Abstract 3003: The effects of autophagy inhibition on HNSCC sensitivity to CTX

Background: Cetuximab (CTX) is a monoclonal antibody commonly used in the treatment of head and neck squamous cell carcinomas (HNSCCs) that acts by targeting the epidermal growth factor receptor (EGFR). Addition of CTX to standard multi-agent chemotherapy only slightly improves the response rate from 20% to 36%, highlighting the urgent need for improved treatment. Autophagy is a naturally occurring mechanism activated within cells to protect them from harsh conditions or stress but can also provide cancerous cells with protection against further treatment attempts. Here, we examine the efficacy of combining CTX with the autophagy inhibitor, SAR405, as well as investigating the specific mechanism of CTX-induced autophagy.

Methods: To measure autophagy, we utilized the Promega LC3 reporter assay, Western blotting for LC3, immunofluorescence for LC3, and an acridine orange assay. We ran our assays using the HNSCC cell lines A253 (HPV-), UM-SCC1 (HPV+), and its CTX-resistant derivative, UM-SCC1-C5 (HPV+). Clonogenic assays were run to measure colony formation, cell counting kit 8 (CCK8) assays to determine cell survival, and flow cytometry to investigate cell cycle status.

Results: In this study, we first were able to demonstrate that CTX can activate pro-survival autophagy. CTX-treated cells had higher LC3 flux and more LC3 puncta than control cells as assessed by western blot and immunofluorescence staining, respectively. CTX-resistant cells demonstrated higher basal LC3 flux compared to the CTX-sensitive parental cells. We also discovered that the use of the autophagy inhibitor, SAR405, could help improve tumor response when combined with CTX. The addition of SAR405 to CTX treatment led to a decrease in colony formation and a decrease in cell survival, overcoming resistance to CTX. Interestingly, we discovered that SAR405 alone led to cell cycle arrest in the G1 phase but did not lead to a statistically significant decrease in cell survival compared to the control, showing that SAR405 is able to arrest cell growth but is not cytotoxic. Finally, knockdown of EGFR or LAPTM4B prevented CTX-induced activation of autophagy.

Conclusion: Through our work, we have been able to demonstrate that CTX is able to activate autophagy, and that this initiation of autophagy plays a cytoprotective role in HNSCC cells. The addition of the autophagy inhibitor SAR405 improved response to CTX treatment. The promising results obtained thus far open the door to future studies investigating the efficacy of combining CTX with more specific autophagy inhibitors.

Citation Format: Samantha T. Bradley, Yong-Syu Lee, Justin H. Skiba, Jaimee Eckers, Adam D. Swick, Rong Hu, Kwang P. Nickel, Zafer Gurel, Pippa F. Cosper, Randall J. Kimple. The effects of autophagy inhibition on HNSCC sensitivity to CTX [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3003.

Abstract 1344: Autophagy contributes to therapeutic resistance in head and neck cancer

Background: In the curative setting for head and neck cancer (HNC) a common treatment is radiation combined with cetuximab, an antibody therapeutic targeting EGFR. Despite decades of research into improved treatments, therapeutic resistance remains a major challenge for this malignancy, with roughly 40% of patients developing recurrent disease. Recent evidence has suggested that autophagy, a cellular stress response, may be an additional contributor to therapy resistance, by protecting HNC cells from the cytotoxic effects of radiotherapy and the growth inhibitory effects of anti-EGFR treatment. The mechanism of radiation-induced autophagy is under current investigation.

Methods: Cell lines were source from commercial sources, cultured under recommended conditions, and identity confirmed by short tandem repeat testing. Induction of autophagy was detected by immunoblot flux assays for LC3 and p62, immunofluorescent staining of autophagic vesicles, LC3 reporter flux assay, and flow cytometry using acridine orange. The effect of autophagy inhibition was tested using clonogenic survival assays. Induction of apoptosis was analyzed by immunoblot against cleaved caspase and PARP and via AnnexinV staining.

Results: We evaluated a panel of both human papillomavirus (HPV) positive and negative HNC cell lines for autophagic response to both cetuximab (CTX) treatment and ionizing radiation (XRT). Flux assays revealed that both CTX and XRT treatment induced autophagy in a time- and dose-dependent manner. Immunofluorescent staining of LC3 to identify autophagic vesicles showed that a relatively small fraction of the total cell population is able to induce this response. Flow cytometry analysis demonstrated that autophagic cells were largely non-apoptoic. For example, in the UM-SCC47 cell line treated with CTX for 48 h, flow cytometry for autophagy (20.8%), apoptosis (13.7%) or dual staining (5.4%) suggests a cytoprotective role for autophagy. The addition of the ULK1 inhibitor, SBI-0206965) to CTX and XRT induced apoptosis as shown by caspase activity and AnnexinV staining and reduced clonogenic cell survival.

Conclusions: These preclinical studies have established the proof of concept for the cytoprotective effect of autophagy in response to anticancer treatments including EGFR inhibition and radiotherapy in HNC. Further, we have identified the addition of specific autophagy inhibitors to standard treatments as a potential strategy to overcome this mechanism of resistance.

Citation Format: Jaimee Eckers, Justin Skiba, Gopika Senthilkumar, Kwang P. Nickel, Adam D. Swick, Randall J. Kimple. Autophagy contributes to therapeutic resistance in head and neck cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1344.

