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Pathways and Therapeutic Targets in Melanoma www.impactjournals.com/oncotarget/ Oncotarget, Vol. 5, No. 7 Pathways and therapeutic targets in melanoma Emma Shtivelman1, Michael A. Davies2, Patrick Hwu2, James Yang3, Michal Lotem4, Moshe Oren5, Keith T. Flaherty6, and David E. Fisher6 1 Cancer Commons, Palo Alto, CA, USA 2 University of Texas MD Anderson Cancer Center, Houston, TX, USA 3 National Cancer Institute, NIH, Washington DC, USA 4 Hadassah Hebrew University Hospital, Jerusalem, Israel 5 The Weizmann Institute of Science, Rehovot, Israel 6 Massachusetts General Hospital Cancer Center, Boston, MA, USA Correspondence to: Emma Shtivelman, mail: [email protected] Keywords: melanoma, targeted therapy, immune therapy Received: March 19, 2014 Accepted: April 07, 2014 Published: April 08, 2014 This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. ABSTRACT: This review aims to summarize the current knowledge of molecular pathways and their clinical relevance in melanoma. Metastatic melanoma was a grim diagnosis, but in recent years tremendous advances have been made in treatments. Chemotherapy provided little benefit in these patients, but development of targeted and new immune approaches made radical changes in prognosis. This would not have happened without remarkable advances in understanding the biology of disease and tremendous progress in the genomic (and other “omics”) scale analyses of tumors. The big problems facing the field are no longer focused exclusively on the development of new treatment modalities, though this is a very busy area of clinical research. The focus shifted now to understanding and overcoming resistance to targeted therapies, and understanding the underlying causes of the heterogeneous responses to immune therapy. TABLE OF CONTENTS INHIBITORS ACQUIRED RESISTANCE TO BRAF AND MEK INTRODUCTION INHIBITORS MOLECULAR SUBTYPES IMMUNOTHERAPY BRAF NRAS Clinical trials targeting PD-1/ PD-L1 GNAQ and GNA11 interactionImmunomodulatory antibodies MITF Adoptive cell transfer KIT Cytokines NF1 Telomerase Adoptive transfer of natural killer cells Receptor tyrosine kinases and PI3K pathway Dendritic cell based immunotherapy MAPK pathway downstream of BRAF responses to immune therapy Cell cycle and apoptosis related genes TumorInfluence microenvironment of targeted therapies and immuneon the Transcriptional factors in melanoma responses melanoma METABOLISM AND AUTOPHAGY AS TARGETS IN INTRINSIC Other significant RESISTANCE genetic TO abnormalities BRAF AND MEK in MELANOMA Immune cell THERAPY infiltrates in melanoma. www.impactjournals.com/oncotarget 1701 Oncotarget NEW PROGNOSTIC MARKERS on the MAPK pathway in cells with non-mutated BRAF CONCLUDING REMARKS avoided; how should melanoma tumors that have no ACKNOWLEDGEMENTS activating mutations in BRAF, such as tumors with REFERENCES mutated NRAS or NF1, or tumors that are wild type for both BRAF and NRAS, be targeted; which targeted or non-targeted drug combinations should be pursued as INTRODUCTION determined by the molecular profile of each and every tumor; what is the future of combination targeted therapy The revolutionary discovery of a striking, if and immunotherapy; and many more. temporary, effect that targeted inhibition of BRAF has on The mutational landscape of melanoma was the clinical course of metastatic melanoma has spiked a examined in several large studies employing NGS new wave of research into molecular targets. In addition, (next-generation sequencing) and large-scale expression it has raised a number of new questions: what are the analyses of tumors. The mutation rate of melanoma, on mechanisms of both inherent and acquired resistance to average, exceeds those reported for other aggressive BRAF inhibitors and the possible ways to overcome this tumors, probably due to the involvement of ultraviolet resistance; how is the activating effect of BRAF inhibition (UV) radiation in the genesis of superficial cutaneous Table 1: Pathways Involved In Melanomagenesis PATHWAY* COMPONENTS MUTATED/ACTIVATED TYPE OF ALTERATION KIT Mutation/amplification EGFR Activation MET Activation; high level of ligand in stroma Receptor tyrosine kinases ERBB4 Mutation FGFR Activation; high levels of ligands Integrin adaptors/ECM signaling NEDD9/HEF Amplification NRAS Mutation BRAF Mutation RAS/RAF/MEK/ERK MEK1 Mutation PIK3CA Mutation PTEN Mutation RAS/PI3K/PTEN/AKT/mTOR AKT1, AKT2 Rare mutation AKT3 Amplification NF1 (PI3K + MAPK pathways) NF1 Mutation RAC Mutation MAP3K5 & MAP3K9 Mutation RHO/RAC/other MAPKs PREX Mutation GRIN2A Mutation Glutamate receptors GRM3 Mutation G proteins other than RAS, GNAQ Mutation effectors of MAPK GNA11 Mutation Apoptosis BCL2A1 Amplification WNT/-catenin CTNNB1 