L'associazione Tipifarnib-Bortezomib nel trattamento delle leucemie acute mieloidi: risultati di uno studio multicentrico di fase I/II e validazione di un profilo genico predittivo di risposta

Background. Outcome of elderly acute myeloid leukemia (AML) patients is dismal. Targeted-therapies might improve current results by overcoming drug-resistance and reducing toxicity. Aim. We conduced a phase II study aiming to assess efficacy and toxicity of Tipifarnib (Zarnestra®) and Bortezomib (Velcade®) association in AML patients >18 years, unfit for conventional therapy, or >60 years, in relapse. Furthermore, we aimed to evaluated the predictive value of the RASGRP1/APTX ratio, which was previously found to be associated to treatment sensitivity in patients receiving Zarnestra alone. Methods. Velcade (1.0 mg/m2) was administered as weekly infusion for 3 weeks (days 1, 8, 15). Zarnestra was administered at dose of 300-600 mg BID for 21 consecutive days. Real-time quantitative-PCR (q-PCR) was used for RASGRP1/APTX quantification. Results. 50 patients were enrolled. Median age was 71 years (56-89). 3 patients achieved complete remission (CR) and 1 partial response (PR). 2 patients obtained an hematological improvement (HI), and 3 died during marrow aplasia. 10 had progressive disease (PD) and the remaining showed stable disease (SD). RASGRP1/APTX was evaluated before treatment initiation on bone marrow (BM) and/or peripheral blood (PB). The median RASGRP/APTX value on BM was higher in responder (R) patients than in non responders (NR) ones, respectively (p=0.006). Interestingly, no marrow responses were recorded in patients with BM RASGRP1/APTX ratio <12, while the response rate was 50% in patients with ratio >12. Toxicity was overall mild, the most common being febrile neutropenia. Conclusion. We conclude that the clinical efficacy of the combination Zarnestra-Velcade was similar to what reported for Zarnestra alone. However we could confirm that the RASGPR1/APTX level is an effective predictor of response. Though higher RASGRP1/APTX is relatively rare (~10% of cases), Zarnestra (±Velcade) may represent an important option in a subset of high risk/frail AML patients.

Die Rolle des anti-apoptotischen Proteins Mcl-1 für die Leber und das hepatozelluläre Karzinom

