Retrovirus-mediated wild-type p53 gene transfer to tumors of patients with lung cancer

Apoptosis in lung fibrosis and repair

Cell death by apoptosis has fundamental significance in both normal lung homeostasis and a variety of pathologic processes, and for this reason apoptosis in the lung is a rapidly growing area of investigation. Evidence from human lung biopsy specimens and from animal models of lung fibrosis points to important roles for apoptosis in both the pathogenesis and resolution of fibrotic lesions. As more evidence accumulates, the more apparent becomes the paucity of information on the regulation of this mode of cell death in the many different cell types of the lung parenchyma. This discussion will review the current state of knowledge regarding the roles of apoptosis in lung fibrosis and will focus on its role in pathogenesis.

Novel therapies for lung cancer

Lung cancer remains the leading cause of cancer mortality in the US. For the majority of patients with advanced non-small cell lung cancer, chemotherapy with or without radiation therapy is the mainstay of treatment. Despite the modest improvement in survival for these patients, prognosis remains dismal. However, the expanding knowledge of tumor biology in recent years has resulted in the promising development of a new class of "molecularly targeted" agents, which selectively target cancer cells at the molecular, biochemical, and genetic level, thus minimizing toxic effects on normal tissues. A wide range of molecularly targeted agents are being actively investigated in lung cancer therapy as single agents or in combination with conventional modalities. In this review, we discuss some of the agents furthest along in development: epidermal growth factor receptor inhibitors, anti-angiogenic agents, inhibitors of biologically important enzymes such as matrix metalloproteinases and farnesyltransferase, gene therapy including gene replacement and antisense therapy, and cell cycle disruptors.

The role of new agents in the treatment of non-small cell lung cancer

Lung cancer is one of the most frequent causes of cancer deaths worldwide. Non-small cell lung cancer (NSCLC) accounts for approximately 80% of cases and no curative treatment is available for the advanced stages of disease (stages III and IV), which comprise the majority of cases. Current treatment regimens with standard chemotherapy offer only a limited survival benefit, and, therefore, the development of new therapeutic strategies is needed. Novel chemotherapeutic drugs such as the epothilones, MEN 10755 and S-1 are being studied in patients with advanced stages of disease. Furthermore, a large number of therapies targeted against critical biological abnormalities in NSCLC are being investigated in clinical trials. The latter approach includes inhibition of growth factors, interference with abnormal signal transduction, inhibition of angiogenesis and gene replacement therapy. Promising results have thus far been obtained with some of these therapies. This review describes the role of new therapeutic agents in the treatment of NSCLC.

The Role of Apoptosis-Related Genes in non—small-Cell Lung Cancer

Both intrinsic and acquired resistance to chemotherapeutic drugs are major obstacles in the treatment of non-small-cell lung cancer. Apart from classical drug resistance mechanisms, the failure of tumor cells to undergo apoptosis also plays an important role in drug resistance. Mutations and defects in the apoptotic pathway are, therefore, additional factors that determine drug resistance. The tumor suppressor gene p53, the retinoblastoma gene, and the bcl-2 family members are important factors in this pathway. Recently much attention has been drawn to different apoptotic pathways induced by naturally occurring death receptor ligands (such as tumor necrosis factor, Fas ligand, and tumor necrosis factor-related apoptosis-inducing ligand) or induced by drugs that affect the downstream pathway from the epidermal growth factor receptor. Insight regarding the proteins that determine sensitivity for chemotherapeutic drugs could provide new targets for cancer treatment, which may help to at least partly overcome drug resistance in non-small-cell lung cancer

Tumor infiltrating lymphocytes and macrophages have a potential dual role in lung cancer by supporting both host-defense and tumor progression

A prerequisite to the developement of an efficient cell and/or gene therapy for lung cancer is a precise characterization of the inflammatory cell populations spontaneously present in the tumor stroma associated with this cancer. This study was designed to define the cytotoxic potential and the relationship with stroma development of tumor infiltrating lymphocytes (TIL) and tumor associated macrophages (TAM). Tumor samples from 48 patients undergoing surgery for non-small cell lung cancer (NSCLC) were analyzed, by immunohistochemistry and in situ hybridization, with a panel of antibodies and probes specific for cell proteins linked to cytotoxicity, cytokines, and growth factors, and the replication status of TIL and TAM was evaluated by in vivo 5-bromodeoxyuridine incorporation. It was shown that, in NSCLC: (1) tumor stroma inflammatory cells are mainly TIL (approximately 2/3) (among them, 80 % are T-cells) and TAM (approximately 1/3), with almost no natural killer (NK) cells, and a few dentritic cells; (2) TAM and TIL are poorly replicating, but mainly recruited to the tumor stroma; (3) more than half TAM show an antibody-dependent cytotoxic potential, and one third of T-cells are TIA-1 positive CD8 activated cytotoxic lymphocytes; (4) cancer cells from only a few tumor express HLA class I and II antigens; (5) TAM production of cytotoxic cytokines [interleukin-1alpha (IL-1alpha), IL-1beta, IL-6, tumor necrosis factor-alpha (TNF-alpha)] and of transforming growth factor-beta1 (TGF-beta1) is low, in contrast to their strong release of platelet-derived growth factor (PDGF). We concluded that, in NSCLC, TIL cytotoxicity is likely to be low because of a poor class I MHC expression by tumor cells, and TAM low production of cytotoxic cytokines is a major limit to their possible cytotoxic activity. In contrast, TAM may favor tumor progression by contributing to tumor stroma formation and angiogenesis through their release of PDGF, in conjunction with TGF-beta1 production by tumor cells.

