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88 Current Molecular Pharmacology, 2012, 5, 88-101 Base Excision Repair, the Redox Environment and Therapeutic Implications S.J. Storr, C.M. Woolston and S.G. Martin* Academic Oncology, University of Nottingham, School of Molecular Medical Sciences, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK Abstract: Control of redox homeostasis is crucial for a number of cellular processes with deregulation leading to a number of serious consequences including oxidative damage such induction of DNA base lesions. The DNA lesions caused by oxidative damage are principally repaired by the base excision repair (BER) pathway. Pharmacological inhibition of BER is becoming an increasingly active area of research with the emergence of PARP inhibitors in cancer therapy. The redox status of the cell is modulated by a number of systems, including a large number of anti-oxidant enzymes who function in the control of superoxide and hydrogen peroxide, and ultimately in the release of the damaging hydroxyl radical. Here we provide an overview of reactive oxygen species (ROS) production and its modulation by antioxidant enzymes. The review also discusses the effect of ROS on the BER pathway, particularly in relation to cancer. Finally, as the modulation of the redox environment is of interest in cancer therapy, with certain agents having the potential to reverse chemo- and radiotherapy resistance or treat therapy related toxicity, we discuss redox modulating agents currently under development. Keywords: Base excision repair, cancer, homeostasis, redox. THE REDOX ENVIRONMENT The term ‘redox’ is used to define the transfer of electrons through reduction and oxidation and the control of redox homeostasis is extremely important for normal cell function and survival. The redox biochemistry that living cells experience is dominated by oxygen. However cells require a reducing environment to function and therefore oxygen and its intermediates, collectively known as reactive oxygen species (ROS), are a constant threat. Cells have adapted to this problem through the development of a complex mechanism of redox buffering systems that aid in the control of ROS levels. These include the thioredoxin and glutathione systems, antioxidants enzymes such as catalase and superoxide dismutase and non-enzymatic antioxidants such as ascorbic acid, -tocopherol and carotenoids. Such control mechanisms, involved in the maintenance of redox homeostasis, have been reviewed by Dröge, 2002 [1]. ROS can be broadly categorised as free radicals such as superoxide (O2•-) and hydroxyl radicals (•OH) or non radicals such as hydrogen peroxide (H2O2). Free radicals are molecules containing one or more unpaired electrons in atomic or molecular orbitals. ROS are hazardous for living organisms and can damage most major cellular constituents. The accumulation of ROS within the cell can lead to oxidative DNA damage, altered cytoplasmic and nuclear signalling and can change the activity and/or expression of proteins that respond to stress. There are a number of human diseases where oxidative damage plays an influential role, such as carcinogenesis, pre-eclampsia, stroke and chronic heart failure, but also in the natural process of ageing [2]. *Address correspondence to this author at the Academic Oncology, University of Nottingham, School of Molecular Medical Sciences, Nottingham University Hospitals NHS Trust, City Hospital Campus, Nottingham, NG5 1PB, UK; Tel: +44 (0)115 823 1846; Fax: +44 (0)115 823 1849; E-mail: [email protected] 1874-4672/12 $58.00+.00 Normal cellular metabolism is the major source of ROS in aerobic cells. Mitochondria use NADH to funnel electrons through the respiratory chain. During this process superoxide can leak from the chain, principally through complexes I and III. Other sources of ROS include membrane bound NADPH oxidase (Nox), which is able to produce ROS involved in cellular signalling triggered by receptor binding. In addition, ROS are produced during pathological processes such as inflammation by neutrophils, eosinophils and macrophages [3]. Exogenous sources of ROS include irradiation by UV light and X-rays and atmospheric pollution. Metal induced oxidative stress is reviewed by Valko et al. (2006) [4]. The fate of the ‘leaked’ superoxide can be either nonenzymatic or enzymatic dismutation to H2O2. The enzymes involved in this reaction are superoxide dismutases (SOD) and superoxide reductases. Superoxide that escapes dismutation can participate in the Harber-Weiss reaction with H2O2 to produce hydroxyl radicals, however, in-vivo these radicals are principally formed through the Fenton reaction when Fe2+ contacts H2O2. In addition, through peroxynitrate formation, ‘leaked’ superoxide can also interact with nitric oxide to form ONOO- which is a powerful oxidant comparable to hydroxyl radicals [5]. H2O2 can specifically and reversibly modify proteins, principally via thiol groups. In the context of this review, the hydroxyl radical is perhaps the most important ROS due to its highly reactive nature. The hydroxyl radical is able to react with proteins and DNA, and has no specific biological partner or agent to modify its actions. Importantly there is no enzyme that functions to supervise its removal from the cellular environment. Therefore its precursor, H2O2, is tightly regulated and it is when these control mechanisms fail that damage can occur. However, the hydroxyl radical has a short half life of less that 1 nano second [6]. In-vivo, peroxynitrite may be one of the principal agents of oxidative damage as it has a longer half life than the hydroxyl radical. In addition, it © 2012 Bentham Science Publishers Base Excision Repair, the Redox Environment does not require iron chelation for production, purely nitric oxide and superoxide; and nitric oxide is readily available, produced by oxidising argenine [7, 8]. Furthermore the reaction between the radicals superoxide and nitric oxide, in the production of peroxynitrite have a rate constant 3.5 times higher than that for SOD catalysed dismutation of superoxide. The chemical biology of peroxynitrite is reviewed by Ferrer-Sueta and Radi (2009) [9] and Burney et al. (1999) [10]. Oxidative stress can trigger two major events, the oxidation of cysteine containing proteins and the formation of reactive sulphur species. These two events can propagate pro- or anti-apoptotic pathways. Thiol oxidation can cause the formation of disulphide bonds which can activate or deactivate the activity of a protein, often by causing conformational changes in protein structure [11]. The redox sensitive sulfhydryl switches are