Different mechanisms of drug resistance to hypomethylating agents in the treatment of myelodysplastic syndromes and acute myeloid leukemia
Introduction
Cancer is one of the main causes of morbidity and mortality in all regions of the world, and its incidence is constantly increasing (Bray et al., 2018). Hematologic malignancies represent a group of diseases derived from bone marrow cells and the lymphatic system with diverse etiologies, incidences, prognoses and survival (Loda et al., 2017). The myelodysplastic syndromes (MDS) comprise a heterogenous group of clonal hematopoietic malignancies characterized by ineffective hematopoiesis, progressive bone marrow failure, cytogenetic and molecular abnormalities and different risks of progression to acute myeloid leukemia (AML) (Cogle, 2015; Messingerova et al., 2016). AML is a heterogeneous neoplastic blood disease with characteristic clonal expansion and accumulation of abnormally differentiated leukemic myeloid blasts in the bone marrow, peripheral blood, and other tissues (Döhner et al., 2015; O’Donnell et al., 2017; Short et al., 2018). Therapy for patients with MDS is focused on reducing symptoms associated with disease and risk of disease progression to AML and improving quality of life. Because of the heterogeneity of MDS, treatment options include different approaches from supportive care to treatment with hypomethylating agents (HMAs) (Steensma, 2018). However, treatment efficacy is frequently limited by the chemoresistance phenotype of cancer cells (Assaraf et al., 2019; Gonen and Assaraf, 2012; Levin et al., 2019, 2021; Li et al., 2016). Chemoresistance is classified into two distinct categories: intrinsic or primary resistance, which is present in tumor cells from the beginning (based on the phenotype of the cells from which the tumor developed and the course of tumor transformation) before the chemotherapeutic agent is administered, and acquired or secondary resistance that develops in initially sensitive cells in response to the toxic stress of chemotherapeutics (Longley and Johnston, 2005). During the development of secondary resistance of tumor cells by repeated exposures to individual chemotherapeutic agents, cross-resistance to pharmacologically related substances and compounds with similar structures and biochemical properties (such as nucleoside analogs) may emerge, as these compounds are often dependent on the same transporters and specific metabolizing pathways or are aimed at the same intracellular targets (Moscow et al., 2010). Resistance to multiple drugs (multidrug resistance, MDR) can also develop, where cells are resistant to a wide range of substances, with no apparent relationship in chemical structure and a fundamentally different mechanism of action (Breier et al., 2013; Li et al., 2016;Wang et al., 2021). Primary and secondary resistance is also a significant problem in the treatment of hematological malignancies, including the treatment of patients with MDS and AML.
For AML and high-risk MDS patients who are not suitable for hematopoietic stem cell transplantation, a suitable treatment protocol is the application of HMAs such as 5-azacytidine (AZA) and 5-aza-2′-deoxycytidine (DAC), which have been found to be beneficial in the treatment of high-risk MDS (Steensma, 2018) and AML (Kubasch and Platzbecker, 2018). However, only 30–60 % of patients with MDS and 18–47 % of patients with AML respond to hypomethylation therapy. Another group of patients responds in the initial cycles of HMA therapy, but the response decreases or disappears during subsequent cycles of treatment. The occurrence of a reduced response to HMAs then significantly worsens the patient's further prognosis and survival time, as no follow-up therapy is approved for these patients (Duong et al., 2014). Resistance to treatment with HMAs is a complex phenomenon in which multiple molecular causes may be involved, working together to eliminate the cytotoxic effect of HMAs on myeloid blasts.
