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The role of microenvironment-derived ligands in regulating EphA2 expression levels.

Supplementary Figure 1. Study flowchart

Revised supplemental figures and tables

Purpose: In an attempt to identify genes that are involved in resistance to SN38, the active metabolite of irinotecan (also known as CPT-11), we carried out DNA microarray profiling of matched HCT116 human colon cancer parental cell lines and SN38-resistant cell lines following treatment with SN38 over time.Experimental Design: Data analysis identified a list of genes that were acutely altered in the parental cells following SN38 treatment as well as constitutively altered in the SN38-resistant cells.Results: Independent validation of 20% of these genes by quantitative reverse transcription-PCR revealed a strong correlation with the microarray results: Pearson's correlation was 0.781 (r2 = 0.61, P < 0.000001) for those genes that were acutely altered in the parental setting following SN38 treatment and 0.795 (r2 = 0.63, P < 0.000002) for those genes that were constitutively altered in the SN38-resistant cells. We then assessed the ability of our in vitro-derived gene list to predict clinical response to 5-fluorouracil/irinotecan using pretreatment metastatic biopsies from responding and nonresponding colorectal cancer patients using both unsupervised and supervised approaches. When principal components analysis was used with our in vitro classifier gene list, a good separation between responding and nonresponding patients was obtained, with only one nonresponding and two responding patients separating with the incorrect groups. Supervised class prediction using support vector machines algorithm identified a 16-gene classifier with 75% overall accuracy, 81.8% sensitivity, and 66.6% specificity.Conclusions: These results suggest that in vitro-derived gene lists can be used to predict clinical response to chemotherapy in colorectal cancer.

EphA2 and overall survival in stage II and III CRC.

Supplementary table 1. Main characteristics of patients receiving different dose levels

Role of p53, Src family kinases and RAS/MAPK pathway in regulating EphA2 expression levels.

Supplementary Data from Clinical Determinants of Response to Irinotecan-Based Therapy Derived from Cell Line Models

Purpose: A phase I study to define toxicity and recommend a phase II dose of the HSP90 inhibitor alvespimycin (17-DMAG; 17-dimethylaminoethylamino-17-demethoxygeldanamycin). Secondary endpoints included evaluation of pharmacokinetic profile, tumor response, and definition of a biologically effective dose (BED).Patients and Methods: Patients with advanced solid cancers were treated with weekly, intravenous (i.v.) 17-DMAG. An accelerated titration dose escalation design was used. The maximum tolerated dose (MTD) was the highest dose at which ≤1/6 patients experienced dose limiting toxicity (DLT). Dose de-escalation from the MTD was planned with mandatory, sequential tumor biopsies to determine a BED. Pharmacokinetic and pharmacodynamic assays were validated prior to patient accrual.Results: Twenty-five patients received 17-DMAG (range 2.5–106 mg/m2). At 106 mg/m2 of 17-DMAG 2/4 patients experienced DLT, including one treatment-related death. No DLT occurred at 80 mg/m2. Common adverse events were gastrointestinal, liver function changes, and ocular. Area under the curve and mean peak concentration increased proportionally with 17-DMAG doses 80 mg/m2 or less. In peripheral blood mononuclear cells significant (P < 0.05) HSP72 induction was detected (≥20 mg/m2) and sustained for 96 hours (≥40 mg/m2). Plasma HSP72 levels were greatest in the two patients who experienced DLT. At 80 mg/m2 client protein (CDK4, LCK) depletion was detected and tumor samples from 3 of 5 patients confirmed HSP90 inhibition. Clinical activity included complete response (castration refractory prostate cancer, CRPC 124 weeks), partial response (melanoma, 159 weeks), and stable disease (chondrosarcoma, CRPC, and renal cancer for 28, 59, and 76 weeks, respectively).Couclusions: The recommended phase II dose of 17-DMAG is 80 mg/m2 weekly i.v. Clin Cancer Res; 17(6); 1561–70. ©2011 AACR.

Supplementary table 1. Clinical-pathological features of the resection-only and chemotherapy/resection stage II/III colorectal cancer patient cohorts with mature survival data in the Singapore dataset. Supplementary table 2. EphA2 and clinical-pathological correlates in CRC. Correlation between EphA2 and CD44, LGR5, CD133, Ki-67 and AXL in 509 stage I-IV CRC cases of the Singapore dataset. Supplementary table 3. Statistical associations between pairs of factors in the surgery only (A) and surgery/chemotherapy (B) stage II/III groups in the Singapore dataset. Supplementary table 4. A. Univariate and multivariate analysis (Cox proportional hazards regression) of resection-chemotherapy stage II/III patient group. B. Final multivariate model (Cox proportional hazards regression) of resection-chemotherapy stage II/III patient group. Supplementary table 5. Statistical association between expression levels of TGF-α and EphA2 using Spearman's Rank Correlation in GSE17536, GSE39582, GSE14333 and The Cancer Genome Atlas (TCGA). Within each dataset the value of Rho and associated p-value is reported.

EphA2 and EFNA1 expression levels in colorectal cancer cells.

Purpose:Small-bowel adenocarcinoma (SBA) is rare, and no standard of care exists for metastatic disease beyond first-line FOLFOX/CAPOX. SBA has higher rates of microsatellite instability (MSI-H) and T-lymphocyte infiltration than other gastrointestinal cancers. We hypothesize that pembrolizumab, a PD-1 inhibitor, will induce antitumor response.Patients and Methods:Patients with previously treated advanced SBA received pembrolizumab 200 mg i.v. every 3 weeks until disease progression (PD), toxicity, or 35 doses maximum. Primary endpoint was confirmed overall response rate (ORR) with secondary progression-free survival (PFS), overall survival (OS), and toxicity assessment endpoints. Outcomes were stratified by tumor location, microsatellite stability (MSS) or instability (MSI-H), and PD-L1 level.Results:Forty patients were treated for a median duration of four cycles (range, 1–35). All patients are off study treatment due to PD (75%), death (10%), 35 cycles completed (8%), refusal (3%), and adverse effects (AEs, 5%). Three confirmed partial responses [PRs; 8%; 95% confidence interval (CI), 2–20] did not meet predefined success criteria of ORR 30%. Median OS (7.1 months; 95% CI, 5.1–17.1) and median PFS (2.8 months; 95% CI, 2.7–4.2) were similar across primary tumor sites. One confirmed PR (3%) was seen in patients with low MSS/MSI tumors and correlated with high tumor mutation burden (TMB). Fifty percent of patients with MSI-H tumors achieved PR and remain alive without progression. Twenty-five patients (63%) had grade ≥3 AEs and 11 patients (28%) had grade 4/5 AEs.Conclusions:In the largest study of SBA to date, pembrolizumab did not induce the hypothesized response rate; however, we did identify responses in key biomarker-selected cohorts.

