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Novel Approaches for Improved Therapeutic Targeting of Hedgehog Signaling in Cancer Stem Cells Verline Justilien and Alan P

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Novel Approaches for Improved Therapeutic Targeting of Hedgehog Signaling in Cancer Stem Cells Verline Justilien and Alan P Molecular Pathways Clinical Cancer Research Molecular Pathways: Novel Approaches for Improved Therapeutic Targeting of Hedgehog Signaling in Cancer Stem Cells Verline Justilien and Alan P. Fields Abstract The Hedgehog (Hh) signaling pathway is critical for embryonic have demonstrated good efficacy as monotherapy in patients with development. In adult tissues, Hh signaling is relatively quiescent basal cell carcinoma and medulloblastoma, but have shown with the exception of roles in tissue maintenance and repair. limited activity in other tumor types. This lack of success is likely Aberrant activation of Hh signaling is implicated in multiple due to many factors, including a lack of patient stratification in aspects of transformation, including the maintenance of the early trials, cross-talk between Hh and other oncogenic signaling cancer stem cell (CSC) phenotype. Preclinical studies indicate pathways that can modulate therapeutic response, and a limited that CSCs from many tumor types are sensitive to Hh pathway knowledge of Hh pathway activation mechanisms in CSCs from inhibition and that Hh-targeted therapeutics block many most tumor types. Here, we discuss Hh signaling mechanisms in aspects of transformation attributed to CSCs, including drug the context of human cancer, particularly in the maintenance resistance, relapse, and metastasis. However, to date, Hh inhibi- of the CSC phenotype, and consider new therapeutic strategies tors, specifically those targeting Smoothened [such as vismode- that hold the potential to expand considerably the scope and gib, BMS-833923, saridegib (IPI-926), sonidegib/erismodegib therapeutic efficacy of Hh-directed anticancer therapy. Clin Cancer (LDE225), PF-04449913, LY2940680, LEQ 506, and TAK-441], Res; 21(3); 505–13. Ó2015 AACR. Disclosure of Potential Conflicts of Interest A.P. Fields reports receiving a commercial research grant from Teva Pharmaceuticals. No potential conflicts of interest were disclosed by the other author. Editor's Disclosures The following editor(s) reported relevant financial relationships: P.S. Steeg reports receiving commercial research grants from Geron, GlaxoSmithKline, and Sanofi. CME Staff Planners' Disclosures The members of the planning committee have no real or apparent conflict of interest to disclose. Learning Objectives Upon completion of this activity, the participant should have a better understanding of Hedgehog signaling mechanisms in cancer stem cells and the biologic rationale for evaluating combined Hedgehog and PKCi inhibition for treatment of patients whose tumors harbor 3q26 amplification. Acknowledgment of Financial or Other Support This activity does not receive commercial support. Background tissue repair/regeneration. Aberrant Hh pathway activation controls multiple aspects of tumorigenesis, including initia- Hedgehog (Hh) is a highly conserved developmental path- tion, progression, and relapse, at least in part, by driving a way involved in organogenesis, stem cell maintenance, and cancer stem cell (CSC) phenotype. Mutational Hh pathway activation drives tumor formation in several tumor types, and Department of Cancer Biology, Mayo Clinic Comprehensive Cancer many other tumors exhibit epigenetic Hh pathway activation. Center, Jacksonville, Florida. Small-molecule Hh inhibitors have been used as monotherapy Corresponding Author: Alan P. Fields, Department of Cancer Biology, Mayo and in combined modalities for cancer treatment. To date, Clinic Comprehensive Cancer Center, Griffin Cancer Research Building, Room however, Hh inhibitors have enjoyed limited success clinically. 212, 4500 San Pablo Road, Jacksonville, FL 32224. Phone: 904-953-6160; Fax: Here, we discuss oncogenic Hh signaling mechanisms and 1-904-953-0277; E-mail: fi[email protected] highlight new therapeutic strategies that may enhance the doi: 10.1158/1078-0432.CCR-14-0507 clinical efficacy and expand the effective use of Hh inhibitors Ó2015 American Association for Cancer Research. to new tumor types. www.aacrjournals.org 505 Downloaded from clincancerres.aacrjournals.org on September 28, 2021. © 2015 American Association for Cancer Research. Justilien and Fields The canonical Hh signaling pathway Hh ligands that induce Hh activation in stromal cells, which then Core Hh signaling components include the Hh ligands [sonic promote tumor growth by producing angiogenic factors (i.e., IGF Hh (Shh); Indian Hh (Ihh), and Desert Hh (Dhh)], the trans- and VEGF) and IL6 and Wnt signaling activation (24–27). Para- membrane receptor proteins Patched 1 and 2 (PTCH1 and crine Hh signaling occurs in pancreatic, lung, esophageal, gastric, PTCH2), the