INTRODUCTION

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Normal animal cells, with few exceptions, do not divide indefinitely. Eventually, cell divisions are arrested and cells enter cellular or replicative senescence (for a review, see reference 10). Replicative senescence is especially stringent in human cells, which almost never spontaneously immortalize (41)

Cellular senescence is a genetically controlled process (for a review, see references 56 and 57). There is strong support for the theory that telomere shortening limits the longevity of human cells in culture (9, 26, 27). It has been proposed that telomere shortening eventually causes chromosome instability, leading to the activation of the DNA damage response pathway followed by p53-dependent cell cycle arrest and senescence (59). Furthermore, the important role of p53 in cellular senescence is supported by the following observations. First, functional inactivation of p53 rescues cells from senescence-related growth arrest and instead they enter crisis at a delayed time point (7, 24, 48, 49, 54). Second, the p21^WAF1 gene, which encodes an inhibitor of cyclin-dependent kinases (15, 28), is transcriptionally regulated by p53 (17, 18) and is overexpressed in senescent cells (45). Third, exposure of human diploid fibroblasts to -irradiation leads to a p53-dependent, prolonged G₁ arrest and induction of p21^WAF1 expression that is reminiscent of senescence (14). Fourth, the DNA binding and transcriptional activities of p53 increase with cell age, and in most cases this occurs in the absence of any marked increase in the level of p53 (1, 4, 36, 47, 60).

p53 is more widely recognized for its role as a tumor suppressor which mediates growth arrest and apoptosis in response to DNA damage (25, 37). Apoptosis is generally viewed as the "cleanest" way a cell can die. Apoptotic cell death does not have a negative effect on surrounding tissues and is not accompanied by inflammation. Analysis of p53 knockout mice showed that in the absence of p53, cells with damaged DNA do not enter cell cycle arrest and die by an alternative death pathway, necrosis (43). Necrosis is characterized by the loss of membrane integrity, cell swelling, and release of the cell contents, which may result in inflammation (20). Not much is known about the molecular mechanisms underlying the necrotic pathway.

Little is known of how cell aging affects the ability of the cells to respond to genotoxic stress. It has been observed that senescent cells are resistant to apoptotic stimuli (22, 62). However the mechanism by which senescent cells resist apoptotic death is not well understood. A different set of data indicates that p53 is modified in senescent cells (60). It has recently been demonstrated that senescence is associated with specific posttranslational modifications of p53 (63).

Based on these observations, we hypothesized that the inability of senescent cells to undergo apoptosis is caused by changes in the state of p53. Furthermore, as senescent cells are resistant to apoptosis, we were interested in understanding the fate of senescent cells subjected to apoptotic stimuli. For this purpose, we studied the effects of DNA-damaging agents, including actinomycin D, UV irradiation, cisplatin, and etoposide, that are known to induce different types of damage on cells at early and late passages in culture. As a model system, we chose the WI-38 human primary diploid fibroblasts, the best-characterized cells with respect to cellular senescence (4, 47).

We found that apoptosis induced by actinomycin D, UV, or a low dose of cisplatin was p53-dependent in WI-38 fibroblasts, whereas apoptosis induced by etoposide or a high dose of cisplatin was p53-independent. Senescent fibroblasts were unable to induce p53-dependent apoptosis, even though p53-independent apoptosis was only slightly reduced. Instead of undergoing p53-dependent apoptosis in response to DNA damage, senescent fibroblasts underwent necrosis. Artificial stabilization of p53 in old cells by proteasome inhibitors led to the induction of apoptosis. Moreover, transient expression of the wild-type p53 in the old cells fully restored their ability to undergo p53-dependent apoptosis, indicating that the absence of p53-dependent apoptosis in old cells was due to their inability to stabilize p53. Our results suggest that stabilization of p53 in response to DNA damage is impaired in old fibroblasts, resulting in a change of the death pathway from apoptosis to necrosis.

	MATERIALS AND METHODS

Top Abstract Introduction Materials and Methods Results Discussion References

Cell culture and transfection. WI-38 human diploid fibroblasts (American Type Culture Collection) were cultured in minimal essential medium with all nonessential amino acids, 10% fetal bovine serum, and 1 mM pyruvate. Twice a week, 10⁵ cells were passaged on a new plate using 0.25% trypsin-EDTA. Care was taken not to let the cells reach 70% confluency.

