Elimination of quiescent/slow-proliferating cancer stem cells by Bcl-XL inhibition in non-small cell lung cancer

Lung cancer is the most common cause of cancer-related mortality worldwide, urging the discovery of novel molecular targets and therapeutic strategies. Stem cells have been recently isolated from non-small cell lung cancer (NSCLC), thus allowing the investigation of molecular pathways specifically active in the tumorigenic population. We have found that Bcl-X_L is constantly expressed by lung cancer stem cells (LCSCs) and has a prominent role in regulating LCSC survival. Whereas chemotherapeutic agents were scarcely effective against LCSC, the small molecule Bcl-2/Bcl-X_L inhibitor ABT-737, but not the selective Bcl-2 inhibitor ABT-199, induced LCSC death at nanomolar concentrations. Differently from gemcitabine, which preferentially eliminated proliferating LCSC, ABT-737 had an increased cytotoxic activity in vitro towards quiescent/slow-proliferating LCSC, which expressed high levels of Bcl-X_L. In vivo, ABT-737 as a single agent was able to inhibit the growth of LCSC-derived xenografts and to reduce cancer stem cell content in treated tumors. Altogether, these results indicate that quiescent/slow-proliferating LCSC strongly depend on Bcl-X_L for their survival and indicate Bcl-X_L inhibition as a potential therapeutic avenue in NSCLC.Lung cancer is the leading cause of cancer-related death in men and is expected to become the main cause of cancer death for women in the near future.^{1, 2} There is increasing evidence that cancer stem cells (CSCs) have a key role in drug resistance, tumor progression and metastasis in multiple tumor types, including lung cancer.³ Lung cancer stem cells (LCSCs) have been previously identified through different criteria including surface expression of CD133, c-kit or through functional properties such as selective drug survival, elevated aldehyde dehydrogenase (ALDH) activity, increased glycolysis and glycine/serine metabolism or low concentrations of reactive oxygen species and ATP.^{4, 5, 6, 7, 8, 9} Importantly, when inoculated into immunocompromised mice, LCSCs give rise to xenografts that histologically reproduce the tumor of origin, thus representing an improved model for in vivo testing of new targeted therapies.¹⁰ Several tumors express elevated levels of anti-apoptotic Bcl-2 family proteins such as Bcl-2, Bcl-X_L and Mcl-1, which affect the apoptotic threshold of neoplastic cells contributing to chemotherapy resistance.¹¹ Inhibition of anti-apoptotic Bcl-2 family members has been for long time regarded as a promising strategy to induce cancer cell death through approaches of increasing specificity. BH3 mimetics such as ABT-737, the related orally available ABT-263 (navitoclax) and the recently developed Bcl-2-selective inhibitor ABT-199 have been shown to exert an antitumor effect in preclinical and clinical settings either as single agents or in combination with conventional or targeted drugs.¹² Recently, a new role for Bcl-2 has emerged in acute myeloid leukemia (AML), where quiescent stem cells characterized by low levels of reactive oxygen species were found to overexpress Bcl-2 and rely on this factor for survival.¹³ Similarly, in chronic myeloid leukemia (CML), quiescent therapy-resistant stem cells were sensitized to tyrosine kinase inhibitors by treatment with a pan-Bcl-2 inhibitor.¹⁴ In solid tumors, the role of Bcl-2 family members in regulating the stem cell compartment is less clear. By analyzing the expression and relative function of Bcl-2 and Bcl-X_L in LCSC, we identified a prevalent role of Bcl-X_L in LCSC survival. Differently from chemotherapy, ABT-737 showed a preferential cytotoxic activity towards quiescent/slowly proliferating LCSC in vitro indicating a potential use of this inhibitor to eradicate chemotherapy-resistant LCSC. In vivo, ABT-737 blocked the progression of LCSC-derived xenografts and reduced CSC content, substantiating its specific effect on the CSC compartment. Altogether, these results indicate for the first time a key role of Bcl-X_L in LCSC, opening new perspectives for the elimination of therapy-resistant cells.