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BOOKCHAPTER

Cellproliferation,apoptosis,repairandregeneration
HPRangMBBSMADPhilHonFBPharmacolSFMedSciFRS,JMRitterDPhilFRCPFBPharmacolSFMedSci,
RJFlowerPhDDScFBPharmacolSFMedSciFRSandGHendersonBScPhDFBPharmacolSFSB
Rang&Dale'sPharmacology,5,6777

Overview
About10billionnewcellsarecreateddailythroughcelldivisionandthismustbe
counterbalancedbytheeliminationofasimilarnumberfromthebodyinanordered
manner.Thischapterexplainshowthisismanaged.Wedealwiththelifeanddeathof
thecelltheprocessesofreplication,proliferation,apoptosis,repairand
regenerationandhowtheserelatetotheactionsofdrugs.Webeginwithcell
replication.Weexplainhowstimulationbygrowthfactorscausescellstodivideand
thenconsidertheinteractionofthesecellswiththeextracellularmatrixwhich
regulatesfurthercellproliferation.Wedescribethecrucialphenomenonofapoptosis
(theprogrammedseriesofeventsthatleadtocelldeath),outliningthechangesthat
occurinacellthatispreparingtodieandtheintracellularpathwaysthatculminatein
itsdemise.Weexplainhowtheseprocessesrelatetotherepairofdamagedtissue,to
thepossibilityofitsregenerationandwhetherthereisscopeformodulatingthiswith
noveldrugs.

CellProliferation
Cellproliferationis,ofcourse,afundamentalbiologicalevent.Itisintegraltomanyphysiological
andpathologicalprocessesincludinggrowth,healing,repair,hypertrophy,hyperplasiaandthe
developmentoftumours.Becausecellsneedoxygentosurvive,angiogenesis(thedevelopmentof
newbloodvessels)necessarilyaccompaniesmanyoftheseprocesses.
Proliferatingcellsgothroughwhatistermedthecellcycle,duringwhichtheyreplicatealltheir
componentsandthendivideintotwoidenticaldaughtercells.Theprocessistightlyregulatedby
signallingpathwaysincludingreceptortyrosinekinasesorreceptorlinkedkinasesandthemitogen
activatedproteinkinase(MAPkinase)cascade(seeCh.3).Inallcases,thepathwayseventuallylead
totranscriptionofthegenesthatcontrolthecellcycle.

Thecellcycle
Intheadult,fewcellsdividerepeatedlyandmostremaininaquiescentphaseoutsidethecycleinthe
phasetermedG0(Fig.5.1(f0010)).Somecellssuchasneuronsandskeletalmusclecellsspendall

theirlifetimeinG0whereasothers,includingbonemarrowcellsandtheepitheliumofthe
gastrointestinaltract,dividedaily.

Fig.5.1
Themainphasesofthecellcycleofdividingcells.

Thecellcycleisanorderedsequentialseriesofphases(Fig.5.1(f0010)).Theseareknownas:
G1:preparationforDNAsynthesis
S:DNAsynthesisandchromosomeduplication
G2:preparationfordivision
M:mitosis,divisionintotwodaughtercells.
Incellsthataredividingcontinuously,G1,SandG2compriseinterphasethephasebetweenone
mitosisandthenext.
CelldivisionrequiresthecontrolledtimingofthecriticalSphaseandMphases.Entryintoeachof
thesephasesistightlyregulatedatcheckpoints(restrictionpoints)atthestartoftheSandMphases.
DNAdamagestopsthecycleatoneorotherofthesecheckpointsandtheintegrityofthisprocessis
criticalforthemaintenanceofgeneticstability.Failureofthecheckpointstostopthecyclewhenitis
appropriatetodosoisahallmarkofcancer.
QuiescentcellsenterG1afterexposuretochemicalmediators,someofwhichareassociatedwith
damage.Forexample,awoundcanstimulateaquiescentskincelltodivide,thusrepairingthelesion.
Theimpetusforacelltoenterthecycle(i.e.tomovefromG0intoG1)maybegrowthfactorsacting
ongrowthfactorreceptors,thoughtheactionofothertypesofligandsonGproteincoupled
receptors(seeCh.3)canalsoinitiatetheprocess.
Growthfactorsstimulatethesynthesisofbothpositiveregulatorsofthecellcyclethatcontrolthe
changesnecessaryforcelldivisionandnegativeregulatorsthatcounterbalancethepositive
regulators.Themaintenanceofnormalcellnumbersintissuesandorgansrequiresabalance

betweenthepositiveandthenegativeregulatorysignals.Apoptosis1(fn0010)alsocontrolscell
numbers.
1ThetermisoriginallyaGreekwordthatdescribesthefallingofleavesorpetalsfromplants.

PositiveRegulatorsoftheCellCycle
Thecyclebeginswhenagrowthfactoractsonaquiescentcell,provokingittodivide.Growthfactors
stimulateproductionoftwofamiliesofproteins,namelycyclinsandserine/threonineprotein
kinasescalledcyclindependentkinases(cdks),codedforbythedelayedresponsegenes.Thecdks
sequentiallyphosphorylatevariousenzymesactivatingsomeandinhibitingotherstocoordinate
theprogressionofthecellthroughthecycle.
Eachcdkisinactiveandmustbindtoacyclin,beforeitcanphosphorylateitstargetprotein(s).After
thephosphorylationeventthecyclinisdegraded(Fig.5.2(f0015))bytheubiquitin/proteasesystem.
Here,severalenzymessequentiallyaddsmallmoleculesofubiquitintothecyclin.Theresulting
ubiquitinpolymeractsasanaddresslabelthatdirectsthecyclintotheproteasomewhereitis
degraded.

Fig.5.2
Schematicrepresentationoftheactivationofacyclindependentkinase(cdk).
[A]Aninactivecdk.[B]Theinactivecdkbindstoacyclinandisactivateditcannowphosphorylateaspecific
proteinsubstrate(e.g.anenzyme).[C]Afterthephosphorylatingevent,thecyclinisdegraded.

Thereareeightmaingroupsofcyclins.Accordingtotheclassicalmodelofthecellcycle(see
Satayanarayana&Kaldis,2009),thoseofprincipalimportanceinthecontrolofthecyclearecyclinsA,
B,DandE.Eachcyclinisassociatedwith,andactivates,aparticularcdk.CyclinAactivatescdks1
and2cyclinB,cdk1cyclinD,cdks4and6andcyclinE,cdk2.Precisetimingofeachstepis
essentialandmanycycleproteinsaredegradedaftertheyhavecarriedouttheirfunctions.The
actionsofthecyclin/cdkcomplexesthroughoutthecellcyclearedepictedinFigure5.3(f0020).

