The scientific impact of the Structural Genomics Consortium: a protein family and ligand-centered approach to medically-relevant human proteins

As many of the structural genomics centers have ended their first phase of operation, it is a good point to evaluate the scientific impact of this endeavour. The Structural Genomics Consortium (SGC), operating from three centers across the Atlantic, investigates human proteins involved in disease processes and proteins from Plasmodium falciparum and related organisms. We present here some of the scientific output of the Oxford node of the SGC, where the target areas include protein kinases, phosphatases, oxidoreductases and other metabolic enzymes, as well as signal transduction proteins. The SGC has aimed to achieve extensive coverage of human gene families with a focus on protein–ligand interactions. The methods employed for effective protein expression, crystallization and structure determination by X-ray crystallography are summarized. In addition to the cumulative impact of accelerated delivery of protein structures, we demonstrate how family coverage, generic screening methodology, and the availability of abundant purified protein samples, allow a level of discovery that is difficult to achieve otherwise. The contribution of NMR to structure determination and protein characterization is discussed. To make this information available to a wide scientific audience, a new tool for disseminating annotated structural information was created that also represents an interactive platform allowing for a continuous update of the annotation by the scientific community.
Introduction
The long-term goal of structural genomics (SG) has been ambitiously defined as “to make three-dimensional atomic level structures of most proteins easily obtainable from knowledge of their corresponding DNA sequences” (http://www.nigms.nih.gov/Initiatives/PSI.htm). Long before this goal is achieved, the multiple specialized SG projects are expected to have a significant impact on many aspects of the biological sciences.
The most readily apparent contribution of SG is the rapid expansion in the number of available protein structures, derived at a reduced cost because of the efficiency of specialized centers. Proper target selection is critical to ensure that the structures solved by SG centers are indeed valuable to the research and industrial community, either because of the intrinsic interest of the proteins investigated, or because of the improved mapping of the protein structure universe, providing homologous structural models.
A second important contribution of SG projects for the scientific community is the development of methods for efficient protein production and structure determination, which could be adopted in smaller research laboratories to improve productivity.
Other scientific deliverables of structural genomics derive from the scale and nature of the operations, and include comparative studies on members of protein families, identifying determinants of specificity, deriving general rules, and improving the capability to predict protein structure and function from gene sequences.
The Structural Genomics Consortium (SGC), operating in the Universities of Oxford and Toronto and the Karolinska Institute, was initiated in 2003 to address needs of industrial and academic pharmaceutical research. The SGC investigates human and apicomplexan proteins; the targets are selected based on their potential as drug targets or involvement in disease processes. Technologically, the SGC focuses on interaction of proteins with small molecules (ligands, inhibitors, substrates and co-factors), and on coverage of protein families. This report provides several examples of the impact of research undertaken at the Oxford node of the SGC, including methodology for high-throughput structure determination, generic means for ligand screening, selected examples of insight from specific structures, insights from family coverage, and the possibilities resulting from the availability of large numbers of purified protein samples. The other SGC nodes share the core technologies but investigate non-overlapping target areas.
Finally, the scientific impact depends on dissemination of structural data. We describe a new platform for distribution of annotated protein structures, which aims at making this data more meaningful to an audience beyond the usual users of the PDB.
Methodology
Protein production
Method adaptation and development for structural genomics involved a change of mindset, no less than developments in instrumentation, chemistry and computer software. Industrialization of protein production––applied to a huge variety of proteins with very divergent chemical properties––is not straightforward. Yet, extensive work in several SG centres have led to a convergence to core procedures, which are widely applicable, and often sufficient to generate purified proteins, crystals and structures (Table 1). Where the core protocol fails, additional steps (e.g., further purification, crystal optimization), or alternative methods (e.g., different cloning vectors) are applied.
Table 1Core protocols employed at the SGC1. Source of DNA1. Sequence-verified cDNA clone collections.2. Synthetic DNA.3. RT-PCR, site-directed mutagenesis.4. Genomic (microbial).2. CloningLigation-independent cloning.Recombinase-based cloning (e.g., Gateway, InFusion).3. Expression vectors and hostsT7 promoters, controlled by Lac repressor.Bacterial vectorsN-terminal hexahistidine tag, cleavable by specific proteases (TEV, Thrombin, C3).Host strains based on BL21(DE3), often expressing rare-codon tRNAs or chaperone proteins.4. Eukaryotic expressionBacoluvirus-infected insect cells.5. Protein expressionRich media, grow at 37°C to mid-log, then induce at low temperature with IPTG.OR: Similar protocol using minimal medium for Selenomethionine or isotopic labelling.6. PurificationTwo-step purification: Affinity chromatography, Gel filtration, all in high-salt buffers (0.5 M NaCl). Optional: tag cleavage and re-purification.7. Ligand and buffer screeningThermal denaturation assays are used to screen purified proteins against 1–103 small molecules and several buffer compositions, to identify stabilizing conditions and potential ligands.8. CrystalliationInitial coarse screens (2–4 × 96 conditions; 3 protein concentrations each). Vapour diffusion, sitting drops, imaged by robots but scoring done by humans.Include ligands identified from screening or biochemical knowledge to promote crystallization.Follow-up screens and crystal optimization.9. Data collection and structure determinationManual or robotic screening of crystals for diffraction properties; data collection in rotating anode or synchrotron sources.Phasing: Molecular replacement (95%), experimental phasing using SeMet derivatives, and MIR.
Several features of this protocol have been optimized to capture a large portion of target proteins. Gene clones have been predominantly obtained from public and commercial cDNA libraries. However, gene synthesis may become the method of choice, allowing to optimize codon frequency, restriction sites, and mRNA structure and to introduce site-directed mutations. Ligation-independent cloning is a generic, high-throughput process that can be uniformly applied regardless of the target gene or the cloning vector. Short N-terminal fusion tags, including a hexahistidine sequence and a specific protease cleavage site, are almost universally used. It has been widely documented, that larger fusion tags (e.g., GST, thioredoxin, MBP) can enhance solubility of proteins that are not soluble when expressed with a short peptide tag. However, such fusion proteins have not been widely used in the SGC, since removal of the tag often leads to loss of solubility.
The standard purification protocol is designed to be widely applicable, and experience has shown that it results in effective purification of a large fraction of proteins solubly expressed in E. coli. A protein presented for crystallization must be homogeneous in composition, post-translational modification and oligomeric state; the presence of protein aggregates may be especially detrimental to subsequent crystallization. Affinity purification of highly-expressed proteins eliminates most other proteins, while gel filtration effectively separates different oligomeric forms of the protein and removes protein aggregates, which may otherwise promote irreversible aggregation of the protein preparation. The use of high salt concentration (typically, 0.5 M NaCl) throughout the purification process seems to reduce protein aggregation and non-specific binding of protein contaminants. Tag cleavage followed by another passage through the affinity column provides a further generic and highly effective purification step, which removes other proteins that bind adventitiously to the first affinity column. The generic purification procedure has provided in the majority of cases protein of sufficient purity to achieve crystallization. In most other cases, the generic procedure could be followed by polishing and protein modification steps to achieve homogeneous preparations.
The greatest barrier to production of human proteins in bacteria is recovery of soluble protein. Less than 15% of protein targets yielded detectable levels of soluble protein when tested as full-length constructs in the SGC, while more than 80% were expressed as insoluble aggregates. The key to achieving higher success rates has been the parallel production of large numbers of truncated constructs, often containing a compact protein domain. Construct design is initially based on domain boundary analysis, using a number of bioinformatic tools; 3–4 endpoints are designated around each of the predicted termini of the domain, resulting in 9–16 constructs. We have consistently found that this approach results in a 4-fold increase in the number of targets that can be produced as soluble proteins; a similar impact has been seen on the production of diffracting crystals, which can be dramatically affected by minute changes in protein termini. Although not rigorously tested, it is presumed that a protein construct that is inherently well-behaved (little tendency to aggregate or denature) will be less dependent on specialized conditions for expression and purification, and may crystallize in a wider range of conditions.
Crystallization, crystal screening and data collection
For successful crystallization of a given target, the SGC’s phase I operation appears to have confirmed that the most important driver for success is to explore protein diversity at the crystallization stage. One major form of variation was discussed above, namely testing multiple constructs of the target. Equally effective has been setting up co-crystallization with multiple ligands, along with varying protein concentration in the primary crystallization screens.
