Combination Of Erlotinib Research Articles

Inhibiting FGFR by toadflax reverses erlotinib resistance in nonsmall cell lung cancer

This study aims to demonstrate the effect of toadflax (bufalin) on erlotinib resistance in nonsmall cell lung cancer (NSCLC) by inhibiting the fibroblast growth factor receptor (FGFR). The microfluidic mobility transferase and caliper mobility-shift assays were employed to detect the FGFR inhibition by bufalin and the binding reversibility. Further, the inhibitory effects of bufalin were determined in HCC827 and HCC827/ER cells in vitro, investigating relative FGFR overexpression by quantitative reverse transcriptase-PCR (RT-qPCR) and FGFR downstream proteins, that is, FGFR substrate 2 (FRS2), extracellular signal-regulated kinase (ERK), and S6 by western blot analysis. Finally, HCC827/ER-inoculated xenograft tumors were constructed to observe the effects of bufalin and bufalin + erlotinib intervention on tumor growth. Bufalin inhibited FGFR by reversibly binding to FGFR1. In addition, the western blot analysis indicated a significant reduction in the expression levels of FGFR, FRS2, ERK, and S6 proteins in HCC827 and HCC827/ER cells, increasing the expression levels of apoptotic caspase-3 and poly-(ADP-ribose) polymerase proteins. Bufalin + erlotinib combination significantly inhibited the apoptosis of HCC827/ER cells and subsequent tumor growth in vivo. In addition, FGFR overexpression significantly reversed the sensitivity of bufalin to HCC827/ER cells, promoting the value-addition of HCC827/ER cells. Further, bufalin + erlotinib significantly reduced the growth of erlotinib-resistant HCC827/ER tumors, induced apoptosis, and inhibited the expression of FGFR and p-ERK proteins. These findings indicated that bufalin could reverse the erlotinib resistance in NSCLC by inhibiting the FGFR expression.

Bevacizumab Erlotinib Switch Maintenance in Chemo-Responsive Advanced Gallbladder and Cholangiocarcinoma (BEER BTC): A Multicenter, Open-Label, Randomized, Phase II Trial.

Patients with chemotherapy-responsive advanced biliary tract cancers (BTCs) are usually observed after 6 months of gemcitabine-based therapy. There is limited prospective evidence for maintenance strategies after chemotherapy. This investigator-initiated, open-label, randomized, integrated phase II-III study enrolled adult patients with advanced BTC from two cancer centers in India. Patients with histologically confirmed advanced biliary tract adenocarcinoma who had at least disease stabilization after 6 months of gemcitabine-based chemotherapy were randomly assigned (1:1) to either active surveillance or switch maintenance, which was a combination of bevacizumab 5 mg/kg intravenous once every 21 days plus erlotinib 100 mg once daily. Both arms were continued until disease progression, unacceptable toxicity, or patient decision to withdraw. The primary end point of the phase II component of the trial was investigator-evaluated progression-free survival. This trial is registered with Clinical Trials Registry of India (CTRI/2019/05/019323I). From May 2021 to November 2022, 98 patients were randomly assigned to active surveillance (n = 49) or bevacizumab-erlotinib (n = 49). A majority of patients had gallbladder cancer (80%). The median follow-up was 13.4 months. The median progression-free survival was 3.1 months (95% CI, 2.47 to 3.64) in the active surveillance group versus 5.3 months (95% CI, 3.53 to 7.04) in the bevacizumab-erlotinib group (hazard ratio, 0.51 [95% CI, 0.33 to 0·74]; P = .0013). The most common grade 3 class-specific adverse events associated with bevacizumab-erlotinib were acneiform rash 1 (2%) and oral stomatitis 1 (2%) with erlotinib and bleeding 1 (2%) with bevacizumab. The combination of bevacizumab and erlotinib as switch maintenance improves progression-free survival with an acceptable safety profile compared with active surveillance in patients with advanced BTCs in this phase II study. The trial moves on to the phase III component to evaluate improvement in overall survival.

Combination of monensin and erlotinib synergistically inhibited the growth and cancer stem cell properties of triple-negative breast cancer by simultaneously inhibiting EGFR and PI3K signaling pathways.