Abstract 856: Selection of radiosensitizers based on HRAS mutation in bladder cancer

Purpose/Objective(s): The ability of activated HRAS to promote radiation resistance and predict for sensitivity to potential radiosensitizers was tested in a bladder cancer model system.

Materials/Methods: Mutations in HRAS, KRAS, and NRAS were analyzed using cBioPortal in a bladder cancer cohort (TCGA). We employed a panel of urothelial carcinoma cell lines-T24 (HRASG12V), J82 and 5637 (RASWT). Cell growth and survival was tested with colony formation and proliferation assays. Radiation survival was assessed by clonogenic survival assay. Immunoblots were used to confirm mutant HRAS expression, and target activation/knockdown in overexpression and knockdown studies. Radiosensitization of mutant-HRAS bladder cancer was tested using a flank cell line xenograft model in nude mice.

Results: Approximately 10% of bladder cancers feature alterations in one of three RAS genes; mutations in HRAS comprise greater than 50% of these. An HRAS activating (G12V) mutation was detected in T24. Consistent with known roles for activated RAS, T24 is relatively insensitive to both cetuximab and radiation. Using both in vivo and in vitro studies, cetuximab exhibited no radiosensitization of T24. Treatment with cetuximab lowered AKT, but not ERK activation. Direct inhibition of the MEK/ERK or PI3K/MTOR pathway by selumetinib or BEZ235, respectively, decreased target protein activation and resulted in significant growth inhibition compared to control (p<0.05). Treatment with either selumetinib or BEZ235 radiosensitized HRASG12V expressing cells (SER 1.3-1.8), but had more modest effects on cells with wild-type HRAS. siRNA knockdown of HRAS radiosensitized T24, but not J82 or 5637 cells relative to non-targeting control. The combination of selumetinib and radiation therapy delayed the growth of T24 tumors in vivo.

Conclusions: Over 10% of bladder cancers feature alterations in the RAS family of genes. These mutations can lead to resistance to cetuximab, either as a single treatment or as a radiosensitizer. Inhibition of downstream MEK/ERK and PI3K/MTOR pathways can radiosensitize tumors with activating mutations in HRAS. Identification of additional mutation/drug combinations that result in radiosensitization may be valuable to advance the design of personalized radiation therapy.

Citation Format: Michael M. Fisher, Adam D. Swick, Kwangok P. Nickel, Randall J. Kimple. Selection of radiosensitizers based on HRAS mutation in bladder cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 856.

Abstract 51: Potential and challenges in co-targeting mTORC and EGFR signaling as a therapeutic strategy in HNSCC

Background: Head and neck squamous cell carcinomas (HNSCCs) have high rates of mutation and other alterations along the PI3K/AKT/mTORC signaling axis. This has led to interest in the use of therapeutics targeting this pathway; however, identifying reliable predictive biomarkers to guide patient selection remains challenging. Despite excellent preclinical data, the use of these compounds as monotherapy has been underwhelming in initial clinical trials. The EGFR monoclonal antibody cetuximab remains the only approved targeted agent for HNSCC and with reasonable toxicity profiles, has potential use in combination therapy.

Methods: Both catalytic mTORC (AZD8055) and PI3K/mTORC(NVP-BEZ-235) inhibitors were tested +/- cetuximab in several in vitro and in vivo pre-clinical models. A panel of HNSCC cell lines and patient derived xenografts (PDX) were evaluated for PI3K/AKT/mTORC pathway mutation by sequencing and potential protein biomarker by immunoblot and IHC. Cell lines were assayed for sensitivity to all three agents by growth inhibition and clonogenic survival assay. DNA replication (BrdU uptake) and apoptosis (Capase 3/7 activity) were investigated to assess the mechanism of inhibition. The specificity of the molecular targeted effects was confirmed by siRNA knockdown. Five unique PDX models that presented PIK3CA mutation or intrinsic cetuximab resistance were treated with a combination of cetuximab and the dual mTORC inhibitor AZD8055 in a nude mouse model. Matched PDX derived cell strains were generated to investigate differences in response observed in in vitro and in vivo settings.

Results: Assessment of the panel of HNSCC cell lines by mutational hotspot sequencing did not reveal any obvious sensitizing mutations, whereas putative protein biomarkers (e.g. PIK3CA, pAKT) were elevated in some cell lines. All cell lines showed modest response to both PI3K/mTORC and dual mTORC inhibition. The addition of cetuximab to either agent produced modest additive effect. Mechanistic studies revealed that growth inhibition rather than death induction was the major anticancer effect. SiRNA knockdown showed similar molecular signaling and functional effects to drug inhibition. Using the PDX models, in vivo single agent mTORC inhibition inhibited growth of a PIK3CA mutant cancer, but had no effect on any PIK3CAWT or a second PIK3CA mutant model. In all models the combination therapy showed greater growth delay than monotherapy. In matched PDX derived cell strains, in vitro responses were similar when grown in 3D culture but cells displayed greater sensitivity when grown in 2D culture, suggesting that tumor microenvironment contributes to response.

