1
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Chen SL, Xu Q, Lin CS. Methotrexate is associated with decreased total thyroxine in patients with rheumatoid arthritis. Inflammopharmacology 2023; 31:2383-2392. [PMID: 37493915 DOI: 10.1007/s10787-023-01299-6] [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: 04/11/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease characterized by joint swelling, pain, and deformation. RA patients have an increased risk of thyroid dysfunction, and drugs of RA treatment may have potential effects on thyroid function. METHODS This is a single-center cross-sectional study including 281 inpatients with RA in the First Affiliated Hospital of Guangzhou University of Chinese Medicine. The purpose of this study is to explore the correlation between RA therapeutic drugs and thyroid function. The medical records of 281 inpatients with RA were collected, including general data, laboratory examination, complications, and RA treatment. Spearman correlation analysis was used to explore the association of independent variables with thyroid function and antibodies in RA patients. Multinomial logistics and binary logistic regression were used for multivariate analysis. The statistically significance level was set as P < 0.05. SPSS 22.0 was used for statistical analysis. RESULTS Patients taking methotrexate (OR = 0.067, 95%CI: 0.008-0.588, P = 0.015) had lower levels of total thyroxine (TT4) (TT4 < 78.38 nmol/L). There was a negative correlation between glucocorticoids (r = - 0.153, P = 0.010) and total triiodothyronine (TT3) level (TT3 ≥ 1.34 nmol/L), but it was not significant in the multivariate regression model of TT3, although the regression model was statistically significant (P = 0.001). CONCLUSION Methotrexate is associated with decreased TT4 levels in RA patients, and glucocorticoids is associated with decreased TT3 levels. Drugs of RA treatment may affect the thyroid function of patients while treating RA, which may be one of the causes of secondary thyroid diseases in RA patients.
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Affiliation(s)
- Shu-Lin Chen
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
- The First Clinical Medicine School, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qiang Xu
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- The First Clinical Medicine School, Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Chang-Song Lin
- Department of Rheumatology, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China.
- The First Clinical Medicine School, Guangzhou University of Chinese Medicine, Guangzhou, China.
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2
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Khodadadi Z, Ektefa F, Naderi F, Fathi F. A computational evidence of the intermolecular hydrogen bonding in leflunomide: chemical shielding tensors. COMPUT THEOR CHEM 2023. [DOI: 10.1016/j.comptc.2023.114027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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3
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Almansoori A, Bhamidimarri PM, Bendardaf R, Hamoudi R. In silico Analysis of Publicly Available Transcriptomics Data Identifies Putative Prognostic and Therapeutic Molecular Targets for Papillary Thyroid Carcinoma. Int J Gen Med 2022; 15:3097-3120. [PMID: 35330879 PMCID: PMC8939872 DOI: 10.2147/ijgm.s345336] [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: 11/06/2021] [Accepted: 02/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Purpose Methods Results Conclusion
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Affiliation(s)
- Asma Almansoori
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
- Correspondence: Asma Almansoori; Rifat Hamoudi, Email ;
| | | | - Riyad Bendardaf
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Department of Oncology, University Hospital Sharjah, Sharjah, United Arab Emirates
| | - Rifat Hamoudi
- Sharjah Institute for Medical Research, University of Sharjah, Sharjah, United Arab Emirates
- College of Medicine, University of Sharjah, Sharjah, United Arab Emirates
- Division of Surgery and Interventional Science, University College London, London, UK
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4
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Adamczuk G, Humeniuk E, Iwan M, Natorska-Chomicka D, Adamczuk K, Korga-Plewko A. The Mitochondria-Independent Cytotoxic Effect of Leflunomide on RPMI-8226 Multiple Myeloma Cell Line. Molecules 2021; 26:5653. [PMID: 34577124 PMCID: PMC8469018 DOI: 10.3390/molecules26185653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/08/2021] [Accepted: 09/14/2021] [Indexed: 11/16/2022] Open
Abstract
Leflunomide, an anti-inflammatory agent, has been shown to be effective in multiple myeloma (MM) treatment; however, the mechanism of this phenomenon has not been fully elucidated. The aim of the study was to assess the role of mitochondria and dihydroorotate dehydrogenase (DHODH) inhibition in the cytotoxicity of leflunomide in relation to the MM cell line RPMI 8226. The cytotoxic effect of teriflunomide-an active metabolite of leflunomide-was determined using MTT assay, apoptosis detection, and cell cycle analysis. To evaluate DHODH-dependent toxicity, the cultures treated with teriflunomide were supplemented with uridine. Additionally, the level of cellular thiols as oxidative stress symptom was measured as well as mitochondrial membrane potential and protein tyrosine kinases (PTK) activity. The localization of the compound in cell compartments was examined using HPLC method. Teriflunomide cytotoxicity was not abolished in uridine presence. Observed apoptosis occurred in a mitochondria-independent manner, there was also no decrease in cellular thiols level. Teriflunomide arrested cell cycle in the G2/M phase which is not typical for DHODH deficiency. PTK activity was decreased only at the highest drug concentration. Interestingly, teriflunomide was not detected in the mitochondria. The aforementioned results indicate DHODH- and mitochondria-independent mechanism of leflunomide toxicity against RPMI 8226 cell line.
