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Reddy M, Ravina M, Goyal H, Kumar A, Kote R. Nivolumab and Cabozantinib Immunotherapy Induced Thyroid Dysfunction Detected on 18 F-FDG PET/CT in Renal Cell Carcinoma. Clin Nucl Med 2024; 49:e523-e524. [PMID: 39192514 DOI: 10.1097/rlu.0000000000005407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
ABSTRACT Targeted immunotherapy became the most advanced approach for cancer treatment. Programmed death-1 (PD-1) expressed on activated T cells can reverse immune suppression and cause T-cell activation. Nivolumab, a PD-1 immune checkpoint inhibitor antibody that is a fully human immunoglobulin G4, blocks PD-1 and promotes antitumor immunity. Cabozantinib (tyrosine kinase inhibitor) inhibits the tyrosine kinase activity of vascular endothelial growth factor receptors 1, 2, and 3. As a result of enhancing immune response in normal tissues, immune-related adverse events can occur. Thyroid dysfunction is a common form of immune-related adverse event and seen on 18 F-FDG PET/CT scans post therapy.
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Affiliation(s)
| | | | | | - Amit Kumar
- Medical Oncology, All India Institute of Medical Sciences, Raipur, India
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Buttar C, Lakhdar S, Nassar M, Landry I, Munira M. Cabozantinib-Induced Severe Cardiac Dysfunction: A Case Report and a Systematic Review of the Literature. Cureus 2022; 14:e23740. [PMID: 35509750 PMCID: PMC9057634 DOI: 10.7759/cureus.23740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/01/2022] [Indexed: 11/11/2022] Open
Abstract
Cabozantinib is a novel multitargeted receptor tyrosine kinase inhibitor commonly used to treat advanced renal cell carcinoma. Cardiotoxicity is not a previously well-described adverse effect of cabozantinib. We present a rare case of a 74-year-old male with a history of renal cell carcinoma who underwent partial nephrectomy. The patient had been recently started on cabozantinib for advanced metastatic renal cell carcinoma. He developed acute onset of heart failure and subclinical hypothyroidism within nine months of treatment. Our case report postulates a causal relationship between cabozantinib and the development of non-ischemic cardiomyopathy.
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McGregor B, Mortazavi A, Cordes L, Salabao C, Vandlik S, Apolo AB. Management of adverse events associated with cabozantinib plus nivolumab in renal cell carcinoma: A review. Cancer Treat Rev 2022; 103:102333. [PMID: 35033866 PMCID: PMC9590624 DOI: 10.1016/j.ctrv.2021.102333] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 12/16/2021] [Accepted: 12/20/2021] [Indexed: 02/03/2023]
Abstract
Tyrosine kinase inhibitors have been successfully developed in combination with immune checkpoint inhibitors to treat advanced renal cell carcinoma (RCC), further advancing treatment. While safety profiles are generally manageable with combination regimens, overlapping adverse events (AEs) and immune-related AEs can make treatment more complex. The CheckMate 9ER study evaluated the tyrosine kinase inhibitor cabozantinib in combination with the anti-programmed cell death protein-1 antibody nivolumab in patients with previously untreated advanced RCC. Cabozantinib + nivolumab demonstrated superiority over sunitinib for progression-free survival, overall survival, and objective response rate. These outcomes supported the approval of cabozantinib + nivolumab as a first-line therapy for advanced RCC. The safety profile was manageable with prophylaxis, supportive care, dose holds and reductions for cabozantinib, and dose holds and immunosuppressive therapy for nivolumab. This review discusses the safety results of CheckMate 9ER and provides guidance on managing some of the more clinically relevant AEs with a focus on overlapping AEs, including diarrhea, elevated amylase/lipase, hepatotoxicity, dermatologic reactions, fatigue, endocrine disorders, and nephrotoxicity. We discuss AE management strategies (prophylaxis, supportive care, dose modification, and immunosuppressive therapy), and provide recommendations for identifying the causative agent of overlapping AEs and for consulting specialists about organ-specific immune-related AEs. Optimizing AE management can maintain tolerability and should be a priority with cabozantinib + nivolumab treatment.
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Affiliation(s)
| | - Amir Mortazavi
- Division of Medical Oncology, Department of Internal Medicine, College of Medicine, The Ohio State University, and the Comprehensive Cancer Center, Columbus, OH, USA
| | - Lisa Cordes
- National Cancer Institute and the Office of Clinical Research at the National Institutes of Health, Bethesda, MD, USA
| | | | - Susan Vandlik
- The Ohio State University Wexner Medical Center and the Comprehensive Cancer Center, Columbus, OH, USA
| | - Andrea B Apolo
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA.
