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Vol. 13, Issue 8, 2894-2908, August 2002
2
1 Integrin Function

andDepartment of Medical Biochemistry, University of Göteborg, SE-405 30 Göteborg, Sweden
Submitted February 1, 2002; Revised April 2, 2002; Accepted May 7, 2002| |
ABSTRACT |
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Overexpression of the growth factor receptor subunit c-erbB2,
leading to its ligand-independent homodimerization and activation, has
been implicated in the pathogenesis of mammary carcinoma. Here, we have
examined the effects of c-erbB2 on the adhesive properties of a mammary
epithelial cell line, HB2/tnz34, in which c-erbB2 homodimerization can
be induced by means of a transfected hybrid "trk-neu" construct.
trk-neu consists of the extracellular domain of the trkA nerve growth
factor (NGF) receptor fused to the transmembrane and cytoplasmic
domains of c-erbB2, allowing NGF-induced c-erbB2 homodimer signaling.
Both spreading and adhesion on collagen surfaces were impaired on
c-erbB2 activation in HB2/tnz34 cells. Antibody-mediated stimulation of
2
1 integrin function restored
adhesion, suggesting a direct role for c-erbB2 in integrin inactivation. Using pharmacological inhibitors and transient
transfections, we identified signaling pathways required for
suppression of integrin function by c-erbB2. Among these was
the MEK-ERK pathway, previously implicated in integrin
inactivation. However, we could also show that downstream of
phosphoinositide-3-kinase (PI3K), protein kinase B (PKB) acted as a
previously unknown, potent inhibitor of integrin function and
mediator of the disruptive effects of c-erbB2 on adhesion and
morphogenesis. The integrin-linked kinase, previously identified as a PKB coactivator, was also found to be required for
integrin inactivation by c-erbB2. In addition, the
PI3K-dependent mTOR/S6 kinase pathway was shown to mediate
c-erbB2-induced inhibition of adhesion (but not spreading)
independently of PKB. Overexpression of MEK1 or PKB suppressed adhesion
without requirement for c-erbB2 activation, suggesting that these two
pathways partake in integrin inhibition by targeting common
downstream effectors. These results demonstrate a major novel role for
PI3K and PKB in regulation of integrin function.
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INTRODUCTION |
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c-erbB2 is a member of the epidermal growth factor
(EGF) receptor tyrosine kinase family and forms functional receptors
for various growth factors (such as EGF and heregulin) by
heterodimerization with other members of the same receptor family.
However, no ligand has been found that binds a c-erbB2 homodimer;
instead, homodimerization is thought to occur in a ligand-independent
manner on overexpression of c-erbB2. This phenomenon is of considerable
interest in cancer research, because a number of studies have linked
c-erbB2 overexpression to poor prognosis in breast carcinomas (De
Potter and Schelfhout, 1995
). Studies of forced c-erbB2 overexpression
in animals and cell lines have demonstrated the oncogenic potential of
c-erbB2, and spontaneous homodimerization leading to tyrosine kinase
activation is most likely an important mechanism for the oncogenicity
of c-erbB2 overexpression (Weiner et al., 1989
; Siegel and
Muller, 1996
).
Because high constitutive overexpression of c-erbB2 in mammary
epithelial cells can be associated with irreversible changes in cell
phenotype, such as loss of epithelial characteristics and acquisition
of anchorage-independent growth (D'Souza et al., 1993
),
studies of the early phases in c-erbB2-induced cell transformation require an inducible system in which c-erbB2 homodimerization can be
regulated. Such a system was recently developed (Baeckström et al., 2000
) by transfection of the immortalized mammary
epithelial cell line HB2 (Berdichevsky et al., 1994a
) with a
hybrid receptor construct, "trk-neu" (Sachs et al.,
1996
), consisting of the extracellular domain of the trkA nerve growth
factor (NGF) receptor fused to the transmembrane and cytoplasmic
domains of c-erbB2. Treatment of these transfectants with NGF can
stimulate the intracellular effects of c-erbB2 homodimerization,
leading to tyrosine kinase activation and substrate domain
phosphorylation. In HB2 transfectants expressing high levels of the
trk-neu hybrid, NGF-induced homodimerization resulted in a dramatic
disruption of morphogenesis of cells grown in three-dimensional culture
in collagen, causing cells to grow in a scattered manner as opposed to
the multicellular, compact, and spherical morphology of untreated
transfectants and parental HB2 cells (Baeckström et
al., 2000
). The disrupted morphology of NGF-treated transfectants,
which was accompanied by decreased proliferation and extensive
apoptosis, could be completely restored by treatment with antibodies
that activate the collagen-binding integrin
2
1, indicating that
the morphogenetic effects of c-erbB2 signaling occur by
integrin inactivation.
To dissect the intracellular signaling mechanisms leading from c-erbB2 homodimerization to inhibition of integrin-dependent morphogenesis, a more rapid and tractable assay for integrin function and morphogenesis than three-dimensional culture is desirable. In the present study, we have instead used c-erbB2-induced inhibition of cell adhesion and spreading on collagen as a readout in a series of transient transfection and inhibitor treatment experiments to identify possible signaling mediators of the antiadhesive properties of c-erbB2. The results of these assays implicate the extracellular-regulated kinase (ERK) mitogen-activated protein (MAP) kinases and protein kinase B (PKB or c-Akt) as parallel and essential components of the pathways linking c-erbB2 signaling to inhibition of integrin function and morphogenesis.
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MATERIALS AND METHODS |
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Reagents
Solubilized bovine collagen I (Vitrogen 100) was obtained from
Cohesion Technologies, Palo Alto, CA. 2.5S NGF from mouse
submaxillary gland was purchased from Promega, Madison, WI. DMRIE-C
reagent was from Life Technologies, Gaithersburg, MD. The substances
PD98059, LY294002, wortmannin, actinomycin D, calphostin C,
chelerythrine chloride, H-89, and bisindolylmaleimide 1 (BIMI) were
purchased from Calbiochem, La Jolla, CA. Cycloheximide, cytochalasin D, o-nitrophenyl-
-D-galactopyranoside
(ONPG), and X-gal were obtained from Sigma, St. Louis, MO.
