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Review Article - (2013) Volume 0, Issue 0

Roles of c-FLIP in Apoptosis, Necroptosis, and Autophagy

Ahmad R Safa1,2*
1Department of Pharmacology &Toxicology, Indiana University School of Medicine, IN 46202, USA
2Indiana University Simon Cancer Center, Indiana University School of Medicine, IN 46202, USA
*Corresponding Author: Ahmad R Safa, Department of Pharmacology & Toxicology, Indiana University School of Medicine, IN 46202, USA, Tel: 317-278-4952, Fax: +1-317-274-8046 Email:


Cellular FLICE (FADD-like IL-1β-converting enzyme)-inhibitory protein (c-FLIP) is a major antiapoptotic protein and an important cytokine and chemotherapy resistance factor that suppresses cytokine- and chemotherapyinduced apoptosis. c-FLIP is expressed as long (c-FLIPL), short (c-FLIPS), and c-FLIPR splice variants in human cells. c-FLIP binds to FADD and/or caspase-8 or -10 and TRAIL receptor 5 (DR5). This interaction in turn prevents Death-Inducing Signaling Complex (DISC) formation and subsequent activation of the caspase cascade. c-FLIPL and c-FLIPS are also known to have multifunctional roles in various signaling pathways, as well as activating and/ or upregulating several cytoprotective and pro-survival signaling proteins including Akt, ERK, and NF-κB. In addition to its role in apoptosis, c-FLIP is involved in programmed necroptosis (necrosis) and autophagy. Necroptosis is regulated by the Ripoptosome, which is a signaling intracellular cell death platform complex. The Ripoptosome contains receptor-interacting protein-1/Receptor-Interacting Protein-3 (RIP1), caspase-8, caspase-10, FADD, and c-FLIP isoforms involved in switching apoptotic and necroptotic cell death. c-FLIP regulates the Ripoptosome; in addition to its role in apoptosis, it is therefore also involved in necrosis. c-FLIPL attenuates autophagy by direct acting on the autophagy machinery by competing with Atg3 binding to LC3, thereby decreasing LC3 processing and inhibiting autophagosome formation. Upregulation of c-FLIP has been found in various tumor types, and its silencing has been shown to restore apoptosis triggered by cytokines and various chemotherapeutic agents. Hence, c-FLIP is an important target for cancer therapy. This review focuses on (1) the anti-apoptotic role of c-FLIP splice variants in preventing apoptosis and inducing cytokine and chemotherapy drug resistance, as well as its roles in necrosis and autophagy, and (2) modulation of c-FLIP expression as a means to enhance apoptosis and modulate necrosis and autophagy in cancer cells.

Keywords: c-FLIP; apoptosis; death receptors; cancer; chemotherapy


Various cell death signaling pathways have been described that are regulated at several levels. While the mitochondrion is the initiation point of these signals [1,2], there are several types of signaling platforms in cells that can initiate cell death. These complexes include the death-inducing signaling complex (DISC) [3], TNF complex II [4], apoptosome [5], PIDDosome [6], and Ripoptosome [7,8]. Interestingly, the c-FLIP isoforms, c-FLIPL, c-FLIPS, and c-FLIPR, regulate apoptosis [by interacting with the death signaling complex downstream of TNF-α receptors, Fas, and TRAIL receptors 1 (DR4) and 2 (DR5), necroptosis, and autophagy]. In this review, I discuss (1) apoptosis signaling pathways and the role of c-FLIP isoforms as critical anti-apoptotic and drug resistance factors, (2) the roles of c-FLIP isoforms in regulating necrosis and autophagy, and (3) the potential for improving the outcome of cancer therapy by targeting c-FLIP isoforms.

Apoptosis Signaling Pathways

Two main signaling pathways, the intrinsic or mitochondrioninitiated pathway and the extrinsic or cell surface death receptors pathway, regulate apoptosis (Figure 1) [1,2,9,10]. In the intrinsic pathway, cytochrome c, apoptosis-inducing factors including Smac/ DIABLO, HtrA2/Omi, and Endonuclease G (endoG) are released from the mitochondrial to the cytosol [11,12]. Upon release, cytochrome c and dATP bind to apoptotic proteinase-activating factor-1 (Apaf-1), and this complex along with adenine nucleotides form the apoptosome and promote procaspase-9 autoactivation [12,13,14]. Apoptosome assembly is a crucially important point in the mitochondrial pathway of apoptosis, consisting of a wheel-like heptamer of seven Apaf-1 molecules and seven cytochrome c molecules that bind and activate the initiator caspase-9, which in turn activates caspases-2, -3, -6, -7, -8, and -10 [13,14]. Apoptosis induced by different death stimuli requires direct activation of Bax and BAK at the mitochondria by a member of the Bcl-2 homology domain-3 (BH3)-only family of proteins including Bid, Bim, or PUMA [15]. The various anti- and pro-apoptotic members of the Bcl-2 family form an interactive network that finally regulates the release of apoptosis triggering factors such as cytochrome c to the cytoplasm [16]. This release of cytochrome c is associated with opening the Permeability Transition Pore (PTP) and a collapse of mitochondrial transmembrane potential (Δψm) due to the intake of Ca2+ following its release into the cytosol from the Endoplasmic Reticulum (ER) [9,17]. In the death receptor-mediated or extrinsic apoptosis pathway (e.g., Fas/Fas ligand interaction, tumor necrosis factor α [(TNF-α)/ TNF receptor 1 (TNFR1), or TRAIL/DR5 interaction and cell death], the initiator caspases-8 and -10 activate the downstream caspases including caspases-3, -6, and -7 [10,18,19]. Active caspases-8 and -10 are known to cleave a pro-apoptotic Bcl-2 family member, Bid, and the truncated Bid induces mitochondrial cytochrome c release [19-23], thereby linking the two pathways. After activation, both caspases-8 and -9 activate caspase-3, which in turn cleaves other caspases and many cellular proteins [24-26]. Scaffidi et al. [27,28] also have identified two different CD95 apoptosis signaling cell types, type I and type II. In type I cells, CD95-mediated apoptosis is initiated by large amounts of active caspase-8 formed at the DISC and subsequent direct cleavage of caspase-3. In contrast, in type II cells, very little DISC formation and small amounts of active caspase-8 sufficient to trigger the mitochondrial apoptosis pathway lead to a significant activation of both caspase-8 and caspase-3. Overexpressed Bcl-2 or BclxL only can block apoptosis in type II cells [28]. These authors [28] have shown that several apoptosisinhibiting or -inducing stimuli only affect apoptosis in type II cells. Interestingly, since c-FLIP acts directly at the DISC, it blocks CD95- mediated apoptosis in both type I and type II cells [28].


Figure 1: Apoptosis signaling pathways and roles of c-FLIP in preventing apoptosis. Interaction of TRAIL with its receptors DR4 and DR5 or binding of Fas ligand to Fas receptor initiates the death receptor (extrinsic) and subsequently mitochondrial apoptosis signaling pathways through FADD-dependent autocatalytic activation of caspases-8 and -10 and Bid cleavage to truncated Bid. c-FLIP isoforms suppress caspase-8 and -10 activation, therefore preventing the downstream apoptosis cascade.

