GLI Signaling in Hematological Malignancies

C H A P T E R

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Canonical and Noncanonical Hedgehog/GLI Signaling in Hematological Malignancies Fritz Aberger,* Daniela Kern,* Richard Greil,† and Tanja Nicole Hartmann† Contents I. Hedgehog Introduction II. Regulation of Canonical HH Signaling and Its Implication in Cancer III. SMO-Independent Modulation of GLI Activity A. RAS–RAF–MEK and PI3K–AKT signaling as modulators of GLI activity B. Modulation of GLI activity by growth factor signaling pathways and oncogenes C. Noncanonical negative regulators of GLI activity IV. Hedgehog in Hematopoiesis and Hematopoietic Stem Cells V. From HSC to CML VI. T- and B-Cell Malignancies A. Hedgehog role in T cells and T-ALL B. Hedgehog role in B cells and B-cell malignancies VII. Outlook Acknowledgments References

26 26 32 32 33 34 35 38 39 39 40 44 46 46

Abstract The highly conserved Hedgehog/GLI signaling pathway regulates multiple aspects of embryonic development and plays a decisive role in tissue homeostasis and the hematopoietic system by controlling cell fate decisions, stem cell self-renewal, and activation. Loss of negative control of Hedgehog signaling contributes to tumor pathogenesis and progression. In the classical view of canonical Hedgehog signaling, Hedgehog ligand binding to its receptor Patched * Division of Molecular Tumor Biology, Department of Molecular Biology, University of Salzburg, Salzburg, Austria Laboratory for Immunological and Molecular Cancer Research, Third Medical Department with Hematology, Oncology, Hemostaseology, Infectiology, and Rheumatology, Paracelsus Medical University, Salzburg, Austria

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Vitamins and Hormones, Volume 88 ISSN 0083-6729, DOI: 10.1016/B978-0-12-394622-5.00002-X

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2012 Elsevier Inc. All rights reserved.

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culminates in the activation of the key pathway activator Smoothened, followed by activation of the GLI transcription factors. Its essential function and druggability render Smoothened well suited to therapeutic intervention. However, recent evidence suggests a critical role of Smoothened-independent regulation of GLI activity by several other signaling pathways including the PI3K/AKT and RAS/RAF/MEK/ERK axes. In addition, the contribution of canonical Hedgehog signaling via Patched and Smoothened to normal and malignant hematopoiesis has been the subject of recent controversies. In this review, we discuss the current understanding and controversial findings of canonical and noncanonical GLI activation in hematological malignancies in light of the current therapeutic strategies targeting the Hedgehog pathway. ß 2012 Elsevier Inc.

I. Hedgehog Introduction The Hedgehog (HH)/GLI pathway was originally identified as a key signaling system that controls multiple processes during invertebrate and vertebrate embryonic development (Ingham and McMahon, 2001; Nusslein-Volhard and Wieschaus, 1980; Teglund and Toftgard, 2010). More recently, the pathway has also been implicated in the control of tissue homeostasis, regeneration, and healing in adult organisms where signaling contributes to the regulation of stem cell activation and self-renewal (Beachy et al., 2004; Ruiz i Altaba et al., 2007). Precise control of the onset, strength, and termination of HH/GLI signaling is a critical requirement for proper pattern formation, cell proliferation, survival, differentiation, and morphogenesis. In line with its pivotal regulatory role in these processes, aberrant activation of HH/GLI signaling by either genetic alterations or uncontrolled expression of selected pathway effectors turned out to be an etiological factor in the initiation and growth of numerous human cancer entities including a wide spectrum of solid tumors and hematological malignancies (reviewed in Barakat et al., 2010; Ruiz i Altaba et al., 2002). Targeted inhibition of inappropriate HH/GLI signaling in cancer patients has therefore become a major interest of biotech and pharmaceutical companies with more than half a dozen novel Hedgehog pathway inhibitors (HPIs) currently evaluated for their therapeutic benefit in several clinical trials (for details, see Table 2.1; Epstein, 2008; Scales and de Sauvage, 2009; Takebe et al., 2011).

II. Regulation of Canonical HH Signaling and Its Implication in Cancer Regulation of Hedgehog signaling is a complex process and a detailed review of the mechanisms of pathway regulation would be beyond the scope of this chapter (for detailed reviews, see Huangfu and Anderson,

Table 2.1

Clinical and preclinical Hedgehog pathway inhibitors

Inhibitor

Target Type

GDC-0449 (Vismodegib)

SMO SMI

Cur-61414 Cyclopamine

SMO SMO SMO Natural SMI

SANT1–4 HhAntag NVP-LDE225

SMO SMI SMO SMI SMO SMI

NVP-LEQ506

SMO SMI

IPI-926

SMO SMI

BMS-833923

SMO SMI

Indication and experimental validation

Clinical trialsa

Company

References

BCC, metastatic colon cancer, gastric cancer, GBM, MB, MM, pancreatic, prostate, ovarian cancer, SCLC BCC BCC, MB

Genentech, Roche

Rudin et al. (2009), Von Phase I/II Hoff et al. (2009)

Curis NA

In vitro MB BCC, MB, advanced solid tumors Advanced/metastatic BCC, refractory MB MB, chondrosarcoma, MF, pancreatic cancer BCC, BCNS, CML, esophageal, gastric, SCLC, solid tumors

NA Curis Novartis Novartis

Williams et al. (2003) Taipale et al. (2000), Thayer et al. (2003), Berman et al. (2003), Sanchez and Ruiz i Altaba (2005) Chen et al. (2002a,b) Romer et al. (2004) Buonamici et al. (2010), Skvara et al. (2011) NA

Infinity

Tremblay et al. (2009)

Phase I/II

Exelixis, Bristol– Myers Squibb

NA

Phase I/II

Failed in phase I Limited use in human

No No Phase I/II Phase I

(Continued)

Table 2.1 (Continued) Indication and experimental validation

Inhibitor

Target Type

PF-04449913

SMO SMI

TAK-441

SMO SMI

Itraconazol Arsenic trioxide

SMO SMI BCC, MB (antifungal) GLI SMI In vitro, in vivo xenografts

HPI 1–4 GANT61 GANT58 Robotnikinin Anti-Hh (5E1)

ND GLI GLI Hh Hh

SMI SMI SMI SMI Antibody

CML, hematologic malignancies, solid tumors BCC

In vitro In vivo, in vitro (various) In vitro In vitro In vivo (GI tumors, HF growth), in vitro

Company

References

Clinical trialsa

Pfizer

NA

Phase I

Millennium Pharma. NA

NA

Phase I

Kim et al. (2010b)

Phase I

Various

Kim et al. (2010a), Beauchamp et al. (2011) Hyman et al. (2009) Lauth et al. (2007a,b) Lauth et al. (2007a,b) Stanton et al. (2009) Ericson et al. (1996), Yauch et al. (2008), Bailey et al. (2008)

No

NA NA NA NA NA

No No No No No

Abbreviations: BCC, basal cell carcinoma; BCNS, basal cell nevous syndrome; CML, chronic myeloid leukemia; EWS, Ewing’s Sarcoma; GBM, glioblastoma multiforme; GI, gastrointestinal; MB, medulloblastoma; MF, myelofibrosis; MM, multiple myeloma; PMF, primary myelofibrosis; SCLC, small cell lung cancer; NA, not applicable; SMI, small molecule inhibitor; ND, not determined in detail. a Clinical trials as listed at http://clinicaltrials.gov on June 21, 2011.

