**Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms**

Emanuela Urso and Michele Maffia

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/55423

#### **1. Introduction**

#### **1.1. Copper and carcinogenesis, a double-edged sword**

Copper is a trace metal essential to the catalysis of a wide range of enzymatic activities, including those involved in the process of energy production (cytochrome c oxidase), the cell response to oxidant injuries (Cu,Zn-superoxide dismutase), the catecholamine (dopamine βmonooxygenase) and melanin (tyrosinase) production, the remodelling of extracellular matrix (lysyl oxidase), blood clotting processes (Factors V and VIII) and iron metabolism (ceruloplas‐ min and hephaestin) [1]. The catalytic properties of copper are linked to its ability to easily assume the oxidized (Cu2+) and reduced (Cu+ ) states, but just the metal reactive behaviour can trigger severe cell alterations through the generation of hydroxyl radicals in Fenton-like reactions [2,3]. When the cytosolic copper concentration is above the optimal level, the newly formed reactive oxygen species (ROS) rapidly bind to DNA, thus inducing the breaking of the nucleic acid strands and initiating a series of cascade events that can lead to significant damage to cell structures and function [4].

Considerable intrinsic oxidative stress and enhanced serum and tissue copper levels depict a disease condition that often accompanies the progression of several tumour forms, in turn resulting from a perturbed energy metabolism, mitochondrial dysfunction, release of cyto‐ kines and inflammation [5]. Copper is intimately involved in all these cell functions, thus targeting the elevated copper levels would be an ideal therapeutic strategy to effectively counteract the tumour development [5].

This issue is anyway highly debated. In fact, the topical delivery of copper complexes to tumour tissues has been demonstrated to kill the cancer cells through a "therapeutic" induction of oxidative stress [6]. At the same time, especially in the case of solid tumours, as *neuroblas‐*

© 2013 Urso and Maffia; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*toma*, copper is directly involved in the spread of the primary tumour, mainly through the stimulation of tumour angiogenesis [6]. It follows that targeting the tumour copper content to limit the cancer aggressiveness requires a comprehensive knowledge of the cell metal man‐ agement under the disease state. Here, the multifaceted contribution of copper to the patho‐ physiology of neuroblastoma will be dissected, with special attention paid to the regulation of membrane copper transporters and their role in sustaining the cancer spread. To make the reader familiar with the main copper transport systems in mammalian cells, a short description has been provided in Box 1.

**i.** cancer energy metabolism

before discussing the pathological topics.

**physiopathological implications**

the ion metabolic disruption a cause or an effect?

in the tumour spread.

blastoma models.

tion.

adaptive strategy aimed at restoring the standard copper status [23].

Copper transport systems are gaining growing importance in the studies about the various aspects of the metal role in neuroblastoma, so the peculiar expression pattern will be described

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

267

Copper critically regulates the degree of neuroblastoma growth and microvascularization, which determines the tumour aggressive phenotype [19,20]. The importance of this metal is emphasized by the strong presence of specific transport proteins in neuroblastoma cells, that testifies to a lively management of tumour copper stores. Highly variegated mechanisms of regulation of copper homeostasis have been specifically reported for neuroblastoma (some of them reviewed here), that make it difficult to establish the nature of copper involvement: is

*Copper import.* It is widely believed that copper import in neuroblastoma cells is mediated by hCtr1 [21]. However, recent work from our laboratory in an *in vitro* neuroblastoma cell model has enlightened a role for the cellular prion protein PrPC in mediating the high affinity copper intake, upon normal metal availability [22]. In addition, we demonstrated that copper shortness induces an up-regulation of PrPC expression in a neuroblastoma cell model, a cell

In support of its involvement in tumorigenesis, the PrPC expression is up-regulated in nervous tissues affected by hypoxia, a condition typically occurring during the growth of a solid tumour [24]. The reader is referred to paragraphs 4.2 and 6.2 for a detailed account of the PrPC functions

*Copper efflux.* The ATP7A copper ATPase (full length 170 KDa protein) is strongly expressed by neuroblastoma cell lines [21,23] and subjected to an articulated copper-dependent regula‐

In many cell types this efflux pump delivers copper to the secretory compartments and, when copper should accumulate inside the cytosol, it traffics toward the cell periphery to export the ion excess [25]. However, peculiar regulative mechanisms have been documented in neuro‐

In fact, it has been demonstrated in the M17 neuroblastoma cell line that fluctuating copper levels (excess/starvation) in the cell microenvironment can favour the interaction of ATP7A proteins with clusterins (apolipoprotein J), the last ones targeting the pumps toward degra‐ dation through the lysosomal pathway [26]. This copper-regulated clusterin function may have multiple implications, if we consider that a recent study on neuroblastoma cell lines, mouse

**3. Copper transport systems in neuroblastoma cells: Regulation and**

**ii.** tumour vascularization

#### **2. Neuroblastoma and Copper: A complex relationship**

Neuroblastoma is the most common pediatric extra-cranial neoplasm [7], whose malignant form accounts for about a 50% of cancer mortality in chemoradiotherapy-treated subjects [8]. The aggressiveness of advanced-staged neuroblastomas is notoriously associated with the N*myc* oncogene amplification, which translates in a strong expression of a pleiotropic transcrip‐ tion factor, responsible for the rich tumour vasculature, the metastatic behaviour, and the chemotherapy resistance [9-11]. Thus, N-*myc* overexpression is a well-known adverse prog‐ nostic factor [12]. Interestingly, the degree of N-*myc* oncogene amplification in neuroblastoma cells has been put in relation to the trace metal cell content (iron, copper, zinc) in both cultured neuroblasts and murine xenografts [13-15]. In particular, the number of N-*myc* oncogene copies has been demonstrated to proportionally correlate with the neuroblastoma copper content. This finding, together with evidences from the literature, lets us suppose that copper accu‐ mulation strictly determines the neuroblastoma invasiveness. Plausible mechanisms under‐ lining the copper dependence of neuroblastoma metastasis are both direct/specific, and mediated by the metal-induced accumulation of ROS.

Referring to the latter category of mechanisms, an *in vitro* study in 31 subjects affected by advanced neuroblastoma revealed an elevated activation of specific tissue matrix metallo proteinases (MMP-2 isoform) and the reduced expression of their specific inhibitors (TIMP-2) [16], that can be associated with copper-induced oxidative stress [17]. In this regard, we observe that metallo proteinases are secreted by tumour cells and facilitate the cancer dissemination by the degradation of the extracellular matrix.

The high copper levels detected in neuroblastoma can at least partly confer a growth advantage to the tumour cells by metal specific pathways. Significantly, copper acts as a cofactor for the cytochrome c oxidase enzyme that allows the conversion of cytosolic ferric ion into the ferrous form, subsequently incorporated into ferritin, the most important iron storage protein. Ironcomplexed ferritin is then secreted by cancer cells, so enriching the serum protein pool. The importance of this copper/iron antagonism is evident if we consider that neuroblastoma patients with high ferritin levels undergo a bad prognosis [18].

Given the complexity of the copper-neuroblastoma relationship, in order to guide the reader through the text, we observe that the lines of copper intervention in neuroblastoma progression can be substantially subdivided as follows:


*toma*, copper is directly involved in the spread of the primary tumour, mainly through the stimulation of tumour angiogenesis [6]. It follows that targeting the tumour copper content to limit the cancer aggressiveness requires a comprehensive knowledge of the cell metal man‐ agement under the disease state. Here, the multifaceted contribution of copper to the patho‐ physiology of neuroblastoma will be dissected, with special attention paid to the regulation of membrane copper transporters and their role in sustaining the cancer spread. To make the reader familiar with the main copper transport systems in mammalian cells, a short description

Neuroblastoma is the most common pediatric extra-cranial neoplasm [7], whose malignant form accounts for about a 50% of cancer mortality in chemoradiotherapy-treated subjects [8]. The aggressiveness of advanced-staged neuroblastomas is notoriously associated with the N*myc* oncogene amplification, which translates in a strong expression of a pleiotropic transcrip‐ tion factor, responsible for the rich tumour vasculature, the metastatic behaviour, and the chemotherapy resistance [9-11]. Thus, N-*myc* overexpression is a well-known adverse prog‐ nostic factor [12]. Interestingly, the degree of N-*myc* oncogene amplification in neuroblastoma cells has been put in relation to the trace metal cell content (iron, copper, zinc) in both cultured neuroblasts and murine xenografts [13-15]. In particular, the number of N-*myc* oncogene copies has been demonstrated to proportionally correlate with the neuroblastoma copper content. This finding, together with evidences from the literature, lets us suppose that copper accu‐ mulation strictly determines the neuroblastoma invasiveness. Plausible mechanisms under‐ lining the copper dependence of neuroblastoma metastasis are both direct/specific, and

Referring to the latter category of mechanisms, an *in vitro* study in 31 subjects affected by advanced neuroblastoma revealed an elevated activation of specific tissue matrix metallo proteinases (MMP-2 isoform) and the reduced expression of their specific inhibitors (TIMP-2) [16], that can be associated with copper-induced oxidative stress [17]. In this regard, we observe that metallo proteinases are secreted by tumour cells and facilitate the cancer dissemination

The high copper levels detected in neuroblastoma can at least partly confer a growth advantage to the tumour cells by metal specific pathways. Significantly, copper acts as a cofactor for the cytochrome c oxidase enzyme that allows the conversion of cytosolic ferric ion into the ferrous form, subsequently incorporated into ferritin, the most important iron storage protein. Ironcomplexed ferritin is then secreted by cancer cells, so enriching the serum protein pool. The importance of this copper/iron antagonism is evident if we consider that neuroblastoma

Given the complexity of the copper-neuroblastoma relationship, in order to guide the reader through the text, we observe that the lines of copper intervention in neuroblastoma progression

**2. Neuroblastoma and Copper: A complex relationship**

mediated by the metal-induced accumulation of ROS.

by the degradation of the extracellular matrix.

can be substantially subdivided as follows:

patients with high ferritin levels undergo a bad prognosis [18].

has been provided in Box 1.

266 Neuroblastoma

Copper transport systems are gaining growing importance in the studies about the various aspects of the metal role in neuroblastoma, so the peculiar expression pattern will be described before discussing the pathological topics.

## **3. Copper transport systems in neuroblastoma cells: Regulation and physiopathological implications**

Copper critically regulates the degree of neuroblastoma growth and microvascularization, which determines the tumour aggressive phenotype [19,20]. The importance of this metal is emphasized by the strong presence of specific transport proteins in neuroblastoma cells, that testifies to a lively management of tumour copper stores. Highly variegated mechanisms of regulation of copper homeostasis have been specifically reported for neuroblastoma (some of them reviewed here), that make it difficult to establish the nature of copper involvement: is the ion metabolic disruption a cause or an effect?

*Copper import.* It is widely believed that copper import in neuroblastoma cells is mediated by hCtr1 [21]. However, recent work from our laboratory in an *in vitro* neuroblastoma cell model has enlightened a role for the cellular prion protein PrPC in mediating the high affinity copper intake, upon normal metal availability [22]. In addition, we demonstrated that copper shortness induces an up-regulation of PrPC expression in a neuroblastoma cell model, a cell adaptive strategy aimed at restoring the standard copper status [23].

In support of its involvement in tumorigenesis, the PrPC expression is up-regulated in nervous tissues affected by hypoxia, a condition typically occurring during the growth of a solid tumour [24]. The reader is referred to paragraphs 4.2 and 6.2 for a detailed account of the PrPC functions in the tumour spread.

*Copper efflux.* The ATP7A copper ATPase (full length 170 KDa protein) is strongly expressed by neuroblastoma cell lines [21,23] and subjected to an articulated copper-dependent regula‐ tion.

In many cell types this efflux pump delivers copper to the secretory compartments and, when copper should accumulate inside the cytosol, it traffics toward the cell periphery to export the ion excess [25]. However, peculiar regulative mechanisms have been documented in neuro‐ blastoma models.

In fact, it has been demonstrated in the M17 neuroblastoma cell line that fluctuating copper levels (excess/starvation) in the cell microenvironment can favour the interaction of ATP7A proteins with clusterins (apolipoprotein J), the last ones targeting the pumps toward degra‐ dation through the lysosomal pathway [26]. This copper-regulated clusterin function may have multiple implications, if we consider that a recent study on neuroblastoma cell lines, mouse models, and human specimens evidenced that this molecular chaperon behaves as a tumour and metastasis suppressor, negatively regulated by N-*myc* in the most aggressive forms [27].

In our opinion, the copper-clusterin link deserves further exploration in the light of the reported elevation in copper neuroblastoma content observed in N-*myc* amplified tumours.

If N-*myc* really down-regulates clusterin (still controversial aspect), one would expect an increase in copper export function and so an overall reduction of the ion cancerogenic action. This evidently contradicts the N-*myc* - tumour malignancy binomial association (where copper should exert a prominent role) and minimizes the contribution of clusterin to the copperdependent tumour progression. In fact, considering that N-*myc* elevates the neuroblastoma copper content, one can suppose that the cytosolic copper lowering due to a down-regulated expression of clusterin is overridden by other cell mechanisms causing the increase of cancer copper levels.

#### Copper uptake

Ctr1 (Copper transporter 1). High-affinity Cu<sup>+</sup> importer, composed of three main domains: an extracellular N-terminal tail containing multiple copper-binding methionine residues; a transmembrane segment consisting of three α-helical regions; an intracellular C-terminal domain. Three subunits assemble to form a homo-trimeric channel (9 Å pore diameter) within the plasma membrane (see [118] for a review).

Ctr2 (Copper transporter 2). Copper permease, whose structure resembles that of Ctr1. Predominantly localized to endosomes and lysosomes, it seems to provide a mechanism of copper recycling from degraded cuproenzymes [119].

PrP<sup>C</sup> (Cellular Prion protein). Endogenous copper-binding glycoprotein, mainly expressed in the central nervous system. The protein structure includes an unstructured N-terminal domain and a Cterminal globular region composed of three α -helices and two short beta-strands. When Cu2+ ions bind to the N-terminal octapeptide repeats (residues 51–90), the protein undergoes endocytosis, that providing a route for cell copper entry [58,59].