Cellular FLICE-like Inhibitory Protein (c-FLIP)

Viral FLICE-Inhibitory Proteins (v-FLIPs) were first identified by a bioinformatic search for a novel death effector domain (DEDcontaining virus-encoded apoptotic regulatory proteins) by Thome et al. [29]. These authors described six v-FLIPs and showed that cells expressing v-FLIPs were resistance to Fas (CD95/APO-1)- ,TRAILR1-, and TNFR1-Induced Apoptosis [29,30]. v-FLIPs contain two DEDs, bind to the DED of FADD and interfere with the FADD-procaspase 8 interaction, leading to suppressed recruitment of procaspase-8 to the DISC and its activation [29]. Shortly after the characterization of v-FLIPs, the mammalian cellular homologue was identified and termed c-FLIP [31]. c-FLIP is also known as Casper, iFLICE, FLAME-1, CASH, CLARP, MRIT, or usurpin [32]. c-FLIP consists of 13 distinct spliced variants, three of which are expressed as proteins: the 26 kDa short form (c-FLIPS), the 24 kDa form of c-FLIP (c-FLIPR), and the 55 kDa long form (c-FLIPL) [33-37] (Figure 2). The three c-FLIP variants can interact with the adaptor protein FADD. The structures of c-FLIPS and the viral FLIP (v-FLIP) proteins are similar, except that the two DEDs of c-FLIPS are followed by 20 amino acids that appear to be crucial for its ubiquitination and targeting for proteasomal degradation [32,34-36]. c-FLIPR also contains two DEDs but lacks the additional carboxy (C)-terminal amino acids that are present in c-FLIPS. The C-terminus of c-FLIPL is longer than that of c-FLIPS and closely resembles the structure of caspases-8 and -10 [32,34-36], but this region of c-FLIPL does not contain a functional caspase domain. This lack of caspase activity is the result of several amino acid substitutions, particularly the crucial cysteine residue in the catalytic domain which is necessary for the catalytic activity of caspases [32,34]. Additionally, c-FLIPL has a caspase-8 cleavage site at position Asp-376 (LEVD); c-FLIPL cleavage at this site produces the proteolytic fragment variant p43c-FLIP [18,19]. The C-terminal region of c-FLIPS and c-FLIPR play a crucial role in ubiquitination and degradation as well as the anti-apoptotic function of these isoforms [18,19,36]. In humans, a single nucleotide polymorphism in a 3’ splice site of the c-FLIP gene determines whether c-FLIPS or c-FLIPR is made [37]. An intact splice site directs production of c-FLIPS, but the splice-dead variant causes production of c-FLIPR [37].


Figure 2: Structures of c-FLIP variants and cleavage products. c-FLIP isoforms (c-FLIPL, c-FLIPS, and c-FLIPR) contain two death effector domains (DED1 and DED2) at their N termini which are required for DISC recruitment. In addition to two DEDs, c-FLIPL has a significant similarity to caspase-8 and has a large (p20) and a small (p12) caspase-like domain which are catalytically inactive. c-FLIPS and c-FLIPR consist of two DEDs and a small C terminus. c-FLIPL can be cleaved by caspase-8 generating the N-terminal fragment p43-FLIP or p22-FLIP. The phosphorylation (P) sites and ubiquitination (U) sites are indicated [35,37,60]. The p20/p12 regions interact with TRAF2 and RIP1, respectively, and Ku70 binds to DED2 [57].

c-FLIP Function

c-FLIP isoforms are Death Effector Domain (DED)-containing proteins that are recruited to the DISC and regulate activation of caspases-8 and -10 in the death receptor signaling pathways (Figure 1). While the functional roles of c-FLIPL and c-FLIPS in apoptosis are well documented, their differential roles in cancer are not well established. Moreover, the function of c-FLIPR in cancer is poorly understood. Recent results demonstrated that expression of c-FLIPR in hematopoietic cells supports an efficient immune response against bacterial infections [37]. In humans a 3’ splice site of the c-FLIP gene (rs10190751A/G) determines whether either c-FLIPS or c-FLIPR is produced [38].

Regulation of c-FLIP Expression

It is well established that c-FLIP is regulated both at the transcriptional and posttranscriptional levels by various stimuli [34,38]. A diverse group of transcription factors are known to transcriptionally regulate the c-FLIP gene [19,34,36,39-47]. The expression of c-FLIP is regulated at the transcriptional, translational, and post-translational levels [19,34,36]. The transcriptional control of c-FLIP isoforms is quite complex and differentially regulated in various cells in a signalspecific manner. While numerous transcription factors trigger c-FLIP transcription including NF-κB, AP-1 (cFos/c-Jun), P53, FoxO, CREB, NFATc2, EGR1, AR, SP1 [19,34,36,39-43], and p63 (NP63) [40], others induce repression of c-FLIP expression such as c-Fos, c-myc, FoxO3a, IRF5, and SP3 [44-47]. E2F1 transcription factor also downregulates c-FLIPS in lung adenocarcinoma [48]. Moreover, in the presence of androgens prostate apoptosis response factor-4 (Par-4) is recruited to the c-FLIP promoter and enhances c-FLIP expression in prostate cancer cells [41]. Viral proteins are capable of targeting cellular signaling pathways that regulate cellular non-specific immune responses and cell death. In this regard, Halder et al. [49] recently demonstrated that influenza A virus matrix protein 1 (M1) activates RelB (an NF-κB member)-mediated survival genes (c-FLIP, cIAP1, and cIAP2).

Post-Transcriptional Regulation of cFLIP Expression

c-FLIPS can also be upregulated at the translational level and cause TRAIL resistance in glioblastoma multiforme (GBM) cells due to activation of the Akt mammalian target of rapamycin (mTOR)-p70 S6 kinase 1 (S6K1) pathway [50,51]. Conversely, inhibition of mTOR or its target S6K1 suppressed polyribosomal accumulation of c-FLIPS mRNA, c-FLIPS protein expression, and promoted TRAIL resistance in GBM cells. Moreover, it has been shown that Rocaglamide (Roc) sensitizes resistant adult Tcell leukemia/lymphoma (ATL) cells to DR4- and DR5-mediated apoptosis by translational suppression of c-FLIPS through inactivation of the translation initiation factor 4E (eIF4E) [52]. c-FLIP variants are short-lived proteins that are predominately degraded by the ubiquitin-proteasome degradation system. Both c-FLIP isoforms can be degraded by the proteasome. However, c-FLIPS is particularly sensitive to ubiquitination and proteasomal degradation, partly due to two crucial lysine residues in the C-terminal 20 amino acids that are unique to c-FLIPS [53]. c-FLIPL and c-FLIPS levels are also regulated by JNK activation via the E3 ubiquitin ligase Itch [54]. Phosphorylation events also play important roles in regulating c-FLIP protein levels. For instance, protein kinase C phosphorylation at the serine 193 (S193) residue of c-FLIPS inhibits its polyubiquitination, stabilizes c-FLIPS levels, and increases cell survival [55]. S193 phosphorylation is markedly increased by treatment with the PKC activator 12-Otetradecanoylphorbol-13-acetate and decreased by inhibition of PKCα and PKCβ. Phosphorylation of the S193 residue also decreased the ubiquitination of c-FLIPL but did not affect its stability, indicating that S193 phosphorylation has a different function in c-FLIPL than in c-FLIPS. Kerr et al. [56] reported a novel interaction between c-FLIP and the DNA repair protein Ku70 and showed that Ku70 regulates FLIP protein stability by inhibiting its polyubiquitination. Moreover, these authors demonstrated that HDAC6 is a critical regulator of Ku70 acetylation and c-FLIP protein stability [57,58]. Reactive Oxygen Species (ROS) have been implicated in the degradation of c-FLIP protein [38,39]. Recently, Wilkie- Grantham et al. [59] uncovered the mechanism by which ROS posttranscriptionally regulate c-FLIP protein levels in prostate cancer cells. They also identified threonine 166 as a novel phosphorylation site and showed that Thr-166 phosphorylation is required for ROS-induced Lys-167 ubiquitination. These authors identified lysine 167 as a novel ubiquitination amino acid of c-FLIPL which is important for ROSdependent degradation and regulates both the stability of c-FLIP and the sensitivity of cancer cells to TRAIL.

