C-kit Inhibitor Research Articles

Abstract 1045: Differentiated tumor cells secrete stem cell factor (SCF) to promote maintenance of cancer stem cells and induce EMT in colorectal tumors

Abstract Colorectal tumors are hierarchically organized in which cancer stem cells (CSCs) are at the top of the hierarchy and give rise to non-tumorigenic differentiated tumor cells (DTC). The maintenance of normal intestinal stem cells requires ‘niche’ signals that are provided, at least in the small intestine, by neighboring differentiated Paneth cells. CSC maintenance may also depend on niche signals although little is known about the nature of such signals and their potential source. For the present study we tested the hypothesis that DTCs could provide CSC-maintaining signals. We used CSC-enriched colonosphere cultures that were established from human colorectal tumors and CSC-derived stably differentiated offspring that was derived from them. We found that DTCs established from multiple colorectal tumors greatly increased the clone-forming capacity of CSCs. This effect was reproduced by DTC-conditioned medium, suggesting the involvement of a secreted factor. By using a cytokine array we identified stem cell factor (SCF) as a major DTC-secreted factor. While SCF was mainly produced by DTCs, its receptor, c-Kit, was mainly expressed by CSCs. Indeed, recombinant SCF enhanced clone-forming capacity to a similar extent as DTC-conditioned medium. Furthermore, basal and DTC-stimulated clone-forming capacity was strongly reduced in the presence of an SCF-neutralizing antibody or in the presence of the cKit inhibitors Imatinib or ISCK03. qPCR and western blot analysis showed that inhibition of cKit caused a strong reduction in the expression of stem cell genes, including LGR5, CD133, OLMF4 and SOX2. Furthermore, DTCs induce the E-to N-cadherin switch in CSCs and to a strong increase in the expression of EMT markers such as vimentin, ZEB1, ZEB2, SNAIL1 and fibronectin. cKIT inhibitors prevented EMT. Our results identify a critical role for non-tumorigenic DTCs in the support of colorectal CSCs. DTCs induce EMT and EMT-associated stem cell characteristics at least in part via paracrine SCF-cKit signaling. We conclude that cKit inhibitors that are widely used in the clinic to treat gastrointestinal stromal tumors (GIST) and acute myeloid leukemia (AML), may have therapeutic value in the treatment of (a subgroup of) colorectal tumors. Citation Format: Szabolcs Fatrai, Susanne J. van Schelven, Inne H.M. Borel Rinkes, Onno Kranenburg. Differentiated tumor cells secrete stem cell factor (SCF) to promote maintenance of cancer stem cells and induce EMT in colorectal tumors. [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 1045. doi:10.1158/1538-7445.AM2014-1045

Imatinib in pulmonary arterial hypertension: c-Kit inhibition.

Pulmonary arterial hypertension (PAH) is a progressive disease characterized by severe remodeling of the pulmonary artery resulting in increased pulmonary artery pressure and right ventricular hypertrophy and, ultimately, failure. Bone marrow-derived progenitor cells play a critical role in vascular homeostasis and have been shown to be involved in the pathogenesis of PAH. A proliferation of c-Kit(+) hematopoietic progenitors and mast cells has been noted in the remodeled vessels in PAH. Imatinib, a tyrosine kinase inhibitor that targets c-Kit, has been shown to be beneficial for patients with PAH. Here we hypothesize that the clinical benefit of imatinib in PAH could be related to c-Kit inhibition of progenitor cell mobilization and maturation into mast cells. As a corollary to the phase 3 study using imatinib in PAH, blood samples were collected from 12 patients prior to starting study drug (baseline) and while on treatment at weeks 4 and 24. Eight were randomized to imatinib and 4 to placebo. Circulating c-Kit(+) and CD34(+)CD133(+) hematopoietic progenitors as well as biomarkers of mast cell numbers and activation were measured. Circulating CD34(+)CD133(+) and c-Kit(+) progenitor cells as well as c-Kit(+)/CD34(+)CD133(+) decreased with imatinib therapy (all P < 0.05). In addition, total tryptase, a marker of mast cell load, dropped with imatinib therapy (P = 0.02) and was related to pulmonary vascular resistance (R = 0.7, P = 0.02). The findings support c-Kit inhibition as a potential mechanism of action of imatinib in PAH and suggest that tryptase is a potential biomarker of response to therapy.

Niche anchorage and signaling through membrane-bound Kit-ligand/c-kit receptor are kinase independent and imatinib insensitive.

