Pheochromocytomas (PHEOs) and paragangliomas (PGLs) are rare, neuroendocrine tumors derived from adrenal or extra-adrenal chromaffin cells, respectively. Metastases are discovered in 3-36% of patients at the time of diagnosis. Currently, only suboptimal treatment options exist. Therefore, new therapeutic compounds targeting metastatic PHEOs/PGLs are urgently needed. Here, we investigated if anthracyclines were able to suppress the progression of metastatic PHEO. We explored their effects on experimental mouse PHEO tumor cells using in vitro and in vivo models, and demonstrated that anthracyclines, particularly idarubicin (IDA), suppressed hypoxia signaling by preventing the binding of hypoxia-inducible factor 1 and 2 (HIF-1 and HIF-2) to the hypoxia response element (HRE) sites on DNA. This resulted in reduced transcriptional activation of HIF target genes, including erythropoietin (EPO), phosphoglycerate kinase 1 (PGK1), endothelin 1 (EDN1), glucose transporter 1 (GLUT1), lactate dehydrogenase A (LDHA), and vascular endothelial growth factor (VEGFA), which consequently inhibited the growth of metastatic PHEO. Additionally, IDA downregulated hypoxia signaling by interfering with the transcriptional activation of HIF1A and HIF2A. Furthermore, our animal model demonstrated the dose-dependent suppressive effect of IDA on metastatic PHEO growth in vivo. Our results indicate that anthracyclines are prospective candidates for inclusion in metastatic PHEO/PGL therapy, especially in patients with gene mutations involved in the hypoxia signaling pathway.

Department of Internal Medicine 3 Nephrology Rheumatology and Endocrinology Faculty of Medicine and Dentistry Palacky University Olomouc Czech Republic

Department of Molecular Medicine Institute of Virology Biomedical Research Center Slovak Academy of Sciences Bratislava Slovak Republic

McKusick Nathans Institute of Genetic Medicine and Institute for Cell Engineering Johns Hopkins University School of Medicine Baltimore Maryland USA

Neuro Oncology Branch Center for Cancer Research National Cancer Institute Bethesda Maryland USA

Section on Medical Neuroendocrinology Eunice Kennedy Shriver National Institute of Child Health and Human Development National Institutes of Health Bethesda Maryland USA

Surgical Neurology Branch National Institute of Neurological Disorders and Stroke National Institutes of Health Bethesda Maryland USA

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Pacak K, Del Rivero J. Pheochromocytoma. In: De Groot L.J., Feingold K.F, editors. Endotext, South Dartmouth, MA: MDText.com, Inc.; 2013.

Kantorovich V, Koch CA, Pacak K. In: Pheochromocytoma and Paraganglioma. De Groot L.J., Feingold K.F, editors. Endotext, South Dartmouth, MA: MD Text.com, Inc.; 2015.

Averbuch SD, Steakley CS, Young RC, Gelmann EP, Goldstein DS, Stull R, Keiser HR. Malignant pheochromocytoma: effective treatment with a combination of cyclophosphamide, vincristine, and dacarbazine. Ann Intern Med. 1988;109:267–73. PubMed

Tanabe A, Naruse M, Nomura K, Tsuiki M, Tsumagari A, Ichihara A. Combination chemotherapy with cyclophosphamide, vincristine, and dacarbazine in patients with malignant pheochromocytoma and paraganglioma. Horm Cancer. 2013;4:103–10. doi: 10.1007/s12672-013-0133-2. PubMed DOI PMC

Harris AL. Hypoxia—a key regulatory factor in tumour growth. Nat Rev Cancer. 2002;2:38–47. doi: 10.1038/nrc704. PubMed DOI

Hockel M, Vaupel P. Tumor hypoxia: definitions and current clinical, biologic, and molecular aspects. J Natl Cancer Inst. 2001;93:266–76. doi: 10.1093/jnci/93.4.266. PubMed DOI

Brown JM. Tumor hypoxia in cancer therapy. Methods Enzymol. 2007;435:297–321. doi: 10.1016/s0076-6879(07)35015-5. PubMed DOI

Kumar V, Gabrilovich DI. Hypoxia-inducible factors in regulation of immune responses in tumour microenvironment. Immunology. 2014;143:512–9. doi: 10.1111/imm.12380. PubMed DOI PMC