Conclusions: The uniform ability of PI3K/mTORC and mTORC inhibition to suppress the growth of HNSCC cells highlights the role of this signaling pathway to drive the proliferation. In vivo, despite some PDX models meeting likely selection criteria, the single agent therapy was largely ineffective. Conversely, the combination treatment produced growth delay and suggests the potential for adding a catalytic mTORC inhibitor to cetuximab therapy for HNSCC patients. Overall, these results add to a growing body of evidence suggesting approaches that attempt to match genetic alternation or other biomarker to the optimal therapy in HNSCC remain complex and challenging.

Citation Format: Adam D. Swick, Prashanth J. Prabakaran, Margot C. Miller, Amal M. Javaid, Michael M. Fisher, Emmanuel Sampene, Irene M. Ong, Mari Iida, Deric L. Wheeler, Kwangok P. Nickel, Justine Y. Bruce, Randall J. Kimple. Potential and challenges in co-targeting mTORC and EGFR signaling as a therapeutic strategy in HNSCC [abstract]. In: Proceedings of the AACR-AHNS Head and Neck Cancer Conference: Optimizing Survival and Quality of Life through Basic, Clinical, and Translational Research; April 23-25, 2017; San Diego, CA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(23_Suppl):Abstract nr 51.

Abstract 5187: Potent radiosensitization of adenoid cystic carcinoma in a patient derived xenograft model using the MDM2 inhibitor AMG 232

Purpose: Adenoid cystic carcinoma (ACC) is a relatively rare cancer that typically arises in major or minor salivary gland tissues of the head and neck. There are currently no approved systemic agents for ACC and no established data supporting the delivery of chemoradiation for ACC patients. The scarcity of validated preclinical model systems has hampered research efforts. We report the successful establishment and propagation of an ACC patient derived xenograft (PDX), genomic evaluation of cancer associated mutations, and in vivo response to MDM2 inhibition combined with radiotherapy. Because TP53 mutations are seen in <5% of ACCs, we investigated the role of a small molecule MDM2 inhibitor, AMG 232.

Methods: An ACC PDX was established and assessed for common cancer-associated mutations using the Illumina TruSeq Amplicon Cancer panel. Xenografts were treated with focal radiation with or without AMG 232. Focal radiation was delivered at 0, 2, 5, or 8 Gy x 8 fractions delivered twice weekly, with AMG 232 (50mg/kg) delivered daily by oral gavage. Tumor size was measured by caliper and comparisons between treatment groups made using a repeated measures ANOVA. A TCD50 was calculated by fitting log-transformed data to a dose-response curve and compared using the extra-sum-of-squares f test. Target inhibition and anti-cancer effect was confirmed via immuno-blotting of tumor lysates, and IHC staining or in situ hybridization of relevant targets within FFPE sections of tumors harvested 2 and 48 hrs post treatment.

Results: The histologic characteristics of the primary human tumor are maintained in subsequent murine passages of this ACC PDX. Mutational profiling determined that the PDX was wildtype for TP53. AMG 232 alone resulted in modest slowing of tumor growth. Radiation alone produced a tumor growth delay in a dose dependent manner but did not result in sustained local tumor control. Strikingly, the combination of AMG 232 with RT (including low dose radiation of 2 Gy) produced dramatic tumor shrinkage and potent tumor control three months after the end of treatment. Target inhibition of MDM2 was confirmed by western blot of tumor lysates and IHC of FFPE samples taken 2 hrs post treatment. Antiproliferative and apoptotic effects were confirmed by western blot of tumor lysates and IHC of FFPE samples taken at 48 hrs post treatment.

Conclusions: This study suggests that MDM2 inhibition may provide potent radiosensitization in TP53 WT ACC. While additional translational models are warranted, the powerful response profile observed suggests that phase I clinical trial evaluation of this combination is worthy for this challenging malignancy.

Citation Format: Amal Javaid, Adam D. Swick, Lauryn Werner, Prashanth Prabakaran, Rong Hu, Kwangok P. Nickel, Irene Ong, Emmanuel Sampene, Justine Bruce, Gregory Hartig, Aaron Wieland, Jude Canon, Paul Harari, Randall Kimple. Potent radiosensitization of adenoid cystic carcinoma in a patient derived xenograft model using the MDM2 inhibitor AMG 232 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5187. doi:10.1158/1538-7445.AM2017-5187

Abstract 5192: Selection of radiosensitizers based on HRAS mutation in head and neck cancer

Purpose/Objective(s): The ability of activated HRAS to promote radiation resistance and predict for sensitivity to potential radiosensitizers was tested in a head and neck cancer model system.

Materials/Methods: Mutations in HRAS, KRAS, and NRAS were analyzed using cBioPortal in a head and neck cancer cohort. The Illumina TruSeq Amplicon Cancer panel was used to screen a panel of head and neck cancer cell lines for mutations in RAS-family genes. Cell growth and radiation survival was assessed by clonogenic survival assay. Immunoblots were used to confirm target activation/knockdown in overexpression and knockdown studies. A tumor control dose 50% (TCD50) assay was employed to investigate radiosensitization of a mutated-HRAS head and neck cancer cell line in a flank xenograft model in nude mice.

