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Capasso G, Mouawad N, Castronuovo M, Ruggeri E, Visentin A, Trentin L, Frezzato F. Focal adhesion kinase as a new player in the biology of onco-hematological diseases: the starting evidence. Front Oncol 2024; 14:1446723. [PMID: 39281374 PMCID: PMC11392731 DOI: 10.3389/fonc.2024.1446723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 07/31/2024] [Indexed: 09/18/2024] Open
Abstract
Focal adhesion kinase (FAK) is a non-receptor tyrosine kinase mainly found in the focal adhesion regions of the plasma membrane and it has a crucial role in migration and the remodeling of cellular morphology. FAK is also linked to several aspects of cancer biology, from cytokine production to angiogenesis, drug resistance, invasion, and metastasis, as well as epithelial-to-mesenchymal transition. The gene locus of FAK is frequently amplified in several human tumors, thus causing FAK overexpression in several cancers. Furthermore, FAK can influence extracellular matrix production and exosome secretion through cancer-associated fibroblasts, thus it has an important role in tumor microenvironment regulation. Although the role of FAK in solid tumors is well known, its importance in onco-hematological diseases remains poorly explored. This review collects studies related to FAK significance in onco-hematological diseases and their microenvironments. Overall, the importance of FAK in blood tumors is increasingly evident, but further research is required to confirm it as a new therapeutic target in hematological contexts.
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Affiliation(s)
- Guido Capasso
- Hematology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Nayla Mouawad
- Hematology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Maria Castronuovo
- Hematology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Edoardo Ruggeri
- Hematology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Andrea Visentin
- Hematology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Livio Trentin
- Hematology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Federica Frezzato
- Hematology Unit, Department of Medicine, University of Padova, Padova, Italy
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Park CS, Yoshihara H, Gao Q, Qu C, Iacobucci I, Ghate PS, Connelly JP, Pruett-Miller SM, Wagner B, Robinson CG, Mishra A, Peng J, Yang L, Rankovic Z, Finkelstein D, Luger S, Litzow M, Paietta EM, Hebbar N, Velasquez MP, Mullighan CG. Stromal-induced epithelial-mesenchymal transition induces targetable drug resistance in acute lymphoblastic leukemia. Cell Rep 2023; 42:112804. [PMID: 37453060 PMCID: PMC10529385 DOI: 10.1016/j.celrep.2023.112804] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 04/05/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023] Open
Abstract
The bone marrow microenvironment (BME) drives drug resistance in acute lymphoblastic leukemia (ALL) through leukemic cell interactions with bone marrow (BM) niches, but the underlying mechanisms remain unclear. Here, we show that the interaction between ALL and mesenchymal stem cells (MSCs) through integrin β1 induces an epithelial-mesenchymal transition (EMT)-like program in MSC-adherent ALL cells, resulting in drug resistance and enhanced survival. Moreover, single-cell RNA sequencing analysis of ALL-MSC co-culture identifies a hybrid cluster of MSC-adherent ALL cells expressing both B-ALL and MSC signature genes, orchestrated by a WNT/β-catenin-mediated EMT-like program. Blockade of interaction between β-catenin and CREB binding protein impairs the survival and drug resistance of MSC-adherent ALL cells in vitro and results in a reduction in leukemic burden in vivo. Targeting of this WNT/β-catenin-mediated EMT-like program is a potential therapeutic approach to overcome cell extrinsically acquired drug resistance in ALL.
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Affiliation(s)
- Chun Shik Park
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Hiroki Yoshihara
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Qingsong Gao
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Chunxu Qu
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Ilaria Iacobucci
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Pankaj S Ghate
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Jon P Connelly
- Center for Advanced Genome Engineering, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Cell and Molecular Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Shondra M Pruett-Miller
- Center for Advanced Genome Engineering, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Cell and Molecular Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Ben Wagner
- Cell and Tissue Imaging Center, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Camenzind G Robinson
- Cell and Tissue Imaging Center, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Ashutosh Mishra
- Center for Proteomics and Metabolomics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Junmin Peng
- Center for Proteomics and Metabolomics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Structural Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Developmental Neurobiology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Lei Yang
- Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Zoran Rankovic
- Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - David Finkelstein
- Department of Computational Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Selina Luger
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA 19106, USA
| | - Mark Litzow
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | | | - Nikhil Hebbar
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - M Paulina Velasquez
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Charles G Mullighan
- Department of Pathology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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Modvig S, Jeyakumar J, Marquart HV, Christensen C. Integrins and the Metastasis-like Dissemination of Acute Lymphoblastic Leukemia to the Central Nervous System. Cancers (Basel) 2023; 15:cancers15092504. [PMID: 37173970 PMCID: PMC10177281 DOI: 10.3390/cancers15092504] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 05/15/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) disseminates with high prevalence to the central nervous system (CNS) in a process resembling aspects of the CNS surveillance of normal immune cells as well as aspects of brain metastasis from solid cancers. Importantly, inside the CNS, the ALL blasts are typically confined within the cerebrospinal fluid (CSF)-filled cavities of the subarachnoid space, which they use as a sanctuary protected from both chemotherapy and immune cells. At present, high cumulative doses of intrathecal chemotherapy are administered to patients, but this is associated with neurotoxicity and CNS relapse still occurs. Thus, it is imperative to identify markers and novel therapy targets specific to CNS ALL. Integrins represent a family of adhesion molecules involved in cell-cell and cell-matrix interactions, implicated in the adhesion and migration of metastatic cancer cells, normal immune cells, and leukemic blasts. The ability of integrins to also facilitate cell-adhesion mediated drug resistance, combined with recent discoveries of integrin-dependent routes of leukemic cells into the CNS, have sparked a renewed interest in integrins as markers and therapeutic targets in CNS leukemia. Here, we review the roles of integrins in CNS surveillance by normal lymphocytes, dissemination to the CNS by ALL cells, and brain metastasis from solid cancers. Furthermore, we discuss whether ALL dissemination to the CNS abides by known hallmarks of metastasis, and the potential roles of integrins in this context.