Detection of apoptosis by DNA ladder. Detached and adherent fibroblasts were harvested, and equal numbers of cells (5 × 10⁵) were suspended in 30 µl of sample buffer (10% glycerol, 10 mM Tris[pH 8], 0.1% [wt/vol] bromophenol blue) mixed at 1:1 ratio with 10-mg/ml RNase A solution. The cells were loaded on an agarose gel which contained two parts: the lower part (from the comb to the end of the gel) consisted of 0.8% agarose in Tris-borate-EDTA; the upper part (from the comb to the beginning of the gel) consisted of 0.8% agarose, 2% sodium dodecyl sulfate (SDS), and 64 µg of proteinase K/ml in Tris-borate-EDTA. The cells were electrophoresed for 10 h at 60 V at room temperature. The gel was stained with 2 mg of ethidium bromide/ml in water for 1 h and then destained with water (16).

Western blot analysis. Detached and adherent fibroblasts were harvested, and equal numbers of cells (10⁶) were lysed in protein sample buffer with 5% -mercaptoethanol and 1 mM phenylmethylsulfonyl fluoride, boiled for 10 min, and loaded on an SDS-polyacrylamide gel. A 7.5 and a 10% running gel were used for the detection of poly(ADP-ribose) polymerase (PARP) and p53, respectively. The proteins were transferred to a nitrocellulose membrane using a semidry transfer cell (Bio-Rad). The blots were probed with either a human p53-specific monoclonal antibody (DO-1) or anti-PARP monoclonal antibody (Biomol). The bands were visualized with the aid of the Super Signal kit (Pierce).

Analysis of apoptosis and necrosis by acridine orange staining. Cells were fixed in 3 ml of a solution containing 80% ethanol and 20% Hanks balanced salt solution (HBSS) and stored at 20°C for a period not exceeding 1 week. On the day of the assay, the cells were gently remixed and centrifuged at 800 rpm on a Sorval GLC-3 centrifuge. The pellets were gently resuspended, washed in 1 ml of HBSS, and centrifuged at 1,000 rpm on a Hettich microcentrifuge. The cells were resuspended in 1 ml of a 1:30 solution of RNase in HBSS and incubated at 37°C for 1.5 h. The cells were then centrifuged at 1,200 rpm in an Eppendorf centrifuge, gently resuspended in 200 µl of HBSS, and transferred to FACS tubes, and 0.5 ml of 0.1 M HCl in HBSS was added. After approximately 1 min, the acid denaturation was quenched by the addition of 2 ml of a solution of 90% citric acid, 10% Na₂HPO₄, and 0.06% acridine orange (Molecular Probes). The cells were analyzed in a FACS SORT flow cytometer (Becton Dickinson). An excitation wavelength of 488 nm was used, 575- and 650-nm emissions were collected, and the data were analyzed with CellQuest software (Becton Dickinson). Low-speed centrifugation and gentle handling of the fixed cells were critical to the success of this assay, as they prevented aggregation and breakage of the cells.

Detection of necrosis by release of DNA. The cellular DNA fragmentation enzyme-linked immunosorbent assay kit from Boehringer Mannheim was used for the detection of bromodeoxyuridine (BrdU)-labeled DNA released from necrotic cells into the cell culture medium. Briefly, WI-38 human fibroblast cells were incubated in culture with the thymidine analogue BrdU, which is incorporated into the genomic DNA. BrdU was added to the medium 24 or 48 h before treatment. The cells were treated with various drugs, as described above, in the presence of BrdU, and the supernatants of the cell cultures were collected after different time intervals. BrdU did not affect the rate of growth, apoptosis, or necrosis of the fibroblasts in the time window used, as determined by FACS analysis of BrdU-treated and untreated cells. The DNA fragments were captured with an anti-DNA antibody bound to a Nunc-Immuno flat-bottom plate and were detected by an anti-BrdU antibody-peroxidase conjugate. The photometric measures were done at a wavelength of 450 nm with a reference wavelength of 690 nm.

	RESULTS

Top Abstract Introduction Materials and Methods Results Discussion References

Apoptosis in human primary fibroblasts. To examine whether cellular aging affects the ability of cells to undergo apoptosis in response to genotoxic stress, we chose WI-38 primary human fibroblasts. Since the detection of apoptosis in fibroblasts is controversial (3, 14, 22, 29, 64), we first analyzed the abilities of various DNA-damaging agents to induce apoptosis in these cells.