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Basolo A, Matrone A, Elisei R, Santini F. Effects of tyrosine kinase inhibitors on thyroid function and thyroid hormone metabolism. Semin Cancer Biol 2021; 79:197-202. [PMID: 33476722 DOI: 10.1016/j.semcancer.2020.12.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/14/2020] [Indexed: 02/06/2023]
Abstract
The increasing knowledge of the molecular mechanisms in the cell signaling pathways of malignant cells, has recently led to the discovery of several tyrosine kinases (TKs), mainly TK receptors (TKR), which play a major role in the pathogenesis of many types of cancer. These receptors, physiologically involved in cell growth and angiogenesis, may harbor mutations or be overexpressed in malignant cells, and represent a target for anticancer therapy. Indeed, several therapeutic agents targeting specific altered pathways such as RET, BRAF, RAS, EGFR and VEGFR, have been identified. Tyrosine kinase inhibitors (TKIs) affect TK dependent oncogenic pathways by competing with ATP binding sites of the TK domain, thus blocking the activity of the enzyme, and thereby inhibiting the growth and spread of several cancers. Although the therapeutic action may be very effective, these molecules, due to their mechanism of multitargeted inhibition, may produce adverse events involving several biological systems. Both hypothyroidism and thyrotoxicosis have been reported during treatment with TKI, as well as an effect on the activity of enzymes involved in thyroid hormone metabolism. The pathogenic mechanisms leading to thyroid dysfunction and changes in serum thyroid function tests occurring in patients on TKI are reviewed and discussed in this manuscript.
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Affiliation(s)
- Alessio Basolo
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Antonio Matrone
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Rossella Elisei
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - Ferruccio Santini
- Department of Clinical and Experimental Medicine, Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
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Woo HY, Heo J. The role of c-MET inhibitors in advanced hepatocellular carcinoma: now and future. ANNALS OF TRANSLATIONAL MEDICINE 2021; 8:1617. [PMID: 33437816 PMCID: PMC7791211 DOI: 10.21037/atm-20-3387] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
- Hyun Young Woo
- Department of Internal Medicine, College of Medicine, Pusan National University and Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jeong Heo
- Department of Internal Medicine, College of Medicine, Pusan National University and Medical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Cabozantinib for neurofibromatosis type 1-related plexiform neurofibromas: a phase 2 trial. Nat Med 2021; 27:165-173. [PMID: 33442015 PMCID: PMC8275010 DOI: 10.1038/s41591-020-01193-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 11/25/2020] [Indexed: 01/29/2023]
Abstract
Neurofibromatosis type 1 (NF1) plexiform neurofibromas (PNs) are progressive, multicellular neoplasms that cause morbidity and may transform to sarcoma. Treatment of Nf1fl/fl;Postn-Cre mice with cabozantinib, an inhibitor of multiple tyrosine kinases, caused a reduction in PN size and number and differential modulation of kinases in cell lineages that drive PN growth. Based on these findings, the Neurofibromatosis Clinical Trials Consortium conducted a phase II, open-label, nonrandomized Simon two-stage study to assess the safety, efficacy and biologic activity of cabozantinib in patients ≥16 years of age with NF1 and progressive or symptomatic, inoperable PN ( NCT02101736 ). The trial met its primary outcome, defined as ≥25% of patients achieving a partial response (PR, defined as ≥20% reduction in target lesion volume as assessed by magnetic resonance imaging (MRI)) after 12 cycles of therapy. Secondary outcomes included adverse events (AEs), patient-reported outcomes (PROs) assessing pain and quality of life (QOL), pharmacokinetics (PK) and the levels of circulating endothelial cells and cytokines. Eight of 19 evaluable (42%) trial participants achieved a PR. The median change in tumor volume was 15.2% (range, +2.2% to -36.9%), and no patients had disease progression while on treatment. Nine patients required dose reduction or discontinuation of therapy due to AEs; common AEs included gastrointestinal toxicity, hypothyroidism, fatigue and palmar plantar erythrodysesthesia. A total of 11 grade 3 AEs occurred in eight patients. Patients with PR had a significant reduction in tumor pain intensity and pain interference in daily life but no change in global QOL scores. These data indicate that cabozantinib is active in NF1-associated PN, resulting in tumor volume reduction and pain improvement.
