Unformatted text preview: 52 SCIENTIFIC A MERIC A N J U LY 2 0 0 6 CREDIT Stem Cells: The Real Culprits in Cancer?
By Michael F. Clarke and Michael W. Becker A dark side of stem cells—their potential to turn malignant—is at the root of a handful of cancers and may be the cause of many more. Eliminating the disease could depend on tracking down and destroying these elusive killer cells ONE AMONG THOUSANDS o f tumor cells may be a cancer stem cell responsible for driving the disease. w w w. s c ia m . c o m fter more than 30 years of declared war on cancer, a few important victories can be claimed, such as 85 percent survival rates for some childhood cancers whose diagnoses once represented a death sentence. In other malignancies, new drugs are able to at least hold the disease at bay, making it a condition with which a patient can live. In 2001, for example, Gleevec was approved for the treatment of chronic myelogenous leukemia (CML). The drug has been a huge clinical success, and many patients are now in remission following treatment with Gleevec. But evidence strongly suggests that these patients are not truly cured, because a reservoir of malignant cells responsible for maintaining the disease has not been eradicated. Conventional wisdom has long held that any tumor cell remaining in the body could potentially reignite the disease. Current treatments therefore focus on killing the greatest number of cancer cells. Successes with this approach are still very much hit-or-miss, however, and for patients with advanced cases of the most common solid tumor malignancies, the prognosis remains poor. Moreover, in CML and a few other cancers it is now clear that only a tiny percentage of tumor cells have the power to produce new cancerous tissue and that targeting these speciﬁc cells for destruction may be a far more effective way to eliminate the disease. Because they are the engines driving the growth of new cancer cells and are very probably the origin of the malignancy itself, these cells
SCIENTIFIC A MERIC A N A KENN BROWN 53 are called cancer stem cells. But they are also quite literally believed to have once been normal stem cells or their immature offspring that have undergone a malignant transformation. This idea— that a small population of malignant stem cells can cause cancer— is far from new. Stem cell research is considered to have begun in earnest with studies during the 1950s and 1960s of solid tumors and blood malignancies. Many basic principles of healthy tissue genesis and development were revealed by these observations of what happens when the normal processes derail. Today the study of stem cells is shedding light on cancer research. Scientists have ﬁlled in considerable detail over the past 50 years about mechanisms regulating the behavior of normal stem cells and the cellular progeny to which they give rise. These fresh insights, in turn, have led to the discovery of similar hierarchies among cancer cells within a tumor, providing strong support for the theory that rogue stemlike cells are at the root of many cancers. Successfully targeting these cancer stem cells for eradication therefore requires a better understanding of how a good stem cell could go bad in the ﬁ rst place. Stem cells’ power to self-renew already exempts them from the rules. Orderly Conduct
t h e h u m a n b ody is a highly compartmentalized system made up of discrete organs and tissues, each performing a function essential to maintaining life. Individual cells that make up these tissues are often short-lived, however. The skin covering your body today is not really the same skin that you had a month ago, because its surface cells have all since sloughed off and been replaced. The lining of the gut turns over every couple of weeks, and the life span of the platelets that help to clot blood is about 10 days. The mechanism that maintains a constant population of working cells in such tissues is consistent throughout the body Overview/Cancer Stem Cells
■ ■ ■ ■ Cancer cells are often perceived as all having the same potential to proliferate and expand the disease, but in many types of cancer only a small subset of tumor cells has that power. T he tumor-generating cells share key traits with stem cells, including an unlimited life span and the ability to generate a diverse range of other cell types, and are therefore considered cancer stem cells. T hese malignant progenitors are believed to spring from regulatory failures in damaged stem cells or their immediate offspring. Cancer treatments must target cancer stem cells to eradicate the disease. and, indeed, is highly conserved among all complex species. It centers on small pools of long-lived stem cells that serve as factories for replenishing supplies of functional cells. This manufacturing process follows tightly regulated and organized steps wherein each generation of a stem cell’s offspring becomes increasingly specialized. This system is perhaps best exempliﬁed by the hematopoietic family of blood and immune cells. All the functional cells found in the blood and lymph arise from a single common parent known as the