Cancer stem cells (CSCs) in triple-negative breast cancer (TNBC) are recognized as a highly challenging subset of cells, renowned for their heightened propensity for relapse and unfavorable prognosis. Monensin, an ionophoric antibiotic, has been reported to exhibit significant therapeutic efficacy against various cancers, especially CSCs. Erlotinib is classified as one of the EGFR-TKIs and has been previously identified as a promising therapeutic target for TNBC. Our research aims to assess the effectiveness of combination of monensin and erlotinib as a potential treatment strategy for TNBC. The combination of monensin and erlotinib was assessed for its potential anticancer activity through various in vitro assays, including cytotoxicity assay, colony formation assay, wound healing assay, transwell assay, mammosphere formation assay, and proportion of CSCs assay. Additionally, an in vivo study using tumor-bearing nude mice was conducted to evaluate the inhibitory effect of the monensin and erlotinib combination on tumor growth. The results indicated that combination of monensin with erlotinib synergistically inhibited cell proliferation, the migration rate, the invasion ability and decreased the CSCs proportion, and CSC markers SOX2 and CD133 in vivo and in vitro. Furthermore, the primary proteins involved in the signaling pathways of the EGFR/ERK and PI3K/AKT are simultaneously inhibited by the combination treatment of monensin and erlotinib in vivo and in vitro. The simultaneous inhibition of the EGFR/ERK and PI3K/AKT/mTOR signaling pathways by the combination of monensin and erlotinib exhibited a synergistic effect on suppressing tumor proliferation and cancer cell stemness in TNBC.

Effect of Sunitinib in the Management of Lung Cancer: A Systematic Review of Clinical Trials

Introduction Lung cancer is the most common cancer in terms of both incidence and mortality. Although usually managed with surgery, novel immunotherapies are gradually becoming more popular. The effect of sunitinib with and without erlotinib in the management of lung cancer is reviewed. Methods Eligible search engines and databases were screened to identify studies published in English. Any randomized clinical trials studying the effect of sunitinib, either alone or in combination with erlotinib, were included. Results Thirteen studies with a total sample size of 1,062 cases were included. Males (59.5%) were more common than females (40.5%), and the average age of patients was 64 ± 5.03. Most of the patients (71.5%) had a positive smoking status, and non-small cell carcinoma was the most common lung cancer type (95.4%). Almost all of the adverse events, such as headache (100%), weight loss (100%), constipation (100%), leukocytopenia (96%), pain (92.3%), hypertension (90%), dyspnea (88.7%), cough (84.3%), fatigue (81.6%), fever/chills (77.3%), thrombocytopenia (75%), nausea (73.8%), neutropenia (72%), anorexia (71.4%), vomiting (65.1%), anemia (61.3%), and diarrhea (54.5%) were more common in the sunitinib-only group. The mean overall survival for patients receiving sunitinib alone was 213 days, whereas, for patients receiving sunitinib combined with erlotinib, it was 270 days. Conclusion Adverse events may be encountered more frequently in treatment with sunitinib alone compared to the combination of sunitinib and erlotinib. However, sunitinib alone may result in higher disease stability and lower disease progression. Nevertheless, combination therapy may yield a longer median overall survival.

Efficacy of Sorafenib in the Management of Non-Small Cell Lung Cancer: A Systematic Review

Introduction The current standard treatment approach for non-small cell lung cancer (NSCLC) is surgery. Recently, targeted therapy has emerged as a promising new treatment option. In this systematic review, the efficacy of sorafenib, when given alone or combined with erlotinib, in managing NSCLC is reviewed. Methods To identify English language studies published up to March 8th, 2024, the Google Scholar, CINAHL, PubMed/MEDLINE, Cochrane Library, Web of Science, and EMBASE databases were screened, and the data were assessed. Results The systematic search revealed 208 papers; however, only 10 were eligible to be included. The sample size was 1080 patients, of which 848 were in the sorafenib group, and 232 were in the sorafenib with erlotinib combination group. In the sorafenib group, the partial response was 2.4%, stable disease was reported in 25%, and 56 cases (6.6%) had progressive disease. In the combination group, partial response, stable disease, and progressive disease were 16.8%, 48.3%, and 19.8%, respectively. In the combination group, the median overall survival was 231 days, and the progression-free survival (PFS) was 141 days. However, in the sorafenib group, the median overall survival was 180 days, and the PFS was 82 days. Fatigue was the most common adverse event, reported in 325 (30.1%) patients. Among them, 235 cases (27.7%) were in the sorafenib group, and 90 cases (38.8%) were in the combination group. Conclusion Combination therapy may result in better overall survival and PFS than sorafenib alone, with slightly similar adverse events.

Abstract 5958: Exploring AKR1C3 as a therapeutic target to overcome erlotinib resistance in lung adenocarcinoma

