1
|
Höfer S, Frasch L, Brajkovic S, Putzker K, Lewis J, Schürmann H, Leone V, Sakhteman A, The M, Bayer FP, Müller J, Hamood F, Siveke JT, Reichert M, Kuster B. Gemcitabine and ATR inhibitors synergize to kill PDAC cells by blocking DNA damage response. Mol Syst Biol 2025; 21:231-253. [PMID: 39838187 PMCID: PMC11876601 DOI: 10.1038/s44320-025-00085-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 12/22/2024] [Accepted: 01/03/2025] [Indexed: 01/23/2025] Open
Abstract
The DNA-damaging agent Gemcitabine (GEM) is a first-line treatment for pancreatic cancer, but chemoresistance is frequently observed. Several clinical trials investigate the efficacy of GEM in combination with targeted drugs, including kinase inhibitors, but the experimental evidence for such rationale is often unclear. Here, we phenotypically screened 13 human pancreatic adenocarcinoma (PDAC) cell lines against GEM in combination with 146 clinical inhibitors and observed strong synergy for the ATR kinase inhibitor Elimusertib in most cell lines. Dose-dependent phosphoproteome profiling of four ATR inhibitors following DNA damage induction by GEM revealed a strong block of the DNA damage response pathway, including phosphorylated pS468 of CHEK1, as the underlying mechanism of drug synergy. The current work provides a strong rationale for why the combination of GEM and ATR inhibition may be useful for the treatment of PDAC patients and constitutes a rich phenotypic and molecular resource for further investigating effective drug combinations.
Collapse
Affiliation(s)
- Stefanie Höfer
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany
| | - Larissa Frasch
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany
| | - Sarah Brajkovic
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany
| | - Kerstin Putzker
- Chemical Biology Core Facility, EMBL Heidelberg, Heidelberg, Germany
| | - Joe Lewis
- Chemical Biology Core Facility, EMBL Heidelberg, Heidelberg, Germany
| | - Hendrik Schürmann
- Bridge Institute of Experimental Tumor Therapy (BIT) and Division of Solid Tumor Translational Oncology (DKTK), West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium (DKTK), partner site Essen, a partnership between German Cancer Research Center (DKFZ) and University Hospital Essen, Essen, Germany
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - Valentina Leone
- Department of Internal Medicine II, University Hospital Rechts der Isar, Technical University Munich, Munich, Germany
| | - Amirhossein Sakhteman
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany
| | - Matthew The
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany
| | - Florian P Bayer
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany
| | - Julian Müller
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany
| | - Firas Hamood
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany
| | - Jens T Siveke
- Bridge Institute of Experimental Tumor Therapy (BIT) and Division of Solid Tumor Translational Oncology (DKTK), West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium (DKTK), partner site Essen, a partnership between German Cancer Research Center (DKFZ) and University Hospital Essen, Essen, Germany
| | - Maximilian Reichert
- Department of Internal Medicine II, University Hospital Rechts der Isar, Technical University Munich, Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany
| | - Bernhard Kuster
- Chair of Proteomics and Bioanalytics, Technical University of Munich, Freising, Germany.
- German Cancer Consortium (DKTK), Partner Site Munich, Munich, Germany.
| |
Collapse
|
2
|
Konstantinopoulos PA, Cheng SC, Lee EK, da Costa AABA, Gulhan D, Wahner Hendrickson AE, Kochupurakkal B, Kolin DL, Kohn EC, Liu JF, Penson RT, Stover EH, Curtis J, Sawyer H, Polak M, Chowdhury D, D'Andrea AD, Färkkilä A, Shapiro GI, Matulonis UA. Randomized Phase II Study of Gemcitabine With or Without ATR Inhibitor Berzosertib in Platinum-Resistant Ovarian Cancer: Final Overall Survival and Biomarker Analyses. JCO Precis Oncol 2024; 8:e2300635. [PMID: 38635934 DOI: 10.1200/po.23.00635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 12/28/2023] [Accepted: 02/29/2024] [Indexed: 04/20/2024] Open
Abstract
PURPOSE The multicenter, open-label, randomized phase 2 NCI-9944 study (NCT02595892) demonstrated that addition of ATR inhibitor (ATRi) berzosertib to gemcitabine increased progression-free survival (PFS) compared to gemcitabine alone (hazard ratio [HR]=0.57, one-sided log-rank P = .044, which met the one-sided significance level of 0.1 used for sample size calculation). METHODS We report here the final overall survival (OS) analysis and biomarker correlations (ATM expression by immunohistochemistry, mutational signature 3 and a genomic biomarker of replication stress) along with post-hoc exploratory analyses to adjust for crossover from gemcitabine to gemcitabine/berzosertib. RESULTS At the data cutoff of January 27, 2023 (>30 months of additional follow-up from the primary analysis), median OS was 59.4 weeks with gemcitabine/berzosertib versus 43.0 weeks with gemcitabine alone (HR 0.79, 90% CI 0.52 to 1.2, one-sided log-rank P = .18). An OS benefit with addition of berzosertib to gemcitabine was suggested in patients stratified into the platinum-free interval ≤3 months (N = 26) subgroup (HR, 0.48, 90% CI 0.22 to 1.01, one-sided log-rank P =.04) and in patients with ATM-negative/low (N = 24) tumors (HR, 0.50, 90% CI 0.23 to 1.08, one-sided log-rank P = .06). CONCLUSION The results of this follow-up analysis continue to support the promise of combined gemcitabine/ATRi therapy in platinum resistant ovarian cancer, an active area of investigation with several ongoing clinical trials.
Collapse
Affiliation(s)
| | - Su-Chun Cheng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Elizabeth K Lee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Alexandre André B A da Costa
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
- Center for DNA Damage and Repair, Dana-Farber Cancer Institute, Boston, MA
| | - Doga Gulhan
- Department of Biomedical Informatics and Ludwig Center at Harvard, Harvard Medical School, Boston, MA
| | | | - Bose Kochupurakkal
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
- Center for DNA Damage and Repair, Dana-Farber Cancer Institute, Boston, MA
| | - David L Kolin
- Department of Pathology, Brigham and Women's Hospital, Boston, MA
| | - Elise C Kohn
- Cancer Therapy Evaluation Program, National Cancer Institute, Bethesda, MD
| | - Joyce F Liu
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Richard T Penson
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA
| | - Elizabeth H Stover
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jennifer Curtis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Hannah Sawyer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Madeline Polak
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Dipanjan Chowdhury
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Alan D D'Andrea
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA
- Center for DNA Damage and Repair, Dana-Farber Cancer Institute, Boston, MA
| | - Anniina Färkkilä
- Research Program in Systems Oncology, FIMM and HiLife, University of Helsinki, Helsinki, Finland
| | - Geoffrey I Shapiro
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Ursula A Matulonis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| |
Collapse
|
3
|
Khamidullina AI, Abramenko YE, Bruter AV, Tatarskiy VV. Key Proteins of Replication Stress Response and Cell Cycle Control as Cancer Therapy Targets. Int J Mol Sci 2024; 25:1263. [PMID: 38279263 PMCID: PMC10816012 DOI: 10.3390/ijms25021263] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/14/2024] [Accepted: 01/17/2024] [Indexed: 01/28/2024] Open
Abstract
Replication stress (RS) is a characteristic state of cancer cells as they tend to exchange precision of replication for fast proliferation and increased genomic instability. To overcome the consequences of improper replication control, malignant cells frequently inactivate parts of their DNA damage response (DDR) pathways (the ATM-CHK2-p53 pathway), while relying on other pathways which help to maintain replication fork stability (ATR-CHK1). This creates a dependency on the remaining DDR pathways, vulnerability to further destabilization of replication and synthetic lethality of DDR inhibitors with common oncogenic alterations such as mutations of TP53, RB1, ATM, amplifications of MYC, CCNE1 and others. The response to RS is normally limited by coordination of cell cycle, transcription and replication. Inhibition of WEE1 and PKMYT1 kinases, which prevent unscheduled mitosis entry, leads to fragility of under-replicated sites. Recent evidence also shows that inhibition of Cyclin-dependent kinases (CDKs), such as CDK4/6, CDK2, CDK8/19 and CDK12/13 can contribute to RS through disruption of DNA repair and replication control. Here, we review the main causes of RS in cancers as well as main therapeutic targets-ATR, CHK1, PARP and their inhibitors.
