1. Introduction
The early 2-factor (E2F) family consists of eight key members in humans; E2F1-8, these members have highly similar DNA-binding domains that directly interact with consensus sequences [
1]. The members are categorized into three subgroups based on sequence similarity and functional activity: activator proteins (E2F1-3), atypical repressors (E2F7-8), and canonical repressors (E2F4-6). Each member has distinct expression and functional patterns that align with their subgroup classification [
2,
3]. E2Fs play a crucial role in the cell cycle by forming the core transcriptional axis. In addition to cell cycle regulation, E2Fs also influence various biological pathways that contribute to malignant progression, such as apoptosis, angiogenesis, and metabolism in several cancers including glioblastoma [
4,
5,
6].Growing evidence indicates that elevated expression of E2F family members is significantly associated with malignant progression in multiple tumor types [
7,
8,
9]. Notably, E2F1 and E2F2 are associated with increased expression of pro-angiogenic genes in breast cancer, potentially contributing to a more aggressive phenotype [
10].Recently, the role of E2F8 in cancer has attracted attention due to its aberrant expression, which is associated with angiogenesis and cancer cell proliferation, leading to adverse clinical outcomes in most human cancers [
11]. Therefore, E2F members may serve as promising therapeutic targets and potential biomarkers for specific cancers.
Recent research, including our own, has used miRNA biomarkers and machine learning techniques to classify different subtypes of GBM that respond to Bevacizumab (BVZ) treatment [
12]. BVZ therapy targets vascular endothelial growth factor (VEGF) and inhibits angiogenesis within the tumor. Current opinion suggests that BVZ therapy may prolong progression-free survival (PFS) in GBM treatment, but there is no evidence of its effect on overall survival (OS). However, our observation indicated that the BVZ-responsive subtype of GBM tends to exhibit greater malignancy compared to non-responsive subtypes, resulting in a shorter overall survival of two or three months. It is possible that the effect of BVZ treatmenton is masked by this increased malignancy. Furthermore, some patients with genetic alterations, such as EGFR vIII-positive GBM show better outcomes with BVZ treatment [
13]. Therefore, it is important to accurately classify, treat, and investigate GBM patients.
Despite responding to treatment, including BVZ therapy, most GBM cases eventually relapse. The underlying mechanisms behind this relapse have been extensively studied. After BVZ treatment, glioblastomas can stimulate the growth of tumor vessels by expressing various angiogenic factors such as bFGF (Fibroblast Growth Factor 2) [
14]. In addition, research has shown that post-treatment recurrent GBM is also driven by pre-existing, treatment-resistant stem-like cells present in the tumor microenvironment [
15]. Moreover, genetic reprogramming and differential oncogene activation, and regulation of self-renewal, tumorigenicity, and metastasis in the relapsed tumor cells and their microenvironments contribute to GBM recurrence [
16].By studying these aspects of relapse mechanisms, we can gain a better understanding of GBM development and progression, leading to the identification of new targets and effective treatments.
Previously, our research identified multiple transcription factors, including members of the E2F family, involved in GBM treated with BVZ [
17]. Despite the impact of BVZ on patient prognosis, overall survival (OS) remains unaffected, and tumor recurrence continues to be a major challenge in GBM treatment. Therefore, this study aims to investigate the influence of E2F family members on the malignancy of BVZ-responsive GBM subtypes before and after treatment. The analysis will be based on the clinicopathological characteristics of the patients. The goal of this study is to gain insights into the molecular mechanisms underlying recurrence and progression following BVZ treatment in GBM patients, and to provide potential guidance for future therapeutic and translational research strategies.
4. Discussion and Conclusions
This study focused on the E2Fs family to explore potential relapse mechanisms in patients with GBM who experience remission after BVZ treatment. BVZ treatment has been shown to have significant impact on transcription factors and their hub genes, including E2Fs, which promoted our investigation. By analyzing clinicopathological characteristics and utilizing machine learning bioinformatics approaches, we gained insights and identified targets related to angiogenesis and proliferation through E2F8 regulation after BVZ treatment. Most importantly, BVZ therapy may worsen disease progression in patients with unresponsive GBM because of increased VEGF expression. Additionally, we have identified the involvement of STUB1 and YWHAQ, suggesting that their potential roles in GBM recurrence and progression in patients who are responsive to BVZ treatment. These findings may guide future therapeutic strategies. However, further experimentation is needed to confirm these results derived from bioinformatics and artificial intelligence analyses.
Previous studies have indicated that E2F7 and E2F8, both considered as atypical E2Fs, function as transcriptional regulators of VEGF expression [
27]. Specifically, they directly bind to and stimulate the VEGF promoter, independent of canonical E2F binding elements, thereby controlling angiogenesis. BVZ, an antibody that neutralizes and inhibits VEGF, thus suppressing angiogenesis, has been found to potentially increase E2F8 expression. This increase in E2F8 expression may reduce the effectiveness of BVZ treatment, rapidly restore VEGF expression and angiogenesis, and increase its hazard of risk, which is lower than that of other E2Fs before treatment. However, the underlying mechanisms responsible for BVZ enhancing E2F8 expression remain unknown. Furthermore, studies on mouse and zebrafish with non-functional E2F7/8 mutant have demonstrated varying degree of defects in angiogenesis and apoptosis, highlighting the crucial role of E2F7/8 in angiogenesis. In mouse model, the inhibition of E2F8 has been shown to suppress the development of various tumors by inhibiting angiogenesis [
28]. Therefore, incorporating E2F8 inhibition into BVZ therapy may potentially enhance the inhibition of angiogenesis and lead to improved treatment efficiency.
