HIGH-THROUGHPUT SCREENING FOR NOVEL ANTI-CANCER ... · high-throughput screening (HTS) approach....
Transcript of HIGH-THROUGHPUT SCREENING FOR NOVEL ANTI-CANCER ... · high-throughput screening (HTS) approach....
HIGH-THROUGHPUT SCREENING FOR NOVEL
ANTI-CANCER RADIOSENSITIZERS FOR
HEAD AND NECK CANCER
by
Emma Ito
A thesis submitted in conformity with the requirements for the degree of
Doctor of Philosophy
Graduate Department of Medical Biophysics
University of Toronto
© Copyright by Emma Ito 2010
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High-Throughput Screening for Novel Anti-Cancer Radiosensitizers for Head and Neck
Cancer
Emma Ito
Doctor of Philosophy
Department of Medical Biophysics
University of Toronto
2010
ABSTRACT
Despite advances in therapeutic options for head and neck cancer (HNC), treatment-
associated toxicities and overall clinical outcomes have remained disappointing. Even with
radiation therapy (RT), which remains the primary curative modality for HNC, the most
effective regimens achieve local control rates of 4555%, with disease-free survival rates of
only 3040%. Thus, the development of novel strategies to enhance tumor cell killing, while
minimizing damage to the surrounding normal tissues, is critical for improving cure rates with
RT. Accordingly, we sought to identify novel radiosensitizing therapies for HNC, exploiting a
high-throughput screening (HTS) approach.
Initially, a cell-based phenotype-driven HTS of ~2,000 commercially available natural
products was conducted, utilizing the short-term MTS cell viability assay. Cetrimonium
bromide (CTAB) was identified as a novel anti-cancer agent, exhibiting in vitro and in vivo
efficacy against several HNC models, with minimal effects on normal fibroblasts. Two major
limitations of our findings, however, were that CTAB did not synergize with radiation, nor
was its precise cellular target(s) elucidated.
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Consequently, an alternative strategy was proposed involving a target-driven RNAi-
based HTS. Since the colony formation assay (CFA) is the gold standard for measuring
cellular effects of radiation in vitro, an automated high-throughput colony-formation read-out
was developed as a more appropriate end-point for radiosensitivity. Although successful as a
tool for the discovery of potent anti-cancer cytotoxics, a technical drawback was its limited
dynamic range. Thus, the BrdU incorporation assay, which measures replicative DNA
synthesis and is a viable CFA alternative, was employed. From an RNAi-based screen of
~7000 human genes, uroporphyrinogen decarboxylase (UROD), a key regulator of heme
biosynthesis, was identified as a novel tumor-selective radiosensitizing target against HNC in
vitro and in vivo. Radiosensitization appeared to be mediated via tumor-selective enhancement
of oxidative stress from perturbation of iron homeostasis and increased ROS production.
UROD was significantly over-expressed in HNC patient biopsies, wherein lower pre-RT
UROD levels correlated with improved disease-free survival, suggesting that UROD
expression could also be a potential predictor for radiation response.
Thus, employing a HTS approach, this thesis identified two novel therapeutic strategies
with clinical potential in the management of HNC.
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ACKNOWLEDGEMENTS
First and foremost, I would like to express my sincere gratitude towards my PhD
supervisor, Dr. Fei-Fei Liu, for her mentorship and professional support throughout the last
four years. My academic achievements and growth as an independent researcher would not
have been made possible without her invaluable guidance and encouragement. She will
continue to be a role model in my personal life and career development. I would also like to
thank the members of my supervisory committee, Dr. Aaron Schimmer and Dr. Anne Koch,
for their guidance and integral role in the completion of my PhD degree. Further, I wish to
acknowledge the members of my examination committee for their time and commitment
towards my thesis defense: Dr. Ernest Lam (Chair), Dr. Laurie Ailles (Medical Biophysics
Examiner), Dr. Meredith Irwin (University of Toronto Examiner), and Dr. Martin Gleave
(External Examiner).
Many present and past members of the Liu lab have contributed immensely to this
thesis. In particular, I would like to thank Angela Hui, Inki Kim, Nehad Alajez, Willa Shi,
Winnie Yue, David Katz, Ken Yip, Joe Mocanu, and Carlo Bastianutto for their conceptual
and technical advice. Other colleagues who have provided guidance and support along the way
include Eduardo Moriyama, Ken Lau, Alessandro Datti, Thomas Sun, and Frederick
Vizeacoumar.
Finally and most importantly, I would like to extend a special thanks to my father
(Hiroshi Ito), mother (Sumiko Ito), brother (Ryoma Ito), and best friend (Ryan Lim) for their
love and continued encouragement. They have been with me on every step of this journey and
I will always be grateful for their steadfast support. I dedicate this thesis to them.
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TABLE OF CONTENTS
ABSTRACT… ............................................................................................................................... II
ACKNOWLEDGEMENTS ....................................................................................................... IV TABLE OF CONTENTS ............................................................................................................ V LIST OF TABLES ...................................................................................................................... IX LIST OF FIGURES ..................................................................................................................... X LIST OF ABBREVIATIONS .................................................................................................... XI
CHAPTER 1: INTRODUCTION ................................................................................................ 1
1.1 Radiation Therapy .................................................................................................................. 2
1.1.1 Background ................................................................................................................ 2
1.1.2 Radiation Biology ...................................................................................................... 2
1.1.3 Cellular Response to Radiation ................................................................................. 4
1.1.3.1 DNA Damage Surveillance ......................................................................... 5
1.1.3.2 DNA Damage Cell Cycle Checkpoints ....................................................... 7 1.1.3.3 DNA Repair ............................................................................................... 10 1.1.3.4 Radiation-Induced Cell Death .................................................................. 13
1.2 Modulation of Radiation Response ...................................................................................... 14
1.2.1 Background .............................................................................................................. 14
1.2.2 Chemical Radiosensitizers ....................................................................................... 15
1.2.2.1 Oxygen ...................................................................................................... 17 1.2.2.2 Halogenated Pyrimidines.......................................................................... 20
1.2.2.3 Modifiers of Microtubule Structure and Function .................................... 22 1.2.2.4 Modifiers of the Nature or Repair of DNA Damage ................................. 23 1.2.2.5 Targets of Cell Signaling Pathways .......................................................... 25
1.3 High-Throughput Screens .................................................................................................... 27
1.3.1 Background .............................................................................................................. 27
1.3.2 Phenotype-Based High-Throughput Screens ........................................................... 29
1.3.3 Target-Based High-Throughput Screens ................................................................. 30
1.3.4 RNA Interference Screens ........................................................................................ 31
1.3.5 Radiosensitizer Discovery Screens .......................................................................... 32
1.4 Head and Neck Cancer......................................................................................................... 33
1.4.1 Background .............................................................................................................. 33
1.4.2 Treatment ................................................................................................................. 33
1.4.2.1 Radiation Therapy .................................................................................... 34 1.4.2.2 Chemotherapy ........................................................................................... 35 1.4.2.3 Molecularly-Targeted Agents ................................................................... 36
1.5 Research Objectives ............................................................................................................. 37
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CHAPTER 2: POTENTIAL USE OF CETRIMONIUM BROMIDE AS AN
APOPTOSIS-PROMOTING ANTICANCER AGENT FOR HEAD AND
NECK CANCER ................................................................................................. 40
2.1 Chapter Abstract .................................................................................................................. 41
2.2 Introduction .......................................................................................................................... 41
2.3 Materials and Methods ......................................................................................................... 43
2.3.1 Cell Lines ................................................................................................................. 43
2.3.2 Small Molecules ....................................................................................................... 43
2.3.3 Small-Molecule High-Throughput Screening .......................................................... 44
2.3.4 Cell Viability Assay .................................................................................................. 45
2.3.5 Colony Formation Assay.......................................................................................... 45
2.3.6 Fluorescence Microscopy ........................................................................................ 45
2.3.7 Caspase Activity Assay ............................................................................................ 46
2.3.8 Cell Cycle Analysis .................................................................................................. 46
2.3.9 Transmission Electron Microscopy ......................................................................... 46
2.3.10 Mitochondrial Depolarization, Calcium Content, and Propidium Iodide Uptake .. 47
2.3.11 ATP Synthase Activity Assay .................................................................................... 47
2.3.12 ATP Luminescence Assay ........................................................................................ 47
2.3.13 Plasma and Mitochondrial Membrane Potential Assays......................................... 48
2.3.14 In Vivo Tumor Model ............................................................................................... 48
2.3.15 Tumor Formation Assay .......................................................................................... 49
2.3.16 Therapeutic Tumor Growth Assay ........................................................................... 49
2.3.17 Statistical Analyses .................................................................................................. 50
2.4 Results .................................................................................................................................. 50
2.4.1 High-Throughput Screening .................................................................................... 50
2.4.2 Validation of HTS Hits and Evaluation of Anti-Cancer Specificity ......................... 51
2.4.3 Evaluation of Combination Therapy ........................................................................ 52
2.4.4 Cetrimonium Bromide Induces Apoptosis ............................................................... 54
2.4.5 Cetrimonium Bromide Perturbs Mitochondrial Function ....................................... 58
2.4.6 Role of M in Cetrimonium Bromide-Mediated Cell Death ................................. 60
2.4.7 Elimination of Tumor Formation ............................................................................. 62
2.4.8 Growth Delay in Established Xenograft Tumors ..................................................... 62
2.4.9 In Vivo Safety and Toxicity ...................................................................................... 63
2.4.10 Evaluation of Cetrimonium Bromide Analogues ..................................................... 65
2.5 Discussion ............................................................................................................................ 67
2.6 Acknowledgments................................................................................................................ 72
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CHAPTER 3: INCREASED EFFICIENCY FOR PERFORMING COLONY
FORMATION ASSAYS IN 96-WELL PLATES - NOVEL
APPLICATIONS TO COMBINATION THERAPIES AND HIGH-
THROUGHPUT SCREENING ......................................................................... 73
3.1 Chapter Abstract .................................................................................................................. 74
3.2 Introduction .......................................................................................................................... 74
3.3 Materials and Methods ......................................................................................................... 76
3.3.1 Cell Lines ................................................................................................................. 76
3.3.2 6-Well Colony Formation Assay .............................................................................. 77
3.3.3 96-Well Colony Formation Assay ............................................................................ 77
3.3.4 High-Throughput Screening .................................................................................... 78
3.4 Results and Discussion ........................................................................................................ 79
3.5 Acknowledgements .............................................................................................................. 88
CHAPTER 4: UROPORPHYRINOGEN DECARBOXYLASE - A NOVEL
RADIOSENSITIZING TARGET FOR HEAD AND NECK CANCER
IDENTIFIED FROM AN RNAI HIGH-THROUGHPUT SCREEN ............ 90
4.1 Chapter Abstract .................................................................................................................. 91
4.2 Introduction .......................................................................................................................... 91
4.3 Materials and Methods ......................................................................................................... 93
4.3.1 Cell Lines ................................................................................................................. 93
4.3.2 Patient Samples ........................................................................................................ 93
4.3.3 Reagents ................................................................................................................... 94
4.3.4 BrdU-Based siRNA High-Throughput Screen ......................................................... 94
4.3.5 Transfections ............................................................................................................ 95
4.3.6 Flow Cytometric Assays ........................................................................................... 95
4.3.7 γ-H2AX Detection .................................................................................................... 95
4.3.8 Hypoxia Treatment................................................................................................... 96
4.3.9 Iron Histochemistry ................................................................................................. 96
4.3.10 Porphyrin Detection................................................................................................. 96
4.3.11 Quantitative Real-Time PCR ................................................................................... 96
4.3.12 Western Blot Analysis .............................................................................................. 97
4.3.13 Colony Formation Assay.......................................................................................... 97
4.3.14 Cell Viability Assay .................................................................................................. 98
4.3.15 In Vivo Tumor Model ............................................................................................... 98
4.3.16 Tumor Formation Assay .......................................................................................... 98
4.3.17 Therapeutic Tumor Growth Assay ........................................................................... 98
4.3.18 In Vivo Knockdown Validation ................................................................................ 99
4.3.19 Statistical Analyses .................................................................................................. 99
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4.4 Results ................................................................................................................................ 100
4.4.1 High-Throughput Screening for Novel Radiosensitizers ....................................... 100
4.4.2 UROD is a Potent Radiosensitizing Target for HNC ............................................ 101
4.4.3 siUROD-Mediated Radiosensitization Differs from Photodynamic Therapy ........ 104
4.4.4 UROD Down-Regulation Promotes Radiation-Induced Apoptosis ....................... 107
4.4.5 siUROD-Mediated Radiosensitization Increases Cellular Oxidative Stress ......... 109
4.4.6 UROD Knockdown Perturbs Cellular Iron Homeostasis ...................................... 112
4.4.7 siUROD Radiosensitizes HNC Models In Vivo ..................................................... 115
4.4.8 UROD Knockdown Modulates Radiosensitivity of Several Cancer Models ......... 118
4.4.9 Clinical Implications of UROD in HNC ................................................................ 119
4.5 Discussion .......................................................................................................................... 121
4.6 Acknowledgments.............................................................................................................. 125
CHAPTER 5: DISCUSSION ................................................................................................... 126
5.1 Research Summary ............................................................................................................ 127
5.2 Future Directions ............................................................................................................... 128
5.2.1 Empirical to Target-Driven Cancer Drug Discovery ............................................ 128
5.2.2 RNAi in Drug Discovery and Therapeutics ........................................................... 130
5.2.3 Clinical Trials for Molecularly-Targeted Therapies ............................................. 133
5.2.4 Developing UROD as a Therapeutic Radiosensitizing Target .............................. 134
5.3 Conclusions ........................................................................................................................ 136
REFERENCES .......................................................................................................................... 137
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LIST OF TABLES
Table 2.1 HTS of the Spectrum Collection small molecule library for novel HNC cytotoxics .. 51
Table 3.1 Comparison of 96-well and 6-well clonogenic assays................................................. 84 Table 3.2 Confirmed hits in the LOPAC1280 library ................................................................. 88
Table 4.1 Primer sequences for mRNA expression analyses ...................................................... 97
Table 4.2 Top-scoring associated network functions ................................................................ 101 Table 4.3 Top scoring molecular and cellular functions ............................................................ 101
Table 5.1 Comparison of therapeutic modalities ....................................................................... 133
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LIST OF FIGURES
Figure 1.1 Direct and indirect effects of ionizing radiation on DNA ............................................ 4
Figure 1.2 DNA damage recognition pathway .............................................................................. 6 Figure 1.3 Cell cycle checkpoint pathways ................................................................................... 9 Figure 1.4 Double-strand break DNA repair pathways ............................................................... 12 Figure 1.5 Therapeutic ratio of radiosensitizing agents ............................................................... 16 Figure 1.6 High-throughput screening approaches ...................................................................... 28
Figure 2.1 Characterization of CTAB as a potential anti-cancer agent for HNC ........................ 53 Figure 2.2 Cetrimonium bromide induces apoptosis in human HNC cells ................................. 55
Figure 2.3 Evaluation of cetrimonium bromide-mediated apoptosis........................................... 57 Figure 2.4 Cetrimonium bromide induces mitochondrial dysfunction ........................................ 59
Figure 2.5 Role of M in cetrimonium bromide-mediated apoptosis ....................................... 61 Figure 2.6 In vivo efficacy of cetrimonium bromide ................................................................... 64 Figure 2.7 Anti-cancer efficacy of cetrimonium bromide analogues .......................................... 66
Figure 3.1 Schematic representation of the 96-well colony formation assay .............................. 81
Figure 3.2 Reproducibility of a 96-well CFA compared to a traditional 6-well CFA ................. 83 Figure 3.3 Dose response curves created using the 96-well CFA ............................................... 87
Figure 4.1 Identification of UROD as a novel radiosensitizing target ...................................... 103
Figure 4.2 Radiosensitizing effect of UROD knockdown is independent of porphyrin
accumulation ............................................................................................................. 106 Figure 4.3 UROD down-regulation promotes radiation-induced cytotoxicity .......................... 108
Figure 4.4 siUROD-mediated radiosensitization enhances cellular oxidative stress ................ 111 Figure 4.5 UROD knockdown induces intracellular iron accumulation.................................... 114 Figure 4.6 In Vivo efficacy of UROD knockdown plus irradiation in HNC models ................. 117
Figure 4.7 Clinical relevance of UROD in human cancers ....................................................... 120
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LIST OF ABBREVIATIONS
M Mitochondrial membrane potential
P Plasma membrane potential
-H2AX Gamma-H2AX
-ray Gamma ray
2D Two-dimensional
3D Three-dimensional
5-FU 5-fluorouracil
53BP1 P53 binding protein 1 60
Co Cobalt-60
AKT V-akt murine thymoma viral oncogene
ALA -aminolevulinic acid hydrochloride
ANOVA Analysis of variance
ASO Anti-sense oligonucleotide
ATM Ataxia telangiectasia mutated
ATP Adenosine-5'-triphosphate
ATPase ATP synthase
ATR Ataxia telangiectasia and Rad3-related
ATRIP ATR interacting protein
BAX BCL2-associated X protein
Bcl-2 B-cell leukemia/lymphoma 2
Br Bromo
BRCA1 Breast cancer 1
BrdU 5-bromo-2-deoxyuridine
Ca2+
Calcium
CCCP Carbonyl cyanide m-chlorophenylhydrazone
CDC25A Cell division cycle 25 homolog A
CDC25C Cell division cycle 25 homolog C
CDK Cyclin-dependent kinase
CFA Colony formation assay
CHK1 Checkpoint kinase 1
CHK2 Checkpoint kinase 2
CI Combination index
Cl Chloro
C-Map Connectivity Map
CM-H2DCFDA 5-(and 6-)chloromethyl-2,7-dichlorodihydrofluorescein diacetate
CML Chronic myelogenous leukemia
CPOX Coproporphyrinogen oxidase
CT Computed-tomography
CTAB Cetrimonium bromide
dATP Deoxyadenosine triphosphate
DDR DNA-damage response
DE Dihydroethidium
DFO Deferoxamine mesylate salt
DFS Disease-free survival
DiBAC4(3) Bis-(1,3-dibutylbarbituric acid)trimethine oxonol
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DiIC1(5) 1,1,3,3,3,3-hexamethylindodicarbocyanine
DLC Delocalized lipophilic cation
DMSO Dimethyl sulfoxide
DNA-PKCS DNA-dependent protein kinase catalytic subunit
dNTP Deoxyribonucleotide triphosphate
DSB Double-strand break
dsDNA Double-stranded DNA
dUrd Deoxyuridine
LIG4 DNA ligase IV
EC Effective concentration
EGFR Epidermal growth factor receptor
EM Electromagnetic
ER Endoplasmic reticulum
FdUMP 5-fluoro-2-deoxyuridine monophosphate
FdUrd Fluoro-deoxyuridine
Fe2+
Ferrous iron
Fe3+
Ferric iron
FFPE Formalin-fixed paraffin-embedded
FTI Farnesyltransferase inhibitor
FTMT Mitochondrial ferritin
GPX1 Glutathione peroxidase
Gy Gray unit
h Hours
H2O2 Hydrogen peroxide
HBO Hyperbaric oxygen
HER2 Human epidermal growth factor receptor 2
HIF-1 Hypoxia-inducible transcription factor-1
HNC Head and neck cancer
HP Halogenated pyrimidine
HPV Human papillomavirus
HR Homologous recombination
HRE Hypoxia response element
HTS High-throughput screen
I Iodo
IGFR Insulin-like growth factor receptor
IMRT Intensity-modulated radiation therapy
IP Intraperitoneal
IR Ionizing radiation
IV Intravenous
JC-1 5,5,6,6-tetrachloro-1,1,3,3-tetraethylbenzimidazolylcarbocyanine
iodide
kDa Kilodalton
kV Kilovolt
LIG4 DNA ligase IV complex
mA Milliamp
MAP Mitogen-activated protein
MDC1 Mediator of DNA-damage checkpoint 1
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MGMT O6-methylguanine DNA-methyltransferase
MOMP Mitochondrial outer membrane permeabilization
MRE11 Meiotic recombination 11
MRN MRE11–RAD50–NBS1
mRNA Messenger RNA
mTOR Mechanistic target of rapamycin
MTS 3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-
sulfophenyl)-2H-tetrazolium, inner salt
NBS1 Nijmegen breakage syndrome 1 (nibrin)
NCI-DTP National Cancer Institute Developmental Therapeutics Program
NHEJ Non-homologous end joining
NIG Nigericin
NOE Normal oral epithelial
NOP Normal oropharyngeal
NPC Nasopharyngeal cancer
NSCLC Non-small cell lung cancer
OER Oxygen enhancement ratio
OLIG Oligomycin
OXPHOS Oxidative phosphorylation
PARP-1 Poly(ADP-ribose) polymerase-1
PBS Phosphate-buffered saline
PCT Porphyria cutanea tarda
PDT Photodynamic therapy
PFA Paraformaldehyde
PI Propidium iodide
PI3K Phosphoinositide 3 kinase
PIDD P53-induced protein with a death domain
PLK1 Polo-like kinase 1
PPIX Protoporphyrin IX
PPOX Protoporphyrinogen oxidase
PTP Permeability transition pore
PUMA p53-upregulated modulator of apoptosis
qRT-PCR Quantitative real-time PCR
RAD50 RAD50 homolog
Ras Rat sarcoma
RER Radiation enhancement ratio
RNAi RNA interference
RPA Replication protein A
RT Radiation therapy
s Seconds
SAPK Stress-activated protein kinase
SCID Severe combined immunodeficient
SD Standard deviaion
SEM Standard error of the mean
shRNA Small hairpin RNA
siCTRL Scrambled control siRNA
siRNA Small interfering RNA
siUROD UROD siRNA
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SLRI Samuel Lunenfeld Research Institute
SOD Superoxide dismutase
SRB Sulforhodamine B
SSB Single-strand break
ssDNA Single-stranded DNA
TLD Tumor-plus-leg diameter
TOP1 DNA topoisomerase 1
TOPBP1 Topoisomerase II binding protein 1
TP Thymidine phosphorylase
TP53 Tumor protein 53
TS Thymidylate synthase
UROD Uroporphyrinogen decarboxylase
UV Ultraviolet
VEGF Vascular endothelial growth factor
VEGFR Vascular endothelial growth factor receptor
WEE1 WEE1 homolog
XLF Cernunnos
XRCC4 X-ray repair complementing defective repair in Chinese hamster cells 4
Z-VAD.FMK Benzyloxycarbonyl-valine-alanine-aspartate fluoromethylketone
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CHAPTER 1: INTRODUCTION
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1.1 Radiation Therapy
1.1.1 Background
Since the discovery of x-rays by German physicist, Wilhelm Conrad Roentgen in 1895,
x-ray technology has continued to evolve and revolutionize modern medicine. Since that time,
their clinical usefulness as a means of cancer treatment has developed into a recognized
medical specialty. Today, radiation therapy (RT) is a mainstay in the standard anti-cancer
therapeutic armamentarium, providing critical curative, adjuvant, and palliative roles in cancer
patient care. In the clinical setting, RT can be delivered as single or multiple treatments of
high-energy radiation to targeted areas of the patient’s body, with the ultimate aim of attaining
the highest probability of cure with the least morbidity. Thus, the dose of radiation that can be
delivered to a tumor is often limited by tolerance of the surrounding normal tissues and the
consequent risk of complications [1]. Over the past decade however, rapid advances in
radiation treatment planning and delivery have markedly improved patient outcomes,
particularly in reducing treatment-associated morbidities [2].
1.1.2 Radiation Biology
Ionizing radiation (IR) is radiation that has sufficient energy to remove electrons from
atoms [1]. Clinical radiotherapy typically utilizes IR to treat cancer patients, wherein waves or
packets of energy in the form of photons are delivered to a pre-defined tumor volume. Sources
of photons generally include x-rays (linear accelerators) and -rays (radioactive decay of 60
Co),
both of which are forms of electromagnetic (EM) radiation. X-ray and -ray photons have
essentially the same properties, but differ in origin; x-rays are emitted by electrons outside the
atomic nuclei (electronic shell), while -rays are released from unstable nuclei [1].
At the molecular level, when x-rays or -rays are absorbed by biological tissues, they
can directly ionize a critical site causing localized damage (direct effect) or interact with other
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molecules to produce reactive free radicals (molecules with unpaired electrons), which can
subsequently damage key biological molecules (indirect effect) (Figure 1.1). Indirect effects
account for ~80% of the damage inferred by a given exposure of IR [3]. Since cells are
predominantly composed of water (~80%), the majority of the energy deposited is initially
absorbed by water (radiolysis), leading to the rapid generation (10-1410
-4 s) and propagation
of reactive radical species, with hydroxyl radicals (●OH) being the most lethal. Although IR is
capable of damaging a variety of intracellular molecules, DNA is considered to be the critical
target of both direct and indirect processes, resulting in DNA single- (SSB) or double-strand
breaks (DSB), DNA base damage, and/or DNADNA or DNAprotein cross-links [4, 5].
DSBs in DNA are considered highly mutagenic and the most lethal type of radiation lesion;
cell lethality following IR has been shown to correlate with the level of residual DSBs [6]. It is
estimated that each gray unit (1 Gy) of radiation produces ~105 ionization events per cell,
leading to ~10003000 DNADNA or DNAprotein cross-links, 1000 damaged DNA bases,
5001000 SSBs, and 2550 DSBs [1].
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Figure 1.1 Direct and indirect effects of ionizing radiation on DNA
Ionizing radiation induces direct DNA damage, and indirect damage via generation of reactive
free radicals (e.g. hydroxyl radical, ●OH) from secondary chemical reactions around the DNA,
often involving water radiolysis. These free radicals can in turn, react chemically with DNA to
induce damage. Indirect and direct damage can lead to DNA single- and double-strand breaks,
base damage, DNA-DNA or DNA-protein cross-links. This figure is adapted from [7].
1.1.3 Cellular Response to Radiation
Upon exposure to ionizing radiation, a complex cellular DNA-damage response (DDR)
cascade, involving genomic surveillance and repair mechanisms is triggered, in an effort to
maintain genetic integrity and stability. In the presence of sublethal chromosome aberrations,
the induction of cell cycle arrest prevents DNA replication and mitosis, providing time for
DNA repair. In cases where the damage is severe and irreparable, the cells irrevocably undergo
cell death. The following sections will focus on the intricate processes involved in cellular
response to radiation-induced DNA damage.
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1.1.3.1 DNA Damage Surveillance
Irradiation-induced DSB lesions are first detected by the heterotrimeric MRN
(MRE11–RAD50–NBS1) complex, which is the primary DNA damage sensor (Figure 1.2).
The recruitment of MRN activates the key DDR signaling kinase ATM (ataxia telangiectasia
mutated), which associates with DSBs and phosphorylates the histone variant H2AX (-
H2AX) at nucleosomes flanking the DSB [8]. The activated ATM then triggers two pathways
(chromatin-response vs. DSB resection), culminating in local chromatin rearrangements and
DNA processing; events essential for initiating DSB repair, checkpoint and cell death
signaling.
In the chromatin-response pathway (CDK-independent), the MDC1 mediator protein
binds to γ-H2AX and recruits additional MRN and ATM proteins, as well as multiple
checkpoint/adaptor proteins (e.g. NBS1, 53BP1, and BRCA1) at sites of DNA breaks,
providing a molecular platform for the efficient amplification of the DNA damage signal [9,
10]. The locally accumulated active ATM then phosphorylates many targets, including the
effector kinase CHK2, to further spread the damage signal [11].