Adenovirus-mediated p53 gene therapy for human cancer

Recent advances in molecular biology have fostered remarkable insights into the molecular basis of neoplasms. Considerable evidence has accumulated that among the mechanisms of human cancer development are overexpression of dominant oncogenes, expression of mutant oncogenes, or specific chromosomal deletions or mutations that induce inactivation of tumor-suppressor genes. This understanding of cancer pathogenesis suggests that restoration of the function of critical gene products could halt or reverse these abnormalities, thus having a therapeutic effect. The p53 tumor suppressor gene has been implicated in many inherited and sporadic forms of malignancies in humans. Preclinical experiments have demonstrated that restoration of wildtype p53 function in the cancer cell by gene transfer is sufficient to cause antitumor effects such as cell-cycle arrest and induction of apoptosis. This approach has entered clinical testing and provided intriguing information about the intratumoral administration of an adenovirus vector expressing the wildtype p53 gene in non-small-cell lung cancer. The clinical study has also provided evidence of the bystander phenomenon, which is important for potential clinical efficacy. This article reviews recent highlights in this rapidly evolving field: p53 gene therapy for human cancer.

Clinical impact of novel treatment strategies

Following two decades of research on the biology of cancer and in particular of lung cancer, we have now a large number of molecular targets that can be utilized to create specific medicines against these cancers. Non-small cell lung cancer represents numerically the most important solid tumor in Western world, and is poorly affected by current therapies, where surgery represents almost the only curative therapy for about 25% of patients who are resectable at diagnosis. An abundant number of targeted therapies are being investigated in NSCLC. Among them are the metalloproteinase inhibitors, several tyrosine kinase inhibitors and several attempts of gene replacement have also been made. Promising results have so far been obtained with some of these approaches, and the outcome of large randomized studies is awaited. Small cell lung cancer (SCLC) represents about 20% of lung carcinomas, and several of the novel approaches that are being attempted for NSCLC, are also being investigated for SCLC. All these novel therapies open a new era of anticancer treatment that will likely complement the currently available therapies in the near future.

Glycerol as a chemical chaperone enhances radiation-induced apoptosis in anaplastic thyroid carcinoma cells

INTRODUCTION

Anaplastic thyroid carcinoma, which is one of the most aggressive, malignant tumors in humans, results in an extremely poor prognosis despite chemotherapy and radiotherapy. The present study was designed to evaluate therapeutic effects of radiation by glycerol on p53-mutant anaplastic thyroid carcinoma cells (8305c cells). To examine the effectiveness of glycerol in radiation induced lethality for anaplastic thyroid carcinoma 8305c cells, we performed colony formation assay and apoptosis analysis.

RESULTS

Apoptosis was analyzed with Hoechst 33342 staining and DNA ladder formation assay. 8305c cells became radiosensitive when glycerol was added to culture medium before X-ray irradiation. Apoptosis was induced by X-rays in the presence of glycerol. However, there was little apoptosis induced by X-ray irradiation or glycerol alone. The binding activity of whole cell extracts to bax promoter region was induced by X-rays in the presence of glycerol but not by X-rays alone.

CONCLUSION

These findings suggest that glycerol is effective against radiotherapy of p53-mutant thyroid carcinomas.

Gene therapy--its potential in surgery

Advances in techniques have resulted in practical applications for gene therapy, which is becoming applicable for the treatment of human disease. This review outlines the advantages and disadvantages of the techniques available. Examples of research efforts in the treatment of diseases of relevance to the surgeon (cardiovascular diseases, cancer, wound healing, fracture repair, and in organ transplantation) are presented.

Advanced NSCLC: from cytotoxic systemic chemotherapy to molecularly targeted therapy

Approximately a third of non-small cell lung cancer patients present with disseminated disease at the time of diagnosis. For these patients, as well as those with recurrent disease, chemotherapy remains the mainstay of treatment. For several decades, researchers have attempted different combinations of drugs in search for the 'best' chemotherapy regimen. Despite the emergence of newer, 'third-generation' cytotoxic agents, success is still modest at best. Fortunately, new insights in tumor biology, leading to the design of molecularly targeted drugs, are opening a new era in cancer treatment. These novel agents target molecular pathways specifically found in cancer cells, thus maximizing the antitumor effect while minimizing toxicities on normal cells.

A novel single tetracycline-regulative adenoviral vector for tumor-specific Bax gene expression and cell killing in vitro and in vivo

Using a binary adenoviral system, we recently showed that the human telomerase reverse transcriptase (hTERT) promoter induces tumor-specific Bax gene expression. However, the strong cytotoxicity of Bax and other pro-apoptotic genes to packaging 293 cells has so far hindered construction of the desired single adenoviral vectors expressing toxic genes. We report here the construction of a single bicistronic adenoviral vector for tumor-specific Bax expression. The vector (Ad/gBax) utilizes the Tet-Off system and expresses a GFP/Bax fusion protein for easy detection. The hTERT promoter drives the expression of tTA, a transactivator capable of binding to TRE (tetracycline-responsive element) in the absence of tetracycline, which in turn induces expression of the GFP-Bax gene. The addition of tetracycline in 293 cells blocks the binding of tTA to TRE and substantially inhibits GFP-Bax expression and toxicity, thus allowing the packaging and production of Ad/gBax. Our data show that Ad/gBax could drive the high expression of GFP-Bax in tumor cells but not in normal cells and mouse tissues. Furthermore, the expression of GFP-Bax fusion protein elicited tumor-specific apoptosis in a variety of human cancer cells in vitro and in vivo at a level comparable to that induced by the binary system. Thus, Ad/gBax may become a potent therapeutic agent for the treatment of cancers.

p53 Gene therapy for lung cancer

The gene transfer of the tumor suppressor p53 gene has been shown to induce tumor regression in preclinical models. Recent phase I and II studies have been completed in lung cancer with adenoviral-mediated transfer of wild-type p53 (Ad-p53) either alone or in combination with chemotherapy or radiotherapy. These studies have demonstrated acceptable toxicity and evidence of tumor regression with intratumoral delivery of Ad-p53. The predominant clinical effect appears to be locoregional in the area of intratumoral delivery. Further phase III studies are needed to determine if Ad-p53 will play a therapeutic role as a novel agent to treat non-small-cell lung cancer.

