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Johansen AM, Forsythe SD, McGrath CT, Barker G, Jimenez H, Paluri RK, Pasche BC. TGFβ in Pancreas and Colorectal Cancer: Opportunities to Overcome Therapeutic Resistance. Clin Cancer Res 2024; 30:3676-3687. [PMID: 38916900 PMCID: PMC11371528 DOI: 10.1158/1078-0432.ccr-24-0468] [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: 02/09/2024] [Revised: 04/16/2024] [Accepted: 05/30/2024] [Indexed: 06/26/2024]
Abstract
TGFβ is a pleiotropic signaling pathway that plays a pivotal role in regulating a multitude of cellular functions. TGFβ has a dual role in cell regulation where it induces growth inhibition and cell death; however, it can switch to a growth-promoting state under cancerous conditions. TGFβ is upregulated in colorectal cancer and pancreatic cancer, altering the tumor microenvironment and immune system and promoting a mesenchymal state. The upregulation of TGFβ in certain cancers leads to resistance to immunotherapy, and attempts to inhibit TGFβ expression have led to reduced therapeutic resistance when combined with chemotherapy and immunotherapy. Here, we review the current TGFβ inhibitor drugs in clinical trials for pancreatic and colorectal cancer, with the goal of uncovering advances in improving clinical efficacy for TGFβ combinational treatments in patients. Furthermore, we discuss the relevance of alterations in TGFβ signaling and germline variants in the context of personalizing treatment for patients who show lack of response to current therapeutics.
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Affiliation(s)
- Allan M Johansen
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Steven D Forsythe
- Neuroendocrine Therapy Section, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Callum T McGrath
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Grayson Barker
- Department of Cancer Biology, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Hugo Jimenez
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Ravi K Paluri
- Section of Hematology/Oncology, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Boris C Pasche
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
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2
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Heib M, Weiß J, Saggau C, Hoyer J, Fuchslocher Chico J, Voigt S, Adam D. Ars moriendi: Proteases as sculptors of cellular suicide. BIOCHIMICA ET BIOPHYSICA ACTA. MOLECULAR CELL RESEARCH 2022; 1869:119191. [PMID: 34973300 DOI: 10.1016/j.bbamcr.2021.119191] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/10/2021] [Accepted: 12/13/2021] [Indexed: 06/14/2023]
Abstract
The Ars moriendi, which translates to "The Art of Dying," encompasses two Latin texts that gave advice on how to die well and without fear according to the Christian precepts of the late Middle Ages. Given that ten to hundred billion cells die in our bodies every day, it is obvious that the concept of a well and orderly ("regulated") death is also paramount at the cellular level. In apoptosis, as the most well-studied form of regulated cell death, proteases of the caspase family are the central mediators. However, caspases are not the only proteases that act as sculptors of cellular suicide, and therefore, we here provide an overview of the impact of proteases in apoptosis and other forms of regulated cell death.
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Affiliation(s)
- Michelle Heib
- Institut für Immunologie, Christian-Albrechts-Universität zu Kiel, Michaelisstr. 5, 24105 Kiel, Germany
| | - Jonas Weiß
- Institut für Immunologie, Christian-Albrechts-Universität zu Kiel, Michaelisstr. 5, 24105 Kiel, Germany
| | - Carina Saggau
- Institut für Immunologie, Christian-Albrechts-Universität zu Kiel, Michaelisstr. 5, 24105 Kiel, Germany
| | - Justus Hoyer
- Institut für Immunologie, Christian-Albrechts-Universität zu Kiel, Michaelisstr. 5, 24105 Kiel, Germany
| | | | - Susann Voigt
- Institut für Immunologie, Christian-Albrechts-Universität zu Kiel, Michaelisstr. 5, 24105 Kiel, Germany
| | - Dieter Adam
- Institut für Immunologie, Christian-Albrechts-Universität zu Kiel, Michaelisstr. 5, 24105 Kiel, Germany.
