Over 100 years have passed since the first observation of the notched wing phenotype in Drosophila melanogaster, and significant progress has been made to characterize the role of the Notch receptor, its ligands, downstream targets, and cross-talk with other signaling pathways. The canonical Notch pathway with four Notch receptors (Notch1-4) and five ligands (DLL1, 3-4, Jagged 1-2) is an evolutionarily conserved cell signaling pathway that plays critical roles in cell-fate determination, differentiation, development, tissue patterning, cell proliferation, and death. In cancer, these roles have a critical impact on tumor behavior and response to therapy. Because the role of Notch remains tissue and context dependent, alterations within this pathway may lead to tumor suppressive or oncogenic phenotypes. Although no FDA-approved therapies currently exist for the Notch pathway, multiple therapeutics (e.g., demcizumab, tarextumab, GSI MK-0752, R04929097, and PF63084014) have been developed to target different aspects of this pathway for both hematologic and solid malignancies. Understanding the context-specific effects of the Notch pathway will be important for individualized therapies targeting this pathway. Clin Cancer Res; 21(5); 955–61. ©2014 AACR.

One hundred years ago, John S. Dexter observed serrations on the wing margin in Drosophila melanogaster (1). Decades later, Artavanis-Tsakonas and Young independently cloned the Notch receptor (2). The Notch signaling pathway is a highly conserved pathway among species (Fig. 1). In mammals, four type I transmembrane Notch receptors (Notch 1-4) are synthesized. After cleavage at the S1 site in the Golgi apparatus by a furin-like convertase, (3) it becomes glycosylated by O-fucosyltransferase (4, 5) and Fringe family N-acetylglucosaminidyl transferases (6); the processed heterodimers reassemble on the cellular membrane (7). The extracellular subunits, of Notch1 and 2, both have 36 EGF repeats; Notch3 and Notch4 have 34 and 29 repeats, respectively, which correlate with affinity for their respective ligands (8). In addition, the receptor contains a negative regulatory region composed of three cysteine-rich Lin12/Notch repeats and a C-terminal region (9, 10). The other primary difference between the receptors rests within the transactivation domain (TAD) with either strong (Notch1), weak (Notch 2), or absent (Notch4) TAD (11). The Notch3 TAD is specific to activation of the hes5 promoter (12).

Figure 1.

Notch receptors (Notch1-4) and ligands (DLL1, 3 and 4, Jagged 1-2) are expressed in tumor, normal, and endothelial cells. After ligand binding, the ICN is generated after cleavage events by ADAM/TACE proteases and γ-secretase. The ICN travels into the nucleus, interacts with multiple transcriptional regulators including CSL, displaces CoR, and recruits MAML to activate transcription of target genes. Potential cancer therapeutics that target Notch signaling include antibodies, peptides, miRNAs, TACE inhibitors, and GSIs. Notch can function as a tumor suppressor or is oncogenic and activates/inhibits different downstream targets depending on the malignancy and microenvironment.

Figure 1.

Notch receptors (Notch1-4) and ligands (DLL1, 3 and 4, Jagged 1-2) are expressed in tumor, normal, and endothelial cells. After ligand binding, the ICN is generated after cleavage events by ADAM/TACE proteases and γ-secretase. The ICN travels into the nucleus, interacts with multiple transcriptional regulators including CSL, displaces CoR, and recruits MAML to activate transcription of target genes. Potential cancer therapeutics that target Notch signaling include antibodies, peptides, miRNAs, TACE inhibitors, and GSIs. Notch can function as a tumor suppressor or is oncogenic and activates/inhibits different downstream targets depending on the malignancy and microenvironment.

Close modal

Close proximity among cells within the microenvironment is required for ligand–receptor binding and interactions because the ligands remain immobilized as transmembrane proteins. Mammals have four distinct ligands [Jagged1-2, Delta-like (DLL) 1, 3, and 4]. Distinct ligand affinities exist for the various receptors, altered by glycosylation, which influences downstream transcriptional activation. Activation of the pathway requires ligand-receptor binding; the ligand undergoes endocytosis within the ligand-emitting cell, which causes a mechanical disruption, changing conformation of the negative regulatory region, and susceptibility of the ectodomain to cleavage by ADAM17 metalloprotease/TNFα converting enzyme (TACE) at site S2 (13, 14). A subsequent cleavage occurs within the TAD at S3 by presenilin-γ-secretase, liberating the intracellular domain of the Notch receptor (ICN; refs. 15, 16). ICN forms a complex with the inactive DNA-binding factor CSL (CBF1/Suppressor of Hairless/Lag1) and recruits other coactivator proteins from the Mastermind-like family of proteins such as MAML1 (17, 18). The target genes activated by Notch depend on the cell type and ligand–receptor interaction at the cell surface. Frequent target genes include transcriptional repressors of the HES and HEY families, MYC, NF-κB, cyclinD1, p21, CCND1/3, BCL2, pre-Tα (pre-T–cell receptor α-chain), GATA3, NRARP, Deltex1, and CCR7 (2, 19). Additional noncognate ligands (e.g., EGFL7; 20) and soluble Jagged ligands have also been described (21).