central to maintaining a balanced redox environment. In normal cells, oxidative stress can cause a range of responses from a transient growth arrest and adaptation, increase in cellular proliferation, permanent growth arrest or senescence, apoptosis or necrosis [12]. In cancer, abnormal cells are continuously under increased oxidative stress due to accelerated cellular proliferation, prolonged stimulation of growth promoting signalling pathways and alterations in metabolic activity. Cellular ROS are able to cause oxidative DNA damage in addition to influencing the numerous aberrantly altered processes. ROS can transmit further cellular signals that are able to influence tumour progression, metabolic pathways and alter transcription by modulating redox controlled transcription factors including p53, activator protein 1 (AP1), and NF-B. In addition, ROS have been implicated in epithelial-mesenchymal transition (EMT), angiogenesis and cell migration and in the mechanism of action of therapeutic interventions including chemotherapy and radiotherapy [3, 13]. ROS mediated molecular and biochemical changes including DNA lesions and mutations, contribute to the heterogenous nature of a cancer and are likely to aid in the generation of therapy resistant subpopulations. The role of ROS in oncogenic transformation has been reviewed by Behrend et al. (2003) [14]. OXIDATIVE DAMAGE TO DNA A high proportion of DNA damage can be attributed to ROS, in particular the hydroxyl radical, and may partly explain the induction of certain spontaneous cancers [15]. The generation of ROS, in particular hydrogen peroxide and the hydroxyl radical, has been shown to be increased in cancer [16]. The hydroxyl radical is able to cause DNA damage by a variety of means including its addition to double bonds of DNA bases and removal of hydrogen from thymine and each of the C-H bonds of 2’-deoxyribose [4]. Each ROS acts via different mechanisms to damage DNA, with superoxide and hydrogen peroxide not directly responsible for oxidative damage, but involved through the accumulation of the hydroxyl radical. The hydroxyl radical can damage all bases, although preferentially acts to oxidise guanine due to its low redox potential [17, 18]. Oxidative DNA damage can be repaired by a number of mechanisms but principally by the base excision repair Current Molecular Pharmacology, 2012, Vol. 5, No. 1 89 (BER) pathway, which removes single lesions [19]. Interestingly there are a number of enzymes within the BER pathway that can themselves be modulated by the redox environment. The removal of larger base lesions containing oligonucleotides is conducted by nucleotide excision repair (NER). The process of oxidative damage repair is reviewed by Barzilai and Yamamoto (2004) [20]. The BER process is implicated in a number of pathologies such as cancer, ageing and neurodegeneration [21]. All of these conditions result in the accumulation of DNA damage, often through defective BER enzymes. The pathway can be subdivided into either short patch (SP) or long patch (LP), which differ in the amount of DNA synthesised during repair, being one to two bases or three to eight bases respectively. BER consists of a number of steps starting with the identification and excision of the lesion, and repair of the DNA. There are a large number of enzymes that cooperate in the BER pathway, through protein-protein interactions and post translational modification, with a degree of overlap, and are reviewed by Fan and Wilson III (2005) [22]. Oxidative damage to DNA can cause a plethora of base lesions, the most frequently described of which is an oxidised guanine, 8-oxo-2’deoxyguanosine (8-oxoG) and there are numerous repair mechanisms to remove them. 8oxoG mutations can cause A:T to C:C and G:C to T:A transversions [17]. In addition lesions can include thymine glycol, 3-methyladenine and double strand breaks. Repair intermediates such as apurinic/apyrimidinic (AP) sites are also damaging to the cell. The repair of oxidised base lesions is initiated by DNA glycosylases such as endonuclease III homologue NTH1 and 8-oxoG DNA glycosylases (OGG1 and OGG2) which generate strand breaks by -elimination (Fig. 1). As well as OGG1 and OGG2 there are a number of other glycosylases that are involved in the process, often recognising different lesions with different affinities such as NEIL1 [23]. In addition, some degree of cooperativity exists between the glycosylases, such as increased turnover of OGG1 by NEIL1 [24]. This process results in 3’-end structures which block DNA polymerase activity. In addition these 3’ blocking structures can also be directly caused by ROS. One of the most influential proteins in the BER pathway is human AP endonuclease, APE1 (APEX, APE, HAP1 and Ref-1), which cleaves phosphodiester bonds 5’ and adjacent to an AP site in addition to 3’ phosphoesterase activity which is utilised to remove the 3’-blocking damage as a result of ROS. Research has shown that APE1 is rate limiting in the repair of 3’-blocking damage [25]. The accumulation of AP sites causes increased mutagenic potential and can result in DNA strand breaks and apoptosis [26]. Interestingly NEIL1 does not require APE1 as it can perform -elimination of the AP site, it may also act as a backup for APE1 in the repair of 8-oxoG with OGG1 [24]. It is outside the scope of the current review to examine the entire BER pathway but there are a large number of enzymes that facilitate the repair of oxidative DNA damage [22] and those with redox regulation will be discussed later. It should be noted at this juncture that although the Xeroderma pigmentosum C (XPC) protein is widely recognised as a component of the NER pathway there is also some degree of cooperativity with BER. XPC has been 90 Current Molecular Pharmacology, 2012, Vol. 5, No. 1 Storr et al. Prdx Family GPx Family Catalase SOD O2•- H2O2 H2O + O2 Fenton reaction •OH OGG1 Repair Fig. (1). Hydrogen peroxide can result in production of the hydroxyl radical via the fenton reaction. The hydroxyl radical can cause oxidative DNA damage, one of the most common lesions is 8-oxoG. DNA can be repaired through the removal of 8-oxoG by the BER pathway initiated by DNA glycosylases, in this example OGG1. shown to act as a cofactor for the efficient cleavage of 8oxoG by OGG1 [27]. THE ROLE OF ANTIOXIDANT PROTEINS IN DNA DAMAGE The production of the hydroxyl radical and ONOO- and therefore the prevention of DNA damage, are effectively maintained in normal cells by the control of H2O2. This control is managed by a number of redox enzymes including the peroxiredoxins (Prdx). Prdx are ubiquitously expressed enzymes that regulate whether H2O2 acts