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Cardador CM, Muehlmann LA, Coelho CM, Silva LP, Garay AV, Carvalho AMDS, Bastos IMD, Longo JPF. Nucleotides Entrapped in Liposome Nanovesicles as Tools for Therapeutic and Diagnostic Use in Biomedical Applications. Pharmaceutics 2023; 15:873. [PMID: 36986734 PMCID: PMC10056227 DOI: 10.3390/pharmaceutics15030873] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/03/2023] [Accepted: 03/06/2023] [Indexed: 03/30/2023] Open
Abstract
The use of nucleotides for biomedical applications is an old desire in the scientific community. As we will present here, there are references published over the past 40 years with this intended use. The main problem is that, as unstable molecules, nucleotides require some additional protection to extend their shelf life in the biological environment. Among the different nucleotide carriers, the nano-sized liposomes proved to be an effective strategic tool to overcome all these drawbacks related to the nucleotide high instability. Moreover, due to their low immunogenicity and easy preparation, the liposomes were selected as the main strategy for delivery of the mRNA developed for COVID-19 immunization. For sure this is the most important and relevant example of nucleotide application for human biomedical conditions. In addition, the use of mRNA vaccines for COVID-19 has increased interest in the application of this type of technology to other health conditions. For this review article, we will present some of these examples, especially focused on the use of liposomes to protect and deliver nucleotides for cancer therapy, immunostimulatory activities, enzymatic diagnostic applications, some examples for veterinarian use, and the treatment of neglected tropical disease.
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Affiliation(s)
- Camila Magalhães Cardador
- Department of Genetics and Morphology, Institute of Biological Sciences, University of Brasília (UnB), Brasilia 70910-900, DF, Brazil
| | | | - Cíntia Marques Coelho
- Laboratory of Synthetic Biology, Department of Genetics and Morphology, Institute of Biological Science, University of Brasília (UnB), Brasilia 70910-900, DF, Brazil
| | - Luciano Paulino Silva
- Laboratório de Nanobiotecnologia (LNANO), Embrapa Recursos Genéticos e Biotecnologia, Brasilia 70770-917, DF, Brazil
| | - Aisel Valle Garay
- Molecular Biophysics Laboratory, Department of Cell Biology, Institute of Biological Science, University of Brasília (UnB), Brasília 70910-900, DF, Brazil
| | | | - Izabela Marques Dourado Bastos
- Pathogen-Host Interface Laboratory, Department of Cell Biology, University of Brasilia (UnB), Brasilia 70910-900, DF, Brazil
| | - João Paulo Figueiró Longo
- Department of Genetics and Morphology, Institute of Biological Sciences, University of Brasília (UnB), Brasilia 70910-900, DF, Brazil
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Therapeutic Targeting of Cancer Stem Cells in Lung, Head and Neck, and Bladder Cancers. Cancers (Basel) 2021; 13:cancers13205098. [PMID: 34680249 PMCID: PMC8534162 DOI: 10.3390/cancers13205098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 01/06/2023] Open
Abstract
Simple Summary Effective cancer treatment hinges upon overcoming therapeutic resistance mechanisms that allow for the continued proliferation of cancer cell subpopulations. Exposure to pharmacotherapy invariably leads to resistance as tumor cells with selected advantageous features evade destruction and alter the tumor composition. Cancer stem cells (CSCs) with features of plasticity that allow for regeneration and differentiation are particularly responsible for this phenomenon. Advances in tumor biology and molecular signaling have highlighted their role in neoplastic initiation, invasion, and maintenance. Novel strategies to direct therapy against these tumor cell subpopulations have the potential to dramatically alter tumor response and change the course of cancer care. Abstract Resistance to cancer therapy remains a significant obstacle in treating patients with various solid malignancies. Exposure to current chemotherapeutics and targeted agents invariably leads to therapy resistance, heralding the need for novel agents. Cancer stem cells (CSCs)—a subpopulation of tumor cells with capacities for self-renewal and multi-lineage differentiation—represent a pool of therapeutically resistant cells. CSCs often share physical and molecular characteristics with the stem cell population of the human body. It remains challenging to selectively target CSCs in therapeutically resistant tumors. The generation of CSCs and induction of therapeutic resistance can be attributed to several deregulated critical growth regulatory signaling pathways such as WNT/β-catenin, Notch, Hippo, and Hedgehog. Beyond growth regulatory pathways, CSCs also change the tumor microenvironment and resist endogenous immune attack. Thus, CSCs can interfere with each stage of carcinogenesis from malignant transformation to the onset of metastasis to tumor recurrence. A thorough review of novel targeted agents to act against CSCs is fundamental for advancing cancer treatment in the setting of both intrinsic and acquired resistance.