c-FLIP inhibits apoptosis

c-FLIP is involved in TRAIL, Fas, TNF-α, and chemotherapeutic drug resistance in a wide range of human malignancies [19,32,34-36]. Moreover, many studies encompassing diverse types of human cancer cells have revealed that the role of c-FLIP in cancer cells is antiapoptotic. Furthermore, interference with c-FLIP expression sensitizes tumor cells to death ligands and chemotherapy in experimental models [10,25]. In addition to its function as an apoptosis modulator, c-FLIP exerts other cellular functions including increased cell proliferation and tumorigenesis [19,34-36].

The structural differences between human c-FLIP variants indicate distinct regulatory roles for c-FLIPL and c-FLIPS in apoptosis. All three c-FLIP isoforms have two DED domains and can bind to the DISC. c-FLIPS and c-FLIPR block procaspase-8 activation and apoptosis [18,19,60-62]. In a similar way to c-FLIPS, c-FLIPL acts as an antiapoptotic molecule when it is present at high concentrations at the DISC [18,63]. c-FLIPL can also act as a pro-apoptotic molecule under strong death receptor stimulation, or in the presence of high levels of c-FLIPS or c-FLIPR which promotes the activation of procaspase-8 at the DISC [11,18,63]. We have previously demonstrated that c-FLIPL or c-FLIPS prevents caspase-8 and -10 activation [64]. We also have demonstrated that c-FLIPL interacts with DR5, FADD, and caspase-8 forming an Apoptotic Inhibitory Complex (AIC) in MCF-7 breast cancer cells [45]. Moreover, silencing the c-FLIP gene by a specific siRNA leads to death ligand-independent but DR5-, FADD-, and caspase-8- and -9-dependent apoptosis in these cells, and the knockdown of c-FLIP expression inhibits breast cancer cell proliferation and triggers spontaneous apoptosis by activating both the death receptor and mitochondrial pathways [64]. Jin et al. [65] have demonstrated that the peptide corresponding to the DR5 binding domain of c-FLIPL induces apoptosis in cancer cells. It is possible that inhibiting the interaction of DR5 and c-FLIPL by peptides or small molecule inhibitors could provide a mechanism by which tumor-selective apoptosis can be achieved. The dynamic interaction between procaspase-8 and c-FLIP isoforms at the DISC and regulation of apoptosis have been thoroughly reviewed [18,32,36,66].

Upregulation of c-FLIP in Human Cancers

c-FLIP has been found to be overexpressed in several types of malignancies and could be associated with cancer progression due to its ability to inhibit the apoptotic process. Elevated expression levels of c-FLIP have been reported in colorectal cancer [67,68], bladder urothelial cancer [69], cervical cancer [70], Burkitt’s lymphoma [71], non-Hodgkin’s lymphoma [72], Head and Neck Squamous Cell Carcinoma (HNSCC) [73], hepatocellular cancers [74], and high-grade prostatic intraepithelial neoplasia (HGPIN) with maximal c-FLIP expression detected in Castrate-Resistant Prostate Cancer (CRPC) [75]. c-FLIP upregulation is also seen in gastric cancer and plays an important role in lymph node metastasis, which ultimately contributes to tumor progression [76]. c-FLIP variants are also expressed in pancreatic intraepithelial neoplasms as well as pancreatic ductal adenocarcinomas, while c-FLIP was not detected in normal pancreatic ducts [77]. While the epithelium of the normal cervix and low-grade squamous intraepithelial lesions were mainly negative for c-FLIP, highgrade intraepithelial lesions as well as cancer samples showed increased c-FLIP expression [78]. This finding suggests that c-FLIP expression may serve as a potential cervical cancer progression marker. Recent results demonstrated that c-FLIP may play an important role in the potential of osteosarcoma to metastasize to the lung [79]. McLornan et al. [80] have provided evidence that c-FLIP may also serve as a prognostic biomarker in Acute Myeloid Leukaemia (AML). While overexpression of the c-FLIPS variant has been reported in human lung adenocarcinomas with low levels of E2F1, c-FLIPL protein expression was not altered [48]. Moreover, Ueffing et al. [39] demonstrated that an increased lymphoma risk is associated with the rs10190751 A genotype causing c-FLIPR expression.

Roles of c-FLIP in Necroptosis and Autophagy

In addition to its role in apoptosis, c-FLIPL also plays an important role in necroptotic cell death [7,8] and autophagy [81-83]. Moreover, vFLIP also plays a major role in autophagy [81,84-86]. Recent results have demonstrated that necroptosis is a programmed receptor-interacting protein 1/receptor-interacting protein-3 (RIP- 1/RIP-3)-dependent necrotic cell death induced when caspase-8 activation is inhibited [88]. Previous reports have shown that c-FLIPL regulates necroptosis through the formation of the signaling platform Ripoptosome, a RIP1/caspase-8-containing intracellular cell death complex [7,8]. Moreover, the cellular inhibitor of apoptosis proteins (cIAPs) block Ripotosome formation. While c-FLIPL prevents Ripoptosome formation, interestingly, c-FLIPS promotes its assembly (Figure 3). Therefore, c-FLIP isoforms in the Ripoptosome determine whether cell death occurs by RIP3-dependent necroptosis or caspasedependent apoptosis [8].


Figure 3: Activation and signaling by the Ripoptosome and its regulation by c-FLIP isoforms. Cellular stress and IAPs proteasomal degradation after treating cells with IAP antagonists triggers formation of the Ripoptosome, a complex of active RIP1, FADD, caspase-8/10, and c-FLIP isoforms). Its formation is independent of the mitochondrial and death receptor pathways. c-FLIPL inhibits. FLIP isoforms. Its formation is independent of the mitochondrial and death receptor pathways. C-FLIPL inhibits Ripoptosome formation [7, 8], while c-FLIPS promotes Ripoptosome assembly [8]. IAPs inhibit Ripoptosome-mediated apoptosis and necrosis [7,8].

Autophagy is a degradation pathway by which cytoplasmic components including various damaged cytoplasmic organelles and unused long-lived proteins are sequestered in the autophagosomes, which are delivered to the lysosome to form an autolysosome for final degradation (Figure 4). Autophagy as a programmed cell survival mechanism is important in regulating and maintaining several normal human physiological processes [88-90]. Autophagy also is implicated in the pathogenesis of several diseases in human including cancer, neurodegenerative diseases, aging, muscle diseases, infection, and immunological diseases [90-96]. While autophagy can suppress tumor growth, it also enables tumor cells to survive under stress [97]. Suppression of autophagy can also sensitize cancer cells to anticancer therapy [99,100], but under the apoptosis deficiency condition, autophagy can also cause cell death termed “autophagic cell death” [94,95,100].


