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Breast Cancer Research and Treatment

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22.10.2016 | Preclinical study

Transcriptome- and proteome-oriented identification of dysregulated eIF4G, STAT3, and Hippo pathways altered by PIK3CA ^H1047R in HER2/ER-positive breast cancer

verfasst von: Feixiong Cheng, Junfei Zhao, Ariella B. Hanker, Monica Red Brewer, Carlos L. Arteaga, Zhongming Zhao

Erschienen in: Breast Cancer Research and Treatment | Ausgabe 3/2016

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Abstract

Purpose

Phosphatidylinositol 3-kinase (PI3K)/AKT pathway aberrations are common in human breast cancer. Furthermore, PIK3CA mutations are commonly associated with resistance to anti-epidermal growth factor receptor 2 (HER2) or anti-estrogen receptor (ER) agents in HER2 or ER positive (HER2⁺/ER⁺) breast cancer. Hence, deciphering the underlying mechanisms of PIK3CA mutations in HER2⁺/ER⁺ breast cancer would provide novel insights into elucidating resistance to anti-HER2/ER therapies.

Methods

In this study, we systematically investigated the biological consequences of PIK3CA ^H1047R in HER2⁺/ER⁺ breast cancer by uniquely incorporating mRNA transcriptomic data from The Cancer Genome Atlas and proteomic data from reverse-phase protein arrays.

Results

Our integrative bioinformatics analyses revealed that several important pathways such as STAT3 and VEGF/hypoxia were selectively altered by PIK3CA ^H1047R in HER2⁺/ER⁺ breast cancer. Protein differential expression analysis indicated that an elevated eIF4G might promote tumor angiogenesis and growth via regulation of the hypoxia-activated switch in HER2⁺ PIK3CA ^H1047R breast cancer. We observed hypo-phosphorylation of EGFR in HER2⁺ PIK3CA ^H1047R breast cancer versus HER2⁺PIK3CA^wild-type (PIK3CA ^WT). In addition, ER and PIK3CA ^H1047R might cooperate to activate STAT3, MAPK, AKT, and Hippo pathways in ER⁺ PIK3CA ^H1047R breast cancer. A higher YAP_pS127 level was observed in ER⁺ PIK3CA ^H1047R patients than that in an ER⁺ PIK3CA ^WT subgroup. By examining breast cancer cell lines having both microarray gene expression and drug treatment data from the Genomics of Drug Sensitivity in Cancer and the Stand Up to Cancer datasets, we found that the elevated YAP1 mRNA expression was associated with the resistance of BCL-2 family inhibitors, but with the sensitivity to MEK/MAPK inhibitors in breast cancer cells.

Conclusions

In summary, these findings shed light on the functional consequences of PIK3CA ^H1047R-driven breast tumorigenesis and resistance to the existing therapeutic agents in HER2⁺/ER⁺ breast cancer.

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Siegel RL, Miller KD, Jemal A (2016) Cancer statistics, 2016. CA Cancer J Clin 66:7–30. doi:10.3322/caac.21332 CrossRefPubMed

Osmanbeyoglu HU, Pelossof R, Bromberg JF, Leslie CS (2014) Linking signaling pathways to transcriptional programs in breast cancer. Genome Res 24:1869–1880. doi:10.1101/gr.173039.114 CrossRefPubMedPubMedCentral

Arteaga CL, Engelman JA (2014) ERBB receptors: from oncogene discovery to basic science to mechanism-based cancer therapeutics. Cancer Cell 25:282–303. doi:10.1016/j.ccr.2014.02.025 CrossRefPubMedPubMedCentral

Mayer IA, Arteaga CL (2016) The PI3K/AKT pathway as a target for cancer treatment. Annu Rev Med 67:11–28. doi:10.1146/annurev-med-062913-051343 CrossRefPubMed

Young CD, Zimmerman LJ, Hoshino D et al (2015) Activating PIK3CA mutations induce an epidermal growth factor receptor (EGFR)/extracellular signal-regulated kinase (ERK) paracrine signaling axis in basal-like breast cancer. Mol Cell Proteomics 14:1959–1976. doi:10.1074/mcp.M115.049783 CrossRefPubMedPubMedCentral