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2006; Ingham et al., 2011; Varjosalo and Taipale, 2007). We will provide in the following an overview of the key steps and players in canonical HH signaling relayed via the Patched/Smoothened/GLI route and subsequently elaborate on the noncanonical Smoothened-independent signals that have been implicated in the control of the GLI zinc finger transcription factors controlling Hedgehog target gene expression. In the absence of HH ligand, HH signaling is actively maintained in a repressed state by the activity of the HH receptor Patched (PTCH). PTCH is a 12-transmembrane domain protein whose intracellular localization is concentrated at the base of the primary cilium, a single antenna-like structure that protrudes from the cell surface of many adherent cell types and functions as a signal transduction compartment (Rohatgi et al., 2007). Although the detailed mechanism of pathway repression by PTCH has not been elucidated, recent studies have shown that unliganded PTCH, which can act catalytically (Taipale et al., 2002), prevents the translocation of the seventransmembrane domain protein and essential pathway effector Smoothened (SMO) into the primary cilium (Rohatgi et al., 2007). This leads to proteolytic cleavage of the latent zinc finger transcription factors GLI3—and to some extent also of GLI2—into C-terminally truncated repressor forms (GLIR) (Wang et al., 2000; Wen et al., 2010). GLIR formation involves preceding and sequential phosphorylation by protein kinase A (PKA), glycogen synthase kinase 3-beta (GSK), and casein kinase I (CKI) (Price and Kalderon, 2002) as well as a functional primary cilium (Huangfu et al., 2003; Wong et al., 2009). Following processing, GLIR translocates to the nucleus to bind to HH target gene promoters and repress target gene expression (Aza-Blanc et al., 1997). GLI signals are also negatively regulated by proteasome-mediated degradation of GLI and by binding to Suppressor of Fused (SUFU), which sequesters GLI proteins in the cytoplasm (Fig. 2.1, left) (reviewed in Ruiz i Altaba et al., 2007; Teglund and Toftgard, 2010). Paracrine or autocrine activation of HH signaling is initiated by binding of secreted and posttranslationally modified HH proteins, that is, Sonic (SHH), Indian (IHH), or Desert (DHH) Hedgehog, to their receptor PTCH (Gallet, 2011; Ingham et al., 2011). The interaction of HH protein with PTCH removes PTCH from the primary cilium, thus allowing SMO to enter the cilium via lateral transport and activate downstream signaling events (Milenkovic et al., 2009; Rohatgi et al., 2007). The translocation and activation of SMO involve association of SMO with b-arrestins and the GPCR kinase GKR2, respectively (Chen et al., 2011; Kovacs et al., 2008; Meloni et al., 2006; Philipp et al., 2008). Active SMO localized in the primary cilium (i) interferes with GLI repressor formation and (ii) triggers release of GLI from SUFU (Humke et al., 2010; Tukachinsky et al., 2010). As a result of these complex regulatory steps, the full-length activator form of GLI, hitherto referred to as GLIA, can translocate to the nucleus, where it binds to target gene promoters and activates transcription of HH target

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Canonical, Smoothened-dependent GLI activation SMO

GL I

GL I

Primary cilium

SU

GL IA

SU

HH

GL

IR

SMO

FU

P

+

FU

PTCH

X

HH

PTCH

GLI

PKA GSK CKI

SUFU

P GLI βTrCP

e

om

as

te

o Pr

Nucleus

GLIR

X

GLIA

Nucleus

GLI targets OFF

GLI targets ON

Noncanonical, Smoothened-independent regulation of GLI activity GPCR RAS*

RTKs (e.g., EGFR, FGFR)

RAS

FGF PLC

PI3K

RAF TGFβR TGFβ

PKC-δ NOTCH1

MEK AKT

SMAD

ERK

?

P JUN

P DYRK1

EWS/FLI1

GLIA miR-324-5p

DYRK2 p53

Numb

Figure 2.1 Smoothened-dependent and -independent regulation of GLI activity. (A) Active repression of HH target gene expression in the absence of ligand stimulation by GLI repressor (GLIR) formation, proteasome-mediated GLI protein degradation and SUFU-dependent cytoplasmic retention of GLI proteins. (B) Activation of HH signaling and target gene expression in response to binding of HH protein to its receptor PTCH, leading to removal of PTCH from the primary cilium and entrance of SMO into the primary cilium via lateral transport mechanisms. In the primary cilium, active SMO prevents cleavage of the full-length GLI into the truncated repressor form and also triggers the dissociation of GLI from SUFU, allowing the GLI activator form (GLIA) to translocate to the nucleus and turn on target gene expression. (C) Smoothened-