View larger version (66K): [in this window] [in a new window]   FIG. 1.   Apoptosis in young and old normal human fibroblasts induced by DNA-damaging agents. Young and old fibroblasts were treated with various DNA-damaging agents (actinomycin D, UV, etoposide, and low [1-µg/ml] and high [10-µg/ml] concentrations of cisplatin), and induction of apoptosis was analyzed by DNA ladder (A), acridine orange staining for chromatin condensation (B), and PARP cleavage (C). (A) After 0, 36, 48, and 72 h of induction, all detached and adherent fibroblasts were collected, and equal numbers of the cells were directly subjected to gel electrophoresis as described in Materials and Methods. MW, 1-kb ladder standard. (B) Percent apoptosis was determined by FACS analysis after acridine orange staining of fibroblasts treated with genotoxic agents. The hatched bars represent young fibroblasts, and the solid bars represent old fibroblasts. All of the experiments were repeated at least three times, and standard errors are shown. (C) Induction of apoptosis in young human fibroblasts was further confirmed by Western blotting with anti-PARP antibodies. The full-length (113-kDa) and apoptosis-specific (89-kDa) fragments of PARP are indicated.

Human fibroblasts undergo p53-dependent or p53-independent apoptosis. We were interested in studying whether there is a correlation between the differential apoptotic responses of the young and old cells and the tumor suppressor protein p53. Apoptosis is known to occur via p53-dependent and p53-independent pathways, depending on the treatment applied and the cell type. We first investigated the involvement of p53 in the induction of apoptosis by genotoxic stress in young human fibroblasts. Upon treatment of young fibroblasts with actinomycin D, cisplatin, and UV, we detected an increase in p53 levels by Western blotting with DO-1 anti-p53 antibodies (Fig. 2A). However, etoposide failed to induce accumulation of p53 (Fig. 2A), which suggests that etoposide, in contrast to actinomycin D, cisplatin, and UV, is unable to stabilize p53. In order to test whether stabilization of p53 is accompanied by its activation, we analyzed the induction of the p53 downstream gene Mdm2 upon genotoxic stress. Induction of Mdm2 was monitored by Western blotting with the anti-Mdm2 antibody (data not shown). We observed strong correlation between accumulation of p53 and induction of the Mdm2 gene in the cells treated with actinomycin D, UV, and low concentrations of cisplatin. Even though fibroblasts treated with high concentrations of cisplatin exhibit high levels of p53, we did not detect any induction of the Mdm2 gene. Etoposide-treated cells, which were found not to accumulate p53 (see above), were unable to induce Mdm2 in response to stress.

View larger version (50K): [in this window] [in a new window]   FIG. 2.   Role of p53 in the induction of apoptosis in young and old human fibroblasts. (A) Accumulation of p53 in young and old fibroblasts upon treatment with various DNA-damaging agents. After 0, 5, 12, 24, 36, and 48 h of induction, all detached and adherent fibroblasts were collected, and equal numbers of cells were subjected to SDS-polyacrylamide gel electrophoresis (PAGE) followed by Western blotting with DO-1 anti-p53 antibodies. The blots were stained with India ink to check the equivalence of protein transfer. One-third of each sample was subjected to SDS-PAGE and stained with Coomassie blue to demonstrate equal loading of samples (shown below each Western blot). (B) Inactivation of p53-dependent apoptosis by transient expression of dominant-negative p53 fragment (DD) or human papillomavirus type 16 protein E6. Young fibroblasts transiently transfected with empty vector (hatched bars), plasmid expressing DD (solid bars), or E6 (dark hatched bars) were treated with various DNA-damaging agents for 36, 48, and 72 h. The level of apoptosis was determined by acridine orange staining followed by FACS analysis. The open bars represent the level of apoptosis in the transfected but untreated cells. All the experiments were repeated at least three times, and standard errors are shown.

Old human fibroblasts are unable to stabilize p53 in response to genotoxic stress. We have found that, unlike young cells, old fibroblasts exhibit negligible levels of p53-dependent apoptosis in response to genotoxic stress. It is well accepted that p53-dependent apoptosis induced by genotoxic stress requires p53 protein stabilization. Hence, we analyzed the stabilization of p53 in old fibroblasts after treatment with actinomycin D, UV irradiation, etoposide, and low and high concentrations of cisplatin, using Western blotting with the DO-1 anti-p53 antibody (Fig. 2A). We detected very low or no stabilization of the p53 protein in old cells compared to that in young cells. However, the basal levels of p53 in young and old fibroblasts were comparable (Fig. 2A), as shown previously (1, 4). This suggests that the reduction in p53-dependent apoptosis in old fibroblasts may be due to their inability to stabilize p53.

