiro Kawada, Katsuhiko Naoki, Kenzo Soejima, Tomoko Betsuyaku. ABT-263 is effective in a subset of non-small cell lung cancer cell lines. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4. doi:10.1158/1538-7445.AM2015-4

    • ©2015 American Association for Cancer Research.
  1. Abstract 2 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Cell Death Mechanisms

Abstract 6: Quantitative assessment of BCL-2:BIM complexes as a pharmacodynamic marker for venetoclax (ABT-199)

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA

The BCL-2-selective inhibitor venetoclax (ABT-199) binds with high affinity to the BH3-binding groove of BCL-2, thereby competing for binding with the BH3-only protein BIM (Souers et al., 2013). Venetoclax is currently being evaluated in clinical trials for CLL, AML, multiple myeloma and NHL. To facilitate these studies, we developed and validated a 384-well electrochemiluminescent ELISA (MSD, Gaithersburg, MD,USA) that quantifies expression of BCL-2, BCL-XL, and MCL-1protein alone or in complex with BIM. We subsequently quantified expression of BCL-2 and BCL-2:BIM complexes in 16 hematologic tumor cell lines. We found the EC50 of venetoclax in these tumor cell lines to correlate strongly with baseline BCL-2:BIM complex levels. This correlation was superior to the correlation between venetoclax EC50 and absolute BCL-2 expression. We also applied the assay to measure disruption of BCL-2:BIM complexes in vivo. Treatment of the Non-Hodgkin’s Lymphoma (NHL) xenograft model SU-DHL-4 with a BCL-2-selective inhibitor resulted in disruption of tumor BCL-2:BIM complexes that aligned with serum and tumor concentrations of inhibitor. Collectively, these data demonstrate that quantifying BCL-2:BIM complexes offers an accurate means of assessing target engagement by venetoclax and, potentially, predicting its efficacy. The utility of this assay is currently being assessed in clinical trials.

Citation Format: Sha Jin, Paul Tapang, Donald J. Osterling, Wenqing Gao, Daniel H. Albert, Andrew J. Souers, Joel D. Leverson, Darren C. Phillips, Jun Chen. Quantitative assessment of BCL-2:BIM complexes as a pharmacodynamic marker for venetoclax (ABT-199). [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 6. doi:10.1158/1538-7445.AM2015-6

    • ©2015 American Association for Cancer Research.
  1. Abstract 3 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Cell Death Mechanisms

Abstract 19: Antitumor activity of selective inhibitors of XPO1/CRM1-mediated nuclear export in diffuse malignant peritoneal mesothelioma: the role of survivin

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA

Survivin, which is highly expressed and promotes cell survival in diffuse malignant peritoneal mesothelioma (DMPM), exclusively relies on the nuclear exportin 1 (XPO1/CRM1) to be released in the cytoplasm and perform its anti-apoptotic function. Here, we explored the efficacy of selective inhibitors of nuclear export (SINEs) in patient-derived DMPM preclinical models. Exposure to individual SINE (KPT-251, KPT-276, KPT-330) was able to induce a time- and dose-dependent inhibition of the growth of two DMPM cell lines without affecting normal cell proliferation. Such a cell growth inhibition was preceded by a decline in the nuclear XPO1/CRM1 levels and an increase in the nuclear accumulation of its cargo proteins p53 and p21, which led to a cell cycle arrest at G1-phase. Our results also indicated that survivin is an essential component of the downstream signaling pathway of XPO1/CRM1 inhibition in DMPM cells. In fact, in both cell lines, exposure to SINEs led to a time-dependent reduction of cytoplasmic survivin levels and, after an initial survivin nuclear accumulation, also to a progressive decrease in the nuclear protein abundance, through the ubiquitin-proteasomal degradation pathway, leading to the complete depletion of total survivin levels. In both DMPM cell models, according to survivin anti-apoptotic activity, drug-induced reduction of cytoplasmic survivin levels correlated with the onset of caspase-dependent apoptosis. We further observed that SINEs can be combined with other survivin inhibitors, such as the survivin suppressant YM155 to achieve enhanced growth inhibition in DMPM cells. Initial in vivo experiments with orally administered KPT-251, KPT-276 and the orally available, clinical stage KPT-330 (selinexor) indicated that each compound was able to significantly reduce the growth of early-stage subcutaneous DMPM xenografts. Interestingly, additional experiments carry out with selinexor demonstrated that the compound was also able to inhibit the growth of late-stage subcutaneous DMPM xenografts in nude mice. Most importantly, oral administration of selinexor to SCID mice reduced the growth of orthotopic DMPM xenografts, which properly recapitulate the dissemination pattern in the peritoneal cavity of human DMPM and, for this reason, represent a valuable model for investigating novel therapeutic approaches for the disease. Consistent with an important role of survivin as a determinant of anti-cancer activity of SINE compounds, a reduction of the protein expression was observed in tumor specimens obtained from selinexor treated mice. Overall, our results (i) demonstrate a marked efficacy of SINEs in DMPM preclinical models, which is, at least in part, dependent on the interference with survivin intracellular distribution and function, and (ii) suggest SINE-mediated XPO1/CRM1 inhibition as a novel therapeutic option for the disease.

Citation Format: Nadia Zaffaroni, Michelandrea De Cesare, Denis Cominetti, Valentina Doldi, Alessia Lopergolo, Marcello Deraco, Paolo Gandellini, Yosef Landesman, Sharon Friedlander, Michael G. Kauffman, Sharon Shacham, Marzia Pennati. Antitumor activity of selective inhibitors of XPO1/CRM1-mediated nuclear export in diffuse malignant peritoneal mesothelioma: the role of survivin. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 19. doi:10.1158/1538-7445.AM2015-19

    • ©2015 American Association for Cancer Research.
  1. Abstract 4 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Cell Death Mechanisms

Abstract 24: The phosphorylation of p53 at serine 46 is essential to induce cell death through palmdelphin in response to DNA damage

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA

Tumor suppressor p53 plays a pivotal role in cell cycle arrest, DNA repair, and apoptosis in response to DNA damage. Promoter selectivity of p53 depends mainly on post-translational modification. Notably, the apoptotic function of p53 is related to its phosphorylation at serine-46 (ser46) to promote pro-apoptotic genes. However, little is known about the pro-apoptotic genes induced by Ser46 phosphorylation. Our research achieved to investigate the pro-apoptotic genes induced by p53 in a phospho-ser46-specific manner using microarray and ChIP sequencing in human cancer cell lines. As a result, palmdelphin (PALMD), an isoform of paralemmin protein, was strongly elicited from the phosphorylation of ser46. The mRNA and protein expression of PALMD increased only in wild type p53 transfected cells, but not in ser46-mutated cells. Importantly, PALMD moved to the nucleus in response to DNA damage and the apoptotic function of PALMD was tightly exerted with localization into nucleus. Interestingly, down-regulation of PALMD by siRNA resulted in necroptosis-like cell death through ATP depletion. Moreover, we found vimentin as a PALMD interacting protein and the depletion of vimentin increased PALMD level to accelerate apoptosis. These results demonstrate that p53 regulates cell death fate (apoptosis or necroptosis-like cell death) through promoting PALMD expression in a phospho-ser46-specific manner in response to DNA damage.

Citation Format: Nurmaa Khund Dashzeveg, Kiyotsugu Yoshida. The phosphorylation of p53 at serine 46 is essential to induce cell death through palmdelphin in response to DNA damage. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 24. doi:10.1158/1538-7445.AM2015-24

    • ©2015 American Association for Cancer Research.
  1. Abstract 5 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Cell Signaling in Cancer 1

Abstract 48: Identification of a novel binding protein playing a critical role in HER2 activation in lung cancer cells

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA

Human epidermal growth factor receptor 2 (HER2) is a member of epidermal growth factor receptor (EGFR) family. Previous studies have revealed that many kinds of malignant tumors have genetic mutations or amplification of HER2, indicating that HER2 alterations are oncogenic. Many kinds of HER2 targeted therapies are effective to HER2 positive tumors, but those treated tumors often get resistance to drugs. Thus, to elucidate HER2 related pathway in cancer biology is important to develop new therapeutic strategy for cancers.

Recently, we newly identified a protein X (a temporary name) as a novel binding protein to HER2 with immunoprecipitation and following LC-Ms/Ms analysis. The protein generally expressed in lung and breast cancers at remarkable level.

We constructed plasmid vectors carrying wild type HER2 and gene X. These vectors were simultaneously introduced to HEK293T cells to examine the binding ability of protein X and HER2 as well as the effect of gene X on HER2-mediated signal-transduction pathway. The approach clearly showed that the expression of gene X, resulted in phosphorylation of HER2 and subsequent activation of oncogenic effector molecules.

We next constructed several kinds of gene X-truncated variants and subjected to the binding assay to look for the binding domain of gene X to HER2. The analysis showed that N-terminal head domain of gene X was essential for the HER2 binding. This domain has an ability to induce HER2 phosphorylation and subsequent activation of the effector kinase, ERK.

In conclusion, we found that gene X is a novel binding protein to HER2 and has a role in HER2 activation.

Citation Format: Tomoaki Ohtsuka, Masakiyo Sakaguchi, Katsuyoshi Takata, Shinsuke Hashida, Mototsugu Watanabe, Ken Suzawa, Yuho Maki, Hiromasa Yamamoto, Junichi Soh, Hiroaki Asano, Kazunori Tsukuda, Shinichiro Miyoshi, Shinichi Toyooka. Identification of a novel binding protein playing a critical role in HER2 activation in lung cancer cells. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 48. doi:10.1158/1538-7445.AM2015-48

    • ©2015 American Association for Cancer Research.
  1. Abstract 6 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Cell Signaling in Cancer 1

Abstract 54: Ezrin enhances signaling and nuclear translocation of the epidermal growth factor receptor in non-small cell lung cancer cells

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA

The cytoskeletal cross linker protein ezrin is a member of the ezrin-radixin-moesin (ERM) family and plays important roles not only in cell motility, cell adhesion, and apoptosis, but also in various cell-signaling pathways. Ezrin interacts with EGFR in the cell membrane and involves in cell motility events, but little is known about the effects of this interaction on the EGFR signaling pathway. We investigated the role of Ezrin in EGFR signaling and nuclear trafficking in non-small cell lung cancer (NSCLC) cell lines. The ligand induced interaction between Ezrin and EGFR was evaluated by immunoprecipitation (IP) and immunofluorescence (IF) in H292 and A549 cells. Ezrin levels were reduced using siRNA in these two cell lines. Downstream signaling protein phosphorylation and nuclear localization of EGFR were detected after EGF treatment. Expressions of nuclear EGFR target genes were evaluated by qPCR. Endogenous Ezrin was found in a complex with EGFR in IP and IF. When Ezrin protein expression was inhibited, phosphorylation levels of EGFR at Y1068, Y1101 and Y845 were reduced as well as phosphorylation levels of downstream signaling pathway proteins ERK and STAT3. Cell fractionation revealed that EGFR nuclear translocation after EGF treatment significantly reduced in Ezrin-knockdown cells. Further, mRNA levels of EGFR target genes AuroraK-A, COX2, Cyclin D1 and iNOS were decreased in Ezrin-knockdown A549 cells. Small molecule ezrin inhibitors showed strong synergy with EGFR inhibitors in cytotoxicity assays. These results suggest that Ezrin has a role as an enhancer in the EGFR pathway and targeting ezrin may potentiate anti-EGFR based therapies in NSCLC.

Citation Format: Yasemin Saygideger Kont, Haydar Celik, Hayriye V. Erkizan, Tsion Minas, Jenny Han, Jeffrey Toretsky, Aykut Uren. Ezrin enhances signaling and nuclear translocation of the epidermal growth factor receptor in non-small cell lung cancer cells. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 54. doi:10.1158/1538-7445.AM2015-54

    • ©2015 American Association for Cancer Research.
  1. Abstract 7 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Cell Signaling in Cancer 1

Abstract 57: Substrates of protein kinase C drive cell rac1-dependent motility

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA

This laboratory has identified and/or characterized substrates of PKC that upon phosphorylation give rise to motility, an aspect of metastasis. By use of the traceable kinase method, we discovered that alpha-tubulin and Cdc42 effector protein-4 (CEP4) are PKC substrates. Phosphorylation of alpha-tubulin stimulates its incorporation into microtubules (MTs), consequently increasing the stability and prolonged growth of MTs and leading to the activation of the small GTPase Rac1. CEP4 undergoes phosphorylation by PKC that results in its release from Cdc42, whereupon CEP4 binds a guanine nucleotide exchange factor (GEF) that in turn activates Rac1 GTPase. These results imply that Rac1 acts as a node in pathways driven by phosphorylated PKC substrates. Since translocation of IQGAP to the membrane is known to be promoted by Rac1, a role is explored in non-transformed human MCF-10A cells that express a specific phospho-mimetic mutant substrate. In addition, the phospho-mimetic mutant for each substrate expressed in human metastatic MDA-MB-231 cells produces different morphologies in 3-D growth assays. This research is being supported by NIH CA125632.

Citation Format: Susan A. Rotenberg, Xin Zhao, Shatarupa De. Substrates of protein kinase C drive cell rac1-dependent motility. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 57. doi:10.1158/1538-7445.AM2015-57

    • ©2015 American Association for Cancer Research.
  1. Abstract 8 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Deregulation of Gene Expression in Prostate Cancer and Sarcoma

Abstract 88: The Nkx3.1 homeobox gene maintains prostatic identity while its loss leads to prostate cancer initiation

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA


Maintenance of epithelial cell identity is tightly coordinated by tissue-specific gene expression programs, which are often deregulated during tumorigenesis. The homeodomain-containing transcription factor, Nkx3.1, is a key regulator of normal prostatic development and is frequently lost at early stages of prostate cancer initiation. In this study, we aim to elucidate detailed mechanisms governing Nkx3.1-driven maintenance of prostate identity and how deregulation of such can lead to prostate tumorigenesis.

Models and Methods

We evaluated the consequences of Nkx3.1 loss or gain of function in vivo using genetically-engineered mouse models and cell-recombination assays. RNA sequencing was performed to generate gene expression profiles, which were analyzed using Gene Set Enrichment analysis (GSEA), and validated by quantitative real-time PCR. In parallel, protein expression was assessed by immunofluorescence and western blot. Immunoprecipitation (IP) and chromatin-immunoprecipitation (ChIP) assays were performed using RWPE1 prostate epithelial cells.


Here, we show that loss of function of Nkx3.1 leads to the progressive down-regulation of a prostate-specific gene expression program and to aberrant expression of genes that are not typically expressed in the prostate epithelium. Conversely, gain of function of Nkx3.1 in non-prostatic epithelium leads to the acquisition of a prostate-like morphology and expression of prostate-related genes. Our findings indicate that the underlying mechanism by which Nkx3.1 promotes prostatic identity is via epigenetic regulation of gene expression. In particular, we show that Nkx3.1 interacts with the histone methyl-transferase complex G9a/Glp. Finally, we demonstrate that this interaction is necessary for maintenance of prostate identity in vivo and that Nkx3.1 and G9a cooperate to control expression of genes that coordinate prostatic epithelial integrity.


Our results suggest that Nkx3.1 promotes prostatic identity by interacting with histone modifying enzymes to coordinate the expression of prostate-specific genes and that the loss of this function results in a failure to maintain prostate identity associated with early stages of prostate tumorigenesis.

Citation Format: Clémentine Le Magnen, Aditya Dutta, Cory Abate-Shen. The Nkx3.1 homeobox gene maintains prostatic identity while its loss leads to prostate cancer initiation. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 88. doi:10.1158/1538-7445.AM2015-88

    • ©2015 American Association for Cancer Research.
  1. Abstract 9 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Deregulation of Gene Expression in Prostate Cancer and Sarcoma

Abstract 90: K63-linked JARID1B ubiquitination by TRAF6 contributes to aberrant elevation of JARID1B in prostate cancer

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA

Aberrant elevation of JARID1B and histone H3 Lys4 trimethylations (H3K4me3) is frequently observed in many diseases including prostate cancer (PCa), yet the mechanisms on the regulations of JARID1B and H3K4me3 through epigenetic modifications still remain poorly understood. In this study we performed immunohistochemistry staining, immunofluorescence imaging, immunoprecipitation, shRNA and Western blotting analysis in mouse embryonic fibroblasts (MEFs), mouse models, and cultured human prostate cancer cells. As a result, we discovered that SKP2 modulates JARID1B and H3K4me3 levels in vitro in PTEN null prostate cancer cells and in vivo in Pten/Trp53 mouse models. We demonstrated that levels of SKP2, JARID1B and H3K4me3 are strikingly elevated in vitro and in vivo when both PTEN and P53 are inactivated. Importantly, SKP2 inactivation resulted in a reduction of cell growth, cell migration and malignant transformation of Pten/Trp53 double null MEFs, and further restrained prostate tumorigenesis of Pten/Trp53 mutant mice. Mechanistically, JARID1B is ubiquitinated by E3 ligase TRAF6 through the K63-linkage in prostate cancer cells. Interestingly, SKP2 contributes to JARID1B ubiquitination machinery as a non-E3 ligase regulator by decreasing TRAF6-mediated ubiquitination of JARID1B. SKP2 deficiency resulted in an increase of JARID1B ubiquitination and in turn a reduction of H3K4me3, and induced senescence through JARID1B accumulation in nucleoli of PCa cells and prostate tumors of mice. Furthermore, we showed that the aberrant levels of SKP2, JARID1B, and H3K4me3 are associated with malignant features of castration-resistant prostate cancer (CRPC) in mice. Overall, our findings reveal a novel network of SKP2- JARID1B, and targeting SKP2 and JARID1B may be a potential strategy for PCa control.

Citation Format: Wenfu Lu, Shenji Liu, Bo Li, Yingqiu Xie, Christine Adhiambo, Qing Yang, Billy R. Ballard, Keiichi I. Nakayama, Robert J. Matusik, Zhenbang Chen. K63-linked JARID1B ubiquitination by TRAF6 contributes to aberrant elevation of JARID1B in prostate cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 90. doi:10.1158/1538-7445.AM2015-90

    • ©2015 American Association for Cancer Research.
  1. Abstract 10 of 10Molecular and Cellular Biology / Poster Presentations – Proffered Abstracts / Poster Presentations – Histone Methylation and Acetylation

Abstract 97: CARM1 preferentially methylates H3R17 over H3R26 through a random kinetic mechanism

Proceedings: AACR 106th Annual Meeting 2015; April 18-22, 2015; Philadelphia, PA

CARM1 (PRMT4) is a type I arginine methyltransferase involved in the regulation of transcription, pre-mRNA splicing, cell cycle progression and the DNA damage response. Overexpression of CARM1 has been implicated in breast, prostate, and colorectal cancers. Since CARM1 appears to be a good target for the development of therapies against these cancers, we studied the substrate specificity and kinetic mechanism of the full-length human enzyme. CARM1 has been shown to methylate both residues R17 and R26 of histone H3. Substrate specificity was examined by testing CARM1 activity with several H3-based peptide substrates using a radiometric assay. Comparison of kcat/KM values reveal that methylation of H3R17 is preferred over H3R26. An R17/R26K peptide produced 8-fold greater kcat/KM value compared to the corresponding R17K/R26 peptide. These effects are KM-driven as kcat values remain relatively constant for the peptides tested. Shortening the peptide at the C-terminus by 5 amino acid residues greatly reduced the specificity (16-24-fold), demonstrating the contribution of distal residues to substrate binding. In contrast, adding residues to the N-terminus of the shortened peptide had a negative effect on activity. CARM1 displays little preference for monomethylated over unmethylated H3R17 (2-5-fold by kcat/KM) suggesting that it operates through a distributive mechanism. Previous crystallographic studies with mouse CARM1 showed that part of the substrate binding groove was formed by cofactor binding, thereby suggesting an ordered kinetic mechanism (Yue et al., EMBO J., 2007). Our results from dead-end and product inhibition studies performed with human CARM1, however, are consistent with a random kinetic mechanism. SAH and sinefungin demonstrate competitive inhibition with respect to SAM and produced noncompetitive inhibition patterns with respect to peptide. Both dimethylated R17 product peptide and dead-end R17K peptide exhibited noncompetitive inhibition patterns with respect to SAM. Furthermore, binding of SAM and peptide substrates were shown to be independent of each other in initial velocity experiments where both substrates were varied. Together, these results elucidate the kinetic mechanism of CARM1 and highlight elements important for binding affinity.

Citation Format: Suzanne L. Jacques, Katrina P. Aquino, Jodi Gureasko, P Ann Boriack-Sjodin, Robert A. Copeland, Thomas V. Riera. CARM1 preferentially methylates H3R17 over H3R26 through a random kinetic mechanism. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 97. doi:10.1158/1538-7445.AM2015-97

    • ©2015 American Association for Cancer Research.



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In Focus: Identity of Cancer Stem Cells

In Focus: Targeting of Cancer Stem Cells

Stem Cells and Cancer

Positron Emission Tomography (PET) and Near-Infrared Fluorescence Imaging: Noninvasive Imaging of Cancer Stem Cells (CSCs) monitoring of AC133+ glioblastoma in subcutaneous and intracerebral xenograft tumors

“To Die or Not To Die” – Time and Order of Combination drugs for Triple Negative Breast Cancer cells: A Systems Level Analysis

Can IntraTumoral Heterogeneity Be Thought of as a Mechanism of Resistance?



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Breakthrough work in cancer

Larry H. Bernstein, MD, FCAP, Curator


Updated 11/22/2015; 12/17/2015


Sequencing Metastatic Cancers Could Lead to Improved Therapies

  • Unravelling the genetic sequences of cancer that has spread to the brain could offer unexpected targets for effective treatment, according to a study (“Genomic characterization of brain metastases and paired primary tumors reveals branched evolution and potential therapeutic targets”) published in Cancer Discovery.

Scientists say they found that the original, or primary, cancer in a patient’s body may have important differences at a genetic level from cancer that has spread to the patient’s brain. This insight could suggest new lines of treatment.

Priscilla Brastianos, M.D., a neurooncologist and director of the Brain Metastasis program at Massachusetts General Hospital, points out that “brain metastases are a devastating complication of cancer. Approximately eight to ten percent of cancer patients will develop brain metastases, and treatment options are limited. Even where treatment is successfully controlling cancer elsewhere in the body, brain metastases often grow rapidly.”

She and her colleagues studied tissue samples from 104 adults with cancer. In collaboration with researchers at the Broad Institute, they analyzed the genetics of biopsies taken from the primary tumor, brain metastases, and normal tissues in each adult. For 20 patients, they also had access to metastases elsewhere in the body.

The team discovered that, in every patient, the brain metastasis and primary tumor shared some of their genetics, but there were also key differences. In 56% of patients, genetic alterations that potentially could be targeted with drugs were found in the brain metastasis but not in the primary tumor.

“We found genetic alterations in brain metastases that could affect treatment decisions in more than half of the patients in our study,” notes Dr. Brastianos. “We could not detect these genetic alterations in the biopsy of the primary tumor. This means that when we rely on analysis of a primary tumor we may miss mutations in the brain metastases that we could potentially target and treat effectively with drugs.”

This study also found that if a patient had more than one brain metastasis, each was genetically similar. The researchers used their findings to map the evolution of a cancer through a patient’s body, and draw up a phylogenetic tree for each patient to demonstrate how the cancer had spread and where each metastasis had come from.

They concluded that brain metastases and the primary tumor share a common genetic ancestor. Once a cancer cell, or clone, has moved from the primary site to the brain, it continues to develop and amass genetic mutations. The genetic similarity of the brain metastases in individual patients suggests that each brain metastasis has developed from a single clone entering the brain.

The genetic changes in brain metastases are independent of any occurring at the same time in the primary tumor, and in metastases elsewhere in the body, the researchers said. Characterization of the genetics of a patient’s primary cancer can be used to optimize treatment decisions, so that drugs that target specific mutations in the cancer can be chosen. However, brain metastases are not routinely biopsied and analyzed.

“When brain metastasis tissue is available as part of clinical care, we are suggesting sequencing and analysis of that sample,” continues Dr. Brastianos. “It may offer more therapeutic opportunities for the patient. Genetic characterization of even a single brain metastasis may be superior to that of the primary tumor or a lymph node biopsy for selection of a targeted treatment.”


Scientists Discover How Cancer Cells Escape Blood Vessels
12/16/2015 –  Anne Trafton, MIT News Office

A rounded cancer cell (top left) sends out nanotubes connecting with endothelial cells. Genetic material can be injected via these nanotubes, transforming the endothelial cells and making them more hospitable to additional cancer cells.  (Image: Sengupta Lab)

A rounded cancer cell (top left) sends out nanotubes connecting with endothelial cells. Genetic material can be injected via these nanotubes, transforming the endothelial cells and making them more hospitable to additional cancer cells. (Image: Sengupta Lab)

Scientists at MIT and Massachusetts General Hospital have discovered how cancer cells latch onto blood vessels and invade tissues to form new tumors — a finding that could help them develop drugs that inhibit this process and prevent cancers from metastasizing.

Cancer cells circulating in the bloodstream can stick to blood vessel walls and construct tiny “bridges” through which they inject genetic material that transforms the endothelial cells lining the blood vessels, making them much more hospitable to additional cancer cells, according to the new study.

The researchers also found that they could greatly reduce metastasis in mice by inhibiting the formation of these nanobridges.

“Endothelial cells line every blood vessel and are the first cells in contact with any blood-borne element. They serve as the gateway into and out of tumors and have been the focus of intense research in vascular and cancer biology. These findings bring these two fields together to add greater insight into control of cancer and metastases,” said Elazer Edelman, the Thomas D. and Virginia W. Cabot Professor of Health Sciences and Technology, a member of MIT’s Institute for Medical Engineering and Science, and one of the leaders of the research team.

The lead author of the paper, which appears in the Dec. 16 issue of Nature Communications, is Yamicia Connor, a graduate student in the Harvard-MIT Division of Health Sciences and Technology (HST). The paper’s senior author is Shiladitya Sengupta, an assistant professor at HST and at Harvard Medical School.

Building bridges

Metastasis is a multistep process that allows cancer to spread from its original site and form new tumors elsewhere in the body. Certain cancers tend to metastasize to specific locations; for example, lung tumors tend to spread to the brain, and breast tumors to the liver and bone.

To metastasize, tumor cells must first become mobile so they can detach from the initial tumor. Then they break into nearby blood vessels so they can flow through the body, where they become circulating tumor cells (CTCs). These CTCs must then find a spot where they can latch onto the blood vessel walls and penetrate into adjacent tissue to form a new tumor.

Blood vessels are lined with endothelial cells, which are typically resistant to intruders.

“Normal endothelial cells should not enable a cancer cell to invade, but if a cancer cell can connect with an endothelial cell, and inject signals that enable this endothelial cell to be controlled and completely transformed, then it facilitates metastasis,” Sengupta said.

The researchers first spotted tiny bridges between cancer cells and endothelial cells while using electron microscopy to study the interactions between those cell types. They speculated that the cancer cells might be sending some kind of signal to the endothelial cells.

“Once we saw that these structures allowed for a ubiquitous transfer of a lot of different materials, microRNAs were an obvious interesting molecule because they’re able to very broadly control the genome of a cell in ways that we don’t really understand,” Connor said. “That became our focus.”

MicroRNA, discovered in the early 1990s, helps a cell to fine-tune its gene expression. These strands of RNA, about 22 base pairs long, can interfere with messenger RNA, preventing it from being translated into proteins.

In this case, the researchers found, the injected microRNA makes the endothelial cells “sticky.” That is, the cells begin to express proteins on their surfaces that attract other cells to adhere to them. This allows additional CTCs to bind to the same site and penetrate through the vessels into the adjacent tissue, forming a new tumor.

“It’s almost like the cancer cells are cooperating with each other to facilitate migration,” Sengupta said. “You just need maybe 1 percent of the endothelial cells to become sticky, and that’s good enough to facilitate metastasis.”

Non-metastatic cancer cells did not produce these invasive nanobridges when grown on endothelial cells.

Erkki Ruoslahti, a professor of cell, molecular, and developmental biology at the University of California at Santa Barbara, said that the discovery is an important advance in understanding tumor metastasis.

“I found it particularly interesting that the transfer of regulatory macromolecules from tumor cells to endothelial cells via intercellular nanotubes appears to be more effective (at least over relatively short distances) than exosome-mediated transfer, which has received a lot of attention lately,” said Ruoslahti, who was not part of the research team.

Shutting down metastasis

The nanobridges are made from the proteins actin and tubulin, which also form the cytoskeleton that gives cells their structure. The researchers found that they could inhibit the formation of these nanobridges, which are about 300 microns long, by giving low doses of drugs that interfere with actin.

When the researchers gave these drugs to mice with tumors that normally metastasize, the tumors did not spread.

Sengupta’s lab is now trying to figure out the mechanism of nanobridge formation in more detail, with an eye toward developing drugs that act more specifically to inhibit the process.

“If we can first understand how these structures are formed, then we can try to design targeted therapies to inhibit their formation, which could be a promising new area for developing drugs that specifically target metastasis,” Connor said.

Source: Massachusetts Institute of Technology


Inspired by Nature

Researchers are borrowing designs from the natural world to advance biomedicine.

By Daniel Cossins | August 1, 2015

When biomedical engineer Jeff Karp has questions, he looks to animals for answers. In 2009, Karp gathered his team at the Brigham and Women’s Hospital in Boston to brainstorm novel ways to capture circulating tumor cells (CTCs) in the bloodstream. They mulled over the latest microfluidic devices. Then the conversation turned to the New England Aquarium, and to jellyfish.

Scientists have tried to grab cancer cells from blood ever since they discovered that tumors shed malignant cells that migrate throughout the vasculature—a process known as metastasis. “If you pluck out these cells, you have a direct indicator of what the cancer looks like,” says Karp. “Then you can screen drugs to get those that will have the greatest impact.” Doctors might also be able to detect such cells during the earliest stages of metastatic cancer, when it’s more readily treatable.

 Image No 2

CANCER-CELL CAPTURE DEVICE: Jellyfish’s long, sticky tentacles grab prey and other food particles from water. Researchers have copied this design by coating the channels of a microfluidic chip with long, tentacle-like strands of DNA that bind a protein on the surface of leukemia cells. The device can process 10 times more blood than existing chips in the same amount of time.
See full infographic: JPG 

The problem is, CTCs make up a tiny fraction of cells in the bloodstream of a person with cancer, meaning an effective diagnostic must process relatively large volumes of blood. However, an existing test, which uses magnetic particles to isolate CTCs, processes just 7.5 milliliters of blood, only a fraction of one percent of the 5 liters of blood in an adult human. Dialysis-like microfluidic devices promise to handle larger volumes and improve efficiency, but the best current prototypes still feature extremely narrow microchannels to ensure CTCs pass within reach of CTC-binding antibodies along the perimeter. “Channel height is extremely low in a lot of the proposed devices, meaning you can barely flow any blood through,” says Karp. (See “Capturing Cancer Cells on the Move,” The Scientist, April 2014.)

Karp wanted to change that. “We asked ourselves, ‘What creatures can capture things at a distance?’” he recalls. One of his graduate students suggested jellyfish, whose long, sticky tentacles grab prey and other food particles from water. Within a year, Karp and his colleagues had designed a microfluidic chip on which 800-micron-wide microchannels are lined with long, tentacle-like strands of DNA that bind a protein on the surface of leukemia cells as they pass through the channels. (See illustration below.) In 2012, Karp showed that the jellyfish-inspired device could process 10 times more blood than existing chips in the same amount of time and trap an average of 50 percent of circulating leukemia cells.1 Karp estimates that a device the size of the standard microscope slide could collect hundreds or thousands of tumor cells in minutes. Encouraged by such results, Karp’s team is now improving the platform, designing chips that can catch any CTC of interest.

The jellyfish is far from the only intriguing organism to have served as a blueprint for scientists in the field of bioinspired medicine. Researchers have taken cues from the adhesive chemistry perfected by mussels and marine worms to create tissue glues that stick in wet and turbulent conditions; from red blood cell membranes to help drug-carrying nanoparticles avoid immune attack; and from the slippery slides that help carnivorous pitcher plants catch prey to produce novel antibacterial surfaces. (See “Bioinspired Antibacterial Surfaces.”) Nature, it seems, provides a compendium of biomedical solutions.

“Nature has used the power of evolution by natural selection to develop the most efficient ways to solve all kinds of problems,” says Donald Ingber, founding director of the Wyss Institute for Biologically Inspired Engineering in Boston. “We’ve uncovered so much about how nature works, builds, controls, and manufactures from the nanoscale up. Now we’re starting to leverage those biological principles.”

Sticking points

Looking to nature is not a new concept, and bioinspiration is just one of several approaches bioengineers employ to devise new medical treatments and devices. But in the last few years, the approach has come to the fore with several promising new products, even if most of them remain a few years away from human trials. “Almost every research institute now has a center for biomimicry or biologically inspired engineering,” says Ingber. “It’s just reaching that tipping point where it’s going to begin to have an impact.”

 Image No 3

TISSUE GLUE: The sandcastle worm (Phragmatopoma californica) builds reef-like shelters by gluing together grains of sand with two separate secretions: one containing negatively charged polyphosphate proteins and the other positively charged polyamine proteins. Researchers mimicked this idea with synthetic polyelectrolytes to create an injectible fluid that can patch fetal membrane ruptures in an in vitro model.
See full infographic: JPG

Medical adhesion is one area where bioinspiration promises to make an impression. Stitches and staples are still the standard for suturing wounds and closing up surgical incisions, but these technologies can damage tissue, leave gaps for bacteria to infiltrate, and increase the risk of inflammation. For years, surgeons have been in need of new medical adhesives that can bond tissue strongly inside the body without provoking inflammation.

