Target therapy in pancreas cancer

In Russia in 2013 pancreatic cancer is the 10th most frequent in men and 12th in women,
giving an incidence of 8.6 / 100000. This rate is higher in Moscow. [1]

In comparison in France in 2018 this cancer is the 9th in men and 7th in
women. Incidence has kept growing in the last decade.

Anatomic considerations : pancreas is mostly retroperitoneal. IVC and

aorta are posterior of head , SMA behind neck / anterior to uncinate
process , splenic V + SMV unite  PV posterior neck splenic artery
crosses superior border.
Foregut  caeliac trunc (splenic A + common hepatic A + L gastric A)
Midgut  SMA hindgut  IMA
Inf pancreatico-duodenal A from SMA+ gastroduodenal A from common
HA head Splenic A  tail
Know risk factors are tabacco consumption, chronic pancreatitis (alcohol),
obesity, diabetic (this one not being strictly identified as causative or consequence of indolent
tumor), but none of them being determinant in epidemiology.

Histology shows 95% of exocrine tunors (5% endocrine like insulinoma) , and 85% are
PDAC (pancreatic ductal carcinoma), the one to be considered here.

Clinical : frequent localisation at the head (60%) and late discovery with obstructive jaundice,
flank pain , Grey-turner / Cullen sign of acute pancreatitis.

A-Molecular biology of PDAC

Target therapies can be classified in 3 main categories [2]:

-inhibit activated oncogene (mutations), mainly KRAS, NRG1, NTKR

-reactivate tumor suppressors , main one involved in PDAC are TP53, CDKN2A and SMAD4
-various vaccinal and immune interventions like checkpoint inhibitors that try to restore anti-
tumoral activity of own immune system.
Other studied targets are β-SMAD4 signalling for tumor microenvironment (TME) , specific
mutations can be found like KDM6A , APOBEC & BRCA (where Olaparib PARP inhibitor
can be used).

These mutations are screen using 2 main techniques : WGS (Whole Genome Sequencing) and
rna-Seq, giving genomic aberrations and transcriptoma. It allows classification of PDAC in 4
main groups according to degree of chromosomal anomalies : stable / locally rearranged /
scattered / unstable.

It appears that some mutations come earlier in pathogenesis of tumor,

like KRAS and TP53.

1-trials on KRAS inhibition : KRAS is on Tyrosine Kinase of RAS

family, is on EGFR (ERBB) pathway. EGFR inhibitors alone (erlotinib
, cetuximab) showed no improvement, but dual EGFR inhibition
panitumumab / erlotinib has allowed to prolunge PFS [3] , and a new EGFR inhibitor ,
afatinib, also showed some improvement probably due to blockade of the whole ERBB
family.

MEK inhibitors selumetinib / trametinib associated with BKM120, a PI3K inhibitor , may
exert an interesting downstream KRAS inhibition and lead to clinical trials in human.

Another way to brake KRAS activity is vaccinal peptidic approach. Some T-cell response has
been proven, inducing in some studies improve in overall survival, both in advanced /
metastatic and resected cases. GI-4000 is one of these vaccine using a killed Saccoromyces
with RAS mutation.

2-NTRK inhibition

Mutated TRK (translocation causing a fusion gene) is abnormaly

active.

Larotrectinib / entrectinib are effective (RR around 70-80%) against

solid tumors exhibiting this mutation, and new targeted TRK inhibitors
are beeing developped selitrectinib and repotrectinib.

3-Reactivating P53 tumor suppressor gene.

This gene is prominent in cell cycle and tumorogenesis.

COTI-2 is a reactivator that is still in test for PDAC with mutant p53 , clinical trial
NCT02433626

4- CDKN2A suppressor gene.

Is also central in cell cycle and apoptosis ,and defects are

frequent in tumoral cells. CDKN2A is the second most
commonly inactivated gene in cancer after p53. It expresses
p16 protein that is tumor suppressor by inhibating CDK4/6.
Indirect way to reactivate deficient CDKN2A effect is to exert
CDK4/6 inhibition. Palbociclib has antitumoral activity in PDAC, but is believed to act in
synergy with some other therapies like PARP inhibitors and checkpoint inhibitors.

5- BRCA mutations.

BRCA mutation is present in around 7% of PDAC. The protein plays

important role in the error-free repair of DNA double-strand breaks, or
apoptosis if repair is not possible.

Olaparib (PARP Tki ) has some efficacity in PAC, allowing 8mo PFS
instead of 4mo in metastatic cancer having the mutation.

