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Published in: Breast Cancer Research 1/2009

Open Access 01-06-2009 | Research article

Prediction of paclitaxel sensitivity by CDK1 and CDK2 activity in human breast cancer cells

Authors: Satoshi Nakayama, Yasuhiro Torikoshi, Takeshi Takahashi, Tomokazu Yoshida, Tamotsu Sudo, Tomoko Matsushima, Yuko Kawasaki, Aya Katayama, Keigo Gohda, Gabriel N Hortobagyi, Shinzaburo Noguchi, Toshiyuki Sakai, Hideki Ishihara, Naoto T Ueno

Published in: Breast Cancer Research | Issue 1/2009

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Abstract

Introduction

Paclitaxel is used widely in the treatment of breast cancer. Not all tumors respond to this drug, however, and the characteristics that distinguish resistant tumors from sensitive tumors are not well defined. Activation of the spindle assembly checkpoint is required for paclitaxel-induced cell death. We hypothesized that cyclin-dependent kinase (CDK) 1 activity and CDK2 activity in cancer cells, which reflect the activation state of the spindle assembly checkpoint and the growth state, respectively, predict sensitivity to paclitaxel.

Methods

Cell viability assays and DNA and chromatin morphology analyses were performed in human breast cancer cell lines to evaluate sensitivity to paclitaxel and the cell cycle response to paclitaxel. We then examined the specific activities of CDK1 and CDK2 in these cell lines and in xenograft models of human breast cancer before and after paclitaxel treatment. Protein expression and kinase activity of CDKs and cyclins were analyzed using a newly developed assay system.

Results

In the cell lines, biological response to paclitaxel in vitro did not accurately predict sensitivity to paclitaxel in vivo. Among the breast cancer xenograft tumors, however, tumors with significantly increased CDK1 specific activity after paclitaxel treatment were sensitive to paclitaxel in vivo, whereas tumors without such an increase were resistant to paclitaxel in vivo. Baseline CDK2 specific activity was higher in tumors that were sensitive to paclitaxel than in tumors that were resistant to paclitaxel.