Old human fibroblasts that are unable to enter p53-dependent apoptosis undergo necrosis. The above-mentioned results showed that old human fibroblasts are unable to undergo p53-dependent apoptosis in response to DNA damage. A question arises as to the fate of those cells with damaged DNA. During preliminary microscopic examination, we observed similar death rates in the young and old cells treated with all the tested DNA-damaging agents (data not shown). Hence, we suspected that necrosis was responsible for the death of DNA-damaged old cells. Release of the cellular matrix from the cell and the appearance of "empty" ghost cells, consisting of only cell membranes, are typical necrotic features (20, 31, 34). As mentioned previously, acridine orange staining followed by FACS analysis was effective in differentiating between viable and apoptotic WI-38 fibroblasts. Acridine orange binds to DNA and hence can detect sub-G₁ DNA content. Moreover, it is dichromatic and undergoes a shift from green to red fluorescence when it binds to the condensed DNA typical of apoptosis. Therefore, it allows the detection of apoptosis even in cells that do not exhibit a sub-G₁ content, like fibroblasts. Figure 3C shows an example of the fluorescence shift of acridine orange due to apoptosis induced by actinomycin D treatment.

View larger version (33K): [in this window] [in a new window]   FIG. 3.   Detection of necrotic and apoptotic cells by acridine orange staining followed by FACS analysis. (A) Density plot of normal cell cycle distribution of untreated fibroblasts. Cell populations at the G1, S, and G2 stages of the cell cycle are indicated. (C) Density plot of empty cells obtained from normal fibroblasts by DNase and RNase treatment for 1.5 h prior to acridine orange staining. This distinct population of empty cells (without DNA and RNA) was used to set the parameters for the identification of the population of necrotic cells. (B and D) Typical examples of young and old fibroblasts undergoing apoptosis or necrosis upon treatment with actinomycin D for 48 h.

View larger version (35K): [in this window] [in a new window]   FIG. 4.   Induction of apoptosis and necrosis in young and old human fibroblasts by various DNA-damaging agents. After 36, 48, and 72 h of treatment, the cells were stained with acridine orange and analyzed by FACS (see Materials and Methods), which allowed the measurement of both apoptosis and necrosis. The open and solid bars represent untreated young and old cells, respectively. The levels of apoptosis and necrosis in young untreated cells were too low to be seen on the graph. The hatched bars represent the level of apoptosis or necrosis in treated cells, and light and dark hatched bars represent young and old cells, respectively. All the experiments were repeated at least three times, and standard errors are shown.

View larger version (33K): [in this window] [in a new window]   FIG. 5.   Induction of necrosis in old human fibroblasts by actinomycin D, UV, and low concentration of cisplatin. Necrosis was analyzed by the release of DNA from necrotic cells into the medium. Total DNA of the old fibroblasts was metabolically labeled with BrdU for 24 or 48 h prior to induction. DNA released into the medium upon induction of necrosis was quantified with a cellular DNA fragmentation enzyme-linked immunosorbent assay kit (see Materials and Methods). The percent of released DNA from the total labeled DNA is shown. Experiments were repeated five times, and standard deviations are indicated.

Stabilization of p53 in old human fibroblasts restores their ability to undergo apoptosis. To examine whether the reduction in p53-dependent apoptosis in old fibroblasts is due to their inability to stabilize p53, we used two approaches. One was aimed at stabilizing p53 in old cells by the inhibition of its proteolysis, and the other approach was to exogenously express the p53 protein by transient transfection of wild-type p53.

(i) Stabilization of p53 by proteasome inhibitors. Degradation of p53 is mediated by the ubiquitin-proteasome pathway (40). In order to induce the accumulation of endogenous p53 in old fibroblasts, we used the proteasome inhibitors MG-115, MG-132, and PSI (proteasome inhibitor I), which were shown to stabilize p53 (11, 23, 39). Importantly, it was demonstrated that apoptosis of immortalized cells induced by MG-115 and PSI is p53 dependent, suggesting that stabilization of p53 plays a key role in apoptosis induced by proteasome inhibitors (39).

