First-in-human phase 0 study of 111In-CHX-A"-DTPA trastuzumab for HER2 tumor imaging

Introduction:

Tumors over-expressing the human epithelial receptor 2 (HER2) or exhibiting amplification or mutation of its proto-oncogene have a poorer prognosis. Using trastuzumab and/or other HER2 targeted therapies can increase overall survival in patients with HER2(+) tumors making it critical to accurately identify patients who may benefit. We report on a Phase 0 study of the imaging agent, ¹¹¹In-CHX-A”-DTPA trastuzumab, in patients with known HER2 status to evaluate its safety and biodistribution and to obtain preliminary data regarding its ability to provide an accurate, whole-body, non-invasive means to determine HER2 status.

Methods:

¹¹¹In-CHX-A”-DTPA trastuzumab was radiolabeled on-site and slowly infused into 11 patients who underwent single (n=5) or multiple (n=6) ɣ-camera (n=6) and/or SPECT (n=8) imaging sessions.

Results:

No safety issues were identified. Visual and semi-quantitative imaging data were concordant with tissue HER2 expression profiling in all but 1 patient. The biodistribution showed intense peak liver activity at the initial imaging timepoint (3.3h) and a single-phase clearance fit of the average time-activity curve (TAC) estimated t_1/2=46.9h (R²=0.97; 95%CI 41.8 to 53h). This was followed by high gastrointestinal (GI) tract activity peaking by 52h. Linear regression predicted GI clearance by 201.2h (R² =0.96; 95%CI 188.5 to 216.9h). Blood pool had lower activity with its maximum on the initial images. Non-linear regression fit projected a t_1/2=34.2h (R² =0.96; 95%CI 25.3 to 46.3h). Assuming linear whole-body clearance, linear regression projected complete elimination (x-intercept) at 256.5hr (R²=0.96; 95%CI 186.1 to 489.2h).

Conclusion:

¹¹¹In-CHX-A”-DTPA trastuzumab can be safely imaged in humans. The biodistribution allowed for visual and semiquantitative analysis with results concordant with tissue expression profiling in 10 of 11 patients. Advances in Knowledge and Implications for Patient Care Using readily available components and on-site radiolabeling ¹¹¹In-CHX-A”-DTPA trastuzumab SPECT imaging may provide an economical, non-invasive means to detect HER2 over-expression.

Abstract OT2-06-01: Phase I/II study of T-DM1 alone versus T-DM1 and metronomic temozolomide in secondary prevention of HER2-Positive breast cancer brain metastases following stereotactic radiosurgery

Background: Brain metastases occur in up to 25-40% of HER2+ breast cancer patients. Standard treatment is limited to surgery or stereotactic radiosurgery (SRS) and/or whole brain radiation therapy (WBRT), with high levels of recurrence or progression, limiting survival and quality of life in most patients. Our group has demonstrated that low doses of temozolomide (TMZ) administered in a prophylactic, metronomic fashion can significantly prevent development of brain metastases in murine models of breast cancer. Based on these findings, we propose a secondary-prevention clinical trial.

Trial Design: Phase I/II open label study. Phase I will follow a standard 3+3 design: T-DM1 3.6 mg/kg IV every 21 days plus TMZ 30, 40 or 50 mg/m2 daily. Phase II: randomization T-DM1 3.6 mg/kg versus T-DM1 3.6mg/kg plus TMZ at recommended phase 2 dose (RP2D). Patients will undergo radiology guided lumbar puncture at baseline and after 6 weeks of treatment (C3D1) for correlative studies, brain MRI, systemic restaging CTs, and questionnaires for evaluation of symptoms and quality of life (MDASI-BT and PROMIS®) every 6 weeks.

Eligibility: HER2+ breast cancer with ≤3 brain metastases, treated with SRS and/or resection ≤6 weeks before enrollment, no leptomeningeal metastases, no previous WBRT, able to complete brain MRI with contrast evaluations, willing to undergo lumbar puncture, ECOG ≤2 and adequate organ and marrow function. HBV, HCV or HIV-positive patients are ineligible.

Specific Aims: Phase I: to identify the maximum tolerated dose (MTD) of TMZ combined with T-DM1. Phase II: to determine if the combination regimen of T-DM1 and TMZ improves the recurrence-free incidence from distant new brain metastases at one year as compared to T-DM1 alone. Biomarkers, including cell free DNA sequencing from CSF, serum and tumor block, serum markers for neuroinflammation, and patient reported outcomes, will be analyzed in an exploratory fashion.

