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Pongratanakul P, Bremmer F, Pauls S, Poschmann G, Kresbach C, Parmaksiz F, Skowron MA, Fuß J, Stephan A, Paffenholz P, Stühler K, Schüller U, Ströbel P, Heidenreich A, Che Y, Albers P, Nettersheim D. Assessing the risk to develop a growing teratoma syndrome based on molecular and epigenetic subtyping as well as novel secreted biomarkers. Cancer Lett 2024; 585:216673. [PMID: 38296184 DOI: 10.1016/j.canlet.2024.216673] [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: 10/30/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 02/05/2024]
Abstract
In germ cell tumors (GCT), a growing teratoma during chemotherapy with decreasing tumor markers was defined as 'growing teratoma syndrome' (GTS) by Logothetis et al. in 1982. So far, its pathogenesis and specific treatment options remain elusive. We aimed at updating the GTS definition based on molecular and epigenetic features as well as identifying circulating biomarkers. We selected 50 GTS patients for clinical characterization and subsequently 12 samples were molecularly analyzed. We further included 7 longitudinal samples of 2 GTS patients. Teratomas (TER) showing no features of GTS served as controls. GTS were stratified based on growth rates into a slow (<0.5 cm/month), medium (0.5-1.5) and rapid (>1.5) group. By analyzing DNA methylation, microRNA expression and the secretome, we identified putative epigenetic and secreted biomarkers for the GTS subgroups. We found that proteins enriched in the GTS groups compared to TER were involved in proliferation, DNA replication and the cell cycle, while proteins interacting with the immune system were depleted. Additionally, GTSrapid seem to interact more strongly with the surrounding microenvironment than GTSslow. Expression of pluripotency- and yolk-sac tumor-associated genes in GTS and formation of a yolk-sac tumor or somatic-type malignancy in the longitudinal GTS samples, pointed at an additional occult non-seminomatous component after chemotherapy. Thus, updating the Logothetis GTS definition is necessary, which we propose as follows: The GTS describes a continuously growing teratoma that might harbor occult non-seminomatous components considerably reduced during therapy but outgrowing over time again.
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Affiliation(s)
- Pailin Pongratanakul
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Department of Urology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Felix Bremmer
- Institute of Pathology, University Medical Center Goettingen, Goettingen, Germany
| | - Stella Pauls
- Molecular Proteomics Laboratory (MPL), Biological and Medical Research Center (BMFZ), Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Gereon Poschmann
- Molecular Proteomics Laboratory (MPL), Biological and Medical Research Center (BMFZ), Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Catena Kresbach
- Institute of Neuropathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fatma Parmaksiz
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Margaretha A Skowron
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Janina Fuß
- Competence Centre for Genomic Analysis, Kiel, Germany
| | - Alexa Stephan
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Pia Paffenholz
- Department of Urology, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Kai Stühler
- Molecular Proteomics Laboratory (MPL), Biological and Medical Research Center (BMFZ), Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ulrich Schüller
- Institute of Neuropathology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Ströbel
- Institute of Pathology, University Medical Center Goettingen, Goettingen, Germany
| | - Axel Heidenreich
- Department of Urology, University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Yue Che
- Department of Urology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Peter Albers
- Department of Urology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Nettersheim
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; Lighthouse Project Germ Cell Tumors, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), Germany.
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Macheroni C, Leite GGF, Souza DS, Vicente CM, Lacerda JT, Moraes MN, Juliano MA, Porto CS. Activation of estrogen receptor induces differential proteomic responses mainly involving migration, invasion, and tumor development pathways in human testicular embryonal carcinoma NT2/D1 cells. J Steroid Biochem Mol Biol 2024; 237:106443. [PMID: 38092129 DOI: 10.1016/j.jsbmb.2023.106443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/27/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023]
Abstract
The aims of the present study were to investigate the global changes on proteome of human testicular embryonal carcinoma NT2/D1 cells treated with 17β-estradiol (E2), and the effects of this hormone on migration, invasion, and colony formation of these cells. A quantitative proteomic analysis identified the presence of 1230 proteins in both E2-treated and control cells. The analysis revealed 75 differentially abundant proteins (DAPs), out of which 43 proteins displayed a higher abundance and, 30 proteins showed a lower abundance in E2-treated NT2/D1 cancer cells. Functional analysis using IPA highlighted some activation processes such as migration, invasion, metastasis, and tumor growth. Interestingly, the treatment with E2 and ERβ-selective agonist DPN increased the migration of NT2/D1 cells. On the other hand, ERα-selective agonist PPT did not modify cell migration, indicating that ERβ is the upstream receptor involved in this process. The activation of ERβ increased the invasion and anchorage‑independent growth of NT2/D1 cells more intensely than ERα. ERα and ERβ may play overlapping roles on invasion and colony formation of these cells. Further studies are required to clarify the mechanism underlying these effects. The molecular mechanisms revealed by proteomic and functional studies might also guide the development of potential targets for a better understanding of the biology of these cells and novel treatments for non-seminoma in the future.
