Background
Prostate cancer (PCa) is the second most frequent malignancy in males, is the fifth leading cause of cancer-related deaths in both developed and developing countries, and accounts for a significant proportion of the health burden worldwide [
1]. Currently, no long-lasting and effective therapies exist for PCa. PCa treatment via androgen deprivation therapy and AR antagonists (castration), along with the emergence of PCa with AR mutations or lack of AR expressio, has been shown to be effective only in the short term [
1]. Other PCA treatment options include surgery, chemotherapy, radiation therapy, and immunotherapy [
2‐
4]. However, with the advent of drug resistance, cancer metastasis, and vigorous weakening of immunity, the effectiveness of these treatment options has decreased. Dietary therapy (or metabolic therapy) using ketogenic diets (KD) is becoming an alternative or complementary approach to cancer treatment [
5]. Most cancer cells are characterized by a lack of mitochondrial enzymes capable of metabolizing ketone bodies and producing ATP.
In contrast, normal cells can use ketone bodies instead of sugar as fuel [
6]. KD combats cancer-induced cachexia and causes minimal side effects [
7]. KD disrupts metabolism and suppresses the “Warburg effect” on which tumor growth depends [
8]. However, the effects of KD on PCa remain unclear. Hence, this study mainly aimed to investigate whether ketone bodies have an anticancer effect on PCa.
β-hydroxybutyrate (BHB), the primary ketone body, is predominantly formed in the liver and formed by the degradation of fatty acids via β-oxidation induced by acetyl coenzyme A. BHB is traditionally considered a normal fuel to support respiration and serve as an alternative energy resource for the brain and heart during fasting and prolonged exercise [
9]. Increasing evidence indicates a strong relationship between BHB and cancer. Several studies have indicated that BHB can suppress the growth and metastasis of glioma, neuroblastoma, pancreatic cancer, and colorectal cancer [
5,
10‐
14] and even enhance the anticancer effects of cisplatin and PD-1 blockade [
15,
16]. In contrast, some studies have demonstrated that BHB promotes the growth and survival of cancer cells [
17,
18], whereas another study showed no impact on growth [
19]. The BHB paradox and the effect of BHB on PCa warrant further in-depth exploration.
Cancer stem cells (CSCs) represent a small number of undifferentiated cells in cancerous tissues. The presence of CSCs with properties of tumor dissemination and metastasis promotion can significantly affect disease progression and clinical management and is a major cause of metastasis and cancer recurrence [
20]. PCa involves highly heterogeneous cells [
21]. CSCs residing in PCa tissue may constitute an important cause of the development and recurrence of PCa as well as the development of androgen-independent and refractory phenotypes [
22,
23]. However, cancer cells can switch between stem and differentiated states in response to treatment or microenvironmental changes [
24,
25]. Therefore, the development of specific anticancer drugs that can eradicate CSCs or induce their differentiation is an innovative therapeutic strategy for PCa.
Indoleacetamide-N-methyltransferase (INMT) acts as a methyltransferase, both as an S-methyltransferase for thymidine and N-methyltransferase for catalyzing the N-methylation of indoles such as tryptamine [
26,
27]. The colocalization of INMT with the sigma-1 receptor in primate spinal motor neurons revealed that it may be a target for treating schizophrenia and amyotrophic lateral sclerosis [
28,
29]. In addition to its association with schizophrenia, the role of INMT in cancer is gradually being recognized. However, whether INMT is an oncogene or cancer suppressor remains controversial in the recently published studies on PCa [
30,
31]. The effect of INMT on PCa and its molecular mechanisms warrant further exploration. β-hydroxybutyrylation (kbhb) is an emerging post-translational modification (PTM) induced by BHB. So far, kbhb has been described in histones and nonhistones [
32,
33]. Mass spectrometry analysis in a previous study showed that INMT might be β-hydroxybutyrylated [
34]. However, the mechanism by which the kbhb of INMT affects its role in cancer has not yet been reported, and our study investigated for the first time the role of INMT kbhb in PCa.
Herein, we aimed to demonstrate that BHB acts as an important ketone body to inhibit the proliferation, migration, and invasion of PCa cells by suppressing their stem-like properties. INMT, whose expression is upregulated by the METTL3–N6-methyladenosine (m6A) axis, is an oncogene in PCa that promotes the stemness of PCa cells through SOX2. BHB inhibits the malignant phenotypes of PCa via kbhb of INMT. Therefore, this study may provide potential metabolic therapy and molecular targets for refractory PCa.