Fig.5.3
Schematicdiagramofthecellcycle,showingtheroleofthecyclin/cyclindependentkinase(cdk)complexes.
TheprocessesoutlinedinthecycleoccurinsideacellsuchastheoneshowninFigure5.4(f0025).Aquiescent
cell(inG0phase),whenstimulatedtodividebygrowthfactors,ispropelledintoG1phaseandpreparesforDNA
synthesis.Progressthroughthecycleisdeterminedbysequentialactionofthecyclin/cdkcomplexesdepicted
herebycolouredarrows,thearrowsbeinggiventhenamesoftherelevantcyclins:D,E,AandB.Thecdksare
givennexttotherelevantcyclins.Thethicknessofeacharrowrepresentstheintensityofthecdkactionatthat
pointinthecycle.Theactivityofthecdksisregulatedbycdkinhibitors.IfthereisDNAdamage,theproductsof
thetumoursuppressorgenep53arrestthecycleatcheckpoint1,allowingforrepair.Ifrepairfails,apoptosis
(seeFig.5.5(f0030))isinitiated.ThestateofthechromosomesisshownschematicallyineachGphaseasa
singlepairinG1,andeachduplicatedandformingtwodaughterchromatidsinG2.Somechangesthatoccur
duringmitosis(metaphase,anaphase)areshowninasubsidiarycircle.Afterthemitoticdivision,thedaughter
cellsmayenterG1orG0phase.Rb,retinoblastomagene.

Theactivityofthesecyclin/cdkcomplexesisnegativelymodulatedatoneorotherofthetwocheck
points.InquiescentG0cells,cyclinDispresentinlowconcentration,andanimportantregulatory
proteintheRbprotein2(fn0015)ishypophosphorylated.Thisrestrainsthecellcycleatcheck
point1byinhibitingtheexpressionofseveralproteinscriticalforfurthercycleprogression.TheRb
proteinaccomplishesthisbybindingtotranscriptionfactorscontrollingtheexpressionofthegenes
thatcodeforproteinsessentialforDNAreplicationduringSphase,suchascyclinsEandA,DNA
polymerase,thymidinekinaseanddihydrofolatereductase.
2SonamedbecausemutationsoftheRbgeneareassociatedwithretinoblastomatumours.

GrowthfactoractiononacellinG0propelsitintoG1,whichpreparesthecellforSphase.The
concentrationofcyclinDincreasesandthecyclinD/cdkcomplexphosphorylatesandactivatesthe
proteinsrequiredforDNAreplication.
InmidG1,thecyclinD/cdkcomplexphosphorylatestheRbprotein,releasingatranscriptionfactor
thatactivatesthegenesforthecomponentsessentialforthenextphaseDNAsynthesis.Theaction
ofthecyclinE/cdkcomplexisnecessaryfortransitionfromG1,pastcheckpoint1,intoSphase.
OnceintoSphase,theprocessesthathavebeensetinmotioncannotbereversedandthecellis
committedtoDNAreplicationandmitosis.CyclinE/cdkandcyclinA/cdkregulateprogressthrough
Sphase,phosphorylatingandthusactivatingtheproteins/enzymesinvolvedinDNAsynthesis.

InG2phase,thecell,whichnowhasdoublethenumberofchromosomes,producesthemessenger
RNAsandproteinsneededtoduplicateallothercellularcomponentsforallocationtothetwo
daughtercells.
CyclinA/cdkandcyclinB/cdkcomplexesareactiveduringG2phaseandarenecessaryforentryinto
Mphase,i.e.forpassingcheckpoint2.ThepresenceofcyclinB/cdkcomplexesinthenucleusis
requiredformitosistocommence.
Mitosisoccursinfourstages:
Prophase.Theduplicatedchromosomes(whichareatthispointatangledmassinthe
nucleus)condense,eachnowconsistingoftwodaughterchromatids(theoriginalchromosome
andacopy).Thesearereleasedintothecytoplasmasthenuclearmembranedisintegrates.
Metaphase.Thechromosomesarealignedattheequatorofthecell(seeFig.5.3(f0020)).
Anaphase.Aspecialisedcytoskeletaldevice,themitoticapparatus,capturesthe
chromosomesanddrawsthemtooppositepolesofthedividingcell(seeFig.5.3(f0020)).
Telophase.Anuclearmembraneformsroundeachsetofchromosomes.Finally,the
cytoplasmdividesbetweenthetwoformingdaughtercells.EachdaughtercellwillbeinG0
phaseandwillremainthereunlessstimulatedintoG1phaseasdescribedabove.
Duringmetaphase,thecyclinAandBcomplexesphosphorylatecytoskeletalproteins,nuclear
histonesandpossiblycomponentsofthespindle(themicrotubulesalongwhichthechromatidsare
pulledduringmetaphase).

NegativeRegulatorsoftheCellCycle
OneofthemainnegativeregulatorsistheRbprotein,whichrestrainsthecellcyclewhileitis
hypophosphorylated.
Inhibitorsofthecdksalsoserveasnegativeregulators,theirmainactionbeingatcheckpoint1.
Therearetwoknownfamiliesofinhibitors:theCIPfamily(cdkinhibitoryproteins,alsotermedKIP
orkinaseinhibitoryproteins)proteinsp21,p27andp57andtheInkfamily(inhibitorsofkinases)
proteinsp16,p19andp15.
Proteinp21isagoodexampleoftheroleofacyclin/cdkinhibitor.Itisunderthecontrolofthep53
geneaparticularlyimportantnegativeregulatorwhichisrelevantincarcinogenesisthatoperates
atcheckpoint1.

Inhibitionofthecycleatcheckpoint1
Thep53genehasbeencalledtheguardianofthegenome.Itcodesforthep53protein,a
transcriptionfactorfoundinonlylowconcentrationsinnormalhealthycells.However,following
DNAdamage,theproteinaccumulatesandactivatesthetranscriptionofseveralgenes,oneofwhich

codesforp21.Proteinp21inactivatescyclin/cdkcomplexes,thuspreventingRbphosphorylation,
whichmeansthatthecycleisarrestedatcheckpoint1.ThisallowsforDNArepair.Iftherepairis
successful,thecycleproceedspastcheckpoint1intoSphase.Iftherepairisunsuccessful,thep53
genetriggersapoptosiscellsuicide.

Inhibitionofthecycleatcheckpoint2
DNAdamagecanarrestthecycleatcheckpoint2,butthemechanismsinvolvedarepoorly
understood.InhibitionoftheaccumulationofcyclinB/cdkcomplexinthenucleusseemstobea
factor.Formoredetailonthecontrolofthecellcycle,seeunderMicroRNAsandSwanton(2004).

