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Programmed cell death is a major component of both cution pathways of cell death may be engaged without
normal development and disease. The roles of cell death either the involvement of caspases or morphological signs
during either embryogenesis or pathogenesis, the signals of apoptosis, and that even the necrotic morphology of
that modulate this event, and the mechanisms of cell cell death may be consistently produced in some cases,
demise are the major subjects that drive research in this including certain plants. Alternative cell death programs
field. Increasing evidence obtained both in vitro and may imply novel therapeutic targets, with important
in vivo supports the hypothesis that a variety of cell death consequences for attempts to treat diseases associated with
programs may be triggered in distinct circumstances. disregulated programmed cell death.
Contrary to the view that caspase-mediated apoptosis
Keywords: programmed cell death; apoptosis; autophagy;
represents the standard programmed cell death, recent
necrosis; neurodegenerative diseases.
studies indicate that an apoptotic morphology can be
produced independent of caspases, that autophagic exe-
Fig. 1. Multiple pathways to apoptosis, both dependent and independent of the activation of caspases. The diagram summarizes the major components
of the pathways reported to underlie cell death in various types of cells and tissues.
FEBS 2004 Alternative pathways of programmed cell death (Eur. J. Biochem. 271) 1641
leads to a reduction in the area of the plasma membrane. ization of actin and degradation of intermediate filaments.
During late stages, both the number and size of vacuoli In contrast, during tamoxifen-induced autophagic cell death
increase, and many of them contain myelin figures or are of MCF-7 cells, intermediate and microfilaments are
filled with lipids, which appear as pale gray inclusions in the redistributed, but largely preserved even beyond the stage
cytoplasm [22]. of nuclear collapse [101]. These data support the concept
The nucleus of a cell undergoing autophagic cell death that autophagic cell death is a separate form of programmed
can become pyknotic and identifiable as such by light cell death that is distinctly different from apoptosis.
microscopy, either in early or in late stages of the In keeping with this interpretation, intensive irradiation
degenerative process. Nevertheless, this nuclear condensa- led to up to 30% cell death in MCF-7 cells without any signs
tion is neither as common nor as remarkable as that of of apoptosis. In this case, cell death was accompanied by the
apoptosis. The late autophagic cell debris is frequently formation of acidic vesicular organelles and lamellar
removed by heterophagy, but this tends to occur in very late structures, which was prevented by 3-methyladenine. How-
stages, and seems to be less conspicuous than the clearance ever, following low-dose irradiation, the presence of acidic
of apoptotic bodies [22]. vesicular organelles correlated with an increased chance of
Autophagic cell death is not an exclusive feature of survival, suggesting that moderate signs of autophagy may
multicellular organisms. In the protozoan pathogen Leish- be associated with a defensive reaction of nonlethally
mania donovani, treatment with antimicrobial peptides damaged cells [102]. The data are consistent with the view
induced cytoplasmic vacuolization and dismantling of the that nonlethal injury can trigger an autophagic defensive
cellular organization without disruption of the plasma reaction, whereas harsh treatment of certain cells can lead to
membrane, with no nuclear fragmentation or DNA cell death largely dependent on autophagy itself.
laddering, and independent of caspase-like activity. Instead, The first step of autophagy is the formation of an
monodansylcadaverine, a biochemical marker of auto- autophagosome, which occurs when a portion of the
phagy, specifically labeled the vacuoles induced by anti- cytoplasm is engulfed by a double membrane vacuole that
microbial peptides [93]. does not contain either acid phosphatases or aryl-sulphatase
Endostatin, an inhibitor of angiogenesis, was shown to activity. The double membrane is derived from ribosome-
induce the formation of autophagic vacuoles in endothelial free areas of rough endoplasmic reticulum [91]. After a
cells. Cell death was not prevented by antioxidants or maturation period that includes the acidification of the
caspase inhibitors, but was reduced by 3-methyladenine, a vacuole, hydrolases are inserted into the autophagosome by
specific inhibitor of autophagy, and serine and cysteine fusion with pre-existing lysosomes or elements deriving
lysosomal protease inhibitors [94]. Neuregulin (NRG; a from the Golgi complex. This process appears to involve
ligand of ErbB), also activates ErbB-2/ErbB-3 heterodimers mannose-6-phosphate receptors located in the autophago-
and induces cell death of prostate cancer LNCaP cells. some membrane, resulting in the formation of a degradative
Neuregulin-induced cell death was not inhibited by broad- vacuole limited by a single membrane named an autolyso-
spectrum caspases inhibitors, but was blocked by 3-methyl- some [103]. Vacuole formation can be regulated by amino
adenine [95]. acids and hormones and by stress [104,105].
