Background
Endometrial cancer (EC) is the most common gynecological malignancy in developed countries. In 2021, approximately 66,570 new cases of EC and 12,940 deaths were expected in the United States [
1]. Unlike other gynecological cancers, the incidence and mortality of EC continue to rise. The mainstay treatment for high-risk EC is surgery combined with chemotherapy and/or radiotherapy [
2]. However, prognosis is still poor for advanced or metastatic disease, and effective treatment remains challenging. In 2018, an open-label international randomized phase 3 trial (PORTEC-3) including 660 patients showed that traditional chemoradiotherapy did not improve quality of life or prolong 5-year overall survival compared with pelvic radiotherapy alone for women with high-risk EC [
3].
Comprehensive genomic approaches can identify genetic and molecular abnormalities to aid the prediction of prognosis and validation of new drug-targeting strategies. These technologies may finally enable precision medicine for individual patients by allowing the selection of specific treatments based on molecular parameters. One gene that is commonly dysregulated in malignant tumors is c-Myc. c-Myc encodes an oncogenic transcription factor that regulates the expression of approximately 30% of all human genes [
4,
5], including genes involved in the cell cycle, proliferation and apoptosis [
6,
7]. A recent study showed that c-Myc is overexpressed in > 70% of endometrial tumors [
8]. However, finding direct c-Myc inhibitors is challenging [
4].
Bromodomain 4 (BRD4) is a member of the bromodomain and extraterminal (BET) family and acts as an epigenetic reader by recruiting transcription complexes to specific sites of chromatin to initiate transcription of oncogenic drivers [
9]. BRD4 facilitates the recruitment of positive transcription elongation factor (p-TEFb) to activate c-Myc transcription [
10]. Aberrant BRD4 expression may contribute to the progression of multiple cancers, including hematological malignancies and several types of solid cancers [
11]. Promising antitumor efficacy of BET inhibitors has been reported, and clinical trials are ongoing for a variety of cancers [
12]. In particular, effects of BET inhibitors on uterine serous carcinoma, an aggressive type of type II EC, have been reported [
13]. The best-studied BET inhibitor is JQ1, a potent and specific BRD4 inhibitor with antitumor and anti-inflammatory activities [
14]. However, the protein expression profile of BRD4 in EC patients has not been characterized, and the mechanism by which BRD4 impacts EC progression remains unknown.
In the present study, we analyzed data from The Cancer Genome Atlas (TCGA) and Gene Expression Omnibus (GEO) as well as clinically isolated endometrial tissues and found that BRD4 is aberrantly expressed in EC tissue compared with normal endometrial tissue. In addition, overexpression of BRD4 was associated with relatively poor prognosis. To explore the effects of the BRD4 inhibitor JQ1 on tumor growth and the underlying mechanism, experiments were performed using EC cell lines and EC xenograft models. Our findings indicate that BRD4 is an oncogene and prognostic predictor in EC that promotes cell proliferation by regulating c-Myc. Accordingly, BRD4 inhibitors could be a promising therapeutic strategy for EC.
Materials and methods
Drugs and reagents
Dimethyl sulfoxide (DMSO) and 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) were purchased from Sigma-Aldrich (St. Louis, MO, USA). The BRD4 inhibitors, JQ1, I-BET151 and OTX015, were all purchased from MedChemExpress (Shanghai, China), dissolved in DMSO, and stored in small aliquots – 20 ℃.
Cell lines and cell culture
Human EC cell lines (HEC-1A, Ishikawa, RL-95 and An3C cells) were purchased from the Cell Bank of the Chinese Academy of Sciences (Shanghai, China). HEC-1A cells were cultured in McCoy’s 5A medium (Thermo Fisher Scientific Inc., Waltham, MA, USA) supplemented with 10% fetal bovine serum (FBS) (Biological Industries, Kibbutz Beit-Haemek, Israel) and 1 mM sodium pyruvate (Thermo Fisher Scientific Inc.). Ishikawa and An3C cells were grown in RPMI 1640 medium (Thermo Fisher Scientific Inc.) with 10% FBS. RL-95 cells were maintained in DMEM/F12 medium (Thermo Fisher Scientific Inc.) with 10% FBS. All cell culture media were supplemented with 100 U/ml penicillin and 100 μg/ml streptomycin (Thermo Fisher Scientific Inc.). Cells were cultured at 37 ℃ in a 5% CO2 atmosphere. For in vitro experiments, BET inhibitors were added to cultured cancer cells at indicated concentrations. Equivalent concentrations of DMSO were added to cells as controls.