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Guo Q, Li L, Gao G, Liu R, Einaga Y, Zhi J. Nanodiamonds Inhibit Cancer Cell Migration by Strengthening Cell Adhesion: Implications for Cancer Treatment. ACS APPLIED MATERIALS & INTERFACES 2021; 13:9620-9629. [PMID: 33595291 DOI: 10.1021/acsami.0c21332] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Nanodiamonds (NDs) are a type of biocompatible nanomaterial with easily modified surfaces and are considered as promising candidates in biomedicine. In this work, the inhibition of tumor cell migration by carboxylated nanodiamonds (cNDs) was investigated. AFM-based single cell adhesion and F-actin staining experiments demonstrated that cNDs treatment could enhance cell adhesion and impair assembly of the cytoskeleton. The mechanism analysis of the regulatory protein expression level also proved that cNDs could inhibit the migration of Hela cells by preventing the epithelial-mesenchymal transition (EMT) process through the transforming growth factor β (TGF-β) signaling pathway. The in vivo pulmonary metastasis model also showed that cNDs effectively reduced the metastasis of murine B16 melanoma cells. In summary, cNDs have been demonstrated to inhibit cancer cell migration in vitro and decrease tumor metastasis in vivo. Therefore, cNDs might have potential utility for specific cancer treatment.
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Affiliation(s)
- Qingyue Guo
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing 100190, P. R. China
- University of Chinese Academy of Sciences, Beijing 100190, P. R. China
| | - Lei Li
- Key Laboratory of Cryogenics, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing, 100190, P. R. China
- University of Chinese Academy of Sciences, Beijing 100190, P. R. China
| | - Guanyue Gao
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing 100190, P. R. China
- University of Chinese Academy of Sciences, Beijing 100190, P. R. China
| | - Runze Liu
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing 100190, P. R. China
| | - Yasuaki Einaga
- Department of Chemistry, Keio University, 3-14-1 Hiyoshi, Yokohama, 223-8522, Japan
| | - Jinfang Zhi
- Key Laboratory of Photochemical Conversion and Optoelectronic Materials, Technical Institute of Physics and Chemistry, Chinese Academy of Sciences, Beijing 100190, P. R. China
- University of Chinese Academy of Sciences, Beijing 100190, P. R. China
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Rossin A, Miloro G, Hueber AO. TRAIL and FasL Functions in Cancer and Autoimmune Diseases: Towards an Increasing Complexity. Cancers (Basel) 2019; 11:cancers11050639. [PMID: 31072029 PMCID: PMC6563024 DOI: 10.3390/cancers11050639] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 04/26/2019] [Accepted: 04/28/2019] [Indexed: 12/31/2022] Open
Abstract
Tumor Necrosis Factor-Related Apoptosis Inducing Ligand (TRAIL/TNFSF10) and Fas Ligand (FasL/TNFSF6), two major cytokines of the TNF (Tumor Necrosis Factor) superfamily, exert their main functions from the immune system compartment. Mice model studies revealed that TRAIL and FasL-mediated signalling both control the homeostasis of the immune cells, mainly from the lymphoid lineage, and function on cytotoxic cells as effector proteins to eliminate the compromised cells. The first clues in the physiological functions of TRAIL arose from the analysis of TRAIL deficient mice, which, even though they are viable and fertile, are prone to cancer and autoimmune diseases development, revealing TRAIL as an important safeguard against autoimmunity and cancer. The naturally occurring gld (generalized lymphoproliferative disease) and lpr (lymphoproliferation) mutant mice develop lymphadenopathy and lupus-like autoimmune disease. The discovery that they are mutated in the fasl and the fas receptor gene, respectively, demonstrates the critical role of the FasL/Fas system in lymphocyte homeostasis and autoimmunity. This review summarizes the state of current knowledge regarding the key death and non-death immune functions that TRAIL and FasL play in the initiation and progression of cancer and autoimmune diseases.
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Affiliation(s)
- Aurélie Rossin
- Université Côte d'Azur, CNRS, Inserm, iBV, 06108 Nice, France.
| | - Giorgia Miloro
- Université Côte d'Azur, CNRS, Inserm, iBV, 06108 Nice, France.
