Molecular Targeted Therapy in Modern Oncology: Imaging Assessment of Treatment Response and Toxicities

Research progress of integrated traditional Chinese and Western medicine in the treatment of advanced gastric cancer

Gastric cancer (GC) is a malignant tumor originating from the gastric epithelium, and its incidence and mortality rates rank third among all malignant tumors worldwide. It is also one of the most common cancers in China and is treated predominantly by Western medicine in clinical practice. However, with the advancements in medical technology and informatics, the values of traditional Chinese medicine (TCM) in preventing and treating GC and improving prognosis have increasingly been recognized. According to TCM, clinical manifestations of GC can be divided into Yege (dysphagia), regurgitation, stomach pain, and Zhengxia (abdominal mass). Due to the unbalanced distribution of health care resources in China, most GC patients already have progressive or advanced-stage disease at the first diagnosis. As a result, most GC patients have poor physical function, and surgery or chemotherapy alone will aggravate the impairment to the immune function and seriously affect the quality of life. In contrast, TCM therapies have shown promising efficacy in the management of these patients. Here we review the role of the integrated TCM and Western medicine in treating advanced GC.

Differences in sensitivity to new therapies between primary and metastatic breast cancer: A need to stratify the tumor response?

OBJECTIVE

We compared therapeutic response of Varlitinib + Capecitabine (VC) versus Lapatinib + Capecitabine (LC) in patients with human epidermal growth factor receptor 2-positive metastatic breast cancer after trastuzumab therapy by assessing changes in target lesion (TL) diameter and volume per location.

METHODS

We retrospectively analyzed the CT data of the ASLAN001-003 study (NCT02338245). We analyzed TL size and number at each location focusing on therapeutic response from baseline to Week 12. We used TL diameter and volume to conduct an inter-arm comparison of the response according to: RECIST 1.1; stratified per TL location and considering TLs independently. Multiple pairwise intra-arm comparisons of therapeutic responses were performed. Considering TL independently, weighted models were designed by adding weighted mean TL responses grouped by location.

RESULTS

We evaluated 42 patients (88 TL) and 35 patients (74 TL), respectively, at baseline and Week 12. We found reductions in breast TL burden in the VC arm compared to the LC arm (p = 0.002 (diameter), p < 0.001 (volume)). Responses and TL sizes at baseline were not correlated. Explained variabilities of volume change per TL location, patient and patient:TL interaction were 36%, 10% and 4% (VC), and 13%, 1% and 23%, (LC). A test of inter-arm difference of responses yielded p = 0.07 (diameter), and p < 0.001 (volume).

CONCLUSIONS

The therapeutic responses differed across tumors' locations; the magnitude of the differences of responses across the tumors' locations were drug-dependent. Stratified analysis of the response by tumor location improved drug comparisons and is a powerful tool to understand TL heterogeneity.

High Expression of UPK3A Promotes the Progression of Gastric Cancer Cells by Inactivating p53 Pathway

Background

Gastric cancer is a common gastrointestinal tract cancer and is a considerable health burden worldwide. TCGA analysis found Uroplakin 3A (UPK3A) was upregulated in gastric cancer tissues. Our study was designed to investigate the underlying mechanism of Uroplakin 3A (UPK3A) in gastric cancer.

Methods

Data from TCGA database were used to assess the expression, and Kaplan-Meier plotter analysis was used to assess the prognosis value of UPK3A. Furthermore, there are effects of UPK3A silencing on the activity, proliferation, migration, and invasion of human gastric cancer cells (SNU-216 and HGC-27) using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT), colony formation, wound healing, and Transwell assays. In addition, the expression of UPK3A, p53, KLF4, ZMAT3, MDM2, and SP1 was detected by qRT-PCR and Western blot assay.

Results

UPK3A was markedly upregulated in gastric cancer tissues compared to that in normal tissues, and patients with high UPK3A level showed poor prognosis. UPK3A was highly expressed in human gastric cancer cell lines compared to that in a normal human gastric epithelial cell line. Silencing of UPK3A inhibited the proliferation, migration, and invasion of gastric cancer cells. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis revealed that UPK3A was involved in the p53 signaling pathway. UPK3A suppressed the activation of p53 signaling pathway, and treatment with Pifithrin-α (an inhibitor of the p53 signaling pathway) or silencing of p53 significantly reversed the effect of UPK3A silencing on the expression of p53, KLF4, ZMAT3, MDM2, and SP1.

