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Chen H, Wang X, Wang Y, Chang X. What happens to regulatory T cells in multiple myeloma. Cell Death Discov 2023; 9:468. [PMID: 38129374 PMCID: PMC10739837 DOI: 10.1038/s41420-023-01765-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 12/03/2023] [Accepted: 12/06/2023] [Indexed: 12/23/2023] Open
Abstract
Abnormal tumor microenvironment and immune escape in multiple myeloma (MM) are associated with regulatory T cells (Tregs), which play an important role in maintaining self-tolerance and regulating the overall immune response to infection or tumor cells. In patients with MM, there are abnormalities in the number, function and distribution of Tregs, and these abnormalities may be related to the disease stage, risk grade and prognosis of patients. During the treatment, Tregs have different responses to various treatment regiments, thus affecting the therapeutic effect of MM. It is also possible to predict the therapeutic response by observing the changes of Tregs. In addition to the above, we reviewed the application of Tregs in the treatment of MM. In conclusion, there is still much room for research on the mechanism and application of Tregs in MM.
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Affiliation(s)
- Huixian Chen
- Medical Research Center, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
- Department of Hematology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Xueling Wang
- Medical Research Center, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
- Department of Gastroenterology, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China
| | - Yan Wang
- Department of Pediatrics, Qilu Hospital of Shandong University, Jinan, 250012, China
| | - Xiaotian Chang
- Medical Research Center, The Affiliated Hospital of Qingdao University, Qingdao, 266003, China.
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Tumor-Derived Extracellular Vesicles in Cancer Immunoediting and Their Potential as Oncoimmunotherapeutics. Cancers (Basel) 2022; 15:cancers15010082. [PMID: 36612080 PMCID: PMC9817790 DOI: 10.3390/cancers15010082] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/16/2022] [Accepted: 12/20/2022] [Indexed: 12/24/2022] Open
Abstract
The tumor microenvironment (TME) within and around a tumor is a complex interacting mixture of tumor cells with various stromal cells, including endothelial cells, fibroblasts, and immune cells. In the early steps of tumor formation, the local microenvironment tends to oppose carcinogenesis, while with cancer progression, the microenvironment skews into a protumoral TME and the tumor influences stromal cells to provide tumor-supporting functions. The creation and development of cancer are dependent on escape from immune recognition predominantly by influencing stromal cells, particularly immune cells, to suppress antitumor immunity. This overall process is generally called immunoediting and has been categorized into three phases; elimination, equilibrium, and escape. Interaction of tumor cells with stromal cells in the TME is mediated generally by cell-to-cell contact, cytokines, growth factors, and extracellular vesicles (EVs). The least well studied are EVs (especially exosomes), which are nanoparticle-sized bilayer membrane vesicles released by many cell types that participate in cell/cell communication. EVs carry various proteins, nucleic acids, lipids, and small molecules that influence cells that ingest the EVs. Tumor-derived extracellular vesicles (TEVs) play a significant role in every stage of immunoediting, and their cargoes change from immune-activating in the early stages of immunoediting into immunosuppressing in the escape phase. In addition, their cargos change with different treatments or stress conditions and can be influenced to be more immune stimulatory against cancer. This review focuses on the emerging understanding of how TEVs affect the differentiation and effector functions of stromal cells and their role in immunoediting, from the early stages of immunoediting to immune escape. Consideration of how TEVs can be therapeutically utilized includes different treatments that can modify TEV to support cancer immunotherapy.