Double-strand break resection can also occur following the recruitment of MRN and
ATM at the DNA lesion. This process requires the activity of cyclin-dependent kinases
(CDK), and is restricted to the S and G2 phases of the cell cycle [12]. DSB resection creates
stretches of single-stranded DNA (ssDNA) that become coated and stabilized by the ssDNA-
binding protein, replication protein A (RPA); forming the critical structural intermediate for
DNA repair by homologous recombination (HR) and ATR (ataxia telangiectasia and Rad3-
related)-dependent signaling [12]. The ssDNARPA scaffold facilitates the recruitment of
ATR through its interacting partner ATRIP [13]. ATR is subsequently activated by TopBP1,
which is also recruited to the ssDNA [14]. The activated ATR is then able to target
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downstream substrates, including the effector signaling kinase CHK1 via the Claspin mediator
protein [15]. Both the ATM- and ATR-dependent branches of the pathway, independently or
in concert, orchestrate the DNA repair, cell death, and checkpoint responses in the damaged
cell.
Figure 1.2 DNA damage recognition pathway
DSBs are initially detected by the MRN sensor complex, which activates the transducer kinase
ATM. ATM phosphorylates histone H2AX in the DSB-flanking chromatin, which serves as a
docking platform for the MDC1 mediator protein. MDC1 recruits more MRN and ATM, as
well as other DDR proteins (e.g. 53BP1 and BRCA1), spreading the damage response
machinery along the chromosome. DSB resection can also occur following MRNATM
recruitment at the break site, wherein ssDNA is formed and stabilized by RPA, which in turn
facilitates recruitment of the ATR-ATRIP complex. Both the ATM- and ATR-dependent
pathways, independently or jointly, orchestrate the DNA repair, cell death, and checkpoint
responses in the damaged cell via downstream effector kinases, CHK1 and CHK2. This figure
is adapted from [11].
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1.1.3.2 DNA Damage Cell Cycle Checkpoints
Following DSB-recognition, accurate genome duplication is controlled by several cell-
cycle checkpoints to prevent cells from initiating DNA replication (G1S checkpoint),
progressing with replication (S checkpoint), or entering mitosis (G2M checkpoint) [16]. As
described above, radiation-activated ATM/ATR proteins phosphorylate the CHK2/CHK1
kinases, which in turn target downstream effectors that affect cell cycle progression (Figure
1.3).
At the G1-phase checkpoint, the dominant response to radiation-induced DNA damage
is the stabilization and activation of P53, a tumor suppressor protein. Initial checkpoint signals
originating from ATM and ATR are transmitted to P53 both directly, and indirectly via CHK2
and CHK1. Phosphorylation of P53 prevents the onset of S-phase via transcriptional up-
regulation of P21, an inhibitor of the CDK4cyclin D and CDK2cyclin E complexes
necessary for S-phase initiation [17]. ATM can also directly phosphorylate and inhibit MDM2,
an ubiquitin ligase of P53, preventing proteasome-mediated P53 degradation [18]. CHK2-
induced P53 phosphorylation further blocks P53MDM2 interactions, promoting nuclear P53
accumulation [19]. The role of ATR-activated CHK1 kinase in P53 phosphorylation and
subsequent stabilization has been demonstrated, but is less well-defined [20].
The S-phase checkpoint is of particular importance since this is when duplication of the
genome takes place. At least two parallel pathways involved in attenuating S-phase in
response to DNA damage and replication disruption have been identified:
ATMCHK2CDC25A and ATMNBS1/BRCA1/SMC1; with the former and latter
pathways communicating to the cell cycle and DNA replication machinery, respectively [21,
22]. Upon exposure to IR, ATM-activated CHK2 phosphorylates and promotes ubiquitin-
dependent degradation of the CDC25A phosphatase, a major regulator of CDK2 activation,
8
which is essential for the assembly of the replication initiation complex during S-phase
initiation and progression (via CDK2cyclin E/A complexes) [22]. ATM-mediated
phosphorylation of NBS1, BRCA1, and SMC1 can also arrest cells in S-phase following IR-
induced damage, wherein NBS1 and BRCA1 are required for optimal ATM-directed
phosphorylation and activation of SMC1, a downstream effector in the ATM/NBS1/BRCA1-
dependent S-phase checkpoint pathway [21]. The precise roles of these proteins and the
mechanism of this pathway remain to be elucidated. Although the involvement of ATR in the
S-phase checkpoint is also relatively undefined, ATR has been shown to initiate a slow IR-
induced S-phase checkpoint response via CHK1 phosphorylation, which in turn
phosphorylates CDC25A, targeting it for degradation [23].
The G2M phase checkpoint primarily serves to allow time for DNA repair prior to
mitosis entry, minimizing the extent of DNA damage passed on to daughter cells. The
ATRCHK1CDC25C/WEE1 pathway involves radiation-activated CHK1 phosphorylation
of the CDC25C phosphatase, which normally dephosphorylates CDK1 and activates the
CDK1cyclin B complex, a major mitosis-promoting factor [24]. CHK1-mediated CDC25C
phosphorylation results in the cytoplasmic sequestration of CDC25C via inhibitory binding by
14-3-3-, providing an effective G2M block upon recognition of DNA damage [24]. P53
reinforces the G2-checkpoint through its transcriptional up-regulation of 14-3-3- [25]. CHK1
also phosphorylates and activates the WEE1 kinase, which maintains the CDK1cyclin B
complex in an inactive form, delaying mitotic entry [26]. Similar to ATR, ATM can also
contribute to the G2M checkpoint through the ATMCHK2CDC25C pathway [27].
9
Figure 1.3 Cell cycle checkpoint pathways
In response to ionizing radiation-induced DNA damage, ATM and/or ATR trigger the
activation of a cell cycle checkpoint. These pathways are characterized by cascades of protein
phosphorylation events (P) that alter the activity, stability, or localization of the modified
protein. A simplified overview of the G1-, S-, and G2-phase checkpoint pathways is
illustrated. This figure is adapted from [16].
10
1.1.3.3 DNA Repair
The two major mechanisms involved in DSB repair are homologous recombination and
non-homologous end joining (NHEJ) (Figure 1.4). HR is a highly precise repair process
occurring primarily during the SG2 phase of the cell cycle, which relies on the presence of
extensive regions of DNA sequence homology on the undamaged sister chromatid or
homologous chromosome to use as a template [28]. In contrast, NHEJ is an error-prone
process predominant in the G1 phase that does not require the presence of a homologous
template; it is the major pathway for repairing non-replication-associated breaks [29].
During HR, a DNA lesion is recognized by the MRN complex, which is recruited to
the DSB to process the DNA ends via resection, generating 3 ssDNA tails [30]. These 3
overhangs are coated by RPA, to prevent secondary structure formation. RPA is subsequently
replaced by the RAD51 recombinase via mediator proteins, including RAD52 [31]. The
resulting RAD51 nucleoprotein filament undergoes an ATP-driven invasion of a homologous
double-stranded template to create a joint molecule intermediate that entails heteroduplex
DNA (D-loop) [32]; this process is mediated by the RAD54 helicase, which promotes invasion
and the dissociation of RAD51 off the dsDNA resulting from the strand-transfer reaction [33].
After strand invasion, a DNA polymerase extends the invading 3 strand, forming a Holliday
junction. Capture of the second resected ssDNA tail into the joint molecule is mediated via
RAD52, which facilitates annealing of the displaced strand with the other end of the DSB,
producing double Holliday junctions [31]. Ligation and resolution of the joint homologous
recombination partners via nicking endonucleases yields two intact DNA duplexes, ultimately
restoring the homologous template and genetic information that was disrupted by the DSB
[28].
11
NHEJ-directed repair is initiated by the binding of the Ku70-Ku80 heterodimeric
complex to both ends of a DSB. The DNA-Ku scaffold subsequently recruits the DNA-
dependent protein kinase catalytic subunit (DNA-PKCS) to the DSB, activating its kinase
activity and multiple roles [29]. DNA-PKCS is involved in the formation of the synaptic
complex, consisting of two DNA ends, two Ku70Ku80 and two DNA-PKCS molecules,
which brings both DNA ends together. Once the two DNA ends have been captured and
tethered, non-compatible DNA ends are processed to form ligatable termini before final repair
of the DSB can occur. Several processing enzymes have been identified, including Artemis,
polynucleotide kinase, and DNA polymerases of the Pol X family [29]; the exact roles and
mechanisms of these end-processors have not been fully elucidated. Finally, recruitment of the
XRCC4DNA ligase IV complex and XLF (LIG4XRCC4 binging protein) by DNA-PKCS,
allows for the final ligation step of the processed DNA ends [34].
12
Figure 1.4 Double-strand break DNA repair pathways
(A) During homologous recombination, DNA ends are first processed by the MRN complex to
create 3 single-strand overhangs, which are bound by RPA. RAD52 mediates RAD51-
recruitment to the ssDNA to form a nucleoprotein filament, which searches for homologous
DNA, leading to strand invasion, strand exchange, and joint molecule formation. Template-
guided DNA synthesis, ligation, and resolution of the two double helices joined by strand
exchange complete the repair of the DSB. (B) Non-homologous end-joining brings the ends of
the DSB together by initial recruitment of the Ku70Ku80 complex and DNA-PKCS. After
synaptic complex formation, non-compatible DNA ends are processed to form ligatable
termini, followed by the repair of the break by the XRCC4DNA ligase IV complex. This
figure is adapted from [28].
13
1.1.3.4 Radiation-Induced Cell Death
Following exposure to IR, cells can undergo apoptosis, mitotic catastrophe, and/or
terminal cell arrest (senescence-like phenotype). The extent to which one mode of cell death
predominates over another is unclear, but may be influenced by cell type, radiation dose, and
the cell’s microenvironment (e.g. relative oxygenation) [1]. Depending on the severity of
damage, the tumor suppressor protein P53 can trigger cell cycle arrest (as described above), or
initiate apoptosis via transcriptional activation of pro-apoptotic proteins, including those of the
Bcl-2 family (e.g. BAX, PUMA) [35, 36]. PIDD (P53-induced protein with a death domain),
another P53 pro-apoptotic target, also plays a critical role in DNA damage-induced apoptosis,
leading to caspase-2 activation and subsequent mitochondrial cytochrome c release [37].
In cells irradiated with lethal doses, whereby the amount of DNA damage is beyond
repair, IR can also induce terminal growth arrest leading to a senescent-like morphology (e.g.
senescence-associated -galactosidase activity). Terminally-arrested cells are metabolically
active, but incapable of division; they eventually die, days to weeks following IR, via necrosis
[38]. It is suggested that the terminal-arrest pathway begins with the transactivation of the
CDK2 inhibitor p21, which is involved in the initial induction of senescent-associated G1-
arrest. Expression of p21 subsequently declines, while stable expression of the CDK4 inhibitor
p16INK4A
is induced, thereby maintaining this arrest [38].
Although IR-induced DNA lesions are lethal if left unrepaired, cell membrane damage
can also contribute to apoptosis. Radiation-induced cleavage of plasma membrane-localized
sphingomyelin by sphingomyelinases results in the rapid formation of ceramide, a lipid second
messenger that is a potent inducer of apoptosis. Subsequent activation of the stress-activated
protein kinase (SAPK) signaling cascade via ceramide will then initiate apoptosis [39].
14
For the majority of cells, mitotic catastrophe-induced necrosis accounts for most of the
cell kill following IR. Mitotic catastrophe is characterized by abnormal nuclear morphology
(e.g. multiple micronuclei or multi-nucleated giant cells) following premature entry into
mitosis by cells manifesting unrepaired DNA breaks and lethal chromosomal aberrations,
often resulting in the generation of non-clonogenic aneuploid and polyploid cell progeny [1]. It
is suggested that the abrogation of the G2M checkpoint is due to over-accumulation of cyclin
B and premature activation of the CDK1cyclin B complex [40]. Radiation-induced mitotic
catastrophe is the predominant mode of cell death in P53-deficient tumor cells, which are
defective in the G1S checkpoint, and can be selectively arrested by the G2-checkpoint upon
DNA damage.
1.2 Modulation of Radiation Response
1.2.1 Background
The greatest challenge for radiation therapy or any cancer therapy is to attain the
highest probability of cure with the least morbidity. In the context of RT, the inherent
radiosensitivity of cells or tissues can be influenced by a number of chemical manipulations,
including endogenous substances (e.g. oxygen), or xenobiotic agents (e.g. chemotherapeutic
radiosensitizers). Clinically, tumor-selective modification of radiosensitivity would allow for
lower radiation doses to be administered, ultimately enhancing tumor response without
increasing damage to surrounding normal tissues within a treatment field. Modification of
radiosensitivity by specific agents of known mechanisms of action can also provide insights
into the molecular basis underlying cellular responses and repair to radiation damage.
15
1.2.2 Chemical Radiosensitizers
Although both RT and chemotherapy have been employed as single-modality cancer
treatments for more than 40 years, the combined chemo-radiotherapy approach has been
adopted only more recently. Optimal combinations and scheduling remain in evolution, and
precise mechanisms underlying the radiation-potentiating effects of chemotherapeutic drugs
are still not fully understood. Many agents act through diverse processes and thus, there is no
universal mechanism that defines the interaction of drugs with radiation leading to
sensitization. Nonetheless, chemo-radiotherapy has become the standard of care for many
cancer patients based on improvements in locoregional disease control and survival.
A theoretical framework defining the possible mechanisms by which chemotherapy
and radiation may interact was first introduced by Steel and Peckham in 1979 [41]. Spatial co-
operation describes the concept that different therapeutic modalities affect distinct anatomical
sites of disease; radiation targets the local tumor, while chemotherapy acts against distant
metastases beyond the radiation field. This co-operative effect requires that the two treatments
not interact with each other and have non-overlapping toxicity profiles. Spatial co-operation is
highly theoretical and rarely observed in clinical situations. The more clinically applicable
interactive scenario is radiation sensitization, whereby chemotherapy co-operates with
radiation within the radiation field, leading to increased cell killing; either to the same degree
as (additive), or more than (supra-additive or synergistic) the expected sum of the respective
single-modality responses [41]. The clinical benefit of this radiosensitizing effect is defined by
its therapeutic ratio (Figure 1.5). With a chemo-radiotherapy approach, the radiation alone
dose-response curves for both the tumor and surrounding normal tissues will shift to the left.
Ideal radiation sensitizers should induce a stronger shift in the tumor response curve compared
to that of the normal tissue, increasing overall efficacy of treatment (radiation enhancement).
16
Alternatively, chemotherapy and RT may interact in an antagonistic manner, wherein the
combined cytotoxic effect is less than the expected sum (infra-additive or radioprotective).
This scenario is clinically advantageous in cases where agents cause selective protection of
normal tissues, allowing administration of higher radiation doses.
Categorizing chemotherapeutic radiosensitizers into well-defined types is challenging
as many agents confer multiple effects. Thus, applying broad categories, some of the most
commonly used classical radiosensitizers and emerging agents, as well as their mechanisms of
sensitization will be reviewed in the following sections.
Figure 1.5 Therapeutic ratio of radiosensitizing agents
Radiosensitizers with a favorable therapeutic ratio induce a greater change in the radiation
dose required for 50% cytotoxicity in cancer tissues (DC; C1 to C2), than that in normal
tissues (DN; N1 to N2). This is represented by a greater leftward shift in the tumor radiation
dose-response curve. This figure is adapted from [42].
17
1.2.2.1 Oxygen
One of the best-studied biological entities that modulate cellular response to radiation
is molecular oxygen (O2). As early as 1909, Gottwald Schwarz reported normal mammalian
cells irradiated under conditions of hypoxia (2% O2) or anoxia (0.02% O2) were less
sensitive to radiation than those irradiated under normoxia (~21% O2; 150 mm Hg) [43]. Since
then, it has become well-established that oxygen can enhance the effectiveness of radiation in
cell killing by a magnitude of two to three compared to irradiation conducted under limited O2
conditions, a principle known as the O2 enhancement effect [43]. The corresponding oxygen
enhancement ratio (OER) describes the ratio of hypoxic to aerated radiation doses required to
achieve equivalent levels of cell kill. Oxygen is thought to act as a direct radiosensitizer
through its ability to stabilize radiation-induced DNA damage into a form that is not readily
repaired. IR exposure generates free radical-mediated broken DNA ends, which can react with
available O2 to generate stable, toxic peroxy radicals, thus chemically modifying the DNA
(“oxygen fixation”). In the absence of O2, the initial DNA radical is reduced, restoring the
DNA to its original composition.
The presence of hypoxia in tumors is a well-established source of resistance to RT.
Hypoxia generally occurs in solid tumors mainly due to insufficient vascularization, which is
unable to adequately satisfy the high nutrient and oxygen demands of the proliferating tumor
cells. Thus, cells situated long distances from a functional blood vessel will become oxygen-
deprived as a result of limited O2 diffusion and perfusion. Hypoxia is also a potent stimulus of
gene expression. The best-characterized biological pathway related to hypoxia is regulated via
the hypoxia-inducible transcription factor-1 (HIF-1), which mediates adaptive response to
changes in tissue oxygenation. HIF-1 is over-expressed in human cancers as a result of
intratumoral hypoxia, as well as genetic alterations [44]. The heterodimeric HIF-1 consists of
18
and subunits, which dimerize under hypoxic conditions and bind to DNA at hypoxia
response elements (HREs) in promoter or enhancer regions of numerous transcriptional target
genes involved in cellular hypoxic responses, such as initiating anaerobic metabolism,
increasing angiogenesis, protecting cells against oxidative stress, and promoting invasiveness
and motility [45]. Accordingly, there is an overwhelming body of evidence supporting the
notion that HIF-1 may be a potential therapeutic radiosensitizing target [45]. Indeed, studies
have reported HIF-1 deficient murine hepatomas to demonstrate increased radioresponsiveness
compared to wild-type tumors [46]. Furthermore, direct inhibition of HIF-1 target genes, such
as vascular endothelial growth factor (VEGF), has been shown to also enhance
radiosensitization. VEGF is a pro-angiogenic/permeability factor, which acts to improve the
availability of oxygen from capillaries via increased vascular permeability, as well as induce
formation of new vessels. Aberrant VEGF/VEGF receptor (VEGFR) signaling in cancer has
been associated with tumor progression and the formation of metastasis. Fittingly, blockage of
the tumor VEGF signal transduction cascade reverses the radioresistant phenotype of
glioblastoma multiforme and melanoma microvasculature and xenograft tumors [47]. Loss of
HIF-1 in in vitro and in vivo models also dramatically reduces VEGF expression and the
capacity to release VEGF during hypoxia [48]. Thus, hypoxia can impact tumor
radioresponsiveness via the physio-chemical reaction of oxygen with radiation-induced
radicals causing damage “fixation”, but also through hypoxia-induced expression of genes that
allow tumor cells to survive under these adverse conditions.
Clinically, tumor hypoxia is associated with poor tumor prognosis and local tumor
relapse after RT; it has also been linked to a more aggressive tumor phenotype [49, 50].
Various methods to overcome hypoxic radioresistance have emerged over the years. One
approach is to increase tumor oxygenation during radiation through the use of hyperbaric
19
oxygen (HBO), red blood cell transfusions, and erythropoietin administration, resulting in a
physical increase in the O2 content of blood. These approaches however, have not gained
widespread use due to their difficulty to translate into clinical practice routinely, and/or
conflicting reports of their efficacy in clinical trials [51]. Another approach that has received
much attention is the development of electron-affinic radiosensitizers. Molecular oxygen-
mimetics, such as nitroimidazoles, partially recapitulate the effects of O2 in the radio-chemical
process and enhance IR-induced DNA strand breaks. Despite initial promise, clinical trials
with nitroimidazoles and its derivatives (e.g. misonidazole, etanidazole) have demonstrated
limited therapeutic benefit in hypoxic radiosensitization, in part due to dose-limiting toxicities,
such as severe peripheral neuropathy [52, 53]. As an alternative to increasing tumor
oxygenation, more recent strategies have attempted to exploit hypoxia for tumor-selective
killing. These so-called “hypoxic cytotoxins” are aimed at destroying, rather than sensitizing,
cells under hypoxic conditions in the absence of radiation. Tirapazamine, the prototypic
hypoxic cytotoxin, shows ~100-fold increased potency under anoxic vs. normoxic conditions
due to its electron-donating property. It is a pro-drug that is specifically reduced in hypoxic
cells, forming radical species that poison topoisomerase II, leading to lethal DNA DSBs [54].
Preclinical studies have demonstrated tirapazamine to potentiate the efficacy of RT on tumor
response [55]. Furthermore, randomized phase I and II clinical trials with tirapazamine in
combination with RT have demonstrated clinical benefits in patients with HNC, warranting
further investigations [56, 57]. A phase III trial of RT tirapazamine was recently launched
for HNC, but has been discontinued by Sanofi-Aventis due to presumed lack of therapeutic
efficacy (personal communication).
20
1.2.2.2 Halogenated Pyrimidines
Halogenated pyrimidines (HPs) structurally mimic thymidine, a normal base required
for DNA synthesis; the difference resides in a replacement of the 5 methyl group of thymine
with a halogen (iodine, bromine, chlorine, or fluorine) [58]. HPs have found practical use in
clinical radiotherapy based on the premise that tumor cells have a higher demand for DNA
replication and therefore, should incorporate more drug than the surrounding normal tissues.
Accordingly, HPs increase the effectiveness of radiation chiefly when administered before and
during RT [58].
The methyl group of thymine is approximately the same size as iodine, bromine, and
chlorine atoms; thus, as the cells undergo DNA synthesis, iodo (I)-, bromo (Br)-, and chloro
(Cl)-deoxyuridine (dUrd) compete with thymidine pools for incorporation into cellular DNA.
As the percentage of replaced thymidine bases increases, so does the extent of HP-mediated
radiosensitization; a thymidine replacement of 1015% correlates with a radiation
enhancement ratio of ~2.0 [58]. The halogen moieties act as electron “sinks” during radiation,
wherein the carbonhalogen bond breaks on electron attachment to liberate free halide and a
carbon-centered free radical. In the presence of oxygen, a peroxyl radical is formed, leading to
DNA strand breaks. Incorporation of BrdUrd and IdUrd into DNA has been associated with
increased induction, and decreased rate of repair of radiation-induced DNA damage [59].
In contrast to iodine, bromine, and chlorine atoms, fluorine atoms are significantly
smaller than the methyl group of thymine. Consequently, fluoro-deoxyuridine (FdUrd) blocks
cells at the G1S interface, inhibiting DNA synthesis. Recent approaches to use the
radiosensitizing nucleosides have focused on other fluorine analogues, especially 5-
fluorouracil (5-FU), gemcitabine, and capecitabine. Among these, 5-FU, administered via
intravenous (IV) infusion, remains the predominant agent in the clinic. After cellular uptake, 5-
21
FU, a uracil analog, is converted to FdUrd by thymidine phosphorylase (TP), which is often
upregulated in tumor vs. adjacent normal tissues; thus, providing tumor-selectivity and a
therapeutic window [60]. Phosphorylation of FdUrd by thymidine kinase generates 5-fluoro-
2-deoxyuridine monophosphate (FdUMP), which then inhibits thymidylate synthase (TS)
activity [61]. TS inactivation results in the depletion of the intracellular pool of thymidine 5-
monophosphate and thymidine 5-triphosphate, which inhibits DNA synthesis and interferes
with DNA repair. Alternatively, 5-FU can be metabolized to 5-fluorouridine triphosphate, a
substrate for RNA polymerase which is readily incorporated into RNA, leading to inhibition of
mRNA polyadenylation with decreased mRNA stability, and alteration of the RNA secondary
structure [61]. The underlying mechanisms of the interaction of IR with 5-FU are still not fully
understood. However, 5-FU-induced radiosensitization appears to be mediated primarily by its
DNA-directed effects, and is dependent on inappropriate S-phase progression in the presence
of drug (i.e. from dysregulated S-phase checkpoints), and a decreased ability to repair
radiation-induced DNA damage [62, 63]. Phase III clinical trials of 5-FU and RT have
reported clinical benefit in cancers of the esophagus, cervix, and rectum [64-66] .
Capecitabine, an oral pro-drug of 5-FU, was developed to decrease the burden of 5-FU
IV administration and increase intra-tumoral bioavailability. Capecitabine is preferentially
metabolized to active 5-FU in tumors via a cascade of three enzymes, the last enzyme being
thymidine phosphorylase. Interestingly, studies have reported local RT to selectively
upregulate TP activity in tumor tissues via induction of tumor necrosis factor [67]; thus, RT
may further increase the therapeutic index of capecitabine due to the lack of TP upregulation
in normal tissues and the anatomically-targeted nature of RT. Preclinical studies have
demonstrated significant radiosensitization of several human cancer xenograft models [67].
22
Clinical trials investigating the efficacy of capecitabine in combination with RT have also
shown therapeutic benefits with low toxicity profiles [68, 69].
Gemcitabine is a pyrimidine analog that has also demonstrated potent radiosensitizing
effects against various solid tumor models, including HNC, colon, pancreatic, breast, and non-
small cell lung (NSCLC) cancers [70], as well as in phase II clinical trials for pancreatic
cancer [71]. Within the cell, gemcitabine is rapidly phosphorylated to its active di-and
triphosphate metabolites. Gemcitabine triphosphate serves as both an inhibitor and substrate
for DNA synthesis [72]. Gemcitabine diphosphate irreversibly inhibits ribonucleotide
reductase, resulting in the rapid decrease in cellular deoxyribonucleotide triphosphate (dNTP)
levels in a cell-specific manner [73]; the selective depletion of deoxyadenosine triphosphate
(dATP) appears to be a common response to gemcitabine in solid tumor cell lines [74].
Reduced dNTP pools may also contribute to the inhibition of DNA synthesis, as well as
promote the incorporation of gemcitabine into DNA through decreasing the level of its
endogenous competitor [72]. Thus, gemcitabine may radiosensitize cells that progress
inappropriately through S-phase by depleting dATP pools, leading to the misincorporation and
misrepair of incorrect bases, collectively enhancing radiation-inflicted DNA damage.
1.2.2.3 Modifiers of Microtubule Structure and Function
Taxanes, such as paclitaxel and its semi-synthetic analog docetaxel, are mitotic
inhibitors. They form high-affinity bonds with microtubules, promoting tubulin polymerization
and stabilization; ultimately interfering with normal microtubule function. At high cytotoxic
doses, both drugs inhibit mitotic spindle formation and block the progression of cells in
mitosis, between prophase and metaphase [75]. The radiosensitization observed after treatment
with paclitaxel or docetaxel in vitro is most likely due to the taxane-induced G2M block in
the cell cycle, leading to synchronization (i.e. cell-cycle pooling) of tumors cells at a point of
23
maximum radiosensitivity [76]. Improved overall outcomes have also been reported in
NSCLC and HNC patients treated with paclitaxel/docetaxel and radiotherapy in phase II
clinical trials, yielding good local regional control and survival rates [77, 78].
1.2.2.4 Modifiers of the Nature or Repair of DNA Damage
Platinum analogs, specifically cisplatin and more recently oxaliplatin, are DNA-
damaging agents being used clinically in combination with RT for the treatment of various
solid tumors. Cisplatin is one of the most commonly used anti-cancer agents for concurrent
chemo-radiotherapy. Its cytotoxicity is primarily ascribed to its interaction with nucleophilic
N7-sites of purine bases in DNA to form both DNAprotein and DNADNA inter-strand and
intra-stand cross-links, thereby distorting the DNA structure, and blocking DNA replication
and transcription [79]. Cisplatin-mediated radiosensitization can occur by several mechanisms.
