Glucocorticoid receptor studies in human leukemia

Vitamin D increases glucocorticoid efficacy via inhibition of mTORC1 in experimental models of multiple sclerosis

The limited efficacy of glucocorticoids (GCs) during therapy of acute relapses in multiple sclerosis (MS) leads to long-term disability. We investigated the potential of vitamin D (VD) to enhance GC efficacy and the mechanisms underlying this VD/GC interaction. In vitro, GC receptor (GR) expression levels were quantified by ELISA and induction of T cell apoptosis served as a functional readout to assess synergistic 1,25(OH)₂D₃ (1,25D)/GC effects. Experimental autoimmune encephalomyelitis (MOG_35-55 EAE) was induced in mice with T cell-specific GR or mTORc1 deficiency. 25(OH)D (25D) levels were determined in two independent cohorts of MS patients with stable disease or relapses either responsive or resistant to GC treatment (initial cohort: n = 110; validation cohort: n = 85). Gene expression of human CD8⁺ T cells was analyzed by microarray (n = 112) and correlated with 25D serum levels. In vitro, 1,25D upregulated GR protein levels, leading to increased GC-induced T cell apoptosis. 1,25D/GC combination therapy ameliorated clinical EAE course more efficiently than respective monotherapies, which was dependent on GR expression in T cells. In MS patients from two independent cohorts, 25D deficiency was associated with GC-resistant relapses. Mechanistic studies revealed that synergistic 1,25D/GC effects on apoptosis induction were mediated by the mTOR but not JNK pathway. In line, 1,25D inhibited mTORc1 activity in murine T cells, and low 25D levels in humans were associated with a reduced expression of mTORc1 inhibiting tuberous sclerosis complex 1 in CD8⁺ T cells. GR upregulation by 1,25D and 1,25D/GC synergism in vitro and therapeutic efficacy in vivo were abolished in animals with a T cell-specific mTORc1 deficiency. Specific inhibition of mTORc1 by everolimus increased the efficacy of GC in EAE. 1,25D augments GC-mediated effects in vitro and in vivo in a T cell-specific, GR-dependent manner via mTORc1 inhibition. These data may have implications for improvement of anti-inflammatory GC therapy.

Glucocorticoid receptors and resistance to glucocorticoids in hematologic malignancies

Glucocorticoids are highly effective in inducing the cytolysis of cells of lymphocytic origin. This property has resulted in their incorporation into chemotherapy regimens used in the treatment of hematologic malignancies. Studies at the molecular and cellular levels have demonstrated that the hormone-induced cytolytic response is mediated through a highly specific cytoplasmic glucocorticoid receptor (GR). The GR has been cloned and sequenced and found to be organized into a discrete series of domains which mediate the receptor functions of hormone binding, nuclear translocation, DNA binding and transcriptional modulation. Thus, the binding of glucocorticoids by the GR induces a series of cellular events which result in the activation or repression of a network of glucocorticoid responsive genes and produces a specific cellular response. Prolonged exposure to glucocorticoids ultimately causes resistance to develop; thereby limiting the usefulness of this class of drugs. Studies addressing the mechanism of resistance have shown that the GR is the primary target of genetic alterations that lead to resistance to cytolysis. Using mouse and human cell lines as model systems, it has been shown that the vast majority of glucocorticoid resistant mutants express low levels or altered forms of the GR. Similarly, in vivo studies on patients have suggested that low GR levels are associated with a poor response to glucocorticoid based therapies. Recently, aberrant GR isolated from a patient with multiple myeloma resistant to glucocorticoids were found to harbor deletions in their hormone binding domains. Sequencing of the receptors suggested that each arose as a result of alternate splicing events. In both cases, the latter event produces a receptor unable to bind hormone leading to the speculation that alternate splicing may serve as a mechanism by which a cell evades the effects of glucocorticoids. The therapeutic implications for patients expressing aberrant receptors is discussed.