as a signal inducer or becomes a harmful oxidant. The enzymes catalyse the reaction by oxidation of the peroxidatic cysteine which can then form a disulphide bond with the resolving cysteine residue; this is mainly reduced by thioredoxin (Fig. 2). During those times when H2O2 is acting as a signalling mediator, the peroxidatic cysteine can become over oxidised to sulfinic acid and reduced back to thiol by a sulfinic acid reductase, sulfiredoxin (Srx) in an ATP dependent mechanism [28, 29]. However over oxidation to sulfonic acid is also a common occurrence which is irreversible and leads to protein degradation [30] or to the formation of oligomeric peroxidase-inactive chaperones [31]. In addition to overoxidation, Prdx activity can also be regulated by phosphorylation and proteolysis [32, 33]. Abnormal expression of Prdx has been found in many kinds of cancers [34-36] and further induction of oxidative stress such as that caused by ionizing radiation can induce their expression [37]. Mice lacking Prdx1 show decreased lifespan and increased tumour incidence and an increased level of 8-oxo-2’deoxyguanosine (8-oxoG) formation [38]. Similar observations have been made for Prdx5 whereby siRNA mediated knockdown results in increased 8-oxoG formation [39]. The aberrant expression of the Prdx family is reviewed by Zhang et al. (2009) [37]. The thioredoxin system has been shown to be both over and under expressed in a number of different cancers [4044]. The activity of thioredoxin can be inhibited by thioredoxin interacting protein (TxNIP), and recycled by the selenoenzyme thioredoxin reductase. Thioredoxin has been implicated in a number of cellular processes including maintaining a reducing cellular environment (through interaction with downstream Prdx), regulating cell growth (via ribonucleotide reductase and promotion of growth factor expression), transcription factor activation (including NFkB, p53, Hypoxia inducing factor HIF-1) and also apoptosis (ASK-1) [45-47]. Thioredoxin translocates to the nucleus in response to oxidative stress induced by hydrogen peroxide, exposure to UV, ionising radiation and platinum based treatments [48, 49]. Debatably one of the most important functions of thioredoxin within the nucleus, excluding its action in controlling hydrogen peroxide levels, is its role in regulating DNA repair through interaction with factors such as p53, which will be discussed later in terms of APE1 redox regulation. In addition to Prdx, both the glutathione peroxidase (GPx) family and catalase function to control H2O2 (Fig. 3). The GPx family consists of 8 members, 5 of which are selenoproteins, GPx -1, 2, 4, 5 and 6, and respond via different mechanisms to selenium deficiency. The family members have been implicated, to varying degrees, in carcinogenesis, with selenium supplementation indicated in some reports [50]. Studies have shown that GPx1 null mice that are heterozygous for manganese superoxide dismutase (MnSOD) show increased oxidative damage, through detection of 8-oxoG, and increased incidence of tumours Base Excision Repair, the Redox Environment Current Molecular Pharmacology, 2012, Vol. 5, No. 1 O2•- H2O2 H2O + O2 SOD Thioredoxin interacting protein (TxNIP) 91 Prdx Family Thioredoxin Thioredoxin s-s Thioredoxin reductase or Thiol oxidation of target protein Fig. (2). The peroxiredoxin (Prdx) family involvement in the control of H2O2 levels within the cell. The thioredoxin system plays an important role in regulating its turnover. O2•- H2O2 H2O + O2 SOD GPx Family GSH GSSG Glutathione reductase NADPH NADP+ Glucose 6-phosphate dehydrogenase Fig. (3). The glutathione redox system and its role in the control of H2O2 levels within the cell by oxidising the tripeptide glutathione (GSH) to glutathione disulphide (GSSG). [51]. Expressing SOD 1 or 2 in retinal pigmented epithelial cells, causes greater oxidative damage, which can be nullified by increased expression of GPx4, and GPx1 to a lesser extent [52]. Glutathione itself also acts as a scavenger molecule against ROS. Current research shows that it is possible to use routine immunohistochemistry of the redox proteins regulating H2O2 and markers of oxidative DNA damage to predict clinical outcome in some cancers [44, 53-57]. The current authors have also demonstrated that members of the thioredoxin and glutathione families can predict response to ROS generating therapies in breast and ovarian cancer [58-61]. DIRECT MODULATION OF DNA REPAIR BY THE REDOX ENVIRONMENT An interesting aspect of the redox environment is its ability to directly affect DNA repair, in addition to causing DNA damage. There are limited examples of this modulation of activity, with a number of them associated with the BER pathway. The direct effect of ROS and the redox environment on the short patch BER pathway is summarised in Fig. (4). As mentioned previously one of the most frequent, and most studied, base lesions caused by oxidative damage is 8oxoG. One of the first observations that redox status had effects on damage repair was conducted using HeLa cervical cancer cells in that cadmium increased the appearance of the ROS-mediated 8-oxoG by the creation of an oxidising environment, but importantly the activity of DNA repair was also impaired leading to increased carcinogenic potential [62]. 8-oxoG is eliminated through the BER pathway through excision by OGG1 and cadmium has since been shown to inactivate OGG1 through cysteine modification [63]. The activity of OGG1 can be directly modulated by the redox environment where a polymorphism switching serine to cysteine at position 326 of the protein is detrimental to DNA repair. Significantly the Ser326Cys polymorphism is 92 Current Molecular Pharmacology, 2012, Vol. 5, No. 1 Storr et al. ROS Modulation Bifunctional glycosylase Decreased activity (with Ser326Cys mutation) OGG1 Increased activity through interaction with YB-1 NEILs NEILs OGG1 OGG / NTH1 P P PUA Redox control of transcription factors NEILs PNK APE1 APE1 OH P Short patch Increased activity with Pol β via thiol switch XRCC1 P Long patch XRCC1 Pol β LigIII and I FEN-1 PCNA PARP Fig. (4). ROS modulation of the BER pathway on an exemplary 8-oxoG lesion as a result of oxidative damage by bifunctional DNA glycosylases. OGG and NTH1 act via elimination with the NEILs acting via elimination. PNK: polynucleotide kinase; LigIII and I: DNA ligase III and I; FEN-1: flap structure-specific endonuclease 1; PCNA: proliferating cell nuclear antigen. The NEIL route of repair may function during active transcription and replication due to its increased affinity for DNA bubbles. associated with an increased risk of developing cancer [64] due to