It has been proposed that radiation-induced free radicals enhance the formation of toxic
platinum intermediates, which increase cell killing [80]. Moreover, IR has been reported to
increase cellular uptake of platinum [81]. Radiation-induced DNA damage that would
typically be repaired can become fixed and lethal via cisplatin’s capacity to scavenge free
electrons formed by the radiationDNA interaction. The resulting inhibition of DNA repair
leads to increased cell-cycle arrest and apoptotic cell death after radiation [82]. Clinically,
concurrent cisplatin-based radiotherapy trials have reported improved overall outcomes for
patients with HNC and cervix cancer [83, 84]. Oxaliplatin, a third-generation cisplatin
analogue, was developed to address the intrinsic or acquired cisplatin resistance that often
arises in tumors. The drug reacts with DNA forming mainly platinated intra-strand cross-links
with two adjacent guanines or adjacent guanineadenine residues [85]. These adducts appear
to be more effective at inhibiting DNA synthesis and are more cytotoxic than those formed by
cisplatin. Oxaliplatin consistently shows activity in cisplatin-resistant cell systems, as well as
24
human tumors [86, 87]. Although less well-studied, oxaliplatin exhibits significant in vitro and
in vivo radiation enhancement [88], and has shown promise in clinical trials with RT for the
treatment of rectal cancer [89].
DNA alkylating agents, such as temozolomide, cause DNA damage by methylating
guanine on the O6 position, activating the p53-regulated DNA damage response pathway [90].
These alkylated lesions are processed by the ubiquitous DNA repair enzyme, O6-
methylguanine DNA-methyltransferase (MGMT). Following removal of the alkyl groups,
MGMT is irreversibly inactivated such that de novo synthesis of MGMT is required for
cellular function [91]. Thus, administering temozolomide on schedules that result in
cumulative and sustained inactivation of MGMT reduces the cell’s capacity for DNA repair
[92], potentiating IR-inflicted DNA damage. Accordingly, tumors with MGMT mutations are
also preferentially radiosensitized by temozolomide [93]. Temozolomide also inhibits
signaling of radiation-induced cell migration and invasion, and decreases tumor cell
repopulation [94]. Temozolomide, which is orally administered, readily crosses the blood-
brain barrier [95], and is therefore commonly used to treat gliomas. A recent phase III clinical
trial has demonstrated a significant survival benefit with minimal additional toxicity in
glioblastoma patients treated with temozolomide plus RT [96].
Molecularly-targeted inhibitors of DNA repair proteins have also emerged as potential
radiosensitizers. Poly(ADP-ribose) polymerase-1 (PARP-1) is a nuclear enzyme that facilitates
DNA base excision repair, and also regulates HR- and NHEJ-mediated DSB repair [97].
PARP-1 activation and subsequent poly(ADP-ribosyl)ation are immediate cellular responses to
radiation-induced DNA damage [98]. Moreover, PARP-1-mediated DNA repair has been
associated with resistance to radiation; thus, inhibition of PARP-1 may be therapeutically
beneficial [99]. Accordingly, preclinical evaluations of PARP-1 inhibitors, such as AG14361,
25
have demonstrated signification radiosensitizing effects in vitro and in vivo, resulting in
enhanced radiation-induced cytotoxicity due to persisting DNA lesions that would normally be
repaired [100]. Ataxia telangiectasia mutated is a serine/threonine protein kinase that also
plays a critical role in regulating cell cycle arrest and DNA repair. ATM inhibitors, such as
wortmannin and caffeine, have garnered attention, demonstrating pre-clinical sensitization of
tumor cells in vitro; their clinical use as radiosensitizers however, are limited by potentially
lethal systemic toxicities [101]. More recently, KU-55933, a novel and specific inhibitor of
ATM was identified, exhibiting in vitro radiosensitization with an enhancement ratio of 2.6 at
2 Gy [102].
1.2.2.5 Targets of Cell Signaling Pathways
Molecularly-targeted therapies that inhibit radioresistance-associated signal
transduction pathways are also being investigated. The Ras protein family is well-studied in
the context of RT as they control key signaling pathways that regulate cell growth and
transformation. The Ras proto-oncogene is overexpressed in approximately 30% of human
tumors, and has been implicated in radioresistance by promoting aberrant survival signals
[103]. The activation of Ras is dependent on the post-translational addition of an isopreynl
group by the farnesyltransferase enzyme. Accordingly, farnesyltransferase inhibitors (FTI)
(e.g. FTI-277, L-744,832) have been used with RT in preclinical studies, successfully
reversing the radioresistant phenotype of human tumor xenografts and cells expressing the
mutant ras oncogene [104, 105]. FTI-induced radiosensitization has been proposed to be
mediated via downregulated signaling through the downstream PI3K/AKT and MAP kinase
pathways, and reduction of tumor hypoxia [104]. Furthermore, a phase I clinical trial of FTI L-
778,123 with concurrent RT for locally advanced pancreatic cancer patients reported no
increase in radiation-induced normal tissue damage, indicating the potential to increase the
26
therapeutic index. Radiosensitization of a patient-derived pancreatic cell line was also
observed [106].
The epidermal growth factor receptor (EGFR) family members are the most mature of
the molecular targets; upon activation, EGFR mediates various cellular responses important
for cell growth, differentiation, and survival. These receptors are overexpressed in a diverse
array of epithelial tumors [107], which often correlates with radioresistance and adverse
clinical outcomes [108, 109]. Currently, two therapeutic strategies have been developed to
inhibit EGFR activity. One approach targets the extracellular ligand-binding domain of EGFR
with monoclonal antibodies (e.g. cetuximab). The second targets the intracellular domain of
EGFR with tyrosine kinase inhibitors (e.g. erlotinib, gefitinib) that compete with the adenosine
triphosphate (ATP)-binding site [109]. Preclinical studies with the EGFR inhibitors
consistently show synergistic enhancement of radiosensitivity both in vitro and in vivo [110].
Due to the pleiotropic effects of EGFR signaling, the precise mechanism of radiosensitization
has not been fully elucidated; however, experimental evidence favors inhibition of cell
proliferation (preventing repopulation) and induction of apoptosis as major mediators of the
radiosensitizing properties of EGFR blockade [111]. The clinical application of EGFR-
mediated radiosensitization has been supported by phase III trials, wherein disease-free and
overall survival advantages were observed in HNC patients treated with RT and concurrent
cetuximab vs. RT alone [112, 113].
Another target attracting attention in the context of RT includes anti-angiogenesis
inhibitors. The process of angiogenesis is mediated by multiple pro-angiogenic and anti-
angiogenic factors, with VEGF playing a central role. Angiogenesis is essential for tumor
growth and progression. Accordingly, VEGF is over-expressed in many cancers, and its
expression can be induced by radiation, promoting tumor radioresistance [114]. Two strategies
27
for blocking VEGF signaling exist, those that target the VEGF ligand via neutralizing
antibodies (e.g. bevacizumab), and those that inhibit the receptor (e.g. PTK787 and SU5416
tyrosine kinase inhibitors). The importance of VEGF signaling in tumor radioresistance is
supported by preclinical observations demonstrating supra-additive tumor growth delays and
cytotoxicity when VEGF/VEGFR antagonists are combined with RT in radioresistant
xenograft models [47, 114] . The precise mechanism of how targeting angiogenesis promotes
tumor radiosensitization remains unclear. The initial concern that anti-angiogenic disruption of
the tumor blood supply may encourage tumor hypoxia, and in turn radioresistance, has been
discounted by recent evidence. Instead, VEGF/VEGFR antagonists are thought to induce
transient normalization of the tumor vasculature, leading to enhanced tumor oxygenation and
radiosensitization [115]. Phase I/II clinical trials to assess the efficacy and safety of the
addition of bevacizumab to concurrent RT have reported encouraging response rates with
acceptable toxicity profiles in rectal cancer [116, 117].
1.3 High-Throughput Screens
1.3.1 Background
High-throughput screening is an approach to anti-cancer drug discovery that has gained
widespread popularity over the past few decades. Initially developed for the pharmaceutical
sector, HTS has recently been adapted by academic institutions for the discovery of novel
therapeutics and biological pathways. HTS entails multiple-well microplates (96-/384-well)
and robotic processing to assay large numbers of potential effectors of biological activity
against targets, with the goal of accelerating drug discovery via large-scale screening of
chemical and genomic libraries often composed of thousands of molecules. As the number of
compounds available for screening has increased, the throughput of assay technology has also
28
kept pace; with the transition from 96-well to 384-well and nano (1,536)-well plate formats,
thereby accelerating screening times and decreasing overall costs [118]. In general, anti-cancer
drug discovery can be broadly divided into two distinct approaches, phenotype- and target-
based screening (Figure 1.6) [118]. Commonly utilized end-points include genetic or protein
markers (e.g. reporter-gene assays, antibody-based cellular immunoassays), functional assays
(e.g. cell division, proliferation, viability, apoptosis), or high-content automated microscope-
based imaging systems (cellular morphology, subcellular localization of protein markers).
Figure 1.6 High-throughput screening approaches
29
Phenotype-based discovery or the forward chemical-biology approach starts with the screening
of chemical libraries for compounds that induce a particular phenotype followed by the
identification of the responsible target. Target-based discovery or the reverse chemical-biology
approach employs chemical library screens to identify ligands for a specific molecular target
of interest. This figure is adapted from [118].
1.3.2 Phenotype-Based High-Throughput Screens
Forward chemical genetics, or phenotype-based screens, assay the response of an
experimental system to chemical perturbations via phenotypic read-outs, followed by
identification of the responsible target. The forward approach often yields novel targets and
insights into unexplored pathways upon identification of the drug target. Cell-based screening
for anti-proliferative effects of plant- and marine-derived natural product small molecule
libraries have recently uncovered new compounds with anti-tumor activity, including extracts
from the Helleborus cyclophyllus flower [119], and a class of DNA-intercalating plakinidines
isolated from the marine sponge, Crella spinulata [120]. The drug discovery process has also
been facilitated by the National Cancer Institute Developmental Therapeutics Program (NCI-
DTP), which has implemented an in vitro anti-cancer screening platform consisting of 60
different human tumor cell lines representing nine common forms of cancer: leukemia, colon,
lung, central nervous system, renal, melanoma, ovarian, breast, and prostate. To date, the NCI-
DTP has screened 3 million synthetic and natural compounds against the cancer panel
utilizing short-term colorimetric cell viability assays. Paclitaxel was discovered from a NCI-
sponsored large-scale plant-screening program, wherein ~35,000 plant species were screened,
identifying the bark extract from the Pacific yew tree, Taxus brevifolia to exert broad anti-
tumor efficacy [121]. It was not until years later that paclitaxel was shown to target
microtubules, uncovering a novel cellular mechanism as a viable anti-cancer therapeutic target
[122].
30
1.3.3 Target-Based High-Throughput Screens
Despite the large number and chemical diversity of the novel anti-cancer cytotoxics
being discovered via phenotype-driven screening, their clinical applications have been limited.
The ultimate goal of drug discovery is to improve the efficacy and selectivity of cancer
treatment by exploiting differences between cancer and normal cells. However, with the
forward-driven HTS approach, mechanism of action is not a primary determinant in selecting
agents for further development; thus, many discovered drugs have a low therapeutic index. As
we further unravel the underlying mechanisms of tumor initiation and progression, the
approach to drug discovery has transitioned from empirical compound-oriented preclinical
screening to target-focused drug screening.
Reverse chemical genetics, or target-based screens, target a specific cellular protein or
gene of interest with chemical perturbations, and elucidate the phenotypic consequences
thereafter. Reverse screens have been successful in identifying molecularly-targeted agents
currently in clinical use. For example, an initial lead compound targeting the Bcr-Abl onco-
protein, 2-phenylaminopyrimidine, was identified via random screening of large chemical
libraries for inhibition of its tyrosine kinase activity in vitro [123]. Further optimizations of the
lead compound led to imatinib mesilate, a 2-phenylaminopyrimidine derivative, which is now
FDA-approved as front-line treatment for chronic myelogenous leukemia (CML) [123]. Since
chemical screens can be costly and time-consuming, alternative approaches to facilitate target-
driven lead compound discovery include in silico virtual screening, which can readily filter
undesirable compounds based on criteria, such as target-binding affinity and chemico-physical
properties. To address the high incidence of imatinib resistance that often arises in patients
with advanced CML, a recent study has employed in silico screening of 200,000 commercially
31
available compounds, identifying two novel Bcr-Abl-targeted tyrosine kinase inhibitors for
further drug design and optimization [124].
1.3.4 RNA Interference Screens
The recent sequencing of the human genome and development of new genomic
technologies have brought promise of a myriad of new targets for the development of
molecularly-targeted therapies. RNA interference (RNAi) is an endogenous cellular process
that controls gene expression at the post-transcriptional level; messenger RNAs (mRNAs) are
targeted for degradation by complementary double-stranded interfering RNA, leading to
selective gene silencing. Since its discovery in the nematode Caenorhabditis elegans, RNAi
has been exploited as a standard tool for studying gene function via synthetic small interfering
RNAs (siRNAs) and small hairpin RNAs (shRNAs) [125]. Initially used to knock-down the
function of individual genes of interest, this technology has been harnessed on a global scale
with the production of RNAi libraries covering the entire human coding transcriptome,
allowing for genome-wide loss-of-function screening. Phenotypic read-outs can range from
simple and commonly used cell viability assays, to complex high-content screens involving
sophisticated microscopic image analyses. Thus, an RNAi screen is essentially a forward
genetics screen using a reverse genetics technique. The first genome-wide (21,127 genes)
synthetic-lethal siRNA screen for chemosensitizers was performed by Whitehurst et al.,
wherein gene targets that reduced the viability of human NSCLC cells in the presence of
sublethal concentrations of paclitaxel were identified, including components of the mitotic
spindle apparatus and proteasome machinery [126]. Thus, new classes of therapeutic targets
were revealed for combinatorial chemotherapy. High-throughput functional-genomic platforms
have also been exploited for the screening of key mediators of proliferation and survival in B-
32
cell lymphoma, utilizing a retroviral-based shRNA library targeting 2,500 human genes,
wherein genes regulating cell cycle, splicing, and NF-B signaling were identified [127].
1.3.5 Radiosensitizer Discovery Screens
As described above, the use of HTS has been fruitful in identifying drug candidates or
molecular targets for anti-cancer therapies. However, technical obstacles have impeded the
development of HTS for radiosensitizers, mainly with respect to read-outs. The colony
formation assay (CFA) is the accepted gold standard for measuring cellular radiation
susceptibility amongst radiation biologists. The long-term kinetics, difficulty in large-scale
automation, and limited robustness (i.e. colony-forming capacity) of the assay however, has
restricted its appeal and amenability to high-throughput platforms. Although CFA is the ideal
assay, radiosensitizers have been discovered using alternative read-outs. A recent forward
screen of 870 commercially available compounds utilizing the MTS cell viability as the end-
point, identified 4-bromo-3-nitropropiophenone (NS-123) as a tumor-selective radiosensitizer
of human glioma cells in vitro and in vivo by a mechanism involving inhibition of DNA repair
[128]. Several reverse screens employing known molecular targets of the DNA repair pathway
as read-outs via in vitro kinase activity assays, have identified KU-55933 (ATM inhibitor), and
NU7441 (DNA-PKCS inhibitor) as potential radiosensitizing agents from libraries of small-
molecule compounds [102, 129]. Novel radiation susceptibility targets have also been
discovered from small shRNA library screens (200 genes) using the sulforhodamine B (SRB)-
based cell growth assay as a read-out, identifying genes involved in cell cycle progression (e.g.
ZDHHC8) as potential molecular targets for radiosensitization [130].
33
1.4 Head and Neck Cancer
1.4.1 Background
Head and neck cancer is the eighth most common cancer worldwide, with an estimated
annual global incidence of approximately 650,000 cases and ~90,000 deaths attributed to this
disease per year [131]. In 2009, it was estimated that there would be 4,550 newly diagnosed
cases, with 1,660 deaths as a result of HNC in Canada [132]. HNC comprises a diverse group
of tumor types arising from the upper aerodigestive tract, including the lip, nasal and oral
cavities, sinuses, pharynx, larynx, and other sites in this anatomical region [133]. The vast
majority of HNC diagnoses (90%) are of squamous epithelial cell origin (oral cavity,
pharynx, larynx), and are thus termed head and neck squamous cell carcinomas (HNSCC)
[133]. Nasopharyngeal carcinoma (NPC) is a less common distinct HNC in that 90% of cases
harbor latent Epstein-Barr virus [134]. HNC is strongly associated with certain environmental
and lifestyle risk factors, including smoking or chewing tobacco, alcohol consumption, UV
light and occupational exposures (e.g. wood dust, paint fumes, asbestos), and certain strains of
viruses, such as the sexually-transmitted human papillomavirus (e.g. HPV16) [133, 135, 136].
1.4.2 Treatment
HNC treatment is complex and depends on the anatomical location of the tumor and
involvement of adjacent organs. The classification system is divided into three clinical stages:
early, loco-regionally advanced, and metastatic or recurrent, where treatment approaches can
vary depending on the disease stage [137]. At the time of presentation, ~3040% of HNC
patients typically have localized disease, 50% have associated regional disease, and ~10%
harbor distant metastases. For all sites and stages in the head and neck region, 5-year survival
rates average ~50% [137]. While treatment of HNC is complex due to the anatomical and
molecular heterogeneity of HNC, some general principles apply, wherein surgery,
34
radiotherapy, chemotherapy, and combinations of these are well accepted. Early-stage disease
is generally treated with single-modality treatments of either surgery or radiation alone. Late-
stage disease is best treated by a combination of surgery and radiation, radiation with or
without chemotherapy, or all three modalities [137]. A major challenge in treating HNC is
obtaining a high cure rate while preserving vital structures and function; tumors often reside in
close proximity to critical organs (e.g. brain, spinal cord, optic nerve), which when damaged
lead to long-term compromises in patients’ quality of life, not to mention fatality.
1.4.2.1 Radiation Therapy
Radiation therapy remains a mainstay of curative therapy for HNC, and is typically
provided in a single fraction (~2 Gy per day) on a schedule of 5 days a week for 7 weeks (total
dose of ~70 Gy) [138]. Recent advances have focused primarily on altered fractionated
(hyperfractionation or accelerated fractionation) RT regimens, and the implementation of
intensity-modulated RT (IMRT).
In accelerated fractionation, the total treatment time is decreased, which in turn,
reduces the repopulation of tumor cells between sessions, allowing for improved locoregional
control. In hyperfractionated schedules, two to three lower-dose fractions (1.11.2 Gy) are
delivered daily, with a higher total dose administered over the same duration as conventional
RT, reducing the potential risk of late toxicities. A recent meta-analysis revealed altered
fractionation RT regimens to demonstrate a small, but significant absolute survival benefit of
3.4% at 5 years, with the benefit being greater for hyperfractionated vs. accelerated RT [138].
There was also improved locoregional control for the altered fractionation schedules vs.
conventional RT (6.4% at 5 years). These modest benefits however, came at the expense of
increased toxicity, mostly in the form of mucositis [138].
35
IMRT is a form of high-precision RT that delivers radiation in a more targeted and
conformal manner via computed-tomography (CT)-guided 3D tumor images; thereby
minimizing radiation exposure to surrounding normal tissues. Recent data suggest that IMRT
is as effective as conventional 2D RT with regard to locoregional control, but is superior in
reducing treatment-related toxicity [139, 140]. However, even with the most effective RT
regimens, the prognosis of patients with HNC remains poor, with 5-year overall survival rates
of 3040% [138].
1.4.2.2 Chemotherapy
Chemotherapy is also an important modality in the management of HNC. The most
commonly utilized cytotoxic agents include cisplatin, carboplatin, 5-FU, paclitaxel, docetaxel,
or mitomycin C, either as single-agents or in multi-agent chemotherapy platforms.
Chemotherapy is often administered concomitantly with RT (concurrent chemo-radiotherapy)
or before RT in the form of induction chemotherapy. A recent meta-analysis of 93 randomized
trials demonstrated that chemotherapy in general improves survival in non-metastatic HNSCC
treated with surgery and/or RT with an overall benefit of 4.5% at 5 years, from 31.1% to
35.6% [141]. Within this study, a greater benefit (6.5% vs. 2.4% at 5 years) was observed in
trials that delivered concomitant chemotherapy with RT, as compared to induction
chemotherapy. Similar conclusions were drawn from a meta-analysis comparing RT to radio-
chemotherapy in NPC, whereby an absolute overall survival benefit of 6% at 5 years was
observed in the chemoradiation arm; most of the benefit was again observed with concomitant
vs. induction chemotherapy [142]. Meta-analyses examining various chemoradiotherapy
regimens have revealed optimal types of drugs to be combined concomitantly with RT, which
include either platinum-based agents alone (cisplatin or carboplatin), or 5-FUplatinum
combinations.
36
Although the addition of chemotherapy to RT has improved outcomes, an increase in
both acute and late toxicities has also been reported. The sensitizing effects of most cytotoxic
agents are not tumor-specific and often affect adjacent normal tissues within the radiation
field. Concurrent chemoradiotherapy trials have consistently reported an increased incidence
of acute grade 3 and 4 toxicity, with mucositis and dermatitis being the most prominent [143].
Cisplatin for example, is a potent radiosensitizer, and the drug most commonly utilized for
chemoradiotherapy in HNC. Currently, the most widely used standard regimen is 100 mg/m2
of cisplatin administered every 3 weeks throughout the course of RT (~70 Gy in 2 Gy daily
fractions) [141]. This regimen, however, causes severe side-effects, both acute (nausea,
vomiting, severe mucositis), and late (nephro-, oto- and neuro-toxicity) toxicities [144].
1.4.2.3 Molecularly-Targeted Agents
Advances in our understanding of the molecular genetics underpinning HNC
development and growth have resulted in the emergence of novel molecularly-targeted
therapies, with the aim of improving efficacy and/or quality of life, while minimizing damage
to surrounding normal tissues. Since molecularly-targeted agents exploit tumor-specific
aberrations, they are thought to provide a theoretical advantage over conventional
chemotherapeutic cytotoxics, in which a major drawback is the exacerbation of normal tissue
toxicity. Evidence is accumulating that a variety of targets involved in different cellular
processes may provide novel opportunities for therapeutic targeting.
Epidermal growth factor receptor is one of the most attractive and widely-investigated
targets in HNC. High levels of EGFR tumor expression have been associated with poor
prognosis in HNC patients, including decreased response to RT, and increased loco-regional
recurrence following definitive RT [109]. Treatments targeting the function of EGFR appear to
show promise in improving clinical outcome for HNC. As mentioned previously, two
37
therapeutic strategies have been developed to inhibit EGFR activity: monoclonal antibodies
against the extracellular ligand-binding domain (e.g. cetuximab), or inhibitors targeting the
intracellular tyrosine kinase domain of EGFR (e.g. erlotinib, gefitinib) [109]. Currently,
cetuximab is the only FDA-approved EGFR-targeted therapy for the treatment of metastatic
HNSCC (as a single agent), and locally advanced HNSCC (in combination with RT). Recent
phase III multi-center trials have demonstrated RT with concurrent cetuximab to significantly
improve overall survival rates when compared to RT alone in patients with loco-regionally
advanced HNSCC [112, 113]. Moreover, the combinatorial regimen was well-tolerated, with
similar rates of toxicity compared with RT alone; in particular, cetuximab did not appear to
exacerbate radiation-induced mucositis or other toxicities. Despite these promising results
however, the 5-year overall survival rate for the combined cetuximab-plus-RT group was still
only 45.6%, underscoring a continued need for further improvements.
A number of other potential agents employing novel targeting approaches are currently
being explored for HNC, including those that target angiogenesis (VEGF inhibitor), protein
turnover (proteasome inhibitor), signal transduction pathways (mTOR and IGFR inhibitors),
and cell cycle regulators (aurora kinase inhibitors) [145]. These molecularly-targeted agents
are not yet FDA-approved for use in HNC, as their safety and activity in HNC are still under
active investigation in pre-clinical and clinical studies.
1.5 Research Objectives
Ionizing radiation therapy plays critical curative, adjuvant, and palliative roles in cancer
patient management; curability however, could be limited by tolerance of normal surrounding
tissues. Thus, the development of therapeutic strategies to enhance the therapeutic ratio is of
utmost importance. Unfortunately, many of the currently utilized radiosensitizers are neither
selective nor tumor-specific. This is particularly a concern in the management of HNC,
38
whereby RT is the primary curative modality, yet tumors often reside in close proximity to
critical organs, which when damaged, lead to long-term compromises in patients’ quality of
life.
Despite the advances in therapeutic options over the recent few decades, treatment
toxicities and overall clinical outcomes have remained disappointing; for all sites and stages in
the head and neck region, 5-year overall survival rates still average ~50% [137]. Even the most
effective RT regimens achieve local control rates of 4555%, with disease-free survival rates
of only 3040% for patients with locally advanced HNSCC [138]. Furthermore, meta-analyses
have documented concurrent RT with chemotherapy to offer an absolute survival advantage of
only 6.5% at 5 years [141]. These modest results underscore the urgent need to develop novel
therapeutic approaches in the treatment of HNC. Accordingly, the overarching objective of this
thesis is to identify novel radiosensitizing therapies for HNC utilizing a high-throughput
screening approach to expedite the discovery process. More specifically, two strategies will be
undertaken: a phenotype-based screen utilizing small molecules (Chapter 2), and a target-
driven screen employing RNAi technology (Chapter 4).
We have previously developed a cell-based phenotype-driven HTS for the large-scale
identification of novel HNC cytotoxics, wherein cell viability served as the read-out [146,
147]; two existing anti-microbials (benzethonium chloride and alexidine dihydrochloride)
were identified from the LOPAC1280 and Prestwick chemical libraries. Thus, employing the
same forward HTS, the Spectrum Collection natural product small molecule library will be
screened for novel anti-cancer radiosensitizing compounds (Chapter 2). The recent sequencing
of the human genome and development of new genomic technologies also provides
opportunities for the discovery of novel molecularly-targeted therapies, wherein genome-wide
loss-of-function screens have moved into the research forefront. Thus, we will also harness
39
high-throughput RNAi technology for the large-scale identification of novel radiosensitizing
targets for HNC (Chapter 4). Since the colony formation assay (CFA) is the gold standard for
measuring cellular effects of radiation in vitro, an automated high-throughput CFA will be
developed to be integrated into the RNAi screen, serving as a more appropriate read-out for
radiosensitivity (Chapter 3). The discovery of novel radiosensitizing compounds or molecular
targets from both screens will be followed by the characterization of in vitro and in vivo
efficacy, elucidation of mechanisms of radiosensitization, and assessment of their clinical
implications in the management of HNC.
40
CHAPTER 2: POTENTIAL USE OF CETRIMONIUM BROMIDE AS AN
APOPTOSIS-PROMOTING ANTICANCER AGENT FOR HEAD AND
NECK CANCER
The data presented in this chapter have been published in:
Ito E, Yip KW, Katz D, Fonseca SB, Hedley DW, Chow S, Xu GW, Wood TE,
Bastianutto C, Schimmer AD, Kelley SO, Liu FF. Molecular Pharmacology
2009; 76: 969-983.
Reprinted with permission from the American Society for Pharmacology and
Experimental Therapeutics. All rights reserved.
