REVIEW Open Access
The role and clinical significance of DNA damage
response and repair pathways in primary brain
Wil L Santivasi and Fen Xia*
Primary brain tumors, in particular, glioblastoma multiforme (GBM), continue to have dismal survivability despite
advances in treating other neoplasms. The goal of new anti-glioma therapy development is to increase their
therapeutic ratios by enhancing tumor control and/or decreasing the severity and incidence of side effects. Because
radiotherapy and most chemotherapy agents rely on DNA damage, the cell’s DNA damage repair and response
(DRR) pathways may hold the key to new therapeutic strategies. DNA double-strand breaks (DSBs) generated by
ionizing radiation and chemotherapeutic agents are the most lethal form of damage, and are repaired via either
homologous recombination (HR) or non-homologous end-joining (NHEJ) pathways. Understanding and exploitation
of the differences in the use of these repair pathways between tumor and normal brain cells will allow for an
increase in tumor cell killing and decreased normal tissue damage. A literature review and discussion on new
strategies which can improve the anti-glioma therapeutic ratio by differentially targeting HR and NHEJ function in
tumor and normal neuronal tissues is the focus of this article.
Keywords: Brain tumor, DNA repair, DNA damage, Homologous recombination (HR), Non-homologous end-joining
Primary brain tumors
In 2012, it is predicted that nearly 23,000 new primary
brain tumors will be diagnosed,  of which 70% will be
gliomas . The most common type of glioma is glio-
blastoma multiforme (GBM), which accounts for 54% of
all gliomas (42% of all primary brain tumors). Five-year
survival is a dismal 4.70% for patients with GBM, 
with a median survival time of just over 3 months fol-
lowing resection . Despite a massive research effort,
outcomes remain dismal in malignant brain tumors.
Our limited understanding of the mechanisms which
underlie brain tumorigenesis severely limit preventative
and therapeutic options for patients. The current stand-
ard treatment for GBM involves surgical resection fol-
lowed by adjuvant radiotherapy (RT), with or without
concomitant chemotherapy . Disappointingly, this
regimen only affords GBM patients a median survival
benefit of 14.6 months- a 12 month improvement over
resection alone [4,6]. It is important to note that radio-
and chemotherapies are, at the molecular level, based on
inducing enough DNA damage in the tumor cell to re-
sult in lethality. Unfortunately, these therapies also cause
DNA damage to surrounding neuronal tissue, resulting
in a variety of local and systemic toxicities. With regard
to ionizing radiation (IR) treatments to the brain, side
effects can be severe and include nausea, vomiting, seiz-
ure, and permanent cognitive and focal neurological def-
As such, there is a substantial research effort seeking
to discover new therapeutic regimens that maximize
tumor killing while minimizing these normal tissue toxi-
cities, based on understanding of the differences in the
behaviors and pathways of healthy and neoplastic cells.
Current research and understanding of DNA damage re-
sponse and repair (DRR) in glioma tumorigenesis and
treatment response is the focus of this review.
* Correspondence: firstname.lastname@example.org
Department of Radiation Oncology, The Ohio State University College of
Medicine, 072A Starling Loving Hall, 300 W. 10th Avenue, Columbus, OH
Cell & Bioscience
© 2013 Santivasi and Xia; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Santivasi and Xia Cell & Bioscience 2013, 3:10
DNA double-strand breaks (DSBs)
A critical feature of the eukaryotic cell is its ability to
maintain genome stability across generations, attributed,
in part, to the sophisticated and precisely regulated
DNA lesion-specific repair mechanisms. Deficiencies in
DRR have been widely associated with a number of
astrocytoma subtypes . The pathways by which cells
rectify DSBs are of particular note, as one unrepaired
DSB can trigger apoptosis . Erroneous repair of DSBs
leads to gross genomic rearrangement, which can result
in genomic instability and tumorigenesis. One example
is the KIAA1549-RAF gene fusion generated by misre-
pair of DSBs found in pediatric astrocytomas . As
such, efficient and faithful DSB repair is critical to nor-
mal cell function and the prevention of neoplastic trans-
formation in brain.