Collapse
Affiliation(s)
- Alvina I. Khamidullina
- Laboratory of Molecular Oncobiology, Institute of Gene Biology, Russian Academy of Sciences, 34/5 Vavilov Street, 119334 Moscow, Russia; (A.I.K.); (Y.E.A.)
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Institute of Gene Biology, Russian Academy of Sciences, 34/5 Vavilov Street, 119334 Moscow, Russia
| | - Yaroslav E. Abramenko
- Laboratory of Molecular Oncobiology, Institute of Gene Biology, Russian Academy of Sciences, 34/5 Vavilov Street, 119334 Moscow, Russia; (A.I.K.); (Y.E.A.)
| | - Alexandra V. Bruter
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Institute of Gene Biology, Russian Academy of Sciences, 34/5 Vavilov Street, 119334 Moscow, Russia
| | - Victor V. Tatarskiy
- Laboratory of Molecular Oncobiology, Institute of Gene Biology, Russian Academy of Sciences, 34/5 Vavilov Street, 119334 Moscow, Russia; (A.I.K.); (Y.E.A.)
- Center for Precision Genome Editing and Genetic Technologies for Biomedicine, Institute of Gene Biology, Russian Academy of Sciences, 34/5 Vavilov Street, 119334 Moscow, Russia
| |
Collapse
|
4
|
Sturm MJ, Henao-Restrepo JA, Becker S, Proquitté H, Beck JF, Sonnemann J. Synergistic anticancer activity of combined ATR and ribonucleotide reductase inhibition in Ewing's sarcoma cells. J Cancer Res Clin Oncol 2023; 149:8605-8617. [PMID: 37097390 PMCID: PMC10374484 DOI: 10.1007/s00432-023-04804-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE Ewing's sarcoma is a highly malignant childhood tumour whose outcome has hardly changed over the past two decades despite numerous attempts at chemotherapy intensification. It is therefore essential to identify new treatment options. The present study was conducted to explore the effectiveness of combined inhibition of two promising targets, ATR and ribonucleotide reductase (RNR), in Ewing's sarcoma cells. METHODS Effects of the ATR inhibitor VE821 in combination with the RNR inhibitors triapine and didox were assessed in three Ewing's sarcoma cell lines with different TP53 status (WE-68, SK-ES-1, A673) by flow cytometric analysis of cell death, mitochondrial depolarisation and cell cycle distribution as well as by caspase 3/7 activity determination, by immunoblotting and by real-time RT-PCR. Interactions between inhibitors were evaluated by combination index analysis. RESULTS Single ATR or RNR inhibitor treatment produced small to moderate effects, while their combined treatment produced strong synergistic ones. ATR and RNR inhibitors elicited synergistic cell death and cooperated in inducing mitochondrial depolarisation, caspase 3/7 activity and DNA fragmentation, evidencing an apoptotic form of cell death. All effects were independent of functional p53. In addition, VE821 in combination with triapine increased p53 level and induced p53 target gene expression (CDKN1A, BBC3) in p53 wild-type Ewing's sarcoma cells. CONCLUSION Our study reveals that combined targeting of ATR and RNR was effective against Ewing's sarcoma in vitro and thus rationalises an in vivo exploration into the potential of combining ATR and RNR inhibitors as a new strategy for the treatment of this challenging disease.
Collapse
Affiliation(s)
- Max-Johann Sturm
- Department of Paediatric and Adolescent Medicine, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
- Research Centre Lobeda, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Julián Andrés Henao-Restrepo
- Placenta Laboratory, Department of Obstetrics, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Sabine Becker
- Department of Paediatric and Adolescent Medicine, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
- Research Centre Lobeda, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Hans Proquitté
- Department of Paediatric and Adolescent Medicine, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - James F Beck
- Department of Paediatric and Adolescent Medicine, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Jürgen Sonnemann
- Department of Paediatric and Adolescent Medicine, Jena University Hospital, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany.
- Research Centre Lobeda, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany.
| |
Collapse
|
5
|
Leibrandt RC, Tu MJ, Yu AM, Lara PN, Parikh M. ATR Inhibition in Advanced Urothelial Carcinoma. Clin Genitourin Cancer 2023; 21:203-207. [PMID: 36604210 PMCID: PMC10750798 DOI: 10.1016/j.clgc.2022.10.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 10/26/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022]
Abstract
The ataxia telangiectasia and Rad3-related (ATR) checkpoint kinase 1 (CHK1) pathway is intricately involved in protecting the integrity of the human genome by suppressing replication stress and repairing DNA damage. ATR is a promising therapeutic target in cancer cells because its inhibition could lead to an accumulation of damaged DNA preventing further replication and division. ATR inhibition is being studied in multiple types of cancer, including advanced urothelial carcinoma where there remains an unmet need for novel therapies to improve outcomes. Herein, we review preclinical and clinical data evaluating 4 ATR inhibitors as monotherapy or in combination with chemotherapy. The scope of this review is focused on contemporary studies evaluating the application of this novel therapy in advanced urothelial carcinoma.
Collapse
Affiliation(s)
- Ryan C Leibrandt
- University of California at Davis School of Medicine, Department of Internal Medicine, Division of Hematology Oncology, Sacramento, California, United States of America
| | - Mei-Juan Tu
- University of California at Davis School of Medicine, Department of Biochemistry and Molecular Medicine, Sacramento, California, United States of America
| | - Ai-Ming Yu
- University of California at Davis School of Medicine, Department of Biochemistry and Molecular Medicine, Sacramento, California, United States of America
| | - Primo N Lara
- University of California at Davis Comprehensive Cancer Center, University of California at Davis School of Medicine, Department of Internal Medicine, Division of Hematology Oncology, Sacramento, California, United States of America
| | - Mamta Parikh
- University of California at Davis Comprehensive Cancer Center, University of California at Davis School of Medicine, Department of Internal Medicine, Division of Hematology Oncology, Sacramento, California, United States of America.
| |
Collapse
|
6
|
da Costa AABA, Chowdhury D, Shapiro GI, D'Andrea AD, Konstantinopoulos PA. Targeting replication stress in cancer therapy. Nat Rev Drug Discov 2023; 22:38-58. [PMID: 36202931 PMCID: PMC11132912 DOI: 10.1038/s41573-022-00558-5] [Citation(s) in RCA: 159] [Impact Index Per Article: 79.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2022] [Indexed: 02/06/2023]
Abstract
Replication stress is a major cause of genomic instability and a crucial vulnerability of cancer cells. This vulnerability can be therapeutically targeted by inhibiting kinases that coordinate the DNA damage response with cell cycle control, including ATR, CHK1, WEE1 and MYT1 checkpoint kinases. In addition, inhibiting the DNA damage response releases DNA fragments into the cytoplasm, eliciting an innate immune response. Therefore, several ATR, CHK1, WEE1 and MYT1 inhibitors are undergoing clinical evaluation as monotherapies or in combination with chemotherapy, poly[ADP-ribose]polymerase (PARP) inhibitors, or immune checkpoint inhibitors to capitalize on high replication stress, overcome therapeutic resistance and promote effective antitumour immunity. Here, we review current and emerging approaches for targeting replication stress in cancer, from preclinical and biomarker development to clinical trial evaluation.
