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Marine natural products for multi-targeted cancer treatment: A future insight. Biomed Pharmacother 2018; 105:233-245. [PMID: 29859466 DOI: 10.1016/j.biopha.2018.05.142] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 05/26/2018] [Accepted: 05/28/2018] [Indexed: 12/28/2022] Open
Abstract
Cancer is world's second largest alarming disease, which involves abnormal cell growth and have potential to spread to other parts of the body. Most of the available anticancer drugs are designed to act on specific targets by altering the activity of involved transporters and genes. As cancer cells exhibit complex cellular machinery, the regeneration of cancer tissues and chemo resistance towards the therapy has been the main obstacle in cancer treatment. This fact encourages the researchers to explore the multitargeted use of existing medicines to overcome the shortcomings of chemotherapy for alternative and safer treatment strategies. Recent developments in genomics-proteomics and an understanding of the molecular pharmacology of cancer have also challenged researchers to come up with target-based drugs. The literature supports the evidence of natural compounds exhibiting antioxidant, antimitotic, anti-inflammatory, antibiotic as well as anticancer activity. In this review, we have selected marine sponges as a prolific source of bioactive compounds which can be explored for their possible use in cancer and have tried to link their role in cancer pathway. To prove this, we revisited the literature for the selection of cancer genes for the multitargeted use of existing drugs and natural products. We used Cytoscape network analysis and Search tool for retrieval of interacting genes/ proteins (STRING) to study the possible interactions to show the links between the antioxidants, antibiotics, anti-inflammatory and antimitotic agents and their targets for their possible use in cancer. We included total 78 pathways, their genes and natural compounds from the above four pharmacological classes used in cancer treatment for multitargeted approach. Based on the Cytoscape network analysis results, we shortlist 22 genes based on their average shortest path length connecting one node to all other nodes in a network. These selected genes are CDKN2A, FH, VHL, STK11, SUFU, RB1, MEN1, HRPT2, EXT1, 2, CDK4, p14, p16, TSC1, 2, AXIN2, SDBH C, D, NF1, 2, BHD, PTCH, GPC3, CYLD and WT1. The selected genes were analysed using STRING for their protein-protein interactions. Based on the above findings, we propose the selected genes to be considered as major targets and are suggested to be studied for discovering marine natural products as drug lead in cancer treatment.
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Máximo P, Ferreira LM, Branco P, Lima P, Lourenço A. The Role of Spongia sp. in the Discovery of Marine Lead Compounds. Mar Drugs 2016; 14:E139. [PMID: 27455286 PMCID: PMC4999901 DOI: 10.3390/md14080139] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 07/06/2016] [Accepted: 07/08/2016] [Indexed: 02/02/2023] Open
Abstract
A comprehensive review on the chemistry of Spongia sp. is here presented, together with the biological activity of the isolated compounds. The compounds are grouped in sesquiterpene quinones, diterpenes, C21 and other linear furanoterpenes, sesterterpenes, sterols (including secosterols), macrolides and miscellaneous compounds. Among other reports we include studies on the intraspecific diversity of a Mediterranean species, compounds isolated from associated sponge and nudibranch and compounds isolated from S. zimocca and the red seaweed Laurentia microcladia. Under biological activity a table of the reported biological activities of the various compounds and the biological screening of extracts are described. The present review covers the literature from 1971 to 2015.
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Affiliation(s)
- Patrícia Máximo
- LAQV-REQUIMTE, Departamento de Química, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, 2829-516 Caparica, Portugal.
| | - Luísa M Ferreira
- LAQV-REQUIMTE, Departamento de Química, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, 2829-516 Caparica, Portugal.
| | - Paula Branco
- LAQV-REQUIMTE, Departamento de Química, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, 2829-516 Caparica, Portugal.
| | - Pedro Lima
- Sea4Us-Biotecnologia de Recursos Marinhos, Ltd., 8650-378 Sagres, Portugal.
- Nova Medical School/Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Campo Mártires da Pátria 130, 1169-056 Lisboa, Portugal.
| | - Ana Lourenço
- LAQV-REQUIMTE, Departamento de Química, Faculdade de Ciências e Tecnologia, Universidade NOVA de Lisboa, 2829-516 Caparica, Portugal.
