Equivalent benefit of rapamycin and a potent mTOR ATP-competitive inhibitor, MLN0128 (INK128), in a mouse model of tuberous sclerosis

Tuberous sclerosis complex (TSC) is a hamartoma syndrome in which brain, renal, and lung tumors develop and cause both morbidity and death. Loss of either TSC1 or TSC2 in TSC hamartomas leads to activation of mTORC1. Rapamycin and related drugs have been shown to have clinical benefit for these tumors in patients with TSC and those with sporadic forms of TSC-related neoplasms. However, lifelong therapy seems to be required, as tumors are not eliminated by this treatment. We examined the potential benefit of MLN0128, a novel potent mTOR ATP-competitive inhibitor, as a therapeutic strategy for renal cystadenomas that develop in A/J Tsc2(+/-) mice. Rapamycin given by intraperitoneal injection at 3 mg/kg 3 times per week, and MLN0128 given by gavage at 0.75 mg/kg 5 times per week had equivalent effects in suppressing tumor development during a 4-week treatment period, with an approximate 99% reduction in microscopic tumor cell volume. Marked reduction in activation of mTOR complex (mTORC)1 and blockade of cell growth was seen with both drugs, whereas only MLN0128 treatment had effects in blocking mTORC2 and 4EBP1 phosphorylation. However, when either drug was discontinued and mice were observed for two additional months, there was dramatic recovery of tumor growth, with extensive proliferation. Hence, longlasting tumor growth control is not achieved with transient treatment with either drug, and MLN0128 and rapamycin have equivalent therapeutic benefit in this mouse model. Differences in side-effect profiles might make MLN0128 more attractive for treatment of patients with TSC-related tumors, but will require additional study in humans.

Renal and liver tumors in Tsc2(+/-) mice, a model of tuberous sclerosis complex, do not respond to treatment with atorvastatin, a 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor

Inactivating mutations of the tumor suppressor gene TSC2 are associated with tumorigenesis in tuberous sclerosis complex (TSC) and lymphangioleiomyomatosis. Statins, as 3-hydroxy-3-methylglutaryl CoA reductase inhibitors, have the potential to limit the growth of these tumors by limiting the isoprenylation of activated GTPases in Tsc2-null cells. We tested atorvastatin as a therapy for (a) ethylnitrosourea (ENU)-enhanced renal cystadenoma and (b) spontaneous liver hemangioma in 129Sv/Jae Tsc2(+/-) mice. ENU-treated Tsc2(+/-) mice were given atorvastatin chow (0.1%, w/w) for 1 or 3 months before sacrifice at 6 months; 129Sv/Jae Tsc2(+/-) mice were given atorvastatin chow (0.1%, w/w) for 6 months before sacrifice at 12 months. All treatment groups were compared with mice of identical genotype and strain background that were fed control chow. Pathologic analyses revealed a predominance of renal cystadenoma in ENU-treated and liver hemangioma in non-ENU-treated 129Sv/Jae Tsc2(+/-) mice. In both cohorts, serum cholesterol levels and levels of phosphorylated S6 and GTP-RhoA in healthy tissue were significantly (>50%) reduced in atorvastatin-treated mice as compared with controls. Following atorvastatin treatment, no significant reduction in tumor size, morphology, or phosphorylated S6 levels was observed for either ENU-associated renal cystadenoma or spontaneous liver hemangioma as compared with the untreated groups. In conclusion, although the marked reduction in cholesterol levels indicates that atorvastatin was effective as an 3-hydroxy-3-methylglutaryl CoA reductase inhibitor, it did not inhibit the growth of tumors that develop in these Tsc2(+/-) models, suggesting that it is unlikely to have benefit as a single-agent therapy for TSC-associated tumors.

