Targeted therapy for nonsmall cell lung cancer: focusing on angiogenesis, the epidermal growth factor receptor and multikinase inhibitors

Erlotinib-Associated Rash in Advanced Non-Small Cell Lung Cancer: Relation to Clinicopathological Characteristics, Treatment Response, and Survival

Systematic treatment of advanced non-small cell lung cancer (NSCLC) includes targeted treatment with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs). The development of skin rash and its intensity have been associated with EGFR TKI's efficacy. The main purpose of this study was to further investigate the potential value of erlotinib-associated rash as a predictor of prognosis and treatment response in a real-world cohort of patients with advanced NSCLC. The medical records of all NSCLC patients treated with erlotinib at the Oncology Unit of GPP, Sotiria Athens General Hospital between January 1, 2014 and August 31, 2016 were retrospectively reviewed. Seventy-nine patient medical records fulfilled the criteria and were included in the study. Development of erlotinib-associated rash was correlated with clinicopathological characteristics of patients, treatment response, and overall survival (OS) using univariate and multivariate Cox regression analysis. The number of patients with rash was greater in the responders group (90% vs. 46.4%, p = 0.015). In univariate analysis, there was a statistically significant association between rash development and time to progression (TTP) [HR: 0.32 (0.17-0.57), p < 0.001]. With multivariate Cox regression analysis, it was found that PS ≥ 2 (HR: 2.01, 95% CI: 1.12-3.60, p = 0.018) and rash (HR: 0.34, 95% CI: 0.18-0.63, p = 0.001) were independently associated with TTP and also that the duration of treatment with erlotinib (HR: 0.58, 95% CI: 0.42-0.80, p = 0.001) and rash (HR: 0.10, 95% CI: 0.20-0.48, p = 0.004) was an independent predictor of survival. Our results suggest that erlotinib-associated rash may represent a clinically valuable biomarker for the prediction of treatment response and OS in patients with advanced NSCLC.

Gefitinib: re-emerging from the shadows

SUMMARY In the past decade, the identification of mutations in the EGFR gene and the sensitivity of activating mutations to EGF receptor–tyrosine kinase inhibitors has improved survival in a subset of non-small-cell lung cancer patients. Over 70% of patients with EGFR mutations have a response to gefitinib therapy. Gefitinib, a first-generation EGF receptor–tyrosine kinase inhibitor, is well tolerated and continues to be widely used. However, eventually most patients develop resistance to gefitinib. This article reviews the pharmacology of gefitinib and summarizes the clinical trials that have resulted in its current day indications.

Effects of autocrine vascular endothelial growth factor (VEGF) in non-small cell lung cancer cell line A549

It is reported that the autocrine loop of the vascular endothelial growth factor (VEGF) is crucial for the survival and proliferation of non-small cell lung cancer (NSCLC) tumors. In this study we aimed to systematically investigate the role of autocrine vascular VEGF in NSCLC cell line A549 through inhibition of endogenous VEGF. A549 cells were transfected with florescence-labeled VEGF oligodeoxynucleotide with lipofectamine. For the experimental group, cells were transfected with VEGF anti-sense oligodeoxynucleotide (ASODN), sense oligodeoxynucleotide (SODN) and mutant oligodeoxynuleotide (MODN) respectively. For the control group cells were mock transfected with lipofectamine or culture medium. At indicated time point after transfection, the expression levels of VEGF mRNA and protein in A549 cells were analyzed by RT-PCR and ELISA respectively. Cell viability was measured by the MTT assay. Cell cycle distribution was detected by flow cytometry. As revealed by RT-PCR assay, the mRNA level of VEGF in cells transfected with ASDON was significantly lower than the other four groups (P < 0.05) at 24 and 48 h after transfection. ELISA assay yielded similar result with significantly decreased level of VEGF protein expression (P < 0.05). The survival fraction of A549 cells transfected with ASDON was significantly lower than the other four groups (P < 0.05) at 24 h after transfection. Also the percentage of G2 phase cells of ASODN group was significantly lower than other four groups. Our data indicate that VEGF expression is efficiently inhibited in A549 cells by ASODN transfection and this inhibition leads to inhibited cell growth and impaired cell cycle distribution.

B1, a novel topoisomerase II inhibitor, induces apoptosis and cell cycle G1 arrest in lung adenocarcinoma A549 cells

In our previous studies, we demonstrated that 2,6-bis-(2-chloroacetamido) anthraquinone (B1) showed a highly significant cytotoxic effect. However, its influence in the cell cycle and apoptotic induction effects has not been investigated yet. Here we report the antiproliferative effect of B1, for which IC50 values were 0.57 μmol/l for lung cancer A549 cells, 0.63 μmol/l for colon cancer HT-29 cells, and 0.53 μmol/l for breast cancer MCF-7 cells. DNA topoisomerase II (Topo II), an essential enzyme in DNA synthesis and meiotic division, is highly expressed in cancer cells. Some currently used clinical anticancer drugs (doxorubicin and mitoxantrone) targeting Topo II are very effective antineoplastic agents. B1, sharing the basic structure of known Topo II inhibitors, demonstrated a significant inhibitory effect on Topo II bioactivity. In A549 cells, B1 increased apoptotic cell population with induction of Fas, Bax, and cleaved poly(ADP-ribose) polymerase and by reduction of Bcl-2 expression. Moreover, cell cycle analysis indicated that B1 induced G1 phase arrest through modulation of G1 cell cycle regulatory proteins, such as the downregulation of cyclin D1 and upregulation of Cip/p21, Kip1/p27, and p53. Thus, our study suggests that B1, with the ability to inhibit Topo II activity and cause cell cycle G1 arrest and apoptosis, has potential as a novel anticancer agent.

