SUMMARY The tricarboxylic acid cycle enzyme fumarate hydratase (FH) has been identified as a tumor suppressor in a subset of human renal cell carcinomas. Human FH deficient cancer cells display high fumarate concentration and ROS levels along with activation of HIF-1. The underlying mechanisms by which FH loss increases ROS and HIF-1 are not fully understood. Here, we report that glutamine dependent oxidative citric acid cycle metabolism is required to generate fumarate and increase ROS and HIF-1 levels. Accumulated fumarate directly bonds the antioxidant glutathione in vitro and in vivo to produce the novel metabolite succinated glutathione (GSF). GSF acts as an alternative substrate to glutathione reductase to decrease NADPH levels and enhance mitochondrial ROS and HIF-1 activation. Increased ROS also correlates with hyper-methylation of histones in these cells. Thus, fumarate serves as a proto-oncometabolite by binding to glutathione which results in the accumulation of ROS.

Through unbiased metabolomics, we identified elevations of the metabolite 2-hydroxyglutarate (2HG) in renal cell carcinoma (RCC). 2HG can inhibit 2-oxoglutaratre (2-OG) dependent dioxygenases which mediate epigenetic events including DNA and histone demethylation. 2HG accumulation, specifically the D- enantiomer, can result from gain of function mutations of isocitrate dehydrogenase (IDH1, IDH2) found in several different tumors. In contrast, kidney tumors demonstrate elevations of the L enantiomer of 2HG (L-2HG). High 2HG tumors demonstrate reduced DNA levels of 5-hydroxymethylcytosine (5hmC) consistent with 2-HG mediated inhibition of TET (Ten Eleven Translocation) enzymes which convert 5-methylcystoine (5mC) to 5hmC. L-2HG elevation is mediated in part by reduced expression of L-2HG dehydrogenase (L2HGDH). L2HGDH reconstitution in RCC cells lowers L-2HG and promotes 5hmC accumulation. Additionally, L2HGDH expression in RCC cells reduces histone methylation and suppresses in vitro tumor phenotypes. Our report identifies L-2HG as an epigenetic modifier and putative oncometabolite in kidney cancer.

Hereditary leiomyomatosis and renal cell cancer (HLRCC) is an inherited cancer syndrome linked to biallelic inactivation of the gene encoding the tricarboxylic acid cycle enzyme fumarate hydratase (FH).Individuals with HLRCC are at risk to develop cutaneous and uterine leiomyomas and an aggressive form of kidney cancer. Pseudohypoxic drive-the aberrant activation of cellular hypoxia response pathways despite normal oxygen tension-is considered to be a likely mechanism underlying the etiology of this tumor. Pseudohypoxia requires the oxygen-independent stabilization of the ␣ subunit of the hypoxia-inducible transcription factor (HIF-1␣). Under normoxic conditions, proline hydroxylation of HIF-1␣ permits VHL recognition and subsequent targeting for proteasomal degradation. Here, we demonstrate that inactivating mutations of FH in an HLRCC-derived cell line result in glucose-mediated generation of cellular reactive oxygen species (ROS) and ROS-dependent HIF-1␣ stabilization. Additionally, we demonstrate that stable knockdown of FH in immortalized renal epithelial cells results in ROS-dependent HIF-1␣ stabilization. These data reveal that the obligate glycolytic switch present in HLRCC is critical to HIF stabilization via ROS generation.Patients with hereditary leiomyomatosis and renal cell cancer (HLRCC) harbor germ line mutations of the FH gene, which encodes the tricarboxylic acid cycle enzyme fumarate hydratase, and affected individuals are at risk for the development of leiomyomas of the skin and uterus (fibroids) as well as kidney cancer (11,25,37). Genetic analysis of tumor samples indicates that FH acts as a tumor suppressor gene (37). The renal tumors that develop in HLRCC patients are notable for their aggressiveness, and effective systemic therapies are lacking at this time. Hence, identification of the molecular mechanisms that underlie the pathogenesis of this disease is needed to facilitate the development of targeted therapeutic strategies. Moreover, such studies may provide further insight into the role of mitochondrial metabolism in both normal and aberrant cellular physiology.FH catalyzes the enzymatic step of the tricarboxylic (TCA) cycle that hydrates fumarate to form malate. Proposed mechanisms for HLRCC tumor formation include apoptotic resistance, oxidative stress, and pseudohypoxic drive (10). Of these, most reports to date support a role for pseudohypoxic drive, based specifically on studies of hypoxia-inducible transcription factor 1␣ (HIF-1␣) expression. Pseudohypoxia is defined as the aberrant activation of hypoxia response pathways under normal oxygen conditions. HIF-1␣ expression is elevated both in HLRCC tumor specimens and in normoxic cells in which FH expression has been transiently suppressed with small interfering RNA (siRNA) (16). HIF-2␣ expression is also elevated in HLRCC tumor samples, although to a lesser extent than is HIF-1␣. In addition, there is clear evidence of upregulated transcription of HIF target genes in HLRCC tumor samples and in FH siRNA-treated cells (16,30). Fur...

