Tumor overexpression of urokinase-type plasminogen activator (uPA) and its specific inhibitor SerpinE1 (plasminogen activator inhibitor type-1) correlates with poor prognosis and increased metastatic potential. Conversely, tumor expression of uPA and another specific inhibitor, SerpinB2 (plasminogen activator inhibitor type-2), are associated with favorable outcome and relapse-free survival. It is not known how overexpression of these uPA inhibitors results in such disparate outcomes. A possible explanation may be related to the presence of a proposed low density lipoprotein receptor (LDLR)-binding motif in SerpinE1 responsible for mitogenic signaling via ERK that is absent in SerpinB2. We now show that complementation of such a LDLR-binding motif in SerpinB2 by mutagenesis of two key residues enabled high affinity binding to very LDLR (VLDLR). Furthermore, the VLDLR-binding SerpinB2 form behaved in a manner indistinguishable from SerpinE1 in terms of enhanced uPA-SerpinB2 complex endocytosis and subsequent ERK phosphorylation and cell proliferation; that is, the introduction of the LDLR-binding motif to SerpinB2 was necessary and sufficient to allow it to acquire characteristics of SerpinE1 associated with malignancy. In conclusion, this study defines the structural elements underlying the distinct interactions of SerpinE1 versus SerpinB2 with endocytic receptors and how differential VLDLR binding impacts on downstream cellular behavior. This has clear relevance to understanding the paradoxical disease outcomes associated with overexpression of these serpins in cancer.SerpinE1 (plasminogen activator inhibitor type-1, PAI-1) 4 and SerpinB2 (plasminogen activator inhibitor type-2, PAI-2) are both efficient inhibitors of the urokinase-type plasminogen activator (uPA), a key enzyme in the tissue remodeling process. Combined tumor overexpression of uPA, its receptor (uPAR), and SerpinE1 (serine protease inhibitor E1) is strongly correlated with poor patient prognosis (1-3) and metastatic potential (4 -8). Consequently, uPA and SerpinE1 expression is recommended as an independent prognostic indicator in node-negative breast cancer (9). On the contrary, tumor expression of SerpinB2 is correlated with increased relapse-free survival in breast cancer (and possibly other cancer types) (10). Further, the relationship between outcome and high SerpinB2 levels in node-negative breast cancer is only relevant if uPA levels are also elevated (1, 11), suggesting that the inhibitory relationship between uPA and SerpinB2 mediates this functionality.Binding of uPA to uPAR has been reported to induce the activation of numerous cell type-specific signaling pathways, such as MAPK/ERK, JAK/STAT, Src, focal adhesion kinase, and Rac, thereby affecting cell adhesion, migration, differentiation, and apoptosis (12). Because uPAR is not a transmembrane protein, being linked to the cell surface by a glycosylphosphatidylinositol anchor, uPA/uPAR signaling is mediated by integrins and several other adaptor molecules, including members of the lo...