Tyrosine kinase inhibitors with antiangiogenic properties for the treatment of non-small cell lung cancer

IMPORTANCE OF THE FIELD

The 5-year survival rate in NSCLC remains < 15% in spite of new chemotherapeutic regimens and targeted therapies. Tyrosine kinase inhibitors (TKIs) with antiangiogenic properties show promise as a new therapeutic approach for NSCLC in recent studies.

AREAS COVERED IN THIS REVIEW

This article reviews significant preclinical and clinical studies related to TKI therapy. Many drugs that target tyrosine kinases involved in tumor angiogenesis have recently been developed. Results of preclinical experiments and clinical trials for NSCLC are quite promising. However, response rates are low and the duration of therapeutic response is short. Mechanisms of resistance may reduce the efficacy of TKI therapy, and biomarkers of response are needed to select patients who are more likely to benefit from the therapy. Studies in mice have shown that antiangiogenic TKIs may increase metastasis, although no clear clinical evidence supports these results.

WHAT THE READER WILL GAIN

An understanding of the mechanisms of action, clinical trial results, biomarkers of response, adverse effects and possible mechanisms of resistance associated with novel TKI therapy in NSCLC.

TAKE HOME MESSAGE

More preclinical and clinical research on the efficacy of TKIs in treating NSCLC is needed, but present results offer great hope for patients.

Cytoplasmic HuR expression correlates with angiogenesis, lymphangiogenesis, and poor outcome in lung cancer

HuR is a ubiquitously expressed RNA-binding protein that stabilizes the mRNAs of certain genes and regulates the translation to proteins. Elevated cytoplasmic expression of HuR has been suggested to be associated with reduced survival in a wide variety of human carcinomas. However, the clinical significance of HuR expression in lung cancer remains unknown. In this study, we examined HuR expression in 132 patients with non-small cell lung carcinoma (NSCLC) by means of immunohistochemistry and correlated clinicopathologic data, lymphatic microvessel density (LVD), or microvessel density (MVD) with HuR immunostaining. HuR was expressed in 80.3% (106/132) of cases and was predominantly localized in the nucleus. Cytoplasmic HuR expression occurred in 40.9% (54/132) of NSCLC specimens and was associated with high MVD and LVD. In univariate analysis, cytoplasmic HuR, but not nuclear HuR expression was found to significantly influence the relapse-free survival and overall survival. In addition, cytoplasmic expression of HuR was identified as an independent prognostic factor for survival in multivariate analysis. Our data provide evidence for a clinically prognostic role of HuR in NSCLC and demonstrate an association between HuR expression, and angiogenesis and lymphangiogenesis.

Efficient inhibition of lung cancer in murine model by plasmid-encoding VEGF short hairpin RNA in combination with low-dose DDP

BACKGROUND

VEGF is a well-validated target for antiangiogenic intervention in cancer. To date, RNAi technology has been proven to be a promising approach for targeted therapy. DDP is frequently used as a first-line drug in chemotherapy for lung cancer but usually causes severe toxicity. In this study, we investigated a novel strategy of administering and combining RNAi mediated VEGF-targeted therapy with DDP for treatment of lung cancer, with the aim of increasing efficacy and decreasing toxicity.

METHODS

In this study, a plasmid encoding VEGF shRNA was constructed to knockdown VEGF both in vitro and in vivo. In vitro, specificity and potency of the targeting sequence were validated in A549 lung adenocarcinoma cells by RT-PCR and ELISA assays. In vivo, therapy experiments were conducted on nude mice bearing A549 xenograft tumors. The VEGF shRNA expressing plasmids were administered systemically in combination with low-dose DDP on a frequent basis. The tumor volume and weight were measured. MVD, the number of apoptotic cells and proliferation index in tumor tissues were assessed by CD31, TUNEL and PCNA immunostaining.

RESULTS

The VEGF shRNA was highly effective in attenuating VEGF expression both in vitro and in vivo. The treatment with the VEGF shRNA alone reduced the mean tumor weight by 49.40% compared with the blank control (P < 0.05). The treatment with the VEGF shRNA plus DDP yielded maximal benefits by reducing the mean tumor weight by 83.13% compared with the blank control (P < 0.01). The enhanced antitumor efficacy was associated with decreased angiogenesis and increased induction of apoptosis.

CONCLUSIONS

Our study demonstrated synergistic antitumor activity of combined VEGF shRNA expressing plasmids and low-dose DDP with no overt toxicity, suggesting potential applications of the combined approach in the treatment of lung cancer.