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Affiliation(s)
- Signe Modvig
- Department of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Jenani Jeyakumar
- Department of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen, Denmark
| | - Hanne Vibeke Marquart
- Department of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2100 Copenhagen, Denmark
| | - Claus Christensen
- Department of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, 2100 Copenhagen, Denmark
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Hughes AM, Kuek V, Kotecha RS, Cheung LC. The Bone Marrow Microenvironment in B-Cell Development and Malignancy. Cancers (Basel) 2022; 14:2089. [PMID: 35565219 PMCID: PMC9102980 DOI: 10.3390/cancers14092089] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/11/2022] [Accepted: 04/20/2022] [Indexed: 11/16/2022] Open
Abstract
B lymphopoiesis is characterized by progressive loss of multipotent potential in hematopoietic stem cells, followed by commitment to differentiate into B cells, which mediate the humoral response of the adaptive immune system. This process is tightly regulated by spatially distinct bone marrow niches where cells, including mesenchymal stem and progenitor cells, endothelial cells, osteoblasts, osteoclasts, and adipocytes, interact with B-cell progenitors to direct their proliferation and differentiation. Recently, the B-cell niche has been implicated in initiating and facilitating B-cell precursor acute lymphoblastic leukemia. Leukemic cells are also capable of remodeling the B-cell niche to promote their growth and survival and evade treatment. Here, we discuss the major cellular components of bone marrow niches for B lymphopoiesis and the role of the malignant B-cell niche in disease development, treatment resistance and relapse. Further understanding of the crosstalk between leukemic cells and bone marrow niche cells will enable development of additional therapeutic strategies that target the niches in order to hinder leukemia progression.
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Affiliation(s)
- Anastasia M. Hughes
- Leukaemia Translational Research Laboratory, Telethon Kids Cancer Centre, Telethon Kids Institute, Perth, WA 6009, Australia; (A.M.H.); (V.K.); (R.S.K.)
- Curtin Medical School, Curtin University, Perth, WA 6102, Australia
| | - Vincent Kuek
- Leukaemia Translational Research Laboratory, Telethon Kids Cancer Centre, Telethon Kids Institute, Perth, WA 6009, Australia; (A.M.H.); (V.K.); (R.S.K.)
- Curtin Medical School, Curtin University, Perth, WA 6102, Australia
- School of Biomedical Sciences, University of Western Australia, Perth, WA 6009, Australia
| | - Rishi S. Kotecha
- Leukaemia Translational Research Laboratory, Telethon Kids Cancer Centre, Telethon Kids Institute, Perth, WA 6009, Australia; (A.M.H.); (V.K.); (R.S.K.)
- Curtin Medical School, Curtin University, Perth, WA 6102, Australia
- School of Medicine, University of Western Australia, Perth, WA 6009, Australia
- Department of Clinical Haematology, Oncology, Blood and Marrow Transplantation, Perth Children’s Hospital, Perth, WA 6009, Australia
| | - Laurence C. Cheung
- Leukaemia Translational Research Laboratory, Telethon Kids Cancer Centre, Telethon Kids Institute, Perth, WA 6009, Australia; (A.M.H.); (V.K.); (R.S.K.)
- Curtin Medical School, Curtin University, Perth, WA 6102, Australia
- Curtin Health Innovation Research Institute, Curtin University, Perth, WA 6102, Australia
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Abstract
In contrast to solid cancers, which often require genetic modifications and complex cellular reprogramming for effective metastatic dissemination, leukaemic cells uniquely possess the innate ability for migration and invasion. Dedifferentiated, malignant leukocytes retain the benign leukocytes' capacity for cell motility and survival in the circulation, while acquiring the potential for rapid and uncontrolled cell division. For these reasons, leukaemias, although not traditionally considered as metastatic diseases, are in fact models of highly efficient metastatic spread. Accordingly, they are often aggressive and challenging diseases to treat. In this Perspective, we discuss the key molecular processes that facilitate metastasis in a variety of leukaemic subtypes, the clinical significance of leukaemic invasion into specific tissues and the current pipeline of treatments targeting leukaemia metastasis.
