BOS172738, a highly potent and selective RET inhibitor, for the treatment of RET-altered tumors including RET-fusion+ NSCLC and RET-mutant MTC: Phase 1 study results

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Background: RET (REarranged during Transfection) gene alterations (mutations and fusions) leading to constitutive kinase activity are identified as drivers of disease progression in multiple tumor types, including non-small cell lung cancer (NSCLC) and medullary thyroid cancer (MTC). BOS172738 is an investigational, potent, selective oral RET kinase inhibitor. This next-generation inhibitor was designed with nanomolar potency against RET and >300-fold selectivity against vascular endothelial growth factor receptor 2, to maximize the potential therapeutic window. Methods: NCT03780517 is a phase 1 study consisting of a dose-escalation and dose-expansion phase. During the escalation, 67 patients with RET-altered advanced solid tumors received once-daily oral doses of BOS172738 (10-150 mg). Intra-patient dose escalation was allowed as was over-accrual to dose levels deemed to be safe. Study endpoints were safety (CTCAE v. 4.03), tolerability and confirmed overall response rate (ORR; RECIST 1.1). The data cutoff was Dec. 11, 2020. Results: BOS172738 exhibited a favorable safety profile (n=67) for long-term administration with most treatment-emergent adverse events (TEAEs) classified as grade ≤2 and deemed unrelated to drug. The most common TEAEs were creatinine phosphokinase (CPK) increase (54%), dyspnea (34%), facial edema, aspartate aminotransferase elevation, anemia (25% each), neutropenia, diarrhea (22% each), fatigue (21%), and constipation (20%). BOS172738 was not associated with hypertension or significant hepatoxicity. BOS172738 demonstrated broad anti-tumor activity with an investigator-assessed ORR of 33% (n=18/54), a NSCLC ORR of 33% (n=10/30), MTC ORR of 44% (n=7/16, including 1 complete response) and one patient with RET fusion+ pancreatic cancer reported a partial response. Responders included patients with brain metastases with one patient whose brain lesion decreased by 43%. The median duration of response has not been reached. Many patients remain on study, including the longest of 659 days, at data cutoff. BOS172738 exhibited dose-dependent exposure (AUC, Cmax), rapid absorption (median Tmax 1 to 4.5 h), and an extended half-life (approximately 65 hours) maximizing target coverage. Conclusions: BOS172738 is a highly potent and selective RET inhibitor with a differentiated safety profile and clinical activity against RET-altered tumors, including patients with brain metastases. BOS172738 continues to be evaluated in patients with NSCLC, MTC, and in patients previously treated with other selective RET inhibitors. Clinical trial information: NCT03780517.

The Efficacy and Tolerability of Levetiracetam as a First Line Monotherapy in Childhood Epilepsy

Introduction To examine efficacy and tolerability of Levetiracetam monotherapy as a first line agent in a national cohort of children with epilepsy, naïve to anti-epileptic medication. Methods A retrospective analysis of children with epilepsy who attended 4 Irish tertiary Paediatric Neurology Clinics (2009-2015) started on Levetiracetam as a first line monotherapy. Results 182 children were identified aged one month to 16 years (mean 6.2 years (SD=5.1) Retention at 6 and 12 months was 88% (n=161) and 83% (n=145) respectively. 75% (n=104) achieved seizure freedom or > 50% improvement in seizure control at 12 months. 30% (n=55) experienced ≥1 adverse effect with aggression (12%; n=21) the most frequent. Treatment was discontinued in 16% (n=29) because of intolerance. Underlying conditions and epilepsy type were not found to influence efficacy or tolerability. Conclusion Levetiracetam monotherapy was observed as effective and safe for children with epilepsy although side effects limit tolerance in a sizeable minority.

Phase 2 study of the focal adhesion kinase inhibitor defactinib (VS-6063) in previously treated advanced KRAS mutant non-small cell lung cancer

OBJECTIVES

KRAS mutations, which occur in approximately 25% of lung adenocarcinoma cases, represent a major unmet clinical need in thoracic oncology. Preclinical studies have demonstrated that KRAS mutant NSCLC cell lines and xenografts with additional alterations in either TP53 or CDKN2A (INK4A/ARF) loci are sensitive to focal adhesion kinase (FAK) inhibition. Defactinib (VS-6063) is a selective oral inhibitor of FAK.

MATERIALS AND METHODS

Patients with previously treated advanced KRAS mutant NSCLC were prospectively assigned to one of four molecularly defined cohorts based on the presence or absence of TP53 or CDKN2A alterations and received treatment with defactinib 400 mg orally BID until disease progression or intolerable toxicity. The primary endpoint was progression-free survival (PFS) at 12 weeks.

RESULTS

Fifty-five patients were enrolled. Mean age was 62 years; 51% were female. The median number of prior lines of therapy was 4 (range 1-8). Fifteen (28%) patients met the 12-week PFS endpoint, with one patient achieving a partial response. Median PFS was 45 days. Clinical efficacy did not correlate with TP53 or CDKN2A status. The most common adverse events were fatigue, gastrointestinal, and increased bilirubin, and were generally grade 1 or 2 in severity.

CONCLUSION

In heavily pretreated patients with KRAS mutant NSCLC, defactinib monotherapy demonstrated modest clinical activity. Efficacy was not associated with TP53 and CDKN2A status. Defactinib was generally well tolerated.

Abstract 2199: BOS172738: A novel highly potent and selective RET kinase inhibitor in Phase 1 clinical development

Background: RET gene alterations including point mutations and gene fusions have been detected in multiple cancers, including colorectal cancer, NSCLC and various thyroid cancers. RET fusion events involve the kinesin family member 5B (KIF5B-RET), as well as a number of other fusion partners such as CCDC6, TRIM33, and NCOA, and are considered to be the driver mutations in NSCLC and other tumors harboring RET fusions. Selective inhibitors of RET kinase recently has been associated with durable objective responses in patients with RET gene-altered NSCLC and papillary thyroid carcinoma. BOS172738 (formerly DS-5010) is an orally available small-molecule RET kinase inhibitor that has previously been shown to have potent in vitro RET inhibitor activity and in vivo potency against transfected allograft and xenograft models. In this study, we discuss additional in vitro characterization and in vivo efficacy in patient derived xenograft (PDX) models driven by RET fusions and emergent resistant mutations.

Results: An expanded kinase profile was conducted with BOS172738 against over 450 kinases, and demonstrated exquisite potency for RET and RET mutations with Kd values ≤ 1 nM for RETwt, RET(M918T), RET(V804L) and RET(V804M). BOS172738 also demonstrated high selectivity over KDR (>300 fold). To confirm this selectivity in vitro, BOS172738 was compared to ponatinib, a multikinase inhibitor with potent activity against both KDR and RET. While BOS172738 demonstrated similar potency to ponatinib (IC50 0.5 µM vs. 0.3 µM) in inhibiting the in vitro proliferation of a NCO4-RET human CRC cell line (CR1520), it resulted in significantly less anti-proliferative activity in HUVEC normal endothelial cells (IC50 2.9 µM vs 0.2 µM). BOS172738 was also evaluated in a number of PDX models of RET fusion cancers, including three CRC PDX models (CR2518:CCDC6-RET, CR1520: NCOA4-RET and CR2545: CCDC6-RET with a V804M mutation) and one NSCLC PDX model (CTG-0838:KIF5B-RET). In all cases tested, BOS172738 demonstrated potent and durable tumor regression at doses of 30 mg/kg, with tumor growth inhibition at lower doses. BOS172738 also demonstrated potent tumor regression on larger, established tumors (>1000 mm3).

