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European Journal of Nutrition

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Open Access 01-06-2018 | Original Contribution

Methyl-donor depletion of head and neck cancer cells in vitro establishes a less aggressive tumour cell phenotype

Authors: Vanessa Hearnden, Hilary J. Powers, Abeir Elmogassabi, Rosanna Lowe, Craig Murdoch

Published in: European Journal of Nutrition | Issue 4/2018

Abstract

Purpose

DNA methylation plays a fundamental role in the epigenetic control of carcinogenesis and is, in part, influenced by the availability of methyl donors obtained from the diet. In this study, we developed an in-vitro model to investigate whether methyl donor depletion affects the phenotype and gene expression in head and neck squamous cell carcinoma (HNSCC) cells.

Methods

HNSCC cell lines (UD-SCC2 and UPCI-SCC72) were cultured in medium deficient in methionine, folate, and choline or methyl donor complete medium. Cell doubling-time, proliferation, migration, and apoptosis were analysed. The effects of methyl donor depletion on enzymes controlling DNA methylation and the pro-apoptotic factors death-associated protein kinase-1 (DAPK1) and p53 upregulated modulator of apoptosis (PUMA) were examined by quantitative-PCR or immunoblotting.

Results

HNSCC cells cultured in methyl donor deplete conditions showed significantly increased cell doubling times, reduced cell proliferation, impaired cell migration, and a dose-dependent increase in apoptosis when compared to cells cultured in complete medium. Methyl donor depletion significantly increased the gene expression of DNMT3a and TET-1, an effect that was reversed upon methyl donor repletion in UD-SCC2 cells. In addition, expression of DAPK1 and PUMA was increased in UD-SCC2 cells cultured in methyl donor deplete compared to complete medium, possibly explaining the observed increase in apoptosis in these cells.

Conclusion

Taken together, these data show that depleting HNSCC cells of methyl donors reduces the growth and mobility of HNSCC cells, while increasing rates of apoptosis, suggesting that a methyl donor depleted diet may significantly affect the growth of established HNSCC.

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Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F (2012) GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11. Available via NLM. 2016

Gatta G, Botta L, Sánchez MJ, Anderson LA, Pierannunzio D, Licitra L, Group EW (2015) Prognoses and improvement for head and neck cancers diagnosed in Europe in early 2000s: the EUROCARE-5 population-based study. Eur J Cancer. doi:10.1016/j.ejca.2015.07.043 CrossRefPubMed

Napier SS, Speight PM (2008) Natural history of potentially malignant oral lesions and conditions: an overview of the literature. J Oral Pathol Med 37(1):1–10. doi:10.1111/j.1600-0714.2007.00579.x CrossRefPubMed

Kreimer AR, Clifford GM, Boyle P, Franceschi S (2005) Human papillomavirus types in head and neck squamous cell carcinomas worldwide: a systematic review. Cancer Epidemiol Biomark Prev 14(2):467–475. doi:10.1158/1055-9965.EPI-04-0551 CrossRef

Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, Jiang B, Goodman MT, Sibug-Saber M, Cozen W, Liu L, Lynch CF, Wentzensen N, Jordan RC, Altekruse S, Anderson WF, Rosenberg PS, Gillison ML (2011) Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol 29(32):4294–4301. doi:10.1200/JCO.2011.36.4596 CrossRefPubMedPubMedCentral

Blount BC, Mack MM, Wehr CM, MacGregor JT, Hiatt RA, Wang G, Wickramasinghe SN, Everson RB, Ames BN (1997) Folate deficiency causes uracil misincorporation into human DNA and chromosome breakage: implications for cancer and neuronal damage. Proc Nat Acad Sci USA 94 (7):3290–3295CrossRefPubMed

Titenko-Holland N, Jacob RA, Shang N, Balaraman A, Smith MT (1998) Micronuclei in lymphocytes and exfoliated buccal cells of postmenopausal women with dietary changes in folate. Mutat Res 417(2–3):101–114CrossRefPubMed