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Affiliation(s)
- Grzegorz Adamczuk
- Independent Medical Biology Unit, Faculty of Pharmacy, Medical University of Lublin, 20-093 Lublin, Poland; (E.H.); (A.K.-P.)
| | - Ewelina Humeniuk
- Independent Medical Biology Unit, Faculty of Pharmacy, Medical University of Lublin, 20-093 Lublin, Poland; (E.H.); (A.K.-P.)
| | - Magdalena Iwan
- Department of Toxicology, Faculty of Pharmacy, Medical University of Lublin, 20-093 Lublin, Poland; (M.I.); (D.N.-C.)
| | - Dorota Natorska-Chomicka
- Department of Toxicology, Faculty of Pharmacy, Medical University of Lublin, 20-093 Lublin, Poland; (M.I.); (D.N.-C.)
| | - Kamila Adamczuk
- Department of Biochemistry and Molecular Biology, Faculty of Medicine, Medical University of Lublin, 20-093 Lublin, Poland;
| | - Agnieszka Korga-Plewko
- Independent Medical Biology Unit, Faculty of Pharmacy, Medical University of Lublin, 20-093 Lublin, Poland; (E.H.); (A.K.-P.)
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5
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Alamri RD, Elmeligy MA, Albalawi GA, Alquayr SM, Alsubhi SS, El-Ghaiesh SH. Leflunomide an immunomodulator with antineoplastic and antiviral potentials but drug-induced liver injury: A comprehensive review. Int Immunopharmacol 2021; 93:107398. [PMID: 33571819 PMCID: PMC7869628 DOI: 10.1016/j.intimp.2021.107398] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/11/2021] [Accepted: 01/11/2021] [Indexed: 12/11/2022]
Abstract
Leflunomide (LF) represents the prototype member of dihydroorotate dehydrogenase (DHODH) enzyme inhibitors. DHODH is a mitochondrial inner membrane enzyme responsible for catalytic conversion of dihydroorotate into orotate, a rate-limiting step in the de novo synthesis of the pyrimidine nucleotides. LF produces cellular depletion of pyrimidine nucleotides required for cell growth and proliferation. Based on the affected cells the outcome can be attainable as immunosuppression, antiproliferative, and/or the recently gained attention of the antiviral potentials of LF and its new congeners. Also, protein tyrosine kinase inhibition is an additional mechanistic benefit of LF, which inhibits immunological events such as cellular expansion and immunoglobulin production with an enhanced release of immunosuppressant cytokines. LF is approved for the treatment of autoimmune arthritis of rheumatoid and psoriatic pathogenesis. Also, LF has been used off-label for the treatment of relapsing-remitting multiple sclerosis. However, LF antiviral activity is repurposed and under investigation with related compounds under a phase-I trial as a SARS CoV-2 antiviral in cases with COVID-19. Despite success in improving patients' mobility and reducing joint destruction, reported events of LF-induced liver injury necessitated regulatory precautions. LF should not be used in patients with hepatic impairment or in combination with drugs elaborating a burden on the liver without regular monitoring of liver enzymes and serum bilirubin as safety biomarkers. This study aims to review the pharmacological and safety profile of LF with a focus on the LF-induced hepatic injury from the perspective of pathophysiology and possible protective agents.
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Affiliation(s)
- Raghad D Alamri
- Faculty of Medicine, University of Tabuk, Tabuk 47713, Saudi Arabia
| | | | | | - Sarah M Alquayr
- Faculty of Medicine, University of Tabuk, Tabuk 47713, Saudi Arabia
| | | | - Sabah H El-Ghaiesh
- Deaprtment of Pharmacology, Faculty of Medicine, Tanta University, Tanta 31527, Egypt; Department of Pharmacology, Faculty of Medicine, University of Tabuk, Tabuk 47713, Saudi Arabia.
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Selective Binding of Cyclodextrins with Leflunomide and Its Pharmacologically Active Metabolite Teriflunomide. Int J Mol Sci 2020; 21:ijms21239102. [PMID: 33265979 PMCID: PMC7730839 DOI: 10.3390/ijms21239102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/19/2022] Open
Abstract
The selectivity of encapsulation of leflunomide and teriflunomide by native α-, β- and γ-cyclodextrins was investigated through 1H NMR and molecular modeling. Thermodynamic analysis revealed the main driving forces involved in the binding. For α-cyclodextrin, the partial encapsulation was obtained while deep penetration was characterized for the other two cyclodextrins, where the remaining polar fragment of the molecule is located outside the macrocyclic cavity. The interactions via hydrogen bonding are responsible for high negative enthalpy and entropy changes accompanying the complexation of cyclodextrins with teriflunomide. These results were in agreement with the molecular modeling calculations, which provide a clearer picture of the involved interactions at the atomic level.