Figure 4: c-FLIPL mediates regulation of autophagy. Upon cellular stress, autophagosome formation can be induced. c-FLIPL attenuates autophagy by directly acting on the autophagy machinery by inhibiting Atg3 binding to LC3, thereby decreasing LC3 processing.

The autophagy pathway is controlled by complex molecular machinery [101,102]. Beclin-1, its binding partner class III phosphoinositide 3-kinase (PI3K) and other cofactors [103] form the complex termed Vps34 which is required for initiating formation of the autophagosome in autophagy [104,105]. During autophagosome formation, the microtubule-associated protein 1 Light Chain 3 (LC3) ubiquitin-like protein is cleaved by the Atg4 cysteine protease which is then activated by the Atg7 E1-like enzyme and transferred to the Atg3 E2 enzyme. LC3 is in turn conjugated to the lipid phosphatidylethanolamine and embedded into the membranes for autophagic vesicle expansion [105-107]. Moreover, c-FLIP or vFLIP plays a role in autophagy [81,85,87], demonstrating that these proteins suppress autophagy by preventing Atg3 from binding and processing LC3. Therefore, FLIP expression effectively suppresses cell death with autophagy resulting from treatment with rapamycin, an effective anti-cancer drug. Lee et al. [81] also initially identified an autophagy pathway checkpoint by which c-FLIP and vFLIP limit the Atg3-mediated step of LC3 conjugation and regulate autophagosome biosynthesis. Moreover, these authors identified the FLIP-derived short peptides (a DED1 alpha2-helix ten amino acid [alpha2] peptide or a DED2 alpha4-helix twelve amino acid [alpha4] peptide of FLIP) which individually bind to FLIP and Atg3, effectively inhibit Atg3- FLIP interaction without affecting Atg3-LC3 interaction, and induce significant growth inhibition and cell death with autophagy. Similarly, a recent study also provides evidence that anti-FLIP peptides induce autophagy by inactivating the anti-autophagy activity of c-FLIP, and that this is associated with their antiviral effects against enterovirus 71 (EV71) [87]. These peptides may potentially be useful as anticancer therapies.

c-FLIP Activates Cytoprotective and Proliferation Pathways

c-FLIP activates several cytoprotective signaling pathways involved in regulating cell survival, proliferation, and carcinogenesis. Overexpression of c-FLIPL activates NF-κB and ERK signaling by binding to adaptor proteins in each pathway, such as TNFR-associated factors 1 (TRAF1) and 2 (TRAF2), Receptor-Interacting Protein 1 (RIP), and Raf-1 [108-110] (Figure 3). The caspase-8 processed N-terminal fragment of c-FLIPL (p43cFLIP) is more efficient than c-FLIPL at recruiting TRAF2 and RIP1, leading to more robust NF-κB activation [110,111]. In non-apoptotic cells, c-FLIP and the procaspase-8 heterodimer and result in a NH2-terminal fragment of c-FLIP (p20- FLIP) which is the key mediator of NF-κB activation by binding to the IKK complex [112]. c-FLIP may also provide the molecular switch from Fas-triggered apoptosis to Fas-promoting cell proliferation [113]. Recently, Golan-Gerst et al. [114] demonstrated that c-FLIP silencing inhibited Fas-induced proliferation of fibrotic lung myofibroblasts and made them susceptible to Fas-induced apoptosis. Piao et al. [115] recently demonstrated that c-FLIP expression controls the homeostasis of Intestinal Epithelial Cells (IEC) and hepatocytes by preventing cell death induced by TNF-α, FasL, and TRAIL. The mammalian target of rapamycin (mTOR) is known to positively regulate cell proliferation and survival through the formation of complexes with raptor (mTOR complex 1; mTORC1) or rictor (mTOR complex 2; mTORC2). Recent results revealed that mTORC2 stabilizes c-FLIPS, hence this cell proliferation/survival signaling complex regulates death receptormediated apoptosis [116]. Recently, Jing et al. [117] demonstrated that the H204 residue of c-FLIPL binds to calmodulin (CaM) and a point mutation at this amino acid was found to markedly reduce CaM binding, which mediates the anti-apoptotic function of c-FLIPL in cholangiocarcinoma cells. Further characterizing the CaM/c-FLIP interaction may provide a new therapeutic target for developing anticancer therapies [117]. By co-immunoprecipitation experiments, Quintavalle et al. [118] demonstrated that the interaction between Akt and c-FLIPL enhances the anti-apoptotic functions of Akt by modulating Gsk3-β activity. Moreover, these authors have shown that c-FLIPL overexpression interferes with Gsk3-β phosphorylation levels and induces resistance to TRAIL in cancer cells. DNA-PK/Akt pathway is also reported to play a role in expression of c-FLIP [119]. Moreover, siRNA-mediated suppression of DNA-PK or treatment with 4,5-dimethoxy-2-nitrobenzaldehyde (DMNB), an inhibitor of DNA-PK, led to decreased phosphorylation of Akt and Bad (a target molecule of Akt), increased expression of DR4/DR5, and downregulation of c-FLIP [88]. Furthermore, c-FLIPL directly interacts with a JNK activator, MAP kinase kinase 7 (MKK7), in a TNFα- dependent manner and inhibits the interactions of MKK7 with MAP/ ERK kinase kinase 1 (MEKK1), apoptosis signal-regulating kinase 1, (ASK1) and TGF-β-activated kinase 1. This interaction of c-FLIPL with MKK7 might selectively suppress JNK activation [120]. c-FLIP may also regulate several potentially harmful signaling pathways including the production of inflammatory cytokines, tumor cell migration and metastasis, and the activation of transcription factors critical during tumorigenesis [121-123]. c-FLIP overexpression can alter cell cycle progression and enhance cell proliferation and carcinogenesis [117]. Increased expression of c-FLIPL inhibited the ubiquitination and proteasomal degradation of β-catenin, resulting in increased cyclin D1, colony formation, and invasive activity in prostate cancer cells. The c-FLIP/β-catenin/cyclin D1 signals contributing to colony formation and invasion were reversed by selectively silencing c-FLIP expression [93]. Similarly, c-FLIP, in cooperation with FADD, enhances canonical Wnt signaling by inhibiting proteasomal degradation of β-catenin [123]. c-FLIP overexpression is also significantly related to the presence of high-risk human papillomavirus (HR-HPV) infection during the progression of cervical squamous cell cancer, and c-FLIP is an early marker of cervical carcinogenesis [124]. Moreover, HPV16 E2 protein interacts with abrogates the apoptosis inhibitory function of c-FLIP and renders cervical cancer cell lines hypersensitive to Fas/ FasL apoptosis [71].