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Zhang L, Yang L, Li JJ, Sun L. Potential use of nucleic acid-based agents in the sensitization of nasopharyngeal carcinoma to radiotherapy. Cancer Lett 2012; 323:1-10. [DOI: 10.1016/j.canlet.2012.03.030] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 03/26/2012] [Accepted: 03/26/2012] [Indexed: 11/27/2022]
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Xu J, Jin C, Hao S, Luo G, Fu D. Pancreatic cancer: gene therapy approaches and gene delivery systems. Expert Opin Biol Ther 2010; 10:73-88. [PMID: 19857184 DOI: 10.1517/14712590903321454] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
IMPORTANCE OF THE FIELD Due to the absence of early diagnosis, the highly invasive and metastatic features and the lack of effective therapeutic modalities, the prognosis of patients with pancreatic cancer is poor. Gene therapy is currently regarded as a potential and promising therapeutic modality for pancreatic cancer. AREAS COVERED IN THIS REVIEW This article summarizes an update of gene therapy approaches and reviews the latest progress in gene delivery systems that have been tested on pancreatic cancer. WHAT THE READER WILL GAIN The treatment effectiveness of gene combination therapy is better than that of the regulation of single-gene or single gene therapy approaches. Naked DNA is limited because of degradation by intracellular and extracellular nucleases. Virus vectors show high transfection efficiency but are limited due to immunogenicity, inflammatory response and potential carcinogenicity. Non-viral vectors, such as cationic polymers or inorganic nanoparticles, show an important feature that they can be easily modified, and the progress of materials science will provide more and better non-viral vectors, accordingly improving the efficiency and safety of gene therapy, which will make them the most promising vectors for pancreatic cancer.
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Affiliation(s)
- Jin Xu
- Fudan University, Pancreatic Disease Institution, Huashan Hospital, Department of General Surgery, Shanghai, China
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Wolkersdörfer GW, Thiede C, Fischer R, Ehninger G, Haag C. Adenoviral p53 gene transfer and gemcitabine in three patients with liver metastases due to advanced pancreatic carcinoma. HPB (Oxford) 2007; 9:16-25. [PMID: 18333108 PMCID: PMC2020772 DOI: 10.1080/13651820600839555] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2006] [Indexed: 12/12/2022]
Abstract
BACKGROUND Current therapies for adenocarcinoma of the pancreas do not improve the life expectancy of patients. METHODS In a non-randomized pilot trail we tested whether a local therapy based upon an adenoviral gene transfer of wild type p53 in combination with gemcitabine administration would be safe in patients with liver metastases due to pancreatic carcinoma. We report on the clinical course of three patients with respect to safety, tolerability and tumor response. RESULTS Transient grade III toxicities occurred with fever, leucopenia, elevation of AP, ALT, AST, GGT, while grade IV toxicity occurred for bilirubin only. Laboratory tests suggested disseminated intravascular coagulation in all three patients, but fine needle biopsies of liver did not show any histological evidence of thrombus or clot formation. Progression of liver metastases was documented in one and stable disease in another patient two months after treatment. However, a major improvement with regression of the indexed lesion by 80% occurred in a third patient after a single administration of 7.5 x 10(12) viral particles, and time to progression was extended to six months. CONCLUSION The combination therapy of viral gene transfer and chemotherapy temporarily controls and diminishes tumor burden. Improvement of the toxicity profile is necessary. Further trials are warranted to improve treatment and life expectancy of patients suffering from fatal diseases such as pancreatic carcinoma.