At the same time, it appears not to be vital to explore chemical space extensively for any given protein preparation; instead, the primary goal of the initial (coarse) screen can be to identify which preparations are “crystallizable”, and a limited set of coarse screen conditions (∼200) generally seems sufficient. Practically, this requires only two 96-well crystallization plates, and by setting up three drops per condition, at different protein-well ratios (in Greiner 3-drop plates), the protein concentration is simultaneously varied. The conditions themselves are derived from those found to be most successful in other high-throughput initiatives [1–3], although according to this “crystallizability” philosophy, the exact composition is probably not important. Naturally, coarse screens do not always yield high-quality crystals that can produce a dataset; however, the SGC operation does not rely on these crystals showing up in coarse screens, and a good optimization infrastructure is in place.
In practice, this diversity exploration leads to large numbers of parallel crystallization experiments, presenting a logistical challenge which, at this scale, can only be met with an efficient robotics and IT infrastructure. For the automation, the SGC has been able to exploit the devices developed on the back of the first wave of structural genomics initiatives, and our investment has been less in developing the machines, than in integrating them and implementing experimental best practices. Particular examples: by minimizing sample requirements with nanolitre crystallization, the available protein can be used in more experiments. The large numbers of drops thereby produced (1.5 million/year) would be practically impossible to view by eye under the microscope, whereas automatic drop imaging on a fixed schedule allows images to be reviewed at leisure at the desk.
Automation has also played an important role in crystal characterization. An automatic sample changer has been used for initial characterization of diffraction quality of a vast number of crystals. This allows to rank the crystals for more careful data collection, especially at the synchrotron, and to direct further efforts at crystal optimization.
A significant saver of upstream efforts has been to exploit each crystal’s diffraction as efficiently as possible, even those traditionally considered to be marginal or problematic. Marginal diffractors would include crystals that are “very small” (<40 μm in longest dimension), twinned, or have streaky or anisotropic diffraction. The latter cases generally require the undivided attention of experienced crystallographers.
Small crystals require an excellent X-ray beam: the PXII beamline of the Swiss Light Source synchrotron provides a beam which is reliably small but also well-aligned and very stable. Most efficient use of the beamline relied on pre-screening all crystals at the laboratory source for thorough work prioritization; real-time data processing during data collection; and close attention to radiation damage of crystals. It has been crucial to have experienced crystallographers on site. Adherence to these good practices has been highly productive: of datasets collected on 24-hour trips to SLS, 66% were used for final structures, while 90% of all depositions relied on synchrotron data. The ability to extract useful data from marginal crystals has been especially productive in combination with the protein/ligand diversity approach of the SGC, as a significant fraction of structures (>50%) could be derived from crystals emerging from the primary screens, saving the need for further optimization.
Phasing and structure solution
Due to the family-based approach, for most SGC targets a homologous structure is already known, and most structures (>95%) can be phased by molecular replacement (MR). While this saves significant experimental efforts upstream compared to experimental phasing, by eliminating the need for selenomethionine-derived protein or heavy atom soaks, we find this does not actually save time overall, because starting phases from MR are heavily phase biased. Removing the bias has required many iterations of careful and incremental model building and refinement by experienced crystallographers who can see the danger signs of a poorly-refined model, and know how to deal with it [4, 5].
The final step, namely finalizing and depositing the model, is in fact a frequent stalling point, not only in high-throughput contexts. The reason is that the final model is not merely a result that can be trivially read off a few measurements, but instead is an interpretation of often rather noisy data, with a lot of detail that is easy to miss, where individual errors influence the clarity in all areas. Moreover, poor model definition affects biologically interesting parts of a structure, and interpreting it becomes a matter of judgment and using in orthogonal information. Indeed, the “final” model is as much scientific hypothesis as result, and depositing the model means signing off on the hypothesis––which is why it has traditionally been a bottleneck in structural genomics efforts.
The SGC has used a peer proofreading system combined with strict timelines to counteract the problem: before deposition, the structure is reviewed by another crystallographer for errors or alternative interpretations, and comments passed back to the original refiner. The intention is threefold: First, to introduce quality control on the final output. Second, the refiner does not feel compelled to spend excessive time on the model to flush out the final errors, since she knows it will be checked. Third, by mixing up refiners and proofreaders, over time this should lead to common interpretations of marginal modeling decisions. The timelines depend on situation and difficulty, but typically allow two weeks for refinement, a day for proofreading, and two further days for deposition.
This approach has made it possible to deposit novel structures at a considerable rate (6 each month from a team of 6 dedicated and 4–5 occasional crystallographers) without compromising quality.
Information infrastructure
An efficient laboratory information management system (LIMS) has been vital to manage not only target tracking, but also capturing and integrating where possible information generated from robotics, as well as capturing human assessments of experimental outcomes, where these could be entered via a client (e.g., scoring of crystallization images).
Fortuitously, the solution we settled on, BeeHive from Molsoft (http://www.molsoft.com/beehive.html), is in essence an extremely intuitive database query tool that enables even inexperienced users to extract information relevant to their current work––including the simplification of data entry. This is a weak point of many LIMS solutions, whose focus often evolves around data entry but have very inflexible retrieval mechanisms. This has proved to be a powerful means of communication between all persons involved in a project, allowing immediate and error-free retrieval of “hard” information (e.g., protein sequence, ligand and buffer conditions and project history), as well as evaluation and prioritization of crystals and of concurrent projects.
Protein characterization and ligand screening
One of the major challenges in structural genomics is identifying the function and evaluating the functional integrity of the proteins. Examining the physical state of a protein––by methods such as analytical ultracentrifugation, chromatography or dynamic light scattering––is valuable in assessing the prospects for crystallization. In contrast, specific activity assays need to be tailored for each protein class, and may be impractical or impossible when the activity of the protein is not known. We have implemented a generic screen, based on the increase in thermal stability of a protein upon ligand binding. The fluorescent readout is based on monitoring of protein unfolding using a hydrophobicity-sensing dye. Differential Scanning Fluorimetry (DSF) assays [6–9] are ideal for screening a large number of compounds for binding to each target protein. Significantly, the shift in Tm (the unfolding transition midpoint) measured by this method is comparable to measurements obtained by differential scanning calorimetry (DSC), the well-established standard method for thermal shift measurements. In selected cases, a direct correlation between Tm shift and binding constants has been observed [8, 10].
Several advantages have been derived from this capability: First, the identification of relatively strong interacting molecules out of several hundreds of candidates. As detailed below, the compounds discovered in this manner are then included in crystallization experiments; in many cases, only protein–ligand complexes yielded diffracting crystals. Secondly, the reactivity profiles provide data on binding selectivity of the protein active site, which is the most crucial information for drug design; we have often followed up the results from ligand screens by analyzing the structures of several protein–ligand complexes. In parallel, the properties of the protein–ligand interactions are studied by biophysical methods and by enzyme inhibition studies. Third, such screens have allowed us to identify ligands or substrates of proteins with unknown function (sometimes termed “de-orphanizing”). Finally, DSF-based screens can be expanded to explore other conditions, such as buffer composition that enhance the stability of a protein. These conditions may then be introduced to improve the outcome of protein purification and crystallization [8].
The limited scale of protein production and other limitations on resources do not allow a full-scale screen as done in the pharmaceutical industry (105 compounds). Rather, we have assembled smaller family-specific compound libraries (10–103 compounds each), which can reasonably be tested against available amounts of protein (∼200 μg for 100 assays). The compound libraries are based on the scientific and patent literature; the chemical structure of prospective compounds is used to search an in-house compilation of vendor databases to identify potential sources. Acquisition of desired compounds is not trivial: not all published compounds, even those appearing in vendor catalogues, are actually available when required; alternative vendors, or collaborative sources may then be accessed. With continuous updating based on current literature and our own experimental results, these libraries have allowed to derive binding profiles and new insights on ligand specificity.