It has been well established that, in mammalian cells,
DSBs are repaired through at least two distinct path-
homologous end-joining (NHEJ). Both repair mechan-
isms have implications in tumorigenesis, impact tumor
response to current treatment, as well as potentially
serve as therapeutic targets in brain tumor management.
Homologous recombination (HR)
HR is a critical pathway for accurate repair of DSBs and
maintenance of genomic stability. HR-mediated repair is
characterized by deriving of the correct sequence from a
homologous strand of intact DNA. This modeling
process allows for high-fidelity repair of DSBs- much
more so than repairs via NHEJ . It is the primary
pathway of DSB repair during the S and G2 phases of
the cell cycle, in part due to the availability of sister
chromatids to be used as repair templates .
HR mediated DSB repair follows a general scheme of
nuclease-mediated resection of damaged DNA ends,
polymerization of new DNA, and ligation to restore
strand integrity. Detailed biochemistry of the pathway
has been well described by others . One of the im-
portant and well-studied proteins in the HR pathway is
BRCA1, a tumor suppressor. BRCA1 serves as a “master
controller” of HR, binding and regulating many down-
stream affectors including Mre11-Rad50-NBS1 (MRN)
complex . The MRN complex binds to DNA ends,
and recruits nucleases, including Eme1, to clean up
damaged bases and initiate the HR process [15,16]. The
binding of MRN also activates ATM, which in turn phos-
phorylates and activates BRCA1 function in activating
cell cycle checkpoints. This prevents the cell from enter-
ing mitosis before damage is repaired . BRCA1 also
indirectly interacts with the key HR effector protein
Rad51. Rad51 and its paralogs such as XRCC3 are critical
in homology searching to identify a homologous se-
quence on the sister chromatid [18,19]. When a
homologous sequence is found, there is an exchange of
the damaged strands, such that each strand is now paired
with a homologous template. The damaged strands are
then extended and ligated, restoring the original double-
HR is a critical pathway for DSB repair fidelity. As
such, dysregulation of HR processes resulting from func-
tional deficiency of HR proteins has been associated with
glioma development in many instances . SNPs in the
XRCC3 gene have been correlated with increased risk of
glioma, [22,23] as have SNPs in BRCA1 and EME1
. Identification of these risk SNPs and the mechan-
isms by which they increase glioma risk may provide
novel targets for new therapies in the future.
Therapeutic significance: induced HR deficiency mediates
tumor sensitization to poly (ADP-ribose) polymerase 1
Given the replication demands in proliferating tumor
cells, the HR pathway, which functions during S/G2,
may be a valuable target for new and high-therapeutic
index GBM treatment regimens. DNA single-strand
breaks (SSBs) can lead to DSBs at the replication fork.
Unrepaired DSBs are lethal to proliferating cells. Dys-
function in the repair of both SSBs and DSBs would be
synthetically lethal. The enzyme poly(ADP-ribose) poly-
merase 1 (PARP1) plays a key role in the repair of SSBs,
 while the tumor suppressor BRCA1 is essential for
HR-mediated repair of DSBs [27,28]. PARP1 inhibitors,
including Olaparib, target cancers which are deficient in
the repair of DSBs, exhibit up to 1,000-fold selectivity in
killing BRCA1-mutated (DSB-repair deficient) cells, and
provide an overall survival and progression-free survival
benefit with minimal toxicity in patients with BRCA1-
deficient familial breast cancer [29-33]. Unfortunately,
the majorities of patients who develop sporadic tumors
including malignant gliomas carry wild-type (wt) BRCA1
and are proficient in DSB repair, precluding them from
this potent avenue of therapy . We have previously
shown that transiently exporting wt-BRCA1 protein
from the nucleus (where DSBs are repaired) to the cyto-
sol (where apoptosis is activated) makes cancer cells de-
fective in the repair of DSBs . We propose to
develop an innovative therapeutic strategy that uses this
export of BRCA1 from nucleus to cytoplasm to transi-
ently convert BRCA1-proficient GBM cells into func-
tionally BRCA1-deficient cells and thereby render them
Experiments conducted in our laboratory have demon-
strated proof of this concept in GBM cells. The HR
pathway was inhibited by causing loss of BRCA1 func-
tion in three ways: (1) siRNA-mediated BRCA1 knock-
down, (2) IR-mediated export of BRCA1 to the cytosol,
Santivasi and Xia Cell & Bioscience 2013, 3:10
Page 2 of 6
and (3) erlotinib-induced BRCA1 nuclear depletion.