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Affiliation(s)
- Carla Macheroni
- Laboratory of Experimental Endocrinology, Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo 669, Vila Clementino, São Paulo, SP 04039-032, Brazil
| | - Giuseppe Gianini Figueirêdo Leite
- Division of Infectious Diseases, Department of Medicine, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo 669, Vila Clementino, São Paulo, SP 04039-032, Brazil
| | - Deborah Simão Souza
- Laboratory of Experimental Endocrinology, Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo 669, Vila Clementino, São Paulo, SP 04039-032, Brazil
| | - Carolina Meloni Vicente
- Laboratory of Experimental Endocrinology, Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo 669, Vila Clementino, São Paulo, SP 04039-032, Brazil
| | - José Thalles Lacerda
- Department of Physiology, Instituto de Biociências, Universidade de São Paulo, Rua do Matão 277, Butantã, São Paulo, SP 05508-090, Brazil
| | - Maria Nathália Moraes
- Instituto de Ciências Ambientais, Químicas e Farmacêuticas, Universidade Federal de São Paulo, Av. Conceição 515, Diadema, São Paulo, SP, 09920-000, Brazil
| | - Maria Aparecida Juliano
- Department of Biophysics, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Três de Maio, 100, Vila Clementino, São Paulo, SP 04044-020, Brazil
| | - Catarina Segreti Porto
- Laboratory of Experimental Endocrinology, Department of Pharmacology, Escola Paulista de Medicina, Universidade Federal de São Paulo, Rua Pedro de Toledo 669, Vila Clementino, São Paulo, SP 04039-032, Brazil.
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3
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Xu J, Erlendsson S, Singh M, Holling GA, Regier M, Ibiricu I, Einstein J, Hantak MP, Day GS, Piquet AL, Smith TL, Clardy SL, Whiteley AM, Feschotte C, Briggs JAG, Shepherd JD. PNMA2 forms immunogenic non-enveloped virus-like capsids associated with paraneoplastic neurological syndrome. Cell 2024; 187:831-845.e19. [PMID: 38301645 PMCID: PMC10922747 DOI: 10.1016/j.cell.2024.01.009] [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: 02/24/2023] [Revised: 09/20/2023] [Accepted: 01/05/2024] [Indexed: 02/03/2024]
Abstract
The paraneoplastic Ma antigen (PNMA) proteins are associated with cancer-induced paraneoplastic syndromes that present with an autoimmune response and neurological symptoms. Why PNMA proteins are associated with this severe autoimmune disease is unclear. PNMA genes are predominantly expressed in the central nervous system and are ectopically expressed in some tumors. We show that PNMA2, which has been co-opted from a Ty3 retrotransposon, encodes a protein that is released from cells as non-enveloped virus-like capsids. Recombinant PNMA2 capsids injected into mice induce autoantibodies that preferentially bind external "spike" PNMA2 capsid epitopes, whereas a capsid-assembly-defective PNMA2 protein is not immunogenic. PNMA2 autoantibodies in cerebrospinal fluid of patients with anti-Ma2 paraneoplastic disease show similar preferential binding to spike capsid epitopes. PNMA2 capsid-injected mice develop learning and memory deficits. These observations suggest that PNMA2 capsids act as an extracellular antigen, capable of generating an autoimmune response that results in neurological deficits.
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Affiliation(s)
- Junjie Xu
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA
| | - Simon Erlendsson
- The Medical Research Council Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge, UK; Novo Nordisk Foundation Center for Protein Research, University of Copenhagen, Copenhagen, Denmark
| | - Manvendra Singh
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, USA
| | - G Aaron Holling
- Department of Biochemistry, University of Colorado Boulder, Boulder, CO, USA
| | - Matthew Regier
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA
| | - Iosune Ibiricu
- Department of Cell and Virus Structure, Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Jenifer Einstein
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA
| | - Michael P Hantak
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA
| | - Gregory S Day
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Amanda L Piquet
- Department of Neurology, University of Colorado, Aurora, CO, USA
| | - Tammy L Smith
- Department of Neurology, University of Utah and George E Wahlen VA Medical Center, Salt Lake City, UT, USA
| | - Stacey L Clardy
- Department of Neurology, University of Utah and George E Wahlen VA Medical Center, Salt Lake City, UT, USA
| | | | - Cédric Feschotte
- Department of Molecular Biology and Genetics, Cornell University, Ithaca, NY, USA
| | - John A G Briggs
- The Medical Research Council Laboratory of Molecular Biology, Francis Crick Avenue, Cambridge, UK; Department of Cell and Virus Structure, Max Planck Institute of Biochemistry, Martinsried, Germany
| | - Jason D Shepherd
- Department of Neurobiology, University of Utah, Salt Lake City, UT, USA.