Duthie SJ, Mavrommatis Y, Rucklidge G, Reid M, Duncan G, Moyer MP, Pirie LP, Bestwick CS (2008) The response of human colonocytes to folate deficiency in vitro: functional and proteomic analyses. J Proteome Res 7(8):3254–3266. doi:10.1021/pr700751y CrossRefPubMed

Freedman ND, Park Y, Subar AF, Hollenbeck AR, Leitzmann MF, Schatzkin A, Abnet CC (2008) Fruit and vegetable intake and head and neck cancer risk in a large United States prospective cohort study. Int J Cancer 122(10):2330–2336. doi:10.1002/ijc.23319 CrossRefPubMed

10.

Kune GA, Kune S, Field B, Watson LF, Cleland H, Merenstein D, Vitetta L (1993) Oral and pharyngeal cancer, diet, smoking, alcohol, and serum vitamin A and beta-carotene levels: a case-control study in men. Nutr Cancer 20(1):61–70. doi:10.1080/01635589309514271 CrossRefPubMed

11.

Pelucchi C, Talamini R, Negri E, Levi F, Conti E, Franceschi S, La Vecchia C (2003) Folate intake and risk of oral and pharyngeal cancer. Ann Oncol 14(11):1677–1681CrossRefPubMed

12.

Petersen LF, Brockton NT, Bakkar A, Liu S, Wen J, Weljie AM, Bismar TA (2012) Elevated physiological levels of folic acid can increase in vitro growth and invasiveness of prostate cancer cells. BJU Int 109(5):788–795. doi:10.1111/j.1464-410X.2011.10437.x CrossRefPubMed

13.

Ly A, Lee H, Chen J, Sie KK, Renlund R, Medline A, Sohn KJ, Croxford R, Thompson LU, Kim YI (2011) Effect of maternal and postweaning folic acid supplementation on mammary tumor risk in the offspring. Cancer Res 71(3):988–997. doi:10.1158/0008-5472.CAN-10-2379 CrossRefPubMed

14.

Piyathilake CJ, Henao OL, Macaluso M, Cornwell PE, Meleth S, Heimburger DC, Partridge EE (2004) Folate is associated with the natural history of high-risk human papillomaviruses. Cancer Res 64(23):8788–8793. doi:10.1158/0008-5472.can-04-2402 CrossRefPubMed

15.

Flatley JE, McNeir K, Balasubramani L, Tidy J, Stuart EL, Young TA, Powers HJ (2009) Folate status and aberrant DNA methylation are associated with HPV infection and cervical pathogenesis. Cancer Epidemiol Biomark Prev 18(10):2782–2789. doi:10.1158/1055-9965.EPI-09-0493 CrossRef

16.

Xiao S, Tang YS, Khan RA, Zhang Y, Kusumanchi P, Stabler SP, Jayaram HN, Antony AC (2012) Influence of physiologic folate deficiency on human papillomavirus type 16 (HPV16)-harboring human keratinocytes in vitro and in vivo. J Biol Chem 287(15):12559–12577. doi:10.1074/jbc.M111.317040 CrossRefPubMedPubMedCentral

17.

Towle R, Truong D, Hogg K, Robinson WP, Poh CF, Garnis C (2013) Global analysis of DNA methylation changes during progression of oral cancer. Oral Oncol 49(11):1033–1042. doi:10.1016/j.oraloncology.2013.08.005 CrossRefPubMed

18.

Ha PK, Califano JA (2006) Promoter methylation and inactivation of tumour-suppressor genes in oral squamous-cell carcinoma. Lancet Oncol 7(1):77–82. doi:10.1016/S1470-2045(05)70540-4 CrossRefPubMed

19.

Bestor T, Laudano A, Mattaliano R, Ingram V (1988) Cloning and sequencing of a cDNA encoding DNA methyltransferase of mouse cells. The carboxyl-terminal domain of the mammalian enzymes is related to bacterial restriction methyltransferases. J Mol Biol 203(4):971–983CrossRefPubMed

20.