Ionizing radiation induced a dose-dependent suppression Similarly to yeast [90], autophagy in mammalian cells is
of cell proliferation and autophagic cell changes in several highly dependent on phosphorylation events. In mammalian
glioblastoma multiform cell lines [96]. Arsenic trioxide, an hepatocytes, the phosphorylation of the ribosomal protein
agent that causes remission in patients with acute promyelo- S6 correlates strongly with inhibition of macroautophagy
cytic leukemia and multiple myeloma without severe side- [106]. The activity of the p70S6-kinase is regulated by the
effects, was shown to inhibit proliferation of glioma cell mTor kinase, and inhibition of S6 phosphorylation caused
lines. The G2/M arrest was accompanied by ultrastructural by inactivation of mTor with rapamycin induces autophagy
features of autophagy, and was inhibited by the autophagy even under nutrient-rich conditions. In yeast, inhibition of
inhibitor bafilomycin A1, whereas general caspase inhibitors the Tor2 kinase results in activation of protein phosphatase
did not block As2O3-induced cell death [97]. In neurobla- 2A and induction of autophagy [107]. Also, in hepatocytes,
stoma cells, dopamine leads to autophagic changes charac- the effect of the phosphatase inhibitor okadaic acid upon
terized by the presence of numerous cytoplasmic vacuoles protein phosphatase 2A inhibits the autophagic process
with inclusions, and accompanied by mitochondrial aggre- [108]. Furthermore, various classes of phosphatidylinositol-
gation, activation of the stress-response kinases SAPK/JNK 3-kinase (PI3K) control the autophagic pathway in distinct
and p38, and increased a-synuclein expression. Both cell ways: class IA PI3K inhibits cytoplasm sequestration and
viability and the increase in a-synuclein expression were degradation, while class III stimulates the sequestration of
prevented by antioxidants, by the specific inhibitors of cytoplasm, implicating the PI3K family as key regulators of
p38 and SAPK/JNK, and by 3-methyladenine [98]. Thus, the autophagic pathway [109].
various agents can lead to autophagic cell death in tumor In a recent study, Inbal and coworkers [110] showed that
cell lines. the expression of death-associated protein kinase (DAPk)
Indeed, Bursch and collaborators [99] had long since and DAPk-related protein kinase (DRP)-1, members of a
shown that the MCF-7 breast carcinoma cell line, which family of Ca2+/calmodulin-regulated Ser/Thr death kinases,
does not express caspase-3 [100], undergoes autophagic cell triggered two major caspase-independent cytoplasmic
death upon treatment with tamoxifen. More recent work events. These were membrane blebbing, a feature common
showed that in apoptotic cell death induced by tyrphostin to various forms of cell death, and extensive autophagy,
A25 in the human colon cancer cell line HT29/HI1, early which is typical of autophagic cell death. Furthermore,
stages of the death process are associated with depolymer- either the expression of the dominant negative mutant of
1642 C. Assunção Guimarães and R. Linden (Eur. J. Biochem. 271) FEBS 2004
DRP-1 or DAPk antisense mRNA reduced autophagy gical features of autophagy in vivo, providing evidence both
induced by antiestrogens, amino acid starvation, or admin- for a direct link between GluRd2-Lc receptor and the
istration of interferon-c. The finding of DRP-1 inside the autophagic pathway in these cells [113], and that beclin-1
autophagic vesicles suggests a direct involvement of this can exert its autophagic functions through interaction with
kinase in the process of autophagy. multiple proteins in the cells [111–113].
Liang and collaborators [111] showed that beclin-1, a Current evidence therefore indicates that that in at least
protein that interacts with bcl-2, promotes autophagy in some instances, autophagy may lead to a caspase-inde-
both an autophagy-defective yeast cell line and in the pendent program of cell demise that fits the concept of
MCF-7 cell line, which normally does not express detectable programmed cell death, subject to complex, multivariate
levels of beclin-1. It was also shown that beclin-1 expression control [Fig. 2]. The next section will examine its relation-
is frequently low in epithelial breast carcinomas, but is ship with apoptosis.