SGC target and biology area selection: relevance for the treatment of human diseases
For any structural genomic organisation target selection is an important consideration as it can have a major impact on the procedures that are implemented during the process of structure determination. There are a number of approaches applied by different structural genomics projects to select targets for structural analysis such as blanket coverage of an organism’s genome, targets with potential novel folds, percentage cut off based on sequence identity or total coverage of selected protein families. The SGC has opted for the family-based approach with an emphasis on protein families whose members are important in human health, disease and are potentially druggable. From our point of view, the main advantages of this approach are 2-fold. Firstly, the methods and procedures identified for one family member can be applied to another family member improving everything from expression, solubility, stability, and purification, to crystallisation and structure determination. Secondly, analysis of the structures from all family members can reveal additional significant information such as ligand binding site specificity, conformational dynamics, understanding of aberrant behaviour of specific family members or the converse revealing common structural properties within all family members.
The availability of high resolution structures constitutes the foundation for structure-guided drug discovery projects. In recent years SG has significantly increased the number of human protein structures available for structure-based design projects [11]. In particular, protein family focused efforts originating from high-throughput structural biology projects have contributed to the structural description of a number of members from human protein families and thus provided valuable structural and chemical information for the design of bioactive compounds. In addition, established expression and crystallization conditions have been used to generate essential reagents, methodologies and technologies which have facilitated research projects in academia and drug discovery programs in industry.
The SGC has focused on providing protein structures to support drug development and understanding of the structural determinants for human disease. Of 160 unique targets deposited by the SGC (in phase 1), clear disease relevance has been established for 70% and a further 18% are likely to be involved in at least one disease. This pattern holds true for all the human protein families the SGC is working on. The following sections provide an overview of the three distinct biological areas selected at the Oxford site of the SGC.
Biology area I: Structural Genomics of human metabolic enzymes
Selection of metabolic enzymes as biological target area at the SGC was based on two distinct features: they are fundamentally involved in a multitude of human diseases, including cardiovascular, metabolic diseases or cancer, and in addition several enzymes constitute possible drug targets. Emphasis has been given to certain metabolic enzyme families such as oxidoreductases (mostly short-chain dehydrogenases/reductases (SDR), medium-chain dehydrogenases/reductases (MDR), long-chain dehydrogenases/reductases, aldehyde dehydrogenases (ALDH), aldo keto reductases (AKR) and 2′oxoglutarate dependent oxygenases (2OGs). In addition, pathways of importance, e.g., in lipid or amino acid metabolism were selected with a distribution of about 1:1 between oxidoreductases and other metabolic enzymes. The target list comprises about 300 metabolic enzymes, and after three years of operation, >60 unique novel structures have been solved. Three points of importance are highlighted in this review: structural characterization of enzymes shown to be causative of metabolic inherited diseases, structure determination of drug discovery targets in metabolic diseases such as metabolic syndrome or osteoporosis, and structure-guided “de-orphanization” of insufficiently characterized human gene products or even entire pathways.
Structural basis of inherited metabolic diseases
Genetic defects in enzymes involved in metabolic pathways such as amino acid or lipid catabolism are causative of a whole spectrum of symptoms, including dysmorphologies, mental retardation, neuropathies or life threatening situations like fasting induced hypoglycemia [12, 13]. Understanding of molecular causes and possible interventions of inherited metabolic diseases requires besides biochemical and clinical management a structural template for explanation of mutational effects.
Thus far the focus has been to a large extent on oxidoreductases in the area of metabolic diseases. Associated disorders comprise electron transfer reactions for energy production (e.g., mitochondrial myopathies), oxidative and reductive roles in the metabolism of amino acids (e.g., hyperprolinemia or branched-chain hydroxyacyl CoA dehydrogenase defects), fatty acids (e.g., inborn errors in α- and β-oxidation of short-, medium- or long-chain fatty acid metabolites), cofactors (e.g., phenylketonuria type 2), hormones (e.g., male pseudohermaphroditism or adrenal hyperplasia), mediators (e.g., congestive heart failure) and lipids (e.g., inborn errors in cholesterol synthesis, CHILD syndrome, Smitz-Opitz Laemmli syndrome as examples). The impact of the structural approach is illustrated by the successful structure determination of phytanoyl-CoA hydroxylase [14], the major molecular cause of Refsum disease, a peroxisomal disorder with severe neurological symptoms. The structure provides a framework to interpret the majority of the disease causing polymorphic alleles, and we were able to map those to changes in the active site, around the Fe2+ and 2-oxoglutarate binding sites in this 2OG enzyme [14].
Metabolic enzymes as drug targets
Oxidoreductions at specific positions of lipid hormones such as steroids selectively alter nuclear receptor binding properties. Therefore, inhibition of dehydrogenases/reductases carrying out these reactions selectively influences cellular hormone levels and transcriptional responses. This concept has recently found great attention with the development of specific inhibitors against 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) as a novel drug target in diabetes and obesity [15–18]. Similar drug development efforts are underway regulating androgen or estrogen levels through specific modulation of distinct hydroxysteroid dehydrogenases (17β- and 3α-HSDs in cancer, inflammation, osteoporosis, ageing, and autoimmune diseases). We determined the structure of human 11β-HSD1 in complex with a clinically relevant inhibitor, carbenoxolone (Wu et al., unpublished) and have provided a platform for drug development efforts. Other hydroxysteroid dehydrogenase structures comprise 17β-HSDs such as types 4, 8, 10, 11 and a novel type 14 (see below), necessary for determination of off-target activities of compounds directed against type 1 and 3 17β-HSDs. Other targets of pharmaceutical relevance successfully pursued are farnesyl diphosphate synthase (FDPS) and geranylgeranyl diphosphate synthase (GGPS), which are critical in synthesis of isoprenoids necessary for covalent modification of GTPases involved in cell signalling and survival. Crystal structures of FDPS complexed with nitrogen-containing bisphosphonates currently used for osteoporosis therapy allowed a molecular mechanism of action to be postulated for these drugs [19] (Fig. 1). Furthermore, several prokaryotic and parasitic dehydrogenases have been identified as novel targets for antibiotic and antiparasite drug development, and thus allow synchronization with the SGC Toronto efforts, where an apicomplexan/protozoan SG program has been established. Thus, structure determination of related human enzymes will facilitate structure aided drug design and allow virtual and focused screening efforts in this emerging disease area.
Fig. 1Bisphosphonate binding to human farnesyl diphosphate synthase. Electron density is shown in green around the clinically used inhibitor risedronate
Deorphanization of metabolic enzymes and pathways
A significant proportion of the metabolic enzymes targeted were at the time of structure determination devoid of assigned activity or function. High throughput protein production, structure determination and functional characterization allowed “deorphanization” of unknown enzymes. We employed ligand screening, enzyme activity assays, expression and subcellular localization data, as well as structure determination combined with docking analysis to describe novel human enzymes. In the absence of co-crystal structures, interpretation of results from biochemical assays and compound screening was rationalized by in silico docking of potential ligands into the active site of the orphan structures. Analysis of the different docking poses was correlated with experimental results, allowing direct visualization of the putative protein–ligand complex. In this manner we determined a novel 17β-HSD14 [20], possibly involved in cancer, and a novel type-2 R-hydroxybutyrate dehydrogenase, involved in ketone body utilization [21]. Further emphasis was given on novel pathways such as mitochondrial fatty acid synthesis. This recently discovered pathway is important in the synthesis of lipoic acid, essential for mitochondrial function. Thus far we have determined three distinct enzymes of this metabolic route, namely the malonyl transferase (2c2n), ketoacyl synthase (2c9h) and the enoyl-ACP reductase (1zsy). These structures represent the only higher eukaryotic structures thus far available for this pathway. The data will be instrumental to compare to the multidomain type I fatty acid synthase, where we recently solved the structure of the malonyl/acyl transferase domain (2jfk, 2jfd). This cytosolic enzyme is involved in production of endogenous fatty acids and lipids, and is discussed as potential target in metabolic diseases and cancer.
Biology area II: Structural Genomics of transmembrane receptor signalling pathways
Complete coverage of the14-3-3 protein family
A human protein family that the SGC has completed the structure determination of all members is the 14-3-3 family. This family consists of seven members (β, ε, η, γ, σ, τ, and ζ) of which σ [22, 23], τ [24] and ζ [25] structures were previously determined. This protein family plays a central role in many fundamental cellular roles such as cell cycle control, apotosis, protein trafficking, signal transduction and stress response [26–28].