#### Cytosolic transport

CCS. Metallo chaperone required for copper delivery to Cu,Zn Superoxide dismutases 1; upregulated in response to copper deficiency [120].

Cox17. Metallo chaperone delivering copper to Sco1 and Cox11 proteins in order to catalyse the cytochrome c oxidase copper loading [121].

Atox1. Metallo chaperone that delivers copper to ATP7A and ATP7B Cu<sup>+</sup> efflux pumps [122].

Metallothioneins. Small cysteine-rich proteins tightly binding copper ions and buffering the ion excess [123].

#### Copper efflux

ATP7A. Cu<sup>+</sup>-transporting P-type ATPase expressed by all cell types, with the exception of liver. Structural features include eight membrane-spanning domains and six N-terminal cysteine-rich metal binding motifs (MXCXXC) [25].

Copper import. It is widely believed that copper import in neuroblastoma cells is mediated by hCtr1 [21]. However, recent work from our laboratory in an in vitro neuroblastoma cell model has

upon normal metal availability [22]. In addition, we demonstrated that copper shortness induces an

tissues affected by hypoxia, a condition typically occurring during the growth of a solid tumour [24].

expression in a neuroblastoma cell model, a cell adaptive strategy aimed at

in mediating the high affinity copper intake,

expression is up-regulated in nervous

3

Coming back to main focus of this paragraph, multiple ATP7A spliced variants can be retrieved in human cells, not necessarily related to disease states, with a cell type-specific expression pattern. The expression of a 11.2 KDa splicing product (103 amino acids) has been reported in SY5Y neuroblastoma cells, harbouring a sequence able to bind copper ions [28]. It has been proposed that such spliced product can work as a copper chaperon to direct the cytosolic

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

269

*Intracellular copper distribution.* Among copper chaperons, the contribution of COMMD1 (Copper Metabolism MURR1 Domain containing 1) to the copper status in neuroblastoma cells is an unexplored issue so far. However, some inputs from the recent scientific literature let us

Endogenous COMMD1 expression has been reported in the SH-SY5Y neuroblastoma cell line, together with the isoform 3. A punctate cytoplasmic distribution, denser in the perinuclear region, has been shown for COMMD1, while COMMD3 appears more diffused [29]. The role of COMMD1 in neuroblastoma progression is potentially articulated on multiple levels of action, even if direct demonstrations are missing and the following dissertation aims at

A role in preventing tumour growth and metastasis has been proposed for COMMD1, based on its ability to repress the NF-KB pathway and the HIF1α/β dimerization and so inhibit the expression of genes involved in tumour angiogenesis [30]. However, as documented in N2a neuroblastoma cell line, upon copper excess, COMMD1 can form a hetero-complex with CCS and SOD1, leading to decreased levels of SOD1 dimers and subsequently reduced anti-oxidant activity [31]. In other words, in the presence of high copper, the COMMD1 cell fate can

COMMD1 is also an interacting partner of ATP7A proteins and, analogously to clusterin, can drive their degradation through a proteasomal pathway [32], this indicating a further contri‐ bution of this chaperon to the neuroblastoma copper content. However, knowledge about

The COMMD1 involvement in determining the neuroblastoma copper condition is strictly linked to the protein XIAP (X-linked inhibitor of apoptosis). XIAP protective action is due to the prevention of the activation of a subset of cell death proteases (caspases 3, 7 and 9) [33,34],

During the last decade, a role for XIAP in controlling the cell copper homeostasis has been described [36]. In fact, the overexpression of XIAP protein (not transcript) selectively reported in chemotherapy-resistant neuroblastomas, but no other tissues [37], may indicate the occurrence of a particular copper status. XIAP is a copper-binding protein that, in the olo-form, favours the ubiquitination and degradation of COMMD1, that in turn interacts with ATP7A to support copper excretion [36]. Where overexpressed, it is reasonable to presume a subse‐ quent consistent reduction of COMMD1 cytosolic protein levels, and so an increase of the

enlightening some aspects of copper-dependent regulation of the protein fate.

copper toward the nuclear compartment.

potentially assume a negative connotation.

and inhibiton of Fas- [35] and Bax-induced apoptosis [33].

these aspects is still limited.

cellular copper content.

hypothesize an involvement.

**Box 1.** Main proteins involved in cell copper homeostasis

restoring the standard copper status [23].

up-regulation of PrP<sup>C</sup>

enlightened a role for the cellular prion protein PrP<sup>C</sup>

In support of its involvement in tumorigenesis, the PrP<sup>C</sup>

Coming back to main focus of this paragraph, multiple ATP7A spliced variants can be retrieved in human cells, not necessarily related to disease states, with a cell type-specific expression pattern. The expression of a 11.2 KDa splicing product (103 amino acids) has been reported in SY5Y neuroblastoma cells, harbouring a sequence able to bind copper ions [28]. It has been proposed that such spliced product can work as a copper chaperon to direct the cytosolic copper toward the nuclear compartment.

models, and human specimens evidenced that this molecular chaperon behaves as a tumour and metastasis suppressor, negatively regulated by N-*myc* in the most aggressive forms [27].

In our opinion, the copper-clusterin link deserves further exploration in the light of the reported elevation in copper neuroblastoma content observed in N-*myc* amplified tumours.

If N-*myc* really down-regulates clusterin (still controversial aspect), one would expect an increase in copper export function and so an overall reduction of the ion cancerogenic action. This evidently contradicts the N-*myc* - tumour malignancy binomial association (where copper should exert a prominent role) and minimizes the contribution of clusterin to the copperdependent tumour progression. In fact, considering that N-*myc* elevates the neuroblastoma copper content, one can suppose that the cytosolic copper lowering due to a down-regulated expression of clusterin is overridden by other cell mechanisms causing the increase of cancer

> Ctr1 (Copper transporter 1). High-affinity Cu<sup>+</sup> importer, composed of three main domains: an extracellular N-terminal tail containing multiple copper-binding methionine residues; a transmembrane segment consisting of three α-helical regions; an intracellular C-terminal domain. Three subunits assemble to form a homo-trimeric channel (9 Å pore diameter) within the plasma

> Ctr2 (Copper transporter 2). Copper permease, whose structure resembles that of Ctr1. Predominantly localized to endosomes and lysosomes, it seems to provide a mechanism of copper

> PrP<sup>C</sup> (Cellular Prion protein). Endogenous copper-binding glycoprotein, mainly expressed in the central nervous system. The protein structure includes an unstructured N-terminal domain and a Cterminal globular region composed of three α -helices and two short beta-strands. When Cu2+ ions bind to the N-terminal octapeptide repeats (residues 51–90), the protein undergoes endocytosis, that

> CCS. Metallo chaperone required for copper delivery to Cu,Zn Superoxide dismutases 1; up-

Cox17. Metallo chaperone delivering copper to Sco1 and Cox11 proteins in order to catalyse the

Atox1. Metallo chaperone that delivers copper to ATP7A and ATP7B Cu<sup>+</sup> efflux pumps [122]. Metallothioneins. Small cysteine-rich proteins tightly binding copper ions and buffering the ion

Copper import. It is widely believed that copper import in neuroblastoma cells is mediated by hCtr1 [21]. However, recent work from our laboratory in an in vitro neuroblastoma cell model has

ATP7A. Cu<sup>+</sup>-transporting P-type ATPase expressed by all cell types, with the exception of liver. Structural features include eight membrane-spanning domains and six N-terminal cysteine-rich

upon normal metal availability [22]. In addition, we demonstrated that copper shortness induces an

tissues affected by hypoxia, a condition typically occurring during the growth of a solid tumour [24].

expression in a neuroblastoma cell model, a cell adaptive strategy aimed at

in mediating the high affinity copper intake,

expression is up-regulated in nervous

enlightened a role for the cellular prion protein PrP<sup>C</sup>

In support of its involvement in tumorigenesis, the PrP<sup>C</sup>

restoring the standard copper status [23].

metal binding motifs (MXCXXC) [25].

**Box 1.** Main proteins involved in cell copper homeostasis

up-regulation of PrP<sup>C</sup>

3

copper levels.

268 Neuroblastoma

Copper uptake

Cytosolic transport

excess [123].

Copper efflux

membrane (see [118] for a review).

recycling from degraded cuproenzymes [119].

providing a route for cell copper entry [58,59].

regulated in response to copper deficiency [120].

cytochrome c oxidase copper loading [121].

*Intracellular copper distribution.* Among copper chaperons, the contribution of COMMD1 (Copper Metabolism MURR1 Domain containing 1) to the copper status in neuroblastoma cells is an unexplored issue so far. However, some inputs from the recent scientific literature let us hypothesize an involvement.

Endogenous COMMD1 expression has been reported in the SH-SY5Y neuroblastoma cell line, together with the isoform 3. A punctate cytoplasmic distribution, denser in the perinuclear region, has been shown for COMMD1, while COMMD3 appears more diffused [29]. The role of COMMD1 in neuroblastoma progression is potentially articulated on multiple levels of action, even if direct demonstrations are missing and the following dissertation aims at enlightening some aspects of copper-dependent regulation of the protein fate.

A role in preventing tumour growth and metastasis has been proposed for COMMD1, based on its ability to repress the NF-KB pathway and the HIF1α/β dimerization and so inhibit the expression of genes involved in tumour angiogenesis [30]. However, as documented in N2a neuroblastoma cell line, upon copper excess, COMMD1 can form a hetero-complex with CCS and SOD1, leading to decreased levels of SOD1 dimers and subsequently reduced anti-oxidant activity [31]. In other words, in the presence of high copper, the COMMD1 cell fate can potentially assume a negative connotation.

COMMD1 is also an interacting partner of ATP7A proteins and, analogously to clusterin, can drive their degradation through a proteasomal pathway [32], this indicating a further contri‐ bution of this chaperon to the neuroblastoma copper content. However, knowledge about these aspects is still limited.

The COMMD1 involvement in determining the neuroblastoma copper condition is strictly linked to the protein XIAP (X-linked inhibitor of apoptosis). XIAP protective action is due to the prevention of the activation of a subset of cell death proteases (caspases 3, 7 and 9) [33,34], and inhibiton of Fas- [35] and Bax-induced apoptosis [33].

During the last decade, a role for XIAP in controlling the cell copper homeostasis has been described [36]. In fact, the overexpression of XIAP protein (not transcript) selectively reported in chemotherapy-resistant neuroblastomas, but no other tissues [37], may indicate the occurrence of a particular copper status. XIAP is a copper-binding protein that, in the olo-form, favours the ubiquitination and degradation of COMMD1, that in turn interacts with ATP7A to support copper excretion [36]. Where overexpressed, it is reasonable to presume a subse‐ quent consistent reduction of COMMD1 cytosolic protein levels, and so an increase of the cellular copper content.

However, the binding of copper to XIAP negatively impacts the protein stability, so a negative feedback exists [38]. In the case of chemotherapy-resistant neuroblastomas, the protein overex‐ pression probably overcomes the effects deriving from copper-driven XIAP inactivation.

Cu2+ ions determine the structural stabilization of the HIF-1α subunit (oxygen-sensitive) through the inhibition of prolyl-4-hydroxilases, which allow the subsequent ubiquitination

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

271

Interestingly, by this way Cu2+ indirectly promotes the synthesis of ceruloplasmin, a plasma and liquor copper chaperon with a ferroxidase activity, whose expression is typically under HIF-1 control [48]. Being ceruloplasmin a major copper vehicle, such mechanism can be interpreted as cancer "self-nourishing". It must be added that HIF-1 target genes also include VEGF (Vascular Endothelial Growth Factor), a recognized chemotactic and mitogen factor [49], and VEGFR-1 (VEGF Receptor-1) [50], both involved in the positive regulation of the sprouting

Further, White et al. (2009) demonstrated that the up-regulation of the hypoxia inducible factor HIF-1α causes the selective distribution of copper ions to the secretory pathway. They observed in tumour-associated macrophages that the hypoxic stress can influence the intra‐ cellular distribution of copper ions, determining an increased ion entry through the high

All these experimental evidences underline the prominent role of copper in sustaining the HIF-1α-dependent adaptation to hypoxia in N-*myc* amplified neuroblastomas, as well as the

HIF-2α, but not HIF-1α, has been shown to be highly expressed in neuroblastoma vascularized areas, and this pattern seems to be associated with an unfavourable patient outcome, due to the occurrence of distal metastasis [41]. In addition, a small subset of neuroblastoma cells strongly HIF-2α-positive has been described, which could represent the cancer stem cells [52]. To our knowledge, no precise data are available about the copper-dependent activity/ activation of HIF-2α, however some molecular evidences collected in other cell models

As an example, Menkes copper ATPase (Atp7a) gene expression has been demonstrated to be strongly induced by HIF-2α in mammalian intestine [53]. HIF-2α has been also demonstrated to induce the expression of DMT1 and Ctr1 (by about 25%) copper importers in human intestinal cells, so determining a parallel increase (fivefold) in the processes of cellular copper uptake [54].

These findings confirm that, independently on the involvement of HIF-1α or HIF-2α, tumour hypoxia activates a series of processes functional to distribute copper toward the secretory pathway (enzyme-complexed) or make it available in the extracellular medium. Here, copper may function as a signalling molecule and sustain the angiogenic processes, essential to the

The scientific literature also suggests that the HIF-2α prolonged response to hypoxia can be alternatively mediated by a high affinity copper-binding protein, namely the cellular prion protein PrPC [55] (Box 1). Accordingly, the PrPC expression degree is elevated in hypoxic

affinity channel Ctr1 and then an elevated efflux through the ATP7A pump [51].

hypoxia-stimulated activation of copper transport activities.

strongly point at a potential existence of such a link.

and degradation of such factor [47].

of blood vessels within the primary tumour.

**4.2. HIF-2α**

neuroblastoma growth.