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Affiliation(s)
- Andrew E Whiteley
- Department of Medicine, Duke University, Durham, NC, USA
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
| | - Trevor T Price
- Department of Medicine, Duke University, Durham, NC, USA
| | - Gaia Cantelli
- European Molecular Biology Laboratory, European Bioinformatics Institute, Hinxton, UK
| | - Dorothy A Sipkins
- Department of Medicine, Duke University, Durham, NC, USA.
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA.
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Genomic Analyses of Pediatric Acute Lymphoblastic Leukemia Ph+ and Ph-Like-Recent Progress in Treatment. Int J Mol Sci 2021; 22:ijms22126411. [PMID: 34203891 PMCID: PMC8232636 DOI: 10.3390/ijms22126411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/04/2021] [Accepted: 06/14/2021] [Indexed: 12/24/2022] Open
Abstract
Pediatric acute lymphoblastic leukemia (ALL) with t(9;22)(q34;q11.2) is a very rare malignancy in children. Approximately 3-5% of pediatric ALL patients present with the Philadelphia chromosome. Previously, children with Ph+ had a poor prognosis, and were considered for allogeneic stem cell transplantation (allo-HSCT) in their first remission (CR1). Over the last few years, the treatment of childhood ALL has significantly improved due to standardized research protocols. Hematopoietic stem cell transplantation (HSCT) has been the gold standard therapy in ALL Ph+ patients, but recently first-generation tyrosine kinase inhibitor (TKI)-imatinib became a major milestone in increasing overall survival. Genomic analyses give the opportunity for the investigation of new fusions or mutations, which can be used to establish effective targeted therapies. Alterations of the IKZF1 gene are present in a large proportion of pediatric and adult ALL Ph+ cases. IKZF1 deletions are present in ~15% of patients without BCR-ABL1 rearrangements. In BCR-ABL1-negative cases, IKZF1 deletions have been shown to have an independent prognostic impact, carrying a three-fold increased risk of treatment failure. The prognostic significance of IKZF1 gene aberrations in pediatric ALL Ph+ is still under investigation. More research should focus on targeted therapies and immunotherapy, which is not associated with serious toxicity in the same way as classic chemotherapy, and on the improvement of patient outcomes. In this review, we provide a molecular analysis of childhood ALL with t(9;22)(q34;q11.2), including the Ph-like subtype, and of treatment strategies.
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Kim HN, Ruan Y, Ogana H, Kim YM. Cadherins, Selectins, and Integrins in CAM-DR in Leukemia. Front Oncol 2020; 10:592733. [PMID: 33425742 PMCID: PMC7793796 DOI: 10.3389/fonc.2020.592733] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 10/22/2020] [Indexed: 12/12/2022] Open
Abstract
The interaction between leukemia cells and the bone microenvironment is known to provide drug resistance in leukemia cells. This phenomenon, called cell adhesion-mediated drug resistance (CAM-DR), has been demonstrated in many subsets of leukemia including B- and T-acute lymphoblastic leukemia (B- and T-ALL) and acute myeloid leukemia (AML). Cell adhesion molecules (CAMs) are surface molecules that allow cell-cell or cell-extracellular matrix (ECM) adhesion. CAMs not only recognize ligands for binding but also initiate the intracellular signaling pathways that are associated with cell proliferation, survival, and drug resistance upon binding to their ligands. Cadherins, selectins, and integrins are well-known cell adhesion molecules that allow binding to neighboring cells, ECM proteins, and soluble factors. The expression of cadherin, selectin, and integrin correlates with the increased drug resistance of leukemia cells. This paper will review the role of cadherins, selectins, and integrins in CAM-DR and the results of clinical trials targeting these molecules.
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Affiliation(s)
- Hye Na Kim
- Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Cancer and Blood Disease Institute, Los Angeles, CA, United States
| | - Yongsheng Ruan
- Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Cancer and Blood Disease Institute, Los Angeles, CA, United States.,Department of Pediatrics, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Heather Ogana
- Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Cancer and Blood Disease Institute, Los Angeles, CA, United States
| | - Yong-Mi Kim
- Children's Hospital Los Angeles, Keck School of Medicine of University of Southern California, Cancer and Blood Disease Institute, Los Angeles, CA, United States
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8
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Ruiz-Aparicio PF, Vanegas NDP, Uribe GI, Ortiz-Montero P, Cadavid-Cortés C, Lagos J, Flechas-Afanador J, Linares-Ballesteros A, Vernot JP. Dual Targeting of Stromal Cell Support and Leukemic Cell Growth by a Peptidic PKC Inhibitor Shows Effectiveness against B-ALL. Int J Mol Sci 2020; 21:ijms21103705. [PMID: 32466311 PMCID: PMC7279155 DOI: 10.3390/ijms21103705] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 05/02/2020] [Accepted: 05/03/2020] [Indexed: 12/11/2022] Open
Abstract
Mesenchymal stem cells (MSC) favour a scenario where leukemic cells survive. The protein kinase C (PKC) is essential to confer MSC support to leukemic cells and may be responsible for the intrinsic leukemic cell growth. Here we have evaluated the capacity of a chimeric peptide (HKPS), directed against classical PKC isoforms, to inhibit leukemic cell growth. HKPS was able to strongly inhibit viability of different leukemic cell lines, while control HK and PS peptides had no effect. Further testing showed that 30% of primary samples from paediatric B-cell acute lymphoblastic leukaemia (B-ALL) were also strongly affected by HKPS. We showed that HKPS disrupted the supportive effect of MSC that promote leukemic cell survival. Interestingly, ICAM-1 and VLA-5 expression increased in MSC during the co-cultures with B-ALL cells, and we found that HKPS inhibited the interaction between MSC and B-ALL cells due to a reduction in the expression of these adhesion molecules. Of note, the susceptibility of B-ALL cells to dexamethasone increased when MSC were treated with HKPS. These results show the relevance of these molecular interactions in the leukemic niche. The use of HKPS may be a new strategy to disrupt intercellular communications, increasing susceptibility to therapy, and at the same time, directly affecting the growth of PKC-dependent leukemic cells.