Before the structural completion of the 14-3-3 family most of the structural studies utilised 14-3-3ζ which provided details of the conserved peptide binding site [25], the primary peptide interaction [29, 30] and secondary target domain interactions [31]. As all of these structures displayed similar overall conformations, structurally it was proposed that 14-3-3s behaved as “molecular anvils” in that their overall structure remained unchanged whether in the apo-form or bound to their target protein [32]. The structure determination of the remaining members allowed for a family-wide comparative study that revealed another story with a major emphasis on the flexibility of 14-3-3s [33]. This was most obviously with the apo-form of 14-3-3β in which one of the subunits was in a similar conformation to all other 14-3-3 structure while the opposing monomer displayed a more open conformation for the peptide binding groove (Fig. 2).
Fig. 2The flexibility of the 14-3-3 is illustrated by the superimposition of 14-3-3β (blue) with 14-3-3η (orange). The monomer conformations of both isoforms are essentially identical on the left hand side. However, the beta monomer on the right side has a more open peptide binding groove and flexibility at the dimeric interface
Additional flexibility of 14-3-3 proteins was observed when all of the family members were superimposed against one subunit. It became instantly clear that the position of the second subunit varied between the different 14-3-3 isoforms [33]. This is achieved through the N-terminal helices that make up the dimeric interface sliding over one another (Fig. 2). The significance of the interface flexibility is that it allows for the widening or shortening of the distance between the two peptide binding grooves hence allowing a 14-3-3 to accommodate structures of varying shapes and sizes. As 14-3-3 are known to have bind hundreds of partners [34–36] this interface flexibility would provide the necessary structural adaptability to accommodate the wide structural range of target proteins.
As all of the human 14-3-3 structures are now known they allow for a detailed bioinformatic analysis of the 14-3-3 family. This approach identified common protein–protein interaction patches at the subunit interfaces plus two additional non-specific protein interaction sites that would attract and bind the globular structured regions of the target protein thus providing a mechanism by which the 14-3-3s can initially attract and then bind a wide range of structurally diverse target proteins [33]. Another more numerous protein–protein interaction family that was targeted by the SGC are the PDZ domains which have been implicated in the regulation of drug transporters [37] and involved in the clustering, targeting and localisation of the target proteins [38]. These domains bind mostly to C-terminal peptides that fall into two classes: class I peptides are –(Ser/Thr)–X–Φ–COO− while class II peptides are –Φ–X–Φ–COO− where X represents any amino acid and Φ represents any hydrophobic residue [39, 40].
PDZ domains
Initial attempts at structure determination of 18 unique human PDZ domains resulted in a successful outcome for only 3 of these targets. To improve our success rate we took advantage of the family based approach and generated new expression clones of the remaining 16 targets with generic class I and II PDZ binding peptides attached to the C-terminus of each domain. The idea was for these peptides to bind adjacent PDZ domains initiating protein–protein interactions and thus crystal nucleation. As such the linker between the predicted end of the PDZ domain and the C-terminal peptide was varied from 2 to 6 amino acids allowing for flexibility but restraining the distance between adjacent domains [41]. Using this approach we have now solved 11 of the remaining 15 targets many of which have thrown up new details regarding peptide selectivity and structural adaptability of the PDZ domain when bound with a peptide.
As expected for most of these domains the peptide interaction was similar to the standard configuration [42, 43] in that the side-chain of the C-terminal hydrophobic residue (position 0) was bound in a conserved hydrophobic pocket and that the peptide’s -2 position Ser/Thr coordinates the His side chain from the αB helix. However, there were a number of surprises of which the biggest was for MPDZ@3 in which a class II mode of binding was observed for a class I peptide which involved a translation of the αB helix (Fig. 6a of [41]).
Biology area III: Structural Genomics of human protein kinases
Kinases play an essential role in most (if not all) signalling pathways and dysregulation has often been linked to disease. Several successful inhibitors developed to target kinases have shown that members of this large protein family are excellent targets for the development of drugs. Currently protein kinases constitute about 25% of presently pursued drug targets in industry [44–47].
There are 518 identified human protein kinases constituting 1.7% of all human genes, which have been grouped into 10 families [48]. Despite the large number of members and their involvement in large variety of pathways, evidence points to a common single ancestral protein. As a result, the structural features as well as key regulatory elements and catalytic mechanism of phosphate transfer are all well conserved. High resolution structures are therefore essential for the rational design of potent and selective inhibitors. Before the contribution of SG efforts, the progression of publicly available kinase structures was linear with only 38 human kinase structures publicly available in 2004 [46]. Currently, 21 novel human kinases structures have been released by the SGC (19 from Oxford), which started to target this protein class in 2004. This increased the number of unique human kinase catalytic domain structures available in the pdb (http://www.pdb.org/pdb/home/home.do) to 93 by the end of 2006.
Many structures, released by SG, were only distantly related catalytic domain structures previously known and in some cases provided the first structural information for a subfamily. Thus, these structures significantly enriched the coverage of the three dimensional structure description of the kinome. Among the structures where the SGC determined the first representative structure of a family were: the NEK (“never in mitosis”/NIMA) family member NEK2, the CDC2 like kinases family member CLK1 and CLK3 as well as the first structure of a NAK (Numb-associated kinases) kinase MPSK1. These kinases are quite diverse in terms of primary structure and it is therefore not surprising that many novel structural features have been discovered. For instance, a novel activation loop architecture characterized by a large helical insert has been discovered in the structure of MPSK1, the structures of CLK1 and CLK3 revealed a family conserved antiparallel beta sheet flanking the kinase hinge region, and the structure of NEK2 identified a short helix following the activation segment DFG motif that may be explored for the development of specific inhibitors [49].
Kinases are extremely flexible proteins that may adopt a number of distinct catalytically active or inactive conformations during their catalytic cycle, upon activation by phosphorylation, or by binding of a regulatory protein, and consequently a number of clinically successful inhibitors have been developed to target specifically the inactive state of kinases [50]. For example the anti-leukaemia drug Imatinib binds selectively to the inactive state cABL characterized by an outward conformation of the DFG motif, a conserved tripeptide motif that ligates Mg2+ ions [51, 52]. It is not clear to date how many kinases are able to adopt this conformation, which makes development of these so-called type II inhibitors possible. In general, these are characterized by largely improved specificity.
For the development of conventional inhibitors that target the active state of kinases information about the plasticity of the catalytic domain greatly facilitates the rational design of inhibitors. Consequently it is desirable that several structures of the same target in complex with different ligands are available. Also here the structural information content regarding ligand binding was significantly increased during the last three years by SG. In 2004, only 38 human kinases had a structure available in the public domain and only 12 publicly available structures contained non-adenosine chemotypes [46]. From the 19 structures of kinase catalytic domains released by our laboratory, 16 were determined in the presence of an non-adenosine kinase inhibitor and several structures were determined in complex with more than one inhibitor scaffold (Table 2, and Fig. 3, showing PAK5 apo/inhibitor).
