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Iannelli F, Zotti AI, Roca MS, Grumetti L, Lombardi R, Moccia T, Vitagliano C, Milone MR, Ciardiello C, Bruzzese F, Leone A, Cavalcanti E, De Cecio R, Iachetta G, Valiante S, Ionna F, Caponigro F, Di Gennaro E, Budillon A. Valproic Acid Synergizes With Cisplatin and Cetuximab in vitro and in vivo in Head and Neck Cancer by Targeting the Mechanisms of Resistance. Front Cell Dev Biol 2020; 8:732. [PMID: 33015030 PMCID: PMC7461984 DOI: 10.3389/fcell.2020.00732] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/15/2020] [Indexed: 12/12/2022] Open
Abstract
Recurrent/metastatic head and neck squamous cell carcinoma (R/M HNSCC) is a devastating malignancy with a poor prognosis. The combination of cisplatin (CDDP) plus cetuximab (CX) is one of the standard first-line treatments in this disease. However, this therapeutic regimen is often associated with high toxicity and resistance, suggesting that new combinatorial strategies are needed to improve its therapeutic index. In our study, we evaluated the antitumor effects of valproic acid (VPA), a well-known antiepileptic agent with histone deacetylase inhibitory activity, in combination with CDDP/CX doublet in head and neck squamous cell carcinoma (HNSCC) models. We demonstrated, in HNSCC cell lines, but not in normal human fibroblasts, that simultaneous exposure to equitoxic doses of VPA plus CDDP/CX resulted in a clear synergistic antiproliferative and pro-apoptotic effects. The synergistic antitumor effect was confirmed in four different 3D-self-assembled spheroid models, suggesting the ability of the combined approach to affect also the cancer stem cells compartment. Mechanistically, VPA enhanced DNA damage in combination treatment by reducing the mRNA expression of ERCC Excision Repair 1, a critical player in DNA repair, and by increasing CDDP intracellular concentration via upregulation at transcriptional level of CDDP influx channel copper transporter 1 and downregulation of the ATPAse ATP7B involved in CDDP-export. Valproic acid also induced a dose-dependent downregulation of epidermal growth factor receptor (EGFR) expression and of MAPK and AKT downstream signaling pathways and prevent CDDP- and/or CX-induced EGFR nuclear translocation, a well-known mechanism of resistance to chemotherapy. Indeed, VPA impaired the transcription of genes induced by non-canonical activity of nuclear EGFR, such as cyclin D1 and thymidylate synthase. Finally, we confirmed the synergistic antitumor effect also in vivo in both heterotopic and orthotopic models, demonstrating that the combined treatment completely blocked HNSCC xenograft tumors growth in nude mice. Overall, the introduction of a safe and generic drug such as VPA into the conventional treatment for R/M HNSCC represents an innovative and feasible antitumor strategy that warrants further clinical evaluation. A phase II clinical trial exploring the combination of VPA and CDDP/CX in R/M HNSCC patients is currently ongoing in our institute.