Preclinical evidences of the importance of XIAP as a target to treat neuroblastoma have been recently collected, all based on the lowering of the threshold for the induction of apoptosis through the depression of XIAP expression. The use of Thymoquinone, a bioactive compound from *nigella sativa*, has been shown to selectively down-regulate XIAP in neuroblastoma cells, but not in normal neuronal cells, with an expected higher copper efflux [39]. Smac (Second mitochondria-derived activator of caspase) mimetics (e.g. LBW242) have been reported to sensitize chemotherapy resistant and XIAP-overexpressing neuroblastomas, by favouring the degradation of XIAP and TNF-α expression [37].

#### **4. Copper-dependence of neuroblastoma metabolic changes**

The oxygen partial pressure within a solid tumour ranges from 5-10 mmHg in highly vascu‐ larized regions to absence (anoxia) around the necrotic areas [40,41]. Most cancer cells tend to adapt to the intra-tumour hypoxic microenvironment by activating a pro-survival signalling, a pro-angiogenic pattern of gene expression and through the metabolic switching from the oxidative phosphorylation to the glycolytic pathways (Warburg effect) [42].

Currently, there is not a homogeneous view on the causative events, but two major factors are usually indicated as responsible, the Hypoxia-Inducible Factors 1 and 2 (HIF1,2), and p53 transcription factor.

HIF1 and 2 are heterodimeric basic helix-loop-helix-PAS domain transcription factors, composed of a constitutively expressed β subunit and a α regulatory subunit (HIF1α/2α), whose expression is induced by hypoxia, cancer-associated mutations, or inflammatory cytokines [43,44].

HIF-1α and HIF-2α are major actors in the cell adaptive response to hypoxic conditions and control the expression of distinct, but functionally converging genes [45]. Each cell type exhibits a peculiar profile of HIF-1α and 2α expression and their functions may also differ. In the case of *neuroblastoma*, at a careful analysis of the expression pattern, tumour stage, and copper status, it can be observed that copper heavily influences the response to hypoxia and that the tumour progression and the evolution of copper metabolism go hand in hand.

#### **4.1. HIF-1α**

HIF-1α, but not HIF-2α, is preferentially expressed and up-regulated by moderate hypoxia in N-*myc* amplified neuroblastoma cell lines and primary tumours, correlating with a poor prognosis [41,46]. In the light of the linear increase of copper neuroblastoma levels with the degree of N-*myc* gene amplification and the proven role of Cu2+ ions in stabilizing the structure of the HIF-1α subunit [47], it can be deduced that copper plays in key role in inducing the neuroblastoma metabolic changes.

Cu2+ ions determine the structural stabilization of the HIF-1α subunit (oxygen-sensitive) through the inhibition of prolyl-4-hydroxilases, which allow the subsequent ubiquitination and degradation of such factor [47].

Interestingly, by this way Cu2+ indirectly promotes the synthesis of ceruloplasmin, a plasma and liquor copper chaperon with a ferroxidase activity, whose expression is typically under HIF-1 control [48]. Being ceruloplasmin a major copper vehicle, such mechanism can be interpreted as cancer "self-nourishing". It must be added that HIF-1 target genes also include VEGF (Vascular Endothelial Growth Factor), a recognized chemotactic and mitogen factor [49], and VEGFR-1 (VEGF Receptor-1) [50], both involved in the positive regulation of the sprouting of blood vessels within the primary tumour.

Further, White et al. (2009) demonstrated that the up-regulation of the hypoxia inducible factor HIF-1α causes the selective distribution of copper ions to the secretory pathway. They observed in tumour-associated macrophages that the hypoxic stress can influence the intra‐ cellular distribution of copper ions, determining an increased ion entry through the high affinity channel Ctr1 and then an elevated efflux through the ATP7A pump [51].

All these experimental evidences underline the prominent role of copper in sustaining the HIF-1α-dependent adaptation to hypoxia in N-*myc* amplified neuroblastomas, as well as the hypoxia-stimulated activation of copper transport activities.

#### **4.2. HIF-2α**

However, the binding of copper to XIAP negatively impacts the protein stability, so a negative feedback exists [38]. In the case of chemotherapy-resistant neuroblastomas, the protein overex‐ pression probably overcomes the effects deriving from copper-driven XIAP inactivation.

Preclinical evidences of the importance of XIAP as a target to treat neuroblastoma have been recently collected, all based on the lowering of the threshold for the induction of apoptosis through the depression of XIAP expression. The use of Thymoquinone, a bioactive compound from *nigella sativa*, has been shown to selectively down-regulate XIAP in neuroblastoma cells, but not in normal neuronal cells, with an expected higher copper efflux [39]. Smac (Second mitochondria-derived activator of caspase) mimetics (e.g. LBW242) have been reported to sensitize chemotherapy resistant and XIAP-overexpressing neuroblastomas, by favouring the

The oxygen partial pressure within a solid tumour ranges from 5-10 mmHg in highly vascu‐ larized regions to absence (anoxia) around the necrotic areas [40,41]. Most cancer cells tend to adapt to the intra-tumour hypoxic microenvironment by activating a pro-survival signalling, a pro-angiogenic pattern of gene expression and through the metabolic switching from the

Currently, there is not a homogeneous view on the causative events, but two major factors are usually indicated as responsible, the Hypoxia-Inducible Factors 1 and 2 (HIF1,2), and p53

HIF1 and 2 are heterodimeric basic helix-loop-helix-PAS domain transcription factors, composed of a constitutively expressed β subunit and a α regulatory subunit (HIF1α/2α), whose expression is induced by hypoxia, cancer-associated mutations, or inflammatory

HIF-1α and HIF-2α are major actors in the cell adaptive response to hypoxic conditions and control the expression of distinct, but functionally converging genes [45]. Each cell type exhibits a peculiar profile of HIF-1α and 2α expression and their functions may also differ. In the case of *neuroblastoma*, at a careful analysis of the expression pattern, tumour stage, and copper status, it can be observed that copper heavily influences the response to hypoxia and that the tumour progression and the evolution of copper metabolism go hand in hand.

HIF-1α, but not HIF-2α, is preferentially expressed and up-regulated by moderate hypoxia in N-*myc* amplified neuroblastoma cell lines and primary tumours, correlating with a poor prognosis [41,46]. In the light of the linear increase of copper neuroblastoma levels with the degree of N-*myc* gene amplification and the proven role of Cu2+ ions in stabilizing the structure of the HIF-1α subunit [47], it can be deduced that copper plays in key role in inducing the

**4. Copper-dependence of neuroblastoma metabolic changes**

oxidative phosphorylation to the glycolytic pathways (Warburg effect) [42].

degradation of XIAP and TNF-α expression [37].

transcription factor.

270 Neuroblastoma

cytokines [43,44].

**4.1. HIF-1α**

neuroblastoma metabolic changes.

HIF-2α, but not HIF-1α, has been shown to be highly expressed in neuroblastoma vascularized areas, and this pattern seems to be associated with an unfavourable patient outcome, due to the occurrence of distal metastasis [41]. In addition, a small subset of neuroblastoma cells strongly HIF-2α-positive has been described, which could represent the cancer stem cells [52]. To our knowledge, no precise data are available about the copper-dependent activity/ activation of HIF-2α, however some molecular evidences collected in other cell models strongly point at a potential existence of such a link.

As an example, Menkes copper ATPase (Atp7a) gene expression has been demonstrated to be strongly induced by HIF-2α in mammalian intestine [53]. HIF-2α has been also demonstrated to induce the expression of DMT1 and Ctr1 (by about 25%) copper importers in human intestinal cells, so determining a parallel increase (fivefold) in the processes of cellular copper uptake [54].

These findings confirm that, independently on the involvement of HIF-1α or HIF-2α, tumour hypoxia activates a series of processes functional to distribute copper toward the secretory pathway (enzyme-complexed) or make it available in the extracellular medium. Here, copper may function as a signalling molecule and sustain the angiogenic processes, essential to the neuroblastoma growth.

The scientific literature also suggests that the HIF-2α prolonged response to hypoxia can be alternatively mediated by a high affinity copper-binding protein, namely the cellular prion protein PrPC [55] (Box 1). Accordingly, the PrPC expression degree is elevated in hypoxic nervous tissues [56], and its overexpression has been shown to confer a highly invasive phenotype to tumour cells [55,57].

**5. Copper promotes the neuroblastoma survival and growth by sustaining**

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

273

Cutting copper supply can represent a valuable therapeutic strategy for neuroblastoma, as the induced mitochondrial impairment and oxidative stress can make neuroblastoma cells vulnerable. Accordingly, even under unstressed environment, mitochondria in this cell type exhibit a high rate of protein oxidation, this indicating a consistent susceptibility to the oxidative injury [68,69]. The positive connotation of a drop in the neuroblastoma cell copper content has been demonstrated and emphasized by a rich literature showing that copper chelation (triethylene tetramine tetrahydrochloride) can effectively promote the apoptosis of

Here follow some argumentations from the literature around the negative impact of copper starvation on neuroblastoma cell survival, extrapolated from *in vitro* preclinical studies.

SH-SY5Y neuroblastoma cells have been widely used as a model to dissect the molecular basis

In particular, the continuous exposure (up to three passages) of SH-SY5Y neuroblastoma cells to the copper-chelating agent Trien has been demonstrated to induce the expression of antioxidants and a 40% apoptotic cell loss at the end of the third passage [70]. Copper has been shown to be important in keeping a critical level of ATP. In fact, the relevant Cu,Zn SOD and cytochrome c oxidase activities were reduced by, respectively, 80 and 68% [70]. Another report has confirmed these findings, indicating that copper starvation by Trien impairs the antioxi‐ dant defences of neuroblastoma cells, with obvious implications with respect to the therapeutic

Arciello et al. (2011) further characterized the effects of Trien treatment in SH-SY5Y neuroblasto‐ ma cells [72]. SOD1 (cuproenzyme) expression decline was associated with a reduction of the enzymeactivity,mainlyduetocoppershortnessratherthantoadecreasedproteinexpression.In fact, copper replenishment was able to reactivate the apo-form of the enzyme, in agreement with previous observations [73]. Copper depletion also favoured the entrance of the SOD1 apo-form (not metallated) into the mitochondria [72], where it was retained due to a partial unfolded and obviouslyinactiveconfiguration.TheauthorsalsoobservedanincreasedexpressionofCCS(Box

It the light of these findings, it can be observed that the neuroblastoma commitment to the apoptotic death was not due to an irreversible mitochondrial damage, even considering that the loss of the mitochondria-associated SOD1 was much less evident than observed for the cytosolic one [72]. However, it is plausible that the absence of copper prevented SOD1 from counteracting the oxidative-mediated damage to mitochondrial proteins [74]. Accordingly, it has been shown that brain tissues exhibit a SOD1 localization inside the mitochondrial matrix

In our laboratory we analysed the anti-oxidant response to copper starvation in a rat neuro‐ blastoma model (B104), investigating in parallel the expression of copper membrane trans‐

**the anti-oxidant enzyme activities**

neuroblastoma cells [70,71].

of the tumour sensitivity to copper.

inhibition of the tumour growth [71].

with an antioxidant function [75].

1), finalized to optimize the copper intracellular distribution [72].

By virtue of a direct involvement of PrPC in the cell copper import [22,58,59], an elevated protein expression under hypoxia could represent a cancer cell strategy to assure the neuro‐ blastoma growth through the enhanced copper intake [23]. In fact, copper stimulates neuro‐ blastoma cell proliferation [60].

Interestingly, although it has been demonstrated that the up-regulation of PrPC in human colorectal carcinoma cells induces the glucose transporter-1 (Glut-1) expression and a subse‐ quent increase in the glycolytic rate via Fyn-HIF-2α pathway [55], the transfection of a plasmid expressing wild-type HIF-2α in N-*myc* amplified neuroblastoma cells has been demonstrated to be marginally involved in the regulation of glycolytic genes [46]. Surprisingly, notwith‐ standing a rise in Glut-1 expression, the glucose influx was not increased [46].

Conclusively, to reinforce the concept of an autonomous cancerogenic role of copper, it can be observed that elevated HIF levels have been observed even under normoxic conditions, meaning that other factors than hypoxia, e.g. copper, can sustain the aerobic glycolysis and induce the expression of HIF-targeted genes.

#### **4.3. p53**

p53 transcription factor is a key tumour suppressor protein, whose functions contribute to prevent cancer progression. Mutated p53 gene products or defects in the integration of proteins with which p53 is connected, are associated with the malignant progression of the majority of human tumours [61]. Neuroblastoma rarely shows mutated p53 at diagnosis, thus therapies result effective at first. However, gene mutations, p53 cytosolic sequestration, or deregulated p53/MDM2 (ubiquitin protein ligase -E3- for p53) pathways have been reported during neuroblastoma relapses or therapies, thus conferring high-level multidrug resistance [62-65].

Loss of p53 function seems to impair the efficiency of mitochondrial respiration by hampering the insertion of copper ions as cofactors into the cytochrome c oxidase enzymatic complex [66]. That would cause the switching from cell respiration to *aerobic glycolysis* (Warburg effect), typical metabolic change observed in cancer cells.

In detail, p53 directly regulates the expression of the SCO2 (Synthesis of Cytochrome c Oxidase) gene, coding for a protein that facilitates the copper delivery to the subunit II of cytochrome c oxidase, determining the assembly of the enzymatic complex [66].

As suggested in [67], given the essential role of copper in determining the Warburg effect in cancer cells, it cannot be excluded that deregulated p53 pathways may affect the expression or function of other proteins involved in cell copper acquisition and utilization.

## **5. Copper promotes the neuroblastoma survival and growth by sustaining the anti-oxidant enzyme activities**

nervous tissues [56], and its overexpression has been shown to confer a highly invasive

By virtue of a direct involvement of PrPC in the cell copper import [22,58,59], an elevated protein expression under hypoxia could represent a cancer cell strategy to assure the neuro‐ blastoma growth through the enhanced copper intake [23]. In fact, copper stimulates neuro‐

Interestingly, although it has been demonstrated that the up-regulation of PrPC in human colorectal carcinoma cells induces the glucose transporter-1 (Glut-1) expression and a subse‐ quent increase in the glycolytic rate via Fyn-HIF-2α pathway [55], the transfection of a plasmid expressing wild-type HIF-2α in N-*myc* amplified neuroblastoma cells has been demonstrated to be marginally involved in the regulation of glycolytic genes [46]. Surprisingly, notwith‐

Conclusively, to reinforce the concept of an autonomous cancerogenic role of copper, it can be observed that elevated HIF levels have been observed even under normoxic conditions, meaning that other factors than hypoxia, e.g. copper, can sustain the aerobic glycolysis and

p53 transcription factor is a key tumour suppressor protein, whose functions contribute to prevent cancer progression. Mutated p53 gene products or defects in the integration of proteins with which p53 is connected, are associated with the malignant progression of the majority of human tumours [61]. Neuroblastoma rarely shows mutated p53 at diagnosis, thus therapies result effective at first. However, gene mutations, p53 cytosolic sequestration, or deregulated p53/MDM2 (ubiquitin protein ligase -E3- for p53) pathways have been reported during neuroblastoma relapses or therapies, thus conferring high-level multidrug resistance [62-65].