c-FLIP and Cancer Treatment

The roles of c-FLIP isoforms as proteins that cause resistance to pro-cell death signals, cytokines, and anticancer drugs have been established [33]. Moreover, small interfering RNAs (siRNAs) that specifically silence the expression of c-FLIPL in diverse human cancer cell lines have been shown to enhance TRAIL-induced DISC recruitment and increase the efficacy of chemotherapeutic agents, thereby elevating apoptosis. Furthermore, small molecules causing degradation of c-FLIP as well as decreasing mRNA and protein levels of c-FLIPL and c-FLIPS splice variants have been found, and much effort is focused on developing other c-FLIP-targeted cancer therapies. c-FLIP therapeutic intervention aimed at inhibiting its transcription and posttranscriptional changes is critical for developing anticancer agents [20,34]. Because of significant resemblance to caspase-8 (Figure 2), c-FLIP protein is a very difficult target for drugs that inhibit its function, since small molecules capable of blocking its recruitment to the DISC would also likely inhibit recruitment of caspase-8 to this complex, thereby inhibiting apoptosis. Therefore, to reduce or inhibit c-FLIP expression, small molecules which target c-FLIP without inhibiting caspases-8 and -10 are needed. Diverse classes of agents that decrease c-FLIP expression and sensitize cancer cells to TRAIL or anticancer drugs have been reviewed [19,34,125]. These include some conventional anticancer drugs including cisplatin, doxorubicin, actinomycin D, cycloheximide, camptothecin, 9-NC, and topotecan; histone deacetylase (HDAC) inhibitors; the inhibitors of MEK1/2, PKC and PI3K, and numerous other compounds [19,34,80,125]. These agents affect c-FLIP transcription, trigger c-FLIP degradation through the ubiquitin-proteasome system, or decrease c-FLIP translation. Moreover, DNA damaging agents are promising drugs with regard to downregulating levels of c-FLIP variants [77-126,127]. Downregulating c-FLIP variants by small molecule therapeutics may be a potential strategy for developing agents to treat diseases in which this protein plays a role in preventing apoptosis, necroptosis, and autophagy. However, downregulation of c-FLIP in various cell types has induced significant cell death in healthy cells.


c-FLIP is involved in inhibiting apoptosis, programmed necroptosis (necrosis) and autophagy. c-FLIP variants induce resistance to death receptor ligands and chemotherapeutic agents in various cancer cells. Moreover, c-FLIP upregulation has been correlated with a poor clinical outcome. Therefore, c-FLIP isoforms may serve as targets for counteracting therapy-resistant human malignancies. Hence, c-FLIP may be a clinically relevant biomarker and a molecular target for developing therapeutics for various diseases. Various classes of agents can downregulate c-FLIP expression. To reduce or inhibit c-FLIP expression, small molecules which target c-FLIP without inhibiting caspases-8 and -10 are needed. Compounds that inhibit or downregulate c-FLIP mRNA expression or cause degradation of c-FLIP at the protein level through proteasome degradation will be of particular interest.


I would like to thank Mary D. Kraeszig for her editorial assistance. The work in the author’s laboratory was supported by research grants from the National Cancer Institute (CA 080734, CA 90878, and CA 101743), Department of Defense (DOD) (OC 06095), and the Indiana University Cancer Center Translational Research Acceleration Collaboration (ITRAC) initiative.


