Frank Stenner

Fibroblast activation protein is expressed by rheumatoid myofibroblast-like synoviocytes

Fibroblast activation protein (FAP), as described so far, is a type II cell surface serine protease expressed by fibroblastic cells in areas of active tissue remodelling such as tumour stroma or healing wounds. We investigated the expression of FAP by fibroblast-like synoviocytes (FLSs) and compared the synovial expression pattern in rheumatoid arthritis (RA) and osteoarthritis (OA) patients. Synovial tissue from diseased joints of 20 patients, 10 patients with refractory RA and 10 patients with end-stage OA, was collected during routine surgery. As a result, FLSs from intensively inflamed synovial tissues of refractory RA expressed FAP at high density. Moreover, FAP expression was co-localised with matrix metalloproteinases (MMP-1 and MMP-13) and CD44 splice variants v3 and v7/8 known to play a major role in the concert of extracellular matrix degradation. The pattern of signals appeared to constitute a characteristic feature of FLSs involved in rheumatoid arthritic joint-destructive processes. These FAP-expressing FLSs with a phenotype of smooth muscle actin-positive myofibroblasts were located in the lining layer of the synovium and differ distinctly from Thy-1-expressing and non-proliferating fibroblasts of the articular matrix. The intensity of FAP-specific staining in synovial tissue from patients with RA was found to be different when compared with end-stage OA. Because expression of FAP by RA FLSs has not been described before, the findings of this study highlight a novel element in cartilage and bone destruction of arthritic joints. Moreover, the specific expression pattern qualifies FAP as a therapeutic target for inhibiting the destructive potential of fibroblast-like synovial cells.

Golgi phosphoprotein 2 (GOLPH2) expression in liver tumors and its value as a serum marker in hepatocellular carcinomas.

Hepatocellular carcinomas (HCCs) and bile duct carcinomas (BDCs) have a poor prognosis. Therefore, surveillance strategies including sensitive and specific serum markers for early detection are needed. Recently, Golgi Phosphoprotein 2 (GOLPH2) has been proposed as a serum marker for HCC, but GOLPH2 expression data in liver tissues was not available. Using tissue microarrays and immunohistochemistry, we semiquantitatively analyzed GOLPH2 protein expression in patients with HCC (n = 170), benign liver tumors (n = 22), BDC (n = 114) and normal liver tissue (n = 105). A newly designed sandwich enzyme‐linked immunoassay (ELISA) was used to analyze GOLPH2 levels in the sera of patients with HCC (n = 62), hepatitis C virus (HCV) (n = 29), BDC (n = 10), and healthy control persons (n = 12). By immunohistochemistry 121/170 (71%) of HCC showed strong GOLPH2 expression, which was significantly associated with a higher tumor grade (P = 0.01). A total of 97/114 (85%) BDCs showed a strong GOLPH2 expression which proved to be an independent prognostic factor for overall survival (P < 0.05). Serum levels of GOLPH2 measured by ELISA were significantly elevated in patients with HCC with underlying HCV infection (median 18 mg/L, P < 0.05) and patients with BDC (median = 14.5 mg/L, P < 0.01) in comparison to healthy controls (median 4 mg/L). Conclusion: GOLPH2 protein is highly expressed in tissues of HCC and BDC. GOLPH2 protein levels are detectable and quantifiable in sera by ELISA. In patients with hepatitis C, serial ELISA measurements in the course of the disease appear to be a promising complementary serum marker in the surveillance of HCC. GOLPH2 should be further evaluated as a serum tumor marker in BDC on a larger scale. (HEPATOLOGY 2009.)