Loss of p53 function seems to impair the efficiency of mitochondrial respiration by hampering the insertion of copper ions as cofactors into the cytochrome c oxidase enzymatic complex [66]. That would cause the switching from cell respiration to *aerobic glycolysis* (Warburg effect),

In detail, p53 directly regulates the expression of the SCO2 (Synthesis of Cytochrome c Oxidase) gene, coding for a protein that facilitates the copper delivery to the subunit II of

As suggested in [67], given the essential role of copper in determining the Warburg effect in cancer cells, it cannot be excluded that deregulated p53 pathways may affect the expression

cytochrome c oxidase, determining the assembly of the enzymatic complex [66].

or function of other proteins involved in cell copper acquisition and utilization.

standing a rise in Glut-1 expression, the glucose influx was not increased [46].

phenotype to tumour cells [55,57].

blastoma cell proliferation [60].

induce the expression of HIF-targeted genes.

typical metabolic change observed in cancer cells.

**4.3. p53**

272 Neuroblastoma

Cutting copper supply can represent a valuable therapeutic strategy for neuroblastoma, as the induced mitochondrial impairment and oxidative stress can make neuroblastoma cells vulnerable. Accordingly, even under unstressed environment, mitochondria in this cell type exhibit a high rate of protein oxidation, this indicating a consistent susceptibility to the oxidative injury [68,69]. The positive connotation of a drop in the neuroblastoma cell copper content has been demonstrated and emphasized by a rich literature showing that copper chelation (triethylene tetramine tetrahydrochloride) can effectively promote the apoptosis of neuroblastoma cells [70,71].

Here follow some argumentations from the literature around the negative impact of copper starvation on neuroblastoma cell survival, extrapolated from *in vitro* preclinical studies.

SH-SY5Y neuroblastoma cells have been widely used as a model to dissect the molecular basis of the tumour sensitivity to copper.

In particular, the continuous exposure (up to three passages) of SH-SY5Y neuroblastoma cells to the copper-chelating agent Trien has been demonstrated to induce the expression of antioxidants and a 40% apoptotic cell loss at the end of the third passage [70]. Copper has been shown to be important in keeping a critical level of ATP. In fact, the relevant Cu,Zn SOD and cytochrome c oxidase activities were reduced by, respectively, 80 and 68% [70]. Another report has confirmed these findings, indicating that copper starvation by Trien impairs the antioxi‐ dant defences of neuroblastoma cells, with obvious implications with respect to the therapeutic inhibition of the tumour growth [71].

Arciello et al. (2011) further characterized the effects of Trien treatment in SH-SY5Y neuroblasto‐ ma cells [72]. SOD1 (cuproenzyme) expression decline was associated with a reduction of the enzymeactivity,mainlyduetocoppershortnessratherthantoadecreasedproteinexpression.In fact, copper replenishment was able to reactivate the apo-form of the enzyme, in agreement with previous observations [73]. Copper depletion also favoured the entrance of the SOD1 apo-form (not metallated) into the mitochondria [72], where it was retained due to a partial unfolded and obviouslyinactiveconfiguration.TheauthorsalsoobservedanincreasedexpressionofCCS(Box 1), finalized to optimize the copper intracellular distribution [72].

It the light of these findings, it can be observed that the neuroblastoma commitment to the apoptotic death was not due to an irreversible mitochondrial damage, even considering that the loss of the mitochondria-associated SOD1 was much less evident than observed for the cytosolic one [72]. However, it is plausible that the absence of copper prevented SOD1 from counteracting the oxidative-mediated damage to mitochondrial proteins [74]. Accordingly, it has been shown that brain tissues exhibit a SOD1 localization inside the mitochondrial matrix with an antioxidant function [75].

In our laboratory we analysed the anti-oxidant response to copper starvation in a rat neuro‐ blastoma model (B104), investigating in parallel the expression of copper membrane trans‐ porters [23]. A significant increase of caspase-3 activity was detected in copper-starved cells, indicating the activation of a cell death program through the induction of oxidative stress. In agreement, the total Cu,Zn SOD activity resulted half-reduced with respect to normal condi‐ tions, as expected in consideration of the role of copper as a cofactor [23]. Interestingly, the cellular prion protein expression in copper-starved neuroblastoma cells was heavily induced. This finding was reconsidered in the light of a rich literature showing that the 64Cu loading and the enzymatic activity of Cu,Zn SOD from the brain of *P-rnp 0/0* mice result 10-50% reduced with respect to the wild-type genotype [76-78].

As an example, the specific binding of copper to angiogenin, a major angiogenic factor, is able to largely increase its efficiency of interaction with endothelial cells [83,84]. This metal is also fundamental for the release of another pro-angiogenic factor involved in angiogenesis, Fibroblast Growth Factor (FGF) 1, as a part of a multiprotein aggregate (FGF1-p40 Syt1-

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

275

If on one hand high copper levels can facilitate the tumour development, on the other the stimulation of copper uptake and egress has been associated with the sprouting of new blood vessels within solid tumours, this depicting a high complex picture. A prominent role of copper

Several experimental evidences point to a crucial role of copper in tumour angiogenesis [86]. Its ability to stimulate the endothelial cell proliferation, migration and sprouting mainly grounds on its role as a powerful inducer/enhancer of the expression of several angiogenic mediators, including VEGF165 and interleukins [82,87], and a stabilizer of the angiogenin interaction with its receptor [83]. Surprisingly, well-characterized pro-angiogenic factors as VEGF165 and bFGF, if administered to microvascular endothelial cell cultures, have been shown to rapidly promote the relocalization of the intracellular copper stores (about 80-90%) toward the cell periphery, where the ion efflux occurs, presumably by the ATP7A transport activity [88]. Such process may result contradictory in the light of the discussed role of copper as a powerful pro-angiogenic mediator. Nevertheless, this mechanism may be considered "cancer self-sustaining", making copper available in the tumour microenvironment (paracrine loop).

In addition, it must be observed that the vascular remodelling and the stimulation of cell migration depend on the activity of copper-dependent secreted enzymes (Lysil Oxidase, LOX),

In support of such hypothesis, a report from Ashino et al. (2010) illustrated how the proangiogenic Platelet Derived Growth Factor (PDGF) determines in vascular smooth muscle cells the translocation of the ATP7A copper transporter from the Trans Golgi Network toward special membrane domains (lipid rafts), where the pump is essential for the correct release of copper bound pro-LOX [89]. The authors also demonstrated that the membrane recruitment of Rac-1, a GTPase involved in the extension of lamellipodia, is dependent on copper and on the expression of the high affinity importer Ctr1 (Copper Transporter 1), this further confirm‐ ing the existence of a solid link between the tumour metastasis and copper homeostasis.

To our knowledge, a few data are reported in the literature around the prion protein role in defining the neuroblastoma aggressiveness. Nevertheless, the substantial expression level observed within the nervous system, which is further elevated by pathological conditions, testifies to a possible involvement of prion protein in the nervous response to cell injuries. In detail, this particular protein may have major implications in modulating the biological

S100A13) [85].

transport systems emerges.

**6.1. Potential role of ATP7A and Ctr1 copper transporters**

so the released metal is probably mostly carried by proteins.

**6.2. Potential role of the cellular prion protein PrPC**

A special attention has been dedicated to the adaptive response actuated by PrPC, that is physiologically and consistently localized on the outer surface of neurons at synapses and gliocytes [79,80]. Under normal conditions, PrPC binds copper ions with high specificity and affinity (femto- to nanomolar range), by the repeated sequences present on its N-terminal region. By virtue of this property and the ability to undergo endocytosis upon copper binding, PrPC is believed to drive the cellular copper intake [22,58,59].

The up-regulation of PrPC upon copper limitation has been interpreted as a compensatory mechanism to re-establish the standard cell copper status through a direct transport activity. It has been also demonstrated to be responsible for the ability of copper-starved cells to almost completely recover the SOD enzyme function upon re-exposure to standard growth condi‐ tions. The authors conclusively demonstrated that the PrPC neuroprotective action in neuro‐ blastoma cells is due to its ability to translocate copper ions into the cytosol. Here, they can act as cofactors in Cu,Zn SOD activation [23].

## **6. Critical role of copper transporters in neuroblastoma vascularization and spread**

Most pro-angiogenic factors implicated in neuroblastoma progression need copper to properly work or exert their own functions by activating copper-dependent pathways and enzymes.

The best known pro-angiogenic mediator, namely the Vascular Endothelial Growth Factor (VEGF), has been demonstrated to be overexpressed in high-risk neuroblastomas at the time of diagnosis and to be a bad prognostic marker [81]. The elevated copper levels detected in malignant neuroblastoma are expected to heavily sustain the VEGF tumour angiogenesis, since this metal is a potent inducer of VEGF expression and reinforces the stimulating effect exerted by hydrogen peroxide [82].

The growth of neuroblastoma is anyway sustained by multiple pro-angiogenic factors other than VEGF [10], including Platelet Derived Growth Factor-A (PDGF-A), Fibroblast Growth Factor-2 (FGF-2), and Angiopoietin-2 (Ang-2), as documented in 22 neuroblastoma cell lines and 37 tumour samples [10]. Many among these factors share an intimate relationship with copper, known to variously enhance their angiogenic action through direct (physical interac‐ tion) or indirect (expression/release) ways.

As an example, the specific binding of copper to angiogenin, a major angiogenic factor, is able to largely increase its efficiency of interaction with endothelial cells [83,84]. This metal is also fundamental for the release of another pro-angiogenic factor involved in angiogenesis, Fibroblast Growth Factor (FGF) 1, as a part of a multiprotein aggregate (FGF1-p40 Syt1- S100A13) [85].

If on one hand high copper levels can facilitate the tumour development, on the other the stimulation of copper uptake and egress has been associated with the sprouting of new blood vessels within solid tumours, this depicting a high complex picture. A prominent role of copper transport systems emerges.

#### **6.1. Potential role of ATP7A and Ctr1 copper transporters**

porters [23]. A significant increase of caspase-3 activity was detected in copper-starved cells, indicating the activation of a cell death program through the induction of oxidative stress. In agreement, the total Cu,Zn SOD activity resulted half-reduced with respect to normal condi‐ tions, as expected in consideration of the role of copper as a cofactor [23]. Interestingly, the cellular prion protein expression in copper-starved neuroblastoma cells was heavily induced. This finding was reconsidered in the light of a rich literature showing that the 64Cu loading and the enzymatic activity of Cu,Zn SOD from the brain of *P-rnp 0/0* mice result 10-50% reduced

A special attention has been dedicated to the adaptive response actuated by PrPC, that is physiologically and consistently localized on the outer surface of neurons at synapses and gliocytes [79,80]. Under normal conditions, PrPC binds copper ions with high specificity and affinity (femto- to nanomolar range), by the repeated sequences present on its N-terminal region. By virtue of this property and the ability to undergo endocytosis upon copper binding,

The up-regulation of PrPC upon copper limitation has been interpreted as a compensatory mechanism to re-establish the standard cell copper status through a direct transport activity. It has been also demonstrated to be responsible for the ability of copper-starved cells to almost completely recover the SOD enzyme function upon re-exposure to standard growth condi‐ tions. The authors conclusively demonstrated that the PrPC neuroprotective action in neuro‐ blastoma cells is due to its ability to translocate copper ions into the cytosol. Here, they can act

**6. Critical role of copper transporters in neuroblastoma vascularization and**

Most pro-angiogenic factors implicated in neuroblastoma progression need copper to properly work or exert their own functions by activating copper-dependent pathways and enzymes.

The best known pro-angiogenic mediator, namely the Vascular Endothelial Growth Factor (VEGF), has been demonstrated to be overexpressed in high-risk neuroblastomas at the time of diagnosis and to be a bad prognostic marker [81]. The elevated copper levels detected in malignant neuroblastoma are expected to heavily sustain the VEGF tumour angiogenesis, since this metal is a potent inducer of VEGF expression and reinforces the stimulating effect

The growth of neuroblastoma is anyway sustained by multiple pro-angiogenic factors other than VEGF [10], including Platelet Derived Growth Factor-A (PDGF-A), Fibroblast Growth Factor-2 (FGF-2), and Angiopoietin-2 (Ang-2), as documented in 22 neuroblastoma cell lines and 37 tumour samples [10]. Many among these factors share an intimate relationship with copper, known to variously enhance their angiogenic action through direct (physical interac‐

with respect to the wild-type genotype [76-78].

as cofactors in Cu,Zn SOD activation [23].

exerted by hydrogen peroxide [82].

tion) or indirect (expression/release) ways.

**spread**

274 Neuroblastoma

PrPC is believed to drive the cellular copper intake [22,58,59].

Several experimental evidences point to a crucial role of copper in tumour angiogenesis [86]. Its ability to stimulate the endothelial cell proliferation, migration and sprouting mainly grounds on its role as a powerful inducer/enhancer of the expression of several angiogenic mediators, including VEGF165 and interleukins [82,87], and a stabilizer of the angiogenin interaction with its receptor [83]. Surprisingly, well-characterized pro-angiogenic factors as VEGF165 and bFGF, if administered to microvascular endothelial cell cultures, have been shown to rapidly promote the relocalization of the intracellular copper stores (about 80-90%) toward the cell periphery, where the ion efflux occurs, presumably by the ATP7A transport activity [88]. Such process may result contradictory in the light of the discussed role of copper as a powerful pro-angiogenic mediator. Nevertheless, this mechanism may be considered "cancer self-sustaining", making copper available in the tumour microenvironment (paracrine loop).

