Targeting the Hedgehog Pathway in Cancer: Current Evidence and Future Perspectives
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cells Review Targeting the Hedgehog Pathway in Cancer: Current Evidence and Future Perspectives Daniel Girardi *, Adriana Barrichello, Gustavo Fernandes and Allan Pereira Division of Medical Oncology, Hospital Sírio-Libanês, Brasilia 70200-730, Brazil; [email protected] (A.B.); [email protected] (G.F.); [email protected] (A.P.) * Correspondence: [email protected]; Tel.: +55-619-8108-2130 Received: 27 December 2018; Accepted: 11 February 2019; Published: 12 February 2019 Abstract: The Hedgehog pathway (HhP) plays an important role in normal embryonic development and its abnormal function has been linked to a variety of neoplasms. Recently, the complex mechanisms involved in this pathway have been deciphered and the cross talks with other important pathways involved in carcinogenesis have been characterized. This knowledge has led to the development of targeted therapies against key components of HhP, which culminated in the approval of vismodegib for the treatment of advanced basal cell carcinoma in 2012. Since then, other compounds have been developed and evaluated in preclinical and clinical studies with interesting results. Today, several medications against components of the HhP have demonstrated clinical activity as monotherapies and in combination with cytotoxic treatment or other targeted therapies against mitogenic pathways that are linked to the HhP. This review aims to clarify the mechanism of the HhP and the complex crosstalk with others pathways involved in carcinogenesis and to discuss both the evidence associated with the growing number of medications and combined therapies addressing this pathway and future perspectives. Keywords: Hedgehog; targeted therapy; SMO inhibitor; GLI 1. Introduction The Hedgehog pathway (HhP) plays a fundamental role in embryonic development, tissue patterning, and wound healing [1]. Aberrant functioning of this pathway is related to several congenital abnormalities and the development of cancer in several organs [2,3]. The idea that alterations in the HhP are linked to carcinogenicity came from the discovery of activating mutations in this pathway in patients with basal cell carcinoma (BCC), medulloblastoma and rhabdomyosarcoma [4–7]. These findings led to a better understanding of the pathway and the development of targeted therapies directed against their effectors [8,9]. In this review, we focus on the characterization of the HhP, its relation with other pathways related to the development of cancer and especially on treatment strategies as a way to fight cancer. 2. Characterization of the HhP and Its Relation with Carcinogenesis The HhP is very complex and can be divided into two different pathways: canonical and noncanonical. The canonical HhP is initiated by the release of three ligands named Sonic Hedgehog (SHH), Desert Hedgehog (DHH), and Indian Hedgehog (IHH) [10]. In the absence of these ligands, the 12-pass transmembrane receptor Patched1 (PTCH1) exerts an inhibitory effect on the transmembrane transducer smoothened (SMO) [11]. Binding of Hedgehog ligands to PTCH1 relieves the repression of SMO by PTCH1, which results in the translocation of SMO to the primary cilium. The primary cilium is a membrane-encased protrusion usually described as a single nonmotile cilium present in a variety of vertebrate cells. In humans, for instance, virtually all other cells have a primary cilium, with Cells 2019, 8, 153; doi:10.3390/cells8020153 www.mdpi.com/journal/cells Cells 2019, 8, 153 2 of 20 the exceptionCells 2019, 8, ofx FOR sperm, PEER REVIEW epithelia cells in the bronchi and oviducts, and ependymal cells that2 of line 22 the brain vesicles. The translocation of SMO to the primary cilium, in turn, initiates an intracellular signal cilium, with the exception of sperm, epithelia cells in the bronchi and oviducts, and ependymal cells cascade that promotes the activation of glioma-associated oncogene (GLI) transcription factors [12]. that line the brain vesicles. The translocation of SMO to the primary cilium, in turn, initiates an Thereintracellular are three memberssignal cascade of the that GLI promotes transcription the activation factor family of glioma (GLI1,-associated GLI2 and oncogene GLI3) that (GLI) share a similartranscription DNA-binding factors domain [12]. There [13 are]. Once three members activated of in the the GLI primary transcription cilium, factor GLIs family dissociate (GLI1, GLI2 from the suppressorand GLI3) of fused that share (SUFU), a similar which DNA is- abinding key cytoplasmic domain [13] negative. Once activated regulator in the of theprimary HhP, cilium, and translocate GLIs into thedissociate nucleus from to initiatethe suppresso the transcriptionr of fused (SUFU), program which related is a key to cytoplasmic the HhP (Figure negative1)[ regulator14]. In the of the absence of HHHhP, ligands, and translocate PTCH1 exerts into the a repressive nucleus to effectinitiate on the SMO transcription by preventing program its related accumulation to the HhP in (Figure the primary cilium.1) [14] In. this In the state, absence SMO of is HH not ligands, capable PTCH1 of activating exerts a repressive GLI transcription effect on SMO factors, by preventing which are its bound to SUFUaccumulation and retained in the inprimary the cytoplasm. cilium. In this In state the cytoplasm,, SMO is not capable the degradation of activating of GLI GLI transcription proteins by the factors, which are bound to SUFU and retained in the cytoplasm. In the cytoplasm, the degradation proteasome can occur through phosphorylation by protein kinase A (PKA), casein kinase 1 (CK1) and of GLI proteins by the proteasome can occur through phosphorylation by protein kinase A (PKA), glycogen synthase kinase 3β (GSK3β)[15,16]. casein kinase 1 (CK1) and glycogen synthase kinase 3β (GSK3β) [15,16]. FigureFigure 1. A 1. simplified A simplified model model for for canonical canonical HhP.HhP. ((A) The Hedgehog Hedgehog receptor receptor PTCH1 PTCH1 inhibits inhibits SMO SMO signalingsignaling in the in absencethe absence of of the the Hedgehog Hedgehog ligand,ligand, which turns turns off off the the Hedgehog Hedgehog signaling signaling pathway. pathway. (B) In(B the) In presence the presence of Hedgehog of Hedgehog ligand, ligand, PTCH1 PTCH1 stops stops inhibiting inhibiting SMO,SMO, resulting resulting in in the the translocation translocation of of SMO to the primary cilium. Once activated in the primary cilium, SMO promotes the release of GLI SMO to the primary cilium. Once activated in the primary cilium, SMO promotes the release of GLI from the SUFU, which allows GLI to enter the nucleus to initiate the transcription program related to from the SUFU, which allows GLI to enter the nucleus to initiate the transcription program related to HhP. Dysregulation of the HhP has been associated with carcinogenesis. HhP. Dysregulation of the HhP has been associated with carcinogenesis. In the noncanonical HhP, activation of the GLI transcription factors can occur independently of Inthe the upstream noncanonical components HhP, of activation the HhP by of cross the talk GLI with transcription other signaling factors cascades can occur [16]. Multiple independently cross of the upstreamtalk and synergistic components interactions of the HhP between by cross HhP talkcomponents with other and signalingother important cascades oncogenic [16]. Multiplepathways cross talk andhave synergistic been shown interactions to activate HhP between and have HhP been components implicated andin several other types important of cancer. oncogenic For example, pathways havecross been talk shown between to activate HhP HhPand the and mechanistic have been target implicated of rapamycin in several (mTOR) types ofpathway cancer. has For been example, crossdescribed talk between in esophageal HhP and carcinoma the mechanistic in which target GLI1 of appears rapamycin to be (mTOR)activated pathway by ribosomal has beenprotein described S6 in esophagealkinase 1 carcinoma(S6K1) through in which direct GLI1 phosphorylation appears to be activated at SEr84 by [17] ribosomal. Conversely, protein another S6 kinase study 1 (S6K1) throughdemonstrated direct phosphorylation that V-akt murine at SEr84 thymoma [17]. Conversely,viral oncogene another homolog study 1 demonstrated(AKT1) is a direct that V-akt transcriptional target of GLI1 [18]. murine thymoma viral oncogene homolog 1 (AKT1) is a direct transcriptional target of GLI1 [18]. Cytotoxic agents, such as radiotherapy and cytokines, can also activate and upregulate the Cytotoxic agents, such as radiotherapy and cytokines, can also activate and upregulate the expression of GLI1 independent of canonical pathway activation. For example, tumor necrosis factor expressionalpha (TNF of GLI1-α) and independent interleukin- of1β canonical (IL-1β) can pathway upregulate activation. the expression For example,of GLI1 through tumor the necrosis nuclear factor alphafac (TNF-tor kappaα) and light interleukin-1 chain enhancerβ (IL-1 of activatedβ) can B upregulate cells (NF-κB) the pathway expression in pancreatic of GLI1 and through breast thecancer nuclear factorcells kappa [19,20] light. Interestingly, chain enhancer evidence of activated now shows Bcells that NF (NF--κBκ B)subunit pathway p65 can inpancreatic bind directly and to breastthe GLI1 cancer cellspromoter [19,20]. Interestingly,region, and inhibition evidence of now NF-κB shows decreased that NF-GLIκ1B activity subunit in p65 breast can cancer bind directlycells [20] to. the GLI1Transforming promoter