Common Co-activation of AXL and CDCP1 in EGFR-mutation-positive Non-smallcell Lung Cancer Associated With Poor Prognosis.

Epidermal growth factor receptor (EGFR)-mutation-positive non-smallcell lung cancer (NSCLC) is incurable, despite high rates of response to EGFR tyrosine kinase inhibitors (TKIs). We investigated receptor tyrosine kinases (RTKs), Src family kinases and focal adhesion kinase (FAK) as genetic modifiers of innate resistance in EGFR-mutation-positive NSCLC. We performed gene expression analysis in two cohorts (Cohort 1 and Cohort 2) of EGFR-mutation-positive NSCLC patients treated with EGFR TKI. We evaluated the efficacy of gefitinib or osimertinib with the Src/FAK/Janus kinase 2 (JAK2) inhibitor, TPX0005 in vitro and in vivo. In Cohort 1, CUB domain-containing protein-1 (CDCP1) was an independent negative prognostic factor for progression-free survival (hazard ratio of 1.79, p=0.0407) and overall survival (hazard ratio of 2.23, p=0.0192). A two-gene model based on AXL and CDCP1 expression was strongly associated with the clinical outcome to EGFR TKIs, in both cohorts of patients. Our preclinical experiments revealed that several RTKs and non-RTKs, were up-regulated at baseline or after treatment with gefitinib or osimertinib. TPX-0005 plus EGFR TKI suppressed expression and activation of RTKs and downstream signaling intermediates. Co-expression of CDCP1 and AXL is often observed in EGFR-mutation-positive tumors, limiting the efficacy of EGFR TKIs. Co-treatment with EGFR TKI and TPX-0005 warrants testing