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7
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Xu Y, Shen D, Liu J, Xu X, Tu J, Qin L, Jiang L, Qian H, Guo F. Long non-coding RNAs as targets for immunosuppressive drug teriflunomide in anti-cancer potential for hepatocellular carcinoma. J Mol Histol 2020; 51:659-673. [PMID: 33034797 DOI: 10.1007/s10735-020-09912-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/22/2020] [Indexed: 11/25/2022]
Abstract
Hepatocellular carcinoma (HCC) is the most common form of liver cancer. Because of the relatively chemotherapy-refractory nature of HCC and significant potential poor hepatic reserve, chemotherapy has not been used consistently in the treatment of HCC. Effective new drugs for HCC are urgently needed. Teriflunomide, which was approved for the treatment of relapsing forms of multiple sclerosis (MS), has been identified as a potential antineoplastic drug. Long noncoding RNAs (lncRNAs) are a novel class of RNA molecules defined as transcripts longer than 200 nucleotides that lack protein coding potential. In this study, we investigated the ability of teriflunomide to act as an antineoplastic drug by examining the effects of teriflunomide treatment on HCC cells. Teriflunomide strongly inhibited the proliferation of HCC cells, induced cell apoptosis and induced cell accumulation in S phases of the cell cycle. LncRNA and mRNA expression profiles of HCC cells treated with teriflunomide compared with controls were performed by using microarray analysis. For comparison, the differentially expressed mRNAs were annotated by using gene ontology (GO) and pathway analyses. The microarray revealed that 2085 lncRNAs and 1561 mRNAs differed in the cells treated with teriflunomide compared with controls. Several GO terms including protein folding, mitochondrial outer membrane, transmembrane receptor protein phosphatase activity, negative regulation of cellular biosynthetic process, DNA packaging complex, and receptor signaling protein activity were enriched in gene lists, suggesting a potential correlation with the action mechanism of teriflunomide. Pathway analysis then demonstrated that JAK-STAT signaling pathway may play important roles in the cell apoptosis induced by teriflunomide. Co-expression network analysis indicated that a number of lncRNAs and mRNAs were included in the co-expression network, and p34710_v4 is the lncRNA with highest degree. Then the mRNAs associated with those differentially expressed lncRNAs were also annotated by using gene ontology (GO) and pathway analyses. The pathway analyses shows that teriflunomide significantly inhibited cell proliferation and promoted cell apoptosis partly by participating in Wnt signaling pathways. These findings suggest that teriflunomide could be a potential drug for chemotherapy and molecularly targeted therapies of HCC.
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Affiliation(s)
- Yinkai Xu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 188, Shi Zi Road, Suzhou, 215006, China
| | - Daoming Shen
- Department of Gastroenterology, Xiangcheng People's Hospital, Suzhou, 215131, China
| | - Jianxia Liu
- Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 188, Shi Zi Road, Suzhou, 215006, China
| | - Xiaolan Xu
- Department of Gastroenterology, Xiangcheng People's Hospital, Suzhou, 215131, China
| | - Junhao Tu
- Department of General surgery, Suzhou Wuzhong People's Hospital, Suzhou, 215128, People's Republic of China
| | - Lei Qin
- Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 188, Shi Zi Road, Suzhou, 215006, China
| | - Liyang Jiang
- Department of Intensive Care Unit, The Affiliated Suzhou Hospital of Nanjing Medical University, 242 Guangji Road, Suzhou, Jiangsu, People's Republic of China.
| | - Haixin Qian
- Department of General Surgery, The First Affiliated Hospital of Soochow University, No. 188, Shi Zi Road, Suzhou, 215006, China.
| | - Fengbao Guo
- Department of Emergency Medicine, The First Affiliated Hospital of Soochow University, No. 188, Shi Zi Road, Suzhou, 215006, People's Republic of China.
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Szekanecz Z, Gomez I, Soós B, Bodoki L, Szamosi S, András C, Juhász B, Váróczy L, Antal-Szalmás P, Szodoray P, Bittner N, Árkosy P, Illés Á, Szűcs G, Dankó K, Bender T, Tamási L, Szekanecz É. Eight pillars of oncorheumatology: Crossroads between malignancies and musculoskeletal diseases. Autoimmun Rev 2020; 19:102658. [PMID: 32942035 DOI: 10.1016/j.autrev.2020.102658] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 03/31/2020] [Indexed: 02/07/2023]
Abstract
ONCORHEUMATOLOGY RELATIONSHIP BETWEEN MALIGNANCIES AND MUSCULOSKELETAL DISEASES: Oncorheumatology is the meeting point of tumor formation and rheumatic musculoskeletal diseases (RMD). Multiple interactions exist between these two medical specialties. One major field is the topic of malignancies associated with rheumatic diseases, while the other topic covers the development of musculoskeletal disease in cancer patients. Within the first group, secondary malignancies may be associated with rheumatic diseases. Mostly sustained inflammation is responsible for transition into cancer. Tumor-associated antigens (TAA) with adhesive properties are present on tumor cells. These molecules may also be expressed by inflammatory leukocytes and soluble TAA levels may be elevated in RMDs. There has been continuous debate with respect to the possible carcinogenicity of conventional and targeted antirheumatic drugs. Very recent data from registries suggest that neither biologics, nor JAK inhibitors increase cancer risk in arthritis patients. The issue of physiotherapy in rheumatic patients with recent or current cancer has also been controversial. Some modalities, primarily exercise, may be safely applied to patients with RMD and cancer. The second large topic includes paraneoplastic syndromes. Musculoskeletal paraneoplasias are triggered by tumor-derived mediators. These syndromes are sometimes slightly different from the classical RMDs. Various chemotherapies may also be associated with autoimmune side effects. Recently, these immune-related complications have also been observed in cancer patients treated with immune-checkpoint inhibitors. Sex hormone-deprivation therapies, such as aromatase inhibitors and anti-androgens are widely used for the treatment of breast and prostate cancer, respectively. These compounds may induce bone loss and lead to osteoporosis. Finally, primary and secondary malignancies of the musculoskeletal system may also interest rheumatologists. In this review, the clinical, practical aspects of these eight pillars of oncorheumatology will be discussed.