widely expressed in normal tissue. The authors suggested
that beclin-1 may be a mammalian gene for autophagy, and
that it inhibits tumorigenesis through activation of this cell
Apoptosis vs. autophagy
death pathway [111]. Kihara and coworkers [112] suggested Notwithstanding the abundant evidence for a role for both
that beclin-1 is a component of the PI3K complex, which is autophagy and apoptosis in various diseases, their interplay
also required for autophagy, and that beclin-1 and PI3K in those pathologies is not yet fully understood. In
control autophagy as a complex at the Trans Golgi network Parkinson’s disease, the ultrastructural study of neurons
[112]. However, in contrast with the poor autophagic of the substantia nigra of affected patients showed signs of
response of MCF-7 cells to amino acid deprivation [111], autophagy, as well as apoptosis [114]. However, it has been
strong autophagic responses were elicited in this cell line shown that expression of a-synuclein mutants, a condition
both by tamoxifen [101] and by irradiation [102]. Thus, frequently found among certain families with Parkinson’s
either beclin-1 can be replaced by other autophagy-inducing disease, induces autophagic cell death with no caspase
proteins, or alternative pathways of autophagy may operate activation, due to alterations of the ubiquitin-dependent
under various stimuli. protein degradation system [115]. This suggests that there
The death of cerebellar Purkinje cells in lurcher animals is may be no obligatory interdependence between apoptosis
due to a mutation in GluRd2 that results in its constitutive and autophagy in the pathology of this disease.
activation (GluRd2-Lc). Yue and collaborators [113] In Alzheimer’s disease, the endosomal–lysosomal system
showed that GluRd2, nPIST and beclin-1 interact, and that was found to be enlarged and highly activated, showing that
autophagy can be induced by nPIST and beclin-1 synergy endocytosis and/or autophagy are accelerated in the neu-
and by the mutated GluRd2-Lc, but not by the wildtype rons of affected brains, even at early stages. The early
GluRd2. Dying lurcher Purkinje cells displayed morpholo- activation of this system could be related to major
FEBS 2004 Alternative pathways of programmed cell death (Eur. J. Biochem. 271) 1643
etiological factors of the disease, such as defective mem- However, there are clear examples of interdependence
brane proteins, apolipoprotein E function, or altered between apoptosis and autophagy. Following damage to
processing of the amyloid precursor protein [116]. In peripheral nerves in adult rats, oligodendrocytes undergo
Huntington’s disease, it was suggested that the accumula- ultrastructural features of apoptotic cell death, but mem-
tion of a mutant isoform of the protein huntingtin in brane-bound cytoplasmic organelles typical of autophagy
lysosomal compartments can activate cell death by auto- were also noticed in the cytoplasm of these cells [129]. In
phagy [117,118]. Finally, in experimental prion disease, sympathetic neurons from the superior cervical ganglia,
bovine or mice brains inoculated with scrapie-infected brain substantial autophagic activity was activated by pro-apop-
tissue showed signs of autophagy, suggesting that the totic factors, and treatment of these cells with 3-methyl-
accumulation of the protease-resistant prion protein iso- adenine decreased their rate of apoptosis [130]. This was
form can lead to sequestration and autophagy of portions of also observed in serum-deprived PC12 cells, and was
the cytoplasm and eventually to neuron loss [119]. Further- accompanied by changes in the activity of lysosomal
more, giant vacuoli were observed in experimental prion proteases, particularly cathepsins B and D [131].
disease induced in hamsters. The incidence of these vacuoli Alternative pathways of execution of cell death induced
correlates with the inoculation pathway, the intensity of the by blockade of protein synthesis were shown among a
process and the incubation period, and they are most relatively homogenous population of postmitotic undiffer-
numerous following intracerebral inoculation. The emer- entiated cells in the developing retinal tissue. Inhibition of
gence of vacuoli was chronologically related to the appear- protein synthesis induced in the immature retina various
ance of fibrils associated with prion disease, suggesting that post-translational, mitochondria-dependent pathways of
this process may be related to disturbed protein turnover cell death. In one pathway autophagy precedes the sequen-
and processing of the prion protein [120]. Despite the tial activation of caspases-9 and -3, and DNA fragmenta-
evidence for autophagy, there are several reports of tion, while, in parallel, caspase-6-dependent mechanisms led
apoptotic cells detected by in situ nick-end DNA labeling to a TUNEL-negative form of cell death. Evidence was also
in human cases of all Alzheimer’s, Huntington’s and provided for additional cell death mechanisms dependent
Creutzfeldt–Jakob diseases [121–123]. on caspase-9 activity, which may be engaged upon selective
The mode of cell death in neurodegenerative disorders inhibition of execution caspases [132]. These results support
remains a matter of controversy [124], and it is possible that the hypothesis of interdependence of autophagy and
both apoptotic and nonapoptotic cell death coexist in the caspase-dependent cell death pathways.