Supplementary table 3. Multivariate model for Overall Survival (Cytotoxic Agents)

Clinical relevance of EphA2 expression in CRC tissues.

Introduction: Because a dose–response relationship is characteristic of conventional chemotherapy, this concept is widely used for the development of novel cytotoxic (CTX) drugs. However, the need to reach the MTD to obtain optimal benefit with molecularly targeted agents (MTA) is controversial. In this study, we evaluated the relationship between dose and efficacy in a large cohort of phase I patients with solid tumors.Experimental Design: We collected data on 1,182 consecutive patients treated in phase I trials in 14 European institutions in 2005–2007. Inclusion criteria were: (i) patients treated within completed single-agent studies in which a maximum-administered dose was defined and (ii) RECIST/survival data available.Results: Seventy-two percent of patients were included in trials with MTA (N = 854) and 28% in trials with CTX (N = 328). The objective response (OR) rate was 3% and disease control at 6 months was 11%. OR for CTX was associated with higher doses (median 92% of MTD); this was not the case for MTA, where patients achieving OR received a median of 50% of MTD. For trials with MTA, patients treated at intermediate doses (40%–80%) had better survival compared with those receiving low or high doses (P = 0.038). On the contrary, there was a direct association between higher dose and better OS for CTX agents (P = 0.003).Conclusion: Although these results support the development of novel CTX based on MTD, we found no direct relationship between higher doses and response with MTA in unselected patients. However, the longest OS was seen in patients treated with MTA at intermediate doses (40%–80% of MTD). Clin Cancer Res; 20(22); 5663–71. ©2014 AACR.

Supplementary Figures S1-S2; Supplementary Tables S1-S2.

Role of EFNA1 in invasion and migration of colorectal cancer cells.

Supplementary table 2. Multivariate model for overall survival (Molecularly Targeted Agents).

Purpose: Apoptosis is essential for chemotherapy responses. In this discovery and validation study, we evaluated the suitability of a mathematical model of apoptosis execution (APOPTO-CELL) as a stand-alone signature and as a constituent of further refined prognostic stratification tools. Experimental Design: Apoptosis competency of primary tumor samples from patients with stage III colorectal cancer (n = 120) was calculated by APOPTO-CELL from measured protein concentrations of Procaspase-3, Procaspase-9, SMAC, and XIAP. An enriched APOPTO-CELL signature (APOPTO-CELL-PC3) was synthesized to capture apoptosome-independent effects of Caspase-3. Furthermore, a machine learning Random Forest approach was applied to APOPTO-CELL-PC3 and available molecular and clinicopathologic data to identify a further enhanced signature. Association of the signature with prognosis was evaluated in an independent colon adenocarcinoma cohort (TCGA COAD, n = 136). Results: We identified 3 prognostic biomarkers (P = 0.04, P = 0.006, and P = 0.0004 for APOPTO-CELL, APOPTO-CELL-PC3, and Random Forest signatures, respectively) with increasing stratification accuracy for patients with stage III colorectal cancer. The APOPTO-CELL-PC3 signature ranked highest among all features. The prognostic value of the signatures was independently validated in stage III TCGA COAD patients (P = 0.01, P = 0.04, and P = 0.02 for APOPTO-CELL, APOPTO-CELL-PC3, and Random Forest signatures, respectively). The signatures provided further stratification for patients with CMS1-3 molecular subtype. Conclusions: The integration of a systems-biology–based biomarker for apoptosis competency with machine learning approaches is an appealing and innovative strategy toward refined patient stratification. The prognostic value of apoptosis competency is independent of other available clinicopathologic and molecular factors, with tangible potential of being introduced in the clinical management of patients with stage III colorectal cancer. Clin Cancer Res; 23(5); 1200–12. ©2016 AACR.

Purpose: EphA2, a member of the Eph receptor tyrosine kinases family, is an important regulator of tumor initiation, neovascularization, and metastasis in a wide range of epithelial and mesenchymal cancers; however, its role in colorectal cancer recurrence and progression is unclear. Experimental Design: EphA2 expression was determined by immunohistochemistry in stage II/III colorectal tumors (N = 338), and findings correlated with clinical outcome. The correlation between EphA2 expression and stem cell markers CD44 and Lgr5 was examined. The role of EphA2 in migration/invasion was assessed using a panel of KRAS wild-type (WT) and mutant (MT) parental and invasive colorectal cancer cell line models. Results: Colorectal tumors displayed significantly higher expression levels of EphA2 compared with matched normal tissue, which positively correlated with high CD44 and Lgr5 expression levels. Moreover, high EphA2 mRNA and protein expression were found to be associated with poor overall survival in stage II/III colorectal cancer tissues, in both univariate and multivariate analyses. Preclinically, we found that EphA2 was highly expressed in KRASMT colorectal cancer cells and that EphA2 levels are regulated by the KRAS-driven MAPK and RalGDS-RalA pathways. Moreover, EphA2 levels were elevated in several invasive daughter cell lines, and downregulation of EphA2 using RNAi or recombinant EFNA1 suppressed migration and invasion of KRASMT colorectal cancer cells. Conclusions: These data show that EpHA2 is a poor prognostic marker in stage II/III colorectal cancer, which may be due to its ability to promote cell migration and invasion, providing support for the further investigation of EphA2 as a novel prognostic biomarker and therapeutic target. Clin Cancer Res; 22(1); 230–42. ©2015 AACR.

