REVIEW

The Vicious Cycle Between α-Synuclein Aggregation and

Autophagic-Lysosomal Dysfunction
Giovanni Bellomo, PhD,1 Silvia Paciotti, PhD,2,3 Leonardo Gatticchi, PhD,3 and Lucilla Parnetti, MD, PhD2*

1
Magnetic Resonance Center (CERM), University of Florence, Sesto Fiorentino (FI), Italy
2
Laboratory of Clinical Neurochemistry, Section of Neurology, University of Perugia, Perugia (PG), Italy
3
Department of Experimental Medicine, University of Perugia, Perugia (PG), Italy

A B S T R A C T : The accumulation and misfolding of pathway dysfunctions’ role in the pathogenesis and pro-
α-synuclein (α-syn) represent the main pathological hall- gression of synucleinopathies opened new perspectives
mark of PD. Overexpression of α-syn and failure of cellu- for novel possible therapeutic strategies. In this article,
lar protein degradation systems play a major role in the evidences and mechanisms of the reciprocal rela-
α-syn aggregation. The discovery of PD-associated genes tion between autophagic-lysosomal pathway impair-
related to the autophagic-lysosomal pathway, such as ment and misfolded α-syn aggregation and propagation
VPS35, LRRK2, GBA1, SMPD1, GALC, ASAH1, SCARB2, are reviewed, together with the most promising com-
CTSD, CTSB, and GLA, confirms the involvement of cellu- pounds targeting autophagic-lysosomal pathway resto-
lar clearance systems dysfunction in PD pathogenesis. Of ration as a disease-modifying strategy for PD treatment.
importance, lysosomal enzyme activity is altered both in © 2019 International Parkinson and Movement Disorder
genetic and sporadic PD. Decreased lysosomal enzymes Society
activities were measured in the same brain regions where
α-syn accumulates, suggesting that a crosstalk between Key Words: alpha-synuclein; Parkinson’s disease; lyso-
α-syn aggregation and autophagic-lysosomal impairment some; GCase; cathepsin-D; autophagy
may exist. The understanding of autophagic-lysosomal

Parkinson’s disease (PD) is an age-related neurodegen- elements.2 Although the presence of LBs in SN has been
erative disease with a complex etiology and varying associated to the death of dopaminergic neurons,3,4
clinical manifestations. The accumulation, misfolding, smaller aggregates rather than LBs, like protofibrils and
and aggregation of the intrinsically disordered protein, soluble oligomers, are currently considered to be the
α-synuclein (α-syn), and its progressive deposition in most toxic species in the amyloidogenic pathway of
large intracellular aggregates, named Lewy bodies (LBs), α-syn.5-7 Among the causes of uncontrolled α-syn accu-
represent the main pathological hallmark of most genetic mulation and aggregation, overexpression of α-syn and
and sporadic forms of PD.1 These inclusions were failure of cellular protein degradation systems play a
recently found to wrap and encase vesicles, lysosomes, major role.8 Mutations in genes associated to the
dysmorphic mitochondria, and disrupted cytoskeletal autophagic-lysosomal pathway (ALP) are recognized as
genetic causes or risks factors for PD onset.9 Autophagy
-*Correspondence
- - - - - - - - - - - - - - -to:- - Prof.
- - - - Lucilla
- - - - - -Parnetti,
- - - - - - -Laboratory
- - - - - - - - -of- -Clinical
- - - - - -Neu-
----- is a catabolic process in which dysfunctional cytoplasmic
components (organelles and proteins) are rerouted
rochemistry, Section of Neurology, University of Perugia, Piazzale Lucio
Severi 1/8, 06132 Perugia (PG), Italy; E-mail: lucilla.parnetti@unipg.it toward the lysosomal environment for degradation.
Relevant conflicts of interest/financial disclosures: Nothing to Three types of autophagy have been identified based on
report. the pathway by which the substrates reach the lysosomal
Full financial disclosures and author roles may be found in the online compartment: macroautophagy, microautophagy, and
version of this article. chaperone-mediated autophagy (CMA).10
Received: 17 June 2019; Revised: 31 August 2019; Accepted: 27 Sep- Macroautophagy is the most well-established type of
tember 2019 autophagy, which is characterized by the formation of
Published online 15 November 2019 in Wiley Online Library double-membrane vesicles (autophagosomes) enclosing
(wileyonlinelibrary.com). DOI: 10.1002/mds.27895 bulky materials. Autophagosomes fuse with lysosomes

34 Movement Disorders, Vol. 35, No. 1, 2020

 α- S Y N U C L E I N A N D A U T O P H A G I C - L Y S O S O M A L
and release their content into the lysosomal lumen,
where acid hydrolases have the task of degrading it. The
master regulator of this process is mTOR (mammalian
target of rapamycin), a 298-kDa serine/threonine kinase,
which negatively modulates macroautophagy through
the regulation of autophagy-related genes (Atg-genes).
An mTOR-dependent pathway also inhibits the translo-
cation from the cytosol to the nucleus of transcriptional
factor EB (TFEB),11,12 which plays a prominent role in
the biogenesis and function of lysosomes.
In microautophagy, cytosolic substrates are directly
taken up by the lysosomes and released onto the lyso-
somal lumen.
Differently from macroautophagy and microautophagy,
CMA is a highly selective catabolic process. Only specific
soluble cytosolic proteins containing a KFERQ-like
amino-acidic sequence are brought to the lysosomes by
CMA. Tagged proteins are recognized by a chaperone
complex involving the heat shock cognate protein of
70 kDa (Hsc70). The complex is translocated to the lyso-
somes and internalized by the lysosomal-associated mem-
brane protein 2a (LAMP2a) receptor. Macroautophagy
and CMA are major degradation pathways for α-syn13,14;
therefore, the knowledge of the relation between α-syn
misfolding and ALP dysfunctions may provide new
insights in the pathogenesis of synucleinopathies and in
the discovery of novel therapeutic targets.
Mutations in Genes Encoding
Autophagic-Lysosomal Proteins
Interfere with PD Pathogenic
Mechanisms
Genetic forms of PD are associated to variants in sev-
eral genes, which range from highly penetrant rare
familial mutations, considered causative of PD (SNCA,
PRKN, LRRK2, PINK1, DJ-1, and VPS35)15 to com-
mon genetic risk factors and genes that confer suscepti-
bility to PD (GBA1, SMPD1, GALC, ASAH1,
SCARB2, CTSD, CTSB, and GLA).15-19 The protein
products of some of these genes play pivotal roles in
regulating autophagy-lysosome function and vesicular
trafficking. Moreover, mutations on some of these regu-
lators has been demonstrated to directly or indirectly
favor α-syn accumulation processes.20-22
In particular, the identification of familial cases with
multiplications of SNCA (the gene encoding for α-syn)
revealed a strong correlation between α-syn accumula-
tion and aggregation, and disease severity.23-25 Although
the physiological role of α-syn is not fully characterized,
it has been shown that it plays important roles in the
supply of synaptic vesicles in presynaptic terminals26,27
and in the movement of microtubules.28,29
V I C I O U S C Y C L E
VPS35 encodes vacuolar protein sorting-associated
protein 35, which is involved in the endosomal-lysosomal
trafficking associated to autophagy. Mutations on VPS35
cause a rare form of autosomal-dominant PD.30 Another
gene which has been defined causative of PD is LRRK2,
which encodes for leucine-rich repeat kinase 2 (LRRK2).
Mutations on LRRK2 are the most common known
genetic causes for PD. The most prevalent pathogenic
mutation, G2019S, increases LRRK2 kinase activity and
impairs the autophagy process, leading to a significant
accumulation of α-syn, as assessed by in in vitro and
in vivo experiments.31-33
GBA1 gene encodes for β-glucocerebrosidase (GCase), a
lysosomal acidic hydrolase involved in glycosphingolipid
catabolism. Whereas GBA1 homozygous mutations cause
Gaucher’s disease (GD), a lysosomal storage disorder, het-
erozygous GBA1 mutation carriers have a 5- to 6-fold
increased risk to develop PD.34 Some researchers suggest
that GBA1 mutations should be considered causative fac-
tors for PD.35 However, the penetrance of PD in GBA1
mutation carriers is low: 7.6%, 13.7%, 21.4%, and
29.7% at 50, 60, 70, and 80 years, under a dominant
model, with no relevant differences among N370S carriers,
L444P carriers, and carriers of rarer mutations.35 This
incomplete penetrance suggests that other genetic and/or
environmental factors are necessary for carriers of GBA1
mutations to manifest α-syn oligomerization and to
develop PD.36 However, a more severe disease phenotype
has been associated to the burden of carried GBA1
mutations.37,38
Recently, variants in other lysosomal genes, even
from the same pathway of GBA1, were also associated
with PD susceptibility.9
Single-nucleotide polymorphisms (SNPs) on SCARB2,
which encodes for lysosomal integral membrane protein
2 (LIMP-2), a protein responsible for GCase trafficking,
have been also shown to be linked to the onset of LB
pathologies.39,40 Although no relevant changes in GCase
activities were recently found in dried blood spots of PD
patients carrying SCARB2 SNPs versus controls,41
homozygous mutations are known to be responsible for
the onset of lysosomal disorders with a systemic reduc-
tion in GCase activity.42 Conversely, overexpression of
LIMP-2 enhanced α-syn clearance and improved lyso-
somal activity of GCase in different cell lines over-
expressing α-syn.43
α-Syn degradation can be achieved following two
main degradative routes, that is, ALP44-48 and ubiquitin-
proteasome system.44,49 Variants in genes, which induce
dysfunction at multiple levels of ALP, gradually lead to
the impairment of protein degradation that may favor
the development of PD. This mechanism creates a
vicious cycle linking α-syn accumulation to ALP dys-
function and vice versa. The causal links among GBA1
and other ALP-related mutations, PD, and α-syn
decreased clearance are still unclear and currently under
Movement Disorders, Vol. 35, No. 1, 2020 35
B E L L O M O E T A L
investigation; some hypotheses, based on recent scientific
evidences, are described below.