Marcotte R, Sayad A, Brown KR et al (2016) Functional genomic landscape of human breast cancer drivers, vulnerabilities, and resistance. Cell 164:293–309. doi:10.1016/j.cell.2015.11.062 CrossRefPubMed

Cancer Genome Atlas Network (2012) Comprehensive molecular portraits of human breast tumours. Nature 490:61–70. doi:10.1038/nature11412 CrossRef

Ciriello G, Gatza ML, Beck AH et al (2015) Comprehensive molecular portraits of invasive lobular breast cancer. Cell 163:506–519. doi:10.1016/j.cell.2015.09.033 CrossRefPubMedPubMedCentral

Koren S, Reavie L, do Couto JP et al (2015) PIK3CA induces multipotency and multi-lineage mammary tumours. Nature 525:114–118. doi:10.1038/nature14669 CrossRefPubMed

10.

Van Keymeulen A, Lee MY, Ousset M et al (2015) Reactivation of multipotency by oncogenic PIK3CA induces breast tumour heterogeneity. Nature 525:119–123. doi:10.1038/nature14665 CrossRefPubMed

11.

Hanker AB, Pfefferle AD, Balko JM et al (2013) Mutant PIK3CA accelerates HER2-driven transgenic mammary tumors and induces resistance to combinations of anti-HER2 therapies. Proc Natl Acad Sci USA 110:14372–14377. doi:10.1073/pnas.1303204110 CrossRefPubMedPubMedCentral

12.

Baselga J, Cortes J, Im SA, Clark E, Ross G, Kiermaier A, Swain SM (2014) Biomarker analyses in CLEOPATRA: a phase III, placebo-controlled study of pertuzumab in human epidermal growth factor receptor 2-positive, first-line metastatic breast cancer. J Clin Oncol 32:3753–3761. doi:10.1200/JCO.2013.54.5384 CrossRefPubMed

13.

Loibl S, von Minckwitz G, Schneeweiss A et al (2014) PIK3CA mutations are associated with lower rates of pathologic complete response to anti-human epidermal growth factor receptor 2 (her2) therapy in primary HER2-overexpressing breast cancer. J Clin Oncol 32:3212–3220. doi:10.1200/JCO.2014.55.7876 CrossRefPubMed

14.

Henry NL, Schott AF, Hayes DF (2014) Assessment of PIK3CA mutations in human epidermal growth factor receptor 2-positive breast cancer: clinical validity but not utility. J Clin Oncol 32:3207–3209. doi:10.1200/JCO.2014.57.6132 CrossRefPubMed

15.

Rexer BN, Chanthaphaychith S, Dahlman K, Arteaga CL (2014) Direct inhibition of PI3K in combination with dual HER2 inhibitors is required for optimal antitumor activity in HER2+ breast cancer cells. Breast Cancer Res 16:R9. doi:10.1186/bcr3601 CrossRefPubMedPubMedCentral

16.

Miller TW, Hennessy BT, Gonzalez-Angulo AM et al (2010) Hyperactivation of phosphatidylinositol-3 kinase promotes escape from hormone dependence in estrogen receptor-positive human breast cancer. J Clin Invest 120:2406–2413. doi:10.1172/JCI41680 CrossRefPubMedPubMedCentral

17.

Sabine VS, Crozier C, Brookes CL et al (2014) Mutational analysis of PI3K/AKT signaling pathway in tamoxifen exemestane adjuvant multinational pathology study. J Clin Oncol 32:2951–2958. doi:10.1200/JCO.2013.53.8272 CrossRefPubMed

18.

Miller TW, Rexer BN, Garrett JT, Arteaga CL (2011) Mutations in the phosphatidylinositol 3-kinase pathway: role in tumor progression and therapeutic implications in breast cancer. Breast Cancer Res 13:224. doi:10.1186/bcr3039 CrossRefPubMedPubMedCentral

19.

