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Mifepristone prevents repopulation of ovarian cancer cells escaping cisplatin-paclitaxel therapy
© Gamarra-Luques et al.; licensee BioMed Central Ltd. 2012
Received: 22 March 2012
Accepted: 29 May 2012
Published: 22 June 2012
Advanced ovarian cancer is treated with cytoreductive surgery and combination platinum- and taxane-based chemotherapy. Although most patients have acute clinical response to this strategy, the disease ultimately recurs. In this work we questioned whether the synthetic steroid mifepristone, which as monotherapy inhibits the growth of ovarian cancer cells, is capable of preventing repopulation of ovarian cancer cells if given after a round of lethal cisplatin-paclitaxel combination treatment.
We established an in vitro approach wherein ovarian cancer cells with various sensitivities to cisplatin or paclitaxel were exposed to a round of lethal doses of cisplatin for 1 h plus paclitaxel for 3 h. Thereafter, cells were maintained in media with or without mifepristone, and short- and long-term cytotoxicity was assessed.
Four days after treatment the lethality of cisplatin-paclitaxel was evidenced by reduced number of cells, increased hypodiploid DNA content, morphological features of apoptosis, DNA fragmentation, and cleavage of caspase-3, and of its downstream substrate PARP. Short-term presence of mifepristone either enhanced or did not modify such acute lethality. Seven days after receiving cisplatin-paclitaxel, cultures showed signs of relapse with escaping colonies that repopulated the plate in a time-dependent manner. Conversely, cultures exposed to cisplatin-paclitaxel followed by mifepristone not only did not display signs of repopulation following initial chemotherapy, but they also had their clonogenic capacity drastically reduced when compared to cells repopulating after cisplatin-paclitaxel.
Cytostatic concentrations of mifepristone after exposure to lethal doses of cisplatin and paclitaxel in combination blocks repopulation of remnant cells surviving and escaping the cytotoxic drugs.
Ovarian cancer is the most lethal gynecologic disease . Because early detection biomarkers are not yet available and the symptomatology is vague, the disease is usually diagnosed at a late stage when growths have extended within the peritoneal cavity [2–4]. At this point, patients usually undergo cytoreductive surgery followed by platinum plus taxane-based chemotherapy [1, 3]. The response to this regime is successful with disease remission in at least 70% of the cases; however, the majority of first responders will relapse within 18 months with a platinum-resistant disease [3–6]. Unfortunately, there is no current agreed maintenance therapy following the initial cisplatin-paclitaxel chemotherapy regimen [5, 6], and the median survival time for patients after recurrence is only approximately two years .
Cisplatin was adopted as primary chemotherapy schedule in the 1970s in association with cyclophosphamide . In the 1990s a microtubule stabilizer, paclitaxel, was shown to potentiate cisplatin-based therapy in ovarian cancer patients with better efficacy than cisplatin-cyclophosphamide [8, 9]. Since these clinical trials, only minor variations in the standard chemotherapeutic schedule for ovarian cancer patients have been implemented. For instance, in the early 2000s it was demonstrated that carboplatin was equality effective as cisplatin in association with paclitaxel but with much less nephrotoxicity, and better tolerability and quality of life than cisplatin . Thus, cisplatin and paclitaxel, and later carboplatin plus paclitaxel, have been broadly accepted as first-line chemotherapy for advanced epithelial ovarian cancer. Another improvement in overall survival was achieved by the adoption of intraperitoneal delivery of these drugs when compared with intravenous administration . However, data worldwide concur that in the past 20 years there has been little change in the 5-year survival rates post-diagnosis of patients with ovarian cancer .
Our laboratory provided evidence that the synthetic steroid mifepristone is effective as a single agent in vitro and in vivo blocking the growth of human epithelial ovarian cancer cells . When used at concentrations likely to be achieved in vivo in humans [13–16], mifepristone inhibited cell growth by inducing G1 cell cycle arrest associated with inhibition of DNA synthesis, downregulation of the transcription factor E2F1 needed for S phase progression, and inhibition of the activity of cyclin dependent kinase 2 [12, 17], which is critical to promote G1 to S phase transition . We also reported that the growth inhibitory effect of mifepristone in ovarian cancer cells does not require the expression of cognate progesterone receptors , and is independent of p53 functionality and platinum sensitivity , making mifepristone an even more interesting chemotherapeutic candidate for ovarian cancer as the majority of tumors in relapsing patients are platinum resistant and p53 mutant . Finally, we have shown in ovarian cancer cells that mifepristone potentiates the lethality of otherwise sub-lethal doses of cisplatin, and synergizes with cisplatin growth inhibiting ovarian cancer cells of different genetic backgrounds and platinum sensitivities .
In this work we set out to study whether mifepristone has the capacity to block repopulation or regrowth of ovarian cancer cells escaping front-line cisplatin plus paclitaxel chemotherapy. We report that although ovarian cancer cells were initially severely damaged by cisplatin-paclitaxel, the cultures eventually recovered due to the proliferation of escape cells. Such cell repopulation, nonetheless, was blunted by the chronic presence of clinically relevant doses of mifepristone.
Cell lines, culture conditions and treatments
The human ovarian carcinoma cell lines OV2008, A2780, and IGROV-1 were obtained in 2003 from Dr. Stephen Howell (University of California, San Diego) . The cells were maintained in RPMI 1640 (Mediatech, Herndon, VA) supplemented with 5% or 10% (OV2008 or A2780/IGROV-1, respectively) heat inactivated FBS (Atlanta Biologicals, Lawrencenville, GA), 10 mM HEPES (Mediatech), 4 mM L-glutamine (Mediatech), 1 mM sodium pyruvate (Mediatech), 100 IU penicillin (Mediatech), and 100 μg/ml streptomycin (Mediatech). SK-OV-3 ovarian cancer cells were obtained from the American Type Culture Collection (ATCC, Manassas, VA) and were routinely maintained in RPMI 1640 (Mediatech) supplemented with 10% FBS (Atlanta Biologicals), 10 mM HEPES (Mediatech), 4 mM L-glutamine (Mediatech), 0.45% D (+) glucose (Sigma Chemical Company, St. Louis, MO), 1 mM sodium pyruvate (Mediatech), 1 X non-essential amino acids (Mediatech), 100 IU penicillin (Mediatech), 100 μg/ml streptomycin (Mediatech), and 0.01 mg/ml human insulin (Roche, Indianapolis, IN) as we previously described [12, 17, 19, 20]. All cell lines were cultured at 37°C in a humidified atmosphere in the presence of 5% CO2.
