Elevated Expression of BIRC6 Protein in Non–Small-Cell Lung Cancers is Associated with Cancer Recurrence and Chemoresistance Xin Dong, MD, Dong Lin,

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Elevated Expression of BIRC6 Protein in Non–Small-Cell Lung Cancers is Associated with Cancer Recurrence and Chemoresistance Xin Dong, MD, Dong Lin, MD, PhD, Chris Low, MSc, Emily A. Vucic, BSc, John C. English, MD, John Yee, MD, Nevin Murray, MD, Wan L. Lam, PhD, Victor Ling, PhD, Stephen Lam, MD, Peter W. Gout, PhD, Yuzhuo Wang, PhD Journal of Thoracic Oncology Volume 8, Issue 2, Pages 161-170 (February 2013) DOI: 10.1097/JTO.0b013e31827d5237 Copyright © 2013 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 1 Immunohistochemical staining of BIRC6 protein in patients’ (A) benign and (B–D), NSCLC tissues. Whereas the benign tissue lacked BIRC6 expression (score, A = 0), the NSCLC tissues showed elevated BIRC6 expression with scores B = 1, C = 2, and D = 3. NSCLC, non–small-cell lung cancer; BIRC6, baculoviral inhibitors of apoptosis proteins repeat-containing 6. Journal of Thoracic Oncology 2013 8, 161-170DOI: (10.1097/JTO.0b013e31827d5237) Copyright © 2013 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 2 Correlation between elevated BIRC6 expression in resected NSCLCs and poorer 3-year relapse-free survival of patients. A, Percentage of NSCLC patients at increasing BIRC6 scores. B, Kaplan–Meier analysis of relapse-free survival of 78 patients grouped on the basis of BIRC6 scores of their resected tumors (BIRC6 score <1 versus score ≥1, log-rank p =0.009. Hazard Ratio=2.458; 95% CI 1.290–4.683). C, Kaplan–Meier analysis of relapse-free survival of 49 patients with resected adenocarcinoma (BIRC6 score <1 versus score ≥1, log-rank p =0.009. Hazard Ratio=2.912; 95% CI 1.317–6.441). D, Kaplan–Meier analysis of relapse-free survival of 22 patients with resected squamous cell carcinoma (BIRC6 score <1 vs. score ≥1, log-rank p =0.348). BIRC6, baculoviral inhibitors of apoptosis proteins repeat-containing 6;NSCLC, non–small-cell lung cancer; CI, confidence interval. Journal of Thoracic Oncology 2013 8, 161-170DOI: (10.1097/JTO.0b013e31827d5237) Copyright © 2013 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 3 Patient-derived subrenal capsule NSCLC tissue xenografts resistant to treatment with cisplatin + vinorelbine (A, B) showed strong IHC staining (brown) of BIRC6 protein, compared with a sensitive xenograft (C, D). Arrows point at the renal capsules of the hosts (×200). E, Shows significant difference in BIRC6 IHC score between chemosensitive and chemoresistant xenografts (p = 0.012). NSCLC, non–small-cell lung cancer; IHC, immunohistochemistry. BIRC6, baculoviral inhibitors of apoptosis proteins repeat-containing 6. Journal of Thoracic Oncology 2013 8, 161-170DOI: (10.1097/JTO.0b013e31827d5237) Copyright © 2013 International Association for the Study of Lung Cancer Terms and Conditions

FIGURE 4 A, Western blot analysis confirming the gene silencing efficacy of BIRC6 siRNA. After transfection of A549 cells with BIRC6 siRNA (80 nM/6 hrs) and subsequent culturing, there was a substantial decrease in the amount of cellular BIRC6 protein, especially at 72 hours, compared with cells transfected with Lipofectamine only (Lipo) or nontargeting siRNA. B, MTT assay showed that transfection with BIRC6 siRNA (80 nM/6 hrs) led to a decrease in the proliferation of A549 cells within 96 hours, compared with controls (Lipo or NT) (p < 0.001). C–E, Apoptosis of A549 cells transfected with (C) Lipo, (D) NT, or (E), BIRC6 siRNA (80 nM/ 6 hrs) and subsequently incubated for 48 hours, as assessed by flow cytometric analysis of Annexin V/7-aminoactinomycin D stained cells. On the basis of Q2+Q3 values (apoptotic cell populations), BIRC6 siRNA slightly increased apoptosis compared with controls, but without statistical significance. (F–H), A549 cells were transfected with (F) Lipo, (G) NT, or (H) BIRC6 siRNA (80 nM/6 hrs), incubated for 24 hours, and subsequently treated with 20 µM cisplatin for another 24 hours. BIRC6 siRNA markedly enhanced cisplatin-induced apoptosis of A549 cells compared with Lipo (p = 0.034) or NT (p = 0.030). (Data are representative of 3 independent experiments). BIRC6, baculoviral inhibitors of apoptosis proteins repeat-containing 6; siRNA, small interfering RNA; MTT, diphenyltetrazolium bromide assay. Journal of Thoracic Oncology 2013 8, 161-170DOI: (10.1097/JTO.0b013e31827d5237) Copyright © 2013 International Association for the Study of Lung Cancer Terms and Conditions