Amelio I, Melino G. The p53 family and the hypoxia-inducible factors (HIFs): determinants of cancer progression. Trends Biochem Sci. 2015;40:425–34. doi: 10.1016/j.tibs.2015.04.007. PubMed DOI

Semenza GL. The hypoxic tumor microenvironment: A driving force for breast cancer progression. Biochim Biophys Acta. 2016;1863:382–91. doi: 10.1016/j.bbamcr.2015.05.036. PubMed DOI PMC

Rankin EB, Giaccia AJ. Hypoxic control of metastasis. Science. 2016;352:175–80. doi: 10.1126/science.aaf4405. PubMed DOI PMC

Semenza GL. Oxygen sensing, hypoxia-inducible factors, and disease pathophysiology. Annu Rev Pathol. 2014;9:47–71. doi: 10.1146/annurev-pathol-012513-104720. PubMed DOI

Holmquist-Mengelbier L, Fredlund E, Lofstedt T, Noguera R, Navarro S, Nilsson H, Pietras A, Vallon-Christersson J, Borg A, Gradin K, Poellinger L, Pahlman S. Recruitment of HIF-1alpha and HIF-2alpha to common target genes is differentially regulated in neuroblastoma: HIF-2alpha promotes an aggressive phenotype. Cancer Cell. 2006;10:413–23. doi: 10.1016/j.ccr.2006.08.026. PubMed DOI

Jochmanova I, Zelinka T, Widimsky J, Jr, Pacak K. HIF signaling pathway in pheochromocytoma and other neuroendocrine tumors. Physiol Res. 2014;63(Suppl 2):S251–62. PubMed

Toledo RA, Qin Y, Srikantan S, Morales NP, Li Q, Deng Y, Kim SW, Pereira MA, Toledo SP, Su X, Aguiar RC, Dahia PL. In vivo and in vitro oncogenic effects of HIF2A mutations in pheochromocytomas and paragangliomas. Endocr Relat Cancer. 2013;20:349–59. doi: 10.1530/erc-13-0101. PubMed DOI PMC

Zhuang Z, Yang C, Lorenzo F, Merino M, Fojo T, Kebebew E, Popovic V, Stratakis CA, Prchal JT, Pacak K. Somatic HIF2A gain-of-function mutations in paraganglioma with polycythemia. N Engl J Med. 2012;367:922–30. doi: 10.1056/NEJMoa1205119. PubMed DOI PMC

Yang C, Sun MG, Matro J, Huynh TT, Rahimpour S, Prchal JT, Lechan R, Lonser R, Pacak K, Zhuang Z. Novel HIF2A mutations disrupt oxygen sensing, leading to polycythemia, paragangliomas, and somatostatinomas. Blood. 2013;121:2563–6. doi: 10.1182/blood-2012-10-460972. PubMed DOI PMC

Keith B, Johnson RS, Simon MC. HIF1alpha and HIF2alpha: sibling rivalry in hypoxic tumour growth and progression. Nat Rev Cancer. 2012;12:9–22. doi: 10.1038/nrc3183. PubMed DOI PMC

Lee K, Qian DZ, Rey S, Wei H, Liu JO, Semenza GL. Anthracycline chemotherapy inhibits HIF-1 transcriptional activity and tumor-induced mobilization of circulating angiogenic cells. Proc Natl Acad Sci U S A. 2009;106:2353–8. doi: 10.1073/pnas.0812801106. PubMed DOI PMC

Yamazaki Y, Hasebe Y, Egawa K, Nose K, Kunimoto S, Ikeda D. Anthracyclines, small-molecule inhibitors of hypoxia-inducible factor-1 alpha activation. Biol Pharm Bull. 2006;29:1999–2003. PubMed

Kaklamani VG, Gradishar WJ. Epirubicin versus doxorubicin: which is the anthracycline of choice for the treatment of breast cancer? Clin Breast Cancer. 2003;4(Suppl 1):S26–33. PubMed

Plosker GL, Epirubicin. Faulds D. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in cancer chemotherapy. Drugs. 1993;45:788–856. PubMed

Nakane M, Takahashi S, Sekine I, Fukui I, Koizumi M, Kage K, Ito Y, Aiba K, Horikoshi N, Hatake K, Ishikawa Y, Ogata E. Successful treatment of malignant pheochromocytoma with combination chemotherapy containing anthracycline. Ann Oncol. 2003;14:1449–51. PubMed

