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Brusatol sensitizes endometrial hyperplasia and cancer to progestin by suppressing NRF2-TET1-AKR1C1-mediated progestin metabolism

Abstract

Progestin resistance is the main obstacle for the conservative therapy to maintain fertility in women with endometrial cancer. Brusatol was identified as an inhibitor of the NRF2 pathway; however, its impact on progestin resistance and the underlying mechanism remains unclear. Here, we found that brusatol sensitized endometrial cancer to progestin by suppressing NRF2-TET1-AKR1C1-mediated progestin metabolism. Brusatol transcriptionally suppressed AKR1C1 via modifying the hydroxymethylation status in its promoter region through TET1 inhibition. Suppression of AKR1C1 by brusatol resulted in decreased progesterone catabolism and maintained potent progesterone to inhibit endometrial cancer growth. This inhibition pattern has also been found in the established xenograft mouse and organoid models. Aberrant overexpression of AKR1C1 was found in paired endometrial hyperplasia and cancer samples from the same individuals with progestin resistance, whereas attenuated or loss of AKR1C1 was observed in post-treatment samples with well progestin response as compared with paired pre-treatment tissues. Our findings suggest that AKR1C1 expression pattern may serve as an important biomarker of progestin resistance in endometrial cancer.

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Fig. 1: Brusatol sensitizes endometrial cancer cell to progestin by downregulating the expression of NRF2 and its downstream genes.
Fig. 2: Brusatol sensitizes endometrial cancer cell to progestin by enhancing progestin metabolism.
Fig. 3: Promoter region hydroxymethylation suppression of AKR1C1 through declined TET1 contributes to brusatol-enhanced progestin sensitivity.
Fig. 4: Ex vivo and in vivo effects of brusatol-mediated reversal of progestin resistance.
Fig. 5: Validation of AKR1C1 as a prognostic marker of progestin resistance.
Fig. 6: A proposed model illustrating that brusatol suppresses progestin metabolism and sensitizes precancerous/endometrial cancers to progestin.

Data availability

The data used and analyzed during the current study are available from the corresponding author on reasonable request.

References

  1. Key, T. J. & Pike, M. C. The dose-effect relationship between ‘unopposed’ oestrogens and endometrial mitotic rate: its central role in explaining and predicting endometrial cancer risk. Br J Cancer 57, 205-212 (1988).

  2. Cherry, N., McNamee, R., Heagerty, A., Kitchener, H. & Hannaford, P. Long-term safety of unopposed estrogen used by women surviving myocardial infarction: 14-year follow-up of the ESPRIT randomised controlled trial. BJOG 121, 700-705; discussion 705 (2014).

  3. Chen, X. J., Zhang, Z. B., Feng, Y. J., Fadare, O., Wang, J., Ai, Z. H. et al. Aberrant survivin expression in endometrial hyperplasia: another mechanism of progestin resistance. Modern Pathol 22, 699-708 (2009).

  4. Jiang, Y., Chen, X., Wei, Y., Feng, Y., Zheng, W. & Zhang, Z. Metformin sensitizes endometrial cancer cells to progestin by targeting TET1 to downregulate glyoxalase I expression. Biomed Pharmacother 113, 108712 (2019).

  5. Zhao, S., Chen, X., Lu, X., Yu, Y. & Feng, Y. Epidermal growth factor receptor signaling enhanced by long-term medroxyprogesterone acetate treatment in endometrial carcinoma. Gynecol Oncol 105, 45-54 (2007).

  6. Satyaswaroop, P. G., Clarke, C. L., Zaino, R. J. & Mortel, R. Apparent resistance in human endometrial carcinoma during combination treatment with tamoxifen and progestin may result from desensitization following downregulation of tumor progesterone receptor. Cancer Lett 62, 107-114 (1992).

  7. Gu, C., Zhang, Z., Yu, Y., Liu, Y., Zhao, F., Yin, L. et al. Inhibiting the PI3K/Akt pathway reversed progestin resistance in endometrial cancer. Cancer Sci 102, 557-564 (2011).

  8. Zhang, Z., Dong, L., Sui, L., Yang, Y., Liu, X., Yu, Y. et al. Metformin reverses progestin resistance in endometrial cancer cells by downregulating GloI expression. Int J Gynecol Cancer 21, 213-221 (2011).

  9. Wang, Y., Wang, Y., Zhang, Z., Park, J. Y., Guo, D., Liao, H. et al. Mechanism of progestin resistance in endometrial precancer/cancer through Nrf2-AKR1C1 pathway. Oncotarget 7, 10363-10372 (2016).