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genes including GLI1. Being a strong transcriptional activator, induction of GLI1 in response to canonical PTCH/SMO-dependent pathway activation causes amplification of the GLIA signal (Ikram et al., 2004; Regl et al., 2002; Ruiz i Altaba et al., 2002). In essence, one can therefore state that the precise regulation of the GLIA/GLIR ratio is the most critical parameter for proper development and homeostasis. This is supported by the fact that the balance of GLIA/GLIR forms determines not only the strength and output of HH signaling but also the fate of a cell. High GLIA/GLIR ratios are mainly associated with proliferation, increased survival, and stem cell self-renewal, while low ratios favor differentiation and quiescence (Stecca et al., 2007). During the past years, numerous studies have unraveled a fundamental role of the HH/GLI pathway in a wide variety of human cancers including solid tumors and hematological malignancies. Current estimates suggest that up to 25% of human cancers display aberrant HH/GLI signaling (Teglund and Toftgard, 2010). These cancers are characterized by uncontrolled and persistent activation of the HH/GLI pathway leading to an increase in GLIA forms, mostly GLI1, at the expense of GLIR forms. High GLIA/GLIR ratios can be the result of (i) loss-of-function mutations in pathway repressors such as PTCH and SUFU, (ii) gain-of-function mutations and amplifications in SMO and GLI2/GLI1, respectively, or (iii) overexpression of and sustained exposure to HH ligands (Kasper et al., 2006a; Stecca and Ruiz, 2010). While it is clear that aberrant activation of HH/GLI signaling is an etiologic factor in many cancers, the identity of the HH signal-receiving cell is more complex as there is evidence for both the tumor cell itself and the tumor-associated stromal cell being the target of HH pathway activation (for detailed reviews, see Scales and de Sauvage, 2009; Teglund and Toftgard, 2010). The widespread involvement of HH/GLI in human malignancies has initiated a remarkable effort to identify selective HPIs. As shown in Table 2.1, most of these small molecule inhibitors target the essential effector protein SMO, which should lead to pathway abrogation by eventually decreasing the GLIA/GLIR ratio. This has already been successfully demonstrated in patients with basal cell carcinoma (BCC) and medulloblastoma showing aberrant SMO-dependent HH/GLI signaling (Rudin et al., 2009; Skvara et al., 2011; Von Hoff et al., 2009). However, there is also

independent regulation of GLI activity. The illustration summarizes recent data on diverse signaling cascades and regulatory proteins impinging on the GLI transcription factors to regulate their transcriptional activity, stability, and expression. Arrows indicate a positive impact on the activity of GLI, inhibitory symbols a negative regulatory interaction including protein destabilization (e.g., numb) or repression of GLI expression (e.g., NOTCH1). RAS*, oncogenic RAS; encircled P, phosphorylation; TGFbR, TGFb receptor; RTK, receptor tyrosine kinase; PLC, phospholipase C; GPCR, G-protein-coupled receptor.

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increasing evidence for SMO-independent stimulation of GLI activity in cancer cells, raising the question of whether SMO antagonists will prove efficient therapeutic drugs in such settings. As SMO function is associated with the primary cilium (Huangfu and Anderson, 2006), this limitation is likely to be relevant for GLI-dependent cancer cells lacking this single cellular protrusion, as is the case for most myeloid and lymphoid cells (Pazour and Witman, 2003). In such cases, targeting SMO-independent mechanisms that impinge upon the GLI transcription factors to modulate their activity becomes more relevant.

III. SMO-Independent Modulation of GLI Activity A. RAS–RAF–MEK and PI3K–AKT signaling as modulators of GLI activity Constitutive activation of RAS signaling is frequently found in human cancers such as pancreatic ductal adenocarcinoma (PDAC) of which the vast majority displays activating K-RAS mutations. Aside from activated RAS, PDAC frequently expresses high levels of HH ligands, pointing to a possible interaction of these two pathways (Lau et al., 2006). Notably, coexpression of a dominant active form of GLI2 and oncogenic K-RAS in the pancreas of transgenic mice led to synergistically enhanced disease progression (Pasca di Magliano et al., 2006). A possible explanation for this cooperative effect came from studies of melanoma, prostate cancer, and glioma cells showing that oncogenic N- and H-RAS as well as active AKT can stimulate the transcriptional activity and nuclear import of GLI1. Further, endogenous GLI activity depends on RAS and PI3K/AKT function and AKT has been shown to enhance GLI protein stability (Riobo et al., 2006b; Stecca et al., 2007). Studies in zebrafish provided additional in vivo evidence for HH/GLI–AKT cooperation. Expression of zebrafish Smoothened in combination with constitutively active human Akt1 induced various tumor types resembling rhabdomyoma, melanoma, and astrocytoma ( Ju et al., 2009). Oncogenic RAS signaling has also been implicated in transcriptional activation and protein stabilization of GLI ( Ji et al., 2007). Aside from its direct effect on GLI, RAS has been shown to promote paracrine tumor-tostroma HH signaling in pancreatic cancer cells by activating HH ligand expression and inhibiting autocrine HH pathway activation in the cancer cells (Lauth et al., 2010). Activation of the MEK/ERK cascade appears to be a central player mediating the GLI activity promoting effect of RAS and also of PKC-d, the latter of which may involve G-protein-coupled receptor signaling including that of SMO (Lauth et al., 2007b; Riobo et al., 2006a;

GLI Signaling in Hematological Malignancies

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Stecca et al., 2007). However, another study has implicated PKC-d in GLI activation downstream of SUFU (Lauth et al., 2007b). Coexpression of GLI1 and dominant active MEK has been shown to drive xenograft growth of human nontumorigenic keratinocytes, while neither factor alone is able to transform these cells, suggesting cooperative interactions between MEK and GLI1 (Schnidar et al., 2009). MEK stabilizes GLI proteins and generally enhances the transcriptional activity of GLI1, which requires the presence of the GLI1 N-terminus (Riobo et al., 2006a; Schnidar et al., 2009; Stecca et al., 2007). Of note, a recent study provided evidence for GLI3 and GLI1 as novel substrate of MAP-kinases (MAPKs) including the MEK substrate ERK2 (Whisenant et al., 2010). Although in vivo evidence is still lacking, it is likely that ERK-mediated phosphorylation of the N-terminus of GLI1 accounts for its increased stability and transcriptional activity, which would also be in line with the notion that deletion of the GLI1 N-terminus abrogates the enhanced transcriptional activity of GLI1 observed upon concomitant basic fibroblast growth factor (bFGF) treatment (Riobo et al., 2006a). Other kinases affecting the activity of GLI proteins in different ways include the dual-specificity tyrosine-(Y)-phosphorylation-regulated kinases DYRK1 and DYRK2. While DYRK1 enhances the transcriptional activity of GLI1 by promoting its nuclear localization (Mao et al., 2002), DYRK2 negatively regulates GLI2 by phosphorylation thereby targeting GLI2 to proteasomal degradation (Varjosalo et al., 2008).