the altered repair capabilities in an oxidising environment. Bravard and colleagues (2006, 2009) showed that oxidation of the mutant cysteine 326 of OGG1 forms a disulphide bond with other cysteines within the protein. It is postulated that the reduction in enzymatic activity is a result of the conformational change induced but can be reversed in the presence of reducing agents such as DTT [63, 65]. Human ribosomal protein S3 plays a role in influencing the recognition of 8-oxoG sites by blocking recognition by OGG1. Interestingly 8-oxoG binding of hS3 can be abrogated by a single amino acid change, which stimulates the repair of 8-oxoG by OGG1 [66, 67]. hS3 has also been shown to influence NF-kB mediated transcription [68] and can interact with p53 and MDM2 with interactions increasing upon exposure to oxidative stress [69]. OGG1 is not the only BER pathway member to be directly modulated by the redox environment. APE1 is a multifunctional protein that in addition to being an A/P endonuclease has redox activity. Human APE1 was first described and cloned as a DNA repair enzyme in 1991 [70, 71] and the redox activity of APE1 was described shortly after in 1992 [72]. These two functional aspects of the protein reside in different, distinct areas of the protein, with the redox domain located in the N-terminal amino region [72, 73]. The redox domain of APE1 can function to modulate DNA damage in an indirect manor through its interaction with transcription factors and is discussed later. There is also evidence that the redox state of APE1 is implicated directly in its DNA repair activity [74-76]. Immediately adjacent to the crucial histidine in the DNA repair active site of APE1 is a cysteine that can be redox regulated [74], potentially interfering with the function of the active site. Ramana et al. (1998), [75] were able to demonstrate that APE1 is activated by non-toxic levels of ROS, but not UV light or alkylating agents, and promotes translocation into the nucleus. The translocation of APE1 into the nucleus in response to ROS has been investigated further. Extracellular ATP stimulates the purinergic receptors (P2) through Ca2+ mobilisation and the production of ROS and is responsible for the localisation of APE1 [77]. In addition phosphorylation by protein kinase C (PKC) following an oxidative challenge has been shown to increase the activity of the APE1 redox domain [78]. NEILs (Nie-like-1 and 2) are other DNA glycosylases involved in the BER pathway. They function by a different mechanism to OGG1 and NTH1 (homologue of E. coli endonuclease III) but all can act on duplex DNA. NEILs, however, preferentially act upon DNA bubbles or single stranded DNA, implying the activity of these glycosylases during active transcription and replication [79]. Oxidative stress causes the translocation of the Y-box binding protein-1 (YB-1) to the nucleus and its stable interaction with NEIL2, increasing NEIL2 activity in the BER pathway. The interaction between NEIL2 and YB-1 is physical and increases the excision activity of NEIL2 seven fold [80]. In addition to OGG1 and APE1, the interaction between XRCC1 (X-ray repair, cross-complementing defective, in Chinese hamster, 1) and DNA polymerase (Pol ) binding Base Excision Repair, the Redox Environment is influenced by the redox environment. Recently, Cuneo and London (2010), [81] examined the crystal structure of the oxidised and reduced N-terminal domain of XRCC1 in complex with Pol and showed that oxidised XRCC1 demonstrated altered folding topology through the formation of a disulphide bond. Most of the structural changes occurred in an area of the protein that was not directly responsible for Pol binding but the oxidative changes were able to enhance affinity. The authors offer an interesting hypothesis whereby APE1, a known binding partner of XRCC1, may play a role in the activation or deactivation of XRCC1s disulfide switch through its redox domain [81]. It is not only the BER pathway that can be modulated directly by oxidative stress. As the role of therapeutic ionising radiation is to induce oxidative stress and create double strand breaks within the cell an element of redox control in the double strand DNA repair pathway may seem paradoxical. However the redox environment seems to play an important role within this pathway. In the nonhomologous end joining (NHEJ) double strand DNA break repair pathway Ku is responsible for binding DNA. An oxidising environment results in lower DNA binding of the protein which is reversible upon reduction. It is unclear how oxidisation affects the ability of the protein to bind DNA as disulphide bonds are not observed but it is possible that cysteine sulfenic acids are formed [82]. The influence exerted by the redox environment functions to increase or decrease the time Ku is bound to the DNA which has an impact upon the likelihood of recruitment of the DNA-PK catalytic subunit (DNA-PKcs) to form the DNA-PK complex [83]. A further redox effect within this process is glucose-6phosphate dehydrogenase (G6PD). G6PD is important in the redox pathway for its role in the oxidative pentose phosphate cycle regulating the NADPH/NADP+ ratio. Genetic defects in G6PD are relatively common, and can lead to an increased susceptibility to oxidative stress. Ayene and colleagues (2002), showed that in G6PD null mutant Chinese hamster ovary cells that Ku binding is inactivated during induced oxidative stress [84]. In another aspect of the double strand DNA pathway, ataxia-telangiectasia mutated (ATM) protein kinase is activated following DNA damage to sense double strand breaks which starts a signalling cascade. Recent research has identified a role of ROS regulation of ATM, whereby elevated ROS activate ATM, to activate the tumour sclerosis complex 2 (TSC2) tumour suppressor in the cytoplasm to repress mTORC1 and induce autophagy [85]. This shows an interesting influence exerted by a redox environment on a DNA damage sensing protein pushing the system to autophagy in response to ROS. Interestingly the redox regulation of a number of other DNA binding proteins has also been described. Human replication protein A (RPA) is a DNA binding protein implicated in DNA replication, repair and recombination. Analysis of RPA using mass spectrometry reveals that in oxidative conditions the cysteines in the zinc-finger motif of the p70 subunit can form disulphide bonds that impair DNA binding [86]. Although these latter examples are proteins not involved in the DNA BER pathway it is interesting to note that oxidative stress plays a role in modulating a number of other DNA repair pathways. Current Molecular Pharmacology, 2012, Vol. 