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4
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Gayer FA, Henkel M, Luft J, Reichardt SD, Fichtner A, Legler TJ, Reichardt HM. The Subtype Identity of Testicular Cancer Cells Determines Their Immunostimulatory Activity in a Coculture Model. Cancers (Basel) 2023; 15:cancers15092619. [PMID: 37174085 PMCID: PMC10177190 DOI: 10.3390/cancers15092619] [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: 03/21/2023] [Revised: 04/20/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
Testicular germ cell cancer (TGCC) is subdivided into several subtypes. While seminomatous germ cell tumors (SGCT) are characterized by an intensive infiltration of immune cells which constitute a pro-inflammatory tumor micromilieu (TME), immune cells in non-seminomatous germ cell tumors (NSGCT) are differently composed and less abundant. Previously, we have shown that the seminomatous cell line TCam-2 promotes T cell and monocyte activation in a coculture model, resulting in mutual interactions between both cell types. Here we set out to compare this feature of TCam-2 cells with the non-seminomatous cell line NTERA-2. Peripheral blood T cells or monocytes cocultured with NTERA-2 cells failed to secrete relevant amounts of pro-inflammatory cytokines, and significantly downregulated the expression of genes encoding activation markers and effector molecules. In contrast, immune cells cocultured with TCam-2 cells produced IL-2, IL-6 and TNFα, and strongly upregulated the expression of multiple pro-inflammatory genes. Furthermore, the expression of genes involved in proliferation, stemness and subtype specification remained unaltered in NTERA-2 cells during coculture with T cells or monocytes, indicating the absence of mutual interactions. Collectively, our findings uncover fundamental differences between SGCT and NSGCT in their capability to generate a pro-inflammatory TME, which possibly impacts the clinical features and prognosis of both TGCC subtypes.
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Affiliation(s)
- Fabian A Gayer
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, 37073 Göttingen, Germany
- Clinic of Urology, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Miriam Henkel
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, 37073 Göttingen, Germany
| | - Juliane Luft
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, 37073 Göttingen, Germany
| | - Sybille D Reichardt
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, 37073 Göttingen, Germany
| | - Alexander Fichtner
- Institute of Pathology, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Tobias J Legler
- Department of Transfusion Medicine, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Holger M Reichardt
- Institute for Cellular and Molecular Immunology, University Medical Center Göttingen, 37073 Göttingen, Germany
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Uemura K, Komatsu M, Hara S, Kawamoto T, Bitoh Y, Itoh T, Hirose T. CYP1A1 Is a Useful Diagnostic Marker for Angiofibroma of Soft Tissue. Am J Surg Pathol 2023; 47:547-557. [PMID: 36876749 DOI: 10.1097/pas.0000000000002029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Angiofibroma of soft tissue (AFST) is a recently described benign fibroblastic neoplasm composed of uniform bland spindle cell proliferation in fibrous and fibromyxoid stroma with prominent thin-walled small branching vessels. A major recurrent genetic abnormality in AFST is t(5;8)(p15;q13), which results in the rearrangement of AHRR and NCOA2 . Owing to a lack of discriminatory IHC markers and potential overlap with other mesenchymal neoplasms, it may be difficult to confirm the diagnosis of AFST in some cases. Triggered by a recent gene expression profile study of AFST, which showed the significant upregulation of AhR/AHRR/ARNT downstream genes (including CYP1A1 ), we used a mouse monoclonal antibody to explore the diagnostic significance of CYP1A1 expression in histologically confirmed AFST cases along with 224 control cases, consisting of 221 neoplastic mimickers and 3 non-neoplastic lesions. We found moderate to strong cytoplasmic expression of CYP1A1 in 13 of 16 AFST cases (sensitivity, 81.3%). In contrast, the vast majority of other examined histologic mimickers exhibited no expression of CYP1A1 (specificity, 97.3%), except for 3 myxofibrosarcomas (3/31), 2 solitary fibrous tumors (2/22), and 2 neurofibroma (1/27). Our results indicate that CYP1A1 immunohistochemistry may aid in the diagnosis of AFST by distinguishing among various kinds of tumors, particularly those harboring prominent vasculature.
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Affiliation(s)
- Kotaro Uemura
- Departments of Diagnostic Pathology
- Pediatric Surgery
| | | | - Shigeo Hara
- Department of Diagnostic Pathology, Kobe City Medical Center General Hospital
| | - Teruya Kawamoto
- Orthopedic Surgery
- Division of Orthopedic Surgery, Kobe University International Clinical Cancer Research Center, Kobe
| | | | | | - Takanori Hirose
- Division of Pathology for Regional Communication, Kobe University Graduate School of Medicine
- Department of Diagnostic Pathology, Hyogo Cancer Center, Akashi, Hyogo Prefecture, Japan
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Radhakrishnan K, Luu M, Iaria J, Sutherland JM, McLaughlin EA, Zhu HJ, Loveland KL. Activin and BMP Signalling in Human Testicular Cancer Cell Lines, and a Role for the Nucleocytoplasmic Transport Protein Importin-5 in their Crosstalk. Cells 2023; 12:cells12071000. [PMID: 37048077 PMCID: PMC10093041 DOI: 10.3390/cells12071000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 03/05/2023] [Accepted: 03/09/2023] [Indexed: 03/29/2023] Open
Abstract
Testicular germ cell tumours (TGCTs) are the most common malignancy in young men. Originating from foetal testicular germ cells that fail to differentiate correctly, TGCTs appear after puberty as germ cell neoplasia in situ cells that transform through unknown mechanisms into distinct seminoma and non-seminoma tumour types. A balance between activin and BMP signalling may influence TGCT emergence and progression, and we investigated this using human cell line models of seminoma (TCam-2) and non-seminoma (NT2/D1). Activin A- and BMP4-regulated transcripts measured at 6 h post-treatment by RNA-sequencing revealed fewer altered transcripts in TCam-2 cells but a greater responsiveness to activin A, while BMP4 altered more transcripts in NT2/D1 cells. Activin significantly elevated transcripts linked to pluripotency, cancer, TGF-β, Notch, p53, and Hippo signalling in both lines, whereas BMP4 altered TGF-β, pluripotency, Hippo and Wnt signalling components. Dose-dependent antagonism of BMP4 signalling by activin A in TCam-2 cells demonstrated signalling crosstalk between these two TGF-β superfamily arms. Levels of the nuclear transport protein, IPO5, implicated in BMP4 and WNT signalling, are highly regulated in the foetal mouse germline. IPO5 knockdown in TCam-2 cells using siRNA blunted BMP4-induced transcript changes, indicating that IPO5 levels could determine TGF-β signalling pathway outcomes in TGCTs.