Background: LY3143921 hydrate is an orally administered ATP-competitive inhibitor of CDC7, a serine/threonine kinase regulatory protein overexpressed in many cancer types. Following successful preclinical studies, a first-in-human phase I trial of LY3143921 hydrate was initiated in patients with advanced solid tumors. We report the pharmacokinetics of LY3143921 hydrate in this ongoing Cancer Research UK study. Methods: Eligible patients were those with histologically proven advanced/metastatic solid tumors for which no further standard therapy options were available. Patients were administered LY3143921 hydrate as a single oral dose on Day -7, followed by daily administration (dose levels 30-270mg) or twice daily administration (dose levels 150 and 180mg) on study days 1-21. Drug administration was carried out with patients in either a fasted or fed state as shown in Table 1. Samples for pharmacokinetic analysis were obtained following a single drug dose on Day -7 at 0.25, 0.5, 1, 2, 4, 6, 8, 12, 24, 48 and 72 hours. Additional samples were taken on Day 1 of treatment at doses of 150 and 180mg to investigate potential differences in pharmacokinetics in fed versus fasted states (Day -7 fed versus Day 1 fasted). Samples were analysed using a validated LC-MS/MS assay with a LLOQ of 0.1 ng/mL. Pharmacokinetic analysis was carried out using Certara WinNonlin software (version 6.3) to determine Cmax, Tmax, area under the curve (AUC), plasma half-life, apparent volume of distribution (Vz/F) and apparent clearance (CL/F) of LY3143921 hydrate. Assessment of dose proportionality was made by assessment of graphical plots of AUC versus dose level. Table 1:Summary of LY3143921 hydrate pharmacokinetic data on Day -7 (single dose data)Dose level (mg)Number of patientsFed / fastedCmax (ng/mL)AUC0-24h (ng/mL.h)Half-life (h)CL/F (L/h)Vz/F (L)301Fasted184.44253.3570.1339601Fasted175.05022.42119.44181201Fasted113031382.1738.212018010Fasted144 - 8142505 ± 9904.2 ± 4.079.5 ± 23.9475 ± 4732704Fasted474 - 15126374 ± 14753.4 ± 1.843.8 ± 8.9226 ± 1581503Fed334 - 6321997 ± 4964.4 ± 1.977.2 ± 16.4514 ± 2881803Fed492 - 16002994 ± 9793.2 ± 0.864.2 ± 19.4290 ± 112 Results: Table 1 provides a summary of the pharmacokinetic parameters obtained on Day -7 following a single dose of LY3143921 hydrate (data expressed as range or mean ± SD as appropriate). Overall dose-dependent increases in exposure (based on Cmax and AUC) were observed. There was a general trend towards higher Cmax and AUC values following administration in a fasted versus fed state following a dose of 180 mg, but this was inconsistent across the limited number of patients for who these data were available on both Day -7 (fed) and Day 1 (fasted). Conclusion: The pharmacokinetic data generated to date are consistent with dose dependent increases in drug exposure observed with a flat dosing regimen for LY3143921 hydrate. Citation Format: Shelby Barnett, Melanie Griffin, Richard H. Wilson, Elizabeth R. Plummer, Jeffry T. Evans, Victoria Coyle, Sally Clive, Lisa Godfrey, Nicola Dobbs, Lesley McGuigan, Sue Brook, Gavin Halbert, Gareth J. Veal. Pharmacokinetics of the CDC7 inhibitor LY3143921 hydrate, a CRUK first-in-human phase I trial in patients with advanced solid tumors [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr 3014.

Purpose: GSK461364 is an ATP-competitive inhibitor of polo-like kinase 1 (Plk1). A phase I study of two schedules of intravenous GSK461364 was conducted. Experimental Design: GSK461364 was administered in escalating doses to patients with solid malignancies by two schedules, either on days 1, 8, and 15 of 28-day cycles (schedule A) or on days 1, 2, 8, 9, 15, and 16 of 28-day cycles (schedule B). Assessments included pharmacokinetic and pharmacodynamic profiles, as well as marker expression studies in pretreatment tumor biopsies. Results: Forty patients received GSK461364: 23 patients in schedule A and 17 in schedule B. Dose-limiting toxicities (DLT) in schedule A at 300 mg (2 of 7 patients) and 225 mg (1 of 8 patients) cohorts included grade 4 neutropenia and/or grade 3–4 thrombocytopenia. In schedule B, DLTs of grade 4 pulmonary emboli and grade 4 neutropenia occurred at 7 or more days at 100 mg dose level. Venous thrombotic emboli (VTE) and myelosuppression were the most common grade 3–4, drug-related events. Pharmacokinetic data indicated that AUC (area under the curve) and Cmax (maximum concentration) were proportional across doses, with a half-life of 9 to 13 hours. Pharmacodynamic studies in circulating tumor cells revealed an increase in phosphorylated histone H3 (pHH3) following drug administration. A best response of prolonged stable disease of more than 16 weeks occurred in 6 (15%) patients, including 4 esophageal cancer patients. Those with prolonged stable disease had greater expression of Ki-67, pHH3, and Plk1 in archived tumor biopsies. Conclusions: The final recommended phase II dose for GSK461364 was 225 mg administered intravenously in schedule A. Because of the high incidence (20%) of VTE, for further clinical evaluation, GSK461364 should involve coadministration of prophylactic anticoagulation. Clin Cancer Res; 17(10); 3420–30. ©2011 AACR.