Myeloid cell leukemia-1 (Mcl-1) ist ein anti-apoptotisches Mitglied der Bcl-2-Proteinfamilie. Als solches ist es in der Lage, die mitochondriale Aktivierung während der Apoptose zu hemmen. Dadurch schützt es Zellen bei zellulärem Stress (wie z.B. Differenzierung, Proliferation oder Virusinfektion) vor Apoptoseinduktion. Aufgrund dieser Eigenschaft ist es unabkömmlich während der Embryogenese und in verschiedenen hämatopoetischen Zellpopulationen. Des Weiteren ist Mcl-1 als Protoonkogen in verschiedenen humanen Tumorentitäten verstärkt exprimiert und kann so zu einer verminderten Apoptosesensitivität von Tumorzellen beitragen. Auch primäre humane Hepatozyten können nach Mcl-1-Induktion durch Wachstumsfaktorbehandlung gegenüber CD95-vermittelter Apoptose geschützt werden. Daher sollte untersucht werden, welche Bedeutung Mcl-1 im hepatozellulären Karzinom (HCC) und in der gesunden Leber einnimmt. Hierzu wurde zunächst humanes HCC-Gewebe hinsichtlich der Expression von Mcl-1 untersucht. Es konnte gezeigt werden, dass Mcl-1 sowohl auf mRNA- als auch auf Protein-Ebene in HCC-Gewebe verstärkt exprimiert ist im Vergleich zu benachbartem Normalgewebe. Auch in verschiedenen HCC-Zelllinien konnte eine starke Mcl-1-Expression nachgewiesen werden. Diese war vor allem über den PI3K/Akt-Signalweg reguliert. Eine Hemmung dieses Signalwegs führte zu einer Reduktion der Mcl-1-Expression und so zu einer Sensitivierung der Zellen gegenüber verschiedenen Chemotherapeutika und zielgerichteten Therapien. Des Weiteren wurde die Mcl-1-Expression spezifisch durch RNA-Interferenz gehemmt. Auch hier konnte gezeigt werden, dass Zellen mit unterdrückter Mcl-1-Expression deutlich sensitiver gegenüber verschiedenen Apoptose-induzierenden Substanzen reagierten. Eine kombinierte Hemmung der Mcl-1-Expression und der PI3-Kinase führte schließlich zu einer nochmals verstärkten Sensitivierung. Im Gegensatz dazu führte eine Überexpression von Mcl-1 zu einer Hemmung der Apoptoseinduktion. Im zweiten Teil der Arbeit wurde eine Mauslinie etabliert, welche spezifisch in Hepatozyten kein Mcl-1 exprimiert, um so die Bedeutung von Mcl-1 für die Leber in vivo zu untersuchen. Es zeigte sich, dass Mcl-1flox/flox-AlbCre-Mäuse bereits im Alter von acht Wochen eine verminderte Lebergröße aufweisen. Dies wurde verursacht durch spontane Apoptoseinduktion in den Mcl-1 negativen Hepatozyten. Hierdurch kam es zu einer Leberschädigung, ersichtlich durch erhöhte Transaminasenwerte, erhöhte Caspase-3-Aktivierung, und Schädigung der Gewebsstruktur. Zudem war als kompensatorischer Effekt die Zellproliferation erhöht, ohne dass sich jedoch das Lebergewicht an das von Kontrolltieren anglich. Interessanterweise kam es in Mcl-1flox/flox-AlbCre-Mäusen als Folge der chronischen Leberschädigung zur Entwicklung einer Leberfibrose, ersichtlich durch eine verstärkte Collageneinlagerung. Weiterhin reagierten Mcl-1flox/flox-AlbCre-Mäuse wesentlich empfindlicher gegenüber Todesrezeptor-vermittelter Apoptose. Diese Daten zeigen zum einen, dass Mcl-1 zur Apoptoseresistenz von HCC-Zellen beitragen kann. Zielgerichtete Therapien, welche die Expression von Mcl-1 hemmen, könnten folglich für die Therapie des HCCs von Interesse sein. Des Weiteren konnte in dieser Arbeit zum ersten Mal gezeigt werden, dass Mcl-1 ein zentraler anti-apoptotischer Faktor für Hepatozyten in vivo ist.

Caratterizzazione biomolecolare delle neoplasie lipomatose

Tra i liposarcomi, il tumore lipomatoso atipico/liposarcoma ben differenziato e il liposarcoma dedifferenziato rappresentano i sottotipi più frequenti. Spesso è difficile distinguere questi tumori da altri con caratteristiche morfologiche simili. Da un punto di vista citogenetico sono caratterizzati dalla presenza di cromosomi soprannumerari giganti e cromosomi ad anello costituiti principalmente da sequenze amplificate della regione 12q13-15. In questa regione mappano numerosi geni tra cui il gene MDM2 (murine double minute-2). La caratterizzazione molecolare di tali sottotipi diventa estremamente importante sia a fini diagnostici sia per un corretto indirizzo terapeutico, soprattutto oggi, dopo l’introduzione nella pratica clinica di terapie biologiche mirate (targeted therapies). Nel presente studio viene analizzato il ruolo dell’analisi FISH per la valutazione dello status di MDM2 nelle neoplasie lipomatose e per stabilire se questo marcatore possa essere utilizzato nella diagnosi differenziale di questi tumori. Sebbene questo studio confermi l’utilità diagnostica dell’amplificazione di MDM2 nella diagnosi del tumore lipomatoso atipico/liposarcoma ben differenziato ed il liposarcoma dedifferenziato, questo marcatore potrebbe avere in futuro anche una più ampia applicazione. Data la recente introduzione degli inibitori selettivi di MDM2 tale ricerca risulta importante non solo a fini diagnostici ma anche per la selezione dei pazienti che potranno in futuro beneficiare del trattamento con tali inibitori. Questo studio è stato effettuato anche per analizzare la rilevanza biologica del percorso che vede coinvolto il gene AKT nel liposarcoma ben differenziato e dedifferenziato e per stabilire se questo percorso possa rappresentare un utile bersaglio terapeutico in questi tumori. I dati ottenuti dimostrano che AKT è espresso ed attivato in tutti i casi di tumore lipomatoso atipico/liposarcoma ben differenziato e liposarcoma dedifferenziato.