Methods
Chemicals and antibodies
The chemical reagents and working concentrations used were as follows: BHB (for cells: 0, 15, and 25 mM; for mice: 100 mg/kg; Sigma-Aldrich, cat. 52,017) and p300 inhibitor A485 (for cells: 2.5 µM; for mice: 30 mg/kg; Sigma-Aldrich, cat. SML2192). The antibodies used were as follows: anti-SLUG (Abcam, cat. ab27568), anti-TWIST1 (Cell Signaling Technology, cat. #90,445), anti-E-cadherin (Abcam, cat. ab231303), anti-vimentin (Sigma-Aldrich, cat. V6630), anti-snail (Sigma-Aldrich, cat. SAB5700806), anti-ZEB1 (Abcam, cat. ab276129), anti-ZEB2 (Abcam, cat. ab191364), anti-GAPDH (Abcam, cat. ab8245), anti-SOX2 (Cell Signaling Technology, cat. #14,962), anti-BMI1 (Abcam, cat. ab269678), anti-CD133 (Abcam, cat. ab284389), anti-KLF4 (Abcam, cat. ab129473), anti-β actin (Cell Signaling Technology, cat. #3700), anti-INMT (Abcam, cat. ab181854), anti-METTL3 (Abcam, cat. ab195352), anti-METTL14 (Abcam, ab220030), anti-ALKBH5 (Abcam, cat. ab195376), anti-FTO (Abcam, cat. ab280081), anti-m6A (Invitrogen, cat. MA5-33030), anti-Ki67 (Abcam, cat. ab15580), and anti-pan BHB-lysine (BHB-K) (PTM BioLabs, China, cat. #PTM-1201RM).
Cell culture
PC3 and LNCaP were purchased from Procell (Wuhan, China), DU145, RWPE-1, and human embryonic kidney 293E (HEK293E) cells from ATCC were gifted by Dr. Qi Li (The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China) and cultured in a humidified environment at 37 °C under 5% CO
2 using their respective media. RWPE-1 cells were maintained in keratinocyte SFM (1×) (Invitrogen, cat. 17,005,042). PC3 and LNCaP cells were cultured in RPMI 1640 supplemented with 15% fetal bovine serum (FBS). DU145 and HEK293E cells were cultured in Dulbecco’s modified Eagle’s medium (DMEM) with 15% FBS. LNCaP and PC3 cells stably overexpressing control and INMT vectors were cultured in RPMI 1640 supplemented with 15% FBS and hygromycin (150 µg/ml) [
30,
31]. LNCaP and PC3 cells stably expressing control shRNA (Sigma-Aldrich, cat. SHC016) and INMT shRNA (Sigma-Aldrich, cat. EHU138831) were cultured in RPMI 1640 supplemented with 15% FBS and puromycin (15 µg/ml) [
31].
Transfection, plasmids, and siRNA
Lipofectamine 3000 (Invitrogen, cat. L3000015) was used to transfect plasmids, whereas Lipofectamine RNAiMAX (Invitrogen, cat. 13,778,030) was used to transfect siRNAs, according to the manufacturer’s instructions of the corresponding kits.
pGL3-INMT-WT, pGL3-INMT-mut, and pGL3-SOX2 plasmids were constructed by inserting the INMT 3′-UTR with wild-type or mutant m6A sites and SOX2 promoters (− 2546/+544) into pGL3 luciferase reporter plasmids (Promega, cat. E1751).
pFlag–METTL3, pFlag–INMT, pFlag–HDAC1, and pFlag–HDAC2 plasmids were constructed by cloning polymerase chain reaction (PCR)-amplified cDNAs of human METTL3, INMT, HDAC1, and HDAC2 into the pFlag–CMV2 expression vectors (Sigma-Aldrich, cat. E7033).
The sequences of METTL3-specific siRNAs were as follows: #1: 5′-CUGCAAGUAUGUUCACUAUGA-3′ and #2: 5′-AGGAGCCAAGAAAAAUCAA-3′).
