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Duncan RM, Reyes L, Moats K, Robinson RM, Murphy SA, Kaur B, Stessman HAF, Dolloff NG. ATF3 Coordinates Antitumor Synergy between Epigenetic Drugs and Protein Disulfide Isomerase Inhibitors. Cancer Res 2020; 80:3279-3291. [PMID: 32561529 PMCID: PMC7442646 DOI: 10.1158/0008-5472.can-19-4046] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 04/06/2020] [Accepted: 06/16/2020] [Indexed: 12/31/2022]
Abstract
Histone deacetylase inhibitors (HDACi) are largely ineffective in the treatment of solid tumors. In this study, we describe a new class of protein disulfide isomerase (PDI) inhibitors that significantly and synergistically enhance the antitumor activity of HDACi in glioblastoma and pancreatic cancer preclinical models. RNA-sequencing screening coupled with gene silencing studies identified ATF3 as the driver of this antitumor synergy. ATF3 was highly induced by combined PDI and HDACi treatment as a result of increased acetylation of key histone lysine residues (acetylated histone 3 lysine 27 and histone 3 lysine 18) flanking the ATF3 promoter region. These chromatin marks were associated with increased RNA polymerase II recruitment to the ATF3 promoter, a synergistic upregulation of ATF3, and a subsequent apoptotic response in cancer cells. The HSP40/HSP70 family genes DNAJB1 and HSPA6 were found to be critical ATF3-dependent genes that elicited the antitumor response after PDI and HDAC inhibition. In summary, this study presents a synergistic antitumor combination of PDI and HDAC inhibitors and demonstrates a mechanistic and tumor suppressive role of ATF3. Combined treatment with PDI and HDACi offers a dual therapeutic strategy in solid tumors and the opportunity to achieve previously unrealized activity of HDACi in oncology. SIGNIFICANCE: This study uses a first-in-class PDI inhibitor entering clinical development to enhance the effects of epigenetic drugs in some of the deadliest forms of cancer.
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Affiliation(s)
- Ravyn M Duncan
- Department of Cellular and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, South Carolina
| | - Leticia Reyes
- Department of Cellular and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, South Carolina
| | - Katelyn Moats
- Department of Cellular and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, South Carolina
| | - Reeder M Robinson
- Department of Cellular and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, South Carolina
| | - Sara A Murphy
- Department of Neurosurgery, Health Science Center at Houston, McGovern Medical School, University of Texas, Houston, Texas
| | - Balveen Kaur
- Department of Neurosurgery, Health Science Center at Houston, McGovern Medical School, University of Texas, Houston, Texas
| | - Holly A F Stessman
- Department of Pharmacology, Creighton University School of Medicine, Omaha, Nebraska
| | - Nathan G Dolloff
- Department of Cellular and Molecular Pharmacology and Experimental Therapeutics, Medical University of South Carolina, Charleston, South Carolina.
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2
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Manni S, Fregnani A, Barilà G, Zambello R, Semenzato G, Piazza F. Actionable Strategies to Target Multiple Myeloma Plasma Cell Resistance/Resilience to Stress: Insights From "Omics" Research. Front Oncol 2020; 10:802. [PMID: 32500036 PMCID: PMC7243738 DOI: 10.3389/fonc.2020.00802] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/23/2020] [Indexed: 12/20/2022] Open
Abstract
While the modern therapeutic armamentarium to treat multiple myeloma (MM) patients allows a longer control of the disease, this second-most-frequent hematologic cancer is still uncurable in the vast majority of cases. Since MM plasma cells are subjected to various types of chronic cellular stress and the integrity of specific stress-coping pathways is essential to ensure MM cell survival, not surprisingly the most efficacious anti-MM therapy are those that make use of proteasome inhibitors and/or immunomodulatory drugs, which target the biochemical mechanisms of stress management. Based on this notion, the recently realized discoveries on MM pathobiology through high-throughput techniques (genomic, transcriptomic, and other "omics"), in order for them to be clinically useful, should be elaborated to identify novel vulnerabilities in this disease. This groundwork of information will likely allow the design of novel therapies against targetable molecules/pathways, in an unprecedented opportunity to change the management of MM according to the principle of "precision medicine." In this review, we will discuss some examples of therapeutically actionable molecules and pathways related to the regulation of cellular fitness and stress resistance in MM.