hematopoietic stem cell (HSC), which resides in bone marrow. The HSC pool represents less than 0.01 percent of bone marrow cells in adults, yet each of these rare cells gives rise to a larger, intermediately differentiated population of progenitor cells. Those in turn divide and differentiate further through several stages into mature cells responsible for speciﬁc tasks, ranging from defending against infection to carrying oxygen to tissues [see box on opposite page]. By the time a cell reaches that ﬁ nal functional stage, it has lost all ability to proliferate or to alter its destiny and is said to be terminally differentiated. The stem cells themselves meanwhile remain undifferentiated, a state they maintain through their unique capacity for self-renewal: to begin producing new tissues, a stem cell divides in two, but only one of the resulting daughter cells might proceed down a path toward increasing speciﬁcity. The other daughter may instead retain the stem cell identity. Numbers in the overall stem cell pool can thus remain constant, whereas the proliferation of intermediate progenitors allows populations of speciﬁc hematopoietic cell types to expand rapidly in response to changing needs. The capacity of stem cells to re-create themselves through self-renewal is their most important deﬁning property. It gives them alone the potential for unlimited life span and future proliferation. In contrast, progenitors have some ability to renew themselves during proliferation, but they are restricted by an internal counting mechanism to a ﬁnite number of cell divisions. With increasing differentiation, the ability of the progenitors’ offspring to multiply declines steadily. The practical signiﬁcance of these distinctions can be observed when hematopoietic stem cells or their descendants are transplanted. After the bone marrow of a mouse is irradiated to destroy the native hematopoietic system, progenitor cells delivered into the marrow environment can proliferate and restore hematopoiesis temporarily, but after four to eight weeks those cells will die out. A single transplanted hematopoietic stem cell, on the other hand, can restore the entire blood system for the lifetime of the animal. The hematopoietic system’s organization has been well understood for more than 30 years, but similar cellular hierarchies have recently been identiﬁed in other human tissues, including brain, breast, prostate, large and small intestines,
J U LY 2 0 0 6 54 SCIENTIFIC A MERIC A N HIERARCHY IN BLOOD-FORMING CELLS
Stem cells in the blood-forming, or hematopoietic, system illustrate principles governing the activity of stem cells in other tissues as well. A small population of hematopoietic stem cells (HSC) in the bone marrow is the source of most of the different blood and immune cell types that circulate in the human body. HSCs reside in an environmental niche, surrounded by stromal cells that provide important regulatory signals to the stem cell. When new blood or immune cells are needed, an HSC divides to produce one daughter cell that remains in the niche and retains the longterm HSC identity and another short-lived daughter termed a multipotent progenitor cell (MPP). The MPP, in turn, divides to produce progenitors committed to generating cells in the myeloid (blood) or lymphoid (immune) lineages. As the descendants of progenitors become increasingly specialized they experience a programmed decline in their ability to proliferate until they stop dividing and are said to be terminally differentiated. Only the stem cell retains unlimited proliferative potential through its ability to renew itself indeﬁnitely by dividing without differentiating. Macrophage Bone marrow Neutrophil Granulocytic/ monocytic precursor Basophil Eosinophil Myeloid progenitor Megakaryocyte Stromal cell Hematopoietic stem cell Multipotent progenitor cell Megakaryocytic/ erythrocytic precursor Erythroblast Platelets Red blood cell Niche B cell precursor Lymphoid progenitor T cell precursor Plasma cell T cell Natural killer cell Pluripotent stem cell Committed progenitors Terminally differentiated cells SELF-RENEWAL PROLIFERATION POTENTIAL DEGREE OF DIFFERENTIATION and skin. Principles of regulated stem cell behavior are also shared across these tissues, including speciﬁc mechanisms for controlling stem cell numbers and for directing decisions about the fates of individual cells. Several genes and the cascades of events triggered by their activity— known as genetic pathways— play key roles in dictating stem cells’ fate and funcw w w. s c ia m . c o m tion, for example. Among these are signaling pathways headed by the Bmi-1, Notch, Sonic hedgehog and Wnt genes. Yet most of these genes were ﬁrst identiﬁed not by scientists studying stem cells but by cancer researchers, because their pathways are also involved in the development of malignancies. Many such similarities between stem cells and cancer cells