The issue of ALP Alterations in
Sporadic PD
To date, familiar forms of PD account for only approxi-
mately 5% of patients. GBA1 mutations, which confer
susceptibility to develop PD, are the most common
genetic risk factors and account for 10% to 15%, a per-
centage that increases to 25% in the Ashkenazi Jewish
population.15,50,51 In PD, sporadic forms represent the
vast majority, being the consequence of the aging process
itself and the combination of harmful environmental fac-
tors added on a susceptible genetic background. Such
convergence of factors leads to an ineffective response
against the accumulation and aggregation of α-syn.52 Of
importance, the activity of some lysosomal enzymes is
found significantly reduced in PD versus controls both in
the presence and in absence of genetic risk factors. Two
studies carried out between 200753 and 200954 showed
decreased activities of GCase in cerebrospinal fluid (CSF)
of PD and DLB (dementia with Lewy bodies) patients
with respect to controls. Subsequent observations in
larger series55,56 not only confirmed the decrease of CSF
GCase activity, but also showed the reduction of
cathepsin-D (CTSD), independently of the GBA1 carrier
status. The reduced activity of GCase in biofluids of both
GBA1 mutation carriers and sporadic PD patients has
been observed also in dried blood spots.37
Similarly, reduced activity of the lysosomal enzyme,
α-galactosidase A (α-Gal A; deficient in Fabry’s disease),
was found in dried blood spots of PD patients com-
pared to controls, both excluding GBA1 and LRRK2
G2019S mutation carriers and considering the entire
cohort.57 Decreased activities of α-Gal A have been also
measured in the leukocytes of sporadic PD patients.58
In brain tissue, GCase activity and content have been
shown to be reduced in the SN and other brain regions in
different studies, both in GBA1 mutation carriers and
sporadic PD patients.59-61 Importantly, Murphy and col-
leagues60 showed that the reduced activity is more evident
at the early PD stage, and that the brain regions in which
GCase activity is most affected are also those in which
α-syn accumulates the most. Chiasserini and colleagues62
reported decreased GCase activity in brain tissues of non-
GBA1-mutation carrier PD and DLB patients, with the
SN and caudate being the most affected regions. Reduced
GCase activity was also found in the cingulate cortex of
PD patients without GBA1 mutations.63 Moors and col-
leagues61 found significantly decreased GCase activity in
the SN of both PD and DLB patients; a similar, though
not significant, trend was also observed in the frontal cor-
tex and putamen. In this series, CTSD activity was signifi-
cantly decreased in the frontal cortex of DLB and PD
36 Movement Disorders, Vol. 35, No. 1, 2020
patients, both in GBA1 mutation carriers and noncar-
riers. Decreased levels of LAMP1, CTSD, and heat shock
protein 73 were also observed in PD nigral neurons when
compared to age-matched controls.64 This decrease was
significantly greater in nigral neurons that contained
α-syn inclusions. This pattern was recapitulated in rats
with targeted overexpression of mutant α-syn in the SN,
which resulted in dopamine cell loss with α-syn inclu-
sions. Significantly reduced α-Gal A and CTSD activities
were found in temporal cortex of PD patients in advanced
stage. The activities of these two enzymes were inversely
correlated with levels of p129S–α-syn and high-molecu-
lar-weight (hMW) α-syn species.65 Of importance, also
cathepsin-B (CTSB) activity correlated negatively with
α-syn hMW species.65 In SN and amygdala of sporadic
PD patients, HSC70 and LAMP2A were found signifi-
cantly reduced with respect to both controls and
Alzheimer’s disease patients.66 Reduction of LAMP2A
protein was also observed in early-stage PD anterior cin-
gulate cortex. Lower levels LAMP2A directly correlated
with the increased levels of α-syn and decreased levels of
HSC70 in the same PD samples, as well as with the accu-
mulation of cytosolic CMA substrate proteins.67 In the
SN of PD patients, decreased levels of LAMP1 and
increased levels of the autophagosomal marker, light
chain 3 (LC3)-II, were also found.64,68 LC3 colocalized
with α-syn in the halo of LB, and it was also detected in
α-syn-positive Lewy neurites. Increased levels of mTOR
protein were found in the temporal cortex of patients
with DLB, particularly in neurons displaying α-syn accu-
mulation.69 The evidence of decreased activity/levels of
different lysosomal enzymes and lysosome-associated pro-
teins in sporadic PD, concomitantly to α-syn accumula-
tion in the same brain regions,60,64,65 seems to indicate a
relationship between lysosomal enzymes failure and
synucleinopathies.
Dysfunction of the ALP Pathway Leads to
Aggregation and Propagation of Misfolded
α-Syn in Cellular and Animal Models
In several animal models, as well as in patients affected
by lysosomal storage disorders, such as GD, GM2
gangliosidosis, Niemann-Pick type C, β-galactosialidosis,
NCL10, and Krabbe’s disease, α-syn accumulation has
been observed.70-72 Moreover, in GD patients, levels of
plasma oligomeric α-syn were found higher with respect
to controls73 and negatively associated with leucocyte
GCase activity.74 Increased plasma oligomeric α-syn
levels were also found in a small group of patients
affected by rarer lysosomal storage disorders, namely
Niemann-Pick type C1 and C2 disease, Krabbe’s dis-
ease, and Wolman’s disease.73
In cellular models (non-neuronal cells, differentiated
neuroblastoma cells, and primary cortical neurons),
blocking the ALP with bafilomycin A1 results in the
 α- S Y N U C L E I N A N D
accumulation of α-syn aggregates.44,75 Similarly, inhibi-
tion of macroautophagy by 3-methyladenine led to an
increase of both endogenous and overexpressed wild-
type (WT) α-syn in PC12 cells.13 Increased monomeric
and aggregated α-syn levels were also found in an
Atg7-depleted mouse model.76,77
α-Syn accumulation was also observed in dopaminer-
gic neurons of VPS35 mutant mice.78 Experiments car-
ried out in neuroblastoma cells showed that expression
of the R524W VPS35 mutant strongly impairs recruit-
ment of retromer-dependent interacting proteins and the
trafficking of cation-independent mannose-6-phosphate
receptor, which resulted in higher levels of α-syn-positive
aggregates when compared to WT or P316S VPS35.79
Also β-hexosaminidase (β-hex) activity seems to influ-
ence α-syn clearance. In a mouse model of Sandhoff dis-
ease, α-syn accumulation in neurons was observed
along with the accumulation GM2 ganglioside.80
Among all the lysosomal enzymes, cathepsins have been
found to be directly involved in the degradation of
monomeric and aggregated α-syn.48,81-84 In particular,
membrane-bound CTSD is able to fully degrade mono-
meric and aggregated α-syn, whereas CTSB and cathepsin-
L (CTSL) can degrade α-syn monomers and fibrils in their
free state.48 However, in murine models overexpressing
A53T α-syn, the latter degradation pathway (CTSB and
CTSL) has recently shown to produce highly aggregation-
prone C-terminus truncated forms of α-syn.85
GCase is not directly involved in α-syn degradation, but
its reduced activity/availability promotes the accumulation
and aggregation of α-syn in different cellular cultures and
animal models.63,86-89 Mazzulli and colleagues63 demon-
strated, in human cortical neurons, that GCase depletion
compromises protein degradation capacity, leading to
FIG. 1. (A) Graphical summary of the mechanisms by which GCase dysfunctions may lead to misfolded α-syn aggregation and propagation.