The stock of cisplatin (cis-diamminedichloroplatinum II) (cisplatin; Sigma) was a 3 mM solution in 0.9% NaCl. Cells were exposed to cisplatin for only 1 h; thereafter, the medium was replaced with fresh cisplatin-free medium. The stock of paclitaxel (Sigma) was a 100 μM solution in DMSO. Cells were exposed to paclitaxel for 3 h; thereafter, the medium was replaced with fresh paclitaxel-free medium. Treatment of cells with mifepristone (Sigma) was done from a 20 mM stock solution in DMSO, which was maintained at −20°C. The maximal concentration of DMSO in medium was less than 0.02% (v/v).
Triplicate cultures were trypsinized, pelleted by centrifugation at 500 g for 5 min, and washed with PBS. The cells were resuspended in ViaCount reagent (Guava Technologies, Hayward, CA) and studied using the Guava ViaCount application in the Guava EasyCyte Mini microcapillary cytometer (Guava Technologies) as we previously reported . For data presentation purposes, when ‘growth’ is indicated, controls are considered 100%, whereas when ‘relative growth’ is stated, the number of cells at the beginning of the experiment was considered as 1.
Phase contrast microscopy
Along the various treatment paradigms, cells maintained in 6-well plates where observed and photographed using a Zeiss Axiovert M200 inverted microscope with a phase contrast objective (Carl Zeiss, Thornwood, NY).
Determination of sub-G1 DNA content and cell cycle stages
After treatment, cells were trypsinized, pelleted by centrifugation at 500 g for 5 min, washed with PBS, and fixed with 4% paraformaldehyde. Cells were once again washed with PBS and pelleted by centrifugation at 500 g for 5 min. Then, approximately 100,000–200,000 cells were resuspended in 200 μl of cell cycle buffer [3.8 mM sodium citrate (Sigma), 7 U/ml RNase A (Sigma), 0.1% (v/v) Triton X-100 (Sigma), and 0.05 mg/ml propidium iodide (Sigma)], at a concentration of 500–1000 cells/μl. Cells were studied for the capacity of their DNA to bind propidium iodide utilizing the Guava EasyCyte Mini microcapillary cytometer and the cell cycle application of the CytoSoft 4.1 software (Guava Technologies). In some circumstances, to calculate changes in hypodiploid DNA content induced by treatment, we expressed the data as specific sub-G1 as follows: specific sub-G1 = [100* (treated sub-G1 – control sub-G1)/(100 – control sub-G1)].
Floating and adherent cells were pelleted and digested overnight at 50°C in a buffer composed of 100 mM NaCl, 10 mM Tris HCl (pH 8.0), 25 mM EDTA (pH 8.0), 0.5% SDS and 0.1 mg/ml proteinase K (Life Technologies, Rockville, MD). The genomic DNA was extracted from the digested cells with phenol/chloroform/isoamyl alcohol (25:24:1, v/v/v), precipitated, and digested for 60 min at 37°C with 1 μg/ml ribonuclease (deoxyribonuclease-free; Roche, Indianapolis, IN). After extraction and precipitation, an equal amount of DNA for each sample (2 μg) was separated by electrophoresis on a 2.5% agarose gel, impregnated with SYBR Gold nucleic acid gel stain (Molecular Probes, Eugene, OR) and photographed with the Amersham Typhoon Fluorescence imaging system (Amersham Biosciences Corp., Piscataway, NJ). A 100 bp DNA ladder (Promega, Madison, WI) was utilized to determine the size of the fragments of DNA.
SDS-PAGE and western blotting
Cells were scraped, pelleted, washed twice with PBS, and lysed by the addition of two volumes of radioimmunoprecipitation assay buffer (RIPA) containing 50 mM Tris- HCl (pH 7.4), 150 mM NaCl, 1% NP-40 (Sigma), 0.25% sodium deoxycholate (Sigma), 1 mM EDTA, 1 mM PMSF (Sigma), 1 μg/ml pepstatin (Sigma), 1 mM orthovanadate (Sigma) and 1 mM sodium fluoride (Sigma). Cells were disrupted by passing them through a 21 gauge needle, and gently rocked on ice for 30 min. Lysates were centrifuged at 16,000 g for 15 min at 4°C, and the supernatant was considered the whole cell extract, which was assayed for protein content by using the bicinchoninic acid method (BCA; Pierce, Rockford, IL). Equivalent amounts of protein (50 μg) per point were loaded in 12% (w/v) acrylamide gels, subjected to SDS-PAGE and transferred to PVDF membranes. The blots were blocked in 5% (v/v) nonfat milk in TBS containing 0.1% (v/v) Tween 20 (T). Blots were then probed overnight with primary antibodies against poly (ADP-ribose) polymerase (PARP) (#9542; 1:1000; Cell Signaling Technologies, Danvers, MA) or caspase caspase-3 (#9662; 1:1000; Cell Signaling). The membranes were washed 3 × 5 min in TBS-T and incubated with 1:10,000 dilution of peroxidase-conjugate secondary antibody (#111-035-003; Jackson ImmunoResearch Laboratories, West Grove, PA) for 30 min at room temperature. The blots were again washed, developed by chemiluminescence, and exposed to radiographic film. Blots were also probed with an antibody directed against glyceraldehyde-3-phosphate dehydrogenase (GAPDH) (ab9485; 1:10,000; Abcam, Cambridge, MA) to control for protein loading.
