Abstract
Chronic lymphocytic leukaemia (CLL) is a malignant lymphoproliferative disease characterized by a dramatic resistance to spontaneous and drug-induced apoptosis. In the present review the role of endogenous nitric oxide (NO) in this resistance has been analysed. Although a contribution of NOS3 cannot be excluded, NO is mainly produced by an inducible NOS (NOS2) that is constitutively expressed by the leukaemia cells, at variance with normal B lymphocytes. The expression of this enzyme in the tumour cells appears to be regulated by engagement of the toll-like receptor-7 (TLR-7) and is modulated by the ligation of the low-affinity IgE receptor/CD23 and by various cytokines such as interleukin-4 (IL-4) and IFN-γ.
According to its concentration, flux, cell type and redox state, NO exerts contrasting effects on apoptosis, activating transduction pathways leading to apoptosis, whereas in other cases protecting cells against spontaneous or induced apoptosis. In CLL cells, the level of endogenous NO is correlated with the abundance of mitochondria and resistance to apoptosis. NO inactivates caspase(s) through oxidation and S-nitrosylation of a cysteine present in their active site, providing an efficient means to block apoptosis. Conversely, a caspase-sensitive down-regulation of iNOS expression and of NO production appears to be associated with the induction of apoptosis by a variety of reagents. Other protective effects of NO on apoptosis probably rely on the modulation through S-nitrosylation-dependent and S-nitrosylation-independent pathways of members of the Bcl-2/Bax family that control the release of apoptogenic factors by mitochondria. If appropriately targeted, NOS inhibitors would provide an efficient mean to reinduce apoptosis in CLL cells and to allow the development of a new therapeutic approach.
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References
Adams, D.J., Levesque, M.C., Weinberg, J.B., Smith, K.L., Flowers, J.L., Moore, J., Colvin, O.M. and Silber, R. (2001). Nitric oxide enhancement of fludarabine cytotoxicity for B-CLL lymphocytes. Leukemia 15, 1852–1859.
Azad, N., Vallyathan, V., Wang, L., Tantishaiyakul, V., Stehlik, C., Leonard, S.S., and Rojanasakul, Y. (2006). S-nitrosylation of Bcl-2 inhibits its ubiquitin-proteasomal degradation: a novel anti-apoptotic mechanism that suppresses apoptosis. J. Biol. Chem. 281, 34124–34134.
Bäckman, E., Bergh, A.C., Lagerdahl, I., Rydberg, B., Sundström, C., Tobin, G., Rosenquist, R., Linderholm, M., and Rosén, A. (2007). Thioredoxin, produced by stromal cells retrieved from the lymph node microenvironment, rescues chronic lymphocytic leukemia cells from apoptosis in vitro Haematologica 92, 1495–1504.
Bakan, N., Taysi, S., Yilmaz, O., Bakan, E., Kuskay, S., Uzun, N., and Gündogdu, M. (2003). Glutathione peroxidase, glutathione reductase, Cu-Zn superoxide dismutase activities, glutathione, nitric oxide, and malondialdehyde concentrations in serum of patients with chronic lymphocytic leukemia. Clin. Chim. Acta. 338, 143–149.
Banerjee, A. and Gerondakis, S. (2007). Coordinating TLR-activated signaling pathways in cells of the immune system. Immunol Cell Biol. 85, 420–424.
Benhar, M., Forrester, M.T., Hess, D.T., and Stamler J.S. (2008). Regulated protein denitrosylation by cytosolic and mitochondrial thioredoxins. Science. 320, 1050–1054.
Billard, C., Izard, J.C., Roman, V., Kern, C., Mathiot, C., Mentz, F., and Kolb, J.P. (2002). Comparative antiproliferative and apoptotic effects of resveratrol, epsilon-viniferin and vine-shots derived polyphenols (vineatrols) on chronic B lymphocytic leukemia cells and normal human lymphocytes. Leuk. Lymphoma. 43, 1991–2002.
Billard, C., Quiney, C., Tang, R., Kern, C., Ajchenbaum-Cymbalista, F., Dauzonne, D., and Kolb, J.P. (2003a). The inducible NO synthase is downregulated during apoptosis of malignant cells from B-cell chronic lymphocytic leukemia induced by flavopiridol and polyphenols. Ann. N. Y. Acad. Sci. 1010, 381–383.