Validation of liquid biopsy-based analysis on the NanoString nCounter platform

L'avaluació dels marcadors moleculars en teixit tumoral per predir el pronòstic del càncer i la resposta al tractament, també coneguda com a tractament personalitzat, ha transformat la pràctica clínica per a molts tipus de càncer. Es va descobrir que aquesta teràpia dirigida per genotipar, millora la supervivència del pacient i per tant s'han introduït diverses plataformes tècniques en els laboratoris clínics. No obstant això, no tots els tumors es poden biopsiar i, sovint, les quantitats de teixit són insuficients per a la caracterització del tumor. L'ARN, l'ADN i les proteïnes lliures circulants de biòpsies líquides, es poden extreure dels fluids corporals i poden reemplaçar o complementar les biòpsies de teixit. Les biòpsies líquides tenen diversos avantatges: la possibilitat de realització d’ estudis de serie o mínimament invasiva i permet analitzar l'heterogeneïtat tumoral. Malauradament, encara hi ha una gran bretxa entre la recerca bàsica i la implementació clínica de biòpsies líquides, principalment a causa de la manca de metodologies estandarditzades. A més, les plataformes tècniques que s'utilitzen actualment, no sempre són adequades per analitzar la baixa quantitat i qualitat de material del tumor derivat d'una biòpsia líquida. En conseqüència, la validació i implementació dels assajos de biomarcadors en biòpsies líquides en els laboratoris clínics, requereixen una plataforma tècnica estandarditzada que sigui sensible, ràpida, fàcil d'utilitzar, relativamente econòmica, flexible i amb poca quantitat de mostra. La plataforma nCounter es pot utilitzar per analitzar tota classe de molècules, inclosos ARN, ADN i proteïnes. La hibridació de codis de barres codificats per colors pels objectius d'interès permet una lectura directa dels nivells d'expressió de gens i proteïnes o la detecció de mutacions. El desenvolupament d'assaigs de biomarcadors en teixits, usant el nCounter, va conduir a l'aprovació per la FDA de l'assaig Prosigna™ per a ús clínic en la tipificació del càncer de mama. Els esforços anteriors també han destacat el potencial d'aquesta plataforma per analitzar molècules derivades i amplificades de biòpsies líquides, encara que es necessiten estudis de validació en l'entorn clínic. En aquesta tesi validem l'ús de la plataforma NanoString nCounter per analitzar material de biòpsies líquides i desenvolupar assajos de biomarcadors clínicament rellevants.La evaluación de los marcadores moleculares en tejido tumoral para el pronóstico del cáncer y la predicción de respuesta al tratamiento (lo que habitualmente se conoce como tratamiento personalizado) ha transformado la práctica clínica a la hora de tratar muchos tipos de cáncer. Son numerosos los trabajos que desde hace tiempo respaldan el efecto que esta terapia dirigida por genotipo tiene sobre los pacientes oncológicos mejorando la supervivencia del paciente; consecuentemente, un amplio rango de plataformas técnicas han sido implementadas en los laboratorios clínicos en los últimos años. Sin embargo, no todos los tumores se pueden biopsiar y, a menudo, las cantidades de tejido son insuficientes para la caracterización del tumor. Las biopsias líquidas, como el ARN, el ADN o las proteínas circulantes tanto libres como encapsuladas en una membrana, pueden extraerse de los fluidos corporales reemplazando o complementando de este modo las tradicionales biopsias de tejido. Las biopsias líquidas tienen varias ventajas: ofrecen la posibilidad de realizar estudios seriados, son mínimamente invasivas y permiten analizar la heterogeneidad tumoral. Desafortunadamente, todavía existe una gran brecha entre la investigación básica y la implementación clínica de las biopsias líquidas, principalmente debido a la falta de metodologías estandarizadas. Además, las plataformas técnicas que se utilizan actualmente no siempre son adecuadas para analizar la baja cantidad y calidad de material del tumor procedente de una biopsia líquida. En consecuencia, la validación e implementación de los ensayos de biomarcadores en biopsias líquidas en los laboratorios clínicos requieren una plataforma técnica estandarizada que sea sensible, rápida, fácil de usar, viable económicamente, flexible y que requiera un aporte inicial de ácidos nucleicos bajo, debido a la baja concentración que normalmente se obtiene en las biopsias líquidas. La plataforma nCounter se puede utilizar para analizar todo tipo de moléculas, incluyendo ARN, ADN y proteínas. La hibridación de diferentes códigos formados por moléculas de colores siguiendo patrones específicos con secuencias de interés permite una lectura directa de los niveles de expresión de genes y proteínas o la detección de mutaciones. El desarrollo de ensayos de biomarcadores en tejidos usando nCounter condujo a la aprobación por la administración de fármacos y alimentos de los Estados Unidos (FDA) del ensayo Prosigna ™ para su uso clínico en la tipificación del cáncer de mama. Numerosos estudios han destacado el potencial de esta plataforma para analizar moléculas derivadas y amplificadas de biopsias líquidas, aunque estudios de validación en el entorno clínico aun son necesarios. El objeto de esta tesis es la validación del uso de la plataforma NanoString nCounter para analizar material de biopsias líquidas y desarrollar ensayos de biomarcadores clínicamente relevantes.The assessment of predictive- and prognostic molecular markers in tumor tissue, also known as personalised treatment, has transformed clinical practice for many cancer types. This genotype-directed therapy was found to improve patient survival, and several technical platforms have been introduced in clinical laboratories since then. However, not all tumors can be biopsied and tissue quantities are often insufficient for tumor characterisation. Liquid biopsies, such as membrane-encapsulated- or circulating free RNA, DNA and proteins, can be derived from body fluids and can replace or complement tissue biopsies. They have several advantages, such as repeated sampling, a minimally invasive character and heterogeneous profiling. Unfortunately, there is still a big gap between basic research and clinical implementation of liquid biopsies, mainly due to the lack of standardised methodologies. In addition, currently used technical platforms are not always suitable to analyze the low quantity and quality of tumor-derived material that can be found in a liquid biopsy. In consequence, large-scale validation and clinical implementation of liquid biopsy-based biomarker assays requires a sensitive, quick, easy-to-use, relatively cheap, flexible and standardized technical platform with low input requirements. The nCounter platform can be used to analyze all types of molecules, including RNA, DNA and proteins. Binding of color coded barcodes to targets of interest allows for either a direct read-out of gene- or protein expression levels or the detection of mutations. Tissue-based biomarker assay development on nCounter led to the FDA approval of the Prosigna™ assay for clinical use in breast cancer subtyping. Previous efforts have also highlighted the potential of this platform to analyze amplified liquid biopsy-derived molecules, although validation studies in the clinical setting are needed. In this thesis we validated the use of the NanoString nCounter platform to analyze material from liquid biopsies and develop clinically relevant biomarker assays.Universitat Autònoma de Barcelona. Programa de Doctorat en Bioquímica, Biologia Molecular i Biomedicin