Cell viability assay
Cell viability was assessed via the CCK8 assay using a CCK8 kit (Abcam, cat. ab228554). Cells (1 × 104/well) inoculated in a 96-well plate were treated with varying concentrations of BHB for 48 h. Then, 20 µl of CCK-8 solution was added to the corresponding wells and incubated for 2 h. Absorbance values at 450 nm were measured using a 96-well plate reader. The concentration of the drug that induced 50% of cell growth inhibition (IC50) was determined.
Colony formation assay was performed to assess the cell proliferation capacity. LNCaP and PC3 cells (2 × 104/well) were inoculated into 6-well plates and treated with or without 15 mM BHB for 48 h. After washing the cells with PBS, the liquid in each well was replaced with fresh medium without drugs. Two weeks later, using methanol fixation and crystal violet staining, the number of colonies containing > 50 cells were counted using an optical microscope.
Cell cycle analysis
LNCaP and PC3 cells were inoculated into 6-well plates at a concentration of 2 × 105/well and treated with or without 15 mM BHB for 48 h. After washing with PBS and fixing overnight at 4 °C with 75% ethanol, the fixed cells were incubated for 30 min under dark conditions with 1 ml of PBS containing propyl iodide (PI) (100 µg/ml) and RNase (50 µg/ml). Flow cytometry was performed to analyze cell cycle distribution. DNA histograms were constructed to indicate the proportion of cells in different cell cycle phases, such as G0/G1, S, and G2/M phases.
Cell apoptosis analysis
Flow cytometric analysis was performed using FITC/Annexin V apoptosis-detecting kits (BD pharmingen, cat. NO 556,547) to determine the apoptosis rate following BHB treatment. After treatment with 0, 15, or 25 mM BHB for 48 h, 1 × 106 cells (LNCaP, PC3, or DU145 cells) were collected and cleaned twice with ice-cold PBS. After centrifugation at 500 ×g for 5 min, the cells were added to 100 µl of binding buffer containing 5 µl of PI and 5 µl of Annexin V-FITC, and the mixture was incubated for 15 min under dark conditions. The apoptosis rate of stained cells was immediately measured at 488 nm using BD FACSAria™ II cell sorters (BD Biosciences, California, USA).
Transwell cell migration and invasion assay
Transwell assay was performed to determine the cell migration and invasive capacity. For migration assays, treated cells were harvested and diluted with serum-free DMEM (1 × 105 cells/ml). Then, 100 ml of cell suspension was inoculated into the small chamber above the transwell insert (Corning, cat. CLS3464; pore size, 8 μm), whereas the bottom chambers were filled with RPMI-1640 containing 20% FBS, serving as a chemoattractant. For invasive assays, the above chambers were precoated with Matrigel (Millipore, cat. E1270); the other steps were the same as the migration assays. The cells were cultured at 37 °C for 24 h under 5% CO2. Migrated and invaded cells at the bottom of the filter were fixed with 4% paraformaldehyde and stained with 0.5% crystal violet (Sigma-Aldrich, cat. C0775) for 20 min. Cells were observed and counted under optical microscopes. Five regions were randomly selected to count the number of cells.
Western blot assay
Whole-cell lysates were prepared using highly active radioimmunoprecipitative assay (RIPA) buffer (Beyotime, cat. P0013B). Protein concentrations were determined via an enhanced protein concentration assay kit (Beyotime, China, P0010S). Whole-cell proteins in the supernatant were electrophoresed on 10% SDS–PAGE gel and then transferred onto the PVDF membrane (Millipore, cat. ISEQ00010). These membranes were subjected to incubation with the corresponding primary and HRP-coupled secondary antibodies. The bands were visualized using BeyoECL plus kit (Beyotime, cat. P0018M).
Real-time reverse transcription PCR (RT–PCR)
Total cellular RNA was purified using Trizol reagent (Beyotime, cat. R0016). Isolated RNA was reverse transcribed using Maxima H Minus first strand cDNA synthesis kits (Thermo Scientific, cat. #K1682). Quantitative real-time PCR (qPCR) was performed using SYBR Green (Takara, cat. #RR820A) via ABI-7500 real-time PCR systems (Applied Biosystems, USA). The specific primers used in this study are listed in Supplemental Table
S1. The relative expression levels of target genes were measured using the 2
−ΔΔCT method.