Analysis of drug interaction
To characterize the pharmacological impact of adding mifepristone to the standard cisplatin-paclitaxel combination chemotherapy, we used the CalcuSyn software (Biosoft, Cambridge, UK). This program utilizes the combination index (CI) as a method for quantifying drug cytotoxic synergism based on the mass-action law as designed by Chou and Talalay [23, 24]. Synergism is defined as a more than expected additive effect, and antagonism is defined as a less than expected additive effect. Percent growth inhibition was used as a variable for the dose–response analyses, and the CI was calculated utilizing as ‘effect level’ or ‘fraction affected’ level the percent growth inhibition divided by 100. For drug interaction purposes, the combination cisplatin-paclitaxel was considered as one variable. Cells were exposed to various doses of cisplatin in the range of 2–20 μM, paclitaxel in the range of 0.5-100 nM, and mifepristone in the range of 5–20 μM. When combinations cisplatin-paclitaxel and cisplatin-paclitaxel-mifepristone were tested, cisplatin was fixed at 20 μM, mifepristone at 10 μM, and paclitaxel was varied in the range of 0.5-100 nM. To the specified drug association, CI = 0.9-1.1 denotes an additive effect, CI = 0.7-0.9 indicates slight synergism, CI = 0.3-0.7 indicates strong synergism, whereas CI >1.1 indicates antagonism. Drug interaction among the combination cisplatin-paclitaxel with mifepristone for the different cell lines was expressed as normalized isobolograms for the most relevant combination data point leading to synergism. The median dose (Dm) of each single drug and the dose reduction index (DRI) were also calculated. Dm values indicate median-effect dose or concentration, which is usually depicted as IC50. DRI is a measure of how much the dose of each drug can be reduced to obtain any given biological effect when compared with the doses for each drug alone. Although a DRI > 1 is beneficial, it does not necessarily indicate synergism; however it is important from a clinical standpoint where dose-reduction predicts reduced toxicity toward the host while retaining therapeutic efficacy.
Clonogenic survival assay
Twenty one days after challenge with the drugs, 500 viable cells were placed in 6-well plates and cultured for 7 days until colonies were large enough to be clearly discerned. At this point, the medium was aspirated; the dishes were washed twice with PBS, fixed with 100% methanol for 30 min, and stained with a filtered solution of 0.5% (w/v) crystal violet (Sigma) for 10 min. The wells were then washed with tap water and dried at room temperature. The colonies, defined as groups of ≥30 cells, were scored manually with the aid of a Nikon Diaphot inverted microscope (Nikon, Garden City, NY). Clonogenic survival was expressed as the number of colonies formed during the different treatment paradigms.
Exposure of ovarian cancer cells to cisplatin and paclitaxel induces substantial growth inhibition and lethality that are either unaffected or enhanced by chronic presence of a cytostatic dose of mifepristone after removal of the cytotoxic agents
We next studied the killing capacity of the various treatment paradigms by assessing the hypo-diploid DNA content, DNA fragmentation, and caspase-3 activation, all known markers of cisplatin-paclitaxel-induced toxicity [4, 27–33]. Cisplatin alone was lethal to all cell lines as assessed by hypodiploid DNA content (Figure 1B), fragmentation of the DNA (Figure 1C) and cleavage of executer of apoptosis, caspase-3, and of its downstream substrate PARP (Figure 1D). Paclitaxel alone induced lethality to all cell lines except to OV2008 cells (Figure 1B-D). As expected, based on our previous studies [12, 17, 19, 20], cells receiving mifepristone monotherapy did not display any evidence of cellular damage at the concentrations used. The combination cisplatin-paclitaxel was lethal to all cell lines, irrespective of their genetic backgrounds (Figure 1B-D). The chronic presence of mifepristone following cisplatin-paclitaxel did not interfere with the toxicity caused by the standard drugs. On the contrary, for instance in IGROV-1 cells, the presence of mifepristone enhanced cisplatin-paclitaxel toxicity as reflected by specific sub-G1 DNA content (Figure 1B) and caspase-3 activation (Figure 1D). Collectively, results in Figure 1 confirm that in combination, cisplatin and paclitaxel are highly efficient in growth inhibiting and/or killing ovarian cancer cells regardless of their genetic makeup, and demonstrate that a follow-up, chronic, non-toxic dose of mifepristone does not interfere with the primary toxicity of cisplatin-paclitaxel.
Time-course of cell growth and cell death-related events occurring following cytotoxic cisplatin-paclitaxel therapy in cells subjected or not to the chronic presence of mifepristone
Cisplatin-paclitaxel combination therapy is efficient in the short term causing substantial cellular damage, yet culture repopulation ensues with time; such repopulation can be prevented by the presence of mifepristone
In summary, data presented in Figures 1–4 suggest that despite cisplatin alone or in combination with paclitaxel is/are efficient in killing ovarian cancer cells, there are cells that escape the cytotoxic challenge. These escape cells do not die. Instead they are capable of repopulating the culture plate. This phenomenon, nonetheless, is abrogated by the presence of mifepristone.
The blockage of repopulation by mifepristone of cells escaping cisplatin-paclitaxel is synergistic from a pharmacological standpoint
To quantify the added efficacy of mifepristone when blocking cell repopulation following cytotoxic cisplatin-paclitaxel therapy, we evaluated the growth inhibition properties of the drugs 7 days following the acute challenge with cisplatin for 1 h, paclitaxel for 3 h, cisplatin for 1 h and paclitaxel for 3 h, or the combination of acute cisplatin-paclitaxel challenge followed or not by chronic exposure to 10 μM mifepristone. Single agent IC50s (concentrations needed to inhibit cellular growth by 50%) ranged from 18.2 to more than 170 nM for paclitaxel, from 3.59 to more than 14 μM for cisplatin, and from 6.8 to 15.8 μM for mifepristone (Additional file 4: Table S1). Cisplatin was more cytotoxic to OV2008, A2780 and IGROV-1 cells, all considered platinum sensitive , when compared to SK-OV-3 cells that were obtained from a patient resistant to clinically achievable concentrations of cisplatin, and are considered semi-resistant in vitro. In terms of paclitaxel response, OV2008 were less sensitive, whereas A2780, IGROV-1 and SK-OV-3 were more sensitive to concentrations lower than 100 nM, confirming previous reports [4, 34–36]. All cell lines were growth inhibited by the cytostatic agent mifepristone, confirming our previous results [12, 17, 20].