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3
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Gholipour E, Kahroba H, Soltani N, Samadi P, Sarvarian P, Vakili-Samiani S, Hosein Pour Feizi AA, Soltani-Zangbar MS, Baghersalimi A, Darbandi B, Movassaghpour A, Talebi M, Motavalli R, Mehdizadeh A, Kazemi A, Yousefi M. Paediatric pre-B acute lymphoblastic leukaemia-derived exosomes regulate immune function in human T cells. J Cell Mol Med 2022; 26:4566-4576. [PMID: 35822529 PMCID: PMC9357647 DOI: 10.1111/jcmm.17482] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 06/24/2022] [Accepted: 06/30/2022] [Indexed: 11/30/2022] Open
Abstract
Exosomes derived from solid tumour cells are involved in immune suppression, angiogenesis and metastasis; however, the role of leukaemia‐derived exosomes has less been investigated. Hence, changes in immune response‐related genes and human T cells apoptosis co‐incubated with exosomes isolated from patients' pre‐B cell acute lymphoblastic leukaemia were evaluated in this in vitro study. Vein blood sample was obtained from each newly diagnosed acute lymphoblastic leukaemia (ALL) patient prior any therapy. ALL serum exosomes were isolated by ultrafiltration and characterized using Western blotting and transmission electron microscopy. Exosomes were then co‐incubated with T lymphocytes and the gene expressions, as well as functions of human T cells were quantified by qRT‐PCR. Apoptosis and caspase‐3 and caspase‐9 protein expression were also evaluated by flowcytometry and Western blotting analysis, respectively. Exosomes isolated from ALL patients affected T lymphocytes and elevated the apoptosis. Moreover, these exosomes altered the T cells profile into regulatory type by increasing the expression of FOXP3 and Tregs‐related cytokines, including TGF‐B and IL‐10. The expression level of Th17‐related transcription factors (RoRγt) and interleukins (IL‐17 and IL‐23) decreased after this treatment. According to our findings, exosomes derived from ALL patients' sera carry immunosuppressive molecules, indicating the possible effect of exosomes as liquid biomarkers for cancer staging.
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Affiliation(s)
- Elham Gholipour
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran.,Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Houman Kahroba
- Departments of Toxicogenomics, GROW School for Oncology and Developmental Biology, Maastricht University, Maastricht, Netherlands.,Center for Environmental Sciences, Hasselt University, Hasselt, Belgium
| | - Nasim Soltani
- Master of Science Neonatal Intensive Care Nursing, Faculity of Nursing and Midwifery, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parisa Samadi
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Parisa Sarvarian
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Sajjad Vakili-Samiani
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | | | - Adel Baghersalimi
- Pediatric Disease Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Bahram Darbandi
- Pediatric Disease Research Center, Guilan University of Medical Sciences, Rasht, Iran
| | - Aliakbar Movassaghpour
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Talebi
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Roza Motavalli
- Stem Cell Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Molecular Medicine, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Amir Mehdizadeh
- Hematology and Oncology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abdolhassan Kazemi
- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mehdi Yousefi
- Research Center for Integrative Medicine in Aging, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
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Paskeh MDA, Entezari M, Mirzaei S, Zabolian A, Saleki H, Naghdi MJ, Sabet S, Khoshbakht MA, Hashemi M, Hushmandi K, Sethi G, Zarrabi A, Kumar AP, Tan SC, Papadakis M, Alexiou A, Islam MA, Mostafavi E, Ashrafizadeh M. Emerging role of exosomes in cancer progression and tumor microenvironment remodeling. J Hematol Oncol 2022; 15:83. [PMID: 35765040 PMCID: PMC9238168 DOI: 10.1186/s13045-022-01305-4] [Citation(s) in RCA: 228] [Impact Index Per Article: 114.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 06/13/2022] [Indexed: 12/14/2022] Open
Abstract
Cancer is one of the leading causes of death worldwide, and the factors responsible for its progression need to be elucidated. Exosomes are structures with an average size of 100 nm that can transport proteins, lipids, and nucleic acids. This review focuses on the role of exosomes in cancer progression and therapy. We discuss how exosomes are able to modulate components of the tumor microenvironment and influence proliferation and migration rates of cancer cells. We also highlight that, depending on their cargo, exosomes can suppress or promote tumor cell progression and can enhance or reduce cancer cell response to radio- and chemo-therapies. In addition, we describe how exosomes can trigger chronic inflammation and lead to immune evasion and tumor progression by focusing on their ability to transfer non-coding RNAs between cells and modulate other molecular signaling pathways such as PTEN and PI3K/Akt in cancer. Subsequently, we discuss the use of exosomes as carriers of anti-tumor agents and genetic tools to control cancer progression. We then discuss the role of tumor-derived exosomes in carcinogenesis. Finally, we devote a section to the study of exosomes as diagnostic and prognostic tools in clinical courses that is important for the treatment of cancer patients. This review provides a comprehensive understanding of the role of exosomes in cancer therapy, focusing on their therapeutic value in cancer progression and remodeling of the tumor microenvironment.