Heeding the call, bioengineers have again turned to the sea. Phillip Messersmith of the University of California, Berkeley, for example, is focused on the protein-filled secretions marine mussels use to fasten themselves to wave-battered rocks. The proteins in these liquid secretions are rich in an amino acid called dihydroxyphenylalanine (DOPA), which features reactive catechol chains. These catechol chains bond tightly with each other in a mussel’s own secretions but also bond with metal atoms present on the surface of rocks. Using this strategy as a blueprint, Messersmith and colleagues chemically synthesized a variant of DOPA to crosslink biocompatible polymers.

Their glue has successfully fastened transplanted insulin-producing islet cells to the outer surface of the liver and nearby tissues in mice.2 The technique could potentially provide an alternative to standard methods of islet transplantation in which islets are infused into the liver vasculature, where they trigger an inflammatory response that quickly kills off about half of the transplanted cells—and impairs the surviving cells’ ability to produce therapeutic insulin. The researchers are also testing the bioinspired adhesive’s ability to repair ruptured fetal membranes, which can lead to premature birth and other serious complications. (See “Mimicking Mussels,” The Scientist, April 2013.)



Gene Test Finds Which Breast Cancer Patients Can Skip Chemo

9/28/2015   Marilynn Marchione, AP Chief Medical Writer

In this Sept. 5, 2013 file photo, chemotherapy is administered to a cancer patient via intravenous drip in Durham, N.C. In a study sponsored by the National Cancer Institute and results published online Monday, Sept. 28, 2015, by the New England Journal of Medicine, a gene-activity test that was used to gauge early-stage breast cancer patient’s risk accurately identified a group of women whose cancers are so likely to respond to hormone-blocking drugs that adding chemo would do little if any good while exposing them to side effects and other health risks. (Gerry Broome, Associated Press)Many women with early-stage breast cancer can skip chemotherapy without hurting their odds of beating the disease – good news from a major study that shows the value of a gene-activity test to gauge each patient’s risk.

The test accurately identified a group of women whose cancers are so likely to respond to hormone-blocking drugs that adding chemo would do little if any good while exposing them to side effects and other health risks. In the study, women who skipped chemo based on the test had less than a 1 percent chance of cancer recurring far away, such as the liver or lungs, within the next five years.

“You can’t do better than that,” said the study leader, Dr. Joseph Sparano of Montefiore Medical Center in New York.

An independent expert, Dr. Clifford Hudis of New York’s Memorial Sloan Kettering Cancer Center, agreed.

“There is really no chance that chemotherapy could make that number better,” he said. Using the gene test “lets us focus our chemotherapy more on the higher risk patients who do benefit” and spare others the ordeal.

The study was sponsored by the National Cancer Institute. Results were published online Monday by the New England Journal of Medicine and discussed at the European Cancer Congress in Vienna.

The study involved the most common type of breast cancer – early stage, without spread to lymph nodes; hormone-positive, meaning the tumor’s growth is fueled by estrogen or progesterone; and not the type that the drug Herceptin targets. Each year, more than 100,000 women in the United States alone are diagnosed with this.

The usual treatment is surgery followed by years of a hormone-blocking drug. But many women also are urged to have chemo, to help kill any stray cancer cells that may have spread beyond the breast and could seed a new cancer later. Doctors know that most of these women don’t need chemo but there are no great ways to tell who can safely skip it.

A California company, Genomic Health Inc., has sold a test called Oncotype DX since 2004 to help gauge this risk. The test measures the activity of genes that control cell growth, and others that indicate a likely response to hormone therapy treatment.

Past studies have looked at how women classified as low, intermediate or high risk by the test have fared. The new study is the first to assign women treatments based on their scores and track recurrence rates.

Of the 10,253 women in the study, 16 percent were classified as low risk, 67 percent as intermediate and 17 percent as high risk for recurrence by the test. The high-risk group was given chemotherapy and hormone-blocking drugs. Women in the middle group were randomly assigned to get hormone therapy alone or to add chemo. Results on these groups are not yet ready – the study is continuing.

But independent monitors recommended the results on the low-risk group be released, because it was clear that adding chemo would not improve their fate.

After five years, about 99 percent had not relapsed, and 98 percent were alive. About 94 percent were free of any invasive cancer, including new cancers at other sites or in the opposite breast.

“These patients who had low risk scores by Oncotype did extraordinarily well at five years,” said Dr. Hope Rugo, a breast cancer specialist at the University of California, San Francisco, with no role in the study. “There is no chance that for these patients, that chemotherapy would have any benefit.”

Dr. Karen Beckerman, a New York City obstetrician diagnosed with breast cancer in 2011, said she was advised to have chemo but feared complications. A doctor suggested the gene test and she scored very low for recurrence risk.

“I was convinced that there was no indication for chemotherapy. I was thrilled not to have to have it,” and has been fine since then, she said.

Mary Lou Smith, a breast cancer survivor and advocate who helped design the trial for ECOG, the Eastern Cooperative Oncology Group, which ran it, said she thought women “would be thrilled” to skip chemo.

“Patients love the idea of a test” to help reduce uncertainty about treatment, she said. “I’ve had chemotherapy. It’s not pretty.”

The test costs $4,175, which Medicare and many insurers cover. Others besides Oncotype DX also are on the market, and Hudis said he hopes the new study will encourage more, to compete on price and accuracy.

“The future is bright” for gene tests to more precisely guide treatment, he said.

Source: Associated Press


Back-to-the-Future with Tumor Cell-Based Avatars

Researchers Looking for Alternatives to Individual Avatars Have Found Reason to Be Hopeful in Tumor-Cell Based Predictive Models

Formidable barriers, including time and expense required to breed and maintain mice engrafted with human tumor tissue, impede the widespread use of mouse avatars.

  • Mice grafted with human tumors, known as patient-derived xenograft (PDX) mice, have migrated from cancer research labs to the clinic.  But as limitations to modeling patient individual tumors in mice emerge, some investigators are turning to cell-based models and applying new methodologies to support and grow cells in culture.

Conceived by Heinz-Herbert Fiebig and colleagues at the University of Freiburg in the early 1980s, it was hoped that PDX mice would more accurately reflect an individual patient’s tumor in a model system and predict tumor responses to drug therapies.  Dr. Fiebig is the founder and CEO of Oncotest, a company that specializes in preclinical pharmacological contract research.

Since their introduction, commercial labs, including Oncotest, the Jackson Laboratory, and Discovery Group plc Horizon (Horizon), have provided access to a wide range of PDX mice made from donated tumor tissue.  The tissue, cryopreserved for future use after biopsy, serves as the basis for offering drug-testing services to researchers and pharmaceutical companies. Oncotest, for example, says it provides drug-testing services to 16 of the 20 largest pharmaceutical companies, using a library of more than 350 PDX mouse models.

And beyond PDX mouse model libraries for pharma companies, companies now offer individualized avatar mice directly to patients developed using their own tumors.  Champions Oncology provides mouse avatars directly to patients, at a cost of $10,000 to $12,000.  Proponents of these mouse models say they can facilitate the identification of a personalized therapeutic regimen, may prove more useful than genomic analysis, and eliminate the cost and toxicity associated with nontargeted chemotherapeutics.

But formidable barriers impede the widespread use of mouse avatars, scientists say, including the time and expense required to breed and maintain mice engrafted with human tumor tissue.  Development of an individualized avatar takes anywhere from three to six months, more time than some critically ill patients can survive and, in about 30% of cases, Champions points out it hasn’t been able to grow the patient’s tumor in mice.

In a study published in Cancer in April 2014, Justin Stebbing, M.D., Ph.D., and colleagues at Imperial College, London, reported that they worked with Champions to develop avatars with the company’s TumorGraft system for 22 patients with advanced sarcoma. But nine patients died before the results were ready. “Within a couple of months after their surgery or biopsy, they get chemotherapy and they pass away,” says Champions CEO Ronnie Morris. “We build the avatar, but the patient can’t use it.”

In this study, the scientists said that of implanted tumors, 22 (76%) successfully engrafted, permitting the identification of treatment regimens for these patients. Although several patients died before completion of TumorGraft testing, a correlation between TumorGraft results and clinical outcome was observed in 13 of the 16 (81%) remaining individuals. No patients died during the TumorGraft-predicted therapy.

On the other hand the authors noted that a primary advantage of Champions’ TumorGraft is “that it allows discrimination between the different standard-of-care therapies that may be available, as well as other potential treatments not normally indicated for that tumor.

“Our increased understanding of tumor heterogeneity, even within a single subtype, means that knowing how patients with the same tumor previously responded to a particular drug is no guarantee that the current patient will respond similarly. TumorGraft overcomes this problem by helping guide oncologists to those treatments that are most likely to provide a positive clinical outcome.”

  • Search for Alternatives

Given the obstacles to using individual avatars to guide patient therapy, researchers in several laboratories are currently looking for alternatives, turning in some cases to tumor-cell based predictive models in a back to the future approach utilizing up-to-date pharmacogenomics and novel cell culture technologies to improve the longstanding odds against success culture of tumor cells from biopsied material.

The team of Jeffrey Engelman, M.D., Ph.D., director of thoracic oncology and molecular therapeutics at Massachusetts General Hospital Cancer Center, has successfully established cell culture models from biopsy samples of lung cancer patients for functional pharmacologic studies. Dr. Engelman noted that while “Genetics has been extremely useful to guiding treatment, in many cases tumor genetics are ambiguous or do not reveal a mutation that informs a therapeutic strategy. These functional pharmacologic studies can identify effective therapeutic choices even when the genetics fail to do so.”

Dr. Engelman and colleagues described in Science a pharmacogenomic platform that facilitates rapid discovery of drug combinations that can overcome drug resistance. Their cell culture models were derived from patients whose disease had progressed while on treatment with epidermal growth factor receptor (EGFR) or anaplastic lymphoma kinase (ALK) tyrosine kinase inhibitors and then subjected to genetic analyses and a pharmacological screen.

With the system they could identify multiple effective drug combinations, they said.  These included the combination of ALK and mitogen-activated protein kinases (MAPK) inhibitors active in an ALK-positive resistant tumor that had developed a MAP2K1 activating mutation. A combination of EGFR and fibroblast growth factor receptor (FGFR) inhibitors was active in an EGFR mutant-resistant cancer with a mutation in FGFR3. Combined ALK and SRC (pp60c-src) inhibition was effective in several ALK-driven patient-derived models, a result not predicted by genetic analysis alone. With further refinements, the authors said their strategy could help direct therapeutic choices for individual patients.

  • Several Approaches

Noting the historical difficulty of coaxing tumor cells obtained from tumor biopsies to grow in culture, Dr. Engelman told GEN that his team typically tries three or four different approaches to optimize the growth of cells from a single biopsy, including 3D culture, organoids, and feeder layers to support the best cancer cell growth.  “We want to get the biopsy to the high-throughput screening phase as quickly as possible and get the results to inform patient therapy as quickly as possible,” he said.

While the application described in their publication involved lung cancer, he notes that his lab is trying the approach on breast cancer, colorectal tumors, and melanoma.  “What’s interesting for us is that there are cancers for which no work has ever been done before,” he noted.

To date, the investigators are “not applying the cell culture technology to the clinic, but are inching closer to doing so,” Dr. Engleman said. “We are confident in the results we get from the screen and believe the data is quite valuable, but we want to make sure there is clinical outcome with therapeutics prior to having a patient enroll in a clinical trial or embark on a specific therapy.”

Dr. Engelman also believes that the technology can be commercialized, but that he is “focused on making it work.” These initial studies demonstrated success in developing NSCLC models NSCLC models in 50% of collected specimens. However, the team believes that success rates could be further improved by using biopsies acquired for specifically for cell line generation.

The authors noted that with their pharmacologic platform, they discovered several previously undescribed combinations in EGFR mutant and ALK-positive lung cancers that were validated in follow-up studies and in vivo.  They speculate that a similar approach could be explored in the future as a diagnostic test to identify therapeutic strategies for individual patients (under the auspices of an IRB-approved protocol).

In their study, they screened the cells after they became fully established cell lines, often requiring two to six months, a time frame that would make this approach less than ideal as a routine diagnostic test. But they say, their results of the program provides the  groundwork for performing screens on viable cells obtained within weeks of a biopsy using newer technologies that would permit screening of the cancer cells while still in the presence of the stroma present in the biopsy.

In a proof of concept study in Nature Methods, investigators working at MGH, Harvard Medical School, the Karolinska Institute, and other institutions showed that circulating tumor cells (CTCs) can be captured in viable form and used to establish cell cultures, potentially bypassing the need for a biopsy as a source of tumor cells to culture.

The investigators captured the CTCs using microchip technology (the Cluster-Chip) developed to capture CTC clusters independently of tumor-specific markers from unprocessed blood.  The device isolates the CTC clusters through specialized bifurcating traps under low-shear stress conditions that preserve their integrity, and, the investigators said,  even two-cell clusters can be efficiently captured.

Maheswaran et al., in Cancer Research, used the device to show that the culture of CTCs in the blood of patients with breast cancer enabled them to study patterns of drug susceptibility linked to the genetic context that is unique to an individual tumor.

The investigators established CTC cultures from six patients with estrogen receptor–positive breast cancer. Three of five CTC lines tested were tumorigenic in mice. Genome sequencing of the CTC lines revealed preexisting mutations in the PIK3CA gene and newly acquired mutations in the estrogen receptor gene (ESR1), PIK3CA gene, and fibroblast growth factor receptor gene (FGFR2), among others. Drug sensitivity testing of CTC lines with multiple mutations revealed potential new therapeutic targets.

The authors noted that with optimization of CTC culture conditions, this strategy could help identify the best therapies for individual cancer patients over the course of their disease.

These and other investigators believe, that cell-based methods, once optimized, could bypass the need for whole animal cancer avatars, providing another resource to help inform the choice of therapies likely to be effective in a given patient.


Linking Phenotypes and Modes of Action Through High-Content Screen Fingerprints

The Use of High-Content Screening as a Powerful Technique for Monitoring Phenotypic Responses

Felix Reisen, Amelie Sauty de Chalon, Martin Pfeifer, Xian Zhang, Daniela Gabriel, Paul Selzer

cytoplasm redix tool compounds targeting different cellular compartments.

Fig. 2. Phenotypes of snuclei are colored purple, the cytoplasm redix tool compounds targeting different cellular compartments. In all figures nuclei are colored purple, the cytoplasm red.

  • In today’s drug discovery campaigns we observe a clear trend toward more complex assay environments. While target-based high-throughput screening (HTS) still plays an important role, phenotypic screening techniques are gaining importance. Phenotypic screening assays are believed to be more closely linked to a given disease state than target-based approaches where the molecular hypothesis might not be relevant for disease pathogenesis.

One approach to phenotypic drug discovery is high-content screening (HCS), an HTS technique based on automated microscopy. HCS allows for highly multiplexed assay readouts that can be used to simultaneously assay several modes of action or toxicity. Additionally, HCS enables screening in a controlled and disease-relevant environment by even using patient-derived cell cultures.

While there are many advantages to phenotypic screening, additional knowledge about the targets being modulated to bring about the desired phenotype can be highly beneficial, for example, in lead optimization, by helping interpretation of structure activity relationships. In addition, knowledge of the target can also help to identify related targets that may bring about challenges in designing selective lead molecules.

Various techniques have been developed to support target identification for compounds active in phenotypic assays. These include approaches such as affinity chromatography, biochemical fractionation, radioactive ligand binding assays, drug affinity responsive target stability. Alternative approaches are based on in vivo chemical genomic assays developed in yeast Saccharomyces cerevisiae or in silico approaches using historic knowledge about compound target associations. In silico methods predict possible targets for a compound by comparing the similarity of the compound’s profile (using chemical similarity, gene expression profile, or HCS experiments) to those of previously characterized compounds with known target.

For the rest of the story, click here.

ASSAY & Drug Development Technologies, published by Mary Ann Liebert, Inc., offers a unique combination of original research and reports on the techniques and tools being used in cutting-edge drug development. GEN presents here one article “Linking Phenotypes and Modes of Action Through High-Content Screen Fingerprints.” Authors of the paper are Felix Reisen, Amelie Sauty de Chalon, Martin Pfeifer, Xian Zhang, Daniela Gabriel, and Paul Selzer.



Immuno-Oncology Landscape Expands

New Techniques Enable Closer Look into Genetic & Cellular Alterations in Tumor Microenvironment

  • For years, researchers and physicians have suspected, and have worked to demonstrate, how the immune system affects susceptibility to, defense against, and progression of certain cancers. It is now understood that the immune system has the ability to influence the fate of developing cancers by not only functioning as a tumor promoter that facilitates cellular transformation, promotes tumor growth, and sculpts tumor cell immunogenicity, but also as an extrinsic tumor suppressor that either destroys developing tumors or restrains their expansion.

In the last few decades, drugs, biologicals, and vaccines targeting certain attributes of the immune system, known as immunotherapeutics, have become available, and emerging clinical data suggest that cancer immunotherapy is likely to become a key part of the clinical management of cancer for years to come.

Although immunotherapies represent a major step forward in cancer care, providing in some cases unprecedented response rates, there is still much work to do to discover new druggable targets, find biomarkers to predict response, as well as gain deeper understanding of why some cancer types are incredibly responsive to immunotherapeutic treatments while others are not.

  • How Immunotherapies Work

Inhibitory costimulatory checkpoints_eBioscience_Fig12031112116


Figure 1.  Inhibitory costimulatory checkpoints are a natural immune mechanism for self-tolerance and minimization of collateral tissue damage. Inhibitory checkpoint receptors such as PD-1, LAG-3, TIM-3, and CTLA-4 are expressed by T cells, and their ligands are expressed by macrophage and dendritic cells. Tumor cells can express multiple inhibitory ligands to repress T-cell function and thereby evade clearance by the immune system.

  • A deeper understanding of cancer as a disease requires the acknowledgement of its inherent heterogeneity. As with the cancer cells within a tumor, the immunological microenvironments in which they grow are similarly heterogeneous. Emerging and well-established scientific tools and techniques for the analysis of cancer cells, immune cells and their microenvironment can be combined to yield new insights into the nature of tumorigenesis, immune system recruitment, and treatment optimization.In general, immunotherapies direct an individual’s immune system to fight cancer by either stimulating it to attack cancer cells or by introducing manufactured immune system components to augment immune function. Immunotherapy treatments work in different ways. Some boost the body’s immune system in a very general way. Others help train the immune system to attack cancer cells specifically.
  • On an immuno-oncological level, the genetic and cellular alterations that define a cancer cell provide the immune system with the means to be recruited to the tumor and generate T-cell responses to recognize and eradicate those cells. Elimination of cancer by T cells is only one step in the cancer immunity cycle. T-cell activation is controlled by both stimulatory and inhibitory checkpoints. Tumors use the expression of inhibitory ligands as a mechanism of suppressing cytotoxic T-cell response and inducing an immunosuppressive environment.
  • Identification of specific cancer T-cell inhibitory signals, such as PD-L1, has prompted the development of a new class of cancer immunotherapy that specifically hinders immune effector inhibition, reinvigorating and potentially expanding preexisting anticancer immune responses (Figure 1).
  • The presence of environment-altering immunosuppressive innate myeloid lineages in the tumor microenvironment may further explain the limited activity observed with previous immune-based therapies and why these therapies may be more effective in combination with agents that target other steps of the cycle.
  • Understanding the Tumor and Its Microenvironment

In addition, the presence and quantity of various immune cell types in the tumor microenvironment may have prognostic value. Many scientists believe that a deepening appreciation of oncology genomics and the quantity and type of antigens expressed by the tumor cells, when coupled with an analysis of the patient’s immune system, will greatly progress the field and unlock the next generation of immunotherapies.

Flow cytometry and immunohistochemistry are established tools for the labeling and analysis of immunological and oncology cellular components. New techniques are likewise becoming more widely used that enable simultaneous detection of proteins and nucleic acids at single-cell resolution.

New Cellular Analysis Tools

  • eBioscience, a business unit of Affymetrix, has recently expanded commercialization of two such novel assays that provide exciting new technologies in the armament of cellular analysis techniques for immuno-oncology research. The first is PrimeFlow™ RNA Assay, which is the only commercially available assay for the simultaneous detection of RNA and protein expression within millions of cells at single-cell resolution using a standard flow cytometer. The assay is compatible with cell surface and intracellular antibody staining, using traditional fluorochromes for multiparameter cellular analysis.
  • With this technology an immune-oncology researcher could explore gene expression heterogeneity among different rare tumor-infiltrating immune cell subsets with single-cell resolution and without laborious cell sorts, as well as compare kinetics of both RNA and protein in the same cell.

Prime Flow RNA assay_eBioscience_Fig21361229223 (1)

Figure 2. The PrimeFlow RNA Assay workflow contains several steps: antibody staining, fixation and permeabilization including intracellular staining if desired, followed by target hybridization with a target-specific probe set containing 20 to 40 oligonucleotide pairs. Next, branched DNA signal amplification is achieved through a series of sequential hybridization steps consisting of pre-amplifiers, amplifiers, and labeled probes, followed by detection by flow cytometric analysis. This results in excellent specificity, low background, and a high signal-to-noise ratio. For simplicity, two RNA targets are shown in the schematic above (red and green), and only 3 of the 20 to 40 oligonucleotide target probe pairs per target RNA are shown.

  • S. Shalapour et al. recently published a study in the journal Nature (April 29, 2015) applying these techniques to mouse models of castrate-resistant prostate cancer demonstrating that the presence of a very specific and rare (0.04–3% of total) B cell population in the tumor microenvironment correlates to a immunotherapeutic response allowing a CTL-dependent eradication of oxaliplatin-treated tumors.
  • ViewRNA® In Situ Hybridization (ISH) Cell and Tissue Assays comprise the second new technique from eBioscience. Similar to the PrimeFlow RNA assay, but compatible with microscopy, these assays enable the visualization of single-copy RNA transcripts within adherent and suspended single cells or single cells in tissue sections, and in the case of ViewRNA ISH Tissue Assays, the spatial separation of tumor subclones by phenotypic RNA expression. Similarly, this technique can be used to visualize and quantitate cellular and molecular attributes of tumor-infiltrating immune cells to elucidate biomarkers of resistance and response. Leveraging these novel cell analysis approaches, immuno-oncology researchers can analyze cellular diversity in the tumor microenvironment as well as the diversity of immune cell responses at a single-cell level.
  • Breakthrough responses to new immunotherapies are stimulating a renewed interest in basic immune biology. With our quest to develop strategies to harness the human immune response against cancer to achieve durable responses and/or complete eradication of cancer in patients safely, we must explore multiple approaches simultaneously. Which immune checkpoints can be manipulated? Are there dual therapies that can be applied to improve responses? Are there biomarkers inherent to the immune system in general, the specific tumor and the tumor microenvironment that can be used to stratify responders?
  • Multiple approaches to cancer therapy exist, and few are as complicated as immune-based therapy. That being said, few therapies in recent history have demonstrated such extraordinary and durable responses for the patients who do respond. As such, many believe that this will be an intensifying area of research and clinical focus for years to come.

New Research for Prostate Cancer Therapies

Dr. Glenn Bubley has been treating patients with prostate cancer for more than 25 years.

“When a patient’s diagnosis is latter-stage prostate cancer, the standard treatment is androgen deprivation therapy [ADT],” says Bubley, Director of the Genitourinary Cancer Program in the Cancer Center at Beth Israel LeadingEdge11182015Deaconess Medical Center. “ADT works by lowering testosterone production and thereby depriving prostate tumors of the ‘fuel’ that helps them grow.”

But, he adds, although this hormone therapy is almost always effective, all tumors eventually grow resistant to ADT — and cancer recurs. Over the past two years, Bubley has been part of a BIDMC scientific team that has been testing a targeted treatment alternative for late-stage prostate cancer using a unique type of study known as a “Co-Clinical Trial.”

This new approach to clinical research — in which specially-created mouse models with genetic mutations are matched with tumor tissue from human cancer patients in order to test new therapies — was developed by BIDMC Cancer Center Director Pier Paolo Pandolfi, MD, PhD.

“Targeted therapies are designed to attack cancers by pinpointing the genes and genetic mutations that underlie diseases,” says Pandolfi (right). “The problem is that cancer cells are genetically complex, sometimes containing hundreds of genetic mutations. We needed to develop a way to cut down on all this ‘genetic noise’ to get at the root of the disease. The Co-Clinical Trial enables us to streamline and expedite the process in order to more quickly test a variety of new cancer drugs.”

Here’s how it works: In the Co-Clinical Trial, human participants are matched with animal models that have been genetically engineered to carry different combinations of just a few major human prostate cancer genes.

“When the animals develop tumors — just as the human patients did — they will receive the same therapies as the patients receive,” says Bubley (right). But, he adds, because each animal has only a few mutations, the researchers will be able to quickly assess which treatments are effective and which are not — and will be able to go back and adjust treatment accordingly for the human patients.

A particular advantage to this approach, say Bubley and Pandolfi, will be the ability to test combinations of different drugs to treat prostate cancer and overcome ADT resistance.

“Going forward, we think that combinations of targeted and conventional therapies may prove to be effective, particularly for drug-resistant disease,” says Bubley. “And the only realistic way to be able to quickly test numerous different drug combinations will be through the Co-Clinical Trial process.”

Nanocarriers May Carry New Hope for Brain Cancer Therapy

Fri, 11/20/2015 – DOE/Lawrence Berkeley National Laboratory
At only 20 nanometers in size and featuring a unique hierarchical structure, 3HM nanocarriers meet all the size and stability requirements for effectively delivering therapeutic drugs to brain cancer tumors. Credit: Ting Xu, Berkeley Lab
At only 20 nanometers in size and featuring a unique hierarchical structure, 3HM nanocarriers meet all the size and stability requirements for effectively delivering therapeutic drugs to brain cancer tumors. Credit: Ting Xu, Berkeley Lab
Glioblastoma multiforme, a cancer of the brain also known as “octopus tumors” because of the manner in which the cancer cells extend their tendrils into surrounding tissue, is virtually inoperable, resistant to therapies, and always fatal, usually within 15 months of onset. Each year, glioblastoma multiforme (GBM) kills approximately 15,000 people in the United States. One of the major obstacles to treatment is the blood brain barrier, the network of blood vessels that allows essential nutrients to enter the brain but blocks the passage of other substances. What is desperately needed is a means of effectively transporting therapeutic drugs through this barrier. A nanoscience expert at Lawrence Berkeley National Laboratory (Berkeley Lab) may have the solution.
Ting Xu, a polymer scientist with Berkeley Lab’s Materials Sciences Division who specializes in self-assembling bio/nano hybrid materials, has developed a new family of nanocarriers formed from the self-assembly of amphiphilic peptides and polymers. Called “3HM” for coiled-coil 3-helix micelles, these new nanocarriers meet all the size and stability requirements for effectively delivering a therapeutic drug to GBM tumors. Amphiphiles are chemical compounds that feature both hydrophilic (water-loving) and lipophilic (fat-loving) properties. Micelles are spherical aggregates of amphiphiles.
In a recent collaboration between Xu, Katherine Ferrara at the University of California (UC) Davis, and John Forsayeth and Krystof Bankiewicz of UC San Francisco, 3HM nanocarriers were tested on GBM tumors in rats. Using the radioactive form of copper (copper-64) in combination with positron emission tomography (PET) and magnetic resonance imaging (MRI), the collaboration demonstrated that 3HM can cross the blood brain barrier and accumulate inside GBM tumors at nearly double the concentration rate of current FDA-approved nanocarriers.
“Our 3HM nanocarriers show very good attributes for the treatment of brain cancers in terms of long circulation, deep tumor penetration and low accumulation in off-target organs such as the liver and spleen,” says Xu, who also holds a joint appointment with the UC Berkeley’s Departments of Materials Sciences and Engineering, and Chemistry. “The fact that 3HM is able to cross the blood brain barrier of GBM-bearing rats and selectively accumulate within tumor tissue, opens the possibility of treating GBM via intravenous drug administration rather than invasive measures. While there is still a lot to learn about why 3HM is able to do what it does, so far all the results have been very positive.”
Glial cells provide physical and chemical support for neurons. Approximately 90-percent of all the cells in the brain are glial cells which, unlike neurons, undergo a cycle of birth, differentiation, and mitosis. Undergoing this cycle makes glial cells vulnerable to becoming cancerous. When they do, as the name “multiforme” suggests, they can take on different shapes, which often makes detection difficult until the tumors are dangerously large. The multiple shapes of a cancerous glial cell also make it difficult to identify and locate all of the cell’s tendrils. Removal or destruction of the main tumor mass while leaving these tendrils intact is ineffective therapy: like the mythical Hydra, the tendrils will sprout new tumors.
Although there are FDA approved therapeutic drugs for the treatment of GBM, these treatments have had little impact on patient survival rate because the blood brain barrier has limited the accumulation of therapeutics within the brain. Typically, GBM therapeutics are ferried across the blood brain barrier in special liposomes that are approximately 110 nanometers in size. The 3HM nanocarriers developed by Xu and her group are only about 20 nanometers in size. Their smaller size and unique hierarchical structure afforded the 3HM nanocarriers much greater access to rat GBM tumors than 110-nanometer liposomes in the tests carried out by Xu and her colleagues.
“3HM is a product of basic research at the interface of materials science and biology,” Xu says. “When I first started at Berkeley, I explored hybrid nanomaterials based on proteins, peptides and polymers as a new family of biomaterials. During the process of understanding the hierarchical assembly of amphiphilic peptide-polymer conjugates, my group and I noticed some unusual behavior of these micelles, especially their unusual kinetic stability in the 20 nanometer size range. We looked into critical needs for nanocarriers with these attributes and identified the treatment of GBM cancer as a potential application.”
Copper-64 was used to label both 3HM and liposome nanocarriers for systematic PET and MRI studies to find out how a nanocarrier’s size might affect the pharmacokinetics and biodistribution in rats with GBM tumors. The results not only confirmed the effectiveness of 3HM as GBM delivery vessels, they also suggest that PET and MRI imaging of nanoparticle distribution and tumor kinetics can be used to improve the future design of nanoparticles for GBM treatment.
“I thought our 3HM hybrid materials could bring new therapeutic opportunities for GBM but I did not expect it to happen so quickly,” says Xu, who has been awarded a patent for the 3HM technology.

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Nonhematologic Cancer Stem Cells [11.2.3]

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

Nonhematologic Stem Cells C8orf4 negatively regulates self-renewal of liver cancer stem cells via suppression of NOTCH2 signalling

Pingping Zhu, Yanying Wang, Ying Du, Lei He, Guanling Huang, et al.
Nature Communications May 2015; 6(7122).

Liver cancer stem cells (CSCs) harbor self-renewal and differentiation properties, accounting for chemotherapy resistance and recurrence. However, the molecular mechanisms to sustain liver CSCs remain largely unknown. In this study, based on analysis of several hepatocellular carcinoma (HCC) transcriptome datasets and our experimental data, we find that C8orf4 is weakly expressed in HCC tumors and liver CSCs. C8orf4 attenuates the self-renewal capacity of liver CSCs and tumor propagation. We show that NOTCH2 is activated in liver CSCs. C8orf4 is located in the cytoplasm of HCC tumor cells and associates with the NOTCH2 intracellular domain, which impedes the nuclear translocation of N2ICD. C8orf4 deletion causes the nuclear translocation of N2ICD that triggers the NOTCH2 signaling, which sustains the stemness of liver CSCs. Finally, NOTCH2 activation levels are consistent with clinical severity and prognosis of HCC patients. Altogether, C8orf4 negatively regulates the self-renewal of liver CSCs via suppression of NOTCH2 signaling.

Like stem cells, CSCs are characterized by self-renewal and differentiation simultaneously9. Not surprisingly, CSCs share core regulatory genes and developmental pathways with normal tissue stem cells. Accumulating evidence shows that NOTCH, Hedgehog and Wnt signaling pathways are implicated in the regulation of CSC self-renewal4. NOTCH signaling modulates many aspects of metazoan development and tissue stemness1011. NOTCH receptors contain four members (NOTCH1–4) in mammals, which are activated by engagement with various ligands. The aberrant NOTCH signaling was first reported to be involved in the tumorigenesis of human T-cell leukaemia1213. Recently, a number of studies have reported that the NOTCH signaling pathway is implicated in regulating self-renewal of breast stem cells and mammary CSCs1415. However, how the NOTCH signaling regulates the liver CSC self-renewal remains largely unknown.

C8orf4, also called thyroid cancer 1 (TC1), was originally cloned from a papillary thyroid carcinoma and its surrounding normal thyroid tissue16. C8orf4 is ubiquitously expressed across a wide range of vertebrates with the sequence conservation across species. A number of studies have reported that C8orf4 is highly expressed in several tumors and implicated in tumorigenesis171819. In addition, C8orf4 augments Wnt/β-catenin signaling in some cancer cells2021, suggesting it may be involved in the regulation of self-renewal of CSCs. However, the biological function of C8orf4 in the modulation of liver CSC self-renewal is still unknown. Here we show that C8orf4 is weakly expressed in HCC and liver CSCs. NOTCH2 signaling is highly activated in HCC tumors and liver CSCs. C8orf4 negatively regulates the self-renewal of liver CSCs via suppression of NOTCH2 signaling.

C8orf4 is weakly expressed in HCC tissues and liver CSCs

To search for driver genes in the oncogenesis of HCC, we performed genome-wide analyses using several online-available HCC transcriptome datasets by R language and Bioconductor approaches. After analysing gene expression profiles of HCC tumor and peri-tumor tissues, we identified >360 differentially expressed genes from both Park’s cohort (GSE36376; ref. 22) and Wang’s cohort (GSE14520; refs 2324). Of these changed genes, we focused on C8orf4, which was weakly expressed in HCC tumors derived from both Park’s cohort (GSE36376) and Wang’s cohort (GSE14520) (Fig. 1a). Lower expression of C8orf4 was further confirmed in HCC samples by quantitative reverse transcription–PCR (qRT–PCR) and immunoblotting (Fig. 1b,c). In this study, HCC patient samples we used included all subtypes of HCC. In addition, these observations were further validated by immunohistochemical (IHC) staining (Fig. 1d). These data indicate that C8orf4 is weakly expressed in HCC tumor tissues.