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Affiliation(s)
- Paola Fernanda Ruiz-Aparicio
- Grupo de Investigación Fisiología Celular y Molecular, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D. C. 111321, Colombia; (P.F.R.-A.); (N.-D.P.V.); (P.O.-M.); (C.C.-C.)
| | - Natalia-Del Pilar Vanegas
- Grupo de Investigación Fisiología Celular y Molecular, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D. C. 111321, Colombia; (P.F.R.-A.); (N.-D.P.V.); (P.O.-M.); (C.C.-C.)
| | - Gloria Inés Uribe
- Grupo de Investigación Oncohematología Pediátrica, Fundación Hospital de la Misericordia, Universidad Nacional de Colombia, Bogotá D. C. 111071, Colombia; (G.I.U.); (J.L.); (J.F.-A); (A.L.-B.)
- Servicio de Patología, Laboratorio de Hematología Especial y Citometría de flujo, Fundación Hospital de la Misericordia, Bogotá D. C. 111071, Colombia
| | - Paola Ortiz-Montero
- Grupo de Investigación Fisiología Celular y Molecular, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D. C. 111321, Colombia; (P.F.R.-A.); (N.-D.P.V.); (P.O.-M.); (C.C.-C.)
| | - Camila Cadavid-Cortés
- Grupo de Investigación Fisiología Celular y Molecular, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D. C. 111321, Colombia; (P.F.R.-A.); (N.-D.P.V.); (P.O.-M.); (C.C.-C.)
| | - Jimmy Lagos
- Grupo de Investigación Oncohematología Pediátrica, Fundación Hospital de la Misericordia, Universidad Nacional de Colombia, Bogotá D. C. 111071, Colombia; (G.I.U.); (J.L.); (J.F.-A); (A.L.-B.)
| | - Jessica Flechas-Afanador
- Grupo de Investigación Oncohematología Pediátrica, Fundación Hospital de la Misericordia, Universidad Nacional de Colombia, Bogotá D. C. 111071, Colombia; (G.I.U.); (J.L.); (J.F.-A); (A.L.-B.)
| | - Adriana Linares-Ballesteros
- Grupo de Investigación Oncohematología Pediátrica, Fundación Hospital de la Misericordia, Universidad Nacional de Colombia, Bogotá D. C. 111071, Colombia; (G.I.U.); (J.L.); (J.F.-A); (A.L.-B.)
| | - Jean-Paul Vernot
- Grupo de Investigación Fisiología Celular y Molecular, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D. C. 111321, Colombia; (P.F.R.-A.); (N.-D.P.V.); (P.O.-M.); (C.C.-C.)
- Instituto de Investigaciones Biomédicas, Facultad de Medicina, Universidad Nacional de Colombia, Bogotá D. C. 111321, Colombia
- Correspondence: ; Tel.: +571-316-5000 (ext. 15057); Fax: +571-316-5466
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Scharff BFSS, Modvig S, Marquart HV, Christensen C. Integrin-Mediated Adhesion and Chemoresistance of Acute Lymphoblastic Leukemia Cells Residing in the Bone Marrow or the Central Nervous System. Front Oncol 2020; 10:775. [PMID: 32528884 PMCID: PMC7256886 DOI: 10.3389/fonc.2020.00775] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 04/21/2020] [Indexed: 12/18/2022] Open
Abstract
Acute Lymphoblastic Leukemia (ALL) is the most common cancer in childhood. Despite a significantly improved prognosis over the last decade with a 5-years survival rate of ~90%, treatment-related morbidity remains substantial and relapse occurs in 10–15% of patients (1). The most common site of relapse is the bone marrow, but early colonization and subsequent reoccurrence of the disease in the central nervous system (CNS) also occurs. Integrins are a family of cell surface molecules with a longstanding history in cancer cell adherence, migration and metastasis. In chronic lymphoblastic leukemia (CLL), the VLA-4 integrin has been acknowledged as a prognostic marker and mounting evidence indicates that this and other integrins may also play a role in acute leukemia, including ALL. Importantly, integrins engage in anti-apoptotic signaling when binding extracellular molecules that are enriched in the bone marrow and CNS microenvironments. Here, we review the current evidence for a role of integrins in the adherence of ALL cells within the bone marrow and their colonization of the CNS, with particular emphasis on mechanisms adding to cancer cell survival and chemoresistance.
