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Amaya L, Abe B, Liu J, Zhao F, Zhang WL, Chen R, Li R, Wang S, Kamber RA, Tsai MC, Bassik MC, Majeti R, Chang HY. Pathways for macrophage uptake of cell-free circular RNAs. Mol Cell 2024; 84:2104-2118.e6. [PMID: 38761795 PMCID: PMC11218042 DOI: 10.1016/j.molcel.2024.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/04/2024] [Accepted: 04/26/2024] [Indexed: 05/20/2024]
Abstract
Circular RNAs (circRNAs) are stable RNAs present in cell-free RNA, which may comprise cellular debris and pathogen genomes. Here, we investigate the phenomenon and mechanism of cellular uptake and intracellular fate of exogenous circRNAs. Human myeloid cells and B cells selectively internalize extracellular circRNAs. Macrophage uptake of circRNA is rapid, energy dependent, and saturable. CircRNA uptake can lead to translation of encoded sequences and antigen presentation. The route of internalization influences immune activation after circRNA uptake, with distinct gene expression programs depending on the route of RNA delivery. Genome-scale CRISPR screens and chemical inhibitor studies nominate macrophage scavenger receptor MSR1, Toll-like receptors, and mTOR signaling as key regulators of receptor-mediated phagocytosis of circRNAs, a dominant pathway to internalize circRNAs in parallel to macropinocytosis. These results suggest that cell-free circRNA serves as an "eat me" signal and danger-associated molecular pattern, indicating orderly pathways of recognition and disposal.
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Affiliation(s)
- Laura Amaya
- Center for Personal Dynamic Regulomes, Stanford University, Stanford, CA 94305, USA; Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Brian Abe
- Center for Personal Dynamic Regulomes, Stanford University, Stanford, CA 94305, USA; Division of Immunology and Rheumatology, Department of Medicine, Stanford University, Stanford, CA 94305, USA
| | - Jie Liu
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Feifei Zhao
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Wenyan Lucy Zhang
- Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Robert Chen
- Center for Personal Dynamic Regulomes, Stanford University, Stanford, CA 94305, USA
| | - Rui Li
- Center for Personal Dynamic Regulomes, Stanford University, Stanford, CA 94305, USA
| | - Steven Wang
- Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Roarke A Kamber
- Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Miao-Chih Tsai
- RNA Medicine Program, Stanford University, Stanford, CA 94305, USA
| | - Michael C Bassik
- Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Ravindra Majeti
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA; Department of Medicine, Division of Hematology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Howard Y Chang
- Center for Personal Dynamic Regulomes, Stanford University, Stanford, CA 94305, USA; Department of Genetics, Stanford University School of Medicine, Stanford, CA 94305, USA; RNA Medicine Program, Stanford University, Stanford, CA 94305, USA; Howard Hughes Medical Institute, Stanford University, Stanford, CA 94305, USA.
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2
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Lith SC, Evers TMJ, Freire BM, van Tiel CM, Vos WG, Mashaghi A, de Vries CJM. Nuclear receptor Nur77 regulates immunomechanics of macrophages. Eur J Cell Biol 2024; 103:151419. [PMID: 38763048 DOI: 10.1016/j.ejcb.2024.151419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/17/2024] [Accepted: 05/08/2024] [Indexed: 05/21/2024] Open
Abstract
Nuclear receptor Nur77 plays a pivotal role in immune regulation across various tissues, influencing pro-inflammatory signaling pathways and cellular metabolism. While cellular mechanics have been implicated in inflammation, the contribution of Nur77 to these mechanical processes remains elusive. Macrophages exhibit remarkable plasticity in their morphology and mechanics, enabling them to adapt and execute essential inflammatory functions, such as navigating through inflamed tissue and pathogen engulfment. However, the precise regulatory mechanisms governing these dynamic changes in macrophage mechanics during inflammation remain poorly understood. To establish the potential correlation of Nur77 with cellular mechanics, we compared bone marrow-derived macrophages (BMDMs) from wild-type (WT) and Nur77-deficient (Nur77-KO) mice and employed cytoskeletal imaging, single-cell acoustic force spectroscopy (AFS), migration and phagocytosis assays, and RNA-sequencing. Our findings reveal that Nur77-KO BMDMs exhibit changes to their actin networks compared to WT BMDMs, which is associated with a stiffer and more rigid phenotype. Subsequent in vitro experiments validated our observations, showcasing that Nur77 deficiency leads to enhanced migration, reduced adhesion, and increased phagocytic activity. The transcriptomics data confirmed altered mechanics-related pathways in Nur77-deficient macrophage that are accompanied by a robust pro-inflammatory phenotype. Utilizing previously obtained ChIP-data, we revealed that Nur77 directly targets differentially expressed genes associated with cellular mechanics. In conclusion, while Nur77 is recognized for its role in reducing inflammation of macrophages by inhibiting the expression of pro-inflammatory genes, our study identifies a novel regulatory mechanism where Nur77 governs macrophage inflammation through the modulation of expression of genes involved in cellular mechanics. Our findings suggest that immune regulation by Nur77 may be partially mediated through alterations in cellular mechanics, highlighting a potential avenue for therapeutic targeting.