B. Modulation of GLI activity by growth factor signaling pathways and oncogenes Given the well-documented role of RAS, MAPK, and PI3K/AKT signaling in the modulation of GLI proteins, it may at first glance not be surprising that growth factor receptor tyrosine kinase (RTK) signaling also affects the activity of GLI in an SMO-independent manner. For instance, treatment with epidermal growth factor (EGF) synergizes with HH signaling in the activation of neural stem cell proliferation (Palma and Ruiz i Altaba, 2004) and bFGF enhances the transcriptional activity of GLI1 (Riobo et al., 2006a). Both interactions could simply be explained by the RTK-mediated activation of intracellular PI3K/AKT and RAS/MAPK signaling branches. However, this interaction appears to be more complex, as in HH/GLI-dependent medulloblastoma cells, FGF signaling actually counteracts the proliferative effect of HH signaling (Fogarty et al., 2007), suggesting context-dependent integration of distinct signal transduction pathways yielding very different outcomes. Our own group has intensely studied the mechanisms of HH/GLI and EGFreceptor (EGFR) signal cooperation in skin cancer. The key findings are that coactivation of EGFR and GLI1 or GLI2 results in selective modulation of GLI target gene expression rather than in a general activation of GLI activity. The integration of both pathways relies on EGFR-mediated activation of

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MEK/ERK signaling. This, in turn, leads to phosphorylation and activation of the JUN/AP1 transcription factor, which itself is a direct GLI target. EGFR-activated JUN/AP1 then together with GLI binds to selected GLI target genes resulting in synergistic transcriptional activation (Kasper et al., 2006b; Laner-Plamberger et al., 2009; Schnidar et al., 2009). Thus, the integration of EGFR and HH/GLI signal cooperation at the level of selected GLI target genes constitutes another mechanism by which growth factor signaling pathways can modulate the activity of GLI proteins (Fig. 2.1). Activation of GLI transcription accounts for another mode of SMOindependent modulation of GLI activity. In frog embryos, bFGF induces Gli2 expression in the ventro-posterior mesoderm through an as-yet unidentified mechanism (Brewster et al., 2000). Gli2 expression is also controlled by transforming growth factor b (TGFb)/SMAD signaling via direct binding of activated SMAD3 to the Gli2 promoter. Intriguingly, the same study also identified an adjacent T-cell factor/lymphoid enhancer binding factor (TCF/ LEF) binding site required for efficient activation of Gli2 in response to TGFb, suggesting cooperative interactions of TGFb/SMAD and Wnt/bcatenin/TCF signaling in the control of Gli2 expression (Dennler et al., 2009). Likewise, TGFb signaling and oncogenic K-RAS signaling induce GLI1 expression in pancreatic cancer cells, and inhibition of GLI1, but not SMO, decreases pancreatic cancer cell survival and proliferation (NolanStevaux et al., 2009). In agreement with these studies, TGFb/SMAD signaling is required for HH/GLI-induced BCC development (Fan et al., 2010). Insulin-like growth factor 2 (IGF2) signaling represents an essential pathway in HH/GLI-dependent medulloblastoma and rhabdomyosarcoma (Hahn et al., 2000). Notably, IGF2 activates AKT and increases transcription of GLI1, suggesting a dual mode for noncanonical GLI activation (Hartmann et al., 2005; Rao et al., 2004). Transcription of GLI1 is also regulated by the EWS–FLI1 fusion oncogene in Ewing sarcoma cells. EWS–FLI1 induces GLI1 transcription via direct binding to the GLI1 promoter, which is a critical molecular mechanism in Ewing sarcoma development, as interference with GLI1 function blocks EWS cell proliferation and tumor growth in vitro and in vivo (Beauchamp et al., 2009, 2011).

C. Noncanonical negative regulators of GLI activity Aside from the numerous oncogenic signals that positively affect GLI activity, there is increasing evidence for noncanonical PTCH-independent repression of GLI activity by tumor suppressor genes (Fig. 2.1). Several studies have demonstrated a negative regulatory interaction between GLI and the p53 tumor suppressor. Stecca and Ruiz i Altaba (2009) found that p53 negatively controls GLI1 transcriptional activity, prevents nuclear GLI1 localization, and reduces GLI1 expression levels. Conversely, GLI1

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expression reduces p53 levels via upregulation of the p53 inhibitor HMD2/ MDM2, suggesting a mutual negative interaction loop between GLI1 and p53 (Abe et al., 2008; Stecca and Ruiz i Altaba, 2009). This would also explain the dramatic enhancement in the tumor phenotype of patched heterozygous mice upon concomitant deletion of p53 (Romer et al., 2004). In neural cells, Numb, a tumor suppressor involved in asymmetric division of stem cells, encodes another PTCH-independent negative regulator of GLI1. Numb inhibits GLI function by targeting GLI1 to Itch-dependent proteasomal degradation (Di Marcotullio et al., 2006). A different negative regulatory mechanism of GLI activity applies to the Notch signaling pathway, which in skin displays tumor suppressor function (Dotto, 2008). Analysis of mice with epidermal-specific deletion of Notch1 revealed upregulation of Gli2 expression and BCC development, respectively, suggesting that Notch1mediated negative control mechanisms actively prevent epidermal Gli2 expression in normal skin (Nicolas et al., 2003). The negative interaction of Notch–HH/GLI may, however, be context- and cell-type-specific as Notch signaling may cooperate with HH/GLI in medulloblastoma development, although data from different laboratories have provided somewhat controversial results (Hallahan et al., 2004; Hatton et al., 2010; Julian et al., 2010). Finally, recent reports have implicated microRNAs as regulators of HH/GLI signaling. For instance, miR125b, miR326, and miR324-5p all suppress SMO expression, while miR324-5p also reduces GLI1 expression (Ferretti et al., 2008). In light of these studies, it is obvious that the regulation of GLI activity is not only subject to canonical HH/PTCH/SMO-dependent signaling but also controlled by the integration of multiple non-HH signals. This concept has led to the funnel hypothesis, which views GLI proteins as an information nexus in the regulation of cell fate, stemness, and cancer (Ruiz i Altaba et al., 2007; Stecca and Ruiz, 2010). The SMO-independent activation of GLI activator forms therefore challenges the efficacy of SMO inhibitors as therapeutic drugs in GLI-dependent cancers lacking classical HH/GLI signaling. This may apply to some cancers of the hematopoietic system where canonical HH/GLI signaling may be compromised by the possible lack of a primary cilium (Pazour and Witman, 2003).