The treated cells were prepared as single-cell suspensions and seeded into ultralow adherence 96-well plates at a density of 800 cells/well containing sphere-forming medium supplemented with serum-free DMEM/F-12 (Invitrogen, cat. 12,634,028), 2% B27 (Invitrogen, cat. 17,504,044), 25 ng/ml epidermal growth factor (EGF; Sigma-Aldrich, cat. E9644), and 25 ng/ml fibroblast growth factor (FGF; Gibco, cat. 13256-029). The cells were incubated at 37 °C for 7–15 days under 5% CO2 and 95% humidity. The number of spheroids with diameters of > 25 or 75 μm was calculated.
Aldehyde dehydrogenase (ALDH) assay
The stem-like tumor cells with highly active ALDH were identified using ALDEFLUOR kits (Stem Cell Technologies, cat. #01700), according to the manufacturer’s instructions. Briefly, 1 × 105 cells were incubated with ALDEFLUOR assay buffer supplemented with ALDH substrate. An aliquot of cells exposed to ALDEFLUOR assay buffer was treated with a specialized ALDH inhibitor (diethylaminobenzaldehyde, DEAB) under the same conditions; this was set as a negative control. After incubation at 37 °C for 40 min, the fluorescence intensity was measured via FACS analysis.
m6A meRIP qRT–PCR
The m6A modification of INMT was measured via MeRIP assays using m6A MeRIP kits (Millipore, cat. 17-10499), according to the manufacturer’s instructions. Briefly, 300 µg of total isolated RNA was chemically fragmented into approximate lengths of 100 nucleotides and then immunoprecipitated with a monoclonal antibody against m6A (Invitrogen, cat. MA5-33030) and prewashed protein A/G Dyna beads (Thermo Scientific, cat. 88,803). The RNAs undergoing m6A modification were eluted with N6-methyladenosine-5′-monophosphate sodium salt (6.7 mM) and extracted using RNeasy kit (Qiagen, cat. 74,004). Both immunoprecipitated and input samples were subjected to qPCR.
Dual luciferase reporter assays
To confirm whether INMT mRNA undergoes METTL3-dependent m6A modifications, pGL3-INMT-WT or pGL3-INMT-mut plasmids were constructed by inserting INMT mRNA 3′-UTRs with wild-type or mutant m6A sites into a region downstream of pGL3 luciferase reporter vector. The cells inoculated into a 12-well plate were transiently transfected with pGL3-INMT-WT or pGL3-INMT-mut, renilla luciferase reporter vectors (pRL-TK), and METTL3 siRNA. After 48 h of transfection, firefly luciferase activity was assessed using a dual luciferase reporter kit (Promega, cat. E1910). Measurement of renilla luciferase activity was used as a control for determining transfection efficiency.
To confirm the effect of INMT on SOX2 promoter activity. The pGL3-SOX2 promoter plasmids were constructed by inserting the SOX2 promoter (− 2546/+544) into a region downstream of pGL3 luciferase reporter vectors (Promega, cat. E1751). Cells stably expressing INMT or control vectors were placed in 12-well plates and transiently transfected with pGL3-SOX2 promoter and renilla luciferase reporter vectors (pRL-TK). The subsequent steps were the same as those described above.
Protein purification
After transfection of 293T cells with Flag–INMT plasmids for 48 h, the cells were collected and lysed with BC500 solution (500 mM NaCl, 20% glycerol, 0.5% Triton X-100, and 20 mM Tris-HCl; pH 7.3) under sonication. The cell lysates were coincubated overnight at 4 °C with anti-Flag M2 magnetic beads. After washing the bead complexes with BC100 buffer (100 mM NaCl, 20% glycerol, 0.1% Triton X-100, and 20 mM Tris-HCl; pH 7.3), a competitive elution procedure with Flag peptide (Sigma-Aldrich, cat. F4799) was performed in BC100 buffer for protein purification.
Evaluation of kbhb of INMT
Evaluation of kbhb of exogenous INMT proteins was performed as follows. First, 293T cells were transfected with Flag–INMT plasmids and then treated with or without 15 mM BHB for 24 h. The Flag–INMT fusion proteins were purified according to the method described previously in this study. Next, the purified proteins were subjected to western blot assay with anti-INMT or anti-pan BHB-K antibodies.