Purpose: A phase I study to define toxicity and recommend a phase II dose of the HSP90 inhibitor alvespimycin (17-DMAG; 17-dimethylaminoethylamino-17-demethoxygeldanamycin). Secondary endpoints included evaluation of pharmacokinetic profile, tumor response, and definition of a biologically effective dose (BED). Patients and Methods: Patients with advanced solid cancers were treated with weekly, intravenous (i.v.) 17-DMAG. An accelerated titration dose escalation design was used. The maximum tolerated dose (MTD) was the highest dose at which ≤1/6 patients experienced dose limiting toxicity (DLT). Dose de-escalation from the MTD was planned with mandatory, sequential tumor biopsies to determine a BED. Pharmacokinetic and pharmacodynamic assays were validated prior to patient accrual. Results: Twenty-five patients received 17-DMAG (range 2.5–106 mg/m2). At 106 mg/m2 of 17-DMAG 2/4 patients experienced DLT, including one treatment-related death. No DLT occurred at 80 mg/m2. Common adverse events were gastrointestinal, liver function changes, and ocular. Area under the curve and mean peak concentration increased proportionally with 17-DMAG doses 80 mg/m2 or less. In peripheral blood mononuclear cells significant (P < 0.05) HSP72 induction was detected (≥20 mg/m2) and sustained for 96 hours (≥40 mg/m2). Plasma HSP72 levels were greatest in the two patients who experienced DLT. At 80 mg/m2 client protein (CDK4, LCK) depletion was detected and tumor samples from 3 of 5 patients confirmed HSP90 inhibition. Clinical activity included complete response (castration refractory prostate cancer, CRPC 124 weeks), partial response (melanoma, 159 weeks), and stable disease (chondrosarcoma, CRPC, and renal cancer for 28, 59, and 76 weeks, respectively). Couclusions: The recommended phase II dose of 17-DMAG is 80 mg/m2 weekly i.v. Clin Cancer Res; 17(6); 1561–70. ©2011 AACR.

Introduction: 40-45% of patients with High Grade Serous Ovarian Cancer (HGSOC) will eventually relapse with platinum resistant disease. Tothill et al and TCGA are two independent gene expression datasets which have demonstrated the presence of a mesenchymal molecular subgroup, characterised by upregulation of angiogenesis regulating genes. Angiogenesis is known to be an integral pathological feature of HGSOC and anti-angiogenics have dominated the field of drug development in EOC. However, despite this, anti-angiogenic agents have failed to demonstrate a significant impact on overall survival (OS) benefit. In this study, we asked if platinum resistance could be associated with an improved response to anti-angiogenic agents and what the underlying biological rationale for this could be. Methods: A meta-analysis of 14 phase II and III clinical trials in EOC were used to investigate the association between platinum resistance and response to anti-angiogenic agents. In addition, we analysed gene expression in 12 matched pre- and post-chemotherapy EOC samples. Novel isogenic cisplatin-resistant HGSOC cell lines were established to study the development of an angiogenic phenotype. Further studies were performed in novel ascites-derived primary cell lines from HGSOC patients with known outcomes following platinum-based chemotherapy. Result: In the clinical trial meta-analysis, an OS benefit for antiangiogenics was observed in platinum-resistant disease (p=0.029), whilst platinum-sensitive EOC only derived progression free survival (PFS) (p= Discussion: We have demonstrated that previous platinum therapy for EOC is associated with an increase in tumor PDGFα and VEGF-A expression, correlating with a response to anti-angiogenic therapies. This data suggests that platinum therapy resistance may inform the selection of EOC patients for novel antiangiogenic therapies in future clinical trials. Citation Format: Aya El Helali, Nuala McCabe, Christopher Steele, Lara Dura Perez, Christina L. O'Neill, Naomi Dickson, Niamh McGivern, Caolan Harkin, Andrena McCavigan, Reinhold J. Medina, Laura A. Knight, Stephen McQuaid, Jacqueline A. James, Caroline O. Michie, Charlie Gourley, W Glenn McCluggage, Denis P. Harkin, Richard H. Wilson, Alan W. Stitt, Richard D. Kennedy. Platinum resistance in epithelial ovarian cancer is dependent on a PDGFR alpha-VEGF-A signalling mechanism that activates downstream angiogenesis pathways [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 7.

Introduction. Triple negative breast cancer (TNBC) makes up 15% of breast cancers and is associated with poor prognosis. TNBC treatment remains hampered by early visceral metastasis and lymph node involvement at the time of diagnosis and limited effective therapeutic options. Advances in treatment that translate to significant improvements in outcome have been painstakingly incremental, despite advances in research technologies and TNBC subtyping. We have identified deoxyuridine 5'-triphosphate nucleotidohydrolase (dUTPase) as a critical gatekeeper that protects tumor DNA from the genotoxic misincorporation of uracil during treatment with anthracyclines that are commonly used in the FEC chemotherapy regimen. dUTPase catalyses the hydrolytic dephosphorylation of deoxyuridine triphosphate (dUTP) to deoxyuridine monophosphate (dUMP). This reaction has the dual function of providing dUMP for thymidylate synthase (TS) as part of the thymidylate biosynthesis pathway and of maintaining low intracellular dUTP pools. This is crucial as DNA polymerase cannot distinguish between dUTP and deoxythymidylate triphosphate (dTTP), leading to dUTP misincorporated into DNA. dUTPase is being evaluated as a target in cancer therapy alongside TS-targeted therapies and uracil misincorporation is believed to be a potential mechanism of cytotoxicity. Hypothesis: Targeting dUTPase and inducing uracil misincorporation during the repair of DNA damage induced by anthracyclines represents a novel strategy to induce TNBC cell lethality. Methods. Inhibition of dUTPase (DUTi) was carried out using SMARTpool siRNA or small molecule inhibition. The effect of DUTi in combination with anthracyclines was determined by growth inhibition and clonogenics assays. DNA damage was assessed by Western blot, immune-fluorescent foci detection, and flow cytometry. Nucleotide metabolites were quantified by LC/MS. Results. DUTi significantly sensitised TNBC cell lines to doxorubicin and epirubicin. In the MDA-MB-231 cancer cells, loss of dUTPase expression resulted in a synergistic 80% reduction in survival compared to 0.075µM doxorubicin alone at 40%. This decrease in survival correlated with increased activation of proteins involved in DNA damage response, including γ-H2AX(Ser139), a marker for dsDNA breaks. We anticipate that quantification of nucleotides will show an imbalance of dUTP:dTTP, subsequently leading to uracil misincorporation and resulting cell death. Discussion. These results suggest that repair of anthracycline-induced DNA damage requires dUTPase to prevent uracil misincorporation and that inhibition of dUTPase is a potential novel strategy to enhance the efficacy of anthracyclines. This shows the potential advantage of a dUTPase inhibitor being added to current chemotherapy regimens for TNBC. Future work will elucidate the mechanism of sensitisation and in vivo translation of combination therapy for TNBC. Citation Format: Craig Davison, Olivier P. Chevallier, Catherine Knowlson, Melanie McKechnie, Robbie Carson, Jaime Esteve, Richard Wilson, Robert D. Ladner, Melissa J. LaBonte (Wilson). Imbalanced nucleotide metabolism sensitizes breast cancer cells to anthracyclines [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 3836.