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Affiliation(s)
- Sabrina Manni
- Department of Medicine, Hematology and Clinical Immunology Branch, University of Padova, Padova, Italy
- Foundation for Advanced Biomedical Research – Veneto Institute of Molecular Medicine (FABR-VIMM), Padova, Italy
| | - Anna Fregnani
- Foundation for Advanced Biomedical Research – Veneto Institute of Molecular Medicine (FABR-VIMM), Padova, Italy
- Department of Surgery, Oncology and Gastroenterology (DISCOG), University of Padova, Padova, Italy
| | - Gregorio Barilà
- Department of Medicine, Hematology and Clinical Immunology Branch, University of Padova, Padova, Italy
- Foundation for Advanced Biomedical Research – Veneto Institute of Molecular Medicine (FABR-VIMM), Padova, Italy
| | - Renato Zambello
- Department of Medicine, Hematology and Clinical Immunology Branch, University of Padova, Padova, Italy
- Foundation for Advanced Biomedical Research – Veneto Institute of Molecular Medicine (FABR-VIMM), Padova, Italy
| | - Gianpietro Semenzato
- Department of Medicine, Hematology and Clinical Immunology Branch, University of Padova, Padova, Italy
- Foundation for Advanced Biomedical Research – Veneto Institute of Molecular Medicine (FABR-VIMM), Padova, Italy
| | - Francesco Piazza
- Department of Medicine, Hematology and Clinical Immunology Branch, University of Padova, Padova, Italy
- Foundation for Advanced Biomedical Research – Veneto Institute of Molecular Medicine (FABR-VIMM), Padova, Italy
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3
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Robinson RM, Reyes L, Duncan RM, Bian H, Strobel ED, Hyman SL, Reitz AB, Dolloff NG. Tuning isoform selectivity and bortezomib sensitivity with a new class of alkenyl indene PDI inhibitor. Eur J Med Chem 2019; 186:111906. [PMID: 31787362 DOI: 10.1016/j.ejmech.2019.111906] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/07/2019] [Accepted: 11/20/2019] [Indexed: 02/07/2023]
Abstract
Protein disulfide isomerase (PDI, PDIA1) is an emerging therapeutic target in oncology. PDI inhibitors have demonstrated a unique propensity to selectively induce apoptosis in cancer cells and overcome resistance to existing therapies, although drug candidates have not yet progressed to the stage of clinical development. We recently reported the discovery of lead indene compound E64FC26 as a potent pan-PDI inhibitor that enhances the cytotoxic effects of proteasome inhibitors in panels of Multiple Myeloma (MM) cells and MM mouse models. An extensive medicinal chemistry program has led to the generation of a diverse library of indene-containing molecules with varying degrees of proteasome inhibitor potentiating activity. These compounds were generated by a novel nucleophilic aromatic ring cyclization and dehydration reaction from the precursor ketones. The results provide detailed structure activity relationships (SAR) around this indene pharmacophore and show a high degree of correlation between potency of PDI inhibition and bortezomib (Btz) potentiation in MM cells. Inhibition of PDI leads to ER and oxidative stress characterized by the accumulation of misfolded poly-ubiquitinated proteins and the induction of UPR biomarkers ATF4, CHOP, and Nrf2. This work characterizes the synthesis and SAR of a new chemical class and further validates PDI as a therapeutic target in MM as a single agent and in combination with proteasome inhibitors.
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Affiliation(s)
- Reeder M Robinson
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Leticia Reyes
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Ravyn M Duncan
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Haiyan Bian
- Fox Chase Chemical Diversity Center, Inc, Doylestown, PA, USA
| | - Eric D Strobel
- Fox Chase Chemical Diversity Center, Inc, Doylestown, PA, USA
| | - Sarah L Hyman
- Fox Chase Chemical Diversity Center, Inc, Doylestown, PA, USA
| | - Allen B Reitz
- Fox Chase Chemical Diversity Center, Inc, Doylestown, PA, USA
| | - Nathan G Dolloff
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, College of Medicine, Medical University of South Carolina, Charleston, SC, USA.