Patients and specimens
Fresh endometrial tissue samples from 50 patients with EC (Type I, n = 33; Type II, n = 17) and 14 patients with leiomyoma who had undergone hysterectomy between January 2010 and June 2012 were obtained from the Department of Gynecology and Obstetrics of Qilu Hospital. Staging and histological subtyping were performed according to the 2009 guidelines of the International Federation of Gynecology and Obstetrics. Fully informed written consent was acquired from the patients before the collection of tissue samples. This study was approved by the Ethics Committee of Qilu Hospital of Shandong University (KYLL-2019(KS)-376). The clinical characteristics of the EC patients are listed in Table
1. All patients were followed up until June 2019. The patients in this study had no history of other previous cancers and did not undergo any preoperative chemotherapy, radiotherapy, or other hormonal therapies. Overall survival (OS) was defined as the time between the date of surgery and the date of patient death directly due to EC or last follow-up. Some tissues were preserved immediately in liquid nitrogen for subsequent western blot assays. All samples were fixed in 4% paraformaldehyde for 24 h, dehydrated, embedded in paraffin blocks, and sectioned (4 μm thickness) for immunohistochemistry (IHC) assays.
Table 1
Characteristics of EC patients
Age, median (range), years | 54 (43–67) |
Surgery, n (%) |
TH/BSO alone | 22 (44%) |
TH/BSO plus lymphadenectomy | 28 (56%) |
FIGO grade, n (%) |
Grade 1 | 27 (54%) |
Grade 2 | 14 (28%) |
Grade 3 | 9 (18%) |
Pathologic type, n (%) |
Type I | 33(66%) |
Type II | 17(34%) |
Stage, n (%) | |
I | 29(58%) |
II | 14(28%) |
III | 7(14%) |
Lymphovascular space involvement, n (%) | 11(22%) |
Deep (≥ 50%) myometrial invasion, n (%) | 15(30%) |
Lymph node involvement, n (%) | 9(18%) |
Adjuvant therapy, n (%) | 22(44%) |
Chemotherapy alone | 10(20%) |
Chemotherapy + Brachytherapy | 12(24%) |
Median follow up time, (95% CI), months | 65(15–79) |
Recurrence, n (%) | 8(16%) |
Immunohistochemistry assays
Endometrial tissue sections were deparaffinized with xylene and rehydrated in different concentrations of ethanol. Hydrogen peroxide was used to block endogenous peroxidase activity, and nonspecific antigens were blocked by incubation in goat serum for 30 min. The sections were then incubated with primary antibodies overnight at 4 °C. The primary antibody against BRD4 was purchased from Abcam (1:50 dilution, Cambridge, UK). After sequential incubation with biotin-labeled goat anti-rabbit IgG polymer and horseradish peroxidase-labeled streptavidin for 30 min each, positive signals were detected using 3,3′-diaminobenzidine (DAB) substrate (Zhongshan Jinqiao Biotechnology, Beijing, China) following the manufacturer’s recommendations. Finally, the stained tissues were evaluated and scored by two blinded investigators.
Scoring of immunoreactivity
Strong positive staining was defined as a brown signal in the nucleus or cytoplasm; moderate staining as a yellow–brown reaction; and weak staining as a light-yellow reaction. The staining intensity was graded as follows: 0 = no staining; 1 = weak staining; 2 = moderate staining; and 3 = strong staining. The percentage of tumor cell staining was graded based on the following criteria: 0 = no staining; 1 = ≤ 10% positive tumor cells; 2 = 11–50% positive tumor cells; 3 = 51–80% positive tumor cells; and 4 = ≥ 81% positive tumor cells. The staining score was calculated by multiplying the intensity score by the quantity score and ranged from 0 to 12. Scores ≥ 8 indicated overexpression of BRD4 in endometrial tissues.
Proliferation assays
Cells (2000 cells in 100 μl/well) were propagated in 96-well culture plates overnight and then exposed to the indicated concentrations of JQ1, OTX015, I-BET151 or transfected with siRNA or BRD4 overexpression lentivirus. After treatment for indicated time, 10 μl of MTT solution (5 mg/ml) was added to each well, and the plates were incubated at 37 ℃ for another 4 h. Then, the medium was removed, and DMSO (100 μl/well) was added to dissolve the formazan product. The absorbance of each well was measured at 570 nm using a microplate reader (Tecan Group Ltd., Männedorf, Switzerland). Three replicate wells were included for each experiment, and the experiments were performed in triplicate.
Cells (800 cells in 2 ml/well) were seeded in 6-well plates and cultured for 48 h. Next, the cells were treated with JQ1 or OTX015 at the indicated concentrations for 14 days at 37 ℃ in 5% CO2. The cells were fixed with paraformaldehyde for 20 min and stained with crystal violet (Beyotime, Beijing, China) for 30 min, and colonies (> 50 cells) were counted.