siRNA-mediated BRCA1 knockdown results in suppres-
sion of HR repair in several cancer and non-cancer cell
model systems. BRCA1 is also a nuclear-cytosolic shut-
tling protein, and its function is regulated by its subcel-
lular location. When in the nucleus, BRCA1 participates
in HR repair of DSBs. When in the cytosol, it enhances
apoptosis. We have recently found that IR induces nu-
clear export of BRCA1 in response to DNA damage via
the CRM1/exportin-dependent pathway. Additionally,
inhibition of EGFR by erlotinib results in DNA damage
and BRCA1 nuclear export . In all three instances,
HR-mediated DSB repair was attenuated, and tumor
cytotoxicity response to the PARP inhibitor ABT-888
was significantly increased versus non-HR-inhibited con-
trols. By inducing tumor-specific HR deficiencies, we be-
lieve that PARP inhibitor therapy will result in more
efficacious, safer treatment of both HR-deficient and
Non-homologous End-joining (NHEJ)
While HR provides some genomic protection, NHEJ is
another major DSB repair pathway in mammalian cells.
In contrast to HR, NHEJ repairs on a wide variety of
DSBs with distinct break structures and sequences 
and functions predominantly during G1 when the HR
repair is not available . However, it demonstrates
decreased fidelity compared to HR, as NHEJ repairs
DSBs using no or little homologous template to
ensure that the repaired strand reflects the original
Similarly to the HR process, NHEJ repair follows a basic
motif of damaged base digestion, re-polymerization/repair,
and ligation. Its details have been well-characterized by
others . Briefly, following identification of the DSB by
the cell, Ku70 and Ku80 bind to the exposed breakpoints
as a heterodimer and serve to recruit other necessary pro-
teins . DNA-dependent protein kinase (DNA-PK) is
recruited to the site and exposes the DNA ends to
recruited nucleases [41,42]. DNA-PK also activates the G1
DNA damage checkpoint and arrests the G1-S transition
. A wide variety of nucleases digest nucleotides from
the DNA on both strands, and strand re-extension is
facilitated by X family DNA polymerases,  although in
a less extensive fashion than occurs in HR . Finally,
the DNA ligase IV complex joins the two repaired DNA
Due to NHEJ’s role as a DNA repair system and
checkpoint activator, it is no surprise that there appears
to be a connection between its malfunction and tumori-
genesis in the brain. SNP variations in several NHEJ
genes, including those that code for the DNA ligase IV
complex,  Ku80 and Ku70,  and DNA-PK’s cata-
lytic subunit  have been correlated with increased risk
of glioma. Furthermore, loss of DNA-PK function has
been demonstrated to increase IR resistance in GBM
Single Strand Break
Single Strand Break
HR DSB Repair
Target HR repair
(BRCA1 nuclear export
using IR, erlotinib)
Figure 1 Targeting HR repair with poly (ADP-ribose) polymerase inhibition results in tumor-specific synthetic lethality. Model depicting
potential targeting of HR repair to increase the therapeutic index of anti-glioma treatment. Sequestration of BRCA1 to the cytoplasm inhibits
repair of DSBs and sensitizes cells to DNA-damaging agents. Following DNA damage, BRCA1 facilitates the repair of DNA in the nucleus. By
targeting BRCA1 subcellular location, tumor cells retain unrepaired damaged DNA and are subsequently sensitized to poly (ADP-ribose)
Santivasi and Xia Cell & Bioscience 2013, 3:10
Page 3 of 6
cells . Despite these implications, it may be possible to
exploit the tumor’s NHEJ deficiency in planning treatment
Therapeutic significance: NHEJ potentiation mediates IR
While proliferating tumor cells can repair DSBs through
both HR during S/G2 and NHEJ during G1, differen-
tiated normal neuronal cells largely rely on NHEJ to sur-
vive from DSBs [37,49]; Thus, exploration of the
difference in regulation of NHEJ activities in GBM ver-