Purpose: We previously found that cellular FLICE-inhibitory protein (c-FLIP), caspase 8, and tumor necrosis factor–related apoptosis-inducing ligand (TRAIL) receptor 2 (DR5) are major regulators of cell viability and chemotherapy-induced apoptosis in colorectal cancer. In this study, we determined the prognostic significance of c-FLIP, caspase 8, TRAIL and DR5 expression in tissues from patients with stage II and III colorectal cancer.Experimental Design: Tissue microarrays were constructed from matched normal and tumor tissue derived from patients (n = 253) enrolled in a phase III trial of adjuvant 5-fluorouracil–based chemotherapy versus postoperative observation alone. TRAIL, DR5, caspase 8, and c-FLIP expression levels were determined by immunohistochemistry.Results: Colorectal tumors displayed significantly higher expression levels of c-FLIP (P < 0.001), caspase 8 (P = 0.01), and DR5 (P < 0.001), but lower levels of TRAIL (P < 0.001) compared with matched normal tissue. In univariate analysis, higher TRAIL expression in the tumor was associated with worse overall survival (P = 0.026), with a trend to decreased relapse-free survival (RFS; P = 0.06), and higher tumor c-FLIP expression was associated with a significantly decreased RFS (P = 0.015). Using multivariate predictive modeling for RFS in all patients and including all biomarkers, age, treatment, and stage, we found that the model was significant when the mean tumor c-FLIP expression score and disease stage were included (P < 0.001). As regards overall survival, the overall model was predictive when both TRAIL expression and disease stage were included (P < 0.001).Conclusions: High c-FLIP and TRAIL expression may be independent adverse prognostic markers in stage II and III colorectal cancer and might identify patients most at risk of relapse. Clin Cancer Res; 16(13); 3442–51. ©2010 AACR.

Background: There is a significant body of in vitro evidence and pre-clinical data which demonstrates that aspirin inhibits the growth of tumours and prevents the development of metastases[1]. A recent meta-analysis using individual patient data from randomized trials evaluating the cardiovascular effects of aspirin reports a reduction in cancer deaths after 5 years (hazard ratio 0.46, 95% confidence interval 0.27-0.77)[2]. Effects on risk of metastases and death following a cancer diagnosis have also been observed[3]. An analysis of the Nurses’ Health Study found that aspirin use following a diagnosis of stage I-III breast cancer was associated with a lower risk of breast cancer death (for those taking aspirin 2-5 times per week, relative risk 0.27, 95% confidence interval 0.15-0.47)[4]. Concerns over toxicity have limited the use of aspirin as a primary prevention agent against cancer. In the adjuvant setting the benefit:risk ratio will be different with higher morbidity and mortality from recurrent cancer potentially outweighing the risks associated with regular aspirin use. The Add-Aspirin trials will investigate whether regular aspirin use after curative treatment for localised malignancy can prevent tumour recurrence and prolong survival. As an inexpensive drug with a potential therapeutic role in several common cancers, aspirin could have a huge impact on the global cancer burden. Trial design: Multicentre, international, phase III, double-blind, placebo-controlled randomized trial in patients with early breast cancer. Participants will be randomised to enteric-coated aspirin 100mg, aspirin 300mg or matching placebo daily for at least 5 years. Parallel trials based on a common infrastructure will be conducted in colorectal, gastro-oesophageal and prostate cancer. Eligibility criteria: Patients who have undergone primary therapy, including curative surgery and appropriate neoadjuvant/adjuvant therapies for histologically confirmed invasive breast cancer which is node positive or node negative with high-risk features. Patients who have already participated in other primary treatment trials may be eligible subject to agreement from the trial management groups. Specific aims: The primary outcome will be disease-free survival. Secondary endpoints include overall survival, toxicity, cardiac morbidity and assessment of overall healthcare benefits. Translational work will investigate mechanisms of action and biomarkers for toxicity and treatment efficacy (including PIK3CA mutation status and COX-2 expression). Statistical methods: Approximately 3100 patients will be needed to test for a 4% improvement in DFS associated with aspirin use. [1] Langley RE et al. Br J Cancer. 2011;105(8):1107-13. [2] Rothwell PM et al. Lancet. 2011;377(9759):31-41. [3] Rothwell PM et al. Lancet. 2012;379(9826):1591-601. [4] Holmes MD et al. J Clin Oncol 2010;28(9):1467-72. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr OT2-4-01.

Purpose: P-glycoprotein (Pgp) antagonists have had unpredictable pharmacokinetic interactions requiring reductions of chemotherapy. We report a phase I study using tariquidar (XR9576), a potent Pgp antagonist, in combination with vinorelbine. Experimental Design: Patients first received tariquidar alone to assess effects on the accumulation of 99mTc-sestamibi in tumor and normal organs and rhodamine efflux from CD56+ mononuclear cells. In the first cycle, vinorelbine pharmacokinetics was monitored after the day 1 and 8 doses without or with tariquidar. In subsequent cycles, vinorelbine was administered with tariquidar. Tariquidar pharmacokinetics was studied alone and with vinorelbine. Results: Twenty-six patients were enrolled. Vinorelbine 20 mg/m2 on day 1 and 8 was identified as the maximum tolerated dose (neutropenia). Nonhematologic grade 3/4 toxicities in 77 cycles included the following: abdominal pain (4 cycles), anorexia (2), constipation (2), fatigue (3), myalgia (2), pain (4) and dehydration, depression, diarrhea, ileus, nausea, and vomiting, (all once). A 150-mg dose of tariquidar: (1) reduced liver 99mTc-sestamibi clearance consistent with inhibition of liver Pgp; (2) increased 99mTc-sestamibi retention in a majority of tumor masses visible by 99mTc-sestamibi; and (3) blocked Pgp-mediated rhodamine efflux from CD56+ cells over the 48 hours examined. Tariquidar had no effects on vinorelbine pharmacokinetics. Vinorelbine had no effect on tariquidar pharmacokinetics. One patient with breast cancer had a minor response, and one with renal carcinoma had a partial remission. Conclusions: Tariquidar is a potent Pgp antagonist, without significant side effects and much less pharmacokinetic interaction than previous Pgp antagonists. Tariquidar offers the potential to increase drug exposure in drug-resistant cancers.

