Kian-Huat Lim

Oncogenically active MYD88 mutations in human lymphoma

The activated B-cell-like (ABC) subtype of diffuse large B-cell lymphoma (DLBCL) remains the least curable form of this malignancy despite recent advances in therapy. Constitutive nuclear factor (NF)-κB and JAK kinase signalling promotes malignant cell survival in these lymphomas, but the genetic basis for this signalling is incompletely understood. Here we describe the dependence of ABC DLBCLs on MYD88, an adaptor protein that mediates toll and interleukin (IL)-1 receptor signalling, and the discovery of highly recurrent oncogenic mutations affecting MYD88 in ABC DLBCL tumours. RNA interference screening revealed that MYD88 and the associated kinases IRAK1 and IRAK4 are essential for ABC DLBCL survival. High-throughput RNA resequencing uncovered MYD88 mutations in ABC DLBCL lines. Notably, 29% of ABC DLBCL tumours harboured the same amino acid substitution, L265P, in the MYD88 Toll/IL-1 receptor (TIR) domain at an evolutionarily invariant residue in its hydrophobic core. This mutation was rare or absent in other DLBCL subtypes and Burkitt’s lymphoma, but was observed in 9% of mucosa-associated lymphoid tissue lymphomas. At a lower frequency, additional mutations were observed in the MYD88 TIR domain, occurring in both the ABC and germinal centre B-cell-like (GCB) DLBCL subtypes. Survival of ABC DLBCL cells bearing the L265P mutation was sustained by the mutant but not the wild-type MYD88 isoform, demonstrating that L265P is a gain-of-function driver mutation. The L265P mutant promoted cell survival by spontaneously assembling a protein complex containing IRAK1 and IRAK4, leading to IRAK4 kinase activity, IRAK1 phosphorylation, NF-κB signalling, JAK kinase activation of STAT3, and secretion of IL-6, IL-10 and interferon-β. Hence, the MYD88 signalling pathway is integral to the pathogenesis of ABC DLBCL, supporting the development of inhibitors of IRAK4 kinase and other components of this pathway for the treatment of tumours bearing oncogenic MYD88 mutations.

Tumour maintenance is mediated by eNOS

Tumour cells become addicted to the expression of initiating oncogenes like Ras, such that loss of oncogene expression in established tumours leads to tumour regression. HRas, NRas or KRas are mutated to remain in the active GTP-bound oncogenic state in many cancers. Although Ras activates several proteins to initiate human tumour growth, only PI3K, through activation of protein kinase B (PKB; also known as AKT), must remain activated by oncogenic Ras to maintain this growth. Here we show that blocking phosphorylation of the AKT substrate, endothelial nitric oxide synthase (eNOS or NOS3), inhibits tumour initiation and maintenance. Moreover, eNOS enhances the nitrosylation and activation of endogenous wild-type Ras proteins, which are required throughout tumorigenesis. We suggest that activation of the PI3K–AKT–eNOS–(wild-type) Ras pathway by oncogenic Ras in cancer cells is required to initiate and maintain tumour growth.

Divergent roles for RalA and RalB in malignant growth of human pancreatic carcinoma cells

BACKGROUND The Ral guanine nucleotide-exchange factors (RalGEFs) serve as key effectors for Ras oncogene transformation of immortalized human cells. RalGEFs are activators of the highly related RalA and RalB small GTPases, although only the former has been found to promote Ras-mediated growth transformation of human cells. In the present study, we determined whether RalA and RalB also had divergent roles in promoting the aberrant growth of pancreatic cancers, which are characterized by the highest occurrence of Ras mutations. RESULTS We now show that inhibition of RalA but not RalB expression universally reduced the transformed and tumorigenic growth in a panel of ten genetically diverse human pancreatic cancer cell lines. Despite the apparent unimportant role of RalB in tumorigenic growth, it was nevertheless critical for invasion in seven of nine pancreatic cancer cell lines and for metastasis as assessed by tail-vein injection of three different tumorigenic cell lines tested. Moreover, both RalA and RalB were more commonly activated in pancreatic tumor tissue than other Ras effector pathways. CONCLUSIONS RalA function is critical to tumor initiation, whereas RalB function is more important for tumor metastasis in the tested cell lines and thus argues for critical, but distinct, roles of Ral proteins during the dynamic progression of Ras-driven pancreatic cancers.

