Biennial and Annual Report on the Rare Diseases Research Activities at the National Institutes of Health FY 2004

National Cancer Institute (NCI)

Overview of Rare Diseases Research Activities

Recent Scientific Advances in Rare Diseases Research (FY2004)

A. Extramural Projects

Mechanisms of Esophageal Carcinogenesis

The annual incidence of esophageal cancers in the U.S. is about 14,000 new cases with a death rate of about 13,300 every year. Esophageal cancers are of two types: squamous and adenocarcinoma. Both types of esophageal cancer are common in the United States and worldwide and, in fact, adenocarcinoma of the esophagus is increasing at a fast rate. However, early diagnosis and meaningful therapeutic approaches remain challenging. The NCI has funded a P01 to the University of Pennsylvania (Dr. Anil Rustgi, PI) to understand the mechanisms for esophageal cancer development and progression and to translate these findings into the clinic. To that end, and as a reflection of the interrelated nature of the work by the different investigators supported by the P01, Drs. El-Deiry and Rustgi have found TRAIL, a natural molecule that causes cells to die. However, esophageal cancer cells are resistant to TRAIL and this has been found to be associated with the increased expression of another survival molecule called Bcl-xL, which nullifies the effect of TRAIL. They are embarking upon studies to inactivate Bcl-xL such that these cancer cells become sensitive to TRAIL and hope to use TRAIL in combination with the downregulation of Bcl-xL as novel therapy for esophageal cancer so as to improve prognosis and survival.

P01-CA-098101

"Mechanisms of Esophageal Carcinogenesis"
Anil K. Rustgi, M.D.
University of Pennsylvania
Philadelphia, PA

Discovery of Genes Involved in Pancreatic Adenocarcinoma

The technologies of array comparative genomic hybridization on a cDNA microarray platform and bioinformatics tools have been optimized to characterize the pancreatic adenocarcinoma genome. Copy number alterations of amplified and deleted genes were defined in a panel of 24 pancreatic adenocarcinoma cell lines and 13 primary tumor specimens. A systematic prioritization scheme was used to select 64 focal minimal common regions of recurrent copy number changes. A complementary expression profile analysis of genes residing within these 64 prioritized minimal common regions identified a subset of candidate genes with statistically significant association between gene dosage and mRNA expression. The integration of this copy number data with expression profiles and other cancer database information provides for a highly efficient entry point for the discovery of genes involved in the pathogenesis of pancreatic adenocarcinoma.

Aguirre, A.J., et. al.,"High-resolution characterization of the pancreatic adenocarcinoma genome," Proc. Natl. Acad. Sci. USA 101: 9067-9072, 2004.

R01-CA-099041

"Genomic and Genetic Characterization of Amplicons in Glioblastoma Multiforme"
Lynda Chin, M.D.
Dana-Farber Cancer Institute
Boston, MA

Transforming and Growth Suppressive Activities of the PAX3-FKHR Oncoprotein

Alveolar rhabdomyosarcoma (ARMS) is a pediatric soft-tissue sarcoma associated with the skeletal muscle lineage. A 2:13 chromosomal translocation, which is an exchange of parts of chromosomes 2 and 13, occurs in most cases of ARMS. This exchange brings together the genes coding for the PAX3 and FKHR transcription factors in a manner that results in a novel fusion protein that is a potent transcriptional activator. The N-terminal PAX3 part of the fusion protein contains the DNA binding domain and the C-terminal FKHR part contains a transcription activation domain. Structure-function studies showed that there are two functionally separable domains (homeodomain and paired box) in the PAX3-FKHR fused protein. The homeodomain is associated with the transformation activity but not the growth suppression activity, whereas the paired box is partially associated with the growth suppression activity. These findings demonstrate that the transforming and growth suppressive activities of PAX3-FKHR are mediated by distinct functional domains that are likely to affect different downstream targets and pathways. These studies could lead to the definition of the downstream targets involved in PAX3-FKHR-mediated transformation and growth suppression.

Xia, S.J. and Barr, F.G., "Analysis of the transforming and growth suppressive activities of the PAX3-FKHR oncoprotein," Oncogene 23: 6864-6871, 2004

R01-CA-064202

"Studies of the t (2:13) of alveolar rhabdomyosarcoma"
Frederic G. Barr, M.D., Ph.D.
University of Pennsylvania
Philadelphia, PA

Autocrine Motility Factor Signaling Enhances Pancreatic Cancer Metastasis

Pancreatic cancer is an extremely aggressive cancer in which the cells are highly motile in both invasion and metastasis. Many different cell-signaling pathways at once are found to be aberrant in this cancer, making it unusually difficult to attack. A new study from NCI-supported researchers has shed light on an important pathway in pancreatic cancer that holds promise of an avenue for therapy. Autocrine motility factor/phosphoglucose isomerase (AMF/PGI) is a ubiquitous and multifunctional enzyme that plays a key role in glucose metabolism in the cell's cytoplasm and is a potent mitogen and motility-inducing factor in the extracellular milieu. Using a mouse model in which human pancreatic cancer cells are implanted into the pancreas of immunodeficient mice, these investigators showed that only the cells that were engineered to express AMF formed large tumors that aggressively metastasized to the liver. They also demonstrated that AMF expression caused the loss of E-cadherin expression in these cells and, further, that the likely cause is the upregulation of a transcription factor, SNAIL, which acts to suppress E-cadherin expression. Because E-cadherin is the cell adhesion molecule that maintains normal tissue structure and keeps cells in an epithelial-type, nonmotile state, its loss (which is known to occur in pancreatic as well as many other motile cancer cells) due to AMF is significant. Given these results, this group sought to determine the pattern of AMF in human tumor samples and found that 11 out of 13 pancreatic cancers, and no normal tissue controls, were strongly positive for AMF protein. The indication that AMF regulates the acquisition of a motile, transformed phenotype through the well-known pathway of E-cadherin means that it could be a useful target for therapy or prevention.

"Autocrine Motility Factor Signaling Enhances Pancreatic Cancer Metastasis" Tsutsumi, S. et al., November 2004, Clinical Cancer Research 10:7775-7784 http://clincancerres.aacrjournals.org/cgi/reprint/10/22/7775

R01-CA-051714

"Motility Factor Receptor"
Avraham Raz, Ph.D.
Wayne State University
Detroit, MI

Thioredoxin Is Downstream of Smad7 in a Pathway That Promotes Growth and Suppresses Cisplatin-induced Apoptosis in Pancreatic Cancer

Pancreatic cancer invades surrounding tissue and metastasizes extremely aggressively and also is exceptionally difficult to attack, due to a great extent to the fact that many different cell-signaling pathways at once are usually found to be aberrant in this cancer. NCI-supported researchers have now gained new insight into how signaling by the growth factor transforming growth factor beta (TGFβ) leads to enhanced malignancy in pancreatic cancer. Dysregulation of the TGFβ pathway is known to be a factor in this and many other cancers and is found in a majority of pancreatic cancer patients. TGFβ signals through the mediation of a set of proteins called Smads. The inhibitory Smad 7, frequently overexpressed in pancreatic cancer, leads to loss of TGFβ's cell growth-suppressing action. In this study, pancreatic cancer cells were engineered to overexpress Smad 7, and the genes whose transcription levels were altered were identified by differential display technology. Thioredoxin (TRX) (a regulator of activation of several transcription factors including AP1, NFκB, and p53) was found to be highly expressed in response to Smad 7 overexpression. They next used laser capture microdissection to isolate cells from human pancreatic cancer samples and found that in half the cancers, TRX expression was increased and corresponded with Smad 7 expression increases as well. When TRX was then inhibited in the Smad 7-overexpressing cells by antisense technology or biochemical inhibition, it attenuated the Smad 7-induced anchorage-independent growth. The apoptosis-inducing drug CDDP had little effect on Smad 7-overexpressing cells but killed them in the presence of TRX inhibitors. This effect appeared to be related to the ability of the Smad 7-overexpressing cells to activate NFκB, a well-known signaling molecule in cellular stress response. These scientists then went on to demonstrate the downregulation of the apoptosis-inducing molecule ASK1 in Smad 7 cells, which TRX inactivates, and the enhanced expression of other apoptosis-resistance signaling pathways also. This demonstration that TRX is induced by Smad 7 expression in pancreatic cancer cells and that it then acts as the effector of several of the known outcomes of the loss of TGFβ tumor suppression offers several potential avenues for therapy by attacking already defined signaling molecules and pathways.