brains of affected patients. Camougrand and coworkers [133] showed in yeast that
This problem is further complicated by claims that the the expression of Bax induces cell death with characteristics
TdT-mediated biotin-dUDP nick-end labeling (TUNEL) of both apoptosis and autophagy, providing a newly
technique may stain not only apoptotic cells [125,126]. For identified function of Bax in autophagic cell death [133].
example, cell death of keratinocytes induced by 5-fluoruracil Developmental cell death of motoneurons in the hawkmoth
exhibits autophagic ultrastructural features, such as cyto- Manduca sexta depends on caspase activation and the loss
plasm vacuolation and chromatin detachment from the of mitochondrial function, showing an accumulation of
nuclear membrane, alongside apoptotic features such as autophagic bodies and vacuoles. Motoneurons displayed a
TUNEL staining and both a decrease in size and increase normal nuclear ultrastructure, without chromatin conden-
in granularity observed by cytometric analysis [127]. The sation, although they were found to be TUNEL-positive,
authors suggested that in this case the TUNEL-positive cells which is diagnostic of fragmented DNA. These results
were dying by autophagy, and cast doubt on the identifi- indicate that the steroid-induced, caspase-dependent moto-
cation of apototic cell death solely using nick-end labeling neuron cell death exhibits intermingled features of both
techniques, such as in some of the neuropathological autophagy and apoptosis [134]. In the fruitfly Drosophila,
surveys cited above. The data show that the incidence of autophagic cell death depends on steroid-regulated genes
mixed cell death features may be more common among encoding transcription regulators, which appear to activate
various cell types than predicted by previous studies. other genes involved in cell degeneration. The latter include
The same stimulus can sometimes lead to the activation genes that function in apoptosis, such as caspases, showing
of distinct and independent cell signaling pathways. that caspase function is required for autophagic cell death
Tumor necrosis factor-alpha (TNFa)-induced cell death during Drosophila development (for a review of apoptosis
in an acute T-lymphoblastic leukaemic cell line developed and autophagy interplay during Drosophila development
with an apoptotic pattern that was preceded by auto- see [135,136]).
phagy. The compound 3-methyladenine, which inhibits the The autophagy inhibitor 3-methyladenine also increased
formation of autophagosomes, also inhibited the cytolysis the sensitivity of HT-29 colon cancer cells to apoptosis
and DNA fragmentation induced by TNFa. However, induced by sulindac sulfide, an inhibitor of cyclo-oxygenase.
inhibition of the fusion of lysosomes with autophago- Mutants that have a low rate of autophagy were more
somes by asparagine did not block TNFa-induced apop- sensitive to sulindac sulfide-induced apoptosis than parental
tosis, and amino acid and protein deprivation enhanced HT-29 cells, and the rate of cytochrome c release was higher
TNFa-induced autophagy, but not apoptosis. These data in mutant cells than in HT-29 cells, suggesting that
suggest that, at least in this case, early stages of autophagy autophagy could delay apoptosis by sequestering mito-
are required for, but do not necessarily result in, TNF-a chondrial death-promoting factors such as cytochrome c
induced apoptosis [128], and also that a cell can switch [137]. In this context, autophagy may represent an attempt
between apoptosis and autophagy as the dominant form of of the cell to recover from a noxious stimulus, rather than a
cell death. necessary stage of execution of cell death.
1644 C. Assunção Guimarães and R. Linden (Eur. J. Biochem. 271) FEBS 2004
The available data thus indicate that cells may die by a death may share more similarities than originally thought
caspase-independent autophagic process either with or (reviewed in [16,154–156]).
without showing signs of apoptosis. In some cases, cells Necrosis has indeed been found to be a potential
may choose between the autophagic and the apoptotic substitute for apoptosis during development. Develop-
execution pathways. Nevertheless, several experiments show ment-related loss of spinal cord and brainstem neurons
that the limits between apoptosis and autophagy may be was not impaired upon genetic deletion of both caspase-3
tenuous, and suggest either considerable overlap or inter- and caspase-9, although the morphology of the forebrain
dependence of both programs of cell demise. suffered a marked perturbation [157]. Furthermore, the loss
of interdigital cells in the mouse embryo, a prototype of
programmed cell death, still occurs by necrosis either upon
Mitochondria and cell deaths caspase inhibition by drugs, or in mice bearing a mutation in
Mitochondria have a central role both in cellular homeo- the apoptosis protease-activating factor 1 (APAF-1) gene.