The Cytoplasmic Deacetylase HDAC6 Is Required for Efficient Oncogenic Tumorigenesis

Histone deacetylase inhibitors (HDACI) are promising antitumor agents. Although transcriptional deregulation is thought to be the main mechanism underlying their therapeutic effects, the exact mechanism and targets by which HDACIs achieve their antitumor effects remain poorly understood. It is not known whether any of the HDAC members support robust tumor growth. In this report, we show that HDAC6, a cytoplasmic-localized and cytoskeleton-associated deacetylase, is required for efficient oncogenic transformation and tumor formation. We found that HDAC6 expression is induced upon oncogenic Ras transformation. Fibroblasts deficient in HDAC6 are more resistant to both oncogenic Ras and ErbB2-dependent transformation, indicating a critical role for HDAC6 in oncogene-induced transformation. Supporting this hypothesis, inactivation of HDAC6 in several cancer cell lines reduces anchorage-independent growth and the ability to form tumors in mice. The loss of anchorage-independent growth is associated with increased anoikis and defects in AKT and extracellular signal-regulated kinase activation upon loss of adhesion. Lastly, HDAC6-null mice are more resistant to chemical carcinogen-induced skin tumors. Our results provide the first experimental evidence that a specific HDAC member is required for efficient oncogenic transformation and indicate that HDAC6 is an important component underlying the antitumor effects of HDACIs.

Targeting tumour-associated macrophages with CCR2 inhibition in combination with FOLFIRINOX in patients with borderline resectable and locally advanced pancreatic cancer: a single-centre, open-label, dose-finding, non-randomised, phase 1b trial

BACKGROUND In pancreatic ductal adenocarcinoma, the CCL2-CCR2 chemokine axis is used to recruit tumour-associated macrophages for construction of an immunosuppressive tumour microenvironment. This pathway has prognostic implications in pancreatic cancer, and blockade of CCR2 restores anti-tumour immunity in preclinical models. We aimed to establish the safety, tolerability, and recommended phase 2 oral dose of the CCR2 inhibitor PF-04136309 in combination with FOLFIRINOX chemotherapy (oxaliplatin and irinotecan plus leucovorin and fluorouracil). METHODS We did this open-label, dose-finding, non-randomised, phase 1b study at one centre in the USA. We enrolled treatment-naive patients aged 18 years or older with borderline resectable or locally advanced biopsy-proven pancreatic ductal adenocarcinoma, an Eastern Cooperative Oncology Group performance status of 1 or less, measurable disease as defined by Response Evaluation Criteria in Solid Tumors version 1.1, and normal end-organ function. Patients were allocated to receive either FOLFIRINOX alone (oxaliplatin 85 mg/m(2), irinotecan 180 mg/m(2), leucovorin 400 mg/m(2), and bolus fluorouracil 400 mg/m(2), followed by 2400 mg/m(2) 46-h continuous infusion), administered every 2 weeks for a total of six treatment cycles, or in combination with oral PF-04136309, administered at a starting dose of 500 mg twice daily in a standard 3 + 3 dose de-escalation design. Both FOLFIRINOX and PF-04136309 were simultaneously initiated with a total treatment duration of 12 weeks. The primary endpoints were the safety, tolerability, and recommended phase 2 dose of PF-04136309 plus FOLFIRINOX, with an expansion phase planned at the recommended dose. We analysed the primary outcome by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01413022. RESULTS Between April 19, 2012, and Nov 12, 2014, we treated 47 patients with FOLFIRINOX alone (n=8) or with FOLFIRINOX plus PF-04136309 (n=39). One patient had a dose-limiting toxic effect in the dose de-escalation group receiving FOLFIRINOX plus PF-04136309 at 500 mg twice daily (n=6); this dose was established as the recommended phase 2 dose. We pooled patients in the expansion-phase group (n=33) with those in the dose de-escalation group that received PF-04136309 at the recommended phase 2 dose for assessment of treatment-related toxicity. Six (75%) of the eight patients receiving FOLFIRINOX alone were assessed for treatment toxicity, after exclusion of two (25%) patients due to insurance coverage issues. The median duration of follow-up for treatment toxicity was 72·0 days (IQR 49·5-89·0) in the FOLFIRINOX alone group and 77·0 days (70·0-90·5) in the FOLFIRINOX plus PF-04136309 group. No treatment-related deaths occurred. Two (5%) patients in the FOLFIRINOX plus PF-04136309 group stopped treatment earlier than planned due to treatment-related toxic effects. Grade 3 or higher adverse events reported in at least 10% of the patients receiving PF-04136309 included neutropenia (n=27), febrile neutropenia (n=7), lymphopenia (n=4), diarrhoea (n=6), and hypokalaemia (n=7). Grade 3 or higher adverse events reported in at least 10% of patients receiving FOLFIRINOX alone were neutropenia (n=6), febrile neutropenia (n=1), anaemia (n=2), lymphopenia (n=1), diarrhoea (n=2), hypoalbuminaemia (n=1), and hypokalaemia (n=3). Therapy was terminated because of treatment-related toxicity in one (17%) of the six patients receiving FOLFIRINOX alone. 16 (49%) of 33 patients receiving FOLFIRINOX plus PF-04136309 who had undergone repeat imaging achieved an objective tumour response, with local tumour control achieved in 32 (97%) patients. In the FOLFIRINOX alone group, none of the five patients with repeat imaging achieved an objective response, although four (80%) of those patients achieved stable disease. INTERPRETATION CCR2-targeted therapy with PF-04136309 in combination with FOLFIRINOX is safe and tolerable. FUNDING Washington University-Pfizer Biomedical Collaborative.