Polyethyleneimine (25 kDa) was from Aldrich, Milwaukee, WI. Antibodies
against PKB, ERK, p70 S6 kinase (S6K), and their respective
phosphorylation-activated forms and antiserum against PTEN were
purchased from Cell Signaling Technology (Beverly, MA). The blocking
antibodies FB12, P1E6, and P1B5 against integrins
1,
2, and
3, respectively, and the integrin
2
1 stimulatory
antibody JBS2 were obtained from Chemicon, Temecula, CA. Hybridoma
cells producing the TS2/16 (stimulatory) and P5D2 (inhibitory)
monoclonal antibodies (mAbs) against the
1
integrin subunit were purchased from American Type Culture
Collection, Manassas, VA, and the Developmental Studies Hybridoma Bank
at the University of Iowa, respectively. The HAS4 stimulatory mAb against integrin
2 (Tenchini et
al., 1993
) was a generous gift from Dr. Fiona Watt, Imperial
Cancer Research Fund, London, UK. Clone 3, a mAb against
integrin-linked kinase (ILK), was from BD Transduction
Laboratories. Antiserum against MEK1 was from Santa Cruz Biotechnology,
Santa Cruz, CA.
cDNA Constructs
The expression plasmids used in this study were gifts generously
provided by the following researchers: pMT2/ILK, pMT2/ILK(K220 M), and
pMT2/ILK(S343D) containing cDNA coding for wild-type, dominant-negative, and activated integrin-linked kinase (ILK), respectively, were from Dr. Ian Hiles, GlaxoWellcome, Uxbridge, United
Kingdom; pCMV5.SNE/PKB
and pCMV5.SNE/PKB
(K179A), used for
expression of HA-tagged wild-type and dominant-negative PKB-
, respectively, were from Dr. Brian A. Hemmings, Friedrich Miescher Institut, Zürich, Switzerland; pCEP4/PTEN coding for wild-type PTEN phosphatase was from Dr. Ramon Parsons, Columbia University, New
York; and pECE/HA-MEK1-ca, coding for a constitutively active mutant
(S218D/S222D) of hamster MEK1 (Pages et al., 1994
), was a
gift from Pär Gerwins, Rudbeck Laboratory, University of Uppsala, Sweden. The reporter plasmids pCMV
and pEGFP-C1 coding for LacZ and
green fluorescent protein (GFP), respectively, were from Clontech, Cambridge, UK. Plasmids were propagated in appropriate
Escherichia coli strains and purified by use of the JetStar
plasmid purification system (Genomed, Bad Oeynhausen, Germany).
Cell Culture
The HB2/tnz34 cell line, (Baeckström et al.,
2000
) a high-expressing trk-neu transfectant derived from the
SV40-immortalized human mammary epithelial cell line HB2 (Berdichevsky
et al., 1994a
), was grown in DMEM (Life Technologies)
supplemented with 10% fetal calf serum (FCS), 5 µg/ml
hydrocortisone, 10 µg/ml insulin, and 5 µg/ml zeocin (Invitrogen,
San Diego, CA).
Inhibitor Treatments
All pharmacological inhibitors were administered as stock solutions in dimethyl sulfoxide (DMSO), and control cells were given the corresponding amount of pure DMSO. Inhibitor concentrations were generally chosen in the range of 5-10 times the IC50 value supplied by the manufacturer. Different concentrations were always tested to rule out overdosage or underdosage effects.
Spreading Assays
Thin (~150 µm) layers of polymerized collagen I were
prepared by smearing 100 µl of neutralized collagen I over the
surface of the wells of six-well plates (before the application of
collagen, the edges of the wells had been prepared with sterilized
vacuum grease to prevent accumulation of liquid at the well periphery). After polymerization for 2 h at 37°C, 1 × 104 to 2 × 104
HB2/tnz34 cells were plated as a single-cell suspension in 2 ml
complete medium per well and incubated for 2 d. The cells were then transfected in situ (see below) or subjected to treatments with
NGF (10 ng/ml) and/or inhibitors for an additional 1-2 d before
fixation with 2% formaldehyde and 0.2% glutardialdehyde in PBS.
Spreading was evaluated in untransfected cells by visual inspection of
two 4× magnification videomicrographs per sample in which cells were
scored either as "round" (>50% of the cell periphery visible as a
sharp edge) or "spread" (>50% diffuse cell boundary). Inhibition
of spreading was calculated as %Ii = (1
si/s0) × 100, where s0 is the frequency of
spread cells in NGF-untreated controls and
si is the frequency of spread cells in
sample i. At least 200 cells per sample per micrograph were evaluated.
Spreading assays of transfected cells were performed after DMRIE-C transfection as described below. Cells were kept with or without NGF (10 ng/ml) for 2 d after transfection (see below) before being fixed, washed once with PBS, and developed with 200 µl X-gal stain (PBS, 3 mM MgCl2, 6.6 mM K4[Fe(CN)6], 6.6 mM K3[Fe(CN)6], 0.6 mg/ml X-gal) per well. Transfected cells were evaluated according to the criteria outlined above, but scoring was performed directly under a light microscope and restricted to cells stained blue by X-gal staining.
Transfections
For analysis of transfected cells in spreading assays, transient
transfections of HB2/tnz34 cells growing on collagen were performed as
follows. For each well, 1 µl of DMRIE-C reagent was mixed and
incubated for 30 min with 100 µl serum-free medium before the
addition of another 100 µl serum-free medium containing a total of
1.5 µg plasmid DNA (0.75 µg plasmid containing gene of interest and
0.75 µg of the LacZ expression vector pCMV
[Clontech]; control
samples were transfected with 1.5 µg of pCMV
only). The transfection mixture was kept for another 15 min at room temperature before 200 µl was transferred to each well (wells were washed with
serum-free medium before transfection). After incubation for 5 h
in CO2 incubator, the transfection mixture was
removed, and wells were washed once with serum-containing medium and
kept overnight with serum-containing medium before incubation with or
without NGF.
To prepare transiently transfected cells for use in the adhesion assays, polyethyleneimine transfections were used. For one 6-cm tissue culture dish, a total of 6 µg plasmid DNA was added to 6 µl 20% glucose solution, and this mixture was then added to 5 µl 0.1 M polyethyleneimine solution, buffered to pH 7.0. After thorough mixing, deionized water was added to 60 µl, and the mixture was left for 10 min at room temperature. This solution was then mixed with 4 ml of fresh complete serum-containing cell culture medium and added to HB2/tnz34 cells grown to 60-70% confluence. The cells were then kept with the DNA-PEI complex-containing medium for 2 d before being detached and subjected to adhesion assay.