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Affiliation(s)
- Mahshid Deldar Abad Paskeh
- Department of Genetics, Faculty of Advanced Science and Technology, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.,Farhikhtegan Medical Convergence Sciences Research Center, Farhikhtegan Hospital Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Maliheh Entezari
- Department of Genetics, Faculty of Advanced Science and Technology, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.,Farhikhtegan Medical Convergence Sciences Research Center, Farhikhtegan Hospital Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Sepideh Mirzaei
- Department of Biology, Faculty of Science, Islamic Azad University, Science and Research Branch, Tehran, Iran
| | - Amirhossein Zabolian
- Young Researchers and Elite Club, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Hossein Saleki
- Young Researchers and Elite Club, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Mohamad Javad Naghdi
- Young Researchers and Elite Club, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Sina Sabet
- Young Researchers and Elite Club, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Mohammad Amin Khoshbakht
- Young Researchers and Elite Club, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Mehrdad Hashemi
- Department of Genetics, Faculty of Advanced Science and Technology, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran.,Farhikhtegan Medical Convergence Sciences Research Center, Farhikhtegan Hospital Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Kiavash Hushmandi
- Division of Epidemiology, Department of Food Hygiene and Quality Control, Faculty of Veterinary Medicine, University of Tehran, Tehran, Iran
| | - Gautam Sethi
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore.,NUS Centre for Cancer Research (N2CR), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117597, Singapore
| | - Ali Zarrabi
- Department of Biomedical Engineering, Faculty of Engineering and Natural Sciences, Istinye University, 34396, Istanbul, Turkey
| | - Alan Prem Kumar
- Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117600, Singapore.,NUS Centre for Cancer Research (N2CR), Yong Loo Lin School of Medicine, National University of Singapore, Singapore, 117597, Singapore
| | - Shing Cheng Tan
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia.
| | - Marios Papadakis
- Department of Surgery II, University Hospital Witten-Herdecke, University of Witten-Herdecke, Heusnerstrasse 40, 42283, Wuppertal, Germany.
| | - Athanasios Alexiou
- Department of Science and Engineering, Novel Global Community Educational Foundation, Hebersham, Australia.,AFNP Med Austria, Vienna, Austria
| | - Md Asiful Islam
- Department of Haematology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.,Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Ebrahim Mostafavi
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, 94305, USA.,Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Milad Ashrafizadeh
- Faculty of Engineering and Natural Sciences, Sabanci University, Orta Mahalle, Üniversite Caddesi No. 27, Orhanlı, Tuzla, Istanbul, Turkey.