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Harding T, Baughn L, Kumar S, Van Ness B. The future of myeloma precision medicine: integrating the compendium of known drug resistance mechanisms with emerging tumor profiling technologies. Leukemia 2019; 33:863-883. [PMID: 30683909 DOI: 10.1038/s41375-018-0362-z] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 10/25/2018] [Accepted: 11/12/2018] [Indexed: 02/07/2023]
Abstract
Multiple myeloma (MM) is a hematologic malignancy that is considered mostly incurable in large part due to the inability of standard of care therapies to overcome refractory disease and inevitable drug-resistant relapse. The post-genomic era has been a productive period of discovery where modern sequencing methods have been applied to large MM patient cohorts to modernize our current perception of myeloma pathobiology and establish an appreciation for the vast heterogeneity that exists between and within MM patients. Numerous pre-clinical studies conducted in the last two decades have unveiled a compendium of mechanisms by which malignant plasma cells can escape standard therapies, many of which have potentially quantifiable biomarkers. Exhaustive pre-clinical efforts have evaluated countless putative anti-MM therapeutic agents and many of these have begun to enter clinical trial evaluation. While the palette of available anti-MM therapies is continuing to expand it is also clear that malignant plasma cells still have mechanistic avenues by which they can evade even the most promising new therapies. It is therefore becoming increasingly clear that there is an outstanding need to develop and employ precision medicine strategies in MM management that harness emerging tumor profiling technologies to identify biomarkers that predict efficacy or resistance within an individual's sub-clonally heterogeneous tumor. In this review we present an updated overview of broad classes of therapeutic resistance mechanisms and describe selected examples of putative biomarkers. We also outline several emerging tumor profiling technologies that have the potential to accurately quantify biomarkers for therapeutic sensitivity and resistance at genomic, transcriptomic and proteomic levels. Finally, we comment on the future of implementation for precision medicine strategies in MM and the clear need for a paradigm shift in clinical trial design and disease management.
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Affiliation(s)
- Taylor Harding
- Department of Genetics, Cell Biology & Development, University of Minnesota, Minneapolis, MN, USA
| | - Linda Baughn
- Department of Laboratory Medicine and Pathology, Division of Laboratory Genetics, Mayo Clinic, Rochester, MN, USA
| | - Shaji Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, USA
| | - Brian Van Ness
- Department of Genetics, Cell Biology & Development, University of Minnesota, Minneapolis, MN, USA.
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Abstract
Immunoglobulin heavy chain (IgH) translocations are common and early oncogenic events in B cell and plasma cell malignancies including B cell non-Hodgkin's lymphoma (NHL) and multiple myeloma (MM). IgH translocations bring oncogenes into close proximity with potent enhancer elements within the IgH locus, leading to oncogene up-regulation. As IgH enhancer activity is tightly controlled by B cell lineage-specific signaling and transcriptional networks, we hypothesized that IgH enhancers are potentially druggable targets/elements. To test this, we developed a molecular imaging-based high-throughput screening platform for discovering inhibitors of IgH enhancer-driven transcriptional activity. As proof of concept, we identified a low micromolar potency molecule (compound 30666) that inhibited immunoglobulin production by MM cells and blocked expression of an array of IgH translocation-induced oncogenes (CCND1, FGFR3/MMSET, and MYC) in MM and NHL cell lines. Prolonged exposure to 30666 significantly reduced the viability of IgH translocation-positive NHL and MM cells, but was less effective against cells lacking IgH translocations. Compound 30666 exhibited suitable pharmacological properties, including metabolic stability in liver microsomes and oral bioavailability in mice, and demonstrated preclinical anti-MM activity in a plasmacytoma mouse model. Our work suggests that IgH enhancers are attractive and potentially druggable targets for IgH translocation driven malignancies.
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Affiliation(s)
- Nathan G Dolloff
- a Department of Cellular and Molecular Pharmacology & Experimental Therapeutics , Medical University of South Carolina , Charleston , SC , USA
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Inhibitors of the protein disulfide isomerase family for the treatment of multiple myeloma. Leukemia 2018; 33:1011-1022. [PMID: 30315229 DOI: 10.1038/s41375-018-0263-1] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 07/24/2018] [Accepted: 08/22/2018] [Indexed: 11/08/2022]
Abstract
Multiple Myeloma (MM) is highly sensitive to disruptions in cellular protein homeostasis. Proteasome inhibitors (PIs) are initially effective in the treatment of MM, although cures are not achievable and the emergence of resistance limits the durability of responses. New therapies are needed for refractory patients, and those that combat resistance to standard of care agents would be particularly valuable. Screening of multiple chemical libraries for PI re-sensitizing compounds identified E61 as a potent enhancer of multiple PIs and MM specific activity. Using a tandem approach of click chemistry and peptide mass fingerprinting, we identified multiple protein disulfide isomerase (PDI) family members as the primary molecular targets of E61. PDIs mediate oxidative protein folding, and E61 treatment induced robust ER and oxidative stress responses as well as the accumulation of ubiquitinylated proteins. A chemical optimization program led to a new structural class of indene (exemplified by lead E64FC26), which are highly potent pan-style inhibitors of PDIs. In mice with MM, E64FC26 improved survival and enhanced the activity of bortezomib without any adverse effects. This work demonstrates the potential of E64FC26 as an early drug candidate and the strategy of targeting multiple PDI isoforms for the treatment of refractory MM and beyond.