  1. Galluzzi L, Kepp O, Trojel-Hansen C, Kroemer G (2012) Mitochondrial control of cellular life, stress, and death. Circ Res 111: 1198-1207.
  2. Andersen JL, Kornbluth S (2013) The tangled circuitry of metabolism and apoptosis. Mol Cell 49: 399-410.
  3. Lavrik I, Golks A, Krammer PH (2005) Death receptor signaling. J Cell Sci 118: 265-267.
  4. Micheau O, Tschopp J (2003) Induction of TNF receptor I-mediated apoptosis via two sequential signaling complexes. Cell 114: 181-190.
  5. Cain K, Bratton SB, Langlais C, Walker G, Brown DG, et al. (2000) Apaf-1 oligomerizes into biologically active approximately 700-kDa and inactive approximately 1.4-MDa apoptosome complexes. J Biol Chem 275: 6067-6070.
  6. Tinel A, Tschopp J (2004) The PIDDosome, a protein complex implicated in activation of caspase-2 in response to genotoxic stress. Science 304: 843-846.
  7. Tenev T, Bianchi K, Darding M, Broemer M, Langlais C, et al. (2011) The Ripoptosome, a signaling platform that assembles in response to genotoxic stress and loss of IAPs. Mol Cell 43: 432-448.
  8. Feoktistova M, Geserick P, Kellert B, Dimitrova DP, Langlais C, et al. (2011) cIAPs block Ripoptosome formation, a RIP1/caspase-8 containing intracellular cell death complex differentially regulated by cFLIP isoforms. Mol Cell 43: 449-463.
  9. Szegezdi E, Macdonald DC, Ní Chonghaile T, Gupta S, Samali A (2009) Bcl-2 family on guard at the ER. Am J Physiol Cell Physiol 296: C941-953.
  10. Yang A, Wilson NS, Ashkenazi A (2010) Proapoptotic DR4 and DR5 signaling in cancer cells: toward clinical translation. Curr Opin Cell Biol 22: 837-844.
  11. Vaux DL (2011) Apoptogenic factors released from mitochondria. Biochim Biophys Acta 1813: 546-550.
  12. Plati J, Bucur O, Khosravi-Far R (2011) Apoptotic cell signaling in cancer progression and therapy. Integr Biol (Camb) 3: 279-296.
  13. Liu X, Kim CN, Yang J, Jemmerson R, Wang X (1996) Induction of apoptotic program in cell-free extracts: requirement for dATP and cytochrome c. Cell 86: 147-157.
  14. Yuan S, Topf M, Reubold TF, Eschenburg S, Akey CW (2013) Changes in Apaf-1 conformation that drive apoptosome assembly. Biochemistry 52: 2319-2327.
  15. Reubold TF, Eschenburg S (2012) A molecular view on signal transduction by the apoptosome. Cell Signal 24: 1420-1425.
  16. Ren D, Tu HC, Kim H, Wang GX, Bean GR, et al. (2010) BID, BIM, and PUMA are essential for activation of the BAX- and BAK-dependent cell death program. Science 330: 1390-1393.
  17. Grimm S (2012) The ER-mitochondria interface: the social network of cell death. Biochim Biophys Acta 1823: 327-334.
  18. Lavrik IN, Krammer PH (2012) Regulation of CD95/Fas signaling at the DISC. Cell Death Differ 19: 36-41.
  19. Safa AR, Day TW, Wu CH (2008) Cellular FLICE-like inhibitory protein (C-FLIP): a novel target for cancer therapy. Curr Cancer Drug Targets 8: 37-46.
  20. Li H, Zhu H, Xu CJ, Yuan J (1998) Cleavage of BID by caspase 8 mediates the mitochondrial damage in the Fas pathway of apoptosis. Cell 94: 491-501.
  21. He B, Lu N, Zhou Z (2009) Cellular and nuclear degradation during apoptosis. Curr Opin Cell Biol 21: 900-912.
  22. Ott M, Norberg E, Zhivotovsky B, Orrenius S (2009) Mitochondrial targeting of tBid/Bax: a role for the TOM complex? Cell Death Differ 16: 1075-1082.
  23. Fischer U, Stroh C, Schulze-Osthoff K (2006) Unique and overlapping substrate specificities of caspase-8 and caspase-10. Oncogene 25: 152-159.
  24. Slee EA, Adrain C, Martin SJ (2001) Executioner caspase-3, -6, and -7 perform distinct, non-redundant roles during the demolition phase of apoptosis. J Biol Chem 276: 7320-7326.
  25. Walsh JG, Cullen SP, Sheridan C, Lüthi AU, Gerner C, et al. (2008) Executioner caspase-3 and caspase-7 are functionally distinct proteases. Proc Natl Acad Sci U S A 105: 12815-12819.
  26. Pop C, Salvesen GS (2009) Human caspases: activation, specificity, and regulation. J Biol Chem 284: 21777-21781.
  27. Scaffidi C, Fulda S, Srinivasan A, Feng L, Friesen C, et al. (1998) EMBO J. 17: 1675-1687.
  28. Scaffidi C, Schmitz I, Zha J, Korsmeyer SJ, Krammer PH, et al. (1999) Differential modulation of apoptosis sensitivity in CD95 type I and type II cells. J Biol Chem 274: 22532-22538.
  29. Thome M, Schneider P, Hofmann K, Fickenscher H, Meinl E, et al. (1997) Viral FLICE-inhibitory proteins (FLIPs) prevent apoptosis induced by death receptors. Nature 386: 517-521.
  30. Bertin J, Armstrong RC, Ottilie S, Martin DA, Wang Y, et al. (1997) Death effector domain-containing herpesvirus and poxvirus proteins inhibit both Fas- and TNFR1-induced apoptosis. Proc Natl Acad Sci U S A 94: 1172-1176.
  31. Irmler M, Thome M, Hahne M, Schneider P, Hofmann K, et al. (1997) Inhibition of death receptor signals by cellular FLIP. Nature 388: 190-195.
  32. Micheau O (2003) Cellular FLICE-inhibitory protein: an attractive therapeutic target? Expert Opin Ther Targets 7: 559-573.
  33. Telieps T, Ewald F, Gereke M, Annemann M, Rauter Y, et al. (2013) Cellular-FLIP, Raji isoform (c-FLIPR ) modulates cell death induction upon T-cell activation and infection. Eur J Immunol .
  34. Safa AR, Pollok KE (2011) Targeting the Anti-Apoptotic Protein c-FLIP for Cancer Therapy. Cancers (Basel) 3: 1639-1671.
  35. Bagnoli M, Canevari S, Mezzanzanica D (2010) Cellular FLICE-inhibitory protein (c-FLIP) signalling: a key regulator of receptor-mediated apoptosis in physiologic context and in cancer. Int J Biochem Cell Biol 42: 210-213.
  36. Oztürk S, Schleich K, Lavrik IN (2012) Cellular FLICE-like inhibitory proteins (c-FLIPs): fine-tuners of life and death decisions. Exp Cell Res 318: 1324-1331.
  37. Ueffing N, Singh KK, Christians A, Thorns C, Feller AC, et al. (2009) A single nucleotide polymorphism determines protein isoform production of the human c-FLIP protein. Blood 114: 572-579.
  38. Fulda S (2013) Targeting c-FLICE-like inhibitory protein (CFLAR) in cancer. Expert Opin Ther Targets 17: 195-201.
  39. Micheau O, Lens S, Gaide O, Alevizopoulos K, Tschopp J (2001) NF-kappaB signals induce the expression of c-FLIP. Mol Cell Biol 21: 5299-5305.
  40. Borrelli S, Candi E, Alotto D, Castagnoli C, Melino G, et al. (2009) p63 regulates the caspase-8-FLIP apoptotic pathway in epidermis. Cell Death Differ 16: 253-263.
  41. Gao S, Wang H, Lee P, Melamed J, Li CX, et al. (2006) Androgen receptor and prostate apoptosis response factor-4 target the c-FLIP gene to determine survival and apoptosis in the prostate gland. J Mol Endocrinol 36: 463-483.
  42. Bartke T, Siegmund D, Peters N, Reichwein M, Henkler F, et al. (2001) p53 upregulates cFLIP, inhibits transcription of NF-kappaB-regulated genes and induces caspase-8-independent cell death in DLD-1 cells. Oncogene 20: 571-580.
  43. Zhang J, Wang Q, Zhu N, Yu M, Shen B, et al. (2008) Cyclic AMP inhibits JNK activation by CREB-mediated induction of c-FLIP(L) and MKP-1, thereby antagonizing UV-induced apoptosis. Cell Death Differ 15: 1654-1662.
  44. Zhang D, Liu J, Wang Y, Chen J, Chen T (2011) shRNA-mediated silencing of Gli2 gene inhibits proliferation and sensitizes human hepatocellular carcinoma cells towards TRAIL-induced apoptosis. J Cell Biochem 112: 3140-3150.
