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Molecular Biology, Pathobiology, and Genetics |
1 Laboratory of Molecular Genetics, Institute for Cancer Research and Treatment, University of Torino Medical School, Candiolo, Italy; 2 The Falck Division of Medical Oncology, Ospedale Niguarda Ca' Granda; and 3 FIRC Institute of Molecular Oncology, Milan, Italy
Requests for reprints: Alberto Bardelli, Laboratory of Molecular Genetics Institute for Cancer Research and Treatment, University of Torino Medical School, Strada Provinciale 142, Km 3.95, Candiolo (Torino) 10060, Italy. Phone: 0039-011-99333601; E-mail: a.bardelli{at}unito.it or Salvatore Siena, Divisione Oncologia Medica Falck, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 320162 Milan, Italy. E-mail: salvatore.siena{at}ospedaleniguarda.it.
| Abstract |
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| Introduction |
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10% of patients with chemotherapy-resistant metastatic colorectal cancers (mCRC; refs. 25). We have reported previously that most patients with mCRC who achieve tumor shrinkage from treatment with anti-EGFR mAbs exhibit increased EGFR gene copy number (2). In these patients, the tumor growth is likely to be driven predominantly by the EGFR pathway (6, 7). A fraction of patients with increased EGFR gene copy number respond, whereas patients with normal EGFR gene copy status are unlikely to respond to the therapy (8). We did not observe a statistical association between clinical response and the mutational status of the EGFR gene (2). This finding is in accordance with other studies, indicating that EGFR mutations are an infrequent event in CRC (9). Regardless of their genetic status, after a variable period, CRCs develop resistance to the mAbs, thus severely impairing their therapeutic potential. For these reasons, it is a clear priority to understand the molecular and cellular basis of primary and acquired resistance to anti-EGFR mAbs, cetuximab and panitumumab. We hypothesized that the lack of primary response or the acquired resistance to anti-EGFR mAbs may be due to constitutive activation of the signaling pathways downstream of the receptor. Our hypothesis is based on the concept that the genes mutated in cancer work in organized pathways. Mutations within a single pathway are often "mutually exclusive," as predicted if the functional effect of each mutation was similar (10, 11). Consequently, only one of the genes involved in a given pathway is generally mutated in any single tumor. This implies that pathways rather than single genes should be the focus of studies aimed at dissecting the molecular basis of targeted therapies. It also suggests that once the "culprit" pathway governing the oncogenic property of a cancer is identified, all the players involved in that pathway (and not only a specific gene) can become a suitable therapeutic target.
Previous work has shown that two main signaling pathways are triggered by activation of the EGFR (12). The first is initiated by the small G-protein RAS, which in concert with the protein kinase RAF activates the mitogen-activated protein kinase (MAPK) cascade. The second involves the lipid kinase phosphatidylinositol 3-kinase that triggers activation of the PDK1-AKT signaling machinery (13).
It has been reported recently that K-RAS mutations negatively correlate with the response to the mAb cetuximab (14). In our previous report, the mutational status of the EGFR signaling effectors (K-RAS, BRAF, or PIK3CA) was not statistically associated with the response, although the K-RAS mutations seemed to be slightly more frequent in nonresponsive patients (2).
To assess whether activation of these signaling pathways could be connected to the response to anti-EGFR mAbs, we used two complementary approaches. First, genetic analysis was used to identify which members of the pathway were oncogenically activated in mCRCs from patients that had received the anti-EGFR mAbs. Second, CRC cell models were used to assess whether activation of effectors downstream the EGFR pathway affected the response to anti-EGFR treatment.
| Materials and Methods |
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CRIB assays. The RAF-CRIB domain pull-down experiment on cells transfected with mutated K-RAS or the control vector was carried out as described previously by Taylor and Shalloway (17). Cells were lysed in a lysis buffer containing 25 mmol/L HEPES (pH 7.3), 0.3 mol/L NaCl, 1 mmol/L MgCl2, 0.5 mmol/L EDTA, 20 mmol/L ß-glycerophosphate, 1 mmol/L sodium vanadate, 1 mmol/L DTT, 0.5% Triton X-100, and 5% glycerol containing 0.5 mmol/L phenylmethylsulfonyl fluoride and 5 µg/mL each of aprotinin and pepstatin. Lysates were then incubated with slurry beads previously linked to glutathione S-transferase (GST)-RAF CRIB domain and GST alone for 2 h at 4°C, washed three times in lysis buffer, resuspended, and loaded on a 12% acrylamide gel. Western blots were carried out as described previously (2).