Notch pathway in cancer

Expression of the four Notch receptors in adult and embryonic tissues varies widely with overlapping expression patterns, but they have unique roles during the generation of hematopoietic stem cells, T-cell and B-cell fate and lineage development, renal progenitor cells, and vascular morphogenesis (2, 22). Dysregulation of the Notch pathway has been implicated in a variety of hematologic and solid malignancies (2). Depending on expression patterns, the Notch pathway can be either oncogenic or tumor suppressive (Fig. 2), involved in either survival or death pathways, proliferation or growth arrest, or differentiation into terminally differentiated cells versus cancer cell “stemness” (23). Abnormal regulation of the Notch pathway may occur by a variety of mechanisms including mutational activation or inactivation, overexpression, posttranslational modifications, and epigenetic regulation (2). In general, it seems suppressive in squamous cancers, but activating in hematologic malignancies and adenocarcinomas, reflecting its normal functions in those tissues.

Figure 2.

Aberrant Notch signaling occurs in a wide variety of solid and hematologic malignancies, and its role may be oncogenic or tumor suppressive depending on the tissue type and cellular context.

Figure 2.

Aberrant Notch signaling occurs in a wide variety of solid and hematologic malignancies, and its role may be oncogenic or tumor suppressive depending on the tissue type and cellular context.

Close modal

Notch as an oncoprotein

Notch1 is a well-characterized oncoprotein in T-cell acute lymphoblastic leukemia (T-ALL) and lymphomas; activating Notch1 mutations (either in the heterodimerization domain leading to a change in amino acid sequence causing ligand-independent metalloprotease cleavage at site S2; 24, or stop codon or frame shift mutations by deletion of the C-terminal PEST domain) are responsible for approximately 55% to 60% of T-ALL cases (25). Evidence for Notch as an oncoprotein in melanocytes (26), prostate (27), and breast tissue also exists (28, 29). Constitutively active Notch1 promotes melanoma cell growth, and the oncogenic effect of Notch1 on primary melanoma cells was mediated by β-catenin (30). The MAPK and PI3K–AKT pathways are both activated in melanoma following Notch1 activation (31). Upregulated Notch signaling has been shown to be oncogenic for multiple hematologic and solid malignancies (2, 19, 32; Fig. 2).

The mechanisms exploited by Notch for oncogenic effects include inhibition of apoptosis and induction of cellular proliferation. Within solid malignancies, activation of Notch can promote epithelial-to-mesenchymal transition. Antiapoptotic effects may occur by Notch inhibiting the proapoptotic transcription factor, Nur77, upregulation of IAP, Bcl2, and FLIP. Increased proliferation may occur through enhanced CDK2, cyclin D1, and HES1 activity. Notch can suppress p53 expression, promote viability via the PI3K/AKT, ERK and NF-κB pathways, and protect against apoptosis via inhibition of JNK activation. Activated Notch can inhibit activity of Smad2-4, leading to decreased TGFβ signaling (Fig. 1; 33).

Notch as a tumor suppressor

Notch has tumor-suppressive roles in several malignancies, including skin cancers (Fig. 1). Notch1 knockout mice develop basal cell carcinomas and have increased Wnt and Hedgehog signaling (34). The mechanism of Notch as a tumor suppressor is less well understood, but may be related to inhibition of proliferation and induction of cell-cycle arrest through upregulation of p21Cip1 and p27Kip1 and inhibition of β-catenin–mediated Wnt signaling (33).

The mechanisms by which Notch pathway can lead to tumor-promoting or -suppressive effects in different cell types are not fully understood. These mechanisms may include differential tissue and cell-specific target genes, and varying cytokines and growth factors present in distinct microenvironments. For example, p21, a target gene in the keratinocytes in the epidermis may contribute to tumor-suppressive effects because it regulates cell-cycle progression (35). This may result from CSL only binding the p21 promoter in certain tissue types, or cross-talk between Notch and p62 (36).

Notch antibodies

Antibodies are most frequently targeted to the extracellular negative regulator region of the Notch receptor or the EGF repeats (37). Several Notch-specific monoclonal antibodies against Notch1, Notch2, or Notch3 have been developed (38). In preclinical models, blocking Notch1 has been shown to decrease T-ALL tumor growth by inhibiting cancer cell growth and by disrupting angiogenesis. However, dual Notch1 and 2 inhibition causes gastrointestinal side effects such as diarrhea (37, 39). A phase I dose-escalation study of OMP-59R5 (humanized Notch2 and 3 blocking monoclonal antibody) in patients with solid tumors is ongoing (NCT01277146).

Alternative antibodies developed against this pathway target ligands (e.g., anti-DLL4 antibody and soluble DLL4-Fc fusion protein). The DLL4 antibody decreased tumor growth in multiple tumor models and caused defective cell fate differentiation. The role of DLL4 has been shown to be necessary for vascularization, but not vessel maintenance and DLL4 blockade promotes nonproductive angiogenesis (40). Multiple early-stage clinical trials are ongoing with demcizumab, an anti-DLL4 monoclonal antibody (41). OMP-21M18 is being tested in combination with gemcitabine with or without Abraxane (Celgene Co.) in pancreatic cancer (NCT01189929), with FOLFIRI in colorectal cancer (NCT01189942), with carboplatin and pemetrexed in lung cancer (NCT01189968), and with paclitaxel in patients with platinum-resistant ovarian cancer (NCT01952249). MedI0639 is another anti-DLL4 antibody being evaluated in patients with advanced solid tumors in phase 1 trials (NCT01577745).

