The Study of Epidermal Growth Factor Receptor, 99Mtechnetium
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The Study of Epidermal Growth Factor Receptor, 99m Technetium-depreotide, and Tumour Markers in the Management of Neuroendocrine Tumours by Tahir H Shah A thesis submitted to University College London for the degree of Doctor of Medicine (Res) January 2009 Neuroendocrine Tumour Unit & Department of Oncology Royal Free and University College Medical School & University College London 91 Riding House Street, London W1W 7B I, Tahir H Shah, confirm that the work presented in this thesis is my own. Where information has been derived from other sources, I confirm that this has been indicated in the thesis. ABSTRACT Purpose: Neuroendocrine Tumours (NETs) are rare and therefore poorly understood. Their slow progression and general poor response to standard chemotherapy regimes implies that their tumour biology is significantly different from most common cancers. There have been major advances in the past few decades in the diagnosis and management of these tumours which are perceived to be associated with improvements in quality and length of life. However, since most NETs have metastasised extensively by the time of diagnosis it is a major challenge indeed to try and effect tumour regression – the ultimate goal of any anti-cancer therapy. Chapters: 2 & 3: The epidermal growth factor receptor (EGFR) is commonly expressed in human tumours and provides an important target for therapy. Several classes of agents including small molecule inhibitors and antibodies are currently under clinical evaluation. These agents have shown interaction with chemotherapeutic agents in vitro and in vivo . However, the mechanisms of these interactions are not clearly understood, particularly in regards to NETs. The purpose of this study was to investigate the expression of EGFR in NET tissue and to determine its mechanisms of action, as well as the effects of modulation of EGFR activation. Experimental Design (Chapter 2): Paraffin-embedded tumour tissue was available from 98 patients with NETs (39 foregut, 42 midgut, four hindgut, five paragangliomas, and four of unknown origin). Immunohistochemical evaluation was performed for the expression of EGFR, p-EGFR, p-Akt, and p-ERK1/2. Results: Ninety-six percent of tumour samples were positive for EGFR expression; 63% were positive for activated EGFR; 76% were positive for activated Akt; and 96% were positive for activated ERK1/2. Importantly, the histological score for the activation of Akt and ERK1/2 correlated with the histological score for activated EGFR. These data provide a rationale for considering EGFR inhibitors in the treatment of NETs. Additionally, direct inhibition of Akt and ERK1/2 may provide further therapeutic options in the treatment of NETs in the future. Experimental Design (Chapter 3): The effects of the EGFR inhibitors gefitinib and erbitux were determined in several NET cell lines. The modulation of DNA-PK activity 1 by these agents was quantitated using a variety of techniques including immunoprecipitations, immunoblotting, cellular fraction extractions and immunohistochemistry. Results: Prolonged EGFR inhibition leads to reduction in DNAPK CS concentration in all tested NET cell lines except RIN, which displays the lowest levels of EGFR expression. This reduction in DNAPK CS is likely to lead to sensitisation of NET cells to ionising radiation, which causes double-strand DNA breaks, DNAPK CS being crucial to their repair. There are direct EGFR/DNAPK CS interactions in NET cell lines, which can be enhanced by EGFR inhibition. EGFR inhibition leads to transfer of DNAPK CS from the nucleus to the cytoplasm in SHP and BON cell lines but not in CRI, RIN, or NCI cell lines. This difference in the observed outcomes may be due to the lack of or mutations in intermediary proteins, though proof is needed for this hypothesis. The re-distribution of DNAPK CS is likely to lead to sensitisation of NET cells to ionising radiation, which causes double-strand DNA breaks, DNAPK CS being crucial to their repair. Chapter 4: Surgery is at present the only therapy with the possibility of achieving a cure. Therefore optimising diagnostic modalities in order to discover the tumours early or to discover all the tumour lesions prior to surgery would be of use. The purpose of this project was to assess the role of 99m Tc-depreotide in patients with negative or weakly positive OctreoScan® (Krenning score ≤ 1; measured on a scale range 0-4). To determine the usefulness of 99m Tc-depreotide scintigraphy for highlighting lesions that may be missed by OctreoScan® and/or CT/MRI imaging. Experimental Design: Prospective analysis of 25 NET patients, with negative or weakly positive ¹¹¹In-pentetreotide scans, who were consecutively enrolled to undergo ¹¹¹In-pentetreotide and 99m Tc-depreotide imaging. The results were compared with either CT or MRI scans. Results: Histology was available for 20 of 25 patients: of these 40% had high grade tumours (cellular proliferation marker Ki67 score > 20%), a further 35% had intermediate grade tumours (Ki67 2-20%), and the remainder 25% had low grade tumours (Ki67<2%). 