Mifepristone blocks time-dependent repopulation and abolishes clonogenic survival of ovarian cancer cells that escape cisplatin-paclitaxel cytotoxic therapy
Ovarian cancer is known as a silent killer due to its late detection and high mortality. Despite that much research has been done to improve the quality and quantity of life of ovarian cancer patients, the overall survival for this disease has remained stagnant at 30% since the introduction of the dual cisplatin-paclitaxel therapy in the mid-1990s. Efforts are geared at finding manners to diagnose the disease early, discovering target therapies, and improving the efficacy of current chemotherapeutic agents. We here provide evidence that when ovarian cancer cells are subjected to clinically relevant exposure times of cisplatin and paclitaxel, and to supra-pharmacological doses of the drugs –i.e. doses exceeding the maximal plasma concentrations that limit their tolerability, reported to be in the range of 50–100 nM for paclitaxel, and of 6–10 μM for cisplatin [37–40]—the therapy is initially successful, yet there are cells that eventually escape toxicity and relapse. Such relapse after remission can be, however, efficiently prevented by adding clinically relevant concentrations of the synthetic steroid mifepristone [13–16].
We modelled in vitro a scenario in which we utilized supra-pharmacological doses of cisplatin and paclitaxel [25, 26] to maximize the cytotoxicity of the drugs, but limited their effect to clinically relevant times. Thus, cells were exposed to cisplatin in the range of 0–20 μM for only 1 h, to paclitaxel in the range of 0–100 nM for only 3 h, and chronically to 10 μM mifepristone, likely to be maintained in vivo[13–16]. Using this in vitro approach, we demonstrate that although the combination cisplatin-paclitaxel used at high doses is very efficacious in killing a large proportion of ovarian cancer cells encompassing broad genetic backgrounds, there are cells that escape the therapy and repopulate the culture following an otherwise apparent successful chemotherapeutic round.
The initial efficacy of the therapy with cisplatin and paclitaxel for ovarian cancer was amply validated and translated to the clinic many years ago [8, 9]. However, the molecular mechanisms whereby cisplatin and paclitaxel alone or in combination cause cell toxicity necessitate further elucidation. Cisplatin displays cytotoxicity targeting the cytoplasm and the nucleus. In the cytoplasm, cisplatin interacts with a wide number of substrates tilting the redox balance to oxidative stress, which facilitates DNA damage . Cisplatin also causes direct mitochondrial dysfunction  and endoplasmic reticulum stress . In the nucleus, cisplatin binds DNA leading to the generation of DNA-DNA inter- and intra-strand adducts. These lesions cause distortions in the DNA that can be recognized by multiple repair pathways. When the extent of damage is limited, cisplatin adducts induce an arrest in the S and G2 phases of the cell cycle to allow the DNA repair mechanisms to re-establish DNA integrity and prevent abortive or abnormal mitosis. In contrast, if DNA damage is beyond repair, cells embark into a delayed death pathway [41, 44–49]. Paclitaxel, on the other hand, acts by binding to intracellular β-tubulin leading to microtubule stabilization and G2-M arrest; thereafter, the cells may either die by apoptosis or necrosis immediately after the mitotic arrest, or following an aberrant mitotic exit into a G1-like multinucleated state . Paclitaxel-induced cell death is, at least in part, mediated through the degradation of Bcl-2 . In contrast to cisplatin, sensitivity to paclitaxel is independent of the p53 tissue expression status [52, 53], while cisplatin-resistant cells retain sensitivity to paclitaxel [27, 36]. There is no doubt of the initial efficacy of the combination cisplatin-paclitaxel; their synergistic pharmacological interaction has been amply proven [28, 29]. In our work we substantiated that adding mifepristone after cisplatin-paclitaxel does not interfere with the efficacy of the dual combination, but rather, in some cases enhances it.
Dual cisplatin-paclitaxel therapy is followed by disease remission; however, it rarely provides cure as the disease eventually relapses after remaining dormant as minimal residual for over a year . Such therapeutic failure is recapitulated in our in vitro toxicity model system in which scarce, yet critical cells escape cisplatin-paclitaxel therapy and regrow as demonstrated by their increase in number and by having a clonogenic survival capacity even superior than that of cells never treated with cisplatin-paclitaxel. When mifepristone was added after the initial toxic cisplatin-paclitaxel combination, repopulation was prevented and the clonogenic capacity of the remaining cells in culture was minimal.
The repopulation of cancer cells that escape or relapse after chemo- or radiotherapy accounts for the lack of long-term success of current cancer therapy. Repopulation of tumor cells was defined in 2005 by Kim and Tannock  as ‘the continuing proliferation, sometimes at an accelerated pace, of surviving tumor cells with the capacity to regenerate the tumor that can occur during a course of chemotherapy or fractionated radiotherapy.’ The mechanism of repopulation of escape cells, however, is less understood: some recent studies provide insights into it. For instance, cancer cells develop the capacity to escape DNA damage caused by pharmacological doses of platinum-based therapy via reverse polyploidy (a.k.a ‘neosis’ [55–57]), leading to the formation of diploid, rapidly proliferating cells with increased platinum resistance . Such diploid descendants are formed upon reactivation of meiosis-specific genes from a polyploid genome [59, 60], and in association with the formation of sub-nuclei that become degraded by autophagy . Thus, a possibility exists that mifepristone blocks repopulation of escape cells by preventing reverse polyploidy. Supporting this hypothesis, we observed that OV2008 cultures that retain certain viability in between courses of cisplatin exposure, show giant cells together with a nascent population of small cells  that may originate from the likely polyploid, giant progenitors. Cultures treated with mifepristone after cisplatin do not show this small pool of repopulating cells; instead, they display an overall reduced number of cells, with predominance of a giant phenotype that ends up committing suicide as marked by cleaved PARP positivity . Similar mechanism may be taking place in cells repopulating after cisplatin-paclitaxel combination therapy, because it is known that the driving force behind this therapy is cisplatin, not paclitaxel . Additionally, within cultures repopulating after cisplatin-paclitaxel we observed a population of cells with hyperploid DNA content that is reduced parallel to cell repopulation and increased percentage of G1 cells. In cultured treated with cisplatin-paclitaxel plus mifepristone, however, such hyperploid population disappears in favor of hypodiploid DNA content consisting with cells dying by apoptosis instead of returning to the cell cycle.