Collapse
Affiliation(s)
| | - Dipanjan Chowdhury
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Geoffrey I Shapiro
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Alan D D'Andrea
- Department of Radiation Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.
- Center for DNA Damage and Repair, Dana-Farber Cancer Institute, Boston, MA, USA.
| | | |
Collapse
|
7
|
Abuetabh Y, Wu HH, Chai C, Al Yousef H, Persad S, Sergi CM, Leng R. DNA damage response revisited: the p53 family and its regulators provide endless cancer therapy opportunities. Exp Mol Med 2022; 54:1658-1669. [PMID: 36207426 PMCID: PMC9636249 DOI: 10.1038/s12276-022-00863-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/22/2022] [Accepted: 08/01/2022] [Indexed: 12/29/2022] Open
Abstract
Antitumor therapeutic strategies that fundamentally rely on the induction of DNA damage to eradicate and inhibit the growth of cancer cells are integral approaches to cancer therapy. Although DNA-damaging therapies advance the battle with cancer, resistance, and recurrence following treatment are common. Thus, searching for vulnerabilities that facilitate the action of DNA-damaging agents by sensitizing cancer cells is an active research area. Therefore, it is crucial to decipher the detailed molecular events involved in DNA damage responses (DDRs) to DNA-damaging agents in cancer. The tumor suppressor p53 is active at the hub of the DDR. Researchers have identified an increasing number of genes regulated by p53 transcriptional functions that have been shown to be critical direct or indirect mediators of cell fate, cell cycle regulation, and DNA repair. Posttranslational modifications (PTMs) primarily orchestrate and direct the activity of p53 in response to DNA damage. Many molecules mediating PTMs on p53 have been identified. The anticancer potential realized by targeting these molecules has been shown through experiments and clinical trials to sensitize cancer cells to DNA-damaging agents. This review briefly acknowledges the complexity of DDR pathways/networks. We specifically focus on p53 regulators, protein kinases, and E3/E4 ubiquitin ligases and their anticancer potential.
Collapse
Affiliation(s)
- Yasser Abuetabh
- 370 Heritage Medical Research Center, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada
| | - H Helena Wu
- 370 Heritage Medical Research Center, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada
| | - Chengsen Chai
- 370 Heritage Medical Research Center, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada
- College of Laboratory Medicine, Chongqing Medical University, Chongqing, 400016, China
| | - Habib Al Yousef
- 370 Heritage Medical Research Center, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada
| | - Sujata Persad
- Department of Pediatrics, University of Alberta, Edmonton, AB, T6G 2E1, Canada
| | - Consolato M Sergi
- Division of Anatomical Pathology, Children's Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, ON, K1H 8L1, Canada
| | - Roger Leng
- 370 Heritage Medical Research Center, Department of Laboratory Medicine and Pathology, University of Alberta, Edmonton, Alberta, T6G 2S2, Canada.
| |
Collapse
|
8
|
Pal SK, Frankel PH, Mortazavi A, Milowsky M, Vaishampayan U, Parikh M, Lyou Y, Weng P, Parikh R, Teply B, Dreicer R, Emamekhoo H, Michaelson D, Hoimes C, Zhang T, Srinivas S, Kim WY, Cui Y, Newman E, Lara PN. Effect of Cisplatin and Gemcitabine With or Without Berzosertib in Patients With Advanced Urothelial Carcinoma: A Phase 2 Randomized Clinical Trial. JAMA Oncol 2021; 7:1536-1543. [PMID: 34436521 PMCID: PMC8391778 DOI: 10.1001/jamaoncol.2021.3441] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 06/01/2021] [Indexed: 01/10/2023]
Abstract
IMPORTANCE Preclinical studies suggest that inhibition of single-stranded DNA repair by ataxia telangiectasia and Rad3 (ATR) may enhance the cytotoxicity of cisplatin, gemcitabine, and other chemotherapeutic agents. Cisplatin with gemcitabine remains the standard up-front therapy for treatment in patients with metastatic urothelial cancer. OBJECTIVE To determine whether the use of the selective ATR inhibitor, berzosertib, could augment the activity of cisplatin with gemcitabine. DESIGN, SETTING, AND PARTICIPANTS In a phase 2 randomized clinical trial, 87 patients across 23 centers in the National Cancer Institute Experimental Therapeutics Clinical Trials Network were randomized to receive either cisplatin with gemcitabine alone (control arm) or cisplatin with gemcitabine plus berzosertib (experimental arm). Key eligibility criteria included confirmed metastatic urothelial cancer, no prior cytotoxic therapy for metastatic disease, 12 months or more since perioperative therapy, and eligibility for cisplatin receipt based on standard criteria. The study was conducted from January 27, 2017, to December 15, 2020. INTERVENTIONS In the control arm, cisplatin, 70 mg/m2, was given on day 1 and gemcitabine, 1000 mg/m2, was given on days 1 and 8 of a 21-day cycle. In the experimental arm, cisplatin, 60 mg/m2, was given on day 1; gemcitabine, 875 mg/m2, on days 1 and 8; and berzosertib, 90 mg/m2, on days 2 and 9 of a 21-day cycle. MAIN OUTCOMES AND MEASURES The primary end point of the study was progression-free survival. The analysis was on all patients who started therapy. RESULTS Of the total of 87 patients randomized, 41 patients received cisplatin with gemcitabine alone and 46 received cisplatin with gemcitabine plus berzosertib. Median age was 67 (range, 32-84) years, and 68 patients (78%) were men. Median progression-free survival was 8.0 months for both arms (Bajorin risk-adjusted hazard ratio, 1.22; 95% CI, 0.72-2.08). Median overall survival was shorter with cisplatin with gemcitabine plus berzosertib compared with cisplatin with gemcitabine alone (14.4 vs 19.8 months; Bajorin risk-adjusted hazard ratio, 1.42; 95% CI, 0.76-2.68). Higher rates of grade 3 vs grade 4 thrombocytopenia (59% vs 39%) and neutropenia (37% vs 27%) were observed with cisplatin with gemcitabine and berzosertib compared with cisplatin with gemcitabine alone; consequently, more dose reductions were needed in the experimental arm. Patients in the experimental arm received a median cisplatin dose of 250 mg/m2, which was significantly lower than the median dose of 370 mg/m2 in the control arm (P < .001). CONCLUSIONS AND RELEVANCE The addition of berzosertib to cisplatin with gemcitabine did not prolong progression-free survival relative to cisplatin with gemcitabine alone in patients with metastatic urothelial cancer, and a trend toward inferior survival was observed with this combination. Berzosertib plus cisplatin with gemcitabine was associated with significantly higher hematologic toxicities despite attenuated dosing of cisplatin with gemcitabine. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02567409.
