What is apoptosis, and why is it important? Andrew G Renehan, senior clinical felloew, Catherine Booth, senior scientist, Christopher S Potten, professor. Cancer Research Campaign Department of Epithelial Biology, Paterson Institute for Cancer Research, Christie Hospital NHS Trust, Manchester Correspondence to: C S Potten, EpiStem Ltd, Incubator Building, Manchester M13 9XX [log in to unmask] <mailto:[log in to unmask]> Philosophers have spent many centuries searching for the meaning of life, but in recent decades cell biologists have become even more fascinated by the meaning of death. Apoptosis describes the orchestrated collapse of a cell characterised by membrane blebbing, cell shrinkage, condensation of chromatin, and fragmentation of DNA followed by rapid engulfment of the corpse by neighbouring cells. It is distinguished from death by necrosis by the absence of an associated inflammatory response. These observations were made by Kerr et al as early as 1972, 1 <http://bmj.com/cgi/content/full/322/7301/#B1> but their importance was underestimated for many years. Today, however, apoptosis is implicated in biological processes ranging from embryogenesis to ageing, from normal tissue homoeostasis to many human diseases, and it has become one of the hottest fields of biomedical research. Summary points _____ Apoptosis is a genetically regulated form of cell death _____ It has a role in biological processes, including embryogenesis, ageing, and many diseases _____ The molecular mechanisms involved in death signals, genetic regulation, activation of effectors have been identified _____ Many existing treatments (such as non-steroidal anti-inflammatories and anticancer treatments) act through apoptosis _____ New treatments aimed at modifying apoptosis are being developed and are likely to be used to manage common diseases in the next decade Biological mechanisms The term apoptosis is often used interchangeably with programmed cell death. In the strictest sense, programmed cell death may be applied to other forms of cell death that require gene expression without fulfilling some, or all, of the morphological criteria of apoptosis. 2 <http://bmj.com/cgi/content/full/322/7301/#B2> Whatever the definition, studies clearly show that apoptosis is genetically regulated. In its simplest model, the stages of apoptosis may be considered as initiation, genetic regulation, and effector mechanisms (figure). 3 <http://bmj.com/cgi/content/full/322/7301/#B3> Initiators of apoptosis include anticancer drugs, gamma and ultraviolet irradiation, deprivation of survival factors such as interleukin-1, and various other cytokines that activate "death receptors" such as Fas and tumour necrosis factor receptors. Through a variety of pathways, these stimuli in turn generate a characteristic pattern of gene expression. The bcl-2 family of genes is the best studied and includes at least 20 members; some are pro-apoptotic or "death genes" and some are anti-apoptotic or "survival genes," including bcl-2 itself. The tumour suppressor gene p53 is also a well characterised apoptotic agent. The principal effectors are a family of proteases termed caspases. Studies in the nematode Caenorhabditis elegens, the fruitfly Drosophila, and the mouse indicate that the molecular machinery of apoptosis is evolutionarily conserved and intrinsic to all metazoan cells. Assessment of apoptosis Morphological assessment is the standard method for identifying and quantifying apoptosis. Other approaches include the use of fluorescence dyes to stain for condensed nuclei or exposed cell surface phosphatidylserine and the detection of fragmented DNA by terminal transferase mediated dUTP-biotin nick end labelling (TUNEL). Levels of cell death in a tissue are often expressed as an apoptotic index. This approach has serious limitations, mainly because of uncertainty about the duration of apoptosis (which may be less than six hours). 4 <http://bmj.com/cgi/content/full/322/7301/#B4> Thus, for instance, a small number of apoptotic cells observed in a static analysis may reflect a considerable contribution to cell turnover. Physiological role The first role of apoptosis is during intrauterine development. It helps to sculpture organ shape and carve out the interdigital webs of the fingers and toes. Apoptotic mechanisms are important determinants of fetal abnormalities; experiments have shown that wild type p53 mouse embryos will readily abort after radiation induced teratogenesis, whereas p53 null embryos will not. 5 <http://bmj.com/cgi/content/full/322/7301/#B5> Both the nervous system and the immune system arise through overproduction of cells followed by the apoptotic death of those that fail to establish functional synaptic connections or productive antigen specificities. Such massacre or altruistic behaviour requires a tightly regulated system. In adulthood, about 10 billion cells die every day simply to keep balance with the numbers of new cells arising from the body's stem cell populations. This normal homoeostasis is not just a passive process but regulated through apoptosis. The same mechanisms serve to "mop up" damaged cells. With ageing, apoptotic responses to DNA damage may be less tightly controlled and exaggerated, contributing to degenerative disease. Alternatively, the apoptotic responses may show reduced sensitivity, contributing to susceptibility to cancer. 6 <http://bmj.com/cgi/content/full/322/7301/#B6> <http://bmj.com/cgi/content/full/322/7301/1536/Fu2> View larger version (17K): [in this window] <http://bmj.com/cgi/content/full/322/7301/1536/Fu2> [in a new window] <http://bmj.com/cgi/content-nw/full/322/7301/1536/Fu2> Apoptotic mechanisms in a human cell. Three major pathways are shown, indicating the main levels: death signals, gene regulation, and effector mechanisms. BH3 and bcl-2 represent the pro-apoptotic and anti-apoptotic members of the bcl-2 family. Apaf-1=apoptosis proteases activating factor Altered apoptosis and disease There is now a long list of diseases associated with altered cell survival. 