Influence of chemoresistance and p53 status on Fluoro-2-deoxy-D-glucose incorporation in cancer
Tim A D Smith
Resistance of
cancers to chemotherapy and the presence of p53 mutations are both associated
with poor prognosis. A considerable number of clinical studies have examined
the influence of these two factors on FDG incorporation with a view to using
FDG-PET as a non-invasive determinant of prognosis. The findings from these
studies are summarised below along with the in-vitro cell studies which help to
explain the respective associations between FDG incorporation, p53 status and
chemoresistance.
Resistance to chemotherapy
Cancer cure is frequently abrogated either by inherent, or acquired
drug resistance. An inherently resistant tumor is one that shows little or no
sensitivity to therapeutic agents without prior exposure to the drug in
question. Acquired resistance is where the tumor is initially sensitive to
treatment but becomes increasingly unresponsive to the agent. Even very
responsive tumors can develop drug resistance during the course of their
treatment [1].
Each cancer cell has thousands of genetic errors [2] and some will
induce differing states of drug sensitivity. When the tumor is exposed to a
specific chemotherapy agent, cells resistance to the drug will dominate.
Residual tumor disease post-chemotherapy is often associated with the presence
of subsets of cells resistant to the chemotherapy agent [1,3]. For example patients
with ovarian cancer have high response rates to initial chemotherapy after
cytoreductive surgery but most develop resistance to chemotherapy during the
course of their treatment [3].
Mechanisms of drug
resistance
There are a number of mechanisms for drug resistance. These include
changes in the rate of drug uptake and efflux, altered drug metabolism,
decreased drug-target complex formation, enhanced DNA
repair mechanisms [4].
Anticancer drugs enter cells by diffusion or trans-membrane
transport proteins. Drug resistance can result from modulation of membrane
receptors e.g. the anti-folate agents methotrexate and tomudex enter the cell
via the reduced folate carrier (RFC) and resistance to methotrexate has been
shown to be associated with decreased expression of RFC [5]. Some
chemotherapeutics directly affect target molecules such as the platinum drugs
that interact directly with DNA. Resistance to platinum drugs can be due to
increased tumour cell levels of molecules that inactivate these compounds such
as glutathione [6]. Drugs such as 5fluorouracil (5FU) require chemical
modification. 5FU is anabolised to a thymidylate synthase inhibitor although
most 5FU is catabolised by dihydropyrimidine dehydrogenase (DPD) and 5FU-resistant
cells have been shown to express higher than normal levels of DPD and increased
levels of thymidylate synthase [5]. A further mechanism of resistance is
induced by changes in the protein target of some drugs e.g. resistance to
paclitaxel and docetaxel include acquired mutations at the drug
binding site of tubulin and differential expression of tubulin
isoforms [7,8] Increased efflux of drugs including taxanes and anthracyclines
can result from expression of the ABC transporter proteins such as P-glycoprotein.
Multi drug resistance (MDR) is the state in which tumor cells are resistant to
a wide range of different chemotherapy drugs including doxorubicin (an
anthracycline), alkaloids (e.g colchicine) due to the presence of the plasma
membrane protein P-glycoprotein (P-gp). Changes in the apoptotic signal
induction pathways are also involved in chemotherapy-resistance [6].
P53 status, drug
resistance and prognosis
To
prevent neoplastic formation, cellular P53 protein responds to DNA damaging
cellular insults by either orchestrating DNA repair mechanisms or, where DNA damage
is irreparable, by induction of apoptosis pathways. In view of its crucial role
in maintaining DNA integrity p53 protein is referred to as the ‘Guardian of the
genome’. In the absence of cell stress p53 protein levels are low but X-rays,
UV, DNA-damaging chemotherapy drugs, DNA synthesis inhibitors, disruptors of
microtubule components, hypoxia, myc introduction into cell, depletion of
intracellular nucleotide precursor pools
all cause increased p53 within minutes. Loss of p53 function through
mutation is associated with many cancer types [9]. Since most anti-cancer
chemotherapy works through induction of apoptosis, loss of p53 function through
mutation is associated with resistance to some drugs including doxorubicin [10]
and cisplatin [11]. Further therapy response and survival have been shown
to be detrimentally influenced by p53 abnormality in patients with leukemia [12],
lymphoma [13] and epithelial ovarian cancer [14].