Results: Activating mutations in one of the three RAS genes are seen in 5-10% of head and neck cancer patients. Mutations in HRAS represent over 50% of these. Screening our panel of head and neck cancer cell lines identified a canonical activating mutation in HRAS (i.e. G12V) in SCC22B. Consistent with known roles for activated HRASG12V, SCC22B is relatively insensitive to both cetuximab and radiation. Using both in vitro and in vivo studies, cetuximab exhibited no ability to radiosensitize SCC22B. Cetuximab treatment decreased AKT, but not ERK activation. Direct inhibition pathways downstream of HRAS by selumetinib (MEK/ERK) or BEZ235 (PI3K/MTOR) decreased target protein activation and resulted in significant growth inhibition compared to control (p<0.05). Treatment with either selumetinib or BEZ235 radiosensitized HRASG12V expressing cells (SER 1.3-1.8) but had more modest effects on cells with wildtype HRAS. siRNA knockdown of HRAS radiosensitized SCC22B, but not SCC1 or SCC6 cells relative to non-targeting control. Overexpression of HRASG12V conferred relative radioresistance in wildtype cell lines. In vivo assessment of the radiosensitizing effects of these compounds (TCD50) is pending.

Conclusion: More than 5% of head and neck cancers harbor activating mutations in one of the RAS family of genes. These mutations lead to resistance to cetuximab, either as a single agent, or as a radiosensitizer. Inhibition of downstream targets such as the MEK/ERK and PI3K/MTOR pathways can radiosensitize tumors harboring activating mutations in HRAS. Identification of additional mutation/drug combinations that result in radiosensitization may be valuable to advance the design of personalized radiation therapy.

Citation Format: Michael M. Fisher, Adam D. Swick, Kwangok P. Nickel, Randall J. Kimple. Selection of radiosensitizers based on HRAS mutation in head and neck cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5192. doi:10.1158/1538-7445.AM2017-5192

Abstract 3307: Induction of autophagy as a mechanism of therapeutic resistance in head and neck cancer

Background: In the curative setting for head and neck cancer (HNC) a commonly used treatment is radiation combined with the anti-EGFR monoclonal antibody cetuximab (CTX). However, despite decades of research into improved treatments, therapeutic resistance remains a major challenge for this malignancy with roughly 40% of patients developing recurrent disease. We are studying the molecular mechanisms by which radiation and cetuximab induce autophagy and how this process can be modulated to improve the efficacy of therapy.

Methods: We evaluated a panel of both human papillomavirus (HPV) positive and negative HNC cell lines for autophagic response to both CTX treatment and ionizing radiation (XRT). Induction of autophagy was detected by immunoblot flux assays for LC3 and p62 and by immunofluorescent staining of autophagic vesicles. siRNA knockdown of EGFR, LAMPT4B, ULK1, Beclin1 and others was used to probe the involvement of different signaling molecules. The addition of specific autophagy inhibitors, such as the ULK1 inhibitor SBI-0206965, to CTX or XRT treatment was tested to determine whether the reduction of autophagic response reduced cell survival in a clonogenic survival assay. Induction of apoptosis was analyzed by immunoblot against cleaved Caspase and PARP and AnnexinV staining.

Results: Flux assays revealed that both CTX and XRT induced autophagy in a time and dose dependent manner. Immunofluorescent staining of LC3 to identify autophagic vesicles showed that a relatively small fraction of the total cell population is able to induce this response. Specific siRNA knockdown of EGFR and LAMPT4B was able to abrogate the induction of autophagy in response to both CTX and XRT. Involvement of alternative downstream pathways involving either ULK1 and Beclin1 or p53 in response to either treatment is under investigation. To determine whether blockade of cytoprotective autophagy can help overcome therapeutic resistance, we tested specific autophagy inhibitors in combination with either CTX or XRT treatment. The addition of the ULK1 inhibitor to CTX or XRT induced apoptosis as shown by caspase activity, AnnexinV staining, and reduced cell survival in clonogenic assays.

Conclusions: Autophagy may play a critical and protective role in how head and neck cancers respond to therapeutic stress. The addition of specific autophagy inhibitors to standard treatments may provide a way to overcome resistance to therapy.

Citation Format: Jaimee C. Eckers, Adam D. Swick, Tyler Fowler, Justin Skiba, Kwangok P. Nickel, Randall J. Kimple. Induction of autophagy as a mechanism of therapeutic resistance in head and neck cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 3307. doi:10.1158/1538-7445.AM2017-3307