Protein extraction and western blot
RIPA buffer with protease inhibitor cocktail, PMSF (0.1 mM) and NaF (10 mM) was used to lyse cells treated with JQ1 or transfected with siRNA. Protein concentrations were determined by the BCA protein assay kit (Beyotime, Beijing, China). Equal amounts of protein (30 μg) were separated by SDS-PAGE on a 10% gel and transferred to a nitrocellulose membrane. After blocking with 5% defatted milk for 1 h at room temperature, the membrane was incubated overnight at 4 ℃ with primary antibodies against BRD4 (Abcam), c-Myc, CDK4, Bax (Santa Cruz, CA, USA), β-Actin, cleaved-Caspase-3 (cl-Caspase3), PARP, cleaved-PARP (cl-PARP), CDC25A, CyclinD1, P21, Rb, phosphorylated Rb (p-Rb), PI3K, AKT, phosphorylated AKT (p-AKT), mTOR, phosphorylated mTOR (p-mTOR) (Cell Signaling Technology, MA, USA). Secondary antibodies were purchased from Cell Signaling. Protein bands were detected using an enhanced chemiluminescent substrate (Thermo Fisher Scientific Inc.). ImageJ software (National Institutes of Health, USA) was used to quantify the immunoblots. β-Actin served as a control.
Apoptosis assay
Apoptosis of JQ1 or OTX015-treated EC cells or cells infected with lentivirus was detected by flow cytometry. Cells were washed with PBS, digested with trypsin without EDTA and resuspended in 100 μl of binding buffer. Next, the cells were stained with 5 μl of Annexin V-FITC and 5 μl of propidium iodide (PI) (BD, NJ, USA). After incubation at room temperature in the dark for 15 min, another 400 μl of binding buffer was added to each tube. Cell apoptosis was analyzed by flow cytometry (BD Biosciences, San Jose, CA, USA) according to the manufacturer’s instructions.
Cell cycle assay
Cell cycle analysis was performed by flow cytometry. Synchronized cells treated with JQ1 or OTX015 for 24 h were washed with PBS, digested with trypsin with EDTA, and fixed in 75% cold ethanol overnight at 4 ℃. The cells were washed twice with PBS and stained with 400 μl of PI/RNase Staining Buffer (BD Biosciences) at room temperature in the dark for 30 min. The cell cycle was then analyzed by flow cytometry according to the manufacturer’s instructions.
Transient transfection of siRNA
Small interfering RNAs (siRNAs) targeting human BRD4 or c-Myc and silencer negative control siRNAs were constructed by GenePharma (Shanghai, China). Cells were seeded into 6-well plates at 2.5 × 105 cells/well and incubated overnight before transfection with 150 nM (final concentration) BRD4 or c-Myc siRNA using Lipofectamine 3000 (Invitrogen) according to the manufacturer’s instructions. For western blot assays, the cells were collected 72 h following transfection. For MTT assays, cells were collected on days 1–5 following transfection.
Exogenous BRD4 overexpression
To establish stable cell lines, lentivirus was purchased from GeneChem (Shanghai, China). Ishikawa cells were infected with the pUbi-BRD4 and pUbi-NC lentivirus. After 48 h, cells were screened with 2 μg/mL puromycin (Solarbio, Beijing, China) for 1–2 weeks to obtain stable cell lines.
Tumor xenograft experiments
Animal experiments were approved by Institutional Animal Care and Use Committees of Qilu Hospital of Shandong University. Ishikawa cells (1 × 107 cells in 100 μl of PBS) were subcutaneously injected into the left armpits of 5-week-old nude mice. When the tumor volume reached approximately 50 mm3, the mice were randomly allocated to the treatment or control group. Depending on the group, JQ1 (50 mg/kg/d) or placebo was administered intraperitoneally daily for 3 weeks. Body weight and tumor volume were measured every other day. Tumor volume was calculated using the following formula: (length × width2)/2. Blood was sampled by extirpation of the eyeball before death and used for routine blood examination. The mice were sacrificed 21 days after initiating JQ1 treatment, and tumors were immediately removed and weighed.
Statistical analyses
Survival probabilities were calculated by the Kaplan–Meier method. Because the number of events was low for overall survival, we could not evaluate the independent prognostic value of BRD4 in a multivariable model adjusting for BMI, disease stage, histological type, and histological grade simultaneously. All experiments were repeated at least three times. Student’s t-test was used to compare differences between two groups. The results are presented as the means ± standard deviations (SD). All statistical tests were two-sided; *P < 0.05 was considered statistically significant, **P < 0.01 moderately significant, and ***P < 0.001 highly significant. GraphPad Prism Version 7.00 was used to perform the statistical analyses.