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Affiliation(s)
- Federica Iannelli
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Andrea Ilaria Zotti
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Maria Serena Roca
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Laura Grumetti
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Rita Lombardi
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Tania Moccia
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Carlo Vitagliano
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Maria Rita Milone
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Chiara Ciardiello
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Francesca Bruzzese
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Alessandra Leone
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Ernesta Cavalcanti
- Laboratory Medicine Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Rossella De Cecio
- Pathology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | | | | | - Franco Ionna
- Maxillo-facial & ENT Surgery Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Francesco Caponigro
- Head and Neck Medical Oncology Unit, Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Elena Di Gennaro
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
| | - Alfredo Budillon
- Experimental Pharmacology Unit-Laboratory of Naples and Mercogliano (AV), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
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Avallone A, Piccirillo MC, Di Gennaro E, Romano C, Calabrese F, Roca MS, Tatangelo F, Granata V, Cassata A, Cavalcanti E, Maurea N, Maiolino P, Silvestro L, De Stefano A, Giuliani F, Rosati G, Tamburini E, Aprea P, Vicario V, Nappi A, Vitagliano C, Casaretti R, Leone A, Petrillo A, Botti G, Delrio P, Izzo F, Perrone F, Budillon A. Randomized phase II study of valproic acid in combination with bevacizumab and oxaliplatin/fluoropyrimidine regimens in patients with RAS-mutated metastatic colorectal cancer: the REVOLUTION study protocol. Ther Adv Med Oncol 2020; 12:1758835920929589. [PMID: 32849914 PMCID: PMC7425244 DOI: 10.1177/1758835920929589] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/04/2020] [Indexed: 01/30/2023] Open
Abstract
Background Despite effective treatments, metastatic colorectal cancer (mCRC) prognosis is still poor, mostly in RAS-mutated tumors, thus suggesting the need for novel combinatorial therapies. Epigenetic alterations play an important role in initiation and progression of cancers, including CRC. Histone-deacetylase inhibitors (HDACi) have shown activity in combination with chemotherapy in the treatment of solid tumors. Owing to its HDACi activity and its safe use for epileptic disorders, valproic acid (VPA) is a good candidate for anticancer therapy that we have largely explored preclinically translating our findings in currently ongoing clinical studies. We have shown in CRC models that HDACi, including VPA, induces synergistic antitumor effects in combination with fluoropyrimidines. Furthermore, unpublished results from our group demonstrated that VPA induces differentiation and sensitization of CRC stem cells to oxaliplatin. Moreover, preclinical and clinical data suggest that HDACi may prevent/reverse anti-angiogenic resistance. Methods/Design A randomized, open-label, two-arm, multicenter phase-II study will be performed to explore whether the addition of VPA to first line bevacizumab/oxaliplatin/fluoropyrimidine regimens (mFOLFOX-6/mOXXEL) might improve progression-free survival (PFS) in RAS-mutated mCRC patients. A sample size of 200 patients was calculated under the hypothesis that the addition of VPA to chemotherapy/bevacizumab can improve PFS from 9 to 12 months, with one-sided alpha of 0.20 and a power of 0.80. Secondary endpoints are overall survival, objective response rate, metastases resection rate, toxicity, and quality of life. Moreover, the study will explore several prognostic and predictive biomarkers on blood samples, primary tumors, and on resected metastases. Discussion The "Revolution" study aims to improve the treatment efficacy of RAS-mutated mCRC through an attractive strategy evaluating the combination of VPA with standard cancer treatment. Correlative studies could identify novel biomarkers and could add new insight in the mechanism of interaction between VPA, fluoropyrimidine, oxaliplatin, and bevacizumab. Trial Registration EudraCT: 2018-001414-15; ClinicalTrials.gov identifier: NCT04310176.
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Affiliation(s)
- Antonio Avallone
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Via M. Semmola, Napoli, 80131, Italy
| | | | - Elena Di Gennaro
- Experimental Pharmacology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Carmela Romano
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Filomena Calabrese
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Maria Serena Roca
- Experimental Pharmacology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Fabiana Tatangelo
- Pathology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Vincenza Granata
- Radiology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Antonio Cassata
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Ernesta Cavalcanti
- Laboratory Medicine Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Nicola Maurea
- Cardiology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Piera Maiolino
- Pharmacy Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Lucrezia Silvestro
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Alfonso De Stefano
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | | | - Gerardo Rosati
- Medical Oncology Unit, S. Carlo Hospital, Potenza, Italy
| | - Emiliano Tamburini
- Dipartimento di Oncologia e Cure Palliative, Azienda Ospedaliera Cardinale G. Panico, Tricase-Lecce, Italy
| | - Pasquale Aprea
- Vascular Access Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Valeria Vicario
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Anna Nappi
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Carlo Vitagliano
- Experimental Pharmacology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Rossana Casaretti
- Experimental Clinical Abdominal Oncology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Alessandra Leone
- Experimental Pharmacology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Antonella Petrillo
- Radiology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Gerardo Botti
- Pathology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Paolo Delrio
- Colorectal Oncological Surgery, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Francesco Izzo
- Hepatobiliary Surgery Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Francesco Perrone
- Clinical Trials Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Napoli, Italy
| | - Alfredo Budillon
- Experimental Pharmacology Unit, Istituto Nazionale Tumori- IRCCS-Fondazione G. Pascale, Via M. Semmola, Napoli, 80131, Italy
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