Novel targets for lung cancer therapy: part II

Lung cancer is the second most common form of cancer in the United States, and although it accounts for 15% of all cancers, it is the most lethal, accounting for approximately 28% of cancer deaths. In 2002, it is estimated that 177,000 new cases of lung cancer will be diagnosed in the United States, and an estimated 160,000 men and women will die from the disease. This mortality rate is greater than that attributable to colorectal, breast, and prostate cancer combined. Systemic treatments for lung cancer with standard chemotherapy agents are still relatively ineffective. Agents targeting novel proliferative and survival pathways in lung cancer are needed to improve treatment outcomes. In recent years, numerous agents inhibiting aberrant processes in tumor cells have undergone clinical evaluation. This review is the second of a two-part series that summarizes pertinent preclinical and clinical information on novel drugs that target critical abnormalities in lung cancer. In this article, agents that were developed to inhibit various aspects of tumor protein trafficking and protein degradation, cell cycle regulation, angiogenesis, and antigenicity are described. Future approaches to treatment are suggested.

Clinical update of Ad-p53 gene therapy for lung cancer

These preliminary Phase I and II gene therapy trials in NSCLC have demonstrated that Ad-p53 gene transfer is associated with low toxicity and evidence of antitumoral activity at the locoregional site. Effort to enhance antitumoral efficacy with chemotherapy and radiation therapy have not increased Ad-p53 toxicity and appear to be feasible. Randomized Phase III studies are now needed to determine the potential of Ad-p53 to improve overall survival in selected subsets of NSCLC patients. Future gene therapy research is required to develop systemic delivery systems and to overcome p53 tumor resistance. It is hoped that these efforts will ultimately lead to a novel mode of therapy to complement conventional chemotherapy, radiation therapy, and surgical treatment strategies.

A phase I/II trial of rAd/p53 (SCH 58500) gene replacement in recurrent ovarian cancer

PURPOSE

To determine the safety, gene transfer, host immune response, and pharmacokinetics of a replication-deficient adenovirus encoding human, recombinant, wild-type p53 (SCH 58500) delivered into the peritoneal cavity (i.p.) alone and sequentially in combination with platinum-based chemotherapy, of patients with recurrent ovarian, primary peritoneal, or fallopian tube cancer containing aberrant or mutant p53.

METHODS

SCH 58500 was administered i.p. to three groups of patients with heavily pretreated recurrent disease. Group 1 (n=17) received a single dose of SCH 58500 escalated from 7.5 x 10(10) to 7.5 x 10(12) particles. Group 2 (n=9) received two or three doses of SCH 58500 given alone for one cycle, and then with chemotherapy for two cycles. The SCH 58500 dose was further escalated to 2.5 x 10(13) particles/dose in group 2. A third group (n=15) received a 5-day regimen of SCH 58500 given at 7.5 x 10(13) particles/dose per day i.p. alone for cycle 1 and then with intravenous carboplatin/paclitaxel chemotherapy for cycles 2 and 3.

RESULTS

No dose-limiting toxicity resulted from the delivery of 236/287 (82.2%) planned doses of SCH 58500. Fever, hypotension abdominal complaints, nausea, and vomiting were the most common adverse events. Vector-specific transgene expression in tumor was documented by RT-PCR in cells from both ascitic fluid and tissue biopsies. Despite marked increases in serum adenoviral antibody titers, transgene expression was measurable in 17 of 20 samples obtained after two or three cycles of SCH 58500. Vector was detectable in peritoneal fluid by 24 hours and persisted for as long as 7 days whereas none was detected in urine or stool. There was poor correlation between CT scans and CA125 responses. CA125 responses, defined as a greater than 50% decrement in serum CA125 from baseline, were documented in 8 of 16 women who completed three cycles of the multidose regimen.

CONCLUSION

CT scans are not a valid measure of response to i.p. SCH 58500 due to extensive adenoviral-induced inflammatory changes. Intraperitoneal SCH 58500 is safe, well tolerated, and combined with platinum-based chemotherapy can be associated with a significant reduction of serum CA125 in heavily pretreated patients with recurrent ovarian, primary peritoneal, or fallopian tube cancer.

Cancer gene therapy: scientific basis

Gene therapy of cancer has been one of the most exciting and elusive areas of therapeutic research in the past decade. Critical developments have occurred in gene therapy targeting cancer cells, cancer vasculature, the immune system, and the bone marrow, itself often the target for severe toxicity from therapeutic agents. We review some recent developments in the field. In each instance, clear preclinical models validated the therapeutic approach and efforts have been made to evaluate the target impact in both preclinical and early clinical trials. Although no cures can consistently be expected from today's cancer gene therapy, the rapid progress may imply that such cures are a few short years away.

Interferon-alpha2b secretion by adenovirus-mediated gene delivery in rat, rabbit, and chimpanzee results in similar pharmacokinetic profiles

Gene delivery, with subsequent protein synthesis and secretion, in vivo has been proposed as an alternative way to deliver a therapeutic protein to the systemic circulation. Interferon-alpha (IFN) protein is effective in the treatment of viral and malignant diseases but has short serum half-life that requires frequent administration. An E1 region-deleted adenovirus vector encoding human IFN-alpha2b gene driven by the cytomegalovirus immediate early promoter (rAd-IFN) was generated to assess the serum concentration-time profiles of expressed IFN protein in animal models. Intravenous administration of rAd-IFN, normalized for body weight, resulted in dose-dependent serum IFN concentrations that persisted 8-40 days with similar concentration-time profiles in rats and rabbits. We sought to determine if serum concentration-time profiles in the rat and rabbit animal models would be predictive for a larger animal and would therefore be relevant models for potential dosing of human patients. Two chimpanzees (approximately 70 kg) dosed with rAd-IFN by intravenous administration normalized to body weight achieved serum IFN concentration-time profiles similar to those observed in rats and rabbits. The role of the immune response in limiting the persistence of transgene expression was highlighted by the persistence of serum IFN concentrations for over 200 days in beige/SCID immunodeficient mice. These studies suggest that serum concentration of secreted transgene products after gene delivery in small animal models may be highly predictive for larger species and will help define dosing strategies in human patients.