Validation of liquid biopsy-based analysis on the NanoString nCounter platform

L'avaluació dels marcadors moleculars en teixit tumoral per predir el pronòstic del càncer i la resposta al tractament, també coneguda com a tractament personalitzat, ha transformat la pràctica clínica per a molts tipus de càncer. Es va descobrir que aquesta teràpia dirigida per genotipar, millora la supervivència del pacient i per tant s'han introduït diverses plataformes tècniques en els laboratoris clínics. No obstant això, no tots els tumors es poden biopsiar i, sovint, les quantitats de teixit són insuficients per a la caracterització del tumor. L'ARN, l'ADN i les proteïnes lliures circulants de biòpsies líquides, es poden extreure dels fluids corporals i poden reemplaçar o complementar les biòpsies de teixit. Les biòpsies líquides tenen diversos avantatges: la possibilitat de realització d' estudis de serie o mínimament invasiva i permet analitzar l'heterogeneïtat tumoral. Malauradament, encara hi ha una gran bretxa entre la recerca bàsica i la implementació clínica de biòpsies líquides, principalment a causa de la manca de metodologies estandarditzades. A més, les plataformes tècniques que s'utilitzen actualment, no sempre són adequades per analitzar la baixa quantitat i qualitat de material del tumor derivat d'una biòpsia líquida. En conseqüència, la validació i implementació dels assajos de biomarcadors en biòpsies líquides en els laboratoris clínics, requereixen una plataforma tècnica estandarditzada que sigui sensible, ràpida, fàcil d'utilitzar, relativamente econòmica, flexible i amb poca quantitat de mostra. La plataforma nCounter es pot utilitzar per analitzar tota classe de molècules, inclosos ARN, ADN i proteïnes. La hibridació de codis de barres codificats per colors pels objectius d'interès permet una lectura directa dels nivells d'expressió de gens i proteïnes o la detecció de mutacions. El desenvolupament d'assaigs de biomarcadors en teixits, usant el nCounter, va conduir a l'aprovació per la FDA de l'assaig Prosigna™ per a ús clínic en la tipificació del càncer de mama. Els esforços anteriors també han destacat el potencial d'aquesta plataforma per analitzar molècules derivades i amplificades de biòpsies líquides, encara que es necessiten estudis de validació en l'entorn clínic. En aquesta tesi validem l'ús de la plataforma NanoString nCounter per analitzar material de biòpsies líquides i desenvolupar assajos de biomarcadors clínicament rellevants.La evaluación de los marcadores moleculares en tejido tumoral para el pronóstico del cáncer y la predicción de respuesta al tratamiento (lo que habitualmente se conoce como tratamiento personalizado) ha transformado la práctica clínica a la hora de tratar muchos tipos de cáncer. Son numerosos los trabajos que desde hace tiempo respaldan el efecto que esta terapia dirigida por genotipo tiene sobre los pacientes oncológicos mejorando la supervivencia del paciente; consecuentemente, un amplio rango de plataformas técnicas han sido implementadas en los laboratorios clínicos en los últimos años. Sin embargo, no todos los tumores se pueden biopsiar y, a menudo, las cantidades de tejido son insuficientes para la caracterización del tumor. Las biopsias líquidas, como el ARN, el ADN o las proteínas circulantes tanto libres como encapsuladas en una membrana, pueden extraerse de los fluidos corporales reemplazando o complementando de este modo las tradicionales biopsias de tejido. Las biopsias líquidas tienen varias ventajas: ofrecen la posibilidad de realizar estudios seriados, son mínimamente invasivas y permiten analizar la heterogeneidad tumoral. Desafortunadamente, todavía existe una gran brecha entre la investigación básica y la implementación clínica de las biopsias líquidas, principalmente debido a la falta de metodologías estandarizadas. Además, las plataformas técnicas que se utilizan actualmente no siempre son adecuadas para analizar la baja cantidad y calidad de material del tumor procedente de una biopsia líquida. En consecuencia, la validación e implementación de los ensayos de biomarcadores en biopsias líquidas en los laboratorios clínicos requieren una plataforma técnica estandarizada que sea sensible, rápida, fácil de usar, viable económicamente, flexible y que requiera un aporte inicial de ácidos nucleicos bajo, debido a la baja concentración que normalmente se obtiene en las biopsias líquidas. La plataforma nCounter se puede utilizar para analizar todo tipo de moléculas, incluyendo ARN, ADN y proteínas. La hibridación de diferentes códigos formados por moléculas de colores siguiendo patrones específicos con secuencias de interés permite una lectura directa de los niveles de expresión de genes y proteínas o la detección de mutaciones. El desarrollo de ensayos de biomarcadores en tejidos usando nCounter condujo a la aprobación por la administración de fármacos y alimentos de los Estados Unidos (FDA) del ensayo Prosigna ™ para su uso clínico en la tipificación del cáncer de mama. Numerosos estudios han destacado el potencial de esta plataforma para analizar moléculas derivadas y amplificadas de biopsias líquidas, aunque estudios de validación en el entorno clínico aun son necesarios. El objeto de esta tesis es la validación del uso de la plataforma NanoString nCounter para analizar material de biopsias líquidas y desarrollar ensayos de biomarcadores clínicamente relevantes.The assessment of predictive- and prognostic molecular markers in tumor tissue, also known as personalised treatment, has transformed clinical practice for many cancer types. This genotype-directed therapy was found to improve patient survival, and several technical platforms have been introduced in clinical laboratories since then. However, not all tumors can be biopsied and tissue quantities are often insufficient for tumor characterisation. Liquid biopsies, such as membrane-encapsulated- or circulating free RNA, DNA and proteins, can be derived from body fluids and can replace or complement tissue biopsies. They have several advantages, such as repeated sampling, a minimally invasive character and heterogeneous profiling. Unfortunately, there is still a big gap between basic research and clinical implementation of liquid biopsies, mainly due to the lack of standardised methodologies. In addition, currently used technical platforms are not always suitable to analyze the low quantity and quality of tumor-derived material that can be found in a liquid biopsy. In consequence, large-scale validation and clinical implementation of liquid biopsy-based biomarker assays requires a sensitive, quick, easy-to-use, relatively cheap, flexible and standardized technical platform with low input requirements. The nCounter platform can be used to analyze all types of molecules, including RNA, DNA and proteins. Binding of color coded barcodes to targets of interest allows for either a direct read-out of gene- or protein expression levels or the detection of mutations. Tissue-based biomarker assay development on nCounter led to the FDA approval of the Prosigna™ assay for clinical use in breast cancer subtyping. Previous efforts have also highlighted the potential of this platform to analyze amplified liquid biopsy-derived molecules, although validation studies in the clinical setting are needed. In this thesis we validated the use of the NanoString nCounter platform to analyze material from liquid biopsies and develop clinically relevant biomarker assays.Universitat Autònoma de Barcelona. Programa de Doctorat en Bioquímica, Biologia Molecular i Biomedicin