Pathogenetic Importance and Therapeutic Implications of NF-κB in Lymphoid Malignancies

Summary:  Derangement of the nuclear factor κB (NF‐κB) pathway initiates and/or sustains many types of human cancer. B‐cell malignancies are particularly affected by oncogenic mutations, translocations, and copy number alterations affecting key components the NF‐κB pathway, most likely owing to the pervasive role of this pathway in normal B cells. These genetic aberrations cause tumors to be ‘addicted’ to NF‐κB, which can be exploited therapeutically. Since each subtype of lymphoid cancer utilizes different mechanisms to activate NF‐κB, several different therapeutic strategies are needed to address this pathogenetic heterogeneity. Fortunately, a number of drugs that block signaling cascades leading to NF‐κB are in early phase clinical trials, several of which are already showing activity in lymphoid malignancies.

Aurora-A Phosphorylates, Activates, and Relocalizes the Small GTPase RalA

ABSTRACT The small GTPase Ras, which transmits extracellular signals to the cell, and the kinase Aurora-A, which promotes proper mitosis, can both be inappropriately activated in human tumors. Here, we show that Aurora-A in conjunction with oncogenic Ras enhances transformed cell growth. Furthermore, such transformation and in some cases also tumorigenesis depend upon S194 of RalA, a known Aurora-A phosphorylation site. Aurora-A promotes not only RalA activation but also translocation from the plasma membrane and activation of the effector protein RalBP1. Taken together, these data suggest that Aurora-A may converge upon oncogenic Ras signaling through RalA.

