Successful targeting of the NRG1 pathway indicates novel treatment strategy for metastatic cancer

Background

NRG1 fusion-positive lung cancers have emerged as potentially actionable events in lung cancer, but clinical support is currently limited and no evidence of efficacy of this approach in cancers beyond lung has been shown.

Patients and methods

Here, we describe two patients with advanced cancers refractory to standard therapies. Patient 1 had lung adenocarcinoma and patient 2 cholangiocarcinoma. Whole-genome and transcriptome sequencing were carried out for these cases with select findings validated by fluorescence in situ hybridization.

Results

Both tumors were found to be positive for NRG1 gene fusions. In patient 1, an SDC4-NRG1 gene fusion was detected, similar gene fusions having been described in lung cancers previously. In patient 2, a novel ATP1B1-NRG1 gene fusion was detected. Cholangiocarcinoma is not a disease type in which NRG1 fusions had been described previously. Integrative genome analysis was used to assess the potential functional significance of the detected genomic events including the gene fusions, prioritizing therapeutic strategies targeting the HER-family of growth factor receptors. Both patients were treated with the pan HER-family kinase inhibitor afatinib and both displayed significant and durable response to treatment. Upon progression sites of disease were sequenced. The lack of obvious genomic events to describe the disease progression indicated that broad transcriptomic or epigenetic mechanisms could be attributed to the lack of prolonged response to afatinib.

Conclusion

These observations lend further support to the use of pan HER-tyrosine kinase inhibitors for the treatment of NRG1 fusion-positive in both cancers of lung and hepatocellular origin and indicate more broadly that cancers found to be NRG1 fusion-positive may benefit from such a clinical approach regardless of their site of origin.

Clinical trial information

Personalized Oncogenomics (POG) Program of British Columbia: Utilization of Genomic Analysis to Better Understand Tumour Heterogeneity and Evolution (NCT02155621).

GABA-ergic transmission in deep cerebellar nuclei

gamma-Aminobutyric acid (GABA) is the inhibitory transmitter released at Purkinje cell axon terminals in deep cerebellar nuclei (DCN). Neurons in DCN also receive excitatory glutamatergic inputs from the inferior olive. The output of DCN neurons, which depends on the balance between excitation and inhibition on these cells, is involved in cerebellar control of motor coordination. Plasticity of synaptic transmission observed in other areas of the mammalian central nervous system (CNS) has received wide attention. If GABA-ergic and/or glutamatergic synapses in DCN also undergo plasticity, it would have major implications for cerebellar function. In this review, literature evidence for GABA-ergic synaptic transmission in DCN as well as its plasticity are discussed. Studies indicate that fast inhibitory postsynaptic potentials (IPSPs) and currents (IPSCs) in neurons of DCN are mediated by GABAA receptors. While GABAB receptors are present in DCN, they do not appear to be activated by Purkinje cell axons. The IPSPs undergo paired-pulse, as well as frequency-dependent, depressions. In addition, tetanic stimulation of inputs can induce a long-term depression (LTD) of the IPSPs and IPSCs. Excitatory synapses do not appear to undergo long-term potentiation or LTD. The LTD of the IPSP is not input-specific, as it can be induced heterosynaptically and is associated with a reduced response of DCN neurons to a GABAA receptor agonist. Postsynaptic Ca2+ and protein phosphatases appear to contribute to the LTD. The N-methyl-D-aspartate receptor-gated, as well as the voltage-gated Ca2+ channels are proposed to be sources of the Ca2+. It is suggested that LTD of GABA-ergic transmission, by regulating DCN output, can modulate cerebellar function.

Whole genome and transcriptome analysis enhances precision cancer treatment options

BACKGROUND

Recent advances are enabling delivery of precision genomic medicine to cancer clinics. While the majority of approaches profile panels of selected genes or hotspot regions, comprehensive data provided by whole genome and transcriptome sequencing and analysis (WGTA) presents an opportunity to align a much larger proportion of patients to therapies.