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Serratì S, Guida M, Di Fonte R, De Summa S, Strippoli S, Iacobazzi RM, Quarta A, De Risi I, Guida G, Paradiso A, Porcelli L, Azzariti A. Circulating extracellular vesicles expressing PD1 and PD-L1 predict response and mediate resistance to checkpoint inhibitors immunotherapy in metastatic melanoma. Mol Cancer 2022; 21:20. [PMID: 35042524 PMCID: PMC8764806 DOI: 10.1186/s12943-021-01490-9] [Citation(s) in RCA: 69] [Impact Index Per Article: 34.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/26/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The immunotherapy with immune checkpoints inhibitors (ICI) has changed the life expectancy in metastatic melanoma (MM) patients. Nevertheless, several patients do not respond hence, the identification and validation of novel biomarkers of response to ICI is of crucial importance. Circulating extracellular vesicles (EVs) such as PD-L1+ EV mediate resistance to anti-PD1, instead the role of PD1+ EV is not fully understood. METHODS We isolated the circulating EVs from the plasma of an observational cohort study of 71 metastatic melanoma patients and correlated the amount of PD-L1+ EVs and PD1+ EVs with the response to ICI. The analysis was performed according to the origin of EVs from the tumor and the immune cells. Subsequently, we analysed the data in a validation cohort of 22 MM patients to assess the reliability of identified EV-based biomarkers. Additionally we assessed the involvement of PD1+ EVs in the seizure of nivolumab and in the perturbation of immune cells-mediated killing of melanoma spheroids. RESULTS The level of PD-L1+ EVs released from melanoma and CD8+ T cells and that of PD1+ EVs irrespective of the cellular origin were higher in non-responders. The Kaplan-Meier curves indicated that higher levels of PD1+ EVs were significantly correlated with poorer progression-free survival (PFS) and overall survival (OS). Significant correlations were found for PD-L1+ EVs only when released from melanoma and T cells. The multivariate analysis showed that high level of PD1+ EVs, from T cells and B cells, and high level of PD-L1+ EVs from melanoma cells, are independent biomarkers of response. The reliability of PD-L1+ EVs from melanoma and PD1+ EVs from T cells in predicting PFS was confirmed in the validation cohort through the univariate Cox-hazard regression analysis. Moreover we discovered that the circulating EVs captured nivolumab and reduced the T cells trafficking and tumor spheroids killing. CONCLUSION Our study identified circulating PD1+ EVs as driver of resistance to anti-PD1, and highlighted that the analysis of single EV population by liquid biopsy is a promising tool to stratify MM patients for immunotherapy.
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Affiliation(s)
- Simona Serratì
- Laboratory of Nanotechnology, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy
| | - Michele Guida
- Rare Tumors and Melanoma Unit, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy
| | - Roberta Di Fonte
- Laboratory of Experimental Pharmacology, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy
| | - Simona De Summa
- Molecular Diagnostics and Pharmacogenetics Unit, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy
| | - Sabino Strippoli
- Rare Tumors and Melanoma Unit, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy
| | - Rosa Maria Iacobazzi
- Laboratory of Experimental Pharmacology, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy
| | - Alessandra Quarta
- CNR NANOTEC-Istituto di Nanotecnologia, National Research Council (CNR), via Monteroni, 73100, Lecce, Italy
| | - Ivana De Risi
- Rare Tumors and Melanoma Unit, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy
| | - Gabriella Guida
- Department of Basic Medical Sciences Neurosciences and Sense Organs, University of Bari, Piazza G. Cesare, 11, 70124, Bari, Italy
| | - Angelo Paradiso
- Scientific Directorate, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy
| | - Letizia Porcelli
- Laboratory of Experimental Pharmacology, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy
| | - Amalia Azzariti
- Laboratory of Nanotechnology, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy.
- Laboratory of Experimental Pharmacology, IRCCS Istituto Tumori Giovanni Paolo II, V.le O. Flacco, 65, 70124, Bari, Italy.
