Proposed mechanism of action of palbociclib and dinaciclib in PAH.

Multiple growth factors,

cytokines, and mitogens induce the activation of cyclindependent kinases (CDKs), e.g., by increasing
the expression of cyclin D1. Palbociclib specifically targets active complexes consisting of cyclin D1
and CDK4 or CDK6, whereas dinaciclib blocks the activity of the cyclin E-CDK2 complex. This leads to
reduced levels of phosphorylated Rb protein and, as a consequence, transcriptional repression of
E2F downstream target genes, e.g., Cyclin A2, CDK1, and PCNA. Thus, palbociclib (and dinaciclib)
interfere with cell cycle progression from G1 into S phase, causing a reduction of proliferation of
pulmonary vascular cells

Mekanisme aksi palbociclib dan dinaciclib yang diusulkan di PAH. Beberapa faktor pertumbuhan,
sitokin, dan mitogen menginduksi aktivasi cyclindependent kinase (CDKs), misalnya, dengan
meningkatkan ekspresi cyclin D1. Palbociclib secara khusus menargetkan kompleks aktif yang terdiri
dari cyclin D1 dan CDK4 atau CDK6, sedangkan dinaciclib memblokir aktivitas kompleks cyclin E-
CDK2. Hal ini menyebabkan penurunan kadar protein Rb terfosforilasi dan, sebagai akibatnya,
represi transkripsi gen target hilir E2F, misalnya, Cyclin A2, CDK1, dan PCNA. Jadi, palbociclib (dan
dinaciclib) mengganggu progresi siklus sel dari fase G1 ke fase S, menyebabkan penurunan
proliferasi sel pembuluh darah paru.
Palbociclib, ribociclib dan abemaciclib menghambat kompleks CDK4/cyclin D1 yang bertanggung
jawab atas fosforilasi dan penghambatan produk gen penekan Rb. Hal ini menyebabkan penurunan
kadar protein Rb terfosforilasi dan, sebagai akibatnya, represi transkripsi gen target hilir E2F,
misalnya, Cyclin A2, CDK1, dan PCNA . Ketika Rb terfosforilasi, sel melanjutkan dari G1 ke Fase S dari
siklus sel, mereplikasi DNA dan mempersiapkan mitosis

