The Notch signalling pathway mediates cell fate decisions1,2 and is tumour suppressive or oncogenic depending on the context2,3. During lung development, Notch pathway activation inhibits the differentiation of precursor cells to a neuroendocrine fate4,5,6. In small-cell lung cancer, an aggressive neuroendocrine lung cancer7, loss-of-function mutations in NOTCH genes and the inhibitory effects of ectopic Notch activation indicate that Notch signalling is tumour suppressive8,9. Here we show that Notch signalling can be both tumour suppressive and pro-tumorigenic in small-cell lung cancer. Endogenous activation of the Notch pathway results in a neuroendocrine to non-neuroendocrine fate switch in 10–50% of tumour cells in a mouse model of small-cell lung cancer and in human tumours. This switch is mediated in part by Rest (also known as Nrsf), a transcriptional repressor that inhibits neuroendocrine gene expression. Non-neuroendocrine Notch-active small-cell lung cancer cells are slow growing, consistent with a tumour-suppressive role for Notch, but these cells are also relatively chemoresistant and provide trophic support to neuroendocrine tumour cells, consistent with a pro-tumorigenic role. Importantly, Notch blockade in combination with chemotherapy suppresses tumour growth and delays relapse in pre-clinical models. Thus, small-cell lung cancer tumours generate their own microenvironment via activation of Notch signalling in a subset of tumour cells, and the presence of these cells may serve as a biomarker for the use of Notch pathway inhibitors in combination with chemotherapy in select patients with small-cell lung cancer.

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We thank A. Berns for Trp53lox mice, S. Fre and S. Artavanis-Tsakonas for Hes1GFP mice, M. Winslow, M. Krasnow, T. Rando, A. Sweet-Cordero, Y. Ouadah and Sage laboratory members for suggestions on the manuscript, and P. Lovelace and J. Ho (fluorescence-activated cell sorting (FACS)), P. Chu (histology), S. Sim and the Stanford Protein and Nucleic Acid (PAN) facility for technical support. We thank the Tumorothèque des Hôpitaux Universitaires de l’Est Parisien (HUEP; the East Paris University Hospitals Tumor Bio-bank) for SCLC samples and N. Rabbe-Mathiot for immunostaining support. This work was supported by the Howard Hughes Medical Institute (K.C.G.), the National Institutes of Health (J.S. R01 CA201513), A*STAR Singapore (J.S.L.), Soutien à la Recherche Clinique (Fondation du Souffle and Fonds de Recherche en Santé Respiratoire, M.W.), and the Legs Poix (Chancellerie des Universités de Paris, M.W.). J.S. is the Harriet and Mary Zelencik Scientist in Children’s Cancer and Blood Diseases.

Author information


  1. Department of Pediatrics, Stanford University School of Medicine, Stanford, California 94305, USA

    • Jing Shan Lim
    • , Alvaro Ibaseta
    • , Sandra Cristea
    • , Dian Yang
    • , Nadine S. Jahchan
    •  & Julien Sage
  2. Department of Genetics, Stanford University School of Medicine, Stanford, California 94305, USA

    • Jing Shan Lim
    • , Alvaro Ibaseta
    • , Sandra Cristea
    • , Dian Yang
    • , Nadine S. Jahchan
    •  & Julien Sage
  3. OncoMed Pharmaceuticals, Inc., Redwood City, California 94063, USA

    • Marcus M. Fischer
    • , Belinda Cancilla
    • , Gilbert O’Young
    • , Jennifer Cain
    • , Yu-Wang Liu
    • , Ann M. Kapoun
    • , Timothy Hoey
    •  & Christopher L. Murriel
  4. Department of Molecular and Cellular Physiology, Stanford University School of Medicine, Stanford, California 94305, USA

    • Vincent C. Luca
    •  & K. Christopher Garcia
  5. Department of Structural Biology, Stanford University School of Medicine, Stanford, California 94305, USA

    • Vincent C. Luca
    •  & K. Christopher Garcia
  6. Howard Hughes Medical Institute, Stanford University School of Medicine, Stanford, California 94305, USA

    • Vincent C. Luca
    •  & K. Christopher Garcia
  7. Sorbonne Universités, UPMC Univ Paris 06, GRC n°04, Theranoscan, F-75252, Paris, France

    • Cécile Hamard
    • , Martine Antoine
    •  & Marie Wislez
  8. AP-HP, Hôpital Tenon, Service de Pneumologie, F-75970, Paris, France

    • Cécile Hamard
    • , Martine Antoine
    •  & Marie Wislez
  9. Department of Pathology, Stanford University School of Medicine, Stanford, California 94305, USA

    • Christina Kong


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J.S.L., M.W., K.C.G., T.H., C.L.M., and J.S. conceptualized the study. J.S.L. designed and performed cell culture assays and experiments using the mouse model. A.I. contributed to immunoblotting and immunostaining. M.M.F., B.C., G.O., J.C., A.M.K., and C.L.M. performed tarextumab and chemotherapy treatments and analysis. S.C. generated TKO allografts. V.C.L. and K.C.G. provided recombinant Dll4. D.Y. and N.S.J. contributed reagents and to data interpretation. C.H., M.A., M.W., and C.K. performed and analysed HES1 immunostaining on patient samples. Y.-W.L. contributed to Luminex assays. J.S.L., T.H., C.L.M., and J.S. wrote the manuscript with input from all authors. J.S. supervised the study, data interpretation, and manuscript preparation.

Competing interests

M.M.F., B.C., G.O., J.C., Y.-W.L., A.M.K., T.H., and C.L.M. are employees and stockholders of OncoMed Pharmaceuticals.

Corresponding author

Correspondence to Julien Sage.

Reviewer Information Nature thanks A. Berns, L. Miele and the other anonymous reviewer(s) for their contribution to the peer review of this work.

Publisher's note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

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    This file contains Supplementary Methods and Supplementary Figure 1. The Supplementary Methods include clinical and biological characteristics of SCLC patients analyzed for the survival study, as well as primer sequences for qRT-PCR, ChIP-qPCR and genotyping. Supplementary Figure 1 contains immunoblot source data for Figures 1h, 2c, 3h and Extended Data Figures 2f, 5h, 5p, 7b and 7c.

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