Conclusion: These results support that BOS172738 is a potent and selective RET kinase inhibitor, with strong antitumor activity against a range of RET fusion proteins, as well as resistant RET active site mutations. BOS172738 is currently being evaluated in a Phase 1 clinical study.

Citation Format: Mitchell Keegan, Keith Wilcoxen, Peter T. Ho. BOS172738: A novel highly potent and selective RET kinase inhibitor in Phase 1 clinical development [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2199.

A phase I study of BOS172738 in patients with advanced solid tumors with RET gene alterations including non-small cell lung cancer and medullary thyroid cancer

TPS3162

Background: RET gene alterations (mutations and fusions) leading to constitutive kinase activity have been identified in various tumor types including non-small cell lung cancer (NSCLC), medullary thyroid (MTC), colon, breast and ovarian cancer. The current generation of multi-kinase inhibitors approved for treatment of such tumors, do not selectively target RET and exhibit significant off-target activity especially against vascular endothelial growth factor receptor 2 (VEGFR2), resulting in dose-limiting toxicities that prevent the full inhibition of RET in those tumors. Recently, early clinical data from a class of more selective RET inhibitors have shown promising results with a more favorable safety profile in patients with RET alterations. BOS172738 is a novel RET inhibitor with nanomolar potency against RET and approximately 300-fold selectivity against VEGFR2. This phase 1 study is assessing the safety and tolerability of BOS172738 in patients with advanced solid tumors with RET alterations. Methods: NCT03780517 is a phase 1, open label, multicenter, dose escalation trial to evaluate the safety, efficacy, pharmacokinetics, and pharmacodynamics of BOS172738, an orally dosed RET kinase inhibitor, in patients with advanced solid tumors with RET gene alterations. RET gene alteration status will be assessed locally but confirmed centrally. The study is comprised of 2 parts: in Part A (dose escalation), patients with advanced solid tumors with RET gene alterations will receive BOS172738 orally once daily in each 28-day cycle. Select patients in Part A are eligible for intrapatient dose escalation. On establishing the recommended phase 2 dose (RP2D), Part B (expansion) will enroll up to an additional 60 patients to 1 of 3 tumor type-specific cohorts. The 3 expansion cohorts will each consist of up to 20 advanced cancer patients with: 1) RET gene-fusion NSCLC; 2) RET gene-mutant MTC; and 3) other RET gene-altered advanced tumors or NSCLC/MTC with prior specific RET gene-targeted therapy. Patients in expansion cohorts will receive BOS172738 daily at the RP2D until disease progression or other discontinuation criteria have been met. The study is currently open to enrollment globally with the first patient entered in 01/2019. Clinical trial information: NCT03780517.

A first-in-Asian phase 1 study to evaluate safety, pharmacokinetics and clinical activity of VS-6063, a focal adhesion kinase (FAK) inhibitor in Japanese patients with advanced solid tumors

Purpose

VS-6063 (also known as defactinib or PF-04554878) is a second-generation inhibitor of focal adhesion kinase and proline-rich tyrosine kinase-2. This phase 1 study evaluated the safety and tolerability, pharmacokinetics, and clinical activity of VS-6063 in Japanese subjects with advanced solid tumor malignancies in a first-in-Asian study setting.

Methods

VS-6063 was administered orally twice daily (b.i.d.) in 21-day cycles to cohorts of three subjects each with a standard 3 + 3 dose-escalation design until disease progression or unacceptable toxicity. Blood samples for pharmacokinetics were collected on Day 1 and 15. The assessments were performed using CTCAE v4.0 for adverse events (AEs), and the Response Evaluation Criteria In Solid Tumors, version v1.1 (RECIST v1.1) for tumor response.

Results

Nine patients were treated across three dose levels (200–600 mg BID). No dose-limiting toxicities were observed at any dose level. Most frequent treatment-related AEs were Grade 1/2 unconjugated hyperbilirubinemia, fatigue, decreased appetite, and diarrhea. Only one subject in the 200 mg BID cohort experienced reversible and transient Grade 3 unconjugated hyperbilirubinemia. PK analyses confirmed that the exposure at the recommended Phase 2 dose (RP2D) of 400 mg BID was comparable with exposures previously reported in non-Japanese subjects. Durable stable disease of approximately 24 weeks was confirmed in two subjects (malignant mesothelioma and rectal cancer).

Conclusions

VS-6063 was well tolerated at all dose levels investigated in this first-in-Asian study. These data support the administration of VS-6063 to Japanese subjects at the RP2D in clinical trials involving solid tumor malignancies.

Abstract P2-09-14: Focal adhesion kinase (FAK) inhibitors VS-6063 and VS-4718 target breast cancer stem cells

Focal adhesion kinase (FAK) is a non-receptor tyrosine kinase that orchestrates cellular signaling through integrins and growth factor receptors and functions in multiple steps of tumorigenesis. Both VS-6063 and VS-4718 are potent, selective, and orally active FAK inhibitors. In a Phase 1 clinical trial, VS-6063 was well tolerated and demonstrated preliminary clinical activity. VS-6063 is currently being tested in multiple clinical studies both as a single agent and in combination with paclitaxel. VS-4718 was shown to inhibit tumor growth and metastasis in preclinical tumor models including triple negative breast cancer and is currently under evaluation in a Phase 1 clinical trial. We report here that the FAK inhibitors VS-6063 and VS-4718 effectively abrogate cancer stem cells (CSCs) in vitro and in vivo in triple negative breast cancer models.

VS-6063 and VS-4718 were evaluated in multiple cancer stem cell assays in vitro. Pre-treatment of SUM159 and MDA-MB-231 breast cancer cells with FAK inhibitors in matrigel reduced the percentage of ALDH-positive cells. The proportion of side population (SP) cancer stem cells was also reduced by FAK inhibition. The expression of ALDH1 in human breast tumor samples has previously been shown to correlate with poor prognosis (Ginestier et al 2007 Cell Stem Cell 1, 555). Significantly, ex vivo treatment of primary human breast tumor tissue with these FAK inhibitors also effectively reduced the proportion of ALDH-positive CSCs. Similar inhibitory effects on CSCs were observed in ovarian cancer cell lines OVCAR-5 and OVCAR-8. In direct contrast, cytotoxic agents such as paclitaxel and carboplatin increased the percentage of cancer stem cells in vitro, suggesting that these agents do not effectively target CSCs. Importantly, combination of either VS-6063 or VS-4718 with cytotoxic agents attenuated the enrichment of cancer stem cells induced by these cytotoxic agents.

The in vivo effect of a FAK inhibitor on cancer stem cells was evaluated in an MDA-MB-231 human breast cancer orthotopic model. Oral administration of VS-4718 significantly reduced the presence of ALDH1-positive cells in tumors as assessed by immunofluorescence. Following dissociation of cells from tumors, CSCs were found to be reduced in VS-4718-treated tumors as measured by multiple assays. Importantly, cells isolated from VS-4718-treated tumors also showed reduced tumor-initiating capability upon re-implantation into immunodeficient mice in limiting dilutions.

Our results provide clear demonstration that while FAK inhibitors significantly inhibit the growth of human breast tumor xenografts, they also preferentially target breast cancer stem cells in direct contrast to standard-of-care agents. These data provide a strong rationale for the clinical development of Verastem's FAK inhibitors in the treatment of breast cancer.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-09-14.