Purpose: Inhibition of steroid sulfatase (STS), the enzyme responsible for the hydrolysis of steroid sulfates, represents a potential novel treatment for postmenopausal women with hormone-dependent breast cancer. Estrone and DHEA are formed by this sulfatase pathway and can be converted to steroids (estradiol and androstenediol, respectively), which have potent estrogenic properties. Experimental Design: STX64 (667 Coumate), a tricylic coumarin-based sulfamate that irreversibly inhibits STS activity, was selected for entry into the first phase I trial of a STS inhibitor in postmenopausal women with breast cancer. STX64 was administered orally (nine patients at 5 mg and five patients at 20 mg) as an initial dose followed 1 week later by 3 × 2 weekly cycles, with each cycle comprising daily dosing for 5 days followed by 9 days off treatment. Blood and tumor tissue samples were collected for the assessment of STS activity and serum was obtained for steroid hormone measurements before and after treatment. Results: The median inhibition of STS activity by STX64 was 98% in peripheral blood lymphocytes (PBL) and 99% in breast tumor tissue at the end of the 5-day dosing period. As expected, serum concentrations of estrone, estradiol, androstenediol, and DHEA all decreased significantly from pretreatment levels. Unexpectedly, androstenedione and testosterone concentrations also decreased. Four patients, all of whom had previously progressed on aromatase inhibitors, showed evidence of stable disease for 2.75 to 7 months. The drug was well tolerated with only minor drug-related adverse events recorded. Conclusion: STX64 is a potent, well-tolerated STS inhibitor. It inhibits STS activity in PBLs and tumor tissues and causes significant decreases in serum concentrations of steroids with estrogenic properties.

With 1.4 million new cases every year, colorectal cancer (CRC) is the fourth most common cancer worldwide [Globocan 2012, WHO]. Despite therapeutic advances and improvements in overall care, TNM staging remains the best prognostic indicator for CRC patients’ clinical outcomes and is pivotal for deciding on use of adjuvant chemotherapy after resection of the tumour. Adjuvant chemotherapy is not recommended for many stage II patients and mostly high-risk patients receive chemotherapy. However, there is a lack of robust biomarkers for identifying patient response to chemotherapy, recurrence and mortality risk. We developed a system model of the BCL2 family of proteins (DR_MOMP) to assess the sensitivity of cells to genotoxic stress and to induce apoptosis triggered by chemotherapy. It calculates the stress dose required to induce mitochondrial outer membrane permeabilization (MOMP) based on absolute protein levels and the interaction of pro- and anti-apoptotic BCL2 family proteins. Cells predicted to require a high stress dose showed decreased cell death rates after being exposed to 5FU and Oxaliplatin. Profiles of BAK, BAX, BCL2, BCL(X)L and MCL1 were determined by Reverse Phase Protein Array (RPPA) technology in FFPE primary tumours collected from two distinct cohorts: stage III CRC patients who underwent adjuvant 5FU-based chemotherapy (n = 128), and stage II CRC patients from a completed clinical trial with patients randomised to adjuvant 5FU-based chemotherapy or observation only (n = 138). Protein profiles were inputted into DR_MOMP to determine chemotherapy sensitivity and to classify patients into high- or low risk categories. Findings were validated on the TCGA COAD cohort using both protein (RPPA) and mRNA (SeqV2 RSEM) expression data. Stage II patients classified as high-risk by DR_MOMP and randomised to observation only had approximately 2-fold increased risk of death from CRC compared to those classified as low-risk or received chemotherapy (HR 2.4; 95% CI 1.2-4.8; p-value = 0.0199). Among stage III patients treated with FOLFOX, those classified as high- versus low-risk had a more than 10-fold increased risk of death from CRC (HR 10.6; 95% CI 2.4-46.3; p-value < 0.0001). We validated this finding in 261 stage II-IV patients of the TCGA COAD cohort (HR 10.6; 95% CI 1.2-12.5; p-value = 0.0125). DR_MOMP predicted mortality risk independent of TNM staging and KRAS mutation status. Our system delivers a novel predictive and prognostic biomarker that could be combined with TNM staging when assessing initial risk and subsequent clinical management of CRC patients. Citation Format: Andreas U. Lindner, Manuela Salvucci, Mattia Cremona, Naser Monsefi, Sarah Curry, Clare Morgan, Alexa Resler, Robert O’Byrne, Orna Bacon, Michael Stuehler, Lorna Flanagan, Richard Wilson, Patrick G. Johnston, Manuel Salto-Tellez, Sophie Camilleri-Broët, Deborah A. McNamara, Bryan T. Hennessy, Elaine W. Kay, Pierre Laurent-Puig, Sandra Van Schaeybroeck, Jochen H.M. Prehn. Retrospective evaluation of a system model of the BCL2 family of proteins as a predictive and prognostic biomarker for the clinical outcome of stage II-IV colorectal cancer patients. [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 4924.