Caspase-8 gene transduction augments radiation-induced apoptosis in DLD-1 cells

Caspase-8 is a member of the cysteine protease family that plays a critical role in death receptor-mediated apoptosis. We previously demonstrated that adenovirally transduced caspase-8 efficiently induced apoptosis in tumor cells (Shinoura et al. (2000) Hum. Gene Ther. 11, 1123-1137). However, to ensure safety in clinical applications some devise for minimization of the dose of adenoviral vector required for sufficient antitumor effect is needed. In this study, we evaluated the proapoptotic effect in DLD-1 colon cancer cells of a combination of low-dose infection with an adenoviral vector expressing caspase-8 and X-ray irradiation. Under these conditions, X-ray irradiation strongly induced apoptosis whereas irradiation without transduction only had a trace proapoptotic effect. Overexpression of bcl-xL strongly blocked the activation of caspase-8 and induction of apoptosis, suggesting that adenovirally transduced caspase-8 was activated at a point downstream of mitochondria. This combination strategy may be a useful modality for gene therapy of colorectal cancer.

Head and neck cancer: gene therapy approaches. Part II: genes delivered

In Part I, the review summarised the safety of adenoviral vectors and provided insight into approaches being undertaken to improve the specificity, durability and potency of adenoviral delivery vehicles. In Part II, brief discussions are held regarding results of preclinical and clinical trials with a variety of different genes, which have demonstrated antitumour activity in squamous cell carcinoma of the head and neck region (HNSCC). Studies have been performed with a variety of immune modulatory genes. Preliminary results demonstrate activity with several cytokine genes, tumour antigen genes and co-stimulatory molecule genes. Despite only preliminary results, thus far, a theoretical attractive feature for the use of gene therapy for the enhancement of immune modulation is that local injection of the gene product appears to be well tolerated. It is also successful in inducing systemic immune response, potentially providing effect to metastatic sites distal from the injected site. Animal studies have confirmed efficacy in the use of specific targeting of molecules regulating cancer growth (EGF receptor [EGFR], super oxide dismutase [SOD], cyclin D1, E1A and Bcl-2). These approaches are discussed. However, the most significant clinical advances for the use of gene therapy in advanced HNSCC involves two agents: Adp53 and ONYX-015. Preliminary Phase I and II results suggest evidence of efficacy and justify accrual Phase III trials, which are currently ongoing.

Molecular biology of lung cancer: clinical implications

This review summarizes the rapidly expanding knowledge of the molecular pathogenesis of lung cancer. It is clear that respiratory epithelial cells require many genetic alterations to become invasive and metastatic cancer. Much more is to be learned, but with modern technology. Clinicians can detect "field cancerized" regions and preneoplastic and malignant cells, therefore offering the opportunity to intercede with biomarker-monitored prevention and early detection efforts. Such molecular screening and detection efforts will likely be coupled to advances in low-dose computed tomographic imaging, positron emission tomography scans, and other imaging modalities. Although this molecular marker approach has great potential, there is not yet a molecular marker validated in large prospective trials that has major independent predictive prognostic value. There is an urgent need for large, adequately powered, carefully designed prospective studies to identify clinically useful new biomarkers. Finally, new therapeutic strategies with genetic manipulation, small molecules, antibodies, vaccines, and, particularly, new drugs targeting specific biologic pathways found to be abnormal in lung provide for future optimism. Researchers need to define their individual value, especially when integrated with standard therapies.

Gene therapy for lung neoplasms

The field of gene therapy is still in its infancy, but significant accomplishments have been achieved. The ability to transfer genes safely and successfully into animals and patients clearly has been established. It is highly likely that in the near future, gene therapy will be shown to have clear therapeutic efficacy in diseases such as the treatment of hemophilia (using adeno-associated virus vectors) and the stimulation of angiogenesis in peripheral vascular disease and myocardial ischemia. Although only Phase 1 cancer gene therapy trials for thoracic malignancy have been conducted (usually in patients with large tumor burdens and at submaximal doses), there are some hints of efficacy at higher doses of vector in trials for localized malignancy. The studies reviewed in this article demonstrate the first attempts to use gene therapy vectors for lung cancer and mesothelioma. Although none of the diseases studied was "cured," valuable lessons have been learned from these trials, especially in defining the challenges of relatively inefficient and transient delivery of transgene in vivo. Using this knowledge, the second phase of gene therapy research has begun, with a strong focus on developing improved vector technology. Given the progress so far, there is little doubt that gene therapy will become a key approach for the treatment of thoracic malignancies in the near future.

Successful adenovirus-mediated wild-type p53 gene transfer in patients with bladder cancer by intravesical vector instillation

PURPOSE

To study safety, feasibility, and biologic activity of adenovirus-mediated p53 gene transfer in patients with bladder cancer.

PATIENTS AND METHODS

Twelve patients with histologically confirmed bladder cancer scheduled for cystectomy were treated on day 1 with a single intratumoral injection of SCH 58500 (rAd/p53) at cystoscopy at one dose level (7.5 x 10(11) particles) or a single intravesical instillation of SCH 58500 with a transduction-enhancing agent (Big CHAP) at three dose levels (7.5 x 10(11) to 7.5 x 10(13) particles). Cystectomies were performed in 11 patients on day 3, and transgene expression, vector distribution, and biologic markers of transgene activity were assessed by molecular and immunohistochemical methods in tumors and normal bladder samples.

RESULTS

Specific transgene expression was detected in tissues from seven of eight assessable patients treated with intravesical instillation of SCH 58500 but in none of three assessable patients treated with intratumoral injection of SCH 58500. Induction of RNA and protein expression of the p53 target gene p21/WAF1 was demonstrated in samples from patients treated with SCH 58500 instillation at higher dose levels. Distribution studies after intravesical instillation of SCH 58500 revealed both high transduction efficacy and vector penetration throughout the whole urothelium and into submucosal tumor cells. No dose-limiting toxicity was observed, and side effects were local and of transient nature.

CONCLUSION

Intravesical instillation of SCH 58500 combined with a transduction-enhancing agent is safe, feasible, and biologically active in patients with bladder cancer. Studies to evaluate the clinical efficacy of this treatment in patients with localized high-risk bladder cancer are warranted.