(B) Putative mechanisms by which α-syn aggregates may impair GCase activity leading to a bidirectional pathogenic loop. [Color figure can be viewed
at wileyonlinelibrary.com]
A U T O P H A G I C - L Y S O S O M A L V I C I O U S C Y C L E
increased α-syn levels. Furthermore, GCase knockdown
and concomitant expression of WT α-syn and A53T α-syn
enhanced α-syn-mediated neurotoxicity through formation
of soluble and insoluble hMW species. A fibrillization-
incompetent mutant (Δ71-82 α-syn) also accumulated, but
showed no toxicity. Accumulation of both soluble and
oligomeric insoluble α-syn was observed also in brains of
GD mouse models (4L/PS-NA), as compared to WT mice.
In GD patients, α-syn dimer/monomer ratio positively cor-
related with levels of glucosylceramide (GlcCer, the GCase
substrate) and the glucosylceramide/ceramide (GlcCer/Cer,
Cer is the GCase product) ratio in red blood cells.90 GlcCer
stabilizes toxic oligomeric α-syn intermediates,63,91-93
which have been shown to diffuse through membranes94
and to inhibit the opening of the proteasome gate.95 These
features may be relevant for the cell-to-cell transmission of
aggregates and protein misfolding cascade.
About the link between GCase reduced activity and
α-syn accumulation, another putative causal factor might
be represented by the reduction of ceramide (Cer) levels
in endosomal and lysosomal compartments, as a conse-
quence of GCase failure. Given that Cer binds CTSD and
triggers its cleavage to the catalytic active form,96,97 lower
levels of Cer may also lead to a decreased capacity of the
lysosome to degrade α-syn98; this mechanism is schema-
tized in Figure 1. Altered Cer levels have been found in
PD. In particular, Cer levels were increased in plasma
samples of PD patients with respect to controls.99-101
Conversely, lower levels of Cer as well as its altered chain
composition have been described in the anterior cingulate
cortex of PD patients with respect to controls.60,102 As a
support for this link between Cer and PD, the inhibition
of acid ceramidase (encoded by ASAH1) by carmofur
resulted in increased Cer levels in GCase-deficient cells as
Movement Disorders, Vol. 35, No. 1, 2020 37
B E L L O M O E T A L
well as reduced α-syn levels in GBA1-PD–derived dopa-
minergic neurons.103 It is also worthy to note that vari-
ants of acid sphingomyelinase (aSMase; encoded by
SMPD1)98,104-106 and galactosylceramidase (GALC)17 are
recognized as susceptibility factors for PD and other syn-
ucleinopathies. Together with GCase, these two enzymes
catalyze the production of Cer within the lysosome.
aSMase belongs to the sphingomyelinase family, responsi-
ble for catalyzing the breakdown of sphingomyelin to Cer
and phosphorylcholine. A recent study showed that
reduced aSMase activity in blood samples is associated to
a 3.5- to 5.8-year earlier onset of PD.107
GALC catalyzes the hydrolysis of different substrates
(i.e., galactosylceramide and galactosylsphingosine).
Galactosylsphingosine levels were higher in the cerebral
cortex of PD patients compared to age-matched con-
trols.71 Furthermore, in vitro experiments have shown
that galactosylsphingosine accelerates aggregation of
α-syn in a dose-dependent manner.108
Thus, in PD, low activity of GCase, aSMase, and
GALC, by decreasing Cer levels, may cause a mild reduc-
tion of CTSD activity. As a consequence, the slowdown
in α-syn degradation may favor its accumulation in cyto-
plasm, endosomes, and lysosomes.109,110 In lysosomes,
acidic pH further promotes α-syn aggregation.111,112
Together with α-syn accumulation, ALP dysfunctions
have also been demonstrated to promote the exocytosis
and cell-to-cell propagation of α-syn aggregates.110,113-118
α-Syn exocytosis has been shown to be related to a
bafilomycin A1–sensitive autophagy pathway in human
neuroblastoma and primary neuron cell lines113,114 and
by inhibition of macroautophagy in immortalized
human neuronal cells.116 Depletion of GCase and the
haploinsufficiency of CTSD in human neuroblastoma
also promoted the secretion of vesicles containing
aggregated α-syn.117,118 These exosomes demonstrated
to be able to transfer aggregates from one cell to another
with high efficiency.114 Moreover, both internalization of
free exogenous extracellular α-syn aggregates in neuronal
cells and accumulation in lysosomes has been confirmed
and characterized.110,115 The enhancement of aggregated
α-syn exocytosis may represent a compensatory mecha-
nism aimed at reducing the intracellular α-syn burden to
prevent neuronal cell death.116 On the other hand, ALP
dysfunctions may also contribute in the progressive
spreading of α-syn misfolding pathology by promoting
recurring cycles of release and uptake of oligomeric and
fibrillar α-syn, leading to a prion-like propagation.47,119
Internalization and Aggregation of Misfolded
α-Syn Leads to Dysfunction of the ALP in
Cellular and Animal Models
As a complementary mechanism mirroring what is
described in the previous section, the internaliza-
tion110,115 and/or accumulation of misfolded α-syn may
38 Movement Disorders, Vol. 35, No. 1, 2020
impair ALP functioning, thus leading to a positive feed-
back loop forward α-syn aggregation.46 In mammalian
cells and in transgenic mice, overexpression of WT and
both A30P and A53T mutated α-syn leads to inhibition
of macroautophagy,120,121 which is caused by a reduc-
tion in autophagosome formation through α-syn/Rab1a
interaction.120 Furthermore, in α-syn transgenic mice,
intracerebral infusion of rapamycin, an inhibitor of
mTOR, resulted in reduced accumulation of α-syn and
in amelioration of associated neurodegenerative alter-
ations.69 Interestingly, the A30P and A53P mutated
α-syn forms bind LAMP2A with higher affinity with
respect to WT α-syn.13,66,122 Binding of mutated α-syn
with LAMP2A blocks CMA with the consequent accu-
mulation of hMW α-syn and formation of insoluble
α-syn oligomers.13 Similarly, also post-translational
modifications of α-syn alter its clearance. The most
prominent effects were caused by phosphorylation and
exposure to dopamine, whereas oxidation and nitration
only slightly alter CMA processes.123
In 2011, Mazzulli and colleagues63 demonstrated that
expression of both WT and A53T α-syn in H4 neuro-
glioma cells, human GD dopaminergic neurons and pri-
mary cortical neurons resulted in a significant decrease
in GCase activity compared to controls, which pro-
voked substrate accumulation and enlargement of lyso-
somes. Conversely, in the same study, expression of a
fibrillization incompetent mutant (Δ71-82 α-syn) did
not affect GCase lysosomal activity. The cause of the
decreased activity may be addressed to an impaired
trafficking of GCase (attributable to the accumulation
of α-syn) through the endoplasmic reticulum/Golgi
apparatus that impedes its correct localization in the
lysosome. This mechanism was observed both in H4
cells63 and in SH-SY5Y cells overexpressing α-syn.59
Subsequently, in a series of investigations, the direct
interaction between monomeric α-syn and GCase was
demonstrated in vitro.124-126 The GCase-α-syn complex
was shown to decrease GCase activity in lysosome-like
environments. However, no information is available
about the possible direct interaction between GCase
and α-syn fibrils or oligomers.
The inhibition of ALP attributable to WT-α-syn was
further investigated: by exposing HEK293 mammalian
cells, and primary cortical neurons from α-syn
expressing mice, to prefibrillar α-syn aggregates, the
obtained LB-like structures could not be degraded by
the ALP because of failure of autophagosomes clear-
ance.127 Accumulation of α-syn aggregates was also
shown to cause lysosome rupture in human glioblas-
toma cell lines,109 probably as a consequence of exces-
sive substrate accumulation as well as the pore-forming
ability of α-syn oligomers.94,128 Recently, α-syn-
triggered ALP dysfunction has been reported also by
Hoffmann and colleagues.110 According to this investi-
gation, ALP can be impaired by exposure to exogenous
 α- S Y N U C L E I N A N D A U T O P H A G I C - L Y S O S O M A L
oligomeric and fibrillar α-syn both in human glioblas-
toma H4 cells and in rat primary neurons. Accumulation
of α-syn aggregates within the lysosomal environment
resulted in reduced CTSD activity and enlargement of
lysosomes. As hypothesized in the previous paragraph, in
GBA1-, GALC-, and SMPD1-related PD, decreased
CTSD activity may also be an indirect effect, given that
the lack of Cer may compromise the activity and
post-translational maturation of CTSD.96,97 Taken
together, these findings support the hypothesis that PD
onset may be linked to ALP dysfunction, leading to α-syn
accumulation/aggregation and vice versa.