Radiosensitization of Adenoid Cystic Carcinoma with MDM2 Inhibition

Purpose: Adenoid cystic carcinoma (ACC) is a rare cancer arising from the major or minor salivary gland tissues of the head and neck. There are currently no approved systemic agents or known radiosensitizers for ACC. Unlike the more common head and neck squamous cell carcinomas that frequently harbor TP53 mutations, ACCs contain TP53 mutations at a rate of <5%, rendering them an attractive target for MDM2 inhibition.Experimental Design: We report the successful establishment and detailed characterization of a TP53-WT ACC patient-derived xenograft (PDX), which retained the histologic features of the original patient tumor. We evaluated this model for response to the MDM2 inhibitor AMG 232 as monotherapy and in combination with radiotherapy.Results: AMG 232 monotherapy induced modest tumor growth inhibition, and radiation monotherapy induced a transient tumor growth delay in a dose-dependent fashion. Strikingly, combination treatment of AMG 232 with radiotherapy (including low-dose radiotherapy of 2 Gy/fraction) induced dramatic tumor response and high local tumor control rates 3 months following treatment. Posttreatment analysis revealed that although both AMG 232 and radiotherapy alone induced TP53 tumor-suppressive activities, combination therapy amplified this response with potent induction of apoptosis after combination treatment.Conclusions: These data identify that MDM2 inhibition can provide potent radiosensitization in TP53-WT ACC. In light of the absence of effective systemic agents for ACC, the powerful response profile observed here suggests that clinical trial evaluation of this drug/radiotherapy combination may be warranted to improve local control in this challenging malignancy. Clin Cancer Res; 23(20); 6044-53. ©2017 AACR.

Co-targeting mTORC and EGFR signaling as a therapeutic strategy in HNSCC

e17509

Background: Head and neck squamous cell carcinomas (HNSCCs) are frequently altered along the PI3K/AKT/mTORC signaling axis leading to development of therapeutics targeting this pathway. Despite excellent preclinical data, the use of these compounds as monotherapy has been underwhelming in initial clinical trials and identification of predictive biomarkers remains challenging. The EGFR monoclonal antibody cetuximab remains the only approved targeted agent for HNSCC and has potential use in combination therapy. Methods: Both catalytic mTORC (AZD8055) and PI3K/mTORC(NVP-BEZ-235) inhibitors were tested +/- cetuximab in a panel of HNSCC cell lines and patient derived xenografts (PDX) evaluated for potential biomarkers of PI3K/AKT/mTORC pathway. Cell lines were assayed for response to all three agents by multiple approaches, and confirmed by siRNA knockdown. Five PDX models that presented PIK3CA mutation or intrinsic cetuximab resistance were treated with a combination of cetuximab and AZD8055. Results: In HNSCC cells no likely sensitizing mutations were identified, whereas putative protein biomarkers were elevated in some lines. All lines showed similar response to both PI3K/mTORC and dual mTORC inhibition with cetuximab combination producing modest additive effect with similar results for siRNA knockdown. In PDX models, in vivo single agent mTORC inhibition inhibited growth of a PIK3CA mutant cancer, but had little effect on any PIK3CAWT or a second PIK3CA mutant model. In all models the combination therapy showed greater growth delay than monotherapy. Conclusions: The uniform ability of PI3K and mTORC inhibition to suppress the growth of HNSCC cells highlights the pathway’s role in driving proliferation. In vivo, despite some PDX models meeting likely selection criteria, the single agent therapy was largely ineffective. Conversely improved response of combination treatment suggests the potential for adding a catalytic mTORC inhibitor to cetuximab therapy. Overall, these results add to a growing body of evidence suggesting approaches that attempt to match biomarkers to the optimal therapy in HNSCC remains complex and challenging.

Cotargeting mTORC and EGFR Signaling as a Therapeutic Strategy in HNSCC

Head and neck squamous cell carcinomas (HNSCC) are frequently altered along the PI3K/AKT/mTORC signaling axis. Despite excellent preclinical data, the use of compounds targeting this pathway as monotherapy has been underwhelming in initial clinical trials, and identification of predictive biomarkers remains challenging. To investigate mTORC-specific inhibition, we tested catalytic mTORC (AZD8055) and PI3K/mTORC (NVP-BEZ-235) inhibitors ± cetuximab in a panel of HNSCC cell lines and patient-derived xenografts (PDX). Cell lines were assayed for response to all agents and siRNA knockdown of targets by multiple approaches. All cell lines showed similar response to both drug and siRNA inhibition of both PI3K and mTORC pathways, with anti-EGFR combination producing modest additive effect. Five PDX models that presented PIK3CA mutation or intrinsic cetuximab resistance were treated with a combination of cetuximab and AZD8055. In vivo single-agent mTORC inhibition inhibited growth of one PIK3CA-mutant cancer, but had little effect on any PIK3CA^WT or a second PIK3CA-mutant model. In all models, the combination therapy showed greater growth delay than monotherapy. The uniform ability of PI3K and mTORC inhibition to suppress the growth of HNSCC cells highlights the pathway's role in driving proliferation. Although single-agent therapy was largely ineffective in vivo, improved response of combination treatment in an array of PDXs suggests the potential for adding a catalytic mTORC inhibitor to cetuximab therapy. Overall, these results add to a growing body of evidence, suggesting that approaches that attempt to match biomarkers to the optimal therapy in HNSCC remain complex and challenging. Mol Cancer Ther; 16(7); 1257-68. ©2017 AACR.

Defining the boundaries and expanding the utility of head and neck cancer patient derived xenografts

BACKGROUND

Patient derived xenografts (PDXs) represent an essential tool in oncologic research, and we sought to further expand our repertoire of head and neck squamous cell carcinoma (HNSCC) while determining potential boundaries for this system.

METHODS

We consented new patients for PDX development and determined if a 24-h time delay from tumor excision to xenograft implantation affected PDX establishment. We developed a tissue microarray (TMA) from formalin fixed, paraffin embedded PDXs and their subsequent passages and carried out quantitative immunohistochemistry for EGFR, pEGFR, pAkt, pERK and ERCC1. First and last passaged PDXs were compared via a paired t-test to examine for the stability of protein expression across passages. We performed a similar comparison of the mutational profile of the patient tumor and resulting xenografts using a targeted sequencing approach.

