Mechanisms Contributing to Tyrosin Kinase Inhibitor Resistance in GISTs: Toward a Personalized Therapy

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal tract. This work considers the pharmacological response in GIST patients treated with imatinib by two different angles: the genetic and somatic point of view. We analyzed polymorphisms influence on treatment outcome, keeping in consideration SNPs in genes involved in drug transport and folate pathway. Naturally, all these intriguing results cannot be considered as the only main mechanism in imatinib response. GIST mainly depends by oncogenic gain of function mutations in tyrosin kinase receptor genes, KIT or PDGFRA, and the mutational status of these two genes or acquisition of secondary mutation is considered the main player in GIST development and progression. To this purpose we analyzed the secondary mutations to better understand how these are involved in imatinib resistance. In our analysis we considered both imatinib and the second line treatment, sunitinib, in a subset of progressive patients. KIT/PDGFRA mutation analysis is an important tool for physicians, as specific mutations may guide therapeutic choices. Currently, the only adaptations in treatment strategy include imatinib starting dose of 800 mg/daily in KIT exon-9-mutated GISTs. In the attempt to individualize treatment, genetic polymorphisms represent a novelty in the definition of biomarkers of imatinib response in addition to the use of tumor genotype. Accumulating data indicate a contributing role of pharmacokinetics in imatinib efficacy, as well as initial response, time to progression and acquired resistance. At the same time it is becoming evident that genetic host factors may contribute to the observed pharmacokinetic inter-patient variability. Genetic polymorphisms in transporters and metabolism may affect the activity or stability of the encoded enzymes. Thus, integrating pharmacogenetic data of imatinib transporters and metabolizing genes, whose interplay has yet to be fully unraveled, has the potential to provide further insight into imatinib response/resistance mechanisms.

IGF system, CD99 and tumor-specific chromosomal translocations: evaluation of their cross-talk and definition of their role in Ewing sarcoma and prostate cancer

Aberrant expression of ETS transcription factors, including FLI1 and ERG, due to chromosomal translocations has been described as a driver event in initiation and progression of different tumors. In this study, the impact of prostate cancer (PCa) fusion gene TMPRSS2-ERG was evaluated on components of the insulin-like growth factor (IGF) system and the CD99 molecule, two well documented targets of EWS-FLI1, the hallmark of Ewing sarcoma (ES). The aim of this study was to identify common or distinctive ETS-related mechanisms which could be exploited at biological and clinical level. The results demonstrate that IGF-1R represents a common target of ETS rearrangements as ERG and FLI1 bind IGF-1R gene promoter and their modulation causes alteration in IGF-1R protein levels. At clinical level, this mechanism provides basis for a more rationale use of anti-IGF-1R inhibitors as PCa cells expressing the fusion gene better respond to anti-IGF-1R agents. EWS-FLI1/IGF-1R axis provides rationale for combination of anti-IGF-1R agents with trabectedin, an alkylator agent causing enhanced EWS-FLI1 occupancy on the IGF-1R promoter. TMPRSS2-ERG also influences prognosis relevance of IGF system as high IGF-1R correlates with a better biochemical progression free survival (BPFS) in PCa patients negative for the fusion gene while marginal or no association was found in the total cases or TMPRSS2-ERG-positive cases, respectively. This study indicates CD99 is differentially regulated between ETS-related tumors as CD99 is not a target of ERG. In PCa, CD99 did not show differential expression between TMPRSS2-ERG-positive and –negative cells. A direct correlation was anyway found between ERG and CD99 proteins both in vitro and in patients putatively suggesting that ERG target genes comprehend regulators of CD99. Despite a little trend suggesting a correlation between CD99 expression and a better BPFS, no clinical relevance for CD99 was found in the field of prognostic biomarkers.

Sviluppo di un tomografo multi-energy per lo studio pre-clinico di nuove metodiche diagnostiche finalizzate al riconoscimento precoce della patologia tumorale