THECELLCYCLE

Thetermcellcyclereferstothesequenceofeventsthattakeplacewithinacellasit
preparesfordivision.ThequiescentorrestingstateiscalledG0.
GrowthfactoractionstimulatesacellinG0toenterthecycle.
Thephasesofthecellcycleare:
G1:preparationforDNAsynthesis
S:DNAsynthesis
G2:preparationfordivision
M,mitosis:divisionintotwodaughtercells.
InG0phase,ahypophosphorylatedprotein,codedforbytheRbgene,arreststhecycle
byinhibitingexpressionofcriticalfactorsnecessaryforDNAreplication.
Progressthroughthecycleiscontrolledbyspecifickinases(cyclindependentkinases
cdks)thatareactivatedbybindingtospecificproteinstermedcyclins.
FourmaincyclinsD,E,AandB,togetherwiththeircdkcomplexesdrivethecycle
cyclinD/cdkalsoreleasestheRbproteinmediatedinhibition.
Thereareproteininhibitorsofcdksinthecell.Proteinp21isparticularlyimportantitis
expressedwhenDNAdamagetriggerstranscriptionofgenep53andarreststhecycleatcheck
point1.

InteractionsbetweenCells,GrowthFactorsandtheExtracellularMatrix

Cellproliferationisregulatedbytheintegratedinterplaybetweengrowthfactors,cells,the
extracellularmatrix(ECM)andthematrixmetalloproteinases(MMPs).TheECMissecretedbythe
cellsandprovidesasupportiveframework.Italsoprofoundlyinfluencescellbehaviourbysignalling
throughthecell'sintegrins.Matrixexpressionbycellsisregulatedbygrowthfactorsandcytokines
(seeVerrecchia&Mauviel,2007Jrvelinenetal.,2009).Theactivityofsomegrowthfactorsis,in
turn,determinedbythematrix,becausetheyaresequesteredbymatrixcomponentsandreleasedby
proteases(e.g.MMPs)secretedbythecells.
Theactionofgrowthfactorsactingthroughreceptortyrosinekinasesorreceptorcoupledkinases
(seeCh.3)isafundamentalpartoftheseprocesses.Importantexamplesincludefibroblastgrowth
factor(FGF),epidermalgrowthfactor(EGF),plateletdependentgrowthfactor(PDGF),vascular
endothelialgrowthfactor(VEGF)andtransforminggrowthfactor(TGF).
Themaincomponentsoftheextracellularmatrixare:
Fibreformingelements,e.g.collagenspecies(themainproteinsofthematrix)andelastin.
Nonfibreformingelements,e.g.proteoglycans,glucoproteinsandadhesiveproteinssuchas
fibronectin.Proteoglycanshaveagrowthregulatingrole,inpartbyfunctioningasareservoir
ofsequesteredgrowthfactors.Othersareassociatedwiththecellsurface,wheretheybindcells
tothematrix.Adhesiveproteinslinkthevariouselementsofthematrixtogetherandalsoform
linksbetweenthecellsandthematrixthroughcellsurfaceintegrins.
OtherproteinsintheECMarethrombospondinandosteopontin,whicharenotstructuralelements
butmodulatecellmatrixinteractionsandrepairprocesses.TheproductionoftheECMcomponents
isregulatedbygrowthfactors,particularlyTGF.
TheECMisatargetfordrugaction.Bothbeneficialandadverseeffectshavebeenreported.Thus
glucocorticoidsdecreasecollagensynthesisinchronicinflammationandcyclooxygenase(COX)2
inhibitorscanmodifyfibroticprocessesthroughaproposedactiononTGF.Statinscandecrease
fibrosisbyinhibitingangiotensininducedconnectivetissuegrowthfactorproduction(Ruprezetal.,
2007)andreduceMMPexpression.Thismaycontributetotheireffectsincardiovasculardiseases(
Tousoulisetal.,2010).TheadverseactionsofsomedrugsattributabletoaneffectontheECMinclude

theosteoporosisandskinthinningcausedbyglucocortoicoids(discussedin Jrvelinenetal.,2009).
TheECMisalsoanimportanttargetinthesearchfornewdrugsthatregulatetissuerepair.

TheRoleofIntegrins
Integrinsaretransmembranekinaselinkedreceptors(seeCh.3)comprisingandsubunits.
InteractionwiththeECMelements(e.g.fibronectin)triggersvariouscellresponses,suchas
cytoskeletalrearrangement(notconsideredhere)andcoregulationofgrowthfactorfunction.
Intracellularsignallingbybothgrowthfactorreceptorsandintegrinsisimportantforoptimalcell
proliferation(Fig.5.4(f0025)).Followingintegrinstimulationanadapterproteinandanenzyme(
focaladhesionkinase),activatethekinasecascadethatcomprisesthegrowthfactorsignalling

pathway.Thereisextensivecrosstalkbetweentheintegrinandgrowthfactorpathways(
Streuli&Akhtar,2009).Autophosphorylationofgrowthfactorreceptors(Ch.3)isenhancedby
integrinactivationandintegrinmediatedadhesiontotheextracellularmatrix(Fig.5.4(f0025))not
onlysuppressestheconcentrationsofcdkinhibitors,butisrequiredfortheexpressionofcyclinsA
andD,andthereforefortheprogressionofthecellcycle.Furthermore,integrinactivationinhibits
apoptosis(seebelow),furtherfacilitatinggrowthfactoraction(seereviewsby Gahmbergetal.,2009
and Barczyketal.,2010).

Fig.5.4
SimplifieddiagramoftheeffectofgrowthfactorsonacellinG0.
Theoveralleffectofgrowthfactoractionisthegenerationofthecellcycletransducers.Acellsuchastheone
depictedwillthenembarkonG1phaseofthecellcycle.Mostgrowthfactorreceptorshaveintegraltyrosine
kinase(seeFig.3.17).Thesereceptorsdimerise,thencrossphosphorylatetheirtyrosineresidues.Theearly
cytosolictransducersincludeproteinsthatbindtothephosphorylatedtyrosineresidues.Optimumeffectrequires
cooperationwithintegrinaction.Integrins(whichhaveandsubunits)connecttheextracellularmatrixwith
intracellularsignallingpathwaysandalsowiththecellcytoskeleton(notshownhere).Gproteincoupled
receptorscanalsostimulatecellproliferation,becausetheirintracellularpathwayscanconnectwiththe
Ras/kinasecascade(notshown).AP,adapterproteinFAkinase,focaladhesionkinaseRb,retinoblastoma
protein.