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Affiliation(s)
| | - Signe Modvig
- Department of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Hanne Vibeke Marquart
- Department of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Claus Christensen
- Department of Clinical Immunology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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10
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Wang S, Hwang EE, Guha R, O'Neill AF, Melong N, Veinotte CJ, Conway Saur A, Wuerthele K, Shen M, McKnight C, Alexe G, Lemieux ME, Wang A, Hughes E, Xu X, Boxer MB, Hall MD, Kung A, Berman JN, Davis MI, Stegmaier K, Crompton BD. High-throughput Chemical Screening Identifies Focal Adhesion Kinase and Aurora Kinase B Inhibition as a Synergistic Treatment Combination in Ewing Sarcoma. Clin Cancer Res 2019; 25:4552-4566. [PMID: 30979745 DOI: 10.1158/1078-0432.ccr-17-0375] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 12/18/2018] [Accepted: 04/09/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE Ewing sarcoma is an aggressive solid tumor malignancy of childhood. Although current treatment regimens cure approximately 70% of patients with localized disease, they are ineffective for most patients with metastases or relapse. New treatment combinations are necessary for these patients. EXPERIMENTAL DESIGN Ewing sarcoma cells are dependent on focal adhesion kinase (FAK) for growth. To identify candidate treatment combinations for Ewing sarcoma, we performed a small-molecule library screen to identify compounds synergistic with FAK inhibitors in impairing Ewing cell growth. The activity of a top-scoring class of compounds was then validated across multiple Ewing cell lines in vitro and in multiple xenograft models of Ewing sarcoma. RESULTS Numerous Aurora kinase inhibitors scored as synergistic with FAK inhibition in this screen. We found that Aurora kinase B inhibitors were synergistic across a larger range of concentrations than Aurora kinase A inhibitors when combined with FAK inhibitors in multiple Ewing cell lines. The combination of AZD-1152, an Aurora kinase B-selective inhibitor, and PF-562271 or VS-4718, FAK-selective inhibitors, induced apoptosis in Ewing sarcoma cells at concentrations that had minimal effects on survival when cells were treated with either drug alone. We also found that the combination significantly impaired tumor progression in multiple xenograft models of Ewing sarcoma. CONCLUSIONS FAK and Aurora kinase B inhibitors synergistically impair Ewing sarcoma cell viability and significantly inhibit tumor progression. This study provides preclinical support for the consideration of a clinical trial testing the safety and efficacy of this combination for patients with Ewing sarcoma.
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Affiliation(s)
- Sarah Wang
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Elizabeth E Hwang
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Rajarshi Guha
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland
| | - Allison F O'Neill
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | | | - Chansey J Veinotte
- IWK Health Centre, Halifax, Nova Scotia, Canada
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Amy Conway Saur
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Kellsey Wuerthele
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
| | - Min Shen
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland
| | - Crystal McKnight
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland
| | - Gabriela Alexe
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts
- Boston University Bioinformatics Graduate Program, Boston, Massachusetts
| | | | - Amy Wang
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland
| | - Emma Hughes
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland
| | - Xin Xu
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland
| | - Matthew B Boxer
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland
| | - Matthew D Hall
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland
| | - Andrew Kung
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jason N Berman
- IWK Health Centre, Halifax, Nova Scotia, Canada
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Mindy I Davis
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, Maryland
| | - Kimberly Stegmaier
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.
| | - Brian D Crompton
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts.
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Fiedler EC, Hemann MT. Aiding and Abetting: How the Tumor Microenvironment Protects Cancer from Chemotherapy. ANNUAL REVIEW OF CANCER BIOLOGY-SERIES 2019. [DOI: 10.1146/annurev-cancerbio-030518-055524] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Disease recurrence following cancer therapy remains an intractable clinical problem and represents a major impediment to reducing the mortality attributable to malignant tumors. While research has traditionally focused on the cell-intrinsic mechanisms and mutations that render tumors refractory to both classical chemotherapeutics and targeted therapies, recent studies have begun to uncover myriad roles for the tumor microenvironment (TME) in modulating therapeutic efficacy. This work suggests that drug resistance is as much ecological as it is evolutionary. Specifically, cancers resident in organs throughout the body do not develop in isolation. Instead, tumor cells arise in the context of nonmalignant cellular components of a tissue. While the roles of these cell-extrinsic factors in cancer initiation and progression are well established, our understanding of the TME's influence on therapeutic outcome is in its infancy. Here, we focus on mechanisms by which neoplastic cells co-opt preexisting or treatment-induced signaling networks to survive chemotherapy.