Statistical Methods: Phase I, MTD will be identified based on the dose level at which 0 or 1 patient in 6 has a DLT. Phase II, to test whether TMZ will increase RFS from 50% to 65% at 12 months. RFS Kaplan-Meier curves will be created for each of the randomized arms and compared using a one-tailed log-rank test, with a one-sided 0.10 significance level of interest to be detected. Patients will be stratified for number of brain lesions and status of systemic metastases (controlled or not).

Target Accrual: 49 evaluable patients per arm (total 98), plus 9 to 18 patients during phase I. Trial will open in Summer 2017, at NIH in Bethesda, MD.

Contact Information: Principal Investigator: Alexandra S Zimmer, MD alexandra.zimmer@nih.gov

Citation Format: Zimmer AS, Gril B, Steinberg S, Smart D, Gilbert M, Armstrong T, Xiao L, Houston N, Biassou N, Brastianos P, Carter S, Lyden DC, Lipkowitz S, Steeg P. Phase I/II study of T-DM1 alone versus T-DM1 and metronomic temozolomide in secondary prevention of HER2-Positive breast cancer brain metastases following stereotactic radiosurgery [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-06-01.

Abstract OT2-07-04: A phase 2 study of ONC201 in recurrent/refractory metastatic breast cancer and advanced endometrial carcinoma

Background: Advanced breast cancer (BC) and endometrial cancer (EC) have limited treatment options with no treatments improving survival. ONC201 is the founding member of a novel class of anticancer drugs called impiridones. The drug is orally bioavailable and crosses the blood brain barrier. Preclinical studies have demonstrated that ONC201 selectively kills various cancer cells, including all subtypes of BC and EC, while having little effect on normal cells. An on-going Phase 1 study of ONC201 has demonstrated clinical benefit in some solid tumors, including EC and glioblastomas.

Trial Design: Phase 2 single arm study of ONC201 with 3 cohorts: Cohort 1, female and male hormone receptor positive breast cancer (HR+BC); Cohort 2, female and male triple negative breast cancer (TNBC); and Cohort 3, EC. All patients will receive ONC201 at the recommended Phase 2 dose of 625mg by mouth q7 days (1 cycle = 28 days). Patients will undergo a baseline biopsy as well as a biopsy after 5 doses of ONC201 (C2D2). Patients will be evaluated for response every two cycles (8 weeks) by RECIST 1.1.

Eligibility Criteria: Measurable disease with >1 biopsiable lesion, willing to undergo biopsies. Cohort 1 (HR+BC) requires prior treatment with >2 lines of hormonal treatment. No prior treatment required for the other cohorts. Patients must have ECOG 0-1 and adequate organ function. Patients with asymptomatic or brain metastases treated > 4 weeks from study entry are eligible. Exclusion criteria include: symptomatic CNS metastases, radiotherapy ≤ 4 weeks from study entry, HIV, Hepatitis B or Hepatitis C.

Specific Aims: Primary objectives for this study are progression free survival (PFS) at 8 months for Cohort 1 (HR+BC) and overall response rate (ORR) for Cohorts 2 and 3 (TNBC and EC). Secondary objectives include safety, clinical benefit rate (CBR = partial response + complete response + stable disease), and overall survival.

Statistical Methods: This study has been designed to pause prior to full accrual to allow for evaluation of futility prior to proceeding to full accrual. In Cohort 1, if >1 of 5 patients is progression-free at 8 months, then we will recruit up to 24 patients. In Cohort 2, if >2 of 10 patients has clinical benefit then we will recruit up to 29 patients. For Cohort 3, if 1 of 13 patients has clinical benefit, then we will recruit up to 25 patients. Additional evaluations of tumor or blood samples performed will be done in an exploratory fashion, with results presented without any formal adjustment for multiple comparisons.

Target Accrual: 24 patients with HR+BC, 29 patients with TNBC, and 25 patients with EC.This trial will open Summer 2017 at the National Institutes of Health (Bethesda, MD).

Contact Information: Principal Investigator Alexandra S Zimmer, MD; alexandra.zimmer@nih.gov

Citation Format: Gatti-Mays ME, Greer Y, Steinberg S, Soltani S, Collins J, Olson M, Ojemuyiwa M, Annunziata C, Lee J-M, Nunes A, Lipkowitz S, Zimmer A. A phase 2 study of ONC201 in recurrent/refractory metastatic breast cancer and advanced endometrial carcinoma [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr OT2-07-04.

