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Supporting information include 3 tables and 3 figures. Table 1 describes the Patients characteristics from which primary cell lines were established. Table 2 the characteristics of ovarian tumor samples from which RNA was extracted. Table 3 the characterization of particle formulations Supplementary figure 1 shows the DNA release in vitro in culture medium. The Supplementary figure 2 the ovarian tumors' uptake of c-CPE-NP in vivo. The Supplementary figure 3 shows the survival curves of the tumor bearing mice treated with vehicle, c-CPE-NP encapsulating the empty plasmid or the p16 DTA c-CPE-NP.

Exposure of all nine cell lines to scalar concentrations of ADC for a total of 6 days. IC50 dose response curves of SYD985, T-DM1 and ADC isotype control in all 9 primary USC cell lines with differential HER2 expression tested in vitro (i.e., three with HER2 3+ expression, two with HER2 2+ expression and four with HER2 1+ expression) at 6 days (ie, 144 hrs).

Uterine serous carcinoma (USC) is an aggressive form of endometrial cancer. Up to 35% of USC may overexpress the HER2/neu oncogene at strong (i.e., 3+) levels by IHC while an additional 40% to 50% express HER2/neu at moderate (2+) or low (1+) levels. We investigated the efficacy of SYD985, (Synthon Biopharmaceuticals), a novel HER2-targeting antibody–drug conjugate (ADC) composed of the mAb trastuzumab linked to a highly potent DNA-alkylating agent (i.e., duocarmycin) in USC. We also compared the antitumor activity of SYD985 in head-to-head experiments to trastuzumab emtansine (T-DM1), a FDA-approved ADC, against multiple primary USC cell lines expressing different levels of HER2/neu in in vitro and in vivo experiments. Using antibody-dependent cellular cytotoxicity (ADCC), proliferation, viability, and bystander killing assays as well as propidium iodide–based flow cytometry assays and multiple in vivo USC mouse xenograft models, we demonstrate for the first time that SYD985 is a novel ADC with activity against USC with strong (3+) as well as low to moderate (i.e., 1+/2+) HER2/neu expression. SYD985 is 10- to 70-fold more potent than T-DM1 in comparative experiments and, unlike T-DM1, it is active against USC demonstrating moderate/low or heterogeneous HER2/neu expression. Clinical studies with SYD985 in patients harboring chemotherapy-resistant USC with low, moderate, and high HER2 expression are warranted. Mol Cancer Ther; 15(8); 1900–9. ©2016 AACR.

Graph showing IC50 values for USPC-ARK-1 cell line after 72 hrs exposure to increasing concentration of neratinib.

Cathepsin B expression. Expression of CTSB vs GAPDH in the primary USC cell lines used for in in vitro validation experiments.

Cell proliferation assay of USPC-ARK-1 cells exposed for 2 weeks as described in the method section to taselisib (A, upper panel) or neratinib (B, lower panel) and treated thereafter with neratinib, taselisib and the combination of both agents at the indicated concentration for 72 hrs. Cell viability was analyzed by flow cytometry and was normalized to the mean of the control group receiving no drug, so that all data were expressed as a proportion of the control. Data are expressed as mean {plus minus} SEM from two independent experiments. As shown in the upper panel, taselisib-resistant USPC-ARK-1 cells while resistant to the PI3K inihibitor remain sensitive to single agent neratinib and highly responsive to the drug combination. In contrast, as shown in the lower panel, in vitro-neratinib-resistant cells demonstrate resistance to both single agent neratinib and taselisib but remain highly sensitive to the exposure to the drug combination.