Notch decoys

Soluble decoys of Notch pathway receptors or ligands are highly potent therapeutics. Notch1, DLL1, and Jagged1 decoys (42) remain under current development. A Notch1 decoy reduced downstream signaling and led to decreased tumor angiogenesis with a 58% decrease in microvessel density (43). Monomeric and dimeric forms of DLL1 soluble decoys have been created by fusing the extracellular domain to either a series of myc epitopes or to the Fc portion of human IgG-1, respectively. Nonimmobilized DLL1 inhibited downstream Notch functioning (44).

γ-Secretase inhibitors

A wide variety of γ-secretase inhibitors (GSI) have entered clinical development. Because of the diversity of GSIs and their substrates, the targeting for Notch cleavage is often not highly specific. However, they have cytostatic and cytotoxic properties and act as competitive inhibitors of presenilin activity. RO4929097 is a GSI that preclinically showed decreased ICN expression in vitro and antitumor activity in multiple xenografts, with intermittent or daily dosing and prolonged efficacy (45). Tumor growth inhibition values ranged from 66% to 91%. Initial clinical testing suggested a favorable toxicity profile with primarily grade 1 or 2 toxicities of fatigue, thrombocytopenia, rash, chills, and anorexia (46). In a phase I study of patients with refractory metastatic or locally advanced solid tumors, tumor responses included one partial response in a patient with colorectal adenocarcinoma, one mixed response in a patient with sarcoma, and one complete FDG-PET response in a patient with melanoma (46). In a phase II study of 33 evaluable patients with metastatic colorectal cancer, there were no objective radiographic responses and 6 patients had stable disease. Development of RO4929097 has been discontinued (47). Another GSI, MRK-003, has been shown to induce cell-cycle arrest and apoptosis by blocking Notch1 (48), with activity in T-ALL (49) and breast cancer (50). A related compound, MK-0752, which binds to presenilin 1, is being tested in multiple phase I studies.

Other GSIs include PF-03084014, which has been tested in combination with chemotherapy in colorectal (51), breast (52), pancreatic (53), and triple-negative breast (TNBC; 54) cancer models, and with fludarabine in primary Notch1-mutated CLL (55). Clinical studies with PF-03084014 are ongoing in patients with leukemia, breast, or pancreatic cancers. Although preclinical and early clinical activity is encouraging, limitations include nonselectivity and possible toxicities (56).

Inhibition of the Notch signaling pathway by GSIs has been shown to increase sensitivity of tumor cells to both cytotoxic chemotherapy and radiation (57, 58); however, the GSIs are not equally effective in combinations. For example, oxaliplatin activates Notch signaling, so while GSI34 sensitizes colon cancer cells to chemotherapy (59), MRK-003 decreases the apoptotic effect by at least 50% (60). This differential effect of GSIs combined with chemotherapy has also been seen in T-ALL where apoptosis is induced in some cell lines, but not in all (58). In TNBC, the combination of MK-0752 with docetaxel in preclinical and concurrent clinical studies decreased breast cancer stem cells (61). The mechanism for the synergistic activity of MK-0752 and PF-03084014 with docetaxel occurs because docetaxel activates the Notch pathway and suppresses NUMB, an endogenous Notch inhibitor (62).

Blocking peptides

Permeable peptides that interfere with the transcriptional nuclear complex represent attractive therapeutic options. A peptide that forms complexes with Notch1 and CSL, forms a transcriptionally inert nuclear complex and inhibits the growth of Notch1-transformed T-ALLs (63). Another peptide, SAHM1, binds to the Notch1 and CSL complex and prevents MAML1 from binding (64). The clinical implication and pharmacodynamics of peptides still remain unknown.

There are two basic approaches to targeting the Notch pathway: one is blocking ligands or receptors with monoclonal antibodies and the other blocking downstream signaling with GSIs. Small-molecule inhibitors tend to have more off target effects or inhibit multiple pathways, and this is typical with GSIs. Antibodies are more specific and tend to have longer duration of effect. The appropriate selection of therapy will depend on a greater understanding of the molecular pathways involved in a particular cancer. For example, mutations in Notch1 affecting its stability would be logical targets for blocking monoclonal antibodies. For targeting vasculature, DLL4, which is an endothelial-specific Notch ligand, can be effectively targeted with a specific antibody.

Rational combination therapies

The Notch pathway interacts with other tumorigenic pathways including the PI3K/AKT, STAT3, and NF-κB pathways. Combinations of GSIs with Hedgehog and Wnt inhibitors suppressed T-ALL growth in vitro (65). Both the Jagged1 and DLL4 ligands have been previously identified as key players in angiogenesis by separate mechanisms. Jagged1 can positively influence tumor angiogenesis by activating the Notch pathway on tumor endothelial cells (66). Rational combinations include targeting VEGF plus DLL4 because the latter can mediate resistance to anti-VEGF therapy. VEGF induces expression of DLL4 in endothelial and cancer cells invitro under hypoxic conditions and activation of Notch by immobilized DLL4 led to downregulation of VEGFR2 via promoter methylation. Blocking DLL4 upregulates VEGFR2 and the resultant increase in nonproductive angiogenesis may be the result of endothelial cells becoming sensitized to VEGF signaling. This response represents a rational, biologic explanation for why targeting Notch ligands may be complementary to anti-VEGF therapy (67). Notch1 activity has been reported to be related to DNA repair pathways and resistance to DNA cross-linking agents in TNBC; a combination with DNA cross-linking agents plus Notch1 inhibitors would be a logical approach (68–70).