In addition, it must be observed that the vascular remodelling and the stimulation of cell migration depend on the activity of copper-dependent secreted enzymes (Lysil Oxidase, LOX), so the released metal is probably mostly carried by proteins.

In support of such hypothesis, a report from Ashino et al. (2010) illustrated how the proangiogenic Platelet Derived Growth Factor (PDGF) determines in vascular smooth muscle cells the translocation of the ATP7A copper transporter from the Trans Golgi Network toward special membrane domains (lipid rafts), where the pump is essential for the correct release of copper bound pro-LOX [89]. The authors also demonstrated that the membrane recruitment of Rac-1, a GTPase involved in the extension of lamellipodia, is dependent on copper and on the expression of the high affinity importer Ctr1 (Copper Transporter 1), this further confirm‐ ing the existence of a solid link between the tumour metastasis and copper homeostasis.

#### **6.2. Potential role of the cellular prion protein PrPC**

To our knowledge, a few data are reported in the literature around the prion protein role in defining the neuroblastoma aggressiveness. Nevertheless, the substantial expression level observed within the nervous system, which is further elevated by pathological conditions, testifies to a possible involvement of prion protein in the nervous response to cell injuries. In detail, this particular protein may have major implications in modulating the biological cascade leading to metastasis in patients with cancer, mainly by virtue of its presumed ability to sustain cell survival and exert a pro-angiogenic action.

that retinoids are able to starve neuroblastoma cells of copper through a significant increase in the ion efflux processes [60]. In fact, the retinoic acid receptor β (RARβ) up-regulates the expression of ATP7A copper efflux pump in BE(2)-C and SH-SY5Y human neuroblastoma cell

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

277

**8. Cell copper transporters modulate the neuroblastoma sensitivity to**

Cisplatin-based chemotherapy is commonly employed for neuroblastoma treatment at an advanced stage [101], but the development of resistance to the drug can affect the therapeutic efficacy. Highly diversified mechanisms have been proposed to explain this behaviour, although a definitive understanding has not been achieved. It has been demonstrated that Cisplatin-resistant neuroblastoma cells undergo an increase in the DNA methyltransferase activities that would depress the transcription of specific and widely undefined genes [102]. In fact, it is known that an acute Cisplatin administration can alter the genome methylation

Increasing evidences point out a central role of (broad substrate spectrum/specific) drug transporters to explain the onset of Cisplatin resistance. In detail, Haber et al. (1999) observed that malignant neuroblastoma forms, carrying the N-*myc* oncogene amplification, show an up regulation of the Multidrug Resistance-associated Protein (MRP) gene, associated with a poor

Interestingly, it has been widely demonstrated that Cisplatin shares with copper the pathways of cellular efflux and entry [105,106]. In particular, the cellular uptake of cisplatin (water soluble) is mediated by a member of the SLC (Solute Carrier) group, namely the copper transporter 1 (SLC31A1) [105-107], by mechanisms that partially overlap with those copperspecific [105,108]. Candidate Cisplatin-binding sequences have been identified in the extrac‐ ellular region of hCtr1, this providing further evidence of the Cisplatin transport activity by

Further, the copper efflux transporters, ATP7A and ATP7B, are known to regulate the efflux

Neuroblastoma cells are known to express both hCtr1 import and ATP7A export proteins, this suggesting that copper transport systems may participate in determining the development of cisplatin resistance. In support of such hypothesis, a recent study on microRNAs expression pattern in variously N-*myc* amplified and cisplatin resistant neuroblastoma cells, led to the identification of eight microRNAs, each one targeting at least one of the two cited copper transporters [111]. Furthermore, it has been demonstrated that ATP7A expression may be a

In the light of these findings, it has been argued that an increased cisplatin sensitivity may arise from the upregulation of Ctr1 transporter or by downregulation of the copper/cisplatin efflux transporter ATP7A. In this sense, a therapeutic regimen combining a preconditioning

of cisplatin, and so their expression may be also predictive of drug sensitivity [110].

models, but not in other cell types.

status in neuroblastoma cells [103].

sensitivity to low affinity substrates, including Cisplatin [104].

target to sensitize cancer cells to Cisplatin [112].

**chemotherapy**

this channel [109].

A modest literature discusses a likely role of prion proteins in influencing the angiogenic processes, given a large disagreement about its actual expression in endothelial cells. In fact, although prion protein has been detected in the capillaries of the intestinal mucosa and kidney [90], normal endothelial cells derived from the umbilical cord and other vessels in the adults do not show detectable prion protein amounts *in vivo* [91]. However, prion protein seems to be up regulated in some pathological circumstances, such as in advanced carotid plaques, in association with the endothelial marker CD105, increasingly expressed in activated endothelia [92], and in brain tissues affected by ischemia [93,94]. By virtue of the latter studies, prion protein could reasonably play a key role in brain tumour progression, being the related gene responsive to the ischemic/hypoxic injury [94]. Accordingly, a neuroprotective action has been described for prion proteins in this context, based on the following evidences: i. prion protein is bound to caveolin-1 and, by recruiting Fyn tyrosine kinase, it can activate the signalling promoting cell survival and angiogenesis events [95]; ii. prion protein co-localizes with the VEGF receptor 2 (KDR), that indicating that prion protein may have a role in VEGF-driven angiogenesis [96].

## **7. Anti-angiogenic therapies target the neuroblastoma copper status: two examples**

#### **7.1. TNP-470**

The administration of angiogenic inhibitors has been introduced as a complement to tradi‐ tional therapies, in order to hinder the tumour spread.

Several anti-angiogenic therapeutics have been incorporated into clinical trials. Among them, in the '90s, TNP-470, an angiogenesis inhibitor, has emerged as a promising adjuvant in dormancy therapies for high-risk neuroblastoma. In particular, its effectiveness in arresting hepatic metastasis of neuroblastoma has been documented in [97] and [98]. In the light of [99], the antiangiogenic activity of TNP-470 is reasonably linked to its interference with the hepatic copper metabolism. In fact, the continuous administration of TNP-470 in both normal and tumourbearing rats has been shown to increase the serum copper levels, as a consequence of a limited hepatic retention [99]. This feature has been associated with a reduced density of hepatic tumour capillaries [99]. Accordingly, when the administration of TNP-470 was interrupted, angiogene‐ sis was activated and at the same time the serum copper levels fell down [99].

#### **7.2. Retinoids target the ATP7A gene expression**

Among the most promising possibilities, retinoids (Vitamin A derivatives) may be of help in arresting the cancer growth and delaying the occurrence of recurrences, because of their proven ability to induce cell differentiation and inhibit the VEGF and FGF-2-induced endo‐ thelial activation [100]. Interestingly, a recent report from Bohlken et al. (2009) demonstrated that retinoids are able to starve neuroblastoma cells of copper through a significant increase in the ion efflux processes [60]. In fact, the retinoic acid receptor β (RARβ) up-regulates the expression of ATP7A copper efflux pump in BE(2)-C and SH-SY5Y human neuroblastoma cell models, but not in other cell types.

cascade leading to metastasis in patients with cancer, mainly by virtue of its presumed ability

A modest literature discusses a likely role of prion proteins in influencing the angiogenic processes, given a large disagreement about its actual expression in endothelial cells. In fact, although prion protein has been detected in the capillaries of the intestinal mucosa and kidney [90], normal endothelial cells derived from the umbilical cord and other vessels in the adults do not show detectable prion protein amounts *in vivo* [91]. However, prion protein seems to be up regulated in some pathological circumstances, such as in advanced carotid plaques, in association with the endothelial marker CD105, increasingly expressed in activated endothelia [92], and in brain tissues affected by ischemia [93,94]. By virtue of the latter studies, prion protein could reasonably play a key role in brain tumour progression, being the related gene responsive to the ischemic/hypoxic injury [94]. Accordingly, a neuroprotective action has been described for prion proteins in this context, based on the following evidences: i. prion protein is bound to caveolin-1 and, by recruiting Fyn tyrosine kinase, it can activate the signalling promoting cell survival and angiogenesis events [95]; ii. prion protein co-localizes with the VEGF receptor 2 (KDR), that indicating that prion protein may have a role in VEGF-driven

**7. Anti-angiogenic therapies target the neuroblastoma copper status: two**

The administration of angiogenic inhibitors has been introduced as a complement to tradi‐

Several anti-angiogenic therapeutics have been incorporated into clinical trials. Among them, in the '90s, TNP-470, an angiogenesis inhibitor, has emerged as a promising adjuvant in dormancy therapies for high-risk neuroblastoma. In particular, its effectiveness in arresting hepatic metastasis of neuroblastoma has been documented in [97] and [98]. In the light of [99], the antiangiogenic activity of TNP-470 is reasonably linked to its interference with the hepatic copper metabolism. In fact, the continuous administration of TNP-470 in both normal and tumourbearing rats has been shown to increase the serum copper levels, as a consequence of a limited hepatic retention [99]. This feature has been associated with a reduced density of hepatic tumour capillaries [99]. Accordingly, when the administration of TNP-470 was interrupted, angiogene‐

Among the most promising possibilities, retinoids (Vitamin A derivatives) may be of help in arresting the cancer growth and delaying the occurrence of recurrences, because of their proven ability to induce cell differentiation and inhibit the VEGF and FGF-2-induced endo‐ thelial activation [100]. Interestingly, a recent report from Bohlken et al. (2009) demonstrated

sis was activated and at the same time the serum copper levels fell down [99].

to sustain cell survival and exert a pro-angiogenic action.

tional therapies, in order to hinder the tumour spread.

**7.2. Retinoids target the ATP7A gene expression**

angiogenesis [96].

**examples**

276 Neuroblastoma

**7.1. TNP-470**

## **8. Cell copper transporters modulate the neuroblastoma sensitivity to chemotherapy**

Cisplatin-based chemotherapy is commonly employed for neuroblastoma treatment at an advanced stage [101], but the development of resistance to the drug can affect the therapeutic efficacy. Highly diversified mechanisms have been proposed to explain this behaviour, although a definitive understanding has not been achieved. It has been demonstrated that Cisplatin-resistant neuroblastoma cells undergo an increase in the DNA methyltransferase activities that would depress the transcription of specific and widely undefined genes [102]. In fact, it is known that an acute Cisplatin administration can alter the genome methylation status in neuroblastoma cells [103].

Increasing evidences point out a central role of (broad substrate spectrum/specific) drug transporters to explain the onset of Cisplatin resistance. In detail, Haber et al. (1999) observed that malignant neuroblastoma forms, carrying the N-*myc* oncogene amplification, show an up regulation of the Multidrug Resistance-associated Protein (MRP) gene, associated with a poor sensitivity to low affinity substrates, including Cisplatin [104].

Interestingly, it has been widely demonstrated that Cisplatin shares with copper the pathways of cellular efflux and entry [105,106]. In particular, the cellular uptake of cisplatin (water soluble) is mediated by a member of the SLC (Solute Carrier) group, namely the copper transporter 1 (SLC31A1) [105-107], by mechanisms that partially overlap with those copperspecific [105,108]. Candidate Cisplatin-binding sequences have been identified in the extrac‐ ellular region of hCtr1, this providing further evidence of the Cisplatin transport activity by this channel [109].

Further, the copper efflux transporters, ATP7A and ATP7B, are known to regulate the efflux of cisplatin, and so their expression may be also predictive of drug sensitivity [110].

Neuroblastoma cells are known to express both hCtr1 import and ATP7A export proteins, this suggesting that copper transport systems may participate in determining the development of cisplatin resistance. In support of such hypothesis, a recent study on microRNAs expression pattern in variously N-*myc* amplified and cisplatin resistant neuroblastoma cells, led to the identification of eight microRNAs, each one targeting at least one of the two cited copper transporters [111]. Furthermore, it has been demonstrated that ATP7A expression may be a target to sensitize cancer cells to Cisplatin [112].

In the light of these findings, it has been argued that an increased cisplatin sensitivity may arise from the upregulation of Ctr1 transporter or by downregulation of the copper/cisplatin efflux transporter ATP7A. In this sense, a therapeutic regimen combining a preconditioning by a copper chelating agent (i.e. Tetrathiomolybdate) and platinum-containing drugs has been proven to enhance the Cisplatin efficacy in a mouse model of cervical cancer, without affecting the integrity of healthy tissues [113].

**Author details**

Lecce, Italy

**References**

Emanuela Urso and Michele Maffia\*

Department of Biological and Environmental Sciences and Technology, University of Salento,

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

279

[1] Tapiero H, Townsend DM, Tew KD. Trace elements in human physiology and path‐

[2] Halliwell B, Gutteridge JM. Oxygen toxicity, oxygen radicals, transition metals and

[3] Halliwell B, Gutteridge JM. Role of free radicals and catalytic metal ions in human

[4] Theophanides T, Anastassopoulou J. Copper and carcinogenesis. Critical reviews in

[5] Gupte A, Mumper RJ. Elevated copper and oxidative stress in cancer cells as a target

[6] Tardito S, Marchiò L. Copper compounds in anticancer strategies. Current Medicinal

[7] Brodeur GM. Neuroblastoma: biological insights into a clinical enigma. Nature Re‐

[8] Matthay KK, Villablanca JG, Seeger RC, Stram DO, Harris RE, Ramsay NK, Swift P, Shimada H, Black CT, Brodeur GM, Gerbing RB, Reynolds CP. Treatment of highrisk neuroblastoma with intensive chemotherapy, radiotherapy, autologous bone marrow transplantation, and 13-cis-retinoic acid. Children's Cancer Group. The New

[9] Shusterman S, Maris JM. Prospects for therapeutic inhibition of neuroblastoma an‐

[10] Eggert A, Ikegaki N, Kwiatkowski J, Zhao H, Brodeur GM, Himelstein BP. High-lev‐ el expression of angiogenic factors is associated with advanced tumor stage in hu‐

[11] Ferrandis E, Da Silva J, Riou G, Bénard I. Coactivation of the MDR1 and MYCN genes in human neuroblastoma cells during the metastatic process in the nude

man neuroblastomas. Clinical Cancer Research 2000;6(5) 1900-1908.

ology. Copper. Biomedicine & Pharmacotherapy 2003;57(9) 386-398.

disease: an overview. Methods in Enzymology 1990;186 1-85.

for cancer treatment. Cancer Treatment Reviews 2009;35(1) 32-46.