Abstract Introduction: Erlotinib has demonstrated promising efficacy in lung adenocarcinoma (LUAD) patients with epidermal growth factor receptor mutation. However, the development of resistance to erlotinib poses a significant challenge in achieving long-lasting treatment responses. Aldo-keto reductase family 1 member C3 (AKR1C3) is associated with tumor progression, drug resistance, and unfavorable prognosis. This study aims to assess the potential of AKR1C3 as a therapeutic target for overcoming erlotinib resistance in LUAD. Methods: AKR1C3 expression was assessed in paired tumor tissues from 100 LUAD patients using reverse transcription quantitative polymerase chain reaction. Both in vitro and in vivo experiments were categorized into four treatment groups: a saline control (CTR), erlotinib (ER), an AKR1C3 inhibitor 3-(4-trifluoromethyl)phenylamino)benzoic acid (BA), and the combination of erlotinib with the AKR1C3 inhibitor (COM). An erlotinib-resistant cell line was established from the LUAD cell line HCC4006. The MTS assay was used to evaluate cell proliferation and viability. The combined effect of erlotinib and the AKR1C3 inhibitor was assessed using Synergyfinder and CompuSyn calculation software. Both cell line-derived xenograft (CDX) and patient-derived xenograft (PDX) models of erlotinib resistance to LUAD were established in NSG mice. The mice received daily oral gavage administration of the drugs for 31 days, while tumor volume was monitored biweekly. Results: AKR1C3 expression was significantly upregulated by more than three-fold in LUAD tumor samples compared to normal counterparts (p < 0.0001). After 24 hours of treatment in erlotinib-resistant cells, the ER and BA groups exhibited inhibition rates of 7% and 9%, respectively, while the COM group demonstrated a substantially higher inhibition rate of 45%. Synergyfinder and CompuSyn analysis revealed a synergy score of 12 and a combination index of 0.5 for the COM group, indicating a robust synergistic effect between the two drugs. In the CDX model, the COM group exhibited a tumor volume reduction of 25% in erlotinib-resistant cells and 64% in parental cells compared to the CTR group. In the PDX model, the COM group displayed a significant reduction of 50.4% in tumor volume compared to the CTR group. There was no significant difference in the weight of body and internal organs among the four treatment groups in both xenograft models. Conclusions: AKR1C3 overexpression was observed in the tumor tissues of LUAD patients. The combination of erlotinib and AKR1C3 inhibitor showed promising efficacy in overcoming erlotinib resistance in both in vitro and in vivo experiments. These findings highlight AKR1C3 as a potential therapeutic target for managing erlotinib resistance in LUAD patients. Targeting AKR1C3 represents a novel approach to overcome resistance and enhance treatment outcomes in LUAD patients undergoing erlotinib therapy. Citation Format: William C. Cho, Kwan P. Li, Chi F. Wong, King Y. Fung, James C. Chow, Ka M. Cheung, Jeffrey C. Chan, Eunice Y. Lau. Exploring AKR1C3 as a therapeutic target to overcome erlotinib resistance in lung adenocarcinoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5958.

Abstract 3290: FTO mediates tumor growth and resistance to erlotinib in NSCLC

Abstract Lung cancer, among the most common cancer types, ranks first in cancer associated deaths. Nearly 85% of the lung cancer cases are non-small cell lung cancer (NSCLC). Epidermal growth factor receptor (EGFR), an established marker for NSCLC, is frequently overexpressed on the cell surface. Amplifying mutations often render these receptors activated in a ligand independent manner, therefore, therapies such as erlotinib, an EGFR tyrosine kinase inhibitor (EGFR-TKI), target these activating mutations and inhibit tumor growth. Nevertheless, patients acquire resistance to EGFR TKI within 9-14 months of treatment. Recent studies show that fat mass and obesity- associated (FTO) gene, initially identified to increase the body mass index, plays a major role in cancer development and acquired therapy resistance in several cancer types. FTO demethylates m6A mRNA and modulates tumorigenesis, and drug resistance. In this study, we explored the functions of FTO in EGFR TKI resistance in NSCLC. To study the expression of FTO in erlotinib resistant cells, we used wildtype-EGFR NSCLC cell lines (H2170, H358) and mutant EGFR NSCLC cell lines (H1975, PC9) that were rendered resistant to erlotinib. Our RT-qPCR results demonstrated that FTO was upregulated by 1.7-3.0 fold in erlotinib resistant H2170, H358, PC9 and H1975 cells. FTO protein was upregulated by 1.3-1.6 fold as seen by western blotting, and by 1.7 to 2.6 fold in the nucleus of erlotinib resistant H1975, H2170 and PC9 cell lines by immunofluorescence. Furthermore, we investigated FTO inhibition with Dac51 (FTOi) on cell viability and cell migration properties. MTT cell viability assay showed a 9-17% decrease in cell viability when treated with a combination of Dac51 and erlotinib compared to Dac51 alone in erlotinib resistant H2170 and PC9 cells, respectively. The combinatory treatment showed an additive effect compared to the Dac51 and erlotinib treatments alone. Wound healing assay revealed an 18% open wound area after 48-hour treatment with both Dac51 and erlotinib compared to 0.1% after treatment with erlotinib alone in erlotinib resistant H2170 cells. To evaluate the effect of siRNA mediated FTO (siFTO) knockdown on cell viability and energy metabolism, MTT and luciferase assays were performed. MTT assay showed a 21-28% decrease in viability in erlotinib resistant H1975, H2170, PC9 cells, demonstrating increase in the erlotinib efficacy, as compared to the mock siRNA treatment. Luciferase assay showed an inverse relationship between the FTO and ATP, where the latter was upregulated by 1.3 to 3.4 folds in erlotinib resistant H1975, H2170 and PC9 cells, when treated with siFTO, suggesting its involvement in the energy requirements of the NSCLC cells. In conclusion, our study suggests FTO was upregulated in erlotinib resistant NSCLC cells on both the gene and protein levels. FTO could mediate resistance to EGFR TKI possibly through cell proliferation and migration and help with prognosis of NSCLC patients. Citation Format: Aayush Rastogi, Rong Qiu, Neelu Puri. FTO mediates tumor growth and resistance to erlotinib in NSCLC [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3290.