Clinical outcome and biological characteristics of Chronic Myeloid Leukemia patients treated with nilotinib front-line

The present work reports the outcome of the GIMEMA CML WP study CML0811, an independent trial investigating nilotinib as front-line treatment in chronic phase chronic myeloid leukemia (CML). Moreover, the results of the proteomic analysis of the CD34+ cells collected at CML diagnosis, compared to the counterpart from healthy donors, are reported. Our study confirmed that nilotinib is highly effective in the prevention of the progression to accelerated/blast phase, a condition that today is still associated with high mortality rates. Despite the relatively short follow-up, cardiovascular issues, particularly atherosclerotic adverse events (AE), have emerged, and the frequency of these AEs may counterbalance the anti-leukemic efficacy. The deep molecular response rates in our study compare favorably to those obtained with imatinib, in historic cohorts, and confirm the findings of the Company-sponsored ENESTnd study. Considering the increasing rates of deep MR over time we observed, a significant proportion of patients will be candidate to treatment discontinuation in the next years, with higher probability of remaining disease-free in the long term. The presence of the additional and complex changes we found at the proteomic level in CML CD34+ cells should be taken into account for the investigation on novel targeted therapies, aimed at the eradication of the disease.

Nuovi protocolli chemioterapici per i sarcomi dei tessuti molli ad alto grado di malignita' negli adulti: Risultati clinici, radiologici e istologici comparando chemioterapia standard e orientata sull'isotopo

I sarcomi dei tessuti molli sono un gruppo eterogeneo di tumori maligni di origine mesenchimale che si sviluppa nel tessuto connettivo. Il controllo locale mediante escissione chirurgica con margini ampi associato alla radioterapia e chemioterapia è il trattamento di scelta. Negli ultimi anni le nuove scoperte in campo biologico e clinico hanno sottolineato che i diversi istotipi posso essere considerati come entità distinte con differente sensibilità alla chemioterapia pertanto questa deve essere somministrata come trattamento specifico basato sull’istologia. Tra Ottobre 2011 e Settembre 2014 sono stati inclusi nel protocollo di studio 49 pazienti con sarcomi dei tessuti molli di età media alla diagnosi 48 anni (range: 20 - 68 anni). I tumori primitivi più frequenti sono: liposarcoma mixoide, sarcoma pleomorfo indifferenziato, sarcoma sinoviale. Le sedi di insorgenza del tumore erano più frequentemente la coscia, il braccio e la gamba. 35 pazienti sono stati arruolati nel Braccio A e trattati con chemioterapia standard con epirubicina+ifosfamide, 14 sono stati arruolati nel Braccio B e trattati con chemioterapia basata sull’istotipo. I dati emersi da questo studio suggeriscono che le recidive locali sembrano essere correlate favorevolmente alla radioterapia ed ai margini chirurgici adeguati mentre la chemioterapia non sembra avere un ruolo sul controllo locale della malattia. Anche se l'uso di terapie mirate, che hanno profili di tossicità più favorevoli e sono quindi meglio tollerate rispetto ai farmaci citotossici è promettente, tali farmaci hanno prodotto finora risultati limitati. Apparentemente l’insieme delle terapie mirate non sembra funzionare meglio delle terapie standard, tuttavia esse devono essere esaminate per singolo istotipo e confrontate con il braccio di controllo. Sono necessari studi randomizzati controllati su ampie casistiche per valutare l’efficacia delle terapie mirate sui differenti istotipi di sarcomi dei tessuti molli. Inoltre, nuovi farmaci, nuove combinazioni e nuovi schemi posologici dovranno essere esaminati per ottimizzare la terapia.