C8orf4 is weakly expressed in HCC tumours and liver CSCs

C8orf4 is weakly expressed in HCC tumours and liver CSCs

Figure 1. C8orf4 is weakly expressed in HCC tumours and liver CSCs

(a)C8orf4 is weakly expressed in HCC patients. Using R language and Bioconductor methods, we analyzed C8orf4 expression in HCC tumor and peri-tumor tissues provided by Park’s cohort (GSE36376) and Wang’s cohort (GSE14520) datasets. (b,c) C8orf4 expression levels were verified in HCC patient samples by quantitative RT–PCR (qRT–PCR) (b) and immunoblotting (c). β-actin served as a loading control. 18S: 18S rRNA. (d) HCC samples were assayed by immunohistochemical staining. Scale bar—left: 50 μm; right: 20 μm. (eC8orf4 is weakly expressed in CD13+CD133+ cells sorted from Huh7 cells and primary HCC samples. C8orf4 messenger RNA (mRNA) was measured by qRT–PCR. Six HCC samples got similar results. (fC8orf4 is much more weakly expressed in oncospheres than non-sphere tumor cells. Non-sphere: Huh7 or HCC primary cells that failed to form spheres. (g) HCC sample tissues were co-stained with anti-C8orf4 and anti-CD13 or anti-CD133 antibodies, then counterstained with DAPI for confocal microscopy. White arrows indicate CD13+ or CD133+ cells. Scale bars: 20 μm. For a,b, data are shown as box and whisker plot. Boxes represent interquartile range (IQR); upper and lower edge corresponds to the 75th and 25th percentiles, respectively. Horizontal lines within boxes represent median levels of gene intensity. Whiskers below and above boxes extend to the 5th and 95th percentiles, respectively. For e and f, Student’s t-test was used for statistical analysis, *P<0.05;**P<0.01, data are shown as mean ± standard deviation. Data are representative of at least three independent experiments. P, peri-tumor; T, tumor.


Notably, C8orf4 was also weakly expressed in embryonic stem cells (ESCs) and induced pluripotent stem cells (iPSCs) by analysis of its expression profiles derived from online datasets (GSE14897; ref. 25 and GSE25417; ref. 26) (Supplementary Fig. 1a,b). C8orf4 was also lowly expressed in normal liver stem cells (Supplementary Fig. 1c,d), suggesting that C8orf4 may be involved in the regulation of self-renewal of liver stem cells. Thus, we propose that C8orf4 might play a role in the maintenance of liver CSCs. Since CD13 and CD133 were widely used as liver CSC surface markers, we sorted CD13+CD133+ cells from Huh7 and Hep3B HCC cell lines as well as HCC samples, serving as liver CSCs. We observed that C8orf4 was weakly expressed in liver CSCs enriched from both HCC cell lines and patient samples (Fig. 1e). Six HCC samples were analyzed for these experiments. Similar results were obtained in CD13+CD133+ cells from Hep3B cells. Furthermore, we performed sphere formation experiments using Huh7 cells and HCC primary sample cells, and detected expression levels of C8orf4. We observed that C8orf4 was dramatically reduced in the oncospheres generated by both HCC cell lines and patient samples (Fig. 1f). In addition, we noticed that C8orf4 expression was negatively correlated with liver CSC markers such as CD13 and CD133 in HCC samples (Fig. 1g), suggesting lower expression of C8orf4 in liver CSCs. Moreover, C8orf4 was mainly located in the cytoplasm of tumour cells. Altogether, C8orf4 is weakly expressed in HCC tumor tissues and liver CSCs.

C8orf4 negatively regulates self-renewal of liver CSCs

We then wanted to look at whether C8orf4 plays a critical role in the self-renewal maintenance of liver CSCs. C8orf4 was knocked out in Huh7 cells through a CRISPR/Cas9 system (Fig. 2a). TwoC8orf4-knockout (KO) cell strains were established and C8orf4 was completely deleted in these two strains. C8orf4 deletion dramatically enhanced oncosphere formation (Fig. 2b). We co-stained SOX9, a widely used progenitor marker, and Ki67, a well-known proliferation marker, in C8orf4 KO sphere cells. We found that SOX9 was strongly stained in C8orf4 KO sphere cells (Supplementary Fig. 2a). In contrast, Ki67 staining was not significantly altered in C8orf4 KO sphere cells versus WT sphere cells. We also digested sphere cells and examined the SOX9 and Ki67 expression by flow cytometry. Similar results were achieved (Supplementary Fig. 2b). Importantly, through serial passage of CSC sphere cells, similar observations were obtained in the fourth generation oncosphere assay (Supplementary Fig. 2c,d). These data suggest that C8orf4 is involved in the regulation of liver CSC self-renewal.

(not shown)

Figure 2: C8orf4 knockout enhances self-renewal of liver CSCs.

  • C8orf4-deficient Huh7 cells were established using a CRISPR/Cas9 system. T7 endonuclease I cleavage confirmed the efficiency of sgRNA (left panel, white arrowheads), and C8orf4-knockout efficiency was confirmed by western blot (right panel). Two knockout cell lines were used.  C8KO#1:C8orf4KO#1;  C8KO#2C8orf4KO#2. (bC8orf4-deficient cells enhanced sphere formation activity. Calculated ratios are shown in the right panel. (cC8orf4-deficient or WT Huh7 cells (1 × 106) were injected into BALB/c nude mice. Tumor sizes were observed every 5 days. (dC8orf4 deficiency enhances tumor-initiating capacity. Diluted cell numbers of Huh7 cells were implanted into BALB/c nude mice for tumor initiation. Percentages of tumor-formation mice were calculated (left panel), and frequency of tumor-initiating cells was calculated using extreme limiting dilution analysis (right panel). Error bars represent the 95% confidence intervals of the estimation. (e) Expression levels of CD13 andCD133 were analyzed in C8orf4-knockout Huh7 cells. (f) C8orf4 was silenced in HCC primary cells and C8orf4 depletion enhanced sphere formation activity. Calculated ratios are shown at the right panel. Three HCC specimens obtained similar results. (g) C8orf4-overexpressing Huh7 cells were established (left panel). C8orf4-overexpressing Huh7 cells and control Huh7 cells were cultured for sphere formation. (h,i) Xenograft tumor growth (h) and frequency of tumor-initiating cells (i) for C8orf4-overexpressing Huh7 cells were analyzed as c,d. (j) C8orf4 overexpression reduces expression of CD133 and CD13 in Huh7 cells. (k) C8orf4 was transfected in HCC primary cells and cultured for sphere formation. Three HCC patient samples obtained similar results. Scale bars: b,f,g,k, 500 μm. Student’s t-test was used for statistical analysis,    *P<0.05; **P<0.01; ***P<0.001, data are shown as mean ± standard deviation. Data represent at least three independent experiments. oeC8orf4, overexpression of C8orf4; oeVec, overexpression vector.

In addition, C8orf4-deficient Huh7 cells overtly increased xenograft tumour growth (Fig. 2c). We then performed sphere formation and digested oncospheres formed by C8orf4-deficient or WT cells into single-cell suspension, then subcutaneously implanted 1 × 104, 1 × 103, 1 × 102 and 10 cells into BALB/c nude mice. Tumour formation was examined for tumour-initiating capacity at the third month. C8orf4 deficiency remarkably enhanced tumour-initiating capacity and liver CSC ratios (Fig. 2d). In addition, C8orf4 deletion significantly enhanced expression levels of the liver CSC markers such as CD13 and CD133 (Fig. 2e). We also silenced C8orf4 in HCC primary cells using a lentivirus infection system and established C8orf4-silenced cells. Two pairs of short hairpin RNA (shRNA) sequences obtained similar knockdown efficiency. C8orf4 knockdown remarkably promoted sphere formation and xenograft tumour growth (Fig. 2f and Supplementary Fig. 2e). These data indicate that C8orf4 deletion potentiates the self-renewal of liver CSCs.
We next overexpressed C8orf4 in Huh7 cells and HCC primary cells using lentivirus infection. We observed that C8orf4 overexpression in Huh7 cells remarkably reduced sphere formation and xenograft tumour growth (Fig. 2g,h). In addition, C8orf4 overexpression remarkably reduced tumour-initiating capacity and expression of liver CSC markers (Fig. 2i,j). Similar results were observed by C8orf4 overexpression in HCC primary cells (Fig. 2k). We tested three HCC samples with similar results. Overall, C8orf4 negatively regulates the maintenance of liver CSC self-renewal and tumour propagation.

C8orf4 suppresses NOTCH2 signaling in liver CSCs

To further determine the underlying mechanism of C8orf4 in the regulation of liver CSCs, we analyzed three major self-renewal signaling pathways, including Wnt/β-catenin, Hedgehog and NOTCH pathways, in C8orf4-deleted Huh7 cells and HCC primary cells. We found that only NOTCH target genes were remarkably upregulated in C8orf4-deficient cells (Fig. 3a), whereasC8orf4 deficiency did not significantly affect the Wnt/β-catenin or the Hedgehog pathway. Given that the NOTCH family receptors have four members, we wanted to determine which NOTCH member was involved in the C8orf4-mediated suppression of liver CSC stemness. We noticed that only NOTCH2 was highly expressed in both Huh7 cells and HCC samples (Fig. 3b). In addition, this result was also confirmed by analysis of NOTCH expression levels derived from Wang’s cohort (GSE14520) and Petel’s cohort (E-TABM-36; ref. 27) (Fig. 3c). Moreover, we analysed expression profiles of C8orf4 and NOTCH target genes using Park’s cohort (GSE36376) and Wurmbach’s cohort (GSE6764; ref. 28). These cohort datasets provided several Notch signaling and its target genes. HEY1NRARP and HES6 genes were highly expressed in HCC tumour tissues (GSE6764; ref. 28), which were further confirmed in HCC samples by real-time PCR (Supplementary Fig. 3a,b). Furthermore, HEY1NRARP and HES6 genes have been reported to be relatively specific NOTCH target genes. We then examined these three genes as the NOTCH2 target genes throughout this study. We found that the C8orf4 expression level was negatively correlated with the expression levels of HEY1 and HES6, suggesting that C8orf4 inhibited NOTCH signaling in HCC patients (Fig. 3d). Finally these results were further confirmed in HCC samples by qRT-PCR (Fig. 3e). To further explore the activation status of NOTCH2 signaling in liver CSCs, we examined the expression levels of NOTCH downstream target genes in oncospheres and CD13+CD133+ cells derived from both Huh7 cells and HCC cells. We observed that NOTCH target genes were highly expressed in liver CSCs (Fig. 3f,g). These observations were verified by immunoblotting (Fig. 3h). In addition, the expression levels of NRARPHES6 and HEY1 were positively related to the expression levels of EpCAM and CD133 derived from Zhang’s cohort (GSE25097; ref. 29) and Wang’s cohort (GSE14520; Supplementary Fig. 3c,d). These data suggest that the NOTCH2 signaling plays a critical role in the maintenance of self-renewal of liver CSCs.

(not shown)

Figure 3: C8orf4 suppresses NOTCH2 signaling in liver CSCs.

(aC8orf4 deficiency or depletion activates NOTCH signaling. The indicated major stemness signalling pathways were analysed in C8orf4-knockout Huh7 cells (left panel) and C8orf4-silenced primary cells of HCC samples (right panel). (b) Four receptor members of NOTCH family were examined in both Huh7 cells (left panel) and 29 pairs of HCC samples (right panel). (cNOTCH receptors were analyzed from Wang’s cohort (left panel) and Petel’s cohort (right panel) datasets. (dHEY1 and HES6 were highly expressed in C8orf4low samples by analysis of Park’s cohort (upper panel) and Wurmbach’s cohort (lower panel). (e) Expression levels of HEY1 and HES6 along with C8orf4 were analysed in HCC samples by qRT–PCR. (f,g) Expression levels of NRARPHEY1 and HES6 in spheres generated by Huh7 cells and HCC primary cells (f) and in CD13+CD133+ cells sorted from Huh7 cells and HCC primary cells (g). Non-sphere: Huh7 cells or HCC cells that failed to form spheres. (h) HEY1, HES6 and NRARP expression in sphere and non-sphere cells was detected by immunoblotting. β-actin was used as a loading control. For c,d, data are shown as box and whisker plot. Box: interquartile range (IQR); horizontal line within box: median; whiskers: 5–95 percentile. For a,b,f,g, Student’s t-test was used for statistical analysis, *P<0.05;**P<0.01; ***P<0.001, data are shown as mean ± standard deviation. Data are representative of at least three independent experiments.

C8orf4 interacts with NOTCH2 that is critical for liver CSCs

On ligand–receptor binding, the NOTCH receptor experiences a proteolytic cleavage by metalloprotease and γ-secretase, releasing a NOTCH extracellular domain (NECD) and a NOTCH intracellular domain (NICD), respectively30. Then the active NICD undergoes nuclear translocation and activates the expression of NOTCH downstream target genes31.Then we constructed the NOTCH2 extracellular domain (N2ECD) and intracellular domain (N2ICD) and examined the interaction with C8orf4 via a yeast two-hybrid approach. Interestingly, we found that C8orf4 interacted with N2ICD, but not N2ECD (Fig. 4a). The interaction was validated by co-immunoprecipitation (Fig. 4b). Through domain mapping, the ankyrin repeat domain of NOTCH2 was essential and sufficient for its association with C8orf4 (Fig. 4c). Taken together, C8orf4 interacts with the N2ICD domain of NOTCH2.

Figure 4: C8orf4 interacts with NOTCH2 that is required for the self-renewal maintenance of liver CSCs.

C8orf4 interacts with NOTCH2 that is required for the self-renewal maintenance of liver CSCs

C8orf4 interacts with NOTCH2 that is required for the self-renewal maintenance of liver CSCs

(a) C8orf4 interacts with N2ICD. Yeast strain AH109 was co-transfected with Gal4 DNA-binding domain (BD) fused C8orf4 and Gal4-activating domain (AD) fused N2ICD. p53 and large T antigen were used as a positive control. (b) Recombinant Flag-N2ICD and GFP–C8orf4 were incubated for co-immunoprecipitation. (c) The ankyrin repeat AR domain is essential and sufficient for the interaction of C8orf4 with N2ICD. Various N2ICD truncation constructs were co-transfected with GFP–C8orf4 for domain mapping. NLS: nuclear location signal. (d) NOTCH2 was knocked down in Huh7 cells and detected by qRT–PCR and immunoblotting. (e) NOTCH2-silenced Huh7 cells were cultured for sphere formation assays. Two pairs of shRNAs against NOTCH2 obtained similar results. (f,g) Xenograft tumor growth (f) and frequency of tumor-initiating cells (g) for NOTCH2-silenced Huh7 cells were analyzed. (h) NOTCH2 was silenced in HCC primary cells and NOTCH2 depletion declined sphere formation activity. Three HCC specimens obtained similar results. (i) Sphere formation capacity was examined in differently treated HCC primary cells. (j) HCC primary cells were treated with indicated lentivirus and implanted into BALB/c nude mice for xenograft tumor growth assays. Scale bars: e,h,i, 500 μm, Student’s t-test was used for statistical analysis, *P<0.05; **P<0.01; ***P<0.001, data are shown as mean ± standard deviation. Data are representative of at least three independent experiments. IB, immunoblotting; IP, immunoprecipitation; NS, not significant.

To further verify the role of NOTCH2 in the maintenance of liver CSC self-renewal, we knocked down NOTCH2 in Huh7 cells and established stably depleted cell lines by two pairs of NOTCH2 shRNAs (Fig. 4d). NOTCH2 knockdown dramatically reduced sphere formation (Fig. 4e), as well as attenuated xenograft tumor growth and tumor-initiating capacity (Fig. 4f,g). Similar observations were achieved in NOTCH2-depleted HCC primary cells (Fig. 4h). In addition, we found that simultaneous knockdown of NOTCH2 and overexpression of C8orf4 failed to reduce sphere formation capacity compared with individual knockdown of NOTCH2 (Fig. 4i), suggesting that NOTCH2 and C8orf4 affected sphere formation through the same pathway. Meanwhile, C8orf4 knockdown failed to rescue the sphere formation ability of NOTCH2-depleted HCC primary cells (Fig. 4i). Similar observations were obtained in Huh7 cells (Supplementary Fig. 4). Finally, NOTCH2 depletion in C8orf4-silenced Huh7 cells or HCC primary cells also abrogated the C8orf4 depletion-mediated enhancement of xenograft tumor growth (Fig. 4j), suggesting that C8orf4 acted as upstream of NOTCH2 signaling. These data suggest that C8orf4 suppresses the liver CSC stemness through inhibiting the NOTCH2 signaling pathway.

C8orf4 blocks nuclear translocation of N2ICD

As shown in Fig. 1g, C8orf4 was mainly localized in the cytoplasm in tumor cells of HCC samples. To confirm these observations, we stained C8orf4 in several HCC cell lines and noticed that C8orf4 also resided in the cytoplasm of Huh7 cells and Hep3B cells (Fig. 5a and Supplementary Fig. 5a). These results were further validated by cellular fractionation (Fig. 5b). Importantly, C8orf4 KO led to nuclear translocation of N2ICD (Fig. 5c). In addition, we also examined the intracellular location of N2ICD in Huh7 spheres. We found that C8orf4 deletion caused complete nuclear translocation of N2ICD in oncosphere cells (Fig. 5d,e), while N2ICD was mainly located in the cytoplasm of WT oncosphere cells. However, we found that C8orf4 KO did not affect subcellular localization of β-catenin (Supplementary Fig. 5b,c). Through luciferase assays, C8orf4 transfection did not significantly influence promoter transcription activity of Wnt target genes such as TCF1, LEF and SOX4 (Supplementary Fig. 5d). These data indicate that C8orf4 resides in the cytoplasm of HCC cells and inhibits nuclear translocation of N2ICD.

C8orf4 deletion causes the nuclear translocation of N2ICD

C8orf4 deletion causes the nuclear translocation of N2ICD

Figure 5: C8orf4 deletion causes the nuclear translocation of N2ICD.

(a) C8orf4 resides in the cytoplasm of Huh7 cells. Huh7 cells were permeabilized and stained with anti-C8orf4 antibody, then counterstained with PI for confocal microscopy. (b) Cellular fractionation was performed and detected by immunoblotting. (c,d) C8orf4 knockout causes the nuclear translocation of N2ICD. C8orf4-deficient Huh7 cells (c) and sphere cells (d) were permeabilized and stained with anti-C8orf4 and anti-N2ICD antibodies, then counterstained with DAPI followed by confocal microscopy. (e) Cellular fractionation was performed in C8orf4-deficient sphere and WT sphere cells followed by immunoblotting. (f) C8orf4-deficient Huh7 cells were implanted into BALB/c nude mice. Xenograft tumors were analyzed by immunohistochemical staining. Red arrowheads denote nuclear translocation of N2ICD. (g) C8orf4-overexpressing Huh7 cells were permeabilized for immunofluorescence staining. (h) Cellular fractionation was performed in C8orf4-overexpressing Huh7 cells for immunoblotting. (i,j) C8orf4 was overexpressed in N2ICD-overexpressing Huh7 cells followed by immunofluorescence staining (i) and immunoblotting (j). (k) NOTCH target genes were measured in cells treated as in i by real-time PCR. Scale bars: a,c,d,g,i, 10 μm; f, 40 μm. Student’s t-test was used for statistical analysis, **P<0.01;***P<0.001, data are shown as mean±s.d.. Data represent at least three independent experiments.

To further determine whether C8orf4 inhibits the NOTCH2 signaling in the propagation of xenograft tumors, we examined the distribution of N2ICD and NOTCH2 target gene activation inC8orf4-deficient xenograft tumor tissues. We found that C8orf4-deficient tumors displayed much more nuclear translocation of N2ICD compared with WT tumors (Fig. 5f). Expectedly, C8orf4-deficient tumors showed elevated expression levels of NOTCH2 target genes such as HEY1, HES6 and NRARP (Supplementary Fig. 5e). Furthermore, C8orf4 overexpression blocked the nuclear translocation of N2ICD (Fig. 5g,h). Consequently, C8orf4-overexpressing tumors showed much less N2ICD nuclear translocation and reduced expression levels of NOTCH2 target genes compared with control tumors (Supplementary Fig. 5f,g). Of note, C8orf4 overexpression in N2ICD-overexpressing Huh7 cells still blocked nuclear translocation of N2ICD (Fig. 5i,j). Consequently, C8orf4 overexpression abolished the activation of Notch2 signaling (Fig. 5k). These results suggest that C8orf4 deletion causes the nuclear translocation of N2ICD leading to activation of NOTCH2 signaling.

NOTCH2 signalling is required for the stemness of liver CSCs

To further verify the role of NRARP and HEY1 in the maintenance of liver CSC self-renewal, we knocked down these two genes in Huh7 cells and established stably depleted cell lines by two pairs of shRNAs. As expected, NRARP knockdown dramatically reduced sphere formation (Fig. 6a,b). NRARP knockdown also attenuated tumor-initiating capacity and liver CSC ratios (Fig. 6c). Similar results were achieved in NRARP-silenced HCC primary cells (Fig. 6d,e). Similarly, HEY1 silencing remarkably reduced sphere formation derived from Huh7 and HCC primary cells (Fig. 6f–i), as well as declined xenograft tumor growth and tumor-initiating capacity (Supplementary Fig. 6a,b). In sum, NOTCH2 signaling is required for the maintenance of liver CSC self-renewal.

(not shown)

Figure 6: Depletion of NRARP and HEY1 impairs stemness of liver CSCs.

(a,b) NRARP-silenced Huh7 cells were established (a) and showed reduced sphere formation capacity (b). Two pairs of shRNAs against NRARP obtained similar results. (c) NRARP-silenced Huh7 cells decline tumour-initiating capacity (left panel) and reduce liver CSC frequency (right panel). Error bars represent the 95% confidence intervals of the estimation. (d,e) NRARP was knocked down in HCC primary cells (d) and sphere formation was detected (e). Three HCC samples were tested with similar results. (f,g) HEY1-silenced Huh7 cells were established (f) and sphere formation was assayed (g). Two pairs of shRNAs against HEY1 obtained similar results. (h,i) HEY1 was knocked down in HCC primary cells (h) and HEY1 depletion impaired sphere formation capacity (i). Three HCC samples were tested with similar results. Scale bars: b,e,g,i, 500 μm. For a,b,di, Student’s t-test was used for statistical analysis, *P<0.05; **P<0.01;  ***P<0.001, data are shown as mean ± standard deviation. Data are representative of at least three independent experiments.

NOTCH2 signaling is correlated with HCC severity

As shown above, the NOTCH2 signaling was highly activated in liver CSCs and involved in the regulation of liver CSC stemness. We further examined the relationship of NOTCH2 signaling with the progression of HCC. First, we analyzed NOTCH2 activation levels in HCC tumor tissues and peri-tumor tissues derived from Park’s cohort (GSE36376). We observed that HEY1HES6 and NRARP were highly expressed in the tumor tissues of HCC patients (Fig. 7a). Consistently, high expression levels of HEY1HES6 and NRARP in HCC tumors were validated by Zhang’s cohort (GSE25097) (Fig. 7b). Importantly, high expression of these three genes was confirmed in HCC samples through quantitative RT–PCR (Fig. 7c), as well as immunoblotting (Fig. 7d). To confirm a causative link between low C8orf4 expression level and nuclear N2ICD, we examined 93 HCC samples (31 peri-tumor, 37 early stage of HCC patients and 25 advanced stage of HCC patients) with immunohistochemistry staining. We observed that nuclear staining of N2ICD appeared in ~10% tumor cells in the majority of early HCC patients we tested (Fig. 7e,f). In advanced HCC patients, nuclear staining of N2ICD in tumor cells increased to ~30% in almost all the advanced HCC patients we examined. Consequently, HEY1 staining existed in ~10% tumor cells with scattered distribution and increased to 30% tumor cells in the advanced HCC patients (Fig. 7e). Consistently, low expression of C8orf4 was well correlated with activation of NOTCH2 signaling (Fig. 7e,f).

NOTCH2 activation levels are consistent with clinical severity and prognosis of HCC patients

NOTCH2 activation levels are consistent with clinical severity and prognosis of HCC patients

Figure 7: NOTCH2 activation levels are consistent with clinical severity and prognosis of HCC patients.

(a,b) NOTCH target genes were highly expressed in HCC tumour tissues derived from Park’s cohort (a) and Zhang’s cohort (b). (c) High expression levels of NOTCH target genes in HCC tumor tissues were verified by qRT–PCR. (d) HEY1 expression in HCC tumor tissues was detected by western blot. (e) IHC staining for N2ICD, C8orf4 and HEY1. These images represent 93 HCC samples. Scale bars, 50 μm. (f) IHC images were calculated using Image-Pro Plus 6. (g) Expression levels of NOTCH target genes were elevated in HCC tumors and advanced HCC patients derived from Wang’s cohort. (hHEY1 expression level was positively correlated with prognosis prediction of HCC patients analyzed by Petel’s cohort and Wang’s cohort. HCC samples were divided into two groups according to HEY1 expression levels followed by Kaplan–Meier survival analysis. For ac, data are shown as box and whisker plot, Box: interquartile range (IQR); horizontal line within box: median; whiskers: 5–95 percentile. For f,g, Student’s t-test was used for statistical analysis, *P<0.05; **P<0.01; ***P<0.001; data are shown as mean ± standard deviation. Experiments were repeated at least three times. aHCC, advanced HCC; CL, cirrhosis liver; eHCC, early HCC; IL, inflammatory liver; NL, normal liver; NS, not significant.

Serial passages of colonies or sphere formation in vitro, as well as transplantation of tumor cells, are frequently used to assess the long-term self-renewal capacities of CSCs32. We used HCC primary cells for serial passage growth in vitro and tested the expression levels of C8orf4HEY1 and SOX9. We found that C8orf4 expression was gradually reduced over serial passages in oncosphere cells (Supplementary Fig. 7a). Consequently, the expression of NOTCH2 targets such as HEY1 and SOX9 was gradually increased in oncosphere cells during serial passages (Supplementary Fig. 7b). In addition, N2ICD nuclear translocation appeared in oncosphere cells with high expression of HEY1 plus low expression of C8orf4 (termed as C8orf4/N2ICDnuc/HEY1+cells) (Supplementary Fig. 7c). These data suggest that the C8orf4/N2ICDnuc/HEY1+ fraction cells represent a subset of liver CSCs.

Through analyzing Wang’s cohort (GSE54238), we noticed that the NOTCH2 activation levels were positively correlated with the development and progression of HCC (Fig. 7g). By contrast, the NOTCH2 pathway was not activated in inflammation liver, cirrhosis liver and normal liver (Fig. 7f). Consistently, similar observations were achieved by analysis of Zhang’s cohort (GSE25097) (Supplementary Fig. 7d). In addition, the NOTCH2 activation levels were consistent with clinicopathological stages of HCC patients derived from Wang’s cohort (GSE14520) (Supplementary Fig. 7e). Finally, HCC patients with higher expression of HEY1 displayed worse prognosis derived from Petel’s cohort (E-TABM-36) and Wang’s cohort (GSE14520) (Fig. 7h). These two cohorts (E-TABM-36 and GSE14520) have survival information of HCC patients. Taken together, the NOTCH2 activation levels in tumor tissues are consistent with clinical severity and prognosis of HCC patients.


CSC have been identified in many solid tumors, including breast, lung, brain, liver, colon, prostate and bladder cancers4633. CSCs have similar characteristics associated with normal tissue stem cells, including self-renewal, differentiation and the ability to form new tumors. CSCs may be responsible for cancer relapse and metastasis due to their invasive and drug-resistant capacities34. Thus, targeting CSCs may become a promising therapeutic strategy to deadly malignancies3536. However, it remains largely unknown about hepatic CSC biology. In this study, we used CD13 and CD133 to enrich CD13+CD133+
subpopulation cells as liver CSCs. Based on analysis of several online-available HCC transcriptome datasets, we found that C8orf4 is weakly expressed in HCC tumors as well as in CD13+CD133+ liver CSCs. NOTCH2 signaling is required for the maintenance of liver CSC self-renewal. C8orf4 resides in the cytoplasm of tumor cells and interacts with N2ICD, blocking the nuclear translocation of N2ICD. Lower expression of C8orf4 causes nuclear translocation of N2ICD that activates NOTCH2 signaling in liver CSCs. NOTCH2 activation levels are consistent with clinical severity and prognosis of HCC patients. Therefore, C8orf4 negatively regulates self-renewal of liver CSCs via suppression of NOTCH2 signaling.

Elucidating signaling pathways that maintains self-renewal of liver CSCs is pivotal for the understanding of hepatic CSC biology and the development of novel therapies against HCC. Several signaling pathways, such as Wnt/β-catenin, transforming growth factor-beta, AKT and STAT3 pathways, have been defined to be implicated in the regulation of liver CSCs37. Not surprisingly, some liver CSC subsets and normal tissue stem cells may share core regulatory genes and common signaling pathways. The NOTCH signaling pathway plays an important role in development via cell-fate determination, proliferation and cell survival3839. The NOTCH family receptors contain four members in mammals (NOTCH1–4), which are activated by binding to their corresponding ligands. A large body of evidence provides that NOTCH signaling is implicated in carcinogenesis40. However, the role of NOTCH signaling in liver cancer is controversial. A previous study reported that NOTCH1 signaling suppresses tumor growth of HCC41. Recently, several reports showed that NOTCH signaling enhances liver tumor initiation424344. Importantly, a recent study showed that various NOTCH receptors have differential functions in the development of liver cancer45. Here we demonstrate that NOTCH2 signaling is activated in HCC tumor tissues and liver CSCs, which is required for the maintenance of liver CSC self-renewal.

C8orf4, also known as TC1, was originally cloned from a papillary thyroid cancer16, 46. The copy number variations of C8orf4 are associated with acute myeloid leukemia and other hematological malignancies19, 47. C8orf4 has been reported to be implicated in various cancers. C8orf4 was highly expressed in thyroid cancer, gastric cancer and breast cancer16, 20, 46. C8orf4 has been reported to enhance Wnt/β-catenin signaling in cancer cells that is associated with poor prognosis20, 21. However, C8orf4 is downregulated in colon cancer48. In this study, we show that C8orf4 is weakly expressed in HCC tumor tissues and liver CSCs. Our observations were confirmed by two HCC cohort datasets. Importantly, C8orf4 negatively regulates the NOTCH2 signaling to suppress the self-renewal of liver CSCs. Therefore, C8orf4 may exert distinct functions in the regulation of various malignancies.

NOTCH receptors consist of noncovalently bound extracellular and transmembrane domains. Once binding with membrane-bound Delta or Jagged ligands, the NOTCH receptors undergoes a proteolytic step by metalloprotease and γ-secretase, generating NECD and NICD fragments11, 31. The NICD, a soluble fragment, is released in the cytoplasm on proteolysis. Then the NICD translocates to the nucleus and binds to the transcription initiation complex, leading to activation of NOTCH-associated target genes49. However, it is largely unclear how the NICD is regulated during NOTCH signaling activation. Here we show that N2ICD binds to C8orf4 in the cytoplasm of liver non-CSC tumor cells, which impedes the nuclear translocation of N2ICD. By contrast, in liver CSCs, lower expression of C8orf4 causes the nuclear translocation of N2ICD, leading to activation of NOTCH signaling.

CSCs or tumour-initiating cells, behave like tissue stem cells in that they are capable of self-renewal and of giving rise to hierarchical organization of heterogeneous cancer cells4. Thus, CSCs harbour the stem cell properties of self-renewal and differentiation. Actually, the CSC model cannot account for tumorigenesis in all tumours. CSCs could undergo genetic evolution, and the non-CSCs might switch to CSC-like cells4. These results highlight the dynamic nature of CSCs, suggesting that the clonal evolution and CSC models can act in concert for tumorigenesis. Furthermore, low C8orf4 expression in tumor cells results in overall Notch2 activation, which then may have more of a progenitor signature and be more aggressive. These cells would likely have a growth advantage in non-adherent conditions and express many of the stemness markers. The dynamic nature of CSCs or persistent NOTCH2 activation may contribute to the high number of C8orf4/N2ICDnuc/HEY1+ cells in advanced HCC tumors and correlation in the patient cohort.

A recent study showed that NOTCH2 and its ligand Jag1 are highly expressed in human HCC tumors, suggesting activation of NOTCH2 signaling in HCC45. In addition, inhibiting NOTCH2 or Jag1 dramatically reduces tumor burden and growth. However, suppression of NOTCH3 has no effect on tumor growth. Dill et al.43 reported that Notch2 is an oncogene in HCC. Notch2-driven HCC are poorly differentiated with a high expression level of the progenitor marker Sox9, indicating a critical role of Notch2 signaling in liver CSCs. Here we found that NOTCH2 and its target genes such as NRARP, HEY1 and HES6 are highly expressed in HCC samples. In addition, depletion of NRARP and HEY1 impairs the stemness maintenance of liver CSCs and tumor propagation. Moreover, the expression levels of NRARP, HEY1 and HES6 in tumors are positively correlated with clinical severity and prognosis of HCC patients. Finally, the NOTCH2 activation status is positively related to the clinicopathological stages of HCC patients. Altogether, C8orf4 and NOTCH2 signaling can be detected for the diagnosis and prognosis prediction of HCC patients, as well as used as targets for eradicating liver CSCs for future therapy. Quantifying the Landscape for Development and Cancer from a Core Cancer Stem Cell Circuit

The authors developed a landscape and path theoretical framework to investigate the global natures and dynamics for a core cancer stem cell gene network. The landscape exhibits four basins of attraction, representing cancer stem cell, stem cell, cancer and normal cell states. They also uncovered certain key genes and regulations responsible for determining the switching between different states. [Cancer Res]

Chunhe Li and Jin Wang
Cancer Res May 13, 2015; 75(10).