The ALP as a Possible Therapeutic
Target For PD
Several compounds activating the autophagic cascade
have been shown to reduce α-syn toxicity in cellular
and animal models.129 Interesting results have been
obtained by using trehalose, a disaccharide able to acti-
vate autophagy processes130-132 and regulate the activ-
ity of TFEB, the main transcriptional regulator of the
coordinated lysosomal expression and regulation net-
work.133,134 The therapeutic effects of trehalose have
been demonstrated in several in vitro and in vivo
models of PD and other neurodegenerative dis-
eases.110,133,135-140 Hoffman and colleagues showed
that exposure of H4 cells and primary neurons to treha-
lose, before α-syn exposure, prevents lysosomal enlarge-
ment and formation of massive α-syn aggregates.110,141
In rats overexpressing A53T α-syn, oral administration
of trehalose significantly reduced α-syn accumulation
and aggregation in the nigrostriatal system and miti-
gated motor asymmetry142 and dopaminergic neurons
neurodegeneration.139 Similar effects were observed in
a neurotoxin MPTP-induced PD mouse model.140
Recently, trehalose has been tested in parallel on rat
and nonhuman primate PD models overexpressing
A53T α-syn.143 In both models, trehalose prevented the
development of striatal dopamine loss and behavioral
deficits. Considering the safety of trehalose in
humans144 and its long half-life in the brain, where
levels of trehalase are low,145 further investigations
aimed at evaluating the efficacy of this disaccharide in
PD treatment and/or prevention are recommended.
The therapeutic potential of overexpressing proteins
actively involved in the ALP has also been evaluated.
Both the overexpression and chemical activation of
TFEB in H4 cells and in rats overexpressing α-syn
decreased the formation of α-syn oligomers146 and
protected midbrain dopaminergic neurons from α-syn
toxicity.147 Similarly, overexpression of LAMP2 in rats
and cellular models of PD restored CMA, reduced
α-syn aggregated species, and increased the viability of
V I C I O U S C Y C L E
neurons located in the SN as well as the axon terminals
located in the striatum.45
Recently, a mitochondrial pyruvate carrier (MPC) inhibi-
tor, MSDC-0160, has been also tested in different models of
PD.148 In an α-syn-based Caenorhabditis elegans model,
MSDC-0160 reduced α-syn toxicity, preventing neuronal
loss. In mice treated with 1-methyl-4-phenylpyridinium
(MPP+), MSDC-0160 modulated mTOR signaling and
protected against the insult caused by this neurotoxin.148
Furthermore, in MPTP-treated mice, administration of
MSDC-0160 protected nigrostriatal neurons, reduced neu-
roinflammation, and improved locomotor behavior. Similar
results were also obtained in a slowly progressive Engrailed1
(En1+/−) genetic mouse model of PD, where the long-term
targeting of MPC preserved motor function, rescued the
nigrostriatal pathway, and reduced neuroinflammation.148
Some studies have also investigated the effects of
Abelson tyrosine kinase (c-Abl) inhibition on Beclin-
1-mediated autophagic α-syn clearance, throughout
treatment with Nilotinib, which is usually used in
patients with Philadelphia chromosome–positive chronic
myelogenous leukemia.149,150 Nilotinib appeared to be
potentially effective in treating motor and nonmotor
symptoms in patients with PD and DLB.151,152 Cur-
rently, two trials investigating safety, pharmacokinetics,
and pharmacodynamics of Nilotinib in patients affected
by PD and PD with dementia (ClinicalTrials.gov ID:
NCT02954978), as well as the ability of this molecule to
pass the blood–brain barrier and to reach its target, are
ongoing (ClinicalTrials.gov ID:NCT03205488).
Given the growing number of findings reporting
decreased GCase activity as a possible cause of
synucleinopathy and neuronal dysfunction observed in
PD, this enzyme got attention as a possible therapeutic
target. Different studies in mouse models of PD showed
that augmentation of GCase activity, throughout
adeno-associated virus–mediated expression of GCase,
reduced α-syn accumulation and protected from α-syn-
induced neurodegeneration by enhancing lysosomal
activity.153,154 However, development of GBA1 gene
therapy as a therapeutic approach for PD must be still
deeper investigated before its clinical use would be
possible.
Small molecular chaperones able to increase GCase
activity are also under investigation. Ambroxol is a
mucolytic agent approved by the European Medicines
Agency, which is able to stabilize and increase GCase
activity by increasing the levels of LIMP-2 and Saposin-
C (GCase cofactor).155 Ambroxol has been shown to
improve α-syn clearance also through the indirect acti-
vation of TFEB.156 To date, an increasing number of
studies have been carried out in different cellular and
animal models to support the therapeutic potential of
Ambroxol as a disease-modifying treatment for syn-
ucleinopathies.157-159 Furthermore, two phase 2 clinical
trials evaluating the safety and efficacy of this drug in
Movement Disorders, Vol. 35, No. 1, 2020 39
B E L L O M O E T A L
PD and PD with dementia patients are currently ongo-
ing (ClinicalTrials.gov ID: NCT02941822 and
NCT02914366).159 Other molecular chaperones, such
as Isofagomine, NCGC758, and NCGC607, seem capa-
ble to increase GCase activity. However, further studies
are needed in order to define their actual efficacy in PD
patients.160-162
Given that accumulation of glycosphingolipids seems to
influence α-syn aggregation,91 substrate reduction has
been suggested as a therapeutic approach alternative to
GCase activation. The use of inhibitors able to block the
activity of the enzyme, glucosylceramide synthase (GCS),
reduces accumulation of glucosylceramide attributed to
GBA1 mutations, reduces accumulation of aggregated
α-syn, and ameliorates behavioral outcomes in mouse
models of synucleinopathy.163 A phase II, double-blind,
placebo-controlled study to assess the safety of the GCS
antagonist, Venglustat (GZ/SAR402671), in early-stage
PD patients carrying the GBA1 mutation is ongoing
(ClinicalTrials.gov ID: NCT02906020).164 This trial will
help in understanding whether GCS inhibition may repre-
sent a suitable strategy for treating PD.
Conclusions and Perspectives
In this review, multiple evidences of the bidirectional
relation between ALP dysfunction and α-syn aggrega-
tion in PD pathogenesis and progression are exposed.
Lysosomal proteins have emerged as promising thera-
peutic targets for PD and other synucleinopathies.
However, the causal link between mutations on GBA1,
SMPD1, GALC, ASAH1, GLA, and SCARB2 and
α-syn accumulation and aggregation is still unclear. In
this review, we considered a hypothesis that takes into
account the effect of Cer, whose levels can be altered by
mutations on some of the cited genes, on the matura-
tion and activation of CTSD that may result in a
decreased degradation of α-syn. Given the inability of
the ALP to degrade the toxic species α-syn, formation
of LB could, in this context, represent a last move of
the cell to store the excess of α-syn and avoid excessive
proteolytic stress.64,165 However, further investigations
are needed to better clarify these aspects. Vice versa,
also the mechanisms of GCase inhibition by α-syn olig-
omers and fibrils should be further investigated to
design new therapies and better understand the link
between lysosomal dysfunctions and sporadic
PD. Clinical trials with compounds able to restore ALP
functions are currently ongoing. More in vitro and
in vivo studies trying to push to the limit of the ability
of lysosomes and lysosomal enzymes to “digest” fibrils
and oligomers or prevent their formation47 are highly
recommended in order to produce further evidence for
the potential of ALP activation as a therapeutic target
for PD treatment.
40 Movement Disorders, Vol. 35, No. 1, 2020
References
1. Spillantini MG, Schmidt ML, Lee VMY, Trojanowski JQ, Jakes R,
Goedert M. α-Synuclein in Lewy bodies. Nature 1997;388:
839–840.
2. Shahmoradian SH, Lewis AJ, Genoud C, et al. Lewy pathology in
Parkinson’s disease consists of crowded organelles and lipid mem-
branes. Nat Neurosci 2019;22:1099–1109.
3. Osterberg VR, Spinelli KJ, Weston LJ, Luk KC, Woltjer RL,
Unni VK. Progressive aggregation of alpha-synuclein and selective
degeneration of lewy inclusion-bearing neurons in a mouse model
of parkinsonism. Cell Rep 2015;10:1252–1260.
4. Rey NL, George S, Steiner JA, et al. Spread of aggregates after
olfactory bulb injection of α-synuclein fibrils is associated with
early neuronal loss and is reduced long term. Acta Neuropathol.
2018;135:65–83.
5. Conway KA, Lee SJ, Rochet JC, Ding TT, Williamson RE,
Lansbury PT. Acceleration of oligomerization, not fibrillization, is
a shared property of both α-synuclein mutations linked to early-
onset Parkinson’s disease: Implications for pathogenesis and ther-
apy. Proc Natl Acad Sci U S A 2000;97:571–576.
6. Volles MJ, Lee SJ, Rochet JC, et al. Vesicle permeabilization by
protofibrillar alpha-synuclein: implications for the pathogenesis
and treatment of Parkinson’s disease. Biochemistry 2001;40:
7812–7819.
7. Ingelsson M. Alpha-synuclein oligomers-neurotoxic molecules in
Parkinson’s disease and other Lewy body disorders. Front Neurosci
2016;10:408.