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Smith AB, Risatti CA, Atasoylu O, Bennett CS, Liu J, Cheng H, TenDyke K, Xu Q. Design, synthesis, and biological evaluation of diminutive forms of (+)-spongistatin 1: lessons learned. J Am Chem Soc 2011; 133:14042-53. [PMID: 21761891 PMCID: PMC3164888 DOI: 10.1021/ja2046167] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The design, synthesis, and biological evaluation of two diminutive forms of (+)-spongistatin 1, in conjunction with the development of a potentially general design strategy to simplify highly flexible macrocyclic molecules while maintaining biological activity, have been achieved. Examination of the solution conformations of (+)-spongistatin 1 revealed a common conformational preference along the western perimeter comprising the ABEF rings. Exploiting the hypothesis that the small-molecule recognition/binding domains are likely to comprise the conformationally less mobile portions of a ligand led to the design of analogues, incorporating tethers (blue) in place of the CD and the ABCD components of the (+)-spongistatin 1 macrolide, such that the conformation of the retained (+)-spongistatin 1 skeleton would mimic the assigned solution conformations of the natural product. The observed nanomolar cytotoxicity and microtubule destabilizing activity of the ABEF analogue provide support for both the assigned solution conformation of (+)-spongistatin 1 and the validity of the design strategy.
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Affiliation(s)
- Amos B Smith
- Monell Chemical Senses Center and Laboratory for Research on the Structure of Matter, Department of Chemistry, University of Pennsylvania , Philadelphia, 19104, United States.
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Qi Y, Ma S. The medicinal potential of promising marine macrolides with anticancer activity. ChemMedChem 2011; 6:399-409. [PMID: 21302362 DOI: 10.1002/cmdc.201000534] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2010] [Revised: 01/08/2011] [Indexed: 12/12/2022]
Abstract
Marine natural products have become a major source of new chemical entities in the discovery of potential anticancer agents that potently suppress various molecular targets. In particular, the marine macrolides, which include an array of novel biomolecules endowed with outstanding cytotoxic and/or antiproliferative activities, are a prominent class of marine natural products that offer continued promise for breakthroughs in anticancer research. Herein we highlight some recent studies of promising marine macrolides, paying particular attention to their discovery, anticancer activities, mechanisms of action, chemical synthesis, and representative analogues.
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Affiliation(s)
- Yunkun Qi
- Department of Medicinal Chemistry, School of Pharmaceutical Sciences, Shandong University, 44, West Culture Road, Jinan 250012, PR China
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Flowers CL, Vogel P. Short diastereoselective synthesis of the C1-C13 (AB spiroacetal) and C17-C28 fragments (CD spiroacetal) of spongistatin 1 and 2 through double chain-elongation reactions. Chemistry 2010; 16:14074-82. [PMID: 20963739 DOI: 10.1002/chem.201002204] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
A unique and practical synthetic sequence for rapid access to polyketides and to further the spiroacetals derived from them, which utilizes a bidirectional Hosomi-Sakurai allylation approach around key allylsilanes in the synthesis of the AB and CD ring systems of spongistatin 1 and 2, is reported. The synthesis of the AB spiroacetal 9 requires 13 steps, with a longest linear sequence of seven steps in an overall yield of 27%. The synthesis of the CD spiroacetal 13 requires 15 steps, with a longest linear sequence of 11 steps in an overall yield of 30%. Both syntheses start from but-3-enol.
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Affiliation(s)
- Christopher L Flowers
- Laboratory of Glycochemistry and Asymmetric Synthesis (LGSA), Swiss Institute of Technology (EPFL), Batochime, 1015 Lausanne, Switzerland
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Favre S, Gerber-Lemaire S, Vogel P. Synthetic Studies toward the CD Spiroketal of Spongistatins. European J Org Chem 2010. [DOI: 10.1002/ejoc.200901285] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Smith AB, Corbett RM, Pettit GR, Chapuis JC, Schmidt JM, Hamel E, Jung MK. Synthesis and biological evaluation of a spongistatin AB-spiroketal analogue. Bioorg Med Chem Lett 2002; 12:2039-42. [PMID: 12113837 DOI: 10.1016/s0960-894x(02)00305-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The synthesis of a simplified analogue of the potent, cytotoxic tubulin-depolymerizing agent spongistatin 1, based on the AB spiroketal framework, is presented. The new structural analogue is an extension of a recently described spongistatin congener reported to disrupt microtubules in breast cancer cells in vitro and to alter the microtubule assembly reaction. Cytotoxicity data on the new structural analogue, as well as the parent congener, are reported. We found no significant cytotoxic or antitubulin activity with either compound.