"Thioreduxin Is Downstream of Smad7 in a Pathway That Promotes Growth and Suppresses Cisplatin-Induced Apoptosis in Pancreatic Cancer" Arnold, N.B. et al., May 2004, Cancer Research 64:3599-3606 http://cancerres.aacrjournals.org/cgi/reprint/64/10/3599

R01-CA-075059

"Dysregulation of TGF Beta Action in Pancreatic Cancer"
Murray Korc, M.D.
Dartmouth College
Hanover, NH

Kaposi's Sarcoma Herpesvirus (KSHV)/Human Herpesvirus 8 (HHV8)

Kaposi's sarcoma (KS) is an aggressive and disseminated cancer of the lungs, gastrointestinal tract, and lymph nodes that is frequently seen in patients with HIV. KSHV/HHV8 virus is etiologically linked to all forms of KS, primary effusion lymphomas (PEL), and multicentric Castleman's disease (MCCD) and sometimes to post-transplant lymphoproliferative disorder (PTLD). Herpesvirus genomes contain a latent and lytic group of genes. Latent genes are few in number, maintain the viral genome in the host cell nucleus, and orchestrate replication of the viral episome during host cell division. Lytic genes become activated and replicate when internal and/or external signals are received by the host cell. Transcription and translation of lytic cycle genes lead to the production of viral offspring. Studies within the past several years by several NCI-supported investigators have shown that some latent viral proteins interfere with the immune system's ability to recognize and destroy infected cells by several mechanisms. One group of NCI-supported investigators studying the lytic proteins have recently discovered that most host cell gene expression is strongly inhibited 10–12 hours after the start of lytic infection, except for rare cellular genes that may play important roles in pathogenesis. These investigations are advancing our understanding of KS pathogenesis and oncogenic sequelae in KS-associated disease states like PEL, MCCD, and PTLD.

R01-CA-073506

"Herpesviral Gene Expression in Kaposi's Sarcoma"
Don E. Ganem
University of California
San Francisco, CA

Aspirin May Reduce Risk of Hodgkin's Lymphoma

In the first study to examine the association between nonsteroidal anti-inflammatory drugs (NSAIDs) and Hodgkin's lymphoma, scientists found regular aspirin use to be associated with a 40-percent decreased risk of the cancer compared to nonregular aspirin use. The population-based case-control study by Ellen Chang, Sc.D., and Nancy Mueller, Sc.D., of Harvard School of Public Health, and colleagues compared data on 565 patients with Hodgkin's lymphoma and 679 controls. A reduction in risk was not observed with regular use of other NSAIDs. However, regular acetaminophen use was associated with a 70-percent increased risk of Hodgkin's lymphoma. Regular analgesic use was defined as having taken at least two tablets per week on average over the preceding 5 years. Dose-response relationships also were seen. Aspirin inhibits the transcription factor B (NF-B), which is involved in immune and inflammatory responses and which, in laboratory studies, appears to be critical in survival of Hodgkin's lymphoma cells. Perhaps aspirin guards against the cancer in this way.

Chang ET, Zheng T, Weir EG, Borowitz M, Mann RB, Spiegelman D, Mueller NE. Aspirin and the risk of Hodgkin's lymphoma in a population-based case-control study. J Natl Cancer Inst 2004 Feb 18; 96(4):305-15.

PubMed Link: http://jncicancerspectrum.oupjournals.org/cgi/content/full/jnci;96/4/305

Dexrazoxane Protective against Heart Disease in Childhood Cancer Survivors

Dexrazoxane (Zinecard), a free-radical scavenger that protects adults who receive anthracycline from developing heart problems, also may protect the heart from damage associated with doxorubicin chemotherapy. Doxorubicin is the most effective treatment for children with acute lymphoblastic leukemia (ALL), the most common malignancy in children, but it also injures myocardial cells. Many childhood cancer survivors experience late effects such as congestive heart failure and have an increased risk of death—sometimes sudden—from cardiac causes. These negative consequences are related, in part, to the toxic effects of doxorubicin and other cancer treatments.

In a study led by Dr. Steven Lipshultz of the University of Miami of more than 200 children newly diagnosed with high-risk ALL enrolled in a multicenter, randomized, controlled trial conducted at the Dana-Farber Cancer Institute in Boston, dexrazoxane was associated with a large and statistically significant reduction in the incidence of myocardial injury, and it did not compromise the anti-leukemic efficacy of doxorubicin, at least in the short term.

The study, published in The New England Journal of Medicine, reports that half of the children were treated using the standard multi-agent protocol for ALL, which includes doxorubicin. The others were treated with an infusion of dexrazoxane 30 minutes before receiving doxorubicin. The researchers used the children's troponin T blood levels during therapy to measure the impact on the cardiovascular system. Troponins are sensitive and specific biomarkers for cardiac injury. Half of the children in the chemotherapy-only arm of the study had elevated troponin T levels, while only 21 percent of the children who received dexrazoxane showed an increase. These findings suggest that doxorubicin-associated myocardial injury in children may be, at least in part, related to oxidative damage. This is an important clue to the pathogenesis of this late effect. Longer follow-up will be needed to determine the long-term influence of dexrazoxane on cardiac function and event-free survival. The optimal dose of dexrazoxane is unknown, but the implications of this study prove that it is possible to increase survival while also reducing the morbidity associated with treatment.

The study was supported, in part, by funding from NCI's 1998 RFA to support research on long-term cancer survivors. That RFA was reissued, and NCI's Office of Cancer Survivorship recently awarded 17 new grants to continue research in this important area of scientific inquiry.

Lipshultz SE, Rifai N, Dalton VM, Levy DE, Silverman LB, Lipsitz SR, et al., the effect of dexrazoxane on myocardial injury in doxorubicin-treated children with acute lymphoblastic leukemia. N Engl J Med. 2004 Jul 8;351(2):145-53.

PubMed: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15247354
Cancer Bulletin Article: http://cancer.gov/NCICancerBulletin/NCI_Cancer_Bulletin_071304.pdf

Development of Proteasome Inhibitor as a Therapy of Multiple Myeloma

Based on initial animal model studies and a phase I trial, the protease inhibitor Bortezomib can overcome resistance to conventional therapy for multiple myeloma. This led to a multicenter phase II trial of Bortezomib in 202 patients, which demonstrated that 35 percent of patients had complete responses. These responses had median duration of 12 months, with survival of 17 months rather than the expected 6–9 months. The associated clinical benefit included increased hemoglobin and decreased transfusions, improved quality of life, improved normal immunoglobulins, and stabilization or improvement in renal function. This trial led to the FDA approval of this novel agent for treatment of relapsed refractory multiple myeloma. Subsequent gene profiling and proteomic studies have provided the basis for combining Bortezomib with conventional therapies (DNA damaging agents) or novel agents (hsp 90 inhibitors, histone deacetylase inhibitors, immunomodulatory drugs) in ongoing clinical trials. From our correlative studies of patients on clinical protocols we have identified mechanisms of resistance to Bortezomib (induction of hsp 27) that can be successfully overcome with p38MAPK inhibitors. Bortezomib therefore represents a first in class novel targeted therapy that can overcome drug resistance and has great promise to improve patient outcome in multiple myeloma.

New Approaches to the Treatment of Patients with Metastatic Melanoma

In this phase I/II clinical trial, the safety and efficacy of BAY 43-9006 in combination with chemotherapy was evaluated. In the study of 35 patients with metastatic melanoma, patients were treated with an oral drug BAY 43-9006 in combination with chemotherapy. BAY 43-9006 is a small molecular inhibitor of several kinases including the raf kinase. In addition, there are indications that this drug also inhibits angiogenesis. Encouraging results have been seen, with 40 percent of patients exhibiting a partial response and the majority of patients showing stabilization of disease. This is a significant achievement in patients with metastatic melanoma in which no therapy has been shown to alter survival. Additional laboratory correlative studies have shown that BAY 43-9006 does inhibit the molecular target BRAF. Overall, these preliminary studies show that a pill combined with chemotherapy shows significant antitumor activity in patients with metastatic melanoma. This unique approach to melanoma cancer treatment may be the first real advance in the treatment of patients with advanced melanoma.

