IntroductionTumor cell responses to chemotherapy include growth arrest and apoptosis. 1 Stress-induced apoptosis 2-4 is associated with alterations in mitochondrial membrane permeabilization and release of several apoptogenic factors, such as cytochrome c (cyto c), 5,6 Smac/DIABLO, 7,8 AIF, 9 EndoG, 10 and HtrA2/Omi. 11 Once released into the cytosol, these mitochondrial proteins trigger both caspase-dependent (by cyto c or second mitochondria-derived activator of caspases [Smac]) and caspase-independent (by AIF or Endo-G) apoptosis. Conversely, inhibitors of apoptosis proteins (IAPs) block the enzymatic activity of caspases that mediate cell death, 12,13 and overexpression of IAPs confers chemoresistance in various tumor types. [14][15][16] Recent studies have shown that the mitochondrial apoptotic protein Smac can abrogate the protective function of IAPs, such as X-linked inhibitor of apoptosis (XIAP). 7,8 XIAP is the most potent caspase inhibitor among IAPs and binds with initiator caspase-9 and executioner caspases 3 and 7 through its BIR3 and BIR2 domains, respectively. 17,18 Stress stimuli trigger the release of Smac from mitochondria into the cytosol, where it binds to and eliminates its inhibitory effect on caspase-9, thereby resulting in activation of caspase-9-mediated apoptotic signaling cascade. 7,[19][20][21] These findings suggest the potential clinical utility of Smac mimetics to trigger apoptosis and overcome drug resistance conferred by IAPs.There are several additional rationales for using Smac mimetic as a potential therapy. First, the cell-permeable Smac peptides, when combined with chemotherapy, inhibited tumor growth in vivo with little toxicity in mice. [22][23][24][25] Second, our prior studies have established that Smac release is critical during most anti-multiple myeloma (MM) agent-induced apoptosis, and that dysfunctional Smac release may, in part, contribute to the development of drug resistance. 26 Third, defects in the mitochondrial apoptotic machinery includes up-regulated antiapoptotic protein Bcl-2, which inhibits Smac activity. 26 Smac mimetics have the ability to circumvent the requirement for mitochondrial processing and release of Smac, thereby potentially triggering apoptosis even in Bcl-2-overexpressing MM cells. Fourth, MM cells have constitutively activated NF-B growth/survival signaling, 27-31 and a Smac mimetic was shown to potentiate apoptosis in TNF-âŁ-treated cells despite NF-B activation. 32 Thus, Smac agonists are promising candidates as novel cytotoxic therapies in MM.Several groups have succeeded in developing potent, smallmolecular-weight Smac mimetic compounds with high affinity for the BIR3 domain of IAPs at pharmacologically achievable concentrations. [32][33][34][35][36] Our prior studies have shown that various anti-MM agents down-regulate IAPs; 37 however, whether or not direct inhibition of XIAP by a Smac mimetic could trigger apoptosis in these cells is undefined. For personal use only. on May 9, 2018. by guest www.bloodjournal.org FromIn the present st...