HER2/neu gene amplification and PIK3CA driver mutations are common in uterine serous carcinoma (USC) and may represent ideal therapeutic targets against this aggressive variant of endometrial cancer. We examined the sensitivity to neratinib, taselisib, and the combination of the two compounds in in vitro and in vivo experiments using PIK3CA-mutated and PIK3CA wild-type HER2/neu–amplified USC cell lines. Cell viability and cell-cycle distribution were assessed using flow-cytometry assays. Downstream signaling was assessed by immunoblotting. Preclinical efficacy of single versus dual inhibition was evaluated in vivo using two USC xenografts. We found both single-agent neratinib and taselisib to be active but only transiently effective in controlling the in vivo growth of USC xenografts harboring HER2/neu gene amplification with or without oncogenic PIK3CA mutations. In contrast, the combination of the two inhibitors caused a stronger and long-lasting growth inhibition in both USC xenografts when compared with single-agent therapy. Combined targeting of HER2 and PIK3CA was associated with a significant and dose-dependent increase in the percentage of cells in the G0–G1 phase of the cell cycle and a dose-dependent decline in the phosphorylation of S6. Importantly, dual inhibition therapy initiated after tumor progression in single-agent–treated mice was still remarkably effective at inducing tumor regression in both large PIK3CA and pan-ErbB inhibitor–resistant USC xenografts. Dual HER2/PIK3CA blockade may represent a novel therapeutic option for USC patients harboring tumors with HER2/neu gene amplification and mutated or wild-type PIK3CA resistant to chemotherapy. Mol Cancer Ther; 14(11); 2519–26. ©2015 AACR.

Variation in body weight of the mice treated with neratinib (40 mg\kg), taselisib (10 mg\kg) and the combination of the two inhibitors. The arrows denote the time point in which we started the combination treatment in single agent resistant mice (after 31 days and after 38 days for taselisib and neratinib group respectively for USPC-ARK-1 and after 25 days and after 45 days for USPC-ARK-2)

Exposure of all nine cell lines to scalar concentrations of ADC for a total of 3 days. IC50 dose response curves of SYD985, T-DM1 and ADC isotype control in all 9 primary USC cell lines with differential HER2 expression tested in vitro (i.e., three with HER2 3+ expression, two with HER2 2+ expression and four with HER2 1+ expression) at 3 days.

Effect on pS6 in uterine serous carcinoma cells lines after exposure to neratinib, taselisib and the combination of both at the indicated concentration in a representative FISH+\PIK3CA mutated USC cell line (USPC-ARK-1) and in a representative FISH+\PIK3CA wild type USC cell line (USPC-ARK-2). A: Graph showing a statistically significant difference in the reduction of the mean fluorescence intensity (MFI) of pS6 in PIK3CA mutated/FISH+ cell line (USPC-ARK-1) after 24 hrs of treatment with taselisib, neratinib and the combination of both (*P=0.03, **P=0.03, ***P=0.0001). B: Graph showing a statistically significant difference in the reduction of the mean fluorescence intensity (MFI) of pS6 in PIK3CA wild type/FISH+ cell line (USPC-ARK-2) after 24 hrs of treatment with taselisib, neratinib and the combination of both (*P=0.01, **P=0.002).

Uterine serous carcinoma (USC) is an aggressive form of endometrial cancer. Up to 35% of USC may overexpress the HER2/neu oncogene at strong (i.e., 3+) levels by IHC while an additional 40% to 50% express HER2/neu at moderate (2+) or low (1+) levels. We investigated the efficacy of SYD985, (Synthon Biopharmaceuticals), a novel HER2-targeting antibody–drug conjugate (ADC) composed of the mAb trastuzumab linked to a highly potent DNA-alkylating agent (i.e., duocarmycin) in USC. We also compared the antitumor activity of SYD985 in head-to-head experiments to trastuzumab emtansine (T-DM1), a FDA-approved ADC, against multiple primary USC cell lines expressing different levels of HER2/neu in in vitro and in vivo experiments. Using antibody-dependent cellular cytotoxicity (ADCC), proliferation, viability, and bystander killing assays as well as propidium iodide–based flow cytometry assays and multiple in vivo USC mouse xenograft models, we demonstrate for the first time that SYD985 is a novel ADC with activity against USC with strong (3+) as well as low to moderate (i.e., 1+/2+) HER2/neu expression. SYD985 is 10- to 70-fold more potent than T-DM1 in comparative experiments and, unlike T-DM1, it is active against USC demonstrating moderate/low or heterogeneous HER2/neu expression. Clinical studies with SYD985 in patients harboring chemotherapy-resistant USC with low, moderate, and high HER2 expression are warranted. Mol Cancer Ther; 15(8); 1900–9. ©2016 AACR.