Conclusion

Our findings showed that UPK3A promotes the progression of gastric cancer by regulating the p53 signaling pathway and could be a potential therapeutic target for gastric cancer.

Chemotherapy-induced bowel ischemia: diagnostic imaging overview

Cancer patients need multimodal therapies to treat their disease increasingly. In particular, drug treatment, as chemotherapy, immunotherapy, or various associations between them are commonly used to increase efficacy. However, the use of drugs predisposes a percentage of patients to develop toxicity in multiple organs and systems. Principle chemotherapy drugs mechanism of action is cell replication inhibition, rapidly proliferating cells especially. Immunotherapy is another tumor therapy strategy based on antitumor immunity activation trough agents as CTLA4 inhibitors (ipilimumab) or PD-1/PD-L1 inhibitors as nivolumab. If, on the one hand, all these agents inhibit tumor growth, on the other, they can cause various degrees toxicity in several organs, due to their specific mechanism of action. Particularly interesting are bowel toxicity, which can be clinically heterogeneous (pain, nausea, diarrhea, enterocolitis, pneumocolitis), up to severe consequences, such as ischemia, a rare occurrence. However, this event can occur both in vessels that supply intestine and in submucosa microvessels. We report drug-related intestinal vascular damage main characteristics, showing the radiological aspect of these alterations. Interpretation of imaging in oncologic patients has become progressively more complicated in the context of "target therapy" and thanks to the increasing number and types of therapies provided. Radiologists should know this variety of antiangiogenic treatments and immunotherapy regimens first because they can determine atypical features of tumor response and then also because of their eventual bowel toxicity.

Src acts as the target of matrine to inhibit the proliferation of cancer cells by regulating phosphorylation signaling pathways

Studies have shown that matrine has antitumor activity against many types of cancers. However, the direct target in cancer cells of its anticancer effect has not been identified. The purpose of this study was to find the molecular target of matrine to inhibit the proliferation of cancer cells and explore its mechanism of action. Herein we showed that matrine inhibited the proliferation of cancer in vitro and in vivo. Pull-down assay with matrine-amino coupling resins and liquid chromatography-mass spectrometry/mass spectrometry (LC-MS/MS) identified Src as the target of matrine. Cellular thermal shift assay (CETSA) and drug affinity responsive target stability (DARTS) provided solid evidences that matrine directly bound to Src. Bioinformatics prediction and pull-down experiment demonstrated that Src kinase domain was required for its interaction with matrine and Ala392 in the kinase domain participated in matrine-Src interaction. Intriguingly, matrine was proven to inhibit Src kinase activity in a non-ATP-competitive manner by blocking the autophosphorylation of Tyr419 in Src kinase domain. Matrine down-regulated the phosphorylation levels of MAPK/ERK, JAK2/STAT3, and PI3K/Akt signaling pathways via targeting Src. Collectively, matrine targeted Src, inhibited its kinase activity, and down-regulated its downstream MAPK/ERK, JAK2/STAT3, and PI3K/Akt phosphorylation signaling pathways to inhibit the proliferation of cancer cells.

Radiological assessment of response and adverse events associated with novel systemic oncological therapies

The last decade has seen a paradigm shift in medical oncology treatment with the rise of novel systemic agents, principally molecular targeted therapy and immunotherapy. These new groups of anti-cancer treatment have revolutionised the prognostic landscape for certain patient cohorts with advanced disease, and it is hoped that through ongoing extensive clinical research, significant survival benefits may be demonstrated in the majority of tumour types. However, radiological response assessment of these new agents has become more nuanced for radiologists, as the behaviour of both responding and progressing tumour burden can be more diverse than with conventional chemotherapy. Additionally, radiologists need to be aware of adverse events associated with these treatments as some side effects carry a high morbidity/mortality and may manifest radiologically before they become clinically apparent. This review discusses radiological response assessment and adverse events associated with these novel agents, which have become fundamental aspects of systemic oncological therapy.

Comparison of CT Volumetry and RECIST to Predict the Treatment Response and Overall Survival in Gastric Cancer Liver Metastases

Purpose

The aim of this study was to compare the diameter and volume of liver metastases on CT images in relation to overall survival and tumor response in patients with gastric cancer liver metastases (GCLM) treated with chemotherapy.

Materials and Methods

We recruited 43 patients with GCLM who underwent chemotherapy as a first-line treatment. We performed a three-dimensional quantification of the metastases for each patient. An independent survival analysis using the Response Evaluation Criteria in Solid Tumors (RECIST) was performed and compared to volumetric measurements. Overall survival was evaluated using Kaplan-Meier analysis and compared using Cox proportional hazard ratios following univariate analyses.