Cancer presents a serious threat to human health. The understanding of the cell fate determination during development and tumor genesis remains challenging in current cancer biology. It was suggested that cancer stem cell (CSC) may arise from normal stem cells, or be transformed from normal differentiated cells. This gives hints on the connection between cancer and development. However, the molecular mechanisms of these cell type transitions and the CSC formation remain elusive. We quantified landscape, dominant paths and switching rates between cell types from a core gene regulatory network for cancer and development. Stem cell, CSC, cancer, and normal cell types emerge as basins of attraction on associated landscape. The dominant paths quantify the transition processes among CSC, stem cell, normal cell and cancer cell attractors. Transition actions of the dominant paths are shown to be closely related to switching rates between cell types, but not always to the barriers in between, due to the presence of the curl flux. During the process of P53 gene activation, landscape topography changes gradually from a CSC attractor to a normal cell attractor. This confirms the roles of P53 of preventing the formation of CSC, through suppressing self-renewal and inducing differentiation. By global sensitivity analysis according to landscape topography and action, we identified key regulations determining cell type switchings and suggested testable predictions. From landscape view, the emergence of the CSCs and the associated switching to other cell types are the results of underlying interactions among cancer and developmental marker genes. This indicates that the cancer and development are intimately connected. This landscape and flux theoretical framework provides a quantitative way to understand the underlying mechanisms of CSC formation and interplay between cancer and development. Major Findings: We developed a landscape and path theoretical framework to investigate the global natures and dynamics for a core cancer stem cell gene network. Landscape exhibits four basins of attraction, representing CSC, stem cell, cancer and normal cell states. We quantified the kinetic rate and paths between different attractor states. We uncovered certain key genes and regulations responsible for determining the switching between different states. IMP3 Promotes Stem-Like Properties in Triple-Negative Breast Cancer by Regulating SLUG

Scientists observed that insulin-like growth factor-2 mRNA binding protein 3 (IMP3) expression is significantly higher in tumor initiating than in non-tumor initiating breast cancer cells and demonstrated that IMP3 contributes to self-renewal and tumor initiation, properties associated with cancer stem cells. [Oncogene]

S Samanta, H Sun, H L Goel, B Pursell, C Chang, A Khan, et al.
 , (18 May 2015) |

IMP3 (insulin-like growth factor-2 mRNA binding protein 3) is an oncofetal protein whose expression is prognostic for poor outcome in several cancers. Although IMP3 is expressed preferentially in triple-negative breast cancer (TNBC), its function is poorly understood. We observed that IMP3 expression is significantly higher in tumor initiating than in non-tumor initiating breast cancer cells and we demonstrate that IMP3 contributes to self-renewal and tumor initiation, properties associated with cancer stem cells (CSCs). The mechanism by which IMP3 contributes to this phenotype involves its ability to induce the stem cell factor SOX2. IMP3 does not interact with SOX2 mRNA significantly or regulate SOX2 expression directly. We discovered that IMP3 binds avidly to SNAI2 (SLUG) mRNA and regulates its expression by binding to the 5′ UTR. This finding is significant because SLUG has been implicated in breast CSCs and TNBC. Moreover, we show that SOX2 is a transcriptional target of SLUG. These data establish a novel mechanism of breast tumor initiation involving IMP3 and they provide a rationale for its association with aggressive disease and poor outcome. Type II Transglutaminase Stimulates Epidermal Cancer Stem Cell Epithelial-Mesenchymal Transition

Researchers investigated the role of type II transglutaminase (TG2) in regulating epithelial mesenchymal transition (EMT) in epidermal cancer stem cells. They showed that TG2 knockdown or treatment with TG2 inhibitor, resulted in a reduced EMT marker expression, and reduced cell migration and invasion. [Oncotarget]

ML Fisher, G Adhikary, W Xu, C Kerr, JW Keillor, RL Ecker
Oncotarget May 08, 2015;

Type II transglutaminase (TG2) is a multifunctional protein that has recently been implicated as having a role in ECS cell survival. In the present study we investigate the role of TG2 in regulating epithelial mesenchymal transition (EMT) in ECS cells. Our studies show that TG2 knockdown or treatment with TG2 inhibitor, results in a reduced EMT marker expression, and reduced cell migration and invasion. TG2 has several activities, but the most prominent are its transamidase and GTP binding activity. Analysis of a series of TG2 mutants reveals that TG2 GTP binding activity, but not the transamidase activity, is required for expression of EMT markers (Twist, Snail, Slug, vimentin, fibronectin, N-cadherin and HIF-1α), and increased ECS cell invasion and migration. This coupled with reduced expression of E-cadherin. Additional studies indicate that NFϰB signaling, which has been implicated as mediating TG2 impact on EMT in breast cancer cells, is not involved in TG2 regulation of EMT in skin cancer. These studies suggest that TG2 is required for maintenance of ECS cell EMT, invasion and migration, and suggests that inhibiting TG2 GTP binding/G-protein related activity may reduce skin cancer tumor survival.

Epidermal squamous cell carcinoma (SCC) is among the most common cancers and the frequency is increasing at a rapid rate [1,2]. SCC is treated by surgical excision, but the rate of recurrence approaches 10% and the recurrent tumors are aggressive and difficult to treat [2]. We propose that human epidermal cancer stem (ECS) cells survive at the site of tumor excision, that these cells give rise to tumor regrowth, and that therapies targeted to kill ECS cells constitute a viable anti-cancer strategy. An important goal in this context is identifying and inhibiting activity of key proteins that are essential for ECS cell survival. Working towards this goal, we have developed systems for propagation of human ECS cells [3]. These cells display properties of cancer stem cells including self-renew and high level expression of stem cell marker proteins [3].

In the present study we demonstrate that ECS cells express proteins characteristic of cells undergoing EMT (epithelial-mesenchymal transition). EMT is a morphogenetic process whereby epithelial cells lose epithelial properties and assume mesenchymal characteristics [4]. The epithelial cells lose cell-cell contact and polarity, and assume a mesenchymal migratory phenotype. There are three types of EMT. This first is an embryonic process, during gastrulation, when the epithelial sheet gives rise to the mesoderm [5]. The second is a growth factor and cytokine-stimulated EMT that occurs at sites of tissue injury to facilitate wound repair [6]. The third is associated with epithelial cancer cell acquisition of a mesenchymal migratory/invasive phenotype. This process mimics normal EMT, but is not as well controlled and coordinated [478]. A number of transcription factors (ZEB1, ZEB2, snail, slug, and twist) that are expressed during EMT suppress expression of epithelial makers, including E-cadherin, desmoplakin and claudins [4]. Snail proteins also activate expression of vimentin, fibronectin and metalloproteinases [4]. Snail factors are not present in normal epithelial cells, but are present in the tumor cells and are prognostic factors for poor survival [4].

An important goal is identifying factors that provide overarching control of EMT in cancer stem cells. In this context, several recent papers implicate type II transglutaminase (TG2) as a regulator of EMT [912]. TG2, the best studied transglutaminase, was isolated in 1957 from guinea pig liver extract as an enzyme involved in the covalent crosslinks proteins via formation of isopeptide bonds [13]. However, subsequent studies reveal that TG2 also serves as a scaffolding protein, regulates cell adhesion, and modulates signal transduction as a GTP binding protein that participates in G protein signaling [14]. TG2 is markedly overexpressed in cancer cells, is involved in cancer development [1518], and has been implicated in maintaining and enhancing EMT in breast and ovarian cancer [10121920]. The G protein function may have an important role in these processes [102123].

In the present manuscript we study the role of TG2 in regulating EMT in human ECS cells. Our studies show that TG2 is highly enriched in ECS cells. We further show that these cells express EMT markers and that TG2 is required to maintain EMT protein expression. TG2 knockdown, or treatment with TG2 inhibitor, reduces EMT marker expression and ECS cell survival, invasion and migration. TG2 GTP binding activity is absolutely required for maintenance of EMT protein expression and EMT-related responses. However, in contrast to breast cancer [910], we show that TG2 regulation of EMT is not mediated via NFκB signaling.

TG2 is required for expression of EMT markers

EMT is a property of tumor stem cells that confers an ability to migrate and invade surrounding tissue [2426]. We first examined whether ECS cells express EMT markers. Non-stem cancer cells and ECS cells, derived from the SCC-13 cancer cell line, were analyzed for expression of EMT markers. Fig. 1A shows that a host of EMT transcriptional regulators, including Twist, Snail and Slug, are increased in ECS cells (spheroid) as compared to non-stem cancer cells (monolayer). This is associated with increased levels of vimentin, fibronectin and N-cadherin, which are mesenchymal proteins, and reduced expression of E-cadherin, an epithelial marker. HIF-1α, an additional marker frequently associated with EMT, is also elevated. We next examined whether TG2 is required to maintain EMT marker expression. SCC-13 cell-derived ECS cells were grown in the presence of control- or TG2-siRNA, to reduce TG2, and the impact on EMT marker level was measured. Fig. 1B shows that loss of TG2 is associated with reduced expression of Twist, Snail, vimentin and HIF-1α. To further assess the role of TG2, we utilized SCC13-Control-shRNA and SCC13-TG2-shRNA2 cell lines. These lines were produced by infection of SCC-13 cells with lentiviruses encoding control- or TG2-specific shRNA. Fig. 1C shows that SCC13-TG2-shRNA2 cells express markedly reduced levels of TG2 and that this is associated with reduced expression of EMT associated transcription factors and target proteins, and increased expression of E-cadherin. To confirm this, we grew SCC13-Control-shRNA and SCC13-TG2-shRNA2 cells as monolayer cultures for immunostain detection of EMT markers. As shown in Fig. 2A, TG2 levels are reduced in TG2-shRNA expressing cells, and this is associated with the anticipated changes in epithelial and mesenchymal marker expression.

Tumor cells that express EMT markers display enhanced migration and invasion ability [2426]. We therefore examined the impact of TG2 reduction on these responses. To measure invasion, control-shRNA and TG2-shRNA cells were monitored for ability to move through matrigel. Fig. 2B shows that loss of TG2 reduces movement through matrigel by 50%. We further show that this is associated with a reduction in cell migration using a monolayer culture wound closure assay. The control cells close the wound completely within 14 h, while TG2 knockdown reduces closure rate (Fig. 2C).

TG2 inhibitor reduces EMT marker expression and EMT functional responses

NC9 is a recently developed TG2-specific inhibitor [2728]. We therefore asked whether pharmacologic inhibition of TG2 suppresses EMT. SCC-13 cells were treated with 0 or 20 μM NC9. Fig. 3A shows that NC9 treatment reduces EMT transcription factor (Twist, Snail, Slug) and EMT marker (vimentin, fibronectin, N-cadherin, HIF-1α) levels. Consistent with these changes, the level of the epithelial marker, E-cadherin, is elevated. Fig. 3B and 3C show that pharmacologic inhibition of TG2 activity also reduces EMT biological response. Invasion (Fig. 3B) and cell migration (Fig. 3C) are also reduced.

Identification of TG2 functional domain required for EMT

We next performed studies to identify the functional domains and activities required for TG2 regulation of EMT. TG2 is a multifunctional enzyme that serves as a scaffolding protein, as a transamidase, as a kinase, and as a GTP binding protein [21]. The two best studied functions are the transamidase and GTP binding/G-protein related activities [21]. Transamidase activity is observed in the presence of elevated intracellular calcium, while GTP binding-related signaling is favored by low calcium conditions (reviewed in [21]). To identify the TG2 activity required for EMT, we measured the ability of wild-type and mutant TG2 to restore EMT in SCC13-TG2-shRNA2 cells, which have reduced TG2 expression (Fig. 4A). SCC13-TG2-shRNA2 cells display reduced expression of EMT markers including Twist, Snail, Slug, vimentin, fibronectin, N-cadherin and HIF-1α, and increased expression of the epithelial maker, E-cadherin, as compared to SCC13-Control-shRNA cells. Expression of wild-type TG2, or the TG2-C277S or TG2-W241A mutants, restores marker expression in SCC13-TG2-shRNA2 cells (Fig. 4A). TG2-C277S and TG2-W241A lack transamidase activity [10,2931]. In contrast, TG2-R580A, which lacks G-protein activity [2931], and TG2-Y516F, which retains only partial G-protein activity [30], do not efficiently restore marker expression. These findings suggest that the TG2 GTP binding function is required for EMT.

We next assayed the ability of the TG2 mutants to restore EMT functional responses-invasion and migration. Fig. 4B4C shows that wild-type TG2, TG2-C277S and TG2-W241A restore the ability of SCC13-TG2-shRNA2 cells to invade matrigel, but TG2-R580A and Y516F are less active. Fig. 4D shows a similar finding for cell migration, in that the TG2-R580A and Y517F mutant are only partially able to restore SCC13-TG2-shRNA2 cell migration. These findings suggest that TG2 GTP binding/G-protein related activity is required for EMT-related migration and invasion by skin cancer cells.

Role of TG2 in regulating EMT in A431 cells

The number of available epidermis-derived squamous cell carcinoma cell lines is limited, and so we compared our findings with A431 cells. A431 cells are squamous cell carcinoma cells established from human vulvar skin. A431 cells were grown as monolayer (non-stem cancer cells) and spheroids (ECS cells) and after 10 d the cells were harvested and assayed for expression of TG2 and EMT makers. Fig. 5A shows that TG2 levels are elevated in ECS cells and that this is associated with increased levels of mesenchymal markers, including Twist, Snail, Slug, vimentin, fibronectin, N-cadherin and HIF-1α. In contrast, E-cadherin levels are reduced. We next examined the impact of TG2 knockdown on EMT marker expression. Fig. 5B shows that mesenchymal markers are globally reduced and E-cadherin level is increased. As a biological endpoint of EMT, we examine the impact of TG2 knockdown on spheroid formation and found that TG2 loss leads to reduced spheroid formation (Fig. 5C). We next examined the impact of NC9 treatment on EMT and found a reduction in EMT markers expression associated with an increase in epithelial (E-cadherin) marker level (Fig. 5D). This loss of EMT marker expression is associated with reduced matrigel invasion (Fig. 5E), reduced spheroid formation (Fig. 5F) and reduced cell migration (Fig. 5G).

Role of NFκB

Previous studies in breast [183236], ovarian cancer [123738], and epidermoid carcinoma [11] indicate that NFκB signaling mediates TG2 impact on EMT. We therefore assessed the role of NFκB in skin cancer cells. As shown in Fig. 6A, the increase in TG2 level observed in ECS cells (spheroids) is associated with reduced NFκB level. In addition, NFκB level is increased in TG2 knockdown cells (Fig. 6B). Thus, increased NFκB is not associated with increased TG2. We next assessed the impact of NFκB knockdown on TG2 control of EMT marker expression. Fig. 6C shows that TG2 is required for increased expression of EMT markers (HIF-1α, snail, twist, N-cadherin, vimentin and fibronectin) and reduced expression of the E-cadherin epithelial marker; however, knockdown of NFκB expression does not interfere with TG2 regulation of these endpoints. We next examined the effect of TG2 knockdown on NFκB and IκBα localization. The fluorescence images in Fig. 6D suggest that TG2 knockdown with TG2-siRNA does not alter the intracellular localization of NFκB or IκBα. This is confirmed by subcellular fractionation assay (Fig. 6E) which compares NFκB level in SCC13-TG2-Control and SCC13-TG2-shRNA2 (TG2 knockdown) cells. We also monitored NFκB subcellular distribution following treatment with NC9, the TG2 inhibitor. Fig. 6F shows that cytoplasmic/nuclear distribution of NFκB is not altered by NC9. Finally, we monitored the impact of TG2 expression on NFκB binding to a canonical NFκB-response element. Increased NFκB binding to the response element is a direct measure of NFκB activity [10]. Fig. 6G shows that overall binding is reduced in nuclear (N) extract prepared from ECS cells (spheroids) as compared to non-stem cancer cells (monolayer), and that NFkB binding, as indicated by gel supershift assay, is also slightly reduced in ECS cell extracts. These findings indicate that NFkB binding is slightly reduced in ECS cells, which are TG2-enriched (Fig. 1A).

We next monitored the role of NFκB on biological endpoints of EMT. Fig. 7A and 7B show that TG2 knockdown reduces migration through matrigel, but NFκB knockdown has no impact. Likewise, TG2 knockdown reduces wound closure, but NFκB knockdown does not. These findings suggest that NFκB does not mediate the pro-EMT actions of TG2 in epidermal squamous cell carcinoma.

The metastatic cascade, from primary tumor to metastasis, is a complex process involving multiple pathways and signaling cascades [3941]. Cells that complete the metastatic cascade migrate away from the primary tumor through the blood to a distant site and there form a secondary tumor. Identifying the mechanisms that allow cells to survive this journey and form secondary tumors is an important goal. The processes involved in epithelial-mesenchymal transition (EMT) are important cancer therapy targets, as EMT is associated with enhanced cancer cell migration and stem cell self-renewal. EMT regulators, including Snail, Twist, Slug, are increased in expression in EMT and control expression of genes associated with the EMT phenotype [42].

TG2 is required for EMT

We have characterized a population of ECS cells derived from epidermal squamous cell carcinoma [3]. The present studies show that these cells, which display enhanced migration and invasion, possess elevated levels of TG2. Moreover, these cells are enriched in expression of transcription factors associated with EMT (Snail, Slug, and Twist, HIF-1α) as well as mesenchymal structural proteins including vimentin, fibronectin and N-cadherin. Consistent with a shift to mesenchymal phenotype, E-cadherin, an epithelial marker, is reduced in level. Additional studies show that TG2 knockdown results in a marked reduction in EMT marker expression and that this is associated with reduced ability of the cells to migrate to close a scratch wound and reduced movement in matrigel invasion assays. We also examined the impact of treatment with a TG2 inhibitor. NC9 is an irreversible active site inhibitor of TG2, that locks the enzyme in an open conformation [284345]. NC9 treatment of ECS cells results in decreased levels of Snail, Slug and Twist. These transcription factors suppress E-cadherin expression [46] and their decline in level is associated with increased levels of E-cadherin. NC9 inhibition of TG2 also reduces expression of vimentin, fibronectin and N-cadherin, and these changes are associated with reduced cell migration and reduced invasion through matrigel.

(Figures are not shown)

We also examined the role of TG2 in A431 squamous cell carcinoma cells derived from the vulva epithelium. TG2 is elevated in A431-derived ECS cells, as are EMT markers, and knockdown of TG2, with TG2-siRNA, reduces EMT marker expression and spheroid formation. Studies with NC9 indicate that NC9 inhibits A431 spheroid formation, EMT, migration and invasion. These studies indicate that TG2 is also required for EMT and migration and invasion in A431 cells. Based on these findings we conclude that TG2 is essential for EMT, migration and invasion, and is likely to contribute to metastasis in squamous cell carcinoma.

TG2 GTP binding activity is required for EMT

TG2 is a multifunctional enzyme that can act as a transamidase, GTP binding protein, protein disulfide isomerase, protein kinase, protein scaffold, and DNA hydrolase [21294447]. The two most studied functions are the transamidase and GTP binding functions [294447]. To identify the TG2 activity responsible for induction of EMT, we studied the ability of TG2 mutants to restore EMT in SCC13-TG2-shRNA2 cells, which express low levels of TG2 and do not express elevated levels of EMT markers or display EMT-related biological responses. These studies show that wild-type TG2 restores EMT marker expression and the ability of the cells to migrate on plastic and invade matrigel. TG2 mutants that retain GTP binding activity (TG2-C277S and TG2-W241A) also restore EMT. In contrast, TG2-R580A, which lacks GTP binding function, does not restore EMT. This evidence suggests that the GTP binding function is essential for TG2 induction of the EMT phenotype in ECS cells. Recent reports suggest that the TG2 is important for maintenance of stem cell survival in breast [91017] and ovarian [123848] cancer cells. Moreover, our findings are in agreement of those of Mehta and colleagues who reported that the TG2 GTP binding function, but not the crosslinking function, is required for TG2 induction of EMT in breast cancer cells [10].

TG2, NFκB signaling and EMT

To gain further insight into the mechanism of TG2 mediated EMT, we examined the role of NFκB. NFκB has been implicated as mediating EMT in breast, ovarian, and pancreatic cancer; however, NFκB may have a unique role in epidermal squamous cell carcinoma. In keratinocytes, NFκB has been implicated in keratinocyte dysplasia and hyperproliferation [49]. However, inhibition of NFκB function has also been shown to predispose murine epidermis to cancer [50]. Here we show that TG2 levels are elevated and NFκB levels are reduced in ECS cells as compared to non-stem cancer cells, and that TG2 knockdown is associated with increased NFκB level. In addition, TG2 knockdown, or inhibition of TG2 by treatment with NC9, does not altered the nuclear/cytoplasmic distribution of NFκB. We further show that elevated levels of TG2 in spheroid culture results in a slight reduction in NFκB binding to the NFκB response element, as measured by gel mobility supershift assay. These molecular assays strongly suggest that NFκB does not mediate the action of TG2 in epidermal cancer stem cells. Moreover, knockdown of NFκB-p65 in TG2 positive cells does not result in a reduction in Snail, Slug and Twist, or mesenchymal marker proteins expression, and concurrent knockdown of TG2 and NFκB does not reduce EMT marker protein levels beyond that of TG2 knockdown alone. These findings suggest that NFκB is not an intermediary in TG2-stimulated EMT in ECS cells. This is in contrast to the required role of NFκB in mediating TG2 induction of cell survival and EMT in breast cancer cells [183233] and ovarian cancer [123738] and epidermoid carcinoma [11]. CD24+ Ovarian Cancer Cells are Enriched for Cancer Initiating Cells and Dependent on JAK2 Signaling for Growth and Metastasis

Investigators showed that CD24+ and CD133+ cells have increased tumorsphere forming capacity. CD133+ cells demonstrated a trend for increased tumor initiation while CD24+ cells vs CD24– cells, had significantly greater tumor initiation and tumor growth capacity. [Mol Cancer Ther]

D Burgos-OjedaR Wu, K McLean, Yu-Chih Chen, M Talpaz, et al.
Molec Cancer Ther May 12, 2015; 14(5)

Ovarian cancer is known to be composed of distinct populations of cancer cells, some of which demonstrate increased capacity for cancer initiation and/or metastasis. The study of human cancer cell populations is difficult due to long requirements for tumor growth, inter-patient variability and the need for tumor growth in immune-deficient mice. We therefore characterized the cancer initiation capacity of distinct cancer cell populations in a transgenic murine model of ovarian cancer. In this model, conditional deletion of Apc, Pten, and Trp53 in the ovarian surface epithelium (OSE) results in the generation of high grade metastatic ovarian carcinomas. Cell lines derived from these murine tumors express numerous putative stem cell markers including CD24, CD44, CD90, CD117, CD133 and ALDH. We show that CD24+ and CD133+ cells have increased tumor sphere forming capacity. CD133+ cells demonstrated a trend for increased tumor initiation while CD24+ cells vs CD24- cells, had significantly greater tumor initiation and tumor growth capacity. No preferential tumor initiating or growth capacity was observed for CD44+, CD90+, CD117+, or ALDH+ versus their negative counterparts. We have found that CD24+ cells, compared to CD24- cells, have increased phosphorylation of STAT3 and increased expression of STAT3 target Nanog and c-myc. JAK2 inhibition of STAT3 phosphorylation preferentially induced cytotoxicity in CD24+ cells. In vivo JAK2 inhibitor therapy dramatically reduced tumor metastases, and prolonged overall survival. These findings indicate that CD24+ cells play a role in tumor migration and metastasis and support JAK2 as a therapeutic target in ovarian cancer. EpCAM-Antibody-Labeled Noncytotoxic Polymer Vesicles for Cancer Stem Cells-Targeted Delivery of Anticancer Drug and siRNA

Researchers designed and synthesized a novel anti-epithelial cell adhesion molecule (EpCAM)-monoclonal-antibody-labeled cancer stem cells (CSCs)-targeting, noncytotoxic and pH-sensitive block copolymer vesicle as a nano-carrier of anticancer drug and siRNA. [Biomacromolecules]

Jing Chen , Qiuming Liu , Jiangang Xiao , and Jianzhong Du
Biomacromolecules May 19, 2015. (just published)

Cancer stem cells (CSCs) have the capability to initiate tumor, to sustain tumor growth, to maintain the heterogeneity of tumor, and are closely linked to the failure of chemotherapy due to their self-renewal and multilineage differentiation capability with an innate resistance to cytotoxic agents. Herein, we designed and synthesized a novel anti-EpCAM (epithelial cell adhesion molecule)-monoclonal-antibody-labeled CSCs-targeting, noncytotoxic and pH-sensitive block copolymer vesicle as a nano-carrier of anticancer drug and siRNA (to overcome CSCs drug resistance by silencing the expression of oncogenes). This vesicle shows high delivery efficacy of both anticancer drug doxorubicin hydrochloride (DOX∙HCl) and siRNA to the CSCs because it is labeled by the monoclonal antibodies to the CSCs-surface-specific marker. Compared to non-CSCs-targeting vesicles, the DOX∙HCl or siRNA loaded CSCs-targeting vesicles exhibited much better CSCs killing and tumor growth inhibition capabilities with lower toxicity to normal cells (IC50,DOX decreased by 80%), demonstrating promising potential applications in nanomedicine. Survival of Skin Cancer Stem Cells Requires the Ezh2 Polycomb Group Protein

Investigators showed that Ezh2 is required for epidermal cancer stem (ECS) cell survival, migration, invasion and tumor formation, and that this is associated with increased histone H3 trimethylation on lysine 27, a mark of Ezh2 action. They also showed that Ezh2 knockdown or treatment with Ezh2 inhibitors, GSK126 or EPZ-6438, reduced Ezh2 level and activity, leading to reduced ECS cell spheroid formation, migration, invasion and tumor growth. [Carcinogenesis]

G Adhikary, D Grun, S Balasubramanian, C Kerr, J Huang and RL Eckert
Carcinogenesis (2015)

Polycomb group (PcG) proteins, including Ezh2, are important candidate stem cell maintenance proteins in epidermal squamous cell carcinoma. We previously showed that epidermal cancer stem cells (ECS cells) represent a minority of cells in tumors, are highly enriched in Ezh2 and drive aggressive tumor formation. We now show that Ezh2 is required for ECS cell survival, migration, invasion and tumor formation, and that this is associated with increased histone H3 trimethylation on lysine 27, a mark of Ezh2 action. We also show that Ezh2 knockdown or treatment with Ezh2 inhibitors, GSK126 or EPZ-6438, reduces Ezh2 level and activity, leading to reduced ECS cell spheroid formation, migration, invasion and tumor growth. These studies indicate that epidermal squamous cell carcinoma cells contain a subpopulation of cancer stem (tumor-initiating) cells that are enriched in Ezh2, that Ezh2 is required for optimal ECS cell survival and tumor formation, and that treatment with Ezh2 inhibitors may be a strategy for reducing epidermal cancer stem cell survival and suppressing tumor formation. Inhibition of STAT3, FAK and Src mediated signaling reduces cancer stem cell load, tumorigenic potential and metastasis in breast cancer

R Thakur, R Trivedi, N Rastogi, M Singh & DP Mishra
Scientific Reports May 14, 2015; 5(10194)

Cancer stem cells (CSCs) are responsible for aggressive tumor growth, metastasis and therapy resistance. In this study, we evaluated the effects of Shikonin (Shk) on breast cancer and found its anti-CSC potential. Shk treatment decreased the expression of various epithelial to mesenchymal transition (EMT) and CSC associated markers. Kinase profiling array and western blot analysis indicated that Shk inhibits STAT3, FAK and Src activation. Inhibition of these signaling proteins using standard inhibitors revealed that STAT3 inhibition affected CSCs properties more significantly than FAK or Src inhibition. We observed a significant decrease in cell migration upon FAK and Src inhibition and decrease in invasion upon inhibition of STAT3, FAK and Src. Combined inhibition of STAT3 with Src or FAK reduced the mammosphere formation, migration and invasion more significantly than the individual inhibitions. These observations indicated that the anti-breast cancer properties of Shk are due to its potential to inhibit multiple signaling proteins. Shk also reduced the activation and expression of STAT3, FAK and Src in vivo and reduced tumorigenicity, growth and metastasis of 4T1 cells. Collectively, this study underscores the translational relevance of using a single inhibitor (Shk) for compromising multiple tumor-associated signaling pathways to check cancer metastasis and stem cell load.

Breast cancer is the most common endocrine cancer and the second leading cause of cancer-related deaths in women. In spite of the diverse therapeutic regimens available for breast cancer treatment, development of chemo-resistance and disease relapse is constantly on the rise. The most common cause of disease relapse and chemo-resistance is attributed to the presence of stem cell like cells (or CSCs) in tumor tissues12. CSCs represent a small population within the tumor mass, capable of inducing independent tumors in vivo and are hard to eradicate2. Multiple signaling pathways including Receptor Tyrosine Kinase (RTKs), Wnt/β-catenin, TGF-β, STAT3, Integrin/FAK, Notch and Hedgehog signaling pathway helps in maintaining the stem cell programs in normal as well as in cancer cells3456. These pathways also support the epithelial-mesenchymal transition (EMT) and expression of various drug transporters in cancer cells. Cells undergoing EMT are known to acquire stem cell and chemo-resistant traits7. Thus, the induction of EMT programs, drug resistance and stem cell like properties are interlinked7. Commonly used anti-cancer drugs eradicate most of the tumor cells, but CSCs due to their robust survival mechanisms remain viable and lead to disease relapse8. Studies carried out on patient derived tumor samples and in vivo mouse models have demonstrated that the CSCs metastasize very efficiently than non-CSCs91011. Therefore, drugs capable of compromising CSCs proliferation and self-renewal are urgently required as the inhibition of CSC will induce the inhibition of tumor growth, chemo-resistance, metastasis and metastatic colonization in breast cancer.

Shikonin, a natural dietary component is a potent anti-cancer compound1213. Previous studies have shown that Shk inhibits the cancer cell growth, migration, invasion and tumorigenic potential12. Shk has good bioavailability, less toxicity and favorable pharmacokinetic and pharmacodynamic profiles in vivo12. In a recent report, it was shown that the prolonged exposure of Shk to cancer cells does not cause chemo-resistance13.Other studies have shown that it inhibits the expression of various key inflammatory cytokines and associated signaling pathways1214. It decreases the expression of TNFα, IL12, IL6, IL1β, IL2, IFNγ, inhibits ERK1/2 and JNK signaling and reduces the expression of NFκB and STAT3 transcription factors1415. It inhibits proteasome and also modulates the cancer cell metabolism by inhibiting tumor specific pyurvate kinase-M214,1516. Skh causes cell cycle arrest and induces necroptosis in various cancer types14. Shk also inhibits the expression of MMP9, integrin β1 and decreases invasive potential of cancer cells1417. Collectively, Shk modulates various signaling pathways and elicits anti-cancer responses in a variety of cancer types.

In breast cancer, Shk has been reported to induce the cell death and inhibit cell migration, but the mechanisms responsible for its effect are not well studied1819. Signaling pathways modulated by Shk in cancerous and non-cancerous models have previously been shown important for breast cancer growth, metastasis and tumorigenicity20. Therefore in the current study, we investigated the effect of Shk on various hallmark associated properties of breast cancer cells, including migration, invasion, clonogenicity, cancer stem cell load and in vivo tumor growth and metastasis.

Shk inhibits cancer hallmarks in breast cancer cell lines and primary cells

We first examined the effect of Shk on various cancer hallmark capabilities (proliferation, invasion, migration, colony and mammosphere forming potential) in breast cancer cells. MTT assay was used to find out effect of Shk on viability of breast cancer cells. Semi-confluent cultures were exposed to various concentrations of Shk for 24 h. Shk showed specific anti-breast cancer activity with IC50 values ranging from 1.38 μM to 8.3 μM in MDA-MB 231, MDA-MB 468, BT-20, MCF7, T47D, SK-BR-3 and 4T1 cells (Fig. 1A). Whereas the IC50 values in non-cancerous HEK-293 and human PBMCs were significantly higher indicating that it is relatively safe for normal cells (Fig. S1A). Shk was found to induce necroptotic cell death consistent with previous reports (Fig. S1B). Treatment of breast cancer cells for 24 h with 1.25 μM, 2.5 μM and 5.0 μM of Shk significantly reduced their colony forming potential (Fig. 1B). To check the effect of Shk on the heterogeneous cancer cell population, we tested it on patient derived primary breast cancer cells. Shk reduced the viability and colony forming potential of primary breast cancer cells in dose dependent manner (Fig. 1C,D). Further we checked its effects on migration and invasion of breast cancer cells. Shk (2.5 μM) significantly inhibited the migration of MDA-MB 231, MDA-MB 468, MCF7 and 4T1 cells (Fig. 1E). It also inhibited the cell invasion in dose dependent manner (Fig. 1F and S1CS1DS1E,S1F). We further examined its effect on mammosphere formation. MDA-MB 231, MDA-MB 468, MCF7 and 4T1 cell mammosphere cultures were grown in presence or absence of 1.25 μM, 2.5 μM and 5.0 μM Shk for 24 h. After 8 days of culture, a dose dependent decrease in the mammosphere forming potential of these cells was observed (Figs. 1G,H). Collectively, these results indicated that Shk effectively inhibits the various hallmarks associated with aggressive breast cancer.

