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Molecular and Cellular Biology, April 2004, p. 3188-3197, Vol. 24, No. 8
0270-7306/04/$08.00+0 DOI: 10.1128/MCB.24.8.3188-3197.2004
Copyright © 2004, American Society for Microbiology. All Rights Reserved.
Department of Genetics and Tumor Cell Biology, St. Jude Children's Research Hospital,1 Department of Molecular Sciences, School of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee 381052
Received 23 October 2003/ Returned for modification 15 December 2003/ Accepted 15 January 2004
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The Cdc2L1 and -2 genes, as well as cdc2l, express a 110-kDa protein kinase isoform which also contains the open reading frame of the smaller mitosis-specific isoform, CDK11p58. The smaller CDK11p58 isoform is generated by an internal ribosome entry site sequence (IRES) found in most species of mRNA encoding the CDK11p110 isoform. The presence or absence of the CDK11p58 isoform must be ascertained by determining whether the 58-kDa protein kinase species is present by sodium dodecyl sulfate (SDS)-polyacrylamide gel electrophoresis and immunoblot analysis (9). CDK11p110/p58 localizes to the nucleoplasm and nuclear speckle-staining regions (i.e., splicing factor centers) (20, 25, 44). The CDK11p110 kinase isoform interacts with the general pre-mRNA splicing factors RNPS1 and 9G8 (both of which are classified like other splicing factors as SR proteins), RNA polymerase II (RNAP II), and casein kinase 2 (CK2) (25, 26, 43). Furthermore, the larger CDK11 kinase isoform coimmunoprecipitates and/or copurifies with these same proteins and with multiple transcriptional elongation factors, including ELL2, TFIIF, TFIIS, and FACT (44).
A subfamily of cyclin-dependent protein kinases, including CDK1, -7, -8, and -9, regulates transcription through phosphorylation of specific amino acids in the carboxyl-terminal domain of the larger RNAP II subunit. The action of these various protein kinases results in the sequential recruitment of various transcriptional repressors and promoters as well as RNA processing factors to the differentially phosphorylated carboxyl-terminal domain (16, 31, 32). This group of protein kinases, perhaps in a cell cycle-specific manner, links various growth factor signaling pathways to transcription and RNA processing events. CDK11p110 associates with RNAP II, the cyclin L regulatory protein, several transcriptional elongation factors, and the pre-mRNA splicing proteins RNPS1 and 9G8 (20, 25, 44). The general splicing factor 9G8 is phosphorylated both in vivo and in vitro by the CDK11p110 kinase. The other known SR protein kinases (i.e., Clk/Sty LAMMER kinases and SRPK-1 and -2) (8, 11, 13, 29) phosphorylate the SR splicing factors almost exclusively in RS domains, thereby changing their subnuclear localization by releasing them from the splicing factor center storage compartments, changing their binding partners during the splicing reaction, changing splice site selection, or altering their ability to interact with nonspecific RNAs (28). Thus far, none has been shown to directly affect the splicing activity of the SR protein. Immunodepletion of CDK11p110 from nuclear extracts leads to a marked reduction of the in vitro splicing activity (20). These observations support the hypothesis that CDK11p110 may play an important role in transcript production and in regulation of RNA processing.
The CDK11p110 protein kinase isoform is detected in all phases of cell cycle, while the CDK11p58 isoform is expressed only during mitosis (9, 36). As mentioned earlier, CDK11p58 is produced by initiation of translation that is controlled by a mitosis-specific IRES present in the coding region of the CDK11p110 transcript. In addition, increased expression of CDK11p58 in Chinese hamster ovary (CHO) fibroblasts results in a late telophase delay due to abnormal cytokinesis and in increased cell death (22).
In summary, CDK11p110 protein kinase isoforms are involved in the regulation of RNA transcription and processing. However, the biological function of CDK11p58 in mammalian cells is unclear. To gain further insight into the function of the CDK11p110/p58 protein kinases in vivo, we disrupted the cdc2l gene encoding these products in embryonic stem (ES) cells. Heterozygous CDK11p110/p58+/- mice are viable and appear to develop normally. However, no homozygous CDK11p110/p58-/-knockout mice were obtained, since deletion of both cdc2l alleles during the early embryonic phase is lethal. CDK11p110/p58-/-blastocysts are not viable and die in utero between 3.5 and 4.0 days postcoitus, most likely due to apoptosis as a result of proliferative defects and mitotic arrest. In vitro culturing of these isolated blastocyst cells confirmed that embryonic cell death was due to apoptosis. The CDK11p110/p58 protein kinases are therefore important for proper cellular proliferation and cell cycle progression during early embryonic development.