Okano M, Bell DW, Haber DA, Li E (1999) DNA methyltransferases Dnmt3a and Dnmt3b are essential for de novo methylation and mammalian development. Cell 99(3):247–257CrossRefPubMed

21.

Ito S, Shen L, Dai Q, Wu SC, Collins LB, Swenberg JA, He C, Zhang Y (2011) Tet proteins can convert 5-methylcytosine to 5-formylcytosine and 5-carboxylcytosine. Science 333(6047):1300–1303. doi:10.1126/science.1210597 CrossRefPubMedPubMedCentral

22.

Poomipark N, Flatley JE, Hill MH, Mangnall B, Azar E, Grabowski P, Powers HJ (2016) Methyl donor status influences DNMT expression and global DNA methylation in cervical cancer cells. Asian Pac J Cancer Prev 17(7):3213–3222PubMed

23.

Lin Y, Hupp TR, Stevens C (2010) Death-associated protein kinase (DAPK) and signal transduction: additional roles beyond cell death. FEBS J 277(1):48–57. doi:10.1111/j.1742-4658.2009.07411.x CrossRefPubMed

24.

Altman BJ, Rathmell JC (2012) Metabolic stress in autophagy and cell death pathways. Cold Spring Harb Perspect Biol 4(9):a008763. doi:10.1101/cshperspect.a008763 CrossRefPubMedPubMedCentral

25.

Hoffmann TK, Sonkoly E, Hauser U, van Lierop A, Whiteside TL, Klussmann JP, Hafner D, Schuler P, Friebe-Hoffmann U, Scheckenbach K, Erjala K, Grénman R, Schipper J, Bier H, Balz V (2008) Alterations in the p53 pathway and their association with radio- and chemosensitivity in head and neck squamous cell carcinoma. Oral Oncol 44(12):1100–1109. doi:10.1016/j.oraloncology.2008.02.006 CrossRefPubMed

26.

White JS, Weissfeld JL, Ragin CC, Rossie KM, Martin CL, Shuster M, Ishwad CS, Law JC, Myers EN, Johnson JT, Gollin SM (2007) The influence of clinical and demographic risk factors on the establishment of head and neck squamous cell carcinoma cell lines. Oral Oncol 43(7):701–712. doi:10.1016/j.oraloncology.2006.09.001 CrossRefPubMed

27.

Rangan SR (1972) A new human cell line (FaDu) from a hypopharyngeal carcinoma. Cancer 29(1):117–121CrossRefPubMed

28.

Scherer WF, Syverton JT, Gey GO (1953) Studies on the propagation in vitro of poliomyelitis viruses. IV. Viral multiplication in a stable strain of human malignant epithelial cells (strain HeLa) derived from an epidermoid carcinoma of the cervix. J Exp Med 97(5):695–710CrossRefPubMedPubMedCentral

29.

Friedl F, Kimura I, Osato T, Ito Y (1970) Studies on a new human cell line (SiHa) derived from carcinoma of uterus. I. Its establishment and morphology. Proc Soc Exp Biol Med 135(2):543–545CrossRefPubMed

30.

Chang SE, Foster S, Betts D, Marnock WE (1992) DOK, a cell line established from human dysplastic oral mucosa, shows a partially transformed non-malignant phenotype. Int J Cancer 52(6):896–902CrossRefPubMed

31.

Berndt A, Hyckel P, Könneker A, Katenkamp D, Kosmehl H (1997) Oral squamous cell carcinoma invasion is associated with a laminin-5 matrix re-organization but independent of basement membrane and hemidesmosome formation. Clues from an in vitro invasion model. Invasion Metastasis 17(5):251–258PubMed

32.