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Affiliation(s)
- Karthika Radhakrishnan
- Centre for Reproductive Health, Hudson Institute of Medical Research, 27-31 Kanooka Grove, Clayton, VIC 3168, Australia
- Correspondence: (K.R.); (K.L.L.)
| | - Michael Luu
- Centre for Reproductive Health, Hudson Institute of Medical Research, 27-31 Kanooka Grove, Clayton, VIC 3168, Australia
| | - Josie Iaria
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3050, Australia
| | - Jessie M. Sutherland
- Priority Research Centre for Reproductive Science, Schools of Biomedical Science & Pharmacy and Environmental & Life Sciences, University of Newcastle, Callaghan, NSW 2305, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW 2305, Australia
| | - Eileen A. McLaughlin
- Priority Research Centre for Reproductive Science, Schools of Biomedical Science & Pharmacy and Environmental & Life Sciences, University of Newcastle, Callaghan, NSW 2305, Australia
- Hunter Medical Research Institute (HMRI), New Lambton Heights, NSW 2305, Australia
- Faculty of Science, Medicine and Health, University of Wollongong, Gwynneville, NSW 2500, Australia
| | - Hong-Jian Zhu
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC 3050, Australia
| | - Kate L. Loveland
- Centre for Reproductive Health, Hudson Institute of Medical Research, 27-31 Kanooka Grove, Clayton, VIC 3168, Australia
- Department of Molecular and Translational Sciences, Monash University, Clayton, VIC 3800, Australia
- Correspondence: (K.R.); (K.L.L.)
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7
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Proteomic profiling of cisplatin-resistant and cisplatin-sensitive germ cell tumour cell lines using quantitative mass spectrometry. World J Urol 2022; 40:373-383. [PMID: 35084545 PMCID: PMC8921118 DOI: 10.1007/s00345-022-03936-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 01/07/2022] [Indexed: 01/23/2023] Open
Abstract
Purpose Advanced testicular germ cell tumours (GCT) generally have a good prognosis owing to their unique sensitivity towards cisplatin-based chemotherapies. However, cisplatin-resistant GCT have a poor outcome. Further studies are mandatory to better understand resistance mechanisms and develop therapeutic strategies for refractory GCTs. Methods Protein levels in cisplatin-resistant GCT cell lines of NTERA-2, NCCIT and 2102EP were analyzed by quantitative proteomic mass spectrometry (MS) in combination with stable isotope labelling by amino acids in cell culture (SILAC). Differentially abundant protein markers of acquired cisplatin resistance were validated by Western blotting. Comprehensive bioinformatical annotation using gene set enrichment analyses (GSEA) and STRING interaction analysis were performed to identify commonly affected pathways in cisplatin resistance and the data were compared to the GCT cohort of the ‘The Cancer Genome Atlas’.
Results A total of 4375 proteins were quantified by MS, 144 of which were found to be differentially abundant between isogenic resistant and sensitive cell line pairs (24 proteins for NTERA-2, 60 proteins for NCCIT, 75 proteins for 2102EP). Western blotting confirmed regulation of key resistance-associated proteins (CBS, ANXA1, LDHA, CTH, FDXR). GSEA revealed a statistically significant enrichment of DNA repair-associated proteins in all three resistant cell lines and specific additional processes for individual cell lines. Conclusion High resolution MS combined with SILAC is a powerful tool and 144 significantly deregulated proteins were found in cisplatin-resistant GCT cell lines. Our study provides the largest proteomic in vitro library for cisplatin resistance in GCT, yet, enabling further studies to develop new treatment options for patients with refractory GCT. Supplementary Information The online version contains supplementary material available at 10.1007/s00345-022-03936-1.