Copyright © 2009 The American Society for Pharmacology and Experimental
Therapeutics
41
2.1 Chapter Abstract
A potential therapeutic agent for human head and neck cancer, cetrimonium bromide
(CTAB), was identified through a cell-based phenotype-driven high-throughput screen of
2,000 biologically active or clinically used compounds, followed by in vitro and in vivo
characterization of its anti-tumor efficacy. The preliminary and secondary screens were
performed on FaDu (hypopharyngeal squamous cancer) and GM05757 (primary normal
fibroblasts), respectively. Potential hit compounds were further evaluated for their anti-cancer
specificity and efficacy in combination with standard therapeutics on a panel of normal and
cancer cell lines. Mechanism of action, in vivo anti-tumor efficacy, and potential lead
compound optimizations were also investigated. In vitro, CTAB interacted additively with -
radiation and cisplatin, two standard HNC therapeutic agents. CTAB exhibited anti-cancer
cytotoxicity against several HNC cell lines, with minimal effects on normal fibroblasts; a
selectivity that exploits cancer-specific metabolic aberrations. The central mode of cytotoxicity
was mitochondria-mediated apoptosis via inhibition of H+-ATP synthase activity and
mitochondrial membrane potential depolarization, which in turn was associated with reduced
intracellular ATP levels, caspase activation, elevated subG1 cell population, and chromatin
condensation. In vivo, CTAB ablated tumor-forming capacity of FaDu cells, and delayed
growth of established tumors. Thus, using a HTS approach, CTAB was identified as a
potential apoptogenic quaternary ammonium compound possessing in vitro and in vivo
efficacy against HNC models.
2.2 Introduction
Head and neck cancer, which comprises a diverse group of cancers affecting the nasal
cavity, sinuses, oral cavity, pharynx, larynx, and other sites in this anatomical region, has an
42
estimated annual global incidence of 533,100 cases [148]. It is the eighth most common cancer
worldwide with the majority being head and neck squamous cell carcinomas [148, 149].
Nasopharyngeal cancer is a distinct HNC in that 7581% of NPC patients globally harbor the
Epstein-Barr virus [134]. HNC is a challenging disease due to its heterogeneity and
complexity of treatments. Patients with locally advanced disease achieve an overall survival
rate of only 50%, despite combined radiation therapy and chemotherapy treatments, which is
unfortunately associated with significant morbidities and toxicities [150], underscoring a
critical need to develop novel therapeutic strategies to improve clinical outcome.
We have previously developed a rapid, cell-based phenotype-driven high-throughput
screen for the large-scale identification of novel HNC cytotoxics [146, 147]. Two existing
anti-microbials (benzethonium chloride and alexidine dihydrochloride) were thus identified
from the LOPAC1280 and Prestwick chemical libraries. In the current study, the Spectrum
Collection small molecule library was screened, identifying cetrimonium bromide as an
effective compound against multiple HNC cell lines, with minimal toxicity on normal
fibroblasts; a selectivity that appears to exploit cancer-specific metabolic aberrations.
CTAB belongs to a group of quaternary ammonium compounds, which also includes
benzethonium chloride and dequalinium chloride, both of which have demonstrated anti-
cancer properties in vitro and in vivo by targeting tumor mitochondria [146, 151, 152].
Quaternary ammonium derivatives have also been reported to show enhanced anti-tumor
activity compared to their parent compounds [153], suggesting that molecules possessing
quaternary ammonium moieties may be highly effective anti-cancer agents.
CTAB is a known component of the broad-spectrum antiseptic cetrimide, which is a
mixture of different quaternary ammonium salts that has been clinically used as a tumoricidal
irrigant in colorectal cancer surgery [154], and scolicidal adjunct to hydatid cyst operations
43
[155]. However, the role of CTAB in cetrimide-mediated anti-microbial and tumoricidal
activities has not been investigated extensively; previous studies have in fact described that
pure CTAB- and cetrimide-induced anti-microbial effects occur via different mechanisms
[156]. To our knowledge, the tumoricidal potential of pure CTAB has not yet been reported,
particularly in the context of HNC. This study therefore evaluated the cancer-specific
properties of pure CTAB, and assessed its mode of action in HNC models.
2.3 Materials and Methods
2.3.1 Cell Lines
FaDu (human hypopharyngeal squamous cell cancer), A549 (non-small cell lung
adenocarcinoma), MCF7 (breast adenocarcinoma), and MRC5 (normal lung fibroblasts) were
obtained from the American Type Culture Collection (Manassas, VA). GM05757 (human
primary normal) fibroblasts were obtained from the Coriell Institute for Medical Research
(Camden, NJ). All cell lines were cultured according to the manufacturer’s specifications.
C666-1 (undifferentiated nasopharyngeal cancer) cells [157] were maintained in RPMI 1640
supplemented with 10% fetal bovine serum (Wisent Inc., Quebec, Canada) and antibiotics
(100 mg/L penicillin and 100 mg/L streptomycin) as previously described [158]. UTSCC-8A
and -42A (human laryngeal squamous cell cancer) cells were maintained in Dulbecco's
modified Eagle's medium supplemented with 10% FBS and antibiotics (100 mg/L penicillin
and 100 mg/L streptomycin); UTSCC cells were a gift from R. Grénman (Turku, Finland). All
experiments were conducted when cells were in an exponential growth phase.
2.3.2 Small Molecules
The Spectrum Collection (2,000 compounds; MicroSource Discovery Systems,
Gaylordsville, CT) was provided by the Samuel Lunenfeld Research Institute High-
44
Throughput Screening Robotics Facility (Toronto, Ontario, Canada). The compounds were
initially dissolved using the BioMek FX (Beckman Coulter Inc., Fullerton, CA) in DMSO at a
concentration of 10 mM, then diluted in sterile H2O to 0.1 mM.
Carbonyl cyanide m-chlorophenylhydrazone (CCCP) was obtained from Sigma-
Aldrich (St. Louis, MO) and dissolved in DMSO (Sigma-Aldrich). The pan-caspase inhibitor,
benzyloxycarbonyl-valine-alanine-aspartate fluoromethylketone (Z-VAD.FMK) was
purchased from BioVision (Mountain View, CA). Oligomycin (Calbiochem, San Diego, CA)
and nigericin (Sigma-Aldrich) were dissolved in ethanol with subsequent dilutions prepared in
H2O. Cisplatin (Mayne Pharma-Hospira, Lake Forest, IL), ouabain (Sigma-Aldrich),
cetrimonium bromide (Sigma-Aldrich), and all analogues (Alfa Aesar, Ward Hill, MA):
cetyltrimethylammonium chloride (analogue 1), dodecyltrimethylammonium bromide
(analogue 2), hexyltrimethylammonium bromide (analogue 3), tetramethylammonium bromide
(analogue 4), and butyltriethylammonium bromide (analogue 5) were dissolved and diluted in
H2O to the appropriate concentrations. In all cases, the vehicle (untreated) control was H2O.
2.3.3 Small-Molecule High-Throughput Screening
The BioMek FX and Samuel Lunenfeld Research Institute High-Throughput Screening
Robotics platform were used for cell seeding, treatment, and viability assessment as previously
described [146]. Briefly, FaDu or GM05757 cells were cultured to 85% confluency,
trypsinized, and re-suspended in growth media (2.5104 cells/mL). Cells were seeded
(5103/well in 96-well plates) in 200 µL of growth medium and incubated for 24 hours at
37°C with 5% CO2 and 95% humidity. Small molecules were then added to a final
concentration of 5 μM. Cells treated with 0.1% DMSO and 166.6 μM cisplatin were used as
negative and positive controls, respectively. After 48 hours, 100 μL of growth medium was
removed from each well. The CellTiter 96 AQueous One Solution Cell Proliferation Assay (3-
45
(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium,
inner salt; MTS; Promega Corp., Madison, WI) was used to detect cell viability according to
the manufacturer’s specifications. A 1-hour MTS incubation time was utilized; and 490 nm
absorbance was measured on a SpectraMax Plus384
microplate reader (Molecular Devices
Corp., Sunnyvale, CA).
2.3.4 Cell Viability Assay
Cells were seeded (5103/well in 96-well plates) in 100
µL of growth medium and
incubated for 24 hours at 37°C. The chemicals were then added, to a total volume
of 5 µL.
After 48 hours, the MTS assay was performed with DMSO (0.1%)- and cisplatin (166.6 µM)-
treated cells serving as negative and positive controls, respectively.
2.3.5 Colony Formation Assay
Cells were seeded (10210
4/well in 6-well plates) in 3 mL of growth medium and
incubated overnight at 37°C. CTAB or vehicle alone (sterile H2O) was then added at the
specified concentrations to a total volume of 50 µL. After 48 hours, fresh growth medium was
added, and the plates were incubated at 37°C. Thirteen days after seeding, colonies were fixed
in 70% ethanol, stained with 10% methylene blue, and colonies of 50 cells were counted.
Where indicated, cells were irradiated 24 hours after small-molecule treatment, delivered at
room temperature using a 137
Cs unit (Gammacell 40 Extractor, MDS Nordion, Ottawa,
Ontario, Canada) at a dose rate of 1.1 Gy/min.
2.3.6 Fluorescence Microscopy
Cells were seeded (3105/T-25 flask), incubated for 24 hours, and treated with CTAB
(5 μM; EC75) or vehicle alone at 37°C. After 48 hours, detached and adherent cells were
pooled, pelleted at 200g, and stained with 10 µM Hoechst 33342 (Invitrogen Corp.,
Carlsbad, CA)-4% formalin-PBS
solution. Representative fields were visualized and
46
photographed with a Zeiss Axioskop HBO 40 microscope (Zeiss, Thornwood, NY) under UV
illumination.
2.3.7 Caspase Activity Assay
Cells were seeded (4105/well in 6-well plates), incubated for 24 hours, and treated
with CTAB or vehicle alone. Detached and adherent cells were then collected and stained
using the CaspGLOW In Situ Caspase Staining Kits (BioVision, Mountain View, CA) for
caspase-2, caspase-3,
caspase-8, and caspase-9 activity according to the manufacturer’s
specifications. Analysis was performed using flow cytometry (FACSCalibur, CellQuest
software, Becton Dickinson, San Jose, CA).
2.3.8 Cell Cycle Analysis
Cells were seeded (3105/T-25 flask), incubated for 24 hours,
and treated with CTAB
or vehicle alone. Detached and adherent cells were then pooled, pelleted at 200g, re-
suspended in 1.5 mL of hypotonic fluorochrome solution (50 µg/mL propidium iodide, 0.1%
sodium citrate, 0.1% Triton X-100; Sigma-Aldrich), and left in the dark at 4°C overnight. Flow
cytometric analysis was then performed, and cell cycle distribution was determined using
FlowJo software (Tree Star, Inc., San Carlos, CA). Apoptotic cells were defined as cells with
DNA content less than G0/G1 (hypodiploid).
2.3.9 Transmission Electron Microscopy
Cells were treated with CTAB or vehicle alone and then processed at the University of
Toronto, Faculty of Medicine Microscopy Imaging Laboratory (Toronto, Ontario, Canada).
Briefly, harvested cells were fixed with Karnosky style fixative (4% paraformaldehyde and
2.5% glutaraldehyde in 0.1 M Sorensen’s phosphate buffer, pH 7.2) followed with 1% osmium
tetroxide. Cells were then dehydrated with ethanol, washed with propylene oxide, treated with
epoxy resin, polymerized at 60°C for 48 hours, sectioned on a Reichert Ultracut E microtome
47
to 80 nm thickness, collected on 300 mesh copper grids, and counterstained with uranyl
acetate and lead citrate. Analysis was performed on a Hitachi H7000 transmission electron
microscope (Hitachi, Tokyo, Japan) at an accelerating voltage of 75 kV.
2.3.10 Mitochondrial Depolarization, Calcium Content, and Propidium Iodide Uptake
DiIC1(5) (1,1,3,3,3,3-hexamethylindodicarbocyanine; Invitrogen) was used to
estimate mitochondrial membrane potential (M); cell permeant indo-1 AM (Invitrogen) was
used to determine changes in cytosolic calcium, and propidium iodide (Invitrogen) uptake was
used to determine cell death as previously described [159]. Briefly, cells were seeded
(0.3106/T-25 flask), incubated for 24 hours, and then treated with CTAB or vehicle alone.
Detached and adherent cells were collected, pelleted at 200g, and re-suspended in medium at
a concentration of 106/mL. DiIC1(5) (40 nM final concentration) and indo-1 AM (2 µM final
concentration) were added to the cell suspensions and incubated at 37°C for 25 minutes,
followed by the addition of propidium iodide (1 µg/mL). Cells were analyzed with a Coulter
Epics Elite flow cytometer (Beckman Coulter; DiIC1(5) excitation 633 nm, 675 20 nm
bandpass; indo-1 AM excitation 360 nm, emission ratio 405/525 nm).
2.3.11 ATP Synthase Activity Assay
Cells were cultured to confluence in a 15-cm Petri dish and pelleted at 200g. Fresh
mitochondrial ATPase was isolated (130 μg/reaction), treated with test compounds or vehicle
alone, and measured for specific activity using the MitoProfile ATP Synthase
Activity/Quantity Rapid Microplate Assay Kit (MitoSciences, Eugene, OR) according to the
manufacturer’s specifications.
2.3.12 ATP Luminescence Assay
Cells were seeded (5103/well in 96-well plates) in 200
µL of growth medium,
incubated for 24 hours at 37°C, then treated with CTAB or vehicle alone. Cellular ATP levels
48
were determined using the luciferin-luciferase based ATP Luminescence Assay Kit
(Calbiochem) as instructed by the manufacturer.
2.3.13 Plasma and Mitochondrial Membrane Potential Assays
Cells were seeded (5105/well in 6-well plates) in 3 mL of growth medium and
incubated for 24 hours at 37°C. Mitochondrial membrane potentials were estimated using the
MitoProbe JC-1 (5,5,6,6-tetrachloro-1,1,3,3-tetraethylbenzimidazolylcarbocyanine iodide)
Assay Kit (Invitrogen) according to the manufacturer’s specifications. DiBAC4(3) (bis-(1,3-
dibutylbarbituric acid)trimethine oxonol; Invitrogen) was used to estimate relative plasma
membrane potentials (P). Briefly, detached and adherent cells were collected, pelleted at
200g, and re-suspended in medium containing 30 nM of DiBAC4(3). Cells were incubated at
37°C for 30 minutes and washed with PBS. Cells were analyzed with a BD LSR II flow
cytometer (BD Biosciences, San Jose, CA; DiBAC4(3) excitation/emission: 488/516 nm; JC-1
excitation 488 nm, emission ratio 595/526 nm). Data were processed with FACSDiva software
(BD Biosciences).
2.3.14 In Vivo Tumor Model
All animal experiments utilized 6 to 8 week-old severe combined immunodeficient
(SCID) BALB/c female mice in accordance with the guidelines of the Animal Care
Committee, Ontario Cancer Institute, University Health Network (Toronto, Ontario, Canada).
The mice were euthanized by CO2 once tumor-plus-leg diameters (TLD) reached 14 mm. TLD
is a well-established tool for assessing in vivo therapeutic efficacy and was employed due to
the use of intra-muscular tumor models, which are not amenable to 2D-measurements of tumor
size.
49
2.3.15 Tumor Formation Assay
Cells were seeded (2106/T-75 flask), incubated for 24 hours, and treated as indicated.
After 48 hours, cells were harvested and implanted into the left gastrocnemius muscle of SCID
mice (2.5105 cells in 100 µL growth medium per mouse), then monitored for tumor
formation by measuring TLDs thrice weekly.
2.3.16 Therapeutic Tumor Growth Assay
The intra-muscular injection of tumor cells into the hind limbs of SCID mice is a well-
established method to generate xenograft models to evaluate in vivo efficacy and potential
toxicities of new therapeutic treatments for HNC, whilst allowing the delivery of local tumor
RT [146, 158, 160]. Briefly, cells were injected into the left gastrocnemius muscle of SCID
mice (2.5105 cells in 100 µL). Once the TLDs reached an average of 7.5 mm (range 7.258.0
mm), mice were randomly assigned to one of the following groups: vehicle, CTAB, RT-plus-
vehicle, or RT-plus-CTAB. Mice were administered one intraperitoneal (IP) injection (100 µL
bolus) daily of either vehicle (PBS) or CTAB (5 mg/kg dissolved in PBS) for five consecutive
days. This dosing regimen was selected based on the CTAB in vivo toxicity profiles (Acute
Toxicity Determination) provided by the National Cancer Institute/National Institutes of
Health Developmental Therapeutics Program In Vivo Screening Database
(http://dtp.nci.nih.gov). A well-tolerated treatment schedule with no evidence of toxicity or
lethality in mice was thus selected. Local tumor RT (4 Gy) was delivered on days 2 and 5,
immediately prior to the IP injections. Briefly, mice were immobilized in a Lucite box and the
tumor-bearing leg was exposed to 100 kV (10 mA) at a dose rate of 10 Gy/min, as previously
described [158]. TLDs and body weights were recorded thrice weekly. This drug-plus-RT
regimen has been established in our lab as a standard protocol that is generally well tolerated
50
in mice, thereby allowing for direct comparisons of therapeutic efficacy between different
experimental intervention strategies in vivo.
2.3.17 Statistical Analyses
All experiments were performed at least three independent times, with the data
presented as the mean SEM. The Z factor was utilized to evaluate the high-throughput
screening power [161]. The statistical differences between treatment groups were determined
using the Student’s t test and one-way ANOVA.
2.4 Results
2.4.1 High-Throughput Screening
The preliminary screen of the Spectrum Collection small molecule library (Z factor of
0.73) was conducted on FaDu cells, which represent a clinically relevant model for the study
of HNC [162, 163]; the counter-screen was performed on GM05757 fibroblasts due to their
ease of manipulation and similar growth kinetics (~20 h doubling-time). Potential hits were
defined as compounds that: (a) decreased FaDu cell viability by 50%, but 10% in GM05757
fibroblasts or (b) induced 3-fold reduction in FaDu viability compared to GM05757.
Eighteen compounds were thus identified to demonstrate preferential toxicity against FaDu
cells (Table 2.1), ranging in function from anti-microbial, apoptosis-promoting, anti-
metabolite, to DNA alkylation. The validity of the screen was corroborated by the
identification of existing chemotherapeutic agents such as novantrone, dactinomycin, and
mechlorethamine, as well as the two recently described anti-cancer agents [146, 147].
Amongst the 18 hits, only one compound, cetrimonium bromide (Figure 2.1A), was identified
with heretofore-unreported tumoricidal properties against HNC; hence, selected for further
evaluation.
51
Table 2.1 HTS of the Spectrum Collection small molecule library for novel HNC
cytotoxics
Eighteen compounds were identified with preferential toxicity against FaDu cells. Percent
inhibition of FaDu cell viability induced by each compound is shown. Validity of the screen
was corroborated by the identification of existing chemotherapeutic agents such as novantrone,
dactinomycin, and mechlorethamine.
Compound Molecular Formula Inhibition (%)
Mitoxantrone Hydrochloride C22H30Cl2N4O6 100
Mitomycin C C15H18N4O5 96
Mechlorethamine C5H11Cl2N 91
Antimycin A C28H40N2O9 91
Deguelin C23H22O6 90
Camptothecin C20H16N2O4 89
Beta-Dihydrorotenone C23H24O6 88
10-Hydroxycamptothecin C20H16N2O5 87
Actinomycin D C62H86N12O16 87
Dihydrorotenone C23H24O6 85
Aklavin Hydrochloride C30H36ClNO10 82
Pyrromycin C30H35NO11 80
Teniposide C32H32O13S 76
Floxuridine C9H11FN2O5 72
Cetrimonium Bromide C19H42BrN 71
Alexidine Dihydrochloride C26H57ClN10 60
Benzethonium Chloride C27H42ClNO2 57
Aminopterin C19H20N8O5 51
2.4.2 Validation of HTS Hits and Evaluation of Anti-Cancer Specificity
A dose-response evaluation of CTAB on six cancer and two normal cell lines was
performed to confirm the initial high-throughput screening results, and to further assess its
anti-cancer potential. HNC is a highly heterogeneous disease; hence, we selected cell line
models representing that spectrum, ranging from nasopharyngeal, laryngeal, to
hypopharyngeal subsites. The effective concentration required to reduce cell viability by 50%
after 48 hours of treatment (EC50) was ~2 μM in FaDu, ~3.8 μM in C666-1, ~3.5 μM in
52
UTSCC-8A, and ~4.2 μM in UTSCC-42A cells (Figure 2.1B). In contrast, the EC50 values
were much higher in normal cells; ~11 μM in MRC5 and ~18 μM in GM05757 fibroblasts.
Furthermore, the other human cancer models demonstrated differential sensitivity with higher
EC50 values of ~17 μM for A549 lung and ~12 μM for MCF7 breast cancer cells. Subsequent
studies focused primarily on FaDu cells, the most CTAB-sensitive cancer cell line.
2.4.3 Evaluation of Combination Therapy
To evaluate the effect of combining CTAB with traditional HNC therapeutics, FaDu
cells were exposed to increasing concentrations of CTAB combined with -radiation or
cisplatin. The clonogenic survival curves demonstrated that CTAB interacted additively with
radiation in a dose-dependent manner (Figure 2.1C), similar to the effect observed with
cisplatin (data not shown).
53
Figure 2.1 Characterization of CTAB as a potential anti-cancer agent for HNC
54
(A) Chemical structure of CTAB. (B) Cell viability dose-response curves for CTAB in six
cancer (FaDu, C666-1, UTSCC-8A, UTSCC-42A, A549, and MCF7) and two normal
(GM05757 and MRC5) cell lines. MTS viability assays were performed 48 h after drug
treatment. Line, 50% cell viability (EC50). (C) Effect of combining CTAB with -radiation on
the clonogenic survival of FaDu cells. Cells (102–10
4 per well) were seeded and incubated
with increasing concentrations of CTAB for 48 h; where indicated, cells were irradiated 24 h
after small-molecule treatment. Ten days later, colonies were counted. Each datum represents
the mean SEM from at least three independent experiments.
2.4.4 Cetrimonium Bromide Induces Apoptosis
In an effort to elucidate the mode of cell death induced by CTAB in HNC, apoptosis
and cell cycle analyses were conducted. Hoechst 33342 staining of FaDu cells treated with
CTAB revealed nuclear condensation and blebbing, consistent with apoptotic nuclear
morphology, which was not observed in CTAB-treated GM05757 fibroblasts (Figure 2.2A).
Flow cytometric DNA content analyses also revealed a dramatic increase in the population of
FaDu and C666-1 cells with subG1 DNA content, but not for the GM05757 fibroblasts (Figure
2.2B). On the other hand, cell cycle arrest was not detected in either HNC cell line (data not
shown). CTAB-induced caspase activation was also evaluated in cells treated for 6, 12, 24, 48,
72, 96, or 120 hours (Figure 2.2C, not all data shown). Activation of the caspase cascade, a
hallmark of apoptosis, was observed as early as 12 hours in CTAB-treated FaDu and C666-1
cells, and continued to increase in a time-dependent manner; in contrast to minimal activation
in the GM05757 fibroblasts. The use of a pan-caspase inhibitor, Z-VAD.FMK, revealed
CTAB-induced cytotoxicity to be highly dependent on caspase activation (Figure 2.2D).
55
Figure 2.2 Cetrimonium bromide induces apoptosis in human HNC cells
56
(A) Hoechst 33342 staining of CTAB-treated (48 h) FaDu cells revealed condensed chromatin
with nuclear blebbing, morphologic indicators of apoptosis, which were absent in GM05757
fibroblasts. Bar, 10 μm. (B) Flow cytometric DNA content analyses of CTAB-treated FaDu
and C666-1 cells revealed a dramatic increase in the population of cells with subG1 DNA
content, but not in GM05757 fibroblasts. (C) Fluorescent caspase inhibitor peptide-based
assays demonstrated significant CTAB-induced caspase activation in FaDu and C666-1 cells,
which increased in a time-dependent manner. Minimal increases in caspase activation were
observed in CTAB-treated GM05757 fibroblasts over 1272 h. **, P0.05 and *, P0.01,
statistically significant fold differences compared to vehicle control. (D) Inhibition of caspase
activation significantly suppressed CTAB-induced apoptosis. FaDu cells were incubated with
or without Z-VAD.FMK (25 μM; 1 h) prior to CTAB treatment for 24 h. Apoptotic fractions
were assessed by flow cytometry. *, P0.01, statistically significant difference compared to
CTAB alone. Each column represents the mean SEM from three independent experiments.
In all cases, cells were treated with 5 μM of CTAB (EC75); vehicle represents sterile H2O.
Transmission electron microscopy was utilized to better define the subcellular
morphological characteristics of apoptosis, such as chromatin condensation and membrane
blebbing. Progressive morphologic abnormalities in the mitochondria were observed after 24,
48, or 96 hours of CTAB treatment in FaDu cells (Figure 2.3A), but not in GM05757
fibroblasts (Figure 2.3B); the rough endoplasmic reticulum (ER) remained relatively intact.
To further investigate the mechanism of apoptosis in CTAB-mediated cell death,
cytosolic calcium increase, which may result from damage of the ER or Ca2+
plasma
membrane channels, as well as mitochondrial membrane potential depolarization, which has
been hypothesized to be a marker of apoptotic cells [164], were evaluated. The proportion of
FaDu cells with depolarized mitochondria increased with longer treatment times (1.5% at 2 h,
4.4% at 4 h, 11.4% at 6 h, and 24.2% at 12 h, vs. 1.2% at 12 h with vehicle alone; Figure 2.3C,
box A). Furthermore, increased cytosolic Ca2+
levels could be observed in cells with
depolarized mitochondria. Loss of membrane integrity and cell death, indicated by propidium
iodide (PI) uptake, also increased with incubation time (0.4% at 2 h, 2.5% at 4 h, 6.8% at 6 h,
and 11.7% at 12 h, vs. 0.3% at 12 h with vehicle alone; Figure 2.3C, box C). The presence of a
57
cell population with decreased M that excluded PI (Figure 2.3C, box D) confirmed that the
collapse of M was a primary cellular event leading to cell death.
Figure 2.3 Evaluation of cetrimonium bromide-mediated apoptosis
58
(A) Transmission electron microscopy was used to visualize the subcellular morphological
characteristics of CTAB-induced cytotoxicity in FaDu cells. Chromatin condensation (top;
black arrow) and membrane blebbing (top; white arrow), as well as mitochondrial autophagy
(middle; arrow) were observed. Rough endoplasmic reticulum (bottom; arrow) appeared to be
unaffected. Bar, 1 μm. (B) Mitochondria (arrow) of CTAB-treated GM05757 fibroblasts
remained intact up to 96 h. Bar, 1 μm. (C) FaDu cells treated for 2, 4, 6, or 12 h with CTAB
were simultaneously stained with DiIC1(5) (M), indo-1 AM (cytosolic Ca2+
), and propidium
iodide (PI; membrane integrity/cell viability). Gates for quantification are shown. Box A,
mitochondrial membrane potential (M) depolarized cells; Box B, M polarized cells; Box
C, M depolarized and dead cells; Box D, M depolarized and viable cells; Box E, M
polarized and viable cells. Each experiment was performed three independent times. In all
cases, cells were treated with 5 μM of CTAB (EC75); vehicle represents sterile H2O.