Evaluation of kbhb of endogenous INMT proteins was performed in LNCaP, PC3, and DU145 cells treated with or without 15 mM BHB for 24 h. The cells were first lysed with RIPA buffer and fragmented ultrasonically. Identification of BHB-K proteins was performed via immunoprecipitation (IP) with BHB-K antibodies, and INMT was detected via western blot assay using anti-INMT antibody.
Similarly, INMT kbhb was evaluated in LNCaP cells transfected with Flag–HDAC1 or Flag–HDAC2 plasmids and treated with 15 mM BHB or 2.5 µM p300 inhibitor A485 for 24 h. The subsequent steps were identical to those described above.
Mouse xenograft assays
Male BALB/c nude mice (5 weeks old, weight 18–22 g) were obtained from the Animal Experiment Center of Zhengzhou University (Zhengzhou, China). They were maintained under standard conditions. Overall, 5 × 10
6 LNCaP cells were diluted with 200 µl of RPMI 1640 medium, prepared as a mixture with Matrigel (Corning, cat. 354,234), and inoculated subcutaneously into the flanks of male nude mice. Tumor size was measured every 3 days using calipers, and the tumor volume was calculated using the following formula: L (longest diameter) × W (shortest diameter)
2 × 0.5. Each mouse’s body weight and living behavior were monitored for overall health status. The mice were euthanized at the end of the studies. The xenograft tumors were removed, weighed, and fixed. Mice were randomly divided into four groups for drug treatments when the measured tumor volume reached 150–200 mm [
3]. They (seven mice for each group) received 0.9% saline as a negative control or 100 mg/kg BHB or 30 mg/kg p300 inhibitor A485 as treatment. The drugs were injected intraperitoneally daily for up to 30 days. Each procedure was approved by the Animal Care and Use Committee of the First Affiliated Hospital of Zhengzhou University. The HE and immunohistochemistry staining for Ki-67 were performed as reported previously [
35]. Mice were injected with LNCaP cells stably transfected with luciferase vector via tail vein for establishing an in vivo bioluminescence imaging model of bone metastasis, and the detailed steps were performed according to the previously reported method [
36].
Statistical analysis
All data were expressed as the mean ± standard deviation (SD). Statistical analysis was performed via GraphPad Prism 8 software. Comparisons of parameters between two groups were calculated using paired two-tailed Student’s t-tests. P-values of < 0.05 were considered to indicate statistical significance.
Discussion
Although the specific role of BHB, a ketone body, is still not well understood, emerging evidence suggests its important role in tumor biology. According to a previous report, BHB can reduce the proliferative capacity of colonic crypt cells and potently inhibit intestinal tumor growth in mouse models and organoids [
13]. In addition, BHB-induced metabolic reprogramming attenuated the growth of pancreatic cancer and cachexia in xenograft mouse models [
11]. Importantly, BHB has a significant inhibitory effect on cancer metastasis, as evidenced by an inhibitory effect on the highly metastatic properties of VM-M3 cells and prolonged survival in VM-M3 xenograft mice [
12]. However, many researchers have also expressed opposite views regarding the effect of BHB on tumors. BHB has been found to increase the “stemness” of cancer cells, driving growth, metastasis, recurrence, and poor clinical outcomes in breast cancer [
17,
41]. In addition, BHB acts as a cellular endogenous or systemic fuel to promote the growth and progression of pancreatic ductal adenocarcinoma [
18]. Thus, it remains unclear whether the effects of BHB on cancer are related to the type of cancer and the underlying mechanisms. Herein, we validated the antimalignant phenotype effect of BHB on PCa using three PCa cell lines in vitro and xenograft mouse models in vivo. Our study is valuable as it reveals new diet-induced endogenous mechanisms that inhibit prostate tumor growth.