Mutation CDK4 Mutation/amplification CDK CCND1 Amplification P14ARF (CDKN2A) Mutation/deletion P53 MDM4 Amplification RB1 P116INK4A (CDKN2A) Mutation/deletion MITF transcriptional program MITF Mutation/amplification MYC transcriptional program MYC Amplification/overexpression ETV1 transcriptional program ETV1 Amplification TERT Promoter region of catalytic subunit Mutation * The order of pathways in this Table has no relationship to their significance in melanoma; it is simply from the cell periphery to the nucleus. www.impactjournals.com/oncotarget 1702 Oncotarget TABLE 2: Genes Known To Be Altered in Melanoma PRIMARY FOUND IN POSSIBLE PATHWAY ABERRATION FREQUENCY SUBTYPES TUMORS WITH… THERAPIES Point mutation 50-60% BRAFi + MEKi BRAF MAPK NRAS wild type BRAFi + EGFRi Gene fusions rare + AKTi MAPK, PI3K, NRAS BRAF wild type 20-25% MEKi + CDKi RALGDS 1% overall; 10% in Point mutation, NRAS BRAF wild Sunitinib, KIT MAPK, PI3K in mucosal; 10% in amplification type mostly nilotinib, imatinib acral Gα(q) family of G NRAS BRAF wild 1%; 40-50% each MEKi + PI3Ki, GNAQ/GNA11 protein α subunits; Point mutation type in uveal enzastaurin MAPK activators Transcription, MITF* Amplification ALL 20% HDACi lineage, cell cycle MAPK, PI3K BRAF, NRAS wild 4% overall; 25% of MEKi + mTORi Mutations, loss of NF1* negative regulator of type and less often BRAF, NRAS wild or PI3Ki expression RAS in mutated type Mutations in 70-80% overall; TERT inhibitors TERT* Telomerase the promoter of ND 33% primary; 85% in preclinical catalytic subunit metastatic Lapatinib ERBB4 PI3K, MAPK Point mutation All types 15-20% (ERBBi) + PI3Ki Activation by MET PI3K, MAPK All types ND Cabozantinib? stromal HGF AKTi, PI3Ki, AKT3 PI3K Amplification All types 25% mTORi BRAF mutated; Point mutation or PTEN PI3K BRAF and NRAS 40-60% PI3Ki deletions wild type PI3K; stabilizes MAGI -- All types -- PI3Ki PTEN Possibly stimulates BRAF and NRAS TACC PI3K AURKA -- 5% PI3Ki, AURKAi mutated signaling RHO/RAC/MAPK; BRAF or NRAS PREX2 Point mutations 14% Rac exchange factor mutated RHO/RAC/MAPK; Regulator of cell BRAF or NRAS RAC1 Point mutations 9% of sun exposed adhesion, invasion, mutated migration BRAF mutated; MAP2K1, MAPK (MEK1/2) Mutations BRAF, NRAF wild 5% ERKi MAP2K2 type MAP3K5, Mutations, loss of RHO/RAC/MAPK All types 85% and 67% MEKi, ERKi MAP3K9 heterozygocity MYC Transcription Amplification All types 20-40% mTORi? ETV1 Transcription Amplification All types 15% TP53 Cell cycle, apoptosis Point mutation All types 10-20% Negative regulator MDM4 Overexpression All types 65% p53-MDM4 i of p53 www.impactjournals.com/oncotarget 1703 Oncotarget CDKN2A BRAF and NRAS Negative regulator Point mutation, (P16INK4a, mutated, KIT 30-40% CDKi of TP53 and RB deletion p14ARF)* amplified Elevated Suppression of expression, ND BCL2, BCL2A1 All types BH3 mimetics apoptosis amplification 30% (BCL2A1) (BCL2A1) More frequent in Cell cycle, G1/S CCND1 Amplifications BRAF, NRAS wild 11% CDKi cyclin type Cell cycle, G1/S More frequent in CDK4* cyclin-dependent Amplifications BRAF, NRAS wild 3% selective CDKi kinase type Catalytic unit of phosphatase, BRAF and NRAS AURKA PPP6C Point mutations 12% sun exposed negative regulator of mutated CDKi CCND1, Aurora Kinase; unknown BRAF and NRAS STK19 Point mutations 5 - 10% function mutated BRAF mutated; Endosome protein SNX3 Point mutations BRAF,NRAS wild 7% sorting type Ionotropic glutamate-gated ion GRIN2A Point mutations -- 25% channel, NMDA binding Possibly accessory GRM3 Point mutations ND 13-18% MAPK signaling Part of histone TRRAP acetyltransferase Point mutations ND 10-13% complex SWI/SNF Chromatin Inactivating BRAF, NRAS ARID2 remodeling, SWI/ 7-9% mutations mutated SNF complex Inactivating BRAF, NRAS wild 1% overall, 84% BAP1 BRCA1 DNA repair mutations type—uveal uveal Integrin adaptor, promotes EMT NEDD9 Amplification Probably all 50-60% and migration; metastasis Bold font of gene names indicates that these mutations are considered to be driver mutations based on presence in familial melanoma and/or high frequency of mutations is sporadic, even though experimental evidence of their precise role in melanomagenesi is not always available. * germline mutations in high-risk melanoma families; MC1R mutation is not listed. Not listed: rare mutations in HRAS, RAF1 and other oncogenes. Some of the data on the mutation frequency are based on relatively small sample tumor sizes and should be considered with caution. Some data are from the cbioportal.org. melanomas. Indeed, the rate of transversions characteristic melanomas in which primaries arose on non-UV-exposed of UV-induced lesions is much higher in melanoma than hairless skin of the extremities (3 and 14 mutations/
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