Erlotinib combination with a mitochondria-targeted ubiquinone effectively suppresses pancreatic cancer cell survival.

Pancreatic cancer is a leading cause of cancer-related deaths. Increased activity of the epidermal growth factor receptor (EGFR) is often observed in pancreatic cancer, and the small molecule EGFR inhibitor erlotinib has been approved for pancreatic cancer therapy by the food and drug administration. Nevertheless, erlotinib alone is ineffective and should be combined with other drugs to improve therapeutic outcomes. We previously showed that certain receptor tyrosine kinase inhibitors can increase mitochondrial membrane potential (Δψm), facilitate tumor cell uptake of Δψm-sensitive agents, disrupt mitochondrial homeostasis, and subsequently trigger tumor cell death. Erlotinib has not been tested for this effect. To determine whether erlotinib can elevate Δψm and increase tumor cell uptake of Δψm-sensitive agents, subsequently triggering tumor cell death. Δψm-sensitive fluorescent dye was used to determine how erlotinib affects Δψm in pancreatic adenocarcinoma (PDAC) cell lines. The viability of conventional and patient-derived primary PDAC cell lines in 2D- and 3D cultures was measured after treating cells sequentially with erlotinib and mitochondria-targeted ubiquinone (MitoQ), a Δψm-sensitive MitoQ. The synergy between erlotinib and MitoQ was then analyzed using SynergyFinder 2.0. The preclinical efficacy of the two-drug combination was determined using immune-compromised nude mice bearing PDAC cell line xenografts. Erlotinib elevated Δψm in PDAC cells, facilitating tumor cell uptake and mitochondrial enrichment of Δψm-sensitive agents. MitoQ triggered caspase-dependent apoptosis in PDAC cells in culture if used at high doses, while erlotinib pretreatment potentiated low doses of MitoQ. SynergyFinder suggested that these drugs synergistically induced tumor cell lethality. Consistent with in vitro data, erlotinib and MitoQ combination suppressed human PDAC cell line xenografts in mice more effectively than single treatments of each agent. Our findings suggest that a combination of erlotinib and MitoQ has the potential to suppress pancreatic tumor cell viability effectively.

Design, synthesis and bioactivity evaluation of the combination of evodiamine and erlotinib linked by indolequinone

Compared with single-targeted therapy, the design and synthesis of heterozygous molecules is still a significant challenge for the discovery of antitumor drugs. Quinone oxidoreductase-1 (NQO1) is a potential target for selective cancer therapy due to its overexpression in many cancer cells and its unique bioredox properties. Based on the principle of combinatorial drug design, we successfully synthesized a new hybrid molecules 13 with an indolequinone structure. We found that the synthesized compounds exhibited much higher cytotoxicity against the tested cancer cells than free drugs. Further mechanism studies confirmed that compound 13 induced cell apoptosis was achieved by regulating p53-dependent mitochondrial pathway and cell cycle arrest at the G0/G1 phase.

Quality of life following treatment with intra-arterial cisplatin with concurrent radiation and erlotinib for locally advanced head and neck cancer

ObjectivesStudies that focus on the feasibility of using erlotinib plus chemoradiation to treat locally advanced head and neck cancer have given hints of improved survival outcomes compared to chemoradiation alone. However, the influence of this treatment regimen on the quality of life of the patients has not been documented. We conducted a study of this triple combination and now have documented follow-up survival data as well as long-term quality of life (QoL) measures.MethodsThree sets of QoL questionnaires were given to patients with a diagnosis of head and neck cancer at two time points, pre- and post-treatment, to assess differences in quality of life after receiving chemotherapy with intra-arterial (IA) cisplatin (150 mg/m2), concomitant radiation (70 Gy), and oral erlotinib (150 mg/day). Additionally, patients were followed for a total of 5 years.ResultsTreatment had a detrimental effect on appearance, taste, and saliva domain scores in their QoL questionnaires. Nonetheless, fewer patients reported pain and anxiety.Significance of resultsThe combination of erlotinib with chemoradiation produced similar adverse effects on the QoL scores of patients with head and neck cancer as compared to chemoradiation alone.