Conclusions

The change in CDK1 specific activity of xenograft tumors after paclitaxel treatment and the CDK2 specific activity before paclitaxel treatment are both associated with the drug sensitivity in vivo. Analysis of cyclin-dependent kinase activity in the clinical setting could be a powerful approach for predicting paclitaxel sensitivity.
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Literature
1.
go back to reference Holmes FA, Walters RS, Theriault RL, Forman AD, Newton LK, Raber MN, Buzdar AU, Frye DK, Hortobagyi GN: Phase II trial of Taxol, an active drug in the treatment of metastatic breast cancer. J Natl Cancer Inst. 1991, 83: 1797-1805. 10.1093/jnci/83.24.1797-a.CrossRefPubMed Holmes FA, Walters RS, Theriault RL, Forman AD, Newton LK, Raber MN, Buzdar AU, Frye DK, Hortobagyi GN: Phase II trial of Taxol, an active drug in the treatment of metastatic breast cancer. J Natl Cancer Inst. 1991, 83: 1797-1805. 10.1093/jnci/83.24.1797-a.CrossRefPubMed
2.
go back to reference Nabholtz JM, Gelmon K, Bontenbal M, Spielmann M, Catimel G, Conte P, Klaassen U, Namer M, Bonneterre J, Fumoleau P, Winograd B: Multicenter, randomized comparative study of two doses of paclitaxel in patients with metastatic breast cancer. J Clin Oncol. 1996, 14: 1858-1867.PubMed Nabholtz JM, Gelmon K, Bontenbal M, Spielmann M, Catimel G, Conte P, Klaassen U, Namer M, Bonneterre J, Fumoleau P, Winograd B: Multicenter, randomized comparative study of two doses of paclitaxel in patients with metastatic breast cancer. J Clin Oncol. 1996, 14: 1858-1867.PubMed
3.
go back to reference Bishop JF, Dewar J, Toner GC, Smith J, Tattersall MH, Olver IN, Ackland S, Kennedy I, Goldstein D, Gurney H, Walpole E, Levi J, Stephenson J, Canetta R: Initial paclitaxel improves outcome compared with CMFP combination chemotherapy as front-line therapy in untreated metastatic breast cancer. J Clin Oncol. 1999, 17: 2355-2364.PubMed Bishop JF, Dewar J, Toner GC, Smith J, Tattersall MH, Olver IN, Ackland S, Kennedy I, Goldstein D, Gurney H, Walpole E, Levi J, Stephenson J, Canetta R: Initial paclitaxel improves outcome compared with CMFP combination chemotherapy as front-line therapy in untreated metastatic breast cancer. J Clin Oncol. 1999, 17: 2355-2364.PubMed
4.
go back to reference Citron ML, Berry DA, Cirrincione C, Hudis C, Winer EP, Gradishar WJ, Davidson NE, Martino S, Livingston R, Ingle JN, Perez EA, Carpenter J, Hurd D, Holland JF, Smith BL, Sartor CI, Leung EH, Abrams J, Schilsky RL, Muss HB, Norton L: Randomized trial of dose-dense versus conventionally scheduled and sequential versus concurrent combination chemotherapy as postoperative adjuvant treatment of node-positive primary breast cancer: first report of Intergroup Trial C9741/Cancer and Leukemia Group B Trial 9741. J Clin Oncol. 2003, 21: 1431-1439. 10.1200/JCO.2003.09.081.CrossRefPubMed Citron ML, Berry DA, Cirrincione C, Hudis C, Winer EP, Gradishar WJ, Davidson NE, Martino S, Livingston R, Ingle JN, Perez EA, Carpenter J, Hurd D, Holland JF, Smith BL, Sartor CI, Leung EH, Abrams J, Schilsky RL, Muss HB, Norton L: Randomized trial of dose-dense versus conventionally scheduled and sequential versus concurrent combination chemotherapy as postoperative adjuvant treatment of node-positive primary breast cancer: first report of Intergroup Trial C9741/Cancer and Leukemia Group B Trial 9741. J Clin Oncol. 2003, 21: 1431-1439. 10.1200/JCO.2003.09.081.CrossRefPubMed
5.