A phase I/IB study of paclitaxel in combination with VS-6063, a focal adhesion kinase (FAK) inhibitor, in patients (pts) with advanced ovarian cancer

TPS2620

Background: Blockade of FAK reduces tumor growth and metastasis through inhibition of tumor cell survival, proliferation and invasion as well as tumor angiogenesis. Furthermore, treatment with FAK inhibitors reduces the proportion of cancer stem cells (CSCs) in a dose dependent manner while paclitaxel treatment enriches for CSCs. (Kolev VN San Antonio Breast Cancer Symposia 2012 abstr P6-11-09). The ability of CSCs to survive exposure to chemotherapy but remain susceptible to novel drugs suggests a unique therapeutic approach whereby standard of care chemotherapy may be sequentially combined with targeted drugs to kill surviving CSCs and thus prevent tumor recurrence and metastasis. VS-6063 (previously PF-04554878) is a potent oral inhibitor of FAK and proline-rich tyrosine-kinase -2. The phase I first-in-man trial explored doses ranging from 12.5 -750 mg twice daily (BID). (Jones SF J Clin Oncol 2011 29:1 suppl; abstr 3002) Dose-limiting toxicities consisted of headache, fatigue, and unconjugated hyperbilirubinemia at various dose levels. A maximum tolerated dose was not defined, but doses > 100 mg BID consistently yielded concentrations above the preclinically predicted minimal efficacious concentration. Seven pts demonstrated stable disease lasting approximately 6 months or greater, including 3 heavily-pretreated ovarian cancer pts (2 platinum resistant). Methods: Pts with advanced or refractory ovarian cancer (≤ 4 prior regimens) will be enrolled. In the phase I portion, VS-6063 is administered continuously at a starting dose of 200mg BID with paclitaxel 80 mg/m2 on days 1, 8, and 15 every 28 days, and will be escalated to 400mg BID if tolerated. Pharmacokinetics will be analyzed. An additional 15 pts with biopsiable disease will be enrolled at the recommended dose. A 10-day run-in with VS-6063 alone will be used to obtain paired tumor biopsies in order to examine the effects on pFAK expression, CSCs, and other biomarkers. Patients will continue treatment until disease progression. Clinical trial information: NCT01778803.

Focal adhesion kinase (FAK) inhibitors VS-6063 and VS-4718 target cancer stem cells

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Background: Focal adhesion kinase (FAK) is a non-receptor tyrosine kinase that orchestrates cellular signaling through integrins and growth factor receptors and functions in multiple steps of tumorigenesis. Both VS-6063 and VS-4718 are potent, selective, and orally active FAK inhibitors. In a phase I clinical trial, VS-6063 was well tolerated and demonstrated preliminary clinical activity. VS-4718 is in late stage preclinical development and has been shown to inhibit tumor growth and metastasis in tumor models. We report here that the FAK inhibitors VS-6063 and VS-4718 effectively abrogate cancer stem cells (CSCs). Methods: VS-6063 and VS-4718 were evaluated in the ALDEFLUOR and Side Population (SP) CSC assays in vitro and in xenograft tumors in vivo. Results: Treating SUM159 breast cancer cells with FAK inhibitors reduced the percentage of ALDEFLUOR+ and SP CSCs. Similar inhibitory effects on CSCs were observed in the ovarian cancer cell lines OVCAR-5 and OVCAR-8 and the mesothelioma cell line H2052. In direct contrast, cytotoxic agents paclitaxel, carboplatin and pemetrexed increased the percentage of CSCs, suggesting that these agents do not effectively target CSCs. Importantly, combination of either VS-6063 or VS-4718 with cytotoxic agents blocked induction of CSCs by these agents. The effect of a FAK inhibitor on CSCs in vivo was evaluated in an MDA-MB-231 human breast cancer orthotopic model. Oral administration of FAK inhibitor substantially reduced the number of ALDH1- positive cells in tumors as assessed by immunofluorescence. Following dissociation of cells from tumors, CSCs were found to be reduced in FAK inhibitor-treated tumors as measured by multiple assays. Furthermore, cells isolated from FAK inhibitor-treated tumors showed reduced tumor-initiating capability upon re-implantation into immunodeficient mice. FAK inhibitor also decreased ALDH1-positive CSCs in an orthotopic MM87 mesothelioma model. Conclusions: Our results provide clear demonstration that FAK inhibitors target cancer stem cells both in vitro and in xenograft tumors in vivo and support the planned clinical development of VS-6063 and VS-4718 to achieve durable clinical responses for cancer patients.

Sensitivity of malignant mesothelioma lacking Merlin to the FAK inhibitor VS-6063: Evaluation of merlin/NF2 status in clinical samples

e18541

Background: Malignant pleural mesothelioma (MPM) is an aggressive tumor in the pleural lining of the lung often resulting from prior exposure to asbestos. MPM patients are usually diagnosed at an advanced stage of disease and the prognosis is poor. Median survival after diagnosis is 9 to 12 months and standard-of-care agents such as cisplatin and pemetrexed have only a modest impact on median survival time for MPM patients. New therapeutic modalities are urgently needed to improve the prognosis of MPM patients. 40-50% of MPM patients exhibit homozygous disruption of the NF2 tumor suppressor gene by mutation and/or deletion resulting in lack of expression of functional merlin protein. Methods: Proliferation of drug-treated mesothelioma cell lines in 3-dimensional (3D) Matrigel culture was assessed by MTS, and MPM xenograft growth was measured in vehicle- vs. FAK inhibitor-treated SCID mice. Since absence of merlin expression can theoretically result from several mechanisms including NF2 mutation and chromosome 22 abnormalities, we assessed NF2 gene deletion by FISH and merlin protein levels by IHC in the same human mesothelioma tumor samples. Results: Among a panel of mesothelioma cell lines in 3D culture, MPM lines lacking expression of merlin protein were found to be especially sensitive to the selective FAK inhibitor VS-6063. In contrast, MPM cell lines with wildtype merlin were less sensitive with EC50 values greater than 1 μM. Accordingly, oral dosing with a FAK inhibitor induced significant tumor growth inhibition in a merlin-negative mesothelioma model in mice. To enable the planned stratification of MPM patients by merlin status, an immunohistochemistry (IHC) assay has been optimized to quantify merlin protein levels. A merlin IHC H-score below the defined cutoff was associated with loss of at least one copy of chromosome 22, indicating that chromosomal deletion is an important mechanism of merlin loss in mesothelioma patients. Conclusions: These data support the clinical development of VS-6063 for treatment of malignant pleural mesothelioma patients stratified by merlin/NF2 status. A potentially pivotal mesothelioma trial is set to initiate in 2013.

Abstract 236: Pharmacological and genetic inhibition of FAK attenuates cancer stem cell function in vitro and in vivo

Focal adhesion kinase (FAK) is a cytoplasmic tyrosine kinase that orchestrates cell signaling through integrins and growth factor receptors. FAK has been implicated in multiple steps of carcinogenesis including tumor initiation, growth and metastasis. Amplification and overexpression of FAK have been observed in multiple aggressive human cancers including breast and ovarian. VS-4718 is a potent and selective FAK kinase inhibitor that was previously shown by us to exhibit preferential inhibitory activities on breast cancer stem cells. We have further extended our investigation of the role of FAK on cancer stem cells to other solid tumors and report here that pharmacological attenuation of FAK activity by VS-4718 or RNAi-mediated depletion of FAK exhibits preferential inhibitory effects on cancer stem cells.