Collapse
Affiliation(s)
- Sumanta K. Pal
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Paul H. Frankel
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Amir Mortazavi
- Department of Internal Medicine, Ohio State University Comprehensive Cancer Center, Columbus
| | - Matthew Milowsky
- Department of Medicine, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Ulka Vaishampayan
- Department of Internal Medicine, University of Michigan Cancer Center, Ann Arbor
| | - Mamta Parikh
- Department of Internal Medicine, UC Davis Comprehensive Cancer Center, Sacramento, California
| | - Yung Lyou
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Peng Weng
- Department of Internal Medicine, University of Kentucky Markey Cancer Center, Lexington
| | - Rahul Parikh
- Department of Internal Medicine, University of Kansas Medical Center, Westwood
| | - Benjamin Teply
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Robert Dreicer
- Department of Medicine, University of Virginia Cancer Center, Charlottesville
| | - Hamid Emamekhoo
- Department of Medicine, University of Wisconsin Cancer Center, Madison
| | - Dror Michaelson
- Department of Medicine, Massachusetts General Hospital, Boston
| | - Christopher Hoimes
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Tian Zhang
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Sandy Srinivas
- Department of Medicine, Stanford Cancer Center, Palo Alto, California
| | - William Y. Kim
- Department of Medicine, UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
| | - Yujie Cui
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Edward Newman
- Department of Medical Oncology and Therapeutics Research, City of Hope Comprehensive Cancer Center, Duarte, California
| | - Primo N. Lara
- Department of Internal Medicine, UC Davis Comprehensive Cancer Center, Sacramento, California
| |
Collapse
|
9
|
A Replication stress biomarker is associated with response to gemcitabine versus combined gemcitabine and ATR inhibitor therapy in ovarian cancer. Nat Commun 2021; 12:5574. [PMID: 34552099 PMCID: PMC8458434 DOI: 10.1038/s41467-021-25904-w] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 09/01/2021] [Indexed: 11/08/2022] Open
Abstract
In a trial of patients with high grade serous ovarian cancer (HGSOC), addition of the ATR inhibitor berzosertib to gemcitabine improved progression free survival (PFS) compared to gemcitabine alone but biomarkers predictive of treatment are lacking. Here we report a candidate biomarker of response to gemcitabine versus combined gemcitabine and ATR inhibitor therapy in HGSOC ovarian cancer. Patients with replication stress (RS)-high tumors (n = 27), defined as harboring at least one genomic RS alteration related to loss of RB pathway regulation and/or oncogene-induced replication stress achieve significantly prolonged PFS (HR = 0.38, 90% CI, 0.17-0.86) on gemcitabine monotherapy compared to those with tumors without such alterations (defined as RS-low, n = 30). However, addition of berzosertib to gemcitabine benefits only patients with RS-low tumors (gemcitabine/berzosertib HR 0.34, 90% CI, 0.13-0.86) and not patients with RS-high tumors (HR 1.11, 90% CI, 0.47-2.62). Our findings support the notion that the exacerbation of RS by gemcitabine monotherapy is adequate for lethality in RS-high tumors. Conversely, for RS-low tumors addition of berzosertib-mediated ATR inhibition to gemcitabine is necessary for lethality to occur. Independent prospective validation of this biomarker is required.
Collapse
|
10
|
Yi YW, Park NY, Park JI, Seong YS, Hong YB. Doxycycline potentiates the anti-proliferation effects of gemcitabine in pancreatic cancer cells. Am J Cancer Res 2021; 11:3515-3536. [PMID: 34354858 PMCID: PMC8332860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/13/2021] [Indexed: 06/13/2023] Open
Abstract
Gemcitabine is often recommended as a first-line treatment for patients with metastatic pancreatic cancer. However, gemcitabine resistance is a major challenge in the treatment of pancreatic ductal adenocarcinoma. Our group serendipitously identified the role of doxycycline as a potentiator of gemcitabine efficacy in pancreatic cancer cells. Doxycycline and gemcitabine co-treatment was significantly more cytotoxic to pancreatic cancer cells compared to gemcitabine alone. Interestingly, doxycycline only exerted synergistic effects when coupled with gemcitabine as opposed to other conventional chemotherapeutics including nucleoside analogs. The anti-clonogenic effects of gemcitabine on pancreatic cancer cells were also enhanced by doxycycline. According to cell cycle analyses, doxycycline prolonged gemcitabine-mediated S phase cell cycle arrest. Further, gene expression profiling analyses indicated that a small set of genes involved in cell cycle regulation were uniquely modulated by gemcitabine and doxycycline co-treatment compared to gemcitabine alone. Western blot analyses indicated that several cell cycle-related proteins, including cyclin D1, p21, and DNA damage inducible transcript 4 (DDIT4), were further modulated by doxycycline and gemcitabine co-treatment. Taken together, our findings indicate that doxycycline enhances the effects of gemcitabine on cell cycle progression, thus rendering pancreatic cancer cells more sensitive to gemcitabine. However, additional studies are required to assess the mechanisms of doxycycline and gemcitabine synergism, which might lead to novel treatment options for pancreatic cancer.
Collapse
Affiliation(s)
- Yong Weon Yi
- Department of Nanobiomedical Science and BK21 PLUS Research Center for Regenerative Medicine, Dankook UniversityCheonan, Korea
| | - Na Young Park
- Department of Translational Biomedical Sciences, Graduate School of Dong-A UniversityBusan 49201, Korea
| | - Joo-In Park
- Department of Translational Biomedical Sciences, Graduate School of Dong-A UniversityBusan 49201, Korea
- Department of Biochemistry, College of Medicine, Dong-A UniversityBusan 49201, Korea
| | - Yeon-Sun Seong
- Department of Nanobiomedical Science and BK21 PLUS Research Center for Regenerative Medicine, Dankook UniversityCheonan, Korea
- Department of Biochemistry, College of Medicine, Dankook UniversityCheonan 31116, Korea
- Graduate School of Convergence Medical Science, Dankook UniversityCheonan 31116, Korea
| | - Young Bin Hong
- Department of Translational Biomedical Sciences, Graduate School of Dong-A UniversityBusan 49201, Korea
- Department of Biochemistry, College of Medicine, Dong-A UniversityBusan 49201, Korea
| |
Collapse
|
11
|
Cecati M, Giulietti M, Righetti A, Sabanovic B, Piva F. Effects of CXCL12 isoforms in a pancreatic pre-tumour cellular model: Microarray analysis. World J Gastroenterol 2021; 27:1616-1629. [PMID: 33958847 PMCID: PMC8058651 DOI: 10.3748/wjg.v27.i15.1616] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/05/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Pancreatic ductal adenocarcinoma (PDAC) is the fourth leading cause of death among cancers, it is characterized by poor prognosis and strong chemoresistance. In the PDAC microenvironment, stromal cells release different extracellular components, including CXCL12. The CXCL12 is a chemokine promoting the communication between tumour and stromal cells. Six different splicing isoforms of CXCL12 are known (α, β, γ, δ, ε, θ) but their role in PDAC has not yet been characterized. AIM To investigate the specific role of α, β, and γ CXCL12 isoforms in PDAC onset. METHODS We used hTERT-HPNE E6/E7/KRasG12D (Human Pancreatic Nestin-Expressing) cell line as a pancreatic pre-tumour model and exposed it to the α, β, and γ CXCL12 isoforms. The altered expression profiles were assessed by microarray analyses and confirmed by Real-Time polymerase chain reaction. The functional enrichment analyses have been performed by Enrichr tool to highlight Gene Ontology enriched terms. In addition, wound healing assays have been carried out to assess the phenotypic changes, in terms of migration ability, induced by the α, β, and γ CXCL12 isoforms. RESULTS Microarray analysis of hTERT-HPNE cells treated with the three different CXCL12 isoforms highlighted that the expression of only a few genes was altered. Moreover, the α and β isoforms showed an alteration in expression of different genes, whereas γ isoform affected the expression of genes also common with α and β isoforms. The β isoform altered the expression of genes mainly involved in cell cycle regulation. In addition, all isoforms affected the expression of genes associated to cell migration, adhesion and cytoskeleton. In vitro cell migration assay confirmed that CXCL12 enhanced the migration ability of hTERT-HPNE cells. Among the CXCL12 splicing isoforms, the γ isoform showed higher induction of migration than α and β isoforms. CONCLUSION Our data suggests an involvement and different roles of CXCL12 isoforms in PDAC onset. However, more investigations are needed to confirm these preliminary observations.