Facilitation of adenoviral wild-type p53-induced apoptotic cell death by overexpression of p33(ING1) in T.Tn human esophageal carcinoma cells

To investigate the effect of p33(ING1) on wild-type p53 gene therapy, T.Tn human esophageal carcinoma cells were stably transfected with p33(ING1) cDNA. Infection with Ad-p53 (recombinant adenovirus containing wild-type p53) into p33-transfected cells reduced cell viability, while infection with empty vector had little effect. This reduced viability was shown to be due to apoptotic cell death by the TUNEL (terminal deoxynucleotidyl transferase-mediated nick end-labeling) assay. Following infection with Ad-p53, levels of p53 were similar in p33-expressing cells and in the parental line. However, levels of p21 and Mdm2 were elevated in p33-transfected cells. Nonetheless, this enhanced expression of Mdm2 appeared to be ineffective in downregulating p53. Transient transfection with mutant Mdm2 prior to Ad-p53 infection provided a significant protection as compared with cells transfected with wild-type Mdm2. These results imply a synergistic effect between p33 and p53 in the induction of apoptosis of human esophageal carcinoma cells. A role for Mdm2 in this synergism is suggested.

Co-transduction of Apaf-1 and caspase-9 highly enhances p53-mediated apoptosis in gliomas

Mutation of the p53 gene plays a critical role in the development of cancer and response to cancer therapy. To analyze the mechanism of cancer development and to improve cancer therapy, it is important to assess which genes are downstream components of p53 in cancers, and whether the expression levels of these genes affect p53-mediated apoptosis. In this study, we transduced the wild type p53 gene along with the Apaf-1 and caspase-9 genes via adenovirus vectors into U251 and U-373MG glioma cells harbouring a mutated p53, and evaluated the degree of apoptosis. Co-induction of Apaf-1 and caspase-9 genes highly enhanced p53-mediated apoptosis in glioma cells. Induction of wild type p53 enhanced the expression levels of Bax, p21/WAF1, and Fas protein. To determine which gene is activated by wild type p53 induction and, in turn, activates Apaf-1 and caspase-9, we transduced the Bax, p21/WAF1 or Fas gene via adenovirus vector to U251 cells to achieve a similar expression level as that induced by the Adv for p53 in U251 cells. U251 cells transduced with Fas concomitant with the Apaf-1 and caspase-9 genes underwent drastic apoptosis. This suggests that induction of wild type p53 upregulates Fas, which in turn may play a role in the activation of Apaf-1 and caspase-9. These results are important for analyzing the mechanism of tumour development and for predicting the therapeutic effect of p53 replacement gene therapy in a particular patient.

Genetic and immunologic therapies for lung cancer

The poor overall survival of lung cancer patients treated with conventional therapies (chemotherapy, radiation therapy, and surgery) mandate novel approaches to treatment. Two novel approaches to treat lung cancer include gene therapy and immunologic therapy. Both treatments have preclinical data suggesting potential clinical use. In gene therapy, the identification of specific genes critical to the development of carcinogenesis has offered the opportunity to target these genes or their products for treatment. One possible gene therapy strategy that has been pursued in phase I and II lung cancer trials is to replace nonfunctional tumor suppressor genes such as mutated or deleted p53 genes with wild-type p53 genes by adenoviral gene transfer (Ad-p53). Transduction of the tumors has been accomplished with direct intratumoral injection or broncheoalveolar lavage. These studies have identified a potential role for radiosensitization of previously radiation-resistant local tumors by combining Ad-p53 with radiation or possibly chemoradiation. Another novel strategy that may allow systemic treatment of lung cancers is immunologic therapies. Immunotherapies have focused on augmenting the immune response to cancer by passive strategies (e.g., antivascular endothelial growth factor) or active nonspecific (e.g., interferon), or by specific (e.g., anti-idiotype therapy) strategies. These novel strategies are currently in clinical trials and will potentially allow additional therapeutic options for patients resistant to conventional therapies.

Emerging new therapies for chemotherapy-resistant cancer using adenoviral vectors

The treatment of cancer by genetic manipulation of either the tumor itself or the patient as a whole offers new avenues for the treatment of otherwise refractory cancers. Gene therapy seeks to correct underlying genetic defects in malignant tissue or to augment the host defense response or to promote selectivity of other therapies. Many innovative and exciting genetic targets have been recently identified. However, the field as a whole is still constrained by limitations of gene delivery. The most common vector for gene delivery is modified adenovirus. In this review, we survey a sampling of current therapeutic approaches that depend upon adenoviral delivery vehicles and outline the advantages and disadvantages of this vector system.

Prostate cancer gene therapy and the role of radiation

Even though prostate cancer is detected earlier than in the pre-PSA era, prostate cancer is the second leading cause of cancer mortality in the American male. Prostate cancer therapy is not ideal, especially for high-risk localized and metastatic cancer; therefore, investigators have sought new therapeutic modalities such as angiogenesis inhibitors, inhibitors of the cell signaling pathway, vaccines, and gene therapy. Gene therapy has emerged as potential therapy for both localized and systemic prostate cancer. Gene therapy has been shown to work supra-additively with radiation in controlling prostate cancer in vivo. With further technological advances in radiation therapy, gene therapy, and the understanding of prostate cancer biology, gene therapy will potentially have an important role in prostate cancer therapy.

The proline-rich domain of p53 is required for cooperation with anti-neoplastic agents to promote apoptosis of tumor cells

In some cell types either DNA damage or p53 expression leads to minimal cell death, while combining the two leads to a strong apoptotic response. To further understand features of p53 that contribute to this increased cell death we used clones of H1299 cells that express wild-type or several mutant forms of p53 under a tetracycline-regulated promoter. In these cells the induction of wild-type p53 leads to significant apoptosis only when combined with exposure to a number of chemotherapeutic agents. A common target of p53, p21, is itself not sufficient to cause apoptosis in the presence of these chemotherapeutic compounds. Many agents also effectively increase cell death when a transcriptionally-defective p53, p53([gln22ser23]), is induced, although a dramatic exception is treatment with 5-FU, which strongly cooperates with wild-type but not p53([gln22ser23]). Our results with 5-FU thus show that genetically separable functions of p53 are involved in its ability to respond to DNA-damaging agents to induce apoptosis. Notably as well, deleting the C-terminal 30 amino acids of p53 does not affect this cooperative effect with DNA-damaging agents. By contrast, a p53 mutant lacking the PXXP-domain between residues 60-90, while at least partially transcriptionally-competent, cannot be rendered apoptotic by any compounds that we tested. Thus the PXXP domain provides an essential component of the ability of p53 to respond to DNA-damaging agents to cause cell death.