stasis and pathological conditions, as not only do they Such necrotic cell death was also observed in normal
serve as the major energy factory of living cells, but they can wild-type mice [158].
also either trigger or amplify the signals that lead to cell Several apoptosis-related molecules have been implicated
death [46,59–62]. Permeabilization of the mitochondrial in necrosis-like forms of cell death. The antiapoptotic
membrane has been associated with cell death by apoptosis proteins Bcl-2 and Bcl-xL as well as caspase inhibitors
[59,138], by mechanisms that are not yet completely delay necrotic cell death induced by cyanide, rotenone or
elucidated (reviewed in [139,140]). Induction of permeability antimycin A [159]. Bcl-2 can also protect neural cells from
transition in the inner mitochondrial membrane may be necrotic cell death induced by the depletion of glutathione
accompanied by release of cytochrome c, Smac/Diablo, [160]. These results indicate that Bcl-2/Bcl-xL and caspases
AIF and endonuclease G, all of which lead to mitochon- modulate not only apoptotic but also some forms of
dria-dependent apoptotic forms of cell death [141–146]. necrotic cell death.
Notwithstanding, the collapse of the mitochondrial trans- In a Jurkat-derived cell line (JB-6) that is deficient in
membrane potential as a consequence of permeability caspase-8, the forced multimerization of Fas-associated
transition is not a universal early feature of apoptosis protein with death domain (FADD) induced caspase-
[147–149]. independent cell death. No DNA fragmentation was
Although mitochondrial involvement in apoptosis is observed and dying cells showed neither condensation nor
broadly documented, permeabilization of mitochondria fragmentation of cells and nuclei, but the cells and nuclei
seems to be an event also shared by autophagy and swelled in a manner similar to that seen in necrosis [161]. In
necrosis. Mitochondria from hepatocytes spontaneously other studies, caspases-3 and -7 were activated in cell death
depolarize after nutrient deprivation before their capture of murine L929 fibrosarcoma cells transfected with human
by an acid lysosomal compartment, suggesting that a Fas receptor, but peptide inhibitors of caspase-1 and -3
permeability transition occurs before the normal autopha- failed to block cell degeneration, and microscopical analysis
gic process [150]. The authors proposed that cells respond showed features of necrosis after a delay of 3 h [162]. These
to mitochondrial permeability transition (MPT) in a results suggest the existence of two distinct pathways of cell
graded manner. When MPT occurs only in a few death triggered by the engagement of Fas receptors, which
mitochondria, autophagy is activated, leading to lysosomal may lead either to classical caspase-dependent apoptosis or
degradation of the affected organelles and cessation of the to necrosis.
signals that stimulate autophagy. When a larger number of Chi and coworkers [163] showed that the expression of
mitochondria are permeabilized apoptosis occurs, probably oncogenically mutated ras gene in human glioma and
due to the higher concentration of molecules such as gastric cancer cell lines causes a necrotic-like cell death
cytochrome c and AIF in the cytoplasm. And finally, when characterized by cytoplasmic vacuoles derived from lyso-
virtually all mitochondria in the cell are affected, MPT somes. Dying cells had relatively well-preserved nuclei that
promotes necrosis, attributed to the uncoupling of oxida- were negative for TUNEL staining. This oncogenic Ras-
tive phosphorylation and accelerated ATP hydrolysis by induced cell death occurred in the absence of caspase
mitochondrial ATPase [151]. This interpretation is consis- activation and was not inhibited by the overexpression of
tent with the hypothesis that autophagy, apoptosis and Bcl-2 [163].
necrosis are part of a continuum of degenerative events These morphological descriptions of cell death recall the
[152,153]. recently suggested concept of necrosis-like programmed cell
death (PCD), where this term was used to Ô… define PCD in
the absence of chromatin condensation, or at best with
Programmed necrosis chromatin clustering to specklesÕ [16]. It seems that the cell
The death and elimination of cells by apoptosis remains death often classified as aborted apoptosis, where PCD
unnoticed by the body’s immune system, while the release of is initiated in the presence of caspase inhibitors, also meets
the intracellular content of necrotic cells into the extracel- this requirement because cells end up dying by alternative
lular space induces an inflammatory response, constituted routes that are independent of caspase activation (reviewed
by the activation of resident phagocytes and attraction of in [164]).