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Affiliation(s)
- Zoltán Szekanecz
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Izabella Gomez
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; National Institute of Rheumatology and Physiotherapy, Budapest, Hungary
| | - Boglárka Soós
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Levente Bodoki
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Szilvia Szamosi
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Csilla András
- Department of Oncology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Balázs Juhász
- Department of Oncology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - László Váróczy
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Antal-Szalmás
- Department of Laboratory Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Szodoray
- Division of Clinical Immunology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary; Institute of Immunology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Nóra Bittner
- Department of Pulmonology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Péter Árkosy
- Department of Oncology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Árpád Illés
- Division of Hematology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Gabriella Szűcs
- Division of Rheumatology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Katalin Dankó
- Division of Clinical Immunology, Department of Medicine, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Tamás Bender
- Buda Hospital of the Hospitaller Order of Saint John of God, Budapest, Hungary
| | - László Tamási
- Department of Rheumatology, Borsod-Abaúj-Zemplén County Hospital and University Teaching Hospital, Miskolc;, Hungary
| | - Éva Szekanecz
- Department of Oncology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
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Cheng L, Wang H, Wang Z, Huang H, Zhuo D, Lin J. Leflunomide Inhibits Proliferation and Induces Apoptosis via Suppressing Autophagy and PI3K/Akt Signaling Pathway in Human Bladder Cancer Cells. Drug Des Devel Ther 2020; 14:1897-1908. [PMID: 32546957 PMCID: PMC7244359 DOI: 10.2147/dddt.s252626] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Bladder cancer is a lethal human malignancy. Currently, treatment for bladder cancer is limited. The anti-tumor effects of leflunomide have attracted much more concern in multiple human cancers. MATERIALS AND METHODS This study evaluated the anti-tumor effects of leflunomide on cell viability, colony formation, apoptosis, and cell cycle in two human bladder carcinoma cell lines, 5637 and T24. Meanwhile, the underlying mechanism including PI3K/Akt signaling pathway and autophagy modulation was also identified. RESULTS Leflunomide markedly inhibited the growth of both bladder cancer cell lines and induced apoptosis and cell cycle arrest in S phase. The phosphorylation levels of Akt and P70S6K in both cell lines were significantly down-regulated with leflunomide treatment. Furthermore, the deceased formation of autophagosomes and the accumulation of LC3II and P62 suggested the blockade of autophagy by leflunomide. Modulation of autophagy with rapamycin and chloroquine markedly attenuated and enhanced the cytostatic effects of leflunomide, respectively. CONCLUSION Leflunomide significantly reduced the cell viability of bladder cancer cells via inducing apoptosis and cell cycle arrest and suppressing the PI3K/Akt signaling pathway. In addition, the blockade of autophagy was observed, and autophagy inhibition enhanced leflunomide-mediating anti-tumor effects. Our data presented here offer novel ideas for comprehensive therapeutic regimes on bladder cancer.
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Affiliation(s)
- Li Cheng
- Department of Urology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, People’s Republic of China
| | - Hao Wang
- Department of Geriatrics, Peking University First Hospital, Beijing, People’s Republic of China
| | - Zicheng Wang
- Department of Urology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui Province, People’s Republic of China
| | - Houbao Huang
- Department of Urology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, People’s Republic of China
| | - Dong Zhuo
- Department of Urology, The First Affiliated Hospital, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, People’s Republic of China
| | - Jian Lin
- Department of Urology, Peking University First Hospital, Beijing, People’s Republic of China
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Madak JT, Bankhead A, Cuthbertson CR, Showalter HD, Neamati N. Revisiting the role of dihydroorotate dehydrogenase as a therapeutic target for cancer. Pharmacol Ther 2018; 195:111-131. [PMID: 30347213 DOI: 10.1016/j.pharmthera.2018.10.012] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Identified as a hallmark of cancer, metabolic reprogramming allows cancer cells to rapidly proliferate, resist chemotherapies, invade, metastasize, and survive a nutrient-deprived microenvironment. Rapidly growing cells depend on sufficient concentrations of nucleotides to sustain proliferation. One enzyme essential for the de novo biosynthesis of pyrimidine-based nucleotides is dihydroorotate dehydrogenase (DHODH), a known therapeutic target for multiple diseases. Brequinar, leflunomide, and teriflunomide, all of which are potent DHODH inhibitors, have been clinically evaluated but failed to receive FDA approval for the treatment of cancer. Inhibition of DHODH depletes intracellular pyrimidine nucleotide pools and results in cell cycle arrest in S-phase, sensitization to current chemotherapies, and differentiation in neural crest cells and acute myeloid leukemia (AML). Furthermore, DHODH is a synthetic lethal susceptibility in several oncogenic backgrounds. Therefore, DHODH-targeted therapy has potential value as part of a combination therapy for the treatment of cancer. In this review, we focus on the de novo pyrimidine biosynthesis pathway as a target for cancer therapy, and in particular, DHODH. In the first part, we provide a comprehensive overview of this pathway and its regulation in cancer. We further describe the relevance of DHODH as a target for cancer therapy using bioinformatic analyses. We then explore the preclinical and clinical results of pharmacological strategies to target the de novo pyrimidine biosynthesis pathway, with an emphasis on DHODH. Finally, we discuss potential strategies to harness DHODH as a target for the treatment of cancer.