Single Agent CEP-701, a Novel FLT3 Inhibitor, Shows Biologic Response and Clinical Activity in Patients with Relapsed or Refractory Acute Myeloid Leukemia

A clinical trial of CEP-701 was conducted at the Johns Hopkins and M. D. Anderson Cancer Centers in adult patients with relapsed and refractory acute myeloid leukemia (AML) with FLT3 mutations. The patients were treated with CEP-701 alone, which they took orally twice a day. Tests were developed to enable us to determine the level of FLT3 inhibition we were attaining in the patients. In the first 3 patients, inadequate FLT3 inhibition (<90 percent) was seen, therefore, the dose of CEP-701 was increased and clinical responses of decreasing leukemia cells were seen in 5 out of 14 patients. What is learned from experiments performed on the leukemia cells and plasma samples from the patients on treatment is that drug levels achieving >90-percent inhibition of FLT3 will demonstrate a decrease in leukemic cells. This study is the first to show that AML patients with FLT3 mutations have clinical responses to FLT3 inhibition and validates this as a target for AML treatment. These studies should encourage companies that have FLT3 inhibitors in development. The lack of response from solely using this inhibitor suggests that the next stage of clinical trial might be a combination of FLT3 inhibitors with chemotherapy.

Phosphatidylinositol Signaling Cascade as a Therapeutic Target in Ovarian Cancer

Vascular endothelial growth factor (VEGF) contributes to neovascularization and to the accumulation of ascites in the peritoneal cavity. Ascites accumulation remains a major cause of morbidity in ovarian cancer. Current study has looked at the effect of immuneutralization of VEGF with a VEGF-trap with and without taxol. Results from mice studies showed virtually no ascites developed in the combined treatment group or group treated with the VEGF-trap alone. Paclitaxel alone reduced ascites by 86 percent compared to controls. In the VEGF-trap plus paclitaxel group, morphologic studies demonstrated that most of the residual tumor showed degenerative changes, apoptosis, and necrosis. In addition, mice treated with the VEGF-trap plus paclitaxel showed no observable side effects; their health and behavior were indistinguishable from normal, non-inoculated mice. These data suggest that combination therapy with VEGF-trap plus paclitaxel may provide a novel therapeutic strategy for treatment of patients with ovarian cancer associated with ascites.

Cross-species Approach to Target Metastasis Regulators

Genetic manipulation of lower organisms has enabled researchers to identify molecules that control basic biological processes in humans and that contribute to disease pathogenesis. During normal development of the Drosophila ovary, a dynamic process called border cell migration occurs that resembles the metastatic behavior of human ovarian cancer cells. The approach is to study human homologs of Drosophila genes to gain new insight into the migratory behavior of ovarian cancer cells. Myosin VI is absent from normal human ovary but is expressed in ovarian cancers at levels that strongly correlate with the aggressiveness of their clinical behavior. Inhibiting myosin VI expression in high-grade ovarian carcinoma cells by using antisense sequences and short interfering RNAs that specifically target the myosin VI gene was found to inhibit the ability of cells to spread and migrate in vitro. In subsequent experiments, researchers investigated the effect of inhibiting myosin VI on ovarian cancer dissemination in a mouse model. By imaging fluorescently labeled human ovarian cancer cells propagated in mice, it was observed that inhibiting myosin VI expression substantially impeded intraperitoneal spread of tumor cells. These studies indicate that (1) myosin VI is a potentially useful prognostic marker of ovarian cancer and (2) inhibiting myosin VI represents a novel approach for controlling dissemination of ovarian cancer.

Brain Cancer Clinical Trials

The Pediatric Brain Tumor Consortium, which currently has 10 active clinical trials, is studying molecularly targeted agents, including angiogenesis inhibitors, farnesyltransferase inhibitors, inhibitors of drug resistance, and inhibitors of epidermal growth factor signaling. These NCI-supported phase I trials provide the basis for the phase II and phase III studies of molecularly targeted agents that will define their role in the treatment of children with cancer.

NCI also supports clinical trials that specifically include children with cancers associated with neurofibromatosis-1 (NF1) through the pediatric clinical trials cooperative group. Of special relevance are the brain tumors associated with NF1 and in particular the low-grade gliomas that develop in these children. The Children’s Oncology Group will complete accrual to its clinical trial for children younger than 10 years of age with progressive low-grade astrocytoma by December 2004. Approximately 400 children have now been entered into this study, including 115 children known to have NF1. For children with NF1, the primary objective of the study is to determine their event-free survival and overall survival following treatment with a regimen of carboplatin and vincristine. Accrual is limited to children with disease that is progressive after surgery or those whose risk of neurologic impairment with progression is high enough to require immediate treatment. Preliminary results from the study should be available in approximately 1 year.

Clinical Development of Agents for Kidney Cancer

Renal cancer is made up of several distinct cellular and genetic subtypes. The most common form of renal cancer, clear cell carcinoma, is related to loss of function of the tumor suppressor, von Hippel-Lindau (VHL). The absence of the functional protein product of the VHL gene leads to activation of several genes, including vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), and other mediators of tumor angiogenesis, growth, and metastasis. The identification of molecular targets in the VHL pathway as well as other pathways relevant to kidney cancer (Ras-Raf-MEK-ERK and EGFR-MAPK-PI3K-Akt-mTOR), have led to partnerships with industries for the clinical development of targeted agents in kidney cancer.
  • Promising results from a small trial of a monoclonal antibody that inhibits VEGF (Avastin®, bevacizumab, Genentech, Inc.) conducted at the NCI intramural program have led to a national trial through the cooperative groups and the Cancer Trial Support Unit (CTSU). The trial (CALGB 90206) opened in October 2003 and is accruing more quickly than anticipated—the targeted enrollment of 700 patients is expected by mid-2005. Questions such as whether interrupting VEGF signaling will lead to prolongation in survival will be answered, in addition to adjunctive studies addressing whether pre- and post-treatment plasma, urine, and/or baseline tumor tissue can select for patients likely to respond to anti-angiogenesis treatment.

  • As of September 2004, 33 letters of intent have been received to study agents in renal cancer; more than 13 new studies have been approved. Agents under study include inhibitors of VEGF, PDGF, HSP-90 (stabilizer of HIF and EGFR), m-TOR, and raf kinase. Other novel agents include SB-715992 (ksp inhibitor), epothilone B, and SAHA. Many of these clinical trials include companion translational research, facilitating bidirectional bench-to-bedside research to accelerate progress in renal cancer.

  • Combinations of targeted agents were the subject of a retreat of thought leaders conducted by DCTD as part of the new Critical Molecular Pathways initiative. This led to a number of pilots, including a formal solicitation in July 2004 for combinations of targeted agents in renal cancer. Interest in combination therapy in renal cancer is supported by preclinical and clinical data, e.g., a phase II study in renal cancer suggesting synergy between a VEGF and EGFR inhibitor (bevacizumab and erlotinib). Intellectual property, liability, and regulatory issues can slow progress in developing combination regimens if more than one company is involved. The NCI has played an important role in facilitating collaborations within the private sector without the need for additional bargaining between the parties. The NCI developed standard language now used in all agreements with industry concerning how data are to be shared and how companies may benefit from any invention that may arise using drug combinations.

  • Variants of kidney cancer other than clear cell have distinct genetic profiles, comprise approximately 15 percent of diagnoses, and are more difficult to study due to their rarity. To find treatments relevant to these subtypes, three trials have opened nationally in the cooperative groups in papillary, collecting duct, and sarcomatoid renal cancers.

  • Novel dendritic cell-based tumor immunotherapy is a very promising approach for cancer treatment. NCI has just funded a phase II clinical trial for treating renal cell carcinoma by dendritoma vaccine. The novelty of this trial is that dendritoma vaccine is made from patient's own tumor cells, dendritic cells, and autologous serum. This vaccine has been very effective in activating patient's functional cytotoxic T lymphocytes that efficiently lyse autologous tumor cells and reduce tumor burden. A total of 29 advanced renal cell cancer patients who have exhausted all available therapies will be recruited and evaluated in this trial, and correlative studies will be conducted to understand the molecular mechanisms of tumor-specific immune responses and treatment effects.