Giant multilocular cystadenoma of the prostate responsive to GnRH antagonists

Giant multilocular cystadenoma of the prostate is a rare, benign, but locally recurrent, tumor that is usually treated by surgery. We report a case initially treated by surgical resection and followed by evaluation of serum prostate-specific antigen values. After evidence of biochemical failure, pathologic recurrence was confirmed and treated by the gonadotropin-releasing hormone antagonist Lupron, with excellent results. The patient was stable without biochemical or radiologic evidence of progression during the last 2.5 years. This result offers a new treatment option for patients with this rare tumor.

Modulation of melphalan and cisplatin cytotoxicity in human ovarian cancer cells resistant to alkylating drugs

We investigated the effect of pharmacological modulators on the cytotoxic activity of melphalan and cisplatin in human ovarian cystadenocarcinoma cells sensitive (OAW42) or resistant (OAW42MER) to bifunctional alkylating agents. By filter elution experiments we observed a reduced accumulation and a faster repair of melphalan-induced DNA interstrand cross-links in the OAW42MER resistant cells than in the OAW42 parental, sensitive cells. Moreover, resistant cells were characterized by an increased level of mRNA encoding enzymes involved in the nucleotide excision repair pathway, such as ERCC (excision repair cross complementing)1 and ERCC2. Among the modulators used, the topoisomerase I inhibitor topotecan was able to increase melphalan cytotoxic activity in sensitive and resistant cell lines. Topotecan also positively modulated cisplatin activity, although to a variable extent in the two cell lines, as a function of treatment schedule. The energolytic compound lonidamine markedly enhanced the cytotoxicity of melphalan and cisplatin, with a potentiating effect in the OAW42MER resistant cells almost 2-fold that of in the OAW42 sensitive cells. No significant potentiation was observed by using calcium channel blockers, such as verapamil and nimodipine. Conversely, an increase in melphalan cytotoxic activity was determined by flunarizine in OAW42MER resistant cells and, to a lesser extent, in OAW42 sensitive cells. However, the calcium blocker failed to modulate cisplatin activity in both cell lines.

[Studies on serum protein fractions of patients with maxillary sinus cancer undergoing a combination of radiotherapy and chemotherapy: II. Relationship between changes in serum protein fractions and prognosis]

We examined the correlations between changes in serum protein fractions and the prognosis of the patients. The levels of 21 protein components of the sera of 36 patients with maxillary sinus cancer were determined by a single radial immunodiffusion method before and after radiation therapy. The patients with maxillary sinus cancer were treated with combined intra-arterial infusion of bleomycin and external irradiation of 60 Co gamma-rays, and were concurrently treated with 5-fluorouracil at 200 mg/day p.o. The levels of the same protein components were also measured in 34 normal adult as a control. All patients were observed 5 years and 12 years after radiation therapy. In patients who had survived at least 5 years after radiation therapy, the Alb, Tf, Hx, IgG and IgM levels measured before radiation therapy were elevated significantly compared with those who had died within 5 years. In those who had survived at least 5 years, the Alb, Tf, Hx, IgG, IgM, IgA and I alpha I levels measured after radiation therapy were elevated significantly compared with those who had died within 5 years, and AT III was reduced. In cases of maxillary sinus cancer following a period of 5 to 12 years after radiation therapy, multiple regression analysis was used to determine whether increased concentrations of serum protein fractions were associated with good prognosis for the original disease, alpha 2HS. IgM, HX, alpha 1AT and alpha 1X before radiation therapy were positively correlated with survival, whereas AT III, Pmg, Cp, IgA, and alpha 1AG showed negative correlations. After radiation therapy, Pmg, Hx, Cp, Cl inh and Fib were found to be positive factors of survival rate, whereas alpha 2M, alpha 2Pl, I alpha 1, IgA, alpha 1AG and C3 were negative factors.