Table 2Protein kinase structures determined by SGCNamePDB IDResolution [Å]Inhibitor nameDisease linkFamilyCLK11Z571.70HymenialdisinePot. GeneticeCMGCCLK3c2EU91.53nonePot. GeneticeCMGCCK1γ12CMW1.75Compound 52CK1CK1γ22C472.405-IodotubercidinGeneticCK1CK1γ3d2CHL1.95Triazolodiamine 1CancerCK1ERK32I6L2.25noneCancerCMGCASK12CLQ2.30StaurosporineInflammation, CVfSTENEK22JAV2.10SU11652CancerOther-NEKPAK4a2CDZ2.40Cdk1 InhibitorCancerSTEPAK52F571.80Cdk1 InhibitorPot. CancerSTEPAK62C301.60noneCancerSTEPIM1b1XWS1.80BIM I, HB1Cancer, InflammationCAMKPIM22IWI2.80HB1Cancer, InflammationCAMKSLKc2J512.10Triazolodiamine 1Pot. CancereSTEMPSK12BUJ2.60StaurosporinePot. CancereOther-NAKSTK102J7T2.0SU11274Not knownSTEDAPK32J902.0Pyridone 6Cancer, InflammationCAMKCAMK1G2JAM1.7SU11652Not knownCAMKCAMK1D2JC62.5GSK inhibitor XIIIGeneticCAMKaPAK4 also deposited as an apo-structure in two different spacegroups: 2BVA, 2J01bStructures with different inhibitors and substrate: PIM1: 2BIK, 2BZH,2BZI, 2BZJ, 2BZK, 2C3I, 2BIL, 2J2I; SLK: 2JA0cCLK3 also deposited as phosphorylated protein: pdb-code: 2EXE. Detailed description of structures of targets solved in Oxford is available in form of “iSee” datapacks freely downloadable on: http://www.sgc.ox.ac.uk/structures/KIN.htmldCK1γ3 with different inhibitors: 2CHL, 2IZR, 2IZS, 2IZU, 2IZTeA formal link to the disease has not been established so far but is likelyfCardiovascular diseaseFig. 3Superimposition of apo-PAK5 (cyan) and the PAK5 purine complex (orange), highlighting the decomposed movements of the glycine-rich loop (flapping) and the αC helix (swinging) [53]
In addition, the SGC has supported development of entirely new inhibitor classes exemplified by co-crystal structures with Ruthenium-half sandwich complexes. These stable organometallic compounds are extremely potent inhibitors for PIM1 kinases [54]. The co-crystal structure of three inhibitors of this class showed that the inert metal centre in this scaffold functions as a hypervalent carbon, allowing it to occupy the binding pocket efficiently with excellent shape complementarity.
Contributions of NMR to Structural Genomics
NMR as a complementary method to crystallography for protein structure determination
The NMR spectroscopy can play an important role in structural genomics, providing complementary information to that obtained from X-ray crystallography. Importantly for large-scale structural genomics projects, NMR provides an alternative route to solving the high resolution, three-dimensional structures of proteins that prove refractory to crystallization. We were able to use NMR to solve the structures of a number of relatively small protein domains (∼20 kDa) in which the domain contained at least one flexible region. The RGS domains from the regulator of G-protein signalling proteins, RGS3, RGS10, RGS14, RGS18, RGS20 were all very good examples of this. Multiple constructs of these were designed, which expressed to high yield in stable, highly soluble form yet did not yield high quality crystals despite many months of concerted effort. The domains were therefore expressed as uniformly 15N-labelled proteins using standard growth methods in E. coli, and their 15N-HSQC spectra were recorded to assess the feasibility of structure determination by NMR. In all cases, excellent spectral dispersion was observed and we were able to obtain almost complete assignment of the protein resonances. We have since deposited the high resolution NMR structures of three RGS domains in the PDB and the resonance assignments of four RGS domains in the BioMagResBank (BMRB). The structures and assignments of two further non-crystallizing domains (Spred2 EVH1 domain and JARID1CA Bright/ARID domain) have also been deposited, and those of several other non-crystallizing domains ‘rescued’ by NMR are currently underway (Table 3).
Table 3Deposited NMR structures and assignmentsGenePDB depositionResonance assignment depositionRGS3–BMRB-15178RGS102I59BMRB-7272RGS142JNUBMRB-15128RGS182OWIBMRB-7106SPRED22JP2BMRB-5939JARID1CA2JRZBMRB-15348
NMR as an assessment tool for the feasibility of structure determination
Further examples where NMR has proven useful as a rescue strategy include particular families of signalling domains which have a known tendency to be partially unfolded in their unliganded states. Some examples include certain WW domain [55, 56]. We successfully identified peptide binding partners for a WW-tandem construct using the SPOTs screening technique [57, 58] following which the most strongly binding peptides were synthesized on a large scale for NMR measurements. Although the 15N-HSQC spectra of this pair of tandem domains in isolation were very unhopeful, the spectra of their complexes showed significant improvements in signal dispersion, indicating that in the complexed form, the protein was better folded. At this point, the protein entered our NMR structure determination pipeline. The recording of a quick 15N-HSQC spectrum has in several cases allowed us to rescue protein constructs with promising but borderline behaviour, for example, proteins showing good signal dispersion but low-medium levels of aggregation. Far from abandoning these constructs, we took these constructs ‘back to the drawing board’ and made rational construct improvements with the help of bio-informatic tools. Successfully re-designed constructs were then re-screened for fold quality by 15N-HSQC. After 2–3 iterations of this procedure, it was often possible to refine promising constructs sufficiently for structure determination. For example, Fig. 4 shows the stepwise improvement in the spectral properties of a hopeful, though initially problematic DNA-recognition domain from the oxygenase protein, JARID1CA. The NMR structure is now deposited (PDB code: 2JRZ). In all of the above cases, a quick 15N-HSQC showed immediately whether the structure determination of a protein, having to failed to crystallize, should be pursued or abandoned, hence reducing unnecessary attrition in the structure determination pipeline.
Fig. 4Visible improvement in quality of 15N-HSQC spectra over two rounds of iterative construct re-design for the JARID1CA Bright/ARID domain. The leftmost (initial) construct shows potential. The structure of the final construct on the far right was determined by NMR (PDB code: 2JRZ)
The study of protein dynamics by NMR
The use of NMR to study the rotational correlation times and internal dynamics of the proteins offers good explanations as to why crystallization sometimes fails even for well-folded proteins. In all of the proteins we rescued by NMR, 15N heteronuclear NOE and 15N T1, T2 relaxation data revealed regions of internal mobility within the proteins, which would have hindered long-range order and impaired or prevented efficient crystal packing. A striking example was the case of the RGS domain from RGS10, in which NMR relaxation data confirmed true local mobility in a region of the domain which not only lacked in NMR restraints, but also showed no electron density in the crystal structure of the complex of RGS10 with G-alpha-i3 (PDB 2IHB). Comparison of mobility in RGS domains from different branches of the phylogenetic tree leads to clues about their specificity and helps to guide further investigations. In some cases, the 15N T1 and T2 data have also identified partial dimerization in proteins that fail to crystallize, thus explaining the latter. NMR relaxation data were in each case confirmed by analytical ultracentrifugation (AUC). The combined information allowed us to decide whether these proteins should be highlighted as candidates for structure determination by NMR and to judge the best conditions under which they should be studied.
Future and outlook
The future role that NMR will play in structural genomics will depend heavily on the continued development and implementation of new, faster methods of data acquisition, processing, resonance- and NOE-assignment and structure determination and refinement. These topics have been covered extensively in other reviews; for a concise summary see [59] and references therein. The potential time gains that could be gained from these methods make high throughput structure determination by NMR a realistic possibility for the future.
Structural bioinformatics and rationalisation of experimental results
A crystal structure of a protein in absence of ligand or substrate may not always provide insight on reaction mechinasms or specificity. Ideally, such information can be derived from additional structures with bound ligands. In the absence of such co-crystals, interpretation of results from biochemical assays and compound screening is more speculative. However, these results can be rationalised with in silico docking of potential ligands into the active site of unliganded protein structures. An example illustrating this point is the analysis of the DHRS10 structure [20]. Analysis of the different docking poses can be correlated with experimental results, allowing direct visualisation of the putative protein–ligand complex. With these results, further modifications of the enzyme can be suggested more reliably, allowing a faster progress towards the complete elucidation of the mechanistics.
Dissemination of structural genomics data and knowledge
Structural genomics produces a wealth of information of different types: DNA and protein seqeuences, biochemical information, coordinates of crystal structures, and structural annotation. This information is deposited in one or more public databases, predominantly the PDB, in addition to publication in journals. This form of data distribution does not adequately disseminate the full information to a wide scientific audience. The first issue is the fragmentation of data between different formats. A user may have to read text information in a journal paper, which may include a few two-dimensional Figures; then download a PDB structure file and image with a separate application; and then perform analysis and alignment of data from, say, SNP database using alignment software. The second issue is that non-structural biologists do not routinely access PDB files, especially of structures that were not published in pubmed-indexed journals.