2.4.5 Cetrimonium Bromide Perturbs Mitochondrial Function
CTAB has previously been reported to compromise bioenergetic homeostasis by
inhibiting H+-ATP synthase [165]. To determine if CTAB induced apoptosis in HNC cells via
inhibition of ATP synthase (ATPase), freshly isolated mitochondria were solubilized, treated
with CTAB, and monitored for enzymatic activity. CTAB reproducibly decreased ATPase
activity in a dose-dependent manner; achieving ~90% inhibition at 50 μM (Figure 2.4A). The
extent of inhibition by CTAB was comparable to that of oligomycin, a potent mitochondrial
H+-ATP synthase inhibitor. Ouabain, a selective Na
+/K
+-ATPase inhibitor had minimal effect
on ATPase activity, validating the specificity of H+-ATPase inhibition by CTAB.
The inhibition of mitochondrial H+-ATPase should lead to a progressive reduction in
intracellular ATP levels; this was indeed observed after 12 hours of CTAB exposure, which
caused a modest (~10%), but statistically significant decrease in ATP content in FaDu cells
(Figure 2.4B). However, by 24 hours, total intracellular ATP level fell to ~12%, and continued
to decline in a time-dependent manner. In contrast, ATP levels in GM05757 fibroblasts were
minimally perturbed.
59
Figure 2.4 Cetrimonium bromide induces mitochondrial dysfunction
(A) Effect of CTAB (2.550 μM) on mitochondrial H+-ATP synthase activity in FaDu cells.
Percent inhibition was calculated by dividing the specific enzyme activity (normalized to
protein quantity) of CTAB- vs. vehicle-treated ATPase. *, P0.01, statistically significant
difference compared to untreated cells (ATPase inhibition set as 0%). (B) GM05757 and FaDu
cells were treated with CTAB for 696 h and assessed for changes in intracellular ATP levels.
In all cases, cells were treated with 5 μM of CTAB (EC75). **, P0.05 and *, P0.01,
statistically significant differences compared to untreated cells (ATP content set as 100%).
Each column represents the mean SEM from at least three independent experiments.
60
2.4.6 Role of M in Cetrimonium Bromide-Mediated Cell Death
Previous findings have suggested that the composition and function of mitochondria in
cancer and normal cells differ, including a higher M [166]. Hence, the relative intrinsic
mitochondrial transmembrane potentials of GM05757, MRC5, A549, and FaDu cells were
measured, demonstrating that FaDu cells had the highest M compared to the low values for
both types of fibroblasts, with an intermediate value for A549 cells (Figure 2.5A). This relative
difference in M reflects the respective differential sensitivity to CTAB (Figure 2.1B).
To further investigate the determinative role of M in CTAB-mediated cell death,
FaDu cells were pre-incubated with CCCP, a protonophore that dissipates the proton gradient;
a low concentration of CCCP was used to effectively uncouple M, without perturbing P
(Figure 2.5B). Mild M uncoupling prior to CTAB treatment significantly suppressed
CTAB-induced apoptosis by 50% (Figure 2.5C). In comparison, oligomycin, another potent
ATPase inhibitor (Figure 2.4A), did not respond to changes in M (Figure 2.5D) and
demonstrated no selective cytotoxicity amongst the different cancer cell lines tested (Figure
2.5E); an observation that was expected since oligomycins are neutral macrolide antibiotics
that could induce cell death independent of M.
To examine the involvement of the electrochemical pH-gradient in CTAB-mediated
apoptosis, FaDu cells were pre-treated with nigericin, a K+/H
+ exchange ionophore that
dissipates the pH gradient across the mitochondrial membrane. Perturbing the pH gradient
prior to CTAB treatment did not protect against cytotoxicity (Figure 2.5F). In fact, a modest
dose-dependent increase in apoptosis was observed, corresponding to the compensatory
increase in M that is anticipated with a pH gradient loss [167], which in turn could enhance
CTAB accumulation within the mitochondria.
61
Figure 2.5 Role of M in cetrimonium bromide-mediated apoptosis
62
(A) Mitochondrial transmembrane potentials of GM05757, MRC5, A549, and FaDu cells. In
cells with high M, the JC-1 dye forms red fluorescent J-aggregates. JC-1 remains in the
green fluorescent monomeric form in cells with low M. The ratio of red to green
fluorescence serves as a read-out for M. *, P0.01, statistically significant difference
compared to FaDu cells. (B) FaDu cells treated with or without CCCP (5 μM) were stained
with DiBAC4(3) and DiIC1(5) to measure relative changes in P and M, respectively. **,
P0.05, statistically significant fold difference compared to untreated cells. (C) Effect of M
on CTAB-mediated cytotoxicity. FaDu cells were incubated in medium with or without CCCP
(5 μM; 1 h) prior to CTAB treatment (5 μM) for 24 h. SubG1 apoptotic fractions were assessed
by flow cytometry. **, P0.05, statistically significant difference compared to CTAB alone.
(D) Effect of M on oligomycin-mediated cytotoxicity. FaDu cells were incubated in
medium CCCP (5 μM; 1 h) prior to oligomycin (OLIG) treatment (30 μM; EC75) for 48 h.
SubG1 apoptotic fractions were assessed by flow cytometry. (E) Cell viability dose-response
curves for oligomycin in four cancer (FaDu, C666-1, A549, and MCF7) cell lines. MTS assays
were performed 48 h after drug treatment. Line, 50% cell viability (EC50). (F) FaDu cells pre-
incubated in medium nigericin (5 or 10 nM; 1 h) prior to CTAB treatment (5 μM; 24 h) were
assessed for apoptosis via flow cytometry. Each datum represents the mean SEM from at
least two independent experiments.
2.4.7 Elimination of Tumor Formation
To evaluate the effect of CTAB on tumorigenesis in vivo, FaDu cells treated with
CTAB (EC75) were injected into the left gastrocnemius muscle of SCID mice (2.5105
cells/mouse); establishing a three-dimensional system that simulates the complex tumor micro-
environment. Mice implanted with CTAB-treated FaDu cells did not develop tumors even
after 100 days (Figure 2.6A). In contrast, mice with vehicle-treated cells (implanted with
6.25104 cells, representing the proportion of viable cells post-treatment with EC75),
developed tumors as early as 15 days, clearly demonstrating that CTAB effectively eliminated
the tumor-forming potential of FaDu cells in SCID mice.
2.4.8 Growth Delay in Established Xenograft Tumors
The therapeutic efficacy of CTAB in treating established FaDu xenograft tumors in
SCID mice was also evaluated. Once the TLDs reached an average of 7.5 mm, the mice were
treated with CTAB (daily 5 mg/kg IP for 5 days). The dosing regimen was not optimized for
63
absorption, distribution, metabolism, or excretion, but a delay in tumor growth (i.e. therapeutic
benefit) was nonetheless observed. CTAB induced a modest reduction in tumor development
compared to the vehicle-treatment arm; delaying the mean time to reach a TLD of 14 mm by
~3.7 days (P0.05; Figure 2.6B). When combined with local tumor RT, CTAB appeared to
have a modest additive effect by extending the mean time to reach 14 mm by ~7.2 days
(P0.05; Figure 2.6B). These data strongly suggest that improving the pharmacokinetics and
bioavailability of CTAB would render this compound highly effective; as the in vivo tumor-
forming capacity of FaDu cells was completely ablated when every tumor cell was exposed to
the drug (Figure 2.6A).
2.4.9 In Vivo Safety and Toxicity
To assess the in vivo safety and toxicity of our CTAB dosing regimen (~0.05% IP), the
body weights of tumor-bearing mice were monitored. The four treatment groups exhibited no
significant difference in overall body weight (Figure 2.6C), indicating that this treatment was
well tolerated, as no evidence of toxicity or lethality was observed.
64
Figure 2.6 In vivo efficacy of cetrimonium bromide
65
(A) FaDu cells treated with vehicle (H2O) or CTAB (5 μM) for 48 h were injected into the left
gastrocnemius muscle of SCID mice. CTAB-treated cells did not form tumors even after 100
days. (B) FaDu xenograft tumors were established in SCID mice; once the tumor-plus-leg
diameters (TLD) reached 7.5 mm, the mice were randomly allocated to one of the following
groups: vehicle, CTAB, local radiation therapy (RT)-plus-vehicle, or RT-plus-CTAB. The
mice were administered one IP injection (5 mg/kg) daily of either vehicle (H2O) or drug for
five consecutive days. Local tumor RT (4 Gy) was delivered on days 2 and 5 before the IP
injections. The mice were euthanized once TLDs reached 14 mm. Solid line, mean time to
reach a TLD of 14 mm. *, P0.05, statistically significant difference between CTAB vs.
vehicle or RT-plus-CTAB vs. RT-plus-vehicle. (C) Total body weight was also recorded for
each group, demonstrating no significant difference. Each datum represents the mean SEM
from three independent experiments (3 mice/treatment group/experiment).
2.4.10 Evaluation of Cetrimonium Bromide Analogues
To explore the structure-function relationship of CTAB with a focus on understanding
the importance of its chain length, five commercially available analogues were evaluated on
FaDu and GM05757 cells (Figure 2.7A). Substitution of Br− with Cl
− did not significantly
diminish the inhibitory actions of the compound (analogue 1). Complete removal of the alkyl
chain however, abolished any anti-cancer activity (analogue 4). Derivatives with carbon chains
Cn12 demonstrated a complete loss of inhibition (analogues 35); as did the sterically bulky
quaternary ammonium group of analogue 5. Only analogues 1 (cetyltrimethylammonium
chloride) and 2 (dodecyltrimethylammonium bromide) retained cytotoxicity and bioactivity
with EC50 values similar to those measured for CTAB: 2.5 μM vs. 14 μM for analogue 1, and 4
μM vs. 30 μM for analogue 2, in FaDu and GM05757 cells, respectively (Figures 2.7B and C).
66
Figure 2.7 Anti-cancer efficacy of cetrimonium bromide analogues
67
(A) Chemical structures of CTAB, cetyltrimethylammonium chloride (analogue 1),
dodecyltrimethylammonium bromide (analogue 2), hexyltrimethylammonium bromide
(analogue 3), tetramethylammonium bromide (analogue 4), and butyltriethylammonium
bromide (analogue 5). (B) Cell viability dose-response curves for CTAB and analogues 15 in
FaDu cells. (C) Dose-response curves for CTAB and analogues in GM05757 fibroblasts. Line,
50% cell viability (EC50). Only analogues 1 and 2 retained selective anti-cancer cytotoxicity
and bioactivity with EC50 values similar to CTAB. MTS viability assays were performed 48 h
after drug treatment. Each datum represents the mean SEM from three independent
experiments.
2.5 Discussion
In the current study, a phenotype-driven HTS of the Spectrum Collection small molecule
library was performed for the large-scale identification of novel HNC cytotoxics. Cetrimonium
bromide, an existing anti-microbial [168], was identified to have anti-cancer efficacy against
several human HNC cell lines with minimal toxicity towards normal cells. Our data document
CTAB to significantly compromise mitochondrial bioenergetic function, inducing cell death
primarily through the intrinsic caspase-dependent apoptotic pathway; non-apoptotic death such
as senescence and mitotic catastrophe were not observed (data not shown). FaDu cells, which
represent a highly aggressive HNC cell line, sustained sufficient damage upon CTAB
treatment to irreversibly inhibit the clonal growth of cultured carcinoma cells in vitro, and
ablate tumorigenicity in vivo. When combined with local RT, CTAB delayed tumor growth
whilst maintaining a favorable toxicity profile. CTAB is a known component of cetrimide,
which has been routinely used during hydatid cyst, and colorectal surgeries at concentrations
that are clinically well tolerated. In rare cases, cardiac ischemia, chemical peritonitis, and
methemoglobinemia have been reported with cetrimide concentrations ranging from ~15%
[168, 169]; 12% cetrimide solutions found in common household products have been
occasionally associated with erythema and skin blistering [170]. No clinical case reports of
toxicity have been described relating to administration of pure CTAB. Nonetheless, the CTAB
68
dosing utilized in our study was well tolerated in the treated mice, with good maintenance of
their body weights.
CTAB is a quaternary ammonium compound, belonging to a group of small molecules,
known as delocalized lipophilic cations (DLCs). Due to their lipophilic nature and delocalized
positive charge, DLCs can penetrate the hydrophobic barriers of plasma and mitochondrial
membranes, and accumulate in the mitochondria in response to the negative transmembrane
potential, resulting in mitochondriotoxicity [171]. Accordingly, the determinative role of M
in CTAB-mediated cytotoxicity was demonstrated as mild M uncoupling prior to CTAB
treatment significantly suppressed the overall level of apoptosis in FaDu cells (Figure 2.5C);
while perturbation of the mitochondrial pH gradient and corresponding compensatory M
increase via nigericin enhanced CTAB-induced apoptosis (Figure 2.5F).
Dysregulation of mitochondrial functions and aberrant metabolic bioenergetics are
mechanisms cancer cells have developed to resist mitochondrial-mediated apoptosis, thereby
surviving in the toxic tumor micro-environment [172]. These features however, can be
exploited for the development of novel anti-cancer therapies targeting mitochondrial proteins
and membranes to promote cell death. Elevated intrinsic plasma and/or mitochondrial
membrane potentials have been reported for various cancer cells [167, 173, 174]; with higher
M attributed to the buildup of the mitochondrial proton gradient, resulting from reduced
oxidative phosphorylation (OXPHOS) [171, 175]. Such M differences of 60 mV can
therefore result in a 10-fold accumulation of DLCs in tumor vs. normal mitochondria [176].
The degree of glycolytic up-regulation also varies between different tumors, which
might in part explain the differential sensitivity to CTAB amongst the various cancer cell lines.
Head and neck cancers, which are often hypoxic, are commonly associated with high aerobic
glycolytic activity and increased aggressiveness [177, 178]; while the MCF7 breast and A549
69
lung cancer cells have relatively lower aerobic glucose consumption rates [179]. Accordingly,
we observed A549 cells to have lower intrinsic M than FaDu cells (Figure 2.5A);
correlating with their relative cytotoxicity profiles (Figure 2.1B). Taken together, the basis of
selectivity of CTAB against HNC cells appears to be rooted at the mitochondrial level, with
subtle differences in M being a key regulator. Thus, CTAB would be predicted to be more
effective against tumors that rely heavily on glycolysis, and are dependent on the Warburg
effect.
Once CTAB is concentrated into the tumor mitochondria, the H+-gradient across the
inner mitochondrial membrane may begin to dissipate, with the consequent M decline
sensed by the mitochondrial permeability transition pore (PTP) [180]. Opening of the PTP
causes mitochondrial outer membrane permeabilization (MOMP), a pivotal event in the
intrinsic apoptotic pathway, leading to the disruption of essential mitochondrial functions,
along with release of apoptogenic factors, such as cytochrome c [181]. We detected M
depolarization as early as 2 hours post-treatment (Figure 2.3C) with caspase-9 activation after
12 hours (Figure 2.2C), indicating that mitochondrial damage is an early event in CTAB-
induced cell death. Structural abnormalities observed at 24 hours (Figure 2.3A) may represent
dysfunctional mitochondria that are being eliminated via autophagy [182]. The high levels of
initiator caspase-9 activation (Figure 2.2C) suggest that mitochondria-mediated apoptosis may
be the primary mechanism by which CTAB exerts its cytotoxic effect.
Increased cytosolic Ca2+
levels were also detected in cells with depolarized
mitochondria, which may be associated with endoplasmic reticulum Ca2+
release during ER-
stress induced apoptosis. Increased cytosolic Ca2+
can trigger mitochondrial Ca2+
overload,
resulting in M collapse, with subsequent MOMP and cytochrome c release, thereby
activating the caspase cascade [183]. The activation of initiator caspases-2 and -8, which was
70
observed to a lesser extent in CTAB-treated HNC cells (Figure 2.2C), is also involved in the
ER-stress response [183, 184]. Collectively, this suggests that activation of both ER- and
mitochondria-mediated apoptotic pathways is responsible for CTAB-induced cytotoxicity.
We and others [165] have demonstrated that CTAB compromises mitochondrial
bioenergetic regulation via inhibition of ATP synthase, which consists of the membrane-
embedded F0 (H+-translocation) and peripheral catalytic F1 (ATP synthesis/hydrolysis)
subcomplexes [185]. The ATPase couples the electrochemical H+-gradient to ATP
synthesis/hydrolysis and is responsible for maintaining the M in response to changes in the
proton motive force [185, 186]. Thus, mitochondrial repolarization via ATP hydrolysis may
occur to counteract the CTAB-induced depolarization in cancer cells. The ability of CTAB to
directly bind and inhibit ATPase will prevent M repolarization, serving as another means of
committing cancer cells to death. It should be noted that the CTAB concentrations required to
significantly inhibit ATPase activity were higher than the cytotoxic doses in FaDu cells
(Figures 2.4A and 1B). Previous studies have observed that higher levels of CTAB are
necessary to inhibit the activity of purified ATPase vs. the enzyme in the presence of sub-
mitochondrial particles (membrane-bound ATPase) [165], which could potentially explain the
difference in concentrations. In comparison, the neutrally charged oligomycin, which was
unresponsive to subtle M changes (Figure 2.5D), and thus demonstrated no selective
cytotoxicity amongst different cancer cell lines (Figure 2.5E), was able to inhibit ATPase at
concentrations much lower than its cytotoxic doses (Figures 2.4A and 2.5E). Thus, CTAB-
induced cell death involves, at least in part, ATPase inhibition, although this might not be its
primary mode of action.
Since mitochondria-mediated cytotoxicity is complex, and can proceed simultaneously
via multiple mechanisms, additional mitochondriotoxic effects cannot be ruled out. The
71
preliminary biological action of cationic CTAB may be the M-driven accumulation in the
tumor mitochondria, initiating a multitude of secondary effects (M depolarization, lipid
peroxidation, ATPase inhibition, etc.) that collectively perturb mitochondrial function and
ultimately, induce apoptosis. The CTAB-induced onion-skin appearance of damaged
mitochondria (Figure 2.3A) is consistent with lipid peroxidation, which has also been reported
with other DLCs via membrane intercalation and reactive oxygen species, resulting in
membrane permeabilization [187, 188]. Thus, the possibility of CTAB promoting membrane
lipid peroxidation also warrants further evaluation.
Interestingly, CTAB has recently been implicated in the regulation of OXPHOS
expression [189], whereby it decreased the transcription of nuclear-encoded OXPHOS genes,
including atp5a1, atp5c1, and atp5o, all of which encode subunits of the ATPase F1 complex.
Furthermore, CTAB has been shown to specifically interact with negatively charged acidic
residues buried in the hydrophobic environments of the F1 moiety [165]. These findings point
towards a unique mechanism by which CTAB appears to be able to down-regulate the
transcription of certain ATPase subunits, as well as physically inhibit their enzymatic
activities.
The desirable anti-cancer activity of CTAB suggests that analogues based on structural
modification may result in more efficacious lead compounds. As such, commercially available
derivatives were exploited to examine the structure-function relationship of CTAB. Our results
indicate that the combination of both the positively charged quaternary nitrogen and non-polar
hydrophobic alkyl chain are indispensable for its cytotoxic effect. This inhibitory action also
appeared to be highly dependent on the length of the alkyl chain, as analogues with shorter
tails exhibited reduced cytotoxicity. Additional testing of cetrimonium analogues with longer
alkyl chains may provide useful starting points for further lead optimization. Taken together,
72
our results suggest that the positively charged polar head of CTAB provides the basis for its
anti-cancer specificity, while the non-polar hydrophobic tail may aid in its insertion into the
plasma membrane. The lipophilic nature, delocalized positive charge, and structural similarity
to sphingosine, a primary component of sphingolipids, may allow CTAB to readily penetrate
the hydrophobic barriers of the lipid bilayer and accumulate within the tumor cell.
In conclusion, we have identified CTAB as a clinically relevant, novel anti-cancer agent
for HNC. P53 is mutated in over ~50% of human cancers [190] and is correlated with poor
prognosis and enhanced resistance to commonly used chemotherapeutic agents [191].
Examination of CTAB-treated wild-type (p53+/+
) and mutant (p53-/-
) colon cancer HCT116
cells [192] demonstrated very similar sensitivity (data not shown), suggesting that CTAB-
mediated toxicity is independent of p53 status; thereby increasing the potential applicability of
CTAB to many different human cancers. Moreover, its favorable toxicity profile, ability to
induce apoptosis in cancer cells at much lower concentrations than its anti-microbial
application [168], and capacity to delay tumor growth in FaDu xenograft models comparable
to paclitaxel [193], a commonly used chemotherapeutic agent in the clinical management of
HNC patients [194], all suggest that optimizing the bio-availability and pharmacokinetics of
CTAB could provide an exciting opportunity for the development of a highly effective drug
candidate, capable of exploiting the metabolic aberrations of human head and neck cancers.
2.6 Acknowledgments
We thank Alessandro Datti, Thomas Sun, and Frederick Vizeacoumar from the Samuel
Lunenfeld Research Institute High-Throughput Screening Robotics Facility for their assistance
with the high-throughput screen.
73
CHAPTER 3: INCREASED EFFICIENCY FOR PERFORMING
COLONY FORMATION ASSAYS IN 96-WELL PLATES - NOVEL
APPLICATIONS TO COMBINATION THERAPIES AND HIGH-
THROUGHPUT SCREENING
The data presented in this chapter have been published in:
Katz D*, Ito E*, Lau KS, Mocanu, JD, Bastianutto, C, Schimmer, AD, Liu, FF.
Biotechniques 2008; 44: ix-xiv. *These authors contributed equally to this work.
Reprinted with permission from BioTechniques. All rights reserved.
Copyright © 2008 BioTechniques.
74
3.1 Chapter Abstract
The colony formation assay is the gold standard for measuring the effects of cytotoxic
agents on cancer cells in vitro; however, in its traditional 6-well format, it is a time consuming
assay, particularly when evaluating combination therapies. In the interest of increased
efficiency, the 6-well CFA was converted to a 96-well format using an automated colony
counting algorithm. The 96-well CFA was validated using ionizing radiation therapy on the
FaDu (human hypopharyngeal squamous cell) and A549 (human lung) cancer cell lines. Its
ability to evaluate combination therapies was investigated by the generation of dose-response
curves for the combination of cisplatin and RT on FaDu and A549 cells. The 96-well CFA was
then transferred to a robotic platform for evaluating its potential as a high-throughput
screening read-out. The LOPAC1280 library was screened against FaDu cells, and 8 putative
hits were identified. Using the 96-well CFA to validate the 8 putative chemicals, 6/8 were
confirmed, resulting in a positive hit rate of 75%. These data indicate that the 96-well CFA can
be adopted as an efficient alternative assay to the 6-well CFA in evaluating single and
combination therapies in vitro, providing a possible read-out that could be utilized on a HTS
platform.
3.2 Introduction
The colony formation assay has been the gold standard for determining the effects of
ionizing radiation therapy on in vitro cellular systems since first described by Puck and
Marcus in 1956 [4]. Despite being the gold standard, the CFA can be time consuming when
counting the number of colonies manually under the microscope. For this reason, many
different assays have been used in lieu of the CFA in order to assess the effects of cytotoxic
agents on cancer cell growth in vitro. While many of these techniques are able to detect
75
specific cellular processes such as apoptosis [195], proliferation [196], or senescence [197],
the CFA is the only assay that monitors a cancer cell’s ability to produce a viable colony after
treatment. Unlike most other assays, the CFA is unbiased to the mode of cell death. It is able to
detect the cytotoxic effect of an agent, regardless of mechanism, as long as the agent affects
the cell’s reproductive ability to form progenies.
Most of the advancements made in cancer therapy in recent years have resulted from
the combination of previous individual modalities, such as radiation and chemotherapy.
Chemotherapy with such agents as cisplatin, 5-fluorouracil, doxorubicin, temozolomide, or
cetuximab, have been combined with radiotherapy for the treatment of head and neck cancer
[198], non-small cell lung carcinoma [199], glioblastoma [96], cervix [84], and bladder
cancers [200], to name a few. Initially, discovery of such combinations was conducted in the
laboratory using tissue culture as the primary testing platform. To assess novel potential
combinations, the majority of experiments were performed in a traditional 6-well tissue culture
plate CFA, with each plate representing a different combination of two potential treatments.
Commonly, such experiments test up to six different doses of radiation (010 Gy) and up to
seven different doses of drug [201]. Using the traditional CFA, this would result in utilizing 42
individual plates. Beyond the technical challenges of conducting an experiment with 42
individual plates, a significant amount of time would be required to manually count the
colonies on all such plates. This underscores the need for a more modern approach to this
assay. With recent improvements in fluorescent probes and high-content microscopy, it is now
possible to adapt the traditional method to a more efficient approach using a 96-well plate and
an automated colony counting algorithm. While this article describes this novel approach in
evaluating combination therapies including radiation and chemical treatment, it can be
76
extended to any combination of treatments including two different chemical treatments
administered concurrently.
Another area of advancement in cancer research is the use of high-throughput
screening for the identification of novel anti-cancer compounds. There are two basic
approaches to HTS. The forward chemical biology approach identifies a phenotype of interest,
after treatment with chemical compounds, and the mechanism is subsequently elucidated
[118]. The reverse chemical biology approach identifies a target, and “hits” are selected as
compounds that modulate that specified molecule [118]. Both forward and reverse approaches
have yielded clinically useful anti-cancer drugs. The forward chemical biology approach is
illustrated by the use of paclitaxel, which was shown to be effective against tumors long before
it was identified to target microtubules [121]. The reverse chemical biology approach has
been highly successful in the identification of the bcr-abl inhibitor, Imatinib (Novartis), used
for treatment of chronic myelogenous leukemia [123], and the src-abl kinase inhibitor,
Dasatinib (Bristol-Myers Squibb), used to treat imatinib-resistant chronic myelogenous
leukemia [202].
In the current study, we have adapted the 6-well CFA to a more efficient 96-well CFA
that will allow for rapid analysis of combination therapies, and opens the potential for high-
throughput drug screening using the CFA as the read-out.
3.3 Materials and Methods
3.3.1 Cell Lines
Human head and neck squamous cell carcinoma FaDu cells were cultured in MEM-
F15 medium containing 10% FBS, 1 mM pyruvate, 1.5 g/L sodium bicarbonate, 100 mg/L
77
penicillin and 100 mg/L streptomycin. Human lung adenocarcinoma A549 cells were cultured
in RPMI media containing 10% FBS, 100 mg/L penicillin and 100 mg/L streptomycin.
3.3.2 6-Well Colony Formation Assay
Cells were trypsinized and plated in 6-well dishes at different densities depending on
the potency of the treatments (from 50104 cells/well). Cells were allowed to attach overnight
and then exposed to RT (016 Gy) or chemical treatment at the corresponding dilution. Forty-
eight hours after chemical treatment, the media was replaced with fresh media, and the plates
were incubated at 37°C. Seven to eleven days later, the cells were fixed and stained with 10%
methylene blue in 70% ethanol. The number of colonies, defined as 50 cells/colony were
counted, and the surviving fraction was calculated as the ratio of the number of colonies in the
treated sample to the number of colonies in the untreated sample. Triplicate wells were set up
for each condition.