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Apolo AB, Nadal R, Tomita Y, Davarpanah NN, Cordes LM, Steinberg SM, Cao L, Parnes HL, Costello R, Merino MJ, Folio LR, Lindenberg L, Raffeld M, Lin J, Lee MJ, Lee S, Alarcon SV, Yuno A, Dawson NA, Allette K, Roy A, De Silva D, Lee MM, Sissung TM, Figg WD, Agarwal PK, Wright JJ, Ning YM, Gulley JL, Dahut WL, Bottaro DP, Trepel JB. Cabozantinib in patients with platinum-refractory metastatic urothelial carcinoma: an open-label, single-centre, phase 2 trial. Lancet Oncol 2020; 21:1099-1109. [PMID: 32645282 PMCID: PMC8236112 DOI: 10.1016/s1470-2045(20)30202-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 03/12/2020] [Accepted: 03/19/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cabozantinib is a multikinase inhibitor of MET, VEGFR, AXL, and RET, which also has an effect on the tumour immune microenvironment by decreasing regulatory T cells and myeloid-derived suppressor cells. In this study, we examined the activity of cabozantinib in patients with metastatic platinum-refractory urothelial carcinoma. METHODS This study was an open-label, single-arm, three-cohort phase 2 trial done at the National Cancer Institute (Bethesda, MD, USA). Eligible patients were 18 years or older, had histologically confirmed urothelial carcinoma or rare genitourinary tract histologies, Karnofsky performance scale index of 60% or higher, and documented disease progression after at least one previous line of platinum-based chemotherapy (platinum-refractory). Cohort one included patients with metastatic urothelial carcinoma with measurable disease as defined by Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. Two additional cohorts that enrolled in parallel (patients with bone-only urothelial carcinoma metastases and patients with rare histologies of the genitourinary tract) were exploratory. Patients received cabozantinib 60 mg orally once daily in 28-day cycles until disease progression or unacceptable toxicity. The primary endpoint was investigator-assessed objective response rate by RECIST in cohort one. Response was assessed in all patients who met the eligibility criteria and who received at least 8 weeks of therapy. All patients who received at least one dose of cabozantinib were included in the safety analysis. This completed study is registered with ClinicalTrials.gov, NCT01688999. FINDINGS Between Sept 28, 2012, and Oct, 20, 2015, 68 patients were enrolled on the study (49 in cohort one, six in cohort two, and 13 in cohort three). All patients received at least one dose of cabozantinib. The median follow-up was 61·2 months (IQR 53·8-70·0) for the 57 patients evaluable for response. In the 42 evaluable patients in cohort one, there was one complete response and seven partial responses (objective response rate 19%, 95% CI 9-34). The most common grade 3-4 adverse events were fatigue (six [9%] patients), hypertension (five [7%]), proteinuria (four [6%]), and hypophosphataemia (four [6%]). There were no treatment-related deaths. INTERPRETATION Cabozantinib has single-agent clinical activity in patients with heavily pretreated, platinum-refractory metastatic urothelial carcinoma with measurable disease and bone metastases and is generally well tolerated. Cabozantinib has innate and adaptive immunomodulatory properties providing a rationale for combining cabozantinib with immunotherapeutic strategies. FUNDING National Cancer Institute Intramural Program and the Cancer Therapy Evaluation Program.
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Affiliation(s)
- Andrea B Apolo
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA.
| | - Rosa Nadal
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Yusuke Tomita
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Nicole N Davarpanah
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Lisa M Cordes
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Seth M Steinberg
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Liang Cao
- Genetics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Howard L Parnes
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Rene Costello
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Maria J Merino
- Laboratory of Pathology, Magnuson Clinical Center, Bethesda, MD, USA
| | - Les R Folio
- Radiology and Imaging Sciences, Magnuson Clinical Center, Bethesda, MD, USA
| | - Liza Lindenberg
- Molecular Imaging Program, Magnuson Clinical Center, Bethesda, MD, USA
| | - Mark Raffeld
- Laboratory of Pathology, Magnuson Clinical Center, Bethesda, MD, USA
| | - Jeffrey Lin
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Min-Jung Lee
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Sunmin Lee
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Sylvia V Alarcon
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Akira Yuno
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Nancy A Dawson
- Lombardi Comprehensive Cancer Center, Medstar Georgetown University Hospital, Washington DC, USA
| | - Kimaada Allette
- Genitourinary Malignancies Branch, Center for Cancer Research, Magnuson Clinical Center, Bethesda, MD, USA
| | - Arpita Roy
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Dinuka De Silva
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Molly M Lee
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Tristan M Sissung
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - William D Figg
- Genitourinary Malignancies Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Piyush K Agarwal
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - John J Wright
- Genitourinary Malignancies Branch, Center for Cancer Research, Magnuson Clinical Center, Bethesda, MD, USA
| | - Yangmin M Ning
- Genitourinary Malignancies Branch, Center for Cancer Research, Magnuson Clinical Center, Bethesda, MD, USA
| | - James L Gulley
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - William L Dahut
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Donald P Bottaro
- Urologic Oncology Branch, Magnuson Clinical Center, Bethesda, MD, USA
| | - Jane B Trepel
- Developmental Therapeutics Branch, Magnuson Clinical Center, Bethesda, MD, USA
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Gabora K, Piciu A, Bădulescu IC, Larg MI, Stoian IA, Piciu D. Current evidence on thyroid related adverse events in patients treated with protein tyrosine kinase inhibitors. Drug Metab Rev 2019; 51:562-569. [PMID: 31718371 DOI: 10.1080/03602532.2019.1687512] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Tyrosine kinase inhibitors (TKI) are gaining more ground in oncology, they are widely used in the treatment of multiple types of cancers; still important side effects limit their efficacy. The aim of this study is to evaluate the existing medical literature on TKI induced thyroid dysfunction, to assess the adverse effects of targeted therapy on thyroid function in oncological patients and to evaluate the effects of thyroid dysfunction on disease prognosis. We included in this review 22 original studies published between 2010 and 2019. We used the PubMed database to search for articles upon the development of hypothyroidism and hyperthyroidism in TKI treated patients. After a careful review of the existing literature, we selected the relevant studies and cross-referenced the bibliography of each paper. A number of 1641 patients were included in our review. We found that thyroid dysfunction is not a rare side effect of TKI treatment, approximately 33% of the total number of patients presented clinical hypothyroidism. We also studied the necessity of thyroid hormone substitution treatment, a quarter of evaluated patients needed substitution therapy. Multiple studies showed that there is a link between a patient developing hypothyroidism and progression free survival. Hypothyroidism is a frequent side effect of TKI treatment, which affects the quality of life, sometimes even determines physicians to stop TKI treatment altogether. Our study underlines the necessity of TSH baseline testing and monitoring in patients treated with TKI agents.