SCIENTIFIC A MERIC A N TA MI TOLPA 55 have been noted. The classical deﬁnition of malignancy itself includes cancer cells’ apparent capacity to survive and multiply indeﬁnitely, their ability to invade neighboring tissues and to migrate (metastasize) to distant sites in the body. In effect, the usual constraints that tightly control cellular proliferation and identity seem to have been lifted from cancer cells. Normal stem cells’ power to self-renew already exempts them from the rules limiting life span and proliferation for most cells. Stem cells’ ability to differentiate into a broad range of cell types allows them to form all the different elements of an organ or tissue system. A hallmark of tumors, too, is the heterogeneity of cell types they contain, as though the tumor were a very disorderly version of a whole organ. Hematopoietic stem cells have been shown to migrate to distant parts of the body in response to injury signals, as have cancer cells. In healthy stem cells, strict genetic regulation keeps their potential for unlimited growth and diversification in check. Remove those control mechanisms, and the result would be some thing that sounds very much like malignancy. These commonalities, along with growing experimental evidence, suggest that failures in stem cell regulation are how many cancers get started, how they perpetuate themselves, and possibly how malignancies can spread. Several possible paths to malignancy become apparent. A chilles’ Heel
t h e p r e s e n c e of s t e m c e l l s in certain tissues, especially those with high cell turnover such as the gut and the skin, seems to be an overly complicated and inefﬁcient system for replacing damaged or old cells. Would it not appear to make more sense for an organism if every cell could simply proliferate as needed to supply replacements for its injured neighbors? On the surface, perhaps — but that would make every cell in the body a potential cancer cell. Malignancies are believed to arise when an accumulation of “oncogenic” changes to key genes within a cell leads to the abnormal growth and transformation of that cell. Gene mutations typically happen through a direct insult, such as the cell MICHAEL F. CLARKE and M ICHAEL W. BECKER worked together in Clarke’s laboratory at the University of Michigan at Ann Arbor, where breast tumor stem cells were first isolated in 2003. Clarke is now associate director, as well as professor of cancer biology and of medicine, at the Stanford Institute for Stem Cell Biology and Regenerative Medicine. He continues to work on identifying cancer stem cells and the mechanisms by which they, as well as normal stem cells, regenerate. Becker is assistant professor of medicine in the hematology and oncology division of the University of Rochester Medical Center. Becker’s research focus is characterizing leukemic stem cells, and his clinical work centers on peripheral blood and bone marrow transplantation.
SCIENTIFIC A MERIC A N being exposed to radiation or chemicals, or simply through random error when the gene is improperly copied before cell division. Because the rare stem cells are the only long-lived cells in the organs where most cancers develop, they represent a much smaller potential reservoir for cumulative genetic damage that could eventually lead to cancer. Unfortunately, because stem cells are so long-lived, they also become the most likely repository for such damage. Indeed, stem cells’ longevity would explain why many cancers develop decades after tissues are subjected to radiation— the initial injury may be only the ﬁrst in a series of mutations required to transform a healthy cell into a malignant one. In addition to accumulating and preserving these oncogenic scars, a stem cell’s enormous proliferative capacity makes it an ideal target for malignancy. Because nature so strictly regulates selfrenewal, a cell population already possessing that ability would need fewer additional mutations for malignant transformation than would cells lacking that capacity. With these considerations in mind, several possible paths to malignancy become apparent. In one model, mutations occur in the stem cells themselves, and their resulting loss of control over self-renewal decisions produces a pool of stem cells predisposed to malignancy. Subsequent additional oncogenic events that trigger proliferation of the malignant cells into a tumor might happen in the stem cells or in their descendants, the committed progenitor cell population. A second model holds that oncogenic mutations initially occur in stem cells but that the ﬁnal steps in transformation to cancer happen only in the committed progenitors. This scenario would require the progenitors’ lost self-renewal capacity to be somehow reactivated. Current evidence supports both models in different cancers. And at least one example exists of both processes playing a role in different stages of the same disease. Chronic myelogenous leukemia is a cancer of the white blood cells caused by the inappropriate fusion of two genes. Insertion of the resulting fused gene will transform a normal hematopoietic stem cell into a leukemia stem cell. Untreated, CML invariably progresses to an acute form known as CML blast crisis. Catriona Jamieson and Irving Weissman, both then at the Stanford University School of Medicine, demonstrated that in patients who progressed to CML blast crisis, the speciﬁc additional genetic events responsible for this more virulent version of the disease had conferred the ability to self-renew on certain progenitor cells. THE AUTHORS Steady Pursuit