View larger version (40K): [in this window] [in a new window]   FIG. 6.   Stabilization of p53 and induction of apoptosis in young and old fibroblasts treated with proteasome inhibitors. Young and old fibroblasts were treated with the following proteasome inhibitors: MG-115 (30 µM), MG-132 (10 µM), and PSI (30 µM). (A) Stabilization of p53 at various time points after treatment was analyzed by Western blotting with DO-1 antibodies. The p53 protein is indicated by arrowheads. The blots were stained with India ink to check the equivalence of protein loading and transfer, and the blots showing equal loading and transfer within young and old cells are presented. (B) Induction of apoptosis was analyzed by acridine orange staining followed by FACS analysis. The percent apoptosis in young (light hatched bars) and old (dark hatched bars) cells treated with proteasome inhibitors is shown. The level of apoptosis in untreated cells (young and old) was too low to be seen on the graph. Experiments were repeated at least three times; standard errors were less than 3% of the average and are not shown on the graph.

(ii) Exogenous expression of wild-type p53. To confirm that the observed apoptosis induced by the proteasome inhibitors is indeed due to an increase in p53 levels rather than stabilization of other factors, we tested whether overexpression of exogenous p53 would force old cells to enter apoptosis instead of undergoing necrosis. To this end, old human fibroblasts were transfected with a plasmid carrying wild-type p53 under the CMV promoter. The efficiency of transfection was ~15%, as monitored by cotransfection with a GFP-harboring plasmid. The population of transfected cells was enriched up to 80% by magnetic cell sorting (see Materials and Methods). The exogenous p53 was highly expressed in transfected old fibroblasts within 48 h after transfection, as shown by Western blotting (Fig. 7A). This high level of p53 in transfected cells induced massive apoptosis even without genotoxic stress (Fig. 7B). Similar massive apoptosis was observed with p53-transfected old fibroblasts that were treated with actinomycin D, UV irradiation, and a low concentration of cisplatin. This may indicate that following exogenous expression of p53, the cells reached a maximum level of p53-dependent apoptosis that could not be further increased by drug treatment. Importantly, the level of DNA damage-induced necrosis was significantly reduced by overexpression of p53 in the old cells in comparison to that observed for the old cells transfected with the control vector. Therefore, by overexpression of exogenous p53, we were able to override senescence-related changes in the old cells and switch them back from the necrotic to the apoptotic pathway of cell death.

View larger version (29K): [in this window] [in a new window]   FIG. 7.   Transient expression of p53 in old fibroblasts restores their ability to undergo apoptosis and inhibits their ability to undergo necrosis. Old fibroblasts were transiently transfected with a plasmid harboring the wild-type p53 gene under the CMV promoter or with the control plasmid containing the CMV promoter alone. The population of transfected cells was enriched using the MACSorter Kk kit. (A) The levels of p53 expression at 48 and 72 h after transfection were analyzed by Western blotting with DO-1 antibodies. The blots were stained with India ink to check the equivalence of protein transfer. One-third of each sample was subjected to SDS-polyacrylamide gel electrophoresis and stained with Coomassie blue to demonstrate equal loading of samples (shown below the Western blot). (B) Immediately following the transfection, cells were subjected to genotoxic stress (actinomycin D, UV, or a low concentration of cisplatin). The levels of induced apoptosis and necrosis 48 and 72 h after treatment were analyzed by acridine orange staining followed by FACS. Experiments were repeated at least three times, and standard errors are shown.

	DISCUSSION

Top Abstract Introduction Materials and Methods Results Discussion References

We were the first to analyze the response of senescent cells to genotoxic stress and the role of p53 in this process. Our main finding is that old cells do not induce p53-dependent apoptosis in response to genotoxic stress, which is likely the result of an inability to stabilize p53. Upon DNA damage, senescent cells that are unable to undergo apoptosis die by necrosis. A summary of our results is shown schematically in Fig. 8.

View larger version (17K): [in this window] [in a new window]   FIG. 8.   Model of the death pathways taken by young and old human fibroblasts in response to various genotoxic stresses.