PIM-1 inhibition with AZD1208 to prevent osimertinib-induced resistance in EGFR-mutation positive non-small cell lung cancer

Aim: The progression free survival of non-small cell lung cancer (NSCLC) patients has been doubled over the last years, but still single epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) lead to incomplete responses. Compensatory signaling pathways are activated upon single EGFR TKIs. We have shown that compounds, which inhibit these pathways, are synergistic with EGFR TKIs. Proviral integration site for Moloney murine leukemia virus (PIM) has been connected to cancer therapy resistance, being involved in receptor tyrosine kinase, signal transducer and activator of transcription 3 (STAT3) and interleukin-6 signaling. We hypothesized that combined PIM and EGFR inhibition may improve the upfront therapy of EGFR-mutation positive NSCLC.Methods: We reviewed the literature on PIM kinases, and performed cell viability assays, gene expression analyses, and immunoblotting experiments to reveal the mechanisms of action of the PIM inhibitor (AZD1208) alone and combined with osimertinib in five EGFR-mutation positive NSCLC cell lines.Results: Osimertinib alone induced the activation of signal transducer and activator of transcription 3 (STAT3) as well as other signaling nodes. Combined osimertinib and AZD1208 yielded moderate synergistic effects in all NSCLC cell lines investigated. Among the EGFR-mutation positive cell lines examined, the H1975 and PC9 cell lines had the highest PIM1 and STAT3 mRNA expression. The combination decreased the osimertinib-induced STAT3 phosphorylation.Conclusion: This study provides a short review on PIM kinases, and shows our results of combined PIM and EGFR inhibition in EGFR-mutation positive NSCLC cell lines. The combination was moderately synergistic but decreased STAT3 phosphorylation, an important signaling node in therapy resistance