Multiple Chemotherapy Drugs for Adjuvant Bladder Cancer Therapy

CALGB 90104 is a new, randomized trial open to investigators nationally through the CTSU. It builds on a large, randomized trial of adjuvant therapy for breast cancer sponsored by NCI, in which patients received multiple chemotherapy drugs, with different mechanisms of action, in a particular sequence. Breast cancer patients receiving chemotherapy in this sequence had improved disease-free survival and overall survival. CALGB 90104 will attempt to extend this observation to the adjuvant therapy of bladder cancer by testing doxorubicin and gemcitabine followed by paclitaxel and cisplatin versus adjuvant cisplatin and gemcitabine.

Gemcitabine for Bladder Cancer

A national phase III trial is under development to test whether the immediate instillation of gemcitabine post-surgically in patients with newly diagnosed or occasionally recurrent superficial bladder cancer is better than the instillation of saline.

The Chronic Lymphocytic Leukemia (CLL) Research Consortium

Since its initial funding in 1999, the CLL Research Consortium has made substantial progress in research on the genetics, biochemistry, and immunology of CLL and has identified promising candidate therapies for this disease. Accomplishments over the past period of funding include: identification of

  • new genetic lesions involved in pathogenesis
  • new mouse model for CLL
  • novel mechanisms regulating cell death in CLL
  • small molecule inhibitors of anti-apoptotic proteins
  • accessory cells involved in leukemia pathogenesis
  • leukemia-cell clearance mechanisms involved in cellular and immune gene therapies
  • leukemia-associated antigens—one seminal paper showed ZAP-70 (a tyrosine kinase) expression is a stronger predictor of the need for early treatment of patients with CLL than is immunoglobulin mutation status (NEJM 351:893-901, 2004)
  • novel pharmacologic and biologic agents for CLL

    improved understanding of
  • the state of T-cell anergy in CLL
  • factors associated with disease heterogeneity

    development of
  • improved algorithms for assessing disease progression risk and response to therapy
  • infrastructure that facilitates bench-to-bedside and bedside-to-bench research
  • a Web-based biomedical informatics system
  • a national tissue bank Investigators of the CLL Consortium continue to interact with the NCI intramural investigators in familial CLL studies. They are accruing families with two or more living cases of CLL (http://dceg.cancer.gov/fam-cllsi.html). These families provide material for genetic studies and for studies to characterize B-cell abnormalities that may be precursor states for CLL. Studies at NCI and elsewhere have found that first-degree relatives of CLL cases from high-risk families have a higher probability of developing monoclonal B-cell lymphocytosis than do individuals from the population at large. Members of the international familial CLL consortium have submitted a paper proposing standards and criteria for B-cell findings that can be applied to both population and high-risk family studies.

    NCI investigators are collaborating with investigators at some of the CLL Research Consortium centers to standardize familial CLL studies. This involves designing a risk factor questionnaire to be used by all participating groups, developing a standard immunophenotyping protocol, and planning for enhanced family accrual and biospecimen collections so that new genome-wide scans can be conducted on CLL family samples pooled from multiple centers.

    The CLL Research Consortium had its annual meeting in Bethesda, MD, in April 2004. Members of the public, professional societies, and advocacy groups as well as staff of NCI and NHLBI were invited to attend.

    In August 2004, in the New England Journal of Medicine, the CLL Research Consortium reported that the level of ZAP-70, a tyrosine kinase, in leukemic cells correlated best with the median time from diagnosis to treatment. Determination of ZAP-70 may become a standard prognostic indicator in patients with CLL. This is important because differences in the clinical course of CLL make decisions about treatment difficult.

    The CLL Research Consortium’s competitive renewal grant application was reviewed in October 2004. Cytogenetic studies that take advantage of newly discovered genetic lesions of CLL and enhanced drug discovery studies based on molecular pathways in the pathogenesis of CLL are highlights of this competitive renewal application.

    Agents in the Drug Development Pipeline for CLL

    Additional research supported by NCI includes basic, preclinical, and clinical studies in multiple areas related to CLL. Promising agents that have shown activity in CLL include flavopiridol, clofarabine, IDEC-152 (anti-CD23 antibody), bortezomib (Velcade), epothilone-B, LMB-2, thalidomide, triapine, pentostatin, denileukin diftitox, and bryostatin.

    Liver Cancer

    The NCI continues to collaborate with NIDDK and the other NIH Institutes and Cancer Centers to sponsor research activities to prevent, diagnose, and treat liver cancer and to promote scientific conferences to exchange information about liver cancer. Over 90 percent of primary carcinomas of the liver are hepatocellular carcinomas (HCC). While HCC is a common cause of cancer and cancer-related mortality worldwide, until recently it has been considered a rare cancer in the United States. New studies demonstrate that liver cancer is the most rapidly rising cause of cancer in the United States, resulting in at least 14,000 deaths annually and ranking as the eighth most common cause of cancer death in men. The recent upsurge in HCC in the United States may be attributable to chronic infection with hepatitis C virus (HCV), which is found in more than half of patients diagnosed with HCC.

    This rise in the incidence of HCC has not been accompanied by improvements in early detection or treatment that might lead to improved patient survival. Liver cancer remains a highly fatal disease with average survival rates after the onset of symptoms of less than 1 year. The rising incidence of liver cancer, its continued high mortality rate, and the lack of effective treatments underlie the need for research into the etiology of HCC critical for the development of early detection methods and interventions that might counteract these trends.

    Experts Conference on Liver Cancer

    To help define the most urgent areas requiring additional research, the NCI co-sponsored an Experts Conference with NIDDK on liver cancer. This conference, “Hepatocellular Carcinoma: Screening, Diagnosis, and Management,” was held in April 2004 at the NIH. The key topics and summary recommendations from the conference were published in a special supplement to the November 2004 issue of Gastroenterology (Reference: Gastroenterology November 2004; 127(5): Suppl 1: S1-S323).

    The summary recommendations focused on the promotion of research in four main areas: surveillance, prevention, early detection, and treatment.

    • For surveillance, a major recommendation is to establish prospective databases of patients with HCC that could provide detailed information on the underlying risk factors for liver disease as well as serum and tissue samples for molecular analyses to further elucidate the pathogenesis of liver cancer and identify biomarkers of HCC risk and diagnosis that might serve as targets of therapeutic interventions.

    • For prevention, the recommendations support research into strategies for primary prevention (public health initiatives to prevent viral hepatitis and other causes of liver disease), secondary prevention (improvement in therapies to treat liver disease), and tertiary prevention (evaluation of hepatoprotective agents and long-term antiviral suppressive therapy to prevent HCC in patients with cirrhosis).

    • For early detection, the recommendations support research for the development of better biomarkers and/or more practical and sensitive imaging methods to detect HCC in high-risk patients as well as epidemiological studies to better define which high-risk individuals warrant active surveillance.

    • For treatment, the recommendations support development and evaluation of innovative local ablative therapies, cytotoxic agents, and molecularly targeted therapies along with basic research to define key molecular pathways that contribute to the malignant transformation of liver cells.

    Based on the recommendations from this conference, NCI and NIDDK are discussing the potential development of a Request for Applications specifically designed to address the main areas of research outlined above.

    Liver Cancer Research Initiatives

    The NCI also continues to be actively involved in the Liver Cancer Working Group included in the Action Plan for Liver Disease Research that is being developed by NIDDK and that will enable trans-NIH and trans-agency coordination of research initiatives in this area. In addition, NCI continues to support other research initiatives related to the surveillance, prevention, early detection, and treatment of liver cancer by outside investigators through research grants to academic institutions and by intramural, government scientists at the NIH.

    The NCI co-sponsored with NIDDK the first 5 years of the 7-year, randomized clinical trial called HALT-C trial (Hepatitis C Antiviral Long-Term Treatment against Cirrhosis). The HALT-C study is designed to determine if continuing interferon treatment over several years will suppress HCV, prevent progression to cirrhosis, prevent liver cancer, and reduce the need for liver transplantation.