Cheng F, Zhao J, Zhao Z (2015) Advances in computational approaches for prioritizing driver mutations and significantly mutated genes in cancer genomes. Brief Bioinform 17(4):642–656. doi:10.1093/bib/bbv068 CrossRefPubMed

20.

Zhao J, Cheng F, Wang Y, Arteaga CL, Zhao Z (2016) Systematic prioritization of druggable mutations in approximately 5000 genomes across 16 cancer types using a structural genomics-based approach. Mol Cell Proteomics 15:642–656. doi:10.1074/mcp.M115.053199 CrossRefPubMed

21.

Li J, Lu Y, Akbani R et al (2013) TCPA: a resource for cancer functional proteomics data. Nat Methods 10:1046–1047. doi:10.1038/nmeth.2650 CrossRefPubMedPubMedCentral

22.

Blair BG, Wu X, Zahari MS et al (2015) A phosphoproteomic screen demonstrates differential dependence on HER3 for MAP kinase pathway activation by distinct PIK3CA mutations. Proteomics 15:318–326. doi:10.1002/pmic.201400342 CrossRefPubMed

23.

Zhu Y, Qiu P, Ji Y (2014) TCGA-assembler: open-source software for retrieving and processing TCGA data. Nat Methods 11:599–600. doi:10.1038/nmeth.2956 CrossRefPubMedPubMedCentral

24.

Yang W, Soares J, Greninger P et al (2013) Genomics of Drug Sensitivity in Cancer (GDSC): a resource for therapeutic biomarker discovery in cancer cells. Nucleic Acids Res 41:D955–961. doi:10.1093/nar/gks1111 CrossRefPubMed

25.

Garnett MJ, Edelman EJ, Heidorn SJ et al (2012) Systematic identification of genomic markers of drug sensitivity in cancer cells. Nature 483:570–575. doi:10.1038/nature11005 CrossRefPubMedPubMedCentral

26.

Heiser LM, Sadanandam A, Kuo WL et al (2012) Subtype and pathway specific responses to anticancer compounds in breast cancer. Proc Natl Acad Sci USA 109:2724–2729. doi:10.1073/pnas.1018854108 CrossRefPubMed

27.

Wang Q, Jia P, Cheng F, Zhao Z (2015) Heterogeneous DNA methylation contributes to tumorigenesis through inducing the loss of coexpression connectivity in colorectal cancer. Genes Chromosom Cancer 54:110–121. doi:10.1002/gcc.22224 CrossRefPubMed

28.

Cheng F, Jia P, Wang Q, Zhao Z (2014) Quantitative network mapping of the human kinome interactome reveals new clues for rational kinase inhibitor discovery and individualized cancer therapy. Oncotarget 5:3697–3710CrossRefPubMedPubMedCentral

29.

Cheng F, Jia P, Wang Q, Lin CC, Li WH, Zhao Z (2014) Studying tumorigenesis through network evolution and somatic mutational perturbations in the cancer interactome. Mol Biol Evol 31:2156–2169. doi:10.1093/molbev/msu167 CrossRefPubMedPubMedCentral

30.

Cheng F, Liu C, Shen B, Zhao Z (2016) Investigating cellular network heterogeneity and modularity in cancer: a network entropy and unbalanced motif approach. BMC Syst Biol 10(Suppl 3):65. doi:10.1186/s12918-016-0309-9 CrossRefPubMedPubMedCentral

31.

Vuong H, Cheng F, Lin CC, Zhao Z (2014) Functional consequences of somatic mutations in cancer using protein pocket-based prioritization approach. Genome Med 6:81. doi:10.1186/s13073-014-0081-7 CrossRefPubMedPubMedCentral

32.

Shannon P, Markiel A, Ozier O, Baliga NS, Wang JT, Ramage D, Amin N, Schwikowski B, Ideker T (2003) Cytoscape: a software environment for integrated models of biomolecular interaction networks. Genome Res 13:2498–2504. doi:10.1101/gr.1239303 CrossRefPubMedPubMedCentral

33.