Integrin-linked kinase (ILK) and src homology 2 domain-containing phosphatase 2 (SHP2): Novel targets in EGFR-mutation positive non-small cell lung cancer (NSCLC)Research in context

Background: The activation of multiple signaling pathways jeopardizes the clinical efficacy of EGFR tyrosine kinase inhibitors (TKIs) in EGFR-mutation positive non-small cell lung cancer (NSCLC). Integrin-linked kinase (ILK) regulates the interactions between tumor cells and extracellular environment to activate signaling pathways and promote cell proliferation, migration, and epithelial-mesenchymal transition. Src homology 2 domain-containing phosphatase 2 (SHP2) is essential for receptor tyrosine kinase signaling and mitogen-activated protein kinase (MAPK) pathway activation. Methods: We analyzed tumor ILK, β-receptor subunit glycoprotein 130 (gp130), SHP2, and stromal hepatocyte growth factor (HGF) and interleukin-6 (IL-6) mRNA expression in baseline tumor specimens of advanced EGFR-mutation positive NSCLC patients treated with EGFR TKIs. Results: ILK, when highly expressed, was an independent poor prognostic factor for the progression-free survival of the patients, both in the univariate (hazard ratio [HR for disease progression, 2.49; 95% CI, 1.37–4.52; P = .0020]) and in the multivariate (HR 3.74; 95% CI, 1.33–10.56; P = .0126) Cox regression model. Patients with high SHP2 expression had an almost 13-month shorter progression-free survival (P = .0094) and an 18-month shorter overall survival (P = .0182) in comparison to those with low SHP2 mRNA expression. Interpretation: The levels of ILK and SHP2 could be predictive for upfront combinatory therapy of EGFR TKIs plus SHP2 or ILK inhibitors. Fund: A grant from La Caixa Foundation, an Instituto de Salud Carlos III grant (RESPONSE, PIE16/00011), an Instituto de Salud Carlos III grant (PI14/01678), a Marie Skłodowska-Curie Innovative Training Networks European Grant (ELBA No 765492) and a Spanish Association Against Cancer (AECC) grant (PROYE18012ROSE). Keywords: Integrin-linked kinase, EGFR mutations, NSCLC, Src homology 2 domain-containing phosphatase 2, Signaling pathway

Association of PALB2 Messenger RNA Expression with Platinum-Docetaxel Efficacy in Advanced Non-Small Cell Lung Cancer.

Partner and localizer of BRCA2 (PALB2) is essential for homologous recombination repair. We examined mRNA levels of DNA repair genes, including partner and localizer of BRCA2 gene (PALB2), ring finger protein 8 gene (RNF8), replication timing regulatory factor 1 gene (RIF1), ATM serine/threonine kinase gene (ATM), and tumor protein p53 binding protein 1 gene (53BP1) as predictive biomarkers for cisplatin-docetaxel in the European phase III BRCA1, DNA repair associated (BRCA1)-receptor-associated protein 80 (RAP80) expression customization (BREC) phase III clinical trial (ClinicalTrials.gov identifier NCT00617656). The study was a prespecified secondary objective of the BREC trial. We assessed mRNA levels of PALB2 and four more DNA repair genes (RNF8, RIF1, ATM and 53BP1) as biomarkers in tissue from 177 patients with cisplatin-docetaxel-treated NSCLC. We examined the relationship of gene expression levels with progression-free survival, overall survival, and response. In 177 patients with NSCLC (who had a median age of 62 years and included 140 men and 91 patients with adenocarcinoma), only high PALB2 mRNA expression was predictive in the progression-free survival Cox regression analysis (hazard ratio = 0.63, 95% confidence interval: 0.42-0.83, p = 0.0080). PALB2 was also predictive of overall survival (hazard ratio = 0.68, 95% confidence interval: 0.42-0.90, p = 0.0266). Among the 158 patients evaluable for response, high PALB2 mRNA expression was predictive of response to cisplatin-docetaxel. Specifically, an objective response rate of 77% to cisplatin-docetaxel was observed for patients with high PALB2 mRNA expression compared with a rate of only 23 % for those with low PALB2 mRNA expression (p = 0.0448). High PALB2 mRNA expression identified patients with NSCLC who significantly benefited from cisplatin-docetaxel chemotherapy in the European BREC phase III clinical trial. The combination of chemotherapy with immunotherapy will become the standard of care, and a predictive marker of response to chemotherapy may accurately guide therapeutic decision making