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Affiliation(s)
- Sanne C Lith
- Amsterdam UMC location University of Amsterdam, Department of Medical Biochemistry, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, University of Amsterdam, The Netherlands; Amsterdam Institute for Immunology and Infectious diseases, University of Amsterdam, The Netherlands
| | - Tom M J Evers
- Medical Systems Biophysics and Bioengineering, Leiden Academic Centre for Drug Research, Faculty of Mathematics and Natural Sciences, Leiden University, Leiden, The Netherlands
| | - Beatriz M Freire
- Amsterdam UMC location University of Amsterdam, Department of Medical Biochemistry, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, University of Amsterdam, The Netherlands; Amsterdam Institute for Immunology and Infectious diseases, University of Amsterdam, The Netherlands
| | - Claudia M van Tiel
- Amsterdam UMC location University of Amsterdam, Department of Medical Biochemistry, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, University of Amsterdam, The Netherlands; Amsterdam Institute for Immunology and Infectious diseases, University of Amsterdam, The Netherlands
| | - Winnie G Vos
- Amsterdam UMC location University of Amsterdam, Department of Medical Biochemistry, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, University of Amsterdam, The Netherlands; Amsterdam Institute for Immunology and Infectious diseases, University of Amsterdam, The Netherlands
| | - Alireza Mashaghi
- Medical Systems Biophysics and Bioengineering, Leiden Academic Centre for Drug Research, Faculty of Mathematics and Natural Sciences, Leiden University, Leiden, The Netherlands.
| | - Carlie J M de Vries
- Amsterdam UMC location University of Amsterdam, Department of Medical Biochemistry, Amsterdam, The Netherlands; Amsterdam Cardiovascular Sciences, University of Amsterdam, The Netherlands; Amsterdam Institute for Immunology and Infectious diseases, University of Amsterdam, The Netherlands.
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3
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Hadiloo K, Taremi S, Heidari M, Esmaeilzadeh A. The CAR macrophage cells, a novel generation of chimeric antigen-based approach against solid tumors. Biomark Res 2023; 11:103. [PMID: 38017494 PMCID: PMC10685521 DOI: 10.1186/s40364-023-00537-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/02/2023] [Indexed: 11/30/2023] Open
Abstract
Today, adoptive cell therapy has many successes in cancer therapy, and this subject is brilliant in using chimeric antigen receptor T cells. The CAR T cell therapy, with its FDA-approved drugs, could treat several types of hematological malignancies and thus be very attractive for treating solid cancer. Unfortunately, the CAR T cell cannot be very functional in solid cancers due to its unique features. This treatment method has several harmful adverse effects that limit their applications, so novel treatments must use new cells like NK cells, NKT cells, and macrophage cells. Among these cells, the CAR macrophage cells, due to their brilliant innate features, are more attractive for solid tumor therapy and seem to be a better candidate for the prior treatment methods. The CAR macrophage cells have vital roles in the tumor microenvironment and, with their direct effect, can eliminate tumor cells efficiently. In addition, the CAR macrophage cells, due to being a part of the innate immune system, attended the tumor sites. With the high infiltration, their therapy modulations are more effective. This review investigates the last achievements in CAR-macrophage cells and the future of this immunotherapy treatment method.
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Affiliation(s)
- Kaveh Hadiloo
- Student Research Committee, School of Medicine, Zanjan University of Medical Sciences, Department of Immunology, Zanjan, Iran
| | - Siavash Taremi
- School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Mahmood Heidari
- School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Abdolreza Esmaeilzadeh
- Department of Immunology, Zanjan University of Medical Sciences, Zanjan, Iran.
- Cancer Gene Therapy Research Center (CGRC), Zanjan University of Medical Sciences, Zanjan, Iran.
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4
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Shakhpazyan N, Mikhaleva L, Bedzhanyan A, Gioeva Z, Sadykhov N, Mikhalev A, Atiakshin D, Buchwalow I, Tiemann M, Orekhov A. Cellular and Molecular Mechanisms of the Tumor Stroma in Colorectal Cancer: Insights into Disease Progression and Therapeutic Targets. Biomedicines 2023; 11:2361. [PMID: 37760801 PMCID: PMC10525158 DOI: 10.3390/biomedicines11092361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 07/31/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Colorectal cancer (CRC) is a major health burden worldwide and is the third most common type of cancer. The early detection and diagnosis of CRC is critical to improve patient outcomes. This review explores the intricate interplay between the tumor microenvironment, stromal interactions, and the progression and metastasis of colorectal cancer. The review begins by assessing the gut microbiome's influence on CRC development, emphasizing its association with gut-associated lymphoid tissue (GALT). The role of the Wnt signaling pathway in CRC tumor stroma is scrutinized, elucidating its impact on disease progression. Tumor budding, its effect on tumor stroma, and the implications for patient prognosis are investigated. The review also identifies conserved oncogenic signatures (COS) within CRC stroma and explores their potential as therapeutic targets. Lastly, the seed and soil hypothesis is employed to contextualize metastasis, accentuating the significance of both tumor cells and the surrounding stroma in metastatic propensity. This review highlights the intricate interdependence between CRC cells and their microenvironment, providing valuable insights into prospective therapeutic approaches targeting tumor-stroma interactions.
