Scott K. Kuwada

Effect of Sulindac and Erlotinib vs Placebo on Duodenal Neoplasia in Familial Adenomatous Polyposis: A Randomized Clinical Trial

IMPORTANCE Patients with familial adenomatous polyposis (FAP) are at markedly increased risk for duodenal polyps and cancer. Surgical and endoscopic management of duodenal neoplasia is difficult and chemoprevention has not been successful. OBJECTIVE To evaluate the effect of a combination of sulindac and erlotinib on duodenal adenoma regression in patients with FAP. DESIGN, SETTING, AND PARTICIPANTS Double-blind, randomized, placebo-controlled trial, enrolling 92 participants with FAP, conducted from July 2010 through June 2014 at Huntsman Cancer Institute in Salt Lake City, Utah. INTERVENTIONS Participants with FAP were randomized to sulindac (150 mg) twice daily and erlotinib (75 mg) daily (n = 46) vs placebo (n = 46) for 6 months. MAIN OUTCOMES AND MEASURES The total number and diameter of polyps in the proximal duodenum were mapped at baseline and 6 months. The primary outcome was change in total polyp burden at 6 months. Polyp burden was calculated as the sum of the diameters of polyps. The secondary outcomes were change in total duodenal polyp count, change in duodenal polyp burden or count stratified by genotype and initial polyp burden, and percentage of change from baseline in duodenal polyp burden. RESULTS Ninety-two participants (mean age, 41 years [range, 24-55]; women, 56 [61%]) were randomized when the trial was stopped by the external data and safety monitoring board because the second preplanned interim analysis met the prespecified stopping rule for superiority. Grade 1 and 2 adverse events were more common in the sulindac-erlotinib group, with an acne-like rash observed in 87% of participants receiving treatment and 20% of participants receiving placebo (P < .001). Only 2 participants experienced grade 3 adverse events. [table: see text]. CONCLUSIONS AND RELEVANCE Among participants with FAP, the use of sulindac and erlotinib compared with placebo resulted in a lower duodenal polyp burden after 6 months. Adverse events may limit the use of these medications at the doses used in this study. Further research is necessary to evaluate these preliminary findings in a larger study population with longer follow-up to determine whether the observed effects will result in improved clinical outcomes. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT 01187901.

The Atypical Histone MacroH2A1.2 Interacts with HER-2 Protein in Cancer Cells

Background: HER-2/c-erbB-2 is commonly overexpressed in cancers, but how its overexpression is achieved is not well understood. Results: HER-2 was found to interact with the atypical histone macroH2A1.2. Conclusion: HER-2 cooperates with macroH2A1.2 to drive HER-2 overexpression in cancer cells. Significance: The discovery of a novel interaction between mH2A1.2 and HER-2 reveals a unique mechanism by which oncogenes can broadly deregulate gene transcription in cancer cells. Because HER-2 has been demonstrated in the nuclei of cancer cells, we hypothesized that it might interact with transcription factors that activate ERBB2 transcription. Macrohistone 2A1 (H2AFY; mH2A1) was found to interact with HER-2 in cancer cells that overexpress HER-2. Of the two human mH2A1 isoforms, mH2A1.2, but not mH2A1.1, interacted with HER-2 in human cancer cell lines. Overexpression of mH2A1.2, but not mH2A1.1, in cancer cells significantly increased HER-2 expression and tumorigenicity. Inhibition of HER-2 kinase activity diminished mH2A1 expression and mH2A1.2-induced ERBB2 transcription in cancer cells. Chromatin immunoprecipitation of mH2A1.2 in cancer cells stably transfected with mH2A1.2 showed enrichment of mH2A1.2 at the HER-2 promoter, suggesting a role for mH2A1.2 in driving HER-2 overexpression. The evolutionarily conserved macro domain of mH2A1.2 was sufficient for the interaction between HER-2 and mH2A1.2 and for mH2A1.2-induced ERBB2 transcription. Within the macro domain of mH2A1.2, a trinucleotide insertion (-EIS-) sequence not found in mH2A1.1 was essential for the interaction between HER-2 and mH2A1.2 as well as mH2A1.2-induced HER-2 expression and cell proliferation.