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Affiliation(s)
- Katalin Gabora
- Department of Nuclear Medicine, Prof. Dr. Ion Chiricuță Institute of Oncology, Cluj Napoca, Romania.,Iuliu Hațieganu Univerisity of Pharmacy and Medicine, Cluj Napoca, Romania
| | - Andra Piciu
- Iuliu Hațieganu Univerisity of Pharmacy and Medicine, Cluj Napoca, Romania
| | | | - Maria Iulia Larg
- Department of Nuclear Medicine, Prof. Dr. Ion Chiricuță Institute of Oncology, Cluj Napoca, Romania.,Iuliu Hațieganu Univerisity of Pharmacy and Medicine, Cluj Napoca, Romania
| | - Ioan-Adrian Stoian
- Iuliu Hațieganu Univerisity of Pharmacy and Medicine, Cluj Napoca, Romania
| | - Doina Piciu
- Department of Nuclear Medicine, Prof. Dr. Ion Chiricuță Institute of Oncology, Cluj Napoca, Romania.,Iuliu Hațieganu Univerisity of Pharmacy and Medicine, Cluj Napoca, Romania
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Jannin A, Penel N, Ladsous M, Vantyghem MC, Do Cao C. Tyrosine kinase inhibitors and immune checkpoint inhibitors-induced thyroid disorders. Crit Rev Oncol Hematol 2019; 141:23-35. [PMID: 31202955 DOI: 10.1016/j.critrevonc.2019.05.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/21/2019] [Accepted: 05/27/2019] [Indexed: 12/11/2022] Open
Abstract
Recently, tyrosine kinase inhibitors (TKI) and immune checkpoint inhibitors (ICPIs) have emerged as new classes of anticancer therapies. Although generally considered less toxic than cytotoxic chemotherapy, these new drugs can cause significant unanticipated side effects including thyroid dysfunction. This review provides a literature assessment of thyroid dysfunctions induced by TKI and ICPIs. We intend to define for these two classes the frequency of thyroid involvement, the potential mechanisms that result in this toxicity, the clinical-biological impact and the therapeutic management. Detection of thyroid dysfunction requires monitoring of TSH, in combination with free T4 if needed and, depending on the clinical impact and the kinetics of biological abnormalities, starting symptomatic treatment of hyperthyroidism and/or correcting hypothyroidism.
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Affiliation(s)
- Arnaud Jannin
- Department of Endocrinology and Metabolism, CHU Lille, 59037 Lille, France.
| | - Nicolas Penel
- Medical Oncology Department, Oscar Lambret Cancer Centre, Lille, France; Medical Oncology Department, CHU Lille, 59037, Lille France.
| | - Miriam Ladsous
- Department of Endocrinology and Metabolism, CHU Lille, 59037 Lille, France.
| | - Marie Christine Vantyghem
- Department of Endocrinology and Metabolism, CHU Lille, 59037 Lille, France; UMR 1190 Translational Research in Diabetes INSERM, 59000 Lille, France.
| | - Christine Do Cao
- Department of Endocrinology and Metabolism, CHU Lille, 59037 Lille, France.