Introduction - MErCuRIC is a Phase Ib/II clinical trial study using a combined MEK1/2 - cMET inhibition in RAS MT and RAS WT (with aberrant c-MET) colorectal cancer patients. As part of the discovery efforts on the cases enrolled in Phase I, we aimed to analyze the mutation status of 10 genes that could potentially be associated to the doublet MEK/MET inhibition. This study compared the MEK/MET-specific panel with the Ion Torrent 50 gene panel, aiming to compare: long-established, commercially available panels against this newly developed panel; the Ion Torrent PGM2 platform against Illumina MiSeq v.3 600 bp chemistry; hot-spot-based against full exomes-designed; and to compare the use of different bioinformatics reporter systems. The overlapping genes between the panels were: EGFR (n = 3); BRAF (n = 4); KRAS (n = 8); NRAS (n = 1); MET (n = 8); PIK3CA (n = 6); and ERBB2 (n = 5). Summary of Method NGS Design - The Multiplicom - MErCuRIC specific MASTR assay includes PTEN, MAP2K1 (MEK), EGFR, KRAS, NRAS, BRAF, PIK3CA, ERBB2, MET and PIK3R1, involving 257 amplicons in 4 plexes covering all coding exons of the 10 genes. Of the 257, 21 are control amplicons to allow for gene deletions/amplifications. The average length of the amplicons is 198 bp ranging from 124 bp to 255 bp. Validation - From a pool of 120 routine tumour samples characterised with a 50 gene mutation panel (Ion Torrent PGM2) and confirmed by Sanger sequencing and/or COBAS (Roche) QPCR, 24 FFPE cases were selected representing colorectal cancer and 4 other solid tumour types; all included a variety of DNA quality, and DNA concentration was standardized prior to library preparation. Pre-analytical handling was in accordance with established protocols in a laboratory, clinically-accredited in the UK for tissue-based, anatomical pathology testing. Results The evaluation of this MEK/MET-specific panel (Illumina MiSeq platform) resulted in 100% coverage of all targets, a higher than 97% on target reads and higher than 99% of all amplicons within 20% of mean coverage. The design minimized the areas of low coverage. A small part of exon 9 of ERBB2 was covered suboptimally: the low covered region is 30 bp in size located at the 5’ end of exon 9. It is unlikely that this low coverage led to false negative results since no mutations are reported in the COSMIC database for this DNA fragment. The results were concordant in relation to mutations involved in the genes stated above. Importantly, the percentages of allele frequency between both methods were similar, with variations ranging from 0.2% to 11.5% with an average variation of 5.2%. Insertion/deletion (Indel) detection however, required alternative bioinformatics pathways. Conclusion After combining well-established quality metrics to cover pre-analytical aspects with suitable technologies such as the MiSeq platform (Illumina) and appropriate bioinformatics, we recognize that this MEK/MET-specific NGS panel is fit for purpose. Citation Format: Perry Maxwell, Jurgen Del Favero, Marc-Aurel Fuchs, Josep Tabernero, Tim Maughan, Mark Middleton, Richard Addams, Christian Rolfo, Brian Hennessey, Pierre Laurent-Puig, Alberto Bardelli, Thierry Andre, Vlad Popovici, Patrick Johnstone, Richard Wilson, Mark Lawler, Sandra Van Schaeybroeck, Manuel Salto Tellez. Validation of a MEK/MET-specific NGS panel for early phase trial interrogation. [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 1396.

Small bowel accounts for only 0.5% of cancer cases in the US; a third of which are adenocarcinomas. But incidence rates have been rising at a rate of 2.4% per year over the last decade. Because of the rarity of this cancer, little is known about its molecular pathology and there are no molecular markers for diagnosis, predicting prognosis or therapeutic intervention. The aim of this study was therefore to look into this disease at a molecular level to better understand its biology and identify biomarkers and potential points of therapeutic intervention. Using a retrospective 28 patient matched normal-tumor cohort next generation sequencing (NGS) was performed using a 50 gene cancer hotspot panel, gene expression arrays were used to profile ∼29,000 RNA transcripts and 450k CpG methylation arrays were used to carry out DNA methylation analysis. We also looked at microsatellite instability (MSI), HER2 and p53 expression. NGS identified novel mutations in IDH1, CDH1, KIT, NRAS, FGFR2, FLT3, NPM1, PTEN, MET, AKT1, RET, NOTCH1 and ERBB4. Previously known mutations such as high-frequency KRAS and TP53 and low-frequency HER2 were also confirmed in our cohort. The average patient had 2.6 mutations with eight patients having only a single mutation to one having seven. Array data revealed 17% of CpGs and 5% of RNA transcripts assayed to be differentially methylated and expressed respectively (p This study has for the first time highlighted the extent of molecular changes taking place in SBA. The clinical potential of TP53 mutations and Kazald1 hypomethylation as prognostic biomarkers and CHN2 as a diagnostic biomarker are focus areas for further research by our group. Citation Format: Muhammad A. Alvi, Darragh G. McArt, Paul Kelly, Marc-Aurel Fuchs, Matthew Alderdice, Clare M. McCabe, Victoria Bingham, Claire McGready, Stephen McQuaid, Perry Maxwell, Peter Hamilton, Jacqueline A. James, Richard Wilson, Manuel Salto-Tellez. Comprehensive molecular pathology analysis of small bowel adenocarcinoma reveals novel targets with clinical utility. [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 4792. doi:10.1158/1538-7445.AM2015-4792