Abstract PD6-01: Analysis of breast cancer in young women in the department of defense (DOD) database

Background: Women under the age of 40 account for approximately 7% percent of breast cancer patients. Breast tumors from young women are often ER-negative, occur in African-American patients, and have other indicators of high risk: yet, multivariate analyses demonstrated that young age is an independent predictor of poor outcome. Due to the unique nature of the patient population served by DOD, a disproportionate number of breast cancer cases in young women are seen. We compare the characteristics, treatment, and outcomes of young patients diagnosed with breast cancer with those of older patients.

Methods: The databases of the Military Health System Repository and the DOD Central Registration were used to identify female breast cancer patients treated at DOD facilities between 1998 and 2007. Information on demographics, breast cancer stage at diagnosis, definitive surgical treatments, systemic treatment, recurrence rate and overall survival was analyzed by age groups at the time of diagnosis (less than 40 years old, 40 to 49 years, and 50 years or older) using X2 testing with significance defined as p< 0.05.

Results: We identified 10,066 women who were diagnosed with invasive breast cancer at DOD facilities between 1998 and 2007, of which 11.3% (1139) were less than 40 years old at diagnosis. 53% of this young cohort were white, 25% were African-American and 8% were Hispanic (14% undisclosed). The percentage of breast cancer among African-American women in the young cohort was higher than in the older cohorts (19.3% in 40-49yo and 10.6% in ≥50yo). High-grade tumors were significantly more frequent in the younger cohort when compared to the older group (49.5% vs 34.7% and 25.2%, p<0.001). <40yo most commonly presented with Stage II disease (45.3%) at diagnosis, while older groups were mostly diagnosed with Stage I disease (41.6% and 52.4%). The most common subtype of breast cancer across ages was ER+ disease, however, <40yo group had proportionally less ER+ (49% vs 61% and 67.3%, P<0.001). There was a higher rate of bilateral mastectomies among the young women (18.4% vs 9.1% and 5.0%, p<0.0001). Independently of the stage of disease, chemotherapy was given significantly more frequently to <40y (90.43%) and 40-49yo (81.44%) than ≥50yo (53.71%). The 10-year overall survival of younger women was similar to the ≥50yo cohort, despite intensive treatment.

Discussion: This study is one of the largest retrospective studies of women under 40 years old with breast cancer. Younger women with invasive breast cancer had more aggressive tumors presenting at higher stages. In this group with good access to healthcare, younger women still had a similar overall survival rate to older women despite receiving more aggressive treatment and potentially having fewer comorbidities than the older group.

Citation Format: Zimmer AS, Gatti-Mays M, Soltani S, Lipkowitz S, Steeg PS, Zhu K, Perkins JG, Hu H, Shao S, Brown D, Shriver CD. Analysis of breast cancer in young women in the department of defense (DOD) database [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD6-01.

Abstract P3-06-02: ONC201 kills breast cancer cells by inhibiting mitochondrial respiration

Background: ONC201 is a small molecule originally identified as a TRAIL inducing compound (Allen et al., Sci. Trans. Med 2013). Two recent studies reported that ONC201 also induces an atypical stress response mediated in part by ATF4 and CHOP (Klein et al., Sci. Signal 2016 and Ishizawa et al., Sci. Signal 2016). ONC201 is currently being tested in phase1/2 clinical trials in multiple cancer types. In this study, we tested the effects of ONC201 on human breast cancer cells.

Methods: We tested ONC201 in 18 human breast cancer cell lines that represent ER+, HER2 amplified, TNBC basal A and TNBC basal B breast cancer. Cell death was analyzed by MTS assay after 5 days of treatment. Cells were treated with GST-TRAIL in parallel for comparison. Z-VAD-FMK was used as a pan-caspase inhibitor. To verify the mechanism of action of ONC201, siRNA against death receptors (DR) 4 and 5 were transfected to cells and tested in MTS assay and Western blotting. Seahorse XF analyzer and live cell imaging were used to further characterize the effect of ONC201.