Cell culture and transfections. CRC cell lines were obtained from the American Type Culture Collection (Manassas, VA) repository with the exception of the DiFi cells that were supplied by Jose Baselga (Vall d'Hebron University, Barcelona, Spain). Cells were grown in medium supplemented with 10% FCS and antibiotics. The constitutively active K-RAS expression vector used was pDCR-H-RasV12, kindly provided by Letizia Lanzetti (Torino Medical School, Candiolo, Torino, Italy). Empty vectors were used as controls for the transfections. Cells were transiently transfected using LipofectAMINE as suggested by the manufacturer.
Proliferation inhibition assay and Western blotting. For cell viability assays, cells were grown in medium supplemented with 2% FCS and incubated for 5 days with increasing concentrations of cetuximab (Komtur Pharmaceuticals, Freiburg, Germany) and/or PD98059 (Calbiochem, Milan, Italy). CRC cells were seeded in 96-well plates, and at the end of the drug incubation period, a tetrazolium saltbased reagent (CellTiter96 Aqueous One Solution, Promega, Milan, Italy) was added to each well according to the instructions provided by the manufacturer. After an incubation of 2 h, absorbance was read at 490 nm on a Beckman Coulter (Milan, Italy) DTX 880 plate reader. Values for control cells were considered as 100% viability. The triplicate values were all within 5% and the mean values were calculated and plotted with error bars representing the SD of triplicate samples from three independent experiments. Western blotting was done as described (2).
Statistics. Data have been analyzed using Stata 9.1 (Stata Corp., College Station, TX); all significance levels were set at P < 0.05. Qualitative comparisons of objective response to therapy (progressive disease, stable disease, and partial response) and gene mutations as predictors were done by the Fisher's exact test to check possible significance; the response to therapy was then analyzed by logistic regression using the presence of gene mutations as regressors. All logistic analyses were checked by means of pseudo R2 value and post tested with Hosmer and Lemeshow goodness-of-fit test followed by receiver operating characteristic analysis to verify sensitivity, specificity, and positive/negative predictive values of each model. The time-to-progression (TTP) analysis was done after Kaplan-Meier and then survivor curves were compared by means of log-rank test. TTP was defined as the time from random assignment of each protocol (see patients characteristics and treatments) until first documented tumor progression or death.
| Results |
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RAS/RAF mutations negatively correlate with progression-free survival of mCRC patients treated with cetuximab or panitumumab. Next, we assessed whether in patients treated with anti-EGFR mAbs the oncogenic activation of downstream signaling pathways was associated with time to tumor progression, which is a more compelling evidence of clinical benefit than objective response especially considering biological agents, such as mAbs. The TTP analysis showed a significantly worse outcome for subjects bearing a mutated K-RAS allele in their tumors compared with those carrying wild-type (WT) K-RAS (P = 0.0443; Fig. 1A ). The same was not observed for CRC patients carrying the BRAF mutation (P = 0.5369), probably due to the limited number of tumors carrying these mutations compared with those carrying the K-RAS mutations. However, the presence of either one or other mutation was still significant (P = 0.0259; Fig. 1B). This could imply that constitutive activation of the RAS/RAF signaling pathway impairs the response to therapy based on anti-EGFR antibodies and is in good agreement with what observed in other models, such as the response of lung cancer to gefitinib or erlotinib (8, 18).
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An activated allele of K-RAS (Gly12Val) was then introduced into DiFi cells alongside with the corresponding control vector using lipid-mediated plasmid DNA transfection. The transfection efficacy was verified using a plasmid encoding for the GFP gene. To assess whether we had successfully expressed an active RAS protein into transfected DiFi cells, we measured the amount of RAS bound to GTP. To this end, we did a RAF-CRIB domain pull-down experiment on cells transfected with mutated K-RAS or the control vector (see details in Materials and Methods). The results clearly indicated that cells transfected with the K-RAS (Gly12Val) plasmid have a significantly higher amount of RAS protein bound to GTP when compared with those transfected with the control vector (Fig. 2A ). We then treated DiFi cells expressing mutated and WT RAS with increasing concentrations of cetuximab (from 520 nmol/L) and measured the percentage of cell viability. We found that cells expressing the activated RAS (K-RAS Gly12Val) were less sensitive to the drug as indicated by their markedly increased survival upon treatment with cetuximab (Fig. 2B). The experiment was repeated twice and each time we obtained comparable results and P values.