England journal of medicine 1999;341(16) 1165-1173.

giogenesis. Cancer Letters 2005;228(1-2) 171-179.

mouse. Cancer Research 1994;54(8) 2256-2261.

diseases. Biochemical Journal 1984;219 1-4.

oncology/hematology 2002;42(1) 57-64.

Chemistry 2009;16(11) 1325-1348.

views. Cancer 2003;3(3) 203-216.

Another copper-dependent mechanism of resistance to cisplatin involves metallothioneins, a family of low molecular weight copper-binding proteins, whose expression is metal-induced in neuroblastoma cell models [114] and elevated in cisplatin-resistant cell lines [115]. When cisplatin enters a cancer cell, it is vulnerable to metallothionein-inactivation [116]. This mechanism assumes a prioritary connotation if we consider that N-*myc* amplified neuroblas‐ tomas show an increased copper content, that translates in a remarkable induction of metal‐ lothioneins and reduced efficacy of Cisplatin-based therapies.

#### **9. Conclusion**

Multifaceted pathophysiological features determine the progression of neuroblastoma malignancies. Mainly on the basis of *in vitro* and pre-clinical studies, copper, playing a key role within the human nervous system, is candidate to be the actual target of novel therapies. Accordingly, high copper levels seem to underline the development of tumour malignancies, even if we honestly observe that the scientific literature does not offer so many clear cues about the nature of *in vivo* copper involvement in neuroblastoma. The conclusive impression is that copper interacts with the neuroblastoma microenvironment at various levels, and the effects may be profoundly different, depending on the interested cell type (e.g. endothelial, neuro‐ blast). The overall effects arise from the sum of specific and sometimes discordant copperdriven processes.

If few clinical data are currently available in this regard, the challenge toward the development of a copper-targeting therapy has anyway been launched. On the other hand, recent studies have recognized for neuroblastoma patients the benefits of preconditioning therapies based on the use of copper chelating agents (i.e. tetrathiomolibdate). Such intriguing approach would modulate the expression and/or subcellular localization of copper transport systems, and so both the cancer metal levels and chemoresistance. However, caution is needed in this sense, since the comprehension of copper metabolism in neuroblastoma cancer cells is still prelimi‐ nary and the routes of copper transport are currently partially known. Significantly, it is only recently that an anion exchanger has been proposed as an additional copper importer in mammalian cells [117].

#### **Acknowledgements**

The authors gratefully acknowledge funding from the Italian Ministry of Education, Univer‐ sity and Research (MIUR) through the project PRIN 2008 200875WHMR, for allowing a part of the experimental activities discussed in this chapter.

#### **Author details**

by a copper chelating agent (i.e. Tetrathiomolybdate) and platinum-containing drugs has been proven to enhance the Cisplatin efficacy in a mouse model of cervical cancer, without affecting

Another copper-dependent mechanism of resistance to cisplatin involves metallothioneins, a family of low molecular weight copper-binding proteins, whose expression is metal-induced in neuroblastoma cell models [114] and elevated in cisplatin-resistant cell lines [115]. When cisplatin enters a cancer cell, it is vulnerable to metallothionein-inactivation [116]. This mechanism assumes a prioritary connotation if we consider that N-*myc* amplified neuroblas‐ tomas show an increased copper content, that translates in a remarkable induction of metal‐

Multifaceted pathophysiological features determine the progression of neuroblastoma malignancies. Mainly on the basis of *in vitro* and pre-clinical studies, copper, playing a key role within the human nervous system, is candidate to be the actual target of novel therapies. Accordingly, high copper levels seem to underline the development of tumour malignancies, even if we honestly observe that the scientific literature does not offer so many clear cues about the nature of *in vivo* copper involvement in neuroblastoma. The conclusive impression is that copper interacts with the neuroblastoma microenvironment at various levels, and the effects may be profoundly different, depending on the interested cell type (e.g. endothelial, neuro‐ blast). The overall effects arise from the sum of specific and sometimes discordant copper-

If few clinical data are currently available in this regard, the challenge toward the development of a copper-targeting therapy has anyway been launched. On the other hand, recent studies have recognized for neuroblastoma patients the benefits of preconditioning therapies based on the use of copper chelating agents (i.e. tetrathiomolibdate). Such intriguing approach would modulate the expression and/or subcellular localization of copper transport systems, and so both the cancer metal levels and chemoresistance. However, caution is needed in this sense, since the comprehension of copper metabolism in neuroblastoma cancer cells is still prelimi‐ nary and the routes of copper transport are currently partially known. Significantly, it is only recently that an anion exchanger has been proposed as an additional copper importer in

The authors gratefully acknowledge funding from the Italian Ministry of Education, Univer‐ sity and Research (MIUR) through the project PRIN 2008 200875WHMR, for allowing a part

the integrity of healthy tissues [113].

**9. Conclusion**

278 Neuroblastoma

driven processes.

mammalian cells [117].

**Acknowledgements**

of the experimental activities discussed in this chapter.

lothioneins and reduced efficacy of Cisplatin-based therapies.

Emanuela Urso and Michele Maffia\*

Department of Biological and Environmental Sciences and Technology, University of Salento, Lecce, Italy

#### **References**


[12] Rubie H, Hartmann O, Michon J, Frappaz D, Coze C, Chastagner P, Baranzelli MC, Plantaz D, Avet-Loiseau H, Bénard J, Delattre O, Favrot M, Peyroulet MC, Thyss A, Perel Y, Bergeron C, Courbon-Collet B, Vannier JP, Lemerle J, Sommelet D. N-Myc gene amplification is a major prognostic factor in localized neuroblastoma: results of the French NBL 90 study. Neuroblastoma Study Group of the Société Francaise d'On‐ cologie Pédiatrique. Journal of Clinical Oncology 1997;15(3) 1171-1182.

[23] Urso E, Manno D, Serra A, Buccolieri A, Rizzello A, Danieli A, Acierno R, Salvato B, Maffia M. Role of the cellular prion protein in the neuron adaptation strategy to cop‐

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

281

[24] McLennan NF, Brennan PM, McNeill A, Davies I, Fotheringham A, Rennison KA, Ritchie D, Brannan F, Head MW, Ironside JW, Williams A, Bell JE. Prion protein ac‐ cumulation and neuroprotection in hypoxic brain damage. The American Journal of

[25] Lutsenko S, Petris MJ (2002) Function and regulation of the mammalian coppertransporting ATPases: insights from biochemical and cell biological approaches.

[26] Materia S, Cater MA, Klomp LW, Mercer JF, La Fontaine S. Clusterin (apolipoprotein J), a molecular chaperone that facilitates degradation of the copper-ATPases ATP7A

[27] Chayka O, Corvetta D, Dews M, Caccamo AE, Piotrowska I, Santilli G, Gibson S, Se‐ bire NJ, Himoudi N, Hogarty MD, Anderson J, Bettuzzi S, Thomas-Tikhonenko A, Sala A. Clusterin, a haploinsufficient tumor suppressor gene in neuroblastomas.

[28] Reddy MC, Majumdar S, Harris ED. Evidence for a Menkes-like protein with a nucle‐

[29] Swart M. Localisation of the COMMD1 and COMMD3 proteins in the kidney and mammalian cells. M.S. thesis. University of Otago, Dunedin, New Zealand; 2010. [30] van de Sluis B, Mao X, Zhai Y, Groot AJ, Vermeulen JF, van der Wall E, van Diest PJ, Hofker MH, Wijmenga C, Klomp LW, Cho KR, Fearon ER, Vooijs M, Burstein E. COMMD1 disrupts HIF-1alpha/beta dimerization and inhibits human tumor cell in‐

[31] Vonk WI, Wijmenga C, Berger R, van de Sluis B, Klomp LW. Cu,Zn superoxide dis‐ mutase maturation and activity are regulated by COMMD1. The Journal of Biological

[32] Materia S, Cater MA, Klomp LW, Mercer JF, La Fontaine S. Clusterin and COMMD1 independently regulate degradation of the mammalian copper ATPases ATP7A and

[33] Deveraux QL, Takahashi R, Salvesen GS, Reed JC. X-linked IAP is a direct inhibitor

[34] Shiozaki EN, Chai J, Rigotti DJ, Riedl SJ, Li P, Srinivasula SM, Alnemri ES, Fairman R, Shi Y. Mechanism of XIAP-mediated inhibition of caspase-9. Molecular Cell

and ATP7B. The Journal of Biological Chemistry 2011;286(12) 10073-10083.

Journal of the National Cancer Institute 2009;101(9) 663-677.

ar targeting sequence. The Biochemical Journal 2000;350 Pt 3 855-863.

vasion. The Journal of Clinical Investigation 2010;120(6) 2119-2130.

ATP7B. The Journal of Biological Chemistry 2012;287(4) 2485-2499.

of cell-death proteases. Nature 1997;388(6639) 300-304.

Chemistry 2010;285(37) 28991-29000.

2003;11(2) 519-527.

per deficiency. Cellular and Molecular Neurobiology 2012;32(6) 989-1001.

Pathology 2004;165(1) 227-235.

Journal of Membrane Biology 2003;191(1) 1-12.


[23] Urso E, Manno D, Serra A, Buccolieri A, Rizzello A, Danieli A, Acierno R, Salvato B, Maffia M. Role of the cellular prion protein in the neuron adaptation strategy to cop‐ per deficiency. Cellular and Molecular Neurobiology 2012;32(6) 989-1001.

[12] Rubie H, Hartmann O, Michon J, Frappaz D, Coze C, Chastagner P, Baranzelli MC, Plantaz D, Avet-Loiseau H, Bénard J, Delattre O, Favrot M, Peyroulet MC, Thyss A, Perel Y, Bergeron C, Courbon-Collet B, Vannier JP, Lemerle J, Sommelet D. N-Myc gene amplification is a major prognostic factor in localized neuroblastoma: results of the French NBL 90 study. Neuroblastoma Study Group of the Société Francaise d'On‐

[13] Gouget B, Sergeant C, Llabador Y, Deves G, Vesvres M, Simonoff M, Benard J. Trace metals and cancer: The case of neuroblastoma. Nuclear Instruments and Methods in

[14] Gouget B, Sergeant C, Benard J, Llabador Y, Simonoff M. N-myc oncogene amplifica‐ tion is correlated to trace metal concentrations in neuroblastoma cultured cells. Nu‐ clear Instruments and Methods in Physics Research Section B 2000;170(3-4) 432-442.

[15] Ortega R, Gouget B, Moretto P, Michelet C, Sergeant C, Llabador Y et al. Trace metal content in distinct genotypes of human neuroblasma cells: preliminary results. Nu‐ clear Instruments and Methods in Physics Research Research Section B: Beam Inter‐

[16] Ara T, Fukuzawa M, Kusafuka T, Komoto Y, Oue T, Inoue M, Okada A. Immunohis‐ tochemical expression of MMP-2, MMP-9, and TIMP-2 in neuroblastoma: association with tumor progression and clinical outcome. Journal of Pediatric Surgery 1998;33(8)

[17] Szatrowski TP, Nathan CF. Production of large amounts of hydrogen peroxide by

[18] Mills CF. Interactions between elements in tissues: Studies in animal models. Federa‐

[19] Meitar D, Crawford SE, Rademaker AW, Cohn SL. Tumor angiogenesis correlates with metastatic disease, N-Myc amplification, and poor outcome in human neuro‐

[20] Ribatti D, Vacca A, Nico B, De Falco G, Giuseppe Montaldo P, Ponzoni M. Angiogen‐ esis and anti-angiogenesis in neuroblastoma. European Journal of Cancer 2002;38(6)

[21] Qian Y, Zheng Y, Abraham L, Ramos KS, Tiffany-Castiglioni E. Differential profiles of copper-induced ROS generation in human neuroblastoma and astrocytoma cells.

[22] Urso E, Rizzello A, Acierno R, Lionetto MG, Salvato B, Storelli C, Maffia M (2010) Fluorimetric analysis of copper transport mechanisms in the B104 neuroblastoma cell model: a contribution from cellular prion protein to copper supplying. Journal of

cologie Pédiatrique. Journal of Clinical Oncology 1997;15(3) 1171-1182.

Physics Research Section B 2001;181(1-4) 465-469.

actions with Materials and Atoms 1997:130(1-4) 449-453.

human tumor cells. Cancer Research 1991;51(3) 794-798.

blastoma. Journal of Clinical Oncology 1996;14(2) 405-414.

Brain Research. Molecular Brain Research 2005;134(2) 323-332.

tion Proceedings 1981;40(8) 2138-2143.

Membrane Biology 233(1–3) 13–21.

1272–1278.

280 Neuroblastoma

750-757.


[35] Hao Z, Mak TW. Type I and type II pathways of Fas-mediated apoptosis are differen‐ tially controlled by XIAP. Journal of Molecular Cell Biology 2010;2(2) 63-64.