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Affiliation(s)
- Nikolay Shakhpazyan
- Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119435 Moscow, Russia; (N.S.); (L.M.); (Z.G.); (N.S.); (A.O.)
| | - Liudmila Mikhaleva
- Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119435 Moscow, Russia; (N.S.); (L.M.); (Z.G.); (N.S.); (A.O.)
| | - Arkady Bedzhanyan
- Department of Abdominal Surgery and Oncology II (Coloproctology and Uro-Gynecology), Petrovsky National Research Center of Surgery, 119435 Moscow, Russia;
| | - Zarina Gioeva
- Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119435 Moscow, Russia; (N.S.); (L.M.); (Z.G.); (N.S.); (A.O.)
| | - Nikolay Sadykhov
- Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119435 Moscow, Russia; (N.S.); (L.M.); (Z.G.); (N.S.); (A.O.)
| | - Alexander Mikhalev
- Department of Hospital Surgery No. 2, Pirogov Russian National Research Medical University, 117997 Moscow, Russia;
| | - Dmitri Atiakshin
- Research and Educational Resource Center for Immunophenotyping, Digital Spatial Profiling and Ultrastructural Analysis Innovative Technologies, Peoples’ Friendship University of Russia, 117198 Moscow, Russia;
- Research Institute of Experimental Biology and Medicine, Burdenko Voronezh State Medical University, 394036 Voronezh, Russia
| | - Igor Buchwalow
- Research and Educational Resource Center for Immunophenotyping, Digital Spatial Profiling and Ultrastructural Analysis Innovative Technologies, Peoples’ Friendship University of Russia, 117198 Moscow, Russia;
- Institute for Hematopathology, 22547 Hamburg, Germany;
| | | | - Alexander Orekhov
- Avtsyn Research Institute of Human Morphology, Petrovsky National Research Center of Surgery, 119435 Moscow, Russia; (N.S.); (L.M.); (Z.G.); (N.S.); (A.O.)
- Laboratory of Angiopathology, Institute of General Pathology and Pathophysiology, 125315 Moscow, Russia
- Institute for Atherosclerosis Research, 121096 Moscow, Russia
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5
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Fang Y, Ma K, Huang YM, Dang Y, Liu Z, Xu Y, Zheng XL, Yang X, Huo Y, Dai X. Fibronectin leucine-rich transmembrane protein 2 drives monocyte differentiation into macrophages via the UNC5B-Akt/mTOR axis. Front Immunol 2023; 14:1162004. [PMID: 37090697 PMCID: PMC10117657 DOI: 10.3389/fimmu.2023.1162004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 03/27/2023] [Indexed: 04/09/2023] Open
Abstract
Upon migrating into the tissues, hematopoietic stem cell (HSC)-derived monocytes differentiate into macrophages, playing a crucial role in determining innate immune responses towards external pathogens and internal stimuli. However, the regulatory mechanisms underlying monocyte-to-macrophage differentiation remain largely unexplored. Here we divulge a previously uncharacterized but essential role for an axon guidance molecule, fibronectin leucine-rich transmembrane protein 2 (FLRT2), in monocyte-to-macrophage maturation. FLRT2 is almost undetectable in human monocytic cell lines, human peripheral blood mononuclear cells (PBMCs), and mouse primary monocytes but significantly increases in fully differentiated macrophages. Myeloid-specific deletion of FLRT2 (Flrt2ΔMyel) contributes to decreased peritoneal monocyte-to-macrophage generation in mice in vivo, accompanied by impaired macrophage functions. Gain- and loss-of-function studies support the promoting effect of FLRT2 on THP-1 cell and human PBMC differentiation into macrophages. Mechanistically, FLRT2 directly interacts with Unc-5 netrin receptor B (UNC5B) via its extracellular domain (ECD) and activates Akt/mTOR signaling. In vivo administration of mTOR agonist MYH1485 reverses the impaired phenotypes observed in Flrt2ΔMyel mice. Together, these results identify FLRT2 as a novel pivotal endogenous regulator of monocyte differentiation into macrophages. Targeting the FLRT2/UNC5B-Akt/mTOR axis may provide potential therapeutic strategies directly relevant to human diseases associated with aberrant monocyte/macrophage differentiation.