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Richter A, Fichtner A, Joost J, Brockmeyer P, Kauffmann P, Schliephake H, Hammerstein-Equord A, Kueffer S, Urlaub H, Oellerich T, Ströbel P, Bohnenberger H, Bremmer F. Quantitative proteomics identifies biomarkers to distinguish pulmonary from head and neck squamous cell carcinomas by immunohistochemistry. JOURNAL OF PATHOLOGY CLINICAL RESEARCH 2021; 8:33-47. [PMID: 34647699 PMCID: PMC8682946 DOI: 10.1002/cjp2.244] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 07/23/2021] [Accepted: 09/01/2021] [Indexed: 12/16/2022]
Abstract
The differentiation between a pulmonary metastasis and a newly developed squamous cell carcinoma of the lung in patients with prior head and neck squamous cell carcinoma (HNSCC) is difficult due to a lack of biomarkers but is crucially important for the prognosis and therapy of the affected patient. By using high‐resolution mass spectrometry in combination with stable isotope labelling by amino acids in cell culture, we identified 379 proteins that are differentially expressed in squamous cell carcinomas of the lung and the head and neck. Of those, CAV1, CAV2, LGALS1, LGALS7, CK19, and UGDH were tested by immunohistochemistry on 194 tissue samples (98 lung and 96 HNSCCs). The combination of CAV1 and LGALS7 was able to distinguish the origin of the squamous cell carcinoma with high accuracy (area under the curve 0.876). This biomarker panel was tested on a cohort of 12 clinically classified lung tumours of unknown origin after HNSCC. Nine of those tumours were immunohistochemically classifiable.
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Affiliation(s)
- Annika Richter
- Institute of Pathology, University Medical Centre Göttingen, Göttingen, Germany
| | - Alexander Fichtner
- Institute of Pathology, University Medical Centre Göttingen, Göttingen, Germany
| | - Jasmin Joost
- Institute of Pathology, University Medical Centre Göttingen, Göttingen, Germany
| | - Philipp Brockmeyer
- Department of Oral and Maxillofacial Surgery, University Medical Centre Göttingen, Göttingen, Germany
| | - Philipp Kauffmann
- Department of Oral and Maxillofacial Surgery, University Medical Centre Göttingen, Göttingen, Germany
| | - Henning Schliephake
- Department of Oral and Maxillofacial Surgery, University Medical Centre Göttingen, Göttingen, Germany
| | | | - Stefan Kueffer
- Institute of Pathology, University Medical Centre Göttingen, Göttingen, Germany
| | - Henning Urlaub
- Bioanalytical Mass Spectrometry Group, Max Planck Institute for Biophysical Chemistry, Göttingen, Germany.,Bioanalytics, Institute for Clinical Chemistry, University Medical Centre Göttingen, Göttingen, Germany
| | - Thomas Oellerich
- Department of Medicine II, Haematology/Oncology, Goethe University, Frankfurt, Germany.,German Cancer Research Centre and German Cancer Consortium, Heidelberg, Germany
| | - Philipp Ströbel
- Institute of Pathology, University Medical Centre Göttingen, Göttingen, Germany
| | | | - Felix Bremmer
- Institute of Pathology, University Medical Centre Göttingen, Göttingen, Germany
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9
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Skowron MA, Becker TK, Kurz L, Jostes S, Bremmer F, Fronhoffs F, Funke K, Wakileh GA, Müller MR, Burmeister A, Lenz T, Stefanski A, Stühler K, Petzsch P, Köhrer K, Altevogt P, Albers P, Kristiansen G, Schorle H, Nettersheim D. The signal transducer CD24 suppresses the germ cell program and promotes an ectodermal rather than mesodermal cell fate in embryonal carcinomas. Mol Oncol 2021; 16:982-1008. [PMID: 34293822 PMCID: PMC8847992 DOI: 10.1002/1878-0261.13066] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 06/22/2021] [Accepted: 07/21/2021] [Indexed: 12/26/2022] Open
Abstract
Testicular germ cell tumors (GCTs) are stratified into seminomas and nonseminomas. Seminomas share many histological and molecular features with primordial germ cells, whereas the nonseminoma stem cell population—embryonal carcinoma (EC)—is pluripotent and thus able to differentiate into cells of all three germ layers (teratomas). Furthermore, ECs are capable of differentiating into extra‐embryonic lineages (yolk sac tumors, choriocarcinomas). In this study, we deciphered the molecular and (epi)genetic mechanisms regulating expression of CD24, a highly glycosylated signaling molecule upregulated in many cancers. CD24 is overexpressed in ECs compared with other GCT entities and can be associated with an undifferentiated pluripotent cell fate. We demonstrate that CD24 can be transactivated by the pluripotency factor SOX2, which binds in proximity to the CD24 promoter. In GCTs, CD24 expression is controlled by epigenetic mechanisms, that is, histone acetylation, since CD24 can be induced by the application histone deacetylase inhibitors. Vice versa, CD24 expression is downregulated upon inhibition of histone methyltransferases, E3 ubiquitin ligases, or bromodomain (BRD) proteins. Additionally, three‐dimensional (3D) co‐cultivation of EC cells with microenvironmental cells, such as fibroblasts, and endothelial or immune cells, reduced CD24 expression, suggesting that crosstalk with the somatic microenvironment influences CD24 expression. In a CRISPR/Cas9 deficiency model, we demonstrate that CD24 fulfills a bivalent role in differentiation via regulation of homeobox, and phospho‐ and glycoproteins; that is, it is involved in suppressing the germ cell/spermatogenesis program and mesodermal/endodermal differentiation, while poising the cells for ectodermal differentiation. Finally, blocking CD24 by a monoclonal antibody enhanced sensitivity toward cisplatin in EC cells, including cisplatin‐resistant subclones, highlighting CD24 as a putative target in combination with cisplatin.