  10. Jiang, T., Chen, N., Zhao, F., Wang, X. J., Kong, B., Zheng, W. et al. High levels of Nrf2 determine chemoresistance in type II endometrial cancer. Cancer Res 70, 5486-5496 (2010).

  11. Lou, H., Du, S., Ji, Q. & Stolz, A. Induction of AKR1C2 by phase II inducers: identification of a distal consensus antioxidant response element regulated by NRF2. Mol Pharmacol 69, 1662-1672 (2006).

  12. Jung, K. A., Choi, B. H., Nam, C. W., Song, M., Kim, S. T., Lee, J. Y. et al. Identification of aldo-keto reductases as NRF2-target marker genes in human cells. Toxicol Lett 218, 39-49 (2013).

  13. Rizner, T. L., Smuc, T., Rupreht, R., Sinkovec, J. & Penning, T. M. AKR1C1 and AKR1C3 may determine progesterone and estrogen ratios in endometrial cancer. Mol Cell Endocrinol 248, 126-135 (2006).

  14. Smuc, T. & Rizner, T. L. Aberrant pre-receptor regulation of estrogen and progesterone action in endometrial cancer. Mol Cell Endocrinol 301, 74-82 (2009).

  15. Beranic, N., Brozic, P., Brus, B., Sosic, I., Gobec, S. & Lanisnik Rizner, T. Expression of human aldo-keto reductase 1C2 in cell lines of peritoneal endometriosis: potential implications in metabolism of progesterone and dydrogesterone and inhibition by progestins. J Steroid Biochem Mol Biol 130, 16-25 (2012).

  16. Beranic, N., Gobec, S. & Rizner, T. L. Progestins as inhibitors of the human 20-ketosteroid reductases, AKR1C1 and AKR1C3. Chem Biol Interact 191, 227-233 (2011).

  17. Sharma, K. K., Lindqvist, A., Zhou, X. J., Auchus, R. J., Penning, T. M. & Andersson, S. Deoxycorticosterone inactivation by AKR1C3 in human mineralocorticoid target tissues. Mol Cell Endocrinol 248, 79-86 (2006).

  18. Bai, M., Yang, L., Liao, H., Liang, X., Xie, B., Xiong, J. et al. Metformin sensitizes endometrial cancer cells to chemotherapy through IDH1-induced Nrf2 expression via an epigenetic mechanism. Oncogene 37, 5666-5681 (2018).

  19. Kang, K. A., Piao, M. J., Ryu, Y. S., Kang, H. K., Chang, W. Y., Keum, Y. S. et al. Interaction of DNA demethylase and histone methyltransferase upregulates Nrf2 in 5-fluorouracil-resistant colon cancer cells. Oncotarget 7, 40594-40620 (2016).

  20. Wang, J., Zhang, D., Du, J., Zhou, C., Li, Z., Liu, X. et al. Tet1 facilitates hypoxia tolerance by stabilizing the HIF-α proteins independent of its methylcytosine dioxygenase activity. Nucleic Acids Res 45, 12700-12714 (2017).

  21. Bai, X., Zhang, H., Zhou, Y., Nagaoka, K., Meng, J., Ji, C. et al. TET1 promotes malignant progression of cholangiocarcinoma with IDH1 wild-type. Hepatology 73, 1747-1763 (2021).

  22. Ren, D., Villeneuve, N. F., Jiang, T., Wu, T., Lau, A., Toppin, H. A. et al. Brusatol enhances the efficacy of chemotherapy by inhibiting the Nrf2-mediated defense mechanism. Proc Natl Acad Sci USA 108, 1433-1438 (2011).

  23. Lee, J. H., Rangappa, S., Mohan, C. D., Sethi, G., Lin, Z. X., Rangappa, K. S. et al. Brusatol, a Nrf2 Inhibitor Targets STAT3 Signaling Cascade in Head and Neck Squamous Cell Carcinoma. Biomolecules 9, 550 (2019).

  24. Xiang, Y., Ye, W., Huang, C., Lou, B., Zhang, J., Yu, D. et al. Brusatol inhibits growth and induces apoptosis in pancreatic cancer cells via JNK/p38 MAPK/NF-κb/Stat3/Bcl-2 signaling pathway. Biochem Bioph Res Co 487, 820-826 (2017).

  25. Feng, L., Li, J., Yang, L., Zhu, L., Huang, X., Zhang, S. et al. Tamoxifen activates Nrf2-dependent SQSTM1 transcription to promote endometrial hyperplasia. Theranostics 7, 1890-1900 (2017).