    Clinical Trials for Lung Cancer

    The NCI is currently sponsoring development of 16 new investigational agents in 28 phase I and phase II clinical trials for patients with liver cancer that are being conducted by the extramural scientific community as well as a multi-institutional phase II trial evaluating radiofrequency ablation in patients with HCC.

    Hepatitis C and Liver Cancer

    In addition, NCI has recently awarded three grants to extramural investigators related to a multi-institute RFA on “Hepatitis C: Natural History, Pathogenesis, Therapy, and Prevention” that will facilitate our understanding of the mechanisms of liver cancer associated with viral infection and may provide new diagnostic and prognostic biomarkers and targets for therapeutic interventions in high-risk patients.

    The main areas of basic HCC research for the intramural investigators at NIH include the etiology and molecular pathogenesis of HCC and molecular profiling and diagnosis. A major focus in this latter category has been to identify molecular signatures that can be used to predict the spread of HCC and to classify chronic liver disease patients who have the potential to develop HCC. NCI researchers have recently analyzed global gene expression patterns in HCC tumors and identified subclasses of HCC that are highly associated with patient survival. The biological differences identified in these subclasses are expected to provide attractive therapeutic targets for certain patients with HCC. NCI intramural investigators are also conducting translational research related to early drug development including the evaluation of novel treatments with immunotherapy or vaccines, radiation, and regional therapies as well as innovative molecular imaging methods for better staging and diagnosis of this cancer.

    Thus, the NCI continues to be actively involved in support of research into the etiology and underlying molecular biology of liver cancer as well as research related to prevention, early detection, and treatment. Through its own divisions and its interactions with the other NIH ICs, the NCI has co-sponsored ongoing clinical trials, research activities, and conferences that contribute significantly to our knowledge of liver cancer. These activities and future initiatives represent a robust research program that is poised to address the most urgent areas requiring additional investigation in this disease.

    Basic Lymphoma Research

    Lymphoma continues to be an area of specific interest in both the laboratory and the clinic, with increasing emphasis on translating preclinical data into clinical testing. NCI-funded research covers a broad spectrum of efforts.

    The NCI extramural basic research portfolio contains a large number of research grants dealing with the molecular and cellular studies of lymphoma and its pathogenesis. Some recent advances in our understanding of lymphoma and its therapy are summarized below.

    • A protein regulating the transcription of genetic information, called CBP, is a tumor suppressor. When this protein is deleted or inactivated in mouse thymoctyes it results in lymphoma. It appears that CBP regulated the levels of proteins that control the cell division cycle and that the appropriate regulation of these cell cycle proteins results in normal lymphocytes becoming lymphoma.

    • CD20 is a B-lymphocyte specific protein that also regulates cell cycle progression during B-cell activation. The majority of B-cell malignancies express CD20. Thus, it has become an effective target for therapy of non-Hodgkin lymphoma. Recent work has developed new monoclonal antibodies against CD20 and a CD20 genetic knockout mouse to study CD20 function in detail in vivo. These new reagents should allow us to gain a better understanding of the molecular mechanisms that influence anti-CD20 immunotherapy.

    • Recent work on the mechanism of action of anti-CD20 monoclonal antibodies against lymphoma has revealed that the complement system is not required for effective anti-CD20 immunotherapy. The B-cell depletion was dependent on an intact monocyte-macrophage network and their associated cell surface receptors. This insight might explain the failure of anti-CD20 therapy in myelosuppressed patients with reduced numbers of tissue monocytes. This information will be valuable in improving the effectiveness of anti-CD20 immunotherapy.

    RAID and RAND Lymphoma Studies to Begin

    The Rapid Access to Intervention Development (RAID) and Rapid Access to NCI Discovery Resources (RAND) programs were initiated to fulfill the recommendation of the Leukemia, Lymphoma, and Myeloma Progress Review Group to develop resources to rapidly translate lead structures into therapeutic agents. Numerous applications have been reviewed and approved. Compounds in development for the treatment of MDS, leukemia, lymphoma, and multiple myeloma include monoclonal antibodies, radiolabeled or toxin-conjugated monoclonal antibodies, vaccines, oligodeoxynucleotides, cytokines, triterpenoids, 8-chloro-AMP, apogossypol, receptor-targeted-liposomal daunorubicin, imexon, subnanoparticles of selenium, and small molecules that target the BCR/ABL oncoprotein.

    Study Agents for Clinical Lymphoma Research

    New generations of established agents and first-generation molecularly targeted agents are now in clinical trials. These novel agents span a broad spectrum of mechanisms. They are evaluated both as single agents and in combination with other approved and other experimental agents. Agents in the clinic supported by NCI include the following:

    Approved Drugs: Approved drugs under evaluation for new indications or novel combinations: Campath-1H antibody, rituximab, IDEC-Y2B8 (anti-CD 20 radioimmunoconjugate), bortezomib (Velcade - proteosome inhibitor), thalidomide, arsenic trioxide, oxaliplatin, gemcitabine.

    Experimental agents: Hu1D10 antibody, LMB-2 antibody, triapine (small molecule ribnonucleotide reductase inhibitor), GTI-2040 (antisense ribonucleotide reductase oligonucleotide), flavopiridol (CDK inhibitor), MLN 518 (tyrosine kinase inhibitor), BMS-247550 (epothilone B analogue), CCI-779 (rapamycin analogue), UCN-01 (CDK inhibitor), bryostatin (CDK inhibitor), tipifarnib (FTI inhibitor), interleukin-12, 506U78 (AraG prodrug), depsipeptide, (histone deacetylase inhibitor), SAHA (histone deacetylase inhibitor), HeFi-1 (anti-CD30 antibody), G3139 (antisense Bcl-2 oligonucleotide).

    A new regimen for flavopiridol, based upon pharmacokinetic data from earlier studies as well as new information on the protein binding of this drug, has shown striking activity in indolent leukemias and will now be evaluated in lymphomas.

    Over 80 studies specific to patients with lymphoma are directly sponsored by the NCI, with more studies that include lymphoma along with other diseases.

    Recent Data from NCI-sponsored Lymphoma Research

    Mature data from multiple clinical studies seeking to define the best use of rituximab were released within the last year. Despite high overall response rates, indolent NHL is characterized by continuous relapse. A study performed by the Eastern Cooperative Oncology Group (ECOG) evaluated the ability of 2 years of maintenance rituximab to prolong remission. The trial showed that maintenance rituximab significantly prolongs progression-free survival (PFS) after CVP chemotherapy in patients with advanced indolent NHL. Extended follow-up will determine whether longer PFS translates into improved survival. Aggressive NHL is curable in approximately half of patients. The addition of rituximab to CHOP has improved cure rates in B-cell aggressive NHL. Another ECOG study confirmed the benefit of adding rituximab to chemotherapy for patients with these diseases and supported the use of maintenance therapy with rituximab in selected patients.

    Data from multiple studies evaluating alternative forms of allogeneic hematopoietic stem cell transplantation have become available within the last year. Immunoablative approaches, where lower doses of chemotherapy still allow for an immune system transplant, consistently suggest less toxicity with significant graft versus lymphoma effects. Continued efforts at modifying the graft anti-tumor and anti-host effects will improve the safety of this approach, which may provide long-term disease control. To test the merits of these two approaches (auto transplant with rituximab and non-myeloablative allotransplant), the Blood and Marrow Transplant Clinical Trials Network, which is cofunded by NCI and NHLBI, has just launched a phase II/III multicenter study. Approximately 350 patients will be enrolled at more than 20 transplant centers in this 6-year study. Patients with a matched sibling donor will receive a nonmyeloablative allo transplant. Patients without a matched donor will receive an auto transplant followed by maintenance therapy with rituximab.

    Phase II Trial for Melanoma

    NCI recently funded a phase II melanoma clinical trial, targeting a specific enzyme defect— argininosuccinate synthesize deficiency found in melanoma cells. Malignant melanoma is usually resistant to drug therapy, which historically has been nonselective in action and often very toxic. This trial takes advantage of the fact that exposure of melanoma cells to arginine deiminase, an enzyme that catalyzes the hydrolysis of arginine to citrulline, results in melanoma cell arginine starvation and apoptotic cell death while minimizing toxicity. A total of 43 stage IV metastatic melanoma patients will be recruited and evaluated in this trial, and parallel molecular correlative assays will be conducted to elucidate the mechanisms of apoptotic cell death, drug resistance, and treatment effect.