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Affiliation(s)
- Joseph T Madak
- Department of Medicinal Chemistry, University of Michigan College of Pharmacy, Rogel Cancer Center, Ann Arbor, MI 48109, USA
| | - Armand Bankhead
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI 48109, USA; Department of Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI 48109, USA
| | - Christine R Cuthbertson
- Department of Medicinal Chemistry, University of Michigan College of Pharmacy, Rogel Cancer Center, Ann Arbor, MI 48109, USA
| | - Hollis D Showalter
- Department of Medicinal Chemistry, University of Michigan College of Pharmacy, Rogel Cancer Center, Ann Arbor, MI 48109, USA.
| | - Nouri Neamati
- Department of Medicinal Chemistry, University of Michigan College of Pharmacy, Rogel Cancer Center, Ann Arbor, MI 48109, USA.
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Chen Y, Huang Q, Zhou H, Wang Y, Hu X, Li T. Inhibition of canonical WNT/β-catenin signaling is involved in leflunomide (LEF)-mediated cytotoxic effects on renal carcinoma cells. Oncotarget 2018; 7:50401-50416. [PMID: 27391060 PMCID: PMC5226591 DOI: 10.18632/oncotarget.10409] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 06/13/2016] [Indexed: 11/25/2022] Open
Abstract
Leflunomide (LEF), an inhibitor of dihydroorotate dehydrogenase (DHODH) in pyrimidine biosynthetic pathway, is an immunomodulatory agent approved for the treatment of rheumatoid arthritis. In this study, we show that LEF significantly reduced cell proliferation of renal carcinoma cells in a concentration-dependent manner. LEF at 50 μM induced S-phase arrest and autophagy. Higher doses of LEF (>50 μM) effectively induced cell apoptosis. Modulating the concentration of LEF resulted in distinct effects on the expression of regulatory proteins associated with cell cycle, apoptosis, and autophagy. In particular, high concentrations of LEF inhibited canonical WNT signaling by promoting nucleo-cytoplasmic shuttling and proteasome-dependent degradation of β-catenin. Mechanistic studies showed that the repression of AKT activation partly accounted for LEF-mediated WNT inhibition. Gene expression microarray revealed that LEF treatment greatly inhibited the expression of FZD10 gene, a receptor mediating WNT/β-catenin activation. In vivo xenograft study in NOD/SCID mice further validated the inhibitory effects of LEF on tumor growth and Wnt/β-catenin signaling. However, LEF treatment also triggered cell autophagy and elevated the expression of WNT3a, which ameliorated its cytotoxic effects. The combination of LEF with a WNT inhibitor IWP-2 or autophagy inhibitor HCQ could yield an enhanced anti-tumor outcome. Taken together, these results identify the potential utility and pharmacological feature of LEF in the chemotherapy of renal cell carcinoma (RCC).
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Affiliation(s)
- Yicheng Chen
- Department of Urology, Sir Run-Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Qiaoli Huang
- Department of Biology, College of Chemistry and Life Sciences, Zhejiang Normal University, Jinhua, Zhejiang 321004, China
| | - Hua Zhou
- Department of Biology, College of Chemistry and Life Sciences, Zhejiang Normal University, Jinhua, Zhejiang 321004, China
| | - Yueping Wang
- Department of Urology, Wuyi First People's Hospital, Wuyi, Zhejiang 321200, China
| | - Xian Hu
- Department of Plastic Surgery, Sir Run-Run Shaw Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang 310016, China
| | - Tao Li
- Department of Biology, College of Chemistry and Life Sciences, Zhejiang Normal University, Jinhua, Zhejiang 321004, China
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12
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Chu M, Zhang C. Inhibition of angiogenesis by leflunomide via targeting the soluble ephrin-A1/EphA2 system in bladder cancer. Sci Rep 2018; 8:1539. [PMID: 29367676 PMCID: PMC5784165 DOI: 10.1038/s41598-018-19788-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 01/02/2018] [Indexed: 12/26/2022] Open
Abstract
Angiogenesis plays an important role in bladder cancer (BCa). The immunosuppressive drug leflunomide has attracted worldwide attention. However, the effects of leflunomide on angiogenesis in cancer remain unclear. Here, we report the increased expression of soluble ephrin-A1 (sEphrin-A1) in supernatants of BCa cell lines (RT4, T24, and TCCSUP) co-cultured with human umbilical vein endothelial cells (HUVECs) compared with that in immortalized uroepithelial cells (SV-HUC-1) co-cultured with HUVECs. sEphrin-A1 is released from BCa cells as a monomeric protein that is a functional form of the ligand. The co-culture supernatants containing sEphrin-A1 caused the internalization and down-regulation of EphA2 on endothelial cells and dramatic functional activation of HUVECs. This sEphrin-A1/EphA2 system is mainly functional in regulating angiogenesis in BCa tissue. We showed that leflunomide (LEF) inhibited angiogenesis in a N-butyl-N-(4-hydroxybutyl)-nitrosamine (BBN)-induced bladder carcinogenesis model and a tumor xenograft model, as well as in BCa cell and HUVEC co-culture systems, via significant inhibition of the sEphrin-A1/EphA2 system. Ephrin-A1 overexpression could partially reverse LEF-induced suppression of angiogenesis and subsequent tumor growth inhibition. Thus, LEF has a significant anti-angiogenesis effect on BCa cells and BCa tissue via its inhibition of the functional angiogenic sEphrin-A1/EphA2 system and may have potential for treating BCa beyond immunosuppressive therapy.