B-Immune checkpoint inhibitors in pancreatic adenocarcinoma [4]

2 families of agents are existing ,now used in several cancers (they represented a major
evolution in melanoma) :

-anti-CTLA-4 Ab (Ipilimumab) is failing alone but is believed to

reinforce effect of a chemotherapy (Gemcitabicine)
-anti / PDL1 (Pembrolizumab) in phase II study showed improvement
compared to chemotherapy alone (Gemcitabicine + Paclitaxel, 9 and
15mo PFS / OS).
These therapies aim at restoring Tcell immune response towards
tumoral cells that escape immunogenicity by inducing tolerance.

Use of these therapeutic agents is to be considered in conjunction to other immunostimulation

action, like combination with granulocyte macrophage colony-stimulating factor vaccine
(GVAX)

C-Vaccinal attempts [5]

Therapeutic vaccines do not aim at preventing the tumor onset, but treating existing tumor by
inducing an adapted immune response (humoral or cytotoxic). Here are some specific targets :

-Mucin : MUC-1 is overexpressed in many cancers, including PAC. There has been a trial
combining CEA , MUC-1 expressed in a poxvirus, and 3 « booster » molecules B7.1, ICAM-
1 and LFA-3. OS was greatly improved (15mo vs 4mo) in responders, even inducing long
term remission (4 years).

-GVAX [6] is a whole-tumor vaccin, that uses patient’s tumoral sample. The tumoral cells are
modified in vitro to express GM-CSF (granulocyte-macrophage colony stimulating factor) in
order to increase recognition of these cells when reinjected into patient’s body. Resected
patients that underwent this trial benefited from 24mo OS ,to be compared to usual poor
survival of traditional treatment.

-Mesothelin [7] of often overexpressed but unfortunatly this doesn’t seem to offer
therapeutic opportunities in PAC : CRS-207 is a vaccine using Listeria expressing Mesothelin
protein , that didn,’t show any improvement compared to control arm of patients with
standard ChT.

D-Car-T cell therapy [8] (Chimeric antigen receptor T cell) was attempted
on pancreatic cancer, in spite this technic is more know to have results in
hematologic cancers. claudin-18 is a protein that has been targeted ,because
often specificly expressed in pancreatic (and gastric) tumors. CAR-
CLDN18.2 is lineage created for the trial, they target cells expressing
Claudin-18 and thus induce a recognition by lymphocyte of tumoral cells.

ORR (Objective Response Rate) observed for a little cohort of patients was
modest (33%), pointing at stromal microenvironment of pancreatic tumor
that makes difficult for immune cells to infiltrate.
- antibody-drug conjugates (ADC) : they aim at bringing and
increased dose of a chemotherapeutic agent at the tumoral place
-DMUC5754A associates anti-MUC16 antibody to
monomethyl auristatin E (MMAE) (anti-microtubule),
-Anetumab-ravtansine puts together an anti-mesothelin
antibody to DM4, in a phase I trial that showed a good tolerance.
In comparison, Trastuzumab emtansine (T-DM1) was approved in
2020 for breast metastatic HER2+ tumors, pointing at the always
difficult achievement of an effective therapy of PDAC.

D-hypoxic tumor microenvironment in pancreatic cancer as a target [9]

Tumor MicroEnvironment (TME) is the cellular and biochemical environment of the tumor.
Regarding PAC, it is not well admited that it plays an important role in high resistance to
most treatments. Here we try to review the specific therapies that can be attempted to weaken
this unfavorable context.

A high level of hypoxia is found withing cells of pancreatic tumors. HIF-1α is often
overexpressed in PAC and is thought to promote epithelial mesenchymal transition (EMT)
and dissemination (metastasis), by down-regulating e-cadherine ,inducing autophagy ,
increasing tumor stem cells (CD133 marker being stimulated by HIF-1α ) , contributes to
chemoresistance and radioresistance, among other mecanisms.

HIF-1α (a transcription factor) is difficult to target directly,

so the indirect signaling can be instead : VEGF , ERK , NF-
κB.

Alpha-solanine reduces pancreas cancer cell proliferation in

vitro, HS-527, an inhibitor of PI3K, curcuma suppresses HIF-
1a by affecting HSP90 and NF-κB pathway, LB-1
(Triptolidenol) alter other molecular signaling (PIK3 / Akt /
mTor) and PX-47_ through ubiquitine-proteasome
degradation, has been triend in conjunction to gemcitabicin, showing improved
radiosensibility. We keep in mind that till now, all these trials, even those showing some
encouraging responses, didn’t really change outcome for most patients, most of them being
« non responders » and very few led to phase III trials.