Results

When patients were classified as responders or non-responders based on volumetric criteria, the median overall survival was 23.6 months [95% confidence interval (CI), 8.63–38.57] and 7.6 months (95% CI, 3.78–11.42), respectively (p = 0.039). The volumetric analysis and RECIST of the non-progressing and progressing groups showed similar results based on the Kaplan-Meier method (p = 0.006) and the Cox proportional hazard model (p = 0.008).

Conclusion

Volumetric assessment of liver metastases could be an alternative predictor of overall survival for patients with GCLM treated with chemotherapy.

A Review of the Mechanisms and Clinical Implications of Precision Cancer Therapy-Related Toxicity: A Primer for the Radiologist

OBJECTIVE. The purpose of this review is to elucidate the mechanisms, types, and clinical significance of molecular targeted therapy (MTT) and immune checkpoint inhibitors (ICIs) and their related toxicity, emphasizing the radiologic manifestations. CONCLUSION. The related toxicities of MTT and ICIs can have acute, recurrent, chronic, and delayed presentations. These toxicities may serve as markers of response and survival. By understanding the clinical significance of drug toxicities, radiologists can play an important role in personalized cancer therapy.

The promise of single-cell mechanophenotyping for clinical applications

Cancer is the second leading cause of death worldwide. Despite the immense research focused in this area, one is still not able to predict disease trajectory. To overcome shortcomings in cancer disease study and monitoring, we describe an exciting research direction: cellular mechanophenotyping. Cancer cells must overcome many challenges involving external forces from neighboring cells, the extracellular matrix, and the vasculature to survive and thrive. Identifying and understanding their mechanical behavior in response to these forces would advance our understanding of cancer. Moreover, used alongside traditional methods of immunostaining and genetic analysis, mechanophenotyping could provide a comprehensive view of a heterogeneous tumor. In this perspective, we focus on new technologies that enable single-cell mechanophenotyping. Single-cell analysis is vitally important, as mechanical stimuli from the environment may obscure the inherent mechanical properties of a cell that can change over time. Moreover, bulk studies mask the heterogeneity in mechanical properties of single cells, especially those rare subpopulations that aggressively lead to cancer progression or therapeutic resistance. The technologies on which we focus include atomic force microscopy, suspended microchannel resonators, hydrodynamic and optical stretching, and mechano-node pore sensing. These technologies are poised to contribute to our understanding of disease progression as well as present clinical opportunities.

A review of the imaging manifestations of immune check point inhibitor toxicities

The past decade has witnessed a paradigm shift in cancer therapy owing to the introduction of immune checkpoint inhibitors (ICIs) and it is now commonplace for radiologists to image patients on therapy with these agents. The purpose of this review is to detail the mechanism, radiological manifestations and clinical significance of ICI related toxicities, according to the organ system involved. ICI related toxicities that have known imaging manifestations include colitis, enterocolitis, pancreatitis, hepatitis, endocrine toxicities, pneumonitis, cardiovascular toxicity and musculoskeletal toxicity. These toxicities may be acute, recurrent or chronic in nature. Radiologists must be aware of the imaging features and clinical significance of these toxicities in order to effectively participate in personalized cancer therapy.

Decoding the Genomic Report for Radiologists

OBJECTIVE. The purpose of this review is to provide a guide for radiologists that explains the language and format of modern genomic reports and summarizes the relevance of this information for modern oncologic imaging. CONCLUSION. Genomic testing plays a critical role in guiding oncologic therapies in the age of targeted treatments. Understanding and interpreting genomic reports is a valuable skill for radiologists involved with oncologic imaging interpretation.

Overview of imaging findings associated with systemic therapies in advanced epithelial ovarian cancer

PURPOSE

To provide an overview for radiologists of the systemic agents used in the treatment of advanced epithelial ovarian cancer (EOC) and their associated toxicities.

RESULTS

EOC is a common gynecological malignancy, with the majority of patients presenting with advanced stage disease at the time of diagnosis. Although primary cytoreductive surgery and chemotherapy are the principal treatments for EOC, recurrence rates of disease remain high. As several molecular targeted therapies have been developed in the last decade, various novel agents have shown efficacy in the treatment of advanced EOC. Advanced EOC will be discussed by outlining the relevant radiological features of toxicities.

CONCLUSION

Knowledge of the systemic therapies utilized in the treatment of advanced EOC and their associated radiological features is critical in diagnostic image interpretation.