CSCs represent a subpopulation within tumors with the potential for self-renewal and nondirectional differentiation [
42]. It drives tumor growth and sows the seeds of metastasis; moreover, it is closely related to therapeutic resistance and relapse of many tumor types, including PCa [
43‐
45]. Therefore, stem cell properties have emerged as a target for cancer therapy. ALDH, SOX2, BMI1, CD133, and KLF4 have previously been used as stemness-associated markers of prostate CSCs [
46‐
49]. Several studies have indicated a potential role of BHB in inhibiting the stemness of CSCs. BHB was reported to significantly reduce the proportion of CD133 + A2780CP cells (an ovarian cancer cell line) [
50]. In addition, BHB exhibited inhibition of proliferative capacity and stemness of glioma stem-like cells by disrupting metabolic homeostasis and mitochondrial function [
8]. Consistent with these studies, our investigations showed that BHB significantly inhibited the stem-like properties of PCa cells. Tumor sphere formation, ALDH activity, and the expression levels of stemness-related factors (SOX2, BMI1, and CD133) in PCa cells were potently reduced after BHB treatment. EMT is an important process governing the characteristic features of CSCs. For example, ZEB1 promotes the migration of CSCs by suppressing repressive stemness microRNAs in pancreatic cancer cells [
51]. TWIST1 upregulates BMI1, a marker of CSCs that is essential for tumor initiation capacity in head and neck squamous cell carcinomas [
52]. Elevated SLUG expression in breast tumors induces overexpression of stem-like genes, such as
BMI1 and
CD133[
53]. Therefore, we speculate that the potential mechanisms of the inhibitory effects of BHB on the stemness of PCa cells may be related to our finding that BHB inhibits the process of EMT.
INMT is a newly emerging molecule that has gained considerable interest; however, its role in cancer remains obscure. INMT expression has been reported to be dysregulated in lung cancer, meningioma, and PCa [
31,
54‐
56]. Our study revealed that INMT expression was upregulated in PCa cells, and this upregulation was mediated via the METTL3–m6A pathway. m6A modification, one of the epigenetic regulatory mechanisms, modulates gene expression and function by regulating many aspects of RNA biology, such as pre-mRNA splicing, nuclear transport, subcellular localization, RNA decay, and translation ability [
57]. As a reversible epitranscriptome modulator, METTL3 is highly expressed in PCa and is essential for the proliferation and metastasis of various PCa cell lines [
39,
58,
59]. Our results consistently showed upregulation of METTL3 in three PCa cell lines and its role in the suppression of INMT mRNA decay. Recent studies have reported conflicting views on the effects of INMT on PCa, with one study suggesting that INMT plays a tumor-suppressive role, whereas the other suggesting that INMT promotes PCa development and castration resistance [
30,
31]. Our results demonstrate that INMT is an oncogenic gene that promotes the stemness characteristics of PCa cells. This enhancement in stem-like properties may be related to the improvement of SOX2 activity. The transcription factor SOX2, which induces pluripotency, is an important embryonic stem cell transcriptional factor capable of inducing cellular reprogramming. SOX2 endows cells with CSC characteristics and a malignant, aggressive phenotype during PCa development [
60]. Our study revealed that INMT can enhance the promoter activity of SOX2.
Previous studies have found that METTL3 is upregulated in PCa and can promote PCa growth and metastasis [
39,
59]. However, the observed anticancer effect of BHB was not achieved through the METTL3–m6A pathway, as BHB did not affect the expression of METTL3. kbhb, a recently discovered and evolutionarily conserved PTM, is driven by BHB and plays a pivotal role in cell function [
32,
33]. The results of mass spectrometry analysis in a previous study and the data from immunoprecipitation assay in our study suggest that INMT may be β-hydroxybutyrylated [
34]. The lysine kbhb of INMT decreased the INMT expression in PCa. Our study revealed a novel finding that BHB exerts its anticancer effects through INMT kbhb, and in vivo experiments also confirmed that the antitumor effect of BHB is diminished when kbhb is inhibited. However, there are some limitations in this study. First, the mechanism underlying the decrease in INMT expression levels after the occurrence of kbhb in INMT warrants in-depth exploration. Besides, the present study only selected the LNCaP cell line as the Xenograft tumor model, which may not rule out the cell-specific effect. Hence, and we will establish a Xenograft tumor model with other cell lines for further validation in the future.
In summary, our results demonstrated that INMT, an oncogenic gene in PCa, is highly expressed in PCa cells via the METTL3–m6A pathway and can promote stem-like properties of these cells. In contrast, BHB, an endogenous ketone of the body, can exert an anti-PCa malignant phenotype by driving INMT kbhb. Our study revealed a novel molecular mechanism that provides a theoretical basis for BHB to become a new alternative for cancer treatment in addition to surgery, chemotherapy, and immunotherapy. However, it remains unclear whether BHB inhibits PCa stemness through multiple pathways and the mechanism by which kbhb regulates INMT expression levels. These details need to be explored further in the future.
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