High-risk neuroblastoma remains one of the most important therapeutic challenges for pediatric oncologists. New agents or regimens are urgently needed to improve the treatment outcome of this fatal tumor. We examined the effect of histone deacetylase (HDAC) inhibitors in a combination with other chemotherapeutics on a high-risk neuroblastoma UKF-NB-4 cell line. Treatment of UKF-NB-4 cells with DNA-damaging chemotherapeutics cisplatin or etoposide combined with the HDAC inhibitor valproate (VPA) resulted in the synergistic antitumor effect. This was associated with caspase-3-dependent induction of apoptosis. Another HDAC inhibitor trichostatin A and a derivative of VPA that does not exhibit HDAC inhibitory activity, valpromide, lacked this effect. The synergism was only induced when VPA was combined with cytostatics targeted to cellular DNA; VPA does not potentiate the cytotoxicity of the anticancer drug vincristine that acts by a mechanism different from that of DNA damage. The VPA-mediated sensitization of UKF-NB-4 cells to cisplatin or etoposide was dependent on the sequence of drug administration; the potentiating effect was only produced either by simultaneous treatment with these drugs or when the cells were pretreated with cisplatin or etoposide before their exposure to VPA. The synergistic effects of VPA with cisplatin or etoposide were associated with changes in the acetylation status of histones H3 and H4. The results of this study provide a rationale for clinical evaluation of the combination of VPA and cisplatin or etoposide for treating children suffering from high-risk neuroblastoma.

Cancer stem cells (CSCs) form a small proportion of tumor cells that have stem cell properties: self-renewal capacity, the ability to develop into different lineages and proliferative potential. The interest in CSCs emerged from their expected role in initiation, progression and recurrence of many tumors. They are generally resistant to conventional chemotherapy and radiotherapy. There are two hypotheses about their origin: The first assumes that CSCs may arise from normal stem cells, and the second supposes that differentiated cells acquire the properties of CSCs. Both hypotheses are not mutually exclusive, as it is possible that CSCs have a diverse origin in different tumors. CD133+ cells (CD133 is marker of CSC in some tumors) isolated from NBL, osteosarcoma and Ewing sarcoma cell lines are resistant to cisplatin, carboplatin, etoposide and doxorubicin than the CD133-ones. Being resistant to chemotherapy, there were many attempts to target CSCs epigenetically including the use of histone deacetylase inhibitors. The diverse influence of valproic acid (histone deacetylase inhibitor) on normal and cancer stem cells was proved in different experiments. We have found an increase percentage of CD133+ NBL cells after their incubation with VPA in a dose that does not induce apoptosis. Further researches on CSCs and clinical application for their detection are necessary: (i) to define the CSC function in carcinogenesis, cancer development and their role in metastasis; (ii) to find a specific marker for CSCs in different tumors; (iii) to explain the role of different pathways that determine their behavior and (iv) to explain mechanisms of chemoresistance of CSCs.