To determine if FAK plays a role in the biology of cancer stem cells, we depleted FAK expression in breast, ovarian and mesothelioma cancer cell lines by RNAi. Our results indicated that shRNA-mediated knock-down of FAK inhibits tumorsphere formation in vitro. In parallel, VS-4718 was evaluated in a multitude of cancer stem cell assays both in vitro and in vivo. Pre-treatment of SUM159 cells with VS-4718 in matrigel reduced the percentage of ALDEFLUOR+ cancer stem cells and side population (SP). Similar effects were observed in ovarian cancer cell lines OVCAR-8 and OVCAR-5 where VS-4718 inhibited cancer stem cells as measured by multiple CSC assays. In an analogous fashion, VS-4718 also reduced the proportion of the ALDEFLUOR+ cells in H2052 human mesothelioma cells. In direct contrast, standard-of-care agents paclitaxel, carboplatin or pemetrexed increased the percentage of cancer stem cells, suggesting these agents do not effectively target cancer stem cells. Importantly combination of VS-4718 with standard-of-care agents attenuated chemotherapy-induced increases in the percentage of cancer stem cells in vitro in all three cancer models.

The in vivo effect of VS-4718 on cancer stem cells was evaluated in SUM159 and MDA-MB-231 human triple negative breast cancer xenograft models. Following systemic administration, VS-4718 significantly reduced the proportion of cancer stem cells in tumors as evidenced by decreases in the percentage of ALDEFLUOR+ cells and tumorsphere-forming efficiency relative to vehicle-treated tumors and significantly abrogated tumor-initiating capabilities of cancer cells in a limiting dilution re-implantation assay.

In summary, our results indicate the importance of FAK in the self-renewal of cancer stem cells in vitro and in vivo, and support the clinical development of FAK inhibitors to target cancer stem cells for the treatment of multiple cancers.

Citation Format: Vihren Kolev, Quentin Wright, Christian Vidal, Irina Shapiro, Mahesh Pavdal, Mitchell Keegan, Qunli Xu, Jonathan Pachter. Pharmacological and genetic inhibition of FAK attenuates cancer stem cell function in vitro and in vivo. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 236. doi:10.1158/1538-7445.AM2013-236

Abstract 924: FAK inhibition preferentially attenuates growth of Merlin-negative malignant mesotheliomas: role of cancer stem cells

Malignant pleural mesothelioma (MPM) is an aggressive tumor in the pleural lining of the lung often caused by asbestos exposure. MPM patients are usually diagnosed at an advanced stage of the disease and the prognosis is poor. Median survival after diagnosis is 9 to 12 months and standard-of-care agents such as pemetrexed are relatively ineffective in increasing median survival time for MPM patients. New therapeutic modalities are urgently needed for MPM patients.

Neurofibromatosis 2 (NF2) is a tumor suppressor gene that encodes the protein Merlin. Biallelic inactivation of NF2 by mutation and/or deletion occurs in ∼40% of MPMs leading to inactive or absent Merlin. Merlin has been demonstrated to play roles in cell adhesion, invasion and cell motility in tumor cell lines partially through regulation of focal adhesion kinase (FAK) which in turn mediates signal transduction by integrins and growth factor receptors. Increased activation of FAK has been demonstrated in NF2-mutated mesothelioma cells, indicating that FAK may represent an important therapeutic target for MPM.

A potent and selective FAK inhibitor VS-4718 was evaluated in a panel of MPM cell lines with wild-type or mutated NF2. Mutant NF2 MPM cells were found to be especially sensitive to the FAK inhibitor VS-4718 in a 3D Matrigel assay with EC50 values below 100 nM, in contrast to wild type NF2 MPM cell lines which were less sensitive with EC50 values above 1 μM. Decrease in cell growth in response to FAK inhibitor treatment was found to result from reduction of cell proliferation and induction of apoptosis. Ectopic expression of a non-phosphorylatable mutant form of NF2 (NF2-S518A) in NF2 mutant MPM cells abolished the enhanced sensitivity to VS-4718 in both proliferation and apoptosis assays, confirming the hypothesis that Merlin loss confers hypersensitivity to FAK inhibition. In addition, VS-4718 inhibited tumor cell growth in an orthotopic Merlin-negative mesothelioma xenograft model in a dose-dependent manner with corresponding inhibition of tumor FAK autophosphorylation. It has been reported that cancer stem cells (CSCs) are enriched in pemetrexed-resistant mesothelioma. Using Aldefluor activity as a measure of CSCs, we have found that the FAK inhibitor VS-4718 preferentially reduced the percentage of CSCs in Merlin-negative MPM in contrast to the standard-of-care agent pemetrexed which increased the percentage of CSCs. In summary, our results indicate that the FAK inhibitor VS-4718 is especially potent in Merlin-negative MPM tumor cells, and that NF2 status may be a valuable stratification marker for response to FAK inhibition. Furthermore, cancer stem cells in Merlin-negative mesotheliomas appear to be particularly resistant to pemetrexed, but sensitive to VS-4718. These data support the clinical development of a selective FAK inhibitor for treatment of Merlin-negative malignant mesothelioma.

Citation Format: Irina M. Shapiro, Vihren N. Kolev, Christian M. Vidal, Jennifer E. Ring, Mitchell Keegan, Qunli Xu, Craig W. Menges, Joseph R. Testa, Jonathan A. Pachter. FAK inhibition preferentially attenuates growth of Merlin-negative malignant mesotheliomas: role of cancer stem cells. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 924. doi:10.1158/1538-7445.AM2013-924

Abstract P6-11-07: The Cancer Stem Cell-Targeting Wnt Inhibitor VS-507 Reduces Breast Cancer Growth and Metastasis

Cancer stem cells (CSCs) support tumor viability and growth through their ability to self-renew and differentiate into heterogeneous tumor tissue. CSCs are typically resistant to standard cytotoxic agents, leading to their enrichment and the consequent regrowth of refractory tumors. While this population has been challenging to directly target therapeutically, we are actively developing novel agents, such as VS-507, that selectively target the cancer stem cell subpopulation in vivo.

Previously, we and others have shown that VS-507, a cancer stem-cell specific agent, inhibits Wnt signaling with corresponding reduction of the LRP6 protein, a Frizzled co-receptor upregulated in breast cancer cell lines. In the current study, we have continued to examine the effect of VS-507 on the Wnt/Beta-catenin signaling pathway to further elucidate its mechanism of action. We determined that VS-507 also decreases expression of the second Frizzled co-receptor LRP5 in MDA-MB-231 breast cancer cells stimulated by Wnt3A. The combined inhibition of the co-receptors LRP5 and LRP6 may contribute to the observed inhibition of Beta-catenin-mediated transcription by VS-507 in a TOP-Flash assay. Accordingly, VS-507 reduced expression of Axin2, a transcriptional target of Beta-catenin.