In hormonally active malignancies such as ERα-positive breast cancers, combination therapy with GSIs has shown promise in clinical trials (71). Combinations of exemestane and RO4929097 (72) and MK-0752 with tamoxifen or letrozole have led to partial responses and stable disease for some patients (73).

Targeting the Notch pathway via specific siRNA and/or miRNAs also remains a relatively untapped area that could hold future benefit in several malignancies. Notch1 has been identified as a direct target gene of miR-34a. Mir-34a has also been found to be downregulated in glioblastoma multiforme compared with normal brain tissues, and by targeting Notch1, tumor growth was inhibited (74). In pancreatic cancer, miR-34 may be involved in pancreatic cancer stem cell self-renewal, potentially via direct modulation of downstream targets Bcl-2 and Notch (75). Restoring miR-34 may provide future therapeutic benefit in brain and pancreatic malignancies.

Multiple strategies exist for targeting the Notch pathway in malignancies, but the most attractive therapies will target the specific Notch alteration within tumor types while avoiding Notch signaling in normal tissues. Overexpression of Notch receptors and/or ligands does not necessarily imply pathway activation, and pathway activation can lead to tumor-suppressive or oncogenic effects. In these cases, simply providing an antibody, peptide, or decoy that targets the Notch receptor may be insufficient to decrease tumor growth or metastasis. Nonspecific inhibition of the Notch pathway with GSIs has been toxic. In a phase I study with RO4929097, several responses were noted, but further development has been discontinued.

Patient selection for therapy

As for many targeted therapies, selecting the correct patient is critical. Patients with activating mutations in their tumors seem to be obvious candidates for Notch therapies, but mutations in other genes (FBXW7) can affect Notch degradation. Also, the stroma affects Notch signaling in endothelial cells and does not require tumor mutation. Markers such as ICN, expression of ligands, or early dynamic monitoring of response need to be integrated with early clinical studies.

Our understanding of the Notch pathway has progressed substantially over the past century from an observation of the notched wing phenotype in Drospholia melanogaster to the context and tissue-dependent roles of this signaling pathway in hematologic and solid malignancies. No FDA-approved Notch targeted therapies currently exist despite the progress in understanding this signaling pathway within different malignancies. GSIs have been the most broadly developed, but due to their lack of specificity, gastrointestinal side effects, and low response rates, further development may be challenging. More selective and potent inhibitors and select combinations with chemotherapy or other biologically targeted drugs should be pursued. Future important directions for this signaling pathway include:

  1. To determine the roles of the Notch pathway at different points in tumorigenesis, metastasis, and self-propagation of cancer stem cells.

  2. To develop biomarkers for sensitivity of cancers and stroma.

  3. To develop rational combination therapies.

No potential conflicts of interest were disclosed.

Conception and design: R.A. Previs, R.L. Coleman, A.L. Harris, A.K. Sood

Development of methodology: A.K. Sood

Acquisition of data (provided animals, acquired and managed patients, provided facilities, etc.): R.A. Previs, A.K. Sood

Analysis and interpretation of data (e.g., statistical analysis, biostatistics, computational analysis): R.L. Coleman

Writing, review, and/or revision of the manuscript: R.A. Previs, R.L. Coleman, A.L. Harris, A.K. Sood

Administrative, technical, or material support (i.e., reporting or organizing data, constructing databases): R.A. Previs, R.L. Coleman, A.K. Sood

Study supervision: A.K. Sood

This work was supported, in part, by NIH grants (P50CA083639, CA109298, P50CA098258, U54CA151668, UH2TR000943, CA016672, U54CA96300, and U54CA96297), the Cancer Prevention Research Institute of Texas (RP110595 and RP120214), an Ovarian Cancer Research Fund Program Project Development Grant, Department of Defense grants (OC120547 and OC093416), the Betty Ann Asche Murray Distinguished Professorship, the RGK Foundation, the Gilder Foundation, the Judi A. Rees Ovarian Cancer Research Fund, the Chapman Foundation, the Meyer and Ida Gordon Foundation (to A.K. Sood), Cancer Research UK (to A.L. Harris), and the Ann Rife Cox Chair in Gynecology (to R.L. Coleman), and the Blanton-Davis Ovarian Cancer Research Program (to A.K. Sood and R.L. Coleman). R.A. Previs was supported by NIH T32 Training Grant CA101642.