Severalmonoclonalantibodiesaretargetedatintegrins,includingnatalizumab,usedtotreat
multiplesclerosisandabciximab,anantithrombotic(Ch.24).

TheRoleofMatrixMetalloproteinases

TheRoleofMatrixMetalloproteinases
DegradationoftheECMbymetalloproteinasesisnecessaryfortissuegrowth,repairand
remodelling.Whengrowthfactorsstimulateacelltoenterthecellcycle,theyalsostimulatethe
secretionofmetalloproteinases(asinactiveprecursors),whichthensculptthematrix,producingthe
localchangesnecessarytoaccommodatetheincreasedcellnumbers.Metalloproteinasesinturn
releasegrowthfactorsfromtheECMand,insomecases(e.g.interleukin[IL]1),processthemfrom
precursortoactiveform.TheactionoftheseenzymesisregulatedbyTIMPS(tissueinhibitorsof
metalloproteinases),whicharealsosecretedbylocalcells.
Inadditiontotheirphysiologicalfunction,metalloproteinasesareinvolvedinthetissuedestruction
thataccompaniesvariousdiseases,suchasrheumatoidarthritis,osteoarthritis,periodontitis,
maculardegenerationandmyocardialrestenosis.Theyalsohaveacriticalroleinthegrowth,
invasionandmetastasisoftumours(Skilesetal.,2004 Clarketal.,2008 Marastonietal.,2008).
Becauseofthis,muchefforthasgoneintodevelopingsyntheticMMPinhibitorsfortreatingcancers
andinflammatorydisorders,althoughclinicaltrialssofarhaveshownlimitedefficacyandsignificant
adverseeffects(see Fingleton,2008).Doxycycline,anantibiotic,alsoinhibitsMMPs,andisused
experimentallyforthispurpose.

INTERACTIONSBETWEENCELLS,GROWTHFACTORSANDTHEMATRIX

Cellssecretethecomponentsoftheextracellularmatrix(ECM)andbecomeembedded
inthistissue.
TheECMinfluencesthegrowthandbehaviourofthecells.Italsoactsasareservoirof
growthfactors.
Integrinsaretransmembranecellularreceptorsthatcaninteractwithelementsofthe
ECM.Theymodulategrowthfactorsignallingpathwaysandalsomediatecytoskeletal
adjustmentswithinthecell.
Growthfactorscausecellstoreleasemetalloproteinasesthatdegradethelocalmatrixso
thatitcanaccommodatetheincreaseincellnumbers.
MetalloproteinasesreleasegrowthfactorsfromtheECMandcanactivatesomethatare
presentinprecursorform.

Angiogenesis
Angiogenesis,whichnormallyaccompaniescellproliferation,istheformationofnewcapillariesfrom
existingsmallbloodvessels.Withoutthis,newtissues(includingtumours)cannotgrow.Angiogenic
stimuliincludecytokinesandvariousgrowthfactors,inparticularvascularendothelialgrowth

factor(VEGF).Thesequenceofeventsinangiogenesisisasfollows:
1.Thebasementmembraneisdegradedlocallybyproteases.
2.Endothelialcellsmigrateout,formingasprout.
3.Followingtheseleadingcells,otherendothelialcellsproliferateundertheinfluenceofVEGF.
4.Matrixmaterialislaiddownaroundthenewcapillary.
Amonoclonalantibody,bevacizumab,whichneutralisesVEGF,isusedasadjuncttreatmentfor
variouscancers(seeCh.56),andfollowinginjectionintotheeye,totreatagerelatedmacular
degeneration,aconditioninwhichretinalbloodvesselsproliferate,causingblindness.

ApoptosisandCellRemoval
Apoptosisiscellsuicide.Itisregulatedbyabuiltingeneticallyprogrammedselfdestruct
mechanismconsistingofspecificsequenceofbiochemicalevents.Itisthusunlikenecrosis,whichis
disorganiseddisintegrationofdamagedcellsthatreleasessubstancesthattriggertheinflammatory
response.3(fn0020)
3Thereareotherformsofprogrammedcelldeath(PCD)includingautophagyand(confusingly)programmed
necrosis.Herewewillfocusonapoptosis,alsoknownasTypeIPCD.

Apoptosisplaysanessentialroleinembryogenesis,shapingorgansduringdevelopmentby
eliminatingcellsthathavebecomeredundant.Itisthemechanismthateachdayunobtrusively
removessome10billioncellsfromthehumanbody.Itisinvolvedinnumerousphysiologicalevents,
includingthesheddingoftheintestinallining,thedeathoftimeexpiredneutrophilsandthe
turnoveroftissuesasthenewborninfantgrowstomaturity.Itisthebasisforthedevelopmentof
selftoleranceintheimmunesystem(Ch.6)andactsasafirstlinedefenceagainstcarcinogenic
mutationsbypurgingcellsthatcouldbecomemalignant.
Impairedapoptosisisalsoimplicatedinthepathophysiologyofmanyconditions,including:
chronicneurodegenerativediseasessuchasAlzheimer's,multiplesclerosisandParkinson's
disease(Ch.40)
conditionswithacutetissuedamageorcellloss,suchasmyocardialinfarction(Ch.21),
strokeandspinalcordinjury(Ch.40)
depletionofTcellsinHIVinfection(Ch.52)
osteoarthritis(Ch.36)
haematologicaldisease,suchasaplasticanaemia(Ch.25)
evasionoftheimmuneresponsebycancercellsandresistancetocancerchemotherapy(Ch.

56)