Phase 2 Trial of Single-agent Everolimus in Chemotherapy-naive Patients with Castration-resistant Prostate Cancer (SAKK 08/08)

BACKGROUND The phosphatase and tensin homolog (PTEN) tumor suppressor gene is deregulated in many advanced prostate cancers, leading to activation of the phosphatidylinositol 3-kinase (PI3K)-Akt-mammalian target of rapamycin (mTOR) pathway and thus increased cell survival. OBJECTIVE To evaluate everolimus, an inhibitor of mTOR, in patients with metastatic castration-resistant prostate cancer (mCRPC), and to explore potentially predictive serum biomarkers by proteomics, the significance of PTEN status in tumor tissue, and the impact of everolimus on immune cell subpopulations and function. DESIGN, SETTING, AND PARTICIPANTS A total of 37 chemotherapy-naive patients with mCRPC and progressive disease were recruited to this single-arm phase 2 trial (ClinicalTrials.gov identifier NCT00976755). INTERVENTION Everolimus was administered continuously at a dose of 10mg daily. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The primary end point was progression-free survival (PFS) at 12 wk defined as the absence of prostate-specific antigen (PSA), radiographic progression, or clinical progression. Groups were compared using Wilcoxon rank-sum tests or Fisher exact tests for continuous and discrete variables, respectively. Time-to-event end points were analyzed using the Kaplan-Meier method and univariate Cox regression. RESULTS AND LIMITATIONS A total of 13 patients (35%; 95% confidence interval, 20-53) met the primary end point. Confirmed PSA response ≥50% was seen in two (5%), and four further patients (11%) had a PSA decline ≥30%. Higher serum levels of carboxypeptidase M and apolipoprotein B were predictive for reaching the primary end point. Deletion of PTEN was associated with longer PFS and response. Treatment was associated with a dose-dependent decrease of CD3, CD4, and CD8 T lymphocytes and CD8 proliferation and an increase in regulatory T cells. Small sample size was the major limitation of the study. CONCLUSIONS Everolimus activity in unselected patients with mCRPC is moderate, but PTEN deletion could be predictive for response. Several serum glycoproteins were able to predict PFS at 12 wk. Prospective validation of these potential biomarkers is warranted. TRIAL REGISTRATION This study is registered with ClinicalTrials.gov with the identifier NCT00976755. Results of this study were presented in part at the 47th Annual Meeting of the American Society of Clinical Oncology (June 3-7, 2011; Chicago, IL, USA) and the annual meeting of the German, Austrian, and Swiss Societies for Oncology and Hematology (September 30-October 4, 2011; Basel, Switzerland).

Quantitative computed tomography liver perfusion imaging using dynamic spiral scanning with variable pitch: feasibility and initial results in patients with cancer metastases.

Purpose:To assess the feasibility and image quality of computed tomography (CT) liver perfusion imaging using an adaptive 4D spiral-mode, developed to extend the z-axis coverage, and to report initial qualitative and quantitative results in patients with cancer metastases. Materials and Methods:A total of 21 patients with liver metastases of various origins underwent CT perfusion imaging (100 kV and 150 mAs/rot) using a 4D spiral-mode with single-source 64-slice CT (n = 7) with a scan range of 6.7cm (protocol A: 16 cycles, 46.5 seconds examination time), or dual-source 128-slice CT with a scan range of 14.8 cm (protocol B: 16 cycles, 46.5 seconds examination time, n = 7; protocol C: 12 cycles, 51.0 seconds examination time, n = 7). Ability to suspend respiration during perfusion imaging was monitored. Two independent readers assessed image quality on a 4-point scale, both before and after motion correction, and performed a qualitative (ie, arterial enhancement pattern and enhancement change over time) and quantitative perfusion (ie, arterial liver perfusion [ALP]; portal-venous perfusion [PVP]; hepatic perfusion index [HPI]) analysis. Results:Of 21 patients, 7 (33%) could suspend respiration throughout the perfusion study and 14 (67%) resumed shallow breathing during the perfusion scan. The 21 patients had a total of 88 metastases. The scan range of protocol A covered at least 1 metastasis in all patients (total 20/34 [58.8%] metastases). The scan range of protocol B and C covered 53 of 54 (98.1%) metastases, whereas one metastasis in segment VIII was only partially imaged. Image quality was diagnostic both before and after motion correction, whereas being significantly better after motion correction (P < 0.001). Qualitative perfusion analysis of 67 metastases revealed diffuse arterial enhancement in 3 (4.5%), sparse enhancement in 11 (16.4%), peripheral-nodular enhancement in 9 (13.4%), rim-like enhancement in 15 (22.4%), and none in 29 (43.3%) metastases. Enhancement over time of 67 metastases showed a centripetal progression in 6 (8.9%), sustained portal phase in 16 (23.9%), wash-out in 16 (23.9%), and none in 29 (43.3%) metastases. Quantitative perfusion analysis revealed significantly higher arterial liver perfusion and HPI in metastases and metastasis borders than in adjacent normal liver tissue (P < 0.001 each). Portal-venous perfusion was significantly lower in metastases and metastasis borders than in normal liver tissue (P < 0.001). There were no significant differences in image quality and qualitative perfusion analysis between the 3 protocols (P = n.s.). Calculated effective radiation doses were 13.4 mSv for protocol A, 30.7 mSv for protocol B, and 23.0 mSv for protocol C. Conclusion:CT perfusion imaging of the liver using the 4D spiral-mode is feasible with diagnostic image quality, and enables the reliable qualitative and quantitative analysis of the normal and metastatic liver parenchyma. Radiation dose issues must be considered when determining the scan range, number of cycles, and scan duration of the perfusion CT protocol.