Section snippets
Resistance to chemotherapeutic treatment
As already mentioned, there is a group of patients with high-risk MDS and AML which are not suitable for induction therapy or hematopoietic stem cell transplantation who do not respond to HMAs. The causes of resistance may be specific for AZA and DAC or may be more general by activating drug detoxification, drug efflux, and accelerating cell renewal mechanisms, which may involve decreased sensitivity of myeloid blasts to other drugs with fundamentally different structures and mechanisms of
Different mechanisms of resistance to AZA and DAC
AZA and DAC are cytosine nucleoside analogs linked to either ribose or 2-deoxyribose, first synthesized in Czechoslovakia in 1964 (Pískala and Šorm, 1964; Pliml and Šorm, 1964). Both drugs have the carbon atom at position 5 of the pyrimidine ring replaced by a nitrogen atom. It is the carbon at this position that is usually methylated by DNA methyltransferases (DNMTs). The mechanism of action of AZA and DAC is not fully understood but could be the result of a combination of hypomethylating
Cross-resistance to hypomethylating agents
Despite the related structure, a different mechanism of primary resistance can be expected for AZA and DAC, as no correlation was observed between the IC50 values for these drugs in human leukemia cell lines THP-1, OCI-AML2, OCI-AML3, MOLM-13, PL-21, HL-60, MV4−11, SIG-M5, ML2, NB4, KG1, MonoMac6, and HEL (Oellerich et al., 2019); or human leukemia and lymphoma cell lines HL60, ML-1, HEL, Raji, Jurkat, TF-1, U937, K562, and MOLT4; prostate cancer cell lines PC3 and DU145; colon cancer cell
Drug uptake
Nucleoside analogs used in cancer and antiviral therapy are transported into cells by two solute carrier (SLC) families: SLC28, also known as the concentrative nucleoside transporter (CNT) family, and SLC29, or the equilibrative nucleoside transporter (ENT) family. The SLC28 family comprises three Na+-dependent cotransporters with different substrate specificities. While CNT1 (encoded by the SLC28A1 gene) prefers pyrimidine as a transport substrate, CNT2 (encoded by the SLC28A2 gene) prefers
Drug efflux
Chemoresistant tumor cells can be not only cross-resistant to structurally and biochemically similar compounds but can also exhibit reduced sensitivity simultaneously to several structurally and functionally different substances. This phenomenon is called multidrug resistance (MDR). The first mechanism of MDR discovered was an increase in the expression of the ABCB1 (MDR1) gene encoding P-glycoprotein (Assaraf et al., 2019; Bellamy et al., 1990; Lepeltier et al., 2020; Li et al., 2016; Su et
Drug metabolism
Inside the cells, activation of the prodrugs AZA and DAC is necessary. The first rate-limiting step is their phosphorylation to the corresponding monophosphate, which is mediated by two different enzymes. While AZA is phosphorylated by uridine-cytidine kinase (UCK), DAC is phosphorylated by deoxycytidine kinase (DCK) (Qin et al., 2009). Changes in the expression of these enzymes could affect the sensitivity of cells to drugs.
In the NCI-60 cancer cell line panel, there was a correlation between
Alterations in DNA damage response
The DNA damage response (DDR) has a crucial role in the normal physiology of the cell, as the maintenance of genomic stability is required for its proper function. As a reaction to the occurrence of DNA damage, DDR will initiate DNA damage repair, but if the damage is too severe and cannot be repaired, apoptosis will be initiated (J. Y. J. Wang, 2019). Alterations in DDR represent a double-edged sword. Disruption of DNA repair can promote mutation propagation and lead to the development of
Alterations in regulation of apoptosis
One of the goals of chemotherapy treatment is the selective induction of apoptosis in neoplastic cells. Apoptosis is the most common mechanism of cell death induced by chemotherapeutics (Ouyang et al., 2012; Shahar and Larisch, 2020). Therefore, defects in apoptotic regulatory pathways may lead to the development of drug resistance (Carneiro and El-Deiry, 2020). For example, deregulation of proapoptotic APAF1 leads to chemoresistance and poor patient outcomes in melanomas (Fujimoto et al., 2004
Possible role of leukemic stem cells in chemoresistance
The presence of chemoresistant leukemic stem cells (LSCs) in niches in the bone marrow (BM) microenvironment may be another mechanism of hematologic malignancy relapse. Niches represent a BM area where hematopoietic stem cells (HSCs) reside under physiological conditions and are protected from environmental stress. The major mediator of HSC migration and homing in the BM is the CXCR4 receptor expressed on the surface of HSCs, which binds to its ligand CXCL12 (produced by BM stromal cells).
Conclusions
Despite the intense interest in the resistance of MDS and AML cells to HMAs, the mechanisms that may reduce the response of these cells to HMAs are not known in detail; therefore, this issue is not fully understood. However, given the many different results of individual studies, we must conclude that there are multiple cellular mechanisms of protection against HMAs. The possibility that only one mechanism of resistance to DAC and AZA alone or both together applies must be ruled out.
The most
Data availability
Data will be made available on request.
No data was used for the research described in the article.
Acknowledgment
This paper was supported by COST actionCA17104-STRATAGEM, and also by MVTS COSTCA17104. Our laboratory is supported by Slovak Research and Development Agency, grant No.: APVV-19-0093 and APVV-19-0094.
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Kristína Šimoničová and Ľuboš Janotka contributed equally to this work.