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Huang C, Tao L, Wang X, Pang Z. Berberine reversed the epithelial‐mesenchymal transition of normal colonic epithelial cells induced by SW480 cells through regulating the important components in the TGF‐β pathway. J Cell Physiol 2018; 234:11679-11691. [PMID: 30536375 DOI: 10.1002/jcp.27835] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/06/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Chao Huang
- Institute of Pharmacology, Sun Yat‐Sen Zhongshan Medical College, Sun Yat‐Sen University Guangzhou China
| | - Liang Tao
- Institute of Pharmacology, Sun Yat‐Sen Zhongshan Medical College, Sun Yat‐Sen University Guangzhou China
| | - Xiu‐lian Wang
- Department of Traditional Chinese Medicine Affiliated Bao’an Hospital of Traditional Chinese Medicine of Shenzhen, Traditional Chinese Medicine University Of Guangzhou Shenzhen China
| | - Zuoliang Pang
- Department of Oncology Affiliated Bao’an Hospital of Shenzhen, Southern Medical University Shenzhen China
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Downregulation of TRAIL-Receptor 1 Increases TGFβ Type II Receptor Expression and TGFβ Signalling Via MicroRNA-370-3p in Pancreatic Cancer Cells. Cancers (Basel) 2018; 10:cancers10110399. [PMID: 30366420 PMCID: PMC6267290 DOI: 10.3390/cancers10110399] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 10/09/2018] [Indexed: 12/28/2022] Open
Abstract
The accumulation of perturbations in signalling pathways resulting in an apoptosis-insensitive phenotype is largely responsible for the desperate prognosis of patients with pancreatic ductal adenocarcinoma (PDAC). Accumulating evidence suggests that the death receptors TRAIL-R1 and TRAIL-R2 play important roles in PDAC biology by acting as either tumour suppressors through induction of cell death or tumour promoters through induction of pro-inflammatory signalling, invasion and metastasis. TRAIL-R2 can also associate with nuclear proteins and alter the maturation of micro RNAs (miRs). By genome-wide miR profiling and quantitative PCR analyses we now demonstrate that knockdown of TRAIL-R1 in PDAC cells decreased the level of mature miR-370 and led to an increased abundance of the type II receptor for transforming growth factor β (TGFβ). Transfection of cells with an artificial miR-370-3p decreased the levels of TGFβ-RII. We further show that transient expression of the miR-370 mimic decreased TGFβ1-induced expression of SERPINE1 encoding plasminogen activator-inhibitor 1 and partially relieved TGFβ1-induced growth inhibition. Moreover, stable TRAIL-R1 knockdown in Colo357 cells increased TGFβ1-induced SERPINE1 expression and this effect was partially reversed by transient expression of the miR-370 mimic. Finally, after transient knockdown of TRAIL-R1 in Panc1 cells there was a tendency towards enhanced activation of Smad2 and JNK1/2 signalling by exogenous TGFβ1. Taken together, our study reveals that TRAIL-R1 through regulation of miR-370 can decrease the sensitivity of PDAC cells to TGFβ and therefore represents a potential tumour suppressor in late-stage PDAC.
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Witte D, Otterbein H, Förster M, Giehl K, Zeiser R, Lehnert H, Ungefroren H. Negative regulation of TGF-β1-induced MKK6-p38 and MEK-ERK signalling and epithelial-mesenchymal transition by Rac1b. Sci Rep 2017; 7:17313. [PMID: 29229918 PMCID: PMC5725500 DOI: 10.1038/s41598-017-15170-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 10/23/2017] [Indexed: 01/26/2023] Open
Abstract
Prompted by earlier findings that the Rac1-related isoform Rac1b inhibits transforming growth factor (TGF)-β1-induced canonical Smad signalling, we studied here whether Rac1b also impacts TGF-β1-dependent non-Smad signalling such as the MKK6-p38 and MEK-ERK mitogen-activated protein kinase (MAPK) pathways and epithelial-mesenchymal transition (EMT). Transient depletion of Rac1b protein in pancreatic cancer cells by RNA interference increased the extent and duration of TGF-β1-induced phosphorylation of p38 MAPK in a Smad4-independent manner. Rac1b depletion also strongly increased basal ERK activation - independent of the kinase function of the TGF-β type I receptor ALK5 - and sensitised cells towards further upregulation of phospho-ERK levels by TGF-β1, while ectopic overexpression of Rac1b had the reverse effect. Rac1b depletion increased an EMT phenotype as evidenced by cell morphology, gene expression of EMT markers, cell migration and growth inhibition. Inhibition of MKK6-p38 or MEK-ERK signalling partially relieved the Rac1b depletion-dependent increase in TGF-β1-induced gene expression and cell migration. Rac1b depletion also enhanced TGF-β1 autoinduction of crucial TGF-β pathway components and decreased that of TGF-β pathway inhibitors. Our results show that Rac1b antagonises TGF-β1-dependent EMT by inhibiting MKK6-p38 and MEK-ERK signalling and by controlling gene expression in a way that favors attenuation of TGF-β signalling.