Kit ligand (KitL) and its tyrosine kinase receptor c-kit are critical for germ cells, melanocytes, mastocytes, and hematopoietic stem cells. Alternative splicing of KitL generates membrane-bound KitL (mb-KitL) or soluble KitL, providing survival or cell migration, respectively. Here we analyzed whether c-kit can function both as an adhesion and signaling receptor to mb-KitL presented by the environmental niche. At contacts between fibroblasts and MC/9 mast cells, mb-KitL, and c-kit formed ligand/receptor clusters that formed stable complexes, which resisted dissociation by c-kit blocking mAbs and provided cell anchorage under physiological shear stresses. Clusters recruited tyrosine-phosphorylated proteins and induced spatially restricted F-actin polymerization. Mutational analysis of c-kit demonstrated kinase-independent mb-KitL/c-kit clustering, anchorage, F-actin polymerization, and Tyr567-dependent cluster phosphorylation. Kinase inhibition of c-kit by imatinib reduced cluster coalescence, but allowed cluster phosphorylation and F-actin polymerization, which required PI3K recruitment and a newly identified juxtamembrane residue. Synergies between integrin and c-kit-mediated spreading and adhesion of MC/9 cells were studied in vitro on immobilized-KitL/fibronectin surfaces. While c-kit blocking antibodies prevented spreading, imatinib blocked spreading induced by soluble- but not immobilized KitL. Thus, "mechanical" activation of c-kit provides signaling, niche-anchorage, and synergies with integrin-mediated adhesion, which is independent of kinase function and resistant to c-kit kinase inhibitors.-

Sustained Inhibition of Receptor Tyrosine Kinases and Macrophage Depletion by PLX3397 and Rapamycin as a Potential New Approach for the Treatment of MPNSTs

Malignant peripheral nerve sheath tumor (MPNST) is a highly aggressive tumor type that is resistant to chemotherapy and there are no effective therapies. MPNSTs have been shown to have gene amplification for receptor tyrosine kinases (RTK), PDGFR and c-Kit. We tested the c-Kit inhibitor, imatinib, and PLX3397, a selective c-Fms and c-Kit inhibitor, to evaluate their efficacy against MPNST cells in vitro and in vivo. We tested the efficacy of imatinib or PLX3397 either alone or in combination with TORC1 inhibitor rapamycin in a cell proliferation assay in vitro and by immunoblotting to determine target inhibition. Immunoblotting and immunohistochemical analysis was further carried out using xenograft samples in vivo. Our in vitro studies show that imatinib and PLX3397 similarly inhibit cell growth and this can be enhanced with rapamycin with comparable target specificity. However, in vivo studies clearly demonstrate that compared with imatinib, PLX3397 results in sustained blockade of c-Kit, c-Fms, and PDGFRβ, resulting in significant suppression of tumor growth. Moreover, staining for Iba-1, a marker for macrophages, indicates that PLX3397 results in significant depletion of macrophages in the growing tumors. The combination of PLX3397 and rapamycin results in even greater macrophage depletion with continued growth suppression, even when the drug treatment is discontinued. Taken together, our data strongly suggest that PLX3397 is superior to imatinib in the treatment of MPNSTs, and the combination of PLX3397 with a TORC1 inhibitor could provide a new therapeutic approach for the treatment of this disease.

Highlights of This Issue

Multiple oncogene fusions, involving the NRG1, ERBB4, BRAF, ALK and RET genes, were identified as drivers for development of invasive mucinous adenocarcinoma (IMA) of the lungs. These fusions, and BRAF and EGFR activating mutations, occurred in approximately 15% of IMA cases. The aberrations were exclusively detected in cases without KRAS mutation, a known major oncogene aberration in IMA. These fusions represent therapeutic targets for tyrosine kinase inhibitors (TKIs) approved for clinical use, in addition to BRAF and EGFR mutations.Malignant peripheral nerve sheath tumors (MPNSTs) are aggressive and therapeutically resistant tumors with gene amplification for receptor tyrosine kinases (RTKs) such as c-Kit and PDGFR. Patwardhan and colleagues tested the efficacy of imatinib and PLX3397, a selective c-Kit and c-Fms inhibitor in MPNST cells and xenografts. Although both drugs showed comparable efficacy in vitro, PLX3397 treatment was superior in blocking RTK pathways and resulted in significant macrophage depletion in vivo. PLX3397 and rapamycin combination further enhanced macrophage depletion and resulted in sustained tumor suppression. PLX3397 and rapamycin combination therapy could provide a new therapeutic approach for the treatment of MPNSTs.Triple negative breast cancer (TNBC) is a heterogenous disease associated with treatment resistance and a lack of effective therapeutic targets. In this study, Chittaranjan and colleagues explore whether manipulating autophagy improves treatment efficacy in TNBC. They find that epirubicin-induced apoptosis was augmented by autophagy suppression in both anthracycline - sensitive and resistant TNBC cells in vitro. In TNBC tumor xenograft mouse models, combined treatment of epirubicin and the autophagy inhibitor hydroxychloroquine significantly reduced the growth of both anthracycline sensitive and resistant TNBC tumors, compared with either monotherapy. These findings support a strategy combining autophagy inhibition with anthracycline therapy for TNBC.Reliable detection and characterization of prostate cancer is still challenging. In a registered prospective diagnostic trial, Hartenbach and colleagues investigated the value of combining the high sensitivity of 18Fluoroethylcholine-(FEC)-PET with the high resolution of T2w endorectal MRI for the detection of primary prostate cancer. They reported significantly higher diagnostic accuracy for the combination of both imaging techniques as compared to each single method in the detection of the clinically significant intraprostatic tumor lesions. Furthermore, FEC-PET enabled noninvasive assessment of tumor aggressiveness in this setting. Combined PET/MRI promises to reduce the number of patients subjected to over- or undertreatment and could potentially enhance the success rate of needle biopsies.