Consequences of needle tract seeding of hepatocellular cancer after liver transplant

Although liver biopsy is a relatively safe procedure, needle tract seeding (NTS) of hepatocellular carcinoma (HCC) is described in up to 5% of patients after liver biopsy. The rate of NTS in patients with HCC who had liver transplantation is unknown. We performed a retrospective analysis of 759 HCC cases from August 1992 to August 2011. Demographics, ethnicities, risk factors, tumor characteristics, treatments, recurrence, and survival were collected. Patients who underwent percutaneous liver biopsy, resection, and transplant were identified. In all, 359 underwent biopsy to diagnose HCC and 42 patients underwent liver transplant. None of 171 patients who underwent radiofrequency ablation alone had seeding. None of the 11 patients who had biopsy and radiofrequency ablation performed in a single session developed NTS; however, two of 12 patients who had biopsy and radiofrequency ablation performed at separate sessions had NTS. Two patients underwent liver transplantation and subsequently developed needle tract seeding eventually died from HCC. Although the incidence of needle tract seeding was low in liver transplant patients, it can potentially change a curative therapy into a non‐curative one. Single‐session liver biopsy and radiofrequency ablation may reduce the risk of needle tract seeding of HCC.

PTEN mosaicism with features of Cowden syndrome

We present the first known case of somatic PTEN mosaicism causing features of Cowden syndrome (CS) and inheritance in the subsequent generation. A 20‐year‐old woman presented for genetics evaluation with multiple ganglioneuromas of the colon. On examination, she was found to have a thyroid goiter, macrocephaly, and tongue papules, all suggestive of CS. However, her reported family history was not suspicious for CS. A deleterious PTEN mutation was identified in blood lymphocytes, 966A>G, 967delA. Genetic testing was recommended for her parents. Her 48‐year‐old father was referred for evaluation and was found to have macrocephaly and a history of Hashimotos thyroiditis, but no other features of CS. Site‐specific genetic testing carried out on blood lymphocytes showed mosaicism for the same PTEN mutation identified in his daughter. Identifying PTEN mosaicism in the probands father had significant implications for the risk assessment/genetic testing plan for the rest of his family. His result also provides impetus for somatic mosaicism in a parent to be considered when a de novo PTEN mutation is suspected.

A rationale for mTOR inhibitors as chemoprevention agents in Peutz-Jeghers syndrome

Peutz-Jeghers patients frequently develop clinically significant complications, namely hemorrhage and bowel obstruction, from small intestinal hamartomatous polyps that frequently require surgery. In addition, many PJS patients develop epithelial malignancies in a variety of organs. The vast majority of PJS is due to germline alterations in the STK11 gene that encodes a protein that modulates PI3-kinase signaling, a key regulator of cell survival and growth. One of the major downstream mediators of PI3-kinase signaling is mTOR, the mammalian target of rapamycin. Several drugs that inhibit the PI3-kinase signal transduction pathway are in development and one, RAD001 (everolimus), an mTOR inhibitor, was recently approved for the treatment of renal cell carcinoma. Effective chemoprevention of intestinal polyps would be a first step in simplifying and improving the management of PJS patients. We present here, the rationale for the first human PJS chemoprevention trial using an mTOR inhibitor.