Apoptosis in young human fibroblasts. Based on the analysis of DNA fragmentation, chromatin condensation, and the cleavage of PARP, we demonstrated that young human fibroblasts are able to undergo apoptosis in response to DNA insults mediated by actinomycin D, UV irradiation, etoposide, and low and high concentrations of cisplatin. Assays of chromatin condensation and caspase-dependent cleavage of PARP in treated fibroblasts showed classical apoptosis. In the DNA fragmentation assay, high-molecular-weight smears were obtained following all treatments, which is in accordance with previous studies reporting that fibroblasts are unable to produce internucleosomal DNA fragmentation during apoptosis (8, 16, 46). This explains why the methods based on detection of extensive DNA fragmentation (terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling) or exclusion of the small DNA fragments from the nucleus (propidium iodide-based detection of a sub-G₁ population) would not be sensitive enough for the analysis of apoptosis in normal human fibroblasts.

Senescent human fibroblasts are resistant to p53-dependent apoptosis and instead undergo necrosis. We have observed that old fibroblasts were unable to undergo p53-dependent apoptosis, while the ability to undergo p53-independent apoptosis was only slightly affected. It was previously reported that, unlike young cells, old fibroblasts were unable to undergo apoptosis in response to stress caused by serum deprivation or oxygen radicals (22, 62). In order to understand what happened with the damaged old cells which were unable to induce p53-dependent apoptosis, we performed detailed analysis of those cells. We found that senescent fibroblasts were dying via a different pathwaynecrosis. The necrotic death that we observed was characterized by the loss of cellular content and a lack of chromatin condensation and membrane blebbing. Our observation that the inhibition of an apoptotic pathway results in necrotic cell death correlates well with data from recent studies that used broad-spectrum caspase inhibitors to block apoptosis (12, 30, 32, 61). Furthermore, data from an assessment of the effect of DNA damage on the limb development of wild-type and p53 knockout mice (43) showed that the damage induced apoptosis in the limbs of wild-type mice but not those of p53^/ mice. However, cell death which exhibited necrotic features was much higher in the limbs of homozygous p53^/ mice. Collectively, these observations suggest that apoptosis and necrosis may be alternative pathways in the process of cell death. The physiological role of necrosis is only starting to be understood. Future studies will show the role played by the change of the death pathway from apoptosis to necrosis in senescence.

Inability of senescent fibroblasts to undergo p53-dependent apoptosis is due to lack of p53 stabilization. Our findings suggest that old cells are unable to undergo p53-dependent apoptosis due to an inability to stabilize p53. This was demonstrated by two independent methods. First, proteasome inhibitors forced the accumulation of p53 in old cells, which in turn induced apoptosis. This indicates that the apoptotic machinery downstream of p53 is functional in old cells. Second, similar results were obtained following overexpression of exogenous p53 in these cells. By the forced accumulation of p53, we were able to restore the inability of old cells to enter p53-dependent apoptosis.

Implications of the change of death pathway from apoptosis to necrosis in senescent cells for anticancer therapy. One of the problems in geriatric medicine is the increased sensitivity of old patients to stress induced by DNA damage and other types of cellular damage (19). This problem becomes crucial in oncology, since cancer is an age-associated disease and anticancer chemotherapy results in severe genotoxic stress to normal tissues. It was observed that some anticancer drugs have a greater toxicity in the elderly than in young patients (6, 38). Our finding of a senescence-related transition of the death pathway from apoptosis to necrosis in old cells provides a good explanation for this augmented toxicity. Analysis of studies concerning the application and toxicity of anticancer drugs in the elderly revealed good correlation between increased toxicity of the drug in the elderly and induction of necrosis in old human fibroblasts (Table 1). Thus, etoposide is widely used for anticancer chemotherapy in old patients (38, 44). Our results show that etoposide induces p53-independent apoptosis in old cells. Cisplatin is one of the most effective and widely used anticancer drugs, and it is considered to have acceptable toxicity for old patients (35, 38). No increased toxicity was observed in the elderly when the cisplatin dose was increased (52, 58), and it was suggested that its toxicity was inversely dependent on the dose administered. We found that a low dose of cisplatin causes necrosis in old cells whereas a high dose induces apoptosis. Actinomycin D is widely used in cancer therapy; however, its severe toxicity in old patients has been reported (52). We found that while in young cells actinomycin D induces apoptosis, in old cells it results in massive necrosis. As previously mentioned, necrosis can result in inflammation, and this can explain the increased toxicity of the necrosis-inducing drugs observed in the elderly. Thus, elucidation of the death pathways induced by genotoxic stress in the context of cellular senescence may contribute to optimization of the current chemotherapeutic regimens.