Billard, C., Kern, C., Tang, R., Ajchenbaum-Cymbalista, F., and Kolb, J.P. (2003b). Flavopiridol downregulates the expression of both the inducible NO synthase and p27(kip1) in malignant cells from B-cell chronic lymphocytic leukemia. Leukemia. 17, 2435–2443.
Billard, C., Menasria, F., Quiney, C., Faussat, A.M., and Kolb, J.P. (2008a). Flavopiridol-induced iNOS downregulation during apoptosis of chronic lymphocytic leukemia cells is caspase-dependent. Leuk. Res. 32, 755–760.
Billard, C., Menasria, F., Quiney, C., Faussat, A.M., Finet, J.P., Combes, S., Kolb, J.P. (2008b). 4-Arylcoumarin analogues of combretastatins stimulate apoptosis of leukemic cells from chronic lymphocytic leukemia patients. Exp. Hematol. 36, 1625–1633.
Caligaris-Cappio, F. and Ghia, P. (2008). Novel insights in chronic lymphocytic leukemia: are we getting closer to understanding the pathogenesis of the disease? J Clin Oncol. 2008 26, 4497–4503.
Carew, J.S., Nawrocki, S.T., Xu, R.H., Dunner, K., McConkey, D.J., Wierda, W.G., Keating, M.J., and Huang P. (2004). Increased mitochondrial biogenesis in primary leukemia cells: the role of endogenous nitric oxide and impact on sensitivity to fludarabine. Leukemia 18, 1934–1940.
Cimmino, A., Calin, G.A., Fabbri, M., Iorio, M.V., Ferracin, M., Shimizu, M., Wojcik, S.E., Aqeilan, R.I., Zupo, S., Dono, M., Rassenti, L., Alder, H., Volinia, S., Liu, C.G., Kipps, T.J., Negrini, M., and Croce, C.M. (2005). miR-15 and miR-16 induce apoptosis by targeting BCL2. Proc. Natl. Acad. Sci. USA 102, 13944–13949.
Cioca, D.P. and Kitano, K. (2002). Apoptosis induction by hypercross-linking of the surface antigen CD5 with anti-CD5 monoclonal antibodies in B cell chronic lymphocytic leukemia. Leukemia 16, 335–343.
Coenen, S., Pickering, B., Potter, K.N., Johnson, P.W.M., Stevenson, F.K., and Packham, G. (2005). Sequence insertions in the Mcl-1 promoter in chronic lymphocytic leukemia are not associated with prognostic markers and are present in normal cells. Hematologica 90, 1285–1286.
Couch, R.D., Browning, R.G., Honda, T., Gribble, G.W., Wright, D.L., Sporn, M.B., and Anderson, A.C. (2005). Studies on the reactivity of CDDO, a promising new chemopreventive and chemotherapeutic agent: Implications for a molecular mechanism of action. Bioorg. Med. Chem. Lett. 15, 2215–2219.
de Vera, M.E., Shapiro, R.A., Nussler, A.K., Mudgett, J.S., Simmons, R.L., Morris Jr, S.M., Billiar, T.R., and Geller, D.A. (1996). Transcriptional regulation of human inducible nitric oxide synthase (NOS2) gene by cytokines: initial analysis of the human NOS2 promoter. Proc. Natl. Acad. Sci. USA 93, 1054–1059.
Diebold, S.S., Kaisho, T., Hemmi, H., Akira, S., and Reis e Sousa, C. (2004). Innate antiviral responses by means of TLR7-mediated recognition of single-stranded RNA. Science 2003, 1529–1531.
Dimmeler, S., Haendeler, J., Nehls, M., and Zeiher, A.M. (1997). Suppression of apoptosis by nitric oxide via inhibition of interleukin-1beta-converting enzyme (ICE)-like and cysteine protease protein (CPP)-32-like proteases. J. Exp. Med. 185, 601–607.
Dimmeler, S., Haendeler, J., Sause, A., and Zeiher A.M. (1998). Nitric oxide inhibits APO-1/Fas-mediated cell death. Cell Growth Differ. 9, 415–422.