Because human breast cancer cell lines represent a mixed population of CSC and non-CSC cells, we evaluated VS-507 across a panel of cell lines by monitoring changes in viability and in the percentage of cancer stem cells. In SUM159 triple negative breast cancer cells, VS-507 had micromolar potency against the bulk population with preferential nanomolar potency against the ALDEFLUOR+ CSC population with similar effects observed in the Hoechst side population (SP) CSC assay. In contrast, cytotoxic anticancer drugs such as paclitaxel and cisplatin increased the percentage of ALDEFLUOR+ cancer stem cells under similar conditions. In vivo, oral administration of VS-507 (15 mg/kg, QD daily) as a single agent partially inhibited MDA-MB-231 tumor growth, consistent with its observed inhibition of the cancer stem cell subpopulation. Furthermore, VS-507 inhibited lung metastasis in a 4T1.2 murine breast cancer model. In summary, these results further elucidate the mechanism by which VS-507 inhibits Wnt/Beta-catenin signaling. VS-507 reduces tumor cell proliferation in vitro with preferential effects on cancer stem cells which translate to inhibition of tumor growth, enhancement of efficacy of cytotoxic agents such as docetaxel, and inhibition of metastasis in mouse models. These data provide additional support for the development of VS-507 as a novel anti-cancer stem cell agent.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-11-07.

Abstract P6-11-09: FAK Inhibitor VS-4718 Attenuates Breast Cancer Stem Cell Function In Vitro and In Vivo

Focal adhesion kinase (FAK) is a cytoplasmic tyrosine kinase that mediates signal transduction by integrins as well as growth factor receptors. FAK has been implicated in multiple steps of carcinogenesis including tumor initiation, growth and metastasis. Amplification and overexpression of FAK have been observed in aggressive human cancers including breast cancer. We have now observed that VS-4718, a selective FAK kinase inhibitor, exhibits preferential inhibitory effects on breast cancer stem cells.

VS-4718 is a potent and selective FAK kinase inhibitor that blocks fibronectin-stimulated FAK autophosphorylation at Tyr397 at low nanomolar concentrations. To determine if FAK plays a role in the biology of breast cancer stem cells, VS-4718 was evaluated in a multitude of cancer stem cell assays both in vitro and in vivo. In parallel, treatment of SUM159 triple negative breast cancer cells in vitro with FAK shRNA inhibits tumorsphere formation. These data taken together indicate a role of FAK in breast cancer stem cell renewal. Similarly, pre-treatment of SUM159 cells with VS-4718 in matrigel attenuated secondary tumorsphere formation. Furthermore, VS-4718 reduced the side population (SP) and the percentage of ALDEFLUOR+ cancer stem cells in SUM159 breast cancer cells in vitro. In direct contrast, standard-of-care agent paclitaxel increased the percentage of ALDEFLUOR+ cancer stem cells in all three assays.

The in vivo effect of VS-4718 on cancer stem cells was evaluated in SUM159 and MDA-MB-231 human triple negative breast cancer xenograft models. Following systemic administration, VS-4718 induced significant reduction of cancer stem cells in tumors as assessed by a decrease in ALDEFLUOR+ cells and tumorsphere-forming efficiency relative to vehicle-treated tumors.

In summary, our results indicate the importance of FAK in the self-renewal of breast cancer stem cells in vitro and in vivo, and support the clinical development of the selective FAK inhibitor VS-4718 to target cancer stem cells for the treatment of triple negative breast cancer.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr P6-11-09.

Abstract LB-192: The FAK inhibitors VS-4718 and VS-5095 attenuate breast cancer stem cell function in vitro and tumor growth in vivo

As a key mediator of integrin signaling, focal adhesion kinase (FAK) regulates cellular responses to extracellular matrix interactions. Amplification and overexpression of FAK have been observed in aggressive human cancers including breast cancer. FAK has been implicated in multiple steps in carcinogenesis including tumor growth, metastasis and angiogenesis. We now demonstrate the importance of FAK in breast cancer stem cell function, and the reduction of cancer stem cell function by the selective FAK inhibitors VS-4718 and VS-5095. VS-4718 and VS-5095 are potent and selective FAK inhibitors which were optimized following high throughput screening. Both VS-4718 and VS-5095 block fibronectin-stimulated FAK autophosphorylation of Tyr397 with low nanomolar cellular potency and are highly selective for FAK among a panel of protein kinases. Consistent with their mechanism of action, VS-4718 and VS-5095 showed greater inhibitory potency on the growth of multiple cancer cell lines in 3D matrigel culture as compared to conventional 2D culture. To determine if FAK plays a role in the biology of breast cancer stem cells in addition to its reported function in normal mammary stem cell biology, the effects of these FAK inhibitors were characterized using two different in vitro assays. It was previously demonstrated that immortalized mammary epithelial cells (HMLEs) driven to undergo epithelial to mesenchymal transition (EMT) by knockdown of E-cadherin (HMLE-shECad) exhibit many of the characteristics of cancer stem cells and can be used to identify agents that selectively target cancer stem cells. VS-4718 exhibited 25-fold greater potency against proliferation of mesenchymal HMLE-shECad cells as compared to epithelial HMLE-shGFP control cells, suggesting preferential effects on breast cancer stem cells. Furthermore, pre-treatment of SUM159 triple negative breast cancer cells with VS-5095 in matrigel attenuated secondary tumorsphere formation, suggesting that FAK is important for the self-renewal function of breast cancer stem cells. The role of FAK in breast cancer stem cell renewal was further corroborated by the observation that FAK shRNA inhibited tumorsphere formation by SUM159 cells. The in vivo efficacy of the FAK inhibitor VS-5095 was evaluated in the MDA-MB-231 human triple negative breast cancer xenograft model. By oral administration, VS-5095 induced significant dose-dependent tumor growth inhibition. In summary, these results demonstrate the importance of FAK in the self-renewal of breast cancer stem cells, and support the clinical development of the selective FAK inhibitors VS-4718 and VS-5095 to target breast cancer stem cells for the treatment of triple negative breast cancer.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr LB-192. doi:1538-7445.AM2012-LB-192

Abstract 3249: Design and synthesis of imidazopyridine derivatives as novel HSP90 inhibitors for the treatment of cancer

The molecular chaperone heat shock protein 90 (HSP90) is involved in folding and stabilization of a wide range of client proteins, including key proteins involved in cancer. Through structure-based design, we synthesized a novel imidazopyridine class of potent HSP90 inhibitors. The synthesis and SAR surrounding this class of compounds will be discussed. The extensive SAR study and lead optimization resulted in the identification of the development candidate CUDC-305, later renamed Debio 0932. Debio 0932 displays high oral bioavailability (96% in mouse), high drug concentrations and a prolonged half-life (20 hr) in tumor tissues. In vitro, Debio 0932 displays potent HSP90 inhibitory activity (IC50, 100 nM) as well as anti-proliferation and apoptosis-inducing activities against a broad range of cancer cell lines (IC50, 40 – 900 nM). In vivo, Debio 0932 is highly effective against various cancer models including NSCLC, AML, breast and colorectal cancers, as well as brain cancers, benefited by its ability to cross the blood-brain barrier to reach therapeutic levels in brain tissue. Debio 0932 also exhibits high selectivity and a favorable safety profile. It was therefore selected as a drug candidate and is currently in Phase 1 clinical trials.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 3249. doi:10.1158/1538-7445.AM2011-3249

CUDC-101, a multitargeted inhibitor of histone deacetylase, epidermal growth factor receptor, and human epidermal growth factor receptor 2, exerts potent anticancer activity

Receptor tyrosine kinase inhibitors have recently become important therapeutics for a variety of cancers. However, due to the heterogeneous and dynamic nature of tumors, the effectiveness of these agents is often hindered by poor response rates and acquired drug resistance. To overcome these limitations, we created a novel small molecule, CUDC-101, which simultaneously inhibits histone deacetylase and the receptor kinases epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor 2 (HER2) in cancer cells. Because of its integrated histone deacetylase inhibition, CUDC-101 synergistically blocked key regulators of EGFR/HER2 signaling pathways, also attenuating multiple compensatory pathways, such as AKT, HER3, and MET, which enable cancer cells to escape the effects of conventional EGFR/HER2 inhibitors. CUDC-101 displayed potent antiproliferative and proapoptotic activities against cultured and implanted tumor cells that are sensitive or resistant to several approved single-targeted drugs. Our results show that CUDC-101 has the potential to dramatically improve the treatment of heterogeneous and drug-resistant tumors that cannot be controlled with single-target agents. Further, they provide a framework to create individual small molecules that simultaneously antagonize multiple biochemically distinct oncogenic targets, suggesting a general paradigm to surpass conventional, single-target cancer therapeutics. Cancer Res; 70(9); 3647-56. (c)2010 AACR.