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Affiliation(s)
- Yaxiong Fang
- Key Laboratory of Molecular Target & Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Kongyang Ma
- Centre for Infection and Immunity Studies (CIIS), School of Medicine, Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Yi-Min Huang
- Key Laboratory of Molecular Target & Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Yuanye Dang
- Key Laboratory of Molecular Target & Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Zhaoyu Liu
- Medical Research Center, Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Yiming Xu
- School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Xi-Long Zheng
- Department of Biochemistry & Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Xiangdong Yang
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yongliang Huo
- Affiliated Cancer Hospital & Institute of Guangzhou Medical University, Experimental Animal Center, Guangzhou Municipal and Guangdong Provincial Key Laboratory of Protein Modification and Degradation, State Key Laboratory of Respiratory Disease, School of Basic Medical Sciences, Guangzhou Medical University, Guangzhou, Guangdong, China
- *Correspondence: Xiaoyan Dai, ; Yongliang Huo,
| | - Xiaoyan Dai
- Key Laboratory of Molecular Target & Clinical Pharmacology and the State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, Guangzhou Medical University, Guangzhou, Guangdong, China
- *Correspondence: Xiaoyan Dai, ; Yongliang Huo,
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6
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An R. MRTF may be the missing link in a multiscale mechanobiology approach toward macrophage dysfunction in space. Front Cell Dev Biol 2022; 10:997365. [PMID: 36172272 PMCID: PMC9510870 DOI: 10.3389/fcell.2022.997365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/10/2022] [Indexed: 11/23/2022] Open
Abstract
Macrophages exhibit impaired phagocytosis, adhesion, migration, and cytokine production in space, hindering their ability to elicit immune responses. Considering that the combined effect of spaceflight microgravity and radiation is multiscale and multifactorial in nature, it is expected that contradictory findings are common in the field. This theory paper reanalyzes research on the macrophage spaceflight response across multiple timescales from seconds to weeks, and spatial scales from the molecular, intracellular, extracellular, to the physiological. Key findings include time-dependence of both pro-inflammatory activation and integrin expression. Here, we introduce the time-dependent, intracellular localization of MRTF-A as a hypothetical confounder of macrophage activation. We discuss the mechanosensitive MRTF-A/SRF pathway dependence on the actin cytoskeleton/nucleoskeleton, microtubules, membrane mechanoreceptors, hypoxia, oxidative stress, and intracellular/extracellular crosstalk. By adopting a multiscale perspective, this paper provides the first mechanistic answer for a three-decade-old question regarding impaired cytokine secretion in microgravity—and strengthens the connection between the recent advances in mechanobiology, microgravity, and the spaceflight immune response. Finally, we hypothesize MRTF involvement and complications in treating spaceflight-induced cardiovascular, skeletal, and immune disease.
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Affiliation(s)
- Rocky An
- Department of Biological and Environmental Engineering, Cornell University, Ithaca, NY, United States
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, NY, United States
- *Correspondence: Rocky An,
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7
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Zhevlakova I, Xiong L, Liu H, Dudiki T, Ciocea A, Podrez E, Byzova TV. Opposite roles of Kindlin orthologs in cell survival and proliferation. Cell Prolif 2022; 55:e13280. [PMID: 35860876 PMCID: PMC9436913 DOI: 10.1111/cpr.13280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/13/2022] [Accepted: 05/19/2022] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE It is unclear why adhesion-dependent cells such as epithelium undergo anoikis without anchorage, while adhesion-independent blood cells thrive in suspension. The adhesive machinery of these cells is similar, with the exception of Kindlin orthologs, Kindlin 2 (K2) and Kindlin 3 (K3). Here we address how Kindlins control cell survival and proliferation in anchorage-dependent and independent cells. MATERIAL AND METHODS To demonstrate the opposite roles of Kindlin's in cell survival we utilized in vivo and in vitro models and K3 and K2 knockdown and knockin cells. We used human lymphocytes from the K3 deficient patients in tumour model, K3 knockout and knockin macrophages and K2 knockout and knockin MEF cells for experiments in under conditions of adhesion and in suspension. RESULTS Depletion of K3 promotes cell proliferation and survival of anchorage-independent cells regardless of cell attachment. In contrast, the absence of K2 in anchorage-dependent cells accelerates apoptosis and limits proliferation. K3 deficiency promotes human lymphoma growth and survival in vivo. Kindlins' interaction with paxillin, is critical for their differential roles in cell anchorage. While disruption of K2-paxillin binding leads to increased apoptosis, the lack of K3-paxillin binding has an opposite effect in adhesion-independent cells. CONCLUSION Kindlin ortologs and their interaction to cytoskeletal protein paxillin define the mechanisms of anchorage dependence. Our study identifies the key elements of the cell adhesion machinery in cell survival and tumour metastasis, proposing possible targets for tumour treatment.