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Affiliation(s)
- Margaretha A Skowron
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | - Teresa K Becker
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | - Lukas Kurz
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | - Sina Jostes
- Department of Oncological Science, Icahn School of Medicine at Mount Sinai, Hess Center for Science and Medicine, New York, NY, USA
| | - Felix Bremmer
- Institute of Pathology, University Medical Center Goettingen, Germany
| | | | - Kai Funke
- Department of Developmental Pathology, Institute of Pathology, University Hospital Bonn, Germany
| | - Gamal A Wakileh
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany.,Department of Urology, University Hospital Ulm, Germany
| | - Melanie R Müller
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | - Aaron Burmeister
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | - Thomas Lenz
- Molecular Proteomics Laboratory, Heinrich-Heine-University Düsseldorf, Germany
| | - Anja Stefanski
- Molecular Proteomics Laboratory, Heinrich-Heine-University Düsseldorf, Germany
| | - Kai Stühler
- Molecular Proteomics Laboratory, Heinrich-Heine-University Düsseldorf, Germany
| | - Patrick Petzsch
- Genomics & Transcriptomics Lab, Heinrich Heine University Düsseldorf, Germany
| | - Karl Köhrer
- Genomics & Transcriptomics Lab, Heinrich Heine University Düsseldorf, Germany
| | - Peter Altevogt
- Skin Cancer Unit, German Cancer Research Center (DKFZ), Heidelberg, Germany.,Department of Dermatology, Venereology and Allergology, University Medical Center Mannheim, Ruprecht-Karl University Heidelberg, Germany
| | - Peter Albers
- Department of Urology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
| | | | - Hubert Schorle
- Department of Developmental Pathology, Institute of Pathology, University Hospital Bonn, Germany
| | - Daniel Nettersheim
- Department of Urology, Urological Research Laboratory, Translational UroOncology, Medical Faculty and University Hospital Düsseldorf, Heinrich Heine University Düsseldorf, Germany
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10
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Lobo J, Leão R, Jerónimo C, Henrique R. Liquid Biopsies in the Clinical Management of Germ Cell Tumor Patients: State-of-the-Art and Future Directions. Int J Mol Sci 2021; 22:ijms22052654. [PMID: 33800799 PMCID: PMC7961393 DOI: 10.3390/ijms22052654] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 02/25/2021] [Accepted: 03/02/2021] [Indexed: 02/06/2023] Open
Abstract
Liquid biopsies constitute a minimally invasive means of managing cancer patients, entailing early diagnosis, follow-up and prediction of response to therapy. Their use in the germ cell tumor field is invaluable since diagnostic tissue biopsies (which are invasive) are often not performed, and therefore only a presumptive diagnosis can be made, confirmed upon examination of the surgical specimen. Herein, we provide an overall review of the current liquid biopsy-based biomarkers of this disease, including the classical, routinely used serum tumor markers—the promising microRNAs rapidly approaching the introduction into clinical practice—but also cell-free DNA markers (including DNA methylation) and circulating tumor cells. Finally, and importantly, we also explore novel strategies and challenges for liquid biopsy markers and methodologies, providing a critical view of the future directions for liquid biopsy tests in this field, highlighting gaps and unanswered questions.
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Affiliation(s)
- João Lobo
- Cancer Biology and Epigenetics Group, IPO Porto Research Center (GEBC CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto) & Porto Comprehensive Cancer Center (P.CCC), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal;
- Department of Pathology, Portuguese Oncology Institute of Porto (IPOP), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
- Department of Pathology and Molecular Immunology, Institute of Biomedical Sciences Abel Salazar, University of Porto (ICBAS-UP), Rua Jorge Viterbo Ferreira 228, 4050-513 Porto, Portugal
| | - Ricardo Leão
- Faculty of Medicine, University of Coimbra, Rua Larga, 3000-370 Coimbra, Portugal;
| | - Carmen Jerónimo
- Cancer Biology and Epigenetics Group, IPO Porto Research Center (GEBC CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto) & Porto Comprehensive Cancer Center (P.CCC), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal;
- Department of Pathology and Molecular Immunology, Institute of Biomedical Sciences Abel Salazar, University of Porto (ICBAS-UP), Rua Jorge Viterbo Ferreira 228, 4050-513 Porto, Portugal
- Correspondence: (C.J.); (R.H.); Tel.: +351-22-225084000 (C.J. & R.H.); Fax: +351-22-5084199 (C.J. & R.H.)
| | - Rui Henrique
- Cancer Biology and Epigenetics Group, IPO Porto Research Center (GEBC CI-IPOP), Portuguese Oncology Institute of Porto (IPO Porto) & Porto Comprehensive Cancer Center (P.CCC), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal;
- Department of Pathology, Portuguese Oncology Institute of Porto (IPOP), R. Dr. António Bernardino de Almeida, 4200-072 Porto, Portugal
- Department of Pathology and Molecular Immunology, Institute of Biomedical Sciences Abel Salazar, University of Porto (ICBAS-UP), Rua Jorge Viterbo Ferreira 228, 4050-513 Porto, Portugal
- Correspondence: (C.J.); (R.H.); Tel.: +351-22-225084000 (C.J. & R.H.); Fax: +351-22-5084199 (C.J. & R.H.)