Elevation of L-2-hydroxylgutarate (L-2-HG) in renal cell carcinoma (RCC) is due in part to reduced expression of L-2-HG dehydrogenase (L2HGDH). However, the contribution of L-2-HG to renal carcinogenesis and insight into the biochemistry and targets of this small molecule remains to be elucidated. Genetic and pharmacologic approaches to modulate L-2-HG levels were assessed for effects on and phenotypes. Metabolomics was used to dissect the biochemical mechanisms that promote L-2-HG accumulation in RCC cells. Transcriptomic analysis was utilized to identify relevant targets of L-2-HG. Finally, bioinformatic and metabolomic analyses were used to assess the L-2-HG/L2HGDH axis as a function of patient outcome and cancer progression. L2HGDH suppresses both cell migration and tumor growth and these effects are mediated by L2HGDH's catalytic activity. Biochemical studies indicate that glutamine is the predominant carbon source for L-2-HG via the activity of malate dehydrogenase 2 (MDH2). Inhibition of the glutamine-MDH2 axis suppresses phenotypes in an L-2-HG-dependent manner. Moreover, growth of RCC cells with basal elevation of L-2-HG is suppressed by glutaminase inhibition. Transcriptomic and functional analyses demonstrate that the histone demethylase KDM6A is a target of L-2-HG in RCC. Finally, increased L-2-HG levels, copy loss, and lower L2HGDH expression are associated with tumor progression and/or worsened prognosis in patients with RCC. Collectively, our studies provide biochemical and mechanistic insight into the biology of this small molecule and provide new opportunities for treating L-2-HG-driven kidney cancers.

Purpose-Despite the proven efficacy of nephron sparing surgery, patients with hereditary renal cancer remain at risk for tumor recurrence. Management options for recurrent tumors include completion nephrectomy, ablation, and repeat partial nephrectomy (RPN). We examine the feasibility and outcomes of RPN performed on the same renal unit.Materials and Methods-We retrospectively reviewed the records of 51 attempted RPN cases on 47 patients from 1992 to 2006. Demographic information as well as intraoperative, perioperative, and renal functional outcome data were collected. Comparison of pre-and postoperative renal function was performed using the two tailed T-test.Results-Major perioperative complications or reoperations occurred in 10 of 51 (19.6%) cases that included one perioperative mortality (1.9%). In cases of successful RPN, there was a statistically significant increase in postoperative serum creatinine (1.35 vs. 1.16 mg/dL, p <0.05) and a significant decrease in creatinine clearance (84.6 mL/min vs. 95.3mL/min, p = 0.05) and renogram split function (52.3% vs. 54.8%, p <0.05). Two patients required long term hemodialysis (3.9%). Ten of the 51 renal units (19.6%) in our study required subsequent operations for additional local recurrence or de novo tumor formations with a median time to subsequent surgery of 50 months. Forty-six of fortyseven patients are alive at median follow up of 56 months.Conclusions-RPN is technically feasible. Although there is a statistically significant decrease in postoperative renal functional studies, most patients retained sufficient function to avoid hemodialysis. RPN may provide acceptable oncologic control despite the anticipated development of locally recurrent or de novo tumors. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. While repeat partial nephrectomy may maintain the balance between tumor control and renal preservation, the feasibility as well as functional and oncologic outcomes of patients undergoing RPN are not well established. There are a few reports of patients with hereditary kidney cancer that have undergone repeat NSS. [4][5][6] However, most of these series report limited numbers which may restrict the ability to make conclusions regarding repeat partial nephrectomy. Our ongoing clinical experience in patients with hereditary kidney cancer who are at risk for metachronous tumor formation has provided a unique opportunity to evaluate the feasibility and outcomes of repeat partial nephrectomy. Keywords NIH Public Access MATERIALS AND METHODSBetween 1992 and 2006, 51 cases of planned RPN on the same renal unit ...