[18F]Fluoro-2-deoxy-D-glucose
positron emission tomography (FDG-PET)
Positron emission tomography (PET) using the glucose analogue
fluoro-2-deoxy-D-glucose (FDG-PET) is becoming a routine tool for probing
tumour metabolism non-invasively and exploits the enhanced glucose utilization
characterized by tumour cells. The fluorinated glucose analogue, 18F
labelled glucose analogue, fluoro-2-deoxy-d-glucose FDG is transported into
tumour cells via a family of glucose transporter proteins (Gluts) then
phosphorylated by the enzyme hexokinase (HK) to FDG-6-phosphate after which it
undergoes little further metabolism (except dephosphorylation by
glucose-6-phosphatase (G-6-Pase)). Higher levels of HK and Glut and low levels
of G-6-Pase have been reported [15] in tumour tissue compared with
corresponding normal tissue. The use of serial FDG-PET scans of patients with
tumours during the course of chemotherapy has been demonstrated by many studies
to be a useful tool in cancer management [16]. Generally, compared with
pre-treatment, responding tumours show decreased FDG uptake within a few days
of starting chemotherapy.
FDG incorporation and
resistance to chemotherapy
Sestabimi is a
substrate for the P-gp pump and so the rate of efflux of 99mTc-sestabimi
can be used to diagnose MDR-related P glycoprotein expression in solid tumours [17].
However the utility of FDG incorporation as an indicator of the MDR phenotype
has been investigated in a number of studies [18-20]. In each of these studies,
consisting respectively of 47 patients with untreated lung cancer [18], 35
patients with intrahepatic cholangiocarcinoma (ICC) [19] and 70 patients with
hepatocellular carcinoma (HCC) [20] expression of P-gp, determined immunohistochemically
and found to negatively correlate with tumour SUV (standardised uptake value).
In-vitro studies [21-23] also showed that cells exhibiting the MDR
phenotype incorporate FDG at lower levels than MDR-negative control cells. Thus Lorke et al [21] found that FDG
incorporation by multi-drug resistant HT-29 colon carcinoma cells grown
in-vitro or as xenografts in SCID mice was lower compared with incorporation by
sensitive HT-29 cells whilst incubation of cells with inhibitors of P-gp showed
that efflux of FDG by the P-gp is a mechanism responsible for decreased FDG
incorporation by cells expressing MDR. Recently Seo et al [22] compared FDG incorporation by PLC/PRF/5 cells and
doxorubicin-resistant P-gp expressing PLC/DOR cells and found FDG incorporation
to be lower in PLC/DOR cells compared with PLC/PRF/5 cells. Treatment with the
P-gp inhibitors Verapamil and cepharanthine restored FDG uptake in PLC/DOR
cells, but not in PLC/PRF/5 cells. Yamada et al [23] have also shown by
treating the multi-drug resistant melanoma cell line SK-MEL 24 with inhibitors
of Pgp that FDG is a substrate for the Pgp pump.
Another possible mechanism responsible for the lower FDG
incorporation by MDR positive tumour cells is decreased expression of glucose
transporters. In a series of colchicine-selected multidrug-resistant (MDR) human
KB carcinoma cell lines MDR resistant cells exhibit decreased glucose transport
which correlated with the sensitivity to the toxic effect of 2-deoxy-D-glucose [24].
Tumor resistance to 5FU has been shown to be directly associated
with changes in FDG incorporation [25] and to induce modifications in pathways
associated with FDG incorporation [26]. Cells
can be selected for drug resistance by exposure to increasing concentrations of
the drug over a period of months or years. We previously reported [25] that although
glucose transport was increased in cells selected for resistance to 5FU
compared with sensitive control MCF-7 cells FDG incorporation by the resistant
cells was actually lower. Using the glucose transport inhibitor phloretin we
demonstrated that the decreased FDG incorporation by the resistant compared
with the sensitive cells was due to increased efflux of FDG via the glucose
transporters. Using a clone of T47D breast tumour cells selected for
5FU-resistance it has also been shown that ATP-synthase activity is diminished in
the resistant cells when compared with WT cells [26].