Adhesion Assays
Ninety-six-well microtiter plates were coated with monomeric
collagen by dispensing Vitrogen 100 serially diluted (10 - 0.005 µg/ml) in 10 mM HCl at 50 µl/well and incubating overnight at +4°C. Plates were then blocked by incubation with 100 µl/well of
PBS containing 0.1% heat-treated BSA at 37°C for 1 h.
Subconfluent cultures of HB2/tnz34 cells were detached by incubation
with Puck's saline containing 0.02% EDTA, mixed with an equal volume
of serum-containing medium, and passed through a 23-gauge needle to
create a single-cell suspension. Cells were then washed in serum-free
medium and resuspended at a density of 2.5 × 105/ml in serum-free medium with 5 mM
MgCl2. The cells were then pretreated with
antibodies or inhibitors (where applicable) for 1 h before
addition of NGF (standard concentration, 50 ng/ml) where applicable,
followed by another 1-h incubation (both incubation steps were
performed at room temperature). A cell suspension (100 µl) was then
dispensed in each well of the coated microtiter plates, and the plates
were left in the incubator for 1 h. Nonadherent cells were then
removed by inversion and flicking of plates, followed by washing three
times by immersion of the plate in PBS containing 5 mM
MgCl2 and aspiration of buffer by water suction
connected to a 21-gauge needle. The amount of adherent cells was
quantified by crystal violet staining after fixation with 4%
formaldehyde as described (Wu et al., 1999
).
Adhesion assay of transfected cells was carried out 2 d after PEI
transfection. Except as otherwise stated, cells were cotransfected with
3 µg each of the construct of interest and the LacZ-encoding vector
pCMV
; control cells were transfected with 6 µg pCMV
. After
fixation, adhered transfected cells were detected by incubation with
the chromogenic LacZ substrate ONPG (0.88 mg ONPG/ml in 0.1 M phosphate
buffer, pH 7.5, containing freshly added 1 mM
MgCl2 and 0.31% vol/vol
-mercaptoethanol) and
quantified by measurement of the absorbance at 490 nm. Differences in
LacZ expression levels between different transfections were compensated
for as follows. For each transfection, duplicate aliquots containing
5 × 104 cells in suspension were incubated
with ONPG, and the absorbance was measured to yield the specific LacZ
activity. For each adhesion assay, the absorbance values were then
normalized by division with the specific LacZ activity of the
transfection in question.
In all adhesion assays, values from duplicate collagen dilution series were then used to calculate ED50 values, i.e., the amount of collagen coated on a well that was required to obtain half-maximal binding under the given experimental conditions.
This was achieved by plotting corrected absorbance versus the logarithm of the collagen concentration, making linear regression analyses of the linear parts of the plots and relating the line parameters to the highest absorbance value obtained in the control series.
Flow Cytometry
HB2/tnz34 cells were detached, washed and incubated with or without NGF as described under Adhesion Assays. The cell suspensions were then transferred to ice and mixed with mAbs against integrin subunits. After a 1-h incubation, the cells were washed three times with cold FACS diluent (DMEM, 10% FCS, 0.02% sodium azide) and then incubated for 1 h on ice with fluorescein-conjugated antimouse immunoglobulin antiserum (Dako, Carpinteria, CA), diluted 1:50 in FACS diluent (in GFP-transfected cells, antibody binding was detected with biotinylated antimouse immunoglobulin antiserum [Dako] followed by allophycocyanin-labeled streptavidin [Wallac Oy, Turku, Finland], both diluted 1:100). After three more washes in FACS diluent, cells were resuspended in PBS and analyzed in a FACSCalibur cytometer (BD Biosciences, Franklin Lakes, NJ).
Western Blots
Lysates of HB2/tnz34 cells growing on plastic were prepared from subconfluent cultures grown on 60-mm cell culture dishes. Cells were washed three times with PBS and lysed in 50 mM Tris-HCl, pH 7.5, 0.15 M NaCl, and 1% Triton X-100 containing protease inhibitor cocktail (Sigma), supplemented with 10 mM sodium pyrophosphate, 1 mM sodium orthovanadate, and 10 mM NaF. After protein concentration determination (BCA assay, Pierce), normalized protein amounts were loaded onto SDS-PAGE gels, separated, and blotted to polyvinylidene difluoride membranes (Hybond-P, Amersham Biosciences, Arlington Heights, IL). Membranes were blocked in PBS containing 5% dry milk and 0.1% Tween-20, treated with primary antibodies diluted in blocking buffer or TBS with 5% BSA and 0.1% Tween-20 according to the antibody supplier's instructions, and washed three times with PBS-0.1% Tween-20. Bound antibody was detected with peroxidase-conjugated secondary antibodies (Dako) followed by visualization with the Enhanced Chemiluminescence system (Amersham Biosciences, Uppsala, Sweden).
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RESULTS |
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Induced c-erbB2 Homodimerization Inhibits Spreading and Adhesion of Mammary Epithelial Cells on Collagen
HB2/tnz34 is a high-expressing trk-neu transfectant of the mammary
epithelial cell line HB2 that exhibits a striking disruption of
integrin-dependent morphogenesis on c-erbB2 homodimer signaling induced by NGF treatment when grown in a three-dimensional collagen matrix (Baeckström et al., 2000
). To understand the
molecular mechanism behind this observation, we wished to identify the
intracellular events that link c-erbB2 homodimer signaling with
inhibition of morphogenesis. Because the morphogenesis assay used in
the previous study requires that cells survive and proliferate for ~1
week, we wished to develop an assay for integrin-dependent
morphogenesis that was faster and thus more amenable to pharmacological
and genetic manipulation than three-dimensional culture. Therefore, we
chose to study spreading on collagen as a simplified morphogenesis assay. In the absence of c-erbB2 signaling, HB2/tnz34 cells spread on a
polymerized collagen surface, typically reaching 75% flat cells after
3 d; however, NGF treatment strongly inhibited this spreading in a
dose-dependent manner (Figure 1, A and
B). By adding NGF to the cells at different time points during a 72-h
incubation, we could conclude that the suppressing effect of c-erbB2
signaling on spreading reached a plateau after ~24 h of induction
(Figure 1C).