    Ongoing and Future Research in Myelodysplasia and Myeloproliferative Disorders

    Ongoing clinical research into therapeutic interventions for MDS/MPD include evaluation of the promising drugs bortezomib (Velcade), tipifarnib (Zarnestra), bevacizumab, imatinib (Gleevec), flavopiridol, Campath-1H, bryostatin, MS-275, epithilone-B, triapine, CCI-779, thalidomide, revlimid, phenylbutyrate, and gemtuzumab ozogamycin. Additional studies are exploring immunoablative hematopoietic stem cell transplantation and leukemia vaccines.

    The NHLBI released an RFA (HL-04-034) titled “Cellular and Genetic Discovery toward Curative Therapy in Myeloproliferative Disorders (MPD)” on May 21, 2004. The NCI is participating in this RFA by providing FY2005 funds to support up to 12 new grants in response to this RFA. The application receipt date is February 16, 2005.

    Rapamycin and Tuberous Sclerosis

    NCI is funding a nonrandomized open label pilot study using rapamycin to reduce or eliminate renal angiomyolipomas associated with either tuberous sclerosis or sporadic lymphangioleiomyomatosis through the Quick Trials for Novel Cancer Therapies initiative. The target accrual is 30 adult patients, with 23 patients already on the trial. This trial takes advantage of the recent discovery of a novel therapeutic target, mTOR kinase, which is involved in regulating cell cycle control and cell growth. Modern imaging methods are being used to diagnose, monitor, and validate rapamycin’s therapeutic effects.

    As a follow up to this study, in December 2004, NCI will fund a consortium to conduct the first multicenter clinical trial for tuberous sclerosis—a phase II trial of rapamycin.

    B. Intramural Projects

    Molecular Signature Identified for Liver Cancer

    A molecular signature has been identified that can be used to predict metastatic hepatocellular cancer (HCC) and patient prognosis. This signature can separate HCC patients into metastatic and nonmetastatic groups and may be useful for diagnosing HCC patients with metastatic potential. Currently, a cross-validation study is being conducted with a larger number of independent HCC patients to refine this signature. A serum profile has been established by determining the serum concentration of osteopontin and matrix metalloproteinase 9 to predict HCC patient survival and metastasis. Both microarray and serum profiling may provide a cross-validation of the metastasis prediction model in preparation for whether it should be recommended for aiding future clinical diagnosis.

    Clinical Trials in Pediatric Sarcoma and Leukemia Patients

    The Pediatric Oncology Branch emphasizes clinical trials in high-risk sarcoma and leukemia patients and new drug development studies for pediatric cancer patients. Current efforts in high-risk sarcoma patients include development of effective immunotherapeutic strategies and utilization of allogeneic bone marrow transplant to generate graft-versus-tumor effects. Similar strategies are being used for recurrent leukemia patients. In addition, specific immunotoxin therapy for recurrent leukemias is currently being evaluated.

    The value of dynamic MRI imaging in predicting response to neoadjuvant chemotherapy is being studied in newly diagnosed osteosarcoma. The predictive value appears to be promising. Preliminary analysis of gene expression profiling on these tumors suggests that profiles may cluster patients into "good" and "poor" prognosis prospectively.

    IRB approval was recently received for a new salvage therapy for recurrent osteosarcoma and Ewing's sarcoma using a combination of sequential gemcitabine/docetaxel based on preliminary in vitro synergy and previous activity of the single agents. This study will be performed through a newly formed sarcoma consortium and is supported by Aventis and Lilly.

    Current research efforts include clinical trials of novel, nonmyeloablative allogeneic stem cell transplant regimens for childhood hematopoietic malignancies. Biologic correlative studies conducted as part of these trials include valuation of chemotherapy-induced immunosuppression, immune recovery after allogeneic transplantation, and the pathophysiology of graft-versus-host disease. Additional clinical trial activities include phase I development of immunotoxins for refractory leukemias and lymphomas. In an effort to improve understanding of the molecular mechanisms of leukemogenesis and identify potential new therapeutic targets, collaborative investigations of gene expression profiles of pediatric leukemias are also being conducted.

    Molecular Markers of Ewing's Sarcoma and Rhabdomyosarcoma Aid Diagnosis

    Many pediatric solid tumors exhibit fundamental cytogenetic abnormalities that have implications in their pathogenesis. The Ewing's sarcoma family of tumors (ESFT) and alveolar rhabdomyosarcoma (RMS) are characterized by consistent chromosomal translocations that result in the fusion of genes and subsequent formation of novel chimeric genes. These molecular markers can be detected by RT-PCR or fluorescence in situ hybridization (FISH) and can be used not only to establish the diagnosis in difficult cases but also to understand the pathogenesis of these tumors. Recently, the products of these fusion genes have become the target of vaccine therapies in newly established protocols in the Center for Cancer Research at the NCI.

    Novel Therapies Devised for Brain and Spinal Cord Tumors

    Novel experimental therapeutics are being developed for children and adults with tumors of the brain and spinal cord. Toward this end, translational laboratory efforts are focusing on new strategies for selective tumor targeting through gene transfer using neural and endothelial stem cells and novel genetic vectors, through the identification of tumor-selective processes such as angiogenesis, and through the identification of tumor-specific markers.

    Angiogenesis inhibition is being explored as a novel therapeutic strategy for the treatment of malignant gliomas. Selective delivery of genes of choice to tumor-associated angiogenesis can result in subsequent destruction of the tumor vascular bed. This novel strategy will be brought to the clinic soon.

    Scientists are additionally in the process of identifying unique proteins expressed on infiltrating glioma cells and on endothelium, associated with the angiogenic response of tumors, for the purpose of identifying novel peptides and single chain antibody molecules. These molecules will be tagged with radioisotopes for diagnostic purposes and conjugated with immunotoxins.

    Gene Expression Profiling Predicts Outcome in Rhabdomyosarcoma and Neuroblastoma

    NCI research scientists have developed substantial efforts in both proteomic and genomic characterization of pediatric tumors. Researchers have carried out reverse-phase protein arrays on a set of 34 rhabdomyosarcomas. Expression of several proteins was highly associated with a high risk for relapse. Gene expression profiling is being performed on a series of neuroblastomas of different stages and prognosis to identify tumor-specific expression patterns or "fingerprints." The analysis has identified patterns of gene expression that accurately predicted outcome. These studies are also continuing in an attempt to identify new potential targets for therapy in poor outcome patients.

    Microarray for Neurofibromatosis Developed to Identify Molecular Targets

    NCI scientists are developing a tissue microarray for pediatric solid tumors and neurofibromatosis type 1 (NF1)-associated tumors with the goal of analyzing these tumors for the presence of targets of new molecularly targeted agents. The microarray will be used to make rational decisions in the drug development for pediatric cancers and NF1.

    Molecular Signature of Malignant Gliomas Sought

    Researchers are in the process of constructing a glioma-specific cDNA microarray chip to develop a molecular classification scheme of malignant gliomas. Through the identification of signature gene expression profiles, they hope to be able to group pediatric and adult gliomas into tumors that are biologically more related. This will allow us to offer more accurate prognoses and begin to address the issue of individualized therapies.

    Metastasis and Therapy Studied in New Mouse Models of Metastatic Osteosarcoma

    Pediatric cancer researchers at NCI have a major focus on osteosarcoma. Researchers have recently developed mouse models of metastatic osteosarcoma and identified novel proteins that appear to play a major role in metastatic behavior in this model and, hopefully, in human osteosarcoma as well. Work is ongoing to determine what signaling pathways mediate these effects on metastatic behavior with the hope that novel therapeutic interventions can be identified and tested for patients with metastatic osteosarcoma. They are also testing novel anti-metastatic agents using this mouse model.

    Artificial Neural Networks Predict Clinical Outcomes in Neuroblastoma

    Researchers at the NCI have used artificial neural networks (ANNs) and DNA microarrays to successfully predict the clinical outcome of patients diagnosed with neuroblastoma (NB). The ANNs also identified a minimal set of 19 genes whose expression levels were closely associated with this clinical outcome.