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Affiliation(s)
- Amos B Smith
- Department of Chemistry, University of Pennsylvania, PA 19104, USA.
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Chaudhuri AR, Tomita I, Mizuhashi F, Murata K, Ludueña RF. Distinct and overlapping binding sites for IKP104 and vinblastine on tubulin. JOURNAL OF PROTEIN CHEMISTRY 1998; 17:685-90. [PMID: 9853684 DOI: 10.1007/bf02780971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
IKP104 is one of a group of tubulin-binding drugs whose interaction with tubulin suggests that it may bind to the protein at or close to the region where vinblastine binds. By itself IKP104 is a potent enhancer of tubulin decay as evidenced by the fact that it induces the exposure of the sulfhydryl groups and hydrophobic areas on tubulin. In this respect, IKP104 differs from vinblastine and other drugs such as phomopsin A, dolastatin 10, rhizoxin, and maytansine which are competitive or noncompetitive inhibitors of vinblastine binding. In contrast, however, in the presence of colchicine, IKP104 behaves differently and strongly stabilizes tubulin, to an extent much greater than does colchicine alone. IKP104 appears to have two classes of binding site on tubulin, differing in affinity; the acceleration of decay appears to be mediated by the low-affinity site (Chaudhuri et al., 1998, J. Protein Chem., in press). We investigated the relationship of the binding of IKP104 and vinblastine. We found that the high-affinity site or sites of IKP104 overlap with or interact with the vinblastine-binding sites, but that the low-affinity site is distinctly different.
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Affiliation(s)
- A R Chaudhuri
- Department of Biochemistry, University of Texas Health Science Center, San Antonio 78284, USA.
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10
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Prasad V, Chaudhuri AR, Curcio M, Tomita I, Mizuhashi F, Murata K, Ludueña RF. Podophyllotoxin and nocodazole counter the effect of IKP104 on tubulin decay. JOURNAL OF PROTEIN CHEMISTRY 1998; 17:663-8. [PMID: 9853681 DOI: 10.1007/bf02780968] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Tubulin, the subunit protein of microtubules, undergoes a time-dependent loss of functional properties known as decay. We have previously shown that the drug 2-(4-fluorophenyl)- -(2-chloro-3,5-dimethoxyphenyl)-3-methyl-6-phenyl-4(1H)-pyridinone (IKP104) accelerates decay, but that in the presence of colchicine, IKP104 becomes a stabilizer of tubulin. To see if this is due to conformational effects specific to colchicine or simply to occupancy at the colchicine site, we examined the effects of nocodazole and podophyllotoxin, two well-known competitive inhibitors of colchicine for binding to tubulin, on IKP104's acceleration of decay. We found that podophyllotoxin abolished IKP104's accelerating effect and, like colchicine, turned it into a stabilizer of tubulin. Nocodazole's effects were similar to those of podophyllotoxin and colchicine, in that it abolished IKP104-induced enhancement of decay; however, in the presence of nocodazole, IKP104 caused little or no stabilization of tubulin. Since colchicine, nocodazole, and podophyllotoxin have very different interactions with tubulin, but all inhibit the IKP104-induced enhancement of decay, our findings suggest that this inhibition arises from occupancy of the colchicine site rather than from a direct conformational effect of these two drugs.