8. Jackson MP, Hewitt EW. Cellular proteostasis: degradation of
misfolded proteins by lysosomes. Essays Biochem 2016;60:
173–180.
9. Karimi-Moghadam A, Charsouei S, Bell B, Jabalameli MR.
Parkinson disease from Mendelian forms to genetic susceptibility:
new molecular insights into the neurodegeneration process. Cell
Mol Neurobiol 2018;38:1153–1178.
10. Galluzzi L, Baehrecke EH, Ballabio A, et al. Molecular definitions
of autophagy and related processes. EMBO J. 2017;36:1811–1836.
11. Vega-Rubin-de-Celis S, Peña-Llopis S, Konda M, Brugarolas J.
Multistep regulation of TFEB by MTORC1. Autophagy 2017;13:
464–472.
12. Settembre C, Zoncu R, Medina DL, et al. A lysosome-to-nucleus
signalling mechanism senses and regulates the lysosome via mTOR
and TFEB. EMBO J 2012;31:1095–1108.
13. Vogiatzi T, Xilouri M, Vekrellis K, Stefanis L. Wild type alpha-
synuclein is degraded by chaperone-mediated autophagy and mac-
roautophagy in neuronal cells. J Biol Chem 2008;283:
23542–23556.
14. Mak SK, McCormack AL, Manning-Bo g AB, Cuervo AM, Di
Monte DA. Lysosomal degradation of α-synuclein in vivo. J Biol
Chem 2010;285:13621–13629.
15. Klein C, Westenberger A. Genetics of Parkinson’s disease. Cold
Spring Harb Perspect Med 2012;2:a008888.
16. Kim CY, Alcalay RN. Genetic forms of Parkinson’s disease. Semin
Neurol. 2017;37:135–146.
17. Chang D, Nalls MA, Hallgrímsdóttir IB, et al. A meta-analysis of
genome-wide association studies identifies 17 new Parkinson’s dis-
ease risk loci. Nat Genet 2017;49:1511–1516.
18. Robak LA, Jansen IE, van Rooij J, et al. Excessive burden of lyso-
somal storage disorder gene variants in Parkinson’s disease. Brain
2017;140:3191–3203.
19. Wise AH, Yang A, Naik H, et al. Parkinson’s disease prevalence in
Fabry disease: a survey study. Mol Genet Metab Rep 2018;14:
27–30.
20. Klein AD, Mazzulli JR. Is Parkinson’s disease a lysosomal disor-
der? Brain 2018;141:2255–2262.
21. Creed RB, Goldberg MS. Analysis of α-synuclein pathology in
PINK1 knockout rat brains. Front Neurosci 2018;12:1034.
 α- S Y N U C L E I N A N D A U T O P H A G I C - L Y S O S O M A L
22. Xu CY, Kang WY, Chen YM, et al. DJ-1 Inhibits α-synuclein
aggregation by regulating chaperone-mediated autophagy. Front
Aging Neurosci 2017;9:308.
23. Stefanis L. α-Synuclein in Parkinson’s disease. Cold Spring Harb
Perspect Med 2012;2:a009399.
24. Kojovic M, Sheerin UM, Rubio-Agusti I, et al. Young-onset parkin-
sonism due to homozygous duplication of α-synuclein in a consan-
guineous family. Mov Disord 2012;27:1827–1829.
25. Mutez E, Leprêtre F, Le Rhun E, et al. SNCA locus duplication car-
riers: from genetics to Parkinson disease phenotypes. Hum Mutat
2011;32:E2079–E2090.
26. Murphy DD, Rueter SM, Trojanowski JQ, Lee VM. Synucleins are
developmentally expressed, and alpha-synuclein regulates the size
of the presynaptic vesicular pool in primary hippocampal neurons.
J Neurosci 2000;20:3214–3220.
27. Cooper AA, Gitler AD, Cashikar A, et al. α-Synuclein blocks
ER-Golgi traffic and Rab1 rescues neuron loss in Parkinson’s
models. Science 2006;313:324–328.
28. Alim MA, Ma QL, Takeda K, et al. Demonstration of a role for
alpha-synuclein as a functional microtubule-associated protein.
J Alzheimers Dis 2004;6:435–442; discussion, 443–449.
29. Cartelli D, Aliverti A, Barbiroli A, et al. α-Synuclein is a novel
microtubule dynamase. Sci Rep 2016;6:33289.
30. Gan-Or Z, Dion PA, Rouleau GA. Genetic perspective on the role
of the autophagy-lysosome pathway in Parkinson disease.
Autophagy 2015;11:1443–1457.
31. di Domenico A, Carola G, Calatayud C, et al. Patient-specific
iPSC-derived astrocytes contribute to non-cell-autonomous neu-
rodegeneration in Parkinson’s disease. Stem Cell Reports 2019;12:
213–229.
32. Ho DH, Kim H, Nam D, et al. LRRK2 impairs autophagy by
mediating phosphorylation of leucyl-tRNA synthetase. Cell Bio-
chem Funct 2018;36:431–442.
33. Orenstein SJ, Kuo SH, Tasset I, et al. Interplay of LRRK2 with
chaperone-mediated autophagy. Nat Neurosci 2013;16:394–406.
34. Sidransky E, Nalls MA, Aasly JO, et al. Multicenter analysis of
glucocerebrosidase mutations in Parkinson’s disease. N Engl J Med
2009;361:1651–1661.
35. Anheim M, Elbaz A, Lesage S, et al. Penetrance of Parkinson dis-
ease in glucocerebrosidase gene mutation carriers. Neurology
2012;78:417–420.
36. Choi JH, Stubblefield B, Cookson MR, et al. Aggregation of
α-synuclein in brain samples from subjects with glucocerebrosidase
mutations. Mol Genet Metab 2011;104:185–188.
37. Alcalay RN, Levy OA, Waters CC, et al. Glucocerebrosidase activ-
ity in Parkinson’s disease with and without GBA mutations. Brain
2015;138:2648–2658.
38. Thaler A, Gurevich T, Bar Shira A, et al. A “dose” effect of muta-
tions in the GBA gene on Parkinson’s disease phenotype. Parkin-
sonism Relat Disord 2017;36:47–51.
39. Michelakakis H, Xiromerisiou G, Dardiotis E, et al. Evidence of an
association between the scavenger receptor class B member 2 gene
and Parkinson’s disease. Mov Disord 2012;27:400–405.
40. Hopfner F, Schulte EC, Mollenhauer B, et al. The role of SCARB2
as susceptibility factor in Parkinson’s disease. Mov Disord 2013;
28:538–540.
41. Alcalay RN, Levy OA, Wolf P, et al. SCARB2 variants and
glucocerebrosidase activity in Parkinson’s disease. NPJ Parkinsons
Dis 2016;2:16004.
42. Zeigler M, Meiner V, Newman JP, et al. A novel SCARB2 muta-
tion in progressive myoclonus epilepsy indicated by reduced
β-glucocerebrosidase activity. J Neurol Sci 2014;339:210–213.
43. Rothaug M, Zunke F, Mazzulli JR, et al. LIMP-2 expression is crit-
ical for β-glucocerebrosidase activity and α-synuclein clearance.
Proc Natl Acad Sci U S A 2014;111:15573–15578.
44. Webb JL, Ravikumar B, Atkins J, Skepper JN, Rubinsztein DC.
α-Synuclein is degraded by both autophagy and the proteasome.
J Biol Chem 2003;278:25009–25013.
V I C I O U S C Y C L E
45. Xilouri M, Brekk OR, Landeck N, et al. Boosting chaperone-
mediated autophagy in vivo mitigates α-synuclein-induced neu-
rodegeneration. Brain 2013;136:2130–2146.
46. Cuervo AM, Stefanis L, Fredenburg R, Lansbury PT, Sulzer D.
Impaired degradation of mutant alpha-synuclein by chaperone-
mediated autophagy. Science 2004;305:1292–1295.
47. Sacino AN, Brooks MMT, Chakrabarty P, et al. Proteolysis of
α-synuclein fibrils in the lysosomal pathway limits induction of
inclusion pathology. J Neurochem 2017;140:662–678.
48. McGlinchey RP, Lee JC. Cysteine cathepsins are essential in lyso-
somal degradation of α-synuclein. Proc Natl Acad Sci U S A 2015;
112:9322–9327.
49. Zhang NY, Tang Z, Liu CW. α-synuclein protofibrils inhibit 26 S
proteasome-mediated protein degradation: Understanding the cyto-
toxicity of protein protofibrils in neurodegenerative disease patho-
genesis. J Biol Chem 2008;283:20288–20298.
50. Schapira AHV. Glucocerebrosidase and Parkinson disease: recent
advances. Mol Cell Neurosci 2015;66:37–42.
51. Thomas B, Beal MF. Parkinson’s disease. Hum Mol Genet 2007;
16:R183–R194.