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Affiliation(s)
| | - Christian Thiede
- Department of Internal Medicine I, University of Technology DresdenGermany
| | - Rainer Fischer
- Department of Pathology, University of Technology DresdenGermany
| | - Gerhard Ehninger
- Department of Internal Medicine I, University of Technology DresdenGermany
| | - Cornelie Haag
- Department of Internal Medicine I, University of Technology DresdenGermany
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6
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García-Morales P, Gómez-Martínez A, Carrato A, Martínez-Lacaci I, Barberá VM, Soto JL, Carrasco-García E, Menéndez-Gutierrez MP, Castro-Galache MD, Ferragut JA, Saceda M. Histone deacetylase inhibitors induced caspase-independent apoptosis in human pancreatic adenocarcinoma cell lines. Mol Cancer Ther 2005; 4:1222-30. [PMID: 16093438 DOI: 10.1158/1535-7163.mct-04-0186] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The antitumor activity of the histone deacetylase inhibitors was tested in three well-characterized pancreatic adenocarcinoma cell lines, IMIM-PC-1, IMIM-PC-2, and RWP-1. These cell lines have been previously characterized in terms of their origin, the status of relevant molecular markers for this kind of tumor, resistance to other antineoplastic drugs, and expression of differentiation markers. In this study, we report that histone deacetylase inhibitors induce apoptosis in pancreatic cancer cell lines, independently of their intrinsic resistance to conventional antineoplastic agents. The histone deacetylase inhibitor-induced apoptosis is due to a serine protease-dependent and caspase-independent mechanism. Initially, histone deacetylase inhibitors increase Bax protein levels without affecting Bcl-2 levels. Consequently, the apoptosis-inducing factor (AIF) and Omi/HtrA2 are released from the mitochondria, with the subsequent induction of the apoptotic program. These phenomena require AIF relocalization into the nuclei to induce DNA fragmentation and a serine protease activity of Omi/HtrA2. These data, together with previous results from other cellular models bearing the multidrug resistance phenotype, suggest a possible role of the histone deacetylase inhibitors as antineoplastic agents for the treatment of human pancreatic adenocarcinoma.
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Affiliation(s)
- Pilar García-Morales
- Instituto de Biologia Molecular y Celular, Ed. Torregaitan, Universidad Miguel Hernandez, 03202 Elche (Alicante), Spain
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Abstract
The prognosis of patients with some kinds of cancers whose patients are often found unresectable upon diagnosis is still dismal. In these fields, development of a new therapeutic modality is needed and gene therapy represents one promising strategy. So far, numerous cancer gene therapy clinical trials based on these principles have been carried out and have shown the safety of such modalities, but have fallen short of the initial expectations to cure cancers. In this review, we would like to make a problem-oriented discussion of current status of cancer gene therapy research by using mainly gastrointestinal cancers as an example. In order to overcome obstacles for full realization of cancer gene therapy, numerous researches have been conducted by many researchers. Various cancer-selective and non-selective genes, as well as lytic viruses themselves have been employed for gene therapy. In the context of gene delivery method, different kinds of viral and non-viral strategies have been utilized. In addition, surrogate assays, such as soluble markers and imaging, have been developed for safer and more informative clinical trials. Many experiments and clinical trials to date have figured out current obstacles for the realization of an effective cancer gene therapy modality. Tireless efforts to overcome such hurdles and continuous infusion of novel concepts into this field should lead to break through technologies and the cure of the patients.
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Affiliation(s)
- Masato Yamamoto
- BMR2-410, 901 19th Street South, Birmingham, AL 35294-2172, USA
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El-Aneed A. Current strategies in cancer gene therapy. Eur J Pharmacol 2005; 498:1-8. [PMID: 15363969 DOI: 10.1016/j.ejphar.2004.06.054] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2004] [Accepted: 06/29/2004] [Indexed: 10/26/2022]
Abstract
Cancer gene therapy is the most studied application of gene therapy. Many genetic alterations are involved in the transformation of a normal cell into a neoplastic one. The two main gene groups involved in cancer development are oncogenes and tumor suppressor genes. While the latter eliminates cancerous cells via apoptosis, the former enhances cell proliferation. Therefore, apoptotic genes and anti-oncogenes are widely used in cancer gene therapy. In addition to oncogenes and tumor suppressor genes, chemotherapy and gene therapy can be combined through suicide gene strategy. A suicide gene encodes for a non-mammalian enzyme; this enzyme is used to convert a non-toxic prodrug into its active cytotoxic metabolite within the cancerous cells. Tumor suppressor genes, anti-oncogenes and suicide genes target cancer cells on the molecular level. On the other hand, cancer is immunogenic in nature; therefore, it can also be targeted on the immunological level. Boosting the immune response against cancerous cells is usually achieved via genes encoding for cytokines. Interleukin-12 gene, for example, is one of the most studied cytokine genes for cancer gene therapy applications. DNA vaccines are also used after conventional treatments to eliminate remnant malignant cells. All these therapeutic strategies and other strategies namely anti-angiogenesis and drug resistant genes are briefly reviewed and highlighted in this article.
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Affiliation(s)
- Anas El-Aneed
- Biochemistry Department, Memorial University of Newfoundland, St. John's, NL, Canada A1B 3X9.