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Affiliation(s)
- Maolin Chu
- Department of Urology, The Second Affiliated Hospital, Harbin Medical University, 246 Xuefu St., Nan Gang District, Harbin, China.
| | - Chunying Zhang
- Department of Urology, The Second Affiliated Hospital, Harbin Medical University, 246 Xuefu St., Nan Gang District, Harbin, China.
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13
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Ren A, Fu G, Qiu Y, Cui H. Leflunomide inhibits proliferation and tumorigenesis of oral squamous cell carcinoma. Mol Med Rep 2017; 16:9125-9130. [PMID: 29039518 DOI: 10.3892/mmr.2017.7755] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 07/04/2017] [Indexed: 11/06/2022] Open
Abstract
Oral squamous cell carcinoma (OSCC) is the most prevalent pathological cancer occurring in the head and neck area. Progress has previously been made regarding treatment strategies of OSCC, however the 5‑year survival rate of these patients is only 50%. The present study examined if leflunomide (LEF), a drug primarily used for the treatment of rheumatoid arthritis, exhibited antitumor effects in OSCC. The results demonstrated that LEF inhibited cell proliferation and blocked the cell cycle at the S phase in OSCC cells, with upregulation of cyclin A protein expression. LEF reduced the expression of dihydroorotate dehydrogenase, which is an essential enzyme in the de novo pyrimidine biosynthetic pathway. LEF additionally inhibited colony formation in soft agar and reduced tumor growth in a xenograft model. The results suggested that LEF may act as a potential therapeutic agent in the treatment of OSCC in the future.
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Affiliation(s)
- Aishu Ren
- State Key Laboratory of Silkworm Genome Biology, Southwest University, Chongqing 400716, P.R. China
| | - Gang Fu
- State Key Laboratory of Silkworm Genome Biology, Southwest University, Chongqing 400716, P.R. China
| | - Yu Qiu
- Chongqing Key Laboratory for Oral Diseases and Biomedical Sciences, Affiliated Hospital of Stomatology, Chongqing Medical University, Chongqing 401147, P.R. China
| | - Hongjuan Cui
- State Key Laboratory of Silkworm Genome Biology, Southwest University, Chongqing 400716, P.R. China
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14
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Imanishi S, Takahashi R, Katagiri S, Kobayashi C, Umezu T, Ohyashiki K, Ohyashiki JH. Teriflunomide restores 5-azacytidine sensitivity via activation of pyrimidine salvage in 5-azacytidine-resistant leukemia cells. Oncotarget 2017; 8:69906-69915. [PMID: 29050250 PMCID: PMC5642525 DOI: 10.18632/oncotarget.19436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 06/19/2017] [Indexed: 12/21/2022] Open
Abstract
Previous studies showed that downregulation of pyrimidine salvage underlies resistance against 5-azacytidine (AZA), indicating an important role for de novo pyrimidine synthesis in AZA resistance. Because de novo pyrimidine synthesis is inhibited by the immunomodulator teriflunomide and its pro-drug leflunomide, we examined the effect of combined treatment with AZA and teriflunomide on AZA resistance to develop a novel strategy to cancel and prevent AZA resistance. Teriflunomide markedly inhibited the growth of AZA-resistant human leukemia cell lines (R-U937 and R-HL-60) in comparison with their AZA-sensitive counterparts (U937 and HL-60). In the presence of a non-toxic concentration of teriflunomide (1 μM), AZA induced apoptosis in AZA-resistant cells and leukemia cells from AZA-resistant patients. AZA acted as a DNA methyltransferase 3A inhibitor in AZA-resistant cells in the presence of 1 μM teriflunomide. Although AZA-sensitive cells acquired AZA resistance after continuous treatment with AZA for 42 days, the growth of AZA-sensitive cells continuously treated with the combination of AZA and teriflunomide was significantly inhibited in the presence of AZA, demonstrating that the combined treatment prevented AZA resistance. These results suggest that combined treatment with AZA and teriflunomide can be a novel strategy to overcome AZA resistance.