Resistance to c-Kit inhibitors in melanoma: insights for future therapies.

Mutations activating the receptor tyrosine kinase c-Kit occur commonly in melanomas arising on mucosal membranes and acral skin. Clinical studies have demonstrated that selective inhibition of c-Kit is effective in treating patients with c-Kit mutant gastrointestinal stromal tumors, but c-Kit inhibitor activity has been disappointing in c-Kit mutant melanoma patients. Activated c-Kit utilises phosphatidylinositol 3-kinase (PI3K) signalling as the dominant effector of cell proliferation and survival with the mitogen-activated protein kinase (MAPK) cascade serving as an ancillary survival pathway. We confirmed that these pathways are re-activated in melanoma cells with acquired resistance to c-Kit inhibitors and that these resistant sublines remain sensitive to the concurrent inhibition of MAPK and PI3K signalling. These findings suggest that durable responses in c-Kit mutant melanoma may require combination therapies that selectively inhibit critical downstream proliferative and survival pathways. We also discuss the interaction between targeted therapies and anti-tumor immune responses and the need to consider immunotherapies in new combinatorial treatment approaches.

Treatment patterns, prescribing decision drivers, and predictors of complete response following disease recurrence in gastrointestinal stromal tumor patients-a chart extract-based approach.

The aim of this study was to investigate tumor characteristics, treatment patterns, and outcomes in recurrent KIT + GIST patients treated in a community practice setting. An online tool was used to retrieve data on 410 patients treated with adjuvant imatinib mesylate (IM) for primary resectable KIT + GIST, who discontinued, had a recurrence, and then restarted IM or initiated sunitinib. Tumor characteristics at recurrence, treatment patterns, and factors associated with post-recurrence complete response (CR) achievement were analyzed. About 72.7% of patients did not have surgery post-recurrence as majority of them had unresectable (45%), metastatic (40%), or multifocal tumors (62.4%). Following recurrence, 76.6% of patients were re-started on IM and 23.4% on sunitinib; patients were 7.37 times more likely to re-start IM if initial treatment duration was ≤18months (p < 0.001). Patients were also more likely to re-start IM if recurrence occurred >12months post-discontinuation, or they had a recurrence inside the GI system, lower or unknown Fletcher risk score at primary diagnosis, or lower mitotic rate, (odds ratio (OR) = 3.54, p < 0.001; OR = 2.64, p = 0.006; OR = 2.55, p = 0.007; and OR = 2.45, p = 0.002, respectively). About 22.4% achieved CR; patients were more likely to achieve CR if they had unifocal tumor at recurrence, inside the GI system, of ≤2cm, or had lower mitotic rate (OR = 2.61, p < 0.001; OR = 2.27, p = 0.036; OR = 2.16, p = 0.023, OR = 1.87, p = 0.017, respectively). IM treatment duration at primary diagnosis, time to develop recurrence after IM discontinuation, tumor location, and mitotic rate at recurrence were the main prescribing decision drivers. Tumor characteristics were the most important factor in achieving CR following c-KIT inhibitor retreatment.

Role of altered growth factor receptor-mediated JAK2 signaling in growth and maintenance of human acute myeloid leukemia stem cells

AbstractAcute myeloid leukemia (AML) is sustained by small populations of leukemia stem cells (LSCs) that can resist available treatments and represent important barriers to cure. Although previous studies have shown increased signal transducer and activator of transcription (STAT)3 and STAT5 phosphorylation in AML leukemic blasts, the role of Janus kinase (JAK) signaling in primary AML compared with normal stem cells has not been directly evaluated. We show here that JAK/STAT signaling is increased in LSCs, particularly from high-risk AML. JAK2 inhibition using small molecule inhibitors or interference RNA reduced growth of AML LSCs while sparing normal stem cells both in vitro and in vivo. Increased JAK/STAT activity was associated with increased expression and altered signaling through growth factor receptors in AML LSCs, including receptor tyrosine kinase c-KIT and FMS-related tyrosine kinase 3 (FLT3). Inhibition of c-KIT and FLT3 expression significantly inhibited JAK/STAT signaling in AML LSCs, and JAK inhibitors effectively inhibited FLT3-mutated AML LSCs. Our results indicate that JAK/STAT signaling represents an important signaling mechanism supporting AML LSC growth and survival. These studies support continued evaluation of strategies for JAK/STAT inhibition for therapeutic targeting of AML LSCs.