Robinson MD, McCarthy DJ, Smyth GK (2010) edgeR: a Bioconductor package for differential expression analysis of digital gene expression data. Bioinformatics 26:139–140. doi:10.1093/bioinformatics/btp616 CrossRefPubMed

34.

Gatza ML, Silva GO, Parker JS, Fan C, Perou CM (2014) An integrated genomics approach identifies drivers of proliferation in luminal-subtype human breast cancer. Nat Genet 46:1051–1059. doi:10.1038/ng.3073 CrossRefPubMedPubMedCentral

35.

Masson N, Ratcliffe PJ (2014) Hypoxia signaling pathways in cancer metabolism: the importance of co-selecting interconnected physiological pathways. Cancer Metab 2:3. doi:10.1186/2049-3002-2-3 CrossRefPubMedPubMedCentral

36.

Ghazoui Z, Buffa FM, Dunbier AK et al (2011) Close and stable relationship between proliferation and a hypoxia metagene in aromatase inhibitor-treated ER-positive breast cancer. Clin Cancer Res 17:3005–3012. doi:10.1158/1078-0432.CCR-10-1704 CrossRefPubMed

37.

Bocanegra M, Bergamaschi A, Kim YH et al (2010) Focal amplification and oncogene dependency of GAB2 in breast cancer. Oncogene 29:774–779. doi:10.1038/onc.2009.364 CrossRefPubMed

38.

Larrea MD, Hong F, Wander SA, da Silva TG, Helfman D, Lannigan D, Smith JA, Slingerland JM (2009) RSK1 drives p27Kip1 phosphorylation at T198 to promote RhoA inhibition and increase cell motility. Proc Natl Acad Sci USA 106:9268–9273. doi:10.1073/pnas.0805057106 CrossRefPubMedPubMedCentral

39.

Braunstein S, Karpisheva K, Pola C et al (2007) A hypoxia-controlled cap-dependent to cap-independent translation switch in breast cancer. Mol Cell 28:501–512. doi:10.1016/j.molcel.2007.10.019 CrossRefPubMed

40.

Garrett JT, Olivares MG, Rinehart C et al (2011) Transcriptional and posttranslational up-regulation of HER3 (ErbB3) compensates for inhibition of the HER2 tyrosine kinase. Proc Natl Acad Sci USA 108:5021–5026. doi:10.1073/pnas.1016140108 CrossRefPubMedPubMedCentral

41.

Chakrabarty A, Sanchez V, Kuba MG, Rinehart C, Arteaga CL (2012) Feedback upregulation of HER3 (ErbB3) expression and activity attenuates antitumor effect of PI3K inhibitors. Proc Natl Acad Sci USA 109:2718–2723. doi:10.1073/pnas.1018001108 CrossRefPubMed

42.

Tkach M, Rosemblit C, Rivas MA et al (2013) p42/p44 MAPK-mediated Stat3Ser727 phosphorylation is required for progestin-induced full activation of Stat3 and breast cancer growth. Endocr Relat Cancer 20:197–212. doi:10.1530/ERC-12-0194 CrossRefPubMed

43.

Pan D (2010) The hippo signaling pathway in development and cancer. Dev Cell 19:491–505. doi:10.1016/j.devcel.2010.09.011 CrossRefPubMedPubMedCentral

44.

Haskins JW, Nguyen DX, Stern DF (2014) Neuregulin 1-activated ERBB4 interacts with YAP to induce Hippo pathway target genes and promote cell migration. Sci Signal 7:ra116. doi:10.1126/scisignal.2005770 CrossRefPubMedPubMedCentral

45.

Basu S, Totty NF, Irwin MS, Sudol M, Downward J (2003) Akt phosphorylates the Yes-associated protein, YAP, to induce interaction with 14–3–3 and attenuation of p73-mediated apoptosis. Mol Cell 11:11–23CrossRefPubMed

46.

Zhao B, Li L, Lei Q, Guan KL (2010) The Hippo-YAP pathway in organ size control and tumorigenesis: an updated version. Genes Dev 24:862–874. doi:10.1101/gad.1909210 CrossRefPubMedPubMedCentral

47.

