Effect of Beta-Agonists on LAM Progression and Treatment

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Effect of Beta-Agonists on LAM Progression and Treatment Effect of beta-agonists on LAM progression and treatment Kang Lea,1,2, Wendy K. Steagalla,1,3, Mario Stylianoub, Gustavo Pacheco-Rodrigueza, Thomas N. Darlingc, Martha Vaughana,3, and Joel Mossa,3 aPulmonary Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892; bOffice of Biostatistics Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20892; and cDepartment of Dermatology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814 Contributed by Martha Vaughan, December 6, 2017 (sent for review April 6, 2017; reviewed by Kevin Brown and Geraldine Finlay) Lymphangioleiomyomatosis (LAM), a rare disease of women, is (11). Although LAM lesions were originally considered to rep- associated with cystic lung destruction resulting from the pro- resent a benign neoplasm, LAM is now accepted as a cancer with liferation of abnormal smooth muscle-like LAM cells with muta- metastatic dissemination of cancer-like LAM cells (12). tions in the tuberous sclerosis complex (TSC) genes TSC1 and/or LAM cells are characterized by mutations in the tuberous TSC2. The mutant genes and encoded proteins are responsible for sclerosis complex (TSC) TSC1 or TSC2 gene that encodes, re- activation of the mechanistic target of rapamycin (mTOR), which is spectively, hamartin and tuberin (13–15). TSC is a rare genetic inhibited by sirolimus (rapamycin), a drug used to treat LAM. Patients disease that affects multiple organ systems and results from who have LAM may also be treated with bronchodilators for asthma- mutations in one of the same two TSC genes (16). Hamartin and like symptoms due to LAM. We observed stabilization of forced tuberin form a cytosolic complex with Tre2-Bub2-Cdc16 domain expiratory volume in 1 s over time in patients receiving sirolimus and family member 7 (TBC1D7) (17). This complex inhibits the long-acting beta-agonists with short-acting rescue inhalers compared mechanistic target of rapamycin (mTOR) pathway, a promoter with patients receiving only sirolimus. Because beta-agonists increase of cell growth through the GTPase-activating protein (GAP) cAMP and PKA activity, we investigated effects of PKA activation on activity of tuberin toward Ras homolog enriched in brain (Rheb) + − the mTOR pathway. Human skin TSC2 / fibroblasts or LAM lung cells (17). Rheb in its GTP-bound form is a critical activator of incubated short-term with isoproterenol (beta-agonist) showed a mTOR; tuberin converts active Rheb-GTP to inactive Rheb- sirolimus-independent increase in phosphorylation of S6, a down- GDP (18). stream effector of the mTOR pathway, and increased cell growth. Cells mTOR, a serine/threonine kinase, is found in mTORC1 and incubated long-term with isoproterenol, which may lead to beta- mTORC2 complexes (19). mTORC1 comprises regulatory- adrenergic receptor desensitization, did not show increased S6 phos- associated protein of mTOR (Raptor), mammalian lethal with phorylation. Inhibition of PKA blocked the isoproterenol effect on Sec13 protein 8 (mLST8; also known as GβL), proline-rich AKT S6 phosphorylation. Thus, activation of PKA by beta-agonists increased substrate of 40 kDa (PRAS40), and DEP domain-containing phospho-S6 independent of mTOR, an effect abrogated by beta- mTOR-interacting protein (Deptor) (20). mTORC2 is also a agonist–driven receptor desensitization. In agreement, retrospective clinical data from patients with LAM suggested that a combination Significance of bronchodilators in conjunction with sirolimus may be preferable to sirolimus alone for stabilization of pulmonary function. Lymphangioleiomyomatosis (LAM) is a destructive lung disease driven by neoplastic LAM cells with a mutated tumor sup- cyclic AMP | sirolimus | lymphangioleiomyomatosis | pressor gene TSC1 or TSC2, leading to increased activity of the tuberous sclerosis complex | bronchodilators mechanistic target of rapamycin (mTOR), which is inhibited by sirolimus (rapamycin). Beta-agonists may treat asthma-like ymphangioleiomyomatosis (LAM), a rare multisystem dis- symptoms due to LAM. We observed stabilization of forced ex- Lease affecting primarily women, is characterized by cystic lung piratory volume in 1 s in patients receiving sirolimus and long- destruction, which can lead to respiratory failure, abdominal acting beta-agonists with short-acting rescue inhalers compared tumors [e.g., renal angiomyolipomas (AMLs)], and lymphatic with patients receiving only sirolimus. Human TSC2+/− skin fi- – involvement (e.g., lymphangioleiomyomas, adenopathy) (1 4). broblasts and LAM cells from explanted lungs treated with Depending on organ involvement, patients may exhibit pro- sirolimus and the short-term, but not long-term, beta-agonist gressive dyspnea on exertion, pneumothoraces, chylous pleural isoproterenol showed increased phospho-S6 levels and cell effusions, ascites, and abdominal hemorrhage (5). LAM is often growth due to activation of a cAMP/PKA-dependent pathway. mistakenly diagnosed as another respiratory disease, such as Long-acting beta-agonists affect phospho-S6 content, leading to asthma, emphysema, chronic bronchitis, or chronic obstructive stabilization of lung function in LAM patients. pulmonary disease (6–8). Many patients are treated with bron- chodilators to alleviate asthma-like symptoms due to LAM dis- Author contributions: K.L., W.K.S., G.P.