Objective: Carcinosarcomas (CS) of the uterus and ovary are highly aggressive neoplasms containing both carcinomatous and sarcomatous elements. While an increasing body of evidence supports the origin of both CS elements from a common epithelial cell that undergoes sarcomatous dedifferentiation, limited information is currently available about the role of somatic mutations (SNV) and copy number variations (CNV) in these rare tumors. Accordingly, the objective of our study was to evaluate the genetic landscape of uterine and ovarian CSs by whole-exome-sequencing (WES). Methods: We analyzed the mutational landscape of 63 fresh frozen CS biopsies and 5 primary CS cell lines by WES, most of which were matched to normal DNA from the same patients. We also performed multi region WES in separate carcinoma and sarcoma areas to resolve the genetic architecture and evolutionary histories of CS. Finally, in transfection experiments we validated somatic histone 2A and 2B mutations as potential drivers of epithelial-mesenchymal transition (EMT). Results: Our results demonstrated the presence of two major genetic types of uterine CSs [i.e., uterine serous carcinoma-like (USC) profile and endometrioid carcinoma-like profile (EAC)] and provided evidence that both subtypes, as well as ovarian CS, arise from sarcomatous transformation of carcinomas. In addition to recurrent mutations in cancer genes previously identified in USC and EAC such as TP53, PIK3CA, PPP2R1A, KRAS, PTEN, CHD4/Mi2b and BCOR, we found an excess of mutations in histones H2A and H2B, as well as significant amplification of the segment of chromosome 6p harboring the histone cluster containing these genes. We also found frequent deletions comprising TP53 and MBD3, (a member with CHD4/Mi2b of the NuRD-chromatin-modification-complex), and frequent amplification of chromosome segments containing PIK3CA, CCNE1, TERT and c-MYC. Amplifications of the histone cluster and TERT were significantly more frequent in CS than their epithelial counterparts. Stable transgenic expression H2A and H2B in USC cell lines demonstrated that mutant, but not wild type H2A and H2B increased expression of markers of epithelial-mesenchymal transition (EMT), suggesting a role in sarcomatous transformation. Comparison of the phylogenetic relationships of carcinomatous and sarcomatous elements of the same tumors demonstrated separate lineages resulting in these two components. Conclusions: Our results provide new insight into the origins and development of uterine and ovarian CS and defined the genetic landscape of this type of malignant tumor. These findings also suggest new therapeutic targets for these highly aggressive neoplasms. Citation Format: Gulden Menderes, Siming Zhao, Carlton L. Schwab, Salvatore Lopez, Jonathan D. Black, Emiliano Cocco, Stefania Bellone, Dan-Arin Silasi, Elena Ratner, Masoud Azodi, Babak Litkouhi, Peter E. Schwartz, Joseph Schlossinger, Richard Lifton, Alessandro Santin. Mutational landscape of uterine and ovarian carcinosarcomas reveals new recurrently-mutated histone core genes as drivers of epithelial-mesenchymal transition. [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 135.