Results: ONC201 reduced cell viability in breast cancer cell lines in all subtypes tested with IC50s ranging from 0.8-5 uM, similar to what has been reported for other cancer cell types. Unexpectedly, ONC201 did not induce caspase 3 or PARP cleavage, and its toxicity was not inhibited by Z-VAD-FMK, nor by siRNA knockdown of DR4 or DR5. By contrast GST-TRAIL induced caspase 3 and PARP cleavage and GST-TRAIL-induced cell death was inhibited by Z-VAD-FMK and by siRNA knockdown of DR5. Live cell imaging revealed ONC201 induces cell membrane ballooning followed by rupture, whereas GST-TRAIL induced classic apoptosis morphology. Together these results suggest that ONC201 kills breast cancer cells via a caspase-independent, DR4/5-independent mechanism distinct from TRAIL-induced apoptosis. Western blots revealed that ONC201 induces ATF4 and CHOP, consistent with the recently published observations. ONC201 also induced phosphorylation of AMP-dependent kinase (AMPK) in multiple breast cancer cell lines, suggesting that cellular ATP level is decreased by ONC201. ATP depletion by ONC201 was confirmed by direct measurement of cellular ATP. Seahorse XF analysis found that ONC201 inhibited mitochondrial oxygen consumption rate (OCR) but did not inhibit glycolysis as measured by the extracellular acidification rate. Long exposure to ONC201 significantly attenuated OCR, while acute treatment did not inhibit OCR. These data suggest that ONC201 inhibits mitochondrial oxidative phosphorylation via an indirect mechanism. Western blots demonstrated that ONC201 decreases expression of multiple mitochondrial proteins involved in oxidative phosphorylation. Both ONC201-induced toxicity and ATP depletion were enhanced when cells were cultured in non-glucose (galactose) medium. This is consistent with ONC201-induced inhibition of mitochondrial respiration. Supplementing glucose to cells grown in galactose medium partially rescued ONC201-dependent ATP depletion and cell death, and reversed ONC201-induced phospho-eIF2, ATF4 and CHOP induction.

Conclusion: Together, these data demonstrate that ONC201 can kill breast cancer cells by a novel mechanism involving inhibition of mitochondrial respiration.

Citation Format: Greer YE, Gilbert SF, Islam C, Ji Y, Gattinoni L, Stuelten C, Voeller D, Lipkowitz S. ONC201 kills breast cancer cells by inhibiting mitochondrial respiration [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-06-02.

Abstract P5-03-06: MEDI3039, a novel highly potent tumor necrosis factor (TNF)-related apoptosis inducing ligand (TRAIL) receptor agonist, induces apoptotic cell death in breast cancer cells

TRAIL receptor agonists are attractive anti-tumor agents because of their capability to induce apoptosis in cancer cells by activating death receptors 4 and 5 (DR4 and DR5) with little toxicity against normal cells. We previously reported that GST-TRAIL efficiently induced cell death in breast cancer cells, particularly mesenchymal triple negative breast cancer (TNBC) – so called basal B breast cancer cells (Rahman et al., Adv. Cancer Res. 2009). Recently, a newly developed multivalent TRAIL receptor agonist designed to activate DR5, has been shown to be a TRAIL super-agonist with significantly enhanced potency in multiple cancer cell lines (Swers et al., Mol Cancer Ther. 2013). We hypothesized that MEDI3039, developed from this TRAIL super-agonist, is a potential new therapeutic agent to be used in human breast cancer treatment.

As model systems, we used 19 breast cancer cell lines that can be categorized into 4 different groups: ER+, HER2 amplified, TNBC basal A and TNBC basal B. MEDI3039- or GST-TRAIL-induced cell death was analyzed by an MTS assay in 96 well format after 72h of treatment. MEDI3039- or GST-TRAIL-induced caspase activation was measured by Caspase-glo 3/7 assay. Z-VAD-FMK was used as a pan-caspase inhibitor. To verify the receptor for MEDI3039, siRNA against DR4 and DR5 were transfected to cells and tested in MTS assay and Western blotting.

MEDI3039 induced cell death in MDA-MB231 (TNBC basal B), and the IC50 was 4.71pM. By contrast, GST-TRAIL induced cell death in this cell line with an IC50 of 624 pM (a 132 fold difference). MEDI3039 and GST-TRAIL induced cell death was completely inhibited by Z-VAD-FMK, indicating that cell death was the result of caspase-mediated apoptotic pathway. Knockdown of DR5, but not DR4, inhibited MEDI3039-induced cell death, demonstrating that MEDI3039-mediated apoptosis requires DR5. MEDI3039 induced cell death in multiple breast cancer cell lines, but the sensitivity varied between cell lines from the four different subtypes. TNBC basal B group was the most sensitive (avg IC50= 1.4 pM), TNBC basal A group was next most sensitive (avg IC50 = 203 pM, HER2 amplified group was less sensitive (avg IC50 = 314 pM), and ER+ group was the least sensitive to MEDI3039 (avg IC50= 403 pM). This was similar to what was observed with GST-TRAIL. Importantly, MEDI3039 was at least 2 orders of magnitude more potent compared with GST-TRAIL in most cell lines tested. Drug combination experiments indicated that MEDI3039 has synergistic effect with multiple drugs, including cisplatin, MK1775. Animal breast cancer xenograft experiments are planned to test the efficacy of MEDI3039 in vivo. Further work to identify biomarker(s) that correlate with MEDI3039 sensitivity, and effective combinations that enhance the toxicity of MEDI3039 especially in the resistant breast cancer subtypes are ongoing. In conclusion, MEDI3039 is a potent TRAIL receptor agonist in breast cancer cells and has potential as a cancer drug in breast cancer patients, especially those with TNBC basal B.