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It has also been shown previously that the disruption of morphogenesis
in collagen caused by c-erbB2 could be reversed by treatment with
antibodies that activate
1 or
2 integrins (Baeckström et
al., 2000
). Because this result indicated that the morphogenetic disruption seen in NGF-activated HB2/tnz34 cells is caused by integrin inactivation, it was of interest to directly assess
the possible influence of c-erbB2 on integrin function. To that
end, we measured the capacity of untreated and NGF-treated HB2/tnz34 cells in suspension to adhere to monomeric collagen coated in serial
dilutions in microtiter wells. As shown in Figure
2A, adhesion was indistinguishable
(~70% cells bound, data not shown) between controls and NGF-treated
cells at high collagen densities (500 ng/well); however, under
conditions in which collagen was limiting, a pronounced, dose-dependent
suppression of adhesion was observed with NGF treatment (Figure 2A). To
be able to compare large and complex sets of data, the results of the
adhesion assays in the rest of this article are presented as the amount
of coated collagen required for half-maximal binding
(ED50; see MATERIALS AND METHODS for details on
calculation); as an example, the ED50 values
corresponding to the data from Figure 2A are presented in Figure 2B,
plotted against the NGF concentration. From these figures, it can be
seen that the c-erbB2-induced inhibition of adhesion reached a plateau at NGF doses
50 ng/ml, where the ED50 value was
typically 10 times higher than in NGF-untreated cells (fold increase
average of >40 assays = 9.86).
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Using an accelerated adhesion assay (in which cells were briefly centrifuged to avoid the time delay required for sedimentation), we could observe inhibition of adhesion after a minimum of 30 min of c-erbB2 signaling, reaching maximum level after 1 h (Figure 2C). As expected for such a rapid response, c-erbB2-induced adhesion downregulation was independent of both transcription and protein synthesis, as shown by its insensitivity to treatment with actinomycin D and cycloheximide, respectively (Figure 2D). The efficiency of cycloheximide treatment was verified in metabolic labeling experiments in which cycloheximide completely abrogated the incorporation of [35S]methionine into proteins (data not shown). No NGF-induced effect on adhesion or spreading was observed in control transfectants not expressing trk-neu (data not shown).
Adhesion to Collagen of HB2/tnz34 Cells Is Mediated by
Integrin
2
1, the Function but Not
Surface Abundance of Which Is Affected by c-erbB2
We next wished to identify the specific integrin(s) of
importance for the binding of HB2/tnz34 cells to collagen in our
adhesion assay. Cells were therefore pretreated with blocking
antibodies to the collagen-binding integrin subunits
1,
2, and
3 and their heterodimerization partner
1 before their adhesion to collagen was
analyzed. As shown in Figure 3A, adhesion
was strongly suppressed by antibodies against the
2 and
1 subunits,
whereas inhibition of
1, which is poorly
expressed in these cells (Berdichevsky et al., 1994b
, and
our unpublished results), or
3 had no
effect on adhesion. We thus concluded that the main integrin
responsible for collagen binding under these conditions was
2
1.
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Our results indicated that the ability of integrin
2
1 to bind collagen
was suppressed by c-erbB2 homodimer signaling. One possible mechanism
for this event would be that c-erbB2 signaling causes a depletion of
the integrin from the cell surface. To test this hypothesis,
HB2/tnz34 cells were left in suspension for 1 h with or without
NGF (conditions identical to those used in the adhesion assays) and
then subjected to FACS analysis using antibodies against the
2 and
1 subunits. The
results showed that no change in surface expression of these
integrin subunits could be detected with NGF treatment (Figure
3B). It thus appeared that the effect of c-erbB2 on the
2
1 integrin
was mediated by a modulation of integrin function rather than
abundance. We assessed this possibility by treating the cells with the
mAbs TS2/16, which activates the binding capacity of
1 integrins, and JBS2, which
specifically stimulates integrin
2
1, before NGF
treatment and adhesion assay. We found that both antibodies almost
completely restored adhesion in the presence of c-erbB2 signaling
(Figure 3C). The anti-
2 antibody HAS4
(Tenchini et al., 1993
), for which a stimulatory role also
has been suggested (Alford et al., 1998
; Baeckström et al., 2000
), had a similar effect. We therefore concluded
that the major cause of c-erbB2-induced suppression of adhesion to collagen is functional inhibition of integrin
2
1.
Although the function of the integrin-stimulating antibodies is generally held to be caused by induction of conformational changes in the extracellular domain, it cannot be concluded that c-erbB2-induced suppression of adhesion also affects integrin conformation. Another possible mode of integrin suppression is by weakening integrin-cytoskeleton interactions, which are essential for integrin function. To analyze this possibity, we treated HB2/tnz34 cells with the actin-depolymerizing drug cytochalasin D. Whereas adhesion was completely abolished at higher concentrations (100 nM, not shown), a concentration of 10 nM caused a suppression of adhesion similar to that with NGF treatment, and addition of NGF to these cells did not significantly affect adhesion further (Figure 3D). The TS2/16 antibody, however, could still restore adhesion in cytochalasin D-treated cells. These data indicate that the effect of c-erbB2 on integrin function is dependent on the integrity of the actin cytoskeleton and suggest that the integrin-cytoskeleton linkage may be affected by c-erbB2.
c-erbB2-induced Integrin Inhibition Is Dependent on the MEK1/2 MAP Kinase Pathway
Next, we wished to determine the intracellular signaling pathways
involved in mediating the antagonistic effects of c-erbB2 signaling on
the function of integrin
2
1. We reasoned that
if such a signaling pathway could be blocked, then the
trk-neu-transfected cells would adhere normally even upon c-erbB2
homodimer signaling. Furthermore, the importance of the pathways
studied for integrin-regulated morphogenesis could also be
assessed by comparison with the effects of the same treatment in the
spreading assay. Using pharmacological inhibitors and transient
transfections, we therefore studied the effects of interference with
the function of intracellular signaling enzymes.
Because a Ras/Raf-initiated pathway, leading to the activation of the
MAP kinases ERK1/2, has previously been implicated in integrin
inactivation (Hughes et al., 1997
) and because the EGF receptor family tyrosine kinases are known to activate Ras, it was of
interest to study the role of this pathway in c-erbB2-induced inhibition of adhesion and spreading. Using Western blotting with antibodies specific for the activated, phosphorylated state of ERK1/2,
we could confirm that this pathway is indeed activated by the c-erbB2
homodimer in HB2/tnz34 cells (Figure 4A).
The importance of ERK activation in integrin regulation by
c-erbB2 was then analyzed by treating HB2/tnz34 cells with NGF in
combination with PD98059, which inhibits the activation of the MAP
kinase kinases MEK1 and MEK2, immediate upstream activators of ERK1/2.