1.
Dexter
JS
. 
The analysis of a case of continuous variation in Drosophila by a study of its linkage relations
.
Am Nat
1914
;
48
:
712
58
.
2.
Ntziachristos
P
,
Lim
JS
,
Sage
J
,
Aifantis
I
. 
From fly wings to targeted cancer therapies: a centennial for notch signaling
.
Cancer Cell
2014
;
25
:
318
34
.
3.
Logeat
F
,
Bessia
C
,
Brou
C
,
LeBail
O
,
Jarriault
S
,
Seidah
NG
, et al
The Notch1 receptor is cleaved constitutively by a furin-like convertase
.
Proc Natl Acad Sci U S A
1998
;
95
:
8108
12
.
4.
Okajima
T
,
Irvine
KD
. 
Regulation of notch signaling by o-linked fucose
.
Cell
2002
;
111
:
893
904
.
5.
Shi
S
,
Stanley
P
. 
Protein O-fucosyltransferase 1 is an essential component of Notch signaling pathways
.
Proc Natl Acad Sci U S A
2003
;
100
:
5234
9
.
6.
Haines
N
,
Irvine
KD
. 
Glycosylation regulates Notch signaling
.
Nat Rev Mol Cell Biol
2003
;
4
:
786
97
.
7.
Blaumueller
CM
,
Qi
H
,
Zagouras
P
,
Artavanis-Tsakonas
S
. 
Intracellular cleavage of Notch leads to a heterodimeric receptor on the plasma membrane
.
Cell
1997
;
90
:
281
91
.
8.
Rebay
I
,
Fleming
RJ
,
Fehon
RG
,
Cherbas
L
,
Cherbas
P
,
Artavanistsakonas
S
. 
Specific Egf repeats of notch mediate interactions with Delta and Serrate - implications for Notch as a multifunctional receptor
.
Cell
1991
;
67
:
687
99
.
9.
Aster
JC
,
Simms
WB
,
Zavala-Ruiz
Z
,
Patriub
V
,
North
CL
,
Blacklow
SC
. 
The folding and structural integrity of the first LIN-12 module of human Notch1 are calcium-dependent
.
Biochemistry
1999
;
38
:
4736
42
.
10.
Gordon
WR
,
Vardar-Ulu
D
,
Histen
G
,
Sanchez-Irizarry
C
,
Aster
JC
,
Blacklow
SC
. 
Structural basis for autoinhibition of Notch
.
Nat Struct Mol Biol
2007
;
14
:
295
300
.
11.
Kurooka
H
,
Kuroda
K
,
Honjo
T
. 
Roles of the ankyrin repeats and C-terminal region of the mouse notch1 intracellular region
.
Nucleic Acids Res
1998
;
26
:
5448
55
.
12.
Ong
CT
,
Cheng
HT
,
Chang
LW
,
Ohtsuka
T
,
Kageyama
R
,
Stormo
GD
, et al
Target selectivity of vertebrate notch proteins. Collaboration between discrete domains and CSL-binding site architecture determines activation probability
.
J Biol Chem
2006
;
281
:
5106
19
.
13.
Brou
C
,
Logeat
F
,
Gupta
N
,
Bessia
C
,
LeBail
O
,
Doedens
JR
, et al
A novel proteolytic cleavage involved in Notch signaling: the role of the disintegrin-metalloprotease TACE
.
Mol Cell
2000
;
5
:
207
16
.
14.
Mumm
JS
,
Schroeter
EH
,
Saxena
MT
,
Griesemer
A
,
Tian
X
,
Pan
DJ
, et al
A ligand-induced extracellular cleavage regulates gamma-secretase-like proteolytic activation of Notch1
.
Mol Cell
2000
;
5
:
197
206
.
15.
De Strooper
B
,
Annaert
W
,
Cupers
P
,
Saftig
P
,
Craessaerts
K
,
Mumm
JS
, et al
A presenilin-1-dependent gamma-secretase-like protease mediates release of Notch intracellular domain
.
Nature
1999
;
398
:
518
22
.
16.
Schroeter
EH
,
Kisslinger
JA
,
Kopan
R
. 
Notch-1 signaling requires ligand-induced proteolytic release of intracellular domain
.
Nature
1998
;
393
:
382
6
.
17.
Nam
Y
,
Sliz
P
,
Song
L
,
Aster
JC
,
Blacklow
SC
. 
Structural basis for cooperativity in recruitment of MAML coactivators to Notch transcription complexes
.
Cell
2006
;
124
:
973
83
.
18.
Wilson
JJ
,
Kovall
RA
. 
Crystal structure of the CSL-Notch-Mastermind ternary complex bound to DNA
.
Cell
2006
;
124
:
985
96
.
19.
Yin
L
,
Velazquez
OC
,
Liu
ZJ
. 
Notch signaling: emerging molecular targets for cancer therapy
.
Biochem Pharmacol
2010
;
80
:
690
701
.
20.
Davis
GE
. 
Vascular balancing act: EGFL7 and Notch
.
Blood
2010
;
116
:
5791
3
.
21.
Lu
J
,
Ye
X
,
Fan
F
,
Xia
L
,
Bhattacharya
R
,
Bellister
S
, et al
Endothelial cells promote the colorectal cancer stem cell phenotype through a soluble form of Jagged-1
.
Cancer Cell
2013
;
23
:
171
85
.
22.
Espinoza
I
,
Miele
L
. 