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Southern blot analysis and PCR genotyping of the mouse cdc2l locus. The G418 and ganciclovir-selected ES cell clones were screened for disruption of the cdc2l gene by Southern blot hybridization of ES cell genomic DNA completely digested with BamHI. A 240-bp genomic sequence that flanked the 5' homologous region used in the disruption construct was labeled by PCR with [32P]dCTP and used as a probe.
The cdc2l genotypes were assessed by using genomic PCR. Genomic DNA was extracted from mouse tails and incubated overnight at 55°C in 200 µl of lysis buffer (200 mM NaCl, 10 mM Tris-HCl [pH 8.0], 0.1% Triton X-100, 1% NP-40, 5 mM EDTA, 400 µg of proteinase K/ml). The sample was then diluted 1:10, and 2 µl of this was used in a standard PCR with Ex Taq polymerase (Takara). A mixture of three different primers was used to detect the wild-type and targeted allele of cdc2l: a, forward (5'-CTTTGACCTCCATGGGCACATG-3'); b, wild-type (5'-CAGAGGCAAGTGGGTTTCTGAG-3'); and c, Neo (5'-CTATCGCCTTCTTGACGAGTTC-3'). Primers a and b will generate a 180-bp wild-type allele, whereas a 320-bp fragment would be expected for the mutant cdc2l allele generated with primers a and c. The PCR amplification protocol consisted of an initial incubation at 94°C for 3 min, followed by 35 cycles at 94°C for 45 s, 60°C for 1 min, and 72°C for 35 s. To confirm the results of PCR genotyping, genomic DNA extracted from mouse tails was digested with BamHI, transferred to a nylon membrane, and subjected to Southern blot hybridization using the 1.3-kb Neo internal probe.
Genotyping of the preimplantation embryos was assessed by nested PCR. Individual embryos and cells from outgrowths in culture were transferred into Eppendorf tubes containing 1 µl of sterile water, to which 3 µl of lysis buffer (0.05% SDS [wt/vol] and 0.035 N NaOH) was added. The samples were boiled for 5 min, and 2.0 µl of this mixture was subjected to the first round of PCR amplification in a total volume of 50 µl using a mixture of three primers: 1 (5'-CAACCATCTGTAAGTCCAATTCCAG-3'), 2 (5'-GCACACACCTTTAAATCCCAGCAC-3'), and 3 (5'-GGCGATGCGCTGCGAATCGGGAG-3') for 20 cycles at 94°C for 45 s, 60°C for 1 min, and 72°C for 35 s. Next, 2.5 µl of the PCR products was used for the second round of PCR amplification for 35 cycles with the mixture of primers a, b, and c as described above.
Blastocyst culturing. Heterozygous male and female mutant mice were bred to obtain cdc2l+/+ (CDK11p110/p58+/+), cdc2l+/- (CDK11p110/p58+/-), and cdc2l-/- mutant (CDK11p110/p58-/-) mouse embryos. The morning of the day on which a vaginal plug was detected was designated embryonic day 0.5 (E0.5). Embryos at different stages of development (E1.5 through E4.0) were collected by flushing oviducts or the uterus with HEPES-buffered medium 2 (M2; Sigma). In some experiments, embryos were fixed immediately for 20 min at 4°C with phosphate-buffered saline (PBS) containing 4% paraformaldehyde, and their nuclei were stained with 4',6'-diamidino-2-phenylindole (DAPI) (Vectashield; Vector). For in vitro culturing, blastocysts were cultured for 16 h to 3 days in tissue culture plates containing complete ES medium containing leukemia inhibitory factor; outgrowths were inspected daily and photographed to monitor their development.
Immunoblot analysis. CDK11p110/p58 wild-type and mutant ES cells were lysed in a buffer containing 25 mM Tris-HCl (pH 8.5), 1 mM dithiothreitol, and 100 mM NaCl by sonication; lysates were then cleared by centrifugation. One hundred micrograms of cell lysate was separated by SDS-12.5% polyacrylamide gel electrophoresis and transferred to a polyvinylidene difluoride membrane. The CDK11p110 and CDK11p58 protein kinases were detected by using a polyclonal antibody against the amino-terminal domain of CDK11p110 (P2N100) or the carboxyl-terminal domain common to both kinases (P1C).