5, No. 1 93 INDIRECT EFFECT OF THE REDOX ENVIRONMENT ON DNA REPAIR In addition to the direct modulation mentioned above the redox environment can also influence DNA repair indirectly through other interactions. For example, the expression of NEIL1 is increased by ROS through the activation of CREB/c-Jun transcription factors [87]. APE1 not only acts directly in BER but also has its own distinct redox domain. This redox domain is itself able to influence DNA repair, primarily through the binding to various transcription factors such as AP-1, HIF-1 and NFB [72, 88, 89]. In the example of HIF-1 activation, expression of both APE1 and the dithiol reducing enzyme thioredoxin potentiate its activation by redox dependent stabilisation of the HIF-1 alpha subunit [88]. Interestingly HIF-1 is able to attenuate APE1 expression in endothelial cells [90]. In addition to the indirect effect upon DNA repair APE1 is also implicated in angiogenesis following oxidative damage. APE1 and HIF-1 are implicated in the formation of the transcriptional complex of the hypoxic response element (HRE) of the VEGF gene, which is increased through selective modification of nucleotides within the HRE by oxidative damage; importantly these hypoxia induced base modifications are associated with transcriptionally active nucleosomes [91-93]. APE1 and thioredoxin can act independently or in concert on various transcription factors in an interaction influenced by ROS [94-96]. Redox dependent transcriptional activation is reviewed by Liu et al. (2005) [97]. APE1 is thought to act in a redox cycle with thioredoxin whereby APE1 is able to maintain transcription factors in their reduced state, and the redox state of APE1 is maintained by thioredoxin, which itself can have a direct action on transcription. The redox regulation of APE1 by thioredoxin is required for the activation of p53 and AP-1 [94, 95]. p53 has been well characterised in respect to it’s acting as a gatekeeper for DNA damage, inducing G1 arrest, to provide time for, and inducing enzymes involved in, DNA repair [98, 99]. An interesting hypothesis has been proposed by Seemann and Hainut (2005) whereby thioredoxin, p53, and APE1 function as an important switch in the BER pathway [100]. In a reduced environment, where basal levels of DNA damage are observed or when thioredoxin recycling is high, APE1 functions principally in the BER pathway. This allows p53 to stimulate the actions of the glycosylases [101] and stabilise interactions between Pol and abasic DNA [102]. In a highly oxidising environment, where excessive DNA damage occurs, APE1 is thought to function through p53 to suppress growth or initiate apoptosis. p53 is subject to redox modulation by reduction of cysteine 277 in its C-terminal part of its DNA binding domain [103]. Thioredoxin itself can also directly enhance the specific DNA binding of p53 [95]. The anti-oxidant functions of p53 are reviewed by Olovnikov et al. (2009) [104]. Further evidence for the importance of the redox environment in DNA repair is highlighted in current research which demonstrates that BRCA1, a breast cancer susceptibility gene, plays an important role in regulating the BER pathway. BRCA1 encodes a tumour suppressor protein 94 Current Molecular Pharmacology, 2012, Vol. 5, No. 1 and mutations within the gene account for 40-50% of hereditary breast cancer. Saha and colleagues (2010), demonstrated that challenging T47D breast cancer cells with H2O2 is able to cause an increase in BRCA1 expression and three BER enzymes; OGG1, NTH1, and APE1[105]. The authors investigated the importance of BRCA1 in influencing the BER pathway and suggest that it acts as a coregulator of the octomer-binding transcription factor OCT1. Expression of BRCA1 is increased in response to H2O2 and can increase 8-oxoG excision by stimulating the expression of OGG1, NTH1 and APE1, and the incising ability of NTH1 [105]. The importance of the oxidative environment on poly (ADP-ribose) polymerase 1 (PARP-1) is also becoming apparent. PARP-1 is a nuclear enzyme involved in DNA repair and cell death. PARP-1 participates in the BER pathway through its interaction with XRCC1 [106]. It is believed that XRCC1 is recruited through the addition of poly (ADP-ribose) to PARP, which at the same time reduces the affinity of PARP for DNA via the large addition of negative charge [107]. The activity of PARP-1 is increased following ROS challenge, through the increase in oxidative DNA damage that signal activation of the enzyme [108]. In addition, PARP-1 has been shown to play a role in chromatin repair. Histones, the main protein in chromatin structure, act as a defence against oxidative DNA damage as they themselves can be oxidised and the level of oxidation determines their fate. Histones that have undergone oxidative damage can cross link with DNA impairing transcription and replication. The PARP-1 mediated poly (ADP-ribosyl)ation of undamaged histones, in addition to the (ADP-ribosyl)ation activation of the proteasome, mediates the degradation of oxidatively damaged histones [109]. H2O2 stimulates the activity of PARP-1 through DNA damage and the mechanism of apoptosis changes with the stimulation intensity. A continuous level of H2O2, rather than a H2O2 bolus, results in different mechanisms of cell death. A H2O2 bolus results in caspase-dependent apoptosis, whereas continuous stimulus results in caspase-independent apoptosis through apoptosis independent factor (AIF) [110, 111]. In fact, arsenic trioxide (As2O3), approved for treatment of acute promyelocytic leukaemia (APL) in patients who have relapsed or are refractory to first line intervention using retinoid and anthracycline chemotherapy, acts in a prooxidative mechanism and can influence PARP-1 mediated apoptosis. As2O3 acts to induce the mitochondrial pathway of apoptosis and appears to inactivate a number of anti-oxidant enzymes [112]. In solid cancers, such as ovarian cancer, As2O3 mediates PARP-1 activation to induce AIF release from mitochondria initiating caspase-independent cell death [113]. There is increasing evidence for a direct role of the redox environment in PARP-1 activation in a mechanism that initially seems counter intuitive. PARP-1 can be inactivated by the oxidation of thiols within its DNA binding zinc finger motif causing expulsion of the zinc ion. Both ONOO and N2O3, formed through superoxide reaction with NO, are capable of inactivating PARP through oxidation or nitrosylation [114]. Further work demonstrated that nitrosylation of PARP-1 impairs the ability to bind to the inducible nitric oxide synthase (iNOS) promoter by negative Storr et al. feedback regulation [115]. This proves