  26. Vartanian, S., Ma, T. P., Lee, J., Haverty, P. M., Kirkpatrick, D. S., Yu, K. et al. Application of Mass Spectrometry Profiling to Establish Brusatol as an Inhibitor of Global Protein Synthesis. Mol Cell Proteomics 15, 1220-1231 (2016).

  27. Liu, Y., Lu, Y., Celiku, O., Li, A., Wu, Q., Zhou, Y. et al. Targeting IDH1-Mutated Malignancies with NRF2 Blockade. J Natl Cancer Inst 111, 1033-1041 (2019).

  28. Oh, E. T., Kim, C. W., Kim, H. G., Lee, J. S. & Park, H. J. Brusatol-Mediated Inhibition of c-Myc Increases HIF-1alpha Degradation and Causes Cell Death in Colorectal Cancer under Hypoxia. Theranostics 7, 3415-3431 (2017).

  29. Turco, M. Y., Gardner, L., Hughes, J., Cindrova-Davies, T., Gomez, M. J., Farrell, L. et al. Long-term, hormone-responsive organoid cultures of human endometrium in a chemically defined medium. Nat Cell Biol 19, 568-577 (2017).

  30. Chen, X., Zhang, Z., Feng, Y., Fadare, O., Wang, J., Ai, Z. et al. Aberrant survivin expression in endometrial hyperplasia: another mechanism of progestin resistance. Mod Pathol 22, 699-708 (2009).

  31. Ai, Z., Yin, L., Zhou, X., Zhu, Y., Zhu, D., Yu, Y. et al. Inhibition of survivin reduces cell proliferation and induces apoptosis in human endometrial cancer. Cancer 107, 746-756 (2006).

  32. Wang, S., Pudney, J., Song, J., Mor, G., Schwartz, P. E. & Zheng, W. Mechanisms involved in the evolution of progestin resistance in human endometrial hyperplasia--precursor of endometrial cancer. Gynecol Oncol 88, 108-117 (2003).

  33. Shan, W., Wang, C., Zhang, Z., Gu, C., Ning, C., Luo, X. et al. Conservative therapy with metformin plus megestrol acetate for endometrial atypical hyperplasia. J Gynecol Oncol 25, 214-220 (2014).

  34. Xie, B. Y., Lv, Q. Y., Ning, C. C., Yang, B. Y., Shan, W. W., Cheng, Y. L. et al. TET1-GPER-PI3K/AKT pathway is involved in insulin-driven endometrial cancer cell proliferation. Biochem Bioph Res Co 482, 857-862 (2017).

  35. Travaglino, A., Raffone, A., Saccone, G., Insabato, L., Mollo, A., De Placido, G. et al. Immunohistochemical predictive markers of response to conservative treatment of endometrial hyperplasia and early endometrial cancer: A systematic review. Acta Obstet Gyn Scan 98, 1086-1099 (2019).

  36. Kensler, T. W., Wakabayashi, N. & Biswal, S. Cell survival responses to environmental stresses via the Keap1-Nrf2-ARE pathway. Annu Rev Pharmacol 47, 89-116 (2007).

  37. Zhang, D. D. Mechanistic studies of the Nrf2-Keap1 signaling pathway. Drug Metab Rev 38, 769-789 (2006).

  38. Hayes, J. D. & McMahon, M. NRF2 and KEAP1 mutations: permanent activation of an adaptive response in cancer. Trends Biochem Sci 34, 176-188 (2009).

  39. Li, Y., Huang, C., Kavlashvili, T., Fronk, A., Zhang, Y., Wei, Y. et al. Loss of progesterone receptor through epigenetic regulation is associated with poor prognosis in solid tumors. Am J Cancer Res 10, 1827-1843 (2020).

  40. Rodriguez, M. I., Warden, M. & Darney, P. D. Intrauterine progestins, progesterone antagonists, and receptor modulators: a review of gynecologic applications. Am J Obstet Gynecol 202, 420-428 (2010).

  41. Kim, J. J. & Chapman-Davis, E. Role of progesterone in endometrial cancer. Semin Reprod Med 28, 81-90 (2010).

  42. Janzen, D. M., Rosales, M. A., Paik, D. Y., Lee, D. S., Smith, D. A., Witte, O. N. et al. Progesterone receptor signaling in the microenvironment of endometrial cancer influences its response to hormonal therapy. Cancer Res 73, 4697-4710 (2013).