3.3.3 96-Well Colony Formation Assay
Cells were trypsinized and plated in 96-well plates at different densities depending on
the stringency of the treatments (from 502500 cells/well). The cells were allowed to attach
overnight and then exposed to RT (016 Gy) or chemical treatment at the corresponding
dilution. RT was administered 24 hours after addition of the chemical, and the media was
replaced 48 hours later. Six days after seeding, cells were fixed in 3.7% formaldehyde at room
temperature for 15 minutes followed by staining with 10 μM Hoescht 33342 (Invitrogen;
Carlsbad, CA, USA) and 10 μM Cell TrackerTM
Orange CMTMR (Invitrogen; Carlsbad, CA,
USA) in serum-free media, and incubated at 37°C for 30 minutes. After staining, the wells
were scanned (4 fields/well) at 4x objective using the IN Cell Analyzer 1000 (GE Healthcare;
Buckinghamshire, England). The excitation and emission filters used for Hoescht 33342 and
Cell TrackerTM
Orange were 360 nm/460 nm and 535 nm/620 nm, respectively. Colonies were
78
recognized by an algorithm setup on the Developer Toolbox software (GE Healthcare;
Buckinghamshire, England) using the overlay of the blue and red images. The algorithm’s
output indicated the location of the colony within the plate, and the number of blue nuclei
contained within the colony. The number of colonies per well was then filtered by a custom
computer program (http://www.uhnres.utoronto.ca/labs/liu/ACC/) to include all colonies with
6 cells/colony and 350 cells/colony. The surviving fraction was then calculated by dividing
the number of colonies by the number of cells seeded, multiplied by 2.217 (to account for the
proportion of the well that was scanned), then divided by the surviving fraction of untreated
cells. Three to eight replicates were set up per treatment.
3.3.4 High-Throughput Screening
FaDu cells were seeded in 96-well plates at a dilution of 250 cells per well in 100 μL of
media using a Biomek®
FX liquid handler (Beckman Coulter; Fullerton, CA, USA). After
allowing the cells to attach overnight, the LOPAC1280 (Sigma-Aldrich; St. Louis, MO, USA)
library of compounds was added to the cells at a final concentration of 0.5 μM. On each plate,
column 1 was the vehicle control and column 12 was 0.5 μM cisplatin, providing the positive
cytotoxic control. After 48 hours, the chemical containing media was removed and fresh media
was replaced in all wells. After 72 hours, the cells were dual stained using Hoescht 33342 and
Cell TrackerTM
Orange CMTMR; the number of colonies per well was then determined, as
described previously for the 96-well CFA. All reagents and media were added and removed
using the robotic platform available at the Samuel Lunenfeld Research Institute Robotics
Facility. The B-score was then used to normalize the data with respect to systematic variation
between plates using the HTS Corrector software [203]. Putative hits were then determined to
be any compounds with a B-score lower than 3 standard deviations from the median B-score.
The LOPAC1280 library was supplied by the Samuel Lunenfeld Research Institute and
79
screened in two independent experiments, the first using plates 1 through 8, and the second
using plates 9 through 16. The data were analyzed and putative hits were selected separately.
All putative hits were re-ordered from Sigma-Aldrich, and fresh batches were used for follow
up testing.
3.4 Results and Discussion
The primary objective of this study was to automate the conduct of the CFA, thereby
increasing efficiency in performing large-scale high-throughput experiments. This task was
addressed by using high-content microscopy, with differentially staining fluorescent dyes for
morphologic distinction of the cell’s nucleus vs. cytoplasm (Figure 3.1A). This allowed the
determination of not only the number of colonies, but also the size of each colony. This
additional level of assessment thereby allowed the filtering of data by removing any colonies
that resulted from a radiation-induced giant cell, or a small aggregate of cells that would not
score as a legitimate colony. The IN Cell Analyzer 1000 provided the necessary flexibility that
could automate both image acquisition and analysis. Upon acquiring the images and utilizing
the Developer Toolbox software, the images were analyzed using an algorithm that first
identified a colony based on adjacent signals from the cytoplasm stained with Cell TrackerTM
Orange CMTMR. Once the colony was defined, the number of cells within this colony was
determined by counting the number of Hoescht 33342 stained nuclei (Figure 3.1B). After
analysis of all the images on a single plate, a list of the well location of each colony, and its
corresponding number of nuclei, was produced (Figure 3.1C). A customized program then
converted this list into a matrix representing the number of colonies per well (Figure 3.1D).
In this process, a filter was also included to define the minimum and maximum number
of nuclei necessary in order to qualify as a colony. The minimum number of cells per colony is
80
determined by assuming a “least growth” scenario wherein cells do not start dividing until the
chemical has been removed, allowing for 72 hours of growth. Given the doubling time of the
cell line being investigated, one could then determine the number of divisions a single cell will
undergo, thereby providing an estimate for the minimum number of cells in a colony. In the
case of FaDu cells, with a doubling time of ~22 hours [204], approximately 3 doublings should
have occurred within 72 hours, thus a colony should constitute at least 8 cells. For practical
purposes, the threshold was set between 6 to 350 nuclei per colony. Once the number of
colonies per well has been determined, the surviving fraction was then calculated in the same
manner as the traditional CFA (Figure 3.1E).
81
Figure 3.1 Schematic representation of the 96-well colony formation assay
(A) Flourescence image obtained using the INCell Analyzer 1000 at 4x objective of FaDu cells
stained with Cell TrackerTM
Orange CMTMR and Hoescht 33342. (B) Colonies are defined
using the Developer Toolbox software as an adjacent set of cytoplasmic signals (blue outline)
containing stained nuclei (green outline). (C) The readout from Developer Toolbox is an excel
worksheet that lists all colonies with their corresponding number of nuclei within a specific
well. (D) A custom software program was created to convert the list output into a matrix
containing the number of colonies per well on the original plate, filtered to include only
colonies with 6 and 350 nuclei. (E) The matrix data are then plotted as a clonogenic
survival curve.
82
Historically, the CFA was first described as a method for assessing the effects of
radiation [4]. Since that time there have been many modifications to this assay with the use of
fluorescent dyes and smaller formats [205], however it has yet to be clearly illustrated whether
these modified protocols are able to recapitulate the traditional gold-standard assay. In order to
clearly validate the previously described protocol, the first set of 96-well experiments was
conducted using RT on the FaDu cells since they produced well-defined single colonies,
facilitating miniaturization of the CFA. At a dilution of 100 cells/well in the control
(untreated) sample, the colonies remained discrete and separable by the image analysis
software after 7 days’ growth. This was achieved in the untreated samples, and could be
extended out to 2500 cells/well in samples exposed to 16 Gy. Survival curves were then
generated using the traditional 6-well CFA format, and compared with that of the 96-well CFA
(Figure 3.2A). The two curves overlap almost completely, indicating that the 96-well CFA
could recapitulate the 6-well CFA. The survival curves generated with the 96-well format
however could only be extended to 8 Gy RT, since beyond this dose, too many radiation-
induced giant cells would confound the analysis. To determine if this method could be
applicable to other cell lines, the experiments were repeated using the A549 cell line (Figure
3.2B). Once again, the 96-well data set was able to reproduce the data from the 6-well assay,
indicating that the 96-well format could recapitulate the traditional assay in the context of
radiation treated colony forming cell lines.
83
Figure 3.2 Reproducibility of a 96-well CFA compared to a traditional 6-well CFA
(A) CFAs were performed on FaDu cells using the 96-well and the 6-well assays. (B) CFAs
were performed on A549 cells using the 96-well and the 6-well assays. Each datum represents
the mean SEM from 3 independent experiments for 6-well data and 2 independent
experiments for 96-well data.
The subsequent studies proceeded to evaluate combination treatments, a major objective
in improving cancer therapy. Hence, FaDu cells were treated with RT combined with
cisplatin, a common clinical regimen for treatment of head and neck squamous cell carcinoma
patients. Again, the 96-well assay appeared to be an excellent representation as the RT alone
curve replicated that of the 6-well assay results (Figure 3.3A). Similarly, the cisplatin data
agree with previously published reports whereby ~50% survival level was observed when
FaDu cells were treated with 0.5 μM cisplatin [206]. The corresponding experiments were
performed with the A549 cells, with similar results obtained (Figure 3.3B).
84
From the time of staining of the plates, the data were obtained within 24 hours using
automated counting. Comparison of estimated time required for these assays indicated time
savings at almost every step of the protocol with the 96-well CFA, but the most substantial
gain was observed at the colony counting step (Table 3.1). Given that the approximate reagent
and consumable costs of both the 6-well and the 96-well assays are similar; this demonstrates
the substantial gain in efficiency of generating and analyzing such volumes of data,
particularly for the determination of multiple permutations of combinatorial therapies. From an
analytical perspective, many different statistical methods could be used to test for additive,
synergistic, or sub-additive interactions of combined therapies. These methods include
isobologram analyses [207], mean inactivation dose [208], or the median effect principle
[209], all of which require the generation of data using a broad range of concentrations of
different treatments. Such experimental data are time consuming to generate using the
traditional 6-well format, which is easily overcome by the efficiency of the 96-well CFA,
enabling the collection of masses of data required for such analyses in a much shorter time
frame.
Table 3.1 Comparison of 96-well and 6-well clonogenic assays
Estimated time savings calculated when using the 96-well CFA vs. the 6-well CFA in a typical
combination therapy experiment with 8 compound doses and 4 RT doses (32 individual
conditions).
Parameters 96-well 6-well
Number of plates used 4 32
Cell seeding 10 min 90 min
Addition of compounds 30 min 90 min
Radiation 15 min 60 min
Change media 10 min 90 min
Colony counting 3 h 12 h
Data analysis Same
Time savings ~14 h
85
The final question we sought to address using the 96-well CFA was its utilization for
HTS of chemical libraries. Our lab has previously identified novel anti-cancer activities of
existing anti-microbial compounds, such as alexidine dihydrochloride [147] and benzethonium
chloride [146]. However the read-out for these screens was the tetrazolium-based MTS assay,
which is a measure of mitochondrial enzymatic activity. There are other read-outs available for
determining cytotoxicity [210], or other specific cellular events [211, 212], however these
assays do not measure reproductive potential. Hence, the 96-well CFA was adopted for the
HTS, anticipating the identification of novel and more potent anti-cancer agents. As an initial
proof of concept experiment, the protocol for performing the assay was transferred to a robotic
platform. The LOPAC1280 library was screened at 0.5 μM final concentration of all
compounds for their ability to inhibit clonogenic growth, as measured by the number of
colonies per well normalized to untreated samples. To correct for systematic variation, the data
were normalized using the B-score, a statistical analysis that accounts for variability across
rows, columns, and plates [213]. After normalization by the B-score, only compounds whose
score was 3 standard deviations from the median B-score value were selected as putative
“hits”. This resulted in the identification of eight such “hits”, many being known anti-cancer
agents such as mitoxantrone [214], idarubicin [215], vincristine [216], and vinblastine sulfate
[216]. All eight of these “hits” were secondarily screened using the 96-well CFA; if the
subsequent IC50 value was 0.5 μM, then they were considered as a confirmed “hit” (Figures
3.3C and D). If the compounds had an IC50 0.5 μM, then they were rejected as a false positive
result. Six of the eight “hits” (75%) were thus confirmed as positive hits (Table 3.2). This
experiment confirmed the proof of concept and illustrated that the 96-well CFA can be used as
a HTS read-out to discover anti-cancer drugs. In this case, the 6 confirmed anti-cancer drugs
were identified from a library of 1,280 compounds for a confirmed hit rate of ~0.5%. In
86
previous screenings of this library conducted by our lab, a confirmed hit rate of ~2% was
observed [146]. However, in these experiments the library was screened at a 10 times higher
concentration. This suggests that the CFA is a suitable read-out in terms of its ability to
identify anti-cancer compounds. One drawback of this read-out is related to the restricted
dynamic range in the 96-well CFA format. Subsequent to the miniaturization of the assay, the
variability observed in the screen as a percentage of the difference between the number of
colonies between the positive and negative controls becomes significant. This underscores the
possibility of a higher false positive hit rate of ~25%, thereby relying on a more rigorous
secondary screen to filter out the unconfirmed “hits”. The advantage of this novel read-out for
HTS is that it is an unbiased assay with respective to the mode of cell death. As long as a
compound inhibits a cancer cell’s ability to grow into a larger population it will be detected
using this assay.
87
Figure 3.3 Dose response curves created using the 96-well CFA
(A) Evaluation of the 96-well CFA on FaDu cells for the analysis of combination therapy of
RT (06 Gy) and cisplatin (01 μM). (B) Evaluation of the 96-well CFA on A549 cells for the
analysis of combination therapy of RT (06 Gy) and cisplatin (00.5 μM) (C) Survival curve
created using the 96-well CFA on FaDu cells treated with ouabain (00.4 μM), an example of
a confirmed hit from the HTS. (D) Survival curve created using the 96-well CFA on FaDu
cells treated with mitoxantrone (05 nM), another example of a confirmed hit from the HTS.
Each datum represents the mean SEM from 2 independent experiments.
88
Table 3.2 Confirmed hits in the LOPAC1280 library
Summary of confirmed hits in the LOPAC1280 library screened at 0.5 μM final concentration
on FaDu cells using the 96-well colony formation assay as the read-out.
Compound B-Score Value
Emetine Dihydrochloride -4.479
Idarubicin -4.781
Mitoxantrone -4.792
Ouabain -4.648
Vincristine Sulfate -5.367
Vinblastine Sulfate Salt -5.754
In conclusion, we have demonstrated a novel CFA conducted in a 96-well plate format,
using high content microscopy with dual fluorescent labeling, as being a highly efficient
method of performing CFA, which faithfully recapitulates the results from the traditional
approach. This newer approach could be transferred to a robotic platform, with potential in
identifying novel anti-cancer compounds using HTS. However, the most significant advantage
of this novel CFA methodology is facilitating the evaluation of multiple permutations of
combination therapies, such as between radiation and drug treatments, whereby such analyses
of these many interactions could be completed within a single day.
3.5 Acknowledgements
This work was supported by funds from the Canadian Institutes of Health Research, and
the Elia Chair in Head and Neck Cancer Research. David Katz is a recipient of a Canadian
Institutes of Health Research Fellowship in the Excellence of Radiation Research for the 21st
Century Program, which is funded by the Lawrence, Ila and William Gifford Scholarship
Fund. Emma Ito is a recipient of a Natural Sciences and Engineering Research Council of
Canada Scholarship. We thank Dr. Alessandro Datti, Thomas Sun, and Frederick Vizeacoumar
from the Samuel Lunenfeld Research Institute HTS Robotics Facility for their assistance with
89
the high-throughput screen, as well as Cyrus Handy of the High-Content Microscopy Facility
at the Samuel Lunenfeld Research Institute.
90
CHAPTER 4: UROPORPHYRINOGEN DECARBOXYLASE - A NOVEL
RADIOSENSITIZING TARGET FOR HEAD AND NECK CANCER
IDENTIFIED FROM AN RNAI HIGH-THROUGHPUT SCREEN
The data presented in this chapter have been submitted to Science Translational
Medicine on January 26, 2010 and is currently under revision.
Ito E, Yue S, Moriyama EH, Hui AB, Kim I, Shi W, Alajez NM, Bhogal N, Li
GH, Datti A, Wrana J, Schimmer AD, Wilson BC, Liu PP, Durocher D, Neel
BG, Sullivan BO, Cummings B, Bristow R, Liu FF.
91
4.1 Chapter Abstract
Uroporphyrinogen decarboxylase (UROD), a key regulator of heme biosynthesis, was
identified from an RNA interference-based high-throughput screen as a novel tumor-selective
radiosensitizing target against head and neck cancer. UROD knockdown plus irradiation
induced caspase-mediated apoptosis and cell cycle arrest in vitro, while delaying tumor growth
in vivo. Radiosensitization appeared to be mediated via enhancement of tumor oxidative stress
from perturbation of iron homeostasis and increased reactive oxygen species production. We
found UROD to be significantly over-expressed in HNC patient biopsies, wherein lower pre-
radiation therapy UROD levels correlated with improved disease-free survival, suggesting that
UROD expression could be a potential predictor for radiation response. UROD down-
regulation radiosensitized several different human cancer models; it also sensitized standard
chemotherapeutic agents, including 5-FU and cisplatin. Thus, our study has uncovered UROD
as a novel potent sensitizer for both radiation and chemotherapy, with potentially broad
applicability for many human malignancies.
4.2 Introduction
Ionizing radiation therapy plays critical curative, adjuvant, and palliative roles in cancer
patient management; curability however, could be limited by tolerance of normal surrounding
tissues. Thus, the development of therapeutic strategies to enhance the therapeutic ratio is of
great importance. Unfortunately, many of the currently utilized radiosensitizers are neither
selective nor tumor-specific. This is particularly a concern in the management of head and
neck cancer, whereby RT is the primary curative modality, yet tumors often reside in close
proximity to critical organs (e.g. brain, spinal cord, optic nerve), which when damaged lead to
long-term compromises in patients’ quality of life, not to mention fatality.
92
HNC is the eighth most common malignancy worldwide, comprising a diverse group
of cancers affecting the sinuses, nasal and oral cavities, pharynx, larynx, and other sites in this
region [131, 133]. In addition to the anatomic and molecular heterogeneity of HNC, most
patients present with locally advanced disease, and/or suffer from other co-morbidities,
rendering HNC particularly challenging to treat. Despite the advances in therapeutic options
over the recent few decades, treatment toxicities and overall clinical outcomes have remained
disappointing [217]. Even the most effective RT regimens achieve local control rates of
4555%, with disease-free survival rates of only 3040% for patients with locally advanced
head and neck squamous-cell carcinomas [138]. Furthermore, meta-analyses have documented
concurrent RT with chemotherapy to offer an absolute survival advantage of only 6.5% at 5
years [141]. These modest results underscore the urgent need to develop novel therapeutic
approaches in the treatment of HNC.
Amongst the new therapies, molecularly-targeted agents have gained momentum [112,
113, 218], but an effective strategy to select appropriate patients does not yet exist, perhaps
due to the complexities of radiation response. Ionizing radiation induces a myriad of physico-
chemical changes at the cellular and molecular level, most of which have not yet been clearly
elucidated. In the current study, we describe an RNA interference-based high-throughput
screen for the large-scale identification of novel anti-cancer radiosensitizing molecular targets.
Uroporphyrinogen decarboxylase, a key regulator of heme biosynthesis, was identified as a
heretofore unreported potent modulator of tumor radioresponse. Here, we present in vitro and
in vivo characterizations of UROD-mediated radiosensitization, and its clinical implications in
the management of HNC.
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4.3 Materials and Methods
4.3.1 Cell Lines
FaDu, A549, SiHa, ME-180, T47D, MDA-MB-231, DU-145, and MRC5 cells were
obtained from the American Type Culture Collection (Manassas, VA). Normal human
oropharyngeal (NOP) and oral epithelial (NOE) cells were purchased from Celprogen (San
Pedro, CA). Untransformed fibroblasts from familial porphyria cutanea tarda (type II) patients
(GM01482, GM00977, GM00961, GM01041) and GM05757 (primary normal human skin)
fibroblasts were obtained from Coriell Institute (Camden, NJ). All cell lines were cultured
according to the manufacturer’s specifications. C666-1 undifferentiated nasopharyngeal cancer
cells [157] were maintained in RPMI 1640 supplemented with 10% fetal bovine serum
(Wisent, Quebec, Canada) and antibiotics (100 mg/L penicillin and 100 mg/L streptomycin).
UTSCC-8 and -42a laryngeal squamous cell cancer cells were a gift from R. Grénman (Turku,
Finland) and maintained as previously described [219]. All cells were maintained in 5% CO2,
21% O2, and 95% humidity at 37°C unless otherwise stated.
4.3.2 Patient Samples
Thirty-eight formalin-fixed paraffin-embedded (FFPE) tissue biopsies from locally
advanced HNSCC patients (Stage III or IV; oropharynx, hypopharynx, or larynx primary SCC
subsites), who participated in a randomized clinical study of two RT fractionation regimens
[220] were utilized with Institutional Research Ethics Board approval. FFPE samples were
macro-dissected for regions of invasive SCC (70% malignant epithelial cell content). Five
normal human larynx and tonsillar FFPE tissues were purchased from Asterand (Detroit, MI).
Total tumor RNA was extracted with RecoverAll Total Nucleic Acid Isolation Kit for FFPE
(Ambion, Austin, TX) as specified by the manufacturer.
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4.3.3 Reagents
Cisplatin, 5-fluorouracil, -aminolevulinic acid hydrochloride (ALA), and
deferoxamine mesylate salt (DFO) were obtained from Sigma-Aldrich (St. Louis, MO). All
compounds were dissolved and/or diluted in complete media.
4.3.4 BrdU-Based siRNA High-Throughput Screen
The Human siGENOME Druggable and Protein Kinase siRNA Libraries (Dharmacon,
Lafayette, CO) were provided by the Samuel Lunenfeld Research Institute (SLRI) HTS
Robotics Facility (Toronto, Canada). Automation of the 96-well siRNA transfection and
bromodeoxyuridine (BrdU) cell proliferation assay (Exalpha Biologicals, Shirley, MA) were
performed using the BioMek FX (Beckman Coulter, Fullerton, CA), SpectraMax Plus384
microplate reader (Molecular Devices, Sunnyvale, CA), and SLRI robotics platform.
Working stock solutions of siRNA were prepared in Opti-MEM I reduced-serum media
(Invitrogen, Carlsbad, CA). Reverse transfections (final concentration of 40 nM siRNA) were
performed with Lipofectamine 2000 (Invitrogen) as specified by the manufacturer. Columns 1
and 2 of each plate contained siRNA targeting DNA ligase IV (LIG4 siGENOME
SMARTpool; Dharmacon), serving as the positive radiosensitizing control, and scrambled
negative siRNA control (ON-TARGETplus Non-Targeting Pool; Dharmacon), respectively.
Twenty-four h post-transfection, 100 µL of complete media was added to each well, then cells
were irradiated using a 137
Cs unit (Gammacell 40 Extractor; MDS Nordion, Ottawa, Canada) at
a dose rate of 0.84 Gy/min. Cells were incubated for an additional 72 h, at which time, BrdU
(Exalpha Biologicals) was added to each well. After 24 h, cells were monitored for BrdU
incorporation on a SpectraMax Plus384
microplate reader according to the manufacturer’s
specifications.
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4.3.5 Transfections
siRNAs targeting UROD (Hs_UROD_2/8 HP GenomeWide siRNAs) and a scrambled
control (AllStars Negative Control siRNA) were purchased from Qiagen (Valencia, CA). A
plasmid vector containing the protein-coding sequence of UROD (Hs_UROD_IM_1 QIAgene
Expression Construct) and an empty vector control (pQE-TriSystem Vector) were also
purchased from Qiagen. All transfections were performed in complete media without
antibiotics using Lipofectamine 2000 and 40 nM of siRNA and/or 1 μg of plasmid DNA.
4.3.6 Flow Cytometric Assays
Flow cytometric analyses were performed on a FACSCalibur Flow Cytometer (BD
Biosciences, San Jose, CA), equipped with FlowJo software (Tree Star, Ashland, OR). Cell
cycle distributions, caspase activation, and mitochondrial membrane potentials were measured
as previously described [219]. Intracellular ROS levels were quantified using the non-specific
5-(and 6-)chloromethyl-2,7-dichlorodihydrofluorescein diacetate (CM-H2DCFDA) dye, and
the superoxide-selective dihydroethidium (DE) dye as instructed by the manufacturer
(Invitrogen).
4.3.7 -H2AX Detection
Global cellular -H2AX protein levels were quantified by flow cytometry using the
H2AX Phosphorylation Assay Kit (Upstate Biotechnology, Lake Placid, NY) as specified by
the manufacturer. To image -H2AX nuclear foci, cells transfected on coverslips were fixed
with 2% paraformaldehyde (PFA)-0.2% Triton X-100, then probed with -H2AX mouse
monoclonal antibody (clone JBW301; Upstate Biotechnology), followed by donkey anti-
mouse Alexa 488 antibody (Invitrogen) and DAPI (4,6-diamidino-2-phenylindole; Invitrogen)
for nuclear staining. Cells were imaged with an Olympus IX81 inverted microscope equipped
with a 16-bit Photometrics Cascade 512B EM-CCD camera (Roper Scientific, Tucson, AZ).
96
4.3.8 Hypoxia Treatment
Transfected cells were immediately exposed to a continuous flow of humidified 0.2%
O2 with 5% CO2 and balanced N2 (Praxair, Ontario, Canada) in an In Vivo2 400 Hypoxia
Chamber (Ruskinn Technology, Pencoed, UK). An OxyLite 4000 oxygen-sensing probe
(Oxford Optronix, Oxford, UK) was used to verify target O2 levels.
4.3.9 Iron Histochemistry
Intracellular Fe2+
and Fe3+
were detected according to Turnbull’s blue and Perl’s
Prussian blue staining protocols [221], respectively. Images were captured with a Nikon
ECLIPSE E600 microscope equipped with a Nikon DXM1200F digital camera (Nikon
Instruments, Melville, NY) for quantitative analysis using SimplePCI imaging software
(Hamamatsu, Sewickley, PA).
4.3.10 Porphyrin Detection
Transfected cells were treated with ALA (500 μM) for 4 h. Cells were lysed with
SOLVABLE (PerkinElmer, Waltham, MA), and intracellular porphyrin levels were measured
spectrofluorometrically using a SpectraMax Plus384
microplate reader (excitation 405 nm,
emission 635 nm). To visualize porphyrin accumulation, transfected cells ALA were stained
with MitoTracker Green FM (Invitrogen) and Hoechst 33342 (Invitrogen) as specified by the
manufacturer. Live cells were imaged on a Zeiss LSM510 confocal microscope (Carl Zeiss
MicroImaging).
4.3.11 Quantitative Real-Time PCR
Primers for PCR amplifications (Table 4.1) were designed using Primer3 software
(http://primer3.sourceforge.net). Total RNA from transfected cells was harvested using the
RNeasy Mini Kit (Qiagen). Total RNA (1 μg) was reverse-transcribed using SuperScript II
Reverse Transcriptase (Invitrogen) as specified by the manufacturer. qRT-PCR was performed
97
using SYBR Green PCR Master Mix (Applied Biosystems, Foster City, CA), and an ABI
PRISM 7900 Sequence Detection System (Applied Biosystems) with cycle parameters
previously described [158]. Relative mRNA levels were calculated using the 2Ct
method
[222].
Table 4.1 Primer sequences for mRNA expression analyses
Gene Forward Reverse
-ACTIN 5-CCCAGATCATGTTTGAGACCT-3 5-AGTCCATCACGATGCCAGT-3
UROD 5-AGGCCTGCTGTGAACTGACT-3 5-CCTGGGGTACAACAAGGATG-3
SOD1 5-AGGGCATCATCAATTTCGAG-3 5-ACATTGCCCAAGTCTCCAAC-3
SOD2 5-TTGGCCAAGGGAGATGTTAC-3 5-AGTCACGTTTGATGGCTTCC-3
GPX1 5-CTCTTCGAGAAGTGCGAGGT-3 5-TCGATGTCAATGGTCTGGAA-3
FTMT 5-ACGTGGCCTTGAACAACTTC-3 5-ATTCCAGCAACGACTGGTTC-3
4.3.12 Western Blot Analysis
Total protein extracts from transfected cells were harvested and prepared for
immunoblotting as previously described [158]. Membranes were probed with anti-UROD
polyclonal (clone L-19; 1:300 dilution; Santa Cruz Biotechnology, Santa Cruz, CA) or anti-
GAPDH monoclonal (1:15000 dilution; Abcam, Cambridge, MA) antibodies, followed by
secondary antibodies conjugated to horseradish peroxidase (1:2000 dilution; Abcam). GAPDH
protein levels were used as loading controls. Western blots were quantified with the Adobe
Photoshop Pixel Quantification Plug-In (Richard Rosenman Advertising & Design, Toronto,
Canada).