Introduction: Uterine serous carcinoma (USC) is an aggressive form of endometrial cancer which carries an extremely poor prognosis. Up to 35% of USC may overexpress the HER2/neu oncogene at strong (i.e., 3+) levels and and additional 45% of USC express HER2/Neu at moderate (2+) or low (1+) levels. For tumors with moderate/low HER2/neu expression, there is no sufficient targeted therapy. SYD985 (Synthon Biopharmaceuticals BV, Nijmegen, The Netherlands) is a novel HER2-targeting antibody-drug conjugate (ADC) composed of the mAb trastuzumab linked to a highly potent DNA-alkylating agent (i.e., duocarmycin). The objective of this study was to explore the anti-tumor activity of SYD985 and to compare it to trastuzumab emtansine (T-DM1) in USC in in vitro and in vivo studies. Methods: Nine primary USC cell lines were evaluated for HER2/neu surface expression by IHC and flow cytometry and gene amplification using FISH assays. The cytotoxicity of SYD985 and T-DM1 was evaluated using cell lines with differential HER2/Neu expression (i.e., 1+, 2+, and 3+). Proliferation and viability experiments were performed using propidium iodide-based, flow cytometry assays. In vivo activity of SYD985 in mouse xenograft models is ongoing. Results: SYD985 was 55 to 115 times more potent when compared to T-DM1 in primary USC cell lines with 1+ and 2+ HER2/neu expression. Specifically, in the HER2/neu 1+ the IC50's for SYD985 and T-DM1 were 0.065 μg/mL and 3.58 μg/mL, respectively (p = 0.004). In the HER2/neu 2+ cell lines the IC50's of SYD985 and T-DM1 were 0.016 μg/mL and 1.82 μg/mL, respectively (p = 0.005). In the HER2/neu 3+ cell lines a statistical trend was noted when comparing the cytotoxicity of SYD985 with T-DM1; the IC50's were 0.011 μg/mL and 0.035 μg/mL, respectively (p = 0.06). Conclusions: SYD985 is a novel ADC endowed with remarkable activity against not only USC with strong (3+) HER2/neu overexpression but also (as previously shown for SYD985 in breast cancer) versus USC with low to moderate (i.e., 1+/2+) HER2/neu expression. SYD985 is significantly more potent than T-DM1 in comparative in vitro experiments. Currently, in vivo experiments in USC xenografts not responsive to T-DM1 are ongoing. This is a significant discovery as we do not currently have an adequate targeted therapy to HER2/neu 1+ and 2+ expressing tumors. Thus, clinical studies with SYD985 in patients with biologically aggressive endometrial cancer (e.g., USC) resistant to standard salvage chemotherapy are warranted. Citation Format: Jonathan D. Black, Salvatore Lopez, Emiliano Cocco, Stefania Bellone, Elena Bonazzoli, Carlton Schwab, Diana English, Peter Goedings, Patrick Beusker, Miranda van der Lee, Marco Timmers, Wim Dokter, Thomas Rutherfor, Peter Schwartz, Alessandro Santin. SYD985, a novel HER2-targeting antibody-drug conjugate, shows strong antitumor activity in primary USC cell lines with low (1+) and moderate (2+) HER2/Neu expression. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 2461. doi:10.1158/1538-7445.AM2015-2461