Citation Format: Greer YE, Tice D, Lipkowitz S. MEDI3039, a novel highly potent tumor necrosis factor (TNF)-related apoptosis inducing ligand (TRAIL) receptor agonist, induces apoptotic cell death in breast cancer cells. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-03-06.

EGFRvIII undergoes activation-dependent downregulation mediated by the Cbl proteins

The overexpression or mutation of tyrosine kinases (TKs), such as the epidermal growth factor receptor (EGFR), can lead to the development of cancer. The most common mutation of the EGFR in glioblastomas is the deletion of exons 2-7 known as the EGFRvIII. This mutant receptor cannot bind EGF but, instead, is constitutively active. The Cbl family of ubiquitin ligases (Cbl, Cbl-b, and Cbl-c) targets the activated EGFR for degradation. As the EGFRvIII is transforming, we investigated whether it could be downregulated by the Cbl proteins. The overexpression of all three Cbl proteins resulted in the ubiquitination and degradation of the EGFRvIII. As with the wild-type EGFR, the TK-binding domain and the RING finger of Cbl-b are sufficient for the downregulation of the EGFRvIII. Also, we found that Cbl-b is recruited to the EGFRvIII and inhibits the transformation of NIH 3T3 cells by the EGFRvIII. Mutation of the Cbl-binding site (Y1045F) in the EGFRvIII inhibits its ubiquitination and downregulation by Cbl-b and enhances its ability to transform. Furthermore, the EGFR TK inhibitor, AG 1478, prevents the downregulation of the EGFRvIII by the Cbl proteins and antagonizes the ability of an immunotoxin directed against the EGFRvIII to kill cells expressing this receptor. In conclusion, the EGFRvIII does not transform by escaping regulation by Cbl proteins and this activation-induced downregulation of the EGFRvIII has an important role in mediating the toxicity of anti-EGFRvIII immunotoxins.

N-(4-hydroxyphenyl) retinamide (4HPR) enhances TRAIL-mediated apoptosis through enhancement of a mitochondrial-dependent amplification loop in ovarian cancer cell lines

The majority of ovarian cancer cells are resistant to apoptosis induced by tumor necrosis factor-related apoptosis-inducing ligand (TRAIL). Subtoxic concentrations of the semisynthetic retinoid N-(4-hydroxyphenyl)retinamide (4HPR) enhanced TRAIL-mediated apoptosis in ovarian cancer cell lines but not in immortalized nontumorigenic ovarian epithelial cells. The enhancement of TRAIL-mediated apoptosis by 4HPR was not due to changes in the levels of proteins known to modulate TRAIL sensitivity. The combination of 4HPR and TRAIL enhanced cleavage of multiple caspases in the death receptor pathway (including the two initiator caspases, caspase-8 and caspase-9). The 4HPR and TRAIL combination leads to mitochondrial permeability transition, significant increase in cytochrome c release, and increased caspase-9 activation. Caspase-9 may further activate caspase-8, generating an amplification loop. Stable overexpression of Bcl-xL abrogates the interaction between 4HPR and TRAIL at the mitochondrial level by blocking cytochrome c release. As a consequence, a decrease in activation of caspase-9, caspase-8, and TRAIL-mediated apoptosis occurs. These results indicate that the enhancement in TRAIL-mediated apoptosis induced by 4HPR is due to the increase in activation of multiple caspases involving an amplification loop via the mitochondrial-death pathway. These findings offer a promising and novel strategy for the treatment of ovarian cancer.