Glucocorticoid resistance in childhood leukemia

Glucocorticoids (GC) are being used in the treatment of childhood leukemia for several decades, most successfully in newly diagnosed acute lymphoblastic leukemia (ALL). However, GC resistance is seen in 10-30% of untreated ALL patients, and is much more frequent in relapsed ALL and in acute nonlymphoblastic leukemia (ANLL). Sensitivity or resistance to GC can be measured using a cell culture drug resistance assay. For this purpose, we use the colorimetric methyl-thiazol-tetrazolium (MTT) assay. We have shown that GC resistance in childhood leukemia is related to clinical and cell biological features, and to the clinical outcome after multi-drug chemotherapy. These results are summarized in this review. In addition, we describe the apoptotic 'cell-lysis pathway' by which GC exert their antileukemic activity. This description provides a model to discuss the mechanisms of GC resistance, and to summarize the relevant literature. Possible levels of resistance relate to the diffusion of GC through the cell membrane, binding to the GC receptor (GCR), activation of the GC-GCR complex, translocation of the complex into the nucleus, binding to DNA, endonuclease-mediated DNA fragmentation, and DNA repair. A low number of GCR has been shown to be the cause of resistance in some children with ALL. However, GC resistance is likely to be caused at the post-receptor level in most leukemias. Unfortunately, there is still a lack of knowledge relating to the clinical relevance of mechanisms of GC resistance at the post-receptor level. Studies on the mechanisms of GC resistance other than those directly related to the GCR should be initiated, especially if patient material is used, as the results might indicate ways to circumvent or modulate GC resistance. A further increase in our knowledge regarding the relation between GC resistance and patient and cell biological features, the clinical relevance of GC resistance, and the mechanisms of GC resistance in leukemia patients, may contribute to further improvement in the results of GC therapy in leukemia.

Glucocorticoid receptors in human malignancies: a review

The present knowledge of the human glucocorticoid receptor (hGCR) in primary malignancies is reviewed. It is concluded that hGCR is present in a large number of these tissues; in all tissue specimens of lymphoid malignancies and in varying fractions of the different solid tumors. The hGCR functions as a hormone dependent, specific enhancer interacting protein in mediating the considerable effects of glucocorticoids on growth regulation, both through stimulation and inhibition of expression of the target genes, including other transcription regulation systems. The processes of receptor activation and regulation, as well as the effects of glucocorticoids, are tissue-specific. Subjects for future research are proposed: Establishment of more cell lines and animal models to extend investigation beyond the present concentration on only a few cell lines, especially CEM-C7, application of 'dynamic' assays to cells obtained from patients, in an attempt to predict development of glucocorticoid resistance, and further investigation of the relationships among GCR and growth factors and oncogenes.

Sequential studies of lymphoblast glucocorticoid receptor levels at diagnosis and relapse in childhood leukemia: an update

For 80 children with relapsed acute lymphoblastic leukemia, glucocorticoid receptor (GR) levels were lower in blast cells from patients who developed relapse while receiving chemotherapy (p = 0.03) and in those who failed reinduction treatment (p = 0.07). Serial determinations of GR at diagnosis and at relapse in blast cells from 41 patients disclosed various changes in receptor content, which were not related to the initial GR levels, the immunophenotype of blast cells or number of relapses. Six of 9 patients for whom reinduction therapy failed and only 7 of 32 patients in whom subsequent remission was induced had decreased GR levels at relapse (p = 0.018). One patient failed reinduction despite a sharp increase in GR level. Although a decrease in GR levels between diagnosis and relapse is associated with steroid resistance, other mechanism(s) can also be responsible for the development of steroid resistance in childhood leukemia.

Impact of treatment efficacy on the prognostic value of glucocorticoid receptor levels in childhood acute lymphoblastic leukemia