Genetic risk factors for anterior cruciate ligament ruptures: COL1A1 gene variant

BACKGROUND

Anterior cruciate ligament (ACL) ruptures are considered the most severe injury sustained in sports. Although various intrinsic and extrinsic risk factors have been identified, the exact aetiology of the injury is not yet fully understood. Recently, the gene encoding for the alpha1 chain of type I collagen (COL1A1) has been shown to be associated with cruciate ligament ruptures and shoulder dislocations.

OBJECTIVE

To determine whether the functional Sp1 binding site polymorphism within intron 1 of the COL1A1 gene is associated specifically with ACL ruptures in an independent population.

METHODS

117 Caucasian participants with surgically diagnosed ACL ruptures, and 130 Caucasian physically active controls without any history of previous ligament or tendon injuries were recruited for this case-control genetic association study. All participants were genotyped for the COL1A1 Sp1 binding site polymorphism (G/T; rs1800012).

RESULTS

The rare TT genotype was significantly (p = 0.031, OR = 0.08, 95% CI <0.01 to 1.46) under-represented in the ACL group (0 out of 117, 0%), compared with the controls (6 out of 130, 4.6%).

CONCLUSION

The TT genotype of the COL1A1 Sp1 binding site polymorphism was significantly under-represented in South African participants with ACL ruptures. We propose that this sequence variant be the first specific genetic element to be included in multifactorial models developed to understand the aetiology and risk factors for ACL rupture.

The novel combination of chlorpromazine and pentamidine exerts synergistic antiproliferative effects through dual mitotic action

Combination therapy has proven successful in treating a wide variety of aggressive human cancers. Historically, combination treatments have been discovered through serendipity or lengthy trials using known anticancer agents with similar indications. We have used combination high-throughput screening to discover the unexpected synergistic combination of an antiparasitic agent, pentamidine, and a phenothiazine antipsychotic, chlorpromazine. This combination, CRx-026, inhibits the growth of tumor cell lines in vivo more effectively than either pentamidine or chlorpromazine alone. Here, we report that CRx-026 exerts its antiproliferative effect through synergistic dual mitotic action. Chlorpromazine is a potent and specific inhibitor of the mitotic kinesin KSP/Eg5 and inhibits tumor cell proliferation through mitotic arrest and accumulation of monopolar spindles. Pentamidine treatment results in chromosomal segregation defects and delayed progression through mitosis, consistent with inhibition of the phosphatase of regenerating liver family of phosphatases. We also show that CRx-026 synergizes in vitro and in vivo with the microtubule-binding agents paclitaxel and vinorelbine. These data support a model where dual action of pentamidine and chlorpromazine in mitosis results in synergistic antitumor effects and show the importance of systematic screening for combinations of targeted agents.

Ability of donor splenocytes with costimulation blockade to induce mixed hematopoietic chimerism and transplantation tolerance

We reported stable mixed chimerism and specific tolerance to a fully allogeneic graft after a minimally myelosuppressive regimen including costimulation blockade (CB), donor bone marrow cells (BMC), and busulfan (Bu), a chemotherapeutic conditioning agent that makes niches for engraftment of BMC. For clinical application, the strategy may have the limitation of the number of donor BMC when a deceased donor offers transplants to multiple recipients. Herein, we examined whether donor splenocytes can serve as an alternative source to induce mixed chimerism and tolerance. When a C57BL/6 (H-2b) recipient was treated with CB (CTLA4-Ig and anti-CD154 mAb, on days 0, 2, 4, 6) and donor BALB/c (H-2d) BMC (2 x 10(7) cells on day 0) in the absence of Bu, survival of BALB/c skin graft was remarkably prolonged but not indefinite (median survival time [MST]: 138 days). The recipients never showed durable chimerism. When the recipient was treated with CB and donor splenocytes ([DST] 2 x 10(7) cells on day 0), survival was not indefinite either (MST: 114 days). When the dose of DST was increased to 2 x 10(8) cells, survival was further prolonged; two of six recipients had indefinite survival (MST: 132 days). Moreover, one recipient showed a low level of chimerism. When treated with CB, donor DST (2 x 10(7) cells on day 0) and Bu (20 mg/kg, day -1), six of seven recipients showed a stable, high level of chimerism and enjoyed tolerance of skin allografts. DST combined with CB and Bu may be an alternative source of hematopoietic stem cells to induce mixed chimerism and transplantation tolerance in our model.

Audit of the management of convulsive status epilepticus in children: the need for a uniform treatment strategy

We conducted a two-year prospective audit to review the paediatric management of Convulsive Status Epilepticus (CSE) in Ireland. Our audit showed that there is considerable variability in the management of CSE in this country. In order to provide optimum care for this potentially life-threatening condition a uniform management strategy is required. We propose a protocol for the treatment of CSE, which should ensure uniform management and optimum care and also provide a template for further study and audit of this important disorder.

Potentially reversible autoimmune limbic encephalitis with neuronal potassium channel antibody

OBJECTIVES

To describe the clinical features and coexisting serum autoantibodies in seven patients with encephalitis associated with autoantibodies to alpha-dendrotoxin-sensitive voltage-gated potassium channels (VGKCs), and to compare this disorder with other autoimmune encephalopathies.

METHODS

Clinical information was obtained from a retrospective review of medical records and telephone interviews. All autoantibody testing was performed in a single laboratory.

RESULTS

The seven patients were examined for subacute cognitive and behavioral changes. Seizures, usually temporal-onset complex partial type, were documented in six patients, and all seven patients had EEG abnormalities. None had symptoms or signs of neuromuscular hyperexcitability. One described hypersalivation. Four patients had additional autoantibody markers of neurologic autoimmunity (muscle acetylcholine receptor, striational, P/Q-type calcium channel, or GAD65), and two had thyroperoxidase antibodies. Two patients had a history of cancer: one had active prostate adenocarcinoma, and the second had a remote history of tongue carcinoma. Cranial MRI demonstrated mesial temporal lobe abnormalities in all patients. One patient improved spontaneously, and six were treated with IV methylprednisolone. Three improved remarkably with treatment. At follow-up evaluation, one had no cognitive deficits, four had mild persistent short-term memory dysfunction, and two had persistent disabling behavioral deficits.