Collapse
Affiliation(s)
- Monia Cecati
- Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Ancona 60126, Italy
| | - Matteo Giulietti
- Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Ancona 60126, Italy
| | - Alessandra Righetti
- Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Ancona 60126, Italy
| | - Berina Sabanovic
- Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Ancona 60126, Italy
| | - Francesco Piva
- Department of Specialistic Clinical and Odontostomatological Sciences, Polytechnic University of Marche, Ancona 60126, Italy
| |
Collapse
|
12
|
Pan YR, Wu CE, Yeh CN. ATM Inhibitor Suppresses Gemcitabine-Resistant BTC Growth in a Polymerase θ Deficiency-Dependent Manner. Biomolecules 2020; 10:E1529. [PMID: 33182492 PMCID: PMC7697425 DOI: 10.3390/biom10111529] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 11/05/2020] [Accepted: 11/05/2020] [Indexed: 12/19/2022] Open
Abstract
Patients with advanced biliary tract cancer (BTC) inevitably experience progression after first-line, gemcitabine-based chemotherapy, due to chemo-resistance. The genetic alterations of DNA damage repair (DDR) genes are usually determined in BTC tumors. In this study, we found that the POLQ mRNA levels are downregulated and the ataxia-telangiectasia mutated (ATM) inhibitor AZD0156 was more sensitive in gemcitabine-resistant BTC sublines than in the parental cell lines. The knockdown of DNA polymerase θ does not affect cell proliferation, but its combination with the ATM inhibitor facilitated cell death in gemcitabine-resistant and gemcitabine-intensive BTC cells. Moreover, in the DNA damage caused by photon, hydrogen peroxide, or chemotherapy drugs, synthetic lethal interactions were found in combination with ATM inhibition by AZD0156 and DNA polymerase θ depletion, resulting in increased DNA damage accumulation and micronucleus formation, as well as reduced cell survival and colony formation. Collectively, our results reveal that ATM acts as a potential target in gemcitabine-resistant and DNA polymerase θ-deficient BTC.
Collapse
Affiliation(s)
- Yi-Ru Pan
- Department of General Surgery and Liver Research Center, Chang Gung Memorial Hospital, Linkou branch, Chang Gung University, Taoyuan 333, Taiwan;
| | - Chiao-En Wu
- Division of Hematology-Oncology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Chang Gung University College of Medicine, Taoyuan 333, Taiwan;
| | - Chun-Nan Yeh
- Department of General Surgery and Liver Research Center, Chang Gung Memorial Hospital, Linkou branch, Chang Gung University, Taoyuan 333, Taiwan;
| |
Collapse
|
13
|
Yu S, Zhang C, Xie KP. Therapeutic resistance of pancreatic cancer: Roadmap to its reversal. Biochim Biophys Acta Rev Cancer 2020; 1875:188461. [PMID: 33157162 DOI: 10.1016/j.bbcan.2020.188461] [Citation(s) in RCA: 67] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 10/20/2020] [Accepted: 10/24/2020] [Indexed: 02/07/2023]
Abstract
Pancreatic cancer is a lethal disease with limited opportunity for resectable surgery as the first choice for cure due to its late diagnosis and early metastasis. The desmoplastic stroma and cellular genetic or epigenetic alterations of pancreatic cancer impose physical and biological barriers to effective therapies, including chemotherapy, radiotherapy, targeted therapy, and immunotherapy. Here, we review the current therapeutic options for pancreatic cancer, and underlying mechanisms and potential reversal of therapeutic resistance, a hallmark of this deadly disease.
Collapse
Affiliation(s)
- Sen Yu
- Department of Gastroenterology and Hepatology, Guangzhou First People's Hospital Affiliated to the South China University of Technology, School of Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Chunyu Zhang
- Department of Gastroenterology and Hepatology, Guangzhou First People's Hospital Affiliated to the South China University of Technology, School of Medicine, Guangzhou, Guangdong, People's Republic of China
| | - Ke-Ping Xie
- Department of Gastroenterology and Hepatology, Guangzhou First People's Hospital Affiliated to the South China University of Technology, School of Medicine, Guangzhou, Guangdong, People's Republic of China.
| |
Collapse
|
14
|
Ding G, Xu X, Li D, Chen Y, Wang W, Ping D, Jia S, Cao L. Fisetin inhibits proliferation of pancreatic adenocarcinoma by inducing DNA damage via RFXAP/KDM4A-dependent histone H3K36 demethylation. Cell Death Dis 2020; 11:893. [PMID: 33093461 PMCID: PMC7582166 DOI: 10.1038/s41419-020-03019-2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 09/05/2020] [Accepted: 09/09/2020] [Indexed: 12/13/2022]
Abstract
Pancreatic adenocarcinoma (PDAC) is an extremely malignant tumor that is associated with low survival rates. Fisetin is a natural flavonoid that shows diverse antitumor effects, including DNA damage, in various cancers. Increasing studies have demonstrated that epigenetic modifications play critical roles in DNA-damage response. However, the epigenetic regulation mechanism of fisetin in cancers is hardly studied. RFXAP is a critical transcription factor for MHC II molecules, however, its transcriptional role in PDAC is poorly understood. The anti-PDAC effect of fisetin was measured by CCK-8, flow cytometry, xenograft tumor nude mice model. DNA-damage levels were examined by immunofluorescence. Bioinformatics analysis was used to examine the expression of RFXAP and other genes involved in DNA-damage response. ChIP sequencing was used to explore the transcriptional role of RFXAP. The expression of target gene KDM4A was measured by qRT-PCR and western blots. KDM4A promoter activity was analyzed using dual-luciferase reporter assay. RFXAP overexpressing or silencing of PDAC cells was used to explore the effect of RFXAP in DNA damage induced by fisetin. We found that fisetin inhibited cell proliferation and induced DNA damage and S-phase arrest in PDAC. Expression of RFXAP and other DNA-damage response genes were upregulated by fisetin. We revealed that RFXAP expression was relatively low in PDAC and correlated with tumor stage and poor prognosis. Then we explored the transcriptional role of RFXAP and found that RFXAP targeted KDM4A, a special demethylase specific for tri- and dimethylated histone H3K36. We found that overexpression of RFXAP upregulated KDM4A and attenuated methylation of H3K36, thereby impairing DNA repair and enhancing the DNA damage induced by fisetin, while RFXAP silencing showed the opposite effect. We also found the function of fisetin in enhancing the effect of chemotherapy on pancreatic cancer cells. Our findings revealed that fisetin induced DNA damage via RFXAP/KDM4A-dependent histone H3K36 demethylation, thus causing inhibition of proliferation in PDAC.