Natural killer cell activity and progression-free survival in ovarian cancer

A longitudinal evaluation of the natural killer (NK) cell activity of peripheral blood lymphocytes was performed in 17 patients with advanced ovarian cancer (treated surgically and with subsequent multiagent chemotherapy) for a median follow-up period of 32 months. At the time of primary treatment, the mean value of NK cell activity was significantly lower in patients who then had disease progression (p < 0.05) than in patients with progression-free survival. During the follow-up period, no significant modifications of the NK cell activity were observed; only at the time of clinical disease progression did the NK cell activity show a significant reduction. We conclude that the NK cell activity is a potentially important prognostic factor.

Glutathione S-transferase activity and isoenzyme composition in benign ovarian tumours, untreated malignant ovarian tumours, and malignant ovarian tumours after platinum/cyclophosphamide chemotherapy

Glutathione S-transferase (GST) isoenzyme composition, isoenzyme quantities and enzymatic activity were investigated in benign (n = 4) ovarian tumours and malignant ovarian tumours, before (n = 20) and after (n = 16) chemotherapy. Enzymatic activity of GST in cytosols was measured by determining 1-chloro-2,4-dinitrobenzene conjugation with glutathione, cytosolic GST subunits were determined by wide pore reversed phase HPLC, using a S-hexylglutathione-agarose affinity column, and isoelectric focussing. Both GST activity and GST pi amount were not related to histopathologic type, differentiation grade, or tumour volume index in untreated malignant tumours. GST isoenzyme patterns were identical in benign tumours and malignant tumours before and after platinum/cyclophosphamide chemotherapy, while GST pi was the predominant transferase. Mean GST activity and GST pi amount were decreased (P < 0.05) in malignant ovarian tumours after platinum/cyclophosphamide chemotherapy compared to untreated ovarian malignant tumours. No relation was found in untreated ovarian tumours between GST pi amount and response to platinum/cyclophosphamide chemotherapy. Thus, within the limitations of the current study no arguments were found for a role of GST in in vivo drug resistance of malignant ovarian tumours to platinum/cyclophosphamide chemotherapy.

P-glycoprotein expression and DNA topoisomerase I and II activity in benign tumors of the ovary and in malignant tumors of the ovary, before and after platinum/cyclophosphamide chemotherapy

P-glycoprotein (P-gp) expression and DNA topoisomerase (Topo) II are important variables in multidrug resistant tumor cell lines. The aim of this study was to evaluate P-gp expression and Topo I and II activity in benign and malignant epithelial ovarian tumors. P-gp expression was analyzed immunohistochemically in cryostat sections of fresh tumor specimens. In the same specimens Topo I and II activity were measured by, respectively, relaxation of supercoiled plasmid pBR322 DNA and decatenation of kinetoplast DNA. P-gp expression (range, 5-100% positive staining cells) was found in 3 of 6 cystadenomas, 0 of 2 borderline tumors, 15 of 21 untreated ovarian cancers, and 8 of 13 platinum/cyclophosphamide treated ovarian cancers. Median Topo I and II activity were elevated in malignant ovarian tumors compared to benign and borderline tumors. No difference was found between median Topo I activity in untreated ovarian cancer and platinum/cyclophosphamide treated ovarian cancer. High Topo II activity (greater than or equal to 8 x 10(2) units/mg protein) was more frequent in untreated compared to platinum/cyclophosphamide treated samples. Respectively, 8- and 16-fold differences in Topo I and II activity were found in the malignant tumors. Topo II activity in malignant tumors correlated with Topo I activity (r = 0.36, P less than 0.05) and the tumor volume index (r = 0.35, P less than 0.05). However, this last weak correlation cannot explain the 16-fold differences in Topo II activity in malignant tumors. Mitotic index and P-gp expression did not correlate with Topo I or II activity. A large variability in P-gp expression and Topo I and II activity was observed in patients with ovarian cancer.

The consequences of unsuspected secondary ovarian neoplasia: a clinical presentation of four case histories

Secondary ovarian neoplasia is a common clinical entity which represents 3 to 8% of all ovarian tumors. However, despite its apparent prevalence, it remains a diagnostic and management dilemma. The ability to differentiate primary ovarian carcinoma from metastatic disease to the ovary has significant therapeutic and prognostic implications. Four case histories are presented which will demonstrate the necessity of formulating a complete differential diagnosis as well as the need for a thorough preoperative bowel examination.