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Affiliation(s)
- Eleanor C. Fiedler
- Koch Institute for Integrative Cancer Research and the Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts 02142, USA
| | - Michael T. Hemann
- Koch Institute for Integrative Cancer Research and the Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts 02142, USA
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12
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Redondo-Muñoz J, García-Pardo A, Teixidó J. Molecular Players in Hematologic Tumor Cell Trafficking. Front Immunol 2019; 10:156. [PMID: 30787933 PMCID: PMC6372527 DOI: 10.3389/fimmu.2019.00156] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 01/17/2019] [Indexed: 12/20/2022] Open
Abstract
The trafficking of neoplastic cells represents a key process that contributes to progression of hematologic malignancies. Diapedesis of neoplastic cells across endothelium and perivascular cells is facilitated by adhesion molecules and chemokines, which act in concert to tightly regulate directional motility. Intravital microscopy provides spatio-temporal views of neoplastic cell trafficking, and is crucial for testing and developing therapies against hematologic cancers. Multiple myeloma (MM), chronic lymphocytic leukemia (CLL), and acute lymphoblastic leukemia (ALL) are hematologic malignancies characterized by continuous neoplastic cell trafficking during disease progression. A common feature of these neoplasias is the homing and infiltration of blood cancer cells into the bone marrow (BM), which favors growth and survival of the malignant cells. MM cells traffic between different BM niches and egress from BM at late disease stages. Besides the BM, CLL cells commonly home to lymph nodes (LNs) and spleen. Likewise, ALL cells also infiltrate extramedullary organs, such as the central nervous system, spleen, liver, and testicles. The α4β1 integrin and the chemokine receptor CXCR4 are key molecules for MM, ALL, and CLL cell trafficking into and out of the BM. In addition, the chemokine receptor CCR7 controls CLL cell homing to LNs, and CXCR4, CCR7, and CXCR3 contribute to ALL cell migration across endothelia and the blood brain barrier. Some of these receptors are used as diagnostic markers for relapse and survival in ALL patients, and their level of expression allows clinicians to choose the appropriate treatments. In CLL, elevated α4β1 expression is an established adverse prognostic marker, reinforcing its role in the disease expansion. Combining current chemotherapies with inhibitors of malignant cell trafficking could represent a useful therapy against these neoplasias. Moreover, immunotherapy using humanized antibodies, CAR-T cells, or immune check-point inhibitors together with agents targeting the migration of tumor cells could also restrict their survival. In this review, we provide a view of the molecular players that regulate the trafficking of neoplastic cells during development and progression of MM, CLL, and ALL, together with current therapies that target the malignant cells.
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Affiliation(s)
- Javier Redondo-Muñoz
- Department of Immunology, Ophthalmology and ERL, Hospital 12 de Octubre Health Research Institute (imas12), School of Medicine, Complutense University, Madrid, Spain.,Manchester Collaborative Centre for Inflammation Research, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, Manchester, United Kingdom
| | - Angeles García-Pardo
- Department of Molecular Biomedicine, Centro de Investigaciones Biológicas (CSIC), Madrid, Spain
| | - Joaquin Teixidó
- Department of Molecular Biomedicine, Centro de Investigaciones Biológicas (CSIC), Madrid, Spain
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13
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Yi L, Hu Q, Zhou J, Liu Z, Li H. Alternative splicing of Ikaros regulates the FUT4/Le X-α5β1 integrin-FAK axis in acute lymphoblastic leukemia. Biochem Biophys Res Commun 2019; 510:128-134. [PMID: 30683310 DOI: 10.1016/j.bbrc.2019.01.064] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Accepted: 01/12/2019] [Indexed: 12/24/2022]
Abstract
Unveiling the mechanism of the relapse of acute lymphoblastic leukemia (ALL) is the key to improve the prognosis of ALL and remains a huge challenge. Glycan-based interactions play a vital role in immune surveillance, cell-cell adhesion and cell-matrix interaction, contributing to treatment failure in tumor. However, the glycan essential for leukemia development and its upstream regulatory mechanism by oncogenic drivers were rarely reported. Here, we demonstrated that LeX, a well-characterized cancer-related glycan epitope, strengthened the cell-matrix interaction via glycosylating α5β1 integrin under the control of the driver oncogenic Ikaros isoform (IK6) in ALL. By analyzing the expression profile of Ikaros and the level of FUT4/LeX in clinical samples, we found that FUT4/LeX was positively correlated with dysfunctional Ikaros isoforms. IK1 (Full length Ikaros) regulates the level of FUT4 as a transcription repressor, while IK6 abolished the wild-type Ikaros mediated transcriptional repression and resulted in higher level of FUT4 expression. Moreover, we demonstrated that FUT4 could activate α5β1-mediated sequential signal transduction and accelerate adhesion and invasion between integrin α5β1 in leukemia cells and fibronectin in extracellular matrix (ECM) via increasing glycosylation. Together, our study provides a new insight into the mechanisms by which Ikaros mutation induced ALL cells invasion and a potential strategy for drug-resistance ALL by blocking LeX in combination with common chemotherapy.