Dugas, B., Mossalayi, D.M., Damais, C., and Kolb, J.P. (1995). Nitric oxide production by human monocytes. Evidence for a role of CD23. Immunol. Today 16, 574–580.
Genaro, A.M., Hortelano, S., Alvarez, A., Martinez, C., and Bosca, L. (1995). Splenic B lymphocyte programmed cell death is prevented by nitric oxide release through mechanisms involving sustained Bcl-2 levels. J. Clin. Invest. 95, 1884–1890.
Gottardi, D., Alfarano, A., De Leo, A.M., Stacchini, A., Bergui, L., and Caligaris-Cappio, F. (1995). Defective apoptosis due to Bcl-2 overexpression may explain why B-CLL cells accumulate in G0. Curr. Top. Microbiol. Immunol. 194, 307–312.
Gottardi, D., Alfarano, A., De Leo, A.M., Stacchini, A., Aragno, M., Rigo, A., Veneri, D., Zanotti, R., Pizzolo, G., and Caligaris-Cappio, F. (1996). In leukemic CD5+ B cells the expression of BCL-2 gene family is shifted toward protection from apoptosis. Br. J. Haematol. 94, 612–618.
Haiat, S., Billard, C., Quiney, C., Ajchenbaum-Cymbalista, F., and Kolb, J.P. (2006). Role of BAFF and APRIL in human B-cell chronic lymphocytic leukemia, B-CLL. Immunology 118, 281–292.
Hammadi, A., Billard, C., Faussat, A.M., and Kolb, J.P. (2008). Stimulation of iNOS expression and apoptosis resistance in B-cell chronic lymphocytic leukemia (B-CLL) cells through engagement of Toll-like receptor 7 (TLR-7) and NF-κB activation. Nitric Oxide 19, 138–145.
Hammadi, A., Billard, C., Bauvois, B., Faussat, A.M., and Kolb, J.P. (2009). Stimulation of Toll-like receptor-7 enhances BAFF and APRIL pathways of survival in chronic lymphocytic leukemia cells. Open Leuk. J. 2, 15–24.
Heil, F., Hemmi, H., Hochrein, H., Ampenberger, F., Kirschning, C., Akira, S., Lipford, G., Wagner, H., and Bauer, S. (2004). Species-specific recognition of single-stranded RNA via toll-like receptor 7 and 8. Science 303, 1526–1529.
Holmgren, A. SNO removal. (2008). Science 320, 1019–1020.
Hortelano, S. and Bosca, L. (1997). 6-Mercaptopurine decreases the Bcl-2/Bax ratio and induces apoptosis in activated splenic B lymphocytes. Mol. Pharmacol. 51, 414–421.
Iyer, A.K., Azad, N., Wang, L., and Rojanasakul, Y. (2008). Role of S-nitrosylation in apoptosis resistance and carcinogenesis. Nitric Oxide 19, 146–151.
Kern, C., Cornuel, J.F., Billard, C., Tang, R., Rouillard, D., Stenou, V., Defrance, T., Ajchenbaum-Cymbalista, F., Simonin, P.Y., Feldblum, S., and Kolb, J.P. (2004). Involvement of BAFF and APRIL in the resistance to apoptosis of B-CLL through an autocrine pathway. Blood 103, 679–688.
Kern, C., Quiney, C., Billard, C., and Kolb, J.P. (2008). Control of B-CLL apoptosis by members of the TNF superfamily. Chapter 10, p 221–234. In Moreau B. (ed.), “Chronic lymphocytic leukemia: new research”. Inès. Nova Sciencepublisher, New York.
Kim, Y.M., Talanian, R.V., and Billiar, T.R. (1997). Nitric oxide inhibits apoptosis by preventing increases in caspase-3-like activity via two distinct mechanisms. J. Biol. Chem. 272, 31138–31148.
Kitada, S., Andersen, J., Akar, S., Zapata, J.M., Takayama, S., Krajewski, S., Wang, H.G., Zhang, X., Bullrich, F., Croce, C.M., Rai, K., Hines, J., and Reed, J.C. (1998). Expression of apoptosis-regulating proteins in chronic lymphocytic leukemia, correlations with in vitro and in vivo chemoresponses. Blood 91, 3379–3389.