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Figure 1: Shk inhibits multiple cancer hallmarks

Shk reduces cancer stem cell load in breast cancer

As Shk exhibited strong anti-mammosphere forming potential; therefore it was further examined for its anti-cancer stem cell (CSC) properties. Cancer stem cell loads in breast cancer cells were assessed using Aldefluor assay which measures ALDH1 expression. MDA-MB 231 cells with the highest number of ALDH1+ cells were selected for further studies (Fig. S2A). We also checked the correlation between ALDH1 expression and mammosphere formation. Sorted ALDH1+ cells were subjected to mammosphere cultures. ALDH1+ cells formed highest number of mammospheres compared to ALDH1-/low and parent cell population, indicating that ALDH1+ cells are enriched in CSCs (Fig. S2B). Shk reduced the Aldefluor positive cells in MDA-MB 231 cells after 24 h of treatment (Fig. 2A,B). Next, we examined the effect of Shk on the expression of stem cell (Sox2, Oct3/4, Nanog, AldhA1 and c-Myc) and EMT (Snail, Slug, ZEB1, Twist, β-Catenin) markers, associated with the sustenance of breast CSCs. Shk (2.5 μM) treatment for 24 h reduced the expression of these markers (Fig. 2C and S2D). Shk also reduced protein expression of these markers in dose dependent manner (Fig. 2D,E and S2C).

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Figure 2: Shk decreases stem cell load in breast cancer cells and enriched CD44+,CD24−/low breast cancer stem cells.

To further confirm anti-CSC properties of Shk, we checked the effect of shikonin on the load of CD44+ CD24− breast CSCs in MCF7 cells grown on matrigel. Shikonin reduced CD44+ CD24− cell load in dose dependent manner after 24 h of treatment (Fig S2E). We also tested its effects on the enriched CSC population. CD44+ CD24− cells were enriched from MCF7 cells using MagCellect CD24− CD44+ Breast CSC Isolation Kit (Fig. S2F). Enriched CSCs formed highest number of mammosphere in comparison to parent MCF7 cell population or negatively selected CD24+ cells (Fig. S2G). Enriched CSCs were treated with indicated doses of Shk (0.625 μM, 1.25 μM and 2.5 μM) for 24 h and were either analyzed for ALDH1 positivity or subjected to colony or mammosphere formation. 2.5 μM dose of Shk reduced ALDH1+ cells by 50% and inhibited colony and mammosphere formation (Fig. S2H2F2G and 2H). Shk also reduced the mRNA expression of CSC markers in CD44+ CD24− cells and patient derived primary cancer cells (Fig. 2I,J). These results collectively indicated that Shk inhibits CSC load and associated programs in breast cancer.

Shk is a potent inhibitor of STAT3 and poorly inhibits FAK and Src

To identify the molecular mechanism responsible for anti-cancer properties of Shk, we used a human phospho-kinase antibody array to study a subset of phosphorylation events in MDA-MB 231 cells after 6h of treatment with 2.5 μM Shk. Amongst the 46 phospho-antibodies spotted on the array, the relative extent of phosphorylation of three proteins decreased to about ≳ 2 fold (STAT3, 3.3 fold; FAK, 2.5 fold and Src, 1.8 fold) upon Shk treatment (Fig. 3A,B). These proteins (STAT3, FAK and Src) are known to regulate CSC proliferation and self renewal212223. Therefore, we focused on these proteins and the result of kinase-array was confirmed by western blotting. Shk effectively inhibits STAT3 at early time point (1 h) while activation of FAK and Src decreased on or after 3 h (Fig. 3C) confirming Shk as a potent inhibitor of STAT3. Shk also reduced the protein expression of STAT3, FAK and Src at 24 h (Fig. 3C).

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Figure 3. Shk inhibits STAT3, FAK and Src signaling pathways.

We also observed that Shk does not inhibit JAK2 at initial time-points (Fig. 3C). This raised a possibility that Shk either regulates STAT3 independent of JAK2 or it binds directly to STAT3. To check the first probability, we activated STAT3 by treating the cells with IL6 (100 ng ml−1) for 1 h followed by treatment with Shk (2.5 μM) for 1 h. Both immunofluorescence and western-blotting results showed that Shk inhibited activated STAT3 without inhibiting JAK2 (Fig. S3AS3B) confirming that Shk inhibits JAK2 mediated activation of STAT3 possibly by binding directly to STAT3. For further confirmation, we performed an in silico molecular docking analysis to examine binding of Shk with the STAT3 SH2 domain. In a major conformational cluster, Shk occupied Lys-707, Lys-709 and Phe-710 binding sites in the STAT3 SH2 domain similar to the STAT3 standard inhibitor S3I-201 (Fig. S3C and S3D). The binding energy of Shk to STAT3 was −4.20 kcal mol−1. Collectively, these results showed that Shk potently inhibits STAT3 activation and also attenuates FAK and Src activation.

STAT3, Src and FAK are differentially expressed and activated in breast CSCs (BCSCs)

STAT3 and FAK are known to play an important role in proliferation and self-renewal of CSCs in various cancer types including breast cancer212224. Src also support CSC phenotype in some cancer types, but there are limited reports of its involvement in breast cancer25. Therefore, we checked the expression and activation of STAT3, FAK and Src in CSCs and non-CSCs. Here we used two methods to enrich the CSCs and non-CSCs. In the first method, the MDA-MB 231 cells were subjected to mammosphere formation for 96 h. After 96 h, mammosphere and non-mammosphere forming cells were clearly visible (Fig. 4A). These mammosphere and non-mammosphere forming cells were separated by using a 70 micron cell strainer. Mammospheres were subjected to two subculture cycles to enrich CSCs. With each passage, the viable single cells (non-mammosphere forming cells) and mammospheres were collected in RIPA lysis buffer and western blotting was done (Fig. 4B). We found that the activation and expression of the STAT3, FAK and Src is higher in enriched mammosphere cultures (Fig. 4C). In the second method, CD44+ CD24− cells were isolated from MCF7 cultures using MagCellect Breast CSC Isolation Kit. STAT3, FAK and Src activation and their mRNA and protein expression were assessed in enriched CSCs and were compared to parent MCF7 cell population. STAT3, FAK and Src all were differentially activated in CSCs (Fig. 4E). High mRNA as well as protein expressions of all the three genes was also observed in CSCs (Fig. 4D,E). Collectively, these results indicate that STAT3, FAK and Src are over expressed and activated in BCSCs.

Figure 4: STAT3, FAK and Src are differentially activated and expressed in breast cancer cells.

  • Representative picture indicating mammosphere and single suspended cells. (B) Schematic outline of mammosphere enrichment. (C) Protein expression and activation of STAT3, FAK and Src was determined in single suspended cells (non-mammosphere forming cells) and mammospheres by western blot. The full size blots corresponding to the cropped blot images are given in  S10. (D) Gene expression of STAT3, FAK and Src was determined in MCF7 parent population and CD44+ CD24−/low MCF7 cells using PCR. The full agarose gel images corresponding to the cropped images are given in Fig. S10. (E) Protein expression and activation of STAT3, FAK and Src was in CD44+ 24− cells and parent population.
STAT3, FAK and Src are differentially activated and expressed in breast cancer cells.

STAT3, FAK and Src are differentially activated and expressed in breast cancer cells.

STAT3 is important for mammosphere formation and CSC programs in breast cancer

As our results indicated that the expression and activation of STAT3, FAK and Src is high in BCSCs and Shk is capable of inhibiting these signaling proteins; therefore to find out functional relevance of each protein and associated effects on their pharmacological inhibition by Shk, we used specific inhibitors against these three. Effect of these inhibitors was first tested on the mammosphere forming potential of MDA-MB 231, MDA-MB 468 and MCF7 cells. A drastic reduction in the mammosphere formation was observed upon STAT3 inhibition. FAK and Src inhibition also reduced the primary and secondary mammosphere formation but STAT3 inhibition showed most potent effect (Fig. 5A and S4). Further, we also checked the effect of these inhibitors on the expression of various CSC and EMT related markers in MDA-MB 231 cells. STAT3 inhibition decreased the expression of most of the CSC and EMT markers (Fig. 5B). These two findings indicated that STAT3 inhibition is more effective in reducing mammosphere forming potential and weakens major CSC programs and the anti-CSC potential of Shk is possibly due to its strong STAT3 inhibitory effect.
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STAT3, FAK and Src activation status correlates with mammosphere forming potential in breast cancer

STAT3, FAK and Src activation status correlates with mammosphere forming potential in breast cancer

Figure 5: STAT3, FAK and Src activation status correlates with mammosphere forming potential in breast cancer.

(A) Bar graph represents number of mammospheres formed from 2500 cells in presence and absence of indicated treatments. MDA-MB 231, MDA-MB 468 and MCF7 24 h mammosphere cultures were treated with Shk (2.5 μM), FAK inhibitor (FAK inhibitor 14; 2.5 μM), Src inhibitor (AZM 475271; 10 μM) and STAT3 inhibitor (WP1066; 10 μM). After 24 h, treatments were removed and cells were allowed to grow in fresh mammosphere culture media for 8 days. (B) Expression of various stem cell and EMT related transcription factors and markers were detected using western blotting in MDA-MB 231 cells with or without indicated treatments. The full size blots corresponding to the cropped blot images are given in Fig. S10. (C) MDA-MB 231, MDA-MB 468 and MCF7 cells were pre-treated with either IL6 (100 ng ml−1), Fibronectin (1 μg ml−1) or EGF (25 ng ml−1) for two population doublings and subjected to mammosphere formation. Bar graph represents average of three independent experiments. (D) MCF7 cells were pre-treated with either IL6 (100 ng ml−1), Fibronectin (1 μg ml−1) or EGF (25 ng ml−1) for two population doublings and subjected to mammosphere formation. After 24 h, cells were treated with DMSO (untreated) or Shk (treated) as indicated in the bar graph. Data are shown as the mean ±SD. (*) p < 0.05 and (**) p < 0.01.

To further check the involvement of these pathways in CSCs, we cultured MDA-MB 231, MDA-MB 468 and MCF7 cells in the presence of either IL6 (100ng ml−1), EGF (25 ng ml−1) or Fibronectin (1 μg ml−1) coated surface for two population doublings. Cells were then subjected to mammosphere formation. In IL6 pre-treated cultures, there was a sharp rise in mammosphere formation, indicating that the STAT3 activation shifts CSC and non-CSC dynamics towards CSCs (Fig. 5C). IL6 is previously known to induce the conversion of non-CSC to CSC via STAT3 activation26. In MCF7 cells, mammosphere forming potential after IL6 pre-treatment increased nearly by three fold. Therefore, we further checked the effectiveness of Shk on mammosphere forming potential in pre-treated MCF7 cells. It was found that Shk inhibits mammosphere formation most effectively in IL6 pre-treated cultures (Fig. 5D). However, in EGF and Fibronectin pre-treated cultures, Shk was relatively less effective. This was possibly due to its weak FAK and Src inhibitory potential. Collectively, these results illustrated that STAT3 activation is significantly correlated with the mammosphere forming potential of breast cancer cells and its inhibition by a standard inhibitor or Shk potently reduce the mammosphere formation.

Shk inhibit CSCs load by disrupting the STAT3-Oct3/4 axis

In breast cancer, STAT3 mediated expression of Oct3/4 is a major regulator of CSC self-renewal2627. As we observed that both Shk and STAT3 inhibitors decreased the Oct3/4 expression (Figs. 2C and 5B), we further checked the effect of STAT3 activation on ALDH1+ CSCs and Oct3/4 expression. On IL6 pre-treatment, number of ALDH1+ cells increased in all three (MDA-MB 231, MDA-MB 468 and MCF7) cancer cells (Fig. 6A). MCF7 cells showed highest increase. Therefore, to check the effect of STAT3 inhibition on CSC load, we incubated IL6 pre-treated MCF7 cells with Shk and STAT3 inhibitor for 24 h and analyzed for ALDH1 positivity. It was observed that both Shk and STAT3 inhibitor reduced the IL6 induced ALDH1 positivity from 10% to < 2% (Fig. 6B). These results suggested that Shk induced inhibition of STAT3 and decrease in BCSC load is interlinked. We further checked the effect of STAT3 activation status on Oct3/4 expression in MDA-MB 231, MDA-MB 468 and MCF7 cells. We observed that expression of Oct3/4 increases with the increase in STAT3 activation (Fig. 6C–E).

(not shown)

Figure 6: STAT3 activation status and its effect on cancer stem cell load

STAT3 transcriptional activity is important in maintaining CSC programs2829. Therefore, we also examined the effect of Shk on STAT3 promoter activity. STAT3 reporter assay was performed in presence of IL6 and Shk; it was found that Shk reduced the promoter activity of STAT3 in a dose dependent manner (Fig. S5). Collectively, these results showed that Shk mediated STAT3 inhibition are responsible for decrease in CSC load and Oct3/4 associated stem cell programs.

Shk inhibits mammosphere formation, migration and invasion through inhibition of STAT3, FAK and Src in breast cancer cells

As the earlier results (Fig. 1) showed that Shk inhibits cell migration and invasion in breast cancer cells, we further examined the effect of STAT3, FAK and Src inhibitors on cell migration and invasion in MDA-MB 231 cells. It was found that STAT3 inhibitor poorly inhibits cell migration while both Src and FAK inhibitors were effective in reducing cell migration (Fig. 7A). All the three inhibitors decreased the cell invasion and MMP9 expression significantly (Fig. 7B and S6). It was also observed that effect of all these inhibitors, except STAT3 inhibitor on mammosphere formation and FAK inhibitor on cell migration, were not comparable to that of Shk. Shk inhibited all these properties more effectively than individual inhibition of STAT3, FAK and Src. This made us to assume that the ability of Shk to inhibit multiple signaling molecules simultaneously is the reason behind its potent anti-cancer effect. To check this notion, we combined STAT3, FAK and Src inhibitors with each other and examined the effect of combinations on invasion, migration and mammosphere forming potential in MDA-MB 231 cells. We observed further decrease in cell migration and invasion on combining STAT3 and FAK, STAT3 and Src, or FAK and Src (Figs. 7A,B). Combination of FAK and Src was not very effective in inhibiting mammosphere formation in MDA-MB 231 cells and CD44+ CD24− MCF7 CSCs. However, their combination with STAT3 decreased the mammosphere forming potential equivalent to that of Shk (Fig. 7C,D). We also compared the mammosphere forming potential of Shk with Salinomycin (another anti-CSC agent) and found that at 2.5 μM dose of Shk was almost two times more potent than Salinomycin (Fig. S7). Collectively, these results indicated that Shk inhibits multiple signaling proteins (STAT3, FAK and Src) to compromise various aggressive breast cancer hallmarks.

Figure 7: Combination of FAK, Src and STAT3 inhibitors is more potent than individual inhibition against various cancer hallmarks.



  • Cell migration and (B) cell invasion potential of MDA-MB 231 cells was assessed in the presence of Shk (2.5 μM), FAK inhibitor (FAK inhibitor 14; 2.5 μM), Src inhibitor (AZM 475271; 10 μM) and STAT3 inhibitor (WP1066; 10 μM). Various combinations of these inhibitors were also used STAT3+FAK inhibitor (WP1066; 10 μM + FAK inhibitor 14; 2.5 μM), STAT3 + Src Inhibitor (WP1066; 10 μM + AZM 475271; 10 μM) and FAK+Src Inhibitor (FAK inhibitor 14; 2.5 μM + AZM 475271; 10 μM). Cell migration and cell invasion was assessed through scratch cell migration assay and transwell invasion after 24 h of treatments. (C,D) Mammosphere forming potential of MDA-MB 231 cells and CD44+ CD24−/low enriched MCF7 cells was assessed in presence of similar combination of STAT3+FAK inhibitor (WP1066; 10 μM + FAK inhibitor 14; 2.5 μM), STAT3 + Src Inhibitor (WP1066; 10 μM+ AZM 475271; 10 μM) and FAK + Src Inhibitor (FAK inhibitor 14; 2.5 μM + AZM 475271; 10 μM). Cells were subjected to mammosphere cultures for 24 h and treated with the indicated inhibitors for next 24 h, followed by media change and growth of mammospheres were monitored for next 8 days. Data are shown as the mean ±SD. (**) p < 0.01.

Shk inhibits breast cancer growth, metastasis and decreases tumorigenicity

To explore whether Shk may have therapeutic potential for breast cancer treatment in vivo, we tested Shk against 4T1-induced breast cancer syngenic mouse model. 4T1 cells (mouse breast cancer cells) are capable of growing fast and metastasize efficiently in vivo30. Prior to the in vivo experiments, we checked the effect of Shk on ALDH1 positivity and on activation of STAT3, FAK and Src in 4T1 cells in vitro. Shk effectively decreased the ALDH1+ cells and inhibited STAT3, FAK and Src in 4T1 cells in vitro (Fig. S8A and S8B). For in vivo tumor generation, 1 × 106 cells were injected subcutaneously in the fourth nipple mammary fat pad of BALB/c mice. When the average size of tumors reached around 50 mm3, mice were divided into three groups, vehicle and two Shk treated groups each received either 2.5 mg Kg−1 or 5.0 mg Kg−1 Shk. Shk was administered via the intraperitoneal injection on every alternate day. It significantly suppressed the tumor growth in 4T1 induced syngenic mouse model (Fig. 8A). The average reduction in 4T1 tumor growth was 49.78% and 89.73% in 2.5 mg Kg−1 and 5.0 mg Kg−1 groups respectively compared with the vehicle treated group (Fig. 8A). No considerable change in body weight of the treated group animals was observed (Fig. S9A). We further examined the effect of Shk on the tumor initiating potential of breast cancer cells. 4T1 induced tumors were excised from the control and treatment groups on the second day after 4th dose of Shk was administered. Tumors were dissociated; cells were allowed to adhere and then re-injected into new animals for secondary tumor formation. Growth of secondary tumors was monitored till day 15 post-reinjection. Shk treated groups showed a marked decrease in secondary tumor formation (Fig. 8D). We also observed a drastic reduction in the number of metastatic nodules in the lungs of treatment group animals (Fig. 8F). The reduction in the metastatic load was not proportional to the decrease in tumor sizes; however within the treatment group, some animals with small tumors were carrying higher number of metastatic nodules. As FAK is an important mediator of cancer metastasis and metastatic colonization, we further examined the effects of Shk on metastatic colonization. For this, 1 × 105 4T1 cells were injected to BALB/c mice through tail vein. Animals were divided into three groups, as indicated above. Shk and vehicle were administered through intraperitoneal injections at alternate days starting from the 2nd day post tail vein injections till 33rd day. The average reduction in total number of metastatic nodules was 88.6% – 90.5% in Shk treated mice compared to vehicle control (Fig. 8F). An inset picture (Fig. 8A lower panel) represents lung morphology of vehicle control and treated groups. We further examined the activation and expression status of STAT3, FAK and Src between vehicle control and treated group tumors. There were low expression and activation of STAT3, FAK and Src in treated tumors as compared to the vehicle control (Fig. 8B,C). Similar trend was observed in ALDH1 expressions (Fig. 8B). Further, the mice tumor sections were subjected to immunohistochemistry, immunofluorescence and hematoxylin and eosin (H&E) staining to study histology and expression of key proteins being examined in this study. Fig. 8G shows representative images of H&E staining, proliferating cell nuclear antigen (PCNA), terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL), STAT3 and Oct3/4 immunostaining. PCNA expression was low while TUNEL positive cells were high in tumor tissues of Shk treated groups. STAT3 and Oct3/4 expression was low in Shk treated groups. These results collectively demonstrated that Shk modulates the expression and activation of STAT3, FAK and Src in vivo and is effective in suppressing tumorigenic potential and metastasis in syngenic mouse model.

Figure 8: Shk inhibits breast cancer growth, tumorigenicity and metastasis in vivo.

Shk inhibits breast cancer growth, tumorigenicity and metastasis in vivo

Shk inhibits breast cancer growth, tumorigenicity and metastasis in vivo

  • Shk inhibited 4T1 tumor growth. Bar graph represents the average tumor volumes in vehicle control and Shk treated tumor bearing mice (n = 6). (*) p < 0.05 and (**) p < 0.01. Inset picture of upper panel represents tumor sizes and lower pane represents lung morphology in vehicle control and Shk treatment groups. (B) Western blot examination of indicated proteins for their expression and activation in vehicle control and treated tumor groups. The full size blots corresponding to the cropped blot images are given in Fig. S10. (C) Gene expression of stem cell and EMT markers in tumor tissues excised from the vehicle control and Shk treated groups (n = 3). (D) Number of secondary tumors formed after injecting indicated cell dilutions from Vehicle treated and Shk treated 4T1 tumors. (E) Number of lung nodules formed in mice injected with 4T1 mouse mammary tumor cells in the mammary fat pad and administered with 2.5 mg Kg−1 Shk or vehicle control on every alternate day for 3 weeks (n = 6). (F) Number of lung nodules in mice injected with 4T1 mouse mammary tumor cells through tail vein and administered with 2.5 mg Kg−1 Shk or vehicle control on every alternate day for 3 weeks. (n = 8) (G) Representative panel of the histological H&E staining, immunofluorescence staining for the STAT3, Oct3/4, cell proliferation marker PCNA and DNA damage indicator-TUNEL staining of tumor sections from vehicle and treatment groups.

Recent studies have shown that aggressiveness, therapy resistance and disease relapse in breast cancer is attributed to a small population of CSCs involved in continuous self-renewal and differentiation through signaling pathways similar to that of the normal stem cells31. Therapeutic targeting of CSCs therefore, has profound clinical implications for cancer treatment31. Recent studies indicated that therapies / agents targeting both differentiated cancer cells and CSCs may possibly have significant therapeutic advantages32. Therefore, it is imperative to look for novel therapeutic agents with lesser side effects urgently for effective targeting of CSCs. In search of novel, nontoxic anti-CSC agents, attention has been focused on natural agents in recent times33,34. In this study, we have used a natural napthoquinone compound, Shk with established antitumorigenic, favorable pharmacokinetic and toxicity profiles and report for the first time its potent anti-CSC properties. Shk significantly inhibits breast cancer cell proliferation in vitroex vivoand in vivo. It decreases the cell migration and invasion of breast cancer cells in vivo, as well as inhibits tumorigenicity, metastasis and metastatic colonization in a syngenic mouse model of breast cancer in vivo. These finding suggest a strong potential of Shk in breast cancer therapy.

We assessed the effect of Shk on the CSC load in breast cancer cells through various functional assays (tumorsphere in vitro and syngenic mouse model of breast cancer in vivo) and quantification of specific stem cell markers. In breast cancer, CD44+ CD24− cells and ALDH1+ cells are considered to be BCSCs2125. Shk significantly decreased the mammosphere formation (Fig. 1HS1G and 2H), ALDH1+ cell and CD44+ CD24− cell loads in vitro (Fig. 2BS2E and S2H). It also reduced the expression of CSC markers (Oct3/4, Sox2, Nanog, c-Myc and Aldh1) in vivo andin vitro (Fig. 2C,DS2C and S2D). These genes are known to regulate stem cell programs and in cancer, they are established promoters and regulators of CSC phenotype353637383940. Decrease in the expression of these genes on Shk treatment indicates its potential to suppress CSC programs. Tumor initiating potential (tumorigenicity) is the bona fide measure of CSCs. Reduction in the tumorigenic potential of cells isolated form Shk treated tumors indicates in vivoanti-CSC effects of Shk.

We further demonstrated that Shk is a potent inhibitor of STAT3 and it also inhibits FAK and Src (Fig. 3A–C). Its STAT3 inhibitory property was found to be responsible for its anti-CSC effects (Figs. 6B and 7B). STAT3 and FAK inhibitors are previously known to compromise CSC growth41,42. Here, we found that pharmacological inhibition of STAT3 was more effective in compromising CSC load than FAK and Src inhibitions (Fig. 5A). STAT3 activation through IL6 increases mammosphere formation more significantly than Src and FAK activation through EGF and Fibronectin (Fig. 5C). This indicates that IL6-STAT3 axis is a key regulator of BCSC dynamics. Ovatodiolide Sensitizes Aggressive Breast Cancer Cells to Doxorubicin Anticancer Activity, Eliminates Their Cancer Stem Cell-Like Phenotype, and Reduces Doxorubicin-Associated Toxicity

Investigators evaluated the usability of ovatodiolide (Ova) in sensitizing triple negative breast cancer (TNBC) cells to doxorubicin (Doxo), cytotoxicity, so as to reduce Doxo effective dose and consequently its adverse effects. Ova-sensitized TNBC cells also lost their cancer stem cell-like phenotype evidenced by significant dissolution and necrosis of formed mammospheres, as well as their terminal differentiation. [Cancer Lett] Glabridin Inhibits Cancer Stem Cell-Like Properties of Human Breast Cancer Cells: An Epigenetic Regulation of miR-148a/SMAd2 Signaling

The authors report that glabridin (GLA) attenuated the cancer stem cell (CSC)-like properties through microRNA-148a (miR-148a)/transforming growth factor beta-SMAD2 signal pathway in vitro and in vivo. In MDA-MB-231 and Hs-578T breast cancer cell lines, GLA enhanced the expression of miR-148a through DNA demethylation. [Mol Carcinog] Ginsenoside Rh2 Inhibits Cancer Stem-Like Cells in Skin Squamous Cell Carcinoma

The effects of ginsenoside Rh2 (GRh2) on Lgr5-positive cancer stem cells (CSCs) were determined by flow cytometry and by tumor sphere formation. Scientists found that GRh2 dose-dependently reduced skin squamous cell carcinoma viability, possibly through reduced the number of Lgr5-positive CSCs. [Cell Physiol Biochem]

Liu S. Chen M. Li P. Wu Y. Chang C. Qiu Y. Cao L. Liu Z. Jia C.
Cell Physiol Biochem 2015;36:499-508

Background/Aims: Treatments targeting cancer stem cells (CSCs) are most effective cancer therapy, whereas determination of CSCs is challenging. We have recently reported that Lgr5-positive cells are cancer stem cells (CSCs) in human skin squamous cell carcinoma (SCC). Ginsenoside Rh2 (GRh2) has been shown to significantly inhibit growth of some types of cancers, whereas its effects on the SCC have not been examined. Methods: Here, we transduced human SCC cells with lentivirus carrying GFP reporter under Lgr5 promoter. The transduced SCC cells were treated with different doses of GRh2, and then analyzed cell viability by CCK-8 assay and MTT assay. The effects of GRh2 on Lgr5-positive CSCs were determined by fow cytometry and by tumor sphere formation. Autophagy-associated protein and β-catenin were measured by Western blot. Expression of short hairpin small interfering RNA (shRNA) for Atg7 and β-catenin were used to inhibit autophagy and β-catenin signaling pathway, respectively, as loss-of-function experiments. Results: We found that GRh2 dose-dependently reduced SCC viability, possibly through reduced the number of Lgr5-positive CSCs. GRh2 increased autophagy and reduced β-catenin signaling in SCC cells. Inhibition of autophagy abolished the effects of GRh2 on β-catenin and cell viability, while increasing β-catenin abolished the effects of GRh2 on autophagy and cell viability. Conclusion: Taken together, our data suggest that GRh2 inhibited SCC growth, possibly through reduced the number of Lgr5-positive CSCs. This may be conducted through an interaction Carcinoma account for more than 80% of all types of cancer worldwide, and squamous cell carcinoma (SCC) is the most frequent carcinoma. Skin SCC causes a lot of mortality yearly, which requires a better understanding of the molecular carcinogesis of skin SCC for developing efficient therapy [1,2]. Ginsenoside Rh2 (GRh2) is a characterized component in red ginseng, and has proven therapeutic effects on inflammation [3] and a number of cancers [4,5,6,7,8,9,10,11,12,13,14], whereas its effects on the skin SCC have not been examined.

Cancer stem cells (CSCs) are cancer cells with great similarity to normal stem cells, e.g., the ability to give rise to various cell types in a particular cancer [15,16]. CSCs are highly tumorigenic, compared to other non-CSCs. CSCs appear to persist in tumors as a distinct population and CSCs are believed to be responsible for cancer relapse and metastasis after primary tumor resection [15,16,17,18]. Recently, the appreciation of the critical roles of CSCs in cancer therapy have been continuously increasing, although the identification of CSCs in a particular cancer is still challenging.

To date, different cell surface proteins have been used to isolate CSCs from a variety of cancers by flow cytometry. Among these markers for identification of CSCs, the most popular ones are prominin-1 (CD133), side population (SP) and increased activity of aldehyde dehydrogenase (ALDH). CD133 is originally detected in hematopoietic stem cells, endothelial progenitor cells and neuronal and glial stem cells. Later on, CD133 has been shown to be expressed in the CSCs from some tumors [19,20,21,22,23], but with exceptions [24]. SP is a sub-population of cells that efflux chemotherapy drugs, which accounts for the resistance of cancer to chemotherapy. Hoechst (HO) has been experimentally used for isolation of SP cells, while the enrichment of CSCs by SP appears to be limited [25]. Increased activity of ALDH, a detoxifying enzyme responsible for the oxidation of intracellular aldehydes [26,27], has also been used to identify CSCs, using aldefluor assay [28,29]. However, ALDH has also been detected in other cell types, which creates doubts on the purity of CSCs using ALDH method [30,31]. Moreover, all these methods appear to be lack of cancer specificity.

The Wnt target gene Lgr5 has been recently identified as a stem cell marker of the intestinal epithelium, and of the hair follicle [32,33]. Recently, we reported that Lgr5 may be a potential CSC marker for skin SCC [34]. We detected extremely high Lgr5 levels in the resected skin SCC specimen from the patients. In vitro, Lgr5-positive SCC cells grew significantly faster than Lgr5-negative cells, and the fold increase in growth of Lgr5-positive vs Lgr5-negative cells is significantly higher than SP vs non-SP, or ALDH-high vs ALDH-low, or CD133-positive vs CD133-negative cells. Elimination of Lgr5-positive SCC cells completely inhibited cancer cell growth in vitro.

Here, we transduced human SCC cells with lentivirus carrying GFP reporter under Lgr5 promoter. The transduced SCC cells were treated with different doses of GRh2, and then analyzed cell viability by CCK-8 assay and MTT assay. The effects of GRh2 on Lgr5-positive CSCs were determined by flow cytometry and by tumor sphere formation. Autophagy-associated protein and β-catenin were measured by Western blot. Expression of short hairpin small interfering RNA (shRNA) for autophagy-related protein 7 (Atg7) and β-catenin were used to inhibit autophagy and β-catenin signaling pathway, respectively, as loss-of-function experiments. Atg7 was identified based on homology to Pichia pastoris GSA7 and Saccharomyces cerevisiae APG7. In the yeast, the protein appears to be required for fusion of peroxisomal and vacuolar membranes. The protein shows homology to the ATP-binding and catalytic sites of the E1 ubiquitin activating enzymes. Atg7 is a mediator of autophagosomal biogenesis, and is a putative regulator of autophagic function [35,36,37,38]. We found that GRh2 dose-dependently reduced SCC viability, possibly through reduced the number of Lgr5-positive CSCs. GRh2 increased autophagy and reduced β-catenin signaling in SCC cells. Inhibition of autophagy abolished the effects of GRh2 on β-catenin and cell viability, while increasing β-catenin abolished the effects of GRh2 on autophagy and cell viability.

Transduction of SCC cells with GFP under Lgr5 promoter

We have recently shown that Lgr5 is CSC marker for skin SCC [34]. In order to examine the role of GRh2 on SCC cells, as well as a possible effect on CSCs, we transduced human skin SCC cells A431 [34] with a lentivirus carrying GFP reporter under Lgr5 promoter (Fig. 1A). The Lgr5-positive cells were green fluorescent in culture (Fig. 1B), and could be analyzed or isolated by flow cytometry, based on GFP (Fig. 1C).

(not shown)

Fig. 1. Transduction of SCC cells with GFP under Lgr5 promoter. (A) The structure of lentivirus carrying GFP reporter under Lgr5 promoter. (B) The pLgr5-GFP-transduced A431 cells in culture. Lgr5-positive cells were green fluorescent. Nuclear staining was done by DAPI. (C) Representative flow chart for analyzing pLgr5-GFP-transduced A431 cells by flow cytometry based on GFP. Gated cells were Lgr5-positive cells. Scar bar is 20µm.

GRh2 dose-dependently inhibits SCC cell growth

Then, we examined the effect of GRh2 on the viability of SCC cells. We gave GRh2 at different doses (0.01mg/ml, 0.1mg/ml and 1mg/ml) to the cultured pLgr5-GFP-transduced A431 cells. We found that from 0.01mg/ml to 1mg/ml, GRh2 dose-dependently deceased the cell viability in either a CCK-8 assay (Fig. 2A), or a MTT assay (Fig. 2B). Next, we questioned whether GRh2 may have a specific effect on CSCs in SCC cells. Thus, we analyzed GFP+ cells, which represent Lgr5-positive CSCs in pLgr5-GFP-transduced A431 cells after GRh2 treatment. We found that GRh2 dose-dependently deceased the percentage of GFP+ cells, by representative flow charts (Fig. 2C), and by quantification (Fig. 2D). We also examined the capability of the GRh2-treated cells in the formation of tumor sphere. We found that GRh2 dose-dependently deceased the formation of tumor sphere-like structure, by quantification (Fig. 2E), and by representative images (Fig. 2F). Together, these data suggest that GRh2 dose-dependently inhibited SCC cell growth, possibly through inhibition of CSCs.

Fig. 2. GRh2 dose-dependently inhibits SCC cell growth. We gave GRh2 at different doses (0.01mg/ml, 0.1mg/ml and 1mg/ml) to the cultured pLgr5-GFP-transduced A431 cells. (A-B) GRh2 dose-dependently deceased the cell viability in either a CCK-8 assay (A), or a MTT assay (B). (C-D) GFP+ cells after GRh2 treatment were analyzed by flow cytometry, showing that GRh2 dose-dependently deceased the percentage of GFP+ cells, by representative flow charts (C), and by quantification (D). The capability of the GRh2-treated cells to form tumor sphere-like structures was examined, shown by quantification (E), and by representative images (F). *p

GRh2 treatment decreases β-catenin and increases autophagy in SCC cells

We analyzed the molecular mechanisms underlying the cancer inhibitory effects of GRh2 on SCC cells. We thus examined the growth-regulatory proteins in SCC. From a variety of proteins, we found that GRh2 treatment dose-dependently decreases β-catenin, and dose-dependently upregulated autophagy-related proteins Beclin, Atg7 and increased the ratio of LC3 II to LC3 I, by quantification (Fig. 3A), and by representative Western blots (Fig.3B). Since β-catenin signaling is a strong cell-growth stimulator and autophagy can usually lead to stop of cell-growth and cell death, we feel that the alteration in these pathways may be responsible for the GRh2-mediated suppression of SCC growth.