Sorafenib Cardiotoxicity Increases Mortality After Myocardial Infarction

Sorafenib is an effective treatment for renal cell carcinoma, but recent clinical reports have documented its cardiotoxicity through an unknown mechanism. Determining the mechanism of sorafenib-mediated cardiotoxicity. Mice treated with sorafenib or vehicle for 3 weeks underwent induced myocardial infarction (MI) after 1 week of treatment. Sorafenib markedly decreased 2-week survival relative to vehicle-treated controls, but echocardiography at 1 and 2 weeks post MI detected no differences in cardiac function. Sorafenib-treated hearts had significantly smaller diastolic and systolic volumes and reduced heart weights. High doses of sorafenib induced necrotic death of isolated myocytes in vitro, but lower doses did not induce myocyte death or affect inotropy. Histological analysis documented increased myocyte cross-sectional area despite smaller heart sizes after sorafenib treatment, further suggesting myocyte loss. Sorafenib caused apoptotic cell death of cardiac- and bone-derived c-kit+ stem cells in vitro and decreased the number of BrdU+ (5-bromo-2'-deoxyuridine+) myocytes detected at the infarct border zone in fixed tissues. Sorafenib had no effect on infarct size, fibrosis, or post-MI neovascularization. When sorafenib-treated animals received metoprolol treatment post MI, the sorafenib-induced increase in post-MI mortality was eliminated, cardiac function was improved, and myocyte loss was ameliorated. Sorafenib cardiotoxicity results from myocyte necrosis rather than from any direct effect on myocyte function. Surviving myocytes undergo pathological hypertrophy. Inhibition of c-kit+ stem cell proliferation by inducing apoptosis exacerbates damage by decreasing endogenous cardiac repair. In the setting of MI, which also causes large-scale cell loss, sorafenib cardiotoxicity dramatically increases mortality.

Inhibition of c-Kit signaling is associated with reduced heat and cold pain sensitivity in humans

The tyrosine kinase receptor c-Kit is critically involved in the modulation of nociceptive sensitivity in mice. Ablation of the c-Kit gene results in hyposensitivity to thermal pain, whereas activation of c-Kit produces hypersensitivity to noxious heat, without altering sensitivity to innocuous mechanical stimuli. In this study, we investigated the role of c-Kit signaling in human pain perception. We hypothesized that subjects treated with Imatinib or Nilotinib, potent inhibitors of tyrosine kinases including c-Kit but also Abl1, PDFGFRα, and PDFGFRβ, that are used to treat chronic myeloid leukemia (CML), would experience changes in thermal pain sensitivity. We examined 31 asymptomatic CML patients (14 male and 17 female) receiving Imatinib/Nilotinib treatment and compared them to 39 age- and sex-matched healthy controls (12 male and 27 female). We used cutaneous heat and cold stimulation to test normal and noxious thermal sensitivity, and a grating orientation task to assess tactile acuity. Thermal pain thresholds were significantly increased in the Imatinib/Nilotinib-treated group, whereas innocuous thermal and tactile thresholds were unchanged compared to those in the control group. In conclusion, our findings suggest that the biological effects of c-Kit inhibition are comparable in mice and humans in that c-Kit activity is required to regulate thermal pain sensitivity but does not affect innocuous thermal and mechanical sensation. The effect on experimental heat pain observed in our study is comparable to those of several common analgesics; thus modulation of the c-Kit pathway can be used to specifically modulate noxious heat and cold sensitivity in humans.

CD117 (c-kit) Expression on CD34+ Cells Participates in the Cytogenetic Response to Imatinib in Patients with Chronic Myeloid Leukemia in the First Chronic Phase

Background: Chronic myeloid leukemia (CML) biology seemed to be perfectly explored especially at the beginning of the tyrosine kinase inhibitors era. Later years with imatinib and second-generation tyrosine kinase inhibitors showed a variety of resistance mechanisms and it became obvious that the bcr-abl chimeric gene is not the only enemy to fight. Some studies assumed the decreased rate of programmed cell death (apoptotic) to be the primary mechanism by which BCR-ABL affects expansion of the leukemic clone in CML. Therefore, the aim of this study was to investigate the role of c-kit inhibition in treatment response. Methods: Cytogenetic analysis, real-time quantitative reverse-transcriptase polymerase chain reaction, flow-cytometric analysis and imatinib serum level quantification were applied. Results: The percentage of CD34+ cells expressing c-kit (CD117) isolated from bone marrow samples of 54 CML patients treated with standard-dose imatinib was significantly lower among imatinib responders. The fraction of apoptotic CD34+CD117+ cells in this patient group was significantly higher than in nonresponders. Conclusion: To achieve optimal treatment response in CML patients, the elimination of CD34+CD117+ may be necessary through an apoptotic pathway.