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Zhao K, Yuan WH, Li WJ, Chi ZP, Wang SR, Chen ZG. Effect of RhoE expression on the migration and invasion of tongue squamous cell carcinoma. HUA XI KOU QIANG YI XUE ZA ZHI = HUAXI KOUQIANG YIXUE ZAZHI = WEST CHINA JOURNAL OF STOMATOLOGY 2021; 39:510-517. [PMID: 34636197 DOI: 10.7518/hxkq.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study aims to investigate the effect of RhoE expression on the migration and invasion of tongue squamous cell carcinoma (TSCC). METHODS Forty-eight TSCC cases were selected from the Maxillofacial Surgery Center of Qingdao Municipal Hospital from 2017 to 2019. The expression of RhoE in the specimens (TSCC and adjacent tissues) was detected by immunohistochemistry, and RhoE mRNA and protein were extracted to further detect the expression of RhoE. SCC-4 and CAL-27 cells were selected for in vitro experiments. Transient transfection was used to overexpress RhoE. Real-time fluorescence quantitative PCR (qRT-PCR) and Western blot analyses were conducted to detect the overexpression efficiency. Scratch test and Transwell cell invasion tests were used to detect the migration and invasion ability of TSCC, respectively. The expression levels of Rho-associated coiled-coil-containing protein kinase 1 (ROCK1), matrix metalloproteinase-2 (MMP-2), and matrix metalloproteinase-9 (MMP-9) were detected by Western blot. Experimental data were analyzed by Graphpad prism 8.2.1 software. RESULTS The expression level of RhoE in TSCC was significantly lower than that in adjacent tissues (P<0.05). The migration and invasion abilities of TSCC were significantly lower than those in the control group (P<0.05). The Western blot showed significantly lower expression levels of ROCK1, MMP-2, and MMP-9 in the experimental group than in the control group (P<0.05). CONCLUSIONS RhoE expression is low in TSCC. Over expression RhoE in TSCC can significantly decrease its migration and invasion abilities. Hence, RhoE may play an important role in regulating the metastasis and invasion of TSCC and provide a new target for gene therapy.
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Affiliation(s)
- Kai Zhao
- School of Stomatology, Qingdao University, Qingdao 266003, China
| | - Wen-Hong Yuan
- Dept. of Stomatology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
| | - Wen-Jian Li
- School of Stomatology, Dalian Medical University, Dalian 116044, China
| | - Zeng-Peng Chi
- College of Stomatology, Weifang Medical University, Weifang 261021, China
| | - Shao-Ru Wang
- School of Stomatology, Dalian Medical University, Dalian 116044, China
| | - Zheng-Gang Chen
- Dept. of Stomatology, Qingdao Municipal Hospital, Qingdao University, Qingdao 266071, China
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Upregulation of lnc-ZNF281 Inhibits the Progression of Glioma via the AKT/GSK-3 β/ β-Catenin Signaling Pathway. J Immunol Res 2021; 2021:5573071. [PMID: 34056009 PMCID: PMC8131163 DOI: 10.1155/2021/5573071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/14/2021] [Accepted: 04/26/2021] [Indexed: 11/17/2022] Open
Abstract
The purpose of this study is to elucidate the roles and potential underlying mechanisms of long noncoding RNA lnc-ZNF281 in glioma. We performed qRT-PCR to detect the expression levels of lnc-ZNF281 in glioma tissues. The effects of lnc-ZNF281 on the proliferative and migrative abilities of T98G and HS683 glioma cells were examined by cell proliferation assay, colony formation assay, wound-healing assay, and transwell assay. Also, the effects of lnc-ZNF281 on AKT/GSK-3β/β-catenin pathway were analyzed. The results showed that the expression of lnc-ZNF281 in glioma tissues was decreased compared with normal tissues. lnc-ZNF281 overexpression inhibited the proliferative and migrative abilities of glioma cells, while lnc-ZNF281 knockdown obtained the opposite findings. Besides, overexpression of lnc-ZNF281 in glioma cells inactivated the AKT/GSK-3β/β-catenin signaling pathway. Furthermore, β-catenin activation reversed the suppressive effects of lnc-ZNF281 on glioma cells. Taken together, lnc-ZNF281 inhibits glioma cell proliferation and migration via AKT/GSK-3β/β-catenin pathway and may serve as a potential target for glioma treatment.
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