The cyclin D/cyclin-dependent kinases 4 and 6 (CDK4/6)–retinoblastoma protein (RB) pathway plays
a key role in the proliferation of both normal breast epithelium and breast cancer cells. A strong
rationale for inhibiting CDK4/6 in breast cancers has been present for many years. However, potent
and selective CDK4/6 inhibitors have only recently become available. These agents prevent
phosphorylation of the RB tumor suppressor, thereby invoking cancer cell cycle arrest in G1. CDK4/6
inhibitors have transited rapidly from preclinical studies to the clinical arena, and three have already
been approved for the treatment of advanced, estrogen receptor (ER)-positive breast cancer
patients on account of striking clinical trial results demonstrating substantial improvements in
progression-free survival. ER-positive breast cancers harbor several molecular features that would
predict their sensitivity to CDK4/6 inhibitors. As physicians gain experience with using these agents
in the clinic, new questions arise: are CDK4/6 inhibitors likely to be useful for patients with other
subtypes of breast cancer? Are there other agents that could be effectively combined with CDK4/6
inhibitors, beyond endocrine therapy? Is there a rationale for combining CDK4/6 inhibitors with
novel immune-based therapies? In this review, we describe not only the clinical data available to
date, but also the biology of the CDK4/6 pathway and discuss answers to these questions. In
particular, we highlight that CDK4 and CDK6 govern much more than the cancer cell cycle, and that
their optimal use in the clinic depends on a deeper understanding of the less well characterized
effects of these enzymes.
Jalur cyclin D/cyclin-dependent kinase 4 dan 6 (CDK4/6)-retinoblastoma protein (RB) memainkan
peran kunci dalam proliferasi epitel payudara normal dan sel kanker payudara. Alasan kuat untuk
menghambat CDK4/6 pada kanker payudara telah ada selama bertahun-tahun. Namun, inhibitor
CDK4/6 yang poten dan selektif baru tersedia belakangan ini. Agen-agen ini mencegah fosforilasi
penekan tumor RB, sehingga memicu penghentian siklus sel kanker di G1. Penghambat CDK4/6 telah
berpindah dengan cepat dari studi praklinis ke arena klinis, dan tiga telah disetujui untuk
pengobatan pasien kanker payudara positif reseptor estrogen (ER) tingkat lanjut karena hasil uji
klinis yang mencolok yang menunjukkan peningkatan substansial dalam perkembangan-
kelangsungan hidup gratis. Kanker payudara ER-positif memiliki beberapa fitur molekuler yang akan
memprediksi sensitivitasnya terhadap inhibitor CDK4/6. Ketika dokter memperoleh pengalaman
menggunakan agen ini di klinik, pertanyaan baru muncul: apakah penghambat CDK4/6 mungkin
berguna untuk pasien dengan subtipe kanker payudara lainnya? Apakah ada agen lain yang dapat
secara efektif dikombinasikan dengan inhibitor CDK4/6, di luar terapi endokrin? Apakah ada alasan
untuk menggabungkan inhibitor CDK4/6 dengan terapi berbasis kekebalan baru? Dalam ulasan ini,
kami menjelaskan tidak hanya data klinis yang tersedia hingga saat ini, tetapi juga biologi jalur
CDK4/6 dan mendiskusikan jawaban atas pertanyaan-pertanyaan ini. Secara khusus, kami menyoroti
bahwa CDK4 dan CDK6 mengatur lebih banyak daripada siklus sel kanker, dan bahwa penggunaan
optimal mereka di klinik bergantung pada pemahaman yang lebih dalam tentang efek yang kurang
baik dari enzim ini.
Direct effects of CDK4/6 inhibition on tumor cells. Different CDK4/6i’s inhibit cell growth
and induce cell death. Despite overlapping effects, there are some characteristics unique to a
specific CDKi, such as induction of vacuolization by abemaciclib. b-Gal, beta-galactosidase;
ICD, immunogenic cell death.

Efek langsung dari penghambatan CDK4/6 pada sel tumor. CDK4/6i yang berbeda menghambat
pertumbuhan sel dan menginduksi kematian sel. Meskipun efek tumpang tindih, ada beberapa
karakteristik unik untuk CDKi tertentu, seperti induksi vakuolisasi oleh abemaciclib. b-Gal, beta-
galaktosidase; ICD, kematian sel imunogenik.
Palbociclib, a CDK4/6 inhibitor, has recently been approved for hormone receptor-positive
breast cancer patients. The effects of palbociclib as a treatment for other malignancies,
including hepatocellular carcinoma (HCC), are of great clinical interest and are under active
investigation. Here, we report the effects and a novel mechanism of action of palbociclib in
HCC. We found that palbociclib induced both autophagy and apoptosis in HCC cells through
a mechanism involving 5′ AMP-activated protein kinase (AMPK) activation and protein
phosphatase 5 (PP5) inhibition. Blockade of AMPK signals or ectopic expression of PP5
counteracted the effect of palbociclib, confirming the involvement of the PP5/AMPK axis in
palbociclib-mediated HCC cell death. However, CDK4/6 inhibition by lentivirus-mediated
shRNA expression did not reproduce the effect of palbociclib-treated cells, suggesting that
the anti-HCC effect of palbociclib is independent of CDK4/6. Moreover, two other CDK4/6
inhibitors (ribociclib and abemaciclib) had minimal effects on HCC cell viability and the
PP5/AMPK axis. Palbociclib also demonstrated significant tumor-suppressive activity in a
HCC xenograft model, which was associated with upregulation of pAMPK and PP5
inhibition. Finally, we analyzed 153 HCC clinical samples and found that PP5 expression
was highly tumor specific and was associated with poor clinical features. Taken together, we
conclude that palbociclib exerted antitumor activity against HCC through the PP5/AMPK axis
independent of CDK4/6. Our findings provide a novel mechanistic basis for palbociclib and
reveal the therapeutic potential of targeting PP5/AMPK signaling with a PP5 inhibitor for the
treatment of hepatocellular carcinoma