[High-dose CDDP therapy using a balloon-occluded arterial infusion (BOAI) in recurrent ovarian cancer]

An intraarterial high-dose CDDP, using a balloon catheter, has been infused into five patients with a recurrent ovarian cancer. The dose of CDDP was 150 mg-200 mg/body. Two patients experienced a partial tumor regression, whereas three showed no change. With regard to the toxicity, the NAG index (NAG activity/urinary creatinine) rose markedly in all patients, but toxicity was almost similar to that seen from a systemic administration. No significant catheter complication occurred.

Malignant clear cell cystadenoma of the ovary

A 50-year-old female had suffered from abdominal distension and a lower abdominal mass for 3 months. Ultrasonographic examination demonstrated a myoma uteri pattern with a large cystic ovarian tumor. Laparotomy was done on August 30, 1983 and simple total hysterectomy with bilateral salpingo-oophorectomy was carried out. FIGO stage IIC ovarian cancer was stated clinically. Histologically, clear cell cystadenoma of right ovary having benign, proliferative and malignant epithelial elements without dense ovarian stroma was found and diagnosed as malignant clear cell cystadenoma. In spite of Cisplatin therapy, the patient expired on April 6, 1984.

[An experimental study of cisplatin and it's antidote, sodium thiosulfate, in ovarian pseudomyxoma implanted into nude mice abdominal cavity]

While Cisplatin was found to be effective in treating pseudomyxoma, its side effects, particularly on the kidneys, were very strong. Recently a "two channel therapy", in which it is used along with sodiumthiosulfate, has been reported to minimize the side effects. The authors used nude mice with pseudomyxoma implanted into the abdominal cavity in an experiment in which Cisplatin was introduced into the abdominal cavity and sodiumthiosulfate injected subcutaneously in a two channel procedure to determine the effect of sodiumthiosulfate on the action of Cisplatin on the pseudomyxoma and on the side effects of Cisplatin. The following results were obtained: The survival rate was improved when sodiumthiosulfate was administered with 40 mg/kg and 20 mg/kg of Cisplatin. Body weight loss was controlled when sodiumthiosulfate was administered with 20 mg/kg of Cisplatin. On the other hand, the histological effect of Cisplatin was also suppressed when sodiumthiosulfate was co-administered. In this study, we failed to observed any histological changes in the kidneys and liver attributable to Cisplatin.

In vivo chemosensitivity testing in patients with gynecologic malignancies and nude mouse xenografts by monitoring cell kinetic parameters and DNA distribution patterns: a preliminary report

Using flow cytometry (FCM) and autoradiography we have evaluated changes in DNA-ploidy patterns as well as cell-cycle perturbations after chemotherapy in 12 patients with accessible tumors and 22 nude mice xenografts. Gynecologic malignancies growing as nude mouse xenografts serve as an experimental model to study the effect of chemotherapy at the cellular level. Excellent correlation was found between fine needle aspiration (FNA) and biopsy material for either FCM or autoradiography. It now appears possible to study the effects of chemotherapy in the patient as well as the animal model using serial FNAs as a microsampling technique.

[Clinical studies on malignant ovarian tumor--with special reference to therapy and prognosis of epithelial ovarian tumor]

Two hundred and ninety-two (75%) patients with common "epithelial" tumors of 391 patients with various kinds of malignant ovarian tumors treated at our hospital and other 14 hospitals between 1971 and 1981 were evaluated particularly to determine 1) the prognostic value of the disease stage and 2) results of therapy. Of the 292 patients, 49.8% were classified in Stage I, 12.8% in Stage II, 27.2% in Stage III and 10.1% in Stage IV. The 5-year survival rates for the various stages were: Stage I, 70.2%; Stage II, 50. 0%; Stage III, 3.4%; and Stage IV, 0%. Postoperative chemotherapy was given to 56.9% of the patients. The prognosis of patients with Stage Ia or Ic who received adjuvant chemotherapy improved, as compared to those who were treated with surgery alone. However, the role of chemotherapy in advanced stages (Stage III and IV) remains unclear.