RESULTS

No patient/tumor characteristics influenced PDX take rate and the 24-h time delay from tumor excision to xenograft implantation did not affect PDX establishment, growth or histology. There was no significant difference in biomarker expression between the first and last passaged PDXs for EGFR, pEGFR, pAkt, and ERCC1. For pERK there was a significant difference (p=0.002), but further analysis demonstrated this only arose in three of 15 PDXs. Targeted sequencing revealed striking stability of passenger and likely driver mutations from patient to xenograft.

CONCLUSIONS

The stability of protein expression across PDX passages will hopefully allow greater investigation of predictive biomarkers in order to identify ones for further pre-clinical and clinical investigation.

Targeting the HER Family with Pan-HER Effectively Overcomes Resistance to Cetuximab

Cetuximab, an antibody against the EGFR, has shown efficacy in treating head and neck squamous cell carcinoma (HNSCC), metastatic colorectal cancer, and non-small cell lung cancer (NSCLC). Despite the clinical success of cetuximab, many patients do not respond to cetuximab. Furthermore, virtually all patients who do initially respond become refractory, highlighting both intrinsic and acquired resistance to cetuximab as significant clinical problems. To understand mechanistically how cancerous cells acquire resistance, we previously developed models of acquired resistance using the H226 NSCLC and UM-SCC1 HNSCC cell lines. Cetuximab-resistant clones showed a robust upregulation and dependency on the HER family receptors EGFR, HER2, and HER3. Here, we examined pan-HER, a mixture of six antibodies targeting these receptors on cetuximab-resistant clones. In cells exhibiting acquired or intrinsic resistance to cetuximab, pan-HER treatment decreased all three receptors' protein levels and downstream activation of AKT and MAPK. This correlated with decreased cell proliferation in cetuximab-resistant clones. To determine whether pan-HER had a therapeutic benefit in vivo, we established de novo cetuximab-resistant mouse xenografts and treated resistant tumors with pan-HER. This regimen resulted in a superior growth delay of cetuximab-resistant xenografts compared with mice continued on cetuximab. Furthermore, intrinsically cetuximab-resistant HNSCC patient-derived xenograft tumors treated with pan-HER exhibited significant growth delay compared with vehicle/cetuximab controls. These results suggest that targeting multiple HER family receptors simultaneously with pan-HER is a promising treatment strategy for tumors displaying intrinsic or acquired resistance to cetuximab. Mol Cancer Ther; 15(9); 2175-86. ©2016 AACR.

Abstract 3044: Patient-derived adenoid cystic carcinoma xenografts to study molecular target modulation of tumor radiosensitivity

Background: Adenoid cystic carcinoma (ACC) is a relatively rare cancer that typically arises in salivary tissues of the head and neck region. Hallmark characteristics include slow growth rate, peri-neural tumor spread, and a high propensity for late distant metastasis. Surgery and radiation are the mainstays of treatment with no effective systemic agents to date. Due to infrequency, studies of novel therapeutics are not routinely feasible. In addition, whether these tumors can be sensitized to radiation by concurrent chemotherapy is not known. We report here the establishment and examination of ACC patient derived xenografts (PDX) to investigate the efficacy of novel chemotherapies and combinations of chemotherapy and radiation.

Methods: PDXs have been established and maintained in NOD-SCID gamma (NSG) mice from both research biopsies and surgical specimens. Common cancer-associated mutations in both the primary patient tumor and PDX were identified using the Illumina TruSeq Amplicon Cancer panel. Well described immunohistochemical markers of ACC were used to compare histological characteristics between the primary tumor and PDX. The ACC PDX was engrafted into the flanks of nude mice and treated with focal radiotherapy (5 Gy x 8 fractions delivered twice weekly), a panel of chemotherapeutic agents, or combination radiochemotherapy. Tumor size was measured over time and comparisons between treatment groups made by the extra-sum-of-squares f test.

Results: PDXs established from ACC maintain the histologic and physical characteristics of the primary tumor. Targeted mutational analysis of ACC identified expected alterations based on previously reported large scale sequencing of other human tumors including mutations in the receptor tyrosine kinases(RTKs) cKit and KDR/VEGFR2. Based on identified tumor mutations, several targeted therapies were selected including dovitinib, a multi-RTK inhibitor, BEZ235, a PI3K/mTORC inhibitor, and cetuximab, an EGFR mAB. Treatment with each of these compounds showed varying degrees of growth inhibition without evidence of frank tumor regression. However, combining these drugs with radiation demonstrated significantly improved tumor control in comparison to drug alone.

Conclusions: Studies using our PDX model suggest that several molecular targeting agents can significantly augment the impact of radiation on ACC tumor growth. These preliminary data identify the rationale to investigate selected molecular drug/radiation combinations for ACC, particularly when driven by tumor specific genetic biomarkers. Expansion of these ACC studies may be valuable to advance the design of new investigational treatment strategies for this challenging tumor.