Collapse
Affiliation(s)
- Guoping Ding
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Xiaodong Xu
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Dan Li
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China.,Department of General Surgery, School of Medicine, Affiliated Hospital of Hangzhou Normal University, Hangzhou, 310000, China
| | - Yuhao Chen
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China.,Emergency Department, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Weimin Wang
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China.,Department of General Surgery, Huzhou Hospital, Zhejiang University School of Medicine, Huzhou, 313003, Zhejiang, China
| | - Dongnan Ping
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China
| | - Shengnan Jia
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China.
| | - Liping Cao
- Department of General Surgery, Sir Run Run Shaw Hospital, School of Medicine, Zhejiang University, Hangzhou, 310000, China. .,Innovation Center for Minimally Invasive Technique and Device, Zhejiang University, Hangzhou, 310000, Zhejiang, China.
| |
Collapse
|
15
|
Konstantinopoulos PA, Cheng SC, Wahner Hendrickson AE, Penson RT, Schumer ST, Doyle LA, Lee EK, Kohn EC, Duska LR, Crispens MA, Olawaiye AB, Winer IS, Barroilhet LM, Fu S, McHale MT, Schilder RJ, Färkkilä A, Chowdhury D, Curtis J, Quinn RS, Bowes B, D'Andrea AD, Shapiro GI, Matulonis UA. Berzosertib plus gemcitabine versus gemcitabine alone in platinum-resistant high-grade serous ovarian cancer: a multicentre, open-label, randomised, phase 2 trial. Lancet Oncol 2020; 21:957-968. [PMID: 32553118 PMCID: PMC8023719 DOI: 10.1016/s1470-2045(20)30180-7] [Citation(s) in RCA: 154] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 03/02/2020] [Accepted: 03/12/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND High-grade serous ovarian cancers show increased replication stress, rendering cells vulnerable to ATR inhibition because of near universal loss of the G1/S checkpoint (through deleterious TP53 mutations), premature S phase entry (due to CCNE1 amplification, RB1 loss, or CDKN2A mRNA downregulation), alterations of homologous recombination repair genes, and expression of oncogenic drivers (through MYC amplification and other mechanisms). We hypothesised that the combination of the selective ATR inhibitor, berzosertib, and gemcitabine could show acceptable toxicity and superior efficacy to gemcitabine alone in high-grade serous ovarian cancer. METHODS In this multicentre, open-label, randomised, phase 2 study, 11 different centres in the US Experimental Therapeutics Clinical Trials Network enrolled women (aged ≥18 years) with recurrent, platinum-resistant high-grade serous ovarian cancer (determined histologically) and Eastern Cooperative Oncology Group performance status of 0 or 1, who had unlimited previous lines of cytotoxic therapy in the platinum-sensitive setting but no more than one line of cytotoxic therapy in the platinum-resistant setting. Eligible patients were randomly assigned (1:1) to receive intravenous gemcitabine (1000 mg/m2) on day 1 and day 8, or gemcitabine plus intravenous berzosertib (210 mg/m2) on day 2 and day 9 of a 21-day cycle until disease progression or intolerable toxicity. Randomisation was done centrally using the Theradex Interactive Web Response System, stratified by platinum-free interval, and with a permuted block size of six. Following central randomisation, patients and investigators were not masked to treatment assignment. The primary endpoint was investigator-assessed progression-free survival, and analyses included all patients who received at least one dose of the study drugs. The study is registered with ClinicalTrials.gov, NCT02595892, and is active but closed to enrolment. FINDINGS Between Feb 14, 2017, and Sept 7, 2018, 88 patients were assessed for eligibility, of whom 70 were randomly assigned to treatment with gemcitabine alone (36 patients) or gemcitabine plus berzosertib (34 patients). At the data cutoff date (Feb 21, 2020), the median follow-up was 53·2 weeks (25·6-81·8) in the gemcitabine plus berzosertib group and 43·0 weeks (IQR 23·2-69·1) in the gemcitabine alone group. Median progression-free survival was 22·9 weeks (17·9-72·0) for gemcitabine plus berzosertib and 14·7 weeks (90% CI 9·7-36·7) for gemcitabine alone (hazard ratio 0·57, 90% CI 0·33-0·98; one-sided log-rank test p=0·044). The most common treatment-related grade 3 or 4 adverse events were decreased neutrophil count (14 [39%] of 36 patients in the gemcitabine alone group vs 16 [47%] of 34 patients in the gemcitabine plus berzosertib group) and decreased platelet count (two [6%] vs eight [24%]). Serious adverse events were observed in ten (28%) patients in the gemcitabine alone group and nine (26%) patients in the gemcitabine plus berzosertib group. There was one treatment-related death in the gemcitabine alone group due to sepsis and one treatment-related death in the gemcitabine plus berzosertib group due to pneumonitis. INTERPRETATION To our knowledge, this is the first randomised study of an ATR inhibitor in any tumour type. This study shows a benefit of adding berzosertib to gemcitabine in platinum-resistant high-grade serous ovarian cancer. This combination warrants further investigation in this setting. FUNDING US National Cancer Institute.
Collapse
Affiliation(s)
| | - Su-Chun Cheng
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | | | - Richard T Penson
- Department of Medical Oncology, Massachusetts General Hospital, Boston, MA, USA
| | - Susan T Schumer
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - L Austin Doyle
- Department of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
| | - Elizabeth K Lee
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Elise C Kohn
- Department of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, USA
| | - Linda R Duska
- Department of Obstetrics and Gynecology, Cancer Center, University of Virginia, Charlottesville, VA, USA
| | - Marta A Crispens
- Department of Obstetrics and Gynecology, Ingram Cancer Center, Vanderbilt University Nashville, TN, USA
| | - Alexander B Olawaiye
- Department of Obstetrics and Gynecology, University of Pittsburgh Cancer Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ira S Winer
- Department of Obstetrics and Gynecology, Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Lisa M Barroilhet
- Department of Obstetrics and Gynecology, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Siqing Fu
- Department of Investigational Cancer Therapeutics, MD Anderson Cancer Center, Houston, TX, USA
| | - Michael T McHale
- Department of Obstetrics and Gynecology, Moores Cancer Center, University of California San Diego, San Diego, CA, USA
| | - Russell J Schilder
- Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Anniina Färkkilä
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Dipanjan Chowdhury
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer Curtis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Roxanne S Quinn
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Brittany Bowes
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Alan D D'Andrea
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Geoffrey I Shapiro
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Ursula A Matulonis
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| |
Collapse
|
16
|
Abstract
DNA damage response (DDR) pathway prevents high level endogenous and environmental DNA damage being replicated and passed on to the next generation of cells via an orchestrated and integrated network of cell cycle checkpoint signalling and DNA repair pathways. Depending on the type of damage, and where in the cell cycle it occurs different pathways are involved, with the ATM-CHK2-p53 pathway controlling the G1 checkpoint or ATR-CHK1-Wee1 pathway controlling the S and G2/M checkpoints. Loss of G1 checkpoint control is common in cancer through TP53, ATM mutations, Rb loss or cyclin E overexpression, providing a stronger rationale for targeting the S/G2 checkpoints. This review will focus on the ATM-CHK2-p53-p21 pathway and the ATR-CHK1-WEE1 pathway and ongoing efforts to target these pathways for patient benefit.