Glucocorticoid receptor (GR) levels were quantitated in leukemic blasts from bone marrow aspirates of 249 children with acute lymphoblastic leukemia (ALL) who were entered on two St. Jude Total Therapy Studies. Of these, 235 were evaluable for analysis of the relation of GR levels to clinical outcome. For the 42 patients in the earlier Total Therapy Study IX, lower GR levels (less than 16,000 sites/cell) were associated with both induction failure and more frequent relapse (p less than 0.01) [Cancer Research, Vol. 42, p. 4801 (1982)]. When patients with 'high-risk' features (leukocyte count greater than 100 X 10(3)/mm3, positive erythrocyte rosette test, central nervous system involvement, and mediastinal mass) were excluded, lower receptor levels were still associated with early and more frequent relapse (p less than 0.02). The other 193 evaluable patients were consecutively admitted to Total Therapy Study X, in which patients with 'standard-risk' or 'high-risk' features were assigned to separate protocols--XS and XH, respectively. Induction chemotherapy in both protocols consisted of prednisone, vincristine and L-asparaginase; patients in the XH protocol received additional epipodophyllotoxin (VM-26) and cytosine arabinoside twice a week for 2 weeks preceding the conventional induction therapy. To compare the prognostic value of GR level in Study X with that of Study IX (which included both 'high-risk' and 'standard-risk' patients but did not separate them into different protocol groups), children in the XH and XS protocols were analysed together. The proportion of patients with 'standard-risk' features was the same in the two studies: 69% in Study IX and 73% in Study X. In Study X, which had a significantly better treatment result (p less than 0.001), lower receptor levels were not associated with induction failure, but were correlated with more frequent relapse (p less than 0.05). When patients in XH and XS protocols were analysed separately, however, receptor levels were no longer related to treatment outcome. Thus, GR level in childhood ALL has prognostic value, but it is not an independent factor and its importance is related to the efficacy of treatment.

The relationship of blast cell glucocorticoid receptor levels to response to single-agent steroid trial and remission response in children with acute lymphoblastic leukemia

Of 263 children with glucocorticoid receptor (GR) levels measured at diagnosis of acute lymphoblastic leukemia (ALL), 27 received single-agent glucocorticoid before combination induction chemotherapy and were evaluable for in vivo clinical response to steroid. Twenty-one were glucocorticoid-responsive and 6 were resistant. There was no difference between the two groups in the distribution of age, sex, white blood cell count, immunophenotype of blasts, initial central nervous system disease or mediastinal mass. The median GR level, however, was appreciably lower in the group of patients with resistant disease (6250 vs 17,800 sites/cell, p = 0.06). Five of 12 patients with GR levels of less than 10,000 sites/cell compared to 1 of 15 with higher levels had glucocorticoid-resistant ALL (p = 0.03). All 21 patients with glucocorticoid-sensitive disease achieved a complete remission after combination induction chemotherapy, but only 3 of 5 evaluable patients in the other group did (p less than 0.04). Two patients were studied both at diagnosis and at relapse; both had decreased GR levels at relapse (below detection in one) and failed to respond to glucocorticoid. We conclude that a lower GR level is associated with glucocorticoid resistance and furthermore that a decrease in the level of GR is a mechanism of acquiring steroid resistance.

Presence and steroid inducibility of glutamine synthetase in human leukemic cells

Glutamine synthetase (EC 6.3.1.2; GS) is present in lymphoblasts from patients with acute lymphoblastic leukemia (ALL) as well as in normal peripheral blood lymphocytes. In 16 out of 20 ALL patients studied exposure of the cells to physiological concentrations of dexamethasone in vitro increased enzyme activity above the control levels. The increase was specific for glucocorticoid receptor ligands. A direct correlation was found between the magnitude of glucocorticoid-mediated increase of GS activity and the cellular levels of specific glucocorticoid receptors assayed in the same cell specimen. Moreover, the basal levels of the enzyme measured in cells prior to exposure to dexamethasone correlated negatively with receptor density. It is suggested that the presence of steroid-inducible GS in ALL cells may prove to be a marker for functional receptor sites.

Significance of glucocorticoid receptors and responses in leukaemia

Glucocorticoid receptor levels and cellular responses to glucocorticoid treatment in vitro were evaluated for the malignant cells from patients with leukaemia. Cells from all cases of lymphoid and myeloid leukaemia contained glucocorticoid receptors; receptor levels and the extent of in vitro responses appeared to depend primarily on cell type and differentiation status. For acute lymphoblastic leukaemia (ALL), high receptor levels were associated with the common ALL phenotype, intermediate levels with null (unclassified) ALL and low levels with T-ALL. Considerable variation in receptor levels and in responses in vitro was observed for acute myeloid leukaemia; receptor levels measured by whole-cell assay did not relate to patient survival.