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Affiliation(s)
- Irina Zhevlakova
- Department of NeurosciencesLerner Research Institute, Cleveland ClinicClevelandOhioUSA
| | - Luyang Xiong
- Department of NeurosciencesLerner Research Institute, Cleveland ClinicClevelandOhioUSA
| | - Huan Liu
- Department of NeurosciencesLerner Research Institute, Cleveland ClinicClevelandOhioUSA
- Present address:
CVRC, Simiches Research CenterMassachusetts General Hospital, Harvard Medical SchoolBostonMassachusettsUSA
| | - Tejasvi Dudiki
- Department of NeurosciencesLerner Research Institute, Cleveland ClinicClevelandOhioUSA
| | - Alieta Ciocea
- Department of NeurosciencesLerner Research Institute, Cleveland ClinicClevelandOhioUSA
- Present address:
Hondros College of NursingWestervilleOhioUSA
| | - Eugene Podrez
- Department of Inflammation and ImmunityLerner Research Institute, Cleveland ClinicClevelandOhioUSA
| | - Tatiana V. Byzova
- Department of NeurosciencesLerner Research Institute, Cleveland ClinicClevelandOhioUSA
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8
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Margraf A, Perretti M. Immune Cell Plasticity in Inflammation: Insights into Description and Regulation of Immune Cell Phenotypes. Cells 2022; 11:cells11111824. [PMID: 35681519 PMCID: PMC9180515 DOI: 10.3390/cells11111824] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 02/01/2023] Open
Abstract
Inflammation is a life-saving immune reaction occurring in response to invading pathogens. Nonetheless, inflammation can also occur in an uncontrolled, unrestricted manner, leading to chronic disease and organ damage. Mechanisms triggering an inflammatory response, hindering such a response, or leading to its resolution are well-studied but so far insufficiently elucidated with regard to precise therapeutic interventions. Notably, as an immune reaction evolves, requirements and environments for immune cells change, and thus cellular phenotypes adapt and shift, leading to the appearance of distinct cellular subpopulations with new functional features. In this article, we aim to highlight properties of, and overarching regulatory factors involved in, the occurrence of immune cell phenotypes with a special focus on neutrophils, macrophages and platelets. Additionally, we point out implications for both diagnostics and therapeutics in inflammation research.
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Lu F, Zhu L, Bromberger T, Yang J, Yang Q, Liu J, Plow EF, Moser M, Qin J. Mechanism of integrin activation by talin and its cooperation with kindlin. Nat Commun 2022; 13:2362. [PMID: 35488005 PMCID: PMC9054839 DOI: 10.1038/s41467-022-30117-w] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 04/15/2022] [Indexed: 12/12/2022] Open
Abstract
Talin-induced integrin binding to extracellular matrix ligands (integrin activation) is the key step to trigger many fundamental cellular processes including cell adhesion, cell migration, and spreading. Talin is widely known to use its N-terminal head domain (talin-H) to bind and activate integrin, but how talin-H operates in the context of full-length talin and its surrounding remains unknown. Here we show that while being capable of inducing integrin activation, talin-H alone exhibits unexpectedly low potency versus a constitutively activated full-length talin. We find that the large C-terminal rod domain of talin (talin-R), which otherwise masks the integrin binding site on talin-H in inactive talin, dramatically enhances the talin-H potency by dimerizing activated talin and bridging it to the integrin co-activator kindlin-2 via the adaptor protein paxillin. These data provide crucial insight into the mechanism of talin and its cooperation with kindlin to promote potent integrin activation, cell adhesion, and signaling.
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Affiliation(s)
- Fan Lu
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
- Department of Biochemistry, Case Western Reserve University, Cleveland, OH, 44106, USA
| | - Liang Zhu
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Thomas Bromberger
- Institute of Experimental Hematology, School of Medicine, Technische Universität München, Munich, D-81675, Germany
| | - Jun Yang
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Qiannan Yang
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Jianmin Liu
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Edward F Plow
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA
| | - Markus Moser
- Institute of Experimental Hematology, School of Medicine, Technische Universität München, Munich, D-81675, Germany.
| | - Jun Qin
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, 9500 Euclid Ave., Cleveland, OH, 44195, USA.
- Department of Biochemistry, Case Western Reserve University, Cleveland, OH, 44106, USA.
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10
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Tang Z, Davidson D, Li R, Zhong MC, Qian J, Chen J, Veillette A. Inflammatory macrophages exploit unconventional pro-phagocytic integrins for phagocytosis and anti-tumor immunity. Cell Rep 2021; 37:110111. [PMID: 34910922 DOI: 10.1016/j.celrep.2021.110111] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 10/14/2021] [Accepted: 11/18/2021] [Indexed: 11/19/2022] Open
Abstract
Blockade of the inhibitory checkpoint SIRPα-CD47 promotes phagocytosis of cancer cells by macrophages and is a promising avenue in anti-cancer therapy. Productive phagocytosis is strictly predicated on co-engagement of pro-phagocytic receptors-namely, Fc receptors (FcRs), integrin CD11b, or SLAMF7-by their ligands on cancer cells. Here, we examine whether additional pro-phagocytic receptors could be harnessed to broaden the scope of phagocytosis. Inflammatory stimuli, including multiple cytokines and Toll-like receptor (TLR) ligands, augment phagocytosis efficiency and fully alleviate the requirement of FcRs, CD11b, and SLAMF7 for phagocytosis. These effects are mediated by the unconventional pro-phagocytic integrins CD11a and CD11c, which act with CD18 to initiate actin polarization, leading to phagocytosis. Some inflammatory stimuli enable phagocytosis even in the absence of SIRPα-CD47 blockade. Higher CD11c expression in macrophage-enriched tumors correlates with improved survival in clinical studies. Thus, inflammatory macrophages exploit unconventional pro-phagocytic integrins for improved phagocytosis and anti-tumor immunity.