an interesting finding, as the oxidative environment can cause inhibition of the DNA binding component of the enzyme, however its activity is activated by oxidative DNA damage. THE REDOX PARADIGM ROS induced DNA damage can result in induction of signal transduction pathways, induction or arrest of transcription, replication errors and therefore genomic instability, all of which are associated with carcinogenesis [116]. It may be logical to assume that, in the cancer setting, reduction of ROS would be beneficial. However, the majority of non-surgical therapies for cancer utilise treatments that function through the production of ROS such as radiotherapy, photodynamic therapy and certain chemotherapy agents. The logic for this strategy is that cancer cells are under increased intrinsic ROS stress and therefore further insult from ROS generating therapies could exhaust the enhanced antioxidant capacity of the cancer cells and lead to apoptosis. Therefore the question still remains ‘is it beneficial or detrimental to reduce ROS?’ Redox buffering systems in cells such as the thioredoxin and glutathione systems and antioxidant enzymes, such as catalase, superoxide dismutases and the peroxidases, are often deregulated in cancer cells and can interfere with the effectiveness of ROS generated by radiotherapy [116-119]. Ionising radiation acts directly via the production of ROS from intracellular H2O to hydrogen peroxide causing oxidative DNA and protein damage and indirectly through cellular signalling. A number of studies have shown, in vitro, that modulation of redox homeostasis can alter the response of cancer cells to low LET radiations such as X-rays and rays i.e. those used in conventional radiotherapy [117, 120122]. Certain chemotherapeutic agents can also produce ROS through a number of mechanisms, including superoxide generation by anthracyclines through the redox quinone cycle, and nucleophilic substitution reactions by platinum complexes. In 1988, Kramer and colleagues demonstrated that the glutathione redox cycle played a role in chemotherapy resistance [123]. A more reducing cellular environment can result in chemotherapy resistance, in part through actions on the multidrug resistance (MDR) transporter P-glycoprotein (P-gp) [123, 124]. This indicates the potential therapeutic significance of increasing cellular ROS levels. It should also be borne in mind however that certain antioxidants, for example thioredoxin reductase [125] and glutathione [126, 127] can become prooxidants at high levels. Thioredoxin has been shown to increase the redox cycling of daunomycin, enhancing apoptosis, demonstrating both novel prooxidant and proapoptotic roles [128]. Significantly, ROS inhibit the function of protein tyrosine phosphatase (PTP) which allows increased growth factor signalling resulting in proliferation, and increases growth factors and matrix metalloproteins (MMP) involved in angiogenesis. However ROS also act to initiate receptor- and mitochondria- mediated apoptosis. The Fas ligand (FL) can cause an increase in ROS which can result in receptormediated apoptosis via Fas receptor binding and signalling through the death receptor pathway; and during Base Excision Repair, the Redox Environment mitochondria-mediated apoptosis ROS modulate the permeability of the transition pore complex to influence the process. The ROS paradigm has been reviewed previously [129]. As part of the debate of the benefits of reducing or increasing ROS in cancer, dietary antioxidant supplements have often been thought to reduce the risk of cancer. Studies have shown some efficacy and the effect on cellular DNA damage and BER activity has been assessed. Caple and colleagues (2009) demonstrated that DNA damage following H2O2 challenge and BER levels differ amongst healthy individuals and that supplementation with an antioxidant supplement containing selenium and vitamins A, C and E, in the group with highest level of DNA damage could mediate a protective effect [130]. However, there is increasing evidence showing that there may be a link between dietary antioxidants and the risk of cancer. For example recent studies have shown that intake of carotene and carotene infers an increased risk of ER and PR negative breast cancer in smokers [131] The action of vitamins however is not always antioxidant, the hormonal form of vitamin D (1,25(OH)2D,3), acts as a pro-oxidant which is able to reverse treatment resistance [132]. The therapeutic advantage of increasing ROS through various mechanisms including inhibition of anti-oxidant enzymes in the treatment of cancer, either as a stand alone agent or in combination with other therapies such as chemotherapy and radiotherapy has been investigated and the main targets discussed in the next section. The differences in the redox environment between normal and malignant tissues and within malignant tissues themselves i.e. hypoxic regions, can alter the response of a tumour to treatment modalities that utilise changes in oxidative stress as a main or by-product of their action. Therefore techniques to non-invasively distinguish these differences between normal and malignant cells could have clinical implications and imaging techniques are currently being developed. Hyodo et al. (2008) review the work conducted so far in this area and demonstrate that cellpermeable nitroxides, coupled with magnetic resonance imaging (MRI) can non-invasively examine the differences between the redox status of tissues [133]. Paramagnetic nitroxide radicals undergo reduction to the corresponding diamagnetic hydroxylamine which can revert to nitroxide in the presence of oxidants or if the cellular oxygen status permits [134]. Hypoxic conditions, tissue redox status and oxidative stress will enhance the conversion of the paramagnetic nitroxide radicals to its corresponding diamagnetic products distinguishing tumour from normal tissue [135]. THE REDOX SYSTEM AS A THERAPEUTIC TARGET The redox system is becoming an increasingly interesting target for cancer therapies, but as indicated above questions remain as to whether increasing or decreasing ROS is beneficial and the most appropriate therapeutic option. By reducing ROS, oxidative DNA damage is reduced. By increasing ROS, mutations through oxidative damage are more likely to occur, however the cell is more likely to initiate an apoptotic pathway. Current Molecular Pharmacology, 2012, Vol. 5, No. 1 95 Various small molecule inhibitors are available for the inhibition of anti-oxidant enzymes involved in the control of cellular H2O2 levels and it is thought that these inhibitors may be of therapeutic benefit when given in combination with