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Guang MHZ, McCann A, Bianchi G, Zhang L, Dowling P, Bazou D, O’Gorman P, Anderson KC. Overcoming multiple myeloma drug resistance in the era of cancer 'omics'. Leuk Lymphoma 2018; 59:542-561. [PMID: 28610537 PMCID: PMC6152877 DOI: 10.1080/10428194.2017.1337115] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Multiple myeloma (MM) is among the most compelling examples of cancer in which research has markedly improved the length and quality of lives of those afflicted. Research efforts have led to 18 newly approved treatments over the last 12 years, including seven in 2015. However, despite significant improvement in overall survival, MM remains incurable as most patients inevitably, yet unpredictably, develop refractory disease. Recent advances in high-throughput 'omics' techniques afford us an unprecedented opportunity to (1) understand drug resistance at the genomic, transcriptomic, and proteomic level; (2) discover novel diagnostic, prognostic, and therapeutic biomarkers; (3) develop novel therapeutic targets and rational drug combinations; and (4) optimize risk-adapted strategies to circumvent drug resistance, thus bringing us closer to a cure for MM. In this review, we provide an overview of 'omics' technologies in MM biomarker and drug discovery, highlighting recent insights into MM drug resistance gleaned from the use of 'omics' techniques. Moving from the bench to bedside, we also highlight future trends in MM, with a focus on the potential use of 'omics' technologies as diagnostic, prognostic, or response/relapse monitoring tools to guide therapeutic decisions anchored upon highly individualized, targeted, durable, and rationally informed combination therapies with curative potential.
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Affiliation(s)
- Matthew Ho Zhi Guang
- Department of Medical Oncology, Jerome Lipper Multiple
Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston,
Massachusetts, USA
- UCD School of Medicine, College of Health and Agricultural
Science and UCD Conway Institute of Biomolecular and Biomedical Research, University
College Dublin, UCD, Belfield, Dublin 4, Ireland
| | - Amanda McCann
- UCD School of Medicine, College of Health and Agricultural
Science and UCD Conway Institute of Biomolecular and Biomedical Research, University
College Dublin, UCD, Belfield, Dublin 4, Ireland
| | - Giada Bianchi
- Department of Medical Oncology, Jerome Lipper Multiple
Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston,
Massachusetts, USA
| | - Li Zhang
- Department of Medical Oncology, Jerome Lipper Multiple
Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston,
Massachusetts, USA
- Department of Hematology, West China Hospital, Sichuan
University, Chengdu, China
| | - Paul Dowling
- Department of Haematology, Mater Misericordiae University
Hospital, Dublin 7, Ireland
| | - Despina Bazou
- Department of Haematology, Mater Misericordiae University
Hospital, Dublin 7, Ireland
| | - Peter O’Gorman
- Department of Haematology, Mater Misericordiae University
Hospital, Dublin 7, Ireland
| | - Kenneth C. Anderson
- Department of Medical Oncology, Jerome Lipper Multiple
Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston,
Massachusetts, USA
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8
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A gene expression signature distinguishes innate response and resistance to proteasome inhibitors in multiple myeloma. Blood Cancer J 2017; 7:e581. [PMID: 28665416 PMCID: PMC5520403 DOI: 10.1038/bcj.2017.56] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 02/09/2017] [Indexed: 02/07/2023] Open
Abstract
Extensive interindividual variation in response to chemotherapy is a major stumbling block in achieving desirable efficacy in the treatment of cancers, including multiple myeloma (MM). In this study, our goal was to develop a gene expression signature that predicts response specific to proteasome inhibitor (PI) treatment in MM. Using a well-characterized panel of human myeloma cell lines (HMCLs) representing the biological and genetic heterogeneity of MM, we created an in vitro chemosensitivity profile in response to treatment with the four PIs bortezomib, carfilzomib, ixazomib and oprozomib as single agents. Gene expression profiling was performed using next-generation high-throughput RNA-sequencing. Applying machine learning-based computational approaches including the supervised ensemble learning methods Random forest and Random survival forest, we identified a 42-gene expression signature that could not only distinguish good and poor PI response in the HMCL panel, but could also be successfully applied to four different clinical data sets on MM patients undergoing PI-based chemotherapy to distinguish between extraordinary (good and poor) outcomes. Our results demonstrate the use of in vitro modeling and machine learning-based approaches to establish predictive biomarkers of response and resistance to drugs that may serve to better direct myeloma patient treatment options.