Biomarker assays in nipple aspirate fluid

The noninvasive technique of nipple aspiration as a potential source of biomarkers of breast cancer risk was evaluated. The feasibility of performing mutagenesis assays, amplifying DNA, and performing protein electrophoresis on nipple aspirate fluid was explored. A tool was developed to measure the level of discomfort, if any, from this procedure. Twenty-five healthy women (20 premenopausal and 5 postmenopausal) were enrolled. Fluid was obtained using a modified breast pump. Premenopausal women were scheduled for four to six weekly aspirations, and postmenopausal women were scheduled for one to two weekly aspirations. Mutagenesis assays were performed using the Salmonella (Ames) assay. DNA amplification of several microsatellite regions was carried out using polymerase chain reaction. Protein was quantified, and two-dimensional protein electrophoresis was performed. Overall, fluid was obtained from 80% of the women, and the level of discomfort was minimal. Acid hydrolysis of one sample resulted in mutagenicity; all six nonhydrolyzed samples were not mutagenic. The ability to amplify DNA ranged from 34% to 96%, depending on length of the microsatellite region examined. The average protein concentration was 71 microg/mL. Two-dimensional protein electrophoresis was successfully performed on samples from two subjects. Nipple aspiration is a simple technique and is easily learned and well tolerated, which yields a reagent useful for a variety of investigations. This technique may facilitate the identification and application of biomarkers for future breast cancer risk assessment and chemopreventive protocols.

Cbl-b-dependent Coordinated Degradation of the Epidermal Growth Factor Receptor Signaling Complex

Cbl proteins function as ubiquitin protein ligases for the activated epidermal growth factor receptor and, thus, negatively regulate its activity. Here we show that Cbl-b is ubiquitinated and degraded upon activation of the receptor. Epidermal growth factor (EGF)-induced Cbl-b degradation requires intact RING finger and tyrosine kinase binding domains and requires binding of the Cbl-b protein to the activated EGF receptor (EGFR). Degradation of both the EGFR and the Cbl-b protein is blocked by lysosomal and proteasomal inhibitors. Other components of the EGFR-signaling complex (i.e. Grb2 and Shc) are also degraded in an EGF-induced Cbl-b-dependent fashion. Our results suggest that the ubiquitin protein ligase function of Cbl-b is regulated by coordinated degradation of the Cbl-b protein along with its substrate. Furthermore, the data demonstrate that Cbl-b mediates degradation of multiple proteins in the EGFR-signaling complex.

Synergistic induction of apoptosis by the combination of trail and chemotherapy in chemoresistant ovarian cancer cells

OBJECTIVES

The aim of this study was to investigate whether TNF-related apoptosis-inducing ligand (TRAIL) alone or in combination with chemotherapy could induce apoptosis in ovarian cancer cells resistant to chemotherapy.

METHODS

Twelve chemoresistant epithelial cancer cell lines were treated with each chemotherapeutic drug alone (cisplatin, doxorubicin, or paclitaxel), TRAIL alone, or the combination. Toxicity was assessed using the MTS assay. To assess whether growth inhibition was due to apoptosis, TUNEL assay, caspase activation (measured by caspase-3 and PARP cleavage), and the sub G0/G1 fraction of cells were measured. Synergism was confirmed by fractional inhibition and dose-effect analysis. Expression of death and decoy receptors was studied by immunoblotting and an RNase protection assay. Statistical comparison of means was performed using Student's t test.

RESULTS

The majority of the chemoresistant cells were also resistant to TRAIL alone. In contrast, the combination of TRAIL and chemotherapy resulted in a significant growth inhibition over a wide range of concentrations. This interaction was synergistic by dose-effect analysis. Flow cytometry demonstrated a significant increase in the fraction of apoptotic cells by the combination compared to each reagent alone. A significant enhancement in caspase and PARP cleavage was observed upon treatment with the combination. Finally, no correlation between induction of apoptosis and level of death receptors was found.

CONCLUSIONS

The data suggest that almost all the ovarian cancer cells, which are resistant to chemotherapy, are also resistant to TRAIL. The combination of TRAIL and chemotherapy overcomes this resistance in a synergistic fashion by triggering caspase-mediated apoptosis. The combination of TRAIL and chemotherapy could be useful as a therapy for chemoresistant ovarian cancers.