traditional cancer therapies which act through the generation of ROS. There are a large number of proteins that could be targeted by this mechanism to aid in ROS production to push the cell to an apoptotic response. This also however, makes this strategy more challenging due to the redundancy of these pathways. In addition to anti-oxidant enzyme modulation, ROS can be generated directly within the cell, such as with arsenicals, organic endoperoxidases and redox cyclers such as motexafin gadolinium. One of the first redox modulating drugs, procarbazine, works by the production of hydrogen peroxidase via oxidation and is used in the treatment of Hodgkins lymphoma [119]. Motexafin gadolinium (Xcytrin), utilizes thioredoxin reductase with NADPH, and other cellular metabolites, increasing oxidative stress in a process known as futile redox cycling [136, 137] and has successfully completed a phase III international study [138]. Arsenic trioxide (As2O3) is able to inhibit GPx, resulting in an increase in H2O2, as well as affecting the mitochondrial respiratory chain thus causing generation of superoxide [139]. However the actions of arsenic compounds have been implicated in a number of ROS generating pathways [140]. Low concentrations of arsenic trioxide have been shown to induce a high rate of clinical remission in acute promyelocytic leukemia (APL) patients [141, 142]. Redox directed cancer therapeutics are comprehensively reviewed by Wondrak (2009) [112]. Pennington et al. (2005) outlines a set of criteria for consideration when selecting a redox target for therapeutic gain and reviews some of the proteins that fulfil some or all of them: 1) be over-expressed or be constitutively active in tumour cells, 2) enhance tumour proliferation, 3) exhibit pro-survival response, 4) enhance resistance to therapeutic modalities i.e. radiotherapy and chemotherapy [118]. The main redox systems already discussed in the context of DNA damage and repair, that have been targeted therapeutically are outlined below. Although impressive in vitro and in vivo effectiveness is often shown translation into clinically efficacy has often been disappointing, for this reason emphasis is given to those agents that have reached clinical evaluation. The Superoxide Dismutase System The SOD system can be targeted using two methods; the inhibitors, TETA, ATN-224 and 2-methoxyestradiol and the mimetics, M40403, mangafodipir, cis-FeMPy2p2p, MnTBAP and TEMPO. The SOD inhibitors act as copper chelators (TETA and ATN-224) or oestrogen derivatives (2methoxyestradiol) to inhibit the dismutation of superoxide to H2O2, causing an increase in superoxide that can act to induce apoptosis. The SOD mimics can be nitroxide free radicals or metal based agents, such as chelates of manganese (II). The mimics act principally through the turnover of superoxide, and have important clinical effects in conditions other than cancer, such as cardioprotective intervention or to limit radiation induced side effects [143] and M40403 and mangafodipir have been trialled as palliative management agents [112]. The inhibitors ATN- 96 Current Molecular Pharmacology, 2012, Vol. 5, No. 1 224 and 2-methoxyestradiol have been the focus of phase II clinical trials for advanced melanoma, prostate cancer, multiple myeloma, recurrent or advanced breast cancer and in numerous cancer types respectively [112]. Results from the phase II trial of 2-methoxyestradiol in taxane-refractory castrate-resistant prostate cancer reveal the study was terminated following futility analysis [144]. In another study of hormone-refractory prostate cancer 2-methoxyestradiol showed a dose response effects on PSA velocity [145]. Storr et al. downstream targets of thioredoxin. There are however, a number of agents that can act upon thioredoxin reductase-1 in a non-specific manner such as motexafin gadolinium as mentioned previously. Chaetocin and gliotoxin are also able to inhibit thioredoxin reductase-1 by acting as competitive substrates for the enzyme however no clinical trials, to our knowledge, are currently underway with these agents. There are a number of other agents that have effects on the thioredoxin system, although often not specific inhibitors; these agents are discussed by Gromer et al. (2004) [47]. The Glutathione System The glutathione (GSH) system can be targeted by the modulation of the pathway using agents including NOV-002, Imexon, L-buthionine R sulfoximine (BSO), and PABA/NO. NOV-002 is a combination of glutathione disulphide (GSSG) and cis-platinum and acts by causing a decreased GSH:GSSG ratio and accumulation of H2O2. Imexon, a thiol reactive electrophile, creates spontaneous thiol adducts with glutathione amongst other actions. BSO depletes glutathione and induces oxidative stress. PABA/NO acts as a glutathione-S-transferase prodrug that is metabolised to nitric oxide. These agents all act to increase oxidative stress by impairing H2O2 turnover. The inhibitor NOV-002 has been the focus of a number of clinical trials for various cancer types including current phase III trials in lung cancer in combination with chemotherapy, and the safety of Imexon is being evaluated. BSO is currently in phase I clinical trials in neuroblastoma and melanoma [112]. The Peroxiredoxin (Prdx) Family There are fewer examples of inhibitors or modulators of enzymatic activity of the Prdx family, the antioxidant enzymes involved in hydrogen peroxide dismutation. An example of an agent that has inhibitory effects on Prdx is conoidin A, able to inhibit Prdx1 and Prdx2 [146]; Ladostigil, an inhibitor of cholinesterase monoamine oxidase inhibitor, has been shown to increase the expression of Prdx1 amongst other anti-oxidant enzymes [147]. The impact of Prdx inhibition has been demonstrated in-vitro by Wang and colleagues (2005) [148]. Their experiments have indicated that specific siRNA knockdown of Prdx1 can cause radiosensitisation in MCF7 breast cancer cells, indicating the possible therapeutic impact of controlling the redox response to radiotherapy. The Prdx are reviewed, in relation to radiotherapy, by Zhang and colleagues (2009) [37]. The Thioredoxin System The thioredoxin system is also a target for inhibition, through the actions of drugs such as PX-12 (IV-2), PX-916, PMX464 and PMX290. PX-12 and PMX464 inactivate thioredoxin through disulphide exchange of cysteine 73 and oxidative formation of a disulphide bridge between cysteine 32 and 35 respectively [149-151]. PX-12 has been examined in clinical trials in advanced metastatic cancers [112], however recent results suggest no anti-tumour effect as a single agent in advanced pancreatic cancer previously treated with gemcitabine [152]. As with PMX464, PMX290 (AJM290) also serves as a specific thioredoxin inhibitor. PX-916 is able to inhibit thioredoxin reductase-1 agonising Catalase Catalase is one of the enzymes responsible for the control of cellular hydrogen peroxide. In 1941, Greenstein et al. reported that liver catalase activity was reduced in rats with subcutaneously implanted hepatic tumours [153]. 