BrdU labeling of cultured blastocysts. E3.5 blastocysts were cultured in ES cell medium containing 10 µM 5'-bromo-2'-deoxyuridine (BrdU) (Sigma) for 16 h. Cells were then fixed in 4% paraformaldehyde for 20 min at 4°C. After three washes with PBS, the cells were treated with 0.5 M HCl for 30 min at room temperature, after which immunofluorescence was performed as described below.
Immunocytochemistry and in situ detection of mitotic arrest and apoptosis. For immunofluorescence experiments, we used the rabbit polyclonal antibodies P1C and P2N100, which recognize the carboxyl-terminal domains of CDK11p110/p58 and the amino-terminal domain of CDK11p110, respectively. To determine the percentage of CDK11p110/p58+/+, CDK11p110/p58+/-, and CDK11p110/p58-/- blastocystcells in mitosis, the E3.5 blastocysts corresponding to these genotypes were cultured for 16 h to 3 days, and the cells were then immunostained with a rabbit polyclonal antibody, Phosphohistone (Ser10) (Cell Signaling Technology, Beverly, Mass.), which detects histone H3 when it is phosphorylated at serine residue 10. Blastocysts were fixed for 20 min in 4% paraformaldehyde, followed by permeabilization with 0.5% Triton X-100 in PBS for 20 min and blocking for 30 min in 5% fetal calf serum in PBS. Primary and secondary antibodies were left on cells for 1 h at room temperature, followed by three 5-min washes with PBS, after which DNA was stained with DAPI for 5 min. Embryos were embedded in Vectashield mounting medium and examined by fluorescent and confocal microscopy. This same procedure was used to immunostain CDK11p110/p58+/- and CDK11p110/p58-/- blastocysts with the P1C polyclonal antisera specific for the kinase domain shared by both CDK11p110 and CDK11p58 isoforms to verify that neither protein kinase isoform was expressed in the CDK11-deficient cells. To determine whether blastocyst cells were undergoing caspase-dependent apoptosis, both DNA fragmentation and caspase 3 enzymatic activity were examined. DNA fragmentation associated with cell death was detected by using an in situ terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick end labeling (TUNEL) apoptosis detection kit (Roche). In brief, to determine whether active caspase 3 was present, we labeled embryos with FAM-DEVD-FMK for 1 h at 37°C. To fluorescently label the DNA in the nuclei, we added DAPI, and the incubation continued for 5 min. Embryos were washed twice in 1x working dilution wash buffer. Caspase 3 enzyme activity was assayed by the processing of its fluorescent substrate, FAM-DEVD-FMK (Intergen), resulting in green fluorescence, while nuclear DNA staining by DAPI resulted in blue fluorescence. Both were analyzed with fluorescence microscopy. For the TUNEL analysis, E3.5 blastocysts were collected as described above, fixed with 4% paraformaldehyde in PBS for 20 min at 4°C, and subjected to permeabilization for 20 min at room temperature with PBS containing 0.2% Triton X-100. TUNEL assays were then performed by using the in situ detection kit (Roche). Briefly, the fixed and permeabilized blastocysts were labeled with the TUNEL reaction mixture for 60 min at 37°C. The nuclei of these blastocysts were also stained with DAPI. Fluorescein-labeled DNA, indicating DNA fragmentation, was then analyzed by using a Nikon fluorescence microscope.