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Affiliation(s)
- Lijun Yi
- Central Laboratory, Jiangxi Provincial Children's Hospital, Yangming Rd, Nanchang, Jiangxi, 330006, China
| | - Qinghua Hu
- Central Laboratory, Jiangxi Provincial Children's Hospital, Yangming Rd, Nanchang, Jiangxi, 330006, China
| | - Jing Zhou
- Central Laboratory, Jiangxi Provincial Children's Hospital, Yangming Rd, Nanchang, Jiangxi, 330006, China
| | - Zhiqiang Liu
- Central Laboratory, Jiangxi Provincial Children's Hospital, Yangming Rd, Nanchang, Jiangxi, 330006, China
| | - Hong Li
- Central Laboratory, Jiangxi Provincial Children's Hospital, Yangming Rd, Nanchang, Jiangxi, 330006, China.
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14
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Barwe SP, Quagliano A, Gopalakrishnapillai A. Eviction from the sanctuary: Development of targeted therapy against cell adhesion molecules in acute lymphoblastic leukemia. Semin Oncol 2017; 44:101-112. [PMID: 28923207 DOI: 10.1053/j.seminoncol.2017.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 05/10/2017] [Accepted: 06/29/2017] [Indexed: 02/04/2023]
Abstract
Acute lymphoblastic leukemia (ALL) is a malignant hematological disease afflicting hematopoiesis in the bone marrow. While 80%-90% of patients diagnosed with ALL will achieve complete remission at some point during treatment, ALL is associated with high relapse rate, with a 5-year overall survival rate of 68%. The initial remission failure and the high rate of relapse can be attributed to intrinsic chemoprotective mechanisms that allow persistence of ALL cells despite therapy. These mechanisms are mediated, at least in part, through the engagement of cell adhesion molecules (CAMs) within the bone marrow microenvironment. This review assembles CAMs implicated in protection of leukemic cells from chemotherapy. Such studies are limited in ALL. Therefore, CAMs that are associated with poor outcomes or are overexpressed in ALL and have been shown to be involved in chemoprotection in other hematological cancers are also included. It is likely that these molecules play parallel roles in ALL because the CAMs identified to be a factor in ALL chemoresistance also work similarly in other hematological malignancies. We review the signaling mechanisms activated by the engagement of CAMs that provide protection from chemotherapy. Development of targeted therapies against CAMs could improve outcome and raise the overall cure rate in ALL.
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Affiliation(s)
- Sonali P Barwe
- Nemours Center for Childhood Cancer Research, A.I. DuPont Hospital for Children, Wilmington, DE.
| | - Anthony Quagliano
- Nemours Center for Childhood Cancer Research, A.I. DuPont Hospital for Children, Wilmington, DE
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15
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Quagliano A, Gopalakrishnapillai A, Barwe SP. Epigenetic drug combination overcomes osteoblast-induced chemoprotection in pediatric acute lymphoid leukemia. Leuk Res 2017; 56:36-43. [PMID: 28171800 PMCID: PMC5366080 DOI: 10.1016/j.leukres.2017.01.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 01/23/2017] [Accepted: 01/25/2017] [Indexed: 01/06/2023]
Abstract
Although there has been much progress in the treatment of acute lymphoblastic leukemia (ALL), decreased sensitivity to chemotherapy remains a significant issue. Recent studies have shown how interactions with the bone marrow microenvironment can protect ALL cells from chemotherapy and allow for the persistence of the disease. Epigenetic drugs have been used for the treatment of ALL, but there are no reports on whether these drugs can overcome bone marrow-induced chemoprotection. Our study investigates the ability of the DNA methyltransferase inhibitor azacitidine and the histone deacetylase inhibitor panobinostat to overcome chemoprotective effects mediated by osteoblasts. We show that the combination of azacitidine and panobinostat has a synergistic killing effect and that this combination is more effective than cytarabine in inducing ALL cell death in co-culture with osteoblasts. We also show that this combination can be used to sensitize ALL cells to chemotherapeutics in the presence of osteoblasts. Finally, we demonstrate that these effects can be replicated ex vivo in a number of mouse passaged xenograft lines from both B-ALL and T-ALL patients with varying cytogenetics. Thus, our data provides evidence that azacitidine and panobinostat can successfully overcome osteoblast-induced chemoprotection in vitro and ex vivo in both B-ALL and T-ALL cells.
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Affiliation(s)
- Anthony Quagliano
- Nemours Center for Childhood Cancer Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, United States; Department of Biological Sciences, University of Delaware, Wilmington, DE 19716, United States
| | - Anilkumar Gopalakrishnapillai
- Nemours Center for Childhood Cancer Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, United States.
| | - Sonali P Barwe
- Nemours Center for Childhood Cancer Research, Alfred I. duPont Hospital for Children, Wilmington, DE 19803, United States; Department of Biological Sciences, University of Delaware, Wilmington, DE 19716, United States.