Quantitative perfusion analysis of malignant liver tumors: dynamic computed tomography and contrast-enhanced ultrasound.

Objective:To prospectively analyze the correlation between quantitative parameters of perfusion derived from dynamic contrast-enhanced CT (DCE-CT) and contrast-enhanced ultrasound (DCE-US) in patients with malignant liver tumors. Materials and Methods:Thirty patients (mean age: 59.4 ± 12.3 years) with primary malignant liver tumors or hepatic metastases of various origin underwent DCE-CT (4D spiral mode, scan range, 14.8 cm; 15 scans; cycle time, 3 seconds) and DCE-US (low mechanical index, <0.1, 2.4 mL microbubbles). DCE-CT and DCE-US images were evaluated by 2 radiologists regarding quantitative perfusion parameters including arterial liver perfusion (ALP), portal-venous perfusion (PVP), and total perfusion (P = ALP + PVP) from DCE-CT, as well as blood inflow velocity (B) and the normalized slope within the calculation range (CVan) from DCE-US. Results:Quantitative assessment was possible with DCE-CT in 12/30 (40%) patients before and in all patients after automated motion correction. With DCE-US, quantitative assessment could not be performed in 9/30 (30.0%) patients due to respiratory motion. Interreader agreements for quantitative perfusion analysis were good with DCE-CT (r = 0.640–0.892, each P < 0.001) and DCE-US (r = 0.761–0.909, each P < 0.001). Moderate significant correlations were found between the perfusion parameters from DCE-CT (P, ALP) and DCE-US (B, CVan) (r = 0.446–0.621, each P < 0.05). No significant correlations were found between PVP from CT and perfusion parameters from DCE-US (B, CVan; each P = nonsignificant). Conclusions:Quantitative evaluation of DCE-CT data was feasible in all patients after automated motion correction, whereas DCE-US data could not be quantitatively evaluated in 30% of patients due to respiratory motion and lack of motion correction software. Quantitative arterial perfusion analysis showed moderate significant correlations for blood flow parameters among modalities.

Targeted therapy of renal cell carcinoma: synergistic activity of cG250-TNF and IFNg.