Pharmacologic downregulation of c‐FLIPL restores juxtacrine death receptor‐mediated apoptosis in cancer cells in a peritoneal carcinomatosis model

Metastasis occurs when circulating cancer cells implant in normal secondary tissues. Paradoxically, many cancer cells express death receptors while many normal tissues express the cognate death receptor ligands, suggesting that cancer cells possess mechanisms to inhibit death receptor signaling. Pharmacological restoration of juxtacrine‐mediated death receptor signaling could prevent cancer cells from implanting in normal tissues such as the peritoneum. The results showed that BAY 11‐7085 significantly inhibited peritoneal carcinomatosis in mice following the introduction of colon and pancreatic cancer cell lines into the intra‐abdominal cavity. Treatment with BAY 11‐7085 restored juxtacrine death receptor signaling during the adhesion of the cancer cells to mesothelial cells, which line the peritoneum. BAY 11‐7085 rapidly inhibited c‐FLIPL expression in colon and pancreatic cancer cell lines during adhesion to mesothelial cells. Pancreatic cancer cells sorted for high c‐FLIPL expression formed peritoneal implants much more readily than cells with low c‐FLIPL expression, and RNAi inhibition of c‐FLIPL in colon cancer cells dramatically reduced peritoneal implantation. This is a novel demonstration that the restoration of death receptor‐mediated apoptotic signaling in cancer cells through the pharmacological inhibition of c‐FLIPL can inhibit tumor implantation in a clinically relevant model of peritoneal carcinomatosis, a fatal disease. Pharmacological inhibitors of FLIP hold promise as a way to curtail cancer cell colonization of secondary tissues.

Synthesis and biological evaluation of sulfonyl acrylonitriles as novel inhibitors to peritoneal carcinomatosis

The vast majority of cancer patients die from metastasis, the process by which cancer cells spread to secondary tissues through body fluids. Peritoneal carcinomatosis is a type of metastasis in which cancer cells gain access to the intra-abdominal cavity and then implant in the peritoneum, the thin tissue that lines the abdominal wall and internal organs. Unfortunately, peritoneal carcinomatosis can occur following surgical resection of intra-abdominal malignancies. We previously reported proapoptotic activity of (2E)-3-[[4-(1,1-dimethylethyl)phenyl]sulfonyl]-2-propenenitrile (BAY 11-7085, 1) on colon and pancreatic cancer cells during adhesion and demonstrated that this compound could significantly inhibit peritoneal carcinomatosis in mice.(1,2) In order to determine the chemical basis of the anti-metastatic properties of BAY 11-7085, a series of analogs were synthesized and evaluated for their ability to induce apoptosis in pancreatic and ovarian cancer cells during adhesion to mesothelial cells, which line the surface of the peritoneum. The co-culture assay results were validated using a murine peritoneal carcinomatosis model. These analogs may greatly benefit patients undergoing surgical resections of colorectal, pancreatic, and ovarian cancers depending on their tolerability.

Regulation of sonic hedgehog expression by integrin β1 and epidermal growth factor receptor in intestinal epithelium

We previously found that conditional deletion of integrin β1 in intestinal epithelium of mice caused early postnatal lethality and intestinal phenotypic changes including excessive proliferation and defective differentiation of intestinal epithelium due to loss of Hedgehog expression. Here, we link these defects to the Hedgehog (Hh) signaling pathway and show that loss of integrin β1 leads to excessive phosphorylation of MEK‐1 and increased expression of ErbB receptors, including the epidermal growth factor receptor (EGFR). We show that increased EGFR signaling attenuates Hh abundance and that an EGFR inhibitor rescues conditional β1 integrin null pups from postnatal lethality. These studies link the loss of Hh expression in the intestinal epithelium of integrin β1‐deficient mice to excessive EGFR/MAPK signaling, and identify a unique mechanism for crosstalk between stromal and epithelial signaling pathways that is critical for intestinal epithelial differentiation and function.