Two other survival mechanisms that may explain repopulation after escape to chemotherapy could be the target of mifepristone interference. Firstly, mifepristone can block the release of survival factors from dying cells, because a recent study demonstrated that cells that are dying as a consequence of the chemotherapy, release chemical mediators (prostaglandins) that promote the growth of still surviving cells; more importantly, this mechanism requires caspase-3 activity in the dying cells , suggesting that caspase-3 has paradoxical functions, on one hand driving apoptotic cell death and on the other promoting the release of survival factors . Secondly, there is also a possibility that mifepristone blocks the growth of scarce tumor initiating cells with the capacity to regenerate the culture and that may remain in culture because are resistant to cisplatin-paclitaxel in contrast to the bulk of differentiated cancer cells that succumb to the chemotherapy . A genetic evolution study of high-grade serous ovarian adenocarcinomas suggests that resistance to cisplatin may develop from pre-existing minor clones that remain as minimal residual disease and become enriched after initial chemotherapy . Within this scenario, mifepristone may block the repopulation of cells that never responded to cisplatin-paclitaxel therapy since, as we have shown, the drug has similar growth inhibition potency in platinum sensitive and platinum resistant ovarian cancer cells .
We provide proof-of-principle that the escape process following cytotoxic therapy can be abrogated by a chronic exposure to mifepristone. Long-term (months to years) of daily administration of mifepristone is feasible and clinically well tolerated . Other synthetic steroid agents with similar structure than mifepristone containing a dimethylaminophenyl substitution at the 11-β position have been developed . We demonstrated that, similar to mifepristone, the related steroids ORG-31710 and CDB-2914 block ovarian cancer cell growth in association with inhibition of the activity of cyclin dependent kinase 2 . It warrants investigation whether these agents are equivalent or more efficient than mifepristone when used to block repopulation following cisplatin-paclitaxel therapy.
Using an in vitro model of recurrence after exposure of ovarian cancer cells to supra-pharmacological doses of cisplatin and paclitaxel, and for clinically relevant exposure times, we demonstrated that a clinically relevant dose of the synthetic steroid mifepristone significantly improves treatment efficacy by reducing the number and clonogenic survival capacity of escape cells. Thus, mifepristone could be used for chronic, non-toxic maintenance therapy following cytotoxic standard cisplatin-paclitaxel chemotherapy to improve treatment efficacy by abrogating relapse of cells escaping cisplatin-paclitaxel.
This study was supported by National Cancer Institute Grant K22CA121991, ARRA Supplement K22CA121991-S1, and R15CA164622 and in part by a South Dakota Board of Regents competitive research grant award (SDBOR/USD 2011-10-06). CGL and MBH were recipients of a visiting scholarship from the National Council for Scientific and Technical Research (CONICET), Argentina. We are indebted to Nahuel Telleria for the edition of the manuscript.
- Vaughan S, Coward JI, Bast RC, Berchuck A, Berek JS, Brenton JD, Coukos G, Crum CC, Drapkin R, Etemadmoghadam D, Friedlander M, Gabra H, Kaye SB, Lord CJ, Lengyel E, Levine DA, McNeish IA, Menon U, Mills GB, Nephew KP, Oza AM, Sood AK, Stronach EA, Walczak H, Bowtell DD, Balkwill FR: Rethinking ovarian cancer: recommendations for improving outcomes. Nat Rev Cancer. 2011, 11 (10): 719-725. 10.1038/nrc3144.View ArticlePubMedPubMed CentralGoogle Scholar
- Lengyel E: Ovarian cancer development and metastasis. Am J Pathol. 2010, 177 (3): 1053-1064. 10.2353/ajpath.2010.100105.View ArticlePubMedPubMed CentralGoogle Scholar
- Bast RC, Hennessy B, Mills GB: The biology of ovarian cancer: new opportunities for translation. Nat Rev Cancer. 2009, 9 (6): 415-428. 10.1038/nrc2644.View ArticlePubMedPubMed CentralGoogle Scholar
- Gubbels JA, Claussen N, Kapur AK, Connor JP, Patankar MS: The detection, treatment, and biology of epithelial ovarian cancer. J Ovarian Res. 2010, 3: 8-10.1186/1757-2215-3-8.View ArticlePubMedPubMed CentralGoogle Scholar
- Agarwal R, Kaye SB: Ovarian cancer: strategies for overcoming resistance to chemotherapy. Nat Rev Cancer. 2003, 3 (7): 502-516. 10.1038/nrc1123.View ArticlePubMedGoogle Scholar
- Yap TA, Carden CP, Kaye SB: Beyond chemotherapy: targeted therapies in ovarian cancer. Nat Rev Cancer. 2009, 9 (3): 167-181. 10.1038/nrc2583.View ArticlePubMedGoogle Scholar
- Ozols RF: Systemic therapy for ovarian cancer: current status and new treatments. Sem Oncol. 2006, 33 (2 Suppl 6): S3-S11.View ArticleGoogle Scholar
- McGuire WP, Hoskins WJ, Brady MF, Kucera PR, Partridge EE, Look KY, Clarke-Pearson DL, Davidson M: Cyclophosphamide and cisplatin compared with paclitaxel and cisplatin in patients with stage III and stage IV ovarian cancer. N Engl J Med. 1996, 334 (1): 1-6. 10.1056/NEJM199601043340101.View ArticlePubMedGoogle Scholar