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Affiliation(s)
- V Prasad
- Department of Biochemistry, University of Texas Health Science Center, San Antonio 78284, USA
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Chen BD, Nakeff A, Valeriote F. Cellular uptake of a novel cytotoxic agent, cryptophycin-52, by human THP-1 leukemia cells and H-125 lung tumor cells. Int J Cancer 1998; 77:869-73. [PMID: 9714056 DOI: 10.1002/(sici)1097-0215(19980911)77:6<869::aid-ijc12>3.0.co;2-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Cryptophycin (CP) is a newly developed anticancer agent isolated from the terrestrial cyanobacteria of the genus Nostoc. CP is a mitotic inhibitor, causing cells to accumulate in mitosis with the disappearance of intracellular microtubules. In this report, we studied the interaction and uptake of a new synthetic CP analog, CP-52, with 2 human tumor cell lines, THP-1 and H-125. In vitro colony-forming assay showed that CP-52 has antiproliferative activity against THP-1 and H-125 cell lines with IC50 of 0.1 ng/ml and 20 microg/ml, respectively; i.e., THP-1 cells are 200,000 times more sensitive to CP-52 than H-125 cells. The uptake of CP-52 by the target cells was carried out using tritiated CP-52 (3H-CP-52). The uptake of 3H-CP-52 by both THP-1 and H-125 cells was rapid, reaching a maximum within 20 min. Dissociation experiments showed that CP-52 interacts with the target cells irreversibly, presumably by binding to specific cellular sites with high affinity. With increasing doses of 3H-CP-52, the uptake was found to be saturable, reaching a steady state as the concentrations of 3H-CP-52 were raised to about 20 microg/ml. Under this condition, the maximal values of CP-52 uptake by THP-1 and H-125 cells was estimated to be 27 and 136 ng/10(5) cells, respectively. The uptake and accumulation of 3H-CP-52 with the target cells was effectively inhibited by prior treatment with unlabeled CP-52 and, to a lesser extent, vinblastine and taxol but not adriamycin, colchicine or mitomycin. In addition, the binding of 3H-CP-52 to purified tubulin was inhibited by vinblastine but not taxol. This finding suggested that CP-52 and taxol interact and bind to distinct regions of tubulin molecules. Further, it suggests that, in addition to tubulin, other intracellular and/or membrane components are involved in mediating the binding of CP-52.
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Affiliation(s)
- B D Chen
- Barbara Ann Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, USA.
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König G, Wright AD. [Marine organisms--producers of pharmacologically active secondary metabolites]. PHARMAZIE IN UNSERER ZEIT 1997; 26:281-8. [PMID: 9513572 DOI: 10.1002/pauz.19970260608] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- G König
- Institut für Pharmazeutische Biologie, Braunschweig
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Chaudhuri AR, Ludueña RF. Interaction of phomopsin A with normal and subtilisin-treated bovine brain tubulin. JOURNAL OF PROTEIN CHEMISTRY 1997; 16:99-105. [PMID: 9112603 DOI: 10.1023/a:1026337900317] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Tubulin, the major component of microtubules, has a tendency to lose its ability to assemble or to bind to ligands in a time-dependent process known as "decay." The decay process also causes tubulin to expose sulfhydryl groups and hydrophobic areas. The antimitotic drug phomopsin A strongly protects the tubulin molecule from decay. Here we have studied the interaction of phomopsin A with alpha beta tubulin and tubulin which has been treated with subtilisin to remove selectively the C-termini of the alpha and beta chains (alpha(s) beta(s)). The binding of phomopsin A to alpha beta tubulin decreases the sulfhydryl titer by approximately 1.0 mol/mol. Selective removal of the peptides from the C-terminal ends does not affect phomopsin A's interaction with tubulin. Moreover, the alpha(s) beta(s) tubulin-phomopsin A complex appears to be more stable than the alpha bet tubulin-phomopsin A complex as determined by the time-dependent increase in exposure of sulfhydryl groups and hydrophobic areas on tubulin. In fact, phomopsin A inhibits the decay process of alpha(s) beta(s) tubulin completely. This observation raises the possibility of determining the conformation of this configuration of tubulin.
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Affiliation(s)
- A R Chaudhuri
- Department of Biochemistry, University of Texas Health Science Center, San Antonio 78284-7760, USA
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Abstract
Griseofulvin is an anti-fungal drug whose mechanism of action is directed against microtubules. Although it inhibits the assembly of mammalian brain tubulin, its binding to tubulin has not been directly measured successfully. We have examined the interaction of griseofulvin with tubulin fluorometrically by measuring the quenching of tubulin tryptophan fluorescence by griseofulvin. From Scatchard analysis, we found that griseofulvin bound to tubulin at one class of binding site with an affinity constant of 1.2 +/- 0.19 x 10(4) M(-1), and the binding was largely reversible. Griseofulvin caused a major change in the conformation of tubulin in that it increased the sulfhydryl titer of tubulin approximately 2-fold. The drug affected both the alpha and beta subunits of tubulin equally. Interestingly, griseofulvin did not increase the sulfhydryl titer of the tubulin-colchicine complex although the binding site of griseofulvin was distinctly different from that of colchicine. The change of conformation of tubulin upon interaction with griseofulvin did not affect the exposure of hydrophobic areas on tubulin as shown by binding of bis-5,5'-[8(N-phenyl)aminonapthalene-1-sulfonic acid] (BisANS). Even in combination with colchicine, griseofulvin had very little effect on BisANS binding to tubulin. Thus, griseofulvin appears to interact with tubulin in a manner that is very different from that of many other tubulin ligands.