Inhibition of c-Kit Is Not Required for Reversal of Hyperglycemia by Imatinib in NOD Mice

(1) Aim/HypothesisRecent studies indicate that tyrosine kinase inhibitors, including imatinib, can reverse hyperglycemia in non-obese diabetic (NOD) mice, a model of type 1 diabetes (T1D). Imatinib inhibits c-Abl, c-Kit, and PDGFRs. Next-generation tyrosine kinase inhibitors for T1D treatment should maintain activities required for efficacy while sparing inhibition of targets that might otherwise lead to adverse events. In this study, we investigated the contribution of c-Kit inhibition by imatinib in reversal of hyperglycemia in NOD mice.(2) MethodsThe T670I mutation in c-Kit, which confers imatinib resistance, was engineered into the mouse genome and bred onto the NOD background. Hematopoietic stem cells (HSCs) from NOD.c-KitT670I mice and NOD.c-Kitwt littermates were expanded in the presence or absence of imatinib to verify imatinib resistance of the c-KitT670I allele. Diabetic mice were treated with imatinib at the onset of hyperglycemia for three weeks, and blood glucose was monitored.(3 )Results In vitro expansion of HSCs from NOD.c-Kitwt mice was sensitive to imatinib, while expansion of HSCs from NOD.c-KitT670I mice was insensitive to imatinib. However, in vivo treatment with imatinib lowered blood glucose levels in both strains of mice.(4) Conclusions/InterpretationThe HSC experiment confirmed that, in NOD.c-KitT670I mice, c-Kit is resistant to imatinib. As both NOD.c-KitT670I and NOD.c-Kitwt mice responded comparably to imatinib, c-Kit inhibition does not substantially contribute to the efficacy of imatinib in T1D. Thus, we conclude that inhibition of c-Kit is not required in next-generation tyrosine kinase inhibitors for T1D treatment, and may be selected against to improve the safety profile.

Crenolanib is a potent inhibitor of FLT3 with activity against resistance-conferring point mutants

AbstractMutations of the type III receptor tyrosine kinase FLT3 occur in approximately 30% of acute myeloid leukemia patients and lead to constitutive activation. This has made FLT3-activating mutations an attractive drug target because they are probable driver mutations of this disease. As more potent FLT3 inhibitors are developed, a predictable development of resistance-conferring point mutations, commonly at residue D835, has been observed. Crenolanib is a highly selective and potent FLT3 tyrosine kinase inhibitor (TKI) with activity against the internal tandem duplication (FLT3/ITD) mutants and the FLT3/D835 point mutants. We tested crenolanib against a panel of D835 mutant cell lines and primary patient blasts and observed superior cytotoxic effects when compared with other available FLT3 TKIs such as quizartinib and sorafenib. Another potential advantage of crenolanib is its reduced inhibition of c-Kit compared with quizartinib. In progenitor cell assays, crenolanib was less disruptive of erythroid colony growth, which may result in relatively less myelosuppression than quizartinib. Finally, correlative data from an ongoing clinical trial demonstrate that acute myeloid leukemia patients can achieve sufficient levels of crenolanib to inhibit both FLT3/ITD and resistance-conferring FLT3/D835 mutants in vivo. Crenolanib is thus an important next-generation FLT3 TKI. This study is registered at clinicaltrials.gov (ID: NCT01657682).

Gene expression profiling of 49 human tumor xenografts from in vitro culture through multiple in vivo passages--strategies for data mining in support of therapeutic studies.

BackgroundDevelopment of cancer therapeutics partially depends upon selection of appropriate animal models. Therefore, improvements to model selection are beneficial.ResultsForty-nine human tumor xenografts at in vivo passages 1, 4 and 10 were subjected to cDNA microarray analysis yielding a dataset of 823 Affymetrix HG-U133 Plus 2.0 arrays. To illustrate mining strategies supporting therapeutic studies, transcript expression was determined: 1) relative to other models, 2) with successive in vivo passage, and 3) during the in vitro to in vivo transition. Ranking models according to relative transcript expression in vivo has the potential to improve initial model selection. For example, combining p53 tumor expression data with mutational status could guide selection of tumors for therapeutic studies of agents where p53 status purportedly affects efficacy (e.g., MK-1775). The utility of monitoring changes in gene expression with extended in vivo tumor passages was illustrated by focused studies of drug resistance mediators and receptor tyrosine kinases. Noteworthy observations included a significant decline in HCT-15 colon xenograft ABCB1 transporter expression and increased expression of the kinase KIT in A549 with serial passage. These trends predict sensitivity to agents such as paclitaxel (ABCB1 substrate) and imatinib (c-KIT inhibitor) would be altered with extended passage. Given that gene expression results indicated some models undergo profound changes with in vivo passage, a general metric of stability was generated so models could be ranked accordingly. Lastly, changes occurring during transition from in vitro to in vivo growth may have important consequences for therapeutic studies since targets identified in vitro could be over- or under-represented when tumor cells adapt to in vivo growth. A comprehensive list of mouse transcripts capable of cross-hybridizing with human probe sets on the HG-U133 Plus 2.0 array was generated. Removal of the murine artifacts followed by pairwise analysis of in vitro cells with respective passage 1 xenografts and GO analysis illustrates the complex interplay that each model has with the host microenvironment.ConclusionsThis study provides strategies to aid selection of xenograft models for therapeutic studies. These data highlight the dynamic nature of xenograft models and emphasize the importance of maintaining passage consistency throughout experiments.Electronic supplementary materialThe online version of this article (doi: 10.1186/1471-2164-15-393) contains supplementary material, which is available to authorized users.