Epithelial ovarian cancer is the most lethal gynecologic malignancy. It is treated through up front surgery followed by chemotherapy or with neoadjuvant chemotherapy before surgical debulking. Achieving complete or optimal cytoreduction improves both progression free and overall survival. In the operating room, no matter the care taken, there is the potential for areas of macroscopic, microscopic and occult metastases to remain unvisualized. The development of a sensitive and specific intraoperative system for the visualization and removal or destruction of metastatic disease may improve patient outcome. Fresh ovarian cancer samples were recently analyzed by our group with genetic fingerprinting. This analysis revealed high expression of claudin-3 and -4, the epithelial receptors for Clostridium Perfringens Enterotoxin (CPE). Although the administration of the full length CPE in mice is toxic, the injection of the only carboxi-terminal fragment (c-CPE) avoids toxicity while preserving the binding to the receptors. Our previous data showed specific binding of FITC conjugated c-CPE (FITC-c-CPE) to primary ovarian cancer cell lines in vitro as well as preferential accumulation of the labeled peptide into ovarian cancer xenografts in vivo. This study evaluates the in vivo distribution of FITC-c-CPE after intraperitoneal (IP) injection of the peptide as well as the kinetics and tumor binding capacity of c-CPE conjugated to the NearInfraRed Dye CW800 (CW800-c-CPE), focusing on the ability of CW800-c-CPE to identify metastases of chemotherapy-resistant ovarian cancer overexpressing claudin-3 and -4 in vivo. We found that fluorescence uptake by the tumor starts 30 minutes after FITC-c-CPE injection with negligible staining of healthy organs. When the abdominal cavity of FITC-c-CPE injected mice was visualized using a fluorescence microscope, strong signal was detected in near microscopic metastatic nodules and in malignant tumor spheroids isolated from the ascites. Similarly, CW800-c-CPE also accumulated in tumors in vivo following IP or systemic (IV) injection. Ex vivo distribution analysis demonstrated a significantly higher mean fluorescence intensity (MFI) in tumor compared to healthy organs (MFI: mean ± STDV: 156.55 ± 23.73, 95.72 ± 18.19, 30.68 ± 5.88, 23.33 ± 4.05, 34.71 ± 12.71, 28.16 ± 6.1413.46 ± 1.35, 19.78 ± 5.43 in the tumor, kidney, liver, spleen, bowel, lungs and brain, respectively; p Citation Format: Emiliano Cocco, Sara Gasparrini, Erik M. Shapiro, Carlton Schwab, Stefania Bellone, Ileana Bortolomai, Salvatore Lopez, Natalia J. Sumi, Elena Bonazzoli, Roberta Nicoletti, Yang Deng, William M. Saltzman, Caroline J. Zeiss, Dan-Arin Silasi, Thomas J. Rutherford, Peter E. Schwartz, Alessandro D. Santin. Fluorescence imaging using Clostridium Perfringens Enterotoxin carboxi-terminal fragment (c-CPE) to target metastatic chemotherapy-resistant human ovarian cancer in xenograft mice. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4937. doi:10.1158/1538-7445.AM2014-4937

Uterine cervical cancer (UCC) is the second leading cause of cancer deaths among women worldwide and results in 275,000 deaths annually. Functional characterization of cancer-associated genetic alterations may lead to new therapeutic approaches using molecularly targeted therapies which have the potential to improve patient outcomes. Consistent with this view, whole exome sequencing studies in a variety of human tumors including cervical cancer have recently identified somatic mutations in genes that encode for the ErbB family receptors. Importantly, some of these mutations have been shown to be “drivers” and to correlate with tumor sensitivity to the exposure to ErbB tyrosine kinase inhibitors in vitro as well as in vivo. In this study we have evaluated whether genetic alterations in the c-erbB2 gene determine the sensitivity of UCC primary cell lines to Afatinib, an EGFR, HER2, and HER4 irreversible tyrosine kinase inhibitor. Ten primary UCC cell lines, (two harboring c-erbB2 gene mutations in the extracellular HER2/neu domain [i.e., the S280F and E375D mutations-ref genome hg18] and eight harboring wild type c-erbB2), established as long term cultures in vitro, were analyzed in our study. The effect of Afatinib on cell growth, cell-cycle distribution and signaling were assessed using flow cytometry and western blot analysis following incubation of primary UCC cell lines with scalar concentrations of Afatinib for 72 hours in vitro. We found that despite similar ErbB2 mRNA expression levels by qRT-PCR in the mutated versus the wild type c-erbB2 groups, IC50 values in response to Afatinib were significantly lower in the group of mutated cell lines than in the non-mutated control UCC (MEAN±SEM = 0.55±0.11 vs. 1.64±0.09 μM, P Our data suggests that Afatinib, a recently FDA approved drug, is highly effective against c-erbB2 mutated UCC in vitro and could represent a valid therapeutic option for patients harboring c-erbB2 mutated advanced/recurrent cervical cancers unresponsive to radiation and/or chemotherapy. Citation Format: Salvatore Lopez, Emiliano Cocco, Bellone Stefania, Ileana Bortolomai, Elena Bonazzoli, Roberta Nicoletti, Carlton Schwab, Diana P. English, Corrado Terranova, Roberto Angioli, Alessandro D. Santin. Afatinib, an irreversible ErbB family inhibitor, demonstrates activity against HER2 mutated cervical cancer in vitro. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4498. doi:10.1158/1538-7445.AM2014-4498