[46] Qing G, Skuli N, Mayes PA, Pawel B, Martinez D, Maris JM, Simon MC. Combinato‐ rial regulation of neuroblastoma tumor progression by N-Myc and hypoxia inducible

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

283

[47] Martin F, Linden T, Katschinski DM, Oehme F, Flamme I, Mukhopadhyay CK, Eck‐ hardt K, Tröger J, Barth S, Camenisch G, Wenger RH. Copper-dependent activation of hypoxia-inducible factor (HIF)-1: implications for ceruloplasmin regulation. Blood

[48] Mukhopadhyay CK, Mazumder B, Fox PL. Role of hypoxia-inducible factor-1 in transcriptional activation of ceruloplasmin by iron deficiency. The Journal of Biologi‐

[49] Tang N, Wang L, Esko J, Giordano FJ, Huang Y, Gerber HP, Ferrara N, Johnson RS. Loss of HIF-1alpha in endothelial cells disrupts a hypoxia-driven VEGF autocrine

[50] Gerber HP, Condorelli F, Park J, Ferrara N. Differential transcriptional regulation of the two vascular endothelial growth factor receptor genes. Flt-1, but not Flk-1/KDR, is up-regulated by hypoxia. The Journal of Biological Chemistry 1997;272(38)

[51] White C, Kambe T, Fulcher YG, Sachdev SW, Bush AI, Fritsche K, Lee J, Quinn TP, Petris MJ. Copper transport into the secretory pathway is regulated by oxygen in

[52] Pietras A, Gisselsson D, Ora I, Noguera R, Beckman S, Navarro S, Påhlman S. High levels of HIF-2alpha highlight an immature neural crest-like neuroblastoma cell co‐ hort located in a perivascular niche. The Journal of Pathology 2008;214(4) 482–488. [53] Xie L, Collins JF. Transcriptional regulation of the Menkes copper ATPase (Atp7a) gene by hypoxia-inducible factor (HIF2{alpha}) in intestinal epithelial cells. American

[54] Pourvali K, Matak P, Latunde-Dada GO, Solomou S, Mastrogiannaki M, Peysson‐ naux C, Sharp PA. Basal expression of copper transporter 1 in intestinal epithelial cells is regulated by hypoxia-inducible factor 2α. FEBS Letters 2012;586(16)

[55] Li QQ, Sun YP, Ruan CP, Xu XY, Ge JH, He J, Xu ZD, Wang Q, Gao WC. Cellular prion protein promotes glucose uptake through the Fyn-HIF-2α-Glut1 pathway to

[56] McLennan NF, Brennan PM, McNeill A, Davies I, Fotheringham A, Rennison KA, Ritchie D, Brannan F, Head MW, Ironside JW, Williams A, Bell JE. Prion protein ac‐ cumulation and neuroprotection in hypoxic brain damage. The American Journal of

support colorectal cancer cell survival. Cancer Science 2011;102(2) 400-406.

factor HIF-1alpha. Cancer Research 2010;70(24):10351-10361.

loop necessary for tumorigenesis. Cancer Cell 2004;6(5) 485-495.

macrophages. Journal of Cell Science 2009;122(Pt 9) 1315-1321.

Journal of Physiology. Cell Physiology 2011;300(6) C1298-C1305.

2005;105(12) 4613-4619.

23659-23667.

2423-2427.

Pathology 2004;165(1) 227-235.

cal Chemistry 2000;275(28) 21048-21054.


[46] Qing G, Skuli N, Mayes PA, Pawel B, Martinez D, Maris JM, Simon MC. Combinato‐ rial regulation of neuroblastoma tumor progression by N-Myc and hypoxia inducible factor HIF-1alpha. Cancer Research 2010;70(24):10351-10361.

[35] Hao Z, Mak TW. Type I and type II pathways of Fas-mediated apoptosis are differen‐ tially controlled by XIAP. Journal of Molecular Cell Biology 2010;2(2) 63-64.

[36] Burstein E, Ganesh L, Dick RD, van De Sluis B, Wilkinson JC, Klomp LW, Wijmenga C, Brewer GJ, Nabel GJ, Duckett CS. A novel role for XIAP in copper homeostasis

[37] Eschenburg G, Eggert A, Schramm A, Lode HN, Hundsdoerfer P. Smac mimetic LBW242 sensitizes XIAP-overexpressing neuroblastoma cells for TNF-α-independent

[38] Mufti AR, Burstein E, Csomos RA, Graf PC, Wilkinson JC, Dick RD, Challa M, Son JK, Bratton SB, Su GL, Brewer GJ, Jakob U, Duckett CS. XIAP Is a copper binding protein deregulated in Wilson's disease and other copper toxicosis disorders. Molec‐

[39] Paramasivam A, Sambantham S, Shabnam J, Raghunandhakumar S, Anandan B, Ra‐ jiv R, Vijayashree Priyadharsini J, Jayaraman G. Anti-cancer effects of thymoquinone in mouse neuroblastoma (Neuro-2a) cells through caspase-3 activation with down-

[40] Kayama T, Yoshimoto T, Fujimoto S, Sakurai Y. Intratumoral oxygen pressure in ma‐

[41] Holmquist-Mengelbier L, Fredlund E, Löfstedt T, Noguera R, Navarro S, Nilsson H, Pietras A, Vallon-Christersson J, Borg A, Gradin K, Poellinger L, Påhlman S. Recruit‐ ment of HIF-1 alpha and HIF-2 alpha to common target genes is differentially regu‐ lated in neuroblastoma: HIF-2 alpha promotes an aggressive phenotype. Cancer Cell

[42] Warburg O. On respiratory impairment in cancer cells. Science 1956;124(3215)

[43] Wang GL, Jiang BH, Rue EA, Semenza GL. Hypoxia-inducible factor 1 is a basic-he‐ lix-loop-helix-PAS heterodimer regulated by cellular O2 tension. Proceedings of the National Academy of Sciences of the United States of America 1995;92(12) 5510-5514.

[44] Wiesener MS, Turley H, Allen WE, Willam C, Eckardt KU, Talks KL, Wood SM, Gat‐ ter KC, Harris AL, Pugh CW, Ratcliffe PJ, Maxwell PH. Induction of endothelial PAS protein-1 by hypoxia: characterization and comparison with hypoxia-inducible fac‐

[45] Beasley NJ, Leek R, Alam M, Turley H, Cox GJ, Gatter K, Millard P, Fuggle S, Harris AL. Hypoxia-inducible factors HIF-1alpha and HIF-2alpha in head and neck cancer: relationship to tumor biology and treatment outcome in surgically resected patients.

through regulation of MURR1. The EMBO Journal 2004;23(1) 244-254.

apoptosis. Cancer Research 2012;72(10) 2645-2656.

regulation of XIAP. Toxicology Letters 2012;213(2) 151-159.

lignant brain tumor. Journal of Neurosurgery 1991;74(1) 55-59.

ular Cell 2006;21(6) 775-785.

2006;10(5) 413-423.

tor-1alpha. Blood 1998;92(7) 2260-2268.

Cancer Research 2002;62(9) 2493-2497.

269-270.

282 Neuroblastoma


[57] Pan Y, Zhao L, Liang J, Liu J, Shi Y, Liu N, Zhang G, Jin H, Gao J, Xie H, Wang J, Liu Z, Fan D. Cellular prion protein promotes invasion and metastasis of gastric cancer. FASEB Journal 2006;20(11) 1886-1888.

[69] Filomeni G, Aquilano K, Rotilio G, Ciriolo MR. Antiapoptotic response to induced GSH depletion: involvement of heat shock proteins and NF-kappaB activation. Anti‐

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

285

[70] Lombardo MF, Ciriolo MR, Rotilio G, Rossi L. Prolonged copper depletion induces expression of antioxidants and triggers apoptosis in SH-SY5Y neuroblastoma cells.

[71] Rossi L, Marchese E, Lombardo MF, Rotilio G, Ciriolo MR. Increased susceptibility of copper-deficient neuroblastoma cells to oxidative stress-mediated apoptosis. Free

[72] Arciello M, Capo CR, D'Annibale S, Cozzolino M, Ferri A, Carrì MT, Rossi L. Copper depletion increases the mitochondrial-associated SOD1 in neuronal cells. Biometals

[73] Rossi L, Ciriolo MR, Marchese E, De Martino A, Giorgi M, Rotilio G. Differential de‐ crease of copper content and copper binding to superoxide dismutase in liver, heart and brain of copper-deficient rats. Biochemical and biophysical research communica‐

[74] Aquilano K, Vigilanza P, Rotilio G, Ciriolo MR. Mitochondrial damage due to SOD1 deficiency in SH-SY5Y neuroblastoma cells: a rationale for the redundancy of SOD1.

[75] Vijayvergiya C, Beal MF, Buck J, Manfredi G. Mutant superoxide dismutase 1 forms aggregates in the brain mitochondrial matrix of amyotrophic lateral sclerosis mice.

[76] Klamt F, Dal-Pizzol F, Conte da Frota ML, Walz R, Andrades ME, da Silva EG, Bren‐ tani RR, Izquierdo I, Fonseca Moreira JC. Imbalance of antioxidant defense in mice lacking cellular prion protein. Free Radical Biology & Medicine 2001;30(10)

[77] Brown DR, Besinger A. Prion protein expression and superoxide dismutase activity.

[78] Brown DR, Schulz-Schaeffer WJ, Schmidt B, Kretzschmar HA. Prion protein-deficient cells show altered response to oxidative stress due to decreased SOD-1 activity. Ex‐

[79] Salès N, Rodolfo K, Hässig R, Faucheux B, Di Giamberardino L, Moya KL. Cellular prion protein localization in rodent and primate brain. The European Journal of Neu‐

[80] Brown DR, Besinger A, Herms JW, Kretzschmar HA. Microglial expression of the

oxidants & Redox Signaling 2005;7(3-4) 446–455.

Radical Biology & Medicine 2001;30(10) 1177-1187.

2011;24(2) 269-278.

1137-1144.

tions 1994;203(2) 1028-1034.

FASEB Journal 2006;20(10) 1683-1685.

The Journal of Neuroscience 2005;25(10) 2463–2470.

The Biochemical Journal 1998;334(Pt 2) 423-429.

prion protein. Neuroreport 1998;9(7) 1425-1429.

perimental Neurology 1997;146(1) 104-112.

roscience 1998;10(7) 2464-2471.

Cellular and Molecular Life Sciences 2003;60(8) 1733-1743.


[69] Filomeni G, Aquilano K, Rotilio G, Ciriolo MR. Antiapoptotic response to induced GSH depletion: involvement of heat shock proteins and NF-kappaB activation. Anti‐ oxidants & Redox Signaling 2005;7(3-4) 446–455.

[57] Pan Y, Zhao L, Liang J, Liu J, Shi Y, Liu N, Zhang G, Jin H, Gao J, Xie H, Wang J, Liu Z, Fan D. Cellular prion protein promotes invasion and metastasis of gastric cancer.

[58] Pauly P, Harris DA. Copper stimulates endocytosis of the prion protein. The Journal

[59] Perera WS, Hooper NM. Ablation of the metal ion-induced endocytosis of the prion protein by disease-associated mutation of the octarepeat region. Current Biology

[60] Bohlken A, Cheung BB, Bell JL, Koach J, Smith S, Sekyere E, Thomas W, Norris M, Haber M, Lovejoy DB, Richardson DR, Marshall GM. ATP7A is a novel target of reti‐ noic acid receptor beta2 in neuroblastoma cells. British Journal of Cancer 2009;100(1)

[61] Vogelstein B, Lane D, Levine AJ. Surfing the p53 network. Nature 2000;408(6810):

[62] Carr-Wilkinson J, O'Toole K, Wood KM, Challen CC, Baker AG, Board JR, Evans L, Cole M, Cheung NK, Boos J, Köhler G, Leuschner I, Pearson AD, Lunec J, Tweddle DA. High Frequency of p53/MDM2/p14ARF Pathway Abnormalities in Relapsed

[63] Keshelava N, Zuo JJ, Waidyaratne NS, Triche TJ, Reynolds CP. p53 mutations and loss of p53 function confer multidrug resistance in neuroblastoma. Medical and Pe‐

[64] Moll UM, Ostermeyer AG, Haladay R, Winkfield B, Frazier M, Zambetti G. Cytoplas‐ mic sequestration of wild-type p53 protein impairs the G1 checkpoint after DNA

[65] Moll UM, LaQuaglia M, Bénard J, Riou G. Wild-type p53 protein undergoes cyto‐ plasmic sequestration in undifferentiated neuroblastomas but not in differentiated tumors. Proceedings of the National Academy of Sciences of the United States of

[66] Matoba S, Kang JG, Patino WD, Wragg A, Boehm M, Gavrilova O, Hurley PJ, Bunz F, Hwang PM. p53 regulates mitochondrial respiration. Science 2006;312(5780)

[67] Turski ML, Thiele DJ. New roles for copper metabolism in cell proliferation, signal‐ ing, and disease. The Journal of Biological Chemistry 2009;284(2) 717-721.

[68] Finkel T, Holbrook NJ. Oxidants, oxidative stress and the biology of ageing. Nature

Neuroblastoma. Clinical Cancer Research 2010;16(4) 1108-1118.

damage. Molecular and Cellular Biology 1996;16(3) 1126-1137.

FASEB Journal 2006;20(11) 1886-1888.

diatric Oncology 2000;35(6) 563-568.

America 1995;92(10) 4407-4411.

2000;408(6809) 239–247.

1650-1653.

2001;11(7) 519–523.

96-105.

284 Neuroblastoma

307-310.

of Biological Chemistry 1998 273(50) 33107–33110.


[81] Jakovljević G, Culić S, Stepan J, Bonevski A, Seiwerth S. Vascular endothelial growth factor in children with neuroblastoma: a retrospective analysis. Journal of Experi‐ mental & Clinical Cancer Research 2009;28 143-1-143-11.

[91] Sivakumaran M. The expression of prion protein (PrPc) by endothelial cells: an in vi‐ tro culture-induced artefactual phenomenon? British journal of haematology

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

287

[92] Krupinski J, Turu MM, Luque A, Badimon L, Slevin M. Increased PrPC expression correlates with endoglin (CD105) positive microvessels in advanced carotid lesions.

[93] Weise J, Crome O, Sandau R, Schulz-Schaeffer W, Bähr M, Zerr I. Upregulation of cellular prion protein (PrPc) after focal cerebral ischemia and influence of lesion se‐

[94] Shyu WC, Lin SZ, Chiang MF, Ding DC, Li KW, Chen SF, Yang HI, Li H. Overex‐ pression of PrPC by adenovirus-mediated gene targeting reduces ischemic injury in a

[95] Massimino ML, Griffoni C, Spisni E, Toni M, Tomasi V. Involvement of caveolae and caveolae-like domains in signalling, cell survival and angiogenesis. Cellular Signal‐

[96] Feng Y, Venema VJ, Venema RC, Tsai N, Behzadian MA, Caldwell RB. VEGF-in‐ duced permeability increase is mediated by caveolae. Investigative ophthalmology &

[97] Yoshizawa J, Mizuno R, Yoshida T, Hara A, Ashizuka S, Kanai M, Kuwashima N, Kurobe M, Yamazaki Y. Inhibitory effect of TNP-470 on hepatic metastasis of mouse

[98] Nagabuchi E, VanderKolk WE, Une Y, Ziegler MM. TNP-470 antiangiogenic therapy for advanced murine neuroblastoma. Journal of Pediatric Surgery 1997;32(2) 287-293.