    Using the 19 predictor genes, the ANNs were also able to partition the subset of patients classified as high risk into good and poor outcome groups as well as predict which of the high-risk patients would fail conventional therapy. This has major clinical implications since we are now able to distinguish a group of ultra-high-risk patients who will not respond to conventional therapy and therefore require alternative treatment strategies. It may also be possible to reduce the intensity and thereby reduce the toxicity of the treatment regime to those predicted to survive based on their gene expression profile.

    NCI scientists can translate findings to the clinic because simple prognostic assays can be developed based on this small number of genes. In fact, three of the genes found to be over-expressed in poor outcome tumors encode proteins secreted into the blood, meaning they could be used as serum prognosis markers in a simple blood test. In collaboration with industry, NCI researchers are now developing clinical assays based on these 19 genes and planning to test for the presence of these serum markers in other patients with NB for the prognostic prediction.

    Targeted Treatment Agents for Neurofibromatosis Tested in Clinical Trials

    The ras family of G-proteins play an important role in the transduction of signals that trigger cell proliferation, and mutations in ras genes are found in 30 percent of all human cancers. Ras proteins undergo post-translational farnesylation, which is required for activity of wild-type and mutant ras proteins, and this step can be inhibited by farnesyltransferase inhibitors, such as R115777. The evaluation of R115777 in children with refractory solid tumors and NF1 is therefore a rational choice. A phase I trial of R115777 for children with these tumors was recently completed, and based on the results of this phase I trial, a multi-institutional, randomized, double-blinded, placebo-controlled, cross-over phase II trial of R115777 for patients with NF1 and progressive plexiform neurofibromas was developed and is open for patient accrual.

    A phase I trial of the antifibrotic agent pirfenidone is coordinated by the NCI researchers in collaboration with Children's National Medical Center, Washington, DC, and the Mayo Clinic, Rochester, MN, and just completed accrual. Subsequently a phase II trial of pirfenidone for children and young adults with NF1 and progressive plexiform neurofibromas was developed at the NCI, and this trial just opened for accrual.

    Gene Expression Profiling Diagnoses Benign versus Malignant Thyroid Tumors

    Classification of human cancers into distinct groups based on their molecular profile rather than their histological appearance may prove to be more relevant to specific cancer diagnoses and cancer treatment regimes. Therefore, in this study, the NCI developed a gene expression approach to diagnose benign versus malignant thyroid lesions in 73 patients with thyroid tumors. Researchers successfully built a 10- and 6-gene model able to differentiate benign versus malignant thyroid tumors. Their results support the premise that a molecular classification system for thyroid tumors is possible, and this in turn may provide a more accurate diagnostic tool for the clinician managing patients with suspicious thyroid lesions.

    A Functional Polymorphism in RGS6 Modulates Bladder Cancer Risk

    RGS proteins negatively regulate G protein signaling. Recent reports have shown that RGS proteins modulate neuronal, cardiovascular, and lymphocytic activity, yet their role in carcinogenesis has not been explored. In an epidemiologic study of 477 bladder cancer patients and 446 matched controls, three noncoding single-nucleotide polymorphisms (SNPs) in RGS2 and RGS6 were each associated with a statistically significant reduction in bladder cancer risk. The risk of bladder cancer was reduced by 74 percent in those individuals with the variant genotype at all three SNPs. In addition, the NCI demonstrated that RGS2 transcripts and several splice variants of RGS6 are expressed in bladder cancer cells. These data provide the first evidence that RGS proteins may be important modulators of cancer risk and validate RGS6 as a target for further study.

    In an ongoing hospital-based case-control study, NCI researchers explored the association between 12 noncoding SNPs in 5 RGS genes identified in the National Center for Biotechnology Information (NCBI) database (dbSNP) and the risk of bladder carcinoma, a cause of over 12,000 deaths per annum in the United States. Results suggest that selected RGS variant SNPs may be important modifiers of cancer risk. To validate the biological significance of these SNPs, researchers also sought to identify functional changes in transcript levels, alternative splicing events, and protein translation efficiency that may result from the presence of the variant alleles.

    Novel RNA-based Antiviral Therapies Devised for Cervical Cancer

    The papillomaviruses are epitheliotropic small DNA tumor viruses that cause both benign and malignant lesions in humans and animals. An oncogenic subset of the human papillomaviruses (including HPV-16, -18, -31, and -33) is associated with the vast majority of cervical cancers as well as squamous cell carcinomas in other locations. Expression of papillomavirus genes is regulated at both transcriptional and posttranscriptional levels. NCI researchers are currently exploiting HPV alternative splicing to develop novel RNA-based antiviral and anticancer therapies. In addition they have been involved in several collaborations on HPV transcriptional and posttranscriptional regulation. Some of the techniques they have developed, such as isoform-specific real-time quantitative RT-PCR (QRT-PCR), are also being used in other collaborations both within and outside the papillomavirus field.

    Targeting HPV-infected cells using specific trans-splicing: The ideal cancer therapy would kill cancer cells and have no effect on normal cells. The expression of spliced human papillomavirus E6/E7 pre-mRNAs by the vast majority of cervical cancers provides an absolute difference between cancer cells and normal cells that can be exploited for the specific targeting of these cells. Through a cooperative research and development agreement (CRADA) between NCI and Intronn, Inc., researchers are investigating the use of Intronn's Spliceosome Mediated RNA Trans-splicing (SMaRT) Technology to develop a novel RNA-based suicide gene therapy for cervical cancer.

    Vaccines Developed Against HPV Virion Proteins

    There is a strong association between malignant progression of human genital lesions and certain human papillomavirus (HPV) types, most frequently HPV-16. NCI research is concerned with development of vaccines against HPV and other targets and elucidation of the PV life cycle. NCI research scientists have generated virus-like particles (VLPs) for HPV-16 and other PVs that consist of the L1 major capsid protein or L1 plus L2, the minor capsid protein. Parenteral injection of purified VLPs induced high titers of neutralizing antibodies and protection from experimental challenge in animal models. Based upon these results, they have validated GMP-grade VLPs and have completed phase 1 and phase 2 clinical trials of an HPV16 L1 VLP vaccine. Vaccines, even those vaccinated in the absence of adjuvant, consistently produced high titers of HPV-16 psuedovirion neutralizing antibodies and reported only minor side effects. Researchers are also developing alternative vaccine candidates, some for use in disease induced by HPV and others for use in diseases unlinked to HPV infection.

    Molecular Genetics of Gynecologic Cancers Characterized

    Gynecologic cancer remains a major health problem for women in this country with approximately 25,000 deaths annually attributed to this problem. The purpose of this project is to characterize the molecular genetics of this group of tumors and ultimately use that information for clinical application in rationally designing therapeutic and prevention trials. NCI scientists have characterized endometrial, cervical, and ovarian specimens that span the histiologic spectrum from benign to malignant for mutations in the ras, p53, cyclin dependent kinase inhibitors, FHIT and Rb genes, and microsatellite instability. These studies should help to identify the molecular genetic events that are important in the genesis of endometrial and cervical cancers and their use for their early detection.

    Evaluation of ovarian tumors revealed that activated ras genes are found in benign (10 percent) and low malignant potential (LMP) tumors (30 percent) but not ovarian carcinomas (5–10 percent). In addition, mutations in the tumor suppressor genes p53 and Rb occur in ovarian carcinomas (48 and 14 percent respectively) but are not present in LMP tumors. This suggests that ovarian carcinoma and LMP tumors are discrete biologic entities.

    To identify potential new markers of ovarian cancer and genes important in its pathogenesis, malignant ovarian epithelium is being compared to its benign counterpart using differential display technology, representational display, and microarrays. As part of the Director's Challenge collaborative grant between this laboratory and MSK, 400 ovarian cancer specimens will be profiled utilizing cDNA microarrays and patterns will be correlated with clinical characteristics such as survival, histology, and stage. Genes that are differentially expressed will be isolated, cloned, and characterized for their role in the development of ovarian cancer.