Two studies have examined FDG incorporation by tumors resistant to tyrosine
kinase inhibitors [27, 28]. In one case
two patients with gastrointestinal stromal tumors that were resistant to
imatinib were associated with low FDG incorporation [27]. Su et al [28] determined
FDG uptake by 4 NSCLC tumor lines with varying levels of sensitivity to the
EGFR kinase inhibitor gefitinib in-vitro or grown as xenografts in nude mice during
treatment with this compound. FDG incorporation was only found to change in
cells sensitive to the gefitinib. Western blot studies carried out on cytosolic
and membrane fractions indicated that this was due to translocation of glucose
transporters from the membrane to the cytosol in the sensitive tumor cells.
Not all studies have found differences in FDG incorporation between
resistant and non-resistant tumor cells. Treatment with paclitaxel increased
FDG uptake to a similar extent by WT human adenocarcinoma-derived ovarian cells
(A2780) and cells that had been selected for resistance to doxorubicin [29].
P53 and FDG incorporation
Patients with Li-Fraumeni syndrome (LFS) have an underlying germline
mutation in their p53 gene resulting in an inherited predisposition to a range
of cancer types [30]. FDG-PET/CT has recently been used to screen for cancers
in such patients [31]. Of 15 asymptomatic patients with LFS cancers were
detected in 3 suggesting that FDG-PET/CT could be utilised in the surveillance
of such patients although the risks of radiation exposure to at rick patients
needs to be examined.
Loss of p53 has been shown to be associated with enhanced rates of
glucose utilisation by tumor cells [32] and many clinical studies have compared
tumor FDG incorporation (usually maximal SUV (standardised uptake value))
between patients with wild type p53 tumours and patients with mutant P53. P53 protein
content is determined using immunohistochemistry and increased p53 expression
is assumed to be due to overexpression of mutant p53. Positive correlations
between p53 expression and FDG incorporation were observed in studies of 90
patients with colorectal cancer [33], two studies of primary breast cancer
consisting of 275 [34] and 86 patients [35], two studies of non-small cell lung carcinoma
(NSCLC) consisting of 149 [36] and 82 [37] patients respectively, 38 patients
with cervical cancer [38], two studies of patients with bone soft tissue
sarcomas consisting of 63 [39] and 89 [40] patients respectively. Further two
small studies of patients with hepatocellular carcinoma [41,42] showed that the lesions with the
highest FDG incorporation expressed mutant p53. Studies that have shown p53
expression not to be related to FDG incorporation are in the minority and
include a small study (19 patients) with ovarian cancer [43], or in a study
using a contrast ratio of lung tumor vs non-involved lung of 71 patients with
c-stage IA lung adenocarcinomas [44] and a study of 75 patients with breast
cancer [45]. Other studies [46] have compared FDG incorporation in tumors of
patients patients according to expression of tumor suppressor genes including
p53 and showed that the groups with aberrant tumor suppressor genes had a
higher FDG incorporation than did tumors without mutations in these genes
Several of these studies [33, 36, 38 and 39] also compared the
protein expression of glucose transporters and hexokinases with p53 status.
Some found glut1 [33, 36, 39] but not glut-3 [33] expression to be positively
associated with p53 expression. However
tumur cells can express several different glucose transporters and their
expression does not necessarily correspond with glucose transport at the
functional level [47].
To determine the effect of abrogation of functional p53 on FDG
incorporation by tumor cells we transfected MCF-7 breast tumor cells with a
dominant negative p53 construct [47]. FDG incorporation was found to be
increased in the p53 abrogated cells compared with wild-type MCF-7 cells. Using
microarray we found that glucose transporters 1, 8, and 10 were expressed in
MCF-7 cells and HK I was the principal HK in MCF-7 cells but was not
differentially expressed at the messenger RNA level in the dominant negative
p53 clones, compared with WT cells. However, increased HK activity was observed
in both dominant negative p53 clones, compared with WT MCF-7.
A further mechanism by which FDG incorporation could be increased in
cells with attenuated p53 levels is through a switch from aerobic to anaerobic
respiration. Pathways associated with p53 Matoba et al 2006 [48] showed that O2
consumption was lower and lactate production higher in p53-/-
compared with p53+/+ HCT116 cells and that this was due to p53
controlling the synthesis of cytochrome c oxidase required for the terminal step
of the respiratory chain catalysing transfer of e- to O2.
Post Comment
No comments