[99] Matsuoka S, Uchino J, Une Y, Ishimura H, Tsuchimoto S, Kamiyama T. Effects of tnp-470 (agm-1470) on tumor-growth, angiogenesis and serum copper levels in liver-

[100] Ribatti D, Alessandri G, Baronio M, Raffaghello L, Cosimo E, Marimpietri D, Montal‐ do PG, De Falco G, Caruso A, Vacca A, Ponzoni M. Inhibition of neuroblastoma-in‐ duced angiogenesis by fenretinide. International Journal of Cancer 2001;94(3)

[101] Dorr RT, Von Hoff DD. Cancer Chemotherapy Handbook. Appleton & Lange: Nor‐

[102] Qiu YY, Mirkin BL, Dwivedi RS. Inhibition of DNA methyltransferase reverses cis‐ platin induced drug resistance in murine neuroblastoma cells. Cancer Detection and

stroke rat model. The Journal of Neuroscience 2005;25(39) 8967-8977.

neuroblastoma. The Journal of Surgical Research 2000;93(1) 82-87.

cancer bearing rats. Oncology Reports 1995;2(4) 583-589.

2003;121(4) 673-674.

ling 2002;14(2) 93-98.

314-321.

walk; 1994. p286-298.

Prevention 2005;29(5) 456-463.

visual science 1999;40(1) 157-167.

Acta Neuropathologica 2008;116(5) 537-545.

verity. Neuroscience Letters 2004;372(1-2) 146-150.


[91] Sivakumaran M. The expression of prion protein (PrPc) by endothelial cells: an in vi‐ tro culture-induced artefactual phenomenon? British journal of haematology 2003;121(4) 673-674.

[81] Jakovljević G, Culić S, Stepan J, Bonevski A, Seiwerth S. Vascular endothelial growth factor in children with neuroblastoma: a retrospective analysis. Journal of Experi‐

[82] Sen CK, Khanna S, Venojarvi M, Trikha P, Ellison EC, Hunt TK, Roy S. Copper-in‐ duced vascular endothelial growth factor expression and wound healing. American journal of physiology. Heart and Circulatory Physiology. 2002;282(5) H1821-H1827.

[83] Soncin F, Guitton JD, Cartwright T, Badet J. Interaction of human angiogenin with copper modulates angiogenin binding to endothelial cells. Biochemical and Biophysi‐

[84] Badet J, Soncin F, Guitton JD, Lamare O, Cartwright T, Barritault D. Specific binding of angiogenin to calf pulmonary artery endothelial cells. Proceedings of the National

[85] Landriscina M, Bagalá C, Mandinova A, Soldi R, Micucci I, Bellum S, Prudovsky I, Maciag T. Copper induces the assembly of a multiprotein aggregate implicated in the release of fibroblast growth factor 1 in response to stress. The Journal of Biological

[86] Lowndes SA, Harris AL. The role of copper in tumour angiogenesis. Journal of mam‐

[87] Bar-Or D, Thomas GW, Yukl RL, Rael LT, Shimonkevitz RP, Curtis CG, Winkler JV. Copper stimulates the synthesis and release of interleukin-8 in human endothelial cells: a possible early role in systemic inflammatory responses. Shock 2003;20(2)

[88] Finney L, Mandava S, Ursos L, Zhang W, Rodi D, Vogt S, Legnini D, Maser J, Ikpatt F, Olopade OI, Glesne D. X-ray fluorescence microscopy reveals large-scale relocali‐ zation and extracellular translocation of cellular copper during angiogenesis. Pro‐ ceedings of the National Academy of Sciences of the United States of America

[89] Ashino T, Sudhahar V, Urao N, Oshikawa J, Chen GF, Wang H, Huo Y, Finney L, Vogt S, McKinney RD, Maryon EB, Kaplan JH, Ushio-Fukai M, Fukai T. Unexpected role of the copper transporter ATP7A in PDGF-induced vascular smooth muscle cell

[90] Lemaire-Vieille C, Schulze T, Podevin-Dimster V, Follet J, Bailly Y, Blanquet-Gros‐ sard F, Decavel JP, Heinen E, Cesbron JY. Epithelial and endothelial expression of the green fluorescent protein reporter gene under the control of bovine prion protein (PrP) gene regulatory sequences in transgenic mice. Proceedings of the National

Academy of Sciences of the United States of America 2000;97(10) 5422-5427.

Academy of Sciences of the United States of America 1989;86(21) 8427-8431.

mental & Clinical Cancer Research 2009;28 143-1-143-11.

cal Research Communications 1997;236(3) 604-610.

mary gland biology and neoplasia 2005;10(4) 299-310.

migration. Circulation Research 2010;107(6) 787-799.

Chemistry 2001;276(27) 25549-25557.

154-158.

286 Neuroblastoma

2007;104(7) 2247-2252.


[103] Tabata K, Sakai H, Nakajima R, Saya-Nishimura R, Motani K, Okano S, Shibata Y, Abiko Y, Suzuki T. Acute application of cisplatin affects methylation status in neuro‐ blastoma cells. Oncology Reports 2011;25(6) 1655-1660.

[115] Kasahara, K, Fujiwara, Y, Nishio, K, Ohmori, T, Sugimoto, Y, Komiya, K, Matsuda, T, & Saijo, N. Metallothionein content correlates with the sensitivity of human small cell

Copper as a Target for Treatment of Neuroblastoma: Molecular and Cellular Mechanisms

http://dx.doi.org/10.5772/55423

289

[116] Siddik, Z. H. Cisplatin: Mode of cytotoxic action and molecular basis of resistance.

[117] Zimnicka, A. M, Ivy, K, & Kaplan, J. H. Acquisition of dietary copper: a role for anion transporters in intestinal apical copper uptake. American Journal of Physiology. Cell

[118] Petris, M. J. The SLC31 (Ctr) copper transporter family. Pflugers Archiv (2004). ,

[119] van den Berghe, P. V, Folmer, D. E, Malingré, H.E, van Beurden, E, Klomp, A. E, van de Sluis, B, Merkx, M, Berger, R, Klomp, L. W. Human copper transporter 2 is local‐ ized in late endosomes and lysosomes and facilitates cellular copper uptake. The Bio‐

[120] Bertinato, J, Iskandar, M, & L'Abbé, M. R. Copper deficiency induces the upregula‐ tion of the copper chaperone for Cu/Zn superoxide dismutase in weanling male rats.

[121] Amaravadi, R, Glerum, D. M, & Tzagoloff, A. Isolation of a cDNA encoding the hu‐ man homolog of COX17, a yeast gene essential for mitochondrial copper recruitment.

[122] Klomp, L. W, Lin, S. J, Yuan, D. S, Klausner, R. D, Culotta, V. C, & Gitlin, J. D. Identi‐ fication and functional expression of HAH1, a novel human gene involved in copper

homeostasis. The Journal of Biological Chemistry (1997). , 272(14), 9221-9226.

[123] Suzuki, K. T, Imura, N, & Kimura, M. Metallothionein III. Birkhäuser Verlag: Basel;

lung cancer cell lines to cisplatin. Cancer Res. (1991). , 51(12), 3237-3242.

Oncogene (2003). , 22(47), 7265-7279.

Physiology (2011). , 300(3), C588-C599.

chemical Journal (2007). , 407(1), 49-59.

Human Genetics (1997). , 99(3), 329-333.

The Journal of Nutrition (2003). , 133(1), 28-31.

447(5), 752-755.

(1993).


[115] Kasahara, K, Fujiwara, Y, Nishio, K, Ohmori, T, Sugimoto, Y, Komiya, K, Matsuda, T, & Saijo, N. Metallothionein content correlates with the sensitivity of human small cell lung cancer cell lines to cisplatin. Cancer Res. (1991). , 51(12), 3237-3242.

[103] Tabata K, Sakai H, Nakajima R, Saya-Nishimura R, Motani K, Okano S, Shibata Y, Abiko Y, Suzuki T. Acute application of cisplatin affects methylation status in neuro‐

[104] Haber M, Bordow SB, Gilbert J, Madafiglio J, Kavallaris M, Marshall GM, Mechetner EB, Fruehauf JP, Tee L, Cohn SL, Salwen H, Schmidt ML, Norris MD. Altered expres‐ sion of the MYCN oncogene modulates MRP gene expression and response to cyto‐

[105] Liang ZD, Stockton D, Savaraj N, Tien Kuo M. Mechanistic comparison of human high-affinity copper transporter 1-mediated transport between copper ion and cispla‐

[106] Safaei R, Howell SB. Copper transporters regulate the cellular pharmacology and sensitivity to Pt drugs. Critical Reviews in Oncology/Hematology 2005;53(1) 13-23.

[107] Song IS, Savaraj N, Siddik ZH, Liu P, Wei Y, Wu CJ, Kuo MT. Role of human copper transporter Ctr1 in the transport of platinum-based antitumor agents in cisplatin-sen‐ sitive and cisplatin-resistant cells. Molecular Cancer Therapeutics 2004;3(12)

[108] Sinani D, Adle DJ, Kim H, Lee J. Distinct mechanisms for Ctr1-mediated copper and cisplatin transport. The Journal of Biological Chemistry 2007;282(37) 26775-26785.

[109] Guo Y, Smith K, Petris MJ. Cisplatin stabilizes a multimeric complex of the human Ctr1 copper transporter: requirement for the extracellular methionine-rich clusters.

[110] Kuo MT, Chen HH, Song IS, Savaraj N, Ishikawa T. The roles of copper transporters

[111] Harvey HM, Bray IM, Stallings RL. Functional analysis of miRNA in chemotherapy resistant neuroblastoma. In: Proceedings of the 103rd Annual Meeting of the Ameri‐ can Association for Cancer Research, AACR, 31 March-4 April 2012, Chicago, Illinois.

[112] Samimi, G, Safaei, R, Katano, K, Holzer, A. K, Rochdi, M, Tomioka, M, Goodman, M, & Howell, S. B. Increased expression of the copper efflux transporter ATP7A medi‐ ates resistance to cisplatin, carboplatin, and oxaliplatin in ovarian cancer cells. Clini‐

[113] Ishida, S, McCormick, F, Smith-McCune, K, & Hanahan, D. Enhancing tumor-specific uptake of the anticancer drug cisplatin with a copper chelator. Cancer Cell (2010). ,

[114] Yasuno, T, Matsumura, T, Shikata, T, Inazawa, J, Sakabe, T, Tsuchida, S, Takahata, T, Miyairi, S, Naganuma, A, & Sawada, T. Establishment and characterization of a cis‐ platin-resistant human neuroblastoma cell line. Anticancer Research (1999). , 19(5B),

The Journal of Biological Chemistry 2004;279(45) 46393-46399.

Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl).

cal Cancer Research (2004). , 10(14), 4661-4669.

in cisplatin resistance. Cancer Metastasis Reviews 2007;26(1) 71-83.

toxic drugs in neuroblastoma cells. Oncogene 1999;18(17) 2777-2782.

blastoma cells. Oncology Reports 2011;25(6) 1655-1660.

tin. Molecular Pharmacology 2009;76(4) 843-853.

1543-1549.

288 Neuroblastoma

17(6), 574-583.

4049-4057.


**Chapter 13**

**Clinical Implications of Neuroblastoma Stem Cells**

Neuroblastoma (NB) is a childhood neoplasm and the cause of ~15% of cancer deaths in children. The clinical behavior of NB is highly variable. While some tumors are easily treatable, nearly 50% of the tumors exhibit very aggressive behavior. The latter tumors are classified as high-risk NB and are characterized by widespread tumor dissemination and poor long-term survival. Determining the prognosis of NBs at the time of diagnosis is important because of the clinical heterogeneity of the disease. Current prognostic factors used by the COG (Child‐ ren's Oncology Group) Neuroblastoma Study for patient stratification and protocol assign‐ ment include: Age (<18 months *vs* >18 months), Stage (1, 2, 4S *vs* 3, 4), *MYCN* status (amplification *vs* non-amplification), Ploidy (diploid *vs* hyperdiploid), International Neuro‐ blastoma Pathology Classification (Shimada system: Favorable *vs* Unfavorable Histology), 1pLOH (present *vs* absent), and 11qLOH (present *vs* absent) [1-3]. About half of high-risk NBs exhibit *MYCN* amplification, which is associated with older age, rapid tumor progression, and the worst prognosis [4]. According to the International Neuroblastoma Pathology Classifica‐ tion, NBs exhibiting *MYCN* amplification have unique histologic features, namely, an undif‐ ferentiated/poorly differentiated appearance and a high mitosis-karyorrhexis index. Nonetheless, certain NB with these histologic characteristics do not show *MYCN* amplification [5]. A previous report suggests that in non-*MYCN*-amplified unfavorable NB tumors, MYC

rather than MYCN expression is responsible for the aggressive phenotype [6].

Current treatment for high-risk NB includes high dosage cytotoxic chemotherapy or myeloa‐ blative cytotoxic therapy with autologous hematopoietic stem cell transplantation [7]. Late relapse is often seen in patients with high-risk NB despite achieving a complete clinical remission. A subset of high-risk NBs, which is refractory to current front-line therapy designed for high-risk NB, is termed ultra high-risk NB [8, 9]. These tumors are totally unresponsive to current therapies, and thus reliable diagnostic tools to identify ultra high-risk NB prior to

and reproduction in any medium, provided the original work is properly cited.

© 2013 Tang and Shimada; licensee InTech. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2013 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

Xao X. Tang and Hiroyuki Shimada

http://dx.doi.org/10.5772/56254

**1. Introduction**

Additional information is available at the end of the chapter
