Piperlongumine and bortezomib synergically inhibit cholangiocarcinoma via ER stress–induced cell death.

Cholangiocarcinoma (CCA) is a lethal malignancy of the cholangiocytes lining the biliary tree. Only 25% of affected patients are eligible for resection due to late-stage diagnosis. Systemic chemotherapy is recommended for those inoperable patients; however, an inadequate response to such treatment remains a significant obstacle. Piperlongumine (PL) is a biologically active alkaloid that selectively kills various cancer cells through the induction of reactive oxygen species (ROS). The role of PL has been shown through its inhibiting the ubiquitin–proteasome system. The mechanism of PL-induced CCA cell death was investigated by inhibiting the UPS and testing the therapeutic potential of combining PL and the proteasome inhibitor bortezomib. A single treatment with PL or BTZ suppressed CCA cell growth. Combined treatment with PL with BTZ produced a synergistic interaction, evidenced by (1) a combination index of < 1 and (2) induction of cell cycle arrest and down-regulation of cell cycle markers. PL induced the accumulation of poly-ubiquitinated proteins in CCA cells but did not affect proteasome activity. PL, in combination with BTZ, amplified the accumulation of poly-ubiquitinated proteins in CCA cells, leading to an endoplasmic reticulum (ER) stress response through the induction of X-box binding protein mRNA splicing. Moreover, PL-combined BTZ promoted the activation of a proapoptotic unfolded protein response via the ATF4-CHOP axis. PL induced CCA cell death via increased accumulation of the poly-ubiquitinated proteins. PL also enhanced the anti-cancer activity of BTZ via ER stress–induced CCA cell death. Thus, the combination of PL and BTZ has potential as an alternative therapeutic option for CCA. [ABSTRACT FROM AUTHOR]