Activation of caspases through the intrinsic apoptosis pathway is dependent on mitochondrial outer membrane permeabilization (MOMP) by BAX and BAK (Figure 2). This results in leakage of cytochrome C, which activates caspase activator APAF1. 20 To explain the mechanism of BAX and BAK activation, three models of interactions between BCL-2 proteins have been described. 21 According to the direct activation model, some BH3-only proteins ('activators') directly bind and activate effectors BAX and BAK. Other BH3-only proteins ('sensitizers') are unable to do this, but in turn function by binding to pro-survival proteins, which then release bound activators. In the indirect activation model, BH3-only proteins solely function as neutralizers of pro-survival proteins, which then release BAX and BAK. As a result, BAX and BAK are activated spontaneously or by an unknown modification, which leads to apoptosis. These two models are not mutually exclusive, and currently a third and unified model is considered most likely. In this unified model, pro-survival proteins sequester both BH3-only proteins and BAX and BAK. When upregulated, BH3-only proteins act by neutralizing prosurvival proteins as well as by activating BAX and BAK, leading to MOMP and subsequent caspase activation. 21,22 The common factor among all BCL-2 family proteins is the presence of BH domains (Figure 3). BH3-only proteins are named thus because they only contain a BH3-domain. Pro-survival BCL-2 proteins, as well as BAX and BAK, contain four BH domains and therefore have a similar overall structure. 21,23 Most BCL-2 proteins contain a transmembrane domain that allows them to localize to intracellular membranes. In some cases, BCL-2 proteins can receive protein modifications that lead to differences in activity, binding affinity, or degradation. 24 MCL-1 is exemplary in this regard, as it is the only BCL-2 family member whose N-terminal tail is rich in putative and experimentally confirmed modification sites, which are targets for phosphorylation, ubiquitination, and cleavage. 25
Pro-apoptotic BH3-only proteinsBH3-only proteins are sensors of cellular stress. Under unstressed conditions, the expression level of many BH3-only proteins is low. Signals such as cytokine deprivation, DNA-damage, ER stress, hypoxia, and anoikis lead to transcriptional or post-translational upregulation of BH3-only proteins. 26 BH3-only proteins have distinct yet overlapping functions, and their expression depends on cell type and cytotoxic condition. 26 For example, BIM can be transcriptionally induced by FOXO3a upon cytokine deprivation, and phosphorylation of BIM can either increase or decrease its activity, depending on the site. BIM regulates apoptosis of