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Di Nunno V, Frega G, Gatto L, Brandi G, Massari F. Hypothyroidism in patients with hepatocellular carcinoma receiving cabozantinib: an unassessed issue. Future Oncol 2019; 15:563-565. [PMID: 30648889 DOI: 10.2217/fon-2018-0758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Affiliation(s)
| | - Giorgio Frega
- Department of Experimental, Diagnostic & Specialty Medicine, Oncology Unit, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Lidia Gatto
- Department of Experimental, Diagnostic & Specialty Medicine, Oncology Unit, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Giovanni Brandi
- Department of Experimental, Diagnostic & Specialty Medicine, Oncology Unit, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Sun ZG, Yang YA, Zhang ZG, Zhu HL. Optimization techniques for novel c-Met kinase inhibitors. Expert Opin Drug Discov 2018; 14:59-69. [PMID: 30518273 DOI: 10.1080/17460441.2019.1551355] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Zhi-Gang Sun
- Central Laboratory, Linyi Central Hospital, Linyi, China
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, China
| | - Yong-An Yang
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, China
| | - Zhi-Gang Zhang
- Department of Cardiology, Linyi Central Hospital, Linyi, China
| | - Hai-Liang Zhu
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing, China
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12
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Konda B, Nabhan F, Shah MH. Endocrine dysfunction following immune checkpoint inhibitor therapy. Curr Opin Endocrinol Diabetes Obes 2017; 24:337-347. [PMID: 28661915 DOI: 10.1097/med.0000000000000357] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Immune checkpoint inhibitors (ICI) represent an important milestone in the modern era of antineoplastic therapy and have ushered optimism amongst oncologists and patients alike. These agents, however, are associated with significant potential toxicities, the importance of which cannot be overstated. The clinical presentation, diagnosis, and management strategies of immune-related endocrinopathies associated with ICI use are described in this case-based review. RECENT FINDINGS An increasing number of ICI have shown promise in the management of various malignancies in the recent years. These include cytotoxic T lymphocyte antigen-4 inhibitors, programmed cell death 1 (PD-1) antibodies, and PD-ligand 1 (PD-L1) antibodies. Several endocrinopathies, including hypophysitis, thyroid dysfunction, hyperglycemia, and primary adrenal insufficiency, have been associated with the use of these agents. Toxicities may range from mild transient laboratory abnormalities to potentially life-threatening ones, warranting immediate therapeutic intervention. Combination ICI therapies may be associated with a greater risk of endocrine dysfunction when compared with monotherapy. The clinical presentation and laboratory assessment of these patients often pose a diagnostic challenge as they may be confused by the symptoms related to their underlying malignancy or potential associated acute illnesses. SUMMARY ICI use is associated with serious endocrinopathies that may have a nonspecific initial presentation. A constant eye for these symptoms and a systematic approach to diagnosis are essential for prompt initiation of therapy and prevention of significant complications.
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Affiliation(s)
- Bhavana Konda
- aDivision of Medical Oncology, Department of Internal Medicine bDivision of Endocrinology, Diabetes, and Metabolism, The Ohio State University and Arthur G. James Cancer Center, Columbus, Ohio, USA
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Krajewska J, Paliczka-Cieslik E, Jarzab B. Managing tyrosine kinase inhibitors side effects in thyroid cancer. Expert Rev Endocrinol Metab 2017; 12:117-127. [PMID: 30063430 DOI: 10.1080/17446651.2017.1300526] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Tyrosine kinase inhibitors (TKIs) are a new group of drugs that show the activity against receptors of different growth factors leading to the inhibition of tumor cells growth and proliferation. To date, four different TKIs have been approved for RAI-refractory DTC or MTC: sorafenib, lenvatinib, vandetanib and cabozantinib. METHODS This review focuses on treatment toxicity related to above-mentioned TKIs administration in thyroid carcinoma. RESULTS TKIs cause a variety of side effects in nearly all treated patients, among them: hypertension, gastrointestinal disturbances (diarrhea, abdominal pain, nausea, vomiting), skin reactions (rashes, acne, hand-foot syndrome), fatigue and weight loss. Most of side effects are mild and moderate and manageable by dose adjustment (dose interruptions and dose reductions) and concomitant therapy. However, some complications although rare may be life-threatening or even fatal. Conclusion: TKIs shows an acceptable toxicity profile in patients with advanced and progressive RAI refractory DTC and MTC but only in experienced hands familiar with TKIs, particularly with diagnostics and management of treatment-related complications and also with thyroid carcinoma, what is essential to safely care for the patients and keep them on kinase inhibitor therapy as long as the treatment is beneficial without an unfavorable impact on their quality of life.
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Affiliation(s)
- Jolanta Krajewska
- a Nuclear Medicine and Endocrine Oncology Department , M.Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch , Gliwice , Poland
| | - Ewa Paliczka-Cieslik
- a Nuclear Medicine and Endocrine Oncology Department , M.Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch , Gliwice , Poland
| | - Barbara Jarzab
- a Nuclear Medicine and Endocrine Oncology Department , M.Sklodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch , Gliwice , Poland
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Zhang GN, Zhang YK, Wang YJ, Barbuti AM, Zhu XJ, Yu XY, Wen AW, Wurpel JND, Chen ZS. Modulating the function of ATP-binding cassette subfamily G member 2 (ABCG2) with inhibitor cabozantinib. Pharmacol Res 2017; 119:89-98. [PMID: 28131876 DOI: 10.1016/j.phrs.2017.01.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Revised: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 12/18/2022]
Abstract
Cabozantinib (XL184) is a small molecule tyrosine kinase receptor inhibitor, which targets c-Met and VEGFR2. Cabozantinib has been approved by the Food and Drug Administration to treat advanced medullary thyroid cancer and renal cell carcinoma. In the present study, we evaluated the ability of cabozantinib to modulate the function of the ATP-binding cassette subfamily G member 2 (ABCG2) by sensitizing cells that are resistant to ABCG2 substrate antineoplastic drugs. We used a drug-selected resistant cell line H460/MX20 and three ABCG2 stable transfected cell lines ABCG2-482-R2, ABCG2-482-G2, and ABCG2-482-T7, which overexpress ABCG2. Cabozantinib, at non-toxic concentrations (3 or 5μM), sensitized the ABCG2-overexpressing cells to mitoxantrone, SN-38, and topotecan. Our results indicate that cabozantinib reverses ABCG2-mediated multidrug resistance by antagonizing the drug efflux function of the ABCG2 transporter instead of downregulating its expression. The molecular docking analysis indicates that cabozantinib binds to the drug-binding site of the ABCG2 transporter. Overall, our findings demonstrate that cabozantinib inhibits the ABCG2 transporter function and consequently enhances the effect of the antineoplastic agents that are substrates of ABCG2. Cabozantinib may be a useful agent in anticancer treatment regimens for patients who are resistant to ABCG2 substrate drugs.