Integrin beta 4 (ITGB4) and its tyrosine-1510 phosphorylation promote pancreatic tumorigenesis and regulate the MEK1-ERK1/2 signaling pathway

Pancreatic cancer is the fourth leading cause of cancer death, with a 5-year survival rate of only 1–4%. Integrin-mediated cell adhesion is critical for the initiation, progression, and metastasis of cancer. In this study we investigated the role of integrin β4 (ITGB4) and its phosphorylation at tyrosine Y1510 (p-ITGB4-Y1510) in the tumorigenesis of pancreatic cancer. We analyzed the expression of ITGB4 and p-ITGB4-Y1510 in pancreatic cancer tissue and cell lines using immunohistochemistry, Western blot, or semi-quantitative reverse transcription PCR. ITGB4 and p-ITGB4-Y1510 were highly expressed in pancreatic cancer (n = 176) compared with normal pancreatic tissue (n = 171). High p-ITGB4-Y1510 expression correlated with local invasion and distant metastasis of pancreatic cancer, and high ITGB4 was significantly associated with poor survival of patients. Inhibition of ITGB4 by siRNA significantly reduced migration and invasion of PC-1.0 and AsPC-1 cells. Overexpression of the mutant ITGB4-Y1510A (a mutation of tyrosine to alanine at 1510 position) in PC-1.0 and AsPC-1 cells not only blocked the ITGB4 phosphorylation at Y1510 but also suppressed the expression of ITGB4 (p < 0.05 vs. wild-type ITGB4). The transfection of PC-1.0 and AsPC-1 cells with ITGB4-Y1510A significantly decreased the level of p-mitogen-activated protein kinase kinase (MEK)1 (T292) and p-extracellular signal-regulated kinase (ERK)1/2 but did not affect the level of p-MEK1 (T386) and p-MEK2 (T394). Overall, our study showed that ITGB4 and its phosphorylated form promote cell migration and invasion in pancreatic cancer and that p-ITGB4-Y1510 regulates the downstream MEK1-ERK1/2 signaling cascades. Targeting ITGB4 or its phosphorylation at Y1510 may be a novel therapeutic option for pancreatic cancer.

Tumour-bowel fistula as a possible complication of pazopanib therapy in retroperitoneal leiomyosarcoma

Pazopanib is a vascular endothelial growth factor receptor tyrosine kinase inhibitor (VEGFR TKI) that inhibits the vascular endothelial growth factor receptor A pathway and has the potential to cause ischaemic bowel changes, including perforation. Here we report a case of a 51-year-old man with large, metastatic, retroperitoneal leiomyosarcoma that developed a tumour-bowel fistula after 4 weeks of pazopanib therapy. He presented to the emergency department with sepsis and 1-week history of worsening fever, chills, nausea and diarrhoea. Abdominal CT findings of mesenteric and portal vein gas, commonly found in mesenteric ischaemia and VEGFR modulator-induced bowel toxicity, provided evidence for the causal relation. Unfortunately, the case was not amenable to surgery and patient succumbed to the illness.

Correlation Between HER-2 Gene Amplification or Protein Expression and Clinical Pathological Features of Breast Cancer

OBJECTIVE

The incidence of breast cancer in females is gradually increasing. Expression of HER-2 gene and protein is critical for predicting the prognosis of breast cancer. This study examined amplification of HER-2 gene and protein expression in breast cancer patients to analyze their correlation with clinical and pathological features.

MATERIALS AND METHODS

Specimens of breast gland tissues were collected from breast cancer patients for measuring HER-2 protein expression by immunohistochemistry (IHC) method. Fluorescent in situ hybridization (FISH) measured HER-2 gene amplification. The consistency of HER-2 protein and gene expression was analyzed in addition to their correlation with clinical and pathological features of patients.

RESULTS

Thirty-six percent patients showed negative expression of HER-2 protein, and 9%, 32%, and 23% of them had positive expression to different levels (+, ++, and +++). Forty percent patients were positive for HER-2 gene amplification, including 3, 21, and 14 cases of (+), (++), and (+++) patients. Expression of HER-2 protein was highly correlated with HER-2 gene amplification (r = 1.262; p < 0.05). Both parameters were correlated with tumor size, differentiation grade, lymph node metastasis, and TNM stage (p < 0.05).

CONCLUSIONS

Combined assay of IHC and FISH for detecting HER-2 protein or gene amplification in breast cancer tissues showed their correlation with tumor size, differentiation grade, lymph node metastasis, and TNM stage.