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Zeng H, Datta K, Neid M, Li J, Parangi S, Mukhopadhyay D. Requirement of different signaling pathways mediated by insulin-like growth factor-I receptor for proliferation, invasion, and VPF/VEGF expression in a pancreatic carcinoma cell line. Biochem Biophys Res Commun 2003; 302:46-55. [PMID: 12593846 DOI: 10.1016/s0006-291x(03)00107-4] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Several oncogenes and growth factors are found to be mutated and overexpressed in adenocarcinoma of the pancreas, and may correlate with its highly aggressive nature. Insulin-like growth factor (IGF-I) and its receptor (IGF-IR) are highly expressed in this tumor type. We examined the IGF-IR-mediated signaling pathways in relation to cell proliferation, invasiveness, and expression pattern of vascular permeability factor/vascular endothelial growth factor (VPF/VEGF) in the pancreatic cancer line ASPC-1. Our findings show that IGF-IR is an important growth factor receptor for cell proliferation and invasion, and VPF/VEGF expression in ASPC-1. Further experiments indicate that IGF-IR mediates different signaling pathways to execute its functions. Activation of Ras by IGF-IR was found to be required for the cell invasion. On the other hand Src activation through IGF-IR is required for the cell proliferation, invasion, and also VPF/VEGF expression. Taken together, our data indicate the importance of IGF-IR in growth and invasiveness of the pancreatic cancer cell lines and also point out the multiple signaling pathways channeled through this receptor.
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Affiliation(s)
- Huiyan Zeng
- Department of Pathology, RN270H, Beth Israel Deaconess Medical Center and Harvard Medical School, 99 Brookline Avenue, Boston, MA 02215, USA
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10
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Abstract
AIM: To explore whether HDV ribozymes have the ability to trans-cleave HCV RNA.
METHODS: Three HDV genomic ribozymes were designed and named RzC1, RzC2 and RzC3. The substrate RNA contained HCV RNA 5’-noncoding region and 5'-fragment of C region (5'-NCR-C). All the ribozymes and HCV RNA 5'-NCR-C were obtained by transcription in vitro from their DNA templates, and HCV RNA 5'-NCR-C was radiolabelled at its 5’-end. Under certain pH, temperature, appropriate concentration of Mg2+ and deionized formamide, these ribozymes were respectively or simultaneously mixed with HCV RNA 5'-NCR-C and reacted for a certain time. The trans-cleavage reaction was stopped at different time points, and the products were separated with polyacrylamide gel electrophoresis (PAGE), displayed by autoradiography. Percentage of trans-cleaved products was measured to indicate the activity of HDV ribozymes.
RESULTS: RzC1 and RzC2 could trans-cleave 26% and 21.8% of HCV RNA 5'-NCR-C under our reaction conditions with 2.5 mol•L-1 deionized formamide respectively. The percentage of HCV RNA 5'-NCR-C trans-cleaved by RzC1, RzC2 or combined usage of the three ribozymes increased with time, up to 24.9%, 20.3% and 37.3% respectively at 90 min point. Almost no product from RzC3 was observed.
CONCLUSION: HDV ribozymes are able to trans-cleave specifically HCV RNA at certain sites under appropriate conditions, and combination of several ribozymes aiming at different target sites can trans-cleave the substrate more efficiently than using only one of them.
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Affiliation(s)
- Yue-Cheng Yu
- Institute of Infectious Diseases of Chinese PLA, Southwest Hospital, Third Military Medical University, Chongqing 400038,China.
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11
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Abstract
Gene transfer technology has the potential to revolutionize cancer treatment. Developments in molecular biology, genetics, genomics, stem cell technology, virology, bioengineering, and immunology are accelerating the pace of innovation and movement from the laboratory bench to the clinical arena. Pancreatic adenocarcinoma, with its particularly poor prognosis and lack of effective traditional therapy for most patients, is an area where gene transfer and immunotherapy have a maximal opportunity to demonstrate efficacy. In this review, we have discussed current preclinical and clinical investigation of gene transfer technology for pancreatic cancer. We have emphasized that the many strategies under investigation for cancer gene therapy can be classified into two major categories. The first category of therapies rely on the transduction of cells other than tumor cells, or the limited transduction of tumor tissue. These therapies, which do not require efficient gene transfer, generally lead to systemic biological effects (e.g., systemic antitumor immunity, inhibition of tumor angiogenesis, etc) and therefore the effects of limited gene transfer are biologically "amplified." The second category of gene transfer strategies requires the delivery of therapeutic genetic material to all or most tumor cells. While these elegant approaches are based on state-of-the-art advances in our understanding of the molecular biology of cancer, they suffer from the current inadequacies of gene transfer technology. At least in the short term, it is very likely that success in pancreatic cancer gene therapy will involve therapies that require only the limited transduction of cells. The time-worn surgical maxim, "Do what's easy first," certainly applies here.