- Piccart MJ, Bertelsen K, James K, Cassidy J, Mangioni C, Simonsen E, Stuart G, Kaye S, Vergote I, Blom R, Grimshaw R, Atkinson RJ, Swenerton KD, Trope C, Nardi M, Kaern J, Tumolo S, Timmers P, Roy JA, Lhoas F, Lindvall B, Bacon M, Birt A, Andersen JE, Zee B, Paul J, Baron B, Pecorelli S: Randomized intergroup trial of cisplatin-paclitaxel versus cisplatin-cyclophosphamide in women with advanced epithelial ovarian cancer: three-year results. J Natl Cancer Inst. 2000, 92 (9): 699-708. 10.1093/jnci/92.9.699.View ArticlePubMedGoogle Scholar
- Ozols RF, Bundy BN, Greer BE, Fowler JM, Clarke-Pearson D, Burger RA, Mannel RS, DeGeest K, Hartenbach EM, Baergen R: Phase III trial of carboplatin and paclitaxel compared with cisplatin and paclitaxel in patients with optimally resected stage III ovarian cancer: a Gynecologic Oncology Group study. J Clin Oncol. 2003, 21 (17): 3194-3200. 10.1200/JCO.2003.02.153.View ArticlePubMedGoogle Scholar
- Armstrong DK, Bundy B, Wenzel L, Huang HQ, Baergen R, Lele S, Copeland LJ, Walker JL, Burger RA: Intraperitoneal cisplatin and paclitaxel in ovarian cancer. N Engl J Med. 2006, 354 (1): 34-43. 10.1056/NEJMoa052985.View ArticlePubMedGoogle Scholar
- Goyeneche AA, Caron RW, Telleria CM: Mifepristone inhibits ovarian cancer cell growth in vitro and in vivo. Clin Cancer Res. 2007, 13 (11): 3370-3379. 10.1158/1078-0432.CCR-07-0164.View ArticlePubMedPubMed CentralGoogle Scholar
- Heikinheimo O, Lahteenmaki PL, Koivunen E, Shoupe D, Croxatto H, Luukkainen T, Lahteenmaki P: Metabolism and serum binding of RU 486 in women after various single doses. Hum Reprod. 1987, 2 (5): 379-385.PubMedGoogle Scholar
- Heikinheimo O: Pharmacokinetics of the antiprogesterone RU 486 in women during multiple dose administration. J Steroid Biochem. 1989, 32 (1A): 21-25.View ArticlePubMedGoogle Scholar
- Shoupe D, Mishell DR, Lahteenmaki P, Heikinheimo O, Birgerson L, Madkour H, Spitz IM: Effects of the antiprogesterone RU 486 in normal women. I. Single-dose administration in the midluteal phase. Am J Obst Gynecol. 1987, 157 (6): 1415-1420.View ArticleGoogle Scholar
- Kawai S, Nieman LK, Brandon DD, Udelsman R, Loriaux DL, Chrousos GP: Pharmacokinetic properties of the antiglucocorticoid and antiprogesterone steroid RU 486 in man. J Pharmacol Exp Ther. 1987, 241 (2): 401-406.PubMedGoogle Scholar
- Goyeneche AA, Seidel EE, Telleria CM: Growth inhibition induced by antiprogestins RU-38486, ORG-31710, and CDB-2914 in ovarian cancer cells involves inhibition of cyclin dependent kinase 2. Invest New Drugs. 2011, published ahead of printGoogle Scholar
- Conradie R, Bruggeman FJ, Ciliberto A, Csikasz-Nagy A, Novak B, Westerhoff HV, Snoep JL: Restriction point control of the mammalian cell cycle via the cyclin E/Cdk2:p27 complex. FEBS J. 2010, 277 (2): 357-367. 10.1111/j.1742-4658.2009.07473.x.View ArticlePubMedGoogle Scholar
- Tieszen CR, Goyeneche AA, Brandhagen BN, Ortbahn CT, Telleria CM: Antiprogestin mifepristone inhibits the growth of cancer cells of reproductive and non-reproductive origin regardless of progesterone receptor expression. BMC Cancer. 2011, 11 (1): 207-10.1186/1471-2407-11-207.View ArticlePubMedPubMed CentralGoogle Scholar
- Freeburg EM, Goyeneche AA, Seidel EE, Telleria CM: Resistance to cisplatin does not affect sensitivity of human ovarian cancer cell lines to mifepristone cytotoxicity. Cancer Cell Int. 2009, 9: 4-10.1186/1475-2867-9-4.View ArticlePubMedPubMed CentralGoogle Scholar
- Gamarra-Luques CD, Telleria CM: Enhancement of the lethality of platinum-based therapy by antiprogestin mifepristone in ovarian cancer. Cancer Epidemiol Bio Prev. 2010, 19 (10): Supplement 1, A113-Google Scholar
- Katano K, Kondo A, Safaei R, Holzer A, Samimi G, Mishima M, Kuo YM, Rochdi M, Howell SB: Acquisition of resistance to cisplatin is accompanied by changes in the cellular pharmacology of copper. Cancer Res. 2002, 62 (22): 6559-6565.PubMedGoogle Scholar
- Chou TC: Drug combination studies and their synergy quantification using the Chou-Talalay method. Cancer Res. 2010, 70 (2): 440-446. 10.1158/0008-5472.CAN-09-1947.View ArticlePubMedGoogle Scholar
- Chou TC: Theoretical basis, experimental design, and computerized simulation of synergism and antagonism in drug combination studies. Pharmacol Rev. 2006, 58 (3): 621-681. 10.1124/pr.58.3.10.View ArticlePubMedGoogle Scholar
- Mansouri A, Ridgway LD, Korapati AL, Zhang Q, Tian L, Wang Y, Siddik ZH, Mills GB, Claret FX: Sustained activation of JNK/p38 MAPK pathways in response to cisplatin leads to Fas ligand induction and cell death in ovarian carcinoma cells. J Biol Chem. 2003, 278 (21): 19245-19256. 10.1074/jbc.M208134200.View ArticlePubMedGoogle Scholar
- Karlsson MO, Molnar V, Freijs A, Nygren P, Bergh J, Larsson R: Pharmacokinetic models for the saturable distribution of paclitaxel. Drug Metab Dispos. 1999, 27 (10): 1220-1223.PubMedGoogle Scholar
- Jones NA, Turner J, McIlwrath AJ, Brown R, Dive C: Cisplatin- and paclitaxel-induced apoptosis of ovarian carcinoma cells and the relationship between bax and bak up-regulation and the functional status of p53. Mol Pharmacol. 1998, 53 (5): 819-826.PubMedGoogle Scholar