4.3.13 Colony Formation Assay
Cells were irradiated (06 Gy) 48 h post-transfection and harvested immediately for
seeding (5005000 cells/well in 6-well plates). Twelve days later, colonies were fixed in 70%
98
ethanol, stained with 10% methylene blue, and colonies of 50 cells were counted. Clonogenic
survival curve data were utilized to evaluate the interactive effects of combinatorial therapies
via the Chou-Talalay combination index method [209]. Radiosensitivity was also expressed in
terms of the mean inactivation dose (D-bar), which represents the area under the survival curve
[208]. Radiosensitization was expressed as an enhancement ratio, defined as the mean
inactivation doses of control to treatment.
4.3.14 Cell Viability Assay
The CellTiter 96 AQueous One Solution Cell Proliferation MTS Assay (Promega,
Madison, WI) was used to detect cell viability according to the manufacturer’s specifications.
4.3.15 In Vivo Tumor Model
All animal experiments utilized 68 week-old SCID BALB/c female mice in
accordance with the guidelines of the Animal Care Committee, Ontario Cancer Institute,
University Health Network (Toronto, Canada). TLDs and body weights were recorded thrice
weekly; mice were euthanized by CO2 once TLDs reached ~14 mm.
4.3.16 Tumor Formation Assay
Cells transfected with siCTRL or siUROD for 48 h were harvested and implanted into
the left gastrocnemius muscle of SCID mice (2.5105 viable cells in 100 µL growth medium
per mouse), followed immediately by administration of local tumor RT (4 Gy). Mice were
immobilized in a Lucite box and the tumor-bearing leg was exposed to 225 kV (13 mA) at a
dose rate of 3.37 Gy/min (X-RAD 225C Biological X-Ray Irradiator; Precision X-Ray, North
Branford, CT).
4.3.17 Therapeutic Tumor Growth Assay
Cells were implanted into the left gastrocnemius muscle of SCID mice (2.5105 viable
cells in 100 µL). Once the TLDs reached an average of ~8 mm, mice were injected
99
intraperitoneally (IP) with 600 pmol of siRNA complexed to in vivo-jetPEI (Polyplus-
Transfection, New York, NY), thrice a week for up to 2 weeks. siRNAs were mixed with in
vivo-jetPEI following the manufacturer’s specifications (nitrogen/phosphate ratio: 8). Local
tumor RT (4 Gy) was delivered on days 5 and 13 post IP-injections.
4.3.18 In Vivo Knockdown Validation
To assess the extent of UROD knockdown in vivo, mice were sacrificed 24 h after the
last treatment described in Section 4.3.17. Tumors were excised, immediately fixed in 10%
formalin for 48 h, 70% alcohol for an additional 48 h, paraffin embedded, and then sectioned
(5 μm). Immunohistochemical analysis was performed using microwave antigen retrieval with
anti-UROD polyclonal antibody (clone B02; 1:500 dilution; Abnova, Walnut, CA) and Level-
2 Ultra Streptavidin Detection System (Signet Laboratories, Dedham, MA). For
immunoblotting, tumors were excised and immediately snap-frozen in liquid nitrogen. 30 mg
of tumor tissue was lysed and homogenized as detailed elsewhere [223]; 30 μg of protein was
analyzed for UROD expression via immunoblotting as described above.
4.3.19 Statistical Analyses
All experiments were performed at least three independent times, with the data
presented as the mean SEM. Statistical differences between treatment groups were
determined using the Student’s t test and one-way ANOVA. The Ingenuity Pathways Analysis
software (Ingenuity Systems, Redwood City, CA) was used to identify functional biological
networks from the HTS data. The right-tailed Fisher Exact test was employed to calculate p-
values and scores (p-score = -log10 p-value), indicating the likelihood of genes being observed
together in a network due to random chance.
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4.4 Results
4.4.1 High-Throughput Screening for Novel Radiosensitizers
The preliminary screen of the Human siGENOME Druggable and Protein Kinase
siRNA Libraries identified 188 target sequences with potential radiosensitizing effects at 2 Gy
in FaDu cells (human hypopharyngeal squamous cell cancer), a clinically relevant model for
the study of HNC [162]; the “hit” threshold was defined as 4 standard deviations below the
mean after b-score normalization (Figure 4.1A). The validity of the screen was corroborated
by the identification of known radiosensitizing targets, such as ATM (ataxia-telangiectasia
mutated), ATR (ataxia-telangiectasia and Rad3-related), and aurora kinase A [224, 225]. To
confirm the initial HTS results, FaDu cells were transfected with the 188 siRNAs IR (Figure
4.1B), and those that decreased the surviving fraction by 30% in the absence of IR were
eliminated, leaving 67 potential hits. Targets which reduced the surviving fraction by 50% at
2 Gy relative to their un-irradiated counterparts were selected for further evaluation. Ingenuity
Pathways Analysis identified the top-scoring functional biological network common amongst
the radiosensitizing targets to involve cell death, cancer, and/or cellular compromise (Table
3.2); the top molecular and cellular functions included cell growth and proliferation (Table
3.3).
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Table 4.2 Top-scoring associated network functions
Sixty-seven radiosensitizing targets identified from the HTS were subjected to Ingenuity
Pathways Analysis. Each functional biological network was assigned a score according to the
number of focus genes present from the HTS dataset. Scores indicate the likelihood of focus
genes found together in a network due to random chance. Scores of 4 have 99.9% confidence
level of significance. UROD was identified in the third network (score 23).
Network Score
Cell death, cancer, cellular compromise 59
Amino acid metabolism, molecular transport, small molecule biochemistry 25
Genetic disorder, hematological disease, DNA replication, recombination, and repair 23
Lipid metabolism, small molecule biochemistry, behavior 20
Table 4.3 Top scoring molecular and cellular functions
Top molecular and cellular functions amongst the 67 radiosensitizing targets identified by
Ingenuity Pathways Analysis.
Function p-value
Cellular growth and proliferation 1.97×10-7
2.73×10-2
Cell death 1.03×10-5
3.09×10-2
Cell cycle 3.52×10-5
2.51×10-2
Cellular compromise 4.56×10-5
2.65×10-2
DNA replication, recombination, and repair 4.56×10-5
2.65×10-2
4.4.2 UROD is a Potent Radiosensitizing Target for HNC
Uroporphyrinogen decarboxylase, a key regulator of heme biosynthesis, was identified
from the HTS as a potent modulator of tumor response to IR, and was selected for further
evaluation due to its novelty in the context of human cancers, and being a well-characterized
enzyme; thereby increasing its potential “druggability”. Clonogenic survival curves confirmed
that UROD down-regulation significantly enhanced radiosensitivity of FaDu cells, a highly
aggressive radioresistant HNC cell line, in a dose-dependent manner (Figure 4.1C). Radiation
enhancement ratios (RER) of 2.0, 1.7, and 1.6 were observed at 2, 4, and 6 Gy, respectively; a
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RER 1 denotes synergistic radiosensitization [208]. The Chou-Talalay combination index
(CI) [209] further confirmed the synergistic interaction between siUROD with IR, wherein the
CI remained significantly below 1 for all tested combinations (Figure 4.1D). Corroboration of
siRNA-mediated UROD knockdown was determined via qRT-PCR and immunoblotting,
demonstrating significant suppression of both mRNA (~88% knockdown) and protein
expression by 48 h post-transfection (Figures 4.1E and F). To ensure this observation was not
due to off-target effects, a rescue plasmid expressing target mRNA refractory to siRNA via
silent mutations was utilized. Co-transfection of FaDu cells with siUROD and the rescue
plasmid completely neutralized any siUROD-mediated effects, with or without IR (Figure
4.1G), further confirming a siUROD-specific process.
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Figure 4.1 Identification of UROD as a novel radiosensitizing target
104
(A) Preliminary screen of the Human siGENOME Druggable (6080 genes) and Protein Kinase
(800 genes) siRNA Libraries at 2 Gy in transfected FaDu cells. (B) 67 target sequences with
potential radiosensitizing effects (50% reduction in surviving fraction at 2 Gy vs. 0 Gy) were
identified. Targets that decreased the surviving fraction by 30% in the absence of IR were not
considered (grey box). Known radiosensitizing targets (grey circles); UROD (black circle);
scrambled siRNA control (black triangle). (C) Clonogenic survival curves of FaDu cells
transfected with siCTRL or siUROD for 48 h, then irradiated (06 Gy). Colonies were counted
12 days post-IR. *p0.05 and **p0.01, siCTRL vs. siUROD for each IR dose. (D) As in (C),
but FaDu cells were transfected with a range of siRNA concentrations (060 nM), combined
with IR (06 Gy) for Chou-Talalay combination index analyses. (E) Relative UROD mRNA
levels in FaDu cells transfected with siCTRL or siUROD for 24, 48, and 120 h, as measured
by qRT-PCR. **p0.01, siCTRL vs. siUROD. (F) UROD protein expression was detected by
immunoblotting at 2472 h post-transfection. (G) FaDu cells were co-transfected with siRNA
(siCTRL or siUROD) and plasmid DNA (empty vector control, pVector or siRNA-resistant
rescue plasmid, pUROD) for 48 h, and then irradiated (4 Gy). Apoptotic fractions were
assessed by flow cytometry 72 h post-IR. **p0.01, siCTRL-pVector vs. siUROD-pVector or
siUROD-pUROD IR. Each datum represents the mean SEM from three independent
experiments.
4.4.3 siUROD-Mediated Radiosensitization Differs from Photodynamic Therapy
UROD is the fifth enzyme in the heme biosynthetic pathway (Figure 4.2A) that
catalyses the decarboxylation of uroporphyrinogen to coproporphyrinogen [226]. Since
porphyrinogens are unstable and readily oxidized to fluorescent porphyrin molecules, UROD
down-regulation was functionally validated by indirectly measuring uroporphyrinogen
accumulation via overall changes in oxidized porphyrin levels (uroporphyrin and other highly
carboxylated porphyrins). Spectrofluorometrically, porphyrin accumulation with siUROD
alone was negligible (~1.3 fold-increase vs. untreated control; Figure 4.2B); thus, FaDu cells
were pre-treated with -aminolevulinic acid (ALA) to artificially induce porphyrin synthesis.
ALA-plus-siUROD significantly increased intracellular porphyrin levels relative to ALA alone
or siCTRL-treated cells (~18.1 vs. ~9.9 and ~10.1 fold-increase). Similar observations were
made via fluorescent microscopy (Figure 4.2C), wherein cells treated with ALA-plus-siUROD
105
exhibited enhanced porphyrin accumulation, reflecting the disruption of heme biosynthesis by
siUROD.
Since the majority of currently utilized photosensitizers in photodynamic therapy
(PDT) are porphyrin based [227], it was of interest to compare the radiosensitizing effects of
siUROD to commonly used photosensitizers. ALA-based PDT is a well established anti-
cancer therapy that utilizes the heme precursor ALA, to induce accumulation of
protoporphyrin IX (PPIX) in neoplastic cells [228, 229]. When ALA-treated cells are exposed
to visible light, PPIX become excited and induce ROS formation, leading to oxidative stress-
mediated cell death. In this study, siUROD-plus-IR was dramatically more cytotoxic compared
to the negligible effects of ALA-plus-IR (Figure 4.2D), indicating that the effects of siUROD
were independent of intracellular porphyrin accumulation (Figures 4.2B and C), thus distinct
from PDT.
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Figure 4.2 Radiosensitizing effect of UROD knockdown is independent of porphyrin
accumulation
107
(A) Heme biosynthetic pathway. CPOX, coproporphyrinogen oxidase; PPOX,
protoporphyrinogen oxidase; Fe, iron. (B) Porphyrin synthesis in mock-, siCTRL-, or
siUROD-transfected FaDu cells was artificially induced with ALA (500 μM, 4 h) prior to
porphyrin extraction at 24 h post-transfection. Porphyrin levels were quantified
spectrofluorometrically and normalized to total cell number. Representative spectral scans
(575750 nm) are shown. **p0.01, siUROD vs. siCTRL or untreated ALA. (C)
Fluorescent microscopy images of transfected cells ALA (500 μM, 1 h). Mitochondria and
nuclei were stained with MitoTracker Green and Hoechst 33342, respectively. Intracellular
porphyrin excited with a wavelength of ~400 nm emits red fluorescence at a peak of ~635 nm.
Scale bar, 10 μm. (D) ALA-treated (2501000 μM, 4 h) and siCTRL- or siUROD-transfected
(48 h-transfection) FaDu cells were irradiated (4 Gy), then cell viability was assessed 96 h
later via MTS assay. **p0.01, siCTRL vs. siUROD IR; untreated vs. ALA IR. In all
cases, each datum represents the mean SEM from three independent experiments.
4.4.4 UROD Down-Regulation Promotes Radiation-Induced Apoptosis
The enhanced tumor radiosensitivity observed with UROD suppression (Figure 4.1C)
was mediated in part by G2-M cell cycle arrest (Figure 4.3A), along with induction of double-
strand DNA breaks, reflected by increased overall -H2AX expression and nuclear foci
formation in siUROD-plus-IR-treated FaDu cells vs. IR alone (Figures 4.3B and C). The
significantly prolonged G2-M arrest and concomitant increase in the subG1 population
suggested that the DNA damage induced by siUROD-plus-IR was more lethal than IR alone,
thereby significantly augmenting apoptosis (Figure 4.3A). The central role of apoptosis in
siUROD-plus-IR-mediated cytotoxicity was further evident by the induction of caspase
activation (Figure 4.3D) and depolarization of the mitochondrial membrane potential (M)
(Figure 4.3E), both classical hallmarks of apoptosis.
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Figure 4.3 UROD down-regulation promotes radiation-induced cytotoxicity
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(A) Flow cytometric DNA content analyses of siCTRL- or siUROD-transfected FaDu cells at
1272 h post-IR (4 Gy). Representative histograms with gates for cell cycle distributions are
shown. *p0.05 and **p0.01, siCTRL vs. siUROD IR at each time point. (B) Flow
cytometric analyses of cellular -H2AX expression levels in transfected FaDu cells at 0240
min post-IR (4 Gy). **p0.01, siCTRL vs. siUROD at each time point. (C) Representative
images of -H2AX nuclear foci formation in siCTRL- and siUROD-transfected FaDu cells 30
min post-IR. Scale bar, 10 μm. (D) Flow cytometric analyses of caspase 9, 8, and 3 activation
in siCTRL or siUROD-transfected FaDu cells at 1248 h post-IR (4 Gy). *p0.05 and
**p0.01, siCTRL vs. siUROD IR at each time point. (E) M depolarization was
quantified by flow cytometry 48 h post-IR in transfected FaDu cells. **p0.01, siCTRL vs.
siUROD IR. Each datum represents the mean SEM from three independent experiments.
4.4.5 siUROD-Mediated Radiosensitization Increases Cellular Oxidative Stress
Heme biosynthesis occurs within the cytoplasm and mitochondrion (Figure 4.2A); the
latter being a major source of intracellular free radicals [230]. Thus, to investigate whether
siUROD mediated its radiosensitizing effects via perturbation of ROS homeostasis,
intracellular levels of oxidants were measured. Mitochondrial superoxide anion radicals (O2●–
),
a primary ROS species, were more prevalent in siUROD-plus-IR vs. IR- or siUROD-treated
FaDu cells (Figure 4.4A). Similarly, global ROS production, as measured by CM-H2DCFDA
which detects many other ROS species (hydrogen peroxide, hydroxyl radical, peroxyl radical,
peroxynitrite anion), was highest in siUROD-plus-IR-treated cells, which increased in a time-
dependent manner (Figure 4.4B).
Many tumors display lower anti-oxidant enzyme levels compared to their normal
counterparts [231-233]. Hence, ROS production in normal oropharyngeal (NOP) and oral
epithelial (NOE) cells was assayed after exposure to siUROD IR (Figures 4.4C and D), after
attaining equivalent degrees of UROD knockdown as verified by qRT-PCR (data not shown).
At 72 h post-IR, both normal cell lines demonstrated significantly less ROS accumulation
compared to FaDu cells, particularly in combination with UROD down-regulation (DE: 1.4
and 1.3 vs. 1.8 fold-increase in NOP and NOE vs. FaDu, respectively; CM-H2DCFDA: 1.5 and
110
2.0 vs. 2.7 fold-increase in NOP and NOE vs. FaDu, respectively). These differential ROS
levels translated into higher survival for the normal vs. FaDu cells after siUROD IR (Figure
4.4E; NOP or NOE vs. FaDu RERs, p0.01), exposing a therapeutic window to exploit the
differential anti-oxidant capacity between normal vs. tumor cells to achieve tumor-selective
siUROD radiosensitization.
Given that ROS production is regulated by oxygen tension, and hypoxia diminishes
radiosensitivity, we also examined the effects of O2 on siUROD radiosensitization.
Interestingly, siUROD alone retained activity under hypoxia comparable to that under
normoxic conditions, and displayed only a partial reduction in radiosensitization (Figure 4.4F).
To further understand the mechanisms of siUROD-plus-IR-mediated cytotoxicity, relative
expression levels of a panel of genes involved in oxidative stress responses were examined. As
expected, anti-oxidants involved in maintaining cellular redox homeostasis, including
superoxide dismutases (SOD1 and SOD2), glutathione peroxidase (GPX1), and mitochondrial
ferritin (FTMT) were all up-regulated in FaDu cells in response to siUROD-plus-IR (Figure
4.4G).
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Figure 4.4 siUROD-mediated radiosensitization enhances cellular oxidative stress
112
(A) Intracellular superoxide anions in siCTRL- or siUROD-transfected FaDu cells at 372 h
post-IR (4 Gy) were detected by flow cytometry with dihydroethidium (DE). *p0.05 and
**p0.01, siCTRL vs. siUROD IR at each time point. (B) Overall ROS levels in transfected
FaDu cells were measured with CM-H2DCFDA at 372 h post-IR (4 Gy). *p0.05 and
**p0.01, siCTRL vs. siUROD IR at each time point. (C) Superoxide radical levels in two
transfected normal head and neck epithelial cells (NOP and NOE) 72 h post-IR (4 Gy).
**p0.01, normals vs. FaDu at 72 h post-IR. (D) Overall ROS levels in transfected NOP and
NOE cells 72 h post-IR (4 Gy). *p0.05 and **p0.01, normals vs. FaDu at 72 h post-IR. (E)
Cell viability of siCTRL or siUROD-transfected FaDu, NOP, and NOE cells at 96 h post-IR (2
Gy) via MTS assay. **p0.01, siCTRL vs. siUROD IR. (F) FaDu cells were transfected with
siCTRL or siUROD and irradiated under normoxia (21% O2) or hypoxia (0.2% O2). Apoptotic
fractions were assessed by flow cytometry 72 h post-IR. *p0.05 and **p0.01, normoxic vs.
hypoxic treatments. (G) Relative mRNA expression of a panel of genes involved in cellular
oxidative stress responses in siCTRL- or siUROD-transfected FaDu cells 48 h post-IR.
Relative fold changes represent average ΔCt values normalized to those of -actin, then
compared to siCTRL-transfected cells. **p0.01, siCTRL vs. siUROD IR. Each datum
represents the mean SEM from three independent experiments.
4.4.6 UROD Knockdown Perturbs Cellular Iron Homeostasis
The induction of mitochondrial ferritin, a nuclear-encoded iron (Fe)-sequestering
protein, in FaDu cells transfected with siUROD IR prompted further investigations into the
role of Fe-homeostasis in siUROD-mediated effects. Mitochondria are intimately involved in
Fe-trafficking for heme biosynthesis and the formation of Fe-sulfur clusters [234]. These
organelles, also being the major source of ROS production, have developed efficient
mechanisms to segregate free Fe from ROS, thereby preventing the production of harmful
hydroxyl radicals (●OH) via Fenton-type reactions [235]. Accordingly, up-regulation of the
FTMT anti-oxidant in siUROD IR treated cells (Figure 4.4G) was associated with markedly
elevated levels of intracellular ferrous (Fe2+
) and ferric (Fe3+
) iron, visible as diffuse deep-
purple staining within the cells (Figure 4.5A). The relative changes in iron species (Figure
4.5B), with Fe2+
reduction vs. Fe3+
increase after IR are likely related to the Fenton reaction,
whereby IR can induce hydrogen peroxide (H2O2) formation, which consumes Fe2+
, and in the
113
process of generating ●OH, converts Fe
2+ to Fe
3+. To corroborate the central role of excess
cellular Fe in mediating siUROD radiosensitization, the Fe-chelator deferoxamine was
introduced prior to IR. Significant suppression (~50%) of siUROD-plus-IR-induced apoptosis
was observed (Figure 4.5C), underscoring the critical role of Fe in mediating this
radiosensitization process.
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Figure 4.5 UROD knockdown induces intracellular iron accumulation
115
(A) Ferrous (Fe2+
) and ferric (Fe3+
) iron staining of siCTRL or siUROD-transfected FaDu cells
at 48 h post-IR (4 Gy). Scale bar, 50 μm. (B) Quantification of intracellular Fe2+
and Fe3+
levels from (A). Deep-purple areas and total area of cultured cells were measured. The ratio
(% area) was calculated by dividing the sum of deep-purple areas by the sum of the total area
from sections. *p0.05 and **p0.01, siCTRL vs. siUROD IR. (C) FaDu cells transfected
with siCTRL or siUROD for 24 h were treated with deferoxamine (DFO; 5 μM), and then
irradiated (4 Gy) 24 h later. Apoptotic fractions were assessed by flow cytometry 72 h post-IR.
**p0.01, - DFO vs. + DFO treatments. Each datum represents the mean SEM from at least
two independent experiments.
4.4.7 siUROD Radiosensitizes HNC Models In Vivo
To evaluate the radiosensitizing efficacy of UROD knockdown in vivo, transfected
FaDu cells were injected into the left gastrocnemius muscle of SCID mice, followed by local
tumor RT. Mice implanted with siUROD or siCTRL-transfected cells started to form tumors at
~23 vs. ~9 days, respectively; delaying the time to reach a tumor-plus-leg diameter (TLD) of
14 mm by ~14 days (p0.001; Figure 4.6A). When combined with RT, siUROD appeared to
synergistically suppress tumor-forming capacity of FaDu cells, wherein tumors developed at
~37 vs. ~12 days in the siUROD-plus-RT vs. siCTRL-plus-RT groups, respectively; extending
the mean time to reach 14 mm by ~27 days (p0.001; Figure 4.6A).
The therapeutic efficacy of siUROD-plus-RT in treating established FaDu tumors was
also evaluated. Tumor-bearing mice were systemically treated with siRNA complexed to a
cationic polymer polyethylenimine with or without local tumor RT. Although no difference in
tumor growth was observed between the siUROD vs. siCTRL groups, siUROD-plus-RT
caused a significant reduction in tumor size compared to the siCTRL-plus-RT arm (p0.001;
Figure 4.6B). The extent of tumor growth delay was reflected by the in vivo level of UROD-
knockdown, verified by both immunoblotting and immunohistochemistry (Figures 4.6C and
D). Despite the fact that this treatment regimen was not optimized for absorption, distribution,
metabolism, or excretion, a therapeutic benefit was nonetheless observed. These data strongly
116
suggest that improving the pharmacokinetics and bioavailability of siUROD would render this
therapeutic approach highly effective, based on the significant suppression of tumor-forming
capacity when FaDu cells were fully exposed to siRNA-mediated UROD knockdown (Figure
4.6A). This therapeutic regimen was well-tolerated based on the minimal differences in mice
body weights between the treatment groups (Figure 4.6E).
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Figure 4.6 In Vivo efficacy of UROD knockdown plus irradiation in HNC models
118
(A) Mock, siCTRL, or siUROD-transfected FaDu cells were implanted into the left
gastrocnemius muscle of SCID mice, followed immediately by local RT (4 Gy). Each
treatment group comprised of 9 mice. ***p0.001, siUROD vs. mock or siCTRL RT. (B)
FaDu tumors were established in SCID mice; once TLDs reached ~8 mm, mice were randomly
assigned to siCTRL, siUROD, siCTRL-plus-RT, or siUROD-plus-RT. Mice were IP-injected
with 600 pmol of jetPEI-complexed siRNA thrice a week for up to 2 weeks (white arrows).
Local tumor RT (4 Gy) was delivered on days 5 and 13 post IP-injections (grey arrows). Each
treatment group comprised of 5 mice. ***p0.001, siUROD vs. siCTRL + RT. (C) UROD
knockdown was assessed in FaDu tumors 24 h after the last treatment as described in (B).
Excised tumors were subjected to immunoblotting for UROD expression. Western blots were
quantified and relative fold changes in UROD protein levels were determined by normalizing
to corresponding GAPDH loading controls, then compared to siCTRL-treated tumors. (D)
UROD knockdown in tumors (black arrows) was also verified by immunohistochemistry. (E)
Average mouse body weight for each treatment group from (B). Each datum represents the
mean SEM from at least two independent experiments.
4.4.8 UROD Knockdown Modulates Radiosensitivity of Several Cancer Models
To assess the applicability of siUROD-induced radiosensitization to other human
cancers, additional HNC, cervix, breast, lung, and prostate cancer cell lines were evaluated;
almost all the cell lines were radiosensitized by siUROD, albeit to different degrees (Figure
4.7A). Examination of the relationship between the extent of radiosensitization and basal
UROD mRNA levels revealed a general trend, wherein cells with lower basal UROD
expression were more readily radiosensitized than those with higher levels (data not shown),
possibly due to greater ease in achieving siRNA-mediated UROD knockdown. To further
corroborate the role of UROD in modulating tumor radiosensitivity, exogenous expression of
UROD was introduced into the most sensitive HNC cell line UTSCC-42a (Figure 4.7B), to
determine whether this phenotype could be reversed. Indeed, over-expression of UROD prior
to IR protected the UTSCC-42a cells against radiation-induced apoptosis (~53% reduction vs.
empty vector control; Figure 4.7C), substantiating the critical role of UROD in modulating
radiosensitivity.
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4.4.9 Clinical Implications of UROD in HNC
The clinical importance of our findings was determined from the analysis of pre-
treatment tumor biopsies from patients with Stage III or IV non-metastatic HNSCC, who were
all participants in a RT clinical trial [220]. Of note, UROD mRNA expression was
significantly higher (~11-fold) compared to that of normal laryngeal and tonsillar epithelial
tissues (p0.05; Figure 4.7D). Furthermore, patients with the lowest quartile level of UROD
expression experienced a superior disease-free survival (DFS) compared to those with the
highest UROD expression (p=0.06; Figure 4.7E); consistent with the notion that higher UROD
levels conferred radioresistance (Figure 4.7C), and supporting the strategy of reducing UROD
to increase radiocurability.
UROD deficiency is responsible for the clinical syndrome of porphyria cutanea tarda
(PCT), a rare non-fatal metabolic disorder, characterized by elevated cellular porphyrin and Fe
levels [226]. Thus, it was of interest to examine whether a naturally occurring state of UROD
deficiency could recapitulate our findings. Indeed, untransformed fibroblasts from familial
PCT patients demonstrated minimal cytotoxicity comparable to UROD-functional primary
normal human fibroblasts (Figure 4.7F), corroborating our previous data that siUROD-
mediated radiosensitization is tumor selective (Figure 4.4E).