Imatinib mesylate-induced hyperpigmentation of the nose and palate.

Dear Editor: Imatinib mesylate, a tyrosine kinase inhibitor targeting c-kit and platelet-derived growth factor, has been used for the treatment of hematologic malignancies. Its cutaneous adverse effects are diverse, including maculopapular exanthema, vasculitis, and Stevens-Johnson syndrome1. A well-established pigmentary change is hypopigmentation, which is characterized by generalized skin lightening, vitiligo-like lesions, and hair graying2. However, paradoxical hyperpigmentary changes were rarely observed3,4. We present a case of hyperpigmentation of the nose and hard palate associated with imatinib mesylate. A 58-year-old man was referred for discoloration of the nose. He was diagnosed with chronic myelogenous leukemia and was treated with imatinib mesylate (Gleevec; Novartis, Basel, Switzerland). Not long after imatinib treatment, he noticed insidious pigmentary changes on his nose. He had no history of skin eruptions or use of other medication. Physical examination revealed an ill-defined, slate-gray patch on the nose and on the hard palate, which suggested a diagnosis of dermal pigmentary disorders including acquired bilateral nevus of Ota-like macules (Fig. 1). Biopsy of the lesional skin and perilesional normal skin of the nose was performed. Fontana-Masson staining showed increased basal pigmentation and dermal melanophages in the lesional skin compared with the perilesional normal skin (Fig. 2A). Imunohistochemical staining with the NKI/beteb antibody confirmed the absence of melanocytes in the dermis (Fig. 2B). Therefore, the pigmentation was speculated to be imatinib-associated hyperpigmentation. Although hypopigmentation is a well-known pigmentary change due to imatinib treatment, paradoxical hyperpigmentation has been rarely reported. In hyperpigmentation, the changes are not generalized like hypopigmentary changes. The disorder pigmentation is localized in the oral cavity, including the hard palate and gum, nose, ear lobe, or nails3,4. The present case was consistent with these features, and the patient showed localized pigmentation on the nose and hard palate. There has been no report about the prognosis of this pigmentary change. In case of hypopigmentation, it could be reversible when the doses are tapered or the treatment is stopped2. Our patient is continuing imatinib treatment, and there has been no change in the pigmentation. It has been suggested that imatinib-induced hypopigmentation is mediated by c-kit inhibition, resulting in reduced tyrosinase activity in melanocytes5. The mechanism of this paradoxical hyperpigmentation is unclear. However, an in vitro study has shown the stimulating effect of imatinib on the tyrosinase activity of cultured melanocytes, which suggests the target-dependent stimulating effects of imatinib mesylate on pigmentation. Further studies are required to elucidate these pigmentary changes related to imatinib mesylate medication. Herein, we report a case of paradoxical hyperpigmentation of the nose and hard palate after imatinib mesylate treatment, warranting further evaluation of this mechanism. Fig. 1 Ill-defined slate grey-colored pigmentation on nose (A) and palate (B). Fig. 2 (A) Increased epidermal pigmentation and dermal melanophages in the lesional skin (L) compared with perilesional normal skin (N) (Fontana-Masson stainining, ×200). (B) There were no melanocytes in the dermis (gp100, ×200).

A Phase I Study Of Nilotinib As a c-Kit Inhibitor Combined With Re-Induction Chemotherapy For Relapsed and Refractory c-Kit Positive Acute Myeloid Leukemia