- Jekunen AP, Christen RD, Shalinsky DR, Howell SB: Synergistic interaction between cisplatin and taxol in human ovarian carcinoma cells in vitro. Br J Cancer. 1994, 69 (2): 299-306. 10.1038/bjc.1994.55.View ArticlePubMedPubMed CentralGoogle Scholar
- Gately DP, Sharma A, Christen RD, Howell SB: Cisplatin and taxol activate different signal pathways regulating cellular injury-induced expression of GADD153. Br J Cancer. 1996, 73 (1): 18-23. 10.1038/bjc.1996.4.View ArticlePubMedPubMed CentralGoogle Scholar
- Hayakawa J, Ohmichi M, Kurachi H, Ikegami H, Kimura A, Matsuoka T, Jikihara H, Mercola D, Murata Y: Inhibition of extracellular signal-regulated protein kinase or c-Jun N-terminal protein kinase cascade, differentially activated by cisplatin, sensitizes human ovarian cancer cell line. J Biol Chem. 1999, 274 (44): 31648-31654. 10.1074/jbc.274.44.31648.View ArticlePubMedGoogle Scholar
- Sorenson CM, Barry MA, Eastman A: Analysis of events associated with cell cycle arrest at G2 phase and cell death induced by cisplatin. J Natl Cancer Inst. 1990, 82 (9): 749-755. 10.1093/jnci/82.9.749.View ArticlePubMedGoogle Scholar
- Ormerod MG, O’Neill C, Robertson D, Kelland LR, Harrap KR: cis-Diamminedichloroplatinum(II)-induced cell death through apoptosis in sensitive and resistant human ovarian carcinoma cell lines. Cancer Chemother Pharmacol. 1996, 37 (5): 463-471. 10.1007/s002800050413.View ArticlePubMedGoogle Scholar
- Selvakumaran M, Pisarcik DA, Bao R, Yeung AT, Hamilton TC: Enhanced cisplatin cytotoxicity by disturbing the nucleotide excision repair pathway in ovarian cancer cell lines. Cancer Res. 2003, 63 (6): 1311-1316.PubMedGoogle Scholar
- Sain N, Krishnan B, Ormerod MG, De Rienzo A, Liu WM, Kaye SB, Workman P, Jackman AL: Potentiation of paclitaxel activity by the HSP90 inhibitor 17-allylamino-17-demethoxygeldanamycin in human ovarian carcinoma cell lines with high levels of activated AKT. Mol Cancer Ther. 2006, 5 (5): 1197-1208. 10.1158/1535-7163.MCT-05-0445.View ArticlePubMedGoogle Scholar
- Wang Y, Niu XL, Qu Y, Wu J, Zhu YQ, Sun WJ, Li LZ: Autocrine production of interleukin-6 confers cisplatin and paclitaxel resistance in ovarian cancer cells. Cancer Lett. 2010, 295 (1): 110-123. 10.1016/j.canlet.2010.02.019.View ArticlePubMedGoogle Scholar
- Judson PL, Watson JM, Gehrig PA, Fowler WC, Haskill JS: Cisplatin inhibits paclitaxel-induced apoptosis in cisplatin-resistant ovarian cancer cell lines: possible explanation for failure of combination therapy. Cancer Res. 1999, 59 (10): 2425-2432.PubMedGoogle Scholar
- Ohtsu T, Sasaki Y, Tamura T, Miyata Y, Nakanomyo H, Nishiwaki Y, Saijo N: Clinical pharmacokinetics and pharmacodynamics of paclitaxel: a 3-hour infusion versus a 24-hour infusion. Clin Cancer Res. 1995, 1 (6): 599-606.PubMedGoogle Scholar
- Rowinsky EK, Jiroutek M, Bonomi P, Johnson D, Baker SD: Paclitaxel steady-state plasma concentration as a determinant of disease outcome and toxicity in lung cancer patients treated with paclitaxel and cisplatin. Clin Cancer Res. 1999, 5 (4): 767-774.PubMedGoogle Scholar
- Kurata T, Tamura T, Shinkai T, Ohe Y, Kunitoh H, Kodama T, Kakinuma R, Matsumoto T, Kubota K, Omatsu H, Nishiwaki Y, Saijo N: Phase I and pharmacological study of paclitaxel given over 3 h with cisplatin for advanced non-small cell lung cancer. Jpn J Clin Oncol. 2001, 31 (3): 93-99. 10.1093/jjco/hye022.View ArticlePubMedGoogle Scholar
- Urien S, Lokiec F: Population pharmacokinetics of total and unbound plasma cisplatin in adult patients. Br J Clin Pharmacol. 2004, 57 (6): 756-763. 10.1111/j.1365-2125.2004.02082.x.View ArticlePubMedPubMed CentralGoogle Scholar
- Galluzzi L, Senovilla L, Vitale I, Michels J, Martins I, Kepp O, Castedo M, Kroemer G: Molecular mechanisms of cisplatin resistance. Oncogene. 2012, 31 (15): 1869-1883. 10.1038/onc.2011.384.View ArticlePubMedGoogle Scholar
- Cullen KJ, Yang Z, Schumaker L, Guo Z: Mitochondria as a critical target of the chemotheraputic agent cisplatin in head and neck cancer. J Bioenerg Biomembr. 2007, 39 (1): 43-50. 10.1007/s10863-006-9059-5.View ArticlePubMedGoogle Scholar
- Mandic A, Hansson J, Linder S, Shoshan MC: Cisplatin induces endoplasmic reticulum stress and nucleus-independent apoptotic signaling. J Biol Chem. 2003, 278 (11): 9100-9106. 10.1074/jbc.M210284200.View ArticlePubMedGoogle Scholar
- Kelland L: The resurgence of platinum-based cancer chemotherapy. Nat Rev Cancer. 2007, 7 (8): 573-584. 10.1038/nrc2167.View ArticlePubMedGoogle Scholar
- Cepeda V, Fuertes MA, Castilla J, Alonso C, Quevedo C, Perez JM: Biochemical mechanisms of cisplatin cytotoxicity. Anticancer Agents Med Chem. 2007, 7 (1): 3-18. 10.2174/187152007779314044.View ArticlePubMedGoogle Scholar
- Rabik CA, Dolan ME: Molecular mechanisms of resistance and toxicity associated with platinating agents. Cancer Treat Rev. 2007, 33 (1): 9-23. 10.1016/j.ctrv.2006.09.006.View ArticlePubMedGoogle Scholar
- Jung Y, Lippard SJ: Direct cellular responses to platinum-induced DNA damage. Chem Rev. 2007, 107 (5): 1387-1407. 10.1021/cr068207j.View ArticlePubMedGoogle Scholar