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11
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Fichtner A, Richter A, Filmar S, Gaisa NT, Schweyer S, Reis H, Nettersheim D, Oing C, Gayer FA, Leha A, Küffer S, Ströbel P, Kaulfuß S, Bremmer F. The detection of isochromosome i(12p) in malignant germ cell tumours and tumours with somatic malignant transformation by the use of quantitative real-time polymerase chain reaction. Histopathology 2020; 78:593-606. [PMID: 32970854 DOI: 10.1111/his.14258] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/20/2020] [Accepted: 09/16/2020] [Indexed: 12/18/2022]
Abstract
AIMS Malignant germ cell tumours (GCTs) of the testis are rare neoplasms, but the most common solid malignancies in young men. World Health Organization guidelines divide GCTs into five types, for which numerous immunohistochemical markers allow exact histological subtyping in the majority of cases. In contrast, a germ cell origin is often hard to prove in metastatic GCTs that have developed so-called somatic malignant transformation. A high percentage, up to 89%, of GCTs are characterised by the appearance of isochromosome 12p [i(12p)]. Fluorescence in-situ hybridisation has been the most common diagnostic method for the detection of i(12p) so far, but has the disadvantages of being time-consuming, demanding, and not being a stand-alone method. The aim of the present study was to establish a quantitative real-time polymerase chain reaction assay as an independent method for detecting i(12p) and regional amplifications of the short arm of chromosome 12 by using DNA extracted from formalin-fixed paraffin-embedded tissue. METHODS AND RESULTS A cut-off value to distinguish between the presence and absence of i(12p) was established in a control set consisting of 36 tumour-free samples. In a training set of 149 GCT samples, i(12p) was detectable in 133 tumours (89%), but not in 16 tumours (11%). In a test set containing 27 primary and metastatic GCTs, all 16 tumours with metastatic spread and/or somatic malignant transformation were successfully identified by the detection of i(12p). CONCLUSION In summary, the qPCR assay presented here can help to identify, further characterise and assign a large proportion of histologically inconclusive malignancies to a GCT origin.
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Affiliation(s)
| | - Annika Richter
- Institute of Pathology, University Medical Centre, Göttingen, Germany
| | - Simon Filmar
- Institute of Pathology, University Medical Centre, Göttingen, Germany
| | - Nadine T Gaisa
- Institute of Pathology, RWTH Aachen University, Aachen, Germany
| | | | - Henning Reis
- Institute of Pathology, West German Cancer Centre, University of Duisburg-Essen, University Hospital Essen, Essen, Germany
| | - Daniel Nettersheim
- Department of Urology, Urological Research Laboratory, Translational UroOncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Christoph Oing
- Department of Oncology, Haematology and Bone Marrow Transplantation with Division of Pneumology, Mildred Scheel Cancer Career Centre HaTriCS4, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian A Gayer
- Department of Urology, University Medical Centre, Göttingen, Germany
| | - Andreas Leha
- Institute of Medical Statistics, University Medical Centre, Göttingen, Germany
| | - Stefan Küffer
- Institute of Pathology, University Medical Centre, Göttingen, Germany
| | - Philipp Ströbel
- Institute of Pathology, University Medical Centre, Göttingen, Germany
| | - Silke Kaulfuß
- Institute of Human Genetics, University Medical Centre, Göttingen, Germany
| | - Felix Bremmer
- Institute of Pathology, University Medical Centre, Göttingen, Germany
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12
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Liu X, Fan Z, Li Y, Li Z, Zhou Z, Yu X, Wan J, Min Z, Yang L, Li D. microRNA-196a-5p inhibits testicular germ cell tumor progression via NR6A1/E-cadherin axis. Cancer Med 2020; 9:9107-9122. [PMID: 33034957 PMCID: PMC7724306 DOI: 10.1002/cam4.3498] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/26/2020] [Accepted: 09/08/2020] [Indexed: 12/19/2022] Open
Abstract
Testicular germ cell tumors (TGCTs) are a diverse group of neoplasms that are derived from dysfunctional fetal germ cells and can also present in extragonadal sites. The genetic drivers underlying malignant transformation of TGCTs have not been fully elucidated so far. The aim of the present study is to clarify the functional role and regulatory mechanism of miR‐196a‐5p in TGCTs. We demonstrated that miR‐196a‐5p was downregulated in TGCTs. It can inhibit the proliferation, migration, and invasion of testicular tumor cell lines including NT‐2 and NCCIT through targeting the NR6A1 gene, which we proved its role in promotion of cell proliferation and repression of cellular junction and aggregation. Mechanistically, NR6A1 inhibited E‐cadherin through binding with DR0 sites in the CDH1 gene promoter and recruiting methyltransferases Dnmt1. Further, NR6A1 promoted neuronal marker protein MAP2 expression in RA‐induced neurodifferentiation of NT‐2 cells and testicular tumor xenografts. Clinical histopathologically, NR6A1 was positively correlated with MAP2, and negatively correlated with E‐cadherin in TGCTs. These findings revealed that the miR‐196a‐5p represses cell proliferation, migration, invasion, and tumor neurogenesis by inhibition of NR6A1/E‐cadherin signaling axis, which may be a potential target for diagnosis and therapy of TGCTs.