Abstract B087: CTNNB1 mutations can mediate resistance to EGFR targeted therapies in Non-Small Cell Lung Cancer

Abstract Resistance to targeted therapy remains an ongoing challenge in lung cancer. β-Catenin (CTNNB1) mutations are observed in lung cancer, often co-occurring with known oncogenic alterations such as EGFR/KRAS/ALK. Oncogenic CTNNB1 mutations disrupt the β-catenin destruction complex upregulating Wnt signaling that may cause resistance to therapies targeting oncogenic drivers. An example of this was identified in post-mortem donated NSCLC tissue of a patient treated with a combination of carboplatin, pemetrexed, and bevacizumab that harbored both an acquired CTNNB1-T41A mutation and an EGFR exon 20 insertion. In addition, the CTNNB1 mutation spectrum was analyzed in lung cancer patients at Moffitt Cancer Center to identify prevalent CTNNB1 mutations for functional analyses. T41A, along with the most frequent Exon 3 CTNNB1 mutations were selected and transduced into HCC827 mutant cell lines to determine their ability to drive resistance to targeted therapies. Subsequently, western blotting and RNA sequencing were performed to assess differences between cells expressing wild-type and the most-resistant CTNNB1 mutant. A viability screen was also performed in which these cells were treated with a panel of drugs with known targets (COCKTAIL), in combination with EGFR TKI erlotinib, to identify new vulnerabilities of this CTNNB1 mutant erlotinib-resistant cells. Our data indicate that some CTNNB1 mutations, T41A, S37F, S45C and D32H, can cause resistance to EGFR inhibitor therapy, while others, D32Y, S33C, S33Y, S45P, and S37C, do not. Western blot analysis shows corresponding stabilization and higher accumulation of active β-catenin in cells expressing CTNNB1 mutants that are resistant to erlotinib. Of the mutations tested, cells expressing CTNNB1 T41A demonstrated the strongest resistance to erlotinib. Further analysis reveals higher levels of β-catenin regulated proteins, like axin2 and survivin, as well as EMT markers, such as vimentin and N-cadherin, in HCC827 CTNNB1 T41A cells when compared to the HCC827 CTNNB1 WT. Pathway analysis of genes differentially expressed between the WT and T41A mutant cells reveal WNT pathway to be the top upregulated pathway in the mutant cells. HCC827 T41A also showed sustained ERK, AKT and GSK3β signaling, and lower PARP cleavage compared to wild type, which may explain the resistance to EGFR TKI seen in these cells. COCKTAIL screening, comparing drug sensitivities of the WT and T41A mutant HCC827 cells to erlotinib in combination with various other targeted agents, identified PI3K, mTOR and MEK inhibitors that can reverse erlotinib resistance in the HCC827 CTNNB1 T41A cells. Our data suggests that CTNNB1 may be an important co-occurring alteration in developing resistance to targeted EGFR therapy. However, we show that different CTNNB1 mutations have differing abilities to drive resistance to EGFR TKI which correlates with the level of stabilization and activation of CTNNB1 and its downstream targets by these mutations. Citation Format: Anurima Majumder, Liznair Bridenstine, Benjamin Meyer, Fumi Kinose, J. Kevin Hicks, Theresa A Boyle, Eric B Haura. CTNNB1 mutations can mediate resistance to EGFR targeted therapies in Non-Small Cell Lung Cancer [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr B087.

BPTF Drives Gastric Cancer Resistance to EGFR Inhibitor by Epigenetically Regulating the C-MYC/PLCG1/Perk Axis.

Erlotinib, an EGFR tyrosine kinase inhibitor, is used for treating patients with cancer exhibiting EGFR overexpression or mutation. However, the response rate of erlotinib is low among patients with gastric cancer (GC). The findings of this study illustrated that the overexpression of bromodomain PHD finger transcription factor (BPTF) is partially responsible for erlotinib resistance in GC, and the combination of the BPTF inhibitor AU-1 with erlotinib synergistically inhibited tumor growth both in vivo and in vitro. AU-1 inhibited the epigenetic function of BPTF and decreased the transcriptional activity of c-MYC on PLCG1 by attenuating chromosome accessibility of the PLCG1 promoter region, thus decreasing the expression of p-PLCG1 and p-Erk and eventually improving the sensitivity of GC cells to erlotinib. In patient-derived xenograft (PDX) models, AU-1 monotherapy exhibited remarkable tumor-inhibiting activity and is synergistic anti-tumor effects when combined with erlotinib. Altogether, the findings illustrate that BPTF affects the responsiveness of GC to erlotinib by epigenetically regulating the c-MYC/PLCG1/pErk axis, and the combination of BPTF inhibitors and erlotinib is a viable therapeutic approach for GC.