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Thompson RM, Dytfeld D, Reyes L, Robinson RM, Smith B, Manevich Y, Jakubowiak A, Komarnicki M, Przybylowicz-Chalecka A, Szczepaniak T, Mitra AK, Van Ness BG, Luczak M, Dolloff NG. Glutaminase inhibitor CB-839 synergizes with carfilzomib in resistant multiple myeloma cells. Oncotarget 2017; 8:35863-35876. [PMID: 28415782 PMCID: PMC5482623 DOI: 10.18632/oncotarget.16262] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 03/01/2017] [Indexed: 01/10/2023] Open
Abstract
Curative responses in the treatment of multiple myeloma (MM) are limited by the emergence of therapeutic resistance. To address this problem, we set out to identify druggable mechanisms that convey resistance to proteasome inhibitors (PIs; e.g., bortezomib), which are cornerstone agents in the treatment of MM. In isogenic pairs of PI sensitive and resistant cells, we observed stark differences in cellular bioenergetics between the divergent phenotypes. PI resistant cells exhibited increased mitochondrial respiration driven by glutamine as the principle fuel source. To target glutamine-induced respiration in PI resistant cells, we utilized the glutaminase-1 inhibitor, CB-839. CB-839 inhibited mitochondrial respiration and was more cytotoxic in PI resistant cells as a single agent. Furthermore, we found that CB-839 synergistically enhanced the activity of multiple PIs with the most dramatic synergy being observed with carfilzomib (Crflz), which was confirmed in a panel of genetically diverse PI sensitive and resistant MM cells. Mechanistically, CB-839 enhanced Crflz-induced ER stress and apoptosis, characterized by a robust induction of ATF4 and CHOP and the activation of caspases. Our findings suggest that the acquisition of PI resistance involves adaptations in cellular bioenergetics, supporting the combination of CB-839 with Crflz for the treatment of refractory MM.
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Affiliation(s)
- Ravyn M. Thompson
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, USA
| | - Dominik Dytfeld
- Karol Marcinkowski University of Medical Sciences, Poznan, Poland
| | - Leticia Reyes
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, USA
| | - Reeder M. Robinson
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, USA
| | - Brittany Smith
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, USA
| | - Yefim Manevich
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | | | | | | | - Magdalena Luczak
- Institute of Bioorganic Chemistry, Polish Academy of Sciences, Poznan, Poland
| | - Nathan G. Dolloff
- Department of Cell and Molecular Pharmacology & Experimental Therapeutics, Medical University of South Carolina, Charleston, SC, USA
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Mitra AK, Mukherjee UK, Harding T, Jang JS, Stessman H, Li Y, Abyzov A, Jen J, Kumar S, Rajkumar V, Van Ness B. Single-cell analysis of targeted transcriptome predicts drug sensitivity of single cells within human myeloma tumors. Leukemia 2015; 30:1094-102. [DOI: 10.1038/leu.2015.361] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 11/30/2015] [Accepted: 12/15/2015] [Indexed: 12/14/2022]
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Abstract
The debut of the proteasome inhibitor bortezomib (Btz; Velcade®) radically and immediately improved the treatment of multiple myeloma (MM), an incurable malignancy of the plasma cell. Therapeutic resistance is unavoidable, however, and represents a major obstacle to maximizing the clinical potential of the drug. To address this challenge, studies have been conducted to uncover the molecular mechanisms driving Btz resistance and to discover new targeted therapeutic strategies and combinations that restore Btz activity. This review discusses the literature describing molecular adaptations that confer Btz resistance with a primary disease focus on MM. Also discussed are the most recent advances in therapeutic strategies that overcome resistance, approaches that include redox-modulating agents, murine double minute 2 inhibitors, therapeutic monoclonal antibodies, and new epigenetic-targeted drugs like bromodomain and extra terminal domain inhibitors.
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Affiliation(s)
- Nathan G Dolloff
- Department of Cellular and Molecular Pharmacology & Experimental Therapeutics, Medical University of South Carolina, Charleston, South Carolina, USA.
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