Citation Format: Prashanth Prabakaran, Kwangok P. Nickel, David T. Yang, Lauryn R. Werner, Justine Y. Bruce, Aaron M. Wieland, Timothy M. McCulloch, Gregory K. Hartig, Paul M. Harari, Adam D. Swick, Randall J. Kimple. Patient-derived adenoid cystic carcinoma xenografts to study molecular target modulation of tumor radiosensitivity. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3044.

Abstract 2129: Induction of autophagy as a mechanism of therapeutic resistance in head and neck cancer

Background and purpose:

Despite decades of research into improved treatments for head and neck cancer, therapeutic resistance remains a major challenge for this malignancy, with roughly 40% of patients developing recurrent disease. Among the plethora of intrinsic and acquired mechanisms of resistance, recent evidence has suggested the cellular process of autophagy may be an additional contributor. This stress response, which normally functions during periods of nutrient deprivation to maintain cellular homeostasis, may have the unintended consequence of protecting tumor cells from the cytotoxic effects of chemotherapy and radiotherapy. We show that autophagy mediates resistance to chemotherapies targeting the EGFR and mTORC pathways in addition to radiotherapy in several head and neck cancer models, begin to elucidate the mechanism of this resistance, and demonstrate that the addition of a specific autophagy inhibitor can block cytoprotective autophagy.

Methods and results:

Building on well established evidence that mTORC inhibition can directly induce autophagy, recent work has established a novel mechanism by which kinase inactive EGFR resulting from either growth factor starvation or anti-EGFR antibody (cetuximab) can upregulate this response via an interaction with LAMPT4B. Treatment of a panel of HNC cell lines with either serum starvation or cetuximab produced increased formation of LC3-B puncta, a marker for autophagasome formation, by IF staining, and was confirmed by Western blot for increased LC3-B flux and decreased p62. SiRNA knockdown of either EGFR or LAMPT4B in HNC cells abrogated the induction of autophagy in response to either serum starvation or cetuximab treatment. We have also shown that radiation induces autophagy in a time and dose dependent manner. The mechanism of radiation-induced autophagy remains a subject of study; preliminary data suggest that both EGFR and LAMPT4B play a role as siRNA knockdown of those mRNAs reduces the autophagic response. To determine whether blockade of cytoprotective autophagy can help overcome therapeutic resistance, we have tested specific autophagy inhibitors in combination with either chemotherapy or radiation. The novel ULK1 inhibitor SBI-0206965 successfully blocks the induction of autophagy in a panel of HNC lines. More compellingly, while neither SBI-0206965 nor the NEDD4 inhibitor Heclin, impacted cell growth in untreated cells, both were effective in reducing cell survival following treatment with radiation, cetuximab, or mTORC inhibitor (AZD8055).

Summary:

These pre-clinical studies have established the proof of concept for the cytoprotective effect of autophagy in response to anti-cancer treatments including EGFR or mTORC inhibition and radiotherapy. Further we have identified the addition of specific autophagy inhibitors to standard treatments as a potential strategy to overcome this mechanism of resistance.

Citation Format: Adam D. Swick, Tan Xiaojun, Tyler Fowler, Kwangok Nickel, Richard A. Anderson, Randall J. Kimple. Induction of autophagy as a mechanism of therapeutic resistance in head and neck cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2129.

Prevalence of Human Papillomavirus in Oropharyngeal Cancer: A Systematic Review

PURPOSE

The global incidence of oropharyngeal squamous cell carcinoma (OPSCC) has been increasing, and it has been proposed that a rising rate of human papillomavirus (HPV)-associated cancers is driving the observed changes in OPSCC incidence. We carried out this systematic review to further examine the prevalence of HPV in OPSCC over time worldwide.

METHODS

A systematic literature search was performed to identify all articles through January 31, 2014, which reported on the prevalence of HPV in OPSCC. Articles that met the inclusion criteria were divided into 4 time frames (pre-1995, 1995-1999, 2000-2004, and 2005 to present) based on the median year of the study's sample collection period. Using a weighted analysis of variance model, we examined the trends of HPV-positivity over time worldwide, in North America, and in Europe.

RESULTS

Our literature search identified 699 unique articles. One hundred seventy-five underwent review of the entire study, and 105 met the inclusion criteria. These 105 articles reported on the HPV prevalence in 9541 OPSCC specimens across 23 nations. We demonstrated significant increases in the percentage change of HPV-positive OPSCCs from pre-1995 to present: 20.6% worldwide (P for trend: P < 0.001), 21.6% in North America (P = 0.013), and 21.5% in Europe (P = 0.033).

CONCLUSIONS

Interestingly, whereas in Europe there was a steady increase in HPV prevalence across all time frames, reaching nearly 50% most recently, in North America HPV prevalence appears to have plateaued over the past decade at about 65%. These findings may have important implications regarding predictions for the future incidence of OPSCC.

Pan-HER Inhibitor Augments Radiation Response in Human Lung and Head and Neck Cancer Models

PURPOSE

Aberrant regulation of the EGF receptor family (EGFR, HER2, HER3, HER4) contributes to tumorigenesis and metastasis in epithelial cancers. Pan-HER represents a novel molecular targeted therapeutic composed of a mixture of six monoclonal antibodies against EGFR, HER2, and HER3.