Kolb, J.P. (2000). Mechanisms involved in the pro- and anti-apoptotic role of NO in human leukemia. Leukemia 14, 1685–1694.
Kolodziejski, P.J., Musial, A., Koo, J.S., and Eissa, N.T. (2002). Ubiquitination of inducible nitric oxide synthase is required for its degradation. Proc. Natl. Acad. Sci. USA 99, 12315–12320.
Kress, C.L., Konopleva, M., Martinez-Garcia, V., Krajewska, M., Lefebvre, S., Hyer, M.L., McQueen, T., Andreeff., M, Reed, J.C., and Zapata, J.M. (2007). Triterpenoids display single agent anti-tumor activity in a transgenic mouse model of chronic lymphocytic leukemia and small B cell lymphoma. PLoS ONE 2, e559.
Lanemo Myhrinder, A., Hellqvist, E., Sidorova, E., Soderberg, A., Baxendale, H., Dahle, C., Willander, K., Tobin, G., Backman, E., Soderberg, O., Rosenquist, R., Horkko, S., and Rosen, A. (2008). A new perspective: molecular motifs on oxidized LDL, apoptotic cells, and bacteria are targets for chronic lymphocytic leukemia antibodies. Blood 111, 3838–3848.
Levesque, M.C., Misukonis, M.A., O’Loughlin, C.W., Chen, Y., Beasley, B.E., Wilson, D.L., Adams, D.J., Silber, R., and Weinberg, J.B. (2003). IL-4 and interferon gamma regulate expression of inducible nitric oxide synthase in chronic lymphocytic leukemia cells. Leukemia 17, 442–450.
Levesque, M.C., Chen, Y., Beasley, B.E., O’Loughlin, C.W., Gockerman, J.P., Moore, J.O., and Weinberg, J.B. (2006). Chronic lymphocytic leukemia cell CD38 expression and inducible nitric oxide synthase expression are associated with serum IL-4 levels. Leuk. Res. 30, 24–28.
Levesque, M.C., Ghosh, D.K., Beasley, B.E., Chen, Y., Volkheimer A.D., O’Loughlin, C.W., Gockerman, J.P., Moore, J.O., and Weinberg, J.B. (2008). CLL cell apoptosis induced by nitric oxide synthase inhibitors: Correlation with lipid solubility and NOS1 dissociation constant. Leuk. Res. 32, 1061–1070.
Li, J., Billiar, T.R., Talanian, R.V., and Kim, Y.M. (1997). Nitric oxide reversibly inhibits seven members of the caspase family via S-nitrosylation. Biochem. Biophys. Res. Commun. 240, 419–424.
Li, J., Bombeck, C.A., Yang, S., Kim, Y.M., and Billiar, T.R. (1999). Nitric oxide suppresses apoptosis via interrupting caspase activation and mitochondrial dysfunction in cultures hepatocytes. J. Biol. Chem. 274, 17325–17333.
Lin, T.S. and Porcu, P. (2004). Flavopiridol: Where do we stand in chronic lymphocytic leukemia? (2004). Leukemia 18, 243–246.
Mannick, J.B., Asano, K., Izumi, K., Kieff, E., and Stamler, J.S. (1994). Nitric oxide produced by human lymphocytes inhibit apoptosis and Epstein-Barr virus reactivation. Cell 79, 1137–1146.
Mannick, J.B., Miao, X.Q., and Stamler, J.S. (1997). Nitric oxide inhibits Fas-induced apoptosis. J. Biol. Chem. 272, 24125–24128.
Mannick, J.B., Hausladen, A., Liu, L., Hess, D.T., Zeng, M., Miao, Q.X., Kane, L.S., Gow, A.J., and Stamler, J.S. (1999). Fas-induced caspase denitrosylation. Science 284, 651–654.
Marks-Konczalik, J., Chu, S.C., and Moss, J. (1998). Cytokine-mediated transcriptional induction of the human inducible nitric oxide synthase gene requires both Activator Protein 1 and Nuclear Factor kB-binding sites. J. Biol. Chem. 273, 22201–22208.
Medina-Palazon, C., Bernard, E., Frost, V., Morley, S., and Sinclair, A.J. (2004). KIPase activity is a novel caspase-like activity associated with cell proliferation. Eur J Biochem. 271, 2716–2723.