Polychemotherapy in ovarian cancer: treatment with Adriamycin, BCNU and cyclophosphamide vs. Adriamycin and cyclophosphamide

The authors compared both therapeutic efficacy and toxicity of two different treatment regimens: ABC = adriamycin, nitrogen mustard (BCNU) and cyclophosphamide (CTX) vs. AC = adriamycin and cyclophosphamide in ovarian cancer. Thirty-one patients were entered under treatment plan ABC and 26 under treatment plan AC simultaneously. Therapeutic evaluation was subdivided into different risk groups (adjuvant therapy, residual disease less than or greater than 2 cm). A similar result could be noted in the two different treatment regimens. Toxicity was more severe and frequent in the group treated with BCNU. The AC regimen was preferred because of its lower incidence of side-effects and for its easier mode of administration.

Pseudomyxoma peritonei

Thirty-eight patients with pseudomyxoma peritonei were treated at the M. D. Anderson Hospital, Houston, from 1954 to 1978. The various treatment regimens used have provided actuarial survival rates of 54% at five years and 18% at ten years. Local or regional disease was the cause of death in 68% of patients, and no patient died of metastatic disease. Initial definitive surgery should consist of effective tumor reduction, omentectomy, appendectomy, and, in the female subject, bilateral oophorectomy. Most patients have been treated adjunctively with either fluorouracil or melphalan (L-phenylalanine mustard) depending on the presumed site of origin, but results in a small number of patients treated with either whole abdominal or strip abdominal radiotherapy suggest that this modality may offer improved survival. Treatment with adjunctive radiotherapy alone has provided a five-year survival rate of 75%, compared with 44% for chemotherapy.

Long-term survival in a case of stage IV carcinoma of the ovary treated with a single chemotherapeutic agent

A case of stage IV carcinoma of the ovary is presented which was treated approximately six years ago in the Department of Radiation Therapy at Queens Hospital Center. On September 12, 1972, the patient had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for a papillary scirrhous cystadenocarcinoma of the left ovary. At the time of the operation, the patient was found to have stage IV carcinoma of the ovary due to metastases of the liver and rectum. She was scheduled to receive pelvic-abdominal postoperative radiation therapy via the moving strip technique. Unfortunately, after completion of two strips, the patient could not tolerate treatment. She then began chemotherapy with a single agent, chlorambucil.Chlorambucil, 0.2 mg/kg/day×25 days/course was administered. The patient received 18 courses. Treatment dosage on a few occasions was decreased and increased again, due to drops in hemoglobin level and white blood cell and platelet counts. At the time of this presentation, the patient has no signs or symptoms of the disease. The introduction of megavoltage radiotherapy and adjuvant chemotherapy postoperatively has significantly improved the prognosis for patients with ovarian carcinoma. However, despite progress in radiotherapy, some patients cannot sustain this kind of treatment due to the unwanted side effects. Such was the case in this patient. She was switched to chemotherapy with excellent results in response and survival, even cure.

Ovarian cancer. Effective treatment after alkylating-agent failure

Combination chemotherapy consisting of hexamethylmelamine and cisplatin, alone or with doxorubicin hydrochloride, was given to 27 patients with advanced ovarian cancer who had disease progression with therapy including alkylating agents. Eighteen (67%) had greater than 50% regression of measurable disease or disease that could be evaluated but not measured, for a projected median duration of seven months. The projected median survival for all patients is nine months from the time of entry into the study and 33 months from the time of diagnosis of ovarian cancer. The treatment could be readily administered on an outpatient basis with a regimen of hydration and diuresis that nearly completely prevented platinum-induced renal tubular damage. Myelosuppression was severe in 11 patients (40%), but there was no treatment-related deaths. Agents of such high activity should be considered as components of initial therapy for stage III and IV cancers.