Bevacizumab plus erlotinib versus erlotinib alone for advanced EGFR-mutant non-small cell lung cancer: a meta-analysis of randomized clinical trials

ObjectivePrevious studies showed that the combination of bevacizumab and erlotinib (combination therapy) significantly prolonged progression-free survival (PFS) but no overall survival (OS) compared to erlotinib alone (monotherapy) for advanced EGFR-mutant non-small cell lung cancer (NSCLC). Two phase III randomized controlled trials (RCTs) had reported the OS results in 2021. This meta-analysis aimed to include the results of the two RCTs to make a decision.Materials and methodsWe systematically searched relevant databases for RCTs on the use of bevacizumab plus erlotinib in advanced EGFR-mutant NSCLC. The main outcomes of interest were PFS, OS, and the reported hazard ratio (HR). Fixed-effect model was used to estimate pooled HR.ResultsTotal 5 RCTs with 935 patients were eligible for this meta-analysis. All studies reached their primary study endpoints including PFS and OS. Compared to monotherapy, combination therapy remarkably prolonged PFS (HR = 0.60, 95% confidence interval CI 0.51–0.70; p < 0.00001); however, OS was similar between the two groups (HR = 0.90, 95% CI 0.76–1.08; p = 0.26). Subgroup analysis demonstrated that in deletion within exon 19 (19del) mutation subgroup, the combination therapy could only prolong PFS (HR = 0.60, 95% CI 0.47–0.76; p < 0.0001) but not OS (HR = 1.00, 95% CI 0.73–1.37; p = 1.00), and also in leucine-to-arginine substitution in exon 21 (L858R) mutation subgroup (HR = 0.59, p < 0.0001 and HR = 0.80, p = 0.18, respectively). For patients with brain metastasis at baseline, the combination therapy achieved a significant better PFS than the monotherapy (HR = 0.60, 95% CI 0.39–0.90; p = 0.01), and a better OS with the difference marginally significant (HR = 0.69, 95% CI 0.46–1.02; p = 0.06).ConclusionsCombination of bevacizumab and erlotinib can prolong progression-free survival but not overall survival compared to erlotinib alone in advanced EGFR-mutant non-small cell lung cancer patients. The combination therapy not only can prolong progression-free survival but also has a tendency to prolong overall survival for patients with brain metastasis at baseline.

Augmented antitumor effects of erlotinib and cabozantinib on A549 non-small cell lung cancer: In vitro and in vivo studies

Non-small cell lung carcinoma is a challenging disease worldwide. This study aims to determine whether combining erlotinib, an epidermal growth factor receptor (EGFR) inhibitor, with cabozantinib, a mesenchymal-epithelial transition factor (c-Met) inhibitor, would have an augmented therapeutic benefit on A549 cells. The combination of erlotinib and cabozantinib (5 µM) inhibited A549 cell viability compared to each monotherapy at ≥ 10 µM as confirmed by the MTT assay. Combination therapy also has a more potent inhibition of cellular migration than monotherapy using the wound-healing assay. Furthermore, mRNA expression analyses for assessing apoptosis, metastasis, and cell cycle-related genes, the results showed that combination therapy significantly inhibits levels of BCL-2, MMP-9, VEGF, and TGF-β while inducing p53, p21, and BAX expression. In terms of oncogenic markers, western blotting analysis showed a significant reduction of BCl-2 expression and elevation in caspase3, p53, and p21 proteins as indicators of cell death via apoptosis. The antitumor in vivo effect of the combination therapy showed significant tumor inhibition compared to monotherapy. In conclusion, combination therapy could be a potential promising strategy to treat non-small cell lung carcinoma.

A protocol of a single arm, prospective, open-label, multicenter, phase II study of ramucirumab and erlotinib in treatment-naïve non-small cell lung cancer patients with EGFR mutation and brain metastases (SPIRAL-BRAIN study).

The combination of erlotinib, a first-generation epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI), and ramucirumab, an anti-vascular endothelial growth factor receptor (VEGFR) antibody, is one of the most effective treatments for patients with non-small cell lung cancer (NSCLC) and EGFR mutation. However, little is known about the safety and efficacy of this combination treatment for patients with brain metastases. This single arm, prospective, open-label, multicenter, phase II study will recruit 32 NSCLC patients with EGFR mutation (except for T790M mutation) and brain metastases (asymptomatic or mild symptoms). Patients will be treated with erlotinib at a dose of 150 mg/body once daily and ramucirumab at a dose of 10 mg/kg once every 2 weeks. The primary endpoint is intracranial overall response rate (iORR) and the secondary endpoints are intracranial disease control rate, intracranial progression-free survival (iPFS), extracranial ORR, extracranial PFS, ORR, overall PFS, overall survival (OS), and safety. The planned number of enrollments was calculated based on a one-sample binomial test (normal approximation) with a two-sided α level of 5% and 80% power, assuming that the expected iORR is 65% and the iORR threshold is 40%. A prospective study to confirm the safety and efficacy of the combined erlotinib plus ramucirumab treatment for NSCLC patients with EGFR mutation and brain metastases is ongoing. Japan Registry of Clinical Trials, jRCTs051220059.