Mendes, R.V., Martins, A.R., de Nucci, G., Murad, F., and Soares, F.A. (2001). Expression of nitric oxide synthase isoforms and nitrotyrosine immunoreactivity by B-cell non-Hodgkin’s lymphomas and multiple myeloma. Histopathology 39, 172–178.
Messmer, B.T., Messmer, D., Allen, S.L., Kolitz, J.E., Kudalkar, P., Cesar, D., Murphy, E.J., Koduru, P., Ferrarini, M., Zupo, S., Cutrona, G., Damle, R.N., Wasil, T., Rai, K.R., Hellerstein, M.K., and Chiorazzi, N. (2005). In vivo measurements document the dynamic cellular kinetics of chronic lymphocytic leukemia B cells. J. Clin. Invest. 115, 755–764.
Mocellin, S., Bronte, V., and Nitti, D. (2007). Nitric oxide, a double edged sword in cancer biology: searching for therapeutic opportunities. Med Res Rev. 27, 317–352.
Mohr, S., Zech, B., Lapetina, E.G., and Brune, B. (1997). Inhibition of caspase-3 by S-nitrosation and oxidation caused by nitric oxide. Biochem. Biophys. Res. Commun. 238, 387–391.
Moshynska, O., Sankaran, K., Pahwa, P., and Saxena A. (2004). Prognostic significance of a short sequence insertion in the MCL-1 promoter in chronic lymphocytic leukemia. J. Natl. Cancer Inst. 96, 673–682.
Musial, A. and Eissa, N.T. (2001). Inducible nitric-oxide synthase is regulated by the proteasome degradation pathway. J. Biol. Chem. 276, 24268–24273.
Muzio, M., Scielzo, C., Bertilaccio, M., Frenquelli, M., Ghia, P., and Caligaris-Cappio, F. (2008). Expression and function of toll like receptors in chronic lymphocytic leukaemia cells. Br. J. Haematol. Nov 19; [Epub ahead of print].
Nikolaev, A.I., Dubovaia, V.I., Litvinov, D.I., Poltaraus, A.B., Ivanov, D.S., Amchenkova, A.M., Narovlianskiĭ, A.N., Panasiuk, A.F., Prasolov, V.S., and Turpaev, K.T. (2002). Identification of genes induced to chondrocytes by nitric oxide. Mol Biol (Mosk). 36, 833–841.
Nisoli, E., Clementi, E., Paolucci, C., Cozzi, V., Tonello, C., Sciorati, C., Bracale, R., Valerio, A., Francolini, M., Moncada, S., and Carruba, M.O. (2003). Mitochondrial biogenesis in mammals: The role of endogenous nitric oxide. Science 299, 896–899.
Nisoli, E., Falcone, S., Tonello, C., Cozzi, V., Palomba, L., Fiorani, M., Pisconti, A., Brunelli, S., Cardile, A., Francolini, M., Cantoni, O., Carruba, M.O., Moncada, S., and Clementi, E. (2004). Mitochondrial biogenesis by NO yields functionally active mitochondria in mammals. Proc. Natl. Acad. Sci. USA 101, 16507–16512.
Nunokawa, Y., Oikawa, S., and Tanaka, S. (1996). Human inducible nitric oxide synthase gene is transcriptionally regulated by nuclear factor-kappaB dependent mechanism. Biochem. Biophys. Res. Commun. 223, 347–352.
Paul-Eugene, N., Mossalayi, M.D., Sarfati, M., Yamaoka, K.A., Aubry, J.P., Bonnefoy, J.Y., Dugas, B., and Kolb, J.P. (1995). Evidence for a role of FcεRII/CD23 in the IL-4-induced nitric oxide production by normal human mononuclear phagocytes. Cell. Immunol. 163, 314–318.
Quiney, C., Dauzonne, D., Kern, C., Fourneron, J.D., Izard, J.C., Mohammad, R.M., Kolb, J.P., and Billard, C. (2004). Flavones and polyphenols inhibit the NO pathway during apoptosis of leukemia B-cells. Leuk. Res. 28, 851–861.