52. Del Tredici K, Braak H. Review: sporadic Parkinson’s disease:
development and distribution of α-synuclein pathology. Neuro-
pathol Appl Neurobiol 2016;42:33–50.
53. Balducci C, Pierguidi L, Persichetti E, et al. Lysosomal hydrolases
in cerebrospinal fluid from subjects with Parkinson’s disease. Mov
Disord 2007;22:1481–1484.
54. Parnetti L, Balducci C, Pierguidi L, et al. Cerebrospinal fluid
β-glucocerebrosidase activity is reduced in Dementia with Lewy
Bodies. Neurobiol Dis 2009;34:484–486.
55. Parnetti L, Chiasserini D, Persichetti E, et al. Cerebrospinal fluid
lysosomal enzymes and alpha-synuclein in Parkinson’s disease.
Mov Disord 2014;29:1019–1027.
56. Parnetti L, Paciotti S, Eusebi P, et al. Cerebrospinal fluid
β-glucocerebrosidase activity is reduced in Parkinson’s disease
patients. Mov Disord 2017;32:1423–1431.
57. Alcalay RN, Wolf P, Levy OA, et al. Alpha galactosidase A activity
in Parkinson’s disease. Neurobiol Dis 2018;112:85–90.
58. Wu G, Yan B, Wang X, et al. Decreased activities of lysosomal acid
alpha-D-galactosidase A in the leukocytes of sporadic Parkinson’s
disease. J Neurol Sci 2008;271:168–173.
59. Gegg ME, Burke D, Heales SJR, et al. Glucocerebrosidase defi-
ciency in substantia nigra of Parkinson disease brains. Ann Neurol
2012;72:455–463.
60. Murphy KE, Gysbers AM, Abbott SK, et al. Reduced
glucocerebrosidase is associated with increased α-synuclein in spo-
radic Parkinson’s disease. Brain 2014;137:834–848.
61. Moors TE, Paciotti S, Ingrassia A, et al. Characterization of brain
lysosomal activities in GBA-related and sporadic Parkinson’s dis-
ease and dementia with Lewy bodies. Mol Neurobiol 2019;56:
1344–1355.
62. Chiasserini D, Paciotti S, Eusebi P, et al. Selective loss of
glucocerebrosidase activity in sporadic Parkinson’s disease and
dementia with Lewy bodies. Mol Neurodegener 2015;10:15.
63. Mazzulli JR, Xu YH, Sun Y, et al. Gaucher disease
glucocerebrosidase and α-synuclein form a bidirectional pathogenic
loop in synucleinopathies. Cell 2011;146:37–52.
64. Chu Y, Dodiya H, Aebischer P, Olanow CW, Kordower JH. Alter-
ations in lysosomal and proteasomal markers in Parkinson’s dis-
ease: relationship to alpha-synuclein inclusions. Neurobiol Dis
2009;35:385–398.
65. Nelson MP, Boutin M, Tse TE, et al. The lysosomal enzyme alpha-
Galactosidase A is deficient in Parkinson’s disease brain in association
with the pathologic accumulation of alpha-synuclein. Neurobiol Dis
2018;110:68–81.
66. Alvarez-Erviti L, Rodriguez-Oroz MC, Cooper JM, et al. Chaper-
one-mediated autophagy markers in Parkinson disease brains. Arch
Neurol 2010;67:1464–1472.
Movement Disorders, Vol. 35, No. 1, 2020 41
B E L L O M O E T A L
67. Murphy KE, Gysbers AM, Abbott SK, et al. Lysosomal-associated
membrane protein 2 isoforms are differentially affected in early
Parkinson’s disease. Mov Disord 2015;30:1639–1647.
68. Dehay B, Bové J, Rodríguez-Muela N, et al. Pathogenic Lysosomal
depletion in Parkinson’s disease. J Neurosci 2010;30:
12535–12544.
69. Crews L, Spencer B, Desplats P, et al. Selective molecular alter-
ations in the autophagy pathway in patients with Lewy body dis-
ease and in models of alpha-synucleinopathy. PLoS One 2010;5:
e9313.
70. Shachar T, Lo Bianco C, Recchia A, Wiessner C, Raas-
Rothschild A, Futerman AH. Lysosomal storage disorders and
Parkinson’s disease: Gaucher disease and beyond. Mov Disord
2011;26:1593–1604.
71. Marshall MS, Jakubauskas B, Bogue W, et al. Analysis of age-
related changes in psychosine metabolism in the human brain.
PLoS One 2018;13:e0193438.
72. Suzuki K, Iseki E, Togo T, et al. Neuronal and glial accumulation
of alpha- and beta-synucleins in human lipidoses. Acta Neuro-
pathol 2007;114:481–489.
73. Pchelina SN, Nuzhnyi EP, Emelyanov AK, et al. Increased plasma
oligomeric alpha-synuclein in patients with lysosomal storage dis-
eases. Neurosci Lett 2014;583:188–193.
74. Nuzhnyi E, Emelyanov A, Boukina T, et al. Plasma oligomeric
alpha-synuclein is associated with glucocerebrosidase activity in
Gaucher disease. Mov Disord 2015;30:989–991.
75. Klucken J, Poehler AM, Ebrahimi-Fakhari D, et al. Alpha-synuclein
aggregation involves a bafilomycin A1-sensitive autophagy path-
way. Autophagy 2012;8:754–766.
76. Ahmed I, Liang Y, Schools S, Dawson VL, Dawson TM, Savitt JM.
Development and characterization of a new Parkinson’s disease
model resulting from impaired autophagy. J Neurosci 2012;32:
16503–16509.
77. Friedman LG, Lachenmayer ML, Wang J, et al. Disrupted
autophagy leads to dopaminergic axon and dendrite degeneration
and promotes presynaptic accumulation of α-synuclein and LRRK2
in the brain. J Neurosci 2012;32:7585–7593.
78. Tang FL, Erion JR, Tian Y, et al. VPS35 in dopamine neurons is
required for endosome-to-Golgi retrieval of Lamp2a, a receptor of
chaperone-mediated autophagy that is critical for α-synuclein deg-
radation and prevention of pathogenesis of Parkinson’s disease.
J Neurosci 2015;35:10613–10628.
79. Follett J, Bugarcic A, Yang Z, et al. Parkinson disease-linked
Vps35 R524W mutation impairs the endosomal association of
retromer and induces α-synuclein aggregation. J Biol Chem 2016;
291:18283–18298.
80. Suzuki K, Iseki E, Katsuse O, et al. Neuronal accumulation of
alpha- and beta-synucleins in the brain of a GM2 gangliosidosis
mouse model. Neuroreport 2003;14:551–554.
81. Sevlever D, Jiang P, Yen SHC. Cathepsin D is the main lysosomal
enzyme involved in the degradation of α-synuclein and generation
of its carboxy-terminally truncated species. Biochemistry 2008;47:
9678–9687.
82. Qiao L, Hamamichi S, Caldwell KA, et al. Lysosomal enzyme
cathepsin D protects against alpha-synuclein aggregation and toxic-
ity. Mol Brain 2008;1:17.
83. Cullen V, Lindfors M, Ng J, et al. Cathepsin D expression level
affects alpha-synuclein processing, aggregation, and toxicity
in vivo. Mol Brain 2009;2:5.
84. Stoka V, Turk V, Turk B. Lysosomal cathepsins and their regula-
tion in aging and neurodegeneration. Ageing Res Rev 2016;32:
22–37.
85. McGlinchey RP, Lacy SM, Huffer KE, Tayebi N, Sidransky E,
Lee JC. C-terminal α-synuclein truncations are linked to cysteine
cathepsin activity in Parkinson’s disease. J Biol Chem 2019;294:
9973–9984.
86. Bae EJ, Yang NY, Lee C, et al. Loss of glucocerebrosidase 1 activity
causes lysosomal dysfunction and α-synuclein aggregation. Exp
Mol Med 2015;47:e153.
42 Movement Disorders, Vol. 35, No. 1, 2020
87. Suzuki M, Fujikake N, Takeuchi T, et al. Glucocerebrosidase defi-
ciency accelerates the accumulation of proteinase K-resistant
α-synuclein and aggravates neurodegeneration in a Drosophila
model of Parkinson’s disease. Hum Mol Genet 2015;24:
6675–6686.
88. Yun SP, Kim D, Kim S, et al. α-Synuclein accumulation and GBA
deficiency due to L444P GBA mutation contributes to MPTP-
induced parkinsonism. Mol Neurodegener 2018;13:1.
89. Abul Khair SB, Dhanushkodi NR, Ardah MT, Chen W, Yang Y,
Haque ME. Silencing of glucocerebrosidase gene in Drosophila
enhances the aggregation of Parkinson’s disease associated
α-synuclein mutant A53T and affects locomotor activity. Front
Neurosci 2018;12:81.