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Affiliation(s)
- David Witte
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, and University of Lübeck, 23538, Lübeck, Germany
| | - Hannah Otterbein
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, and University of Lübeck, 23538, Lübeck, Germany
| | - Maria Förster
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, and University of Lübeck, 23538, Lübeck, Germany
| | - Klaudia Giehl
- Signal Transduction of Cellular Motility, Internal Medicine V, Justus-Liebig-University Giessen, 35392, Giessen, Germany
| | - Robert Zeiser
- Department of Hematology and Oncology, Freiburg University Medical Center, Albert-Ludwigs-University, 79106, Freiburg i.Br., Germany
| | - Hendrik Lehnert
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, and University of Lübeck, 23538, Lübeck, Germany
| | - Hendrik Ungefroren
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, and University of Lübeck, 23538, Lübeck, Germany. .,Department of General and Thoracic Surgery, UKSH, Campus Kiel, 24105, Kiel, Germany.
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Ungefroren H, Witte D, Lehnert H. The role of small GTPases of the Rho/Rac family in TGF-β-induced EMT and cell motility in cancer. Dev Dyn 2017; 247:451-461. [DOI: 10.1002/dvdy.24505] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 03/30/2017] [Accepted: 04/01/2017] [Indexed: 12/12/2022] Open
Affiliation(s)
- Hendrik Ungefroren
- First Department of Medicine; University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, and University of Lübeck; Lübeck Germany
- Department of General and Thoracic Surgery; UKSH, Campus Kiel; Kiel Germany
| | - David Witte
- First Department of Medicine; University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, and University of Lübeck; Lübeck Germany
| | - Hendrik Lehnert
- First Department of Medicine; University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, and University of Lübeck; Lübeck Germany
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Melzer C, Hass R, von der Ohe J, Lehnert H, Ungefroren H. The role of TGF-β and its crosstalk with RAC1/RAC1b signaling in breast and pancreas carcinoma. Cell Commun Signal 2017; 15:19. [PMID: 28499439 PMCID: PMC5429551 DOI: 10.1186/s12964-017-0175-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 05/08/2017] [Indexed: 12/14/2022] Open
Abstract
This article focusses on the role of TGF-β and its signaling crosstalk with the RHO family GTPases RAC1 and RAC1b in the progression of breast and pancreatic carcinoma. The aggressive nature of these tumor types is mainly due to metastatic dissemination. Metastasis is facilitated by desmoplasia, a peculiar tumor microenvironment and the ability of the tumor cells to undergo epithelial-mesenchymal transition (EMT) and to adopt a motile and invasive phenotype. These processes are controlled entirely or in part by TGF-β and the small RHO GTPase RAC1 with both proteins acting as tumor promoters in late-stage cancers. Data from our and other studies point to signaling crosstalk between TGF-β and RAC1 and the related isoform, RAC1b, in pancreatic and mammary carcinoma cells. Based on the exciting observation that RAC1b functions as an endogenous inhibitor of RAC1, we propose a model on how the relative abundance or activity of RAC1 and RAC1b in the tumor cells may determine their responses to TGF-β and, ultimately, the metastatic capacity of the tumor.