go back to reference Henderson IC, Berry DA, Demetri GD, Cirrincione CT, Goldstein LJ, Martino S, Ingle JN, Cooper MR, Hayes DF, Tkaczuk KH, Fleming G, Holland JF, Duggan DB, Carpenter JT, Frei E, Schilsky RL, Wood WC, Muss HB, Norton L: Improved outcomes from adding sequential paclitaxel but not from escalating doxorubicin dose in an adjuvant chemotherapy regimen for patients with node-positive primary breast cancer. J Clin Oncol. 2003, 21: 976-983. 10.1200/JCO.2003.02.063.CrossRefPubMed Henderson IC, Berry DA, Demetri GD, Cirrincione CT, Goldstein LJ, Martino S, Ingle JN, Cooper MR, Hayes DF, Tkaczuk KH, Fleming G, Holland JF, Duggan DB, Carpenter JT, Frei E, Schilsky RL, Wood WC, Muss HB, Norton L: Improved outcomes from adding sequential paclitaxel but not from escalating doxorubicin dose in an adjuvant chemotherapy regimen for patients with node-positive primary breast cancer. J Clin Oncol. 2003, 21: 976-983. 10.1200/JCO.2003.02.063.CrossRefPubMed
6.
go back to reference Mamounas EP, Bryant J, Lembersky B, Fehrenbacher L, Sedlacek SM, Fisher B, Wickerham DL, Yothers G, Soran A, Wolmark N: Paclitaxel after doxorubicin plus cyclophosphamide as adjuvant chemotherapy for node-positive breast cancer: results from NSABP B-28. J Clin Oncol. 2005, 23: 3686-3696. 10.1200/JCO.2005.10.517.CrossRefPubMed Mamounas EP, Bryant J, Lembersky B, Fehrenbacher L, Sedlacek SM, Fisher B, Wickerham DL, Yothers G, Soran A, Wolmark N: Paclitaxel after doxorubicin plus cyclophosphamide as adjuvant chemotherapy for node-positive breast cancer: results from NSABP B-28. J Clin Oncol. 2005, 23: 3686-3696. 10.1200/JCO.2005.10.517.CrossRefPubMed
7.
go back to reference Blagosklonny MV, Giannakakou P, el-Deiry WS, Kingston DG, Higgs PI, Neckers L, Fojo T: Raf-1/bcl-2 phosphorylation: a step from microtubule damage to cell death. Cancer Res. 1997, 57: 130-135.PubMed Blagosklonny MV, Giannakakou P, el-Deiry WS, Kingston DG, Higgs PI, Neckers L, Fojo T: Raf-1/bcl-2 phosphorylation: a step from microtubule damage to cell death. Cancer Res. 1997, 57: 130-135.PubMed
8.
go back to reference Blagosklonny MV, Schulte T, Nguyen P, Trepel J, Neckers LM: Taxol-induced apoptosis and phosphorylation of Bcl-2 protein involves c-Raf-1 and represents a novel c-Raf-1 signal transduction pathway. Cancer Res. 1996, 56: 1851-1854.PubMed Blagosklonny MV, Schulte T, Nguyen P, Trepel J, Neckers LM: Taxol-induced apoptosis and phosphorylation of Bcl-2 protein involves c-Raf-1 and represents a novel c-Raf-1 signal transduction pathway. Cancer Res. 1996, 56: 1851-1854.PubMed
9.
go back to reference Yu D, Liu B, Jing T, Sun D, Price JE, Singletary SE, Ibrahim N, Hortobagyi GN, Hung MC: Overexpression of both p185c-erbB2 and p170mdr-1 renders breast cancer cells highly resistant to Taxol. Oncogene. 1998, 16: 2087-2094. 10.1038/sj.onc.1201729.CrossRefPubMed Yu D, Liu B, Jing T, Sun D, Price JE, Singletary SE, Ibrahim N, Hortobagyi GN, Hung MC: Overexpression of both p185c-erbB2 and p170mdr-1 renders breast cancer cells highly resistant to Taxol. Oncogene. 1998, 16: 2087-2094. 10.1038/sj.onc.1201729.CrossRefPubMed
10.
go back to reference Giannakakou P, Sackett DL, Kang YK, Zhan Z, Buters JT, Fojo T, Poruchynsky MS: Paclitaxel-resistant human ovarian cancer cells have mutant β-tubulins that exhibit impaired paclitaxel-driven polymerization. J Biol Chem. 1997, 272: 17118-17125. 10.1074/jbc.272.27.17118.CrossRefPubMed Giannakakou P, Sackett DL, Kang YK, Zhan Z, Buters JT, Fojo T, Poruchynsky MS: Paclitaxel-resistant human ovarian cancer cells have mutant β-tubulins that exhibit impaired paclitaxel-driven polymerization. J Biol Chem. 1997, 272: 17118-17125. 10.1074/jbc.272.27.17118.CrossRefPubMed
11.