Quiney, C., Billard, C., Faussat, A.M., Salanoubat, C., Ensaf, A., Nait-Si, Y., Fourneron, J.D., and Kolb, J.P. (2006). Pro-apoptotic properties of hyperforin in leukemic cells from patients with B-cell chronic lymphocytic leukemia. Leukemia 20, 491–497.
Roman, V., Zhao, H., Fourneau, J.M., Marconi, A., Dugas, N., Dugas, B., Sigaux, F., and Kolb, J.P. (2000). Expression of a functional inducible nitric oxide synthase in hairy cell leukaemia and ESKOL cell line. Leukemia 14, 696–705.
Roman, V., Billard, C., Kern, C., Ferry-Dumazet, H., Izard, J.C., Mohammad, R., Mossalayi, D.M., and Kolb, J.P. (2002). Analysis of resveratrol-induced apoptosis in human B-cell chronic leukaemia. Br. J. Haematol. 117, 842–851.
Rössig, L., Fichtlscherer, B., Breitschopf, K., Haendeler, J., Zeiher, A.M., Mülsch, A, and Dimmeler, S. (1999). Nitric oxide inhibits caspase-3 by S-Nitrosation in vivo. J. Biol. Chem. 274, 6823–6826.
Sanz, L., Garcia-Marco, J.A., Casanova, B., de la Fuente, M.T., Garcıa-Gila, M., Garcia-Pardo, A., and Silva, A. (2004). Bcl-2 family gene modulation during spontaneous apoptosis of B-chronic lymphocytic leukemia cell. Biochem. Biophys. Res. Comm. 315, 562–567.
Secchiero, P., di Iasio, M.G., Gonelli, A., Barbarotto, E., Melloni, E., Tiribelli, M., Chiaruttini, C., and Zauli, G. (2007). Differential gene expression induction by TRAIL in B chronic lymphocytic leukemia (B-CLL) cells showing high versus low levels of Zap-70. J. Cell. Physiol. 213, 229–236.
Tambyrajah, W.S., Bowler, L.D., Medina-Palazon, C., and Sinclair, A.J. (2007). Cell cycle-dependent caspase-like activity that cleaves p27(KIP1) is the beta(1) subunit of the 20S proteasome. Arch. Biochem. Biophys. 466, 186–193.
Tiscornia, A.C., Cayota, A., Landoni, A.I., Brito, C., Oppezzo, P., Vuillier, F., Robello, C., Dighiero, G., Gabús, R., and Pritsch, O. (2004). Post-transcriptional regulation of inducible nitric oxide synthase in chronic lymphocytic leukemia B cells in pro- and antiapoptotic culture conditions. Leukemia 18, 48–56.
Walker, G., Pfeilschifter, J., Otten, U., and Kunz, D. (2001). Proteolytic cleavage of inducible nitric oxide synthase (iNOS) by calpain I. Biochim. Biophys. Acta 1568, 216–224.
Wood, D.E. and Newcomb, E.W. (1999). Caspase-dependent activation of calpain during drug-induced apoptosis. J. Biol. Chem. 274, 8309–8315.
Zaher, M., Akrout, I, Mirshahi, M, Kolb, J.P., and Billard, C. (2009). Noxa upregulation is associated with apoptosis of chronic lymphocytic leukemia cells induced by hyperforin but not flavopiridol. Leukemia 23, 594–596.
Zech, B., Wilm, M., van Eldik, R., and Brüne, B. (1999). Mass spectrometry analysis of nitric oxide-modified caspase-3. J. Biol. Chem. 274, 20931–20936.
Zhao, H., Dugas, N., Mathiot, C., Dugas, B., Sigaux, F., and Kolb, J.P. (1998). B-cell chronic lymphocytic leukemia cells express a functional inducible nitric oxide synthase displaying anti-apoptotic activity. Blood 92, 1031–1043.
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This work was supported by INSERM, University Pierre et Marie Curie and Canceropole Ile-de-France.
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Billard, C., Quiney, C., Kolb, JP. (2010). Inhibition of Apoptosis by Endogenous Nitric Oxide in Chronic Lymphocytic Leukaemia. In: Bonavida, B. (eds) Nitric Oxide (NO) and Cancer. Cancer Drug Discovery and Development. Springer, New York, NY. https://doi.org/10.1007/978-1-4419-1432-3_9
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