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FIG. 1. Targeted disruption of the mouse cdc2l gene locus by homologous recombination. (A) Structure of the targeting vector and partial restriction map of cdc2l gene locus in mouse before and after homologous recombination. Exons are represented by vertical black boxes, and the position of the Southern blot probe (P) is indicated by the horizontal black box. Restriction enzymes: B, BamHI; X, XbaI; S, SacI; BX, BstXI. The mutated cdc2l allele was detected by a set of PCR primers: a, b, and c. The primers 1, 2, and 3 were used for the first round of the nested PCR amplification for blastocyst genotyping. (B) Southern blot analysis of CDK11p110/p58 mutant ES cell lines. Genomic DNA isolated from ES cell clones following positive (G418) and negative (ganciclovir) selection were digested with BamHI and analyzed by Southern blotting using 5' probe, yielding the predicted 5.8-kb band in addition to a 9.0-kb wild-type (WT) band. PCR amplification with primers d and e generated a 5.2-kb band containing the mutated allele. (C) Genotype analysis by Southern blot analysis (top) and PCR (bottom) of tail DNA of mice from heterozygote intercrosses. Tail DNA samples digested with BamHI were subjected to Southern blot hybridization with the 1.3-kb Neo probe, yielding a 1.7-kb band. The same DNA samples were also subjected to PCR with primers a and b for the WT allele and with primers a and c for the mutated (KO) allele, yielding amplification products of 180 and 320 bp, respectively. (D) The genotypes of the CDK11p110/p58 embryos from CDK11p110/p58+/- intercrosses were determined by nested PCR (see Materials and Methods). (E) Immunoblot analysis of CDK11p110/p58 expression in WT and heterozygous targeted ES cell lines. Whole-cell lysates from a WT ES cell line (+/+) and targeted ES cell line (+/-) were analyzed by immunoblotting with the CDK11p110-specific anti-P2N100 antibody. (F) Immunostaining of E3.5 CDK11p110/p58+/- and CDK11p110/p58-/- blastocysts with an affinity-purified C-terminal CDK11 polyclonal antibody, P1C, generated to a protein kinase domain shared by the CDK11p110 and CDK11p58 isoforms. The primary antibody was then detected with a fluorescein isothiocyanate-labeled secondary antibody (green, bottom panels) and indicates the presence of one or both of the protein kinases. The absence of a signal indicates that neither protein kinase is present in the blastocyst cells. To verify cellular integrity, we also stained blastocysts with DAPI, a reagent that specifically detects nuclear DNA (blue, top panels). White bar, 100 µm.
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TABLE 1. Genotype of offspring from CDK11p110/p58+/- heterozygote intercrossesa
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To further evaluate the role of CDK11p110/p58 in cell viability, we also attempted to generate ES cells with both cdc2l (CDK11p110/p58) alleles mutated by sequential gene targeting using CDK11p110/p58+/- ES cell clones. The mouse cdc2l gene was disrupted as described in detail in Materials and Methods. Nine targeted ES cell clones were isolated from 378 clones analyzed by PCR. All homologous recombination events occurred only at the previously targeted allele, and there were no CDK11p110/p58-/- ES cell clones obtained. All of the above data suggest that the CDK11p110/p58 protein kinases are essential for cell survival, and not for development, and that disruption of the cdc2l locus as well as the resulting loss of the CDK11p110/p58 kinases leads to an early embryonic lethality. Embryos lacking the CDK11p110/p58 kinases cease to develop before implantation, most likely just after the depletion of their maternal CDK11p58 mRNA and CDK11p110 mRNA and protein supplies. This difference is proposed due to the extremely short half-life of the CDK11p58 protein, which is degraded rapidly in late mitosis compared to the much longer half-life of the CDK11p110 protein, which is expressed throughout the cell cycle.