sus normal neurons may provide neuronal protection
from IR-induced cytotoxicity without affording the same
benefit to tumor cells, thereby improving therapeutic
gain. One promising target is glycogen synthase kinase
3β (GSK3β), which regulates glucose metabolism by
phosphorylating glycogen synthase and inhibits glycogen
synthesis. Interestingly, we and others have recently
demonstrated that GSK3β is also involved in suppression
of NHEJ activity . Furthermore, inhibition of GSK3β
either genetically or by its specific inhibitors (lithium or
SB216763) accelerates NHEJ-mediated DSB repair and
protects hippocampal neurons from IR-induced apop-
tosis via restoration of DNA-PK-dependent NHEJ repair
of DNA DSBs,  and attenuates neuro-cognitive tox-
icity in mice. Most importantly, this GSK3β-mediated
radioprotection does not occur in glioma cells examined
in the studies [51-53].
The differential effect on NHEJ and radiation protec-
tion in normal neuron versus tumor cells may be attrib-
uted to following: (1) GSK3β is constitutively expressed
at high level in differentiated cells but not expressed in
proliferating cells,  (2) additional inhibition of GSK3β
activity in proliferating tumor cells. 40% of primary gli-
omas demonstrate loss of phosphatase and tensin homo-
log (PTEN) function . Canonically, PTEN inhibits
the action of AKT, which in turn inhibits GSK3β .
As such, loss of PTEN function and /or increased AKT
activity in tumor cells results in strong suppression
in GSK3β activity. While most gliomas demonstrate
markedly decreased GSK3β function,  lithium or
SB216763 will not be able to generate significant modifica-
tion in GSK3β-NHEJ activity as in normal neuronal cells.
Together, these findings have demonstrated that the differ-
ence in GSK3β-mediated NHEJ regulation between
healthy neural tissue and glioma cells can be exploited to
benefit the patient, and have provided strong preclinical
evidence and rational for clinical implementation of
GSK3β inhibition in combination with standard GBM
treatment (Figure 2).
Current therapies for primary brain gliomas are not ef-
fective in tumor control and often cause severe and dele-
terious neruo-congnitive and systemic toxicities. It is
urgent to develop novel treatment with significantly
improved therapeutic gains. By utilizing the strategies
outlined above, it is possible to exploit differences be-
tween tumors’ and CNS cells’ DRR pathways, specifically
their DSB repair mechanisms. An increased therapeutic
ratio can be accomplished by either tumor-specific
sensitization (BRCA1 nuclear export and HR attenu-
ation) or by neuron-specific radioprotection (GSK3β in-
hibition and NHEJ potentiation). As we proceed toward
Repair Failure Repair
Figure 2 Targeting GSK3β results in neuroprotection from IR-induced neurotoxicity. Model depicting potential targeting of GSK3β-NHEJ
signaling pathway to decrease neurotoxicity and increase the therapeutic index of anti-glioma treatment. Inhibition of GSK3β results in the
upregulation of DNA-PK dependent NHEJ repair in neural but not tumor cells. By targeting GSK3β, neurons, but not GBM cells, gain enhanced
DNA repair functionality, and therefore protected from IR-induced neuronal cell death.
Santivasi and Xia Cell & Bioscience 2013, 3:10
Page 4 of 6
genetics-driven, individualized cancer therapeutics, a
deep understanding of the DRR pathways will become
even more important, as they will likely harbor new
treatment targets and provide new insights into how
tumorigenesis occurs in the brain.
The authors declare that they have no competing interests.
WLS & FX participated in the literature search. WLS drafted the manuscript.
FX edited the manuscript. All authors read and approved the final
Received: 22 August 2012 Accepted: 6 December 2012
Published: 6 February 2013
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