ov e r t h e pa s t de c a de , evidence that stem cells could become malignant and that only certain cancer cells shared a variety of traits with stem cells strengthened the idea that the driving force underlying tumor growth might be a subpopulaJ U LY 2 0 0 6 56 POSSIBLE PATHS TO CANCER
The existence of cancer stem cells that drive tumor growth has been established in several blood cancers and a handful of solid tumor types, but how these malignant stem cells arise is still uncertain. Like a normal stem cell, a cancer stem cell has the ability to self-renew by dividing without differentiating and can therefore potentially give rise to an unlimited number of the abnormal differentiated cells that make up the bulk of a tumor. Those progeny have a ﬁnite life span and are not themselves tumorigenic — that is, they cannot generate new cancer cells. The behavior of normal stem cells is tightly controlled by their own genetic programming in concert with signals they receive from their environmental niche. Changes in the way cancer stem cells carrying oncogenic gene mutations respond to niche signaling may therefore play an important role in the cells’ ﬁnal transition to malignancy (a, b and c). Alternatively, mutations in the stem cell might be preserved in its immature descendants, the progenitor cells, which subsequently undergo further mutations that reactivate the self-renewal capacity normally possessed only by stem cells (d). Evidence of all these possibilities has been observed in different cancers. Cancer stem cell Abnormal progenitor cell Abnormal differentiated cell Niche cell Alternative niche cell a b Tumor Niche EXPANDED NICHE. Cancer stem cells with oncogenic
mutations are held in check by healthy niche signals until a further alteration in the cancer stem cells or in the niche causes the niche to expand. The larger niche allows the malignant stem cells to increase their own population and consequently the number of abnormal cells they generate. ALTERNATIVE NICHE. Oncogenic mutations in cancer stem cells include changes that enable the cells to adapt to a new niche. The cancer stem cells can expand their own numbers and prolif eration and possibly invade neighboring tissues or metastasize to distant locations in the body. c d
Mutated stem cell Self-renewing malignant progenitor TA MI TOLPA NICHE INDEPENDENCE. Mutation renders stem cells that are already predisposed to malignancy independent of niche signaling, lifting all normal environmental controls on the cancer stem cells’ self-renewal and proliferation. SELF-RENEWAL MUTATION. Progenitor cells predisposed to malignancy by oncogenic mutations inherited from their parent stem cell undergo further mutation that restores the ability to self-renew. These progenitors thereby gain unlimited life span and tumorigenic capacity and become cancer stem cells. w w w. s c ia m . c o m SCIENTIFIC A MERIC A N 57 matically sort different living cell populations based on the unique surface markers they bear. Techniques for sorting live cancer cells and for determining A second crucial event in the evolution of cancer stem cell whether they possess the ability to self-renew have led studies was the advent during the 1990s of conclusive tests for to the positive identiﬁcation of cancer stem cells within self-renewal. Assays to establish self-renewal in human cells larger cancer cell populations. In the cancers listed below, did not exist until Weissman of Stanford and John E. Dick of the malignant stem cells have been demonstrated capable the University of Toronto developed methods that allowed of self-renewal and able to regenerate the entire mixture normal human stem cells to grow in mice. Using ﬂow cytomof cell types found in the original tumor. Those properties etry and this new mouse model, Dick began in 1994 to publish mean that a small number of cancer stem cells could have a series of seminal reports identifying cancer stem cells in leugiven rise to the whole tumor, could continually replenish kemia. In 2003 Richard Jones of Johns Hopkins University its much larger cell population — the majority of which is identiﬁed a cancer stem cell population in multiple myeloma. nontumorigenic— and could reconstitute the original cancer Earlier the same year our own laboratory group at the Unieven if most or all of the tumor were destroyed. Eradicating versity of Michigan at Ann Arbor had published the ﬁrst evithe disease would therefore require treatments to target dence of cancer stem cells in solid tumors. By transplanting the cancer stem cells successfully. sorted populations of cells from human breast tumors into C ANCER TYPE (year cancer stem cells identified) mice, we were able to conﬁrm that not all human breast cancer A cute myeloid leukemia (1994) cells have the same capacity to generate new tumor tissue. Acute lymphoblastic leukemia (1997) Only one