A new multi-energy CT for small animals is being developed at the Physics Department of the University of Bologna, Italy. The system makes use of a set of quasi-monochromatic X-ray beams, with energy tunable in a range from 26 KeV to 72 KeV. These beams are produced by Bragg diffraction on a Highly Oriented Pyrolytic Graphite crystal. With quasi-monochromatic sources it is possible to perform multi-energy investigation in a more effective way, as compared with conventional X-ray tubes. Multi-energy techniques allow extracting physical information from the materials, such as effective atomic number, mass-thickness, density, that can be used to distinguish and quantitatively characterize the irradiated tissues. The aim of the system is the investigation and the development of new pre-clinic methods for the early detection of the tumors in small animals. An innovative technique, the Triple-Energy Radiography with Contrast Medium (TER), has been successfully implemented on our system. TER consist in combining a set of three quasi-monochromatic images of an object, in order to obtain a corresponding set of three single-tissue images, which are the mass-thickness map of three reference materials. TER can be applied to the quantitative mass-thickness-map reconstruction of a contrast medium, because it is able to remove completely the signal due to other tissues (i.e. the structural background noise). The technique is very sensitive to the contrast medium and is insensitive to the superposition of different materials. The method is a good candidate to the early detection of the tumor angiogenesis in mice. In this work we describe the tomographic system, with a particular focus on the quasi-monochromatic source. Moreover the TER method is presented with some preliminary results about small animal imaging.

Doxorubicina coniugata alla albumina umana lattosaminata: azione antineoplastica sui carcinomi epatocellulari indotti nel ratto dalla dietilnitrosammina

The experiments described in the thesis for my PhD were addressed to the study of the anticancer activity of a conjugate of doxorubicin (DOXO) with lactosaminated human albumin (L-HSA) on hepatocellular carcinomas (HCCs) induced in rats by diethylnitrosamine. L-HSA is a neoglycoprotein exposing galactosyl residues. The conjugate was prepared to improve the chemo therapeutic index of DOXO in the treatment of the well differentiated (WD) HCCs whose cells mantain the receptor for galactosyl terminating glycoproteins and consequently can actively internalize L-HSA. In my first experiments I found that L-HSA coupled DOXO produced concentrations of DOXO higher than those raised by an equal dose of free drug, not only in WD HCCs, but also in the poorly differentiated forms (PD) of these tumors which do no express the receptor for galactosyl terminating glycoproteins. Subsequently I provided evidence that penetration of L-HSA-DOXO in PD HCCs was due to a non-specific adsorption mediated by the DOXO residues of the conjugate which interact with the cell surface mainly because at physiological pH they are positively charged and bind to anionic phospholipids of the cell membrane. In subsequent experiments, by ultrasound technique, I studied the action of free and L-HSA coupled DOXO on the growth of rat HCCs. I found that L-HSA coupled DOXO hindered the development of new neoplastic nodules and inhibited the growth of the established tumors. In contrast, the free drug neither inhibited the development of HCCs nor prevented the growth of the established tumors. Moreover, the free drug produced a severe loss of weight of rats, a sign of severe toxicity, which was not caused by the conjugate. In conclusion assuming that the results obtained in rats can be applied to patients, the results of my thesis suggest that the conjugate by increasing the efficacy and tolerability of DOXO could improve the value of this drug in the treatment of human HCCs.

Rag2-/-;gammac-/- immunodeficient mice, a new preclinical model to study antitumor approaches

Animal models have been relevant to study the molecular mechanisms of cancer and to develop new antitumor agents. Anyway, the huge divergence in mouse and human evolution made difficult the translation of the gained achievements in preclinical mouse based studies. The generation of clinically relevant murine models requires their humanization both concerning the creation of transgenic models and the generation of humanized mice in which to engraft a functional human immune system, and reproduce the physiological effects and molecular mechanisms of growth and metastasization of human tumors. In particular, the availability of genotypically stable immunodepressed mice able to accept tumor injection and allow human tumor growth and metastasization would be important to develop anti-tumor and anti-metastatic strategies. Recently, Rag2-/-;gammac-/- mice, double knockout for genes involved in lymphocyte differentiation, had been developed (CIEA, Central Institute for Experimental Animals, Kawasaki, Japan). Studies of human sarcoma metastasization in Rag2-/-; gammac-/- mice (lacking B, T and NK functionality) revealed their high metastatic efficiency and allowed the expression of human metastatic phenotypes not detectable in the conventionally used nude murine model. In vitro analysis to investigate the molecular mechanisms involved in the specific pattern of human sarcomas metastasization revealed the importance of liver-produced growth and motility factors, in particular the insulin-like growth factors (IGFs). The involvement of this growth factor was then demonstrated in vivo through inhibition of IGF signalling pathway. Due to the high growth and metastatic propensity of tumor cells, Rag2-/-;gammac-/- mice were used as model to investigate the metastatic behavior of rhabdomyosarcoma cells engineered to improve the differentiation. It has been recently shown that this immunodeficient model can be reconstituted with a human immune system through the injection of human cord blood progenitor cells. The work illustrated in this thesis revealed that the injection of different human progenitor cells (CD34+ or CD133+) showed peculiar engraftment and differentiation abilities. Experiments of cell vaccination were performed to investigate the functionality of the engrafted human immune system and the induction of specific human immune responses. Results from such experiments will allow to collect informations about human immune responses activated during cell vaccination and to define the best reconstitution and experimental conditions to create a humanized model in which to study, in a preclinical setting, immunological antitumor strategies.