Molecular mechanisms of shikonin and its derivatives in cancer therapy

The identification of molecular processes involved in cancer development and prognosis opened avenues for targeted therapies, which made treatment more tumor-specific and less toxic than conventional therapies. One important example is the epidermal growth factor receptor (EGFR) and EGFR-specific inhibitors (i.e. erlotinib). However, challenges such as drug resistance still remain in targeted therapies. Therefore, novel candidate compounds and new strategies are needed for improvement of therapy efficacy. Shikonin and its derivatives are cytotoxic constituents in traditional Chinese herbal medicine Zicao (Lithospermum erythrorhizin). In this study, we investigated the molecular mechanisms underlying the anti-cancer effects of shikonin and its derivatives in glioblastoma cells and leukemia cells. Most of shikonin derivatives showed strong cytotoxicity towards erlotinib-resistant glioblastoma cells, especially U87MG.ΔEGFR cells which overexpressed a deletion-activated EGFR (ΔEGFR). Moreover, shikonin and some derivatives worked synergistically with erlotinib in killing EGFR-overexpressing cells. Combination treatment with shikonin and erlotinib overcame the drug resistance of these cells to erlotinib. Western blotting analysis revealed that shikonin inhibited ΔEGFR phosphorylation and led to corresponding decreases in phosphorylation of EGFR downstream molecules. By means of Loewe additivity and Bliss independence drug interaction models, we found erlotinb and shikonin or its derivatives corporately suppressed ΔEGFR phosphorylation. We believed this to be a main mechanism responsible for their synergism in U87MG.ΔEGFR cells. In leukemia cells, which did not express EGFR, shikonin and its derivatives exhibited even greater cytotoxicity, suggesting the existence of other mechanisms. Microarray-based gene expression analysis uncovered the transcription factor c-MYC as the commonly deregulated molecule by shikonin and its derivatives. As validated by Western blotting analysis, DNA-binding assays and molecular docking, shikonin and its derivatives bound and inhibited c-MYC. Furthermore, the deregulation of ERK, JNK MAPK and AKT activity was closely associated with the reduction of c-MYC, indicating the involvement of these signaling molecules in shikonin-triggered c-MYC inactivation. In conclusion, the inhibition of EGFR signaling, synergism with erlotinib and targeting of c-MYC illustrate the multi-targeted feature of natural naphthoquinones such as shikonin and derivatives. This may open attractive possibilities for their use in a molecular targeted cancer therapy.

Gonadotropin-releasing hormone type II antagonist induces apoptosis in MCF-7 and triple-negative MDA-MB-231 human breast cancer cells in vitro and in vivo

Triple-negative breast cancer does not express estrogen and progesterone receptors, and no overexpression/amplification of the HER2-neu gene occurs. Therefore, this subtype of breast cancer lacks the benefits of specific therapies that target these receptors. Today chemotherapy is the only systematic therapy for patients with triple-negative breast cancer. About 50% to 64% of human breast cancers express receptors for gonadotropin-releasing hormone (GnRH), which might be used as a target. New targeted therapies are warranted. Recently, we showed that antagonists of gonadotropin-releasing hormone type II (GnRH-II) induce apoptosis in human endometrial and ovarian cancer cells in vitro and in vivo. This was mediated through activation of stress-induced mitogen-activated protein kinases (MAPKs) p38 and c-Jun N-terminal kinase (JNK), followed by activation of proapoptotic protein Bax, loss of mitochondrial membrane potential, and activation of caspase-3. In the present study, we analyzed whether GnRH-II antagonists induce apoptosis in MCF-7 and triple-negative MDA-MB-231 human breast cancer cells that express GnRH receptors. In addition, we ascertained whether knockdown of GnRH-I receptor expression affects GnRH-II antagonist-induced apoptosis and apoptotic signaling.

The Role of PTEN in Tumor Angiogenesis

During the past 20 years, the phosphatase and tensin homolog PTEN has been shown to be involved in major physiological processes, and its mutation or loss is often associated with tumor formation. In addition PTEN regulates angiogenesis not only through its antagonizing effect on the PI3 kinase pathway mainly, but also through some phosphatase-independent functions. In this paper we delineate the role of this powerful tumor suppressor in tumor angiogenesis and dissect the underlying molecular mechanisms. Furthermore, it appears that, in a number of cancers, the PTEN status determines the response to chemotherapy, highlighting the need to monitor PTEN expression and to develop PTEN-targeted therapies.