Signaling pathways in pancreatic ductile adenocarcinoma and potential therapeutic targets

Pancreatic ductile adenocarcinoma (PDAC) has a dismal prognosis, with an overall 5-year survival of &lt;10%. At present, PDAC is treated using systemic chemotherapeutic regimens, which have shown survival benefit in clinical trials. Unfortunately, the survival benefit offered by the current standards do not greatly impact the 5-year overall survival statistics with the disease and are associated with toxicity. The large majority of PDACs are associated with a mutation in Kirsten Ras (KRAS), which results in constative activation of downstream signaling resulting in oncogenesis, tumor progression, cellular survival, and metastasis. Due to the lack of druggable sites, designing direct KRAS inhibitors have proven difficult and extensive effort has been placed in finding upstream or downstream targets as potential therapeutic avenues. The epidermal growth factor receptor (EGFR), hedgehog (HH), and mTOR signaling pathways have all gained recent attention as potential candidates for targeted PDAC therapies. Erlotinib, an EGFR small-molecule inhibitor, has shown promise in preclinical studies against PDAC. It is currently the only Food and Drug Administration (FDA) approved targeted therapy for PDAC when used in conjunction with gemcitabine. However, clinical trials comparing erlotinib plus gemcitabine to gemcitabine alone have demonstrated only modest statistical significance in overall survival. Due to the unique hypovascular microenvironment in PDAC, designated by the term desmoplasia, the HH signaling pathway has also gained recent research interest. Recent studies have shown lithium, a divalent cation originally FDA approved for bipolar disorder, to inhibit PDAC progression through its mechanism of glycogen synthase 3 inhibition in the HH pathway. Metformin, a biguanide medication used in type II diabetes mellitus, has been shown to inhibit mammalian target of rapamycin complex 1 (mTORC1) signaling indirectly through its activation of AMPK. Preclinical studies have demonstrated tumor regression, induction of apoptosis, and effects on the microenvironment in PDAC through the inhibition of mTORC1 by metformin. We present compelling scientific rationale, based on unique signal transduction pathways, tumor pathophysiology, and therapeutics potential for the combination of erlotinib, lithium, and metformin for the treatment of PDAC.

A phase I/IB trial of binimetinib in combination with erlotinib in NSCLC harboring activating KRAS or EGFR mutations

BackgroundActivating mutations in EGFR or KRAS are highly prevalent in NSCLC, share activation of the MAPK pathway and may be amenable to combination therapy to prevent negative feedback activation. MethodsIn this phase 1/1B trial, we tested the combination of binimetinib and erlotinib in patients with advanced NSCLC with at least 1 prior line of treatment (unless with activating EGFR mutation which could be treatment-naïve). A subsequent phase 1B expansion accrued patients with either EGFR- or KRAS-mutation using the recommended phase 2 dose (RP2D) from Phase 1. The primary objective was to evaluate the safety of binimetinib plus erlotinib and establish the RP2D. Results43 patients enrolled (dose-escalation = 23; expansion = 20). 17 harbored EGFR mutation and 22 had KRAS mutation. The RP2D was erlotinib 100 mg daily and binimetinib 15 mg BID × 5 days/week. Common AEs across all doses included diarrhea (69.8%), rash (44.2%), fatigue (32.6%), and nausea (32.6%), and were primarily grade 1/2. Among KRAS mutant patients, 1 (5%) had confirmed partial response and 8 (36%) achieved stable disease as best overall response. Among EGFR mutant patients, 9 were TKI-naïve with 8 (89%) having partial response, and 8 were TKI-pretreated with no partial responses and 1 (13%) stable disease as best overall response. ConclusionsBinimetinib plus erlotinib demonstrated a manageable safety profile and modest efficacy including one confirmed objective response in a KRAS mutant patient. While clinical utility of this specific combination was limited, these results support development of combinations using novel small molecule inhibitors of RAS, selective EGFR- and other MAPK pathway inhibitors, many of which have improved therapeutic indices. Clinical Trial RegistrationNCT01859026

Biological medicines for diffuse intrinsic pontine glioma (DIPG) eradication (BIOMEDE): Final results of an international randomized phase II platform trial comparing 3 targeted therapies in combination with radiotherapy from ITCC, SIOPE-Brain and ANZCHOG.