Aberrant cellular morphology and defective growth associated with CDK11p110/p58-/- embryonic cells. To more directly analyze the early embryonic lethality associated with the CDK11p110/p58-/- mice, we isolated blastocysts at different stages of development from intercrosses between heterozygous mutant mice, cultured them, and then examined the morphological differences among all types of embryos found. We observed that at the E3.5 stage of development, homozygous mutant (CDK11p110/p58-/-) blastocysts were morphologically distinguishable from their wild-type (CDK11p110/p58+/+) and heterozygous (CDK11p110/p58+/-) counterparts (Fig. 2A through F). Both CDK11p110/p58+/+ and CDK11p110/p58+/- blastocysts appeared normal, whereas the homozygous CDK11p110/p58-/- cells failed to form fully expanded blastocysts, which are composed of the hollow vesicle of the trophectoderm surrounding a fluid-filled cavity and a small group of internal cavity mass cells. The E3.5 CDK11p110/p58-/- blastocysts also appeared to be growth retarded at the morula stage of development (Fig. 2E). To further define the precise time point at which the CDK11p110/p58-/- embryos stop developing, we collected embryos from the E2.5 morula stage of heterozygous intercrosses and found that CDK11p110/p58-/- embryos at this stage appeared to be normal and did not have any morphological differences from those of the other genotypes (Fig. 2G through L), suggesting that embryos deficient in the CDK11p110/p58 kinases stop further development between E2.5 and E3.5. In an attempt to better understand the growth capacity of the CDK11p110/p58-/- embryos, we collected E3.5 and E2.5 blastocysts and cultured them individually in vitro in the presence of recombinant leukemia inhibitor for 16 h to 3 days. Unlike wild-type and heterozygous blastocysts that hatched from the zona pellucida, attached to the culture dish, generated apparently normal trophoblast giant cells (TG), and then continued to proliferate, the CDK11p110/p58-/- embryos never hatched and in fact gradually became smaller after in vitro culturing for several days and finally collapsed. This finding suggests that the CDK11p110/p58-/- homozygous blastocysts were incapable of implanting in the uterus and so died during the culture period (Fig. 2G through L). These results demonstrated that the development of CDK11p110/p58-/- embryos is impaired during in vitro culturing and reinforced in vivo observations that the growth of the CDK11p110/p58-/- blastocysts is arrested putatively after the maternally provided CDK11p110/p58 mRNA and protein stores are depleted.
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FIG. 2. Morphological analysis of the outgrowths derived from the CDK11p110/p58 blastocysts. Blastocysts were derived from CDK11p110/p58+/- intercrosses, explanted at E3.5 (day 0), and grown in culture for 3 days, during which time they developed outgrowths. The CDK11p110/p58+/+ (A and B) and CDK11p110/p58+/- (C and D) blastocysts grew normally. In contrast, CDK11p110/p58-/- (E and F) blastocysts stop further growth and development after E3.5. Magnification, x11.2 for panels A through F. Embryos at E2.5 and their outgrowths after 4 days in culture in panels G through L. CDK11p110/p58+/+ (G and H), CDK11p110/p58+/- (I and J), and CDK11p110/p58-/- (K and L) embryos are indistinguishable at E2.5. All images are not shown to scale (magnification, x6.5 for day 4 wild-type and heterozygous outgrowth [panels H and J]; x13 for panels G, I, K, and L). ICM, inner cell mass; TG, trophoblast giant cell.
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FIG. 3. CDK11p110/p58 protein kinase deficiency resulted in apoptosis of the blastocyst cells. CDK11p110/p58+/+, CDK11p110/p58+/-, and CDK11p110/p58-/- blastocysts were isolated at E3.5 from CDK11p110/p58+/- intercrosses. The caspase 3 activity of the blastocysts was detected by the fluorescence of its covalently bound inhibitor, FAM-DEVD-FKM. Caspase 3 activity (B, D, and F) and nuclear DNA staining by DAPI (A, C, and E) were both examined by fluorescence microscopy. Bar, 50 µm.
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FIG. 4. Analysis of blastocyst cell apoptosis by TUNEL. CDK11p110/p58+/- (A) and CDK11p110/p58-/- (B) blastocysts were isolated at E3.5 from CDK11p110/p58+/- intercrosses. After 12 h in culture, the fixed, permeabilized blastocysts were stained with TUNEL reagents (E and F) and DAPI (C and D). Bar, 50 µm.
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FIG. 5. Failure of the CDK11p110/p58-/- blastocyst cells to proliferate normally. CDK11p110/p58 blastocysts at E3.5 were recovered from CDK11p110/p58+/- intercrosses and grown in culture in the presence of 10 µM BrdU for 16 h. The fixed blastocysts (panels A, E, and I) were then stained with anti-BrdU antibody (panels C, G, and K), an antibody specific to the M-phase-specific marker histone H3 phosphorylated at Ser10 (panels D, H, and L), and DAPI (panels B, F, and J). The genotype of each embryo was determined by using nested PCR. Representative CDK11p110/p58+/+ (A to D), CDK11p110/p58+/- (E to H), and CDK11p110/p58-/- (I to L) blastocysts are shown. ICM, inner cell mass. Bar, 50 µm.