Notch inhibitors for cancer treatment
.
Pharmacol Ther
2013
;
139
:
95
110
.
23.
South
AP
,
Cho
RJ
,
Aster
JC
. 
The double-edged sword of Notch signaling in cancer
.
Semin Cell Dev Biol
2012
;
23
:
458
64
.
24.
Malecki
MJ
,
Sanchez-Irizarry
C
,
Mitchell
JL
,
Histen
G
,
Xu
ML
,
Aster
JC
, et al
Leukemia-associated mutations within the NOTCH1 heterodimerization domain fall into at least two distinct mechanistic classes
.
Mol Cell Biol
2006
;
26
:
4642
51
.
25.
Weng
AP
,
Ferrando
AA
,
Lee
W
,
Morris
JPt
,
Silverman
LB
,
Sanchez-Irizarry
C
, et al
Activating mutations of NOTCH1 in human T cell acute lymphoblastic leukemia
.
Science
2004
;
306
:
269
71
.
26.
Bedogni
B
,
Warneke
JA
,
Nickoloff
BJ
,
Giaccia
AJ
,
Powell
MB
. 
Notch1 is an effector of Akt and hypoxia in melanoma development
.
J Clin Invest
2008
;
118
:
3660
70
.
27.
Santagata
S
,
Demichelis
F
,
Riva
A
,
Varambally
S
,
Hofer
MD
,
Kutok
JL
, et al
JAGGED1 expression is associated with prostate cancer metastasis and recurrence
.
Cancer Res
2004
;
64
:
6854
7
.
28.
Weijzen
S
,
Rizzo
P
,
Braid
M
,
Vaishnav
R
,
Jonkheer
SM
,
Zlobin
A
, et al
Activation of Notch-1 signaling maintains the neoplastic phenotype in human Ras-transformed cells
.
Nat Med
2002
;
8
:
979
86
.
29.
Reedijk
M
,
Odorcic
S
,
Chang
L
,
Zhang
H
,
Miller
N
,
McCready
DR
, et al
High-level coexpression of JAG1 and NOTCH1 is observed in human breast cancer and is associated with poor overall survival
.
Cancer Res
2005
;
65
:
8530
7
.
30.
Balint
K
,
Xiao
M
,
Pinnix
CC
,
Soma
A
,
Veres
I
,
Juhasz
I
, et al
Activation of Notch1 signaling is required for beta-catenin-mediated human primary melanoma progression
.
J Clin Invest
2005
;
115
:
3166
76
.
31.
Liu
ZJ
,
Xiao
M
,
Balint
K
,
Smalley
KS
,
Brafford
P
,
Qiu
R
, et al
Notch1 signaling promotes primary melanoma progression by activating mitogen-activated protein kinase/phosphatidylinositol 3-kinase-Akt pathways and up-regulating N-cadherin expression
.
Cancer Res
2006
;
66
:
4182
90
.
32.
Roy
M
,
Pear
WS
,
Aster
JC
. 
The multifaceted role of Notch in cancer
.
Curr Opin Genet Dev
2007
;
17
:
52
9
.
33.
Leong
KG
,
Karsan
A
. 
Recent insights into the role of Notch signaling in tumorigenesis
.
Blood
2006
;
107
:
2223
33
.
34.
Nicolas
M
,
Wolfer
A
,
Raj
K
,
Kummer
JA
,
Mill
P
,
van Noort
M
, et al
Notch1 functions as a tumor suppressor in mouse skin
.
Nat Genet
2003
;
33
:
416
21
.
35.
Rangarajan
A
,
Talora
C
,
Okuyama
R
,
Nicolas
M
,
Mammucari
C
,
Oh
H
, et al
Notch signaling is a direct determinant of keratinocyte growth arrest and entry into differentiation
.
EMBO J
2001
;
20
:
3427
36
.
36.
Nguyen
BC
,
Lefort
K
,
Mandinova
A
,
Antonini
D
,
Devgan
V
,
Della Gatta
G
, et al
Cross-regulation between Notch and p63 in keratinocyte commitment to differentiation
.
Genes Dev
2006
;
20
:
1028
42
.
37.
Aste-Amezaga
M
,
Zhang
N
,
Lineberger
JE
,
Arnold
BA
,
Toner
TJ
,
Gu
M
, et al
Characterization of Notch1 antibodies that inhibit signaling of both normal and mutated Notch1 receptors
.
PLoS ONE
2010
;
5
:
e9094
.
38.
Li
K
,
Li
Y
,
Wu
W
,
Gordon
WR
,
Chang
DW
,
Lu
M
, et al
Modulation of Notch signaling by antibodies specific for the extracellular negative regulatory region of NOTCH3
.
J Biol Chem
2008
;
283
:
8046
54
.
39.
Wu
Y
,
Cain-Hom
C
,
Choy
L
,
Hagenbeek
TJ
,
de Leon
GP
,
Chen
Y
, et al
Therapeutic antibody targeting of individual Notch receptors
.
Nature
2010
;
464
:
1052
7
.
40.
Ridgway
J
,
Zhang
G
,
Wu
Y
,
Stawicki
S
,
Liang
WC
,
Chanthery
Y
, et al
Inhibition of Dll4 signaling inhibits tumor growth by deregulating angiogenesis
.
Nature
2006
;
444
:
1083
7
.
41.
Hu
W
,
Lu
C
,
Dong
HH
,
Huang
J
,
Shen
DY
,
Stone
RL
, et al
Biological roles of the Delta family Notch ligand Dll4 in tumor and endothelial cells in ovarian cancer