subpopulation of the cells was able to re-create the original tumor in the new environment. We then compared Chronic myelogenous leukemia (1999) the phenotype, or physical traits, of those new tumors with Breast (2003) that of the patient samples and found that the proﬁle of the Multiple myeloma (2003) new tumors recapitulated the original. This ﬁnding indicated Brain (2004) that the transplanted tumorigenic cells could both self-renew Prostate (2005) and give rise to all the different cell populations present in the original tumor, including the nontumorigenic cells. Our study attested to the presence of a hierarchy of cells tion of stemlike cancer cells. The theory has a longer history, within a breast cancer similar to those identiﬁed in blood mabut in the past the technology to prove it was lacking. By the 1960s a few scientists were already beginning to lignancies. Since then, the investigation of cancer stem cell note that groups of cells within the same tumor differed in biology has exploded, as labs across the world continue to ﬁnd their ability to produce new tumor tissue. In 1971 C. H. Park similar subpopulations of tumorigenic cells in other forms of and his colleagues at the University of Toronto showed that cancer. In 2004, for example, the laboratory of Peter Dirks of within a culture of cells taken from an original, or “primary,” the University of Toronto identiﬁed cells from primary human myeloma (a cancer affecting plasma cells in bone marrow), the central nervous system tumors with the capacity to regenerate cells displayed signiﬁcant differences in their ability to prolif- the entire tumor in mice. In addition, he found a high number erate. At the time, Park’s group could not interpret this phe- of the purported cancer stem cells present in one of the fastestnomenon decisively, because at least two explanations were growing forms of human brain cancer, medulloblastoma, possible: all the cells might have had the ability to multiply in compared with far fewer tumorigenic cells found in less agculture but by chance only some of them did, or else a hierar- gressive brain tumor types. A related area of recent intensive investigation is also prochy of cells was present in the tumor and cancer stem cells were giving rise to cells that were nontumorigenic, or incapable of viding support for the cancer stem cell model. The signaling environment, or niche, in which tumors reside appears to proliferation. Philip J. Fialkow of the University of Washington had al- strongly inﬂuence the initiation and maintenance of maligready demonstrated in 1967 that the stem cell model was prob- nancy. Studies of normal body cells as well as of stem cells have ably the correct one for leukemia. Using a cell-surface protein already established the essential role of signals emanating marker called G-6-PD, which can identify a cell’s lineage, Fi- from surrounding tissue and the supportive extracellular maalkow showed that in some women with leukemia, both the trix in sustaining a given cell’s identity and in directing its tumorigenic cells as well as their more differentiated nontu- behavior. Normal cells removed from their usual context in the body and placed in a dish have a tendency to lose some of morigenic progeny had all arisen from the same parent cell. These early studies were critical in the development of the their differentiated functional characteristics, for example. stem cell model for cancer, but they were still limited by re- Stem cells, in contrast, must be cultured on a medium that searchers’ inability to isolate and examine different cell popu- provides signals telling them to remain undifferentiated, or lations within a tumor. A key event in stem cell biology, there- they will quickly begin proliferating and differentiating— fore, was the commercial availability, beginning in the 1970s, seemingly as though that is their default programmed behavior, of an instrument called a ﬂow cytometer, which can auto- and only the niche signals hold it in check. C ornering Cancer Stem Cells 58 SCIENTIFIC A MERIC A N J U LY 2 0 0 6 In the body, stem cell niches are literal enclaves surrounded by speciﬁc cell types, such as stromal cells that form connective tissue in the bone marrow. With a few exceptions, stem cells always remain in their niche and are sometimes physically attached to it by adhesion molecules. Progenitor cells, on the other hand, move away from the niche, often under escort by guardian cells, as they become increasingly differentiated. The importance of niche signaling in maintaining stem cells’ undifferentiated state and in keeping them quiescent until they are called on to produce new cells suggests that these local environmental signals could exert similar regulatory control over cancer stem cells. Intriguing experiments have shown, for example, that when transplanted into a new niche, stem cells predisposed to malignancy because of oncogenic mutations will nonetheless fail to produce a tumor. Conversely, normal stem cells transplanted into a tissue environment that has been previously damaged by radiation do give rise to tumors. Many