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Affiliation(s)
- Catharina Melzer
- Biochemistry and Tumor Biology Lab, Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany
| | - Ralf Hass
- Biochemistry and Tumor Biology Lab, Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany
| | - Juliane von der Ohe
- Biochemistry and Tumor Biology Lab, Department of Obstetrics and Gynecology, Hannover Medical School, Hannover, Germany
| | - Hendrik Lehnert
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.,First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Hendrik Ungefroren
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany. .,First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany. .,Department of General and Thoracic Surgery, UKSH, Campus Kiel, Kiel, Germany.
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Yalcin A, Solakoglu TH, Ozcan SC, Guzel S, Peker S, Celikler S, Balaban BD, Sevinc E, Gurpinar Y, Chesney JA. 6-phosphofructo-2-kinase/fructose 2,6-bisphosphatase-3 is required for transforming growth factor β1-enhanced invasion of Panc1 cells in vitro. Biochem Biophys Res Commun 2017; 484:687-693. [DOI: 10.1016/j.bbrc.2017.01.178] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2017] [Accepted: 01/31/2017] [Indexed: 12/12/2022]
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Witte D, Zeeh F, Gädeken T, Gieseler F, Rauch BH, Settmacher U, Kaufmann R, Lehnert H, Ungefroren H. Proteinase-Activated Receptor 2 Is a Novel Regulator of TGF-β Signaling in Pancreatic Cancer. J Clin Med 2016; 5:E111. [PMID: 27916875 PMCID: PMC5184784 DOI: 10.3390/jcm5120111] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 11/22/2016] [Accepted: 11/28/2016] [Indexed: 02/06/2023] Open
Abstract
TGF-β has a dual role in tumorigenesis, acting as a tumor suppressor in normal cells and in the early stages of tumor development while promoting carcinogenesis and metastasis in advanced tumor stages. The final outcome of the TGF-β response is determined by cell-autonomous mechanisms and genetic alterations such as genomic instability and somatic mutations, but also by a plethora of external signals derived from the tumor microenvironment, such as cell-to-cell interactions, growth factors and extracellular matrix proteins and proteolytic enzymes. Serine proteinases mediate their cellular effects via activation of proteinase-activated receptors (PARs), a subclass of G protein-coupled receptors that are activated by proteolytic cleavage. We have recently identified PAR2 as a factor required for TGF-β1-dependent cell motility in ductal pancreatic adenocarcinoma (PDAC) cells. In this article, we review what is known on the TGF-β-PAR2 signaling crosstalk and its relevance for tumor growth and metastasis. Since PAR2 is activated through various serine proteinases, it may couple TGF-β signaling to a diverse range of other physiological processes, such as local inflammation, systemic coagulation or pathogen infection. Moreover, since PAR2 controls expression of the TGF-β type I receptor ALK5, PAR2 may also impact signaling by other TGF-β superfamily members that signal through ALK5, such as myostatin and GDF15/MIC-1. If so, PAR2 could represent a molecular linker between PDAC development and cancer-related cachexia.
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Affiliation(s)
- David Witte
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), and University of Lübeck, D-23538 Lübeck, Germany.
| | - Franziska Zeeh
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), and University of Lübeck, D-23538 Lübeck, Germany.
| | - Thomas Gädeken
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), and University of Lübeck, D-23538 Lübeck, Germany.
| | - Frank Gieseler
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), and University of Lübeck, D-23538 Lübeck, Germany.
| | - Bernhard H Rauch
- Department of General Pharmacology, Institute of Pharmacology, University Medicine Greifswald, D-17487 Greifswald, Germany.
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, D-07747 Jena, Germany.
| | - Roland Kaufmann
- Department of General, Visceral and Vascular Surgery, Jena University Hospital, D-07747 Jena, Germany.
| | - Hendrik Lehnert
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), and University of Lübeck, D-23538 Lübeck, Germany.
| | - Hendrik Ungefroren
- First Department of Medicine, University Hospital Schleswig-Holstein (UKSH), and University of Lübeck, D-23538 Lübeck, Germany.
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