.
Cancer Res
2011
;
71
:
6030
9
.
42.
Small
D
,
Kovalenko
D
,
Kacer
D
,
Liaw
L
,
Landriscina
M
,
Di Serio
C
, et al
Soluble Jagged 1 represses the function of its transmembrane form to induce the formation of the Src-dependent chord-like phenotype
.
J Biol Chem
2001
;
276
:
32022
30
.
43.
Funahashi
Y
,
Hernandez
SL
,
Das
I
,
Ahn
A
,
Huang
J
,
Vorontchikhina
M
, et al
A notch1 ectodomain construct inhibits endothelial notch signaling, tumor growth, and angiogenesis
.
Cancer Res
2008
;
68
:
4727
35
.
44.
Varnum-Finney
B
,
Wu
L
,
Yu
M
,
Brashem-Stein
C
,
Staats
S
,
Flowers
D
, et al
Immobilization of Notch ligand, Delta-1, is required for induction of notch signaling
.
J Cell Sci
2000
;
113
:
4313
8
.
45.
Luistro
L
,
He
W
,
Smith
M
,
Packman
K
,
Vilenchik
M
,
Carvajal
D
, et al
Preclinical profile of a potent gamma-secretase inhibitor targeting notch signaling with in vivo efficacy and pharmacodynamic properties
.
Cancer Res
2009
;
69
:
7672
80
.
46.
Tolcher
AW
,
Messersmith
WA
,
Mikulski
SM
,
Papadopoulos
KP
,
Kwak
EL
,
Gibbon
DG
, et al
Phase I study of RO4929097, a gamma secretase inhibitor of Notch signaling, in patients with refractory metastatic or locally advanced solid tumors
.
J Clin Oncol
2012
;
30
:
2348
53
.
47.
Strosberg
JR
,
Yeatman
T
,
Weber
J
,
Coppola
D
,
Schell
MJ
,
Han
G
, et al
A phase II study of RO4929097 in metastatic colorectal cancer
.
Eur J Cancer
2012
;
48
:
997
1003
.
48.
Lewis
HD
,
Leveridge
M
,
Strack
PR
,
Haldon
CD
,
O'Neil
J
,
Kim
H
, et al
Apoptosis in T cell acute lymphoblastic leukemia cells after cell cycle arrest induced by pharmacological inhibition of notch signaling
.
Chem Biol
2007
;
14
:
209
19
.
49.
Tammam
J
,
Ware
C
,
Efferson
C
,
O'Neil
J
,
Rao
S
,
Qu
X
, et al
Down-regulation of the Notch pathway mediated by a gamma-secretase inhibitor induces anti-tumor effects in mouse models of T-cell leukaemia
.
Br J Pharmacol
2009
;
158
:
1183
95
.
50.
Pandya
K
,
Meeke
K
,
Clementz
AG
,
Rogowski
A
,
Roberts
J
,
Miele
L
, et al
Targeting both Notch and ErbB-2 signaling pathways is required for prevention of ErbB-2-positive breast tumor recurrence
.
Br J Cancer
2011
;
105
:
796
806
.
51.
Arcaroli
JJ
,
Powell
RW
,
Varella-Garcia
M
,
McManus
M
,
Tan
AC
,
Quackenbush
KS
, et al
ALDH+ tumor-initiating cells exhibiting gain in NOTCH1 gene copy number have enhanced regrowth sensitivity to a gamma-secretase inhibitor and irinotecan in colorectal cancer
.
Mol Oncol
2012
;
6
:
370
81
.
52.
Zhang
CC
,
Pavlicek
A
,
Zhang
Q
,
Lira
ME
,
Painter
CL
,
Yan
Z
, et al
Biomarker and pharmacologic evaluation of the gamma-secretase inhibitor PF-03084014 in breast cancer models
.
Clin Cancer Res
2012
;
18
:
5008
19
.
53.
Yabuuchi
S
,
Pai
SG
,
Campbell
NR
,
de Wilde
RF
,
De Oliveira
E
,
Korangath
P
, et al
Notch signaling pathway targeted therapy suppresses tumor progression and metastatic spread in pancreatic cancer
.
Cancer Lett
2013
;
335
:
41
51
.
54.
Zhang
CC
,
Yan
Z
,
Zong
Q
,
Fang
DD
,
Painter
C
,
Zhang
Q
, et al
Synergistic effect of the gamma-secretase inhibitor PF-03084014 and docetaxel in breast cancer models
.
Stem Cells Transl Med
2013
;
2
:
233
42
.
55.
Lopez-Guerra
M
,
Xargay-Torrent
S
,
Rosich
L
,
Montraveta
A
,
Roldan
J
,
Matas-Cespedes
A
, et al
The gamma-secretase inhibitor PF-03084014 combined with fludarabine antagonizes migration, invasion and angiogenesis in NOTCH1-mutated CLL cells
.
Leukemia
2014 Apr 30
.
[Epub ahead of print]
.
56.
Wong
GT
,
Manfra
D
,
Poulet
FM
,
Zhang
Q
,
Josien
H
,
Bara
T
, et al
Chronic treatment with the gamma-secretase inhibitor LY-411,575 inhibits beta-amyloid peptide production and alters lymphopoiesis and intestinal cell differentiation
.
J Biol Chem
2004
;
279
:
12876
82
.
57.
Wang
Z
,
Li
Y
,
Ahmad
A
,
Azmi
AS
,
Banerjee
S