TP53: a key gene in human cancer

TP53 is mutated in most types of human cancers and is one of the most popular genes in cancer research. The p53 protein is a sensor of multiple forms of genotoxic, oncogenic and non-genotoxic stress. It suppresses growth and controls survival of stressed cells, and as such, is the focal point of selection pressures in tissues exposed to carcinogens or to oncogenic changes. Thus, the clonal expansion of cells with mutations in TP53 may be seen as the result of a selection process intrinsic to the natural history of cancer. In this review, we discuss the nature of these various forms of selection pressure. We present a hypothesis to explain why TP53 is often mutated as either an early or a late event in cancer. Furthermore, we also summarise current knowledge on the molecular consequences of mutation for loss of wild-type protein function, dominant-negative activity, and a possible gain of oncogenic function.

Novel approaches to the treatment of non-small cell lung cancer

Prognosis of non-small cell lung carcinomas (NSCLC) remains poor, especially in advanced disease. The introduction of new cytotoxic agents in the past decade did only attain minor improvements in survival. It is rather clear that chemotherapy may have reached a plateau, and that it will be difficult to obtain better results in advanced NSCLC by chemotherapy alone. Novel treatment modalities are urgently needed in advanced NSCLC. Backed-up by advances in the understanding of tumor cell biology, a new generation of anticancer agents specifically directed at targets such as tyrosine kinases, farnesyl transferase, angiogenesis factors, matrixmetalloproteinases and oncogenes has been developed in recent years. In this review, we give a brief summary of the state-of-the-art treatment of NSCLC, highlighting its limitations. Novel systemic approaches are then discussed in detail with focus on their mechanistic rationale, stage of clinical development and possible drawbacks. Finally, perspectives of future applications and impact on the treatment of NSCLC are also discussed.

Connexin 26 gene therapy of human bladder cancer: induction of growth suppression, apoptosis, and synergy with Cisplatin

The connexin 26 (Cx26) gene encodes a protein involved in gap junctional intercellular communication and is a putative tumor suppressor. We constructed a Cx26 adenovirus vector (Ad-Cx26) and used it to infect human bladder cancer cell lines UM-UC-3, UM-UC-6, UM-UC-14, and T24. Infection with Ad-Cx26 suppressed the growth of these cell lines in vitro and prevented tumor formation in vivo. Cell cycle accumulation or arrest at the G(1) phase was noted in UM-UC-3 cells and at the G(2)/M phase in UM-UC-6, UM-UC-14, and T24 cells. Apoptosis was noted in UM-UC-3, UM-UC-6, and UM-UC-14 cells both in vitro and in vivo. These effects were not seen with control adenovirus (Ad-CTR) or mock infection. Ad-Cx26 did not significantly alter the growth of the immortalized normal human bladder cell line SV-HUC. Direct injection of Ad-Cx26 into established UM-UC-3 and UM-UC-14 tumors in nude mice resulted in Cx26 expression, apoptosis, and significantly decreased growth compared with Ad-CTR treated tumors. Delayed resumption of tumor growth was associated with loss of Cx26 expression. Combination therapy with Ad-Cx26 and cisplatin resulted in decreased growth in vitro compared with either agent alone. We explored combination therapy with Ad-Cx26 and cisplatin to improve the in vivo efficacy of Cx26 gene therapy. In vivo therapy with Ad-Cx26 and cisplatin resulted in long-term suppression of tumor growth. These data demonstrate that combining gene and chemotherapy can result in dramatic synergy in vivo.

Gene transfer into solid tumours--is a special application device beneficial?

The replacement of inactivated tumour suppressor genes is a promising approach in cancer therapy. The aim of this study was to evaluate the influence of technical determinants on the efficiency of adenoviral-mediated gene transfer into solid tumours. Therefore, we compared the efficacy of two different injection needle types, a conventional needle and a modified needle characterised by perforations at the side of the shaft in vivo. The total amount of adenoviral vector DNA and the activity of the transferred reporter gene were quantitatively analysed by polymerase chain reaction (PCR) specific for the E4 region of the Ad vector genome and the beta-galactosidase assay, respectively. The levels of adenoviral DNA, as well as the total beta-galactosidase activity, varied widely, but were not significantly different for the two groups. These results suggest, that the efficiency of intratumoral gene transfer cannot be improved by the design of the application device.

Cancer gene therapy: fringe or cutting edge?

Direct targeting of cancer cells with gene therapy has the potential to treat cancer on the basis of its molecular characteristics. But although laboratory results have been extremely encouraging, many practical obstacles need to be overcome before gene therapy can fulfil its goals in the clinic. These issues are not trivial, but seem less formidable than the challenge of killing cancers selectively and rationally--a challenge that has been successfully addressed.

An evolutionary-game model of tumour-cell interactions: possible relevance to gene therapy

Evolutionary games have been applied as simple mathematical models of populations where interactions between individuals control the dynamics. Recently, it has been proposed to use this type of model to describe the evolution of tumour cell populations with interactions between cells. We extent the analysis to allow for synergistic effects between cells. A mathematical model of a tumour cell population is presented in which population-level synergy is assumed to originate through the interaction of triplets of cells. A threshold of two cooperating cells is assumed to be required to produce a proliferative advantage. The mathematical behaviour of this model is explored. Even this simple synergism (minor clustering effect) is sufficient to generate qualitatively different cell-population dynamics from the models published previously. The most notable feature of the model is the existence of an unstable internal equilibrium separating two stable equilibria. Thus, cells of a malignant phenotype can exist in a stable polymorphism, but may be driven to extinction by relatively modest perturbations of their relative frequency. The proposed model has some features that may be of interest to biological interpretations of gene therapy. Two prototypical strategies for gene therapy are suggested, both of them leading to extinction of the malignant phenotype: one approach would be to reduce the relative proportion of the cooperating malignant cell type below a certain critical value. Another approach would be to increase the critical threshold value without reducing the relative frequency of cells of the malignant phenotype.