of the same genetic pathways identiﬁed with signaling between stem cells and their niche have been associated with cancer, which also suggests a role for the niche in the ﬁnal transition to malignancy. For example, if malignant stem cells were being held in check by the niche but the niche was somehow altered and expanded, the malignant stem cell pool would have room to grow as well. Another possibility is that certain oncogenic mutations within cancer stem cells could permit them to adapt to a different niche, again letting them increase their numbers and expand their territory. Still a third alternative is that mutations might allow the cancer stem cells to become independent of niche signals altogether, lifting environmental controls on both self-renewal and proliferation. Destroy the engine driving the disease, leaving nontumorigenic cells to die off. Closing In
t h e i m pl ic at ion s of a stem cell model of cancer for the way we understand as well as treat malignancies are clear and dramatic. Current therapies take aim against all tumor cells, but our studies and others have shown that only a minor fraction of cancer cells have the ability to reconstitute and perpetuate the malignancy. If traditional therapies shrink a tumor but miss these cells, the cancer is likely to return. Treatments that speciﬁcally target the cancer stem cells could destroy the engine driving the disease, leaving any remaining nontumorigenic cells to eventually die off on their own. Circumstantial evidence supporting this approach already exists in medical practice. Following chemotherapy for testicular cancer, for example, a patient’s tumor is examined to assess the effects of treatment. If the tumor contains only mature cells, the cancer usually does not recur and no further treatment is necessary. But if a large number of immaturelooking— that is, not fully differentiated— cells are present in
w w w. s c ia m . c o m the tumor sample, the cancer is likely to return, and standard protocol calls for further chemotherapy. Whether those immature cells are recent offspring that indicate the presence of cancer stem cells remains to be proved, but their association with the disease prognosis is compelling. Stem cells cannot be identiﬁed based solely on their appearance, however, so developing a better understanding of the unique properties of cancer stem cells will ﬁ rst require improved techniques for isolating and studying these rare cells. Once we learn their distinguishing characteristics, we can use that information to target cancer stem cells with tailored treatments. If scientists were to discover the mutation or environmental cue responsible for conferring the ability to self-renew on a particular type of cancer stem cell, for instance, that would be an obvious target for disabling those tumorigenic cells. Encouraging examples of this strategy’s promise have been demonstrated by Craig T. Jordan and Monica L. Guzman of the University of Rochester. In 2002 they identiﬁed unique molecular features of malignant stem cells believed to cause acute myeloid leukemia (AML) and showed that the cancer stem cells could be preferentially targeted by speciﬁc drugs. Last year they reported their discovery that a compound derived from the feverfew plant induces AML stem cells to commit suicide while leaving normal stem cells unaffected. Some research groups are hoping to train immune cells to recognize and go after cancer stem cells. Still others are exploring the use of existing drugs to alter niche signaling in the hope of depriving cancer stem cells of the environmental cues that help them thrive. Yet another idea under investigation is that drugs could be developed to force cancer stem cells to differentiate, which should take away their ability to self-renew. Most important is that cancer investigators are now on the suspects’ trail. With a combination of approaches, aimed at both targeting genetic pathways unique to the maintenance of cancer stem cells and disrupting the cross talk between tumor cells and their environment, we hope to be able soon to ﬁ nd and arrest the real culprits in cancer. MORE TO EXPLORE
The Reversal of Tumor Growth. A rmin C. Braun in Scientiﬁc American, Vol. 213, No. 5, pages 75–83; November 1965. The Proteus Effect: Stem Cells and Their Promise for Medicine. A nn B. Parson. Joseph Henry Press, 2004. Context, Tissue Plasticity, and Cancer: Are Tumor Stem Cells Also Regulated by the Microenvironment? Mina J. Bissell and Mark A. LaBarge in Cancer Cell, Vol. 7, pages 17–23; January 2005. Leukaemia Stem Cells and the Evolution of Cancer-Stem-Cell Research. Brian J. P. Huntly and D. Gary Gilliland in Nature Reviews Cancer, Vol. 5, No. 4, pages 311–321; April 2005. Stem Cells and Cancer: Two Faces of Eve. Michael F. Clarke and Margaret Fuller in Cell, Vol. 124, pages 1111–1115; March 24, 2006. SCIENTIFIC A MERIC A N 59 ...
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This note was uploaded on 02/11/2011 for the course LIFE SCIEN LS2 taught by Professor Soliman during the Spring '10 term at UCLA.
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