,
Kong
D
, et al
Targeting Notch signaling pathway to overcome drug resistance for cancer therapy
.
Biochim Biophys Acta
2010
;
1806
:
258
67
.
58.
Andersson
ER
,
Lendahl
U
. 
Therapeutic modulation of Notch signaling–are we there yet?
Nat Rev Drug Discov
2014
;
13
:
357
78
.
59.
Meng
RD
,
Shelton
CC
,
Li
YM
,
Qin
LX
,
Notterman
D
,
Paty
PB
, et al
gamma-Secretase inhibitors abrogate oxaliplatin-induced activation of the Notch-1 signaling pathway in colon cancer cells resulting in enhanced chemosensitivity
.
Cancer Res
2009
;
69
:
573
82
.
60.
Timme
CR
,
Gruidl
M
,
Yeatman
TJ
. 
Gamma-secretase inhibition attenuates oxaliplatin-induced apoptosis through increased Mcl-1 and/or Bcl-xL in human colon cancer cells
.
Apoptosis
2013
;
18
:
1163
74
.
61.
Schott
AF
,
Landis
MD
,
Dontu
G
,
Griffith
KA
,
Layman
RM
,
Krop
I
, et al
Preclinical and clinical studies of gamma secretase inhibitors with docetaxel on human breast tumors
.
Clin Cancer Res
2013
;
19
:
1512
24
.
62.
Takebe
N
,
Nguyen
D
,
Yang
SX
. 
Targeting notch signaling pathway in cancer: clinical development advances and challenges
.
Pharmacol Ther
2014
;
141
:
140
9
.
63.
Weng
AP
,
Nam
Y
,
Wolfe
MS
,
Pear
WS
,
Griffin
JD
,
Blacklow
SC
, et al
Growth suppression of pre-T acute lymphoblastic leukemia cells by inhibition of notch signaling
.
Mol Cell Biol
2003
;
23
:
655
64
.
64.
Moellering
RE
,
Cornejo
M
,
Davis
TN
,
Del Bianco
C
,
Aster
JC
,
Blacklow
SC
, et al
Direct inhibition of the NOTCH transcription factor complex
.
Nature
2009
;
462
:
182
8
.
65.
Okuhashi
Y
,
Itoh
M
,
Nara
N
,
Tohda
S
. 
Effects of combination of notch inhibitor plus hedgehog inhibitor or Wnt inhibitor on growth of leukemia cells
.
Anticancer Res
2011
;
31
:
893
6
.
66.
Noguera-Troise
I
,
Daly
C
,
Papadopoulos
NJ
,
Coetzee
S
,
Boland
P
,
Gale
NW
, et al
Blockade of Dll4 inhibits tumor growth by promoting non-productive angiogenesis
.
Nature
2006
;
444
:
1032
7
.
67.
Dufraine
J
,
Funahashi
Y
,
Kitajewski
J
. 
Notch signaling regulates tumor angiogenesis by diverse mechanisms
.
Oncogene
2008
;
27
:
5132
7
.
68.
Brennan
K
,
Clarke
RB
. 
Combining Notch inhibition with current therapies for breast cancer treatment
.
Ther Adv Med Oncol
2013
;
5
:
17
24
.
69.
Nefedova
Y
,
Sullivan
DM
,
Bolick
SC
,
Dalton
WS
,
Gabrilovich
DI
. 
Inhibition of Notch signaling induces apoptosis of myeloma cells and enhances sensitivity to chemotherapy
.
Blood
2008
;
111
:
2220
9
.
70.
Hernandez
SL
,
Banerjee
D
,
Garcia
A
,
Kangsamaksin
T
,
Cheng
WY
,
Anastassiou
D
, et al
Notch and VEGF pathways play distinct but complementary roles in tumor angiogenesis
.
Vascular cell
2013
;
5
:
17
.
71.
Rizzo
P
,
Miao
H
,
D'Souza
G
,
Osipo
C
,
Song
LL
,
Yun
J
, et al
Cross-talk between notch and the estrogen receptor in breast cancer suggests novel therapeutic approaches
.
Cancer Res
2008
;
68
:
5226
35
.
72.
Albain
KS
,
Czerlanis
C
,
Zlobin
A
,
Covington
KR
,
Rajan
P
,
Godellas
C
, et al
Modulation of cancer stem cell biomarkers by the Notch inhibitor MK-0752 added to endocrine therapy for early stage ER+ breast cancer
.
Cancer Res
2011
;
71
:
Abstract nr S1–5
.
73.
Means-Powell
JA
,
Minton
SE
,
Mayer
IA
,
Abramson
VG
,
Ismail-Khan
R
,
Arteaga
CL
, et al
A phase Ib dose escalation trial of RO4929097 (a {gamma}-secretase inhibitor) in combination with exemestane in patients with ER + metastatic breast cancer
.
Cancer Res
2012
;
72
:
Abstract nr P2-14-04
.
74.
Li
WB
,
Ma
MW
,
Dong
LJ
,
Wang
F
,
Chen
LX
,
Li
XR
. 
MicroRNA-34a targets notch1 and inhibits cell proliferation in glioblastoma multiforme
.
Cancer Biol Ther
2011
;
12
:
477
83
.
75.
Ji
Q
,
Hao
X
,
Zhang
M
,
Tang
W
,
Yang
M
,
Li
L
, et al
MicroRNA miR-34 inhibits human pancreatic cancer tumor-initiating cells
.
PLoS ONE
2009
;
4
:
e6816
.