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Affiliation(s)
- Zhenghai Tang
- Laboratory of Molecular Oncology, Institut de recherches cliniques de Montréal (IRCM), Montréal, QC H2W 1R7, Canada
| | - Dominique Davidson
- Laboratory of Molecular Oncology, Institut de recherches cliniques de Montréal (IRCM), Montréal, QC H2W 1R7, Canada
| | - Rui Li
- Laboratory of Molecular Oncology, Institut de recherches cliniques de Montréal (IRCM), Montréal, QC H2W 1R7, Canada; Department of Medicine, McGill University, Montréal, QC H3G 1Y6, Canada
| | - Ming-Chao Zhong
- Laboratory of Molecular Oncology, Institut de recherches cliniques de Montréal (IRCM), Montréal, QC H2W 1R7, Canada
| | - Jin Qian
- Laboratory of Molecular Oncology, Institut de recherches cliniques de Montréal (IRCM), Montréal, QC H2W 1R7, Canada
| | - Jun Chen
- Laboratory of Molecular Oncology, Institut de recherches cliniques de Montréal (IRCM), Montréal, QC H2W 1R7, Canada; Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, Guangdong 510080, China.
| | - André Veillette
- Laboratory of Molecular Oncology, Institut de recherches cliniques de Montréal (IRCM), Montréal, QC H2W 1R7, Canada; Department of Medicine, McGill University, Montréal, QC H3G 1Y6, Canada; Department of Medicine, University of Montréal, Montréal, QC H3C 3J7, Canada.
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11
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Nguyen HTT, Xu Z, Shi X, Liu S, Schulte ML, White GC, Ma YQ. Paxillin binding to the PH domain of kindlin-3 in platelets is required to support integrin αIIbβ3 outside-in signaling. J Thromb Haemost 2021; 19:3126-3138. [PMID: 34411430 PMCID: PMC9080902 DOI: 10.1111/jth.15505] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/05/2021] [Accepted: 08/18/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Kindlin-3 is essential for supporting the bidirectional signaling of integrin αIIbβ3 in platelets by bridging the crosstalk between integrin αIIbβ3 and the cytoplasmic signaling adaptors. OBJECTIVE In this study, we identified a previously unrecognized paxillin binding site in the pleckstrin homology (PH) domain of kindlin-3 and verified its functional significance. METHODS Structure-based approaches were employed to identify the paxillin binding site in the PH domain of kindlin-3. In addition, the bidirectional signaling of integrin αIIbβ3 were evaluated in both human and mouse platelets. RESULTS In brief, we found that a β1-β2 loop in the PH domain of kindlin-3, an important part of the canonical membrane phospholipid binding pocket, was also involved in mediating paxillin interaction. Interestingly, the binding sites of paxillin and membrane phospholipids in the PH domain of kindlin-3 were mutually exclusive. Specific disruption of paxillin binding to the PH domain by point mutations inhibited platelet spreading on immobilized fibrinogen while having no inhibition on soluble fibrinogen binding to stimulated platelets. In addition, a membrane-permeable peptide derived from the β1-β2 loop in the PH domain of kindlin-3 was capable of inhibiting platelet spreading and clot retraction, but it had no effect on soluble fibrinogen binding to platelets and platelet aggregation. Treatment with this peptide significantly reduced thrombus formation in mice. CONCLUSION Taken together, these findings suggest that interaction between paxillin and the PH domain of kindlin-3 plays an important role in supporting integrin αIIbβ3 outside-in signaling in platelets, thus providing a novel antithrombotic target.