We have approached this challenge by developing a new intuitive dissemination concept in conjunction with Molsoft LLC (San Diego, CA) [60]. This concept, (which we denoted iSee) integrates all the information associated with any given target solved by SGC into a small, self-contained file, annotated by the authors (Fig. 5). The file not only allows the direct visualisation of text information, but also offers an interactive visualisation feature fully integrated to the structural data being presented. At any stage, the annotation written by the expert can be coupled with an interactive molecular graphics scene. Transition between each anotated viewpoint is fully animated on-the-fly, to convey a sense of three-dimensionality which is vital for the user to grasp the spatial relationship between different features on a structure.
Fig. 5Screenshot of iSee datapack. The annotation text (top left panel) includes links (blue text), which lead to structural images focused at areas of interest, simultaneously accessing other types of information (sequence alignment, small molecule formulae, etc.)
Each of these files (called an iSee datapack), as well as the software needed to visualise them (ICM-Browser) are available for free download from our website (http://www.sgc.ox.ac.uk/iSee).
We also maintain and curate each of these files by revising each datapack quarterly to ensure that all the recently disclosed information is added (either by ourselves through follow-up experiments or by external collaborators working on the same targets). Each of the datapacks has a built-in automated updating function that can be executed on user’s request.

protein kinase
reductase
high-throughput
dehydrogenase
14-3-3
pdz
binding specificity
protein crystallography


Strategies to Reduce Alcohol-Exposed Pregnancies

Introduction
Prenatal alcohol exposure remains a leading preventable cause of birth defects and developmental disabilities in the United States, with the prevalence of alcohol consumption by women in childbearing age remaining high and unchanged over time (Fig. 1). This paper provides a summary of current knowledge and information on recognition and prevention of an alcohol-exposed pregnancy, including overall alcohol exposure burden among women of child-bearing age, diagnostic criteria for fetal alcohol syndrome (FAS), and recommendations for screening, assessment and interventions to reduce alcohol exposed pregnancies.
Burden of alcohol exposure in pregnancy
Most women reduce their alcohol use substantially when they realize they are pregnant, but significant numbers continue to drink at levels that can be hazardous to the fetus [1, 2]. Of particular concern are the group of sexually active women who are not planning to become pregnant (about half of all pregnancies in the US), but do so and continue alcohol use during the early stages of embryonic and fetal development [1]. For many women, pregnancy recognition does not occur until the 6th week of gestation [3]. According to national survey data, in 2002 about 8% of women aged 18 to 44 years were sexually active, fertile, not using any form of birth control, and at risk of becoming pregnant [1]. This group of women also report high rates of binge drinking, with 1 in 5 in the age category of 18 to 24 years reporting multiple episodes of binge drinking, and are therefore at risk for an alcohol-exposed pregnancy.
Fig. 1Weighted percentage of alcohol consumption for non-pregnant women aged 18 to 44 years during the previous 30 days, BRFSS, United States. Data were not collected in 1994, 1996, 1998, and 2000. Frequent refers to = 7 drinks/week or binge. Binge drinking refers to = 5 drinks on one occasion
Adverse fetal outcomes
Prenatal alcohol exposure can result in a wide range of adverse outcomes including fetal alcohol syndrome (FAS), although not all infants exposed to alcohol in utero develop the same severity of effects as do others. The term fetal alcohol spectrum disorder (FASD) has been introduced to describe the range of physical, mental and behavioral effects that can occur in an individual exposed to alcohol in utero. Because diagnostic criteria are not available for all conditions along the spectrum, there are no prevalence rates available for the full spectrum. Prevalence rates of FAS range from 0.3 to 2.0 cases per 1,000 live births [4] depending on the methodology used, and the sub-populations assessed. Reported rates are higher among infants born to women who are American Indian/Alaska Native or African American, unmarried, smokers, have low incomes, and have a history of previous drug use or mental health conditions [5, 6]. In an effort to promote the more complete recognition of FAS, guidelines for identifying and referring persons with FAS have been collaboratively developed and disseminated recently [4] (www.cdc.gov/ncbddd/fas/documents/fas_guidelines_accessible.pdf).
Approaches to reducing alcohol-exposed pregnancies
A 1996 report from the Institute of Medicine addressing prevention of FAS recommended implementation of preventative actions at multiple levels including individual, group, and universal levels [7]. To date, most of the effective prevention strategies identified have focused on the individual level. In 2004 the U.S. Preventive Services Task Force (USPSTF) released a report recommending screening and behavioral interventions to reduce alcohol misuse in adults in primary care settings [8], www.preventiveservices.ahrq.gov.
The report concluded that effective interventions include brief counseling comprised of feedback regarding screening and assessment information, advice, goal-settings and follow-up assistance. The report further cited complementary practices of motivational interviewing, assessing readiness to change, and use of the 5 A’s behavioral counseling framework of assess, advice, agree, assist and arrange. Validated screening instruments are available for screening pregnant and non-pregnant women of reproductive age including the T-ACE, TWEAK, and AUDIT [9]. More information on these instruments is available at the following website: www.nih.gov/publications/Assessing/Alcohol/Index.htm.
Primary healthcare providers can play a pivotal role in identifying women of reproductive age (during pregnancy and before pregnancy occurs) who are at high risk for an alcohol-exposed pregnancy and providing them with advice, counseling, and referral as appropriate. This strategy has widespread support among professional organizations including the American College of Obstetricians and Gynecologist (ACOG), and the American Academy of Pediatrics (AAP), as well the U.S. Office of the Surgeon General, and the U.S. Department of Health and Human Services.
A useful example of an intervention targeting groups of women using many of the components described in the recommendation of the USPSTF is found in a CDC sponsored study, Project CHOICES, a feasibility pilot study that targeted non-pregnant women at high risk for an alcohol-exposed pregnancy [10]. Project CHOICES was conducted in diverse sub-populations of women determined to have higher proportions of individuals at risk for an alcohol-exposed pregnancy. Compared to the overall estimated 2% of childbearing women at risk for an alcohol-exposed pregnancy, the Project CHOICES intervention settings (e.g. a jail, alcohol and drug treatment facilities, and primary care clinics) had an overall rate of 12.5% of women at risk for an alcohol-exposed pregnancy. A unique aspect of the intervention is that it focused not only on reducing risk drinking, but also addressed pregnancy postponement as a route for avoiding an alcohol-exposed pregnancy. The intervention consisted of 4 brief motivational interventions sessions and 1 consultation visit to a family planning provider. All participants were at risk for an alcohol-exposed pregnancy in that they were sexually active, fertile, risky drinkers and not taking effective measures to avoid pregnancy. At the 6 month follow-up assessment, 68.5% were at reduced risk because they had either changed their risk drinking, instituted effective contraception, or both. Subsequently, the Project CHOICES Research Group completed a randomized controlled trail to test the efficacy of the intervention with a report of the study findings currently underway.
Universal level interventions have not received recent attention with the exceptions of the 2005 release of U.S. Surgeon General’s Advisory on Alcohol Use and Pregnancy, http://www.hhs.gov/surgeongeneral/pressrelease/sg0222205.html. This advisory drew attention to the continuing problem of FASD and the continuing high rates of alcohol use, including binge drinking, among childbearing aged women in the U. S. The impact of the advisory has provided support for those seeking to inform and educate the public healthcare system overall to this important public health concern.
Summary
In addition to the adverse effects of alcohol on the fetus, alcohol use can leads to other adverse effects on the health of women including reproductive health conditions that are not addressed in this brief. Though the approaches mentioned here are primarily aimed at reduction of prenatal alcohol-related pregnancies, any reduction in hazardous alcohol consumption among women will add to improvements in the general health of women. Multiple federal and non-fedral health agencies and organizations recommend that pregnant women and those planning a pregnancy should abstain from alcohol use. Although assessment and interventions are valuable tools to recognize and address alcohol use and secondary pregnancy outcomes, they are underutilized in primary care settings. To reduce the burden of alcohol exposed pregnancies and alcohol’s impact on the health of families, it is critical for physicians and health care providers to consistently screen childbearing-aged women for alcohol use with validated screening tools which can be embedded in the patient screening protocol. Tools are now available for pediatricians and child health care providers to enhance early recognition of FASD and reduce secondary conditions that often accompany physical maturation [4]. Brief clinician-delivered behavioral interventions to women and their partners, counseling regarding effective contraceptive options when not planning a pregnancy, and improving access to such services for those who are unable reduce their alcohol intake can help more women reduce their risk for an alcohol exposed pregnancy [11]. Referral to needed social services should complement health services in order to achieve maximum benefits of primary care-based attempts to reduce alcohol-exposed pregnancies. Given the levels of alcohol use among childbearing aged women, primary care-based individual level assessment and intervention continues to remain a critical prevention strategy for reducing alcohol-exposed pregnancies.