Hayashi I, Sohn KJ, Stempak JM, Croxford R, Kim YI (2007) Folate deficiency induces cell-specific changes in the steady-state transcript levels of genes involved in folate metabolism and 1-carbon transfer reactions in human colonic epithelial cells. J Nutr 137(3):607–613CrossRefPubMed

33.

Friesen RW, Novak EM, Hasman D, Innis SM (2007) Relationship of dimethylglycine, choline, and betaine with oxoproline in plasma of pregnant women and their newborn infants. J Nutr 137(12):2641–2646CrossRefPubMed

34.

Balada E, Ordi-Ros J, Serrano-Acedo S, Martinez-Lostao L, Rosa-Leyva M, Vilardell-Tarres M (2008) Transcript levels of DNA methyltransferases DNMT1, DNMT3A and DNMT3B in CD4 + T cells from patients with systemic lupus erythematosus. Immunol 124 (3):339–347. doi:10.1111/j.1365-2567.2007.02771.x CrossRef

35.

Nikolaidis G, Raji OY, Markopoulou S, Gosney JR, Bryan J, Warburton C, Walshaw M, Sheard J, Field JK, Liloglou T (2012) DNA methylation biomarkers offer improved diagnostic efficiency in lung cancer. Cancer Res 72(22):5692–5701. doi:10.1158/0008-5472.CAN-12-2309 CrossRefPubMedPubMedCentral

36.

Moat SJ, Hill MH, McDowell IF, Pullin CH, Ashfield-Watt PA, Clark ZE, Whiting JM, Newcombe RG, Lewis MJ, Powers HJ (2003) Reduction in plasma total homocysteine through increasing folate intake in healthy individuals is not associated with changes in measures of antioxidant activity or oxidant damage. Eur J Clin Nutr 57(3):483–489. doi:10.1038/sj.ejcn.1601554 CrossRefPubMed

37.

Nakano E, Taiwo FA, Nugent D, Griffiths HR, Aldred S, Paisi M, Kwok M, Bhatt P, Hill MH, Moat S, Powers HJ (2005) Downstream effects on human low density lipoprotein of homocysteine exported from endothelial cells in an in vitro system. J Lipid Res 46(3):484–493. doi:10.1194/jlr.M400339-JLR200 CrossRefPubMed

38.

Flatley JE, Sargent A, Kitchener HC, Russell JM, Powers HJ (2014) Tumour suppressor gene methylation and cervical cell folate concentration are determinants of high-risk human papillomavirus persistence: a nested case control study. BMC Cancer 14:803. doi:10.1186/1471-2407-14-803 CrossRefPubMedPubMedCentral

39.

Duthie SJ (2011) Folate and cancer: how DNA damage, repair and methylation impact on colon carcinogenesis. J Inherit Metab Dis 34(1):101–109. doi:10.1007/s10545-010-9128-0 CrossRefPubMed

40.

Ulrich CM, Potter JD (2007) Folate and cancer—timing is everything. JAMA 297(21):2408–2409. doi:10.1001/jama.297.21.2408 CrossRefPubMed

41.

Niculescu MD, Zeisel SH (2002) Diet, methyl donors and DNA methylation: interactions between dietary folate, methionine and choline. J Nutr 132(8 Suppl):2333S–2335S

42.

Shin W, Yan J, Abratte CM, Vermeylen F, Caudill MA (2010) Choline intake exceeding current dietary recommendations preserves markers of cellular methylation in a genetic subgroup of folate-compromised men. J Nutr 140(5):975–980. doi:10.3945/jn.110.121186 CrossRefPubMedPubMedCentral

43.

Doucette MM, Stevens VL (2001) Folate receptor function is regulated in response to different cellular growth rates in cultured mammalian cells. J Nutr 131(11):2819–2825CrossRefPubMed

44.

Hultberg B (2003) Modulation of extracellular homocysteine concentration in human cell lines. Clin Chim Acta 330(1–2):151–159CrossRefPubMed

45.