Down-regulation of the erbB-2 receptor by trastuzumab (herceptin) enhances tumor necrosis factor-related apoptosis-inducing ligand-mediated apoptosis in breast and ovarian cancer cell lines that overexpress erbB-2

We investigated whether combined treatment with tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) and trastuzumab could enhance the specific killing of cells that overexpress the erbB-2 receptor. The combination resulted in an enhancement of TRAIL-mediated apoptosis in all cell lines overexpressing erbB-2 receptor compared with either reagent alone. In contrast, there was no effect in cell lines with low levels of the erb-B2 receptor. Trastuzumab treatment resulted in down-regulation of the erbB-2 receptor in all erbB-2-overexpressing cell lines. Similar enhancement of TRAIL toxicity was observed when the erbB-2 receptor was down-regulated using antisense oligodeoxynucleotides. Down-regulation of the erbB-2 receptor protein by trastuzumab or antisense oligodeoxynucleotides decreased Akt kinase activation but not mitogen-activated protein kinase activation. Down-regulation of Akt kinase activity by a phosphatidylinositol 3'-kinase inhibitor (LY294002) also resulted in enhancement of TRAIL-mediated apoptosis. Expression of a constitutively active form of Akt kinase in an erbB-2-overexpressing cell line completely abrogated the increase in TRAIL-mediated apoptosis by trastuzumab and significantly reduced the biological effect of either reagent alone. Therefore, down-regulation of the erbB-2 receptor by trastuzumab enhances TRAIL-mediated apoptosis by inhibiting Akt kinase activity. These data suggest that the combination of trastuzumab and TRAIL may allow enhanced therapeutic efficacy and specificity in the treatment of erbB-2-overexpressing tumors.

SETA is a multifunctional adapter protein with three SH3 domains that binds Grb2, Cbl, and the novel SB1 proteins

Expression of the src homology 3 (SH3)-encoding, expressed in tumorigenic astrocytes (SETA) gene is associated with astrocyte transformation in culture and tumors in the adult brain. SETA binds to the apoptosis regulator apoptosis-linked gene 2 (ALG-2) interacting protein 1 (AIP1), and modulates apoptosis in astrocytes. The predicted protein structure of SETA revealed two SH3 domains, while related proteins were reported to have three. Here we report the identification of an additional SH3 domain N-terminal to the previously identified SETA sequence. Yeast two-hybrid screening of a p53(-/-) astrocyte cDNA library with this SH3 domain identified a novel gene, SETA binding protein 1 (SB1), with 55% amino acid identity to the renal tumor antigen, NY-REN-45. In vitro confrontation and co-immunoprecipitation experiments confirmed the binding of SB1 to SETA. Evidence that SETA binds to the CD2 protein, the proto-oncogene c-Cbl, and the signal transduction molecule Grb2, and can dimerize via its C-terminal coiled coil (CC) domain is also presented.

Inhibition of NF-kappaB activity enhances TRAIL mediated apoptosis in breast cancer cell lines

Most breast cancer cell lines are resistant to TNF-related apoptosis inducing ligand (TRAIL) induced apoptosis. In sensitive breast cancer cell lines TRAIL rapidly induces the cleavage and activation of caspases leading to the subsequent cleavage of downstream caspase substrates. In contrast, there is no caspase activation in the resistant cell lines. The transcription factor NF-KB can inhibit apoptosis induced by a variety of stimuli including activation of death receptors. We investigated whether NF-kappaB contributes to the resistance of breast cancer cells to TRAIL induced apoptosis. All of the resistant breast cancer cell lines expressed NF-kappaB and had detectable NF-kappaB activity in nuclear extracts prior to treatment with TRAIL. Upon TRAIL treatment, a significant increase in NF-kappaB activity was seen in most of the cell lines. To directly test if NF-kappaB activity contributes to the resistance of these cell lines to TRAIL, we transiently transfected the resistant cell lines with an inhibitor of NF-kappaB (IkappaBdeltaN) and measured TRAIL induced apoptosis in control and transfected cells. All of the resistant cell lines tested showed an increase in TRAIL induced apoptosis when transfected with the IKBdeltaN. These results demonstrate that TRAIL resistant breast cancer cells fail to rapidly activate the apoptotic machinery but they do activate NF-kappaB. Inhibition of NF-kappaB activity increases the sensitivity to TRAIL mediated apoptosis in resistant cells. These results suggest that agents which inhibit NF-kappaB should increase the clinical efficacy of TRAIL in breast cancer cells.