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Affiliation(s)
| | - Zhen Xu
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Collaborative Research Program for Cell Adhesion Molecules, Shanghai University School of Life Sciences, Shanghai, China
| | - Xiaofeng Shi
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- The second Affiliated Hospital of Nanjing Medical University, Nanjing, China
- The Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | - Shuzhen Liu
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | | | - Gilbert C. White
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Department of Biochemistry, Medical College of Milwaukee, Milwaukee, Wisconsin, USA
| | - Yan-Qing Ma
- Versiti Blood Research Institute, Milwaukee, Wisconsin, USA
- Collaborative Research Program for Cell Adhesion Molecules, Shanghai University School of Life Sciences, Shanghai, China
- Department of Biochemistry, Medical College of Milwaukee, Milwaukee, Wisconsin, USA
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12
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Chen Y, Zhao H, Xiao Y, Shen P, Tan L, Zhang S, Liu Q, Gao Z, Zhao J, Zhao Y, Guo Y, Feng Y. Pan-cancer analysis reveals an immunological role and prognostic potential of PXN in human cancer. Aging (Albany NY) 2021; 13:16248-16266. [PMID: 34135128 PMCID: PMC8266322 DOI: 10.18632/aging.203154] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/19/2021] [Indexed: 12/24/2022]
Abstract
Paxillin (PXN) is a protein involved in numerous physiological processes, and its presence is closely related to the occurrence and development of many types of tumors. However, no studies have analyzed PXN from a pan-cancer perspective. We analyzed PXN expression, immune cell infiltration, prognosis, and biological function across different types of tumors included in The Cancer Genome Atlas and Gene Expression Omnibus datasets. The results showed that expression of PXN varies in different tumors. Expression of PXN strongly correlated with prognosis in patients with tumors; higher PXN expression usually was linked to poor overall and disease-free survival. Expression of PXN in breast invasive carcinoma and lymphoid neoplasm diffuse large B-cell lymphoma was related to the degree of CD8+ T-cell infiltration, and infiltration of cancer-associated fibroblasts, such as kidney renal papillary cell carcinoma and brain lower-grade glioma, was also observed in other tumors. The results of pan-cancer analysis showed that abnormal PXN expression was related to poor prognosis, immune infiltration, and protein phosphorylation in different tumor types. Therefore, the PXN gene may become a potential biomarker of clinical tumor prognosis.
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Affiliation(s)
- Yun Chen
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Han Zhao
- Department of Ophthalmology, Eye, Ear, Nose, and Throat Hospital of Fudan University, Shanghai 200000, China.,Laboratory of Myopia, NHC Key Laboratory of Myopia, Fudan University, Chinese Academy of Medical Sciences, Shanghai 200000, China.,Shanghai Key Laboratory of Visual Impairment and Restoration, Fudan University, Shanghai 200000, China
| | - Yan Xiao
- Nursing Department, Ganzhou Municipal Hospital, Gannan Medical University, Ganzhou, Jiangxi 341000, China
| | - Peijun Shen
- Department of Gastroenterology, The Third Xiangya Hospital of Central South University, Changsha, Hunan 410011, China.,Hunan Key Laboratory of Nonresolving Inflammation and Cancer, Central South University, Changsha, Hunan 410011, China
| | - Li Tan
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Shaohui Zhang
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Qiong Liu
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Zhengrong Gao
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jie Zhao
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Yaqiong Zhao
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Yue Guo
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Yunzhi Feng
- Department of Stomatology, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
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13
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Santoni M, Massari F, Montironi R, Battelli N. Manipulating macrophage polarization in cancer patients: From nanoparticles to human chimeric antigen receptor macrophages. Biochim Biophys Acta Rev Cancer 2021; 1876:188547. [PMID: 33932561 DOI: 10.1016/j.bbcan.2021.188547] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/14/2021] [Accepted: 04/14/2021] [Indexed: 12/11/2022]
Abstract
Chimeric antigen receptor (CAR) T cell treatment has provided notable results in hematological tumors. Unfortunately, this evidence has not been translated into improved outcomes in solid malignancies so far, where several reports have suggested that T cells encounter substantial difficulties in penetrating and surviving in the tumor microenvironment (TME). Thus, researchers have recently investigated other immune cell types as CAR platforms, in order to overcome the limitations of CAR T cells. Among them, CAR-macrophages (M) technology has emerged as a novel perspective for cancer patients, on the basis of preclinical studies observing that CAR expression in human macrophages could play a crucial role in enhancing phagocytosis, polarizing M2 to M1 phenotype, and stimulating T cell anti-tumor activity. Herein, we provide an overview of current scenario of CAR-Ms in several solid tumors, also focusing on the biological rationale behind this promising therapeutic approach and future research directions in this setting.
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Affiliation(s)
- Matteo Santoni
- Oncology Unit, Macerata Hospital, via Santa Lucia 2, 62100 Macerata, Italy.
| | - Francesco Massari
- Medical Oncology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni - 15, Bologna, Italy
| | - Rodolfo Montironi
- Section of Pathological Anatomy, Polytechnic University of the Marche Region, School of Medicine, United Hospitals, via Tronto 10/A, 60100 Ancona, Italy,.
| | - Nicola Battelli
- Oncology Unit, Macerata Hospital, via Santa Lucia 2, 62100 Macerata, Italy.