go back to reference Sève P, Mackey J, Isaac S, Trédan O, Souquet PJ, Pérol M, Lai R, Voloch A, Dumontet C: Class III β-tubulin expression in tumor cells predicts response and outcome in patients with non-small cell lung cancer receiving paclitaxel. Mol Cancer Ther. 2005, 4: 2001-2007. 10.1158/1535-7163.MCT-05-0244.CrossRefPubMed Sève P, Mackey J, Isaac S, Trédan O, Souquet PJ, Pérol M, Lai R, Voloch A, Dumontet C: Class III β-tubulin expression in tumor cells predicts response and outcome in patients with non-small cell lung cancer receiving paclitaxel. Mol Cancer Ther. 2005, 4: 2001-2007. 10.1158/1535-7163.MCT-05-0244.CrossRefPubMed
12.
go back to reference Yu D: Mechanisms of ErbB2-mediated paclitaxel resistance and trastuzumab-mediated paclitaxel sensitization in ErbB2-overexpressing breast cancers. Semin Oncol. 2001, 28 (5 Suppl 16): 12-17. 10.1016/S0093-7754(01)90277-5.CrossRefPubMed Yu D: Mechanisms of ErbB2-mediated paclitaxel resistance and trastuzumab-mediated paclitaxel sensitization in ErbB2-overexpressing breast cancers. Semin Oncol. 2001, 28 (5 Suppl 16): 12-17. 10.1016/S0093-7754(01)90277-5.CrossRefPubMed
13.
go back to reference Andre F, Hatzis C, Anderson K, Sotiriou C, Mazouni C, Mejia J, Wang B, Hortobagyi GN, Symmans WF, Pusztai L: Microtubule-associated protein tau is a bifunctional predictor of endocrine sensitivity and chemotherapy resistance in estrogen receptor-positive breast cancer. Clin Cancer Res. 2007, 13: 2061-2067. 10.1158/1078-0432.CCR-06-2078.CrossRefPubMed Andre F, Hatzis C, Anderson K, Sotiriou C, Mazouni C, Mejia J, Wang B, Hortobagyi GN, Symmans WF, Pusztai L: Microtubule-associated protein tau is a bifunctional predictor of endocrine sensitivity and chemotherapy resistance in estrogen receptor-positive breast cancer. Clin Cancer Res. 2007, 13: 2061-2067. 10.1158/1078-0432.CCR-06-2078.CrossRefPubMed
14.
go back to reference Sudo T, Nitta M, Saya H, Ueno NT: Dependence of paclitaxel sensitivity on a functional spindle assembly checkpoint. Cancer Res. 2004, 64: 2502-2508. 10.1158/0008-5472.CAN-03-2013.CrossRefPubMed Sudo T, Nitta M, Saya H, Ueno NT: Dependence of paclitaxel sensitivity on a functional spindle assembly checkpoint. Cancer Res. 2004, 64: 2502-2508. 10.1158/0008-5472.CAN-03-2013.CrossRefPubMed
15.
go back to reference Nigg EA: Mitotic kinases as regulators of cell division and its checkpoints. Nat Rev Mol Cell Biol. 2001, 2: 21-32. 10.1038/35048096.CrossRefPubMed Nigg EA: Mitotic kinases as regulators of cell division and its checkpoints. Nat Rev Mol Cell Biol. 2001, 2: 21-32. 10.1038/35048096.CrossRefPubMed
16.
go back to reference Meikrantz W, Schlegel R: Suppression of apoptosis by dominant negative mutants of cyclin-dependent protein kinases. J Biol Chem. 1996, 271: 10205-10209. 10.1074/jbc.271.17.10205.CrossRefPubMed Meikrantz W, Schlegel R: Suppression of apoptosis by dominant negative mutants of cyclin-dependent protein kinases. J Biol Chem. 1996, 271: 10205-10209. 10.1074/jbc.271.17.10205.CrossRefPubMed
17.
go back to reference Shen SC, Huang TS, Jee SH, Kuo ML: Taxol-induced p34cdc2 kinase activation and apoptosis inhibited by 12-O-tetradecanoylphorbol-13-acetate in human breast MCF-7 carcinoma cells. Cell Growth Differ. 1998, 9: 23-29.PubMed Shen SC, Huang TS, Jee SH, Kuo ML: Taxol-induced p34cdc2 kinase activation and apoptosis inhibited by 12-O-tetradecanoylphorbol-13-acetate in human breast MCF-7 carcinoma cells. Cell Growth Differ. 1998, 9: 23-29.PubMed
18.