CONCLUSIONS

Voltage-gated potassium channel antibodies are a valuable serologic marker of a potentially reversible autoimmune encephalopathy. The neurologic manifestations of this disorder are indistinguishable from paraneoplastic limbic encephalitis but are distinct from Morvan syndrome and Hashimoto encephalopathy.

Macrophage depletion improves survival of porcine neonatal pancreatic cell clusters contained in alginate macrocapsules transplanted into rats

BACKGROUND

Macrophages can accumulate on the surface of empty and islet-containing alginate capsules, leading to loss of functional tissue. In this study, the effect of peritoneal macrophage depletion on the biocompatibility of alginate macrocapsules and function of macroencapsulated porcine neonatal pancreatic cell clusters (NPCCs) was investigated.

METHODS

Clodronate liposomes were injected into the peritoneal cavities of normoglycemic Lewis rats 5 and 2 days before the transplantation. Empty or NPCC-containing Ca-alginate poly L-lysine (PLL)-coated macrocapsules were transplanted into the peritoneal cavities of rats injected with either clodronate liposomes or saline. On days 7, 14 and 21, samples were evaluated by immunohistochemistry for cellular immune responses on the surface of the macrocapsules and for macrophage populations in omental tissue. To assess the function of macroencapsulated NPCCs, insulin secretory responses to glucose and theophylline were measured after capsule retrieval.

RESULTS

In saline-injected control groups, all of the empty and NPCC-containing macrocapsules were overgrown with macrophages, this being especially severe on NPCC-containing macrocapsules. In the clodronate liposomes-injected group, the majority of the empty macrocapsules were free of macrophage accumulation and the NPCC-containing macrocapsules were less overgrown than in control animals. Higher insulin responses to glucose and theophylline were observed in NPCCs retrieved from rats injected with clodronate liposomes.

CONCLUSION

We conclude that depletion of peritoneal macrophages with clodronate liposomes improve the survival of macroencapsulated NPCCs.

Plasma exchange for severe attacks of CNS demyelination: predictors of response

The authors reviewed 59 consecutive patients treated with plasma exchange (PE) for acute, severe attacks of CNS demyelination at Mayo Clinic from January 1984 through June 2000. Most patients had relapsing-remitting MS (n = 22, 37.3%), neuromyelitis optica (NMO) (n = 10, 16.9%), and acute disseminated encephalomyelitis (n = 10, 16.9%). PE was followed by moderate or marked functional improvement in 44.1% of treated patients. Male sex (p = 0.021), preserved reflexes (p = 0.019), and early initiation of treatment (p = 0.009) were associated with moderate or marked improvement. Successfully treated patients improved rapidly following PE, and improvement was sustained.

Increase in beta-cell mass in transplanted porcine neonatal pancreatic cell clusters is due to proliferation of beta-cells and differentiation of duct cells

A 20-fold increase in beta-cell mass has been found after transplantation of porcine neonatal pancreatic cell clusters (NPCCs). Here the mechanisms leading to this increased beta-cell mass were studied. NPCCs (4000 islet equivalents) generated after 8 days culture of digested neonatal pig pancreas were transplanted beneath the renal capsule of streptozotocin (STZ) diabetic and normoglycemic nude mice. Grafts were removed at 10 days, 6 weeks, and 20 weeks after transplantation for immunostaining and insulin content. Proliferation of beta-cells and duct cells was assessed morphometrically using double immunostaining for Ki-67 with insulin or cytokeratin 7 (CK7). Graft maturation was assessed with double immunostaining of CK7 and insulin. Apoptosis was determined using propidium iodide staining. beta-cell proliferation in NPCCs was higher after 8 days of culture compared with that found in neonatal pig pancreas. After transplantation, beta-cell proliferation remained high at 10 days, decreased somewhat at 6 weeks, and was much lower 20 weeks after transplantation. Diabetic recipients not cured at 6 weeks after transplantation had significantly higher beta-cell proliferation compared with those cured and to normoglycemic recipients. The size of individual beta-cells, as determined by cross-sectional area, increased as the grafts matured. Graft insulin content was 20-fold increased at 20 weeks after transplantation compared with 8 days cultured NPCCS: The proliferation index of duct cells was significantly higher in neonatal pig pancreas than in 8 days cultured NPCCs and in 10-day-old grafts. The incidence of apoptosis in duct cells appeared to be low. About 20% of duct cells 10 days post transplantation showed costaining for CK7 and insulin, a marker of protodifferentiation. In conclusion, the increase in beta-cell mass after transplantation of NPCCs is due to both proliferation of differentiated beta-cells and differentiation of duct cells into beta-cells.

Islets in alginate macrobeads reverse diabetes despite minimal acute insulin secretory responses

BACKGROUND

Encapsulation of islets has been widely investigated as a treatment for diabetes. The characteristics and dynamics of insulin secretion by encapsulated islets in response to glucose and other secretagogues are not well understood.

METHODS

In our study, macroencapsulated syngeneic islets at 3-4 wk after transplantation were studied for insulin release in response to i.v. glucose (hyperglycemic clamps at 250 or 350 mg/dl plasma glucose), arginine (i.v. bolus, 100 mg/kg), glucagon-like peptide-1 (i.v. infusion for 20 min, 2.2 pmol/kg/min), and meal challenge. Syngeneic islets (6000 islets) were encapsulated in alginate macrobeads (2-3 mm diameter) with or without poly-L-lysine coating and transplanted into the peritoneal cavity of STZ-diabetic Lewis rats. Normal (nontransplanted) and diabetic Lewis rats transplanted with "naked" islets under the kidney capsule served as controls.

RESULTS

Animals transplanted with macrobeads displayed subnormal insulin responses to glucose, arginine, and glucagon-like peptide-1 despite achieving normoglycemia faster than animals with renal subcapsular islet transplants. Plasma insulin responses to meal challenges were blunted in animals with macrobeads resulting in increased plasma glucose excursions.

CONCLUSIONS

We conclude that, after transplantation into diabetic Lewis rats, macroencapsulated islets have significantly impaired insulin secretion despite achieving normal fed glycemic levels.

Use of single-frequency bioimpedance at 50 kHz to estimate total body water in patients with multiple organ failure and fluid overload

OBJECTIVE

To investigate the relationship between single-frequency bioimpedance at 50 kHz (both total body impedance and segmental impedance) and total body water, measured using tritiated water in the presence of the severe fluid retention seen in multiple organ failure.

DESIGN

Prospective, controlled study.

SETTING

General intensive care unit.

SUBJECTS

Twenty patients with multiple organ failure and 30 normal volunteers, of whom a subgroup of ten had total body water measured.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Total body water and total and segmental bioimpedance values at 50 kHz were measured using tritiated water and a Holtain body composition analyzer in 20 patients with multiple organ failure and in ten normal volunteers. An additional 20 normal volunteers also had segmental and total body impedance measured. There was no difference in the linear regression lines constructed for the patients and the volunteers, but the SEM in the patients (7.6 L) was four times that seen in the normal subjects (1.9 L). In a further seven patients, the impedance technique overestimated the change in total body water, deduced from acute changes in weight, by between 0% and 46% (median, 12%). In the patients, who were supine, the knee-ankle segment contributed significantly more to total body impedance than it did in the normal volunteers (42.5% vs. 34.4%; p < .001), who were upright and mobile immediately before the measurement.