  45. Ricci MS, Jin Z, Dews M, Yu D, Thomas-Tikhonenko A, et al. (2004) Direct repression of FLIP expression by c-myc is a major determinant of TRAIL sensitivity. Mol Cell Biol 24: 8541-8555.
  46. Li W, Zhang X, Olumi AF (2007) MG-132 sensitizes TRAIL-resistant prostate cancer cells by activating c-Fos/c-Jun heterodimers and repressing c-FLIP(L). Cancer Res 67: 2247-2255.
  47. Zhang X, Zhang L, Yang H, Huang X, Otu H, et al. (2007) c-Fos as a proapoptotic agent in TRAIL-induced apoptosis in prostate cancer cells. Cancer Res 67: 9425-9434.
  48. Salon C, Eymin B, Micheau O, Chaperot L, Plumas J, et al. (2006) E2F1 induces apoptosis and sensitizes human lung adenocarcinoma cells to death-receptor-mediated apoptosis through specific downregulation of c-FLIP(short). Cell Death Differ 13: 260-272.
  49. Halder UC, Bhowmick R, Roy Mukherjee T, Nayak MK, Chawla-Sarkar M (2013) Phosphorylation Drives an Apoptotic Protein to Activate Antiapoptotic Genes: PARADIGM OF INFLUENZA A MATRIX 1 PROTEIN FUNCTION. J Biol Chem 288: 14554-14568.
  50. Panner A, Nakamura JL, Parsa AT, Rodriguez-Viciana P, Berger MS, et al. (2006) mTOR-independent translational control of the extrinsic cell death pathway by RalA. Mol Cell Biol 26: 7345-7357.
  51. Panner A, Parsa AT, Pieper RO (2006) Translational regulation of TRAIL sensitivity. Cell Cycle 5: 147-150.
  52. Bleumink M, Köhler R, Giaisi M, Proksch P, Krammer PH, et al. (2011) Rocaglamide breaks TRAIL resistance in HTLV-1-associated adult T-cell leukemia/lymphoma by translational suppression of c-FLIP expression. Cell Death Differ 18: 362-370.
  53. Poukkula M, Kaunisto A, Hietakangas V, Denessiouk K, Katajamäki T, et al. (2005) Rapid turnover of c-FLIPshort is determined by its unique C-terminal tail. J Biol Chem 280: 27345-27355.
  54. Chang L, Kamata H, Solinas G, Luo JL, Maeda S, et al. (2006) The E3 ubiquitin ligase itch couples JNK activation to TNFalpha-induced cell death by inducing c-FLIP(L) turnover. Cell 124: 601-613.
  55. Kaunisto A, Kochin V, Asaoka T, Mikhailov A, Poukkula M, et al. (2009) PKC-mediated phosphorylation regulates c-FLIP ubiquitylation and stability. Cell Death Differ 16: 1215-1226.
  56. Kerr E, Holohan C, McLaughlin KM, Majkut J, Dolan S, et al. (2012) Identification of an acetylation-dependant Ku70/FLIP complex that regulates FLIP expression and HDAC inhibitor-induced apoptosis. Cell Death Differ 19: 1317-1327.
  57. Yu Z, Wang R, Xu L, Xie S, Dong J, et al. (2011) β-Elemene piperazine derivatives induce apoptosis in human leukemia cells through downregulation of c-FLIP and generation of ROS. PLoS One 6: e15843.
  58. Espada L, Meo-Evoli N, Sancho P, Real S, Fabregat I, et al. (2012) ROS production is essential for the apoptotic function of E2F1 in pheochromocytoma and neuroblastoma cell lines. PLoS One 7: e51544.
  59. Wilkie-Grantham RP, Matsuzawa S, Reed JC (2013) Novel Phosphorylation and Ubiquitination Sites Regulate Reactive Oxygen Species-dependent Degradation of Anti-apoptotic c-FLIP Protein. J Biol Chem 288: 12777-12790.
  60. Dohrman A, Kataoka T, Cuenin S, Russell JQ, Tschopp J, et al. (2005) Cellular FLIP (long form) regulates CD8+ T cell activation through caspase-8-dependent NF-kappa B activation. J Immunol 174: 5270-5278.
  61. Kataoka T (2005) The caspase-8 modulator c-FLIP. Crit Rev Immunol 25: 31-58.
  62. Day TW, Huang S, Safa AR (2008) c-FLIP knockdown induces ligand-independent DR5-, FADD-, caspase-8-, and caspase-9-dependent apoptosis in breast cancer cells. Biochem Pharmacol 76: 1694-1704.
  63. Jin TG, Kurakin A, Benhaga N, Abe K, Mohseni M, et al. (2004) Fas-associated protein with death domain (FADD)-independent recruitment of c-FLIPL to death receptor 5. J Biol Chem 279: 55594-55601.
  64. Valmiki MG, Ramos JW (2009) Death effector domain-containing proteins. Cell Mol Life Sci 66: 814-830.
  65. Ryu BK, Lee MG, Chi SG, Kim YW, Park JH (2001) Increased expression of cFLIP(L) in colonic adenocarcinoma. J Pathol 194: 15-19.
  66. Ullenhag GJ, Mukherjee A, Watson NF, Al-Attar AH, Scholefield JH, et al. (2007) Overexpression of FLIPL is an independent marker of poor prognosis in colorectal cancer patients. Clin Cancer Res 13: 5070-5075.
  67. Korkolopoulou P, Goudopoulou A, Voutsinas G, Thomas-Tsagli E, Kapralos P, et al. (2004) c-FLIP expression in bladder urothelial carcinomas: its role in resistance to Fas-mediated apoptosis and clinicopathologic correlations. Urology 63: 1198-1204.
  68. Wang W, Wang S, Song X, Sima N, Xu X, et al. (2007) The relationship between c-FLIP expression and human papillomavirus E2 gene disruption in cervical carcinogenesis. Gynecol Oncol 105: 571-577.
  69. Valnet-Rabier MB, Challier B, Thiebault S, Angonin R, Margueritte G, et al. (2005) c-Flip protein expression in Burkitt's lymphomas is associated with a poor clinical outcome. Br J Haematol 128: 767-773.
  70. Valente G, Manfroi F, Peracchio C, Nicotra G, Castino R, et al. (2006) cFLIP expression correlates with tumour progression and patient outcome in non-Hodgkin lymphomas of low grade of malignancy. Br J Haematol 132: 560-570.
  71. Li X, Pan X, Zhang H, Lei D, Liu D, et al. (2008) Overexpression of cFLIP in head and neck squamous cell carcinoma and its clinicopathologic correlations. J Cancer Res Clin Oncol 134: 609-615.
  72. Du X, Bao G, He X, Zhao H, Yu F, et al. (2009) Expression and biological significance of c-FLIP in human hepatocellular carcinomas. J Exp Clin Cancer Res 28: 24.
  73. McCourt C, Maxwell P, Mazzucchelli R, Montironi R, Scarpelli M, et al. (2012) Elevation of c-FLIP in castrate-resistant prostate cancer antagonizes therapeutic response to androgen receptor-targeted therapy. Clin Cancer Res 18: 3822-3833.
  74. Zhou XD, Yu JP, Liu J, Luo HS, Chen HX, et al. (2004) Overexpression of cellular FLICE-inhibitory protein (FLIP) in gastric adenocarcinoma. Clin Sci (Lond) 106: 397-405.
  75. Haag C, Stadel D, Zhou S, Bachem MG, Möller P, et al. (2011) Identification of c-FLIP(L) and c-FLIP(S) as critical regulators of death receptor-induced apoptosis in pancreatic cancer cells. Gut 60: 225-237.
  76. Ili CG, Brebi P, Tapia O, Sandoval A, Lopez J, et al. (2013) Cellular FLICE-like inhibitory protein long form (c-FLIPL) overexpression is related to cervical cancer progression. Int J Gynecol Pathol 32: 316-322.
  77. Rao-Bindal K, Rao CK, Yu L, Kleinerman ES (2013) Expression of c-FLIP in pulmonary metastases in osteosarcoma patients and human xenografts. Pediatr Blood Cancer 60: 575-579.
  78. McLornan D, Hay J, McLaughlin K, Holohan C, Burnett AK, et al. (2013) Prognostic and therapeutic relevance of c-FLIP in acute myeloid leukaemia. Br J Haematol 160: 188-198.
  79. Lee JS, Li Q, Lee JY, Lee SH, Jeong JH, et al. (2009) FLIP-mediated autophagy regulation in cell death control. Nat Cell Biol 11: 1355-1362.
  80. Giampietri C, Petrungaro S, Padula F, D'Alessio A, Marini ES, et al. (2012) Autophagy modulators sensitize prostate epithelial cancer cell lines to TNF-alpha-dependent apoptosis. Apoptosis 17: 1210-1222.
  81. He MX, He YW (2013) A role for c-FLIP(L) in the regulation of apoptosis, autophagy, and necroptosis in T lymphocytes. Cell Death Differ 20: 188-197.
  82. Liang C (2012) Viral FLIPping autophagy for longevity. Cell Host Microbe 11: 101-103.