As shown in Figure 4B, treatment with PD98059 resulted in restoration
of adhesion and spreading in NGF-treated HB2/tnz34 cells. These results
indicate that activation of a MEK-ERK pathway is required for
inactivation of integrin
2
1 by c-erbB2 and
suggest that this effect is important for disruption of spreading
morphogenesis.
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Activation of Phosphoinositide-3-Kinase-Dependent Pathway(s) Is Also Required for c-erbB2-induced Integrin Inactivation
Although our results supported the notion that the MEK1/2 pathway
is required for integrin inactivation, they did not exclude the
possibility that other intracellular signals are equally important for
this process. Phosphoinositide-3-kinase (PI3K) is another major
effector of receptor tyrosine kinases that regulates a number of
pathways of crucial importance to a variety of cellular functions. We
could readily detect c-erbB2-induced activation of PI3K in HB2/tnz34
cells by measuring the activating phosphorylations at Thr308 and Ser473
in PKB, a well-established PI3K effector, on NGF treatment (Figure
5A). The PI3K dependence of this event
was verified by the abrogating effect on PKB phosphorylation of
treatment with LY294002 and wortmannin, two pharmacological PI3K
inhibitors. To investigate a possible role of PI3K in integrin
regulation by c-erbB2, we used these two PI3K inhibitors in our
adhesion and spreading assays. Although wortmannin completely restored primary adhesion to collagen in NGF-treated HB2/tnz34 cells (Figure 5B), LY294002 was without effect under standard conditions for this
assay (1 h of inhibitor treatment followed by addition of NGF).
Intriguingly, spreading of these cells was restored by LY294002 but not
wortmannin. Wortmannin is known to be more unstable than LY294002;
however, repeated additions of fresh wortmannin during the 24-h
incubation with NGF also failed to restore spreading. We asked
ourselves whether the difference in response to LY294002 between the
spreading and adhesion readouts could be a result of the difference in
the duration of the assays (2 h in adhesion assay vs. 24 h in
spreading assays). We therefore studied the influence of LY294002
on the adhesion of cells that had been pretreated with NGF for 24 h. Under these conditions, adhesion was indeed restored (Figure 5B). It
thus appears that the sensitivity to LY294002 of the
integrin-regulating PI3K response varies with the duration of
the c-erbB2 signaling. Long-term NGF treatment, however, did not change
the effect of LY294002 or wortmannin on NGF-induced activating PKB
phosphorylation compared with the short-term conditions shown in Figure
5A (data not shown).
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As an alternative to the PI3K inhibitor treatments, we also examined the effect of overexpressing the phosphoinositide-3-phosphatase PTEN, which antagonizes PI3K function by lowering the intracellular levels of 3-phosphoinositides. A wild-type PTEN expression plasmid was introduced into HB2/tnz34 cells in transient transfections, in which cotransfected LacZ was used as a reporter gene to identify transfected cells. The cells were then used in adhesion and spreading assays, in which the adhesive properties of the transfected cells could be selectively evaluated after exposure to chromogenic LacZ substrates (see MATERIALS AND METHODS for details). Using this technique, we found that PTEN could restore integrin function in both spreading and adhesion assays (Figure 5C). We therefore tentatively concluded that PI3K is required for integrin inactivation by c-erbB2 but that the dependence is likely to be complex, with different downstream components showing differences in influence on adhesion, sensitivity to inhibitors, and dependence on signal duration.
PKB and Integrin-Linked Kinase Mediate Integrin Regulation Downstream of PI3K
To resolve the question of the possible importance of
PI3K-dependent pathways in c-erbB2-induced integrin
inactivation, we sought to interfere with the function of individual
PI3K effectors and study the resulting effect on adhesion and
spreading. We had already established that PKB was activated by c-erbB2
in our system (Figure 5A). PKB is a major mediator of PI3K signaling,
which has been implicated in diverse biological phenomena, such as
metabolic control, protection against apoptosis, and cell motility
(Chan et al., 1999
; Kim, 2001
). In addition to its
requirement for direct binding to 3-phosphoinositides, activation of
PKB is also dependent on the upstream activators
phosphoinositide-dependent kinase (PDK-1) and, interestingly, ILK, a
putative serine/threonine kinase that also binds the
1 integrin, promoting its
phosphorylation and functional downregulation (Hannigan et
al., 1996
). To elucidate whether c-erbB2-induced integrin
inactivation is dependent on PKB and/or ILK, we transiently transfected
wild-type and dominant-negative PKB and ILK constructs into HB2/tnz34
cells and studied the behavior of transfected cells in adhesion and
spreading assays. The results of these assays showed a striking
restoration of adhesion and spreading by dominant-negative PKB and ILK
in NGF-treated HB2/tnz34 cells (Figure 6,
A and B). Indeed, overexpression of wild-type PKB was sufficient to
suppress adhesion in the absence of NGF. In contrast, wild-type ILK
transfection did not alter adhesion or spreading (data not shown).
|
Because the adhesion-suppressing response of PKB transfection (measured
as ED50 value) was >5 times stronger than that
of NGF-induced c-erbB2 signaling and because the duration of elevated PKB signaling by necessity was much longer after PKB transfection than
the standard 1-h NGF treatment, we asked whether some mechanism other than integrin inactivation might be involved in this
effect. We therefore analyzed the effect of PKB overexpression on the levels of integrin
2 and
1 surface expression in flow cytometry, using
coexpressed GFP as a reporter for transfection. In this assay,
integrin levels were unaffected by PKB (shown for
2 in Figure 6D; identical results were
obtained in similar experiments in which the other constructs used in
this study were expressed; data not shown). Moreover, when
PKB-transfected cells were treated with the integrin-activating
antibody TS2/16, adhesion was restored by >95% (see Figure 8A),
strongly indicating that integrin inactivation is indeed the
major mediator of the antiadhesive effect of PKB. These results
demonstrate a novel role for PKB as a potent regulator of the
functional status of integrins and as a mediator of the antiadhesive and antimorphogenetic effects of strong c-erbB2
homodimer signaling.