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14
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Dudiki T, Mahajan G, Liu H, Zhevlakova I, Bertagnolli C, Nascimento DW, Kothapalli CR, Byzova TV. Kindlin3 regulates biophysical properties and mechanics of membrane to cortex attachment. Cell Mol Life Sci 2021; 78:4003-4018. [PMID: 33783564 PMCID: PMC11071771 DOI: 10.1007/s00018-021-03817-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/01/2021] [Accepted: 03/18/2021] [Indexed: 12/19/2022]
Abstract
Kindlin3 (K3), a FERM domain containing protein expressed in hematopoietic cells controls integrin activation and thus hemostatic and inflammatory responses. However, its role in the mechanics of plasma membrane remains unclear. Here, we show that genetic knockout of K3 in microglia and macrophages resulted in defective plasma membrane tension and membrane blebbing. Atomic force microscopy (AFM) of K3-deficient cells revealed a significant loss in membrane-to-cortex attachment (MCA), and consequently reduced membrane tension. This loss in MCA is amplified by the mislocalization of the cell cortex proteins-ezrin, radixin, and moesin (ERM)-to the plasma membrane of microglia and macrophages. Re-expression of K3 in K3-deficient macrophages rescued the defects and localization of ERMs implying a key role for K3 in MCA. Analysis of two K3 mutants, K3int affecting integrin binding and activation, and K3pxn/act disrupting binding to paxillin and actin but not integrin functions, demonstrated that the role of K3 in membrane mechanics is separate from integrin activation. The K3pxn/act mutant substantially diminished both membrane tension and Yes-associated protein (YAP) translocation to the nucleus, while preserving integrin activation, cell spreading, and migration. Together, our results show that K3 coordinates membrane mechanics, ERM protein recruitment to the membrane, and YAP translocation by linking integrin at the membrane to paxillin and actin of the cytoskeleton. This novel function of K3 is distinct from its role in integrin activation.
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Affiliation(s)
- Tejasvi Dudiki
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Gautam Mahajan
- Chemical and Biomedical Engineering Department, Washkewicz College of Engineering, Cleveland State University, Cleveland, OH, 44115, USA
| | - Huan Liu
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Irina Zhevlakova
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Chase Bertagnolli
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA
| | | | - Chandrasekhar R Kothapalli
- Chemical and Biomedical Engineering Department, Washkewicz College of Engineering, Cleveland State University, Cleveland, OH, 44115, USA.
| | - Tatiana V Byzova
- Lerner Research Institute, Cleveland Clinic, Cleveland, OH, 44195, USA.
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15
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Sun H, Zhi K, Hu L, Fan Z. The Activation and Regulation of β2 Integrins in Phagocytes and Phagocytosis. Front Immunol 2021; 12:633639. [PMID: 33868253 PMCID: PMC8044391 DOI: 10.3389/fimmu.2021.633639] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/11/2021] [Indexed: 01/10/2023] Open
Abstract
Phagocytes, which include neutrophils, monocytes, macrophages, and dendritic cells, protect the body by removing foreign particles, bacteria, and dead or dying cells. Phagocytic integrins are greatly involved in the recognition of and adhesion to specific antigens on cells and pathogens during phagocytosis as well as the recruitment of immune cells. β2 integrins, including αLβ2, αMβ2, αXβ2, and αDβ2, are the major integrins presented on the phagocyte surface. The activation of β2 integrins is essential to the recruitment and phagocytic function of these phagocytes and is critical for the regulation of inflammation and immune defense. However, aberrant activation of β2 integrins aggravates auto-immune diseases, such as psoriasis, arthritis, and multiple sclerosis, and facilitates tumor metastasis, making them double-edged swords as candidates for therapeutic intervention. Therefore, precise regulation of phagocyte activities by targeting β2 integrins should promote their host defense functions with minimal side effects on other cells. Here, we reviewed advances in the regulatory mechanisms underlying β2 integrin inside-out signaling, as well as the roles of β2 integrin activation in phagocyte functions.
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Affiliation(s)
- Hao Sun
- Department of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Kangkang Zhi
- Department of Vascular Surgery, Changzheng Hospital, Shanghai, China
| | - Liang Hu
- Department of Cardiology, Cardiovascular Institute of Zhengzhou University, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zhichao Fan
- Department of Immunology, School of Medicine, UConn Health, Farmington, CT, United States
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16
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Zhu L, Plow EF, Qin J. Initiation of focal adhesion assembly by talin and kindlin: A dynamic view. Protein Sci 2020; 30:531-542. [PMID: 33336515 DOI: 10.1002/pro.4014] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 12/07/2020] [Accepted: 12/08/2020] [Indexed: 12/15/2022]
Abstract
Focal adhesions (FAs) are integrin-containing protein complexes regulated by a network of hundreds of protein-protein interactions. They are formed in a spatiotemporal manner upon the activation of integrin transmembrane receptors, which is crucial to trigger cell adhesion and many other cellular processes including cell migration, spreading and proliferation. Despite decades of studies, a detailed molecular level understanding on how FAs are organized and function is lacking due to their highly complex and dynamic nature. However, advances have been made on studying key integrin activators, talin and kindlin, and their associated proteins, which are major components of nascent FAs critical for initiating the assembly of mature FAs. This review will discuss the structural and functional findings of talin and kindlin and their immediate interaction network, which will shed light upon the architecture of nascent FAs and how they act as seeds for FA assembly to dynamically regulate diverse adhesion-dependent physiological and pathological responses.
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Affiliation(s)
- Liang Zhu
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Edward F Plow
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jun Qin
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
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