Immunotherapeutic targeting of G250/Carbonic anhydrase IX (CA‐IX) represents a promising strategy for treatment of renal cell carcinoma (RCC). The well characterized human‐mouse chimeric G250 (cG250) antibody has been shown in human studies to specifically enrich in CA‐IX positive tumors and was chosen as a carrier for site specific delivery of TNF in form of our IgG‐TNF‐fusion protein (cG250‐TNF) to RCC xenografts. Genetically engineered TNF constructs were designed as CH2/CH3 truncated cG250‐TNF fusion proteins and eucariotic expression was optimized under serum‐free conditions. In‐vitro characterization of cG250‐TNF comprised biochemical analysis and bioactivity assays, alone and in combination with Interferon‐γ (IFNγ). Biodistribution data on radiolabeled [125J] cG250‐TNF and antitumor activity of cG250‐TNF, alone and in combination with IFNγ, were measured on RCC xenografts in BALB/c nu/nu mice. Combined administration of cG250‐TNF and IFNγ caused synergistic biological effects that represent key mechanisms displaying antitumor responses. Biodistribution studies demonstrated specific accumulation and retention of cG250‐TNF at CA‐IX‐positive RCC resulting in growth inhibition of RCC and improved progression free survival and overall survival. Antitumor activity induced by targeted TNF‐based constructs could be enhanced by coadministration of low doses of nontargeted IFNγ without significant increase in side effects. Administration of cG250‐TNF and IFNγ resulted in significant synergistic tumoricidal activity. Considering the poor outcome of renal cancer patients with advanced disease, cG250‐TNF‐based immunotherapeutic approaches warrant clinical evaluation.

A Pooled Analysis of Sequential Therapies with Sorafenib and Sunitinib in Metastatic Renal Cell Carcinoma

Objective: To evaluate the optimal sequence for the receptor tyrosine kinase inhibitors (rTKIs) sorafenib and sunitinib in metastatic renal cell cancer. Methods: We performed a retrospective analysis of patients who had received sequential therapy with both rTKIs and integrated these results into a pooled analysis of available data from other publications. Differences in median progression-free survival (PFS) for first- (PFS1) and second-line treatment (PFS2), and for the combined PFS (PFS1 plus PFS2) were examined using weighted linear regression. Results: In the pooled analysis encompassing 853 patients, the median combined PFS for first-line sunitinib and 2nd-line sorafenib (SuSo) was 12.1 months compared with 15.4 months for the reverse sequence (SoSu; 95% CI for difference 1.45–5.12, p = 0.0013). Regarding first-line treatment, no significant difference in PFS1 was noted regardless of which drug was initially used (0.62 months average increase on sorafenib, 95% CI for difference –1.01 to 2.26, p = 0.43). In second-line treatment, sunitinib showed a significantly longer PFS2 than sorafenib (average increase 2.66 months, 95% CI 1.02–4.3, p = 0.003). Conclusion: The SoSu sequence translates into a longer combined PFS compared to the SuSo sequence. Predominantly the superiority of sunitinib regarding PFS2 contributed to the longer combined PFS in sequential use.

Structure-Activity Profiles of Ab-Derived TNF Fusion Proteins

TNF application in humans is limited by severe side effects, including life-threatening symptoms of shock. Therefore, TNF can be successfully applied as a tumor therapeutic reagent only under conditions that prevent its systemic action. To overcome this limitation, genetic fusion of TNF to tumor-selective Abs is a favored strategy to increase site-specific cytokine targeting. Because wild-type TNF displays its bioactivity as noncovalently linked homotrimer, the challenge is to define structural requirements for a TNF-based immunokine format with optimized structure-activity profile. We compared toxicity and efficacy of a dimerized CH2/CH3 truncated IgG1-TNF fusion protein and a single-chain variable fragment-coupled TNF monomer recognizing fibroblast-activating protein. The former construct preserves its dimeric structure stabilized by the natural disulfide bond IgG1 hinge region, while the latter trimerizes under native conditions. Analysis of complex formation of wild-type TNF and of both fusion proteins with TNFR type 1 (TNF-R1) using surface plasmon resonance correlated well with in vitro and in vivo toxicity data. There is strong evidence that TNF subunits in a trimeric state display similar toxicity profiles despite genetic fusion to single-chain variable fragment domains. However, LD50 of either immunodeficient BALB/c nu/nu or immunocompetent BALB/c mice was significantly decreased following administration of TNF in the formation of IgG1-derived dimeric fusion protein. Reduction of unspecific peripheral complexation of TNF-R1 resulted in higher anticancer potency by immunotargeting of fibroblast-activating protein-expressing xenografts. The broader therapeutic window of the IgG1-derived TNF fusion protein favors the dimeric TNF-immunokine format for systemic TNF-based tumor immunotherapy.