1 exception being for TH-302 , hypoxia-activated prodrug Evofosfamide, which converts into
active alkilating agent in context of hypoxia, which reached phIII MAESTRO study, in
combination with gemcitabine did not demonstrate a franck improvement in overall survival
(OS).

-Bevafizumab, in a more traditional approach altering trophic / vascular substrate of tumor,

has been tried in addition of ChT with no better overcome.
- CXCR4 receptor antagonist plerixafor ,which breaks CXCL12-CXCR4 bond between
tumoral cells and TME
E-Another approach to alter Tumoral Micro Environment (TME) : Nanoparticles [10]

Acces of therapeutic agents to tumor being one of the

main difficulties, it has become a specific target in
pancreatic cancer research. TME is constituted of
cancer-associated fibroblasts (CAFs), extra cellular
matrix ECM (non cellular components like collagen,
elastin etc). We saw that this TME is presenting specific
biologic aspects like hypoxia, and neo-vascularisation.

One of the main immune cells that are involved in anti-

tumoral response are DC (dendritic cells), that are APCs (Antigen presenting cells). NPs
interact with APCs (monocytes and dendritic cells), increasing the
expression of costimulatory molecules .

From here they are a solution to deliver antineoplastic agents to cancer

cells and antigenic material to APCs.

Among attemps to alter this tumoral surrounding we can quote :

-Use of nanoparticles (NP) to acces the tumoral burden, thanks to better

accumulation of small particles in cancer zone thanks to tortuous vessels
and increased permeability of lymphatic canals. One drug already
approved is Nab-Paclitaxel (Abraxane) that showed some partial
responses.

-CAF, more precisely Pancreatic stellate cells (PSCs) that are a precursor in PDAC ,as a target
of an iron oxide NP + relaxin-2 (RLX, size 60nm) ,that aims at TGF-β / SMAD4 tumor
microenvironment pathway, this is only an in vitro study on cellular line of human pancreatic
cancer cells.

-liposomal irinotecan (encapsulated topoisomerase ChT with NP) was approved in USA in
2015 for clinical use in metastatic PDAC, for patients who already have received gemcitabine.

- MUC4β-loaded polyanhydride nanoparticles are considered as a way to stabilise antigen

MUC4, increase antigeninc response, in the context of a vaccine targeting pancreactic tumoral
cells.

Conclusion

At this day, we cannot say that research brought clinical promises in PDAC treatment in spite
of generalisation of tumoral molecular profil that can now be done in routine in some centers.
A lot of difficulties are encontered in understanding the resistance of this cancer to all
therapeutic approaches.
Only accumulation of trials will lead to new insights, recent evolutions involving RNA ,
accelerated due to COVID vaccine, are also signs that the situation may change in the decade.
References

[1] https://romj.org/2020-0415 pancreatic cancer in Russia. Treatments

[2] https://jhoonline.biomedcentral.com/articles/10.1186/s13045-020-00958-3 Molecular
alterations and targeted therapy in pancreatic ductal adenocarcinoma

[3] https://pubmed.ncbi.nlm.nih.gov/30679315/ A Phase II Randomized Trial of

Panitumumab, Erlotinib, and Gemcitabine Versus Erlotinib and Gemcitabine in Patients with
Untreated, Metastatic Pancreatic Adenocarcinoma

[4]https://www.medecinesciences.org/en/articles/medsci/full_html/2019/12/msc190189/msc1
90189.html immune checkpoints in pancreatic cancer

[5] https://pubmed.ncbi.nlm.nih.gov/32247999/ Immunotherapy for pancreatic cancer: A

2020 update

[6] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7541669/ A Phase 2 Study of Allogeneic

GM-CSF Transfected Pancreatic Tumor Vaccine (GVAX) with Ipilimumab as Maintenance
Treatment for Metastatic Pancreatic Cancer

[7] https://pubmed.ncbi.nlm.nih.gov/31126960/ mesothelin , CRS-207

[8] https://pubmed.ncbi.nlm.nih.gov/32140943/ Dilemma and Challenge of Immunotherapy

for Pancreatic Cancer

|9] https://pubmed.ncbi.nlm.nih.gov/33436044/ Targeting hypoxic tumor microenvironment

in pancreatic cancer

[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7773537/ The application of

nanoparticles in cancer immunotherapy: Targeting tumor microenvironment