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Affiliation(s)
- Guan-Nan Zhang
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences,St. John's University, Queens, New York, 11439, USA
| | - Yun-Kai Zhang
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences,St. John's University, Queens, New York, 11439, USA
| | - Yi-Jun Wang
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences,St. John's University, Queens, New York, 11439, USA
| | - Anna Maria Barbuti
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences,St. John's University, Queens, New York, 11439, USA
| | - Xi-Jun Zhu
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences,St. John's University, Queens, New York, 11439, USA; The Affiliated High School of South China Normal University, Guangzhou, Guangdong, 510630, China
| | - Xin-Yue Yu
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences,St. John's University, Queens, New York, 11439, USA; Zhixin High School, Guangzhou, Guangdong, 510000, China
| | - Ai-Wen Wen
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences,St. John's University, Queens, New York, 11439, USA; Guangdong Pharmaceutical University, Guangzhou, Guangdong, 510515, China
| | - John N D Wurpel
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences,St. John's University, Queens, New York, 11439, USA
| | - Zhe-Sheng Chen
- Department of Pharmaceutical Sciences, College of Pharmacy and Health Sciences,St. John's University, Queens, New York, 11439, USA.
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Shintani T, Kusuhara Y, Daizumoto K, Dondoo TO, Yamamoto H, Mori H, Fukawa T, Nakatsuji H, Fukumori T, Takahashi M, Kanayama H. The Involvement of Hepatocyte Growth Factor-MET-Matrix Metalloproteinase 1 Signaling in Bladder Cancer Invasiveness and Proliferation. Effect of the MET Inhibitor, Cabozantinib (XL184), on Bladder Cancer Cells. Urology 2016; 101:169.e7-169.e13. [PMID: 28013036 DOI: 10.1016/j.urology.2016.12.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Revised: 11/09/2016] [Accepted: 12/03/2016] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To clarify the invasive mechanisms of muscle-invasive bladder cancer (BCa) would be useful for the determination of appropriate treatment strategies. We previously showed that hepatocyte growth factor (HGF)-MET signaling is correlated with invasiveness of BCa cells. Here, we investigated the effects of the MET inhibitor, cabozantinib (XL184), on BCa cells. METHODS We first conducted Western blot analysis to investigate MET expression in BCa cell lines. Next, we examined the effect of cabozantinib on their proliferation and invasive abilities using MTT and Matrigel invasion assays, respectively. Invasion assays were performed using the xCELLigence system. Additionally, to investigate the biological function of HGF-MET signaling, we analyzed gene expression profiles and performed real-time polymerase chain reaction analyses of 5637 cells that were cultivated with or without HGF stimulation, with or without cabozantinib. RESULTS MET was highly expressed in 4 of 5 BCa cell lines, and 5637 and T24 cells showed especially high protein expression of MET. Cabozantinib suppressed cell proliferation and invasion (cell index; mock, 1.49 vs HGF, 2.26 vs HGF + XL184, 1.47, P < .05). Gene expression profile analysis indicated that matrix metalloproteinase 1 (MMP1) was significantly elevated at the mRNA level with addition of HGF. Moreover, cabozantinib suppressed HGF-induced MMP1 expression in 5637 T24 cells. CONCLUSIONS These data indicate that cabozantinib suppressed MMP1 expression by blocking HGF-MET signaling and that HGF-MET-MMP1 signaling is involved in the invasiveness and proliferation of BCa cells. These results suggest that cabozantinib might prove useful for future treatment of muscle-invasive BCa.