Functional Imaging of Pheochromocytoma with Ga-DOTATOC and C-HED in a Genetically Defined Rat Model of Multiple Endocrine Neoplasia

Rats affected by the MENX multitumor syndrome develop pheochromocytoma (100%). Pheochromocytomas are uncommon tumors and animal models are scarce, hence the interest in MENX rats to identify and preclinically evaluate novel targeted therapies. A prerequisite for such studies is a sensitive and noninvasive detection of MENXassociated pheochromocytoma. We performed positron emission tomography (PET) to determine whether rat pheochromocytomas are detected by tracers used in clinical practice, such as 68Ga-DOTATOC (somatostatin analogue) or (11)C-Hydroxyephedrine (HED), a norepinephrine analogue. We analyzed four affected and three unaffected rats. The PET scan findings were correlated to histopathology and immunophenotype of the tumors, their proliferative index, and the expression of genes coding for somatostatin receptors or the norepinephrine transporter. We observed that mean 68Ga-DOTATOC standard uptake value (SUV) in adrenals of affected animals was 23.3 ± 3.9, significantly higher than in control rats (15.4 ± 7.9; P = .03). The increase in mean tumor-to-liver ratio of (11)C-HED in the MENX-affected animals (1.6 ± 0.5) compared to controls (0.7 ± 0.1) was even more significant (P = .0016). In a unique animal model, functional imaging depicting two pathways important in pheochromocytoma biology discriminated affected animals from controls, thus providing the basis for future preclinical work with MENX rats.

The phosphoinositide 3-kinase signaling pathway as a therapeutic target in grade IV brain tumors

Brain tumors comprise a wide variety of neoplasia classified according to their cellular origin and their morphological and histological characteristics. The transformed phenotype of brain tumor cells has been extensively studied in the past years, achieving a significant progress in our understanding of the molecular pathways leading to tumorigenesis. It has been reported that the phosphoinositide 3-kinase (PI3K)/AKT signaling pathway is frequently altered in grade IV brain tumors resulting in uncontrolled cell growth, survival, proliferation, angiogenesis, and migration. This aberrant activation can be explained by oncogenic mutations in key components of the pathway or through abnormalities in its regulation. These alterations include overexpression and mutations of receptor tyrosine kinases (RTKs), mutations and deletions of the phosphatase and tensin homologue deleted on chromosome 10 (PTEN) tumor suppressor gene, encoding a lipid kinase that directly antagonized PI3K activity, and alterations in Ras signaling. Due to promising results of preclinical studies investigating the PI3K/AKT pathway in grade IV brain tumors like glioblastoma and medulloblastoma, the components of this pathway have emerged as promising therapeutic targets to treat these malignant brain tumors. Although an arsenal of small molecule inhibitors that target specific components of this signaling pathway is being developed, its successful application in the clinics remains a challenge. In this article we will review the molecular basis of the PI3K/AKT signaling pathway in malignant brain tumors, mainly focusing on glioblastoma and medulloblastoma, and we will further discuss the current status and potential of molecular targeted therapies.

Targeting phosphoinositide 3-kinase signalling in lung cancer

Lung cancer is the leading cause of cancer-related mortality worldwide and more than 1 million people annually die in consequence of lung cancer. Although an improvement in lung cancer treatment could be achieved, especially in the last decade, the development of additional therapeutic strategies is urgently required in order to provide improved survival benefit for patients. Lung cancer formation is caused by genetic modifications commonly caused by tobacco smoking. Numerous studies have demonstrated the role of extracellular growth factors in lung cancer cell proliferation, metastasis, and chemoresistance. Mutations and amplifications in molecules related to receptor tyrosine signalling, such as EGFR, ErbB2, c-Met, c-Kit, VEGFR, PI3K, and PTEN are only some of the alterations known to contribute to the development of lung cancer. The phosphoinositide 3-kinase (PI3K) pathway, fundamental for cell development, growth, and survival, is known to be frequently altered in neoplasia, including carcinomas of the lung. Based on the high frequency of alterations, which include mutations and amplifications, leading to over-activation of certain upstream/downstream mediators, targeting components of the PI3K signalling pathway is considered to be a promising therapeutic approach in cancer treatment. In this article we will summarize the current knowledge about the involvement of PI3K signalling in lung cancer and discuss the development of targeted therapies involving PI3K pathway inhibitors.

