EGFR- and VEGF(R)-targeted small molecules show synergistic activity in colorectal cancer models refractory to combinations of monoclonal antibodies.

PURPOSE: Epidermal growth factor receptor (EGFR) and VEGF(R) signaling show extensive cross-talk, providing a rationale for joint targeting of the two pathways. However, combinations of monoclonal antibodies (mAb) targeting EGFR and VEGF showed disappointing activity in patients with colorectal cancer (CRC). We speculated that inhibition of surface receptors and ligands might only partly prevent oncogenic signaling whereas small-molecule tyrosine kinase inhibitors (TKI) would also influence intracellular signaling. EXPERIMENTAL DESIGN: Mice with CRC xenografts were treated with two TKIs, vargatef and afatinib, or with two mAbs, bevacizumab and cetuximab, and their influence on tumor growth, viability, in vivo DNA synthesis, and the presence of phosphorylated EGFR and VEGFR was determined. The activity of the TKIs was further characterized in CRC cells with different KRAS status. RESULTS: Vargatef and afatinib together showed strong tumor growth inhibition toward HT-29 xenografts compared with either drug alone, which was associated with a 5-fold increase in apoptotic tumor cell death. In comparison, bevacizumab and cetuximab together were exclusively cytostatic with no more activity than either drug alone. Exposure to the two TKIs was accompanied by a marked decrease of tumor-associated intracellular phospho-VEGFR1 and phospho-EGFR, whereas similar exposure to the two mAbs had no detectable effect. A synergistic activity of vargatef plus afatinib was observed in all eight CRC cell lines examined, independent of KRAS status. CONCLUSIONS: Our results indicate that attenuation of intracellular EGFR and/or VEGF signaling is required for cytotoxic activity. These findings provide a rationale for trials of the TKIs, even in patients with mutant KRAS.

Targeting EGFR and VEGF(R) pathway cross-talk in tumor survival and angiogenesis.

The last decade has witnessed the approval of monoclonal antibodies (mAbs) and small molecule tyrosine kinase inhibitors (TKIs) for targeting of oncogenic signaling pathways. Generally, the clinical activity of these agents has been less than expected, in part due to unsuspected feed-back loops and cross-talk between different signaling pathways, thereby suggesting the interest of inhibiting multiple pathways. The extensive degree of EGFR-VEGF(R) pathway cross-talk identifies these pathways as particularly promising for joint targeting. Activation of the EGFR pathway increases the production of tumor-derived VEGF that acts on endothelial cells in a paracrine manner to promote angiogenesis. Accordingly, exposure to EGFR inhibitors is accompanied by attenuation of VEGF expression while resistance to EGFR inhibitors is frequently associated with enhanced VEGF levels. Recent data have expanded the biological activities of the two pathways by documenting a role for VEGF signaling in tumor cell survival and demonstrating the expression of EGFR by some tumor-associated endothelial cells. At least part of these signaling events are intracrine (intracellular and autocrine) and thus not readily accessible for the mAbs which target extracellular ligands and membrane receptors. This may explain why two major clinical trials combining EGFR and VEGF-targeted mAbs gave disappointing results and suggest a need for compounds that are able to inhibit intracrine signaling. Clinical application of new combinations should be preceded by preclinical development guided by functional biomarker analysis to identify active drug combinations and to facilitate the identification of patient subgroups likely, or not, to respond to dual pathway inhibition.

Netrin-1 induces apoptosis in human cervical tumor cells via the TAp73alpha tumor suppressor.

Netrins and their receptors deleted in colon cancer (DCC), neogenin, UNC5, and integrins are involved in axon guidance, epithelial morphogenesis, vascular pattering, cancer cell survival, invasion, tumor angiogenesis, and metastasis. Here, we considered the possible contribution of the p53-related apoptosis mediators p63 and p73 in the mechanisms underlying the antagonism between netrin-1 and DCC at the cell death control. We have showed that ectopic expression and external addition of netrin-1 in HeLa and HEK-293 cells with inactive p53 lead to impaired cell viability and induction of apoptosis. These responses were associated with up-regulation of the proapoptotic protein TAp73alpha, decreased Bcl-2/Bax ratio, and caspase-3 cleavage, with no change in protein levels of the antiapoptotic NH(2)-terminal-truncated DeltaNp73alpha isoform, p73 adapter Yap-1 and p73 E3 ubiquitin ligase Itch, and p63, as well as the transcripts encoding p63, TAp73alpha, and DeltaNp73alpha. However, the proteasome inhibitor MG132 potentiated, while DCC counteracted, netrin-1-induced TAp73alpha. Consistently, netrin-1 expression correlated with stabilization of the TAp73alpha protein and lower levels of TAp73alpha ubiquitination that was conversely enhanced by DCC, in a netrin-dependent manner. Our data indicate that netrin-1 selectively up-regulates TAp73alpha by preventing its ubiquitination and degradation. Targeted repression of p73alpha by shRNA reversed TAp73alpha and the apoptosis induced by netrin-1, and exacerbated the growth of HeLa tumor xenografts. Apoptosis induced by cisplatin was markedly enhanced in netrin-1 or DCC-expressing cells. Collectively, our data reveal that the transcriptionally active TAp73alpha tumor suppressor is implicated in the apoptosis induced by netrin-1 in a p53-independent and DCC/ubiquitin-proteasome dependent manner.