G-protein–coupled receptor-like protein smooth- colon, lymphomas, multiple myelomas, and prostate cancers ened (SMO), and the glioma-associated oncogene transcription (25, 27–34). Reverse paracrine Hh signaling has also been factors 1 to 3 (GLI1, GLI2, and GLI3; reviewed in ref. 1; Fig. 1). described in lymphomas and multiple myelomas, in which Hh Primary cilia localize these components to activate or repress ligand produced in bone marrow stroma activates Hh signaling in signaling (2). Canonical Hh signaling is activated when Hh adjacent tumor cells (35). ligand binds PTCH to relieve PTCH-mediated SMO inhibition at the base of the primary cilium (3). SMO then translocates to Hh pathway activation in cancer stem cells the cilium tip (4), driving a signaling cascade that results in Lineage tracing studies have demonstrated the existence of a nuclear GLI translocation and activation. GLI activates tran- subpopulation of tumor cells exhibiting stem-like properties scription of context-specific genes regulating self-renewal, cell (36–38). These tumor-initiating cells or CSCs exhibit self-renew- fate, survival, angiogenesis, epithelial-to-mesenchymal transi- al, enhanced tumor initiation, and differentiation into transiently tion, and cell invasion (reviewed in ref. 5). As Hh transcrip- amplifying cells that populate the bulk tumor. These cells func- tional targets, GLI1 and PTCH establish a feedback loop that tion in tumor maintenance, metastasis, relapse, and chemoresis- regulates Hh signaling (6). tance. Hh signaling drives CSC maintenance in lung, breast, Several accessory proteins promote or suppress Hh pathway pancreas, and colon cancers; glioblastoma; multiple myeloma; activity (Fig. 1). Hh ligands are synthesized as precursors that and chronic myelogenous leukemia (CML; refs. 16, 18, 20, 22, 39– undergo autocatalytic cleavage, addition of a carboxy-terminal 42). Hh signaling is selectively activated in CSCs compared with cholesterol moiety, and amino-terminal palmitoylation mediated bulk tumor cells from these tumor types (18, 20, 22, 41, 42), and by Skinny Hh/Hh acyltransferase (Ski/HHAT) to produce mature directly drives the CSC phenotype by regulating expression of CSC ligand, the secretion of which is facilitated by the transmembrane markers aldehyde dehydrogenase, BMI1, WNT2, and CD44 transporter-like protein dispatched (Disp; ref. 1). Growth arrest- (20, 27, 43). Pharmacologic or genetic Hh inhibition in these specific 1 (GAS1), CAM-related/downregulated by oncogenes tumor types decreases self-renewal, tumor growth, and metastasis (CDO), brother of CDO (BOC), and glypican-3 are coreceptors (16, 18, 20, 22, 39–42). Hh signaling also regulates ABCG2 and that facilitate ligand binding to PTCH (1), whereas Hedgehog MDR expression, suggesting a role in the chemoresistance char- interacting peptide represses signaling by sequestering Hh ligand acteristic of CSCs (44–48). b b (7). Protein kinase A (PKA), glycogen synthase 3 (GSK3 ), casein – kinase I (CK1), Skip–Cullin–Fbox protein, btransducin repeat Clinical Translational Advances containing protein (bTrCP), and a suppressor complex composed Hh pathway inhibitors of fused kinase (Fu), suppressor of fused (SUFU), and costal2 Four major modes of Hh inhibition have been exploited (Cos2) regulate GLI expression, stability, and localization therapeutically: (i) SMO inhibition; (ii) receptor-ligand dis- (reviewed in ref. 1). Alterations in one or more of these modulatory ruption; (iii) inhibition of ligand processing; and (iv) GLI mechanisms can lead to pathway deregulation and cancer. inhibition (Fig. 1). Cyclopamine, a naturally occurring SMO inhibitor, established Hh as a viable therapeutic target (49, 50). Hh signaling in cancer Although cyclopamine is not clinically useful due to its low Both ligand-dependent and ligand-independent mechanisms potency and bioavailability, more potent and specificSMO result in aberrant Hh pathway activation in cancer. Germline or inhibitors vismodegib, BMS-833923, saridegib (IPI-926), soni- somatic loss-of-function PTCH or SUFU, and gain-of-function degib/erismodegib (LDE225), PF-04449913, LY2940680, LEQ SMO, mutations constitutively activate ligand-independent Hh 506, and TAK-441 (Fig. 1) have been developed and evaluated signaling and drive basal cell carcinoma (BCC), medulloblastoma clinically (Table 1, Clinicaltrials.gov). SMO inhibitors are par- (MB), rhabdomyosarcoma, and meningioma tumor develop- ticularly effective against MBs and BCCs harboring SMO or ment (8–11). GLI1 amplification occurs in glioblastoma and PTCH mutations, and FDA approval of vismodegib for rhabdomyosarcoma, and activating mutations in GLI1 and GLI3 advanced BCC solidified Hh as a bona fide therapeutic target. are evident in pancreatic adenocarcinomas (12–14), although the Hh signaling has also been blocked by disrupting Hh ligand– function of these mutations is not fully explored. Pallister–Hall
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