- Wang D, Lippard SJ: Cellular processing of platinum anticancer drugs. Nat Rev Drug Discov. 2005, 4 (4): 307-320. 10.1038/nrd1691.View ArticlePubMedGoogle Scholar
- Fayad W, Brnjic S, Berglind D, Blixt S, Shoshan MC, Berndtsson M, Olofsson MH, Linder S: Restriction of cisplatin induction of acute apoptosis to a subpopulation of cells in a three-dimensional carcinoma culture model. Int J Cancer. 2009, 125 (10): 2450-2455. 10.1002/ijc.24627.View ArticlePubMedGoogle Scholar
- Abal M, Andreu JM, Barasoain I: Taxanes: microtubule and centrosome targets, and cell cycle dependent mechanisms of action. Curr Cancer Drug Targets. 2003, 3 (3): 193-203. 10.2174/1568009033481967.View ArticlePubMedGoogle Scholar
- Haldar S, Chintapalli J, Croce CM: Taxol induces bcl-2 phosphorylation and death of prostate cancer cells. Cancer Res. 1996, 56 (6): 1253-1255.PubMedGoogle Scholar
- Debernardis D, Sire EG, De Feudis P, Vikhanskaya F, Valenti M, Russo P, Parodi S, D’Incalci M, Broggini M: p53 status does not affect sensitivity of human ovarian cancer cell lines to paclitaxel. Cancer Res. 1997, 57 (5): 870-874.PubMedGoogle Scholar
- Wahl AF, Donaldson KL, Fairchild C, Lee FY, Foster SA, Demers GW, Galloway DA: Loss of normal p53 function confers sensitization to Taxol by increasing G2/M arrest and apoptosis. Nat Med. 1996, 2 (1): 72-79. 10.1038/nm0196-72.View ArticlePubMedGoogle Scholar
- Kim JJ, Tannock IF: Repopulation of cancer cells during therapy: an important cause of treatment failure. Nat Rev Cancer. 2005, 5 (7): 516-525. 10.1038/nrc1650.View ArticlePubMedGoogle Scholar
- Erenpreisa J, Cragg MS: Cancer: a matter of life cycle?. Cell Biol Int. 2007, 31 (12): 1507-1510. 10.1016/j.cellbi.2007.08.013.View ArticlePubMedGoogle Scholar
- Illidge TM, Cragg MS, Fringes B, Olive P, Erenpreisa JA: Polyploid giant cells provide a survival mechanism for p53 mutant cells after DNA damage. Cell Biol Int. 2000, 24 (9): 621-633. 10.1006/cbir.2000.0557.View ArticlePubMedGoogle Scholar
- Sundaram M, Guernsey DL, Rajaraman MM, Rajaraman R: Neosis: a novel type of cell division in cancer. Cancer Biol Ther. 2004, 3 (2): 207-218.View ArticlePubMedGoogle Scholar
- Puig PE, Guilly MN, Bouchot A, Droin N, Cathelin D, Bouyer F, Favier L, Ghiringhelli F, Kroemer G, Solary E, Martin F, Chauffert B: Tumor cells can escape DNA-damaging cisplatin through DNA endoreduplication and reversible polyploidy. Cell Biol Int. 2008, 32 (9): 1031-1043. 10.1016/j.cellbi.2008.04.021.View ArticlePubMedGoogle Scholar
- Kalejs M, Ivanov A, Plakhins G, Cragg MS, Emzinsh D, Illidge TM, Erenpreisa J: Upregulation of meiosis-specific genes in lymphoma cell lines following genotoxic insult and induction of mitotic catastrophe. BMC Cancer. 2006, 6: 6-10.1186/1471-2407-6-6.View ArticlePubMedPubMed CentralGoogle Scholar
- Salmina K, Jankevics E, Huna A, Perminov D, Radovica I, Klymenko T, Ivanov A, Jascenko E, Scherthan H, Cragg M, Erenpreisa J: Up-regulation of the embryonic self-renewal network through reversible polyploidy in irradiated p53-mutant tumour cells. Exp Cell Res. 2010, 316 (13): 2099-2112. 10.1016/j.yexcr.2010.04.030.View ArticlePubMedGoogle Scholar
- Erenpreisa J, Salmina K, Huna A, Kosmacek EA, Cragg MS, Ianzini F, Anisimov AP: Polyploid tumour cells elicit paradiploid progeny through depolyploidizing divisions and regulated autophagic degradation. Cell Biol Int. 2011, 35 (7): 687-695. 10.1042/CBI20100762.View ArticlePubMedGoogle Scholar
- Freeburg EM, Goyeneche AA, Telleria CM: Mifepristone abrogates repopulation of ovarian cancer cells in between courses of cisplatin treatment. Int J Oncol. 2009, 34 (3): 743-755.PubMedPubMed CentralGoogle Scholar
- Huang Q, Li F, Liu X, Li W, Shi W, Liu FF, O’Sullivan B, He Z, Peng Y, Tan AC, Zhou L, Shen J, Han G, Wang XJ, Thorburn J, Thorburn A, Jimeno A, Raben D, Bedford JS, Li CY: Caspase 3-mediated stimulation of tumor cell repopulation during cancer radiotherapy. Nat Med. 2011, 17 (7): 860-866. 10.1038/nm.2385.View ArticlePubMedPubMed CentralGoogle Scholar
- Galluzzi L, Kepp O, Kroemer G: Caspase-3 and prostaglandins signal for tumor regrowth in cancer therapy. Oncogene. 2011, published ahead of printGoogle Scholar
- Kvinlaug BT, Huntly BJ: Targeting cancer stem cells. Expert Opin Ther Targets. 2007, 11 (7): 915-927. 10.1517/14728184.108.40.2065.View ArticlePubMedGoogle Scholar
- Cooke SL, Ng CK, Melnyk N, Garcia MJ, Hardcastle T, Temple J, Langdon S, Huntsman D, Brenton JD: Genomic analysis of genetic heterogeneity and evolution in high-grade serous ovarian carcinoma. Oncogene. 2010, 29 (35): 4905-4913. 10.1038/onc.2010.245.View ArticlePubMedPubMed CentralGoogle Scholar
- Grunberg SM, Weiss MH, Russell CA, Spitz IM, Ahmadi J, Sadun A, Sitruk-Ware R: Long-term administration of mifepristone (RU486): clinical tolerance during extended treatment of meningioma. Cancer Invest. 2006, 24 (8): 727-733. 10.1080/07357900601062339.View ArticlePubMedGoogle Scholar
- Benagiano G, Bastianelli C, Farris M: Selective progesterone receptor modulators 1: use during pregnancy. Expert Opin Pharmacother. 2008, 9 (14): 2459-2472. 10.1517/146565220.127.116.119.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/12/200/prepub
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