autoimmune/inflammatorydiseasessuchasmyastheniagravis(Ch.13),rheumatoidarthritis
(Ch.26),andbronchialasthma(Ch.28)
viralinfectionswithineffectiveeradicationofvirusinfectedcells(Ch.52).
Apoptosisisparticularlyimportantintheregulationoftheimmuneresponseandinthemany
conditionsinwhichitisanunderlyingcomponent.ThereisevidencethatTcellshaveanegative
regulatorypathwaycontrolledbysurfaceprogrammedcelldeathreceptors(e.g.thePD1receptor),
andthatthereisnormallyabalancebetweenthestimulatorypathwaystriggeredbyantigensandthis
negativeregulatoryapoptosisinducingpathway.Thebalanceisimportantinthemaintenanceof
peripheraltolerance.Adisturbanceofthisbalanceisseeninautoimmunedisease,intheexhaustion
ofTcellsinchronicviraldiseasessuchasHIV,andpossiblyintumourescapefromimmune
destruction( Zhaetal.,2004).
Apoptosisisadefaultresponse,i.e.continuousactivesignallingbytissuespecifictrophicfactors,
cytokinesandhormones,andcelltocellcontactfactors(adhesionmolecules,integrins,etc.)are
requiredforcellsurvivalandviability.Theselfdestructmechanismisautomaticallytriggeredunless
itisactivelyandcontinuouslyinhibitedbytheseantiapoptoticfactors.Differentcelltypesrequire
differingsetsofsurvivalfactors,whichfunctiononlylocally.Ifacellstraysorisdislodgedfromthe
areaprotectedbyitsparacrinesurvivalsignals,itwilldie.
Withdrawalofthesesurvivalfactorswhichhasbeentermeddeathbyneglectisnottheonly
pathwaytoapoptosis(seeFig.5.5(f0030)).Thedeathmachinerycanbeactivatedbyligandsthat
stimulatedeathreceptorsandbyDNAdamage.Butitisgenerallyacceptedthatcellproliferation
processesandapoptosisaretightlyintegrated.

Fig.5.5
Asimplifieddiagramofthetwomainsignallingpathwaysinapoptosis.
Thedeathreceptorpathwayisactivatedwhendeathreceptorssuchasmembersofthetumournecrosisfactor
(TNF)familyarestimulatedbyspecificdeathligands.Thisrecruitsadapterproteinsthatactivateinitiator
caspases(e.g.caspase8),whichinturnactivateeffectorcaspasessuchascaspase3.Themitochondrial
pathwayisactivatedbydiversesignals,onebeingDNAdamage.InthepresenceofDNAdamagethatcannotbe
repaired,thep53protein(seetextandFigs5.3(f0020)and5.4(f0025))activatesasubpathwaythatreleases
cytochromecfromthemitochondrion,withsubsequentinvolvementoftheapoptosomeandactivationofan
initiatorcaspase,caspase9.Theapoptosomeisacomplexofprocaspase9,cytochromecandapoptotic
activatingproteasefactor1(Apaf1).Boththesepathwaysconvergeontheeffectorcaspase(e.g.caspase3),
whichbringsaboutthedemiseofthecell.Thesurvivalfactorsubpathwaynormallyrestrainsapoptosisby
inhibitingthemitochondrialpathwaythroughactivationoftheantiapoptoticfactorBcl2.ThereceptorlabelledR
representstherespectivereceptorsfortrophicfactors,growthfactors,celltocellcontactfactors(adhesion
molecules,integrins),etc.Continuousstimulationofthesereceptorsisnecessaryforcellsurvival/proliferation.If
thispathwayisnonfunctional(showningrey),thisantiapoptoticdriveiswithdrawn.IAP,inhibitorofapoptosis.

MorphologicalChangesinApoptosis
Asthecelldiesitroundsup,thechromatincondensesintodensemasses,thecytoplasmshrinksand
thereisblebbingoftheplasmamembrane.Finally,mediatedbyafamilyofproteolyticenzymes
knownascaspases,thecellistransformedintoaclusterofmembraneboundentities.Thiscellular
corpsedisplayseatmesignals,suchasphosphatidylserineonitssurface,whicharerecognizedby
macrophages,whichthenphagocytosetheremains.Itisimportantthatthesecellularfragmentsare
enclosedbyamembranebecauseotherwisethereleaseofcellconstituentscouldtriggeran
inflammatoryreaction.Anadditionalsafeguardagainstthisisthatphagocytosingmacrophages
releaseantiinflammatorymediatorssuchasTGF,Annexin1andIL10.

TheMajorPlayersinApoptosis
Therepertoireofreactionsinapoptosisisextremelycomplexandvariesbetweenspeciesandcell
types.Yetitcouldbethatthepivotalreaction(s)thatleadtoeithercellsurvivalorcelldeathare
controlledbyasinglegeneorcombinationofgenes.Ifso,thesegenescouldbedesirabletargetsfor
drugsusedtotreatmanyproliferativediseases.

Onlyasimpleoutlineofapoptosiscanbegivenhere.Porttetal.(2011)havereviewedthewholeareain
detail.Themajorplayersarethecaspasesafamilyofcysteineproteasespresentinthecellin
inactiveform.Theseundertakedelicateproteinsurgery,selectivelycleavingaspecificsetoftarget
proteins(enzymes,structuralcomponentsallofwhichcontainacharacteristicmotifrecognisedby
thecaspases),inactivatingsomeandactivatingothers.Acascadeofaboutninedifferentcaspasesare
required,somefunctioningasinitiatorsthattransmittheinitialapoptoticsignals,andothersbeing
responsibleforthefinalphaseofcelldeath(Fig.5.5(f0030)).
Theexecutionercaspases(e.g.caspase3)cleaveandinactivatecellconstituentssuchastheDNA
repairenzymes,proteinkinaseC,andcytoskeletalcomponents.ADNAaseisactivatedthatcuts
genomicDNAbetweenthenucleosomes,generatingDNAfragmentsofapproximately180basepairs.
However,notallcaspasesaredeathmediatingenzymessomehavearoleintheprocessingand
activatingofcytokines(e.g.caspase8isactiveinprocessingtheinflammatorycytokinesIL1andIL
18).
Besidesthecaspases,anotherpathwaycanbetriggeredbyapoptoticinitiatingfactor(AIF),a
proteinreleasedfromthemitochondriathatentersthenucleusandtriggerscellsuicide.

PathwaystoApoptosis
Therearetwomainroutestocelldeath:stimulationofdeathreceptorsbyexternalligands(the
extrinsicpathway)andaninternalmitochondrialpathway.Bothroutesactivateinitiatorcaspases
andconvergeonafinalcommoneffectorcaspasepathway.

TheExtrinsicPathway
Lurkingintheplasmamembraneofmostcelltypesaremembersofthetumournecrosisfactor
receptor(TNFR)superfamily(alsoknownasFasreceptors),whichfunctionasdeathreceptors(Fig.
5.5(f0030)).ImportantfamilymembersincludeTNFR1andCD95(alsoknownasFasligandsor

Apo1),buttherearemanyothers(e.g.PD1,adeathreceptorthatcanbeinducedonactivatedT
cells,asdiscussedabove).
Eachreceptorhasadeathdomaininitscytoplasmictail.Stimulationofthereceptorsbyaligand
suchastumournecrosisfactor(TNF)itselforTRAIL4(fn0025)causesthemtotrimeriseandrecruit
anadapterproteinthatbindstotheirdeathdomains.Theresultingcomplexactivatescaspase8(and
probablycaspase10),whichinturnactivatetheeffectorcaspases(Fig.5.5(f0030)).
4TRAIListumournecrosisfactorrelatedapoptosisinducingligand',ofcoursewhatelse?SeeJanssen
etal.(2005)fordiscussionofaroleofTRAIL.PDL1,aligandforthePD1receptor,isfoundonallhaemopoietic
cellsandmanyothertissues.