Genetic engineering and preclinical evaluation of oncolytic herpes simplex viruses retargeted to cancer-specific receptors

Oncolytic virotherapy exploits the ability of viruses to infect and kill cells. It is suitable as treatment for tumors that are not accessible by surgery and/or respond poorly to the current therapeutic approach. HSV is a promising oncolytic agent. It has a large genome size able to accommodate large transgenes and some attenuated oncolytic HSVs (oHSV) are already in clinical trials phase I and II. The aim of this thesis was the generation of HSV-1 retargeted to tumor-specific receptors and detargeted from HSV natural receptors, HVEM and Nectin-1. The retargeting was achieved by inserting a specific single chain antibody (scFv) for the tumor receptor selected inside the HSV glycoprotein gD. In this research three tumor receptors were considered: epidermal growth factor receptor 2 (HER2) overexpressed in 25-30% of breast and ovarian cancers and gliomas, prostate specific membrane antigen (PSMA) expressed in prostate carcinomas and in neovascolature of solid tumors; and epidermal growth factor receptor variant III (EGFRvIII). In vivo studies on HER2 retargeted viruses R-LM113 and R-LM249 have demonstrated their high safety profile. For R-LM249 the antitumor efficacy has been highlighted by target-specific inhibition of the growth of human tumors in models of HER2-positive breast and ovarian cancer in nude mice. In a murine model of HER2-positive glioma in nude mice, R-LM113 was able to significantly increase the survival time of treated mice compared to control. Up to now, PSMA and EGFRvIII viruses (R-LM593 and R-LM613) are only characterized in vitro, confirming the specific retargeting to selected targets. This strategy has proved to be generally applicable to a broad spectrum of receptors for which a single chain antibody is available.

Analisi preclinica di nuove strategie terapeutiche basate sull'inibizione di protein-chinasi nell'osteosarcoma.

Scopo: L’obiettivo del presente programma di studio è stato quello di identificare e validare nuovi possibili bersagli terapeutici per l’osteosarcoma (OS) partendo dall’analisi del chinoma umano. Risultati: L’analisi del profilo di espressione genica ottenuta su 21 campioni clinici di OS ad alto grado di malignità ha permesso di selezionare le seguenti chinasi di possibile rilevanza biologica per l’OS: AURK-A, AURK-B, CDK2, PIK3CA, PLK-1. Le chinasi selezionate sono state validate tramite RNA interference. Successivamente è stata valutata l’efficacia dei relativi inibitori specifici: VX-680 e ZM-447439 inibitori delle Aurora-chinasi, Roscovitina di CDK2 e NMS1 di PLK-1, già inclusi in studi clinici. In termini d’inibizione della crescita cellulare le linee sono risultate maggiomente sensibili ai farmaci VX-680 e NMS1. E’ stata osservata una minor sensibilità ai farmaci VX-680, ZM447439 e NMS1 nelle linee doxorubicina(DX)-resistenti (caratterizzate da elevati livelli di espressione di ABCB1), indicando questi farmaci come potenziali substrati di ABCB1. La Roscovitina, nonostante i valori di IC50 elevati, non sembrerebbe substrato di ABCB1. La validazione preclinica di VX-680 e ZM447439 è stata completata. La forte inibizione della crescita è causata da endoreduplicazione per mancata citodieresi con conseguente formazione di una popolazione iperploide e apoptosi. Inoltre, VX-680 inibisce la motilità e la capacità di formare colonie. Esperimenti di associazione farmacologica mostrano che VX-680 interagisce positivamente con tutti i chemioterapici convenzionali impiegati nel trattamento dell’OS. NMS-1 produce interazioni positive con la DX in linee cellulari DX-resistenti, probabilmente grazie all’effetto revertante esercitato su ABCB1. La Roscovitina produce interazioni positive con CDDP e DX nelle varianti resistenti, effetto probbilmente dovuto al ruolo di CDK2 nei meccanismi di riparo del DNA. Conclusioni: L’analisi in vitro dell’attività degli inibitori ha permesso di identificare VX-680 come nuovo farmaco di potenziale interesse clinico, soprattutto in virtù delle sue interazioni sinergiche con i chemioterapici di uso convenzionale nel trattamento dell’osteosarcoma.