Adenovirus-mediated transfer of heme oxygenase-1 cDNA attenuates severe lung injury induced by the influenza virus in mice

Heme oxygenase-1 (HO-1) is an inducible heat shock protein that regulates heme metabolism to form bilirubin, ferritin and carbon monoxide. Based on recent evidence that HO-1 is involved in the resolution of inflammation by modulating apoptotic cell death or cytokine expression, the present study examined whether overexpression of exogenous HO-1 gene transfer provides a therapeutic effect on a murine model of acute lung injury caused by the type A influenza virus. We demonstrate herein that the transfer of HO-1 cDNA resulted in (1) suppression of both pathological changes and intrapulmonary hemorrhage; (2) enhanced survival of animals; and (3) a decrease of inflammatory cells in the lung. TUNEL analysis revealed that HO-1 gene transfer reduced the number of respiratory epithelial cells with DNA damage, and caspase assay suggested that HO-1 suppressed lung injury via a caspase-8-mediated pathway. These findings suggest the feasibility of HO-1 gene transfer to treat lung injury induced by a pathogen commonly seen in the clinical setting. Since oxidative stress and lung injury are involved in many lung disorders, such as pneumonia induced by a variety of microorganisms and pulmonary fibrosis, HO-1 may be useful for wider clinical applications in gene therapy targeting lung disorders including acute pneumonia and pulmonary fibrosis.

Human papillomavirus and vulval intra-epithelial neoplasia

The association between human papillomavirus vulval skin infection and vulval intra-epithelial neoplasia is strong. Vulval skin carcinogenesis is, however, multifactorial. Both human papillomavirus oncogenic subtype infection and p53 mutations are likely to contribute to the risk of malignant transformation of normal epithelium. The long-term cumulative risk of developing vulval squamous carcinoma following the diagnosis of high-grade vulval intra-epithelial neoplasia is thought to be approximately 6% per decade, but observational data supporting this are mostly non-population based and retrospective. Surgical treatment may reduce this risk, but the rates of recurrence and treatment-related morbidity are high. Surveillance should therefore be discussed as an alternative. New treatments being researched include photodynamic therapy, human papillomavirus vaccines, immunotherapy, immune modulators and gene therapy. The advantages of these new modalities over surgery is the potential to preserve body image and sexual functioning while targeting more generalized epithelial molecular dysfunction.

Adenovirus-mediated transfer of the p53 family genes, p73 and p51/p63 induces cell cycle arrest and apoptosis in colorectal cancer cell lines: potential application to gene therapy of colorectal cancer

p53 gene therapy is being tested clinically for the treatment of human cancer, however, some cancer models (in vivo and in vitro) are resistant to p53. To explore the potential use of two p53 homologues, p73 and p51/p63, in cancer gene therapy, we introduced p53, p73 and p51/p63 into colorectal cancer cell lines via adenoviral vectors, and compared their effects on cell growth. Among 10 cell lines tested, six cell lines displayed a similar response following transduction of p53, p73beta or p51A/p63gamma; two lines underwent cell-cycle arrest, three lines exhibited apoptosis and one line showed no-effect following transduction. The effect on cell-cycle progression was variable in the other four cell lines. Interestingly, three cell lines were resistant to p53-mediated apoptosis, including two lines having endogenous wild-type p53 alleles, but underwent apoptosis after transduction of p73beta or p51A/p63gamma. Similar to p53, transduction of p51A/p63gamma induced extensive apoptosis when combined with adriamycin or X-radiation in SW480 cells, which are normally resistant to apoptosis. Transduction of p73beta and p51A/p63gamma also reduced the tumorigenicity of two colorectal cancer cells in vivo. These results suggest that adenovirus-mediated p73beta and p51A/p63gamma transfer are potential novel approaches for the treatment of human cancers, particularly for tumors that are resistant to p53 gene therapy.

Improvement of porphyrin cellular delivery and activity by conjugation to a carrier peptide

The chemical nuclease metalloporphyrin (manganese(III) porphyrin) can cleave DNA irreversibly and can thus constitute a potential antitumor drug. However, these molecules show low permeability to cell surface membranes. We report here the conjugation of an amphipathic carrier peptide to improve considerably its cellular delivery. The metalloporphyrin-peptide conjugate can be internalized by cells within only 5 min of incubation with a yield as high as 80%. Furthermore, the metalloporphyrin-peptide conjugate is able to cleave in vitro high or low molecular weight DNA to the same extend as metalloporphyrin alone without affecting the sequence-specific cleaving activity of the porphyrin. The conjugate is 100-fold more efficient at inducing tumor cells death than the free metalloporphyrin via a mechanism involving genomic DNA cleavage. The results are promising for further therapeutic applications with antitumor drugs such as metalloporphyrin, and also with other existing drugs by using a carrier peptide system in order to improve the cellular uptake of such molecules.

Targeting tumor angiogenesis with gene therapy

A recent target of cancer gene therapy is tumor angiogenesis. An appealing feature of gene therapy targeting the tumor vasculature is that it is readily accessible, particularly when the carrier and its gene are administered systemically. Several gene-based viral and nonviral therapies that target tumor angiogenesis have demonstrated the "proof of principle" of antiangiogenic therapy in preclinical models. The utility of antiangiogenic gene therapy in a clinical setting will depend in large part on developing vectors with minimal toxicity and with increased in vivo transfection efficiency. In this review, we discuss the current status and future directions of antiangiogenic gene therapy.