Themitochondrialpathway

ThispathwaycanbetriggeredbyDNAdamageorbywithdrawalofcellsurvivalfactorsorother
factors.Insomeway,thecellcanauditsuchdamageanddecidewhethertoinitiatetheapoptotic
pathway.Itispossiblethatpromyelocyticleukaemiabodies,largecomplexesofproteinsinthe
nucleus,participateinthistask( Wyllie,2010),althoughhowtheydosoisnotclear.
RegulatingtheapoptoticeventarethemembersoftheBcl2proteinfamily,agroupofproteinswith
homologousdomainsallowinginteractionsbetweenindividualmembers.Ifthecellselectsthe
apoptoticroute,thep53proteinactivatesp21andproapoptoticmembersoftheBcl2familyBid,
BaxandBak.Inadditiontotheseproapoptoticindividuals,thisfamilyhasantiapoptoticmembers
(e.g.Bcl2itself).5(fn0030)Thesefactorscompetewitheachotheronthesurfaceofthemitochondria
andtheoutcomedependsupontherelativeconcentrationsofthesemolecularplayers.Inthecaseof
aproapoptoticsignal,oligomersofBaxandorBakformporesinthemitochondrialmembrane
throughwhichproteinssuchascytochromeccanleak.
5AnotherbrakeoncelldeathisafamilyofcaspaseinhibitingproteinscalledIAPs(inhibitorsofapoptosis
proteins).

Whenreleased,cytochromeccomplexeswithaproteintermedApaf1(apoptoticproteaseactivating
factor1)andthetwothencombinewithprocaspase9andactivatesit.Thislatterenzyme
orchestratestheeffectorcaspasepathway.Thetriumvirateofcytochromec,Apaf1andprocaspase9
istermedtheapoptosome(Fig.5.5(f0030)see Riedl&Salvesen,2007).Nitricoxide(seeCh.20)is
anothermediatorthatcanhaveproapoptoticandantiapoptoticactions.
Innormalcells,survivalfactors(specifiedabove)continuouslyactivateantiapoptoticmechanisms.
Thewithdrawalofsurvivalfactorscancausedeathinseveraldifferentwaysdependingonthecell
type.AcommonmechanismistippingthebalancebetweenBcl2familymembersleadingtolossof
theantiapoptoticproteinaction,withtheresultantunopposedactionoftheproapoptoticBcl2
proteins(seeFig.5.5(f0030)).
Thetwomaincelldeathpathwaysareconnectedtoeachother,inthatcaspase8inthedeath
receptorpathwaycanactivatetheproapoptoticBcl2proteinsandthusactivatethemitochondrial
pathway.

MicroRNAs,thecellcycleandapoptosis
MicroRNAs(miRNAs),discoveredonlyinthepastdecade,areafamilyofsmallnoncodingRNAs
presentinthegenomesofplantsandanimals.Theyarenowknowntoinhibittheexpressionofgenes
codingforcellcycleregulation,apoptosis(Fig5.5(f0030)),celldifferentiationanddevelopment(
Carletonetal.,2007 LynamLennonetal.,2009).About3%ofhumangenesencodeformiRNAand

some30%ofhumangenescodingforproteinsareregulatedbymiRNAs.
AlteredmiRNAexpressionisnowbelievedtobelinkedtoavarietyofdiseases,includingdiabetes,
obesity,Alzheimer's,cardiovascularsystemdiseases,inflam
matoryconditions,neurodegenerative
diseases(Barbatoetal.,2009),aswellascarcinogenesis,metastasisandresistancetocancertherapies

( Wurdinger&Costa,2007 Garzonetal.,2009).miRNAsarealsobelievedtofunctionasoncogenes
and/ortumoursuppressorgenesandtoregulateTcells( Zhouetal.,2009).Notsurprisingly,
miRNAsarebeingheraldedastargetsfornewdrugdevelopmentforavarietyofdiseasestates(
Liuetal.,2008 Stenvangetal.,2008 Tsai&Yu,2010).

APOPTOSIS

Apoptosisisprogrammedcelldeath.Itisanessentialbiologicalprocessandcriticalfor
(e.g.)embryogenesisandtissuehomeostasis.
Apoptosisdependsuponacascadeofproteasescalledcaspases.Twosetsofinitiator
caspasesconvergeonasetofeffectorcaspases,whichbringabouttheapoptoticevent.
Twomainpathwaysactivatetheeffectorcaspases:thedeathreceptorpathwayandthe
mitochondrialpathway.
Stimulationofthetumournecrosisfactorreceptorfamilyinitiatesthedeath
receptorpathway.Themaininitiatoriscaspase8.
ThemitochondrialpathwayisactivatedbyinternalfactorssuchasDNAdamage,
whichresultsintranscriptionofgenep53.Thep53proteinactivatesasubpathway
thatreleasescytochromecfromthemitochondrion.This,inturn,complexeswith
proteinApaf1andtogethertheyactivateinitiatorcaspase9.
Inundamagedcells,survivalfactors(cytokines,hormones,celltocellcontactfactors)
continuouslyactivateantiapoptoticmechanisms.Withdrawalofsurvivalfactorscauses
celldeaththroughthemitochondrialpathway.
Theeffectorcaspases(e.g.caspase3)initiateacascadeofproteasesthatcleavecell
constituents,DNA,cytoskeletalcomponents,enzymes,etc.Thisreducesthecelltoa
clusterofmembraneboundentitiesthatareeventuallyphagocytosedbymacrophages.

PathophysiologicalImplications
Asmentionedabove,cellproliferationandapoptosisareinvolvedinmanyphysiologicaland
pathologicalprocesses.Theseare:
thegrowthoftissuesandorgansintheembryoandlaterduringchildhood
thereplenishmentoflostortimeexpiredcellssuchasleukocytes,gutepitheliumanduterine
endometrium
immunologicalresponses,includingdevelopmentofimmunologicaltolerancetohostproteins

repairandhealingafterinjuryorinflammation
thehyperplasia(increaseincellnumberandinconnectivetissue)associatedwithchronic
inflammatory,hypersensitivityandautoimmunediseases(Ch.6)
thegrowth,invasionandmetastasisoftumours(Ch.56)
regenerationoftissues.
Theroleofcellproliferationandapoptosisinthefirsttwoprocesseslistedisselfevidentandneeds
nofurthercomment.Theirinvolvementinimmunetoleranceisdiscussedbrieflyabovebuttheother
processesrequirefurtherdiscussion.