The breadth of application of the siUROD-sensitization strategy was further broadened
when non-toxic doses of cisplatin or 5-fluorouracil were significantly sensitized in FaDu cells,
in a dose-dependent manner (Figure 4.7G). These two drugs are commonly utilized in HNC
management; hence, siUROD could play a significant role in enhancing the outcome for both
radiotherapy and chemotherapy in HNC patients, allowing lower treatment doses to be
administered without compromising cure.
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Figure 4.7 Clinical relevance of UROD in human cancers
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(A) Cell viability assessment of siCTRL or siUROD-transfected cancer cells at 96 h post-IR (2
Gy) via MTS assay. Human HNC (red), cervix (blue), breast (green), lung (black), and
prostate (orange) cancer cell lines. *p0.05 and **p0.01, siCTRL vs. siUROD IR. (B)
Relative UROD mRNA expression in UTSCC-42a cells transfected with UROD-expressing
plasmid (pUROD) or empty vector control (pVector) for 48 h, determined via qRT-PCR.
***p0.001, pVector vs. pUROD. (C) UTSCC-42a cells transfected with pUROD or pVector
for 48 h were irradiated (2 Gy). Apoptotic fractions were assessed by flow cytometry 72 h
post-IR. Representative histogram of cell cycle distribution is shown. ***p0.001, pUROD vs.
pVector + IR. (D) Total RNA was extracted from 38 HNSCC patient tumor biopsies and 5
normal laryngeal and tonsillar epithelial tissues, and assessed for relative levels of UROD
mRNA expression. Fold change was determined by normalizing to -actin levels, and
comparing to the average from normal tissues. Solid line, mean fold change. *p0.05, tumor
vs. normal tissues. (E) Kaplan-Meier plot of DFS for the HNSCC patients from (D);
trichotomized based on interquartile range (low, medium, vs. high levels of UROD mRNA
expression). DFS was defined as absence of relapse or death, calculated from the time of
diagnosis. Median follow-up time was 6.9 years (range 2.310.8 yrs). (F) Cell viability
assessment of irradiated (2 Gy) primary normal human fibroblasts (MRC5, GM05757) and
untransformed fibroblasts from PCT patients (GM01482, GM00977, GM00961, GM01041) 96
h post-IR via MTS assay. *p0.05, MRC5 vs. PCT fibroblasts. (G) siCTRL- or siUROD-
transfected FaDu cells were treated with increasing doses of cisplatin (0.010.25 μM) or 5-FU
(125 μM) for 24 h, then assessed for cell viability 96 h later. ***p0.001 and **p0.01,
siCTRL drug vs. siUROD drug. Each datum represents the mean SEM from three
independent experiments.
4.5 Discussion
Intrinsic oxidative stress in cancer cells, due in part to oncogenic transformation, with
resultant increased metabolic activity and mitochondrial dysfunction, have long been
recognized to promote tumor genetic instability, cell growth, and proliferation [236]. Recently,
this distinct biochemical feature has been exploited for selective anti-cancer therapies [237,
238], wherein elevated basal levels of ROS-mediated signalling rendered neoplastic cells more
vulnerable to manipulations that enhanced oxidative stress. Thus, the addition of exogenous
ROS-inducing agents would increase intracellular ROS to toxic levels, triggering cell death in
cancer cells with already reduced antioxidant defence mechanisms [231-233]; whereas normal
cells have a greater capacity to contend with oxidative insults by virtue of their lower basal
ROS output, along with an intact anti-oxidant response system. These phenomena were
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recapitulated in this current study, wherein ROS levels were significantly augmented in tumor
cells after siUROD-plus-IR (Figures 4.4A and B), with the induction of cell cycle arrest and
apoptosis (Figure 4.3A). The compensatory anti-oxidant response (Figure 4.4G) was
inadequate compared to the capacity of normal cells, which demonstrated only a modest
elevation in ROS, with minimal consequences on viability (Figures 4.4C-E).
The novelty of our UROD discovery relates to the opportunity to perturb iron
homeostasis as the initiator of oxidative stress in tumor cells. Several lines of evidence support
a Fe-mediated mechanism of radiosensitization for UROD down-regulation, although we
cannot preclude Fe-independent mechanisms that might also contribute to this process. Firstly,
mitochondrial ferritin was significantly up-regulated by siUROD, even at early times post-
transfection (Figure 4.4G and data not shown), which was associated with a concomitant
increase in intracellular Fe (Figures 4.5A and B). Secondly, siUROD-plus-IR-induced
apoptosis was significantly suppressed by the Fe-chelator, deferoxamine (Figure 4.5C). Iron,
which exists in two oxidative states (Fe2+
and Fe3+
), is an essential element required for many
critical biological processes, including respiration, DNA synthesis, and O2 transport [234].
Transition metals such as Fe however, can also be powerful catalysts for ROS formation. In
the presence of H2O2, Fe2+
can be oxidized to Fe3+
via the Fenton reaction, producing highly
toxic hydroxyl radicals. When heme synthesis is disrupted, large quantities of iron, which
would normally be incorporated into PPIX to form heme, continue to be imported into the
mitochondria, causing an elevation in FTMT levels to sequester the excess Fe2+
and minimize
oxidative damage [239]. In cancers, the accretion of cellular Fe is further exacerbated by the
over-expression of transferrin receptor-1, a major mechanism of Fe-uptake to sustain the high
requirements of cellular and protein turn-over, plus DNA synthesis [240]. Our data
demonstrate the elevated Fe and consequential ROS formation due to siUROD alone to be
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non-lethal (Figure 4.3A); significant cytotoxicity was only observed when combined with IR,
which is clinically advantageous since RT is anatomically-targeted. Presumably, with siUROD
alone, the excess free Fe2+
led to an increase in the ambient concentration of free radicals with
which the cells can cope; however, the additional ROS insults induced by IR overwhelmed the
cell’s anti-oxidant capacity, resulting in the observed enhanced cell death.
Excess Fe2+
might also increase the effective range of radicals produced by -radiation.
Upon IR, superoxide and hydroxyl radicals are formed [241], both of which can react with
themselves to form H2O2, initiating the Fenton reaction and ultimately, oxidative damage.
Thus, the same phenomenon (i.e. Fe-overload) that cancer cells rely on for rapid proliferation
and DNA synthesis could be exploited for the liberation of detrimental radicals with -
radiation, exposing the double-edged sword of iron in cancer cells.
Similar to PDT, our siUROD radiosensitizing strategy exploits the heme pathway to
harness its anti-cancer effects; however, siUROD is distinct and superior for several reasons.
Tumor hypoxia severely hampers PDT efficacy, since molecular O2 is a prerequisite for the
production of photo-induced singlet oxygen molecules [242, 243]. However, siUROD-plus-IR
retained radiosensitizing efficacy even under hypoxia (Figure 4.4F), likely due to its reliance
on the Fe2+
-catalyzed Fenton reaction to yield highly cytotoxic radicals. H2O2 can be generated
via recombination of free radicals formed from water radiolysis [241]; hence, there is less
reliance on the presence of O2. The applicability of PDT is further limited since the light
source used to excite porphyrins and its derivatives occupy the visible spectrum, which cannot
penetrate tissues 0.8 cm, restricting PDT to superficial lesions [244]. Moreover, porphyrins
cannot be excited by the high-energy photons of x-rays or -rays [245], thereby accounting for
the modest radiosensitizing efficacies of porphyrins [244, 246, 247]. Thus, siUROD provides a
clear therapeutic advantage with significant sensitization by -rays, a mainstay in the standard
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anti-cancer therapeutic armamentarium. The possibility of utilizing siUROD as an adjunct to
photosensitizers also warrants additional examination, further broadening its potential clinical
application.
There is a paucity of literature surrounding UROD and cancer. Only a few studies have
reported enhanced heme biosynthesis in human cancers, wherein increased UROD activity was
observed in breast tumors vs. normal tissues [248, 249]; the basis for which remained unclear.
Our current study is the first such report in HNC, whereby UROD was markedly over-
expressed in primary HNSCC vs. corresponding normal tissues (Figure 4.7D). A potential
predictive value for UROD was also revealed, wherein lower levels of pre-treatment UROD
expression appeared to correlate with improved DFS in HNSCC patients treated with RT
(Figure 4.7E). The power of this association may be underestimated due to the skewed
outcome, in that there were only 8 non-relapsed vs. 30 relapsed cases. Thus, additional
evaluation of more balanced HNC cohorts is strongly warranted. The possible role of UROD
over-expression in predicting radioresistance was strongly supported by the reversal of the
radiosensitive phenotype of UTSCC-42a cells (Figure 4.7C); thereby facilitating the selection
of cancer patients who would be amenable to UROD-mediated radiosensitization.
The potential therapeutic application of siUROD in human cancers appears to be quite
extensive. UROD down-regulation not only radiosensitized a wide range of solid cancers
while sparing normal cells (Figures 4.7A and F and 4.4E), but also surprisingly sensitized
tumor cells to standard chemotherapeutic agents (Figure 4.7G). In theory, an ideal “sensitizer”
should have no inherent cytotoxicity, and should exert its effect only when administered with
RT or chemotherapy. However, many of the so-called “radiosensitizers” commonly used today
(e.g. cisplatin) exhibit inherent systemic toxicities and cause damage to normal tissues [250].
Overall, siUROD alone induced a modest reduction in tumor survival, which was significantly
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enhanced by IR. A few cancer cell lines demonstrated sensitivity to siUROD alone;
nonetheless these siUROD-mediated effects IR were tumor-selective, underscoring a clear
therapeutic window and potential therapeutic advantage of utilizing siUROD as either a stand-
alone anti-cancer treatment, or a sensitizing strategy combined with either RT or
chemotherapy. Furthermore, a naturally occurring state of UROD deficiency causes PCT, a
chronic non-fatal disorder [226]; hence, a transient development of “PCT” during the weeks of
RT and/or chemotherapy should be well-tolerated. Evidence for minimal toxicity is provided
by the few case reports wherein no significant increase in toxicities was observed when PCT-
cancer patients underwent RT [251-253].
Thus, the novel identification of down-regulating UROD has significant implications in
the management of human cancers. The therapeutic application of this approach is broad and
effective in the tumor-selective enhancement of radiation and chemotherapy efficacy.
Furthermore, the recent identification of an endogenous inhibitor against UROD [254], along
with the already described crystal structure of human UROD [255] provide important insights
to pave the path for the development of small molecule inhibitors targeting UROD. Finally,
our discovery uncovers the translational significance of iron homeostasis and dysregulation in
cancer, warranting further investigations into this important biological process.
4.6 Acknowledgments
We thank Thomas Sun and Frederick Vizeacoumar for assistance with the HTS; Nadine
Kolas and Yanina Eberhard for technical guidance; and Melania Pintilie for statistical advice.
This work was supported by the Canadian Institutes of Health Research (Grant 69023), the
Elia Chair in Head and Neck Cancer Research, and in part from the Ministry of Health and
Long-Term Planning.
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CHAPTER 5: DISCUSSION
127
5.1 Research Summary
Despite the recent advances in therapeutic options for HNC, treatment-associated
toxicities and overall clinical outcomes have remained disappointing. Radiation therapy, which
remains the primary curative modality for HNC, is often administered concomitantly with
radiosensitizing agents; many of which are neither selective nor tumor-specific. Thus, this
thesis focused on the goal of improving outcome for HNC patients by searching for novel
therapeutic strategies that synergize with radiation to enhance tumor cell killing, with minimal
damage to the surrounding normal tissues. In order to expedite this discovery process, a high-
throughput screening approach was employed.
In our initial attempt to search for novel radiosensitizers, we conducted a cell-based
phenotype-driven HTS of ~2,000 commercially available natural products, utilizing the short-
term tetrazolium-based MTS assay as a read-out for cell viability (Chapter 2). Although this
work was successful in identifying cetrimonium bromide as a novel tumor-selective
apoptogenic agent with in vitro and in vivo efficacy against several HNC models, two major
limitations of our discovery were that CTAB did not synergize with IR, nor was its precise
cellular target(s) elucidated. Furthermore, the HTS itself did not incorporate radiation
treatment; hence, the screen parameters were not ideal for discovering radiosensitizers.
Subsequently, in the continued search for novel radiosensitizers, an alternative strategy
was proposed involving a target-driven siRNA-based HTS. Radiation treatment was also
integrated into the screen, allowing for the direct assessment of the effects of both gene
knockdown and radiation. In terms of read-outs, it is well established that the clonogenic assay
is the gold standard for measuring cellular effects of IR in vitro. However, the long-term
kinetics, difficulty in large-scale automation, and limited robustness (i.e. colony-forming
capacity) of the assay has restricted its appeal and amenability to high-throughput platforms.
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Although this thesis was successful in developing an automated, 96-well high-throughput CFA
as a powerful and time-effective tool in the discovery of potent anti-cancer cytotoxics (Chapter
3), a technical drawback was its limited dynamic range due to the smaller surface area of the
96-well format and fewer cells that could be plated. Thus, we utilized the BrdU incorporation
assay, a viable CFA alternative, which measures replicative DNA synthesis and detects all
modes of cell death with long-term kinetics that is reflective of the therapeutic response; the
BrdU assay is also more sensitive and has a wider dynamic range compared to the MTS assay.
From the siRNA-based HTS of ~7000 human genes, uroporphyrinogen decarboxylase was
identified as a novel, potent radiosensitizing target against HNC models in vitro and in vivo;
wherein radiosensitization appeared to be mediated via tumor-selective enhancement of
oxidative stress. Thus, employing a high-throughput screening approach, this thesis was
successful in identifying two novel therapeutic strategies with clinical potential in the
management of HNC.
5.2 Future Directions
5.2.1 Empirical to Target-Driven Cancer Drug Discovery
Advances in our understanding of the molecular mechanisms underpinning tumor
development and growth has instigated a paradigm shift in our approach to cancer-based drug
discovery; transitioning the focus from the development of non-specific cytotoxic
chemotherapy to the rational design of target-based anti-cancer therapeutics. Despite the
successful application of chemoradiotherapy over the past few decades, the main drawback of
chemotherapy lies in its exacerbation of normal tissue toxicities. Thus, improving the
therapeutic index is a fundamental objective to enhancing cure rates with RT. As revealed in
this thesis, one approach is through the use of molecularly-targeted radiosensitizers that exploit
129
tumor-specific aberrations to enhance IR-mediated tumor cell killing. In this respect, their
relative tumor-specificity and generally broad therapeutic margin might offer a theoretical
advantage over classical cytotoxics, as overlapping toxicity with RT on normal tissues is
potentially minimized. Additionally, targeted therapies may offer the prospect of improved
patient selection, rational dosing, predictable side-effects, known mechanisms of resistance,
and the testing of rational combination regimens [256].
Fittingly, this paradigm shift in drug discovery has also prompted a transition from
empirical compound-orientated preclinical screening to target-focused drug screening.
However, contrary to initial expectations, target-driven screens are now faced with challenges,
mainly due to the fundamental and theoretical limits of this approach. First, target-based
screening frequently involves ex cellulo assays that do not fully recapitulate in cellulo
complexities. The pharmacologic effect resulting from the inhibition of a specific molecular
target may be influenced by interactions with other proteins within pathways or networks in
the cell. Thus, target-based screening assays may not be predictive of drug effects within the
context of the whole cell, resulting in unexpectedly lower efficacy and/or unforeseeable
adverse effects [256]. Second, only a minority of potential cancer targets are considered
pharmacologically tractable by the pharmaceutical industry. Amongst the four basic types of
cellular macromolecules, proteins, nucleic acids, lipids, and polysaccharides, the latter three
are not readily amenable to drug-targeting. Thus, the majority of clinically successful
chemotherapeutic drugs exert their effects by targeting proteins [257]. An analysis of known
Lipinski rule-of-five compliant drugs suggests there are only ~399 non-redundant molecular
targets from ~130 protein families, which bind these drugs. More globally, assuming that the
sequence and functional similarities within a gene family are indicative of a conserved drug
binding-site architecture, then only ~3,051 of the predicted 30,000 genes in the human genome
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code for a “druggable” protein [257]. At present, ~50% of the proteins expressed by the
genome are functionally unclassified; some of which might prove to be druggable [257].
Moreover, alternative therapeutic strategies including those based on antibody, protein, and
oligonucleotide (e.g. anti-sense oligonucleotides, RNAi) technologies, may further expand the
scope of potential druggable targets to those not amenable to rule-of-five compliant therapies.
5.2.2 RNAi in Drug Discovery and Therapeutics
The use of RNAi technology has become not only a dynamic tool for expediting the
cancer drug discovery process, but has also been making strides to serve as a powerful
therapeutic; thus, tackling the aforementioned limitations of target-oriented drug screening.
The large-scale identification of novel cancer targets via genome-wide RNAi screens can be
conducted both at the cellular and whole-animal level, enabling the direct assessment of loss-
of-function phenotypes for specific targets in cellulo and in vivo [258]. RNAi has also become
an important part of the target validation process, wherein tumor xenograft models of shRNA-
transfected cells may be used to confirm target knockdown-mediated suppression of tumor
development. In particular, inducible shRNA systems, which allow tumor xenografts to
become established before silencing target expression, reflects to an extent, the
pharmacological administration of therapies to established tumors [258]. As demonstrated in
this thesis, systemic or localized intra-tumoral siRNA delivery in mice xenograft models are
alternative methods for in vivo target validation; this approach, which simulates more or less
clinical practice, also allows for the assessment of treatment-associated systemic toxicities
[259]. In addition to target identification and validation, RNAi technology can be employed to
streamline the later stages of drug discovery. The combination of RNAi and in vitro
phenotype-based small-molecule screens can be a powerful approach to improve compound
identification and lead optimization. Specific cellular phenotypes associated with RNAi-screen
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target hits can be applied to secondary cell-based chemical screens to identify candidate small
molecules that can recapitulate the inhibitory effects of target RNAi [258]. Genomic
approaches, together with RNAi, can also be used to enhance lead optimization, wherein
molecular expression profiles of target RNAi and lead compounds identified from the in vitro
screen can be generated and compared. The compounds that most effectively reproduce the
RNAi-generated profile would be given priority for further development [258]. In fact, gene-
expression signatures can now be accurately compared, independent of the platform on which
they were created via the Connectivity Map (C-Map), a large compendium of gene-expression
profiles from cultured human cells treated with various chemicals and genetic reagents [260].
Thus, microarray signatures generated from RNAi-screen hits can also be compared to those
within C-Map to identify compounds with similar profiles. If the identified compounds are
already approved for another indication, this could further expedite clinical development.
Clinically, RNAi-based therapeutics represent a fundamentally new way to treat cancer
by addressing targets that are otherwise “non-druggable” with existing medicines. In contrast
to Lipinski rule-of-five compliant drugs, siRNAs are too large (13 kDa) and negatively-
charged to cross cellular membranes. Furthermore, naked siRNAs are relatively unstable in
biological fluids and tissues due to degradation by nucleases, contributing to their short half-
lives in vivo [259]. Thus, the effective and non-toxic delivery of RNAi serves as perhaps the
most challenging and significant barrier to successfully translating RNAi technology to a
clinical application. Considerable progress has been made in optimizing siRNA delivery via
chemical modifications to its sugars, backbone, or bases of the oligoribonucleotides,
conferring improved potency and stability against nuclease degradation. Other strategies to
facilitate the delivery and therapeutic efficacy of siRNAs involve the use of liposomes and
lipid complexes, cationic polymers, or conjugates with targeting small molecules, proteins, and
132
antibodies for cell type-specific delivery [259]. Numerous proof-of-concept studies with tumor
xenograft models in mice have demonstrated the efficacy of local and systemic RNAi using
various delivery strategies. For example, therapeutic siRNAs targeting PLK1, HER2, and
VEGF have been successful in suppressing tumor growth in prostate and ovarian carcinoma
xenograft models [261-263]. The application of RNAi therapeutics for cancer treatment is also
progressing in the clinic. The first non-human primate study on targeted, systemic delivery of
siRNA against ribonucleotide reductase subunit M2 (CALAA-01) was conducted by Calando
Pharmaceuticals in 2007, demonstrating multiple, systemic doses of siRNA administration to
be safe [264]. CALAA-01 is now in phase I clinical testing for systemic administration to
patients with relapsed or refractory solid tumors. Pre-clinical development of a second siRNA
therapeutic targeting HIF-2 (CALAA-02) is also underway.
If successful, RNAi-based cancer drugs would address some of the major limitations of
traditional pharmaceutical drugs, comprising small-molecules and protein- or antibody-based
therapeutics (Table 5.1). The main advantages of an RNAi strategy include its amenability to
all targets, even those classified as “non-druggable”. Furthermore, lead compounds can be
quickly identified and optimized, as synthetic siRNAs are relatively easy to mass-produce
[259]. Compared to other oligonucleotide-based strategies, such as anti-sense oligonucleotides
(ASO), RNAi is much more potent [265]. Thus, RNAi-based therapeutics demonstrate great
promise as a potential new class of pharmaceutical drugs with the capacity to fill a significant
gap in modern medicine.
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Table 5.1 Comparison of therapeutic modalities
Key features of two major classes of traditional pharmaceutical drugs (small molecules, and
antibodies proteins) compared to RNAi as a therapeutic approach. This table is adapted from
[259].
Small Molecules Antibodies and Proteins RNAi
• Antagonism or agonism of
target
• Antagonism or agonism of target • Antagonism only
• Extracellular and
intracellular targets
• Extracellular targets • All targets, including
“non-druggable”
targets
• Not all target classes can be
modulated selectively and
potently
• Highly selective and potent • Highly selective and
potent
• Lead ID and optimization
slow
• Lead ID and optimization slow • Rapid lead ID and
optimization
• Easy to synthesize • Difficult to produce • Easy to synthesize
5.2.3 Clinical Trials for Molecularly-Targeted Therapies
With the abundance of pre-clinical evidence supporting the role of molecularly-
targeted agents in enhancing tumor response to RT, combining these two modalities appears to
be a rational strategy for cancer treatment. However, translating this approach from promising
pre-clinical findings to clinical trials has been challenging. Despite the increasing number of
targeted agents accrued over the last decade, few have made it into the clinic. There is limited
clinical data available for assessing the true benefits of combining targeted agents with RT.
Moreover, it remains controversial whether these agents can rival cytotoxic chemotherapy in
terms of radiosensitization; thus, clinical trials comparing RT alone, RT-plus-chemotherapy,
vs. RT-plus-targeted agents should be performed to substantiate the widespread notion that
molecularly-targeted radiosensitizers are more efficacious and less toxic than cytotoxic drugs.
The impediment and lack of concordance between pre-clinical and clinical results may be a
result of various factors. Pre-clinical data are often based on a limited number of cell-line
models, which cannot truly reflect the molecular heterogeneity of patient tumors [266].
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Furthermore, there have been limited efforts put towards optimizing combinatorial treatment
regimens (e.g. concentration, exposure, sequence) pre-clinically and clinically. There have also
been limited attempts to determine the predictors of treatment response, and to apply these
biomarkers for patient selection [266]. More recently, it has been recognized that traditional
clinical designs for evaluating cytotoxic chemotherapy may be inappropriate for targeted
agents. For instance, the conventional phase I trial design to establish maximum tolerated
doses may be unsuitable for agents that are intrinsically less toxic to normal tissues or are used
at sub-cytotoxic doses to elicit radiosensitization [266]. A move towards combined phase I/II
studies aimed at defining an optimum dose with simultaneous consideration of tumor effect
and toxicity has been proposed; thus, novel trial designs and surrogate endpoints may be
needed. Given that RT is a curative therapeutic modality for many cancers, it will be a
challenge for clinical researchers to optimally apply this combined approach in further
improving clinical outcome and minimizing toxic side-effects. As such, the National Cancer
Institute Radiation Modifier Working Group is currently working to propose appropriate
clinical trial designs for assessing the combination of molecularly-targeted agents and RT
[267].
5.2.4 Developing UROD as a Therapeutic Radiosensitizing Target
From the two novel therapeutic strategies identified in this thesis, UROD demonstrated
significant potential as a tumor-selective radiosensitizing target, warranting priority for further
pre-clinical assessment. Drug development pipelines often contain compounds in which the
exact cellular mechanisms of action remain poorly understood, slowing their development.
Thus, to further expand our current knowledge and breadth of application of this therapeutic
target, future directions include determining the applicability of our siUROD radiosensitization
strategy to other human cancer models. In addition to the 10 cancer cell lines studied to date
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(Figure 4.7A), a panel of additional cell lines in which IR plays a curative or adjuvant role
(e.g. colon, stomach) should be examined for in vitro and in vivo efficacy. With the
identification of a range of sensitivities to siUROD-plus-IR from the cell lines tested above,
global gene-expression analyses should provide insights into the determinants of siUROD-
mediated radiosensitization. Microarray profiling of pairs of sensitive vs. resistant cells within
one cancer model may reveal a putative “siUROD radiosensitizing signature”, which could be
used as a clinical biomarker when selecting suitable candidates for treatment. In an effort to
acquire additional biological insights as to whether major oncogenic aberrations influence
siUROD radiosensitization, isogenic cell lines with specific common mutations (e.g. p53,
EGFR, ras) should also be tested. Lastly, follow-up studies on the clinical translational
observations reported in this thesis (Figures 4.7D and E) should be conducted. These data were
based on a skewed cohort wherein only 8 of the 38 HNSCC patients did not relapse. Hence,
this translational study should be repeated by performing UROD immunohistochemistry on an
independent larger-sized cohort of HNSCC patients who have been treated with RT to confirm
whether UROD expression would indeed provide a predictive value for clinical outcome.
In addition to the promising pre-clinical findings reported in this thesis, the recent
identification of an endogenous inhibitor against UROD [254], along with the already
described crystal structure of human UROD [255] advance the development of small molecule
inhibitors against the target. Thus, in silico virtual screening or secondary cell-based chemical
screens to identify potential lead candidates that can mimic the inhibitory effects of siUROD
are warranted. Given the evolving power of RNAi technology in drug discovery, and our
expertise with in vitro and in vivo siRNA delivery, it is only fitting that we exploit its use to
enhance our lead identification and optimization efforts for UROD inhibitors. In combination
with other genomic tools (e.g. microarray profiling, C-Map) as described in the previous
136
sections, it is anticipated that a lead compound can be identified. Furthermore, with the
substantial progress being made in terms of RNAi-based therapeutics, it is also plausible to
pursue siUROD as a drug in itself. Any lead UROD inhibitors that are identified will be
subjected to rigorous in vitro and in vivo assessments, as described above to ensure a smooth
transition from pre-clinical to clinical testing.
5.3 Conclusions
In conclusion, this thesis has laid the foundation for the future discovery and
development of novel HNC therapeutics via RNAi and high-throughput screening, with both
target- and phenotype-based screens continuing to play important roles as we further shift into
an era of molecular-targeting. The use of RNAi, and in particular high-throughput RNAi
approaches, has the potential to streamline many of the stages of drug discovery, ranging from
initial target identification to drug development. As the focus continues to progress towards
molecular-targeting, there is great potential to develop rational, hypothesis-driven, mechanism-
based molecular therapeutics for HNC. As such, UROD and the remaining 66 radiosensitizing
targets identified from our RNAi screen provide promising, therapeutically exploitable
avenues for advancing the quality and effectiveness of RT in HNC management. Although
many challenges exist, the powerful and constantly evolving techniques of genomics,
molecular biology, and chemical biology provide an unprecedented opportunity to address
these issues, ensuring excellent prospects for improving clinical outcome for HNC.
137
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