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Affiliation(s)
- Satoshi Imanishi
- Department of Molecular Oncology, Institute for Medical Science, Tokyo Medical University, Nishi-Shinjuku, Shinjuku, Tokyo, Japan
| | - Ryoko Takahashi
- Department of Molecular Oncology, Institute for Medical Science, Tokyo Medical University, Nishi-Shinjuku, Shinjuku, Tokyo, Japan
| | - Seiichiro Katagiri
- Department of Hematology, Tokyo Medical University, Nishi-Shinjuku, Shinjuku, Tokyo, Japan
| | - Chiaki Kobayashi
- Department of Molecular Oncology, Institute for Medical Science, Tokyo Medical University, Nishi-Shinjuku, Shinjuku, Tokyo, Japan.,Department of Hematology, Tokyo Medical University, Nishi-Shinjuku, Shinjuku, Tokyo, Japan
| | - Tomohiro Umezu
- Department of Molecular Oncology, Institute for Medical Science, Tokyo Medical University, Nishi-Shinjuku, Shinjuku, Tokyo, Japan.,Department of Hematology, Tokyo Medical University, Nishi-Shinjuku, Shinjuku, Tokyo, Japan
| | - Kazuma Ohyashiki
- Department of Hematology, Tokyo Medical University, Nishi-Shinjuku, Shinjuku, Tokyo, Japan
| | - Junko H Ohyashiki
- Department of Molecular Oncology, Institute for Medical Science, Tokyo Medical University, Nishi-Shinjuku, Shinjuku, Tokyo, Japan
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15
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Abstract
Cancer is a major health issue worldwide, and the global burden of cancer is expected to increase in the coming years. Whereas the limited success with current therapies has driven huge investments into drug development, the average number of FDA approvals per year has declined since the 1990s. This unmet need for more effective anti-cancer drugs has sparked a growing interest for drug repurposing, i.e. using drugs already approved for other indications to treat cancer. As such, data both from pre-clinical experiments, clinical trials and observational studies have demonstrated anti-tumor efficacy for compounds within a wide range of drug classes other than cancer. Whereas some of them induce cancer cell death or suppress various aspects of cancer cell behavior in established tumors, others may prevent cancer development. Here, we provide an overview of promising candidates for drug repurposing in cancer, as well as studies describing the biological mechanisms underlying their anti-neoplastic effects.
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Affiliation(s)
- Linda Sleire
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway
| | - Hilde Elise Førde
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway
| | - Inger Anne Netland
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway
| | - Lina Leiss
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway
| | - Bente Sandvei Skeie
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Jonas Lies vei, 71, 5021 Bergen, Norway
| | - Per Øyvind Enger
- Oncomatrix Research Group, Department of Biomedicine, University of Bergen, Jonas Lies vei 91 5009 Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Jonas Lies vei, 71, 5021 Bergen, Norway.
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16
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Ma H, Du X, Zhang S, Wang Q, Yin Y, Qiu X, Da P, Yue H, Wu H, Xu F. Achaete-scute complex homologue-1 promotes development of laryngocarcinoma via facilitating the epithelial-mesenchymal transformation. Tumour Biol 2017; 39:1010428317705752. [PMID: 28618959 DOI: 10.1177/1010428317705752] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Laryngeal cancer is one of the most common fatal cancers among head and neck carcinomas, whose mechanism, however, remains unclear. The proneural basic-helix-loop-helix protein achaete-scute complex homologue-1, a member of the basic helix-loop-helix family, plays a very important role in many cancers. This study aims to explore the clinical value and mechanism of achaete-scute complex homologue-1 in laryngeal cancer. Methods including Cell Counting Kit-8, flow cytometry, Transwell invasion assays, and scratch assay were adopted to further explore the bio-function of achaete-scute complex homologue-1, whose expression was examined in fresh and paraffin chip of laryngeal carcinoma tissues by means of western blot and immunohistochemistry, after the interference of achaete-scute complex homologue-1; achaete-scute complex homologue-1, an overexpression in laryngeal carcinoma whose carcinogenicity potential was confirmed via western blot, was correlative with T classification (p = 0.002), histological differentiation (p = 0.000), lymph node metastasis (p = 0.000), and poor survival (p = 0.000). Multivariate analysis shows that achaete-scute complex homologue-1 overexpression is an independent prognostic factor unfavorable to laryngeal carcinoma patients (p = 0.000). Moreover, knocking down achaete-scute complex homologue-1 expression could significantly suppress the proliferation, migration, and invasion of laryngeal carcinoma cell in vitro and disorder epithelial-mesenchymal transformation-associated protein expression. Achaete-scute complex homologue-1 plays an important role in the genesis and progression of laryngeal carcinoma and may act as a potential biomarker for therapeutic target and prognostic prediction.