Background: Pro-inflammatory signaling within the tumor microenvironment is proposed to aid tumor progression and metastasis in a number of cancer types, including colorectal cancer (CRC). The pro-inflammatory chemokine, CXCL8 (interleukin-8) has been associated with tumor size, Dukes stage, liver metastasis and overall survival in CRC. This chemokine is expressed by multiple cell types within the tumor microenvironment including tumor cells, innate immune, and vascular endothelial cells. Additionally, the elevated expression of both CXCL8 receptors, CXCR1 and CXCR2, in CRC tumor epithelium relative to normal adjacent tissue indicates that CRC is receptive to both an autocrine tumor-derived stimulus and a paracrine ‘stromal-derived’ stimulus. Objectives: Our first objective was to characterise how mutation of the oncogene K-Ras may regulate CXCL8 expression and signaling in CRC cells in vitro. Secondly, we sought to characterise the importance of CXCL8 in modulating survival of K-Ras mutant CRC cells. Results: Mutation of K-Ras or the catalytic subunit of phosphatidyl-inositol-3 kinase (PI3KCA) is indicated in 35-40% and 15-18% of colorectal adenocarcinomas, respectively. The HCT-116 cell line harbours mutations in both K-Ras and PI3KCA. Basal CXCL8, CXCL1 and CXCR1/2 levels were significantly elevated in K-Ras mutant HCT-116 cells relative to isogenic HKH-2 K-Ras wild-type cells. Treatment with inhibitors of AKT and/or MEK attenuated CXCL8 transcript levels and secretion in K-Ras mutant cells, but conversely increased CXCR1/2 gene expression. Attenuation of CXCL8 gene expression using siRNA demonstrated a concurrent loss of cell viability in CRC cells; this effect was significantly marked in K-Ras mutant HCT-116 cells, consistent with increased dependence of these cells on elevated CXCL8 signaling. Moreover, attenuation of CXCR2 signaling potentiated the sensitivity of K-Ras mutant HCT-116 cells to oxaliplatin and 5-FU. In addressing mechanisms underpinning CXCL8-promoted resistance, treatment with recombinant human CXCL8 was shown to increase expression of anti-apoptotic proteins Bcl-XL and Bcl-2 and furthermore, induce phosphorylation of multiple tyrosine kinases (RTKs) including EGFR, c-MET and FGFR1. Furthermore, blockade of CXCR2 signaling attenuated oxaliplatin-induced increases in anti-apoptotic protein expression in HCT-116 cells. Conclusions: CXCL8 signaling is elevated in K-Ras and PI3KCA mutant cancers. The up-regulation of autocrine CXCL8 signaling is linked to the promotion of cell survival, principally mediated through the inhibition of apoptosis and promotion of RTK signaling. The clinical relevance of CXCL8 signaling in modulating outcome of K-Ras mutant CRC to current treatments remains to be determined. However, CXCL8-directed therapies may be relevant as chemo-sensitizing agents in K-Ras and/or PIK3CA mutant tumors. Citation Format: Laura M. Campbell, Olabode Oladipo, Pamela J. Maxwell, Daniel Longley, Richard H. Wilson, David JJ Waugh. Pro-inflammatory CXCL8 signaling potentiates survival of K-Ras mutant colorectal cancer cells. [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 5267. doi:10.1158/1538-7445.AM2014-5267

Background: Oral cancer therapies are often complicated by variable absorption leading to highly variable plasma pharmacokinetics (PK) and thus unpredictable toxicity and efficacy. Rucaparib, a poly (ADP-ribose) polymerase inhibitor (PARPi), is being developed for treatment of tumors associated with homologous recombination repair deficiency with a pre-specified target plasma trough level. While efficacy has been shown for PARPis, dose interruptions/reductions due to adverse events (AEs) are common for PARPis. Here, we report the PK results for oral rucaparib in patients and assess exposure predictability. Methods: Rucaparib PK was studied in two Phase I studies. CO-338-010 (N=39) is an ongoing Phase I/II monotherapy study examining safety, PK, and preliminary efficacy of oral rucaparib administered continuously 40-500 mg once (qd) or 240-600 mg twice daily (bid) (NCT01482715). The effect of a high-fat meal on rucaparib PK was examined at 40 mg (N=3) and 300 mg (N=6). A4991014 (N=53) is an ongoing Phase I study currently assessing rucaparib in combination with carboplatin (CBDCA) (NCT01009190). Patients received lead-in oral rucaparib on Day -5 followed by CBDCA on Day 1 and oral rucaparib qd on Days 1-14 of every 21-day treatment cycle. Patients in earlier cohorts also had a single lead-in dose of intravenous rucaparib for calculating oral bioavailability. Plasma rucaparib levels were determined using a validated LC-MS/MS method. Results: Rucaparib exhibited good oral absorption with a dose-independent oral bioavailability of 36% and median Tmax ranging from 1 to 6 hours. Exposure generally exhibited dose proportional kinetics up to 1200 mg daily dose (600 mg bid). The target trough level of 2 μM was achieved in 100% of patients (n=14) at ≥240 mg bid with low inter-patient variability ( Conclusions: Rucaparib showed desirable dose- and time- independent PK with low inter- and intra- patient variability in exposure compared to published olaparib data. Predictable PK following oral dosing may lead to low rates of over- and under- dosing, potentially minimizing AEs associated with high unpredictable exposures, an important attribute for maintenance therapy. Rucaparib's low inter-patient variability is beneficial for uniform flat dosing strategies. This will be explored in the two upcoming studies, ARIEL2 and ARIEL3. Citation Information: Mol Cancer Ther 2013;12(11 Suppl):A218. Citation Format: Geoffrey Shapiro, Rebecca Kristeleit, Mark Middleton, Howard Burris, L. Rhoda Molife, Jeff Evans, Richard Wilson, Patricia LoRusso, James Spicer, Veronique Dieras, Manish Patel, Erin Dominy, Dayna Simpson, Heidi Giordano, Andrew R. Allen, Sarah S. Jaw-Tsai, Ruth Plummer. Pharmacokinetics of orally administered rucaparib in patients with advanced solid tumors. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr A218.

Aim of study: The aims of this work were (i) to characterize CXC-chemokine and receptor expression in colorectal cancer (CRC) and (ii) study the role of CXC-chemokine signalling in modulating CRC cell sensitivity to Oxaliplatin and anti-EGFR therapy. Methods and Materials: CXC-chemokine and receptor expression was analysed in a retrospective study of colorectal cancer biopsy specimens in stage II and stage III CRC patients (n=254) who took part in a randomized phase III study comparing adjuvant 5FU chemotherapy with surgery alone between 1994 and 1997. For the in vitro work, studies were carried out in a panel of CRC cell lines comprising HCT116 clonal derivatives and LoVo cells. CXCL8 ligand and receptor expression was assessed by flow cytometry, qRT-PCR, western blotting and ELISA. Anti-apoptotic and EGFR signalling was also assessed using qRT-PCR and western blotting. NF-κB activity was assessed by electrophoretic mobility shift assay (EMSA) and Oxaliplatin response was assessed using cell counts. Results: Expression of CXCR1, CXCR2 and CXCL1 was elevated in tumor epithelium relative to the histologically normal adjacent colorectal cells (p Conclusions: Our studies suggest CRC malignant epithelium is subject to increased autocrine CXC-chemokine signaling compared to the adjacent normal colorectal tissue and this may reflect a role for the signaling in this disease. In-vitro work suggests that chemotherapy-induced CXC-chemokine signaling may underpin CRC chemoresistance through multiple pathways. These results support a role for CXC-chemokine signaling in the promotion of CRC and modulating sensitivity of this disease to current treatment Citation Information: Mol Cancer Ther 2009;8(12 Suppl):A76.