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Affiliation(s)
- Terumichi Shintani
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
| | - Yoshito Kusuhara
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
| | - Kei Daizumoto
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
| | - Tsogt-Ochir Dondoo
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
| | - Hiroki Yamamoto
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
| | - Hidehisa Mori
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
| | - Tomoya Fukawa
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
| | - Hiroyoshi Nakatsuji
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan.
| | - Tomoharu Fukumori
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
| | - Masayuki Takahashi
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
| | - Hiroomi Kanayama
- Department of Urology, Institute of Biomedical Sciences, Tokushima University, Graduate School, Tokushima, Japan
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16
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Krajewska J, Olczyk T, Jarzab B. Cabozantinib for the treatment of progressive metastatic medullary thyroid cancer. Expert Rev Clin Pharmacol 2015; 9:69-79. [PMID: 26536165 DOI: 10.1586/17512433.2016.1102052] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Cabozantinib (XL-184) is a potent inhibitor of MET, VEGFR 2/KDR, RET and other receptor tyrosine kinases, such as KIT, AXL and FLT3. Its efficacy against MTC has been demonstrated in a prospective, randomized, placebo-controlled study (EXAM). Cabozantinib comparing to placebo significantly prolonged progression free survival both in hereditary and sporadic MTC, 11.2 vs 4.0 months, respectively. Final analysis showed no global differences in overall survival (OS) between cabozantinib and placebo. However, in a subgroup with RET M918T mutation the difference in OS was significant: 44.3 vs 18.9 months, respectively. Among the most frequent cabozantinib-related adverse events (AEs), observed in >30% of patients were diarrhea, palmar-plantar erythrodysesthesia, decreased weight, decreased appetite, nausea, fatigue, dysgeusia, hair color changes and hypertension. Expert Commentary: Cabozantinib constitutes an effective treatment option with acceptable toxicity in MTC patients showing either germinal or sporadic tumor RET M918T mutation as the drug prolonged OS in these subjects.
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Affiliation(s)
- Jolanta Krajewska
- a Nuclear Medicine and Endocrine Oncology Department , M.Sklodowska-Curie Memorial Cancer Center and Institute of Oncology , Gliwice , Poland
| | - Tomasz Olczyk
- a Nuclear Medicine and Endocrine Oncology Department , M.Sklodowska-Curie Memorial Cancer Center and Institute of Oncology , Gliwice , Poland
| | - Barbara Jarzab
- a Nuclear Medicine and Endocrine Oncology Department , M.Sklodowska-Curie Memorial Cancer Center and Institute of Oncology , Gliwice , Poland
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17
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Pani F, Atzori F, Baghino G, Boi F, Tanca L, Ionta MT, Mariotti S. Thyroid Dysfunction in Patients with Metastatic Carcinoma Treated with Sunitinib: Is Thyroid Autoimmunity Involved? Thyroid 2015; 25:1255-61. [PMID: 26414109 DOI: 10.1089/thy.2015.0170] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Sunitinib is a tyrosine kinase inhibitor (TKI) inducing thyroid dysfunction, but the precise mechanism(s) involved remains to be explained, including the role of thyroid autoimmunity. The objective of this study was to evaluate thyroid function, parameters of autoimmunity, and thyroid ultrasound findings in patients with metastatic cancer and normal thyroid function/autoimmunity before the initiation of sunitinib therapy. This was a prospective, observational cohort study. METHODS Twenty-seven patients with metastatic carcinomas at comparable tumor stages were evaluated over 12-18 months after initiating therapy with sunitinib given at a daily oral dose of 50 mg for four weeks (ON), followed by one to two weeks off therapy (OFF). Serum thyrotropin (TSH), free thyroxine (fT4), free triiodothyronine (fT3), and antithyroglobulin (TgAb), and antithyroid peroxidase (TPOAb) autoantibodies were measured in all cases. Thyroid morphology and volume were evaluated by echo-color Doppler ultrasound. RESULTS A total of 16/27 patients (60%) became hypothyroid (TSH range 7-114 mIU/L) within 30-120 days of therapy. The thyroid volume decreased in 24/27 (89%) patients (from M = 14.6 mL, SD = 6.4 mL to M = 3.8 mL, SD = 2.6 mL after 12 months; p < 0.001), together with the appearance of mild to severe hypoechogenicity. TPOAb (40-3000 IU/mL) became detectable in 7/27 (25%) patients, and TPOAb-positive patients displayed a higher degree of hypothyroidism and volume reduction. The progression-free survival (PFS) was significantly longer in patients developing TPOAb (10.8 months) than in the other group of patients (5.8 months). CONCLUSIONS These data confirm the thyroid inhibitory effect of sunitinib, in keeping with the key role of kinases in controlling thyroid function and growth. However, the novel appearance of TPOAb in a subgroup of patients with more severe hypothyroidism and longer survival indicates that sunitinib may also trigger/exacerbate thyroid autoimmunity contributing to thyroid failure. The development of TPOAb was associated with a longer PFS.