(not shown)

Figure 3. GRh2 treatment decreases β-catenin and increases autophagy in SCC cells.

Inhibition of autophagy abolishes the effects of GRh2 on β-catenin

In order to find out the relationship between β-catenin and autophagy in this model, we inhibited autophagy using a shRNA for Atg7, and examined its effect on the changes of β-catenin by GRh2. First, the inhibition of Atg7 in A431 cells by shAtg7 was confirmed by RT-qPCR (Fig. 4A), and by Western blot (Fig. 4B). Inhibition of Atg7 resulted in abolishment of the effects of GRh2 on other autophagy-associated proteins (Fig. 4B), and resulted in abolishment of the inhibitory effect of GRh2 on β-catenin (Fig. 4B). Moreover, the effects of GRh2 on cell viability were completely inhibited (Fig. 4C). Together, inhibition of autophagy abolishes the effects of GRh2 on β-catenin. Thus, the regulation of GRh2 on β-catenin needs autophagy-associated proteins.

Fig. 4. Inhibition of autophagy abolishes the effects of GRh2 on β-catenin.

A431 cells were transfected with shRNA for Atg7, or scrambled sequence (scr) as a control. (A) RT-qPCR for Atg7. (B) Quantification of β-catenin, Beclin, Atg7 and LC3 by Western blot. (C) Cell viability by CCK-8 assay. *p

Overexpression of β-catenin abolishes the effects of GRh2 on autophagy

Next, we inhibited the effects of GRh2 on β-catenin by overexpression of β-catenin in A431 cells. First, the overexpression of β-catenin in A431 cells was confirmed by RT-qPCR (Fig. 5A), and by Western blot (Fig. 5B). Overexpression of β-catenin resulted in abolishment of the effects of GRh2 on autophagy-associated proteins (Fig. 5B). Moreover, the effects of GRh2 on cell viability were completely inhibited (Fig. 5C). Together, inhibition of β-catenin signaling abolishes the effects of GRh2 on autophagy. Thus, the regulation of GRh2 on autophagy needs β-catenin signaling. This model is thus summarized in a schematic (Fig. 6), suggesting that GRh2 may target both β-catenin signaling and autophagy, which interacts with each other in the regulation of SCC cell viability and growth.

Fig. 5. Overexpression of β-catenin abolishes the effects of GRh2 on autophagy. A431 cells were transfected with β-catenin, or scrambled sequence (scr) as a control. (A) RT-qPCR for β-catenin. (B) Quantification of β-catenin, Beclin, Atg7 and LC3 by Western blot. (C) Cell viability by CCK-8 assay. *p

Fig. 6. Schematic of the model. GRh2 may target both β-catenin signaling and autophagy, which interacts with each other in the regulation of SCC cell viability and growth.

Understanding the cancer molecular biology of skin SCC and identification of an effective treatment are both critical for improving the current therapy [1]. Lgr5 has been recently identified as a novel stem cell marker of the intestinal epithelium and the hair follicle, in which Lgr5 is expressed in actively cycling cells [32,33]. Moreover, we recently showed that Lgr5-positive are CSCs in skin SCC [34]. Thus, specific targeting Lgr5-positive cells may be a promising therapy for skin SCC.

In the current study, we analyzed the effects of GRh2 on the viability of SCC. Importantly, we not only found that GRh2 dose-dependently decreases SCC cell viability, but also dose-dependently decreased the number of Lgr5-positive CSCs in SCC cells. These data suggest that the CSCs in SCC may be more susceptible for the GRh2 treatment, and the decreases in CSCs may result in the decreased viability in total SCC cells. This point was supported by following mechanism studies. Activated β-catenin signaling by WNT/GSK3β prevents degradation of β-catenin and induces its nuclear translocation [39]. Nuclear β-catenin thus activates c-myc, cyclinD1 and c-jun to promote cell proliferation, and activates Bcl-2 to inhibit apoptosis [39]. High β-catenin levels thus are a signature of CSCs. Therefore, it is not surprising that CSCs are more affected than other cells when GRh2 targets β-catenin signaling.

In addition, GRh2 appears to target autophagy. Although altered metabolism may be beneficial to the cancer cells, it can create an increased demand for nutrients to support cell growth and proliferation, which creates metabolic stress and subsequently induces autophagy, a catabolic process leading to degradation of cellular components through the lysosomal system [40]. Cancer cells use autophagy as a survival strategy to provide essential biomolecules that are required for cell viability under metabolic stress [40]. However, autophagy not only results in a staring in cell growth, but also may result in cell death [40]. Increases in autophagy may substantially decrease cancer cell growth. Thus, GRh2 has its inhibitory effect on skin SCC cells through a combined effect on cell proliferation (by decreasing β-catenin) and autophagy [40].

Interestingly, our data suggest an interaction between β-catenin and autophagy. This finding is consistent with previous reports showing that autophagy negatively modulates Wnt/β-catenin signaling by promoting Dvl instability [41,42], and with other studies showing that β-catenin regulates autophagy [38,43,44].

Of note, we have checked other SCC lines and essentially got same results. Together with our previous reports showing that Lgr5-positive cells are CSCs in skin SCC [34], these findings thus highlight a future engagement of Lgr5-directed GRh2 therapy, which could be performed in a sufficiently frequent manner, to substantially improve the current treatment for skin SCC.

Normal vs Cancer Thyroid Stem Cells: The Road to Transformation
The authors discuss new insights into thyroid stem cells as a potential source of cancer formation in light of the available information on the oncogenic role of genetic modifications that occur during thyroid cancer development. Understanding the fine mechanisms that regulate tumor transformation may provide new ground for clinical intervention in terms of prevention, diagnosis and therapy. [Oncogene] Abstract
Cancer Stem Cells: A Potential Target for Cancer Therapy
The identification of cancer stem cells (CSCs) and a better understanding of the complex characteristics of CSCs will provide invaluable diagnostic, therapeutic and prognostic targets for clinical application. The authors introduce the dysregulated properties of CSCs in cancers and discuss the possible challenges in targeting CSCs for cancer treatment. [Cell Mol Life Sci] Abstract
Targeting Cancer Stem Cells Using Immunologic Approaches
Wicha, M; Chang, A; Yingxin, X; Xiaolian, Z; Ning, N; Liu, Shuang, Q, L; Pan, Q
Stem Cells 2015-04-15 4.15 | Apr 22
Targeting Notch, Hedgehog, and Wnt Pathways in Cancer Stem Cells: Clinical Update
Ivy, P; Takebe, N
Nat Rev Clin Oncol 2015-04-07 4.14 | Apr 15
Hypoxia-Inducible Factors in Cancer Stem Cells and Inflammation
Liu, Y; Peng, G
Trends Pharmacol Sci 2015-04-06 4.14 | Apr 15
NANOG in Cancer Stem Cells and Tumor Development: An Update and Outstanding Questions
Tang, D; Chao, HP; Wang, J; Yang, Tao; Jeter, C
Stem Cells 2015-03-26 4.12 | Apr 1

Two Genes Control Breast Cancer Stem Cell Proliferation and Tumor Properties

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Personalized Medicine in Cancer [Chapter 3]

Writer and Curator:  Larry H Bernstein, MD, FCAP

Personalized Medicine in Cancer

This chapter has the following ten Subsection:

3.1 The path to personalized medicine

3.2 Role of Nanobiotechnology in Developing Personalized Medicine for Cancer

3.3 The HER-2 Receptor and Breast Cancer: Ten Years of Targeted
Anti–HER-2 Therapy and Personalized Medicine

3.4 Personalized Medicine is not yet here

3.5 Biomarkers for personalized oncology: recent advances and future challenges.

3.6 Personalized oncology: recent advances and future challenges.

3.7  Pharmacogenomic biomarkers for personalized cancer treatment.

3.8 Limits to forecasting in personalized medicine: An overview

3.9 The genome editing toolbox: a spectrum of approaches for targeted modification

3.10 The Path to Personalized Medicine


3.1 The path to personalized medicine

Joanne M Meyer* and Geoffrey S Ginsburg
Current Opinion in Chemical Biology 2002, 6:434–438

Advances in personalized medicine, or the use of an individual’s molecular profile to direct the practice of medicine, have been greatly enabled through human genome research. This research is leading to the identification of a range of molecular markers for predisposition testing, disease screening and prognostic assessment, as well as markers used to predict and monitor drug response. Successful personalized medicine research programs will not only require strategies for developing and validating biomarkers, but also coordinating these efforts with drug discovery and clinical development.

The realization of personalized medicine, or the fine tailoring of the practice of medicine to an individual, is being fostered through numerous efforts aimed at characterizing individual differences in molecular processes underlying disease pathogenesis, disease progression and the response to therapeutics. Once these molecular differences are understood, therapeutic development will be enhanced by using the information to identify individuals more likely to benefit from a given intervention strategy. High-throughput genomic technologies are already providing the data that will serve as the foundation of personalized medicine.

Individual differences in the development of disease and response to therapeutics
Clearly, for many common diseases, there is abundant evidence to suggest that the molecular underpinnings of disease susceptibility, and its natural history, differ markedly among individuals. For example, while it has been demonstrated in numerous investigations that the development of obesity, asthma, type 2 diabetes and cardiovascular disease are under genetic control [1–4], there is no evidence to suggest that the genetic basis is due to variation in just a single gene. Instead, the consensus has emerged that subtle genetic differences in one or many of several genes serve as risk factors for these illnesses. Thus, while genetic variants in the melanocortin-4 receptor may explain some risk for developing obesity [5], and polymorphisms in PPARgamma may correlate with the risk of developing type 2 diabetes [6•], these variants do not explain all of these genetic diseases. There are certainly more genetic variants, or predisposition markers, to uncover. In the context of personalized medicine, the ultimate goal of these types of studies is to provide a suite of markers that can be used to assess one’s lifetime risk of developing disease in the presence of various environmental (e.g. diet, lifestyle) variables.

As with disease predisposition, individual differences characterize disease progression. For example, some individuals with impaired glucose tolerance will proceed quite rapidly to type 2 diabetes, whereas others proceed slowly. Similarly, individuals diagnosed with rheumatoid arthritis may or may not develop erosive disease. In both of these cases, genetic variation, that is, variation measured at the DNA level, may be a good predictor of the individual differences that emerge as disease progresses. For example, Brinkman et al. [7] have demonstrated that a polymorphism in TNF-α correlates with erosive rheumatoid arthritis, but shows no association with non-erosive disease. Alternatively, variation in disease progression may be best predicted by a combination of genetic and environmental factors, the impact of which is indexed through changes in gene expression in relevant tissues, or changes in secreted protein levels in serum or synovial fluid. In our laboratories, we are using a range of genomics technologies to find markers for disease progression that are both stable (DNA) as well as dynamic (mRNA, protein), giving us the opportunity to evaluate the utility of both types of markers in prospective studies.

Given that individual variability in disease predisposition and progression exists and has the potential of being molecularly characterized, it is not at all surprising that such differences also characterize response to therapeutics (see Figure 1). Marked individual variation in the efficacy and toxicity of therapeutic compounds is common and can have a profound impact on the success of a pharmaceutical clinical development program. Clearly, molecular markers that predict the variation in these endpoints could be extremely useful in clinical trials, drug development and clinical practice, as they would allow the identification of patients who would benefit most from the drug.

Technological advances drive broad biomarker discovery. While the existence of individual differences in disease predisposition, progression and response to therapeutics is far from a novel concept, our ability to comprehensively measure the molecular markers that track these processes, and draw proper inferences from large amounts of molecular data, is novel. Over the past decade, significant advancements have been made in technologies to discover variation at the mRNA, DNA and protein levels. Indeed, with the advent of glass and nylon microarray technologies for gene-expression studies, it is quite feasible to characterize the expression levels of 30 000 genes in tissue samples from dozens, if not hundreds, of individuals. Certainly, several years ago, although it would have been theoretically possible to assess this number of genes using northern blot analysis, it never would have been undertaken in a sample from even a single individual. In the same fashion, highthroughput technologies for DNA polymorphism discovery and single nucleotide polymorphism (SNP) genotyping, coupled with broad academic and commercial initiatives to characterize genetic variation genome-wide [8•], are resulting in catalogs of variants that can be used in large-scale experiments. To complement these efforts, searches for ‘haplotype blocks’, or correlated patterns of SNPs that can be adequately represented by fewer SNPs, are underway and have the promise of reducing the amount of genotyping required for genome-wide searches [9•,10•]. For proteinbased discovery initiatives, traditional 2D electrophoresis experiments are used in conjunction with advanced mass spectrometry to discover protein markers in a range of complex fluids, including serum, plasma, synovial fluid and cerebral spinal fluid.

Coupled with the advent of these technologies have been extensive efforts to collect appropriate tissues and fluids for mRNA, DNA and protein analysis. These collections have been part of pharmaceutical clinical trials, as well as clinical studies established for the purpose of characterizing biomarkers. The latter studies may involve small numbers of patient samples for initial biomarker discovery efforts, as well as large-scale, disease registry initiatives designed to evaluate and, in some cases, prospectively validate, biomarkers in the relevant patient populations.

Figure 1  (not shown) The role of molecular biomarkers in disease management. Areas where molecular biomarkers will benefit personalized medicine include disease predisposition, screening and prognosis, as well as drug response and drug monitoring. The nature of the markers (DNA, mRNA or protein) will vary with the disease and the stage of their application. Rx indicates treatment.

The predictive value of biomarkers The impact that advanced genomic technologies and carefully designed biomarker studies will have on the personalization of medicine is foreshadowed in the current literature. For example, Mallal et al. [13•] conducted a pharmacogenetic investigation (i.e. a genetic study of drug response) of abacavir, an HIV-1 nucleoside reverse transcriptase inhibitor. They implicated MHC alleles that predict response to hypersensitivity among 5% of the HIV cases receiving the drug. Their findings suggest that screening patients for the presence of the predisposing MHC haplotype could reduce the prevalence of hypersensitivity to abacavir from 9% to 2.5%. While this study is small in scale in its characterization of genetic variation, it adds to the existing literature on several other variants (including those in MDR1, the multidrug transporter P-glycoprotein and CYP2D6, a cytochrome P450 isoszyme) that correlate with the pharmacokinetic (drug clearance) characteristics of protease inhibitors and non-nucleoside reverse transcriptase inhibitors [14]. Additionally, genetic polymorphisms in chemokines and chemokine receptors (including RANTES, MIP-1α and CCR5) have been found to correlate with both the susceptibility to HIV-1 infection and the progression of disease [15•]. Taken together, these findings may lead to the development of a panel of polymorphisms that would personalize HIV therapy, by determining when to initiate therapy and how to choose compounds that will maximize efficacy and minimize adverse effects.

Figure 2 (not shown) Personalized medicine — integrating drug discovery and development through molecular medicine. Genomically derived biomarkers are being identified throughout the drug discovery and clinical development process. They will not only support personalized medicine, but will also enhance drug discovery and clinical development by generating new targets, validating targets and identifying patients that will benefit from novel therapeutics.

Pharmacogenetic efforts have also successfully characterized polymorphisms that correlate with response to asthma therapeutics. For example, Drazen et al. [16•] showed that a promotor polymorphism in 5-lipoxygenase, which alters transcription levels of the gene, also correlates with response to a derivative of the drug Zileuton, a 5-lipoxygenase inhibitor. Of the individuals who did not respond to Zileuton, 20% carried rare variant alleles at this locus. By contrast, all of the responders had wild-type alleles. Similarly in a study of genetic polymorphisms of the β-adrenergic receptor, Drysdale et al. [17•] demonstrated that a haplotype, or SNP signature across the gene, correlated strongly with asthma patients’ response to β-agonists. These two examples again demonstrate the possibility of using an individual’s genotype to suggest a therapeutic strategy that is more likely to be efficacious. Certainly, before such tests are incorporated into clinical practice, additional genetic markers would have to be coupled with the existing polymorphisms to make the resulting tests highly sensitive and specific.

In addition to these DNA-based strategies, recent applications of proteomics and expression profiling have generated a range of screening, prognostic and drug-response or ‘pharmacogenomic’ biomarkers. Many advances in the use of these technologies have been in oncology, where there is a tremendous need for serum-based screening markers and where tissue samples for expression profiling studies are easily obtained. For example, Petricoin et al. [18•] demonstrated that proteomic spectra, derived from a mass spectrometry analysis of serum, could be used to distinguish women with ovarian cancer from unaffected women. Indeed, the protein markers on a ‘training set’ of 100 samples and a validation set of 110 additional samples, had a sensitivity of 100% and a specificity of 94%. These encouraging results suggest that a serum-based protein assay may indeed become a viable mode of ovarian cancer screening in the general population. mRNA strategies for identifying prognostic markers for cancers have also proved successful. For example, in our collaborative studies [19•], we have shown that Melastatin, a melanocyte-specific gene identified through a genomics analysis of benign and malignant melanoma, is an effective prognostic marker for cutaneous malignant melanoma. In this work, uniform melastatin mRNA expression correlated strongly with disease-free survival, even after adjusting for other prognostic factors. In a similar fashion, mRNA strategies have generated pharmacogenomic markers for ovarian cancer. Hartmann et al. [20] studied the expression of 30 000 human genes in 51 tumors that were sensitive and resistant to platinum–paclitaxel chemotherapy and identified a subset of 10 markers that were highly predictive of outcome in an independent sample of tumors. Overall, these examples of biomarker studies in oncology demonstrate the broad application such markers will have for cancer screening, prognosis and response to therapeutics.

Turning biomarker discoveries into personalized medicines All of the examples cited provide excellent demonstrations of the power of new technologies to deliver a range of biomarkers that index individual differences in disease predisposition, progression and response to therapeutics. Thus, they clearly form a basis for the ‘personalization’ of medicine. However, the discovery of these markers is not sufficient for the pharmaceutical industry to deliver personalized medicines. Indeed, the delivery of such medicines will require the careful integration of biomarker discovery and validation programs into drug discovery and clinical development programs (see Figure 2). This integration will serve two key purposes. First, and foremost, by initiating SNP, expression profiling and proteomics biomarker programs early on in the drug discovery process, one can carefully weave the discovery and validation of biomarkers into drug discovery and development timelines; the risk of ‘retro-fitting’ biomarker programs to a clinical trial would be avoided.

Conclusions Clearly, several challenges remain to achieve a successful integration of large-scale, biomarker studies with drug development. While there has been an incredible advance in high-throughput, molecular technologies, over the past several years, further improvements in technologies and validation strategies are required to capture the true extent of individual differences in molecular markers. For example, although it is plausible to consider screening the genome for SNPs or haplotypes that correlate with disease pre-disposition or drug response, the current cost of SNP genotyping makes this impractical. Additionally, bioinformatic and statistical advances are needed to extract the most relevant data from the wealth of molecular information generated by new technologies, and these advances must be effectively communicated to the heath-care environment. Finally, and most importantly, plans must be in place to provide adequate validation for the enormous number of candidate biomarkers that will emerge from the studies. Validation will require access to large, and in some cases, prospective, collections of well annotated clinical samples with appropriate consent and security issues addressed. While these issues, as well as the commercial and regulatory considerations around the development of personalized medicines, are indeed challenging, the successful execution of biomarker programs will have an enormous impact on our ability to tailor medical practice to the individual.

3.2 Role of Nanobiotechnology in Developing Personalized Medicine for Cancer

K. K. Jain
Technol Cancer Res Treat Dec 2005; 4(6): 645-650

Personalized medicine simply means the prescription of specific therapeutics best suited for an individual. Personalization of cancer therapies is based on a better understanding of the disease at the molecular level. Nanotechnology will play an important role in this area. Nanobiotechnology is being used to refine discovery of biomarkers, molecular diagnostics, drug discovery and drug delivery, which are important basic components of personalized medicine and are applicable to management of cancer as well. Examples are given of the application of quantum dots, gold nanoparticles, and molecular imaging in diagnostics and combination with therapeutics – another important feature of personalized medicine. Personalized medicine is beginning to be recognized and is expected to become a part of medical practice within the next decade. Personalized management of cancer, facilitated by nanobiotechnology, is expected to enable early detection of cancer, more effective and less toxic treatment increasing the chances of cure.

3.3 The HER-2 Receptor and Breast Cancer: Ten Years of Targeted Anti–HER-2 Therapy and Personalized Medicine

Jeffrey S. Ross,  Elzbieta A. Slodkowska,  W. Fraser Symmans, et al.
The Oncologist 2009; 14:320 –368


  1. Contrast the current strengths and limitations of the three main slide-based techniques (IHC, FISH, and CISH) currently in clinical use for testing breast cancer tissues for HER-2 status.
  2. Compare the efficacy of trastuzumab- and lapatinib-based regimens in the adjuvant and metastatic settings as reported in published clinical trials and regulatory approval databases.
  3. Contrast the list of biomarkers that have been associated with clinical resistance to trastuzumab and lapatinib and describe their current level of validation.

The human epidermal growth factor receptor (HER-2) oncogene encodes a transmembrane tyrosine kinase receptor that has evolved as a major classifier of invasive breast cancer and target of therapy for the disease. The validation of the general prognostic significance of HER-2 gene amplification and protein overexpression in the absence of anti–HER-2 targeted therapy is discussed in a study of 107 published studies involving 39,730 patients, which produced an overall HER-2– positive rate of 22.2% and a mean relative risk for overall survival (OS) of 2.74. The issue of HER-2 status in primary versus metastatic breast cancer is considered along with a section on the features of metastatic HER- 2–positive disease. The major marketed slide-based HER-2 testing approaches, immunohistochemistry, fluorescence in situ hybridization, and chromogenic in situ hybridization, are presented and contrasted in detail against the background of the published American Society of Clinical Oncology–College of American Pathologists guidelines for HER-2 testing. Testing issues, such as the impact of chromosome 17 polysomy and local versus central HER-2 testing, are also discussed. Emerging novel HER-2 testing techniques, including mRNA-based testing by real-time polymerase chain reaction and DNA microarray methods, HER-2 receptor dimerization, phosphorylated HER-2 receptors, and HER-2 status in circulating tumor cells, are also considered. A series of biomarkers potentially associated with resistance to trastuzumab is discussed with emphasis on the phosphatase and tensin homologue deleted on chromosome ten/Akt and insulin-like growth factor receptor pathways. The efficacy results for the more recently approved small molecule HER- 1/HER-2 kinase inhibitor lapatinib are also presented along with a more limited review of markers of resistance for this agent. Additional topics in this section include combinations of both anti–HER-2 targeted therapies together as well as with novel agents including bevacizumab, everolimus, and tenespimycin. A series of novel HER-2–targeting agents is also presented, including pertuzumab, ertumaxomab, HER-2 vaccines, and recently discovered tyrosine kinase inhibitors. Biomarkers predictive of HER-2 targeted therapy toxicity are included, and the review concludes with a consideration of HER-2 status in the prediction of response to non–HER-2 targeted treatments including hormonal therapy, anthracyclines, and taxanes.

Biology, Pathology, Diagnosis, And Clinical Significance Of Her-2–Positive Breast Cancer

The human epidermal growth factor receptor 2 (HER-2, HER-2/neu, c-erbB-2) gene, first discovered in 1984 by Weinberg and associates [1], is localized to chromosome 17q and encodes a transmembrane tyrosine kinase receptor protein that is a member of the epidermal growth factor receptor (EGFR) or HER family (Fig. 1) [2]. This family of receptors is involved in cell– cell and cell–stroma communication primarily through a process known as signal transduction, in which external growth factors, or ligands, affect the transcription of various genes, by phosphorylating or dephosphorylating a series of transmembrane proteins and intracellular signaling intermediates, many of which possess enzymatic activity. Signal propagation occurs as the enzymatic activity of one protein turns on the enzymatic activity of the next protein in the pathway [3]. Major pathways involved in signal transduction, including the Ras/mitogen-activated protein kinase pathway, the phosphatidylinositol 3 kinase (PI3K)/Akt pathway, the Janus kinase/signal transducer and activator of transcription pathway, and the phospholipase C pathway, ultimately affect cell proliferation, survival, motility, and adhesion. Receptor activation requires three variables, a ligand, a receptor, and a dimerization partner [4]. After a ligand binds to a receptor, that receptor must interact with another receptor of identical or related structure in a process known as dimerization in order to trigger phosphorylation and activate signaling cascades. Therefore, after ligand binding to an EGFR family member, the receptor can dimerize with various members of the family (EGFR, HER-2, HER-3, or HER-4). It may dimerize with a like member of the family (homodimerization) or it may dimerize with a different member of the family (heterodimerization). The specific tyrosine residues on the intracellular portion of the HER-2/neu receptor that are phosphorylated, and hence the signaling pathways that are activated, depend on the ligand and dimerization partner. The wide variety of ligands and intracellular crosstalk with other pathways allow for significant diversity in signaling. Although no known ligand for the HER-2 receptor has been identified, it is the preferred dimerization partner of the other family members. HER-2 heterodimers are more stable [5, 6] and their signaling is more potent [7] than receptor combinations without HER-2. HER-2 gene amplification and/or protein overexpression has been identified in 10%–34% of invasive breast cancers [1]. Unlike a variety of other epithelial malignancies, in breast cancer, HER-2 gene amplification is uniformly associated with HER-2 (p185neu) protein overexpression and the incidence of single copy overexpression is exceedingly rare [8]. HER-2 gene amplification in breast cancer has been associated with increased cell proliferation, cell motility, tumor invasiveness, progressive regional and distant metastases, accelerated angiogenesis, and reduced apoptosis [9].When classified by routine clinicopathologic parameters and compared with HER-2– negative tumors, HER-2–positive breast cancer is more often of intermediate or high histologic grade, more often lacking estrogen receptors (ERs) and progesterone receptors (PgRs) (ER and PgR negative), and featuring positive lymph node metastases at presentation [1]. In the recent molecular classification of breast cancer, positive HER-2 status does not constitute a unique molecular category and is identified in both the “HER-2” and “luminal” tumor classes [10].

Figure 1 (not shown)

Figure 1. The human epidermal growth factor receptor (HER) gene family. This image depicts the complex crosstalk between members of the HER family of receptor tyrosine kinases and intracellular signaling. Activated HER receptors can function to both stimulate and inhibit downstream signaling of members of other biologic pathways. Note that HER-2 has no activating ligands and HER-3 lacks a tyrosine kinase domain. HER-2–mediated signaling is associated with cell proliferation, motility, resistance to apoptosis, invasiveness, and angiogenesis. The figure shows the complexity of signaling pathways initiated by, and influenced by, HER family protein receptors at the cell surface.

HER-2 Status and Prognosis in Breast Cancer Both morphology-based and molecular-based techniques have been used to measure HER-2/neu status in breast cancer clinical samples [11–117]. By a substantial majority, abnormalities in HER-2 expression at the gene, message, or protein level have been associated with adverse prognosis in both lymph node–negative and lymph node–positive breast cancer. Of the 107 studies considering 39,730 patients listed in Table 1, 95 (88%) of the studies determined that either HER-2 gene amplification or HER-2 (p185 neu) protein overexpression predicted breast cancer outcome on either univariate or multivariate analysis. In 68 (73%) of the 93 studies that featured multivariate analysis of outcome data, the adverse prognostic significance of HER-2 gene, message, or protein overexpression was independent of all other prognostic variables. In only 13 (12%) of the studies, no correlation between HER-2 status and clinical outcome was identified. Of these 13 noncorrelating studies, eight (62%) used immunohistochemistry (IHC) on paraffin-embedded tissues as the HER-2/protein detection technique, two (15%) used fluorescence in situ hybridization (FISH), two (15%) used Southern analysis, and one (7%) used a real-time polymerase chain reaction (RT-PCR) technique. Of the 15 studies that used the FISH technique, 13 (87%) showed univariate prognostic significance of gene amplification, and 11 of these (85%) showed prognostic significance on multivariate analysis as well. The two studies that used chromogenic in situ hybridization (CISH) HER-2 gene amplification detection techniques both found that HER-2 amplification was an independent predictor of outcome on multivariate analysis [100, 112]. However, interpretation of these studies is complicated by the fact that most studies included patients who received variable types of systemic adjuvant therapy; therefore, the pure prognostic value of HER-2 overexpression in the absence of any systemic adjuvant therapy is incompletely understood.

Table 1 HER-2 status and prognosis in breast cancer (not shown)

HER-2 Positivity Rates The frequency of HER-2 positivity in all of the studies presented in Table 1 was 22.2%, with a range of 9%–74%. The HER-2–positive rate was similar for IHC, at 22% (range, 10%–74%), and FISH, at 23.9% (range, 14.7%– 68%). In current practice, HER-2–positive rates have trended below 20%, with most investigators currently reporting that the true positive rate is in the range of 15%–20%. The HER-2– positive rate may be higher when metastatic lesions are tested, and tertiary hospitals and cancer centers report slightly higher rates than community hospitals and national reference laboratories. Relative Risk and Hazard Ratio In Table 1, a number of studies provided data as to the relative risk (RR) of untreated HER-2–positive breast cancer being associated with an adverse clinical outcome. For OS, the mean RR was 2.74 (range, 1.39 – 6.93) and the median was 2.33; for disease-free survival (DFS), the mean RR was 2.04 (range, 1.30 –3.01) and the median was 1.8. In several studies, the RR was estimated with a hazard ratio (HR) model. The mean HR was 2.12 (range, 1.6 –2.7) and the median was 2.08. HER-2 Expression and Breast Pathology The association of HER-2–positive status with specific pathologic conditions of the breast is summarized in Table 2. HER-2 overexpression has been consistently associated with higher grades and extensive forms of ductal carcinoma in situ (DCIS) and DCIS featuring comedo-type necrosis [118 –121]. The incidence of HER-2 positivity in DCIS has varied in the range of 24%–38% in the published literature, which appears to be slightly higher than that for invasive breast cancer [118 –121]. Routine testing for HER-2 status in DCIS is not widely performed. However, should anti– HER-2 targeted therapies directed at HER-2–positive DCIS result in a reduction in the development of invasive disease, the widespread use of HER-2 testing in DCIS would be adopted. Finally, the invasive carcinoma that develops in association with HER-2–positive DCIS may, on occasion, not feature a HER-2–positive status, a finding that has led investigators to believe that HER-2 gene amplification may not be required for the local progression of breast cancer [122]. Compared with invasive ductal carcinoma (IDC), HER-2 gene amplification occurs at a significantly lower rate in invasive lobular carcinoma (ILC) (10%), but has also been linked to an adverse outcome [85]. HER-2 positivity is linked exclusively to the pleomorphic variant of ILC and is not encountered in classic ILC [123]. HER-2 amplification is strongly correlated with tumor grade in both IDC and ILC. For example, in one study, only one of 73 grade I IDC cases and one of 67 low-grade classic ILC cases showed HER-2 amplification detected by FISH [86]. HER-2 overexpression and HER-2 amplification have been a consistent feature of both mammary and extramammary Paget’s disease [124, 125] (Fig. 2). HER-2 amplification and HER-2 overexpression have been associated with adverse outcome in some studies of male breast carcinoma [126 –129], but not in others [130 –132]. The incidence of HER-2 positivity appears to be lower in male breast cancer than in female breast cancer [126 –132]. Documented responses in male breast cancer to HER-2–targeting agents have been described, and therefore treatment with trastuzumab is an acceptable option for these patients, but the true activity rate remains uncertain [133]. The rate of HER-2 overexpression in mucinous (colloid) breast cancers is extremely low, although, on occasion, it has been associated with aggressive disease [134 –136]. In medullary breast carcinoma, HER-2 testing has consistently found negative results [137]. Similarly, HER-2 positivity is extremely rare in cases of tubular carcinoma [138]. HER-2 status has not been consistently linked to the presence of inflammatory breast cancer [139, 140]. Molecular studies of hereditary breast cancer including cases with either BRCA1 or BRCA2 germline mutations have found a consistently lower incidence of HER-2–positive status for these tumors [141].

Figure 2 not shown

Figure 2. Human epidermal growth factor receptor (HER)-2–positive Paget’s disease of the nipple. In this patient, who presented with HER-2–positive invasive duct carcinoma, classic clinical features of Paget’s disease of the nipple were present. A section of the nipple from the mastectomy specimen shows 3+ continuous cell membrane immunoreactivity for HER-2 protein. Nearly 100% of Paget’s disease of the breast cases are HER-2 positive (see text).

Breast sarcomas and phyllodes tumors have consistently been HER-2 negative [142]. Finally, low-level HER-2/neu overexpression has been identified in benign breast disease biopsies and is associated with a greater risk for subsequent invasive breast cancer [143].

HER-2 Status in Primary Versus Metastatic Breast Cancer The majority of studies that have compared the HER-2 status in paired primary and metastatic tumor tissues have found an overwhelming consistency in the patient’s status regardless of the method of testing (IHC versus FISH) [144 –151]. However, several recent studies indicated 20%–30% discordance rates between the HER-2 status of primary and metastatic lesions. Some of these studies have featured relatively high HER-2–positive rates on both paired specimens (> 35% positive), which has created concern about the conclusions of these reports [152]. Also, considering that 10%–30% discordance rates have been reported even when the same tumor is tested repeatedly, it remains uncertain if the discordance rates seen between primary and metastatic sites is higher than expected by the less than perfect reproducibility of the various HER-2 assays. Increasingly, emerging data suggest that there are changes in HER-2 expression between primary and metastatic disease. This is particularly true after intervening HER-2– directed therapy, but also happens in the absence of such treatment. In cases where the original primary HER-2 test result is questioned because of technical or interpretive issues and in patients where there has been an unusually long (i.e., > 5-year) interval between the primary occurrence and the detection of metastatic disease, retesting of a metastatic lesion may be warranted. Thus, although routine HER-2 testing of metastatic disease is advocated by some investigators, the preponderance of data indicates that the HER-2 status remains stable and that routine retesting of HER-2 may not be needed for most patients with metastatic disease.