c-erbB2 Activates a PKB-Independent, Rapamycin-Sensitive Pathway That Is Required for Inhibition of Adhesion but Not Spreading
The complex response of c-erbB2-induced integrin
inactivation to PI3K inhibitors prompted us to search for additional
PI3K effectors that might mediate this effect apart from, or perhaps as
an effector of, PKB. Because treatment with inhibitors against protein
kinases A or C (which both are activated by PDK-1; Cantrell, 2001
) was
unable to restore spreading or adhesion in NGF-treated HB2/tnz34 cells
(Table 1), these signaling molecules are
unlikely to play an important role in integrin regulation by
c-erbB2.
|
The p70 S6 kinase is also reported to be indirectly activated by
PI3K in a PDK-1- and possibly also PKB-dependent manner (Dufner and
Thomas, 1999
). Activating phosphorylation of S6K was found to be
induced by c-erbB2 homodimer signaling in a manner sensitive to
inhibition of PI3K but not of MEK (Figure
7A). We therefore analyzed the influence
on c-erbB2-induced integrin inactivation of rapamycin, which
inhibits activation of S6K by the upstream kinase mammalian target of
rapamycin (mTOR). As shown in Figure 7B, rapamycin potently restored
primary adhesion, but not spreading, in NGF-treated HB2/tnz34 cells.
S6K or some other mTOR effector is therefore likely to be a necessary
mediator of the antiadhesive effect of PI3K. The mTOR/S6K pathway has
been implicated primarily in selective regulation of protein synthesis
(Gingras et al., 2001
). Because c-erbB2-induced
integrin inactivation was shown to be independent of protein
synthesis (Figure 2D), our results suggest a novel mode of function for
S6K, or some other mTOR effector, in integrin regulation.
|
Some studies have suggested a role for PKB in activation of the
mTOR-S6K pathway, although this connection has been disputed (Dufner
and Thomas, 1999
). We analyzed a possible link between PKB and mTOR-S6K
in c-erbB2-induced integrin regulation by treating PKB-transfected HB2/tnz34 cells with rapamycin in adhesion assays. As
shown in Figure 7C, the suppression of adhesion caused by PKB was
completely unaffected by rapamycin treatment, indicating that PKB and
the rapamycin-sensitive pathway act as parallel and independent mediators of the integrin-inactivating effect of PI3K. This
conclusion was further strengthened by the observed lack of S6K
activation on PKB transfection (data not shown).
The MEK and PKB Pathways Appear to Regulate Integrin Activity via Common Target(s)
The reversal of c-erbB2-induced disruption of adhesion and
spreading observed when the function of either MEK or PKB was inhibited strongly indicated that both signaling pathways were required for
integrin inactivation by c-erbB2. It was therefore somewhat surprising that suppression of integrin function could be
achieved solely by overexpression of PKB in the absence of c-erbB2
homodimer signaling (Figure 6A). First, to test the possibility that
PI3K or PKB could activate MEK, we searched for evidence of cross talk between these pathways by using inhibitor treatments, transfections, or
combinations of both. As shown in Table
2, no manipulation of the PI3K or PKB
pathways had any effect on ERK phosphorylation, and conversely, neither
activated MEK1 nor the MEK inhibitor PD98059 could influence the
activation status of PKB (in addition, we showed that the
rapamycin-sensitive pathway also is independent of the MEK pathway).
These results clearly indicated that the MEK and PKB pathways were
acting in a parallel manner. Another possible explanation for the
apparent MEK independence of the effect of PKB on adhesion would be
that the constitutive MEK activity in unstimulated cells was sufficient
to support integrin inactivation when combined with increased
PKB activity. However, when we inhibited MEK signaling by treatment
with PD98059, the integrin-inactivating effect of PKB
overexpression was not diminished (Figure
8A). Thus, it appears that PKB, when
expressed at a sufficiently high level, can mediate integrin
inactivation in the absence of MEK activity. This in turn suggests that
the MEK and PKB pathways may use common downstream targets for
regulating integrin activity. Such a hypothesis would predict
that stimulation of the MEK pathway in the absence of PKB signaling
also would be sufficient for integrin inactivation. As shown in
Figure 8B, transient transfection with constitutively active MEK1 was
indeed capable of suppressing adhesion in the absence of NGF-induced
c-erbB2 homodimer signaling, an effect that was not perturbed by
cotransfection with dominant-negative PKB. The suppressive effect of
MEK transfection appeared considerably weaker than that induced by PKB;
however, this discrepancy may be explained by the higher degree of
overexpression of PKB compared with MEK (Figure 8C), although it should
be kept in mind that the MEK used was a constitutively active mutant,
whereas PKB was wild-type. We also confirmed that the
adhesion-suppressing effect of MEK1 transfection could be reversed by
integrin activation mediated by treatment with the TS2/16 mAb
(Figure 8B). It therefore appears that overexpression of either PKB or
MEK1 overrides the requirement for activation of both pathways to
achieve integrin inactivation. These results are thus in
accordance with the hypothesis that the MEK and PKB pathways may use
common downstream effectors for downregulation of integrin
function.
|
|
| |
DISCUSSION |
|---|
|
|
|---|
The present study was prompted by the profound effect of intense
c-erbB2 homodimer signaling on morphogenesis of mammary epithelial cells in three-dimensional collagen culture and its reversal by integrin activation observed previously (Baeckström
et al., 2000
). Here, we have attempted to elucidate the
intracellular events that mediate this morphogenetic effect. Adhesion
assays have been used to study the regulation of integrin
function without interference from other phenomena, whereas spreading
assays were used as a simplified indicator of morphogenesis. Our
findings can be summarized as follows.
Integrin Function Is Negatively Affected by c-erbB2
This was suspected from the earlier finding that the inhibition of
morphogenesis in collagen caused by c-erbB2 homodimer signaling could
be reversed by antibodies that activate
2 or
1 integrins (Baeckström et
al., 2000
). However, the present study provides direct evidence
that c-erbB2 inhibits integrin-dependent matrix adhesion.
Specifically, we have shown that primary adhesion to collagen of
HB2/tnz34 cells is dependent on integrin
1 and
2 subunits and
that c-erbB2-induced inhibition of adhesion can be completely reversed
by mAbs that induce an active conformation in the
2
1 integrin.
Moreover, the restoration of adhesion caused by inhibitor treatments
(discussed below) was consistently abrogated by incubation with an
2-blocking antibody, and in no case did these
inhibitors cause increased surface expression of integrin
2 or
1 (data not
shown). Together, these findings strongly indicate that the function of
integrin
2
1
is suppressed by c-erbB2 and that the manipulations that restore
adhesion do so by relieving this suppression.