go back to reference Wang TH, Wang HS, Soong YK: Paclitaxel-induced cell death: where the cell cycle and apoptosis come together. Cancer. 2000, 88: 2619-2628. 10.1002/1097-0142(20000601)88:11<2619::AID-CNCR26>3.0.CO;2-J.CrossRefPubMed Wang TH, Wang HS, Soong YK: Paclitaxel-induced cell death: where the cell cycle and apoptosis come together. Cancer. 2000, 88: 2619-2628. 10.1002/1097-0142(20000601)88:11<2619::AID-CNCR26>3.0.CO;2-J.CrossRefPubMed
19.
go back to reference Arriola E, Moreno A, Varela M, Serra JM, Falo C, Benito E, Escobedo AP: Predictive value of HER-2 and topoisomerase IIα in response to primary doxorubicin in breast cancer. Eur J Cancer. 2006, 42: 2954-2960. 10.1016/j.ejca.2006.06.013.CrossRefPubMed Arriola E, Moreno A, Varela M, Serra JM, Falo C, Benito E, Escobedo AP: Predictive value of HER-2 and topoisomerase IIα in response to primary doxorubicin in breast cancer. Eur J Cancer. 2006, 42: 2954-2960. 10.1016/j.ejca.2006.06.013.CrossRefPubMed
20.
go back to reference Muss HB, Thor AD, Berry DA, Kute T, Liu ET, Koerner F, Cirrincione CT, Budman DR, Wood WC, Barcos M, Henderson IC: c-erbB-2 expression and response to adjuvant therapy in women with node-positive early breast cancer. N Engl J Med. 1994, 330: 1260-1266. 10.1056/NEJM199405053301802.CrossRefPubMed Muss HB, Thor AD, Berry DA, Kute T, Liu ET, Koerner F, Cirrincione CT, Budman DR, Wood WC, Barcos M, Henderson IC: c-erbB-2 expression and response to adjuvant therapy in women with node-positive early breast cancer. N Engl J Med. 1994, 330: 1260-1266. 10.1056/NEJM199405053301802.CrossRefPubMed
21.
go back to reference van Diest PJ, Wall van der E, Baak JP: Prognostic value of proliferation in invasive breast cancer: a review. J Clin Pathol. 2004, 57: 675-681. 10.1136/jcp.2003.010777.CrossRefPubMedPubMedCentral van Diest PJ, Wall van der E, Baak JP: Prognostic value of proliferation in invasive breast cancer: a review. J Clin Pathol. 2004, 57: 675-681. 10.1136/jcp.2003.010777.CrossRefPubMedPubMedCentral
22.
go back to reference Potemski P, Kusinska R, Watala C, Pluciennik E, Bednarek AK, Kordek R: Cyclin E expression in breast cancer correlates with negative steroid receptor status, HER2 expression, tumor grade and proliferation. J Exp Clin Cancer Res. 2006, 25: 59-64.PubMed Potemski P, Kusinska R, Watala C, Pluciennik E, Bednarek AK, Kordek R: Cyclin E expression in breast cancer correlates with negative steroid receptor status, HER2 expression, tumor grade and proliferation. J Exp Clin Cancer Res. 2006, 25: 59-64.PubMed
23.
go back to reference Morgan DO: Cyclin-dependent kinases: engines, clocks, and microprocessors. Annu Rev Cell Dev Biol. 1997, 13: 261-291. 10.1146/annurev.cellbio.13.1.261.CrossRefPubMed Morgan DO: Cyclin-dependent kinases: engines, clocks, and microprocessors. Annu Rev Cell Dev Biol. 1997, 13: 261-291. 10.1146/annurev.cellbio.13.1.261.CrossRefPubMed
24.
go back to reference Dougherty MK, Schumaker LM, Jordan VC, Welshons WV, Curran EM, Ellis MJ, El-Ashry D: Estrogen receptor expression and sensitivity to paclitaxel in breast cancer. Cancer Biol Ther. 2004, 3: 460-467.CrossRefPubMed Dougherty MK, Schumaker LM, Jordan VC, Welshons WV, Curran EM, Ellis MJ, El-Ashry D: Estrogen receptor expression and sensitivity to paclitaxel in breast cancer. Cancer Biol Ther. 2004, 3: 460-467.CrossRefPubMed
25.
go back to reference Ishihara H, Yoshida T, Kawasaki Y, Kobayashi H, Yamasaki M, Nakayama S, Miki E, Shohmi K, Matsushima T, Tada S, Torikoshi Y, Morita M, Tamura S, Hino Y, Kamiyama J, Sowa Y, Tsuchihashi Y, Yamagishi H, Sakai T: A new cancer diagnostic system based on a CDK profiling technology. Biochim Biophys Acta. 2005, 1741: 226-233.CrossRefPubMed Ishihara H, Yoshida T, Kawasaki Y, Kobayashi H, Yamasaki M, Nakayama S, Miki E, Shohmi K, Matsushima T, Tada S, Torikoshi Y, Morita M, Tamura S, Hino Y, Kamiyama J, Sowa Y, Tsuchihashi Y, Yamagishi H, Sakai T: A new cancer diagnostic system based on a CDK profiling technology. Biochim Biophys Acta. 2005, 1741: 226-233.CrossRefPubMed