PATIENTS AND METHODS

Samples from 570 patients with advanced or metastatic cancer of diverse types enrolled in the Personalized OncoGenomics (POG) program underwent WGTA. DNA-based data, including mutations, copy number, and mutation signatures, were combined with RNA-based data, including gene expression and fusions, to generate comprehensive WGTA profiles. A multidisciplinary molecular tumour board used WGTA profiles to identify and prioritize clinically actionable alterations and inform therapy. Patient responses to WGTA-informed therapies were collected.

RESULTS

Clinically actionable targets were identified for 83% of patients, 37% of whom received WGTA-informed treatments. RNA expression data were particularly informative, contributing to 67% of WGTA-informed treatments; 25% of treatments were informed by RNA expression alone. Of a total 248 WGTA-informed treatments, 46% resulted in clinical benefit. RNA expression data were comparable to DNA-based mutation and copy number data in aligning to clinically beneficial treatments. Genome signatures also guided therapeutics including platinum, PARP inhibitors, and immunotherapies. Patients accessed WGTA-informed treatments through clinical trials (19%), off-label use (35%), and as standard therapies (46%) including those which would not otherwise have been the next choice of therapy, demonstrating the utility of genomic information to direct use of chemotherapies as well as targeted therapies.

CONCLUSIONS

Integrating RNA expression and genome data illuminated treatment options that resulted in 46% of treated patients experiencing positive clinical benefit, supporting the use of comprehensive WGTA profiling in clinical cancer care.

CLINICAL TRIAL NUMBER

NCT02155621.

Mouse skin photosensitization with benzoporphyrin derivatives and Photofrin: macroscopic and microscopic evaluation

A comparative study, at both the macroscopic and microscopic level, of skin photosensitivity caused by four isomeric forms of benzoporphyrin derivative (BPD) has been carried out, and compared to effects of Photofrin. Animals injected intravenously with BPD analogues and exposed to light 3 h later showed extensive photosensitivity. Animals receiving the monoacid derivatives of BPD (BPD-MA and BPD-MB) showed markedly more photosensitivity than those receiving the diacid derivatives (BPD-DA and BPD-DB). Animals receiving BPD analogues which were exposed to light 24 h or more later showed only minimal reactivity. Histological examination of biopsies taken after photosensitizer injection and light exposure showed extensive changes in epidermis and dermis, including epidermal erosion, degranulation of the stratum granulosum, spongiosis, depletion in cellularity and mast cell degranulation. These changes were noted to be similar to changes caused by Photofrin.

Mechanisms involved in tetanus-induced potentiation of fast IPSCs in rat hippocampal CA1 neurons

In the present study, possible mechanisms involved in the tetanus-induced potentiation of gamma-aminobutyric acid-A (GABA-A) receptor-mediated inhibitory postsynaptic currents (IPSCs) were investigated using the whole cell voltage-clamp technique on CA1 neurons in rat hippocampal slices. Stimulations (100 Hz) of the stratum radiatum, while voltage-clamping the membrane potential of neurons, induces a long-term potentiation (LTP) of evoked fast IPSCs while increasing the number but not the amplitude of spontaneous IPSCs (sIPSCs). The potentiation of fast IPSCs was input specific. During the period of IPSC potentiation, postsynaptic responses produced by 4,5,6,7-tetrahydroisoxazolo[5,4-c]pyridin-3-ol hydrochloride and baclofen, GABA-A and GABA-B agonists respectively, were not significantly different from control. CGP 36742, a GABA-B antagonist, blocked the induction of tetanus-induced potentiation of evoked and spontaneous IPSCs, while GTPgammaS, an activator of G proteins, substitution for GTP in the postsynaptic recording electrode did not occlude potentiation. Since GABA-B receptors work through G proteins, our results suggest that pre- but not postsynaptic GABA-B receptors are involved in the potentiation of fast IPSCs. A tetanus delivered when GABA-A responses were completely blocked by bicuculline suggests that GABA-A receptor activation during tetanus is not essential for the induction of potentiation. Rp-cAMPs, an antagonist of protein kinase A (PKA) activation, blocks the induction of potentiation of fast IPSCs. Forskolin, an activator of PKA, increases baseline evoked IPSCs as well as the number of sIPSCs, and a tetanic stimulation during this enhancement uncovers a long-term depression of the evoked IPSC. Sulfhydryl alkylating agents, N-ethylmaleimide and p-chloromercuribenzoic acid, which have been found to presynaptically increase GABA release and have been suggested to have effects on proteins involved in transmitter release processes occurring in nerve terminals, occlude tetanus-induced potentiation of evoked and spontaneous IPSCs. Taken together our results suggest that LTP of IPSCs originates from a presynaptic site and that GABA-B receptor activation, cyclic AMP/PKA activation and sulfhydryl-alkylation are involved. Plasticity of IPSCs as observed in this study would have significant implications for network behavior in the hippocampus.