90. Moraitou M, Dermentzaki G, Dimitriou E, et al. α-Synuclein
dimerization in erythrocytes of Gaucher disease patients: correla-
tion with lipid abnormalities and oxidative stress. Neurosci Lett
2016;613:1–5.
91. Taguchi YV, Liu J, Ruan J, et al. Glucosylsphingosine promotes
α-synuclein pathology in mutant GBA-associated Parkinson’s dis-
ease. J Neurosci 2017;37:9617–9631.
92. McGlinchey R, Lee J. Effect of glucocerebrosidase and its substrate,
glucosylceramide on α-synuclein aggregation and degradation.
FASEB J 2015;29:564.7.
93. Zunke F, Moise AC, Belur NR, et al. Reversible conformational
conversion of α-synuclein into toxic assemblies by
glucosylceramide. Neuron 2018;97:92-107.e10.
94. Fusco G, Chen SW, Williamson PTF, et al. Structural basis of mem-
brane disruption and cellular toxicity by α-synuclein oligomers. Sci-
ence 2017;358:1440–1443.
95. Thibaudeau TA, Anderson RT, Smith DM. A common mechanism
of proteasome impairment by neurodegenerative disease-associated
oligomers. Nat Commun 2018;9:1097.
96. Heinrich M, Wickel M, Schneider-Brachert W, et al. Cathepsin D
targeted by acid sphingomyelinase-derived ceramide. EMBO J
1999;18:5252–5263.
97. Liu F, Li X, Lu C, et al. Ceramide activates lysosomal cathepsin B
and cathepsin D to attenuate autophagy and induces ER stress to
suppress myeloid-derived suppressor cells. Oncotarget 2016;7:
83907–83925.
98. Gan-Or Z, Liong C, Alcalay RN. GBA-associated Parkinson’s dis-
ease and other synucleinopathies. Curr Neurol Neurosci Rep 2018;
18:44.
99. Mielke MM, Maetzler W, Haughey NJ, et al. Plasma ceramide and
glucosylceramide metabolism is altered in sporadic Parkinson’s dis-
ease and associated with cognitive impairment: a pilot study. PLoS
One 2013;8:e73094.
100. Guedes LC, Chan RB, Gomes MA, et al. Serum lipid alterations in
GBA-associated Parkinson’s disease. Parkinsonism Relat Disord
2017;44:58–65.
101. Kurz J, Parnham MJ, Geisslinger G, Schiffmann S. Ceramides as
novel disease biomarkers. Trends Mol Med 2019;25:20–32.
102. Abbott SK, Li H, Muñoz SS, et al. Altered ceramide acyl chain
length and ceramide synthase gene expression in Parkinson’s dis-
ease. Mov Disord 2014;29:518–526.
103. Kim MJ, Jeon S, Burbulla LF, Krainc D. Acid ceramidase inhibition
ameliorates α-synuclein accumulation upon loss of GBA1 function.
Hum Mol Genet 2018;27:1972–1988.
104. Clark LN, Chan R, Cheng R, et al. Gene-wise association of vari-
ants in four lysosomal storage disorder genes in neu-
ropathologically confirmed Lewy body disease. PLoS One 2015;10:
e0125204.
105. Dagan E, Schlesinger I, Ayoub M, Mory A, Nassar M, Kurolap A,
et al. The contribution of Niemann-Pick SMPD1 mutations to
Parkinson disease in Ashkenazi Jews. Parkinsonism Relat Disord
2015;21:1067–1071.
106. Gan-Or Z, Ozelius LJ, Bar-Shira A, et al. The p.L302P mutation in
the lysosomal enzyme gene SMPD1 is a risk factor for Parkinson
disease. Neurology 2013;80:1606–1610.
 α- S Y N U C L E I N A N D A U T O P H A G I C - L Y S O S O M A L
107. Alcalay RN, Mallett V, Vanderperre B, et al. SMPD1 mutations,
activity, and α-synuclein accumulation in Parkinson’s disease. Mov
Disord 2019;34:526–535.
108. Smith BR, Santos MB, Marshall MS, et al. Neuronal inclusions of
α-synuclein contribute to the pathogenesis of Krabbe disease.
J Pathol 2014;232:509–521.
109. Freeman D, Cedillos R, Choyke S, et al. Alpha-synuclein induces
lysosomal rupture and cathepsin dependent reactive oxygen species
following endocytosis. PLoS One 2013;8:e62143.
110. Hoffmann AC, Minakaki G, Menges S, et al. Extracellular aggre-
gated alpha synuclein primarily triggers lysosomal dysfunction in
neural cells prevented by trehalose. Sci Rep 2019;9:544.
111. Grey M, Dunning CJ, Gaspar R, et al. Acceleration of α-synuclein
aggregation by exosomes. J Biol Chem 2015;290:2969–2982.
112. Paciotti S, Bellomo G, Gatticchi L, Parnetti L. Are we ready for
detecting α-synuclein prone to aggregation in patients? The case of
“protein-misfolding cyclic amplification” and “real-time quaking-
induced conversion” as diagnostic tools. Front Neurol. 2018;
9:415.
113. Jang A, Lee HJ, Suk JE, Jung JW, Kim KP, Lee SJ. Non-classical
exocytosis of alpha-synuclein is sensitive to folding states and pro-
moted under stress conditions. J Neurochem 2010;113:1263–1274.
114. Alvarez-Erviti L, Seow Y, Schapira AH, et al. Lysosomal dysfunc-
tion increases exosome-mediated alpha-synuclein release and trans-
mission. Neurobiol Dis 2011;42:360–367.
115. Apetri MM, Harkes R, Subramaniam V, Canters GW, Schmidt T,
Aartsma TJ. Direct observation of α-synuclein amyloid aggregates
in endocytic vesicles of neuroblastoma cells. PLOS One 2016;11:
e0153020.
116. Fussi N, Höllerhage M, Chakroun T, et al. Exosomal secretion of
α-synuclein as protective mechanism after upstream blockage of
macroautophagy. Cell Death Dis 2018;9:757.
117. Bae EJ, Yang NY, Song M, et al. Glucocerebrosidase regulates per-
petual cell-to-cell transmission of α-synuclein. Nat Commun 2014;
5:4755.
118. Bae EJ, Yang NY, Lee C, Kim S, Lee HJ, Lee SJ. Haploinsufficiency
of cathepsin D leads to lysosomal dysfunction and promotes cell-
to-cell transmission of α-synuclein aggregates. Cell Death Dis
2015;6:e1901.
119. Steiner JA, Angot E, Brundin P. A deadly spread: cellular mecha-
nisms of α-synuclein transfer. Cell Death Differ 2011;18:
1425–1433.
120. Winslow AR, Chen CW, Corrochano S, et al. α-Synuclein impairs
macroautophagy: implications for Parkinson’s disease. J Cell Biol
2010;190:1023–1037.
121. Erustes AG, Stefani FY, Terashima JY, et al. Overexpression of
α-synuclein in an astrocyte cell line promotes autophagy inhibition
and apoptosis. J Neurosci Res 2018;96:160–171.
122. Xilouri M, Vogiatzi T, Vekrellis K, Park D, Stefanis L. Abberant
alpha-synuclein confers toxicity to neurons in part through inhibi-
tion of chaperone-mediated autophagy. PLoS One 2009;4:e5515.
123. Martinez-Vicente M, Talloczy Z, Kaushik S, et al. Dopamine-
modified alpha-synuclein blocks chaperone-mediated autophagy.
J Clin Invest 2008;118:777–788.
124. Yap TL, Gruschus JM, Velayati A, et al. α-Synuclein interacts with
glucocerebrosidase providing a molecular link between Parkinson
and Gaucher diseases. J Biol Chem 2011;286:28080–28088.
125. Yap TL, Velayati A, Sidransky E, Lee JC. Membrane-bound
α-synuclein interacts with glucocerebrosidase and inhibits enzyme
activity. Mol Genet Metab 2013;108:56–64.
126. Yap TL, Jiang Z, Heinrich F, et al. Structural features of
membrane-bound glucocerebrosidase and α-synuclein probed by
neutron reflectometry and fluorescence spectroscopy. J Biol Chem.
2015;290:744–754.
127. Tanik SA, Schultheiss CE, Volpicelli-Daley LA, Brunden KR,
Lee VMY. Lewy body-like α-synuclein aggregates resist degrada-
tion and impair macroautophagy. J Biol Chem 2013;288:
15194–15210.
V I C I O U S C Y C L E
128. Stefanovic AND, Stöckl MT, Claessens MMAE, Subramaniam V.
α-Synuclein oligomers distinctively permeabilize complex model
membranes. FEBS J 2014;281:2838–2850.
129. Moors TE, Hoozemans JJM, Ingrassia A, et al. Therapeutic poten-
tial of autophagy-enhancing agents in Parkinson’s disease. Mol
Neurodegener 2017;12:11.