EXPERIMENTAL DESIGN

In the current study, we examine the capacity of Pan-HER to augment radiation response across a series of human lung and head and neck cancers, including EGFR inhibitor-resistant cell lines and xenografts.

RESULTS

Pan-HER demonstrates superior antiproliferative and radiosensitizing impact when compared with cetuximab. The mechanisms underlying these effects appear to involve attenuation of DNA damage repair, enhancement of programmed cell death, cell-cycle redistribution, and induction of cellular senescence. Combined treatment of Pan-HER with single or fractionated radiation in human tumor xenografts reveals a potent antitumor and regrowth delay impact compared with Pan-HER or radiation treatment alone.

CONCLUSIONS

These data highlight the capacity of Pan-HER to augment radiation response in lung and head and neck cancer models and support investigation of Pan-HER combined with radiation as a promising clinical therapeutic strategy.

Abstract 3603: Molecular targeting of cetuximab resistant head and neck cancer

Despite promising preclinical data, the EGFR targeted monoclonal antibody, cetuximab, has limited use as single agent therapy in the treatment of head and neck cancer due to the development of therapeutic resistance. Improved approaches to treat these cancers will need to address the evolving molecular landscape of head and neck cancer. Recent reports describing mutations or copy number alterations in PI3K and PTEN as potential causes of cetuximab resistance have sparked interest in therapeutics that target these pathways as alternatives to or in combination with EGFR targeting drugs.

Using both in vitro and in vivo models of head and neck squamous cell carcinoma (HNSCC) we have recapitulated the diversity of responses to cetuximab observed in the patient population and are testing alternative therapies. Examining an array of HNSCC cell lines, including both human papillomavirus (HPV) positive and negative lines, we observed a wide range of sensitivities to this drug, with little to no growth inhibition in some lines even at micromolar concentrations. For lines that were sensitive to drug, effective growth inhibition, demonstrated in both proliferation and colony formation assays, was linked with suppressed phosphorylation of both Akt and ERK/MAPK signaling downstream of EGFR. Additionally, in the sensitive HPV+ HNSCC lines, cetuximab treatment induced apoptosis marked by caspase activity. Both sensitive and resistant HNSCC lines were then tested for response to both AZD8055, a dual mTORC1/2 inhibitor and BEZ235, a PI3K/mTORC1 inhibitor, resulting in both growth inhibition and successful suppression of phosphorylation of their Akt and S6 targets, suggesting that these drugs may be useful alternatives or adjuvants for cetuximab treatment.

In vivo models of HNSCC were also utilized to test the efficacy of cetuximab treatment and begin to evaluate alternative or combination therapies. Using immunocompromised mouse models, both cell line xenografts and novel patient derived xenografts presented a range of sensitivities to cetuximab. In an effort to identify potential biomarkers that would predict response to cetuximab, IHC staining of pre-treatment tumor samples was carried out and demonstrated that low phospho-Akt and phospho-ERK levels correlated with cetuximab sensitivity. Initial in vivo studies using the PI3K/mTORC inhibitors AZD8055 and BEZ235 to treat both cetuximab sensitive and resistant xenografts, have shown that these compounds may be effective at suppressing growth in both categories of tumors. These studies provide initial pre-clinical data to support the use of PI3K inhibition for the treatment of head and neck cancer.

Citation Format: Adam D. Swick, Dana Gunderson, Molly Smith, Grace Blitzer, Andrew Stein, Kwangok P. Nickel, Randall J. Kimple. Molecular targeting of cetuximab resistant head and neck cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3603. doi:10.1158/1538-7445.AM2015-3603

Xenograft assessment of predictive biomarkers for standard head and neck cancer therapies

Head and neck squamous cell carcinoma (HNSCC) remains a challenging cancer to treat with overall 5-year survival on the order of 50–60%. Therefore, predictive biomarkers for this disease would be valuable to provide more effective and individualized therapeutic approaches for these patients. While prognostic biomarkers such as p16 expression correlate with outcome; to date, no predictive biomarkers have been clinically validated for HNSCC. We generated xenografts in immunocompromised mice from six established HNSCC cell lines and evaluated response to cisplatin, cetuximab, and radiation. Tissue microarrays were constructed from pre- and posttreatment tumor samples derived from each xenograft experiment. Quantitative immunohistochemistry was performed using a semiautomated imaging and analysis platform to determine the relative expression of five potential predictive biomarkers: epidermal growth factor receptor (EGFR), phospho-EGFR, phospho-Akt, phospho-ERK, and excision repair cross-complementation group 1 (ERCC1). Biomarker levels were compared between xenografts that were sensitive versus resistant to a specific therapy utilizing a two-sample t-test with equal standard deviations. Indeed the xenografts displayed heterogeneous responses to each treatment, and we linked a number of baseline biomarker levels to response. This included low ERCC1 being associated with cisplatin sensitivity, low phospho-Akt correlated with cetuximab sensitivity, and high total EGFR was related to radiation resistance. Overall, we developed a systematic approach to identifying predictive biomarkers and demonstrated several connections between biomarker levels and treatment response. Despite these promising initial results, this work requires additional preclinical validation, likely involving the use of patient-derived xenografts, prior to moving into the clinical realm for confirmation among patients with HNSCC.