IV. Hedgehog in Hematopoiesis and Hematopoietic Stem Cells Adult hematopoiesis begins in the bone marrow with the differentiation of multipotent hematopoietic stem cells into progenitors, and further into all blood cell types of the myeloid and lymphoid lineages. As with other developmental signaling pathways such as Wnt or Notch signaling, the role of HH signaling in normal and malignant hematopoiesis and in the

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regulation of adult stem and progenitor cell pools has been the subject of intense studies. While HH signaling was initially reported to be of great importance for these processes, recent studies have challenged this view and have led to an ongoing discussion on the contribution of HH to the different aspects of hematopoiesis. A role of HH in human hematopoiesis was first described in 2001 when Bhardwaj et al. (2001) observed that primitive CD34þ human blood cells express SHH, PTCH, and SMO. Addition of exogenous SHH to in vitro expansion cultures increased the number of functional progenitor cells and promoted their differentiation. HH inhibition preserved the primitive state of the human progenitors and their capability to repopulate the murine bone marrow when adoptively transferred to NOD/SCID mice. Further, high levels of SHH stimulation caused proliferation of hematopoietic stem and progenitor cells (HSC/Ps) via downstream signaling cascades involving the hematopoietic inducer bone morphogenetic protein 4 (Bhardwaj et al., 2001). In a later study, IHH but not SHH was found to be expressed by bone marrow stromal cells (Kobune et al., 2004). Consistently, IHH gene transfer into stromal cells enhanced their hematopoietic supporting potential. Expansion of repopulating cells on these IHH-overexpressing stromal cells resulted in increased engraftment in NOD/SCID mice. While in these assays IHH was presented by the stromal cells, it is important to note that it is also intrinsically present on CD34þ cells and may also support the proliferative capacity of the HSC/Ps in an autocrine manner (Kobune et al., 2004). Subsequently, several mouse models with modulation of HH signaling pathway members were used to elucidate HH signaling activity in the hematopoietic system. HH signaling activity is increased with impaired activity of the pathway suppressor PTCH1, encoded by the tumor suppressor gene PTCH1. Mice carrying only one allele of Ptch (Ptchþ/ mice) exhibited a higher expression of GLI1 and cyclin-D1 in primitive Lin- Sca-1þ c-Kitþ (LSK) hematopoietic cells along with an increase of their total number and frequency (Trowbridge et al., 2006). In addition, the heterozygous mice demonstrated an enhanced ability to regenerate the hematopoietic system following its ablation with 5-fluorouracil (5-FU) in both primary and transplant models. However, these phenomena turned out to be transient and the regeneration capacity of the HSCs could not be sustained beyond 8weeks posttransplantation despite continued HH activity (Trowbridge et al., 2006). Uhmann et al. (2007) used a tamoxifen-inducible Ptch1 deletion to demonstrate that Ptch1 is necessary for commitment to the B- and T-cell lineage fate. They did not find any influence of Ptch ablation on the myeloid lineage (Uhmann et al., 2007). However, transfer assays of Lin- bone marrow cells from tPtch/ mice into Rag2/ g/ mice lacking mature lymphocytes suggested that the defects in lymphoid lineage commitments were caused by the Ptch defect in the stromal compartment rather than in the progenitors (Uhmann et al., 2007). To further determine cell-intrinsic versus -extrinsic

GLI Signaling in Hematological Malignancies

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hematopoietic effects of Hh signaling activation, Siggins et al. (2009) used inducible, cell-type-specific deletion models of Ptch1. Hematopoieticspecific deletion of Ptch1 using a tamoxifen-inducible Cre-ER recombinase under the control of the stem cell leukemia enhancer did not lead to Hh signaling activation in hematopoietic cells or to any phenotypic effects. In contrast, deletion of Ptch1 in epithelial cells led to the apoptosis of lymphoid progenitors, whereas deletion of Ptch1 in the bone marrow cell niche led to increased numbers in LKS cells and increased mobilization of myeloid progenitors (Siggins et al., 2009). Whether or not SMO and SMO-dependent HH signaling play a role in hematopoiesis is a subject of strong controversy. Obviously, the effects of SMO deletion are highly contextual and dependent on the timing of deletion. Dierks et al. (2008) transplanted murine Smo/ fetal liver cells into sublethally irradiated mice and observed no significant effect of the Smo defect on long-term reconstitution of the bone marrow. However, they noted that the short-term repopulation of the bone marrow by HSCs was impaired (Dierks et al., 2008). When challenging the hematopoietic regeneration capacity of these mice by injecting 5-FU, they found reduced regeneration 10days but not 40days after the treatment. Thus, loss of Smo seems to affect short-term progenitors rather than long-term repopulating HSCs (Dierks et al., 2008). In contrary, Zhao et al. (2009), using a Vav-driven Cre-mediated Smo deletion model, observed a clear defect in long-term HSC function in this mouse model including decreased reconstitution of the bone marrow in transplantation assays. While the above-mentioned reports mostly supported the by-then consensus view that HH signaling is needed in adult hematopoiesis, two seminal studies published back-to-back challenged this view in 2009 when they both suggested its complete dispensability (Gao et al., 2009; Hofmann et al., 2009). Both studies were based on use of an inducible conditional Smo knockout model in adult mice. A Cre recombinase under the control of myxovirus-resistance 1 (Mx1) gene promoter (Mx1-Cre) allowed for interferon-inducible Smo deletion by stimulation with polyI:polyC. This deletion of Smo in adult mice did not change their hematopoiesis. Consistently, no differences in peripheral blood counts, colony formation in vitro, and HSC/Ps numbers upon Smo deletion could be detected by the authors of both groups (Gao et al., 2009; Hofmann et al., 2009). Strikingly, HSCspecific gene expression signature was preserved in the Smo-deficient HSCs (Gao et al., 2009) and pharmacological inhibition of Hh signaling did not affect murine hematopoiesis (Hofmann et al., 2009). One explanation for these observations might be that despite the expression of Hh upstream elements, Hh signaling activity is shut off in the adult murine hematopoietic system. Indeed, expression of the downstream elements Gli1, Gli2, or Gli3, which serve as a sign for pathway activity, was not detectable in these LSKs and myeloid progenitors (Gao et al., 2009).

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Focusing on the positive downstream effector Gli1, Merchant et al. (2010) found that mice with a homozygous LacZ insertion in the first exon of Gli1 displayed an increase in the long-term (LT)-HSC compartment. Glinull LT-HSCs were more quiescent and had a higher engraftment potential upon transplantation. However, in the proliferative progenitor compartment, impaired myeloid differentiation and defective hematopoiesis in response to stress was observed (Merchant et al., 2010).