Bevacizumab and erlotinib (BE) first-line therapy in advanced non-squamous non-small-cell lung cancer (NSCLC) (stage IIIB/IV) followed by platinum-based chemotherapy (CT) at disease progression: A multicenter phase II trial (SAKK 19/05)

This phase II trial aimed to evaluate feasibility and efficacy of a first-line combination of targeted therapies for advanced non-squamous NSCLC: bevacizumab (B) and erlotinib (E), followed by platinum-based CT at disease progression (PD).

Evidence of prognostic relevant expression profiles of heat-shock proteins and glucose-regulated proteins in oesophageal adenocarcinomas

A high percentage of oesophageal adenocarcinomas show an aggressive clinical behaviour with a significant resistance to chemotherapy. Heat-shock proteins (HSPs) and glucose-regulated proteins (GRPs) are molecular chaperones that play an important role in tumour biology. Recently, novel therapeutic approaches targeting HSP90/GRP94 have been introduced for treating cancer. We performed a comprehensive investigation of HSP and GRP expression including HSP27, phosphorylated (p)-HSP27((Ser15)), p-HSP27((Ser78)), p-HSP27((Ser82)), HSP60, HSP70, HSP90, GRP78 and GRP94 in 92 primary resected oesophageal adenocarcinomas by using reverse phase protein arrays (RPPA), immunohistochemistry (IHC) and real-time quantitative RT-PCR (qPCR). Results were correlated with pathologic features and survival. HSP/GRP protein and mRNA expression was detected in all tumours at various levels. Unsupervised hierarchical clustering showed two distinct groups of tumours with specific protein expression patterns: The hallmark of the first group was a high expression of p-HSP27((Ser15, Ser78, Ser82)) and low expression of GRP78, GRP94 and HSP60. The second group showed the inverse pattern with low p-HSP27 and high GRP78, GRP94 and HSP60 expression. The clinical outcome for patients from the first group was significantly improved compared to patients from the second group, both in univariate analysis (p = 0.015) and multivariate analysis (p = 0.029). Interestingly, these two groups could not be distinguished by immunohistochemistry or qPCR analysis. In summary, two distinct and prognostic relevant HSP/GRP protein expression patterns in adenocarcinomas of the oesophagus were detected by RPPA. Our approach may be helpful for identifying candidates for specific HSP/GRP-targeted therapies.

Therapeutic approaches to patients with hypereosinophilic syndromes

Hypereosinophilic syndromes (HES) are a heterogeneous group of disorders that range from asymptomatic eosinophilia > 1,500/mL to aggressive disease complicated by life-threatening end organ involvement, including endomyocardial fibrosis and thromboembolism. To complicate matters further, similar clinical manifestations can occur in the setting of marked eosinophilia due to helminth infection, drug hypersensitivity, and other causes. In the past, therapy was guided only by the exclusion of these secondary causes of eosinophilia and the severity of the clinical manifestations. More recently, the availability of novel targeted therapies and a better understanding of the etiologies of some subtypes of HES have necessitated a more structured approach.

Therapy response with diffusion MRI: an update

The efficiency of an oncological treatment regimen is often assessed by morphological criteria such as tumour size evaluated by cross-sectional imaging, or by laboratory measurements of plasma biomarkers. Because these types of measures typically allow for assessment of treatment response several weeks or even months after the start of therapy, earlier response assessment that provides insight into tumour function is needed. This is particularly urgent for the evaluation of newer targeted therapies and for fractionated therapies that are delivered over a period of weeks to allow for a change of treatment in non-responding patients. Diffusion-weighted MRI (DW-MRI) is a non-invasive imaging tool that does not involve radiation or contrast media, and is sensitive to tissue microstructure and function on a cellular level. DW-MRI parameters have shown sensitivity to treatment response in a growing number of tumour types and organ sites, with additional potential as predictive parameters for treatment outcome. A brief overview of DW-MRI principles is provided here, followed by a review of recent literature in which DW-MRI has been used to monitor and predict tumour response to various therapeutic regimens.