Yang C, Zhuang Z, Fliedner SM, Shankavaram U, Sun MG, Bullova P, Zhu R, Elkahloun AG, Kourlas PJ, Merino M, Kebebew E, Pacak K. Germ-line PHD1 and PHD2 mutations detected in patients with pheochromocytoma/paraganglioma-polycythemia. J Mol Med (Berl) 2015;93:93–104. doi: 10.1007/s00109-014-1205-7. PubMed DOI

Dahia PL, Ross KN, Wright ME, Hayashida CY, Santagata S, Barontini M, Kung AL, Sanso G, Powers JF, Tischler AS, Hodin R, Heitritter S, Moore F, et al. A HIF1alpha regulatory loop links hypoxia and mitochondrial signals in pheochromocytomas. PLoS Genet. 2005;1:72–80. doi: 10.1371/journal.pgen.0010008. PubMed DOI PMC

Semenza GL. Regulation of vascularization by hypoxia-inducible factor 1. Ann N Y Acad Sci. 2009;1177:2–8. doi: 10.1111/j.1749-6632.2009.05032.x. PubMed DOI

Dal Ben D, Palumbo M, Zagotto G, Capranico G, Moro S. DNA topoisomerase II structures and anthracycline activity: insights into ternary complex formation. Curr Pharm Des. 2007;13:2766–80. PubMed

Inge TH, Harris NL, Wu J, Azizkhan RG, Priebe W. WP744 is a novel anthracycline with enhanced activity against neuroblastoma. J Surg Res. 2004;121:187–96. doi: 10.1016/j.jss.2004.03.027. PubMed DOI

Lorenz K, Brauckhoff M, Behrmann C, Sekulla C, Ukkat J, Brauckhoff K, Gimm O, Dralle H. Selective arterial chemoembolization for hepatic metastases from medullary thyroid carcinoma. Surgery. 2005;138:986–93. doi: 10.1016/j.surg.2005.09.020. discussion 93. PubMed DOI

Kumar P, Bryant T, Breen D, Stedman B, Hacking N. Transarterial embolization and doxorubicin eluting beads-transarterial chemoembolization (DEB-TACE) of malignant extra-adrenal pheochromocytoma. Cardiovasc Intervent Radiol. 2011;34:1325–9. doi: 10.1007/s00270-011-0137-7. PubMed DOI

Semenza GL. Involvement of hypoxia-inducible factor 1 in human cancer. Intern Med. 2002;41:79–83. PubMed

Safran M, Kim WY, O'Connell F, Flippin L, Gunzler V, Horner JW, Depinho RA, Kaelin WG., Jr Mouse model for noninvasive imaging of HIF prolyl hydroxylase activity: assessment of an oral agent that stimulates erythropoietin production. Proc Natl Acad Sci U S A. 2006;103:105–10. doi: 10.1073/pnas.0509459103. PubMed DOI PMC

Bishop T, Ratcliffe PJ. HIF hydroxylase pathways in cardiovascular physiology and medicine. Circ Res. 2015;117:65–79. doi: 10.1161/circresaha.117.305109. PubMed DOI PMC

Semenza GL. HIF-1 and tumor progression: pathophysiology and therapeutics. Trends Mol Med. 2002;8:S62–7. PubMed

Welsh SJ, Powis G. Hypoxia inducible factor as a cancer drug target. Curr Cancer Drug Targets. 2003;3:391–405. PubMed

Brouwers FM, Petricoin EF, 3rd, Ksinantova L, Breza J, Rajapakse V, Ross S, Johann D, Mannelli M, Shulkin BL, Kvetnansky R, Eisenhofer G, Walther MM, Hitt BA, et al. Low molecular weight proteomic information distinguishes metastatic from benign pheochromocytoma. Endocr Relat Cancer. 2005;12:263–72. doi: 10.1677/erc.1.00913. PubMed DOI

Favier J, Gimenez-Roqueplo AP. Pheochromocytomas: the (pseudo)-hypoxia hypothesis. Best Pract Res Clin Endocrinol Metab. 2010;24:957–68. doi: 10.1016/j.beem.2010.10.004. PubMed DOI