-R., M.V., and J.M. designed research; K.L., W.K.S., ease. In fact, in a study of 235 patients who had LAM, about 49% and G.P.-R. performed research; T.N.D. contributed new reagents/analytic tools; K.L., W.K.S., and M.S. analyzed data; and K.L., W.K.S., G.P.-R., T.N.D., M.V., and J.M. wrote used bronchodilators regularly (9). the paper. LAM is characterized by proliferation of abnormal smooth Reviewers: K.B., National Jewish Health; and G.F., UpToDate/Wolters Kluwer. muscle-like LAM cells in the lung, resulting in parenchymal The authors declare no conflict of interest. cystic destruction. LAM cells are believed to proliferate in axial Published under the PNAS license. lymphatics and lung interstitium, leading to airway and lymphatic 1K.L. and W.K.S. contributed equally to this work. obstruction (2, 10). While LAM cells may be largely parenchy- 2Present address: Department of Biochemistry and Molecular Medicine, School of Medi- mal, Hayashi et al. (11) showed bronchial involvement by LAM cine and Health Sciences, The George Washington University, Washington, DC 20037. cells in explanted lungs of all 30 patients examined. A significant 3To whom correspondence may be addressed. Email: [email protected], vaughanm@ portion of these patients also had markers of chronic in- nih.gov, or [email protected]. flammation (e.g., mononuclear cell infiltration, goblet cell hy- This article contains supporting information online at www.pnas.org/lookup/suppl/doi:10. perplasia, squamous cell metaplasia, thickening of basal lamina) 1073/pnas.1719960115/-/DCSupplemental. E944–E953 | PNAS | Published online January 16, 2018 www.pnas.org/cgi/doi/10.1073/pnas.1719960115 Downloaded by guest on October 1, 2021 multimer, sharing proteins, such as mLST8 and Deptor, with P = 0.0417; adjusted for initial DLCO, sirolimus treatment, and PNAS PLUS mTORC1, whereas the defining component of mTORC2 is time of visit). A statistical interaction was seen between use of Raptor-independent companion of mTOR (Rictor) (21, 22). The bronchodilators and sirolimus treatment, such that the effect of mTORC1 substrates [e.g., P70 S6 kinase (P70), 4E-binding bronchodilator use on pulmonary function was different in pa- protein 1 (4EBP1), unc-51–like autophagy-activating kinase 1 tients not receiving sirolimus compared with those being treated (ULK1)] regulate cell size, proliferation, and autophagy in a with the drug. In patients not receiving sirolimus, those tak- phosphorylation-dependent fashion (23). Activation of S6 ki- ing bronchodilators tended to have lower percent predicted nases by mTOR promotes phosphorylation of several substrates, FEV1 compared with those not using bronchodilators, whereas including ribosomal protein S6, eukaryotic initiation factor 4B subjects on sirolimus had the opposite pattern (P < 0.001). (eIF4B), programmed cell death 4 (PDCD4), eukaryotic elon- Subjects not on sirolimus and on bronchodilators had lower gation factor 2 kinase (eEF-2K), and S6K1 Aly/REF-like target percent predicted DLCO compared with those not using bron- (SKAR) (23). Phosphorylation of S6, a component of the 40S chodilators, whereas subjects on sirolimus had similar DLCO ribosomal subunit, is associated with increased protein synthesis regardless of bronchodilator use (P = 0.002). Overall, the rate of and cell proliferation (24). mTORC2 regulates metabolism and change of FEV1 was −1.187 ± 0.077 (mean ± SE) percent cytoskeletal organization by phosphorylating AGC kinases, such predicted FEV1 per year in those without bronchodilator use as Akt and PKC (22, 25, 26). and −1.358 ± 0.104 with bronchodilator use, and the rate of The absence of functional tuberin leads to persistence of Rheb change of DLCO was −1.618 ± 0.065 percent predicted DLCO in its GTP-bound state with mTORC1 activation, as was observed per year without bronchodilator use and −1.563 ± 0.093 with in LAM lung lesions and AMLs. Sirolimus (rapamycin), bound bronchodilator use. These values are not significantly different. to FK506-binding protein 12 (FKBP12), interacts directly with Since the interaction of sirolimus treatment and bronchodila- mTORC1, inhibiting its
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