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Affiliation(s)
- Jennifer F Tseng
- Division of Molecular Medicine, Children's Hospital, Department of Genetics, Harvard Medical School, Enders 861, 320 Longwood Avenue, Boston, MA 02115, USA
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12
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Löhr JM, Saller R, Salmons B, Günzburg WH. Microencapsulation of genetically engineered cells for cancer therapy. Methods Enzymol 2002; 346:603-18. [PMID: 11883094 DOI: 10.1016/s0076-6879(02)46080-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Affiliation(s)
- J-Matthias Löhr
- Department of Molecular Gastroenterology, Medical Clinic II, University of Heidelberg, D-68167 Mannheim, Germany
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13
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Nagata J, Kijima H, Hatanaka H, Asai S, Miyachi H, Takagi A, Miwa T, Mine T, Yamazaki H, Nakamura M, Kondo T, Scanlon KJ, Ueyama Y. Reversal of cisplatin and multidrug resistance by ribozyme-mediated glutathione suppression. Biochem Biophys Res Commun 2001; 286:406-13. [PMID: 11500053 DOI: 10.1006/bbrc.2001.5399] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
gamma-Glutamylcysteine synthetase (gamma-GCS) is a key enzyme in glutathione (GSH) synthesis, and is thought to play a significant role in intracellular detoxification, especially of anticancer drugs. Increased levels of GSH are commonly found in the drug-resistant human cancer cells. We designed a hammerhead ribozyme against gamma-GCS mRNA (anti-gamma-GCS Rz), which specifically down-regulated gamma-GCS gene expression in the HCT-8 human colon cancer cell line. The aim of this study was to reverse the cisplatin and multidrug resistance for anticancer drugs. The cisplatin-resistant HCT-8 cells (HCT-8DDP cells) overexpressed MRP and MDR1 genes, and showed resistance to not only cisplatin (CDDP), but also doxorubicin (DOX) and etoposide (VP-16). We transfected a vector expressing anti-gamma-GCS Rz into the HCT-8DDP cells (HCT-8DDP/Rz). The anti-gamma-GCS Rz significantly suppressed MRP and MDR, and altered anticancer drug resistance. The HCT-8DDP/Rz cells were more sensitive to CDDP, DOX and VP-16 by 1.8-, 4.9-, and 1.5-fold, respectively, compared to HCT-8DDP cells. The anti-gamma-GCS Rz significantly down-regulated gamma-GCS gene expression as well as MRP/MDR1 expression, and reversed resistance to CDDP, DOX and VP-16. These results suggested that gamma-GCS plays an important role in both cisplatin and multidrug resistance in human cancer cells.
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Affiliation(s)
- J Nagata
- Department of Pathology, Tokai University School of Medicine, Bohseidai, Kanagawa, 259-1193, Japan
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14
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Abstract
RNA enzymes--ribozymes--are being developed as treatments for a variety of diseases ranging from inborn metabolic disorders to viral infections and acquired diseases such as cancer. Ribozymes can be used both to downregulate and to repair pathogenic genes. In some instances, short-term exogenous delivery of stabilized RNA is desirable, but many treatments will require viral-mediated delivery to provide long-term expression of the therapeutic catalyst. Current gene therapy applications employ variations on naturally occurring ribozymes, but in vitro selection has provided new RNA and DNA catalysts, and research on trans-splicing and RNase P has suggested ways to harness the endogenous ribozymes of the cell for therapeutic purposes.
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Affiliation(s)
- A S Lewin
- Dept of Molecular Genetics and Microbiology and the Powell Gene Therapy Center, University of Florida, Gainesville 32610-0266, USA.
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Halloran CM, Ghaneh P, Neoptolemos JP, Costello E. Gene therapy for pancreatic cancer--current and prospective strategies. Surg Oncol 2000; 9:181-91. [PMID: 11476989 DOI: 10.1016/s0960-7404(01)00011-1] [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: 12/18/2022]
Abstract
Pancreatic ductal adenocarcinoma is one of the most common causes of cancer death in the developed world. Long-term survival is currently only achieved through surgical resection. Most patients have locally advanced or metastatic disease at the time of diagnosis and are therefore not amenable to resection, whilst chemotherapy and radiotherapy are by and large ineffective. Gene therapy offers an alternative to current adjuvant strategies. With approximately two-thirds of all gene therapy trials worldwide directed at cancer, the gene therapy approaches that are currently being explored for pancreatic cancer are specifically examined. Gene delivery systems, genetic targets, and combined gene delivery with chemotherapy are discussed in the context of pancreatic cancer treatment.
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Affiliation(s)
- C M Halloran
- Department of Surgery, Royal Liverpool University Hospital, 5th Floor UCD Building, Daulby Street, Liverpool, L69 3GA, UK.
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