Lyons AJ, Jones J (2007) Cell adhesion molecules, the extracellular matrix and oral squamous carcinoma. Int J Oral Maxillofac Surg 36(8):671–679. doi:10.1016/j.ijom.2007.04.002 CrossRefPubMed

46.

Wang TP, Hsu SH, Feng HC, Huang RF (2012) Folate deprivation enhances invasiveness of human colon cancer cells mediated by activation of sonic hedgehog signaling through promoter hypomethylation and cross action with transcription nuclear factor-kappa B pathway. Carcinogenesis 33(6):1158–1168. doi:10.1093/carcin/bgs138 CrossRefPubMed

47.

Graziosi L, Mencarelli A, Renga B, D’Amore C, Bruno A, Santorelli C, Cavazzoni E, Cantarella F, Rosati E, Donini A, Fiorucci S (2013) Epigenetic modulation by methionine deficiency attenuates the potential for gastric cancer cell dissemination. J Gastrointest Surg 17 (1):39–49. doi:10.1007/s11605-012-1996-1 (discussion p. 49) CrossRefPubMed

48.

Jhaveri MS, Wagner C, Trepel JB (2001) Impact of extracellular folate levels on global gene expression. Mol Pharmacol 60(6):1288–1295CrossRefPubMed

49.

Lin DW, Chung BP, Kaiser P (2014) S-adenosylmethionine limitation induces p38 mitogen-activated protein kinase and triggers cell cycle arrest in G1. J Cell Sci 127(Pt 1):50–59. doi:10.1242/jcs.127811 CrossRef

50.

Garcia-Crespo D, Knock E, Jabado N, Rozen R (2009) Intestinal neoplasia induced by low dietary folate is associated with altered tumor expression profiles and decreased apoptosis in mouse normal intestine. J Nutr 139(3):488–494. doi:10.3945/jn.108.095661 CrossRefPubMed

51.

Cao DZ, Sun WH, Ou XL, Yu Q, Yu T, Zhang YZ, Wu ZY, Xue QP, Cheng YL (2005) Effects of folic acid on epithelial apoptosis and expression of Bcl-2 and p53 in premalignant gastric lesions. World J Gastroenterol 11(11):1571–1576CrossRefPubMedPubMedCentral

52.

Hsu HC, Chiou JF, Wang YH, Chen CH, Mau SY, Ho CT, Chang PJ, Liu TZ (2013) Folate deficiency triggers an oxidative-nitrosative stress-mediated apoptotic cell death and impedes insulin biosynthesis in RINm5F pancreatic islet β-cells: relevant to the pathogenesis of diabetes. PLoS One 8(11):e77931. doi:10.1371/journal.pone.0077931 CrossRefPubMedPubMedCentral

53.

Xie X, Clausen OP, De Angelis P, Boysen M (1999) The prognostic value of spontaneous apoptosis, Bax, Bcl-2, and p53 in oral squamous cell carcinoma of the tongue. Cancer 86(6):913–920CrossRefPubMed

54.

Deiss LP, Feinstein E, Berissi H, Cohen O, Kimchi A (1995) Identification of a novel serine/threonine kinase and a novel 15-kD protein as potential mediators of the gamma interferon-induced cell death. Genes Dev 9(1):15–30CrossRefPubMed

55.

Nakano K, Vousden KH (2001) PUMA, a novel proapoptotic gene, is induced by p53. Mol Cell 7(3):683–694CrossRefPubMed

56.

Stempak JM, Sohn KJ, Chiang EP, Shane B, Kim YI (2005) Cell and stage of transformation-specific effects of folate deficiency on methionine cycle intermediates and DNA methylation in an in vitro model. Carcinogenesis 26(5):981–990. doi:10.1093/carcin/bgi037 CrossRefPubMed

57.

Ghoshal K, Li X, Datta J, Bai S, Pogribny I, Pogribny M, Huang Y, Young D, Jacob ST (2006) A folate- and methyl-deficient diet alters the expression of DNA methyltransferases and methyl CpG binding proteins involved in epigenetic gene silencing in livers of F344 rats. J Nutr 136(6):1522–1527CrossRefPubMedPubMedCentral

58.

