Reciprocal positive regulation between Cx26 and PI3K/Akt pathway confers acquired gefitinib resistance in NSCLC cells via GJIC-independent induction of EMT

Gefitinib efficiency in non-small-cell lung cancer (NSCLC) therapy is limited due to development of drug resistance. The molecular mechanisms of gefitinib resistance remain still unclear. In this study, we first found that connexin 26 (Cx26) is the predominant Cx isoform expressed in various NSCLC cell lines. Then, two gefitinib-resistant (GR) NSCLC cell lines, HCC827 GR and PC9 GR, from their parental cells were established. In these GR cells, the results showed that gefitinib resistance correlated with changes in cellular EMT phenotypes and upregulation of Cx26. Cx26 was detected to be accumulated in the cytoplasm and failed to establish functional gap-junctional intercellular communication (GJIC) either in GR cells or their parental cells. Ectopic expression of GJIC-deficient chimeric Cx26 was sufficient to induce EMT and gefitinib insensitivity in HCC827 and PC9 cells, while knockdown of Cx26 reversed EMT and gefitinib resistance in their GR cells both in vitro and in vivo. Furthermore, Cx26 overexpression could activate PI3K/Akt signaling in these cells. Cx26-mediated EMT and gefitinib resistance were significantly blocked by inhibition of PI3K/Akt pathway. Specifically, inhibition of the constitutive activation of PI3K/Akt pathway substantially suppressed Cx26 expression, and Cx26 was confirmed to functionally interplay with PI3K/Akt signaling to promote EMT and gefitinib resistance in NSCLC cells. In conclusion, the reciprocal positive regulation between Cx26 and PI3K/Akt signaling contributes to acquired gefitinib resistance in NSCLC cells by promoting EMT via a GJIC-independent manner.Lung cancer, of which non-small-cell lung cancer (NSCLC) is the most common form, remains the leading cause of cancer-related deaths worldwide.¹ Currently, gefitinib, as the first epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), is one of the most accepted therapies against NSCLC carrying EGFR mutations. However, almost all NSCLC patients who initially respond well to EGFR-TKIs eventually develop acquired resistance.² Development of effective therapeutic interventions to overcome gefitinib resistance is an urgent need.Epithelial-mesenchymal transition (EMT), during which cancer cells lose epithelial markers such as E-cadherin but gain mesenchymal markers such as vimentin, is known to be deeply involved in cancer progression and chemotherapy resistance. Specially in NSCLC, EMT plays pivotal roles in the acquired resistance to EGFR-TKIs such as gefitinib.^{3, 4} For example, restoring E-cadherin expression or silencing EMT regulator Slug increases gefitinib sensitivity in NSCLC cells with a mesenchymal phenotype.^{5, 6} Accumulating evidences indicate that constitutively activation of the phosphoinositide 3-kinase (PI3K)/Akt signaling is a central feature of EMT in many cancers including NSCLC.^{7, 8} However, the exact mechanism for the acquired gefitinib resistance of NSCLC remains unclear.Connexins (Cxs) are a family of transmembrane proteins, which compose the intercellular gap junctions between the neighboring cells.⁹ Gap junctions directly connect the cytoplasms of adjacent cells, thereby mediating direct exchange of signaling molecules smaller than 1 kDa, such as ions, small metabolites, and second messengers. This process is termed gap-junctional intercellular communication (GJIC). Cx expression and/or GJIC are frequently reduced or loss in malignant cell lines and cancers, while restoration of Cx expression and/or GJIC retarded tumor growth and increased cytotoxicities of chemotherapeutics such as cisplatin and docetaxel.^{10, 11, 12, 13} Therefore, Cxs have long been deemed tumor suppressors. However, increasing new observations were apparently contradicting the ''dogma'' and became clear that Cxs and GJIC also contribute to cancer progression and chemoresistance. For example, Cx32 expression was detected in breast cancer and significantly increased in lymph node metastases compared with primary tumors, suggesting Cx32 may be a sign of more malignant phenotype of breast cancer.¹⁴ Besides, cytoplasmic accumulation of Cx32 exerted favorable effects for hepatocellular carcinoma (HCC) progression including invasion and metastasis by Cx linked, but GJIC-independent mechanism.¹⁵ Recently, Gielen et al.¹⁶ reported that increasing the level of Cx43 confers temozolomide resistance in human glioma cells whereas knockdown of Cx43 sensitizes them to temozolomide treatment via both GJIC-dependent and -independent mechanisms.Up to now, there are ~21 isoforms of Cxs that distribute in almost all human organs in tissue-specific patterns.¹⁷ Cx26, one of the most common isoforms of Cxs, is predominantly expressed in lung tissue.^{18, 19} Despite Cx26 has been considered as a potential tumor suppressor or chemotherapy sensitizer in some types of tumors,^{20, 21} Ito et al.²² found that Cx26 helps lung squamous cell carcinoma (SCC, one histological type of NSCLC), acquire aggressive phenotypes, lymph node metastasis, and poor prognosis, indicating that a potential role of Cx26 on the malignant development of SCC. However, the roles of Cx26 and its derived GJIC in the development of gefitinib resistance in NSCLC have not been explored.In this study, to clarify the potential role of Cx26 and its derived GJIC in gefitinib resistance in NSCLC, we first surveyed the expression of four major Cxs in different gefitinib-sensitive NSCLC cell lines and found a positive correlation between high level of Cx26 and gefitinib insensitivity in NSCLC cells. Such an association was further confirmed in established gefitinib-resistant (GR) HCC827 and PC9 cell lines both in vitro and in vivo. Importantly, we find a positive mutual regulation between Cx26 and PI3K/Akt pathway, which confers acquired gefitinib resistance in NSCLC cells by GJIC-independent induction of EMT.