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Activation of NOTCH signaling via DLL1 is mediated by APE1-redox-dependent NF-κB activation in oesophageal adenocarcinoma
  1. Lei Chen1,2,
  2. Heng Lu2,
  3. Dunfa Peng2,3,
  4. Long Long Cao2,4,
  5. Farah Ballout2,
  6. Kannappan Srirmajayam5,
  7. Zheng Chen2,3,
  8. Ajaz Bhat6,
  9. Timothy C Wang7,
  10. Anthony Capobianco2,3,
  11. Jianwen Que7,
  12. Oliver Gene McDonald3,8,
  13. Alexander Zaika2,3,
  14. Shutian Zhang1,
  15. Wael El-Rifai2,3
  1. 1 Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, Beijing, China
  2. 2 Department of Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
  3. 3 Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, Florida, USA
  4. 4 Department of Gastric Surgery, Fujian Medical University Union Hospital, Fujian, China
  5. 5 Department of Molecular Pharmacology, University of Miami Miller School of Medicine, Miami, Florida, USA
  6. 6 Sidra Medicine, Doha, Ad Dawhah, Qatar
  7. 7 Department of Medicine, Columbia University Medical Center, New York, New York, USA
  8. 8 Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida, USA
  1. Correspondence to Professor Wael El-Rifai, Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; wxe45{at}; Professor Shutian Zhang, Department of Gastroenterology, Capital Medical University Affiliated Beijing Friendship Hospital, Beijing, China; zhangshutian{at}


Objective Oesophageal adenocarcinoma (EAC) arises in the setting of Barrett’s oesophagus, an intestinal metaplastic precursor lesion that can develop in patients with chronic GERD. Here, we investigated the role of acidic bile salts, the mimicry of reflux, in activation of NOTCH signaling in EAC.

Design This study used public databases, EAC cell line models, L2-IL1β transgenic mouse model and human EAC tissue samples to identify mechanisms of NOTCH activation under reflux conditions.

Results Analysis of public databases demonstrated significant upregulation of NOTCH signaling components in EAC. In vitro studies demonstrated nuclear accumulation of active NOTCH1 cleaved fragment (NOTCH intracellular domain) and upregulation of NOTCH targets in EAC cells in response to reflux conditions. Additional investigations identified DLL1 as the predominant ligand contributing to NOTCH1 activation under reflux conditions. We discovered a novel crosstalk between APE1 redox function, reflux-induced inflammation and DLL1 upregulation where NF-κB can directly bind to and induce the expression of DLL1. The APE1 redox function was crucial for activation of the APE1-NF-κB-NOTCH axis and promoting cancer cell stem-like properties in response to reflux conditions. Overexpression of APE1 and DLL1 was detected in gastro-oesophageal junctions of the L2-IL1ß transgenic mouse model and human EAC tissue microarrays. DLL1 high levels were associated with poor overall survival in patients with EAC.

Conclusion These findings underscore a unique mechanism that links redox balance, inflammation and embryonic development (NOTCH) into a common pro-tumorigenic pathway that is intrinsic to EAC cells.

  • gastroesophageal reflux disease
  • cancer
  • oxidative stress

Data availability statement

Data are available upon reasonable request.

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Data availability statement

Data are available upon reasonable request.

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  • Contributors Conceptualisation and overall content: WE-R, SZ, LC. Methodology: LC, HL, AB, JQ and AZ. Validation: LC, HL and DLP. Formal analysis: LC and LLC. In vitro studies: LC, HL, KS, FB and ZC. In vivo studies: LC, HL and OGMD. Troubleshooting experiments: WE-R, TCW, AC and AZ. Data curation: LC, HL and WE-R. Supervision: WE-R, HL and DLP. Funding acquisition and resources: WE-R.

  • Funding This study was funded by the United States National Cancer Institute (Grant number: R01CA206563, R01CA224366, and P01CA268991).

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.