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Affiliation(s)
- A R Chaudhuri
- Department of Biochemistry, University of Texas Health Science Center, San Antonio, 78284-7760, USA
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Smith CD, Zhang X. Mechanism of action cryptophycin. Interaction with the Vinca alkaloid domain of tubulin. J Biol Chem 1996; 271:6192-8. [PMID: 8626409 DOI: 10.1074/jbc.271.11.6192] [Citation(s) in RCA: 69] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Cryptophycin is a potent antitumor agent that depletes microtubules in intact cells, including cells with the multidrug resistance phenotype. To determine the mechanism of action of cryptophycin, its effects on tubulin function in vitro were analyzed. Cryptophycin reduced the in vitro polymerization of bovine brain microtubules by 50% at a drug:tubulin ratio of 0.1. Cryptophycin did not alter the critical concentration of tubulin required for polymerization, but instead caused substoichiometric reductions in the amount of tubulin that was competent for assembly. Consistent with its persistent effects on intact cells, cryptophycin-treated microtubule protein remained polymerization-defective even after cryptophycin was reduced to sub-inhibitory concentrations. The effects of cryptophycin were not due to denaturation of tubulin and were associated with the accumulation of rings of microtubule protein. The site of cryptophycin interaction with tubulin was examined using functional and competitive binding assays. Cryptophycin blocked the formation of vinblastine-tubulin paracrystals in intact cells and suppressed vinblastine-induced tubulin aggregation in vitro. Cryptophycin inhibited the binding of [3H]vinblastine and the hydrolysis of [gamma32P]GTP by isolated tubulin, but did not block the binding of colchicine. These results indicate that cryptophycin disrupts the Vinca alkaloid site of tubulin; however, the molecular details of this interaction are distinct from those of other antimitotic drugs.
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Affiliation(s)
- C D Smith
- Department of Pharmacology, Fox Chase Cancer Center, Philadelphia, Pennsylvania 19111, USA
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Bai R, Taylor GF, Cichacz ZA, Herald CL, Kepler JA, Pettit GR, Hamel E. The spongistatins, potently cytotoxic inhibitors of tubulin polymerization, bind in a distinct region of the vinca domain. Biochemistry 1995; 34:9714-21. [PMID: 7626642 DOI: 10.1021/bi00030a009] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The highly cytotoxic, sponge-derived, antimitotic macrolide polyether spongistatin 1 has been previously shown to inhibit microtubule assembly, the binding of vinblastine and GTP to tubulin, and displacement of GDP bound in the exchangeable site of tubulin. We have now examined in detail inhibition by spongistatin 1 of both [3H]vinblastine and [3H]dolastatin 10 binding to tubulin. We found spongistatin 1 to be a noncompetitive inhibitor of the binding of both radiolabeled drugs to tubulin, in contrast to competitive patterns obtained with vincristine versus [3H]vinblastine and with a chiral isomer of dolastatin 10 versus [3H]dolastatin 10. Since dolastatin 10 is itself a noncompetitive inhibitor of vinca alkaloid binding to tubulin, this implies at least three distinct binding sites for the structurally complex and diverse natural products that interfere with each others binding to tubulin and with nucleotide exchange. Spongistatin 1, in contrast to both vinca alkaloids and peptide antimitotic agents like dolastatin 10, does not induce formation of a GTP-independent, morphologically distinctive polymer ("aggregate"). We also examined eight compounds closely related structurally to spongistatin 1 (spongistatins 2-9). The most distinctive in their properties were spongistatins 6 and 8. These two compounds, despite activity comparable to spongistatin 1 as inhibitors of tubulin polymerization and [3H]vinblastine binding, had much reduced activity as inhibitors of nucleotide exchange and [3H]dolastatin 10 binding. Spongistatins 1 and 6 were compared for effects on dolastatin 10-induced aggregate formation in conjunction with effects on [3H]dolastatin 10 binding. Spongistatin 6 was about 4-fold less active than spongistatin 1 as an inhibitor of aggregation and over 20-fold less active as an inhibitor of dolastatin 10 binding.
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Affiliation(s)
- R Bai
- Division of Cancer Treatment, National Cancer Institute, National Institutes of Health, Bethesda, Maryland 20892, USA
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