10003 Background: DIPG is the most aggressive brain cancer in children and adolescents with a median survival of 9 months. Surgery is not possible due to the invasive nature of the disease in a critical area of the brain; only radiotherapy has shown a transient palliative effect on disease progression and no adjuvant therapy has proven to increase disease control. Methods: We launched a large randomized biomarker-driven platform trial to compare three targeted therapies (erlotinib, everolimus and dasatinib) in combination with 54 Gy radiotherapy, in newly diagnosed patients with DIPG (NCT02233049). A central pathological review was performed prior to study entry to confirm the diagnosis of DIPG with H3K27me3 loss (with or without H3K27M mutation) and assess biomarkers. The randomization was designed so that a drug could not be allocated if the corresponding biomarker was absent in the tumor (EGFR overexpression for erlotinib, mTOR activation for everolimus, no specific biomarker for dasatinib). Tumors underwent whole genome sequencing and RNAseq to evaluate prognostic and theranostic biomarkers. Primary endpoint was overall survival. Results: Among the 279 DIPG patients screened for the randomized trial between October 2014 and September 2019, 233 were enrolled in 45 centers in 7 countries; among the 46 screen failures, the diagnosis of DIPG could not be confirmed in 23 patients. No biopsy- or treatment-related death was reported. Serious adverse events &gt; = 3 unrelated to disease progression were reported in 40% of patients, 34%, 36% and 46%, in the erlotinib, everolimus and dasatinib arms, respectively (p = 0.32). With a median follow-up of 5.3 years, median overall survival (OS) from the date of randomization was 9.0 (95% confidence interval, 7.4-14.4), 11.3 (10.3-13.4) and 9.4 (7.7-10.7) months for erlotinib, everolimus and dasatinib, respectively (p = 0.45). OS were not statistically different from those of a historical biopsy-proven cohort. The molecular profiling with copy number aberrations (CNA) had a strong impact on survival (log-rank test, p = 0.0001) as shown by the preliminary analysis of the first hundred patients identifying a group of tumors with very poor prognosis with a HR for death of 1.96 (1.07-3.64) characterized by TP53 mutations (p = 3.05e-11) associated with more CNA (p &lt; 0.0001). Conclusions: This trial demonstrated the feasibility and safety of a large randomized trial for DIPG based on biomarker information from a stereotactic biopsy at diagnosis in an international multicenter setting and generated new tumor biological insights to further develop innovative therapies. Clinical trial information: NCT02233049 .

Antitumor effects of erlotinib in combination with berberine in A431 cells

BackgroundFirst-generation epidermal growth factor receptor tyrosine kinase inhibitors (EGFR-TKIs), such as erlotinib, have been shown to target tumors with L858R (exon 21) and exon 19 deletions, resulting in significant clinical benefits. However, acquired resistance often occurs due to EGFR mutations. Therefore, novel therapeutic strategies for treatment of patients with EGFR-positive tumors are needed. Berberine (BBR) is an active alkaloid extracted from pharmaceutical plants such as Coptis chinensis. Berberine has been shown to significantly inhibit EGFR activity and mediate anticancer effects in multiple preclinical studies. We investigated whether combining BBR with erlotinib could augment erlotinib-induced cell growth inhibition of EGFR-positive cells in a mouse xenograft model.MethodsWe examined the antitumor activities and potential mechanisms of erlotinib in combination with berberine in vitro and in vivo using the MTT assay, immunoblotting, flow cytometry, and tumor xenograft models.ResultsIn vitro studies with A431 cells showed that synergistic cell growth inhibition by the combination of BBR and erlotinib was associated with significantly greater inhibition of pEGFR and pAKT, and inhibition of cyclin D and Bcl-2 expression compared to that observed in response to BBR or erlotinib alone. The efficacy of the combination treatment was also investigated in nude mice. Consistent with the in vitro results, BBR plus erlotinib significantly reduced tumor growth.ConclusionOur data supported use of BBR in combination with erlotinib as a novel strategy for treatment of patients with EGFR positive tumors.

Combinatorial immunotherapy with gemcitabine and ex vivo-expanded NK cells induces anti-tumor effects in pancreatic cancer

Pancreatic cancer is difficult to diagnose at the initial stage and is often discovered after metastasis to nearby organs. Gemcitabine is currently used as a standard treatment for pancreatic cancer. However, since chemotherapy for pancreatic cancer has not yet reached satisfactory therapeutic results, adjuvant chemotherapy methods are attempted. It can be expected that combining immune cell therapy with existing anticancer drug combination treatment will prevent cancer recurrence and increase survival rates. We isolated natural killer (NK) cells and co-cultured them with strongly activated autologous peripheral blood mononuclear cells (PBMCs) as feeder cells, activated using CD3 antibody, IFN-r, IL-2, and γ-radiation. NK cells expanded in this method showed greater cytotoxicity than resting NK cells, when co-cultured with pancreatic cancer cell lines. Tumor growth was effectively inhibited in a pancreatic cancer mouse xenograft model. Therapeutic efficacy was increased by using gemcitabine and erlotinib in combination. These findings suggest that NK cells cultured by the method proposed here have excellent anti-tumor activity. We demonstrate that activated NK cells can efficiently inhibit pancreatic tumors when used in combination with gemcitabine-based therapy.