Discussion
There is a clear need for novel prognostic biomarkers for EC to ensure adequate risk stratification and to facilitate the development of individualized therapies. The goals of this study were threefold. The first and primary goal was to evaluate the expression of BRD4 in EC tissues and its implications for prognosis. Second, the antitumor effects of the BRD1 inhibitor JQ1 on EC were evaluated in vitro and in vivo. The third goal was to explore the potential mechanism(s) underlying the effects of JQ1 on endometrial tumors.
BRD4 is an epigenetic reader that has been implicated in the regulation of the development and progression of various cancers [
11]. No published studies have evaluated the expression of BRD4 in clinically derived EC tissues or analyzed BRD4 as a prognostic factor. Overexpression of BRD4 has been reported in a variety of malignant tumor types, including breast cancer, hematological malignancies, and lung cancer [
9,
15]. In the present study, western blot and IHC analyses of BRD4 protein expression in EC and normal endometrial tissues showed that BRD4 is overexpressed in endometrial tumors and that nuclear BRD4 expression levels are negatively correlated with overall patient survival time. These data indicate that BRD4 may be a useful adjunct tissue biomarker for postoperative risk stratification of EC patients. BRD4 expression was also a significant independent risk factor in multivariate analysis. The small number of patients is a limitation of this study. Because this was a single-center study with a limited sample size, univariate and multivariate analyses were not performed. However, our results are supported by analyses of BRD4 expression and its relationship with prognosis using TCGA and GEO datasets.
Mechanistically, JQ1 potently and specifically inhibits the binding of the BRD4 protein to chromatin in a competitive manner [
16]. As a result, downstream genes of BRD4 cannot be transcribed [
10]. Efficacy of JQ1 alone or in combination with other chemotherapeutic drugs has been observed in a variety of tumor types, including common gynecological malignancies such as ovarian cancer [
17], cervical cancer [
18], and uterine serous carcinoma, a form of type II EC [
13]. Consistent with these previous findings, JQ1 reduced cell viability and colony formation in four EC cell lines. JQ1 induces cell apoptosis by promoting an imbalance of mitochondrial apoptotic pathway proteins (Bcl2 and Bax) and enhancing the expression of apoptotic proteins such as cleaved caspase-3 and cleaved PARP. Moreover, BRD4 knockdown suppressed the proliferation of EC cells. These results suggest that the effects of JQ1 may be related to suppression of BRD4 function.
The EC cell lines HEC-1A and Ishikawa are both derived from type I EC [
19]. Gene mutations in PIK3CA, PIK3R1, and PTEN are commonly detected in type I EC and may lead to activation of the PI3K/Akt/mTOR pathway [
20], which is central to cell growth and proliferation in cancer [
21]. In the present study, JQ1 suppressed the expression of PI3K and phosphorylation of AKT and mTOR, supporting the potential application of JQ1 as a potentially novel regimen for the treatment of EC.
In addition to triggering apoptosis, JQ1 suppressed EC cell growth by inducing G1 cell cycle arrest. JQ1 has been reported to cause human neuroblastoma cell cycle arrest in G1 phase mainly by inhibiting the MYCN and mTOR signaling pathways [
22]. JQ1 also decreases the proportion of cells in G2 phase and increases the share of cells in G1 phase in a preclinical model of pancreatic cancer [
23]. Our investigation of the mechanism of JQ1 showed that treatment with JQ1 alone significantly downregulated the expression levels of CDC25A, CyclinD1, and CDK4, inhibited the activity of Rb, and upregulated the expression of P21, a cell cycle-related factor that mainly suppresses the activity of CDK2/CDK4. CDC25A has dual phosphatase activity and catalyzes the activation of CDK, a cell cycle regulator that plays an important role in the cell cycle transition and mitosis. CDK4 is a member of the serine/threonine kinase family, and the CDK4/CyclinD1 complex regulates the evolution of G1 phase. Our results thus provide insights on the mechanism by which JQ1 regulates the cell cycle in EC.
The four EC cell lines examined in this study varied in their sensitivity to JQ1, and further experiments suggested that this sensitivity may be correlated with expression level of BRD4. As an epigenetic reader, BRD4 activates the transcription of a myriad of genes, including the oncogene c-Myc. Studies have shown that inhibition of c-Myc expression is an essential mechanism by which JQ1 suppresses the progression of various tumors through BRD4 inhibition [
24,
25]. Overexpression and amplification of c-Myc is commonly observed in EC [
26], and thus c-Myc may be a novel therapeutic target for EC. In our study, dose-dependent and time-dependent decreases in c-Myc expression were observed in cells treated with JQ1. In addition, the level of downregulation of c-Myc using siRNA transfection was approximately equivalent to the level of suppression of cell proliferation. These data imply that the cytotoxic effects of JQ1 in EC cell lines are at least partially mediated by c-Myc.
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