52% of patients had completely negative and 48% had weakly positive OctreoScan®. 32% of these same patients had significantly positive 99 mTc- 2 depreotide scans (Krenning score ≥ 2), with the histology demonstrating intermediate or high grade tumours. Chapter 5: Some NETs follow an indolent course compared to others which display a rapidly progressive course with only short-lived response to therapy. Being able to confidently predict the long-term prognosis is obviously desirable. The aims of this project were to determine the diagnostic and prognostic value of serum alpha- fetoprotein (AFP) and human chorionic gonadotrophin beta (hCG β) in NETs . Patients and methods: a database containing biochemical, histological, and survival data on 360 NET patients was constructed. This data was statistically assessed, using SPSS statistics package, to determine the utility of commonly measured tumour markers with particular emphasis on AFP and hCG β. Results: AFP and hCG β were raised in 9.5% and 12.3% of patients respectively, and jointly raised in 9.1% of patients in whom it was measured. AFP levels associated strongly and positively with tumour grade, serum CgA, hCG β levels and worse survival. hCG β levels also associated strongly and positively with serum CgA, AFP levels and worsening survival. 3 ACKNOWLEDGEMENTS The work carried out in this thesis was completed under the supervision of Dr Martyn Caplin at Royal Free Hospital and Professor Daniel Hochhauser at the Department of Oncology, UCL and was generously funded by the ‘Quiet Cancer Appeal’ of The Times Newspaper. I would like to thank Martyn and Daniel for their guidance over the two years I spent with them. I have benefited greatly from their mentorship and will continue to rely on their advice and guidance in the future. I would like to thank all my lab colleagues for their help and guidance and particularly Korsa Khan for her self-less attitude towards helping newcomers. 4 COMMUNICATIONS PRESENTATIONS European Neuroendocrine Tumour Society annual conference 2006: Effect of cisplatin and ionizing radiation on epidermal growth factor receptor in neuroendocrine tumor cell lines. PUBLICATIONS T. Shah, M. E. Caplin et al. The role of alpha fetoprotein and β-human chorionic gonadotrophin as tumour markers in neuroendocrine tumours. Br J Cancer. 2008; 99: 72-7. T Shah, D Hochhauser, R Frow, A Quaglia, A Dhillon, M Caplin. EGFR expression and activation in neuroendocrine tumours. J Neuroendocrinology 2006: 18; 355 – 360. T. Shah, J. Buscombe, D Hochhauser, M. Caplin. The role of 99 Tc-depreotide in neuroendocrine tumour imaging. Nuclear Medicine Communications 2008 May;29(5):436-40. B J Friedmann, M Caplin, B Savic, T Shah, C J Lord, A Ashworth, J A Hartley, D Hochhauser.Interaction of the epidermal growth factor receptor and the DNA-dependant protein kinase pathway following gefitinib treatment. Molecular Cancer Therapeutics 2006: 5(2); 209 – 217. AWAITING SUBMISSION Expression of ErbB family of receptors in neuroendocrine tumour tissue. Srirajaskanthan R, Shah T , Caplin ME. Consequences of EGFR activation and their relation to survival outcomes in neuroendocrine tumour patients. Shah T , Srirajaskanthan R, Caplin ME. 5 TABLE OF CONTENTS ABSTRACT 1 ACKNOWLEDGEMENTS 4 COMMUNICATIONS 5 TABLE OF CONTENTS 6 INDEX OF FIGURES 11 INDEX OF TABLES 13 ABBREVIATIONS 14 CHAPTER 1 INTRODUCTION 16 1.1 Neuroendocrine Tumours 17 1.1.1 Incidence and Mortality 19 1.2 Diagnosis 22 1.2.1 Tumour markers 22 1.2.2 Imaging 22 1.2.3.1 Imaging in suspected primary 22 1.2.2.2 Imaging for detecting the primary tumour when 23 the patient has already presented with metastases 1.3 Management 24 1.3.1 Biotherapy 26 1.3.1.1 Somatostatin analogues 26 1.3.1.2 IFN alpha treatment in NETs 27 1.3.2 Chemotherapy 28 1.3.2.1 Well differentiated neuroendocrine tumours of 28 the pancreas 1.3.2.2 Well differentiated tumours of the gastrointestinal tract 29 1.3.2.3 Poorly differentiated tumours of the gastrointestinal 29 tract 1.3.3 Somatostatin receptor targeted radionuclide therapy 30 1.3.4 Chemoembolisation of liver metastases 32 1.3.5 Sequential hepatic artery embolization 33 1.3.6 Trans-catheter arterial chemoembolization (TACE) 33 1.4 Promising fields for study in the management of NETs: 34 6 Modulation of DNA-damage repair mechanisms through better understanding of EGFR/DNA-PK CS interactions 1.4.1 Intrinsic causes of DNA Damage 34 1.4.2 DNA-Interactive Chemotherapeutic Agents 34 1.4.3 Cellular Response to DNA Damage 35 1.4.4 DNA-Dependent Protein Kinase (DNA-PK) and 36 its role in NHEJ 1.5 Epidermal Growth Factor Receptor (EGFR) 39 1.5.1 ErbB receptors are activated by ligand-induced dimerization 39 1.5.2 Growth Factor Ligands that Regulate the Four 40 ErbB Receptors 1.5.3 Domain Organisation and Relationships with the ErbB 40 Receptor Family 1.5.4 ErbB Receptor Signalling 41 1.5.5 System Controls of the ErbB Signalling Network 43 1.5.5.1 Positive-feedback loops.