The Antifungal Antibiotic Clotrimazole Alters Calcium Homeostasis of Leukemic Lymphoblasts and Induces Apoptosis
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Leukemia (2002) 16, 1344–1352 2002 Nature Publishing Group All rights reserved 0887-6924/02 $25.00 www.nature.com/leu The antifungal antibiotic clotrimazole alters calcium homeostasis of leukemic lymphoblasts and induces apoptosis C Ito1, C Tecchio1, E Coustan-Smith1, T Suzuki1, FG Behm2,3, SC Raimondi2,3, C-H Pui1,2,3 and D Campana1,2,3 1Department of Hematology-Oncology, St Jude Children’s Research Hospital, Memphis, TN, USA; 2Department of Pathology, St Jude Children’s Research Hospital, Memphis, TN, USA; and 3University of Tennessee College of Medicine, Memphis TN, USA Clotrimazole is an antimycotic imidazole derivative that inter- ease16,17 and the treatment of secretory diarrheas that involve 2+ feres with cellular Ca homeostasis. We investigated the chloride secretion through IK channels.18 effects of clotrimazole on acute lymphoblastic leukemia (ALL) Interest in clotrimazole as a potential antileukemic com- cells. Treatment with 10 M clotrimazole (a concentration achi- evable in vivo) reduced cell recovery from cultures of all nine pound derives from the following observations. First, clotrima- ALL cell lines studied (B-lineage: OP-1, SUP-B15, RS4;11, zole suppresses the proliferation of carcinoma and melanoma NALM6, REH, and 380; T-lineage: MOLT4, CCRF-CEM, and cell lines and blocks metastasis of melanoma in immuno- CEM-C7). After 4 days of culture, median cell recovery was 10% deficient mice without evident systemic toxicity.19 Second, Ͻ (range, 1% to 37%) of cell recovery in parallel untreated cul- clotrimazole has been shown to inhibit normal lymphocyte tures. Clotrimazole also inhibited recovery of primary ALL cells proliferation,20,21 at least partially by blocking IK chan- cultured on stromal feeder layers. After leukemic cells from 16 15,22 cases of ALL were cultured for 7 days with 10 M clotrimazole, nels, and it reportedly exerts beneficial effects in patients median cell recovery was Ͻ1% (range, Ͻ1% to 16%) of that in with rheumatoid arthritis.23,24 Importantly, concentrations of parallel untreated cultures. Clotrimazole was active against leu- clotrimazole and its metabolites that effectively interfere with kemic cells with genetic abnormalities associated with poor Ca2+ metabolism and block IK channels are achievable in response to therapy and against multidrug-resistant cell lines. vivo.25–27 In contrast, mature T lymphocytes and bone marrow stromal cells were not affected. Clotrimazole induced depletion of intra- We investigated the effects of clotrimazole on ALL cells and cellular Ca2+ stores in ALL cells, which was followed by found that the drug markedly suppresses the recovery of ALL apoptosis, as shown by annexin V binding and DNA fragmen- cells from culture. This effect was observed both in leukemic tation. Thus, clotrimazole is cytotoxic to ALL cells at concen- cell lines and in primary leukemic lymphoblasts sustained in trations achievable in vivo. vitro by bone marrow-derived stroma. Surprisingly, although Leukemia (2002) 16, 1344–1352. doi:10.1038/sj.leu.2402510 clotrimazole was reported to inhibit cell proliferation of vari- Keywords: clotrimazole; acute lymphoblastic leukemia; apoptosis; 15,19,21,28,29 multidrug resistance ous cell types without apparent cytotoxicity, its pri- mary mechanism of action in ALL cells was induction of apoptosis. Introduction Materials and methods Residual drug-resistant leukemic cells cause disease recur- rence in approximately 20% of children and 65% of adults Cells after intensive chemotherapy for acute lymphoblastic leuke- mia (ALL).1,2 Recurrent ALL is particularly resistant to chemo- Bone marrow cells were collected at the time of diagnosis therapy, as is newly diagnosed ALL with BCR-ABL, MLL gene (n = 14) or relapse (n = 2) from patients with ALL, ages 1 to 17 rearrangements or near-haploidy.1,2 Thus, the cure rates for years (median, 8 years) (Table 1). Fourteen cases were B-lin- ALL cannot be significantly improved unless new drugs are + + + eage ALL (CD19 ,CD22 and HLA-DR ); four of these were developed that bypass cellular mechanisms of resistance. pre-B ALL (cytoplasmic immunoglobulin heavy chains were The imidazole derivative clotrimazole is an antimycotic + present). The remaining two cases were T-lineage ALL (CD3 , agent that modulates cellular ionic signaling pathways that are + + CD2 and CD7 ). The viability of cells was Ͼ90% in all crucial to cell survival and growth. In blood cells and other samples, as demonstrated by trypan blue dye exclusion. Per- cell types, the transduction of external signals via surface ipheral blood lymphocytes