Radiofrequency ablation of osseous metastases for the palliation of pain

A number of different methods have been proposed for pain relief in cancer patients with bone metastases, each with different indications, contraindications and complications (systemic analgesics, bisphosphonates, antitumor chemotherapy, radiotherapy, systemic radio-isotopes, local surgery and vertebroplasty). The ideal treatment has to be fast, safe, effective and tolerable for the patient. CT-guided radiofrequency (RF) ablation may fulfill these criteria. Our experience in the treatment of 30 patients (34 lesions) with painful bone metastases using RF ablation was assessed. There was a significant decrease in the mean past-24-h Brief Pain Inventory (BPI) score for worst pain, for average pain and for pain interference during daily life (4.7, 4.8 and 5.3 units respectively) 4 and 8 weeks after treatment. There was a marked decrease (3 out of 30 patients 4 and 8 weeks after treatment) in the use of analgesics. CT-guided RF ablation appears to be effective for treatment of painful bone metastases.
Introduction
Painful bone metastases are a common cause of morbidity in patients with metastatic cancer, especially when combined with possible neural compression and pathologic fractures. Several solid cancers are associated with bone involvement, most often, prostate and breast. Thirty to seventy percent of cancer patients develop bone metastases [1]. They indicate widespread disease. Treatment of local disease may reduce the pain of these patients who, in most cases, have a life expectancy of months. Such treatment must be fast, safe, effective and tolerable.
A number of treatment methods are available that have variable success and complications. Radiation therapy is the preferred treatment in this setting, but other modalities such as chemotherapy, hormonal therapy, radiopharmaceutical therapy and surgery—alone or in combination with non-steroid anti-inflammatory drugs (NSAIDs), opioids and adjuvant drugs—are used for pain palliation [1–3].
Radiofrequency (RF) ablation is a relatively new method for the treatment of painful bone metastases. Previously, tumour ablation was performed with percutaneous ethanol injection under CT guidance [4]. Administration of 95% ethanol was described in 25 terminally ill cancer patients with 27 bone lesions who had been unsuccessfully treated by radiation therapy and/or chemotherapy.
Radiofrequency ablation has been employed for the treatment of hepatocellular carcinoma (HCC), liver metastases, renal and lung tumours, as well as for the treatment of osteoid osteoma, for which it has become the treatment of choice [1–3]. Competing methods include chemical ablation (with ethanol or acetic acid) and thermal therapies, such as with laser, microwave, ultrasound and cryoablation [5]. The aim of this study was to demonstrate the effectiveness of RF ablation of bone metastases using CT guidance.
Materials and methods
Thirty patients were retrospectively identified. There were 19 men and 11 women. Their ages were between 47 and 91 years (mean ± standard deviation [SD]: 66.53 ± 10.56 years). The patients had bone metastases, which were treated with RF ablation under CT guidance, at our hospital, over a period of 4 years. All treated lesions were osteolytic with a combination of bone destruction and a soft tissue mass. In 26 there was a solitary lesion, and in 4 patients there were two such lesions, resulting in a total number of 34 metastases. Bone metastases were diagnosed by bone scintigraphy and spiral CT. The diagnosis was confirmed with a core biopsy obtained at the beginning of the procedure. Their topographical distribution and the originating primary malignancies are presented in Table 1. In our study the most common treated metastases originated from colon cancer, which was probably related to the patient population treated at the oncology department of our hospital.
Table 1Bone metastasis classification, with regard to the primary malignant lesion and the site of the skeleton involvedSite of primary neoplasm originnSite of metastasisnColon13Pelvis15Breast7Ribs6Prostate2Sacrum5Lung4Femur3Renal2Spine3Thyroid1Scapula2Skin melanoma1Tibia 1Total30Total34
Lesion diameter was between 1 and 14 cm (mean ± SD: 3.9 ± 2.6 cm). For sizes over 3 cm, two or more electrode placements were needed (with a maximum of five). Previously obtained imaging examinations were evaluated for lesion characteristics and feasibility of electrode positioning and ablation. Lesions located in proximity to the spinal cord and major nerves (less than 1 cm) were excluded from RF treatment. Patient selection criteria are summarised in Table 2. The study was in accordance with the ethical principles of the Helsinki Declaration and informed consent was obtained in each case.
Table 2Criteria for the selection of patients to undergo radiofrequency ablationPatient selection criteriaBrief Pain Inventory (BPI) score above 4Lesions not responding to chemotherapy and/or radiation therapy (completion of therapy at least 3 weeks before the radiofrequency ablation session)Chemotherapy-associated complications that halted this treatmentLesions adjacent to structures sensitive to irradiationPatients with life expectancy greater than 2 months who were not eligible for surgical treatment Patients who preferred this treatment over the other alternatives
Physical examination was performed by the oncologist and in collaboration with the radiologist performing the ablation. Pain was assessed with the Brief Pain Inventory (BPI) The use of analgesics was recorded the day before the procedure.
Before the procedure blood cell count and blood clotting analysis were performed. Minimal requirements were: platelet (PLT) count >50,000/ml (normal range, 150,000–350,000/ml); prothrombin time (PT), international normalised ratio (INR) <1.3 (normal range, 0.8–1.2); and partial thromboplastin time (PTT) <34 s (normal range, 25–34 s). The procedure was performed under conscious sedation (administration of 3 mg of bromazepam PO and 50 mg of pethidine hydrochloric acid intramurally, 45 min prior to the procedure) and was trained in regular breathing and breath-holding (suspended respiration) before the procedure. He/she was placed in the appropriate position (prone, supine, or lateral, depending on the site of the lesion) and a scan of the desired area with a 5-mm slice thickness was performed, using a Picker 5000® (Philips Medical Systems, Amsterdam, The Netherlands).
At least one of two staff radiologists with extensive experience in biopsies and tumour ablations was involved in all ablations.
The lesion’s exact location and depth, in relation to the overlying skin, was determined on CT. The skin was then prepared with povidone iodine (10%) solution. Local anaesthesia (15 ml of 2% lidocaine hydrochloride solution) was administered.
Radiofrequency ablation was performed with a RITA Model 1500® electrosurgical generator (RITA Medical Systems, Mountain View, CA, USA) and a seven-array, 2- to 3-cm multitined electrode for lesions smaller than 3 cm (20 out of 34), or a nine-array multitined electrode for larger lesions (14 out of 34). The electrode tip was inserted to approximately 1 cm from the centre of the target. The electrodes were then deployed slowly, taking into account the need to ablate the lesion–bone interface. The net ablation time was ~15 min at an energy level of 90–110 W, with the target goal temperature set to 80–110°C. During the procedure the infusion port of the electrode was flushed with a 2% lidocaine hydrochloride solution in order to reduce patient discomfort and to decrease tissue overheating and vaporisation. The number of electrode placements, individual (per electrode) and total ablation times, the total energy delivered to the target and the lesion temperatures achieved were recorded.
After each session a dual-phase spiral CT examination with intravenous contrast medium was performed in order to assess response, as confirmed by low lesion attenuation values and lack of contrast enhancement.
Patients were hospitalised and observed for 24 h. Analgesics were administered if required. Before patient discharge the pain was re-evaluated with the BPI score. Post-ablation assessment was completed with telephone interview after one, four and eight week. The BPI score and the use of analgesics were recorded again.
Results
For lesions smaller than 3 cm (20 out of 34), one placement was adequate, while for the remaining 14 out of 34 cases of lesions that were larger than 3 cm, two or more placements were required; one lesion sized 14 cm required five placements, accomplished in two sessions (since more deployments are required in larger lesions). The total procedure time ranged between 33 and 65 min (mean ± SD: 42 ± 11 min; Table 3). There were no complications and post-treatment CT revealed a good response, as confirmed by low lesion attenuation values and a lack of contrast medium enhancement, consistent with necrosis. Post-procedural CT did not demonstrate any major complications (such as haemorrhage, thrombosis of neighbouring veins, or skin burns).