Collapse
|
17
|
Wappler J, Arts M, Röth A, Heeren RMA, Peter Neumann U, Olde Damink SW, Soons Z, Cramer T. Glutamine deprivation counteracts hypoxia-induced chemoresistance. Neoplasia 2019; 22:22-32. [PMID: 31765939 PMCID: PMC6883317 DOI: 10.1016/j.neo.2019.10.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 10/12/2019] [Accepted: 10/14/2019] [Indexed: 12/29/2022] Open
Abstract
The microenvironment of solid tumors is a key determinant of therapy efficacy. The co-occurrence of oxygen and nutrient deprivation is a common phenomenon of the tumor microenvironment and associated with treatment resistance. Cholangiocarcinoma (CCA) is characterized by a very poor prognosis and pronounced chemoresistance. A better understanding of the underlying molecular mechanisms is urgently needed to improve therapy strategies against CCA. We sought to investigate the importance of the conditionally essential amino acid glutamine, a centrally important nutrient for a variety of solid tumors, for CCA. Glutamine levels were strongly decreased in CCA samples and the growth of established human CCA cell lines was highly dependent on glutamine. Using gradual reduction of external glutamine, we generated derivatives of CCA cell lines which were able to grow without external glutamine (termed glutamine-depleted (GD)). To analyze the effects of coincident oxygen and glutamine deprivation, GD cells were treated with cisplatin or gemcitabine under normoxia and hypoxia. Strikingly, the well-established phenomenon of hypoxia-induced chemoresistance was completely reversed in GD cells. In order to better understand the underlying mechanisms, we focused on the oncogene c-Myc. The combination of cisplatin and hypoxia led to sustained c-Myc protein expression in wildtype cells. In contrast, c-Myc expression was reduced in response to the combinatorial treatment in GD cells, suggesting a functional importance of c-Myc in the process of hypoxia-induced chemoresistance. In summary, these findings indicate that the mechanisms driving adaption to tumor microenvironmental changes and their relevance for the response to therapy are more complex than expected.
Collapse
Affiliation(s)
- Jessica Wappler
- Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany
| | - Martijn Arts
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Anjali Röth
- Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany; ESCAM - European Surgery Center Aachen Maastricht, Aachen, Germany; ESCAM - European Surgery Center Aachen Maastricht, Maastricht, the Netherlands
| | - Ron M A Heeren
- The Maastricht MultiModal Molecular Imaging Institute (M4I), Division of Imaging Mass Spectrometry, Maastricht University, Maastricht, the Netherlands
| | - Ulf Peter Neumann
- Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; ESCAM - European Surgery Center Aachen Maastricht, Aachen, Germany; ESCAM - European Surgery Center Aachen Maastricht, Maastricht, the Netherlands
| | - Steven W Olde Damink
- Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; ESCAM - European Surgery Center Aachen Maastricht, Aachen, Germany; ESCAM - European Surgery Center Aachen Maastricht, Maastricht, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Zita Soons
- Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
| | - Thorsten Cramer
- Department of General, Visceral and Transplantation Surgery, RWTH University Hospital Aachen, Aachen, Germany; Department of Surgery, Maastricht University Medical Center, Maastricht, the Netherlands; ESCAM - European Surgery Center Aachen Maastricht, Aachen, Germany; ESCAM - European Surgery Center Aachen Maastricht, Maastricht, the Netherlands; NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
| |
Collapse
|
18
|
Qi W, Xu X, Wang M, Li X, Wang C, Sun L, Zhao D, Sun L. Inhibition of Wee1 sensitizes AML cells to ATR inhibitor VE-822-induced DNA damage and apoptosis. Biochem Pharmacol 2019; 164:273-282. [PMID: 31014753 DOI: 10.1016/j.bcp.2019.04.022] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 04/19/2019] [Indexed: 12/18/2022]
Abstract
Resistance to standard induction therapy and relapse remain the primary challenges for improving therapeutic effects in acute myeloid leukemia (AML); thus, novel therapeutic strategies are urgently required. Ataxia telangiectasia and Rad3-related protein (ATR) is a key regulator of different types of DNA damage, which is crucial for the maintenance of genomic integrity. The ATR-selective inhibitor VE-822 has proper solubility, potency, and pharmacokinetic properties. In this study, we investigated the anti-leukemic effects of VE-822 alone or combined with Wee1-selective inhibitor AZD1775 in AML cells. Our results showed that VE-822 inhibited AML cell proliferation and induced apoptosis in a dose-dependent manner. AZD1775 significantly promoted VE-822-induced inhibition of AML cell proliferation and led to a decreased number of cells in the G2/M phase. VE-822 and AZD1775 decreased the protein levels of ribonucleotide reductase M1 (RRM1) and M2 (RRM2) subunits, key enzymes in the synthesis of deoxyribonucleoside triphosphate, which increased DNA replication stress. VE-822 combined with AZD1775 synergistically induced AML cell apoptosis and led to replication stress and DNA damage in AML cell lines. Our study demonstrated that AZD1775 synergistically promotes VE-822-induced anti-leukemic activity in AML cell lines and provides support for clinical research on VE-822 in combination with AZD1775 for the treatment of AML patients.
Collapse
Affiliation(s)
- Wenxiu Qi
- Jilin Provincial Key Laboratory of BioMacromolecules of Chinese Medicine, Jilin Ginseng Academy, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Xiaohao Xu
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Manying Wang
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Xiangyan Li
- Jilin Provincial Key Laboratory of BioMacromolecules of Chinese Medicine, Jilin Ginseng Academy, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Chaonan Wang
- Jilin Provincial Key Laboratory of BioMacromolecules of Chinese Medicine, Jilin Ginseng Academy, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Liping Sun
- Jilin Provincial Key Laboratory of BioMacromolecules of Chinese Medicine, Jilin Ginseng Academy, Changchun University of Chinese Medicine, Changchun, Jilin, China
| | - Daqing Zhao
- Jilin Provincial Key Laboratory of BioMacromolecules of Chinese Medicine, Jilin Ginseng Academy, Changchun University of Chinese Medicine, Changchun, Jilin, China.
| | - Liwei Sun
- Research Center of Traditional Chinese Medicine, The Affiliated Hospital to Changchun University of Chinese Medicine, Changchun, Jilin, China.
| |
Collapse
|
19
|
Ubhi T, Brown GW. Exploiting DNA Replication Stress for Cancer Treatment. Cancer Res 2019; 79:1730-1739. [PMID: 30967400 DOI: 10.1158/0008-5472.can-18-3631] [Citation(s) in RCA: 137] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 01/08/2019] [Accepted: 01/28/2019] [Indexed: 12/12/2022]
Abstract
Complete and accurate DNA replication is fundamental to cellular proliferation and genome stability. Obstacles that delay, prevent, or terminate DNA replication cause the phenomena termed DNA replication stress. Cancer cells exhibit chronic replication stress due to the loss of proteins that protect or repair stressed replication forks and due to the continuous proliferative signaling, providing an exploitable therapeutic vulnerability in tumors. Here, we outline current and pending therapeutic approaches leveraging tumor-specific replication stress as a target, in addition to the challenges associated with such therapies. We discuss how replication stress modulates the cell-intrinsic innate immune response and highlight the integration of replication stress with immunotherapies. Together, exploiting replication stress for cancer treatment seems to be a promising strategy as it provides a selective means of eliminating tumors, and with continuous advances in our knowledge of the replication stress response and lessons learned from current therapies in use, we are moving toward honing the potential of targeting replication stress in the clinic.