leukocytes into the necrotic area [18]. Until recently, Biochemical mechanisms of the execution of necrosis are
necrosis has often been viewed as an accidental and beginning to be identified in plants. Recessive genetic
uncontrolled cell death process. Nevertheless, there is mutations in the Rn locus in soybean lead to progressive
growing evidence that necrotic and apoptotic forms of cell browning of the root, accompanied by incidence of necrotic
FEBS 2004 Alternative pathways of programmed cell death (Eur. J. Biochem. 271) 1645
as well as apoptotic cell death within the same tissue, but in caspase-mediated apoptosis represents the standard PCD,
distinct cells [165]. The appearance of necrotic cells in the recent studies indicate that an apoptotic morphology can be
root preceded visible browning and lesion formation at the produced without the involvement of caspases, that auto-
macroscopic level, exhibiting a flocculent nucleoplasm, phagic execution pathways of cell death may be engaged
increased vacuolation, condensed cytoplasm and presence without either the involvement of caspases or morphological
of swollen malformed organelles [165]. signs of apoptosis, and that even the necrotic morphology of
Rcr3 is a plant disease-resistance protein that recognizes cell death may be consistently produced in some cases,
pathogens and activates plant defenses. This protein is a including the natural history of at least some plants.
secreted papain-like cysteine endopeptidase and is specific- Particularly in the case of autophagic cell death, but to a
ally required for Cf-2 function, e.g. resistance to pathogens lesser extent also in the case of controlled necrosis,
in tomato, a hypersensitive response that results in cell components have been identified at the molecular level that
death. Genetic analysis showed that Rcr3 is allelic to the Ne justify the assumption of an intracellular program mediating
(Necrosis) gene, which suppresses the Cf-2-dependent auto- either form of cell death under upstream command. Distinct
necrosis induced by plant pathogens [166]. These data may from the idea that a requirement for protein synthesis
represent, at least in plants, the first examples of genes defines genetically programmed cell death, the ÔprogramsÕ
related to the induction of necrotic-like PCD. appear in general to be ready for action. Together with
It is not known whether any of the necrosis-related genes abundant evidence that the apoptosis execution pathways
of plants have homologs in animal cells. However, compo- are essentially independent of protein synthesis, both
nents of a necrotic program are beginning to emerge. autophagy and programmed necrosis have so far been
Integration of the BH3 protein BNIP3 to mitochondria traced to post-translational signal transducers, such as
triggers a necrotic-like form of PCD [167]. The necrotic-like protein kinases and phosphatases. In all of these cases, it
cell death triggered by engagement of the Fas/FADD signal would appear that only the simplest definition of PCD,
transduction system in mammalian cells was reported to much like the original concept of Ôa sequence of events …
depend on the kinase RIP as an effector molecule [168]. that lead to death of the cellÕ [20] would resist close scrutiny.
These data support the hypothesis that, besides uncontrol- There is much to be said in favor of undecorated concepts,
lable necrosis that may occur following either massive which more often than not represent the essential features
mechanical aggression or harsh chemical treatment of upon which myriad variations can be identified, quite
tissues, a program of cell demise with morphological typical of biological systems.
characteristics of necrosis may be found with components Despite the long-standing evidence for alternative cell
largely distinct from either apoptosis or autophagy. death strategies, it is still often assumed that caspase-
mediated apoptosis is either the major, or the most frequent,
form of PCD. Although statistics may eventually prove this
Conclusion and perspectives point, this is by no means warranted. Indeed, the dominance
Increasing evidence obtained in many model systems both of apoptosis among the published examples of PCD may be
in vitro and in vivo supports the hypothesis that a variety of due to the fact that apoptosis is the only form of cell death
cell death programs may be triggered in distinct circum- that has long been categorized not only on the basis of its
stances [Fig. 3]. Contrary to the widely held view that defining ultrastructural changes, but also on the basis of
cytological features recognizable by either conventional 5. Domen, J. (2000) The role of apoptosis in regulating
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Acknowledgements Molecular Basis of Cell Death. New York, Cold Springer. Harbor
Laboratory Press, pp. 47–60.
Research in the authors’ lab was supported by CNPq, FAPERJ,
22. Clarke, P.G.H. (1990) Developmental cell death: morphological
PRONEX-MCT, and a fellowship from the John Simon Guggenheim
diversity and multiple mechanisms. Anat. Embryol. 181, 195–213.
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