were obtained from healthy receptors triggers the production of inositol (1,4,5)-trisphosph- + donors. Mononuclear cells were separated by density gradient ate and the resultant release of Ca2 from the endoplasmic centrifugation (Lymphoprep, Nycomed, Oslo, Norway) and reticulum.3–5 Normally, this release induces the opening of + then washed three times in phosphate-buffered saline and plasma membrane Ca2 channels and activates the intermedi- + + + once in AIM-V (Gibco, Grand Island, NY, USA), a serum-free, ate-conductance Ca2 -activated K (IK) channel, allowing Ca2 cytokine-free tissue culture medium. These studies were influx from the extracellular space.3–9 Clotrimazole disrupts + + approved by the St Jude Children’s Research Hospital Insti- cellular Ca2 homeostasis by releasing Ca2 from intracellular + tutional Review Board, and informed consent was given by stores while inhibiting Ca2 influx and blocking IK chan- the patients, their parents or guardians, or both. nels.7,10–15 It is being evaluated clinically for the treatment of The B-lineage ALL cell lines RS4;11,30 380,31 REH,32 OP133 IK channel-driven erythrocyte dehydration in sickle cell dis- and NALM634 and the T-lineage ALL cell lines MOLT-435 and CCRF-CEM were available in our laboratory.36 The cell lines CEM-C737 and SUP-B1538 were obtained from Dr G Melnyco- vych (University of Kansas Medical Center, Kansas City, MO, Correspondence: D Campana, Department of Hematology-Oncology, St Jude Children’s Research Hospital, 332 North Lauderdale, Memphis USA) and Dr SD Smith (University of Chicago, Chicago, IL, TN 38105-2794, USA; Fax: 901-495 3749 USA), respectively; the drug-resistant subclones of CCRF-CEM 39,40 Received 2 November 2001; accepted 8 February 2002 (CEM-VLB100 and CEM/VM-1) were obtained from Dr WM Clotrimazole induced apoptosis of leukemic cells C Ito et al 1345 Table 1 Immunophenotypes and karyotypes of 16 cases of ALL Patient No. Age Immunophenotypec Karyotype (years) 1a 5 Early B 46,XY,t(9;22)(q34;q11.2)[19] 2 8 Early B 46,XY,t(9;22)(q34;q11.2)[23] 3a 17 Pre-B 58,XY,+X,+2,+3,+5,+6,t(9;22)(q34;q11.2),−13,+14,+17,+18,+19,+20,+21,+der(22)t(9;22),+mar [3]/46,XY[20] 4 9 Early B 47,XY,+X,t(11;19)(q23;p13.3)[22]/46,XY[4] 5b 4 Early B 47,XY,+21[3]/46,XY,del(9)(p21)[2]/47,XY[23] 6 4 Pre-B 54,XX,+X,+4,+6,+10,+14,+17,+18,+21/56,XX,+X,+4,+6,+10,+14,+17,+18,+21,+mar,+mar 7 8 Early B 29,XY,+4,+8,+18,+21,+mar[5]/57,XY,+X,+?Y,+4,+5,del(5)(p13),?del(6) (q21),+6,+8,+9,+14,+18,+21,+mar[6] 8 15 Pre-B 46,XY,del(3)(q21q26)[9]/46,XY[5] 9b 6 Pre-B 47,XX,+10,del(11)(q23),t(1;12)(p22;p13),t(4;12)(q21;p13)[7]/45,X, −X,t(4;12)(q21;p13)[2] 10 1 Early B 45,XX,−7,del(1)(q32),dic(7;12)(p11.2;p11.2)[10]/46,XX[8] 11 14 Early B 46,XX[23] 12 14 Early B 46,XX,del(11)(q23)[4]/46,XX[24] 13b 8 Early B 46,XX,t(8;9)(q12–13;p22),t(15;19)(q15;p13)[19]/46,idem,−14,+mar[1] 14 3 Early B 47,XY,add(19)(p13),+21[8]/46,XY[17] 15 4 T Insufficient material 16 16 T 46,XY,del(6)(q15q21)[5]/46,XY[5] aStudied at the time of relapse. bt(12;21)-positive by fluorescence in situ hybridization. cEarly B, CD19+, CD10+/−; Pre-B, same plus cytoplasmic ; T, CD7+, cytoplasmic or surface CD3+. Beck (University of Illinois Cancer Center, Chicago, IL, USA). ocyanate (FITC) and anti-CD3 conjugated to phycoerythrin All cell lines were maintained in RPMI-1640 (BioWhittaker, (PE); T-lineage ALL cells were incubated with anti-CD7 FITC. Walkersville, MD, USA) with 10% fetal calf serum (FCS; Normal peripheral blood lymphocytes were incubated with BioWhittaker), l-glutamine, and antibiotics. anti-CD3 FITC. All monoclonal antibodies and isotype- matched nonreactive controls were purchased from Becton Dickinson (San Jose, CA, USA) or Dako (Carpinteria, CA, Cell culture USA). The cells were washed twice in phosphate-buffered saline with 0.2% bovine serum albumin and 0.2% sodium Bone marrow stromal cells derived from healthy bone marrow azide, resuspended in 0.5% paraformaldehyde, and analyzed transplant donors were depleted of T cells by CD6- and CD8- with a FACScan flow cytometer and Cell Quest software mediated rabbit complement lysis. Stroma was prepared in (Becton Dickinson). An identical procedure was used for cell 96-well flat-bottomed plates (Costar, Cambridge, MA, USA) lines except that immunophenotyping was omitted. and fed with RPMI-1640, 10% FCS, and 10−6 m hydrocorti- We set ‘gates’ around the area of the light-scatter dot plot sone (Sigma, St Louis, MO, USA), as previously described.41–44 that included virtually all leukemic cells. These gates were To prepare cultures of primary leukemic cells, we removed used to count cells with the same light-scattering properties the media from the bone marrow stroma and washed the before and after culture with or without clotrimazole.