RepairandHealing
Repairoccurswhentissuesaredamagedorlost.Itisalsoimplicatedintheresolutionofthelocal
inflammatoryreactiontoapathogenorchemicalirritant.Insomeinstances,damageortissueloss
canleadtoregeneration,whichisquitedifferenttorepairandisconsideredseparatelybelow.
Thereisconsiderableoverlapbetweenthemechanismsactivatedininflammationandrepair.Both
entailanorderedseriesofeventsincludingcellmigration,angiogenesis,proliferationofconnective
tissuecells,synthesisofextracellularmatrixandfinallyremodellingallcoordinatedbythegrowth
factorsandcytokinesthatareappropriatefortheparticulartissueinvolved.TGFisakeyregulator
ofseveraloftheseprocesses.

REPAIR,HEALINGANDREGENERATION

Repairandhealingoccurswhentissuesaredamaged.Itisacommonsequelto
inflammation.Connectivetissuecells,whitebloodcellsandbloodvesselsarecommonly
involved.
Regenerationisthereplacementofthetissueororganthathasbeendamagedorlost.It
dependsuponthepresenceofapoolofprimitivestemcellsthathavethepotentialto
developintoanycellinthebody.Completeregenerationofatissueororganisrarein
mammals.Themorerapidrepairprocessesoftenaccompaniedbyscarringusually
makegoodthedamage.Thismaybeanevolutionarytradeoffinmammalsforthelost
powerofregeneration.
However,itmightbepossibletoactivateregenerativepathwaysinmammalsatleast
tosomeextentandinsomeorgans.

Hyperplasia

Hyperplasia(cellproliferationandmatrixexpansion)isahallmarkofchronicinflammatoryand
autoimmunediseasessuchasrheumatoidarthritis(Chs6and26),psoriasis,chroniculcersand
chronicobstructivelungdisease.Italsounderliesthebronchialhyperreactivityofchronicasthma(
Ch.28)andglomerularnephritis.

Cellproliferationandapoptoticeventsarealsoimplicatedinatherosclerosis(Ch.23),restenosisand
myocardialrepairafterinfarction(Ch.21).

TheGrowth,InvasionandMetastasisofTumours
Growthfactorsignallingsystems,antiapoptoticpathwaysandcellcyclecontrollersareofincreasing
interestastargetsfornovelapproachestothetreatmentofcancer.SeeChapter56.

StemCellsandRegeneration
Regenerationoftissuereplacesthatlostfollowingdamageordiseaseandallowsrestorationof
function.Manyanimals(e.g.amphibians)haveimpressiveregenerativepowersandcanevenregrow
anentireorgansuchasalimboratail.Theessentialprocessistheactivationofstemcellsapoolof
undifferentiatedcellsthathavethepotentialtodevelopintoanyofthemorespecialisedcellsinthe
body(totipotentorpluripotentcells).Notonlydoamphibianshaveaplentifulsupplyofthese
primitivecellsbutmanyoftheirmorespecialisedcellscandedifferentiate,becomingstemcells
again.Thesecanthenmultiplyandretracethefetaldevelopmentalpathwaysthatgeneratedthe
organ,proliferatingagainandagainandeventuallydifferentiatingintothevariouscelltypesneeded
toreplacethemissingstructure.
However,duringevolution,mammalshavelostthisabilityinallbutafewtissues.Bloodcells,
intestinalepitheliumandtheouterlayersoftheskinarereplacedcontinuouslythroughoutlifebut
thereisalowturnoverandreplacementofcellsinorganssuchasliver,kidneyandbone.This
physiologicalrenewaliseffectedbylocaltissuespecificstemcells.
Almostaloneamongmammalianorgans,theliverhassignificantabilitytoreplaceitself.Itcan
regeneratetoitsoriginalsizeinaremarkablyshorttime,providedthatatleast25%hasbeenleft
intact.6(fn0035)Thematureparenchymallivercellsparticipateinthisprocessaswellasalltheother
cellularcomponentsoftheliver.
6ThereisanaccountofliverregenerationinGreekmythology.PrometheusstolethesecretoffirefromZeusand
gaveittomankind.Topunishhim,ZeushadhimshackledtoacragintheCaucasusandeverydayaneagletoreat
hisfleshanddevouredmuchofhisliver.Duringthenight,however,itregeneratedandinthemorningwaswhole
again.Thelegenddoesn'tsaywhethertherequisite25%wasleftaftertheeaglehadhaditsfill,andthe
regenerationdescribedseemsunrealisticallyfastratlivertakes2weeksormoretogetbacktotheoriginalsize
after66%hepatectomy.

Itisnecessarytodistinguishembryonicstemcells(EScells)fromadultstemcellsandprogenitor
cells.EScellsarethetruepluripotentcellsoftheembryowhichareabletodifferentiateintoany
othercelltype.Adultstemcells(AScells)haveamorerestrictedcapabilitywhereasprogenitorcells