The death domain kinase RIP is essential for TRAIL (Apo2L)-induced activation of IkappaB kinase and c-Jun N-terminal kinase

Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) (Apo2 ligand [Apo2L]) is a member of the TNF superfamily and has been shown to have selective antitumor activity. Although it is known that TRAIL (Apo2L) induces apoptosis and activates NF-kappaB and Jun N-terminal kinase (JNK) through receptors such as TRAIL-R1 (DR4) and TRAIL-R2 (DR5), the components of its signaling cascade have not been well defined. In this report, we demonstrated that the death domain kinase RIP is essential for TRAIL-induced IkappaB kinase (IKK) and JNK activation. We found that ectopic expression of the dominant negative mutant RIP, RIP(559-671), blocks TRAIL-induced IKK and JNK activation. In the RIP null fibroblasts, TRAIL failed to activate IKK and only partially activated JNK. The endogenous RIP protein was detected by immunoprecipitation in the TRAIL-R1 complex after TRAIL treatment. More importantly, we found that RIP is not involved in TRAIL-induced apoptosis. In addition, we also demonstrated that the TNF receptor-associated factor 2 (TRAF2) plays little role in TRAIL-induced IKK activation although it is required for TRAIL-mediated JNK activation. These results indicated that the death domain kinase RIP, a key factor in TNF signaling, also plays a pivotal role in TRAIL-induced IKK and JNK activation.

Negative regulation of lymphocyte activation and autoimmunity by the molecular adaptor Cbl-b

The signalling thresholds of antigen receptors and co-stimulatory receptors determine immunity or tolerance to self molecules. Changes in co-stimulatory pathways can lead to enhanced activation of lymphocytes and autoimmunity, or the induction of clonal anergy. The molecular mechanisms that maintain immunotolerance in vivo and integrate co-stimulatory signals with antigen receptor signals in T and B lymphocytes are poorly understood. Members of the Cbl/Sli family of molecular adaptors function downstream from growth factor and antigen receptors. Here we show that gene-targeted mice lacking the adaptor Cbl-b develop spontaneous autoimmunity characterized by auto-antibody production, infiltration of activated T and B lymphocytes into multiple organs, and parenchymal damage. Resting cbl-b(-/-) lymphocytes hyperproliferate upon antigen receptor stimulation, and cbl-b(-/-) T cells display specific hyperproduction of the T-cell growth factor interleukin-2, but not interferon-gamma or tumour necrosis factor-alpha. Mutation of Cbl-b uncouples T-cell proliferation, interleukin-2 production and phosphorylation of the GDP/GTP exchange factor Vav1 from the requirement for CD28 co-stimulation. Cbl-b is thus a key regulator of activation thresholds in mature lymphocytes and immunological tolerance and autoimmunity.

Ubiquitin ligase activity and tyrosine phosphorylation underlie suppression of growth factor signaling by c-Cbl/Sli-1

Receptor desensitization is accomplished by accelerated endocytosis and degradation of ligand-receptor complexes. An in vitro reconstituted system indicates that Cbl adaptor proteins directly control downregulation of the receptor for the epidermal growth factor (EGFR) by recruiting ubiquitin-activating and -conjugating enzymes. We infer a sequential process initiated by autophosphorylation of EGFR at a previously identified lysosome-targeting motif that subsequently recruits Cbl. This is followed by tyrosine phosphorylation of c-Cbl at a site flanking its RING finger, which enables receptor ubiquitination and degradation. Whereas all three members of the Cbl family can enhance ubiquitination, two oncogenic Cbl variants, whose RING fingers are defective and phosphorylation sites are missing, are unable to desensitize EGFR. Our study identifies Cbl proteins as components of the ubiquitin ligation machinery and implies that they similarly suppress many other signaling pathways.

cbl-b inhibits EGF-receptor-induced apoptosis by enhancing ubiquitination and degradation of activated receptors

Studies in C. elegans and Drosophila melanogaster suggest that cbl proteins are inhibitors of epidermal growth factor receptor (EGFR) function. Here we describe that overexpression of cbl-b, a homologue of the c-cbl protooncogene, inhibits EGFR-induced apoptosis in MDA-MB-468 breast cancer cells. Overexpression of cbl-b results in a shortened duration of EGFR activation upon EGF stimulation. This is demonstrated by decreased amounts of phosphorylated EGFR as well as by inhibition of multiple downstream signaling pathways. The inhibition of signaling by cbl-b results from increased ubiquitination and degradation of the activated EGFR. The inhibitory effects of cbl-b overexpression on apoptosis and on EGFR signaling are reversed by blocking proteosomal degradation of the EGFR. These data demonstrate that the mechanism by which cbl-b inhibits EGFR-induced apoptosis is by activation-dependent degradation of the EGFR. They imply that this mechanism may be a general one whereby cbl proteins regulate intracellular signaling.