V. From HSC to CML Chronic myeloid leukemia (CML) is a myeloproliferative clonal disorder that originates from a transformed hematopoietic stem or multipotent progenitor cell. CML is characterized by the Philadelphia chromosome, resulting from the translocation t(9;22) between chromosomes 22 and 9. The resulting Bcr–Abl fusion gene encodes a constitutively active tyrosine kinase and results in strong malignant hematopoiesis and gross disturbances in the normal hematopoietic bone marrow environment (Sawyers, 1992). Looking at GLI1 and PTCH in CD34þ cells from CML patients, Dierks et al. (2008) observed higher transcript levels in samples from CML patients compared to those from healthy donors. To further evaluate this finding, they induced a CML-like disorder in mice by introducing a Bcr–Abl retrovirus in fetal liver cells that were either Smo negative (Smo/) or heterozygous for Ptch (Ptchþ/). These cells were then transplanted into lethally irradiated recipient mice. The retroviral transduction caused upregulation of Smo in the respective Bcr–Abl-positive cells, with higher efficiency in the Ptchþ/ model than in WT. Smo/ Bcr-Abl cells had a reduced potential for expansion, and the disease developed with longer latency and at lower frequency. Treatment with the Smo inhibitor cyclopamine-induced apoptosis in the leukemic cells ex vivo and reduced their clonogenic potential (Dierks et al., 2008). The therapeutic potential of Smo inhibition was then explored in combination with the Abl inhibitor nilotinib, both in vitro and in vivo. In vitro, the combination of both agents induced apoptosis of CML cells while sparing those from healthy donors. In vivo, combination treatment of leukemic mice reduced their tumor burden and prolonged their overall survival (Dierks et al., 2008). Analogous findings were made by Zhao et al. (2009). When they transplanted Bcr–Abltransduced hematopoietic Smo/ or WT progenitors into irradiated mice, the Smo/ cells caused CML in about half of the recipients and with increased latency, whereas transduced WT cells caused leukemia in almost all recipients. Vice versa, transduction of cells harboring constitutively active Smo strongly accelerated the disease progression. Treatment of the diseased mice with cyclopamine extended their overall survival, and

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leukemic cells from these treated mice were unable to induce the disease upon subsequent transplantation (Zhao et al., 2009). The regulation of the stem cell compartment in CML is dynamic, in particular, during disease progression to a blast crisis and might involve a complex cross-regulation of Hh, Wnt, Notch, and hox signaling pathways (Sengupta et al., 2007). Significant upregulation of Ptch1 and cyclin D1, upon other proteins, marks the blast crisis with Shh-dependent Stat3 activation hypothetically regulating the interconnection between the signaling pathways (Sengupta et al., 2007). In light of this complex time- and tissue-dependent regulation, it is not difficult to see why inconsistent data on the role of Smo in malignant hematopoiesis exist. For example, Hofmann et al. (2009) induced AML by transducing whole bone marrow from Smo-null or WT animals with retrovirus harboring the leukemia-associated disease allele MLL-AF9 and could not detect any influence of Smo deficiency on the replating potential of the transduced cells on methylcellulose or on AML development when transplanting these cells into mice (Hofmann et al., 2009).

VI. T- and B-Cell Malignancies A. Hedgehog role in T cells and T-ALL The complexity of the Hh signaling pathway also becomes apparent when dissecting its contribution to T-lymphocyte differentiation in the thymus. Hh signaling regulates distinct stages of thymocyte development (Drakopoulou et al., 2010; El Andaloussi et al., 2006; Outram et al., 2000; Rowbotham et al., 2007). Using several experimental models to ablate Smo function in a T-cell specific manner, El Andaloussi et al. (2006) found that Smo-dependent Hh signaling is necessary for early T-cell progenitor survival, proliferation, and differentiation (El Andaloussi et al., 2006). However, recent data from Uhmann et al. ( Ji, 2011), who analyzed celltype-specific deletion of Ptch in mice, suggested that T-cell development in thymus is independent of T-cell intrinsic Ptch expression but that Ptch is involved in either the homing of thymic progenitors or their further development. Expression of constitutively active Gli2 or activation of the Hh signaling pathway with Shh shifts the balance in the thymocyte subpopulations toward the CD8þ population suggesting that Hh signaling affects CD4/8 lineage commitment (Rowbotham et al., 2007). As TCR signal strength during repertoire selection controls decision toward the single positive lineage (Kappes and He, 2005), this could point to an influence of Hh signaling on TCR signals (Rowbotham et al., 2007). Evidence for proliferative and/or antiapoptotic effects of Hh ligands on T lymphocytes were first reported by the group around Lamb and Howie

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(Lowrey et al., 2002; Stewart et al., 2002). While Shh addition did not have any effect on resting CD4þ T cells, it significantly enhanced the proliferation of activated ones. In addition, when activated T lymphocytes were exposed to Shh, increased transcription of Ptch, which is known as a classical downstream target of canonical Hh signaling, was found in about half of the investigated samples (Stewart et al., 2002). Lack of Smo can result in loss of the CD8þ T-cell population (Dierks et al., 2008). However, as conditional Smo deletion in the T-cell lineage did not affect the activation of T cells (El Andaloussi et al., 2006), the requirement of T-cell intrinsic Smo remains undetermined. In line with this, Smo was found to be dispensable for the induction of T-acute lymphoblastic leukemia (T-ALL) (Gao et al., 2009). When the authors transformed Smo/ or WT adult murine cells with an activated form of Notch and transplanted them to recipients to induce a Notch-dependent T-ALL, they did not find any role of Smo in the onset or progression of this disease. In addition, treatment of several T-ALL lines with cyclopamine did not reveal any role of Smo in leukemic cell survival or proliferation (Gao et al., 2009). However, other signaling pathways involved in survival of malignant T-lymphocyte might regulate Gli in noncanonical ways. For example, Singh et al. (2009) found that the SHH/GLI axis is activated in anaplastic large cell lymphoma with expression of anaplastic lymphoma kinase (ALKþ) and described a cross talk of the PI3K/Akt axis and GLI in these cells.