Toll-Like Receptor Signaling

Toll-like receptors (TLRs) are protective immune sentries that sense pathogen-associated molecular patterns (PAMPs) such as unmethylated double-stranded DNA (CpG), single-stranded RNA (ssRNA), lipoproteins, lipopolysaccharide (LPS), and flagellin. In innate immune myeloid cells, TLRs induce the secretion of inflammatory cytokines (Newton and Dixit 2012), thereby engaging lymphocytes to mount an adaptive, antigen-specific immune response (see Fig. 1) that ultimately eradicates the invading microbes (Kawai and Akira 2010). Figure 1. TLR signaling (simplified view). Identification of TLR innate immune function began with the discovery that Drosophila mutants in the Toll gene are highly susceptible to fungal infection (Lemaitre et al. 1996). This was soon followed by identification of a human Toll homolog, now known as TLR4 (Medzhitov et al. 1997). To date, 10 TLR family members have been identified in humans, and at least 13 are present in mice. All TLRs consist of an amino-terminal domain, characterized by multiple leucine-rich repeats, and a carboxy-terminal TIR domain that interacts with TIR-containing adaptors. Nucleic acid–sensing TLRs (TLR3, TLR7, TLR8, and TLR9) are localized within endosomal compartments, whereas the other TLRs reside at the plasma membrane (Blasius and Beutler 2010; McGettrick and O’Neill 2010). Trafficking of most TLRs from the endoplasmic reticulum (ER) to either the plasma membrane or endolysosomes is orchestrated by ER-resident proteins such as UNC93B (for TLR3, TLR7, TLR8, and TLR9) and PRAT4A (for TLR1, TLR2, TLR4, TLR7, and TLR9) (Blasius and Beutler 2010). Once in the endolysosomes, TLR3, TLR7, and TLR9 are subject to stepwise proteolytic cleavage, which is required for ligand binding and signaling (Barton and Kagan 2009). For some TLRs, ligand binding is facilitated by coreceptors, including CD14 and MD2. Following ligand engagement, the cytoplasmic TIR domains of the TLRs recruit the signaling adaptors MyD88, TIRAP, TRAM, and/or TRIF (see Fig. 2). Depending on the nature of the adaptor that is used, various kinases (IRAK4, IRAK1, IRAK2, TBK1, and IKKe) and ubiquitin ligases (TRAF6 and pellino 1) are recruited and activated, culminating in the engagement of the NF-κB, type I interferon, p38 MAP kinase (MAPK), and JNK MAPK pathways (Kawai and Akira 2010; Morrison 2012). TRAF6 is modified by K63-linked autoubiquitylation, which enables the recruitment of IκB kinase (IKK) through a ubiquitin-binding domain of the IKKγ (also known as NEMO) subunit. In addition, a ubiquitin-binding domain of TAB2 recognizes ubiquitylated TRAF6, causing activation of the associated TAK1 kinase, which then phosphorylates the IKKβ subunit. Pellino 1 can modify IRAK1 with K63-linked ubiquitin, allowing IRAK1 to recruit IKK directly. TLR4 signaling via the TRIF adaptor protein leads to K63-linked polyubiquitylation of TRAF3, thereby promoting the type I interferon response via interferon regulatory factor (IRFs) (Hacker et al. 2011). Alternatively, TLR4 signaling via MyD88 leads to the activation of TRAF6, which modifies cIAP1 or cIAP2 with K63-linked polyubiquitin (Hacker et al. 2011). The cIAPs are thereby activated to modify TRAF3 with K48-linked polyubiquitin, causing its proteasomal degradation. This allows a TRAF6–TAK1 complex to activate the p38 MAPK pathway and promote inflammatory cytokine production (Hacker et al. 2011). TLR signaling is turned off by various negative regulators: IRAK-M and MyD88 short (MyD88s), which antagonize IRAK1 activation; FADD, which antagonizes MyD88 or IRAKs; SHP1 and SHP2, which dephosphorylate IRAK1 and TBK1, respectively; and A20, which deubiquitylates TRAF6 and IKK (Flannery and Bowie 2010; Kawai and Akira 2010). Figure 2. TLR signaling. (Adapted with kind permission of Cell Signaling Technology [http://www.cellsignal.com].) Deregulation of the TLR signaling cascade causes several human diseases. Patients with inherited deficiencies of MyD88, IRAK4, UNC93B1, or TLR3 are susceptible to recurrent bacterial or viral infections (Casanova et al. 2011). Chronic TLR7 and/or TLR9 activation in autoreactive B cells, in contrast, underlies systemic autoimmune diseases (Green and Marshak-Rothstein 2011). Furthermore, oncogenic activating mutations of MyD88 occur frequently in the activated B-cell-like subtype of diffuse large B-cell lymphoma and in other B-cell malignancies (Ngo et al. 2011). Inhibitors of various TLRs or their associated kinases are currently being developed for autoimmune or inflammatory diseases and also hold promise for the treatment of B-cell malignancies with oncogenic MyD88 mutations. Many TLR7 and TLR9 agonists are currently in clinical trials as adjuvants to boost host antitumor responses in cancer patients (Hennessy et al. 2010).

Advanced pancreatic adenocarcinoma: a review of current treatment strategies and developing therapies.

Pancreatic adenocarcinoma is one of the deadliest solid malignancies. A large proportion of patients are diagnosed with locally advanced or metastatic disease at the time of presentation and, unfortunately, this severely limits the number of patients who can undergo surgical resection, which offers the only chance for cure. Recent therapeutic advances for patients with advanced pancreatic cancer have extended overall survival, but prognosis still remains grim. Given that traditional chemotherapy is ineffective in curing advanced pancreatic adenocarcinoma, current research is taking a multidirectional approach in the hopes of developing more effective treatments. This article reviews the major clinical trial data that is the basis for the current chemotherapy regimens used as first- and second-line treatments for advanced pancreatic adenocarcinoma. We also review the current ongoing clinical trials, which include the use of agents targeting the oncogenic network signaling of K-Ras, agents targeting the extracellular matrix, and immune therapies.

Neoadjuvant Therapy of Pancreatic Cancer: The Emerging Paradigm?

Pancreatic cancer remains one of the deadliest cancers due to difficulty in early diagnosis and its high resistance to chemotherapy and radiation. It is now clear that even patients with potentially resectable disease require multimodality treatment including chemotherapy and/or radiation to improve resectability and reduce recurrence. Tremendous efforts are currently being invested in refining preoperative staging to identify optimal surgical candidates, and also in developing various neoadjuvant or adjuvant regimens to improve surgical outcome. Although at present no studies have been done to directly compare the benefit of neoadjuvant versus adjuvant approaches, accumulating evidence suggests that the neoadjuvant approach is probably beneficial for a subset of the patient population, particularly those with borderline resectable disease in which complete surgical resection is almost certainly unachievable. In this article, we review the literature and rationales of neoadjuvant chemotherapy and chemoradiation, as well as their potential limitations and caveats. We also review the pathological findings following neoadjuvant therapies, and potential surgical complications that may be associated with neoadjuvant therapies.