Amifostine (WR2721) restores transcriptional activity of specific p53 mutant proteins in a yeast functional assay

Many p53 mutants found in human cancer have an altered ability to bind DNA and transactivate gene expression. Re-expression of functional p53 in cells in which the endogenous TP53 gene is inactivated has been demonstrated to restore a non-tumorigenic phenotype. Pharmacological modulation of p53 mutant conformation may therefore represent a mechanism to reactivate p53 function and consequently improve response to radio- and chemotherapy. We have recently reported that the radio- and chemoprotector Amifostine (WR2721, Ethyol) activates wild-type p53 in cultured mammalian cells. In the present study, we have used a yeast functional assay to investigate the effect of WR2721 on the transcriptional activity of p53. WR2721 restored this activity in a temperature-sensitive mutant V272M (valine to methionine at codon 272) expressed at the non-permissive temperature and it also partially restored the transcriptional activity of several other conformationally flexible p53 mutants. The results indicate that the yeast functional assay may be used to identify compounds that modulate p53 activity, with potential therapeutic implications.

Adenovirus-mediated transfer of p53 augments hyperthermia-induced apoptosis in U251 glioma cells

PURPOSE

Hyperthermia kills glioma cells by inducing apoptosis and is thereby an effective therapeutic modality for the treatment of malignant gliomas. However, cells harboring mutated p53 are refractory to hyperthermia-induced apoptosis. In this study, we assessed whether or not adenovirus (Adv)-mediated transduction of p53 overrides this resistant mechanism.

METHODS AND MATERIALS

We transduced the p53 wild-type tumor suppressor gene into U251 glioma cells harboring mutated p53 using Adv vectors in combination with hyperthermia (43, 44.5 degrees C), and evaluated the degree of cell death and apoptosis.

RESULTS

The percentage of cells that had died, as measured by trypan blue staining, among U251 cells infected with the Adv for p53 (Adv-p53) and treated with hyperthermia, was significantly higher than the percentage of cells that had died among U251 cells infected with Adv-p53 and not treated with hyperthermia, or those infected with the control Adv for dE (Adv-dE) and treated with hyperthermia. The degree of apoptosis, measured at 24 h after treatment, in hyperthermia-treated U251 cells infected with Adv-p53 (43 degrees C, 73%; 44.5 degrees C, 92%) was much higher than that infected with Adv-p53 (41%), or that infected with control Adv-dE and treated with hyperthermia (43 degrees C, 1.3%; 44.5 degrees C, 19%). Treatment with combined hyperthermia and Adv-p53 infection induced cleavage of caspase-3 in U251 cells.

CONCLUSION

These results indicate that Adv-mediated transduction of p53 would render glioma cells highly sensitive to hyperthermia.

Cell differentiation and chemotherapy influence p53 and Mdm2 immunoreactivity in human HT29 colon cancer cells grown in scid mice

Absence of a functional p53 gene product can lead to increased p53 accumulation in cancer cells. In this contribution, the association between cell differentiation, chemotherapy and p53 immunoreactivity in human HT29 colon cancer cells grown in scid mice as undifferentiated cells and as mucin containing signet-ring cells was investigated. Mutated p53 was more frequently expressed in the undifferentiated tumour cells than in the signet-ring cells. 5-fluorouracil (5FU) treatment resulted in a substantial increase in the p53-positive signet-ring cell population (from 17% to 45%) and in an increased Mdm2 immunoreactivity. These findings indicate that mutated p53 expression is related to the differentiation pattern and that tumour cells devoid of mutated p53 immunoreactivity are preferentially eliminated by 5FU treatment.

Immunotherapy of established tumors in mice by intratumoral injection of an adenovirus vector harboring the human IL-2 cDNA: induction of CD8(+) T-cell immunity and NK activity

Intratumoral (i.t.) injections of an adenovirus encoding the human interleukin-2 (IL-2) under the control of the RSV (Ad-pRSV-IL-2) or CMV (Ad-pCMV-IL-2) promoter were performed in established mastocytoma P815 tumors in B6D2 mice. Both early and long-term survival were found increased in mice treated with Ad-pCMV-IL-2 as compared with those obtained with Ad-pRSV-IL-2: tumor regression was observed in 30--50% of mice for the former and 5--15% for the latter. Difference in efficacy between the two vectors was directly correlated to the amount of IL-2 produced i.t. between 24 and 48 hours postinjection, which reached 10--20 ng/tumor for Ad-pCMV-IL-2 and 0.3--0.5 ng/tumor for Ad-pRSV-IL-2. In both cases, expression in the tumor was clearly detectable for a period of 7--10 days postinjection. Serum IL-2 was not detectable in mice treated with Ad-pRSV-IL-2, whereas expression peaked at a total of 1--2 ng at 24 hours but declined very rapidly in the Ad-pCMV-IL-2-treated group. Constant production of IL-2 inside the tumor was necessary for successful therapy because i.t. injections of recombinant IL-2 at levels up to 1 microg for five consecutive days did not lead to antitumoral activity. Evidence of induced systemic immunity following Ad-pCMV-IL-2 injections was obtained from rechallenge experiments in which tumor-free mice after treatment rejected a subsequent contralateral injection of a lethal dose of P815 tumor cells and from the observation that regression of nontreated tumors occurred in animals bearing bilateral tumors that were treated i.t. in a single tumor with Ad-pCMV-IL-2. P815-specific cytotoxic T lymphocytes (CTL) were found specifically in spleen cells from cured mice or rechallenged mice but not in control mice. Interestingly, limiting dilution analysis of anti-P815 CTL precursor (CTLp) frequency revealed a significant increase in mice cured of their tumor as compared to that obtained in naive mice or control mice treated or not with Ad-IL-2 but whose tumor was growing. In vivo depletion of T-cell subsets, as well as natural killer cells at the time of i.t. injections with Ad-pCMV-IL-2, demonstrated that both CD8(+) T cells and natural killer cells, but not CD4(+) T cells, were required for successful therapy. Finally, mice preimmunized with Ad-null viruses were severely compromised in their capacity to eradicate established P815 tumors after Ad-pCMV-IL-2 therapy, at least when neutralizing antibody titers reached a critical level.