B. Hedgehog role in B cells and B-cell malignancies The influence of HH signals on differentiation and malignant transformation of B cells is still poorly understood although several studies have looked into the role of hedgehog signaling in B-cell malignancies. Sacedon et al. (2005) suggested that the production of Shh by follicular dendritic cells provides antiapoptotic effects to B cells within germinal centers (GCs). Further, blockade of Hh signaling by addition of cyclopamine or anti-Shh antibody to proliferating GC B-cell cultures reduced their proliferation and their ability to produce different immunoglobulin isotypes (Sacedon et al., 2005). Later, a comparative approach of immunohistochemical detection of SHH expression in the microenvironment of several B-cell malignancies was pursued by Kim et al. (2009). The authors confirmed SHH expression by follicular dendritic cells in nonmalignant lymph nodes and further investigated its expression in lymph nodes from diffused large B-cell lymphoma (DLBCL), follicular lymphoma, and chronic lymphocytic leukemia (CLL) patients. They found SHH positivity in 91% of investigated cases of DLBCL. It is important to note, however, that SHH was expressed by the tumor cells rather than by the tumor microenvironment indicating an autocrine loop of SHH signaling in this leukemia (Kim et al., 2009). Low expression of SHH was also found in a subset of centroblasts in 29% of

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investigated lymph nodes from follicular lymphoma patients. In contrast, none of the five investigated lymph nodes from CLL patients was clearly positive for SHH, albeit prolymphocytes and paraimmunoblasts inside proliferation centers displayed sporadic SHH expression (Kim et al., 2009) (see also below). With regard to the major HH receptors and downstream transcription factors, most studies have reported positive transcriptional expression data and a reduction in tumor cell viability in vitro following treatment with the SMO inhibitor cyclopamine (see below). However, the fact that cyclopamine exhibits significant off-target effects at high doses (Yauch et al., 2008) complicates our understanding of the existing data. Dierks et al. (2007) established a variety of Myc-positive primary lymphoma cell cultures from Em-Myc mice, a well-established model for mouse B-cell lymphomas. Activation of Hh signaling activity in these cells by either stimulation with recombinant Shh or Ihh or treatment with the Smo agonist purmorphamine increased lymphoma cell survival, which could be reversed by Hh antagonism with 5E1 or cyclopamine. In addition, cyclopamine treatment of mice with fully developed disease effectively inhibited lymphoma growth (Dierks et al., 2007). In DLBCL, canonical SMO-dependent signaling via stroma-secreted SHH seems to be involved in development of chemoresistance of the malignant B lymphocytes (Kim et al., 2009; Singh et al., 2010, 2011). Such multidrug resistance may—at least in part—arise from high expression of the adenosine triphosphate-binding cassette drug transporter ABCG2 on the malignant cells (Kim et al., 2009), which enables efflux of chemotherapeutic drugs such as doxorubicin (Gottesman et al., 2002). The majority of investigated DLBCL cell lines turned out to be SMO positive and sensitive toward SMO inhibition with cyclopamine (compared to the negative control compound tomatidine). The same group of authors linked HH signaling to ABCG2 expression in DLBCL (Singh et al., 2011). Activation of HH signaling by SHH addition or coculture of DLBCL with a human stromal cell line increased ABCG2 expression accompanied by increased chemotolerance. Vice versa, cyclopamine treatment of the DLBCL cell lines resulted in decreased ABCG2 mRNA levels compared to treatment with tomatidine, consistent with the presence of a GLI transcription binding site within the ABCG2 promoter (Singh et al., 2011). Hegde et al. demonstrated that GLI1 and GLI2 were expressed in several mantle cell lymphoma cell lines and primary MCL cells from human patients (Hegde et al., 2008a). In one of the investigated cell lines, JVM2, HH signaling activity upon SHH treatment could be confirmed by increased GLI1 transcription; and SHH significantly influenced cell proliferation in an SMO-dependent manner which could be antagonized by cyclopamine. On the contrary, SHH-mediated HH signaling or effects by SMO inhibition could not be demonstrated in several other investigated cell lines. From these data, the authors deduced subset-specific differences based

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on the classical (JVM2) versus blastoid cytological nature of the malignant B cells (Hegde et al., 2008a). However, an additional explanation might be that canonical signaling via SMO takes place only in JVM2 cells, which express higher levels of SMO as compared to the other cell lines. In contrast to the differential dependence on SMO, functional intrinsic GLI was shown to be indispensable for proliferation in all investigated cell lines, as demonstrated by antisense experiments, and is also involved in chemoresistance of the cells (Hegde et al., 2008a). In CLL, canonical Hh signaling via SMO could not be definitely proven (Fig. 2.2). CLL is a non-Hodgkin lymphoma characterized by leukemic accumulation of malignant B lymphocytes in peripheral blood, invariable infiltration of bone marrow, and progressive infiltration of secondary lymphoid organs. In vitro, CLL cells undergo rapid spontaneous apoptosis if not cocultured with stromal cells or with cells of the monocyte lineage such as “nurse-like” cells (Burger et al., 2000; Kurtova et al., 2009). Also, it is thought that proliferation of CLL takes place in specific proliferation centers inside lymph nodes and bone marrow (Schmid and Isaacson, 1994) and this is governed by microenvironmental stimuli. This high dependence on cell– cell contact or soluble factors secreted by the microenvironment prompted an investigation into the contribution of stroma-derived HH ligands on tumor cell survival in CLL. Based on the finding that GLI1 transcription is increased upon incubation of CLL cells with conditioned medium derived from stromal cells and that cyclopamine induces a decrease in cell viability, Hegde et al. (2008b) suggested that HH ligands secreted by the stromal cells contribute to CLL cell protection in the coculture system via canonical SMO-dependent HH signaling. While we could confirm a cyclopaminemediated decrease in CLL cell viability when using the same dosage, we also observed a reduction in viability by tomatidine, the negative control compound (Desch et al., 2010). Further, SMO expression is strongly reduced in CLL as compared to normal B lymphocytes, and siRNA-mediated knockdown of SMO in a CLL cell line exhibiting higher SMO levels did not decrease its cell viability. Moreover, CLL cells did not specifically react to SHH (Desch et al., 2010). In contrast, we could define an intrinsic, SMO-independent role of GLI in CLL cell survival (Fig. 2.2). Treatment of CLL cells with the GLI antagonist GANT61 massively reduced their cell viability without affecting the viability of normal B lymphocytes and this could be verified by knockdown experiments of GLI and transcriptional reduction of the cognate HH–GLI target gene PTCH. Notably, we observed a strong in vitro response of fludarabine-resistant CLL samples toward GLI inhibition, suggesting a therapeutic potential of GLI targeting especially in this difficult-totreat group. We could not confirm a robust role of HH ligands secreted by stromal cells in supporting the survival of CLL cells and suggest that factors other than HH ligands from these accessory cells are beneficial for CLL cell

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Stromal cell

SHH, IHH, DHH, CXCL12

CXCL12 SHH IHH DHH

Cell adhesion molecules RAF

PTCH

? SMO

ECM

CXCR4

?