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Effect of combinatorial therapies simultaneously targeting the EGFR and the RAS/RAF/MAPK signaling pathways in CRC cells. Our results suggest that constitutive oncogenic activation of the RAS/RAF signaling pathway significantly impairs the therapeutic potential of mAbs (such as cetuximab) aimed at targeting the EGFR in CRCs. It is therefore tempting to speculate that the concomitant blockade of both the EGFR and the RAS signaling could be effective in inhibiting the proliferation of cancer cells. Several inhibitors targeting the RAS signaling pathway have been developed (19, 20). Among them, the MAPK/extracellular signal-regulated kinase kinase inhibitors, such as PD0325901 and ARRY-142886, have shown good preclinical activity (20, 21) and have entered recently clinical trials. To assess whether concomitant inhibition of the EGFR and of the RAS signaling pathway could be effective, we took advantage of PD98059, a powerful cell-permeable inhibitor of MAPKs that acts as downstream effector of RAS (22). For these experiments, we selected CRC cell lines that have been found previously to carry either WT (HT29 and HCT8) or mutated (HCT116 and DLD-1) K-RAS. To confirm that HCT116 and DLD-1 cells indeed harbor mutated K-RAS alleles, we extracted the corresponding genomic DNA and sequenced the K-RAS locus. We confirmed that HCT116 and DLD-1 display the same Gly13Asp K-RAS mutation (data not shown). The cell lines were treated with increasing concentration of cetuximab and PD98059 and their viability was measured (Fig. 3 ). These experiments indicate that, in cancer cells harboring oncogenic K-RAS, the simultaneous inhibition of both the EGFR and the RAS downstream signaling effectors can be more effective than targeting either pathway alone.
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| Discussion |
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In the present study, we report that the presence of mutations (most of which are thought to be gain of function) in K-RAS and BRAF are associated with the lack of response to anti-EGFR mAb treatment in mCRCs patients. It has been reported previously that the Gly12Val K-RAS mutation is associated with increased risk of relapse in CRC (23). This implies that the negative association we found with the occurrence of K-RAS/BRAF mutations may not only be due to resistance or lack of response to anti-EGFR mAbs. However, the cellular models in which we inserted the Gly12Val mutation indicate that the presence of an active K-RAS allele directly affects the responsiveness of CRC cells to anti-EGFR mAb, such as cetuximab.
Our results have several implications. The first is that most patients with CRC carrying mutated K-RAS or BRAF are not likely to experience significant benefit on either cetuximab or panitumumab treatment. However, the same patients should not be excluded from anti-EGFR mAbs treatment as we found that there are few mCRCs, in which the presence of K-RAS mutations is compatible with a clinical response to this therapeutic regimen. The molecular determinants of response in this subset of patients are presently unknown, and this observation therefore warrants further investigations. The second suggestion stemming from our present work is that clinical trials designed to test multitherapies with both anti-EGFR and anti-MAPK inhibitors should be considered for mCRC patients.
| Acknowledgments |
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Grant support: Italian Association for Cancer Research (AIRC; A. Bardelli and S. Siena), Italian Ministry of Health (A. Bardelli), Regione Piemonte (A. Bardelli), Italian Ministry of University and Research (A. Bardelli), Association for International Cancer Research UK (A. Bardelli), European Union FP6, MCSCs contract 037297 (A. Bardelli), and Oncologia Ca' Granda ONLUS (S. Siena). S. Benvenuti is supported by an AIRC fellowship.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
We thank Dr. Michele Nichelatti (Service of Clinical Epidemiology and Biostatistics, Oncology and Hematology Department, Ospedale Niguarda Ca' Granda) for criticisms and statistical analysis.
| Footnotes |
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Received 11/ 9/06. Revised 1/17/07. Accepted 1/18/07.
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A. Lievre, J.-B. Bachet, V. Boige, A. Cayre, D. Le Corre, E. Buc, M. Ychou, O. Bouche, B. Landi, C. Louvet, et al. KRAS Mutations As an Independent Prognostic Factor in Patients With Advanced Colorectal Cancer Treated With Cetuximab J. Clin. Oncol., January 20, 2008; 26(3): 374 - 379. [Abstract] [Full Text] [PDF] |
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D. J. Chen and C. S. Nirodi The Epidermal Growth Factor Receptor: A Role in Repair of Radiation-Induced DNA Damage Clin. Cancer Res., November 15, 2007; 13(22): 6555 - 6560. [Abstract] [Full Text] [PDF] |
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A. Sartore-Bianchi, M. Moroni, S. Veronese, C. Carnaghi, E. Bajetta, G. Luppi, A. Sobrero, C. Barone, S. Cascinu, G. Colucci, et al. Epidermal Growth Factor Receptor Gene Copy Number and Clinical Outcome of Metastatic Colorectal Cancer Treated With Panitumumab J. Clin. Oncol., August 1, 2007; 25(22): 3238 - 3245. [Abstract] [Full Text] [PDF] |
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