Immunodiagnosis in ovarian cancer: blocking factor activity

Tumor immunology studies have been utilized for development of a blocking factor assay for therapy monitoring in ovarian cancer. The blocking factor index was defined as the arithmetic difference between assays conducted in the presence and absence of the patient's serum compared to incubations with normal control lymphocytes. Eighteen advanced ovarian epithelial malignancies have shown blocking factor activity during treatment. Blocking factor has abated in eight patients whose clinical disease completely regressed. Chemotherapy was discontinued after 18 to 24 months. In 10 patients, blocking factor persisted and chemotherapy has been continued. Some of these patients showed decreasing blocking factor; others have shown increases, which led to death due to disseminated disease in four cases. Blocking factor activity was found to correlate with tumor growth.

A Phase II Study of Combined Adriamycin, L-PAM, and Methotrexate with Citrovorum Factor Rescue in Advanced Ovarian Carcinomas

In a phase II study of combined adriamycin, L-PAM, and methotrexate with citrovorum factor rescue, 14 of 15 patients with primary advanced or recurrent ovarian malignant tumors obtained an objective remission. In remission, all patients improved their quality of life. So far the median duration of remission is 5+ months for the complete responders and 7 months for the partial responders. Myelosuppression of varying severity occurred in 93 % of the courses. The regimen proved highly effective, although toxic in some advanced patients.

Quadrichemotherapy for advanced ovarian carcinoma

In an effort to improve the length and rate of objective responses in patients with advanced ovarian carcinoma, a combination of four drugs was administered. Vincristine (10 mug/kg intravenously weekly), actinomycin D (500 mug intravenously weekly), oral methotrexate (1.25 mg daily), and oral cyclophosphamide (50 mg daily) were given to 25 evaluable patients with FIGO Stage III and IV ovarian carcinoma. After 12 weeks the vincristine and methotrexate were discontinued; cyclophosphamide and methotrexate were continued until disease progression was evident. Objective responses occurred in 56% of the patients. Toxicity was minimal. Patients not previously treated with radiotherapy or chemotherapy had a higher complete response rate (30%) than patients previously treated (13.3%). Mean length of complete response was 10.6+ months. The 1-year survival rate of these patients was 69.5% and the 5-year rate 22.7%. While the results are encouraging, single agent chemotherapy with an alkylating agent produces similar responses.

Acute leukemia in advanced ovarian carcinoma after treatment with alkylating agents

Two cases of advanced ovarian carcinoma treated with chlorambucil and terminating in acute leukemia are presented and the literature reviewed. The first patient was diagnosed by laparotomy as having Stage III ovarian carcinoma, and total abdominal hysterectomy and bilateral salpingo-ophorectomy were performed. After 7 years and 2 months of chemotherapy, acute myeloblastic leukemia was diagnosed, and the patient expired 4 months later. At autopsy no residual ovarian tumor was found. The second patient had a right oophorectomy after the diagnosis of Stage III ovarian carcinoma had been made. After 5 years and 9 months of chemotherapy she developed acute myelomonocytic leukemia and expired 2 months later, with residual ovarian tumor present on autopsy. The benefits of surgical reexploration in occasional cases of good clinical remission after chemotherapy are discussed in view of potential carcinogenicity of cytostatic agents.

[1st report on programmed chemotherapy of ovarian carcinoma]

A prospective study with regard to a cytostatic drugs combination treatment, partly synchronized and carried out in team work, of advanced ovarian carcinoma is being accomplished at the II. Women's Clinic of the University of Munich. The team consists of one oncologically orientated internal specialist, one radiotherapist, and one surgeon. The therapeutic procedure should be discussed; a report is given about the experiences gained so far in 41 patients, i.e. until May 1st, 1975.

Pseudomyxoma peritonaei: a report of ten cases

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