Targeted therapeutic approach for an anaplastic thyroid cancer in vitro and in vivo

Anaplastic thyroid carcinoma (ATC) is among the most aggressive human malignancies, being responsible for the majority of thyroid cancer‐related deaths. Despite multimodal therapy including surgery, chemotherapy, and radiotherapy, the outcome of ATC is poor. The human ATC cell line MB1, derived from tumor tissue of a 57‐year‐old man with thyroid cancer and pronounced neutrophilia, was established from surgically excised tumor tissue. The karyotype of the cell line shows many chromosomal abnormalities. Preclinical investigations have shown antitumor activity and effectiveness of the BRAF kinase inhibitor Sorafenib and the proteasome inhibitor Bortezomib. After establishment of the MB1 cell line these agents were applied in vitro and, showing activity in a cell culture model, were also used for in vivo treatment. Sorafenib had some clinical effect, namely normalization of leucocytosis, but had no sustained impact on subsequent tumor growth and development of distant metastasis. Molecular diagnostics of the tumor demonstrated no BRAF mutations in exons 11 and 15 concordant with a rather modest effect of Sorafenib on MB1 cell growth. Clinical benefit was seen with subsequent bortezomib therapy inducing a temporary halt to lymph node growth and a progression‐free interval of 7 weeks. Our observations together with previous data from preclinical models could serve as a rationale for selecting those patients suffering from ATC most likely to benefit from targeted therapy. A prospective controlled randomized trial integrating kinase and proteasome inhibitors into a therapeutic regime for ATC is warranted. (Cancer Sci 2008; 99: 1847–1852)

Alpha‐fetoprotein and serum golgi phosphoprotein 2 are equally discriminative in detecting early hepatocellular carcinomas

Li et al. have analyzed golgi phosphoprotein 2 (GOLPH2) serum levels in a cohort of patients with liver cirrhosis, healthy controls, and patients with hepatocellular carcinoma (HCC). They found elevated serum levels of GOLPH2 (sGOLPH2) in early HCC cases. From their findings, the authors conclude that sGOLPH2 is a better marker than alpha-fetoprotein (AFP) for detection of early HCC. In our patients, no significant differences between controls, viral hepatitis (HBV/HCV), and HCC (independent of etiology) were found. However, HCC arising in a hepatitis C virus background had significantly higher GOLPH2 serum levels than healthy controls.1 The findings of Li, Wu, and Fan prompted us to conduct an extended analysis of our dataset. No significant difference of sGOLPH between early HCCs (T1/2 [United Network for Organ Sharing–modified Tumor-Node-Metastasis stages 1 and 2]) and late HCCs (T3/4) was seen. Li et al. had comparable levels of sGOLPH2 in healthy individuals and patients with liver cirrhosis. Although we did not compare cirrhosis with early HCCs, we too see a trend (P 0.097) of rising values when comparing controls (median 5.7 mg/L) to early HCCs (median 15.8 mg/L). With regard to the notion of Li et al. that sGOLPH2 is a superior marker of early HCC, we find AFP (cutoff 10 ng/mL) and sGOLPH2 (cutoff 10 mg/L) to be equally discriminative and recommend the complementary use of both markers to improve the detection and surveillance of HCCs. We agree that larger studies of GOLPH2 should be pursued to define the role of GOLPH2 in serum-based diagnosis and monitoring of HCC. Ideally, this should be embedded in a prospective, randomized controlled trial.