Mertins P, Mani DR, Ruggles KV et al (2016) Proteogenomics connects somatic mutations to signalling in breast cancer. Nature 534:55–62. doi:10.1038/nature18003 CrossRefPubMed

48.

Lin L, Sabnis AJ, Chan E et al (2015) The Hippo effector YAP promotes resistance to RAF- and MEK-targeted cancer therapies. Nat Genet 47:250–256. doi:10.1038/ng.3218 CrossRefPubMedPubMedCentral

49.

Cheng F, Zhao J, Fooksa M, Zhao Z (2016) A network-based drug repositioning infrastructure for precision cancer medicine through targeting significantly mutated genes in the human cancer genomes. J Am Med Inform Assoc 23:681–691. doi:10.1093/jamia/ocw007 CrossRefPubMed

50.

Cheng F, Murray JL, Zhao J, Sheng J, Zhao Z, Rubin DH (2016) Systems biology-based investigation of cellular antiviral drug targets identified by gene-trap insertional mutagenesis. PLoS Comput Biol 12:e1005074. doi:10.1371/journal.pcbi.1005074 CrossRefPubMedPubMedCentral

51.

Wang W, Huang J, Wang X, Yuan J, Li X, Feng L, Park JI, Chen J (2012) PTPN14 is required for the density-dependent control of YAP1. Genes Dev 26:1959–1971. doi:10.1101/gad.192955.112 CrossRefPubMedPubMedCentral

52.

Guo C, Wang X, Liang L (2015) LATS2-mediated YAP1 phosphorylation is involved in HCC tumorigenesis. Int J Clin Exp Pathol 8:1690–1697PubMedPubMedCentral

53.

Browne G, Taipaleenmaki H, Bishop NM, Madasu SC, Shaw LM, van Wijnen AJ, Stein JL, Stein GS, Lian JB (2015) Runx1 is associated with breast cancer progression in MMTV-PyMT transgenic mice and its depletion in vitro inhibits migration and invasion. J Cell Physiol 230:2522–2532. doi:10.1002/jcp.24989 CrossRefPubMedPubMedCentral

54.

Zhao B, Ye X, Yu J et al (2008) TEAD mediates YAP-dependent gene induction and growth control. Genes Dev 22:1962–1971. doi:10.1101/gad.1664408 CrossRefPubMedPubMedCentral

55.

Barretina J, Caponigro G, Stransky N et al (2012) The Cancer Cell Line Encyclopedia enables predictive modelling of anticancer drug sensitivity. Nature 483:603–607. doi:10.1038/nature11003 CrossRefPubMedPubMedCentral

56.

Tse C, Shoemaker AR, Adickes J et al (2008) ABT-263: a potent and orally bioavailable Bcl-2 family inhibitor. Cancer Res 68:3421–3428. doi:10.1158/0008-5472.CAN-07-5836 CrossRefPubMed

57.

Oakes SR, Vaillant F, Lim E et al (2012) Sensitization of BCL-2-expressing breast tumors to chemotherapy by the BH3 mimetic ABT-737. Proc Natl Acad Sci USA 109:2766–2771. doi:10.1073/pnas.1104778108 CrossRefPubMed

58.

Shutes A, Onesto C, Picard V, Leblond B, Schweighoffer F, Der CJ (2007) Specificity and mechanism of action of EHT 1864, a novel small molecule inhibitor of Rac family small GTPases. J Biol Chem 282:35666–35678. doi:10.1074/jbc.M703571200 CrossRefPubMed

59.

Giehl K, Keller C, Muehlich S, Goppelt-Struebe M (2015) Actin-mediated gene expression depends on RhoA and Rac1 signaling in proximal tubular epithelial cells. PLoS One 10:e0121589. doi:10.1371/journal.pone.0121589 CrossRefPubMedPubMedCentral

60.