  83. Leidal AM, Cyr DP, Hill RJ, Lee PW, McCormick C (2012) Subversion of autophagy by Kaposi's sarcoma-associated herpesvirus impairs oncogene-induced senescence. Cell Host Microbe 11: 167-180.
  84. Won M, Jun EJ, Khim M, Hong SH, Park NH, et al. (2012) Antiviral protection against enterovirus 71 mediated by autophagy induction following FLICE-inhibitory protein inactivation. Virus Res 169: 316-320.
  85. Walsh CM, Edinger AL (2010) The complex interplay between autophagy, apoptosis, and necrotic signals promotes T-cell homeostasis. Immunol Rev 236: 95-109.
  86. Mizushima N, Levine B (2010) Autophagy in mammalian development and differentiation. Nat Cell Biol 12: 823-830.
  87. Kroemer G, Mariño G, Levine B (2010) Autophagy and the integrated stress response. Mol Cell 40: 280-293.
  88. Zhang Q, Kang R, Zeh HJ 3rd, Lotze MT, Tang D (2013) DAMPs and autophagy: cellular adaptation to injury and unscheduled cell death. Autophagy 9: 451-458.
  89. Choi AM, Ryter SW, Levine B (2013) Autophagy in human health and disease. N Engl J Med 368: 651-662.
  90. Shintani T, Klionsky DJ (2004) Autophagy in health and disease: a double-edged sword. Science 306: 990-995.
  91. Mizushima N, Levine B, Cuervo AM, Klionsky DJ (2008) Autophagy fights disease through cellular self-digestion. Nature 451: 1069-1075.
  92. Levine B, Kroemer G (2008) Autophagy in the pathogenesis of disease. Cell 132: 27-42.
  93. Levine B, Mizushima N, Virgin HW (2011) Autophagy in immunity and inflammation. Nature 469: 323-335.
  94. Mizumura K, Cloonan SM, Haspel JA, Choi AM (2012) The emerging importance of autophagy in pulmonary diseases. Chest 142: 1289-1299.
  95. White E, DiPaola RS (2009) The double-edged sword of autophagy modulation in cancer. Clin Cancer Res 15: 5308-5316.
  96. Yang ZJ, Chee CE, Huang S, Sinicrope FA (2011) The role of autophagy in cancer: therapeutic implications. Mol Cancer Ther 10: 1533-1541.
  97. Amaravadi RK, Lippincott-Schwartz J, Yin XM, Weiss WA, Takebe N, et al. (2011) Principles and current strategies for targeting autophagy for cancer treatment. Clin Cancer Res 17: 654-666.
  98. Shimizu S, Kanaseki T, Mizushima N, Mizuta T, Arakawa-Kobayashi S, et al. (2004) Role of Bcl-2 family proteins in a non-apoptotic programmed cell death dependent on autophagy genes. Nat Cell Biol 6: 1221-1228.
  99. He C, Klionsky DJ (2009) Regulation mechanisms and signaling pathways of autophagy. Annu Rev Genet 43: 67-93.
  100. Chen Y, Klionsky DJ (2011) The regulation of autophagy - unanswered questions. J Cell Sci 124: 161-170.
  101. Kang R, Zeh HJ, Lotze MT, Tang D (2011) The Beclin 1 network regulates autophagy and apoptosis. Cell Death Differ 18: 571-580.
  102. Takacs-Vellai K, Vellai T, Puoti A, Passannante M, Wicky C, et al. (2005) Inactivation of the autophagy gene bec-1 triggers apoptotic cell death in C. elegans. Curr Biol 15: 1513-1517.
  103. Funderburk SF, Wang QJ, Yue Z (2010) The Beclin 1-VPS34 complex--at the crossroads of autophagy and beyond. Trends Cell Biol 20: 355-362.
  104. Levine B, Klionsky DJ (2004) Development by self-digestion: molecular mechanisms and biological functions of autophagy. Dev Cell 6: 463-477.
  105. Nakatogawa H, Ichimura Y, Ohsumi Y (2007) Atg8, a ubiquitin-like protein required for autophagosome formation, mediates membrane tethering and hemifusion. Cell 130: 165-178.
  106. Kataoka T, Budd RC, Holler N, Thome M, Martinon F, et al. (2000) The caspase-8 inhibitor FLIP promotes activation of NF-kappaB and Erk signaling pathways. Curr Biol 10: 640-648.
  107. Chaudhary PM, Eby MT, Jasmin A, Kumar A, Liu L, et al. (2000) Activation of the NF-kappaB pathway by caspase 8 and its homologs. Oncogene 19: 4451-4460.
  108. Kataoka T, Tschopp J (2004) N-terminal fragment of c-FLIP(L) processed by caspase 8 specifically interacts with TRAF2 and induces activation of the NF-kappaB signaling pathway. Mol Cell Biol 24: 2627-2636.
  109. Yu JW, Shi Y (2008) FLIP and the death effector domain family. Oncogene 27: 6216-6227.
  110. Golks A, Brenner D, Krammer PH, Lavrik IN (2006) The c-FLIP-NH2 terminus (p22-FLIP) induces NF-kappaB activation. J Exp Med 203: 1295-1305.
  111. Gilot D, Serandour AL, Ilyin GP, Lagadic-Gossmann D, Loyer P, et al. (2005) A role for caspase-8 and c-FLIPL in proliferation and cell-cycle progression of primary hepatocytes. Carcinogenesis 26: 2086-2094.
  112. Golan-Gerstl R, Wallach-Dayan SB, Zisman P, Cardoso WV, Goldstein RH, et al. (2012) Cellular FLICE-like inhibitory protein deviates myofibroblast fas-induced apoptosis toward proliferation during lung fibrosis. Am J Respir Cell Mol Biol 47: 271-279.
  113. Piao X, Komazawa-Sakon S, Nishina T, Koike M, Piao JH, et al. (2012) c-FLIP maintains tissue homeostasis by preventing apoptosis and programmed necrosis. Sci Signal 5: ra93.
  114. Zhao L, Yue P, Khuri FR, Sun SY (2013) mTOR complex 2 is involved in regulation of Cbl-dependent c-FLIP degradation and sensitivity of TRAIL-induced apoptosis. Cancer Res 73: 1946-1957.
  115. Jing G, Yuan K, Liang Q, Sun Y, Mao X, et al. (2012) Reduced CaM/FLIP binding by a single point mutation in c-FLIP(L) modulates Fas-mediated apoptosis and decreases tumorigenesis. Lab Invest 92: 82-90.
  116. Quintavalle C, Incoronato M, Puca L, Acunzo M, Zanca C, et al. (2010) c-FLIPL enhances anti-apoptotic Akt functions by modulation of Gsk3β activity. Cell Death Differ 17: 1908-1916.
  117. Kim MJ, Kim HB, Bae JH, Lee JW, Park SJ, et al. (2009) Sensitization of human K562 leukemic cells to TRAIL-induced apoptosis by inhibiting the DNA-PKcs/Akt-mediated cell survival pathway. Biochem Pharmacol 78: 573-582.
  118. Nakajima A, Komazawa-Sakon S, Takekawa M, Sasazuki T, Yeh WC, et al. (2006) An antiapoptotic protein, c-FLIPL, directly binds to MKK7 and inhibits the JNK pathway. EMBO J 25: 5549-5559.
  119. Leverkus M, Diessenbacher P, Geserick P (2008) FLIP ing the coin? Death receptor-mediated signals during skin tumorigenesis. Exp Dermatol 17: 614-622.
  120. Shen Y, Herde R, Doxey BW, Xu C, Gray PD, et al. (2012) Pharmacologic downregulation of c-FLIP(L) restores juxtacrine death receptor-mediated apoptosis in cancer cells in a peritoneal carcinomatosis model. Int J Cancer 130: 1494-1503.
  121. Naito M, Katayama R, Ishioka T, Suga A, Takubo K, et al. (2004) Cellular FLIP inhibits beta-catenin ubiquitylation and enhances Wnt signaling. Mol Cell Biol 24: 8418-8427.
  122. Wang W, Fang Y, Sima N, Li Y, Li W, et al. (2011) Triggering of death receptor apoptotic signaling by human papillomavirus 16 E2 protein in cervical cancer cell lines is mediated by interaction with c-FLIP. Apoptosis 16: 55-66.
  123. Yang JK (2008) FLIP as an anti-cancer therapeutic target. Yonsei Med J 49: 19-27.
  124. Stagni V, Mingardi M, Santini S, Giaccari D, Barilà D (2010) ATM kinase activity modulates cFLIP protein levels: potential interplay between DNA damage signalling and TRAIL-induced apoptosis. Carcinogenesis 31: 1956-1963.
  125. Ding L, Yuan C, Wei F, Wang G, Zhang J, et al. (2011) Cisplatin restores TRAIL apoptotic pathway in glioblastoma-derived stem cells through up-regulation of DR5 and down-regulation of c-FLIP. Cancer Invest 29: 511-520.
Citation: Safa AR (2013) Roles of c-FLIP in Apoptosis, Necroptosis, and Autophagy. J Carcinogene Mutagene S6:003.

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