Kovacheva VP, Mellott TJ, Davison JM, Wagner N, Lopez-Coviella I, Schnitzler AC, Blusztajn JK (2007) Gestational choline deficiency causes global and Igf2 gene DNA hypermethylation by up-regulation of Dnmt1 expression. J Biol Chem 282(43):31777–31788. doi:10.1074/jbc.M705539200 CrossRefPubMed

59.

Gao Q, Steine EJ, Barrasa MI, Hockemeyer D, Pawlak M, Fu D, Reddy S, Bell GW, Jaenisch R (2011) Deletion of the de novo DNA methyltransferase Dnmt3a promotes lung tumor progression. Proc Natl Acad Sci USA 108(44):18061–18066. doi:10.1073/pnas.1114946108 CrossRefPubMed

60.

Mizuno S, Chijiwa T, Okamura T, Akashi K, Fukumaki Y, Niho Y, Sasaki H (2001) Expression of DNA methyltransferases DNMT1, 3 A, and 3B in normal hematopoiesis and in acute and chronic myelogenous leukemia. Blood 97(5):1172–1179CrossRefPubMed

61.

Sun J, Ji J, Huo G, Song Q, Zhang X (2015) miR-182 induces cervical cancer cell apoptosis through inhibiting the expression of DNMT3a. Int J Clin Exp Pathol 8(5):4755–4763PubMedPubMedCentral

62.

van Kempen PM, Noorlag R, Braunius WW, Stegeman I, Willems SM, Grolman W (2014) Differences in methylation profiles between HPV-positive and HPV-negative oropharynx squamous cell carcinoma: a systematic review. Epigenetics 9(2):194–203. doi:10.4161/epi.26881 CrossRefPubMed

63.

Leung RC, Liu SS, Chan KY, Tam KF, Chan KL, Wong LC, Ngan HY (2008) Promoter methylation of death-associated protein kinase and its role in irradiation response in cervical cancer. Oncol Rep 19(5):1339–1345PubMed

64.

Kim YI (2006) Folate: a magic bullet or a double edged sword for colorectal cancer prevention? Gut 55(10):1387–1389. doi:10.1136/gut.2006.095463 CrossRefPubMedPubMedCentral

65.

Bistulfi G, Foster BA, Karasik E, Gillard B, Miecznikowski J, Dhiman VK, Smiraglia DJ (2011) Dietary folate deficiency blocks prostate cancer progression in the TRAMP model. Cancer Prev Res (Phila) 4(11):1825–1834. doi:10.1158/1940-6207.CAPR-11-0140 CrossRef

66.

Deghan Manshadi S, Ishiguro L, Sohn KJ, Medline A, Renlund R, Croxford R, Kim YI (2014) Folic acid supplementation promotes mammary tumor progression in a rat model. PLoS One 9(1):e84635. doi:10.1371/journal.pone.0084635 CrossRefPubMedPubMedCentral

67.

Kadaveru K, Protiva P, Greenspan EJ, Kim YI, Rosenberg DW (2012) Dietary methyl donor depletion protects against intestinal tumorigenesis in Apc(Min/+) mice. Cancer Prev Res (Phila) 5(7):911–920. doi:10.1158/1940-6207.CAPR-11-0544 CrossRef

Title: Methyl-donor depletion of head and neck cancer cells in vitro establishes a less aggressive tumour cell phenotype
Authors: Vanessa Hearnden
Hilary J. Powers
Abeir Elmogassabi
Rosanna Lowe
Craig Murdoch
Publication date: 01-06-2018
Publisher: Springer Berlin Heidelberg
Published in: European Journal of Nutrition / Issue 4/2018
Print ISSN: 1436-6207
Electronic ISSN: 1436-6215
DOI: https://doi.org/10.1007/s00394-017-1411-5

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