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Affiliation(s)
- Xiaowen Liu
- Institute of Molecular Medicine and Oncology, College of Biology, Hunan University, Changsha, P.R. China
| | - Ziling Fan
- Institute of Molecular Medicine and Oncology, College of Biology, Hunan University, Changsha, P.R. China
| | - Ye Li
- Institute of Molecular Medicine and Oncology, College of Biology, Hunan University, Changsha, P.R. China
| | - Zhilan Li
- Cancer Research Institute, Xiangya School of Medicine, Central South University, Changsha, P.R. China.,Department of Pathology, Xiangya Hospital, Central South University, Changsha, P.R. China
| | - Zhuan Zhou
- Cancer Research Institute, Xiangya School of Medicine, Central South University, Changsha, P.R. China
| | - Xuehui Yu
- Cancer Research Institute, Xiangya School of Medicine, Central South University, Changsha, P.R. China
| | - Jingyu Wan
- Institute of Molecular Medicine and Oncology, College of Biology, Hunan University, Changsha, P.R. China
| | - Ziqian Min
- Institute of Molecular Medicine and Oncology, College of Biology, Hunan University, Changsha, P.R. China
| | - Lifang Yang
- Cancer Research Institute, Xiangya School of Medicine, Central South University, Changsha, P.R. China
| | - Dan Li
- Institute of Molecular Medicine and Oncology, College of Biology, Hunan University, Changsha, P.R. China
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13
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Skowron MA, Vermeulen M, Winkelhausen A, Becker TK, Bremmer F, Petzsch P, Schönberger S, Calaminus G, Köhrer K, Albers P, Nettersheim D. CDK4/6 inhibition presents as a therapeutic option for paediatric and adult germ cell tumours and induces cell cycle arrest and apoptosis via canonical and non-canonical mechanisms. Br J Cancer 2020; 123:378-391. [PMID: 32418994 PMCID: PMC7403155 DOI: 10.1038/s41416-020-0891-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 04/03/2020] [Accepted: 04/22/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Germ cell tumours (GCTs) are the most common solid malignancies in young men. Although high cure rates can be achieved, metastases, resistance to cisplatin-based therapy and late toxicities still represent a lethal threat, arguing for the need of new therapeutic options. In this study, we analysed the potential of cyclin-dependent kinase 4/6 (CDK4/6) inhibitors palbociclib and ribociclib (PaRi) as molecular drugs to treat cisplatin-resistant and -sensitive paediatric and adult GCTs. METHODS Ten GCT cell lines, including cisplatin-resistant subclones and non-malignant controls, were treated with PaRi and screened for changes in viability (triphenyl tetrazolium chloride (XTT) assay), apoptosis rates (flow cytometry, caspase assay), the cell cycle (flow cytometry), the transcriptome (RNA-sequencing, quantitative reverse transcriptase-polymerase chain reaction (qRT-PCR) and on protein level (western blot). Expression profiling was performed on paediatric and adult GCT tissues (expression microarrays, qRT-PCR, immunohistochemistry, 'The Cancer Genome Atlas' database). RESULTS We demonstrate that adult GCTs highly express CDK4, while paediatric GCTs strongly express CDK6 instead. Thus, both GCT types are potentially treatable by PaRi. GCTs presented as highly sensitive towards PaRi, which caused a decrease in viability, cell cycle arrest and apoptosis. Although GCTs mainly arrested in the G1/G0 phase, some embryonal carcinoma cell lines were able to bypass the G1/S checkpoint and progressed to the G2/M phase. We found that upregulation of CDK3 and downregulation of many mitosis regulation factors, like the HAUS genes, might be responsible for bypassing the G1/S checkpoint and termination of mitosis, respectively. We postulate that GCT cells do not tolerate these alterations in the cell cycle and eventually induce apoptosis. CONCLUSION Our study highlights PaRi as therapeutic options for cisplatin-resistant and -sensitive paediatric and adult GCTs.
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Affiliation(s)
- Margaretha A Skowron
- Department of Urology, Urological Research Lab, Translational UroOncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Marieke Vermeulen
- Department of Urology, Urological Research Lab, Translational UroOncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Anna Winkelhausen
- Department of Urology, Urological Research Lab, Translational UroOncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Teresa K Becker
- Department of Urology, Urological Research Lab, Translational UroOncology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Felix Bremmer
- Institute of Pathology, University Medical Center Goettingen, Goettingen, Germany
| | - Patrick Petzsch
- Genomics and Transcriptomics Lab, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Stefan Schönberger
- Department of Pediatric Hematology and Oncology, University Hospital Bonn, Bonn, Germany
| | - Gabriele Calaminus
- Department of Pediatric Hematology and Oncology, University Hospital Bonn, Bonn, Germany
| | - Karl Köhrer
- Genomics and Transcriptomics Lab, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Peter Albers
- Department of Urology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Daniel Nettersheim
- Department of Urology, Urological Research Lab, Translational UroOncology, University Hospital Düsseldorf, Düsseldorf, Germany.
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