3-amino1:2:4-triazole is able to inhibit catalase irreversibly in the presence of a continuous supply of hydrogen peroxide [154]. The inhibitor has been shown to promote thyroid tumour formation in rats when given in combination with carcinogen [155]. As with some of the redox proteins mentioned above we are unaware of any clinical trials examining catalase inhibitory effects. Catalase mimics are reviewed by Day (2009) [156]. Altering DNA Repair Through the Redox Environment Due to the redox domain of APE1 this enzyme is the current target of two approaches to modulate its activity for cancer therapy. The first is the inhibition of its DNA repair facility and the second is to inhibit its redox ability. Both approaches are the subject of other articles in the current publication. The inhibitors for APE1 DNA repair activity have been previously reviewed by Fishel and Kelley (2007) [157]. Examples of inhibitors of the redox domain of APE1 include E3330 and analogues benzoquinone and napthoquinone which are able to inhibit the redox function of APE-1 and the growth of an ovarian cancer cell line [158]. MSH2 is a gene that encodes components of the DNA mismatch repair pathway. Treatment with methotrexate causes the accumulation of 8-oxoG in cells lacking functional MSH2. MSH2 is a relatively common mutation in hereditary non-polyposis colon cancer (HNPCC). Martin and colleagues (2009) demonstrated that although 8-oxoG accumulated in both MSH2 deficient and proficient cells, accumulation only occurred in deficient cells with rapid clearance in proficient cells. The group investigated this interaction further by specific knockdown of dihydrofolate reductase and demonstrated that methotrexate seemed to modulate folate synthesis via inhibition of dihydrofolate reductase to explain MSH2 involvement [159]. Antioxidant Supplement Due to the importance of redox homeostasis and the implications of oxidative DNA damage the dietary supplementation by antioxidants is of interest. To date the information surrounding dietary supplementation and cancer risk has shown inconclusive results. Antioxidant supplementation and cancer risk is reviewed by Loft et al. (2008) [160]. Base Excision Repair, the Redox Environment CONCLUSIONS AND FUTURE DIRECTIONS Redox homeostasis is critical for the function of the cell. ROS play important cellular roles in mediating signal pathways; however aberration of such normal pathways can lead to oxidative DNA damage. Oxidative DNA damage is repaired principally through the BER pathway allowing excision of lesions such as 8-oxoG. The accumulation of oxidative DNA lesions can result in genomic instability, and increased risk of cancer. In the cancer setting, cells have aberrant ROS production; this increased production of ROS can lead to further DNA mutations, in addition to increased cellular signalling. Perhaps surprisingly the generation of ROS is the mechanism of action of most cancer therapeutics such as radiotherapy and chemotherapy, and the current interest is to try and circumvent resistance to these therapies. In a healthy cell there are a number of anti-oxidant enzymes that serve to modulate the redox environment by controlling the production of superoxide and hydrogen peroxide to mitigate the production of the damaging hydroxyl radical. These enzyme pathways are altered during carcinogenesis, and current interest is to modulate their actions to allow the accumulation of ROS in the case of therapy resistance, or reducing ROS to manage treatment toxicity. There are a number of agents that inhibit enzymes involved in redox homeostasis, or involve the direct modulation of the redox state of the cell. The development of inhibitors of the BER pathway is an area of intense focus with the aim of mirroring the successes observed with the current generation of PARP inhibitors, especially in BRCA related disease. It is hoped that a similar strategy may be possible for enzymes such as APE1 [161]. The effects of altered BER pathways in patients remain to be elucidated, such as the accumulation of AP sites in terms of APE1 inhibitors. However, due to the potential mutagenic effects of modulating these pathways secondary cancers may become apparent. Interestingly, many of the enzymes involved in the BER pathway are subject to some degree of regulation by ROS, often activated in the case of elevated stress levels. This may suggest that ROS generating therapies, in addition to anti-oxidant enzyme modulators and inhibitors of the BER pathway may be of interest. Further research is required to understand the full impact of redox homeostasis on the cell, its involvement in modulating the BER response in addition to causing the initial oxidative DNA damage. ABREVIATIONS Current Molecular Pharmacology, 2012, Vol. 5, No. 1 97 EMT = Epithelial-mesenchymal transition FL = Fas ligand G6PD = Glucose-6-phosphate dehydrogenase GPx = Glutathione peroxidase GSH = Glutathione GSSG = Glutathione disulphide HNPCC = Hereditary cancer HRE = Hypoxic response element non-polyposis iNOS = Inducible nitric oxide synthase LP = Long patch MDR = Multidrug resistance MMP = Matrix metalloproteins colon MnSOD = Manganese superoxide dismutase MRI = Magnetic resonance imaging NEILs = Nie-like-1 and 2 NER = Nucleotide excision repair NF-B = Nuclear factor-B NHEJ = Non-homologous end joining Nox = NADPH oxidase OGG1 and OGG2 = 8-oxoG DNA glycosylases 8-oxoG = 8-oxo-2’deoxyguanosine P2 = Purinergic receptors PARP-1 = Poly (ADP-ribose) polymerase 1 P-gp = MDR transporter P-glycoprotein PKC = Protein kinase C Prdx = Peroxiredoxins PTP = Protein tyrosine phosphatase ROS = Reactive oxygen species RPA = Replication protein A (human), SOD = Superoxide dismutases SP = Short patch Srx = Sulfiredoxin TSC2 = Tumour sclerosis complex 2 TxNIP = Thioredoxin interacting protein XPC = Xeroderma pigmentosum C XRCC1 = X-ray repair, cross-complementing defective, in Chinese hamster, 1 AIF = Apoptosis independent factor AP = Apurinic/apyrimidinic AP-1 = Activator protein 1 APE1 = AP endonuclease-1 (human) [1] APL = Acute promyelocytic leukaemia [2] As2O3 = Arsenic trioxide ATM = Ataxia-telangiectasia mutated [3] BER = Base excision repair [4] BSO = L-buthionine R sulfoximine REFERENCES Dröge, W. 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