BackgroundA previous study in relapsed/refractory AML, combining re-induction chemotherapy with imatinib as a c-kit inhibitor, demonstrated that effective inhibition of downstream pAkt was associated with a higher CR rate (Brandwein et al, 2011). Nilotinib is also a c-kit inhibitor which diffuses into cells and is therefore not affected by potential defects in active cellular influx mechanisms. MethodsPatients age 18-65 with acute myeloid leukemia (AML) who had persistent leukemia after 3+7 induction with cytarabine and daunorubicin, or relapsed within 24 months of achieving CR, and whose blasts were c-kit (CD117) positive, were enrolled in a phase I clinical trial with nilotinib on Days 1-12 combined with mitoxantrone 10 mg/m2/day IV Days 6-10, etoposide 100 mg/m2/day IV Days 6-10 and cytarabine 1.5 g/m2 IV q12h x 4 doses on Days 11-12. None of the cases harbored c-kit mutations. Nilotinib was escalated through 2 dose levels (400 mg daily and 400 mg BID) in successive 6 patient cohorts; up to 2/6 dose-limiting toxicities (DLTs) were permitted. ResultsAt the 400 mg once daily nilotinib dose there were 2 DLTs, both hematologic and consisting of prolonged platelet and neutrophil recovery. At the 400 mg BID dose there was one DLT, consisting of grade 3 transient liver enzyme elevation; 5/6 patients experienced transient grade I-II bilirubin elevations at this dose. The median time to ANC > 0.5 x109/L was 38 days (range 28-54) and to platelets > 20 x109/L was 30 days (range 28-54). Complete responses were seen in 10 patients, 5/6 at each dose level.AML blasts from peripheral blood were assayed for pAKT, pERK and pS6 by flow cytometry, after stimulation with stem cell factor (SCF), on Days 1 and 6, pre- and 1.5 and 3 hours post-nilotinib dosing on each day. A decrease in the level of SCF-stimulated pAkt of at least 50% on Day 6 post-nilotinib, as compared to baseline, was seen in 1/6 patients at the 400 mg BID dose; the remaining 11 cases did not demonstrate an appreciable decrease in pAkt and other intermediates as compared to pre-nilotinib levels. Ex vivo dose titration curves showed that nilotinib inhibited c-kit mediated ERK and Akt activation in the blast cells of all cases, but concentrations >10 micromolar were needed to produce 50% inhibition in most cases. ConclusionsThe results indicate that nilotinib can be safely combined with this re-induction chemotherapy regimen, at doses up to 400 mg BID. Although the CR rate was high, in most cases nilotinib did not demonstrate significant inhibition of the c-kit pathway in leukemia cells in vivo. Dose titration curves showed that concentrations needed to produce 50% inhibition were generally above those achievable in vivo. Disclosures:Brandwein:Novartis: Honoraria, Research Funding. Off Label Use: nilotinib for acute myeloid leukemia.

Activities Of Commonly Used Tyrosine Kinase Inhibitors Against Wild-Type C-KIT and Potential Impact On Normal Hematopoiesis

The receptor tyrosine kinase (RTK) c-KIT is important in early hematopoiesis, and impaired c-KIT activity is associated with abnormal erythroid and megakaryotic function in animal models. Several approved and investigational small molecule tyrosine kinase inhibitors have off-target activity against c-KIT, with resultant potential for hematopoietic toxicity. To investigate the association between c-KIT inhibition by TKIs and myelosuppression, we determined the inhibitory activity of a series of TKIs against c-KIT using immunoblot estimates of IC50 concentrations, and compared those results with the compounds' effects on human hematopoiesis in progenitor cell assays. For this study, we used quizartinib, crenolanib, sorafenib, imatinib, pazopanib, and dasatinib. IC50s against FLT3 and c-Kit were established for each kinase with assays performed both in culture medium (RPMI/10%fetal bovine serum) and 100% human plasma. Colony formation assays with normal human bone marrow were performed in quadruplicate with clinically achievable levels of each drug, adjusting for plasma protein binding (and based on published pharmacokinetic data from plasma samples of human subjects). Out of the six TKIs studied, most showed limited to no inhibition of the formation of colony-forming unit-granulocyte macrophage (CFU-GM). Three TKIs, quizartinib, pazopanib, and dasatinib, demonstrated inhibition of burst-forming unit-erythroid (BFU-E) colonies. The highest doses of these drugs inhibited growth of BFU-E colonies by 30% versus untreated control. These same three drugs are also the most potent c-Kit inhibitors of this group, with IC50s of 35, 7.5, and 1.4 nM, respectively, in culture medium. The remaining TKIs, crenolanib, sorafenib, and imatinib, showed far less BFU-E inhibition, none inhibiting colony formation by more than 25%. These TKIs also had higher c-Kit IC50 values of 65, 395, and 122 nM, respectively. We conclude that c-KIT inhibition correlates with eythroid progenitor cell suppression in vitro, and that TKIs that achieve c-KIT inhibitory levels in vivo would be predicted to cause anemia. During clinical development of TKIs that have c-KIT inhibitory activity, attention should be paid to the therapeutic index between the targeted kinase (e.g., FLT3) and c-KIT, so as to avoid unnecessary myelosuppresive effects. Dose range determinations to spare c-Kit inhibition would lead to a decreased risk of disrupting normal hematopoiesis, making treatment far more manageable for these patients. Disclosures:Levis:Ambit Biosciences: Consultancy.

Abstract B240: Novel protein fusion toxins targeting c-kit positive neuroendocrine tumors.