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16
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Krause DS, Scadden DT. A hostel for the hostile: the bone marrow niche in hematologic neoplasms. Haematologica 2016; 100:1376-87. [PMID: 26521296 DOI: 10.3324/haematol.2014.113852] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Our understanding of the biology of the normal hematopoietic stem cell niche has increased steadily due to improved murine models and sophisticated imaging tools. Less well understood, but of growing interest, is the interaction between cells in the bone marrow during the initiation, maintenance and treatment of hematologic neoplasms. This review summarizes the emerging concepts of the normal and leukemic hematopoietic bone marrow niche. Furthermore, it reviews current models of how the microenvironment of the bone marrow may contribute to or be modified by leukemogenesis. Finally, it provides the rationale for a "two-pronged" approach, directly targeting cancer cells themselves while also targeting the bone microenvironment to make it inhospitable to malignant cells and, ultimately, eradicating cancer stem-like cells.
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Affiliation(s)
- Daniela S Krause
- Georg-Speyer-Haus, Institute for Tumor Biology and Experimental Therapy, Frankfurt am Main, Germany
| | - David T Scadden
- Department of Stem Cell and Regenerative Biology and Harvard Stem Cell Institute, Harvard University, Center for Regenerative Medicine and Cancer Center, Massachusetts General Hospital, Boston, USA
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17
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Imatinib and Nilotinib increase glioblastoma cell invasion via Abl-independent stimulation of p130Cas and FAK signalling. Sci Rep 2016; 6:27378. [PMID: 27293031 PMCID: PMC4904410 DOI: 10.1038/srep27378] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 05/17/2016] [Indexed: 01/04/2023] Open
Abstract
Imatinib was the first targeted tyrosine kinase inhibitor to be approved for clinical use, and remains first-line therapy for Philadelphia chromosome (Ph+)-positive chronic myelogenous leukaemia. We show that treatment of human glioblastoma multiforme (GBM) tumour cells with imatinib and the closely-related drug, nilotinib, strikingly increases tyrosine phosphorylation of p130Cas, focal adhesion kinase (FAK) and the downstream adaptor protein paxillin (PXN), resulting in enhanced cell migration and invasion. Imatinib and nilotinib-induced tyrosine phosphorylation was dependent on expression of p130Cas and FAK activity and was independent of known imatinib targets including Abl, platelet derived growth factor receptor beta (PDGFRβ) and the collagen receptor DDR1. Imatinib and nilotinib treatment increased two dimensional cell migration and three dimensional radial spheroid invasion in collagen. In addition, silencing of p130Cas and inhibition of FAK activity both strongly reduced imatinib and nilotinib stimulated invasion. Importantly, imatinib and nilotinib increased tyrosine phosphorylation of p130Cas, FAK, PXN and radial spheroid invasion in stem cell lines isolated from human glioma biopsies. These findings identify a novel mechanism of action in GBM cells for two well established front line therapies for cancer resulting in enhanced tumour cell motility.
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18
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Layton Tovar CF, Mendieta Zerón H. Intracellular Signaling Pathways Involved in Childhood Acute Lymphoblastic Leukemia; Molecular Targets. Indian J Hematol Blood Transfus 2015; 32:141-53. [PMID: 27065575 DOI: 10.1007/s12288-015-0609-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Accepted: 10/09/2015] [Indexed: 01/17/2023] Open
Abstract
Acute lymphoblastic leukemia (ALL) is a malignant disease characterized by an uncontrolled proliferation of immature lymphoid cells. ALL is the most common hematologic malignancy in early childhood, and it reaches peak incidence between the ages of 2 and 3 years. The prognosis of ALL is associated with aberrant gene expression, in addition to the presence of numerical or structural chromosomal alterations, age, race, and immunophenotype. The Relapse rate with regard to pharmacological treatment rises in childhood; thus, the expression of biomarkers associated with the activation of cell signaling pathways is crucial to establish the disease prognosis. Intracellular pathways involved in ALL are diverse, including Janus kinase/Signal transducers and transcription activators (JAK-STAT), Phosphoinositide-3-kinase-protein kinase B (PI3K-AKT), Ras mitogen-activated protein kinase (Ras-MAPK), Glycogen synthase kinase-3β (GSK-3β), Nuclear factor-kappa beta (NF-κB), and Hypoxia-inducible transcription factor 1α (HIF-1α), among others. In this review, we present several therapeutic targets, intracellular pathways, and molecular markers that are being studied extensively at present.
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Affiliation(s)
- Cristian Fabián Layton Tovar
- Facultad de Medicina, Universidad Autónoma del Estado de México (UAEMex), Paseo Tollocan esq. Jesús Carranza, Col. Moderna de la Cruz, 50180 Toluca, Estado de Mexico Mexico
| | - Hugo Mendieta Zerón
- Facultad de Medicina, Universidad Autónoma del Estado de México (UAEMex), Paseo Tollocan esq. Jesús Carranza, Col. Moderna de la Cruz, 50180 Toluca, Estado de Mexico Mexico ; Asociación Científica Latina A.C. (ASCILA) and Ciprés Grupo Médico (CGM), Felipe Villanueva sur 1209, Col. Rancho Dolores, 50170 Toluca, Estado de Mexico Mexico
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