26.
go back to reference Wehland J, Henkart M, Klausner R, Sandoval IV: Role of microtubules in the distribution of the Golgi apparatus: effect of taxol and microinjected anti-α-tubulin antibodies. Proc Natl Acad Sci USA. 1983, 80: 4286-4290. 10.1073/pnas.80.14.4286.CrossRefPubMedPubMedCentral Wehland J, Henkart M, Klausner R, Sandoval IV: Role of microtubules in the distribution of the Golgi apparatus: effect of taxol and microinjected anti-α-tubulin antibodies. Proc Natl Acad Sci USA. 1983, 80: 4286-4290. 10.1073/pnas.80.14.4286.CrossRefPubMedPubMedCentral
27.
go back to reference Hasegawa Y, Goto M, Hanai N, Ijichi K, Adachi M, Terada A, Hyodo I, Ogawa T, Furukawa T: Evaluation of optimal drug concentration in histoculture drug response assay in association with clinical efficacy for head and neck cancer. Oral Oncol. 2007, 43: 749-756. 10.1016/j.oraloncology.2006.09.003.CrossRefPubMed Hasegawa Y, Goto M, Hanai N, Ijichi K, Adachi M, Terada A, Hyodo I, Ogawa T, Furukawa T: Evaluation of optimal drug concentration in histoculture drug response assay in association with clinical efficacy for head and neck cancer. Oral Oncol. 2007, 43: 749-756. 10.1016/j.oraloncology.2006.09.003.CrossRefPubMed
28.
go back to reference Ohie S, Udagawa Y, Kozu A, Komuro Y, Aoki D, Nozawa S, Moossa AR, Hoffman RM: Cisplatin sensitivity of ovarian cancer in the histoculture drug response assay correlates to clinical response to combination chemotherapy with cisplatin, doxorubicin and cyclophosphamide. Anticancer Res. 2000, 20: 2049-2054.PubMed Ohie S, Udagawa Y, Kozu A, Komuro Y, Aoki D, Nozawa S, Moossa AR, Hoffman RM: Cisplatin sensitivity of ovarian cancer in the histoculture drug response assay correlates to clinical response to combination chemotherapy with cisplatin, doxorubicin and cyclophosphamide. Anticancer Res. 2000, 20: 2049-2054.PubMed
29.
go back to reference Jänicke RU, Sprengart ML, Wati MR, Porter AG: Caspase-3 is required for DNA fragmentation and morphological changes associated with apoptosis. J Biol Chem. 1998, 273: 9357-9360. 10.1074/jbc.273.16.9357.CrossRefPubMed Jänicke RU, Sprengart ML, Wati MR, Porter AG: Caspase-3 is required for DNA fragmentation and morphological changes associated with apoptosis. J Biol Chem. 1998, 273: 9357-9360. 10.1074/jbc.273.16.9357.CrossRefPubMed
30.
go back to reference Lu KH, Lue KH, Chou MC, Chung JG: Paclitaxel induces apoptosis via caspase-3 activation in human osteogenic sarcoma cells (U-2 OS). J Orthop Res. 2005, 23: 988-994. 10.1016/j.orthres.2005.01.018.CrossRefPubMed Lu KH, Lue KH, Chou MC, Chung JG: Paclitaxel induces apoptosis via caspase-3 activation in human osteogenic sarcoma cells (U-2 OS). J Orthop Res. 2005, 23: 988-994. 10.1016/j.orthres.2005.01.018.CrossRefPubMed
Metadata
Title
Prediction of paclitaxel sensitivity by CDK1 and CDK2 activity in human breast cancer cells
Authors
Satoshi Nakayama
Yasuhiro Torikoshi
Takeshi Takahashi
Tomokazu Yoshida
Tamotsu Sudo
Tomoko Matsushima
Yuko Kawasaki
Aya Katayama
Keigo Gohda
Gabriel N Hortobagyi
Shinzaburo Noguchi
Toshiyuki Sakai
Hideki Ishihara
Naoto T Ueno
Publication date
01-06-2009
Publisher
BioMed Central
Published in
Breast Cancer Research / Issue 1/2009
Electronic ISSN: 1465-542X
DOI
https://doi.org/10.1186/bcr2231

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