Features of Metastatic HER-2–Positive Breast Cancer Metastatic HER-2–positive breast cancer retains the phenotype of the primary tumor not only in HER-2 status, but also is typically ER/PgR negative, moderate to high tumor grade, DNA aneuploid with high S phase fraction, and featuring ductal rather than lobular histology. In the era prior to the initiation of HER-2–targeted therapy, HER-2–positive breast cancer was more likely to spread early to major visceral sites including the axillary lymph nodes, bone marrow, lungs, liver, adrenal glands, and ovaries [153]. In the post–HER-2 targeted therapy era, the incidence of progressive visceral metastatic disease in HER-2–positive tumors has diminished and has frequently been superseded by the development of clinically significant central nervous system (CNS) metastatic disease [154 –157]. It is widely held that the success in the control of visceral disease with trastuzumab has unmasked previously occult CNS disease and, because of the inability of the therapeutic antibody to cross the blood– brain barrier, allowed brain metastases to progress during the extended OS duration of treated patients [154, 155]. The small-molecule drug lapatinib has shown some promise for targeting HER-2–positive CNS metastases that are resistant to trastuzumab-based therapies in initial studies [158].

Interaction of HER-2 Expression with Other Prognosis Variables HER-2 gene amplification and protein overexpression have been associated consistently with high tumor grade, DNA aneuploidy, high cell proliferation rate, negative assays for nuclear protein receptors for estrogen and progesterone, p53 mutation, topoisomerase IIa amplification, and alterations in a variety of other molecular biomarkers of breast cancer invasiveness and metastasis [159 –161].

Figure 3. Human epidermal growth factor receptor (HER)-2 testing.
(not shown)  (A): Immunohistochemistry (IHC). This panel depicts the four categories of HER-2 IHC staining including 0 and 1+ (negative), 2+ (equivocal), and 3+ (positive) using the American Society of Clinical Oncology–College of American Pathologists guidelines for HER-2 IHC scoring. (B): Fluorescence in situ hybridization (FISH). This panel demonstrates a case of invasive duct carcinoma, on the left, negative for HER-2 gene amplification (gene copy number < 4) and a case of HER-2 gene–amplified breast cancer (gene copy number > 6),

FISH. The FISH technique (Fig. 3B), like IHC, is a morphology-driven slide-based DNA hybridization assay using fluorescent-labeled probes. Both the hybridization steps and the slide scoring can be automated. FISH has the advantages of a more objective scoring system and the presence of a built-in internal control consisting of the two HER-2 gene signals present both in benign cells and in malignant cells that do not feature HER-2 gene amplification.

IHC Versus FISH. Although the FISH method is more expensive and time-consuming than IHC, numerous studies have concluded that this cost is well borne by the greater accuracy and more precise use of anti–HER-2 targeted therapies [179 –180, 182–183]. FISH is considered to be more objective and reproducible in a number of systematic reviews [165, 180, 183–186]. In one study, the concordance rates between IHC and FISH were highest in tumors scored by IHC as 0 and 1+ and lowest for 2+ and 3+ cases [183]. Currently, the majority (approximately 80%) of HER-2 testing in the U.S. commences with a screen by IHC, with results of 0 and 1+ considered negative, 2+ considered equivocal and referred for FISH testing, and 3+ considered positive. In a pharmacoeconomic study of patients being considered for trastuzumab-based treatment for HER-2– positive tumors, FISH was found to be a cost-effective diagnostic approach “from a societal perspective” [187].

CISH and Silver In Situ Hybridization. The CISH method (Fig. 3E) and silver in situ hybridization (SISH) method feature the advantages of both IHC (routine microscope, lower cost, familiarity) and FISH (built-in internal control, subjective scoring, the more robust DNA target) [190, 191]. The CISH technique uses a single HER-2 probe, detects HER-2 gene copy number only, and was recently approved by the FDA to define patient eligibility for trastuzumab treatment. The SISH method employs both HER-2 and chromosome 17 centromere probes hybridized on separate slides and is currently under review by the FDA. Numerous studies have confirmed a very high concordance between CISH and FISH, typically in the 97%–99% range [191–203]. Similar to FISH, CISH has its highest correlation with IHC 0, 1+, and 3+ results and lowest correlation with IHC 2+ staining.

Chromosome 17 Polysomy. The incidence of chromosome 17 polysomy has varied from as low as 4% to as high as 30% in studies of invasive breast cancer [204 –208]. This may reflect differences in the definition of polysomy ranging from a low-level definition of more than two copies per cell to a high of more than four copies per cell of the chromosome. Most studies have linked chromosome 17 polysomy with greater HER-2 protein overexpression [204 –207], but some have found that protein overexpression only occurs in the presence of selective HER-2 gene amplification [204].

The 2007 ASCO-CAP Guidelines. In early 2007, a combined task force from ASCO and the CAP issued a series of recommendations designed to improve the accuracy of tissue-based HER-2 testing in breast cancer [212]. A summary of the ASCO-CAP guidelines is provided in Table 4. Highlights of these recommendations include (a) standardizing fixation in neutral-buffered formalin for no less than 6 hours and no more than 48 hours, (b) unlike their respective FDA-approval specifications, defining equivocal zones for the IHC, FISH, and CISH tests, (c) establishing a standardized quality assurance program for testing laboratories, and (d) requiring the participation of these laboratories in a proficiency testing program [212]. The published guidelines were designed to improve the overall precision and reliability of all types of slide-based HER-2 tests and remained neutral as to the relative superiority of one test over the others.

Figure 4. Real-time polymerase chain reaction (RT-PCR). In this RT-PCR assay using the Taqman RT-PCR System (Applied Biosystems Inc., Foster City, CA), note the detection of increased human epidermal growth factor receptor(HER)-2 mRNA expression in green detected at lower numbers of amplification cycles compared with the two housekeeping genes shown in red and blue.

Figure 5. DNA microarray. In this image, increased expression of human epidermal growth factor receptor (HER)-2 mRNA has been detected using a proprietary DNA microarray system (Millennium Pharmaceuticals, Inc., Cambridge, MA). The microarray demonstrates the coexpression of seven genes (HER-2 is second from the bottom) related to the amplification of HER-2 DNA in this case of HER-2–positive breast cancer.

Her-2–Targeted Therapy and the Treatment of Her-2–Positive Breast Cancer

Trastuzumab: HER-2 Testing and the Prediction of Response to Trastuzumab Therapy Using recombinant technologies, trastuzumab (Herceptin; Genentech, South San Francisco, CA), a monoclonal IgG1 class humanized murine antibody, was developed by the Genentech Corporation to specifically bind the extracellular portion of the HER-2 transmembrane receptor. This antibody therapy was initially targeted specifically for patients with advanced relapsed breast cancer that overexpresses HER-2 protein [262]. Since its launch in 1998, trastuzumab has become an important therapeutic option for patients with HER-2–positive breast cancer and is widely used for its approved indications in both the adjuvant and metastatic settings (Fig. 6) [185, 263–265]. Although trastuzumab is approved as a single-agent regimen, most patients are treated with trastuzumab plus cytotoxic agents. Table 5 summarizes the significant clinical trials that contributed to the regulatory approvals of trastuzumab.

This topic is scheduled for another article.

Trastuzumab Combinations. Since the FDA approval in 1998 of two trastuzumab plus chemotherapy combinations, a number of additional approaches have gained favor in the clinical practice community. The National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines [284] currently recommend the following regimens for the first-line treatment of HER-2–positive MBC: trastuzumab plus single agents— either paclitaxel (every 3 weeks or weekly), docetaxel (every 3 weeks or weekly), or vinorelbine (weekly). For combination therapies, the NCCN recommends trastuzumab plus paclitaxel and carboplatin (every 3 weeks) or docetaxel plus carboplatin. Recently, carboplatin-based trastuzumab combinations have gained interest as a result of both the apparent boost in efficacy as measured by a higher overall response rate and longer progression-free survival time and the cardioprotective benefits of avoiding an anthracycline-containing regimen [285].

Neoadjuvant Setting The results of trastuzumab-based neoadjuvant studies (Table 5) have received significant recent interest in the oncology community [289]. Virtually all completed and in progress clinical trials have demonstrated a significant enhancement in the rate of pathologic complete response (pCR), the primary endpoint in these studies, in cases of patients with HER-2–positive breast cancer that received trastuzumab in the neoadjuvant setting [290 –297]. This benefit of the addition of trastuzumab in the neoadjuvant setting appears to be independent of, if not enhanced by, the coexistence of ER positivity [297]. Among the potential explanations for the apparent greater chemosensitivity of HER-2–positive tumors cotreated with trastuzumab in the neoadjuvant setting is the concept that HER-2 gene amplification is in some way related to the growth and survival of breast cancer stem cells [298, 299].

Biomarkers of Trastuzumab Resistance Since trastuzumab was introduced for the treatment of MBC in 1998, there has been growing interest in the discovery and potential clinical utility of biomarkers designed to predict resistance to the drug. Current approaches to HER-2 testing provide a negative predictor of drug response: the test does not predict which patients will respond to trastuzumab, it predicts which patients are unlikely to benefit.

Neoadjuvant Setting The Neo-ALTTO trial is a randomized, open-label, multicenter, phase III study comparing the efficacy of neoadjuvant lapatinib plus paclitaxel with that of trastuzumab plus paclitaxel and with concomitant lapatinib and trastuzumab plus paclitaxel given as neoadjuvant treatment in HER-2– positive primary breast cancer [337].

Biomarkers of Lapatinib Resistance In that lapatinib was approved 9 years after trastuzumab, considerably less information has been published concerning markers of efficacy or resistance to the drug [331, 341– 343].

Trastuzumab Since its introduction in the MBC setting and continuing throughout its advance into use in both the adjuvant and neoadjuvant settings, trastuzumab has been associated with the development of a variety of toxicities [384]. In the original registration trial for MBC, trastuzumab was associated with a variety of adverse events, including pain, gastrointestinal disturbances, minor hematologic deficiencies, pulmonary symptoms, and congestive heart failure (CHF) [265]. Cardiac toxicity has remained the most significant limiting factor for the use of trastuzumab [384 –389]. A major consideration in the development of cardiac toxicity in patients treated with trastuzumab has been their prior or concomitant exposure to anthracycline drugs, also associated with dose-dependent irreversible heart damage [384 – 389].

Lapatinib The most frequent adverse reactions in the lapatinib– capecitabine registration trial for MBC combination were diarrhea (65%), palmar–plantar erythrodysesthesia (53%), nausea (44%), rash (28%), vomiting (26%), and fatigue (23%) [332]. In a comprehensive analysis of the clinical trials featuring lapatinib in combination with various other agents, the overall incidence of LVEF decline was 1.6%, with 0.2% of patients experiencing symptomatic CHF [389].

HER-2 Status and the Prediction of Response to Non–HER-2 Targeted Therapy The use of HER-2 status to predict responsiveness or resistance to hormonal therapies, advocated by a number of oncologists, remains controversial. It has been reported that ER-positive/HER-2–positive patients are either less responsive or completely resistant to single-agent tamoxifen [391–393]. When measured as continuous variables, the expression of HER-2 appears to be inversely related to the expression of ER and PgR even in hormone receptor–positive tumors [394].

Anthracyclines HER-2 overexpression has also been associated with enhanced response rates to anthracycline-containing chemotherapy regimens in most, but not all, studies [42, 410 – 414].

Radiation Therapy Initially, in the era prior to the introduction of anti–HER-2 targeted therapy, HER-2–positive status was associated with a higher rate of local recurrence in some studies of breast cancer treated with surgery and radiation therapy alone, but not in others [427– 429]. However, although large-scale, randomized, prospective studies are lacking, HER-2–positive tumors treated with trastuzumab-based neoadjuvant chemotherapy combined with external-beam radiation have indicated a favorable response in locally advanced breast cancer [430].

Summary The history of the discovery of the HER-2 oncogene in an animal model in 1984, the translation of this finding to the clinical behavior of human breast cancer, and the introduction of the first anti-HER targeted therapy in 1998 is clearly a triumph of “bench to bedside” medicine. In the 10 years that have now passed since the regulatory approval of the first anti–HER-2 targeted therapy, trastuzumab, thousands of preclinical and clinical studies have considered HER-2 as a prognostic factor, its ability to predict response to hormonal and cytotoxic treatments, the best way to test for it in routine specimens, and the clinical efficacy of targeting it in a wide variety of clinical settings. Given the proven efficacy of trastuzumab and lapatinib for the treatment of MBC, and also in the adjuvant and neoadjuvant settings, the critical issue as to which test (IHC versus FISH versus CISH versus mRNA based) is the most accurate and reliable method to determine HER-2 status in breast cancer has continued to increase in importance.

3.4 Personalized Medicine is not yet here

ESMO Personalized Medicine
Written by Dr Marina Garassino for ESMO

The aim of personalised medicine is clearly to make therapy more efficient for patients. A very, very small step in the process is to try to identify for every patient the main molecular driver of their tumour. We have to understand that patients differ between each other, although they may have the same cancer type; for example, every patient with breast cancer or bowel cancer will have a unique tumor. This is entirely new knowledge, so what we are trying to do now in the medical community is to identify for each patient his/ her type of disease and then to give the drug that will work best. We are moving forward with an incredible amount of new data and innovative knowledge on genetic characteristics and subsequent proteomic changes* in the tumor. The challenge is now about how to exploit this information in order to offer targeted treatment and generally improve patient care.

For a number of years we have classified tumors according to their site of origin and using a classification system called “TNM”. Researchers and clinicians once thought that all cancers that derived from the same site were biologically similar and they differed perhaps only in their pathohistological* grading. This grading is a score which classifies tumors from 1 to 3, where 1 is the least aggressive tumor and 3 is the most undifferentiated tumor. Other clinical differences were distinguished based on the presence of regional node metastases or distant metastases. Most of the tumors were therefore classified within the “TNM” system, where T corresponds to the diameter of the primary tumor, N to the presence of regional nodes, and M to distant metastases. For at least three decades, personalization of oncology was based only on these parameters and on the patient’s physical condition, and even now these represent the fundamental elements for treatment decisions. Chemotherapy, surgery and radiation therapy were once the only treatment options for cancer. Although these treatments are still used, oncologists know that some patients respond better to certain drugs than to others and that a surgical approach is not always indicated. In recent years, researchers have studied thousands upon thousands of samples from all types of tumors. They have discovered that tumors derived from the same body site can differ in very important ways.

Firstly, there is histology*. The pathologist is able to distinguish different subtypes of cancer with the microscope. When a patient is diagnosed with a cancer, he/she will undergo a biopsy or a fine-needle aspiration. In some tumor types, debulking or removal of the primary tumor also allows sampling for tissue examination. Some cells of the tumor which have been removed will be taken and analyzed. This examination allows the pathologist to confirm a cancer diagnosis, but, through particular colorations of the tissue sample, the pathologist is also able to provide clinicians with a lot of additional information, such as the tumor’s histological characterization, its hormone sensitivity, and its grade of differentiation*.

For example, in the treatment of lung cancer the histology provides very useful tools to decide the best drug for the treatment of the patient. Clinical studies have shown that for a patient with lung adenocarcinoma* there might be more chance of a response if the drugs pemetrexed or bevacizumab are added to the chemotherapy, while for a patient with lung cancer of squamous* histology, it would be more beneficial to add gemcitabine or vinorelbine. A similar example may be observed Personalization of Oncological Treatments: The Story 12 for other cancers. For the treatment of esophageal cancer it is mandatory to know if the tumor is squamous or not, because although deriving from the same organ, the treatment approach is completely different.

This information is a useful tool in the first step of the personalization process. For example, lung cancer can be divided as a first step into non-small cell lung cancer and small cell lung cancer, which are two completely different neoplasms*. Within the non-small cell lung cancer category, there are again several different tumor types. Breast cancer can also be divided into two major categories: the hormone-sensitive neoplasms and the HER2-positive diseases. Lung and breast cancers are only two examples, because it is possible to recognize several entities within the same tumor type for many other cancers.

Molecular subsets of lung adenocarcinoma Lung cancer subtypes
Figure 2. Lung Cancer – Not One Disease: Histological (Tissue) and Molecular Subtypes of Lung Cancer (not shown) On the left side, four histological subtypes of lung cancer. On the right side, a pie chart showing the percentage distribution of molecular subsets of lung adenocarcinoma. Adapted from Petersen I. Dtsch Arztebl Int 2011; 108(31-32):525-531 (left) and Pao W & Hutchinson KE. Nature Med 2012; 18(3): 349-351.

Personalization depends on a multidisciplinary approach; we need a range of experts, because we need the medical oncologist, the surgeon and the expertise of the molecular pathologist, who should be part of the team in a more effective, integrated way than before. We don’t need the pathology report alone; we need to interact with all professionals, including nurses, who are dealing with the patient. This, to me, will create a lot of problems in terms of organization of care and in terms of cost, but it is the only way to bring together knowledge on the biology and pathology of tumors for effective treatment in every single patient. Our effort at ESMO is to bring this broad knowledge to the general public, to medical oncologists and to the community of doctors involved in cancer.

We have to deeply analyze each tumor of every patient in order to identify those genetic characteristics that make the tumor able to survive. As a result, we can choose the appropriate drugs to target the specific alterations. The clearest examples of this process are in melanoma, lung cancer and breast cancer. For instance, in lung cancer, the presence of mutations in the epidermal growth factor receptor (EGFR) renders the tumor highly sensitive to EGFR tyrosine kinase inhibitors. When oncologists identify these mutations in a patient’s tumor, they may observe that the lesion disappears a few weeks after treatment. A similar response may be observed after treatment with BRAF inhibitors in patients with melanoma or with gastrointestinal stromal tumors (GIST) that express the c-kit gene. Unfortunately, oncogene addiction is not the only process underlying carcinogenesis* and tumor growth. The tumor environment and so-called “epigenetic” alterations* play an important role in rendering the fight against cancer more and more challenging. Despite the enormous recent advances, a specific alteration has not been identified in all cancers. The hope is that the possibility of sequencing the full genome – which means every gene – will give us new insights and therefore new drugs for our patients.

In the DNA of some individuals a “germline” mutation* may be present. This means that a particular mutation is conferring susceptibility to that person to develop a particular type of cancer during his/her life. For instance, BRCA is an alteration for which there is a particular predisposition to have a breast cancer or ovarian cancer in one’s life. A woman with a BRCA gene mutation can transmit this alteration to her female descendants, so her daughters and following generations of female family members can therefore inherit this predisposition.

Mutations that are not germline are called somatic mutations*, which are acquired mutations and are found generally only in the tumor. Distinct from germline mutations, somatic mutations are not inherited.

The move from blockbuster or empirical medicine* towards personalized medicine is a stepwise process. We are currently on the second step of stratified medicine and moving up the stairs towards personalized medicine.

Will molecular pathology evolve from pathology? You need to give a name to a tumor, and a pathologist is the professional who gives a name to tumors. The variety of cancers is broad; when we say “sarcoma”, “carcinoma”, or “lymphoma”, we actually say nothing, because we have hundreds and hundreds of diseases within these categories that need to be recognized. And the reason for recognizing them is exactly related to personalization. The biology of cancer is very complex, and admittedly we have been very naive in the past. We always thought that the problem was how genes become altered in the cancer cell, but actually it is even more complex than that and also involves the way genes direct how they are read; it is the flow of information that comes from genes to the making of their proteins which is as important as the aberration of the genome.

We are facing obstacles currently because the whole issue of tissue sampling has been regulated under the umbrella of privacy, which is of course important. Defending your rights as a human being is a key issue, but we should also try to focus a little bit on the necessity to use that tissue. Of course, we need to have rules, but the approach we are currently facing is basically preventing clinical research and translational research under the excuse of protecting our privacy as human beings, and this is an increasing obstacle. We as researchers, as molecular geneticists, as pathologists, are really looking into a future in which it is becoming increasingly difficult to try to answer the basic question of cancer genomics. Why? Because it is becoming increasingly difficult to use tissue for these purposes.

With the new therapeutic approach and the use of targeted therapy, molecular testing is gaining a very relevant role. It is very important for us, as advocates, to educate patients in these issues. So patients have to receive very clear and transparent information. It should be the doctor who explains to the patient the reason why molecular testing is performed; the doctor has to explain that molecular testing will find whether there is some tumor characteristic which can be targeted with one of these therapies, in order to determine if maybe the patient is the right candidate to receive targeted therapy and perhaps to benefit from it. The communication between the doctor and patient must be very accurate and must educate, meaning that the patient has to understand the precise situation. This can be important also to empower the patient in treatment decisions, but it is important that he/she knows that not every patient may be a candidate for receiving targeted therapy and to understand why this is the case.

  • Different tumour types are increasingly divided into very small subgroups carrying a rare molecular alteration.
  • Most new drugs are targeting these infrequent events.
  • Clinical trials are testing the use of high throughput molecular technologies* in the context of personalized cancer medicine.
  • There are a growing number of newer techniques to optimize genomic testing, including the virtual cell program, which foresees testing of a piece of patient’s tumor tissue in the laboratory in order to mimic what would happen in the human body (e.g. drug sensitivity).
  • Clinical research is today focusing on target identification at the patient level.

Targeted therapy drugs work differently to standard chemotherapeutic drugs. They attack cancer cells and, in particular, the targets which are strategic points for cell survival, cell replication and metastases. They generally create little damage to normal cells. In fact, these drugs tend to have different side effects to traditional chemotherapeutic drugs. Targeted therapies are used to treat many kinds of tumors: certain types of lung, pancreatic, head and neck, liver, colorectal, breast, melanoma and kidney cancers. Targeted therapies are a major focus of cancer research today

Many future advances in cancer treatment will probably come from this area. There are many different targeted therapies in use and new forms are appearing all the time. Depending on the type of cancer and the way it spreads, targeted therapy can be used to cure the cancer, to slow the cancer’s growth, to kill cancer cells that may have spread to other parts of the body or to relieve symptoms caused by the cancer.

We can divide targeted therapies into two main categories: antibody drugs and small molecules. Antibody drugs are man-made versions of immune system proteins that have been designed to attack the external part of cells at certain targets, generally called receptors. Receptors can be considered the antennas of the cells. They transmit signals from the surrounding environment to the nucleus of the cell. Some receptors are fundamental to the vital processes of the cell. Targeting certain receptors means preventing the transmission of some survival signals to the tumor cells.

Trastuzumab (Herceptin®) is, after tamoxifen, the second targeted therapy drug ever used to treat cancer and it is a monoclonal antibody directed at a receptor called HER2. This targeted therapy greatly improves the survival rate of women with breast cancer expressing the HER2 receptor. Therefore, the determination on tissue blocks of the presence of expression of HER2 is one of the best examples of personalization of treatment.

A knowledge of the cancer characteristics and a determination of the tissue characteristics of each patient allows the doctor to select patients for the best treatment.

Other examples of monoclonal antibodies are cetuximab and panitumumab, which have been developed to treat colon cancer. At first it seemed as if these drugs were a failure, because they did not work in many patients. Then it was discovered that if a cancer cell has a specific genetic mutation, known as KRAS, these drugs will not work.

This is another excellent example of using individual tumor genetics to predict whether or not a treatment will work. In the past, the oncologist would have had to try each therapy on every patient and then change the therapy if the cancer continued to grow.

The other type of targeted therapy drugs are not antibodies. Since antibodies are large molecules, this other type is called “small-molecule” targeted therapy drugs. The small molecules attack cancer cells from the inner vital processes. Also, in this case, the small molecules prevent the broadcast of vital signals that regulate the survival of the tumor. There are several examples of targeted drugs that changed the natural history of some cancers.

One example is imatinib mesylate (Gleevec®), which is used in GIST, a rare cancer of the gastrointestinal tract, and in certain kinds of leukemia. Imatinib targets abnormal proteins, or enzymes, that form on and inside cancer cells and promote uncontrolled tumor growth. Blocking these enzymes inhibits cancer cell growth. Gefitinib (Iressa®) is used to treat advanced non-small cell lung cancer. This drug hits the internal part of the EGFR. These receptors are found on the surface of many normal cells, but certain cancer cells have many more of them. EGFR take in the signal that tells the cell to grow and divide. When gefitinib blocks this signal, it can slow or stop cell growth. However, gefitinib does not work in all patients when trying to treat lung cancer, but only

Personalization of Treatment in a particular subtype. About 10% of patients show genetic alterations called “EGFR mutations” in their tumors at diagnosis. These particular mutations mean that the EGFR is always turned on and therefore there is a continuous signal to the cell to grow and divide. Gefitinib is able to switch off this signal and to stop cell growth in this subtype of patients. After a few weeks, the tumor disappears. Unfortunately, these mutations are rare and they are mainly present in never-smokers, who are the minority of patients.

Another, similar example in lung cancer is provided by crizotinib (Xalkori®). Patients with ALK translocations, which is another rare type of alteration present mainly in never smokers, experience a rapid shrinkage in their tumors when treated with this drug.

Another example of small molecules is represented by sunitinib (Sutent®). This drug is used to treat advanced kidney cancer and some GIST. Sunitinib is considered a multitarget agent because it blocks the vascular endothelial growth factor (VEGF) receptor and other enzymes. By doing all of this, sunitinib slows cancer growth and stops tumors from creating their own blood vessels to help them grow and metastasize. In this case, no biomarkers have been identified to help select patients who are responders from patients who are nonresponders.

Exploring the clinical utility of comprehensive genomic testing. After the patient’s informed consent, tumor and normal DNA is extracted in a certified laboratory. After targeted somatic mutation testing, more extended testing is performed in a research environment. Test results are shared with the treating oncologists, and validation of research findings is pursued if any clinically relevant research findings are found. Therapeutic decisions are based only on validated test results.

We really have to strengthen and reinforce in the future all the collaborative ways to work, without any – or minimal, at least – competitive ways of thinking. We have to work together to make the science evolve and forget about the national or regional representation of research that we have had in the past. I think the priority now is to have really good networks of institutions in order to make new treatments rapidly reach our patients.

3.5 Biomarkers for personalized oncology: recent advances and future challenges.

Kalia M
Metabolism. 2015 Mar;64(3 Suppl 1):S16-21

Cancer is a group of diseases characterized by the uncontrolled growth and spread of abnormal cells and oncology is a branch of medicine that deals with tumors. The last decade has seen significant advances in the development of biomarkers in oncology that play a critical role in understanding molecular and cellular mechanisms which drive tumor initiation, maintenance and progression. Clinical molecular diagnostics and biomarker discoveries in oncology are advancing rapidly as we begin to understand the complex mechanisms that transform a normal cell into an abnormal one. These discoveries have fueled the development of novel drug targets and new treatment strategies. The standard of care for patients with advanced-stage cancers has shifted away from an empirical treatment strategy based on the clinical-pathological profile to one where a biomarker driven treatment algorithm based on the molecular profile of the tumor is used. Recent advances in multiplex genotyping technologies and high-throughput genomic profiling by next-generation sequencing make possible the rapid and comprehensive analysis of the cancer genome of individual patients even from very little tumor biopsy material. Predictive (diagnostic) biomarkers are helpful in matching targeted therapies with patients and in preventing toxicity of standard (systemic) therapies. Prognostic biomarkers identify somatic germ line mutations, changes in DNA methylation, elevated levels of microRNA (miRNA) and circulating tumor cells (CTC) in blood. Predictive biomarkers using molecular diagnostics are currently in use in clinical practice of personalized oncotherapy for the treatment of five diseases: chronic myeloid leukemia, colon, breast, lung cancer and melanoma and these biomarkers are being used successfully to evaluate benefits that can be achieved through targeted therapy. Examples of these molecularly targeted biomarker therapies are: tyrosine kinase inhibitors in chronic myeloid leukemia and gastrointestinal tumors; anaplastic lymphoma kinase (ALK) inhibitors in lung cancer with EML4-ALk fusion; HER2/neu blockage in HER2/neu-positive breast cancer; and epidermal growth factor receptors (EGFR) inhibition in EGFR-mutated lung cancer. This review presents the current state of our knowledge of biomarkers in five selected cancers: chronic myeloid leukemia, colorectal cancer, breast cancer, non-small cell lung cancer and melanoma.

3.6 Personalized oncology: recent advances and future challenges.

Kalia M1
Metabolism. 2013 Jan;62 Suppl 1:S11-4

Personalized oncology is evidence-based, individualized medicine that delivers the right care to the right cancer patient at the right time and results in measurable improvements in outcomes and a reduction on health care costs. Evolving topics in personalized oncology such as genomic analysis, targeted drugs, cancer therapeutics and molecular diagnostics will be discussed in this review. Biomarkers and molecular individualized medicine are replacing the traditional “one size fits all” medicine. In the next decade the treatment of cancer will move from a reactive to a proactive discipline. The essence of personalized oncology lies in the use of biomarkers. These biomarkers can be from tissue, serum, urine or imaging and must be validated. Personalized oncology based on biomarkers is already having a remarkable impact. Three different types of biomarkers are of particular importance: predictive, prognostic and early response biomarkers. Tools for implementing preemptive medicine based on genetic and molecular diagnostic and interventions will improve cancer prevention. Imaging technologies such as Computed Tomography (CT) and Positron Emitted Tomography (PET) are already influencing the early detection and management of the cancer patient. Future advances in imaging are expected to be in the field of molecular imaging, integrated diagnostics, biology driven interventional radiology and theranostics. Molecular diagnostics identify individual cancer patients who are more likely to respond positively to targeted chemotherapies. Molecular diagnostics include testing for genes, gene expression, proteins and metabolites. The use of companion molecular diagnostics is expected to grow significantly in the future and will be integrated into new cancer therapies a single (bundled) package which will provide greater efficiency, value and cost savings. This approach represents a unique opportunity for integration, increased value in personalized oncology.

3.7  Pharmacogenomic biomarkers for personalized cancer treatment.

Rodríguez-Antona C1Taron M.
J Intern Med. 2015 Feb; 277(2):201-17

Personalized medicine involves the selection of the safest and most effective pharmacological treatment based on the molecular characteristics of the patient. In the case of anticancer drugs, tumor cell alterations can have a great impact on drug activity and, in fact, most biomarkers predicting response originate from these cells. On the other hand, the risk of developing severe toxicity may be related to the genetic background of the patient. Thus, understanding the molecular characteristics of both the tumor and the patient, and establishing their relation with drug outcomes will be critical for the identification of predictive biomarkers and to provide the basis for individualized treatments. This is a complex scenario where multiple genes as well as pathophysiological and environmental factors are important; in addition, tumors exhibit large inter- and intraindividual variability in space and time. Against this background, the huge amounts of biological and genetic data generated by the high-throughput technologies will facilitate pharmacogenomic progress, suggest novel druggable molecules and support the design of future strategies aimed at disease control. Here, we will review the current challenges and opportunities for pharmacogenomic studies in oncology, as well as the clinically established biomarkers. Lung and renal cancer, two areas in which huge progress has been made in the last decade, will be used to illustrate advances in personalized cancer treatment; we will review EGFR mutation as the paradigm of targeted therapies in lung cancer, and discuss the dissection of lung cancer into clinically relevant molecular subsets and novel advances that suggest an important role of single nucleotide polymorphisms in the response to antiangiogenic agents, as well as the challenges that remain in these fields. Finally, we will present new approaches and future prospects for personalizing medicine in oncology.

3.8 Limits to forecasting in personalized medicine: An overview

John Ioannidis
International Journal of Forecasting 2009; 25(4):773-783.

Biomedical research is generating massive amounts of information about potential prognostic factors for health and disease. However, few prognostic factors or systems are robustly validated, and still fewer have made a convincing difference in health outcomes or in prolonging life expectancy. For most diseases and outcomes, a considerable component of the prognostic variance remains unknown, and may remain so for the foreseeable future. I discuss here some of the main problems in medical forecasting that pose obstacles to personalized medicine. Their recognition may help identify solutions to improve personalized prognosis, or at least understand and cope with the component of the future that we cannot predict. Much prognostic research is stuck at generating “publishable units”, without any interest in conclusively proving their worth, let alone moving them into real life applications. Information is reported selectively and reporting is deficient. The replication record of prognostic claims is poor. Even among replicated prognostic effects, few are convincingly shown to add much information besides what is already known through more simple, traditional measurements. There are few efforts to systematize prognostic knowledge. Most prognostic effects are subtle when traced to the molecular level, where most current research operates. Many researchers, clinicians, and the public are not appropriately educated to interpret prognostic information. We still have not even agreed on what the important health outcomes are that we want to predict and intervene for, and some subjectivity may be unavoidable. Finally, without concomitant effective, affordable, and non-harmful interventions, prognosis alone is of questionable value, and wrong prognosis or a wrong interpretation thereof can be harmful. The identification of these problems also suggests a roadmap on what could be done to amend them. Solutions include a systematic approach to the design, conduct, reporting, replication, and clinical translation of prognostic research; as well as the education of researchers, clinicians, and the general public. Finally, we need to recognize that perfect individualized health forecasting is not a realistic target in the foreseeable future, and we have to live with considerable residual uncertainty.
Limits to forecasting in personalized medicine: An overview. Available from: [accessed May 12, 2015].

3.9 The genome editing toolbox: a spectrum of approaches for targeted modification

Joseph K Cheng,  Hal S Alper

Current Opinion in Biotechnology 2014; 30C:87-94.

The increase in quality, quantity, and complexity of recombinant products heavily drives the need to predictably engineer model and complex (mammalian) cell systems. However, until recently, limited tools offered the ability to precisely manipulate their genomes, thus impeding the full potential of rational cell line development processes. Targeted genome editing can combine the advances in synthetic and systems biology with current cellular hosts to further push productivity and expand the product repertoire. This review highlights recent advances in targeted genome editing techniques, discussing some of their capabilities and limitations and their potential to aid advances in pharmaceutical biotechnology.
The genome editing toolbox: a spectrum of approaches for targeted modification. Available from: [accessed May 12, 2015].