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50 to 60%) than that in either their wild-type or heterozygous counterparts (
10%) (Fig. 6A and B, inset). These results confirm that the majority of the cells from the CDK11p110/p58-null blastocysts were arrested during mitosis before E3.5. Taken together, the facts that (i) these blastocysts did not synthesize new DNA as shown by the BrdU-labeling experiments, (ii) the blastocysts consisted of a high percentage of cells positive for phosphorylated Ser10 on histone H3 (a mitotic marker), and (iii) the blastocysts were unable to produce CDK11p110/p58-/- ES cells after numerous attempts are all proof that the blastocyst cells from CDK11p110/p58-/- mouse embryos underwent cell death as a result of cell cycle arrest rather than of a specific developmental defect.
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FIG. 6. Representative confocal microscopy images of CDK11p110/p58+/+ (A) and CDK11p110/p58-/- mutant (B) embryos stained with DAPI (blue) and anti-PHH3 antibody (red). Bar,100 µm. Increased number of cells undergoing mitotic arrest observed in the CDK11p110/p58-/- mutant embryos at E3.5 are shown. Mitotic arrest was determined by counting the number of cells positive for phospho-Ser-histone H3 (PHH3), the M-phase-specific marker. The percentage of PHH3-positive blastocyst cells from among the total number of blastocyst cells (determined by DAPI staining of cellular nuclei) is represented in the inset bar graph.
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Recently, an additional member of the CDK kinase family, CDK11p110, was identified as a regulator of RNA processing events and of transcription (20, 25, 26, 44), and a second CDK11 isoform, CDK11p58, has been shown to be expressed only during mitosis due to an IRES present in the CDK11p110 mRNA (9). While the exact function of the CDK11p58 isoform is not known at this time, its mitosis-specific expression strongly suggests that it regulates events during mitosis. In the present study, we have examined the effect(s) of the loss of CDK11p110/p58 function, due to the disruption of its corresponding cdc2l gene in mice, on normal embryonic development. Additionally, attempts to generate cdc2l-/- ES cells that do not express the CDK11p110/p58 kinases also proved to be unsuccessful after several different attempts (data not shown). While we cannot specifically attribute the resulting embryonic lethal phenotype to the specific loss of CDK11p110 or CDK11p58, the experiments reported here demonstrate that these particular CDK protein kinases are essential for the normal growth of a wide range of cell types. Additionally, these studies have shown that the loss of these protein kinase activities results in the failure of E3.5 CDK11p110/p58-null blastocyst cells to survive due to apoptosis induced by proliferative failure and mitotic arrest. Since E3.5 blastocyst cells are in the process of making the transition from early embryonic cell divisions that rely on a number of maternal mRNAs and proteins to promote their survival to cells whose survival is no longer dependent on such maternal products, it is likely that disruption of the cdc2l gene results in the complete loss of both CDK11p110 and CDK11p58 kinase function in postblastocyst cells. Therefore, we can conclude that the function of one or both of the CDK11 kinase isoforms is absolutely essential for the continued survival, and therefore development, of the postblastocyst murine cells. Additional conditional cdc2l gene knockouts, as well as cdc2l gene knock-in experiments, will now be needed to determine whether one or both of the CDK11 kinase isoforms is essential for normal cell growth and development. Furthermore, these results suggest that it may be of interest to examine the effects of crossing CDK11p110/p58 gene hypomorphs with well-known mouse tumor models to determine whether the decreased expression of one or both of these protein kinases might mediate tumorigenesis. Several recent reviews on the potential of pre-mRNA splicing factors to function as mediators of tumorigenesis suggest that this possibility should be considered (6, 12, 17). In addition, the phenotype of the CDK11p110/p58-/- blastocyst cells, which includes both proliferative failure and mitotic arrest, also supports the possible involvement of the CDK11 protein kinases in cancer and/or disease. Finally, the human Cdc2L genes are localized to human chromosome 1 band p36.3 (14), a chromosomal region that is frequently deleted or translocated in a number of different human tumors, including neuroblastoma, breast cancer, melanoma, and lymphoma, and the region has been proposed as the location of at least two tumor suppressor genes (38). Such studies will help us to determine whether the CDK11p110 and/or CDK11p58 protein kinases function as possible tumor suppressors or mediators of tumorigenesis, perhaps due to haploinsufficiency of one or both of the kinases.
This research was supported by a grant from the NIH (2RO1 GM44088-13) to V.J.K., from the NIH to SJCRH (P30 CA21765-25) and by the generous support of the American Lebanese Syrian Associated Charities (ALSAC).
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