130. Tanji K, Miki Y, Maruyama A, et al. Trehalose intake induces
chaperone molecules along with autophagy in a mouse model of
Lewy body disease. Biochem Biophys Res Commun 2015;465:
746–752.
131. Sarkar S, Davies JE, Huang Z, Tunnacliffe A, Rubinsztein DC.
Trehalose, a novel mTOR-independent autophagy enhancer, accel-
erates the clearance of mutant huntingtin and alpha-synuclein.
J Biol Chem 2007;282:5641–5652.
132. Rodríguez-Navarro JA, Rodríguez L, Casarejos MJ, et al. Treha-
lose ameliorates dopaminergic and tau pathology in parkin
deleted/tau overexpressing mice through autophagy activation.
Neurobiol Dis 2010;39:423–438.
133. Palmieri M, Pal R, Nelvagal HR, et al. mTORC1-independent
TFEB activation via Akt inhibition promotes cellular clearance in
neurodegenerative storage diseases. Nat Commun 2017;8:14338.
134. Rusmini P, Cortese K, Crippa V, et al. Trehalose induces
autophagy via lysosomal-mediated TFEB activation in models of
motoneuron degeneration. Autophagy 2019;15:631–651.
135. Hosseinpour-Moghaddam K, Caraglia M, Sahebkar A. Autophagy
induction by trehalose: Molecular mechanisms and therapeutic
impacts. J Cell Physiol 2018;233:6524–6543.
136. Emanuele E. Can trehalose prevent neurodegeneration? Insights
from experimental studies. Curr Drug Targets 2014;15:551–557.
137. Wu F, Xu HD, Guan JJ, et al. Rotenone impairs autophagic flux
and lysosomal functions in Parkinson’s disease. Neuroscience
2015;284:900–911.
138. Kaur S, Nazir A. Potential role of protein stabilizers in ameliora-
tion of Parkinson’s disease and associated effects in transgenic
Caenorhabditis elegans model expressing alpha-synuclein. RSC
Adv 2015;5:77706–77715.
139. He Q, Koprich JB, Wang Y, et al. Treatment with trehalose pre-
vents behavioral and neurochemical deficits produced in an AAV
α-synuclein rat model of Parkinson’s disease. Mol Neurobiol 2016;
53:2258–2268.
140. Pupyshev AB, Tikhonova MA, Akopyan AA, Tenditnik MV,
Dubrovina NI, Korolenko TA. Therapeutic activation of
autophagy by combined treatment with rapamycin and trehalose in
a mouse MPTP-induced model of Parkinson’s disease. Pharmacol
Biochem Behav 2019;177:1–11.
141. Parnetti L, Bellomo G. The issue of waste disposal in Parkinson’s
disease pathogenesis. Mov Disord 2019;34:985–985.
142. Whishaw IQ, Kolb B (eds). The Behavior of the Laboratory Rat: A
Handbook with Tests. New York, NY: Oxford University Press;
2005.
143. Howson PA, Johnston TH, Ravenscroft P, Hill MP, Su J,
Brotchie JM, Koprich JB. Beneficial effects of trehalose on striatal
dopaminergic deficits in rodent and primate models of
synucleinopathy in Parkinson’s disease. J Pharmacol Exp Ther
2019;369:364–374.
144. Richards AB, Krakowka S, Dexter LB, Schmid H,
Wolterbeek APM, Waalkens-Berendsen DH, et al. Trehalose: a
review of properties, history of use and human tolerance, and
results of multiple safety studies. Food Chem Toxicol 2002;40:
871–898.
145. Sacktor B. Trehalase and the transport of glucose in the mamma-
lian kidney and intestine. Proc Natl Acad Sci U S A 1968;60:
1007–1014.
146. Kilpatrick K, Zeng Y, Hancock T, Segatori L. Genetic and chemi-
cal activation of TFEB mediates clearance of aggregated α-syn-
uclein. PLoS One 2015;10:e0120819.
147. Decressac M, Mattsson B, Weikop P, Lundblad M, Jakobsson J,
Björklund A. TFEB-mediated autophagy rescues midbrain dopa-
mine neurons from α-synuclein toxicity. Proc Natl Acad Sci U S A
2013;110:E1817–E1826.
Movement Disorders, Vol. 35, No. 1, 2020 43
B E L L O M O E T A L
148. Ghosh A, Tyson T, George S, et al. Mitochondrial pyruvate carrier
regulates autophagy, inflammation, and neurodegeneration in
experimental models of Parkinsons disease. Sci Transl Med 2016;
8:368ra174.
149. Karuppagounder SS, Brahmachari S, Lee Y, Dawson VL,
Dawson TM, Ko HS. The c-Abl inhibitor, nilotinib, protects dopa-
minergic neurons in a preclinical animal model of Parkinson’s dis-
ease. Sci Rep 2014;4:4874.
150. Hebron ML, Lonskaya I, Moussa CEH. Nilotinib reverses loss of
dopamine neurons and improves motor behavior via autophagic
degradation of α-synuclein in Parkinson’s disease models. Human
molecular genetics. Hum Mol Genet 2013;22:3315–3328.
151. Pagan FL, Hebron ML, Wilmarth B, et al. Pharmacokinetics and
pharmacodynamics of a single dose Nilotinib in individuals with
Parkinson’s disease. Pharmacol Res Perspect 2019;7:e00470.
152. Pagan F, Hebron M, Valadez EH, et al. Nilotinib effects in
Parkinson’s disease and dementia with Lewy bodies. J Parkinsons
Dis 2016;6:503–517.
153. Rocha EM, Smith GA, Park E, et al. Glucocerebrosidase gene ther-
apy prevents α-synucleinopathy of midbrain dopamine neurons.
Neurobiol Dis 2015;82:495–503.
154. Sardi SP, Clarke J, Viel C, et al. Augmenting CNS
glucocerebrosidase activity as a therapeutic strategy for parkinson-
ism and other Gaucher-related synucleinopathies. Proc Natl Acad
Sci U S A 2013;110:3537–3542.
155. Ambrosi G, Ghezzi C, Zangaglia R, Levandis G, Pacchetti C,
Blandini F. Ambroxol-induced rescue of defective
glucocerebrosidase is associated with increased LIMP-2 and
saposin C levels in GBA1 mutant Parkinson’s disease cells. Neuro-
biol Dis 2015;82:235–242.
156. McNeill A, Magalhaes J, Shen C, et al. Ambroxol improves lyso-
somal biochemistry in glucocerebrosidase mutation-linked
Parkinson disease cells. Brain 2014;137:1481–1495.
44 Movement Disorders, Vol. 35, No. 1, 2020
157. Yang SY, Beavan M, Chau KY, Taanman JW, Schapira AHV. A
human neural crest stem cell-derived dopaminergic neuronal model
recapitulates biochemical abnormalities in GBA1 mutation carriers.
Stem Cell Reports 2017;8:728–742.
158. Migdalska-Richards A, Daly L, Bezard E, Schapira AHV.
Ambroxol effects in glucocerebrosidase and α-synuclein transgenic
mice. Ann Neurol 2016;80:766–775.
159. Migdalska-Richards A, Ko WKD, Li Q, Bezard E, Schapira AHV.
Oral ambroxol increases brain glucocerebrosidase activity in a
nonhuman primate. Synapse 2017;71:e21967.
160. Sanchez-Martinez A, Beavan M, Gegg ME, Chau KY,
Whitworth AJ, Schapira AH. Parkinson disease-linked GBA muta-
tion effects reversed by molecular chaperones in human cell and fly
models. Sci Rep 2016;6:31380.
161. Mazzulli JR, Zunke F, Tsunemi T, Toker NJ, Jeon S, Burbulla LF,
et al. Activation of β-glucocerebrosidase reduces pathological
α-synuclein and restores lysosomal function in Parkinson’s patient
midbrain neurons. J Neurosci. 2016;36:7693–7706.
162. Aflaki E, Borger DK, Moaven N, et al. A new glucocerebrosidase
chaperone reduces α-synuclein and glycolipid levels in iPSC-derived
dopaminergic neurons from patients with Gaucher disease and par-
kinsonism. J Neurosci 2016;36:7441–7452.
163. Sardi SP, Viel C, Clarke J, et al. Glucosylceramide synthase inhibi-
tion alleviates aberrations in synucleinopathy models. Proc Natl
Acad Sci U S A 2017;114:2699–2704.
164. Judith Peterschmitt M, Gasser T, Isaacson S, et al. Safety, tolerabil-
ity and pharmacokinetics of oral venglustat in Parkinson disease
patients with a GBA mutation. Mol Genet Metab 2019;126:S117.
165. Olanow CW, Perl DP, DeMartino GN, McNaught KSP. Lewy-
body formation is an aggresome-related process: a hypothesis. Lan-
cet Neurol 2004;3:496–503.