Detection of weakly expressed genes in the rostral ventrolateral medulla of the rat using micropunch and reverse transcription-polymerase chain reaction techniques

1. The present study describes the use of reverse transcription-polymerase chain reaction (RT-PCR) to detect weakly expressed neurotransmitter receptor mRNA in tissue micropunched from the rostral ventrolateral medulla (RVLM) and other discrete areas of the medulla oblongata of the rat. 2. Micropunches were made from 240 microns transverse medullary sections. Punched regions included the RVLM, hypoglossal nucleus (XIIn), ventrolateral subnucleus of the nucleus tractus solitarius (NTS) and spinal trigeminal nucleus (STN). RNA was extracted and reverse transcribed into cDNA, which was probed for the presence of seven genes: glyceraldehyde phosphate dehydrogenase (GAPDH), neuron-specific enolase (NSE), tyrosine hydroxylase (TH), phenylethanolamine N-methyltransferase (PNMT), glucocorticoid receptor (GCR), mineralocorticoid receptor (MCR) and the adenosine 5'-triphosphate (ATP) receptor subunit P2X2-1. Each transcript was detected using a semi-nested PCR protocol, which used three primers. 3. Tyrosine hydroxylase was detected in the RVLM and NTS and PNMT was also detected in the RVLM, which agrees with the distribution of catecholamine neurons in the medulla. Expression of GCR mRNA was detected in the RVLM and the XIIn but not in the NTS (it was not probed for in the STN punches). The P2X2-1 receptor message was detected in all areas. Expression of MCR mRNA was detected in the RVLM only. 4. This method offers a simple way to detect the presence of low-abundance receptor mRNA in discrete brain regions.

A Canadian guideline on the use of next-generation sequencing in oncology

Rapid advancements in next-generation sequencing (ngs) technology have created an unprecedented opportunity to decipher the molecular profile of tumours to more effectively prevent, diagnose, and treat cancer. Oncologists now have the option to order molecular tests that can guide treatment decisions. However, to date, most oncologists have received limited training in genomics, and they are now faced with the challenge of understanding how such tests and their interpretation align with patient management. Guidance on how to effectively use ngs technology is therefore needed to aid oncologists in applying the results of genomic tests. The Canadian guideline presented here describes best practices and unmet needs related to ngs-based testing for somatic variants in oncology, including clinical application, assay and sample selection, bioinformatics and interpretation of reports performed by laboratories, patient communication, and clinical trials.

Response to angiotensin blockade with irbesartan in a patient with metastatic colorectal cancer

BACKGROUND

A patient suffering from metastatic colorectal cancer, treatment-related toxicity and resistance to standard chemotherapy and radiation was assessed as part of a personalized oncogenomics initiative to derive potential alternative therapeutic strategies.

PATIENTS AND METHODS

Whole-genome and transcriptome sequencing was used to interrogate a metastatic tumor refractory to standard treatments of a patient with mismatch repair-deficient metastatic colorectal cancer.

RESULTS

Integrative genomic analysis indicated overexpression of the AP-1 transcriptional complex suggesting experimental therapeutic rationales, including blockade of the renin-angiotensin system. This led to the repurposing of the angiotensin II receptor antagonist, irbesartan, as an anticancer therapy, resulting in the patient experiencing a dramatic and durable response.

CONCLUSIONS

This case highlights the utility of comprehensive integrative genomic profiling and bioinformatics analysis to provide hypothetical rationales for personalized treatment options.