Common Co-activation of AXL and CDCP1 in EGFR-mutation-positive Non-smallcell Lung Cancer Associated With Poor Prognosis

Epidermal growth factor receptor (EGFR)-mutation-positive non-smallcell lung cancer (NSCLC) is incurable, despite high rates of response to EGFR tyrosine kinase inhibitors (TKIs). We investigated receptor tyrosine kinases (RTKs), Src family kinases and focal adhesion kinase (FAK) as genetic modifiers of innate resistance in EGFR-mutation-positive NSCLC. We performed gene expression analysis in two cohorts (Cohort 1 and Cohort 2) of EGFR-mutation-positive NSCLC patients treated with EGFR TKI. We evaluated the efficacy of gefitinib or osimertinib with the Src/FAK/Janus kinase 2 (JAK2) inhibitor, TPX0005 in vitro and in vivo. In Cohort 1, CUB domain-containing protein-1 (CDCP1) was an independent negative prognostic factor for progression-free survival (hazard ratio of 1.79, p = 0.0407) and overall survival (hazard ratio of 2.23, p = 0.0192). A two-gene model based on AXL and CDCP1 expression was strongly associated with the clinical outcome to EGFR TKIs, in both cohorts of patients. Our preclinical experiments revealed that several RTKs and non-RTKs, were up-regulated at baseline or after treatment with gefitinib or osimertinib. TPX-0005 plus EGFR TKI suppressed expression and activation of RTKs and downstream signaling intermediates. Co-expression of CDCP1 and AXL is often observed in EGFR-mutation-positive tumors, limiting the efficacy of EGFR TKIs. Co-treatment with EGFR TKI and TPX-0005 warrants testing. Keywords: Lung cancer, EGFR, Resistance, AXL, CDCP1, Combination therapie

Common Co-activation of AXL and CDCP1 in EGFR-mutation-positive Non-smallcell Lung Cancer Associated With Poor Prognosis.

Epidermal growth factor receptor (EGFR)-mutation-positive non-smallcell lung cancer (NSCLC) is incurable, despite high rates of response to EGFR tyrosine kinase inhibitors (TKIs). We investigated receptor tyrosine kinases (RTKs), Src family kinases and focal adhesion kinase (FAK) as genetic modifiers of innate resistance in EGFR-mutation-positive NSCLC. We performed gene expression analysis in two cohorts (Cohort 1 and Cohort 2) of EGFR-mutation-positive NSCLC patients treated with EGFR TKI. We evaluated the efficacy of gefitinib or osimertinib with the Src/FAK/Janus kinase 2 (JAK2) inhibitor, TPX0005 in vitro and in vivo. In Cohort 1, CUB domain-containing protein-1 (CDCP1) was an independent negative prognostic factor for progression-free survival (hazard ratio of 1.79, p=0.0407) and overall survival (hazard ratio of 2.23, p=0.0192). A two-gene model based on AXL and CDCP1 expression was strongly associated with the clinical outcome to EGFR TKIs, in both cohorts of patients. Our preclinical experiments revealed that several RTKs and non-RTKs, were up-regulated at baseline or after treatment with gefitinib or osimertinib. TPX-0005 plus EGFR TKI suppressed expression and activation of RTKs and downstream signaling intermediates. Co-expression of CDCP1 and AXL is often observed in EGFR-mutation-positive tumors, limiting the efficacy of EGFR TKIs. Co-treatment with EGFR TKI and TPX-0005 warrants testing