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Affiliation(s)
- Huaci Ma
- 1 Department of Otorhinolaryngology, Affiliated Hospital of Nantong University, Nantong, China
| | - Xiaodong Du
- 2 Department of Otolaryngology/Head and Neck Surgery, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Shu Zhang
- 1 Department of Otorhinolaryngology, Affiliated Hospital of Nantong University, Nantong, China
| | - Qiang Wang
- 1 Department of Otorhinolaryngology, Affiliated Hospital of Nantong University, Nantong, China
| | - Yong Yin
- 1 Department of Otorhinolaryngology, Affiliated Hospital of Nantong University, Nantong, China
| | - Xiaoxia Qiu
- 1 Department of Otorhinolaryngology, Affiliated Hospital of Nantong University, Nantong, China
| | - Peng Da
- 1 Department of Otorhinolaryngology, Affiliated Hospital of Nantong University, Nantong, China
| | - Huijun Yue
- 1 Department of Otorhinolaryngology, Affiliated Hospital of Nantong University, Nantong, China
| | - Hao Wu
- 1 Department of Otorhinolaryngology, Affiliated Hospital of Nantong University, Nantong, China
| | - Fenglei Xu
- 3 Department of Otolaryngology/Head and Neck Surgery, The Second Hospital of Shandong University, Jinan, China
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17
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Malignancy Incidence, Management, and Prevention in Patients with Rheumatoid Arthritis. Rheumatol Ther 2017; 4:333-347. [PMID: 28508282 PMCID: PMC5696277 DOI: 10.1007/s40744-017-0064-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Indexed: 12/17/2022] Open
Abstract
Traditional and biologic disease-modifying antirheumatic drugs (DMARDs) are effective medications for the management of rheumatoid arthritis (RA). However, the effects of these medications on immune function raises concern that they may increase long-term cancer risk. The baseline risk for some cancers appears to differ in patients with RA compared to the general population, with the former having an increased risk of lymphoma, lung cancer and renal cancer, but a decreased risk of colorectal and breast cancer. Some DMARDs appear to increase the rate of specific cancer types (such as bladder cancer with cyclophosphamide), but few appear to increase the overall cancer risk. Studying the link between lymphoma and disease severity in RA is complicated because patients with persistently active disease are at increased risk for lymphoma, and disease severity correlates with more intense use of immunosuppressive medications. Overall, cancer risk in patients with RA is slightly above that of the general population, with the increased risk likely secondary to an increased risk of lymphomas in those with high disease activity. Risk mitigation includes management of RA disease activity as well as age- and sex-appropriate cancer screening.
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18
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Chaiyawat P, Settakorn J, Sangsin A, Teeyakasem P, Klangjorhor J, Soongkhaw A, Pruksakorn D. Exploring targeted therapy of osteosarcoma using proteomics data. Onco Targets Ther 2017; 10:565-577. [PMID: 28203090 PMCID: PMC5295800 DOI: 10.2147/ott.s119993] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Despite multimodal therapeutic treatments of osteosarcoma (OS), some patients develop resistance to currently available regimens and eventually end up with recurrent or metastatic outcomes. Many attempts have been made to discover effective drugs for improving outcome; however, due to the heterogeneity of the disease, new therapeutic options have not yet been identified. This study aims to explore potential targeted therapy related to protein profiles of OS. In this review of proteomics studies, we extracted data on differentially expressed proteins (DEPs) from archived literature in PubMed and our in-house repository. The data were divided into three experimental groups, DEPs in 1) OS/OB: OS vs osteoblastic (OB) cells, 2) metastasis: metastatic vs non-metastatic sublines plus fresh tissues from primary OS with and without pulmonary metastasis, and 3) chemoresistance: spheroid (higher chemoresistance) vs monolayer cells plus fresh tissues from biopsies from good and poor responders. All up-regulated protein entities in the list of DEPs were sorted and cross-referenced with identifiers of targets of US Food and Drug Administration (FDA)-approved agents and chemical inhibitors. We found that many targets of FDA-approved antineoplastic agents, mainly a group of epigenetic regulators, kinases, and proteasomes, were highly expressed in OS cells. Additionally, some overexpressed proteins were targets of FDA-approved non-cancer drugs, including immunosuppressive and antiarrhythmic drugs. The resulting list of chemical agents showed that some transferase enzyme inhibitors might have anticancer activity. We also explored common targets of OS/OB and metastasis groups, including amidophosphoribosyltransferase (PPAT), l-lactate dehydrogenase B chain (LDHB), and pyruvate kinase M2 (PKM2) as well as the common target of all categories, cathepsin D (CTSD). This study demonstrates the benefits of a text mining approach to exploring therapeutic targets related to protein expression patterns. These results suggest possible repurposing of some FDA-approved medicines for the treatment of OS and using chemical inhibitors in drug screening tests.
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Affiliation(s)
- Parunya Chaiyawat
- Orthopedic Laboratory and Research Netting Center, Department of Orthopedics
| | | | - Apiruk Sangsin
- Orthopedic Laboratory and Research Netting Center, Department of Orthopedics
| | - Pimpisa Teeyakasem
- Orthopedic Laboratory and Research Netting Center, Department of Orthopedics
| | | | | | - Dumnoensun Pruksakorn
- Orthopedic Laboratory and Research Netting Center, Department of Orthopedics; Excellence Center in Osteology Research and Training Center, Chiang Mai University, Chiang Mai, Thailand
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19
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García-Vilas JA, Quesada AR, Medina MÁ. Screening of synergistic interactions of epigallocatechin-3-gallate with antiangiogenic and antitumor compounds. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.synres.2016.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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Chemopreventive effect of leflunomide against Ehrlich's solid tumor grown in mice: Effect on EGF and EGFR expression and tumor proliferation. Life Sci 2015; 141:193-201. [DOI: 10.1016/j.lfs.2015.10.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 08/07/2015] [Accepted: 10/02/2015] [Indexed: 02/07/2023]
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21
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McFadden D, Souba WW. Change is good! The Journal of Surgical Research: 2014-2015. J Surg Res 2015; 197:1-4. [PMID: 25982043 DOI: 10.1016/j.jss.2015.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- David McFadden
- Department of Surgery, University of Connecticut Health Center, Hartford, CT.
| | - Wiley W Souba
- Department of Surgery, Dartmouth College of Medicine, Hanover, NH
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