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Affiliation(s)
- Fabiana Pani
- 1 Endocrinology Unit, University of Cagliari , Cagliari, Italy
| | - Francesco Atzori
- 2 Medical Oncology Unit, Department of Medical Sciences, University of Cagliari , Cagliari, Italy
| | - Germana Baghino
- 1 Endocrinology Unit, University of Cagliari , Cagliari, Italy
| | - Francesco Boi
- 1 Endocrinology Unit, University of Cagliari , Cagliari, Italy
| | - Luciana Tanca
- 3 Medical Oncology, Businco Hospital , Cagliari, Italy
| | - Maria Teresa Ionta
- 2 Medical Oncology Unit, Department of Medical Sciences, University of Cagliari , Cagliari, Italy
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18
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Weitzman SP, Cabanillas ME. The treatment landscape in thyroid cancer: a focus on cabozantinib. Cancer Manag Res 2015; 7:265-78. [PMID: 26316818 PMCID: PMC4547654 DOI: 10.2147/cmar.s68373] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Although patients with thyroid cancer generally fare well, there is a subset for which this is not necessarily true. Progress in understanding the molecular aberrations in thyroid cancer has led to a change in the management of these cases. Since 2011, four multikinase inhibitors (MKIs) have been approved by the US Food and Drug Administration for thyroid cancer – cabozantinib and vandetanib for medullary thyroid cancer and sorafenib and lenvatinib for differentiated thyroid cancer. This change in the treatment landscape has raised challenges for practitioners who may not be familiar with the use of MKIs or with the treatment and natural history of advanced thyroid cancer in general. This article reviews the epidemiology, molecular drivers, and initial treatment of patients with thyroid cancer and offers practical guidance to assist with the determination of when to appropriately start an MKI. As an example, cabozantinib and its efficacy are discussed in detail. Close monitoring is required for all patients on targeted agents to assess for adverse effects and response to therapy. An approach to managing drug-related adverse events is detailed. Since these drugs are not curative and have not yet proven to prolong overall survival, it is critical to weigh the risks and benefits of treatment at every visit. The potential value of changing to a different agent following failure of an MKI is also addressed.
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Affiliation(s)
- Steven P Weitzman
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Maria E Cabanillas
- Department of Endocrine Neoplasia and Hormonal Disorders, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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19
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Mazzola CR, Chin J. Targeting the VEGF pathway in metastatic bladder cancer. Expert Opin Investig Drugs 2015; 24:913-27. [DOI: 10.1517/13543784.2015.1041588] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Clarisse R Mazzola
- Western University, Division of Urology and Division of Surgical Oncology, London, Ontario, Canada ;
| | - Joseph Chin
- Western University, Division of Urology and Division of Surgical Oncology, London, Ontario, Canada ;
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20
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Leiser D, Medová M, Mikami K, Nisa L, Stroka D, Blaukat A, Bladt F, Aebersold DM, Zimmer Y. KRAS and HRAS mutations confer resistance to MET targeting in preclinical models of MET-expressing tumor cells. Mol Oncol 2015; 9:1434-46. [PMID: 25933688 DOI: 10.1016/j.molonc.2015.04.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Revised: 03/23/2015] [Accepted: 04/05/2015] [Indexed: 12/16/2022] Open
Abstract
The MET receptor tyrosine kinase is often deregulated in human cancers and several MET inhibitors are evaluated in clinical trials. Similarly to EGFR, MET signals through the RAS-RAF-ERK/MAPK pathway which plays key roles in cell proliferation and survival. Mutations of genes encoding for RAS proteins, particularly in KRAS, are commonly found in various tumors and are associated with constitutive activation of the MAPK pathway. It was shown for EGFR, that KRAS mutations render upstream EGFR inhibition ineffective in EGFR-positive colorectal cancers. Currently, there are no clinical studies evaluating MET inhibition impairment due to RAS mutations. To test the impact of RAS mutations on MET targeting, we generated tumor cells responsive to the MET inhibitor EMD1214063 that express KRAS G12V, G12D, G13D and HRAS G12V variants. We demonstrate that these MAPK-activating RAS mutations differentially interfere with MET-mediated biological effects of MET inhibition. We report increased residual ERK1/2 phosphorylation indicating that the downstream pathway remains active in presence of MET inhibition. Consequently, RAS variants counteracted MET inhibition-induced morphological changes as well as anti-proliferative and anchorage-independent growth effects. The effect of RAS mutants was reversed when MET inhibition was combined with MEK inhibitors AZD6244 and UO126. In an in vivo mouse xenograft model, MET-driven tumors harboring mutated RAS displayed resistance to MET inhibition. Taken together, our results demonstrate for the first time in details the role of KRAS and HRAS mutations in resistance to MET inhibition and suggest targeting both MET and MEK as an effective strategy when both oncogenic drivers are expressed.
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Affiliation(s)
- Dominic Leiser
- Department of Radiation Oncology, Department of Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Michaela Medová
- Department of Radiation Oncology, Department of Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Kei Mikami
- Department of Radiation Oncology, Department of Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Lluís Nisa
- Department of Radiation Oncology, Department of Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Deborah Stroka
- Department of Visceral Surgery, Department of Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Andree Blaukat
- Merck Serono an Affiliate of Merck Serono Research & Development, Merck KGaA, 64271 Darmstadt, Germany
| | - Friedhelm Bladt
- Merck Serono an Affiliate of Merck Serono Research & Development, Merck KGaA, 64271 Darmstadt, Germany
| | - Daniel M Aebersold
- Department of Radiation Oncology, Department of Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Switzerland
| | - Yitzhak Zimmer
- Department of Radiation Oncology, Department of Clinical Research, Inselspital, Bern University Hospital, and University of Bern, Switzerland.
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