Table 3Lesion characteristics andtreatmentNumber of lesionsSize of lesion (cm)Number of electrode placementsTime of radiofrequency energy deposition (min)15<31553157427352816391841019410114515Total 34
Eleven patients reported no pain reduction during the first 24 h after the procedure and were treated with analgesics (opioids or an opioid/NSAID combination). Nineteen of the 30 patients reported early pain reduction. In none of the patients was increased pain reported. Prior to the procedure, the mean past-24-h BPI score for worst pain was 8.3 (on a numerical rating scale where 0 indicates no pain, and 10 indicates worst pain imaginable), mean pain was 6.8, and mean pain interference with daily life 7.5. These scores were reduced to 7.4, 4.7 and 6.5 24 h after the procedure, dropped to 4.9, 3.2 and 4.0 after 1 week, to 3.6, 2.00 and 2.2 after 4 weeks, and to 2.1, 1.4 and 1.7 after 8 weeks respectively. These results revealed a marked decrease in pain with subsequent improvement in the life quality for all participants since the first week post-treatment that lasted throughout the 8-week follow-up (Fig. 1). For all time points, the mean past-24-hour BPI score for worst pain, for average pain and for pain interference in daily life improved in comparison to preprocedural symptoms (p < 0.001, paired t test; Figs. 2, 3, 4).
Fig. 1Mean Brief Pain Inventory (BPI) scores over time for patients treated with radiofrequency ablation. a Worst pain. b Average pain. c Interference of pain in everyday lifeFig. 2Computed tomography scan a during and b after the radiofrequency session with the patient in a supine position. The electrode is deployed inside the metastatic lesion of the left acetabulum (metastasis from breast cancer). There is no enhancement after intravenous contrast media administration. Before the radiofrequency session, the average pain score was 7. During the first 24 h after radiofrequency, it was 4 and 1, 4 and 8 weeks later the average pain scores were 3, 2 and 0 respectivelyFig. 3Computed tomography scan images at the level of the sacrum show a, b two different electrode placements within a soft tissue mass involving the sacrum and right iliac bone (metastasis from thyroid cancer). Before the radiofrequency session, the average pain score was 7. During the first 24 h after radiofrequency, it was 4 and 1, 4, and 8 weeks later the average pain scores were 3, 2 and 1 respectivelyFig. 4Computed tomography scan image during the electrode placement inside a a metastatic lesion involving a rib (the primary neoplasm originates in the lung). Immediately after the radiofrequency session the contrast enhancement CT scan revealed a hypodense area (necrosis) inside the lesion. Before the radiofrequency session, the average pain score was 6. During the first 24 h after RF, it was 4, and 1, 4 and 8 weeks later the average pain scores were 2, 2 and 1 respectively
Prior to RF ablation 27 out of 30 patients received opioids or an opioid/NSAID combination. The remaining 3 patients received NSAIDs. One week after treatment 5 out of 30 patients were treated with a combination of NSAID/low-dose opioids. Six out of thirty used NSAIDs. After 4 and 8 weeks only 3 out of 30 patients received any medication NSAIDs. One patient died during the 8-week follow-up for reasons not related to RF ablation.
Discussion
In patients with cancer, pain originating from bone metastases can be difficult to treat. A number of treatment options are available, including NSAIDs, opioids, and adjuvant drugs medications, radiation therapy, chemotherapy, hormonal therapy, radiopharmaceutical therapy, surgery and vertebroplasty.
Medication represents the first line of treatment. NSAIDs and adjuvant drugs represent basic medication, potentially followed by NSAID/low-dose opioid combinations, and finally increasing the opioid dose.
Radiation therapy is another treatment option that may also be employed in pathologic or impending fractures [6]. Approximately 70% of patients undergoing radiation therapy will experience pain relief after between 2–3 days and up to 4 weeks after treatment. However, radiation therapy may also cause complications, mostly from damage of adjacent soft tissues [6].
Chemotherapy and radiopharmaceutical therapy are the only systemic methods of treatment that deal with even small foci of metastatic cells. However, not all metastases are sensitive to chemotherapeutic agents. Chemotherapy is often not well tolerated and is associated with complications. Radiopharmaceutical therapy can be more useful in treating patients with multifocal bone metastases. It has been reported that radiopharmaceuticals proved efficient in pain palliation mostly in bone metastases from breast, prostate and perhaps small cell lung cancer. As in the case of chemotherapy, all agents have advantages and possible side effects. Radiopharmaceutical agents vary with regard to the analgesic efficacy, duration of pain palliation, ability to repeat treatments, toxicity and expense [7].
The term “ablation” refers to the local destruction of the tumour by the means of application of either chemical agents (ethanol, acetic acid), or local deposition of some form of energy (radiofrequency, laser, microwave, ultrasound and cryoablation). Image-guided RF ablation is currently used for the treatment of various tumours with good results. According to preliminary results by Dupuy et al. [8], RF ablation can provide palliative treatment for patients with painful osseous metastases. Later on, Callstrom et al. [9] reported results after treating 12 patients and concluded that this modality provides an effective and safe alternative method of pain palliation in patients with osteolytic metastases. A multicentre study involving 43 patients with painful osseous metastases was carried out by Goetz et al. [10] and showed again significant reduction of pain and decrease in the use of opioids, with only minor complications.
The proposed mechanisms by which RF ablation decreases pain may involve: pain transmission inhibition by destroying sensory nerve fibres in the periosteum and bone cortex; reduction of lesion volume with decreased stimulation of sensory nerve fibres; destruction of tumour cells that are producing nerve-stimulating cytokines (tumour necrosis factor-alpha [TNF-α], interleukins, etc.) and inhibition of osteoclast activity [11, 12].
In our patients, we observed a considerable reduction of pain and improvement of the quality of life, as measured by the BPI score.
A decrease in the use of analgesic medications was notable in our series and possibly greater than others reported in previous studies [9, 10].
The reduction of the procedural time is limited by both the time needed to achieve the optimal target temperature, and the size of the lesion, because more than one deployment is required in larger bone metastases. Although a few patients reported mild discomfort during the ablation, none of the sessions was forced to stop owing to considerable patient distress. There were none of the possible adverse effects, including infection, haemorrhage, neurological complications, skin burns, or the so-called post-ablation syndrome (low-grade fevers ≤100°F [37.8°C]), myalgias, and malaise for up to 1 week after the procedure). Pain reduction was fast and occurred within the first 24 h for some and during the first week in the majority of the patients. This appears to be a fairly well-tolerated procedure and the combination of conscious sedation and local anaesthesia is adequate for its needs.
In the spine, RF ablation may be contraindicated due to the close relationship with the spinal cord and nerve root. Vertebroplasty may be used for pain relief and stabilisation of osteolytic lesions. Pain relief occurs within hours or days (mean 24 h) of the procedure, sometimes after a transient worsening of pain [13]. Mechanical or thermal damage to the adjacent soft tissue from needle positioning or cement leakage are the potential complications.
In our study, there were no lesions threatening the stability of the spine.
There are two conflicting studies in the literature concerning the use of RF ablation in spinal metastases. One of them has demonstrated that the presence of cancellous or cortical bone between the lesion and the spinal canal can provide adequate safety for the procedure [14, 15]. Another study in an in vivo animal model, with the use of magnetic resonance imaging (MRI) and pathological evaluation, has demonstrated that the placement of the electrode against the posterior vertebral body wall resulted in damage of the spinal cord [16]. In most series, lesions within 1 cm of the spinal cord, lesions involving the posterior wall and lesions with cortical bone destruction with involvement of soft tissue were considered to represent contraindications to treatment [17]. All spinal metastases treated in our series involved the anterior part of the vertebral body.
The follow-up period for this study was 8 weeks, a period that we believed was sufficient to demonstrate that RFA provides effective palliation. There is, however, a need for randomised prospective studies, to evaluate the method and to compare it with other treatment modalities, such as radiation therapy. Continued follow-up is warranted to determine the long-term efficacy of this interventional approach.
In conclusion, imaged-guided RF ablation of painful bone metastases is promising. It appears to be effective, safe and well tolerated by patients.

radiofrequency ablation
osseous metastases
pain
minimally invasive treatment