  43. Lee, II, Maniar, K., Lydon, J. P. & Kim, J. J. Akt regulates progesterone receptor B-dependent transcription and angiogenesis in endometrial cancer cells. Oncogene 35, 5191-5201 (2016).

  44. Zhang, D. D. & Chapman, E. The role of natural products in revealing NRF2 function. Nat Prod Rep 37, 797-826 (2020).

  45. Mote, P. A., Balleine, R. L., McGowan, E. M. & Clarke, C. L. Colocalization of progesterone receptors A and B by dual immunofluorescent histochemistry in human endometrium during the menstrual cycle. J Clin Endocrinol Metab 84, 2963-2971 (1999).

  46. Yang, S., Fang, Z., Gurates, B., Tamura, M., Miller, J., Ferrer, K. et al. Stromal PRs mediate induction of 17beta-hydroxysteroid dehydrogenase type 2 expression in human endometrial epithelium: a paracrine mechanism for inactivation of E2. Mol Endocrinol 15, 2093-2105 (2001).

  47. Terzaghi-Howe, M. & McKeown, C. Inhibition of carcinogen-altered rat tracheal epithelial cells by normal epithelial cell-conditioned medium. Cancer Res 46, 917-921 (1986).

  48. Terzaghi-Howe, M. Inhibition of carcinogen-altered rat tracheal epithelial cell proliferation by normal epithelial cells in vivo. Carcinogenesis 8, 145-150 (1987).

  49. Arnold, J. T., Kaufman, D. G., Seppala, M. & Lessey, B. A. Endometrial stromal cells regulate epithelial cell growth in vitro: a new co-culture model. Hum Reprod 16, 836-845 (2001).

  50. Uchida, H., Maruyama, T., Nagashima, T., Asada, H. & Yoshimura, Y. Histone deacetylase inhibitors induce differentiation of human endometrial adenocarcinoma cells through up-regulation of glycodelin. Endocrinology 146, 5365-5373 (2005).

  51. Shi, M., Zhang, H., Li, M., Xue, J., Fu, Y., Yan, L. et al. Normal endometrial stromal cells regulate survival and apoptosis signaling through PI3K/AKt/Survivin pathway in endometrial adenocarcinoma cells in vitro. Gynecol Oncol 123, 387-392 (2011).

  52. Yin, M., Zhou, H. J., Lin, C., Long, L., Yang, X., Zhang, H. et al. CD34(+)KLF4(+) Stromal Stem Cells Contribute to Endometrial Regeneration and Repair. Cell Rep 27, 2709-2724 (2019).

  53. Tsuchida, K., Tsujita, T., Hayashi, M., Ojima, A., Keleku-Lukwete, N., Katsuoka, F. et al. Halofuginone enhances the chemo-sensitivity of cancer cells by suppressing NRF2 accumulation. Free Radical Bio Med 103, 236-247 (2017).

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Acknowledgements

This work was supported by grants from the National Natural Science Foundation of China (grants 81872111 and 81672562), National Key Technology R&D Program of China (2019YFC1005200 and 2019YFC1005201), Shanghai Municipal Science and Technology Committee of Shanghai outstanding academic leaders plan (19XD1423100), the project of Outstanding Medical Doctor for Z.Z., Shanghai Municipal Education Commission—Gaofeng Clinical Medicine Grant Support (20181714). We thank all members in Z.Z. lab.

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Z.Z., S.W. and J.L. performed study concept and designed the study. M.H., D.S. and J.Y. performed most of the experiments and wrote the manuscript. Y.F., Z.Q., B.H. and Q.Z. performed part of the experiments. M.H., D.S., J.Y., Y.F., Z.Q., B.H. and Q.Z. analyzed and interpreted the data. X.C., Y.W., H.Z., Y.W., Y.F. and W.Z. provided technical and material support. Z.Z. and J.L. revised the manuscript with comments from all authors. All authors read and approved the final manuscript.

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Correspondence to Jingjie Li, Sufang Wu or Zhenbo Zhang.

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Human endometrial hyperplasia and cancer tissue samples were obtained from Shanghai General Hospital Affiliated to Shanghai Jiao Tong University and Shanghai First Maternity and Infant Hospital Affiliated to Tongji University School of Medicine. Patients’ informed consent was obtained. All animal studies were approved by the Animal Ethics Committee of Shanghai General Hospital experimental protocols.

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Hu, M., Sun, D., Yu, J. et al. Brusatol sensitizes endometrial hyperplasia and cancer to progestin by suppressing NRF2-TET1-AKR1C1-mediated progestin metabolism. Lab Invest (2022). https://doi.org/10.1038/s41374-022-00816-5

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