PI3K

? RTK

MEK

ERK AKT

? CLL cell

GLIA*

Survival (e.g., via BCL2

)

Figure 2.2 Model of SMO-independent GLI activity regulation in CLL. Stromal cells support the survival of CLL cells by cell contact-dependent and -independent signals. Stromal cells express secreted factors including HH ligands (SHH, IHH, and DHH) and chemokines such as the CXCR4 ligand CXCL12. As we have shown that genetic and pharmacological targeting of GLI—but not of SMO—reduces survival of CLL cells, we propose SMO-independent regulation of GLIA forms in CLL. Possible GLI activating signals could be provided by RAF/MEK/ERK and/or by PI3K/AKT signaling in response to CXCL12-mediated CXCR4 activation or downstream of adhesion molecules and B-cell antigen receptor signaling. In either scenario, the signals would be funneled through GLIA forms, resulting in increased expression of GLI target genes such as the prominent prosurvival factor BCL2 (Regl et al., 2004).

survival and/or proliferation. However, it is also possible that microenvironment-induced signals converge on GLI by noncanonical mechanisms. For example, we recently observed that the presence of protective stromal

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cells can activate Akt pathways in CLL (Hofbauer et al., 2010). Convergence of the GLI and PI3K/Akt and MEK pathways have already been demonstrated in solid tumors (Schnidar et al., 2009; Stecca and Ruiz, 2010; Stecca et al., 2007) and could also occur in CLL. Nevertheless, as our study was mostly focused on the peripheral blood pool of CLL cells, which is mainly cell-cycle arrested and nonproliferative, we do not discount the possibility that canonical SMO-dependent Hh signaling is important for malignant cell proliferation or for maintenance of a tumor-initiating subpopulation in CLL. Prolymphocytes and paraimmunoblasts inside proliferation centers displayed sporadic SHH expression (Kim et al., 2009). Thus, HH pathway activity may occur in a small subpopulation, which is responsible for CLL leukemogenesis. In multiple myeloma, a subset of cells with active HH signaling is markedly concentrated in the tumor stem cell compartment (Peacock et al., 2007). Accordingly, inhibition of HH signaling blocks clonal expansion of the disease but hardly affects the bulk of terminally differentiated plasma cells (Peacock et al., 2007). In a study of pre-B acute lymphocytic leukemia (B-ALL), all cells of investigated cell lines and primary samples expressed the major HH pathway components PTCH1, PTCH2, SMO, and GLI1. Inhibition of HH signaling primarily impacted a highly clonogenic cell population expressing aldehyde dehydrogenase (ALDH) (Lin et al., 2010). Treatment with cyclopamine or the SMO inhibitor IPI-926 reduced the frequency of ALDHþ cells in each cell line, as well as their clonogenic capacity. IPI-926 also mainly affected the self-renewal potential of B-ALL cells in vivo. When the cell line Reh was injected into NOD/SCID mice and then treated with IPI-926, no effects were observed in the primary transplantation model. However, in subsequent bone marrow transplantation experiments, a loss of serial transplantation ability of the leukemia due to SMO inhibition was observed (Lin et al., 2010). Although in CLL, such a cancer stem cell or clonogenic subpopulation with self-renewal capacity has not yet been identified, it is possible that during proliferation HH pathway could be switched on by environmental factors, thus restoring the renewal potential of the cells.

VII. Outlook The complexity of HH/GLI signal transduction including its context dependence and the various noncanonical variations of GLI regulation by pathway cross talk and signal integration pose challenges in defining the precise role of HH and GLI in cancer, particularly in hematopoietic diseases. The impressive list of highly specific HH pathway inhibitors currently tested in clinical trials (see Table 2.1) raises the hope that targeting HH signaling

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will mark a leap forward in molecular medicine and oncology, eventually providing a therapeutic benefit to many cancer patients. Results of the first clinical trials with BCC and medulloblastoma patients treated with SMO inhibitors are highly promising while others have been disappointing (Rudin et al., 2009; Skvara et al., 2011; Von Hoff et al., 2009). Whether the failure of SMO inhibition in ovarian or metastatic colorectal cancer has to do with SMO-independent regulation of GLI activator forms remains to be addressed. Also, in HH-dependent medulloblastoma, treatment with SMO inhibitors can cause a dramatic, yet transient response that is rapidly compensated by the development of drug resistance (Rudin et al., 2009). SMO inhibitor resistance has been ascribed to the selection for SMO mutants with reduced drug affinity, to amplification of GLI2 and/or parallel activation of PI3K/AKT signaling (Buonamici et al., 2010; Yauch et al., 2009). In summary, and despite the first successful trials with SMO inhibitors in BCC patients, we propose that the proper combination of therapeutic compounds simultaneously targeting SMO and positively interacting pathways such as PI3K/AKT, RAS/RAF/MEK/ERK, or RTK signaling will eventually turn out to be the most successful strategy. In fact, a number of studies have provided evidence for an increased anticancer effect of such combinations at least in vitro and in preclinical mouse models (Buonamici et al., 2010; Mimeault et al., 2007; Schnidar et al., 2009; Stecca et al., 2007). The design of proper therapeutic strategies for GLI-dependent yet SMO-independent malignant diseases such as CLL is likely to be more challenging as transcription factors are generally considered poorly druggable targets. However, the identification of HH pathway inhibitors acting downstream of SMO including GLI antagonists (Hyman et al., 2009; Lauth et al., 2007a) may open new avenues for novel therapeutic opportunities, although their in vivo anticancer activity still needs rigorous testing. In addition, the discovery that arsenic trioxide (ATO), which is successfully used for the treatment of anaplastic promyelocytic leukemia (de The and Chen, 2010), efficiently reduces survival of CLL cells from patients with poor prognosis (Merkel et al., 2008), and directly affects GLI activation and stability (Beauchamp et al., 2011; Kim et al., 2010a,b), represents an important step toward anti-GLI activator-based strategies. In the future, it will therefore be necessary to critically evaluate the therapeutic efficacy of single agent therapies compared to combination regimes with compounds that target SMO, GLI, and GLI activity enhancing signaling pathways. Targeting HH signaling has developed into an exciting field of research, with a realistic chance of identifying novel rationale-based drug combinations that are likely to exceed the therapeutic benefit of current regimens in a variety of human malignancies.

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ACKNOWLEDGMENTS Work of the authors has been supported by the Austrian Science Fund FWF (projects P20652 to F. A., W1213 to F. A. and R. G., SFB program P021 to R. G.), the Austrian Genome Research Program GEN-AU (project MedSys MOGLI to F. A.), the priority program “Life Sciences and Health” of the University of Salzburg to F. A., the Austrian National Bank (project 13420 to T. N. H.), the Paracelsus Medical University Salzburg (project E-10/11/058-HAR to T. N. H.), the “Klinische Malignom und Zytokinforschung Salzburg-Innsbruck GmbH,” and the province of Salzburg.

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