CONCLUSIONS

Although single-frequency bioimpedance does give an indication of total body water and change in total body water, it is neither precise nor accurate enough to be the sole guide to fluid therapy. The proportion of total impedance contributed by the knee-ankle segment, which contains relatively little water, was significantly greater in the patients than in the controls, probably reflecting better drainage of fluid from the lower limb in the supine position.

Caspase-mediated fragmentation of calpain inhibitor protein calpastatin during apoptosis

Two cysteine protease families (caspase and calpain) participate in apoptosis. Here we report that the endogenous calpain inhibitor calpastatin is fragmented by caspase(s) to various extents during early apoptosis in two cell types. In anti-fas or staurosporine-treated Jurkat T-cells, the high-molecular-weight form (HMW) of calpastatin (apparent Mr 110 K) was extensively degraded to immunoreactive fragments of Mr 75 K and 30 K In apoptotic SH-SY5Y human neuroblastoma cells, HMW calpastatin was degraded to a major immunoreactive fragment of 75 K. In both cell types, fragmentation of HMW calpastatin was blocked by a caspase-specific inhibitor carbobenzoxy-Asp-CH2OC(O)-2,6-dichlorobenzene. In vitro translated HMW calpastatin was sensitive to proteolysis by recombinant caspase-1, -3, and -7. By contrast, in vitro translated LMW calpastatin (which lacks domains L and I) was cleaved into multiple fragments only by caspase-1 and was relatively resistant to caspase-3, -7, and other caspases tested. Consistently with that, purified erythroid LMW calpastatin was also highly susceptible to caspase-1 digestion. Recombinant human calpastatin spanning domain I through III (CAST(DI-III)) was found cleaved by caspase-1 at at least three sites, located in either the A or the C helix of domains I and III (ALDD137*L, LSSD203*F and ALAD404*S), while only a single site (ALDD137*L) was cleaved by caspase-3. These findings suggest that both HMW and LMW calpastatins are more vulnerable to caspase-1 than to caspase-3. Surprisingly, both erythroid LMW calpastatin and recombinant CAST(DI-III) fragmented by caspase-1 suffered only a less than twofold reduction of inhibitory activity toward calpain. We propose that the proteolysis of calpastatin in early apoptosis might have yet unidentified effects on the cross-talk between the two protease systems.

Catalysis by hamster dihydroorotase: zinc binding, site-directed mutagenesis, and interaction with inhibitors

Hamster dihydroorotase is the central domain of a trifunctional protein which has been cloned, overexpressed, and purified from Escherichia coli. Using the cDNA encoding the dihydroorotase domain, site-directed mutagenesis of amino acid residues conserved between species has enabled identification of three ligands of zinc at the catalytic site as His15, 17 and 158. The underlined amino acids of the nonapeptide sequence Ile12-Asp13-Val14-His15-Val16-His17- Leu18-Arg19-Glu20 from hamster are conserved between dihydroorotases from 8 species. It is proposed that the residues Asp13-His15-->ZnII form a triad at the active site and that Arg19, for which even the conservative mutation Arg19-->Lys yields an inactive enzyme, is involved in substrate binding. Site-directed mutagenesis of the conserved His186-->Ala yielded a mutant enzyme with a reduced affinity for 65Zn2+. The Km for dihydroorotate (DHO) increased from 4.0 to 11 microM, while the Vmax decreased from 1.2 to 0.53 mumol min-1 (mg of protein)-1, implicating this residue in only a minor way with binding of DHO and in catalysis. The mutation Asp230-->Glu resulted in a 14-fold increase in Km and a 16-fold decrease in Vmax, indicating involvement of this conserved residue in both binding and catalysis. The mutation Lys239-->Gly increased the Km for DHO 110-fold with a 2-fold increase in Vmax, suggesting that this residue may form a hydrogen bond with the substrate.(ABSTRACT TRUNCATED AT 250 WORDS)

Energy metabolism during CAPD: a controlled study

Abnormalities of energy metabolism may exacerbate the high prevalence of protein-calorie malnutrition and inadequate calorie intake in continuous ambulatory peritoneal dialysis (CAPD) patients, leading to further nutritional depletion. In a controlled study, using indirect calorimetry, we evaluated oxygen consumption (VO2), CO2 production, resting energy expenditure, and respiratory exchange ratio (RER) in 12 CAPD patients at rest and during a standard CAPD exchange and in 11 healthy nonuremic control patients. In addition, we investigated the influence of nutritional status and dialysis adequacy on energy metabolism in the CAPD group. There was no significant difference in resting energy parameters between the two groups. Unlike the control group, blood glucose and RER were maintained during prolonged fasting in the CAPD patients. This observation indicates that all the absorbed glucose was used as a metabolic fuel preventing fat oxidation. There was no significant relationship between energy expenditure and dialysis adequacy. There was no significant relationship between nutritional state (including energy intake) and energy expenditure despite evidence of malnutrition in 41% of the patients. If maintenance of "normal levels" of energy expenditure occurs in dialysis patients with suboptimal calorie intake (especially with evidence of protein-calorie malnutrition), this inability to conserve energy may act as an additional risk factor for ongoing malnutrition.

Manipulation of substrate utilization with somatostatin in patients with secondary multiple organ dysfunction syndrome

OBJECTIVES

To determine whether glucose utilization and metabolic substrate (glucose and fat) oxidation could be manipulated in patients with secondary multiple organ dysfunction syndrome.

DESIGN

Prospective study.

SETTING

Intensive care units (ICU) of two university hospitals.

PATIENTS

Eight adults free of hepatic disease and hemodynamically stable at the time of study, but with failed respiratory and gastrointestinal systems, who thus required mechanical ventilation and intravenous nutrition.

INTERVENTIONS

Patients were infused with 20% dextrose through central venous cannulas at rates that increased and maintained (clamped) their plasma glucose concentration at 216 mg/dL (12 mmol/L) for 3 hrs. Somatostatin was infused continuously during the second and third hours of the clamp to reduce plasma concentrations of endogenous insulin and glucagon. Exogenous insulin was administered together with somatostatin during the third hour to restore basal insulin concentrations. Energy expenditure was measured by indirect calorimetry throughout the study and blood samples were withdrawn regularly for determination of metabolite and hormone concentrations. Main statistical comparisons were made between the baseline data (first hour of the study) and data collected during the second and third hours of the clamp.

MEASUREMENTS AND MAIN RESULTS

Plasma glucagon concentrations were reduced by nearly 50% (p < .05) toward the end of the study, whereas no significant changes in plasma concentrations of cortisol or growth hormone occurred. Energy expenditure did not change significantly at any time during the clamp procedure. Glucose utilization (6.1 mg/kg/min [34 mumol/kg/min]) during the first hour of the hyperglycemic clamp, decreased by 53% (p < .05) with the infusion of somatostatin during the second hour of the clamp. However, once exogenous insulin was infused during the third hour, glucose utilization increased by 55% (p < .05) when compared with the baseline (hour 1) rate. Glucose oxidation was nearly doubled during the third hour of the study when compared with oxidation rates during the first and second hours. Fat oxidation decreased steadily during the 3-hr clamp.

CONCLUSIONS

Glucagon has a significant inhibitory effect on glucose utilization during intravenous glucose infusion in the multiple organ dysfunction syndrome patient. Pharmacologic intervention with somatostatin and insulin (physiologic dose) can facilitate glucose utilization and oxidation in these patients. Further investigations are needed to determine whether long-term alteration of glucose and fat metabolism would be beneficial in the patient with secondary multiple organ dysfunction syndrome.