3.10 The Path to Personalized Medicine

Margaret A. Hamburg, and Francis S. Collins
N Engl J Med Jul 22, 2010; 363(4): 301-304

Researchers have discovered hundreds of genes that harbor variations contributing to human illness, identified genetic variability in patients’ responses to dozens of treatments, and begun to target the molecular causes of some diseases. In addition, scientists are developing and using diagnostic tests based on genetics or other molecular mechanisms to better predict patients’ responses to targeted therapy.

The challenge is to deliver the benefits of this work to patients. As the leaders of the National Institutes of Health (NIH) and the Food and Drug Administration (FDA), we have a shared vision of personalized medicine and the scientific and regulatory structure needed to support its growth. Together, we have been focusing on the best ways to develop new therapies and optimize prescribing by steering patients to the right drug at the right dose at the right time.

We recognize that myriad obstacles must be overcome to achieve these goals. These include scientific challenges, such as determining which genetic markers have the most clinical significance, limiting the off-target effects of gene-based therapies, and conducting clinical studies to identify genetic variants that are correlated with a drug response. There are also policy challenges, such as finding a level of regulation for genetic tests that both protects patients and encourages innovation. To make progress, the NIH and the FDA will invest in advancing translational and regulatory science, better define regulatory pathways for coordinated approval of codeveloped diagnostics and therapeutics, develop risk-based approaches for appropriate review of diagnostics to more accurately assess their validity and clinical utility, and make information about tests readily available.

Moving from concept to clinical use requires basic, translational, and regulatory science. On the basic-science front, studies are identifying many genetic variations underlying the risks of both rare and common diseases. These newly discovered genes, proteins, and pathways can represent powerful new drug targets, but currently there is insufficient evidence of a downstream market to entice the private sector to explore most of them. To fill that void, the NIH and the FDA will develop a more integrated pathway that connects all the steps between the identification of a potential therapeutic target by academic researchers and the approval of a therapy for clinical use. This pathway will include NIH-supported centers where researchers can screen thousands of chemicals to find potential drug candidates, as well as public– private partnerships to help move candidate compounds into commercial development.

The NIH will implement this strategy through such efforts as the Therapeutics for Rare and Neglected Diseases (TRND) program. With an open environment, permitting the involvement of all the world’s top experts on a given disease, the TRND program will enable certain promising compounds to be taken through the preclinical development phase — a time-consuming, high-risk phase that pharmaceutical firms call “the valley of death.” Besides accelerating the development of drugs to treat rare and neglected diseases, the TRND program may also help to identify molecularly distinct subtypes of some common diseases, which may lead to new therapeutic possibilities, either through the development of targeted drugs or the salvaging of abandoned or failed drugs by identifying subgroups of patients likely to benefit from them.

Another important step will be expanding efforts to develop tissue banks containing specimens along with information linking them to clinical outcomes. Such a resource will allow for a much broader assessment of the clinical importance of genetic variation across a range of conditions. For example, the NIH is now supporting genome analysis in participants in the Framingham Heart Study, obtaining biologic specimens from babies enrolled in the National Children’s Study, and performing detailed genetic analysis of 20 types of tumors to improve our understanding of their molecular basis.

As for translational science, the NIH is harnessing the talents and strengths of its Clinical and Translational Sciences Award program, which currently funds 46 centers and has awardees in 26 states, and its Mark O. Hatfield Clinical Research Center (the country’s largest research hospital, in Bethesda, MD) to translate basic research findings into clinical applications. Just as the NIH served as an initial home for human gene therapy, the Hatfield Center can provide specialized diagnostic services for rare and neglected diseases, offer a state-of-the-art manufacturing facility for novel therapies, and pioneer clinical trials of other innovative biologic therapies, such as those using human embryonic stem cells or induced pluripotent stem cells.

Today, about 10% of labels for FDA-approved drugs contain pharmacogenomic information — a substantial increase since the 1990s but hardly the limit of the possibilities for this aspect of personalized medicine.1 There has been an explosion in the number of validated markers but relatively little independent analysis of the validity of the tests used to identify them in biologic specimens.

The success of personalized medicine depends on having accurate diagnostic tests that identify patients who can benefit from targeted therapies. For example, clinicians now commonly use diagnostics to determine which breast tumors overexpress the human epidermal growth factor receptor type 2 (HER2), which is associated with a worse prognosis but also predicts a better response to the medication trastuzumab. A test for HER2 was approved along with the drug (as a “companion diagnostic”) so that clinicians can better target patients’ treatment (see table).

Increasingly, however, the use of therapeutic innovations for a specific patient is contingent on or guided by the results from a diagnostic test that has not been independently reviewed for accuracy and reliability by the FDA. For example, in 2006, the FDA granted approval to rituximab (Rituxan) for use as part of firstline treatment in patients with certain cancers. Since then, a laboratory has marketed a test with the claim that it can identify the approximately 20% of patients who are more likely to have a response to the drug. The FDA has not reviewed the scientific justification for this claim, but health care providers may use the test results to guide therapy. This undermines the approval process that has been established to protect patients, fails to ensure that physicians have accurate information on which to make treatment decisions, and decreases the chances that physicians will adopt a new therapeutic–diagnostic approach. The FDA is coordinating and clarifying the process that manufacturers must follow regarding their claims, including defining the times when a companion diagnostic must be approved or cleared before or concurrently with approval of the therapy. The agency will ensure that claims that a test will improve the care of patients are based on solid evidence, and developers will get straightforward, consistent advice about the standards for review and the best way to demonstrate that the combination works as intended.

In February, the NIH and the FDA announced a new collaboration on regulatory and translational science to accelerate the translation of research into medical products and therapies; this effort includes a joint funding opportunity for regulatory science. Working with academic experts, companies, doctors, patients, and the public, we intend to help make personalized medicine a reality. A recent example of this collaboration is an effort to identify new investigational agents to which certain tumors, identified by their genetic signatures, are responsive. Real progress will come when clinically beneficial new products and approaches are incorporated into clinical practice. As the field advances, we expect to see more efficient clinical trials based on a more thorough understanding of the genetic basis of disease. We also anticipate that some previously failed medications will be recognized as safe and effective and will be approved for subgroups of patients with specific genetic markers.

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Metastatic Disease (4.3)

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

In the preceding discussions the hematological and nonhematological cancers were elaborated.  These were tumors of blood or solid tumors that are malignant.  Malignant solid tumors have a loss of normal architecture.  Malignant cancers of the blood forming organ also have a disruption of the architecture in the blood forming organs, and they are circulating elements that are either acutely increased in number or chronically increased to very high circulating counts as well as many cells in the marrow.  The diagnosis depends on the type of cell elements and the stage of maturation.  In the case of blood cell cancers, one might consider an intermediate stage that has a long course that is in the case of the myelogenous series, myeloid dysplasia, which includes myelofibrosis, which in either case is not a benign course. In the case of solid tumors, there is an anatomic structure of the cancer site.

The usual structure for a carcinoma is either adjoining cells surrounding a vascular supply, as in the liver, a parenchymal gland, as in pancreas, a tubular structure, as the gastrointestinal tract and lungs (which are embryologically and outpouching of the gut), or a skin surface.  In the case of carcinomas, the cells mature from a basement membrane of small flattened cells that overlie a fibrovascular matrix and an underlying myxoid stroma, perhaps beneath which is a muscular organ, then covered by a flat layer of cells. In the case of all epithelial structures there is an orderly maturation of epithelium from the basal layer to the mature epithelial cells that are elongate, have a brush border, and secrete into the glandular structure.  The cell maturation becomes disrupted and disorderly to different degrees in the development of malignancy from a dysplasia to low grade malignancy, to high grade anaplastic cancer.

The development of a cancer implies the loss of tissue architecture, the replication of cells, the development of a neoplasms circulation (which is the topic of vascular endothelial growth factor (VEGF)), the overgrowth of the circulation so that the tumor has insufficient blood supply, and vascular invasion.  We refer to the Warburg Hypothesis with respect to the malignancy relying on glycolysis in the presence of oxygen (aerobic glycolysis), but it may be questionable to imply that there is sufficient oxygen supply.  In some cases a cancer may occur from a longstanding inflammatory focus.  This has been seen to occur in osteomyelitis and in gastrointestinal fistulas.  The growth of a neoplasm, when it exceeds its blood supply, requires adaptive changes. The most obvious to consider would be a decreased reliance of mitochondrial respiration.  Warburg refer to the increase production of lactic acid as analogous to Pasteur observation of fermentation in yeast (Pasteur effect).  He measured the lactic acid production by various tissues, and the consumption with the oxygen consumption showed that in many tissues approximately two molecules of lactate are prevented from appearing when one molecule of oxygen is consumed – a relationship that Meyerhof had found in muscle. This he expressed as the “Meyerhof quotient”:

Anaerobic glycolysis – aerobic glycolysis/oxygen consumption

Ref: Otto Warburg: Cell Physiologist, Biochemist, and Eccentric
Hans Krebs in collaboration with Roswitha Schmid
Clarendon Press, Oxford, 1981. Pp 19-25.

The special feature of cancer cells was the high rate of glycolysis in the presence of oxygen, whereas muscle can form lactate from carbohydrate in the absence of oxygen. This led to the discovery that all animal tissues are capable of glycolysis both aerobically and anaerobically.  Pasteur had established 60 years earlier that the rates of fermentation are generally hiugh anaerobically, but low aerobically. This led Warburg to the conclusion that cancer cells are distinguished from noncancer cells by their failure to suppress glycolysis in the presence of oxygen. He discovered in 1926 that the link between respiration and fermentation can be severed by a specific inhibitor, ethylcarbylamine. He looked at carbylethylamine as an inhibitor of the ‘Pasteur effect’, and determined that the catalyst was a heavy metal ion. But the proposed mechanism was shown not to be correct by Engelhardt, Lynen, Bucher, Lowry, Racker, and Sols.The activity of the enzyme phospofructokinase is regulated by the concentrations of ATP, ADP and inorganic phosphate (Pi). The “allosteric properties” of PFK could account for the ‘Pasteur effect’.  ATP inactivates PFK, while ADP and Pi activate it. Further, etylcarbylamine was found to be an uncoupler of oxidative phosphorylation (OxPhos), but Warburg was right in postulating that a heavy metal was involved since heavy metals are involved in
OxPhos.  The explanation for this is now that when malignant transformation occurs, the cells’ energy supply is redirected from their normal function to growth. This change was found to be irreversible upon restoration of oxygen supply.

The topic of discussion is metastasis. What does it have to do with malignancy and respiration? Metastasis is the other key feature of cancer cells. What it has to do with respiration would probably tie in with the change in the cells’ energy supply that is directed toward proliferation. As the cell metabolism is reconfigured, there is also a change in the cell signaling with respect to apoptosis and the events regarding autophagy.  This has to extend beyond the mitochondria, mainly because autophagy involves mitophagy, the ER and the entire cytoskeleton.  This means that the cytoplasmic relationship to the intercellular matrix and the fibroblast stroma would have to be affected, as the cell breaks away from its close association with adjacent cells.  Cells can migrate to adjacent lymphatic structures, and either enter the circulation by way of the lymphatics or by invasion of the venous circulation directly. In any case, entry into the circulation allows for transport to distant sites.  With respect to migration to distant sites, we recall the hypothesis of Paget that the cells metastasize directly into the circulating blood, and they may ‘seed’ to favorable organs.

The discussion now turns to the assessment of apoptosis as a means to inhibition of cancer cell lines, which proliferate if unchecked and migrate away from the primary site.  I use a few examples from a symposium volume of the Annals of the New York Academy of Sciences:

Apoptosis: From Signaling Pathways to Therapeutic Tools.
Ed, Mark Diederich
ANYAA9 2003; 1010:1-799
The role of β-glucuronidase in induction of apoptosis by Genistein Combined Polysaccharide (GCP) in xenogenetic mice bearing human mammary cancer cells.
Yuan L, Wagatsuma C, Sun B, Kim Jung-Hwan, Surh Young-Joon
Ann NY Acad Sci 2003;1010: 347-349.

  • GCP inhibits tumor cell growth through multiple mechanisms, including induction of tumor apoptosis
  • The biological activities of genistein (aglycon) are more evident in tumor tissues than in normal tissues.
  • Hiugh doses of genistein administration rarely induces toxicity to normal tissues.
  • Higher levels of β-glucuronidase expression in tumor tissues results in more genistein aglycon, leading to tumor destruction.

Induction of apoptosis in human pancreatic cancer cells by docosahexanoic acid
Merendino N, Molinari R, Loppi B, Pessina G, D’Aquino M, Tomassi G, Velotti F.
Ibid 361-364.

Polyunsaturated fatty acids have been indicated to induce anti-proliferative and/or apoptotic effects in various tumor cells. We showed that, at a 200-μM concentration, both alpha-linoleic (18:2 n-6; LA) or docosahexaenoic (22:6 n-3; DHA) acid inhibited cell growth, while only DHA induced apoptosis in the human Paca-44 pancreatic cancer cell line. Investigating the mechanism underlying DHA-induced apoptosis, we showed that DHA induced a rapid and dramatic (>60%) intracellular depletion of reduced glutathione (GSH), without affecting oxidized glutathione (GSSG). Moreover, using two specific inhibitors of carrier-mediated GSH extrusion, cystathionine or methionine, we observed that GSH depletion occurred via an active GSH extrusion, and that inhibition of GSH efflux completely reversed apoptosis. These results provide the first evidence for a possible causative role of GSH depletion in DHA-induced apoptosis.

Opposite phenotypes of cancer and aging arise from alternative regulation of common signaling pathways.
Ukraintseva SV1, Yashin AI.
Ann N Y Acad Sci. 2003 Dec; 1010:489-92.

Phenotypic features of malignant and senescent cells are in many instances opposite. Cancer cells do not “age”; their metabolic, proliferative, and growth characteristics are opposite to those observed with cellular aging (both replicative and functional). In many such characteristics cancer cells resemble embryonic cells. One can say that cancer manifests itself as a local, uncontrolled “rejuvenation” in an organism. Available evidence from human and animal studies suggests that the opposite phenotypic features of aging and cancer arise from the opposite regulation of genes participating in apoptosis/growth arrest or growth signal transduction pathways in cells. This fact may be applicable in the development of new anti-aging treatments. Genes that are contrarily regulated in cancer and aging cells (e.g., proto-oncogenes or tumor suppressors) could be candidate targets for anti-aging interventions. Their “cancer-like” regulation, if strictly controlled, might help to rejuvenate the human organism.

CUGBP2 Plays a Critical Role in Apoptosis of Breast Cancer Cells in Response to Genotoxic Injury
Mukhopadhyay D, Jung J, Murmu N, Houchen CW, Dieckgraefe BK, Anant A
Ibid 504–509.

 Posttranscriptional control of gene expression plays a key role in regulating gene expression in cells undergoing apoptosis. Cyclooxygenase-2 (COX-2) is a crucial enzyme in the conversion of arachidonic acid to prostaglandin E2 (PGE2) and is significantly upregulated in many types of adenocarcinomas. COX-2 overexpression leads to increased PGE2 production, resulting in increased cellular proliferation. PGE2 enhances the resistance of cells to ionizing radiation. Accordingly, understanding mechanisms regulating COX-2 expression may lead to important therapeutic advances. Besides transcriptional control, COX-2 expression is significantly regulated by mRNA stability and translation. We have previously demonstrated that RNA binding protein CUGBP2 binds AU-rich sequences to regulate COX-2 mRNA translation. In the current study, we have determined that expression of both COX-2 mRNA and CUGBP2 mRNA are induced in MCF-7 cells, a breast cancer cell line, following exposure to 12 Gy γ-irradiation. However, only CUGBP2 protein is induced, but COX-2 protein levels were not altered. Silencer RNA (siRNA)-mediated inhibition of CUGBP2 reversed the block in COX-2 protein expression. Furthermore, MCF-7 cells underwent apoptosis in response to radiation injury, which was also reversed by CUGBP2 siRNAs. These data suggest that CUGBP2 is a critical regulator of the apoptotic response to genotoxic injury in breast cancer cells.

Multiple and synergistic deregulations of apoptosis-controlling genes in pancreatic carcinoma cells
A Trauzold,1 S Schmiedel,1 C Röder,1 C Tams,1 M Christgen,1 S Oestern,1 A Arlt,2 S Westphal,1 M Kapischke,1 H Ungefroren,1 and H Kalthoff1,
Ibid 510-513.  Br J Cancer. 2003 Nov 3; 89(9): 1714–1721.

CD95, TRAIL-R1 (tumor necrosis factor-related apoptosis inducing ligand-receptor 1) and TRAIL-R2 are members of the TNF-receptor family of transmembrane proteins that are capable of inducing apoptosis (Wiley et al, 1995Pitti et al, 1996Pan et al, 1997Peter et al, 1998). Following ligand binding, the receptors oligomerize and the pro-apoptotic molecules TRADD, FADD and FLICE/caspase-8 are recruited to their intracellular death domain forming the ‘death-inducing signaling complex’ (DISC) (Krammer, 1999). The subsequent events leading to apoptosis depend on the specific cell type being challenged. In type I cells the bulk induction of caspase-8 at the DISC leads to the direct activation of the effector caspase 3. In type II cells only little amounts of caspase-8 are activated at the DISC requiring the pro-apoptotic mitochondrial amplification loop for efficient caspase-3 activation (Scaffidi et al, 1998).
In Vivo Imaging of Chemotherapy-Induced Apoptosis in Human Cancers
T Belhocine, N Steinmetz, A Green, P Rigo
Ibid 525-529.

Rationale. Induction of apoptosis in sensitive tumor cells is the main mechanism of action of chemotherapy agents in human cancers. Also, the assessment of drug-induced apoptosis soon after chemotherapy may be an early predictor of treatment efficacy. Patients and Methods. A phase I/II study was prospectively conducted in 15 patients presenting with proven lung cancers (n= 10), breast cancers (n= 2), and lymphomas (n= 3) to assess the value of the 99mTc-radiolabeled recombinant human (rh) Annexin V for imaging apoptosis immediately after completion of the first course of chemotherapy. Early Annexin V findings post-chemotherapy (day+1, day+2) were also compared to the tumor status at 6 to 12 weeks post-treatment.
Results. All lung and lymphoma patients with an increased tracer uptake post-treatment (n= 8) had either partial or complete tumor response. Five patients with no tracer uptake had progressive disease. However, two breast cancers had a response to treatment, although no significant tracer uptake was observed. Tumor response and survival time were significantly correlated with the 99mTc-labeled Annexin V uptake. No serious events related to tracer administration were noted. Conclusion. Preliminary results of this pilot study demonstrate the feasibility of the 99mTc-labeled Annexin V uptake for the in vivo imaging of apoptosis after one course of chemotherapy. If confirmed on larger series, these promising results may open new perspectives in the management of oncology patients.

In vivo photoacoustic imaging of chemotherapy-induced apoptosis in squamous cell carcinoma using a near-infrared caspase-9 probe.
Yang Q1Cui HCai SYang XForrest ML.
J Biomed Opt. 2011 Nov; 16(11):116026.

Anti-cancer drugs typically exert their pharmacological effect on tumors by inducing apoptosis, or programmed cell death, within the cancer cells. However, no tools exist in the clinic for detecting apoptosis in real time. Microscopic examination of surgical biopsies and secondary responses, such as morphological changes, are used to verify efficacy of a treatment. Here, we developed a novel near-infrared dye-based imaging probe to directly detect apoptosis with high specificity in cancer cells by utilizing a noninvasive photoacoustic imaging (PAI) technique. Nude mice bearing head and neck tumors received cisplatin chemotherapy (10 mg/kg) and were imaged by PAI after tail vein injection of the contrast agent. In vivo PAI indicated a strong apoptotic response to chemotherapy on the peripheral margins of tumors, whereas untreated controls showed no contrast enhancement by PAI. The apoptotic status of the mouse tumor tissue was verified by immunohistochemical techniques staining for cleaved caspase-3 p11 subunit. The results demonstrated the potential of this imaging probe to guide the evaluation of chemotherapy treatment.

Noninvasive imaging techniques are necessary for early cancer detection and evaluation of the chemotherapeutic effect on tumors. Current diagnostic imaging techniques generally include γ-scintigraphy, magnetic resonance imaging, computed tomography, and ultrasonography; however, these techniques only give morphological information on the tumor. These techniques do not report the biochemical response of the tumor to treatment and physical changes in the tumor in response to treatment may take days to weeks to fully manifest. Positron emission topography and SPECT can indirectly detect tumor response to treatment due to changes in metabolic activity and blood perfusion, respectively. However, no clinical imaging technique can directly detect the biochemical response, e.g., apoptosis, of tumors to treatment. Since apoptosis often occurs within in the first 18 to 36 h after treatment, direct imaging of apoptosis would rapidly indicate if there is a response in the tumor to chemotherapy.

Photoacoustic imaging (PAI) overcomes the spatial and resolution limitations of conventional imaging techniques at a relatively low cost,12 and it has shown its potential to monitor the growth of melanoma brain tumors3 and melanoma metastasis in sentinel lymph nodes.4 However, ascribed to the fact that PAI utilizes the optical absorption of tissues for contrast, it cannot differentiate normal from cancerous cells unless the cells are overexpressing chromomeric marker (e.g., melanomas) or labeled by reporter moieties as contrast agent to enhance the contrast between normal and pathological tissues. In this case, application of a contrast agent such as fluorochromes is expected to facilitate both the visualization of head and neck squamous cell carcinoma (HNSCC) cancer cells and their response to treatment in vivo by PAI.

We have synthesized a near-infrared fluorescent imaging probe – IR780-linker-Val-Ala-Glu(OMe)-FMK by conjugating a fluorochrome (IR780) to Z-Val-Ala-Glu (OMe), a cell permeable caspase inhibitor. The activation of caspase family of cysteine proteases has been recognized as a critical event of apoptosis, which is a physiological process of type I programmed cell death. Typically anti-cancer agents act on cancer cells to induce apoptosis, so apoptosis is a rapid and definite indicator of tumor response. For this reason, apoptosis is used in screening drug candidates in cell culture. The fluoromethyl ketone of the tripeptides valine, alanine, and O-methyle-glutamic acid [Val-Ala-Glu(OMe)-FMK] can specifically and irreversibly bind to the cysteine residue at the active site of caspase-9.5 Our preliminary in vitro cell-imaging test with prostate cancer DU 145 cells demonstrated the sensitivity of this imaging probe for cell apoptosis.6 In this study, we evaluated the application of IR780-linker-Val-Ala-Glu(OMe)-FMK for PAI to detect procaspase-9 activation caused by anticancer drug treatment in living nude mice bearing HNSCC tumors.

Increase in PA amplitude within the HNSCC tumor after intravenous injection of imaging agent

Increase in PA amplitude within the HNSCC tumor after intravenous injection of imaging agent

Fourteen micron (thickness) sections of the tumor tissue were stained with a goat primary polyclonal antibody for cleaved caspase-3 p11 subunit (Asp-175-Ser-176) and a donkey anti-goat secondary antibody with a fluorescein isothiocyanate (FITC) fluorophore (Santa Cruz Biotechnology Inc., Santa Cruz, California). Cell nuclei were stained with 4,6-diamidino-2-phenylindole (DAPI).

Maximum amplitude projection images obtained from the PAI of the HNSCC tumor region shown in Fig. ​(Fig.2).2 were converted to grayscale images. The grayscale images at various time points were linearly aligned using the scale-invariant feature transform function of Fiji/ImageJA software (ver. 20110307, (Fig. ​(Fig.3).3). Quantification of PA signal intensity within the tumor region was performed in triplet for each image by measuring the mean gray value (units: gray/pixel) of the circled tumor region. The extent of signal enhancement was calculated by normalizing the tumor signal against a background reading taken immediately before injection of the imaging agent (Fig. ​(Fig.2).2)

Apoptosis in the tumor tissues was independently verified by immunohistochemical staining for caspase 3, a downstream indicator of apoptosome-activated caspase-mediated apoptosis that would not cross-react with the caspase-9 PA probe. Figure ​(Figure4a) 4a represents a control section stained with the secondary antibody alone (autofluorescence of the tissue without apparent staining); while, Fig. ​(Fig.4b).4b shows the immunostaining of the caspase-3 p11 subunit (green) and the DAPI staining of cell nuclei. The intense green fluorescence in these sections suggests the wide spread apoptosis of cells in the tumor tissues after intravenous administration of high-dose cisplatin. In addition, cells on the peripheral of the tumor stained more strongly for caspase 3 (green fluorescence) compared to cells at the tumor interior. This was consistent with the PA imaging of apoptosis that showed strong apoptosis at the tumor peripheral, suggesting chemotherapeutics had penetrated the outer layers of the tumor and induced apoptosis.

Immunostaining for apoptosis in tumor

Immunostaining for apoptosis in tumor

Immunostaining for apoptosis in tumor. (a) Representative control section stained with secondary antibody alone and (b) tissue section of the HNSCC tumor stained for caspase-3 p11 subunit after cisplatin treatment.

I now consider mechanisms of metastasis as currently viewed.

Metastasis mechanisms.
Geiger TR1Peeper DS.
Biochim Biophys Acta. 2009 Dec; 1796(2):293-308.

Metastasis, the spread of malignant cells from a primary tumor to distant sites, poses the biggest problem to cancer treatment and is the main cause of death of cancer patients. It occurs in a series of discrete steps, which have been modeled into a “metastatic cascade”. In this review, we comprehensively describe the molecular and cellular mechanisms underlying the different steps, including Epithelial-Mesenchymal Transition (EMT), invasion, anoikis, angiogenesis, transport through vessels and outgrowth of secondary tumors. Furthermore, we implement recent findings that have broadened and challenged the classical view on the metastatic cascade, for example the establishment of a “premetastatic niche”, the requirement of stem cell-like properties, the role of the tumor stroma and paracrine interactions of the tumor with cells in distant anatomical sites. A better understanding of the molecular processes underlying metastasis will conceivably present us with novel targets for therapeutic intervention.

Axis of evil: molecular mechanisms of cancer metastasis Thomas Bogenrieder1 and Meenhard Herlyn1
Oncogene (2003) 22, 6524–6536.

Although the genetic basis of tumorigenesis may vary greatly between different cancer types, the cellular and molecular steps required for metastasis are similar for all cancer cells. Not surprisingly, the molecular mechanisms that propel invasive growth and metastasis are also found in embryonic development, and to a less perpetual extent, in adult tissue repair processes. It is increasingly apparent that the stromal microenvironment, in which neoplastic cells develop, profoundly influences many steps of cancer progression, including the ability of tumor cells to metastasize. In carcinomas, the influences of the microenvironment are mediated, in large part, by bidirectional interactions (adhesion, survival, proteolysis, migration, immune escape mechanisms lymph-/angiogenesis, and homing on target organs) between epithelial tumor cells and neighboring stromal cells, such as fibroblasts as well as endothelial and immune cells. In this review, we summarize recent advances in understanding the molecular mechanisms that govern this frequently lethal metastatic progression along an axis from primary tumor to regional lymph nodes to distant organ sites. Affected proteins include growth factor signaling molecules, chemokines, cell–cell adhesion molecules (cadherins, integrins) as well as extracellular proteases (matrix metalloproteinases). We then discuss promising new therapeutic approaches targeting the microenvironment. We note, however, that there is still too little knowledge of how the many events are coordinated and integrated by the cancer cell, with conspiratorial help by the stromal component of the host. Before drug development can proceed with a legitimate chance of success, significant gaps in basic knowledge need to be filled.

Metastases to regional lymph nodes are detected at diagnosis and surgery in approximately one-third of breast, colorectal, uterine cervix, and oral cavity and pharynx cancer patients, and one-quarter of esophageal, lung pancreas, gastric and bladder cancer patients (Greenlee et al., 2001). The high mortality rates associated with cancer are caused by the metastatic spread of tumor cells from the site of their origin. In fact, metastases are the cause of 90% of cancer deaths (Hanahan and Weinberg, 2000). The prognosis for a patient who is diagnosed with advanced invasive or metastatic disease remains little better than it was decades ago (Sporn, 1997). Tumor cells invade either the blood or lymphatic vessels to access the general circulation and then establish themselves in other (visceral) tissues. Ultimately, they become surgically unresectable, with pharmacological or radiological long-term control being uncommon (Stacker et al., 2002).

Although the genetic basis of tumorigenesis may vary greatly between different cancer types, the cellular and molecular steps required for metastasis are generally similar for all solid tumor cells (Woodhouse et al., 1997Liotta and Kohn, 2003). Not surprisingly, the molecular mechanisms that propel invasive growth and metastasis are also found in embryonic development, and, however to a less perpetual/chronic/aggressive/quantitatively different extent, in adult tissue maintenance (e.g. involving stem cell differentiation) and repair processes (‘tumors are wounds that do not heal’) (Dvorak, 1986). We now view cancer as a complex tissue resulting from disrupted organ homeostasis, rather than focusing on the cancer cell, and the genes within it, alone (Hanahan and Weinberg, 2000;Bissell and Radisky, 2001Bogenrieder and Herlyn, 2002Wiseman and Werb, 2002). Normal tissue homeostasis is maintained between epithelial cells and their microenvironment, such as fibroblasts, endothelial and immunocompetent cells, and the extracellular matrix (ECM). Similarly, during malignant transformation and progression, there are (however deregulated) reciprocal and conspirational interactions between the neoplastic cells and the adjacent stromal cells (Hsu et al., 2002). A series of recent investigations have shown that aberrations in the stroma can both precede and stimulate the development of cancers (reviewed in Bissell and Radisky, 2001Wiseman and Werb, 2002).

The process of metastasis involves an intricate interplay between altered cell adhesion, survival, proteolysis, migration, lymph-/angiogenesis (see articles in this issue by R Kerbel and P Campochiaro, pp. NNN–NNN), immune escape mechanisms, and homing on target organs (Table 1). However, there is still very little knowledge of how these events are coordinated by the cancer cell, with conspirational help by the stromal component (microenvironment) of the host (Clark, 1991Hsu et al., 2002). This process is usually said to be ‘uncontrolled’. As we shall see, however, it is by no means purely stochastic, but rather a finely tuned molecular machinery with active tumor cell–host collaboration. Thus, all explanations of ‘success’ of the metastatic axis contain a strong element of determinism. Whereas the early steps in the metastastic campaign are completed very efficiently, metastasis is an inefficient process in its later steps, especially the regulation of cancer cell growth at the secondary sites (Luzzi et al., 1998Cameron et al., 2000Chambers et al., 2002). Given that spread of the tumor to distant organs is usually lethal, more intense studies of these molecular mechanisms assume general importance to develop more effective anticancer strategies. In the following discussion of specific molecular mechanisms, we have often chosen to draw mainly from examples that pertain to melanoma progression, although similar processes are most likely also operating during oncogenesis of a wide range of cancers.

The classical metastatic cascade encompasses intravasation by tumor cells, their circulation in lymph and blood vascular systems, arrest in distant organs, extravasation, and growth into metastatic foci (Herlyn and Malkowicz, 1991;Woodhouse et al., 1997). Ann Chambers et al. (2001),(2002) have demonstrated in murine models that the limiting factor for metastasis formation is growth after extravasation (Figure 1a). Recently, this extravasation model has been challenged by Ruth Muschel and co-workers (Al-Mehdi et al., 2000Wong et al., 2002), who showed that tumor cells can readily proliferate after arrest in blood vessels, suggesting that extravasation is not a prerequisite for metastatic growth (Figure 1b). In a separate series of experiments, Mary Hendrix and co-workers described that tumor cells can even have endothelial cell-like functions and form channels that allow fluid flow (Maniotis et al., 1999Folberg et al., 2000) (Figure 1c). The group has identified some of the players, such as EphA2 and VE-cadherin, on aggressive melanoma cells that are shared with endothelial cells and that are likely involved in ‘vasculogenic mimicry’. Vasculogenic mimicry is the ability of aggressive cancer cells to form de novo vessel-like networks in vitro in the absence of endothelial cells or fibroblasts, concomitant with their expression of vascular-associated cellular marker (Sood et al., 2001,2002). Tumor cell plasticity is demonstrated by the ability of tumor cells to adopt a variety of phenotypes, including an endothelial phenotype (Sood et al., 2001, 2002). These exciting new findings underscore the plasticity of malignant cells from advanced tumor progression stages, and they require from tumor biologists a more dynamic view of the metastatic cascade. If the biological phenotype of metastasis must be portrayed flexibly, then we need a new ‘yardstick,’ a normal cell, to better characterize and understand the many faces of metastasis. We need to understand how the malignant cells exert cooperation from the normal cells. Our central hypothesis is that both normal and malignant cells utilize the same molecules for invasion, but that differences in downstream signaling events allow the tumor cells to dominate over normal cells in the microenvironment. This ‘dominant plasticity’ model of cancer metastasis takes into account the flexible response of malignant cells to microenvironmental pressures while maintaining dominance over the normal parenchymal and stromal cells.

Models of metastasis

Models of metastasis

Models of metastasis. (a) According to Chambers and co-workers, only a very small population of injected cells (2%) form micrometastases, although over 87% are arrested in the liver. Furthermore, not all of the micrometastases persist, and the progressively growing metastases that kill the mice arise only from a small subset (0.02%) of the injected cells. (b) Muschel and co-workers recently proposed a new model for pulmonary metastasis in which endothelium-attached tumor cells that survived the initial apoptotic stimuli proliferate intravascularly. Thus, a principal tenet of this new model is that the extravasation of tumor cells is not a prerequisite for metastatic colony formation and that the initial proliferation takes place within the blood vessels. (c) The unique ability of aggressive tumor cells to generate patterned networks, similar to the patterned networks during embryonic vasculogenesis, and concomitantly to express vascular markers associated with endothelial cells, their precursors and other vascular cells has been termed ‘vasculogenic mimicry’ by Hendrix and co-workers

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