Rosenblatt AE, Garcia MI, Lyons L, Xie Y, Maiorino C, Desire L, Slingerland J, Burnstein KL (2011) Inhibition of the Rho GTPase, Rac1, decreases estrogen receptor levels and is a novel therapeutic strategy in breast cancer. Endocr Relat Cancer 18:207–219. doi:10.1677/ERC-10-0049 PubMedPubMedCentral

61.

Katz E, Sims AH, Sproul D, Caldwell H, Dixon MJ, Meehan RR, Harrison DJ (2012) Targeting of Rac GTPases blocks the spread of intact human breast cancer. Oncotarget 3:608–619CrossRefPubMedPubMedCentral

62.

Cameron D, Fallon M, Diel I (2006) Ibandronate: its role in metastatic breast cancer. Oncologist 11(Suppl 1):27–33. doi:10.1634/theoncologist.11-90001-27 CrossRefPubMed

63.

Kelland L (2007) The resurgence of platinum-based cancer chemotherapy. Nat Rev Cancer 7:573–584. doi:10.1038/nrc2167 CrossRefPubMed

64.

Gupta SC, Singh R, Pochampally R, Watabe K, Mo YY (2014) Acidosis promotes invasiveness of breast cancer cells through ROS-AKT-NF-kappaB pathway. Oncotarget 5:12070–12082CrossRefPubMedPubMedCentral

65.

Hinnebusch AG (2012) Translational homeostasis via eIF4E and 4E-BP1. Mol Cell 46:717–719. doi:10.1016/j.molcel.2012.06.001 CrossRefPubMed

66.

Jiang W, Jia P, Hutchinson KE, Johnson DB, Sosman JA, Zhao Z (2015) Clinically relevant genes and regulatory pathways associated with NRASQ61 mutations in melanoma through an integrative genomics approach. Oncotarget 6:2496–2508CrossRefPubMed

67.

Guo X, Xu Y, Zhao Z (2015) In-depth genomic data analyses revealed complex transcriptional and epigenetic dysregulations of BRAFV600E in melanoma. Mol Cancer 14:60. doi:10.1186/s12943-015-0328-y CrossRefPubMedPubMedCentral

68.

Cheng F, Hong H, Yang SY, Wei YQ (2016) Individualized network-based drug repositioning infrastructure for precision oncology in the panomics era. Brief Bioinform. doi:10.1093/bib/bbw051

69.

Gossage L, Eisen T, Maher ER (2015) VHL, the story of a tumour suppressor gene. Nat Rev Cancer 15:55–64. doi:10.1038/nrc3844 CrossRefPubMed

70.

Mamo A, Cavallone L, Tuzmen S et al (2012) An integrated genomic approach identifies ARID1A as a candidate tumor-suppressor gene in breast cancer. Oncogene 31:2090–2100. doi:10.1038/onc.2011.386 CrossRefPubMed

71.

Haibe-Kains B, El-Hachem N, Birkbak NJ, Jin AC, Beck AH, Aerts HJ, Quackenbush J (2013) Inconsistency in large pharmacogenomic studies. Nature 504:389–393. doi:10.1038/nature12831 CrossRefPubMedPubMedCentral

Titel: Transcriptome- and proteome-oriented identification of dysregulated eIF4G, STAT3, and Hippo pathways altered by PIK3CA H1047R in HER2/ER-positive breast cancer
verfasst von: Feixiong Cheng
Junfei Zhao
Ariella B. Hanker
Monica Red Brewer
Carlos L. Arteaga
Zhongming Zhao
Publikationsdatum: 22.10.2016
Verlag: Springer US
Erschienen in: Breast Cancer Research and Treatment / Ausgabe 3/2016
Print ISSN: 0167-6806
Elektronische ISSN: 1573-7217
DOI: https://doi.org/10.1007/s10549-016-4011-9

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Transcriptome- and proteome-oriented identification of dysregulated eIF4G, STAT3, and Hippo pathways altered by PIK3CA ^H1047R in HER2/ER-positive breast cancer

Abstract

Purpose

Methods

Results

Conclusions

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Springer Medizin

Abstract

Purpose

Methods

Results

Conclusions

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