7 <http://bmj.com/cgi/content/full/322/7301/#B7> Increased apoptosis is characteristic of AIDS; neurodegenerative diseases such as Alzheimer's disease, Parkinson's disease, and amyotrophic lateral sclerosis; ischaemic injury after myocardial infarction, stroke, and reperfusion; and in autoimmune diseases such as hepatitis and graft versus host disease. Decreased or inhibited apoptosis is a feature of many malignancies, autoimmune disorders such as systemic lupus erythematosus, and some viral infections. View this table: [in this window] <http://bmj.com/cgi/content/full/322/7301/1536/Fu3> [in a new window] <http://bmj.com/cgi/content-nw/full/322/7301/1536/Fu3> The role of apoptosis in cancer has probably received the greatest research effort. 8 <http://bmj.com/cgi/content/full/322/7301/#B8> Observations that patterns of spontaneous and induced apoptosis differ between the small and large intestine has led to a plausible explanation for the differences in incidence of cancer between these two sites. 9 <http://bmj.com/cgi/content/full/322/7301/#B9> Studies in p53 null mice show an increased preponderance of premature tumours and offer strong evidence that such apoptotic related genes are pivotal to development of tumours. In addition, tumours develop methods to evade elimination by the immune system; one such mechanism involves tumours expressing Fas, which enables them to delete (by apoptosis) antitumour lymphocytes. This phenomenon is known as the "tumour counterattack." 10 <http://bmj.com/cgi/content/full/322/7301/#B10> There is also increasing evidence that systemic stimuli such as insulin-like growth factor I (anti-apoptotic) and insulin-like growth factor binding protein 3 (pro-apoptotic) may influence the development and progression of many common cancers. 11 <http://bmj.com/cgi/content/full/322/7301/#B11> Potential treatments This brief review has shown that many human diseases may result when cells die that shouldn't or others live that should die. Modulation of apoptotic processes may thus offer valuable methods of treatment. It is now known that many existing drugs (for example, non-steroidal anti-inflammatories) act by altering the levels of apoptosis. Virtually all cytotoxic drugs and radiotherapy programmes induce apoptosis in tumour cells, and resistance to apoptosis is associated with treatment failure. These therapies also induce apoptosis in normal cells, and side effects on bone marrow, gut, and oral mucosa limit the dose that can be used. Many more new treatment strategies are currently in preclinical trials and show promise (box). 3 <http://bmj.com/cgi/content/full/322/7301/#B3> 12 <http://bmj.com/cgi/content/full/322/7301/#B12> If future clinical studies are fruitful, this translation from basic science to clinical practice will be unique as it will affect not just one, but a broad range of disorders---and many patients will benefit. Footnotes Competing interests: None declared. References 1. Kerr JF, Wyllie AH, Currie AR. Apoptosis: a basic biological phenomenon with wide-ranging implications in tissue kinetics. Br J Cancer 1972; 26: 239-257 [Medline] <http://bmj.com/cgi/external_ref?access_num=4561027&link_type=MED> . 2. Sperandio S, de Belle I, Bredesen DE. An alternative, nonapoptotic form of programmed cell death. Proc Nat Acad Sci 2000; 97: 14376-14381 [Abstract/Full Text] <http://bmj.com/cgi/ijlink?linkType=ABST&journalCode=pnas&resid=97/26/14376> . 3. Renehan AG, Bach SP, Potten SC. The relevance of apoptosis for cellular homeostasis and tumorogenesis in the intestine. Can J Gastroenterol 20001; 15: 1666-1676. 4. Potten CS. What is an apoptotic index measuring? A commentary. Br J Cancer 1996; 74: 1743-1748 [Medline] <http://bmj.com/cgi/external_ref?access_num=8956787&link_type=MED> . 5. Norimura T, Nomoto S, Katsuki M, Gondo Y, Kondo S. p53-dependent apoptosis suppresses radiation-induced teratogenesis. Nat Med 1996; 2: 577-580 [Medline] <http://bmj.com/cgi/external_ref?access_num=8616719&link_type=MED> . 6. Martin K, Kirkwood TB, Potten CS. Age changes in stem cells of murine small intestinal crypts. Exp Cell Res 1998; 241: 316-323 [Medline] <http://bmj.com/cgi/external_ref?access_num=9637773&link_type=MED> . 7. Thompson CB. Apoptosis in the pathogenesis and treatment of disease. Science 1995; 267: 1456-1462 [Medline] <http://bmj.com/cgi/external_ref?access_num=7878464&link_type=MED> . 8. Wyllie AH, Bellamy CO, Bubb VJ, Clarke AR, Corbet S, Curtis L, et al. Apoptosis and carcinogenesis. Br J Cancer 1999; 80(suppl 1): 34-37 [Medline] <http://bmj.com/cgi/external_ref?access_num=10466759&link_type=MED> . 9. Potten CS, Booth C. The role of radiation-induced and spontaneous apoptosis in the homeostasis of the gastrointestinal epithelium: a brief review. Comp Biochem Physiol B Biochem Mol Biol 1997; 118: 473-478 [Medline] <http://bmj.com/cgi/external_ref?access_num=9467859&link_type=MED> . 10. O' Connell J, Bennett MW, O' Sullivan GC, Collins JK, Shanahan F. Fas counter-attack---the best form of tumor defense? Nat Med 1999; 5: 267-268 [Medline] <http://bmj.com/cgi/external_ref?access_num=10086376&link_type=MED> . 11. Renehan AG, Painter JE, Atkin WS, Potten CS, Shalet SM, O'Dwyer ST. High-risk colorectal adenomas and serum insulin-like growth factors. Br J Surg 2001; 88: 107-113 [Medline] <http://bmj.com/cgi/external_ref?access_num=11136321&link_type=MED> . 12. Nicholson DW. From bench to clinic with apoptosis-based therapeutic agents. Nature Insights 2000; 407: 810-816. Edward E. Rylander, M.D. Diplomat American Board of Family Practice. Diplomat American Board of Palliative Medicine.