Lorenzo FR, Yang C, Tang Ng, Fui M, Vankayalapati H, Zhuang Z, Huynh T, Grossmann M, Pacak K, Prchal JT. A novel EPAS1/HIF2A germline mutation in a congenital polycythemia with paraganglioma. J Mol Med (Berl) 2013;91:507–12. doi: 10.1007/s00109-012-0967-z. PubMed DOI PMC

Comino-Mendez I, de Cubas AA, Bernal C, Alvarez-Escola C, Sanchez-Malo C, Ramirez-Tortosa CL, Pedrinaci S, Rapizzi E, Ercolino T, Bernini G, Bacca A, Leton R, Pita G, et al. Tumoral EPAS1 (HIF2A) mutations explain sporadic pheochromocytoma and paraganglioma in the absence of erythrocytosis. Hum Mol Genet. 2013;22:2169–76. doi: 10.1093/hmg/ddt069. PubMed DOI

Tanaka T, Yamaguchi J, Shoji K, Nangaku M. Anthracycline inhibits recruitment of hypoxia-inducible transcription factors and suppresses tumor cell migration and cardiac angiogenic response in the host. J Biol Chem. 2012;287:34866–82. doi: 10.1074/jbc.M112.374587. PubMed DOI PMC

Weiss RB, Sarosy G, Clagett-Carr K, Russo M, Leyland-Jones B. Anthracycline analogs: the past, present, and future. Cancer Chemother Pharmacol. 1986;18:185–97. PubMed

Liu Y, Chen F, Wang S, Guo X, Shi P, Wang W, Xu B. Low-dose triptolide in combination with idarubicin induces apoptosis in AML leukemic stem-like KG1a cell line by modulation of the intrinsic and extrinsic factors. Cell Death Dis. 2013;4:e948. doi: 10.1038/cddis.2013.467. PubMed DOI PMC

Shaul P, Frenkel M, Goldstein EB, Mittelman L, Grunwald A, Ebenstein Y, Tsarfaty I, Fridman M. The structure of anthracycline derivatives determines their subcellular localization and cytotoxic activity. ACS Med Chem Lett. 2013;4:323–8. doi: 10.1021/ml3002852. PubMed DOI PMC

Sadurska E. Current Views on Anthracycline Cardiotoxicity in Childhood Cancer Survivors. Pediatr Cardiol. 2015;36:1112–9. doi: 10.1007/s00246-015-1176-7. PubMed DOI PMC

Barry E, Alvarez JA, Scully RE, Miller TL, Lipshultz SE. Anthracycline-induced cardiotoxicity: course, pathophysiology, prevention and management. Expert Opin Pharmacother. 2007;8:1039–58. doi: 10.1517/14656566.8.8.1039. PubMed DOI

Barrett-Lee PJ, Dixon JM, Farrell C, Jones A, Leonard R, Murray N, Palmieri C, Plummer CJ, Stanley A, Verrill MW. Expert opinion on the use of anthracyclines in patients with advanced breast cancer at cardiac risk. Ann Oncol. 2009;20:816–27. doi: 10.1093/annonc/mdn728. PubMed DOI

Minotti G, Menna P, Salvatorelli E, Cairo G, Gianni L. Anthracyclines: molecular advances and pharmacologic developments in antitumor activity and cardiotoxicity. Pharmacol Rev. 2004;56:185–229. doi: 10.1124/pr.56.2.6. PubMed DOI

Fliedner SM, Yang C, Thompson E, Abu-Asab M, Hsu CM, Lampert G, Eiden L, Tischler AS, Wesley R, Zhuang Z, Lehnert H, Pacak K. Potential therapeutic target for malignant paragangliomas: ATP synthase on the surface of paraganglioma cells. Am J Cancer Res. 2015;5:1558–70. PubMed PMC

Giubellino A, Shankavaram U, Bullova P, Schovanek J, Zhang Y, Shen M, Patel N, Elkahloun A, Lee MJ, Trepel J, Ferrer M, Pacak K. High-throughput screening for the identification of new therapeutic options for metastatic pheochromocytoma and paraganglioma. PLoS One. 2014;9:e90458. doi: 10.1371/journal.pone.0090458. PubMed DOI PMC

Reactive Oxygen Species: A Promising Therapeutic Target for SDHx-Mutated Pheochromocytoma and Paraganglioma

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