E2F8 plays a significant role in cancer by affecting the proliferation and differentiation of cancer stem cells (CSCs). CSCs are a small group of cancer cells that can self-renew and give rise to a diverse lineage of tumor-forming cells. They are largely responsible for tumor growth, progression, and recurrence [
29]. Studies have shown that E2F8 is upregulated in various cancers, including glioblastoma, ovarian cancer, and hepatocellular carcinoma, where it promotes cell proliferation and other effects [
11,
30]. Moreover, the regulation of E2F8 throughout the cell cycle demonstrates extensive coordination between phosphorylation, ubiquitination, and transcription in the mammalian cell cycle. E2F8 is involved in the regulation of cyclin D1 and promotes the accumulation of S-phase cells in hepatocellular carcinoma, further highlighting its role in cell proliferation [
31].Additionally, E2F8 is one of the E2F family of transcription factors and is crucial for various cellular processes, including those associated with cancer stem cells [
3]. Therefore, targeting E2F8may present a promising therapeutic approach to disrupt cancer stem cells and hinder tumor growth and progression.
MicroRNAs, as post-transcriptional regulators, play a vital role in the initiation, recurrence, and progression of GBM [
32,
33,
34], particularly let-7a, which regulates cancer stemness [
35]. In this study, we found that let-7a is involved in the E2F8 regulated network after BVZ treatment in its responded patients. Generally, highly expressed miRNAs act as negative regulators; however, it has been reported thatlet-7 expression levels were significantly reduced in tumor initiating cells (TICs) but increased in differentiated tumor cells in breast cancer [
36]. In tumor cells, Inhibiting let-7 by antisense oligonucleotides enhanced the self-renewal capacity of the cells, indicating the role of let-7 in suppressing tumorigenicity by downregulating CSC properties. On the other hand, CSCs have a strong ability to adapt their metabolism to survive and proliferate under adverse environmental conditions like hypoxia and acidosis because cancer cells heavily rely on glycolytic fermentation for energy metabolism even when oxygen is available. Related studies have shown that the let-7/Lin28 axis regulates cancer progression and CSC activity through aerobic glycolysis in hepatocellular carcinoma cells (HCC) with high Lin28 and low let-7 expression [
37].This suggests that the miRNA let-7 may also be a target to block or inhibit GBM recurrence by inhibiting CSC growth.
Furthermore, STUB1, an E3 ligase, plays a vital role in cancer by regulating multiple pathways and participating in the E2F8 regulatory network. The study reveals that STUB1 inhibitors suppress interferon gamma (IFNγ) responses by degrading IFNγ receptor 1 (IFNGR1). As a result, STUB1 inhibitors enhance tumor response to checkpoint immunotherapy[
38]. Additional studies demonstrate that in lung cancer, knocking down STUB1 increases the likelihood of metastasis to the lungs of mice when injected intravenously or subcutaneously. In breast and lung cancer, STUB1 interacts with various proteins through its ubiquitination-dependent proteasome activity. It acts as a negative regulator associated with different proteins, affecting cell cycle progression and metastasis [
39,
40].
YWHAQ belongs to the 14-3-3 (YWHA) proteins, which are phospho-serine/-threonine binding proteins that are highly conserved and participate in many important cellular processes, including metabolism, protein transport, signal transduction, apoptosis and cell cycle regulation. YWHAQ is upregulated in patients with amyotrophic lateral sclerosis (ALS) [
41]. While its expression in cancer has not been extensively reported, other members of the family have been studied in cancer. For example, YWHAZ, also known as 14-3-3ζ, is frequently upregulated in various cancers and acts as an oncogene, promoting tumor progression through multiple cellular activities. In breast cancer tissues, the expression levels of DAAM1(Dishevelled-associated activator of morphogenesis 1) and YWHAZ were significantly upregulated and colocalized, with YWHAZ binding to DAAM at its phosphorylated site regulating cancer cell migration and strongly associated with poor prognosis [
42]. The World Health Organization (WHO) now recognizes four categories of endometrial stromal tumor, with YWHAE, another 14-3-3 protein, translocation identifying high-grade endometrial stromal sarcoma (HG-ESSs). This highlights the impact of the YWHA family in molecular genetics in cancer and supports for a new classification system [
43].
Accurate BVZ treatment is highly recommended. Our previous study showed that BVZ treatment in its unresponsive patients of GBM resulted in multiple side effects, including aging [
17]. In this study, we found that BVZ treatment is most likely to increase VEGF expression, particularly in patients with BVZ unresponsive GBM. This increase may lead to GBM recurrence and affect the OS of GBM patients treated with BVZ.
In conclusion, a closer examination of E2F members provides new insights into the mechanisms of glioblastoma recurrence after bevacizumab (BVZ) treatment, specifically associated with E2F8. However, there is still much more to explore. It is important to note that although the E2F family positively influences angiogenesis, proliferation, and cancer progression, they also regulate some negative regulators or tumor suppressors. This results in complex regulation of tumor growth and diverse responses to cancer treatments. Therefore, targeting hub genes like E2F8 or multiple targets simultaneously may yield favorable outcomes in cancer treatment.