Association of Sulindac and Erlotinib vs Placebo With Colorectal Neoplasia in Familial Adenomatous Polyposis: Secondary Analysis of a Randomized Clinical Trial

Importance Patients with familial adenomatous polyposis (FAP) are at markedly increased risk for colorectal polyps and cancer. A combination of sulindac and erlotinib led to a 71% reduction in duodenal polyp burden in a phase 2 trial. Objective To evaluate effect of sulindac and erlotinib on colorectal adenoma regression in patients with FAP. Design, Setting, and Participants Prespecified secondary analysis for colorectal adenoma regression was carried out using data from a double-blind, randomized, placebo-controlled trial, enrolling 92 patients with FAP, conducted from July 2010 to June 2014 in Salt Lake City, Utah. Interventions Patients were randomized to sulindac, 150 mg twice daily, and erlotinib, 75 mg daily (n = 46), vs placebo (n = 46) for 6 months. Main Outcomes and Measurements The total number of polyps in the intact colorectum, ileal pouch anal anastomosis, or ileo-rectum were recorded at baseline and 6 months. The primary outcomes were change in total colorectal polyp count and percentage change in colorectal polyps, following 6 months of treatment. Results Eighty-two randomized patients (mean [SD] age, 40 [13] years; 49 [60%] women) had colorectal polyp count data available for this secondary analysis: 22 with intact colon, 44 with ileal pouch anal anastomosis and 16 with ileo-rectal anastomosis; 41 patients received sulindac/erlotinib and 41 placebo. The total colorectal polyp count was significantly different between the placebo and sulindac-erlotinib group at 6 months in patients with net percentage change of 69.4% in those with an intact colorectum compared with placebo (95% CI, 28.8%-109.2%; P = .009). Conclusion and Relevance In this double-blind, placebo-controlled, randomized trial we showed that combination treatment with sulindac and erlotinib compared with placebo resulted in significantly lower colorectal polyp burden after 6 months of treatment. There was a reduction in polyp burden in both those with an entire colorectum and those with only a rectal pouch or rectum. Trial Registration clinicaltrials.gov Identifier: NCT01187901

Abstract LB-074: Regression of duodenal neoplasia in familial adenomatous polyposis patients using COX and EGFR inhibition: A randomized placebo-controlled trial

The objective of this trial was to test the effect of a combination of COX and EGFR inhibition on duodenal adenoma progression in patients with familial adenomatous polyposis (FAP). FAP is caused by mutations in the APC gene and is characterized by the development of hundreds of colorectal adenomas and colorectal cancer. FAP patients are also at increased risk for duodenal neoplasia with a ∼10% lifetime risk of duodenal carcinoma. Surgical and endoscopic management of duodenal neoplasia is difficult and chemoprevention has not been successful. Preclinical data has illustrated that a combination of cyclooxygenase (COX) and epidermal growth factor (EGFR) inhibition diminishes small intestinal adenoma development by 87% in mice with germline Apc mutations. Therefore, we conducted a double blind, randomized, placebo-controlled trial in which FAP patients received combination therapy with 150 mg sulindac twice per day and 75 mg erlotinib daily or placebo for 6 months (NCT01187901). The total number and diameter of polyps in a 10cm segment of the proximal duodenum were mapped at baseline and 6 months. The primary outcome was change in total polyp burden, calculated as the sum of the diameters of polyps. We also evaluated RNA expression in duodenal tissue and polyps at endpoint from 10 patients on drug and 10 patients on placebo by RNA sequencing. Seventy-three randomized patients were included in the intention to treat analysis. Over six months, the median change in total duodenal polyp burden was an increase of 8.0 mm from baseline burden in the placebo group (23.0 to 31.0 mm) and the median change in the sulindac-erlotinib group was a decrease of 8.5 mm (29.0 to 19.5 mm). The estimated net difference in change between the two groups was -19.0 mm (95% CI: -32.0, -10.9; P Part of this abstract was presented as part of a preliminary presentation. Citation Format: Deborah W. Neklason, Don A. Delker, Kenneth M. Boucher, Priyanka Kanth, Kathryn Byrne, Philip Bernard, Wade Samowitz, Michelle W. Done, Therese Berry, Lisa Pappas, Laurel Smith, Danielle Sample, Rian Davis, Matthew K. Topham, Randall W. Burt, Scott K. Kuwada, N Jewel Samadder. Regression of duodenal neoplasia in familial adenomatous polyposis patients using COX and EGFR inhibition: A randomized placebo-controlled trial. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr LB-074.