Abstract Currently, the treatment options for patients with neuroendocrine carcinomas (NECs) are limited. Stem cell factor is found to have a trophic role in neuroendocrine cancer cells through an autocrine growth loop, which leads to the activation of the c-kit receptor. NECs like neuroblastomas, small cell lung carcinomas and poorly differentiated human colon carcinoma cells (CRCs) over-express both the c-kit receptor and its ligand, stem cell factor (SCF), as compared to normal cells. The role of the known c-kit inhibitor imatinib has already been investigated in these cell types and has shown promising results. We developed SCF-based c-kit targeting protein fusion toxins against neuroendocrine carcinomas, such as neuroblastomas and colorectal carcinomas. In this study, SCF was cloned from the HepG2 cell line and mutated in order to optimize its expression. The mutated SCF was recombinantly fused with bacterial toxins (Diphtheria toxin (DT) and Pseudomonas exotoxin A (PE)) to form c-kit targeting fusion toxins. These proteins were expressed in E.coli and purified by affinity chromatography followed by size exclusion chromatography. Flow cytometric analysis was used to monitor receptor expression on c-kit positive neuroblastoma cell lines (IMR 32 and SHSY5Y), colon carcinoma cell lines (HT-29, HCT 116 and DLD-1), and the c-kit negative cell line, MCF-7. In vitro binding, internalization and toxicity studies were performed on the above cell lines in order to characterize the purified chimeric toxins. Annexin V binding assays and cell cycle analysis were performed additionally, to prove their efficacy. The ID50 values for the toxins were found to correlate with the receptor expression on these cell lines. The novel c-kit targeting protein fusion toxins reported in our study offer a promising strategy for therapeutics against neuroendocrine tumors and warrant further testing in such tumors with c-kit autocrine and paracrine loops. Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B240. Citation Format: Swati Choudhary, Alessa Pardo, Reinhard Rosinke, Stefan Barth, Janendra K. Batra, Rama S. Verma. Novel protein fusion toxins targeting c-kit positive neuroendocrine 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 B240.

Nilotinib Interferes with the Signalling Pathways Implicated in Acetaminophen Hepatotoxicity

Nilotinib, a second-generation tyrosine kinase inhibitor, has been recently approved for the treatment for chronic myeloid leukaemia. The objective of this study was to explore the potential effects of clinically relevant doses of nilotinib against acetaminophen (APAP)-induced hepatotoxicity in mice. To simulate the clinical application in human beings, nilotinib (25 and 50 mg/kg) was administered to mice 2 hr after APAP intoxication (500 mg/kg). The results indicated that nilotinib (25 mg/kg) (i) abolished APAP-induced liver injury and necro-inflammation, (ii) increased hepatic-reduced glutathione (GSH) and its related enzymes synthesis, (iii) suppressed hepatic oxidative/nitrosative stress cascades, (iv) decreased neutrophil accumulation in the liver, and (v) prevented the over-expression of B-cell lymphoma-2 (bcl-2), cyclin-D1 and stem cell factor receptor (c-Kit) proteins in the liver. Although nilotinib (50 mg/kg) acted through the same mechanisms, there was severe depletion in hepatic GSH content by nilotinib itself at that dose level, rather than the potent stimulation observed by using a dose of 25 mg/kg. Consequently, the mortality rate after 18 hr was 100% for nilotinib (50 mg/kg) + APAP (750 mg/kg) versus 60% for APAP (750 mg/kg) and 40% for nilotinib (25 mg/kg) + APAP (750 mg/kg) in the survival analysis experiment. In conclusion, nilotinib can counteract the hepatotoxicity produced by a non-lethal dose of APAP. However, there is a risk of aggravating the mortality for a lethal dose of APAP when nilotinib is co-administered at doses relatively high, or near to the clinical range because of hepatic GSH depletion and c-kit inhibition.

The Src and c-Kit kinase inhibitor dasatinib enhances p53-mediated targeting of human acute myeloid leukemia stem cells by chemotherapeutic agents

AbstractThe SRC family kinases (SFKs) and the receptor tyrosine kinase c-Kit are activated in human acute myeloid leukemia (AML) cells. We show here that the SFKs LYN, HCK, or FGR are overexpressed and activated in AML progenitor cells. Treatment with the SFK and c-KIT inhibitor dasatinib selectively inhibits human AML stem/progenitor cell growth in vitro. Importantly, dasatinib markedly increases the elimination of AML stem cells capable of engrafting immunodeficient mice by chemotherapeutic agents. In vivo dasatinib treatment enhances chemotherapy-induced targeting of primary murine AML stem cells capable of regenerating leukemia in secondary recipients. Our studies suggest that enhanced targeting of AML cells by the combination of dasatinib with daunorubicin may be related to inhibition of AKT-mediated human mouse double minute 2 homolog phosphorylation, resulting in enhanced p53 activity in AML cells. Combined treatment using dasatinib and chemotherapy provides a novel approach to increasing p53 activity and enhancing targeting of AML stem cells.