areabletodifferentiateonlyintoasinglecelltype.EScellsareabsentintheadultmammal,butAS
cellsarepresent,althoughtheyarefewinnumber.Ifamammalisinjuredoritstissueisremoved,
repairprocessesoftenwithsubsequentscarringusuallymakegoodthedamage.Itseemsthat
rapidclosureofthedefectaftertissueloss(whichismuchmorespeedilyaccomplishedbyrepair
mechanisms)takespriorityoverregeneration.
Untilrecently,itwasassumedthatthiswas(withafewexceptions)anunalterablesituation,but
recentworkhassuggestedthatitmightbepossibletoactivatetheregenerativepathwaysin
mammalsatleasttosomeextentandinsomeorgans.Replacementofentirelimbsismanifestly
notpossibleinhumans,butregenerationoflimitedamountsoftissueorofasmallpartofanorgan
maywellbefeasible.Forthistohappen,itisnecessarytoencouragesomestemcellstoproliferate,
developanddifferentiateattherelevantsitesorandthisisarathermoreremoteprospectin
humanstopersuadesomelocalspecialisedcellstodedifferentiate.Thiscanoccurinsome
mammalsunderspecialcircumstances.However,itmaybethatrepairistheJanusfaceof
regeneration,beinganevolutionarytradeoffinmammalsforthelostpowerofregeneration.
Wherearetherelevantstemcellsthatcouldbecoaxedintoregenerativeservice?Various
possibilitiesarebeingvigorouslyinvestigatedandinsomecasestestedclinically.Theseinclude:
embryonicstemcells(limitedavailabilityandseriousethicalissues)
bonemarrowderivedmesenchymalstemcells(Huangetal.,2009 Stapenbeck&Miyoshi,2009)
musclederivedstemcells(Sinananetal.,2006)
humaninducedpluripotentstemcells(Nishikawaetal.,2008)
tissueresidentprogenitorcells.
Foratissuesuchasthelivertoregenerate,localtissuespecificstemcellsmustbestimulatedby
growthfactorstoenterthecellcycleandtoproliferate.Otheressentialprocessesincludethose
alreadydiscussedsuchasangiogenesis,activationofMMPsandinteractionbetweenthematrixand
fibronectintolinkallthenewelementstogether.Theconcomitantreplacementofcomponentsofthe
lostconnectivetissue(fibroblasts,macrophages,etc.)wouldalsobenecessary.
Becausemosttissuesdonotregeneratespontaneously,mechanismsthatcouldrestoreregenerative
abilitycouldbeofimmensetherapeuticvalue.Stemcelltherapyhasbecomeanattractiveprospect
fortreatingallmannerofdiseases,rangingfromerectiledysfunctionandurinaryincontinenceto
heartdiseaseandneurodegeneration.Animalstudieshaveconfirmedthatthisisapotentially
rewardingareaalthoughroutinestemcelltherapyinhumansisstilladistantprospect.Theliterature
isdauntingbutthefollowingexamplesprovideaninsightintotheobstaclesandaspirationsofthe
field:repairofdamagedheartmuscle(Ch.21see Lovell&Mathur,2011),repairofretinal
degeneration( Ong&daCruz,2012),stroke( Banerjeeetal.,2011)andreplacementofinsulin
secretingcellstotreattypeIdiabetesmellitus(Ch.31 Voltarellietal.,2007).

TherapeuticProspects
Theoretically,alltheprocessesdescribedinthischaptercouldconstituteusefultargetsfornewdrug
development.Below,welistthoseapproachesthatareprovingorarelikelytoprovefruitful.

ApoptoticMechanisms
Compoundsthatcouldmodifyapoptosisarebeingintensivelyinvestigated(Melnikova&Golden,2004
MacFarlane,2009).Herewecanonlyoutlinesomeofthemoreimportantapproaches.

Drugsthatpromoteapoptosisbyvariousmechanismswereheraldedasapotentialnewapproachto
cancertreatment,andareactivelybeingstudied,thoughnonehasyetbeenapprovedforclinicaluse.
Potentialproapoptotictherapeuticapproachesneedtobetargetedpreciselytothediseasedtissueto
avoidtheobviousrisksofdamagingothertissues.Examplesincludethefollowing:
AnantisensecompoundagainstBcl2(oblimersen)isbeingtestedforchroniclymphocytic
leukaemia.
Obatoclax,asmallmoleculeinhibitorofBcl2action,isbeingtestedfortreating
haematologicalmalignancies.Fordetailssee MacFarlane(2009).
MicroRNAtechnologycouldalsobeusedtopromoteapoptosis(seeFig.5.5(f0030)).
MonoclonalagonistantibodiestothedeathreceptorligandTRAIL(e.g.lexatumumab)are
undergoingclinicaltrialsfortreatmentofsolidtumoursandlymphomas( MacFarlane,2009).
Anewdrug,bortezomib,whichinhibitstheproteasome,isavailableforthetreatmentof
selectedcancers.ItcausesthebuildupofBax,anapoptoticpromoterproteinoftheBcl2
familythatactsbyinhibitingantiapoptoticBcl2.BortezomibactspartlybyinhibitingNFB
action(seeCh.3).
Oneofthemostcancerspecificgenescodesforanendogenouscaspaseinhibitor,survivin.
Thisoccursinhighconcentrationsincertaintumoursandasmallmoleculesuppressorof
survivinisinclinicaltrial( Giaccone&Rajan,2009),theobjectivebeingtoinducecancercell
suicide.
Inhibitingapoptosismightpreventortreatawiderangeofcommondegenerativedisorders.
Unfortunately,successindevelopingsuchinhibitorsforclinicalusehassofarprovedelusiveanda
numberhavebeenfoundtolackefficacyinclinicaltrials.Currentareasofinterestincludethe
following:
BlockingthePD1deathreceptorwithatargetedantibodyisapotentiallyfruitfulnewavenue
toexploreforthetreatmentofHIV,hepatitisBandhepatitisCinfections,aswellasother
chronicinfectionsandsomecancersthatexpresstheligandforPD1(Williams&Bevan,2006).
Severalcaspaseinhibitorsareunderinvestigationfortreatingmyocardialinfarction,stroke,

liverdisease,organtransplantationandsepsis.Emricasanisonesuchcandidateundergoing
trialsinpatientsrequiringlivertransplants.

AngiogenesisandMetalloproteinases
ThesearchforclinicallyusefulantiangiogenicdrugsandMMPinhibitorsiscontinuing,buthasnot
sofarbeensuccessful.Atpresent,onlyonenewdrughasbeenapprovedforuseincancertreatment:
bevacizumab,amonoclonalantibodythatneutralisesVEGF,whichisalsousedtotreatagerelated
maculardegeneration,adiseasealsoassociatedwithexcessiveproliferationofretinalbloodvessels.

CellCycleRegulation
Themainendogenouspositiveregulatorsofthecellcyclearethecdks.Severalsmallmoleculesthat
inhibitcdksbytargetingtheATPbindingsitesofthesekinaseshavebeendevelopedanexampleis
flavopiridol,currentlyinclinicaltrials,whichinhibitsallthecdks,causingarrestofthecellcycle
italsopromotesapoptosis,hasantiangiogenicpropertiesandcaninducedifferentiation(
Dickson&Schwartz,2009).

Somecompoundsaffectupstreampathwaysforcdkactivationandmayfindauseincancer
treatment.Examplesareperifosine(althoughitsfutureisuncertainatthemoment)and
lovastatin(acholesterolloweringdrug,seeCh.23,whichmayalsohaveanticancerproperties).
Bortezomib,aboronatecompound,covalentlybindstheproteasome,inhibitingthedegradationof
proapoptoticproteins.Itisusedintreatingmultiplemyeloma(seeCh.56).
Ofthevariouscomponentsofthegrowthfactorsignallingpathway,receptortyrosinekinases,the
Rasproteinandcytoplasmickinaseshavebeenthesubjectsofmostinterest.Kinaseinhibitors
recentlyintroducedforcancertreatmentincludeimatinib,gefitinibanderlotinib(seeCh.56).

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