Collapse
Affiliation(s)
- Tajinder Ubhi
- Department of Biochemistry, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada.,Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, Ontario, Canada
| | - Grant W Brown
- Department of Biochemistry, University of Toronto, 1 King's College Circle, Toronto, Ontario, Canada. .,Donnelly Centre for Cellular and Biomolecular Research, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
20
|
Abstract
The chemical treatment of cancer started with the realization that DNA damaging agents such as mustard gas present notable antitumoural properties. Consequently, early drug development focused on genotoxic chemicals, some of which are still widely used in the clinic. However, the efficacy of such therapies is often limited by the side effects of these drugs on healthy cells. A refinement to this approach is to use compounds that can exploit the presence of DNA damage in cancer cells. Given that replication stress (RS) is a major source of genomic instability in cancer, targeting the RS-response kinase ataxia telangiectasia and Rad3-related protein (ATR) has emerged as a promising alternative. With ATR inhibitors now entering clinical trials, we here revisit the biology behind this strategy and discuss potential biomarkers that could be used for a better selection of patients who respond to therapy.
Collapse
Affiliation(s)
- Emilio Lecona
- Genomic Instability Group, Spanish National Cancer Research Centre (CNIO), Madrid, Spain
| | - Oscar Fernandez-Capetillo
- Genomic Instability Group, Spanish National Cancer Research Centre (CNIO), Madrid, Spain.
- Science for Life Laboratory, Division of Genome Biology, Department of Medical Biochemistry and Biophysics, Karolinska Institute, Stockholm, Sweden.
| |
Collapse
|
21
|
Wallez Y, Dunlop CR, Johnson TI, Koh SB, Fornari C, Yates JWT, Bernaldo de Quirós Fernández S, Lau A, Richards FM, Jodrell DI. The ATR Inhibitor AZD6738 Synergizes with Gemcitabine In Vitro and In Vivo to Induce Pancreatic Ductal Adenocarcinoma Regression. Mol Cancer Ther 2018; 17:1670-1682. [PMID: 29891488 PMCID: PMC6076438 DOI: 10.1158/1535-7163.mct-18-0010] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 04/16/2018] [Accepted: 05/30/2018] [Indexed: 12/12/2022]
Abstract
Pancreatic ductal adenocarcinoma (PDAC) is among the deadliest cancers, and overall survival rates have barely improved over the past five decades. The antimetabolite gemcitabine remains part of the standard of care but shows very limited antitumor efficacy. Ataxia telangiectasia and Rad3-related protein (ATR), the apical kinase of the intra-S-phase DNA damage response, plays a central role in safeguarding cells from replication stress and can therefore limit the efficacy of antimetabolite drug therapies. We investigated the ability of the ATR inhibitor, AZD6738, to prevent the gemcitabine-induced intra-S-phase checkpoint activation and evaluated the antitumor potential of this combination in vitro and in vivo In PDAC cell lines, AZD6738 inhibited gemcitabine-induced Chk1 activation, prevented cell-cycle arrest, and restrained RRM2 accumulation, leading to the strong induction of replication stress markers only with the combination. Moreover, synergistic growth inhibition was identified in a panel of 5 mouse and 7 human PDAC cell lines using both Bliss Independence and Loewe models. In clonogenic assays, the combination abrogated survival at concentrations for which single agents had minor effects. In vivo, AZD6738 in combination with gemcitabine was well tolerated and induced tumor regression in a subcutaneous allograft model of a KrasG12D; Trp53R172H; Pdx-Cre (KPC) mouse cancer cell line, significantly extending survival. Remarkably, the combination also induced regression of a subgroup of KPC autochthonous tumors, which generally do not respond well to conventional chemotherapy. Altogether, our data suggest that AZD6738 in combination with gemcitabine merits evaluation in a clinical trial in patients with PDAC. Mol Cancer Ther; 17(8); 1670-82. ©2018 AACR.
Collapse
Affiliation(s)
- Yann Wallez
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom.
| | - Charles R Dunlop
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
| | - Timothy Isaac Johnson
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
| | - Siang-Boon Koh
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
- Massachusetts General Hospital Cancer Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Chiara Fornari
- Safety and ADME Translational Sciences Department, Drug Safety and Metabolism, IMED Biotech Unit, AstraZeneca, Cambridge, United Kingdom
| | - James W T Yates
- Oncology, IMED Biotech Unit, AstraZeneca, Cambridge, United Kingdom
| | | | - Alan Lau
- Oncology, IMED Biotech Unit, AstraZeneca, Cambridge, United Kingdom
| | - Frances M Richards
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom.
| | - Duncan I Jodrell
- Cancer Research UK Cambridge Institute, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
22
|
Fordham SE, Blair HJ, Elstob CJ, Plummer R, Drew Y, Curtin NJ, Heidenreich O, Pal D, Jamieson D, Park C, Pollard J, Fields S, Milne P, Jackson GH, Marr HJ, Menne T, Jones GL, Allan JM. Inhibition of ATR acutely sensitizes acute myeloid leukemia cells to nucleoside analogs that target ribonucleotide reductase. Blood Adv 2018; 2:1157-1169. [PMID: 29789314 PMCID: PMC5965047 DOI: 10.1182/bloodadvances.2017015214] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/09/2018] [Indexed: 12/20/2022] Open
Abstract
The ataxia telangiectasia and Rad3-related (ATR) protein kinase promotes cancer cell survival by signaling stalled replication forks generated by replication stress, a common feature of many cancers including acute myeloid leukemia (AML). Here we show that the antileukemic activity of the chemotherapeutic nucleoside analogs hydroxyurea and gemcitabine was significantly potentiated by ATR inhibition via a mechanism involving ribonucleotide reductase (RNR) abrogation and inhibition of replication fork progression. When administered in combination with gemcitabine, an inhibitor of the M1 RNR subunit, the ATR inhibitor VX-970, eradicated disseminated leukemia in an orthotopic mouse model, eliciting long-term survival and effective cure. These data identify a synergistic interaction between ATR inhibition and RNR loss that will inform the deployment of small molecule inhibitors for the treatment of AML and other hematologic malignancies.
Collapse
Affiliation(s)
- Sarah E Fordham
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helen J Blair
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Claire J Elstob
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ruth Plummer
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Yvette Drew
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Nicola J Curtin
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Olaf Heidenreich
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Deepali Pal
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - David Jamieson
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Park
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - John Pollard
- Vertex Pharmaceuticals (Europe) Ltd, Abingdon, Oxfordshire, United Kingdom
| | - Scott Fields
- Vertex Pharmaceuticals (Europe) Ltd, Abingdon, Oxfordshire, United Kingdom
| | - Paul Milne
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; and
| | - Graham H Jackson
- Department of Haematology, Freeman Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Helen J Marr
- Department of Haematology, Freeman Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Tobias Menne
- Department of Haematology, Freeman Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Gail L Jones
- Department of Haematology, Freeman Hospital, Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - James M Allan
- Newcastle Cancer Centre, Northern Institute for Cancer Research, Newcastle University, Newcastle upon Tyne, United Kingdom
| |
Collapse
|