Integrin function can be regulated by changing integrin
extracellular conformation, clustering of integrins at the cell
surface, or integrin-cytoskeleton attachment. The present
study cannot conclusively identify at what level(s) the antiadhesive
signal from c-erbB2 acts. However, because no effect of NGF was seen in
the cytochalasin D-treated cells (Figure 3D), it is likely that a cytoskeleton-dependent mechanism plays an important role. Detection of changes in
1 extracellular
conformation using activation epitope-specific antibodies has been
attempted (data not shown), but although a reproducibly suppressive
effect of NGF could be seen, the interpretation of these results was
hampered by the very weak binding of the conformation-specific
antibodies to untreated as well as manganese-activated cells. It is
possible that the regulation of
1
integrin activity in epithelial cells involves more subtle
changes in extracellular conformation.
The MEK-ERK and PI3K Pathways Are Both Required for c-erbB2-induced Integrin Inhibition
Our data strongly indicate an important role for the Raf-MEK
pathway, because PD98059, a substance that inhibits the activation of
MEK1/2 by Raf, potently restored spreading and adhesion in NGF-treated
HB2/tnz34 cells (Figure 2). Hughes et al. (1997)
showed the
potential of this pathway to inhibit integrin activation. Apart
from confirming this previous observation, we have demonstrated the
relevance of the integrin-inactivating capacity of the ERK pathway in a wider context, both with respect to its role as a mediator
of c-erbB2 signaling to the
2
1 integrin
and with respect to its function in disruption of morphogenesis. The
integrin-inactivating downstream effector(s) of ERK are still
not characterized, but both our data and those of Hughes et
al. clearly indicate that regulation of transcription or protein
synthesis is not involved. We have also established that the effect of
PD98059 (as well as that of the other adhesion-restoring inhibitors
wortmannin and rapamycin) was insensitive to cycloheximide treatment
(data not shown). As will be discussed below, our data suggest that the ERK signal and those of other pathways may target a common
integrin-regulating effector.
In our initial characterization of the possible PI3K dependence of
c-erbB2-induced inhibition of adhesion and spreading using the two
widely used pharmacological PI3K inhibitors LY294002 and wortmannin,
the paradoxical result was obtained that adhesion was restored by
wortmannin but not LY294002, whereas the reverse was the case for cell
spreading (Figure 5B). In the case of LY294002, a time-dependent effect
is suggested by the observation that after prolonged (24 h) c-erbB2
activation, the adhesion-suppressing response of HB2/tnz34 cells
becomes sensitive to LY294002, although the duration of the inhibitor
treatment is not changed. Because overexpression of the
3-phosphoinositide phosphatase PTEN as well as inhibition of at least
two different PI3K effectors also restored integrin function
(see below), we feel that it is safe to conclude that c-erbB2-induced
integrin inactivation indeed is PI3K-dependent. As a tentative
explanation for the observed difference in response to PI3K inhibitors,
one may speculate that PI3K elicits integrin-activating as well
as integrin-inactivating mechanisms and that the balance between opposing effects on integrin function downstream of
PI3K may be sensitive to how PI3K is inhibited and/or to the duration of the PI3K signal. The slight difference in inhibition efficiency beteween LY294002 and wortmannin seen in Figure 5A may be of importance in this context. Different PI3K effectors have previously been reported
to respond differently to LY294002 compared with wortmannin (Adi
et al., 2001
). Although wortmannin is known to be capable of
inhibiting myosin light chain kinase (Nakanishi et al.,
1992
) and mTOR (Gingras et al., 2001
) in addition to PI3K,
these kinases are not likely to be direct mediators of the effect of
wortmannin in our experiments, because the concentrations required for
their inhibition (~200 nM) are far higher than the 25 nM used
in our adhesion assays.
Although PI3K has often been implicated in downstream events
after integrin-ligand binding, only a small number of reports describe a role for PI3K in the regulation of integrin function (e.g., Shimizu et al., 1995
; Zhang et al., 1996
);
moreover, in those studies, PI3K was found to enhance
integrin-mediated matrix adhesion. Likewise, the morphogenetic
effects of PTEN overexpression were described by Tamura et
al. (1998)
as antagonistic to spreading. These observations are
thus in apparent conflict with our data, which indicate that
integrin function is inhibited by PI3K and restored by PTEN. It
should be kept in mind, however, that whereas the cells used by Tamura
et al. were mesenchymal in origin and Shimizu et
al. and Zhang et al. studied hematopoietic cells, our system consists of epithelial cells. Regulation of matrix adhesion is
likely to be highly cell-type specific, given the radically different
adhesion requirements of different cell types. It should also be noted
that our experiments have neither addressed nor elucidated the
possibility of an active role for PTEN in c-erbB2-induced integrin inactivation.
Downstream of PI3K, ILK, PKB, and a Rapamycin-Sensitive Pathway Mediate Integrin Inactivation Initiated by c-erbB2
A major novel finding in this study is the crucial role of PKB in
mediating the integrin-inactivating effects of c-erbB2
demonstrated by the restoration of both adhesion and spreading on
transfection with dominant negative forms of PKB or the PKB coactivator
ILK (Figure 6). Like PI3K, PKB has often been implicated in events after integrin engagement (outside-in signaling; e.g. Khwaja
et al., 1997
); however, to the best of our knowledge, this
is the first report of a crucial role for PKB in cellular regulation of
integrin function (inside-out signaling). Interestingly, PKB has recently been implicated in cancer cell motility and invasion (Kim,
2001
). This effect was partly explained by increased metalloproteinase production, and no changes in primary adhesion to collagen were observed on PKB transfection. However, only one relatively high collagen coating concentration was used in the adhesion assays and, as
shown in the present study, suppression of adhesion caused by
integrin inactivation may not be evident under conditions in which the supply of matrix is not limiting. Another recent report (Kirk
et al., 2000
) demonstrated phosphorylation of
integrin
3 at a cytoplasmic threonine
by PKB; however, the report did not investigate possible changes in the
functional status of the integrin after this event. The
threonine residue in question is situated in a region that is conserved
between
integrins, and it is a possibility worth exploring
that a similar event is taking place in
1
integrins on c-erbB2-induced activation of PKB and that this
contributes to integrin inactivation.
Our data also identify ILK as a necessary mediator of the
integrin-inactivating effects of c-erbB2. Although ILK was
initially identified as a molecule that binds, phosphorylates, and
inactivates integrin
1 (Hannigan
et al., 1996
), very little is known about this aspect of ILK
function. Instead, the bulk of our present knowledge about ILK pertains
to its role in activating downstream effectors such as PKB, glycogen
synthase kinase-3, and the
-catenin pathway (Delcommenne et
al., 1998
; Tan et al., 2001
). However, in HB2/tnz34
cells, neither downregulation of adhesion nor PKB phosphorylation could
be observed after overexpression of either wild-type ILK or a
putatively activated S343D mutant (Lynch et al., 1999
) (data
not shown). It is therefore possible that these effects of ILK are
cell-type dependent or that higher expression levels of ILK than those
achieved in the present study are necessary to suppress adhesion and/or
cause PKB phosphorylation in HB2/tnz34 cells. These observations, and
the finding that PKB is capable of causing integrin
inactivation, raise the intriguing possibility that downregulation of
matrix adhesion by ILK (Hannigan et al., 1996
) is mediated
by PKB. One may speculate that ILK recruits PKB to the vicinity of
integrin cytoplasmic domains, in which PKB becomes activated
and phosphorylates the integrins or associated proteins
necessary for integrin function. Because ILK has been shown to
have a vital function in Drosophila that is independent of
its kinase activity (Zervas et al., 2001
), one may speculate that ILK regulates integrin function both as a
kinase-independent adapter molecule and, perhaps more subtly, as an
integrin-proximal activator of PKB.
The surprising result that c-erbB2-induced inhibition of adhesion can
be reversed by treatment with rapamycin indicates a previously unknown
function for the protein kinase mTOR, which has been known primarily as
a specific regulator of protein synthesis (Gingras et al.,
2001
). The best-described effector of mTOR is S6K, a protein kinase
known to phosphorylate the S6 ribosomal protein, thereby mediating a
major part of the translation-regulating function of mTOR (Proud,
1996
). Neither kinase has earlier been implicated in regulation of cell
adhesion. Because S6K but not mTOR is reported to be dependent on PI3K
for activation (Gingras et al., 2001
), it is possible that
the observed rapamycin-sensitive suppression of adhesion is mediated by
activation of S6K by PI3K and that mTOR itself plays a permissive role.
On the basis of the present data, however, it is not possible to decide
whether it is S6K or some other mTOR effector that is mediating
integrin inhibition. In either case, this pathway is likely to
be acting in parallel with and not downstream of PKB, because rapamycin was unable to restore the suppression of adhesion caused by
transfection with wild-type PKB; in addition, PKB overexpression failed
to induce activating phosphorylation of S6K (data not shown). In contrast to these data, an interesting recent report (Neshat et al., 2001
) found that a rapamycin analog could antagonize growth of cells expressing activated PKB (or lacking PTEN). However, that
study did not directly analyze the influence of PKB signaling on S6K activity.
The MEK and PKB Pathways May Use Common Downstream Mediators to Inhibit Integrin Function
Our results regarding the MEK and PKB dependence of
c-erbB2-induced integrin inactivation presented us with an
apparent paradox: on one hand, the observation that inhibition of
either PKB or MEK is sufficient to restore integrin function in
the presence of c-erbB2 signaling strongly indicated that both pathways
are necessary mediators of the antiadhesive effect of c-erbB2. On the
other hand, we had found that overexpression of either wild-type PKB or
constitutively active MEK was sufficient to inhibit integrin function in the absence of c-erbB2 signaling. Even when inhibiting constitutive MEK signaling in PKB-transfected cells or vice versa, we
failed to observe interdependence between the two pathways in
suppression of adhesion (Figure 8), suggesting that MEK and PKB use a
common downstream effector to exert their antiadhesive function (Figure
9). One possible explanation for this
apparent contradiction is that when PKB is strongly overexpressed, the putative common effector is activated to a sufficient degree to make
MEK signaling redundant (and vice versa); however, at the level of
signaling achieved by trk-neu homodimerization, both MEK and PKB are
necessary to reach the signaling intensity necessary for
integrin inactivation. Identification of the putative common effector(s) is evidently an urgent task for future research.
|
When the influences of different signaling molecules mediating the effects of c-erbB2 are summarized, there is a striking similarity between the responses in adhesion and spreading assays: with the exception of the rapamycin-sensitive effector, all pathways that were shown to be important for adhesion also affected spreading. This correlation suggests that the mechanisms that govern the rapid modulation of integrin activation status also are critical to the longer-term effects of c-erbB2 on cellular morphogenesis. Such a conclusion strengthens the concept of a crucial role for integrin regulation in c-erbB2-induced conversion of cellular phenotype.
PKB has recently emerged as an important mediator of a variety of
cancer-associated effects of c-erbB2 signaling, including desensitization to tumor-preventing mechanisms, such as cell cycle arrest by p21WAF (Zhou et al., 2001
),
hormone dependence (Wen et al., 2000
), and tumor necrosis
factor-induced apoptosis (Zhou et al., 2000
). Because impairment of
2
1
integrin-mediated adhesion has been strongly associated with
breast cancer progression (Zutter et al., 1990
, 1995
), the
results of the present study may present yet another aspect of PKB
function in c-erbB2-induced carcinogenesis. The influence of
integrin inactivation on the emerging carcinoma cell is likely
to include increased motility and invasiveness, facilitating tumor cell
dissemination and metastasis. This process would be further enhanced by
the recently identified PKB-mediated matrix metalloproteinase
production (Kim, 2001
). The versatility of PKB in mediating the
carcinogenic effects of c-erbB2 makes this kinase an interesting target
for novel strategies in cancer treatment.
| |
ACKNOWLEDGMENTS |
|---|
The authors thank Drs. Ian Hiles, Brian Hemmings, Ramon Parsons, and Pär Gerwins for generously providing expression plasmids; Dr. Fiona Watt for the gift of the HAS4 antibody; and Dr. Staffan Johansson for critical reading of the manuscript. The P5D2 hybridoma developed by E. A. Wayner was obtained from the Developmental Studies Hybridoma Bank developed under the auspices of the National Institute of Child Health and Human Development and maintained by the University of Iowa. This work was supported by the Swedish Cancer Fund (grant no. 99 3317), Assar Gabrielsson's Fund, the Lars Hierta Memorial Fund, Magn. Bergvall's Foundation, Adlerbert's Research Foundation, and the Swedish Society of Medicine.
| |
FOOTNOTES |
|---|
* Corresponding author. E-mail address: dan.baeckstrom{at}medkem.gu.se.