    Genome Expression Profiling of Ovarian Cancer Reveals Activated Pathways

    Ovarian cancer is the most lethal type of gynecologic cancer in the Western world. The high case fatality rate is due in part because most ovarian cancer patients present with advanced stage disease that is essentially incurable. In order to obtain a whole genome assessment of aberrant gene expression in advanced ovarian cancer, NCI research scientists used oligonucleotide microarrays comprising over 40,000 features to profile 37 advanced stage papillary serous primary carcinomas. We identified 1,191 genes that were significantly (P < 0.001) differentially regulated between the ovarian cancer specimens and normal ovarian surface epithelium. The list of differentially expressed genes includes ones that are involved in cell growth, differentiation, adhesion, apoptosis, and migration. Based on our expression results, a signaling pathway associated with tumor cell migration, spread, and invasion was identified as being activated in advanced ovarian cancer. The data generated in this study represent a comprehensive list of genes aberrantly expressed in serous papillary ovarian adenocarcinoma and may be useful for the identification of potentially new and novel markers and therapeutic targets for ovarian cancer.

    Recombinant Immunotoxins Developed for Ovarian and Pancreatic Cancer Therapy

    Mesothelin is a differentiation antigen present on normal mesothelial cells and overexpressed in several human tumors, including mesothelioma and ovarian and pancreatic adenocarcinoma. Mesothelin is a promising candidate for tumor-specific therapy, given its limited expression in normal tissues and high expression in several cancers. We have developed a recombinant anti-mesothelin immunotoxin (SS1P) that targets ovarian cancers, mesotheliomas, and pancreatic cancers and is currently in clinical trials. Recombinant immunotoxin SS1P shows significant activity in preclinical models including complete regression of mesothelin-expressing tumor xenografts in mice as well as cytotoxic activity in vitro against tumor cells obtained directly from patients with ovarian cancer and peritoneal mesothelioma. NCI researchers are using animal models to evaluate therapies that could enhance antibody delivery, with the goal of translating these findings to the clinic. Two phase 1 trials with immunotoxin SS1P are now open.

    Targeted Systemic Radiotherapeutics Evaluated for Intraperitoneal Cancers

    Evaluations are being performed of the therapeutic efficacy of targeted systemic radiotherapeutics for treating metastatic intraperitoneal cancer, such as pancreatic cancer, while simultaneously optimizing their value in conjunction with chemotherapeutics. The majority of targeted ratation therapies have employed a single administration of a single isotope, while in fact, dose fractionation and combination therapies with other modalities clearly provide superior results. Studies combining the use of targeted α-emitters with chemotherapeutics are novel and unique to the NCI.

    Cytogenetic Signature of Vaginal Squamous Cell Carcinoma Identified

    NCI intramural scientists used comparative genomic hybridization to establish a pattern of genomic imbalances in vaginal squamous cell carcinomas. Analysis of 16 tumors revealed that 70 percent of vaginal carcinomas carry relative copy number increases that map to chromosome arm 3q. Other recurring gains were observed on chromosome arms 5p and 19p. Chromosomal losses were infrequent. The cytogenetic data were related to the presence of human papillomavirus genomes, expression of laminin-5 as a marker for invasiveness, and expression levels of markers for proliferative activity and mutated TP53. The results suggest that vaginal carcinomas are defined by a specific distribution of chromosomal aneuploidies and that the pattern of genomic imbalances is strikingly similar to that observed in squamous cell carcinomas of the uterine cervix. Age at diagnosis, tumor size, and increased laminin-5 expression have a significant influence on the survival time. As in other malignant diseases, early detection greatly affects survival rates. It is therefore a perceived goal to analyze and understand the genetic mechanisms leading to vaginal tumorigenesis.

    Techniques Evaluated for Early Detection of Esophageal Cancer

    Esophageal cancer has a very poor prognosis, primarily because most tumors produce symptoms only after they have spread beyond the esophageal wall and are unresectable. Significant improvement in survival will require successful strategies to diagnose and treat more cases at earlier, more curable stages of the disease. A project is being carried out in Linxian, China, a county with very high rates of esophageal cancer, to evaluate techniques that may be useful in a practical early detection and treatment program. The project includes five studies: the Cytology Sampling Study, the Mucosal Staining Study, the Endoscopic Staging Study, the Endoscopic Therapy Pilot Study, and the Chemoregression Study.

    Molecular Genetics of Kidney Cancer Studied

    In order to identify the genes that cause kidney cancer and develop molecular therapeutics for this disease, we have studied the inherited forms of cancer of the kidney. Individuals with the inherited form of kidney cancer associated with von Hippel Lindau (VHL) are predisposed to develop tumors in the brain, spine, eyes, pancreas, adrenal gland, and inner ear. By studying VHL families we were able to perform genetic linkage analysis to localize and subsequently identify the VHL gene on chromosome 3. NCI scientists have identified the VHL gene mutation in the germline of 246/246 VHL kindreds and are currently studying genotype/phenotype relationships as well as evaluating minimally invasive forms of therapy for kidney and adrenal tumors in VHL. The VHL gene has been shown to be the gene for the hereditary form of renal carcinoma associated VHL as well as the common form of sporadic (nonhereditary) kidney cancer (clear cell renal carcinoma).

    Angiogenesis in Renal Cell Cancer Targeted in Laboratory and Clinical Studies

    Renal cell cancer (RCC) is a highly vascular tumor that contains a mutation in the VHL tumor suppressor gene in over 80 percent of clear cell carcinomas. This mutation is linked to deregulation of vascular endothelial growth factor (VEGF), a potent angiogenic agent. NCI researchers are currently beginning a new initiative directed at identifying the mediators of angiogenesis and growth of RCC and neutralizing these biological activities in preclinical tumor models and in patients with RCC. In preclinical models of RCC xenografts in nude mice, we are evaluating neutralizing antibodies to FGF-5. RCC was found to express FGF-5 when expression screening of a cDNA library from an RCC line revealed FGF-5 as the targeted RCC-associated tumor antigen. This molecule, originally identified by its ability to transform 3T3, is expressed in approximately 60 percent of RCC lines and some prostate and breast cancer lines. Researchers have not found it expressed by normal adult tissues by RT-PCR, and it therefore represents an excellent therapeutic target for multiple adenocarcinomas including RCC.

    Parallel to these laboratory studies, the NCI is conducting clinical protocols of anti-angiogenic agents. In a new, accruing clinical protocol, we are evaluating the efficacy of a humanized neutralizing antibody to hVEGF (Genentech, Inc.) in a randomized, double-blind, placebo-controlled format in patients with progressive, metastatic RCC. In this 150-patient trial, we are also evaluating the use of novel noninvasive imaging techniques to evaluate anti-angiogenic agents in clinical trials. The next generation of clinical studies will be combinations of agents if the anti-VEGF monoclonal antibody demonstrates any significant clinical activity.

    Gene Expression Profiles Provide Diagnosis and Prognosis of Lymphoid Malignancies

    To provide a molecular basis for the diagnosis of human lymphoid malignancies, NCI researchers are exploiting DNA microarray technology to profile gene expression in these cancers on a genomic scale. An NCI laboratory created a novel DNA microarray, the "Lymphochip," which is enriched in genes that are expressed in and/or function in lymphocytes. They have used Lymphochip and Affymetrix microarrays to profile gene expression in diffuse large B-cell lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma, follicular lymphoma, multiple myeloma, and in a wide variety of normal lymphoid subsets.

    One central goal of these studies is to relate gene expression to clinical outcome, thereby establishing a quantitative, reproducible, and informative molecular diagnosis of the lymphoid malignancies. The studies have revealed previously unknown types of diffuse large B-cell lymphoma that are indistinguishable by current diagnostic methods but have strikingly distinct gene expression profiles, originate from different stages of B-cell differentiation, utilize distinct oncogenic mechanisms, and differ in their ability to be cured by current chemotherapy. For several lymphoid malignancies, we have identified molecular profiles that predict the length of survival or the ability to be cured by chemotherapy, thereby providing clinically useful prognostic indicators. A major effort has been mounted to create a diagnostic microarray that could provide these molecular diagnoses and prognoses to patients with lymphoid malignancies.

    Importantly, the genes that are associated with clinical prognosis have provided new targets for therapy of the lymphoid malignancies. Functional genomics, chemical genetics, and molecular biological techniques are being used to validate these and other molecular targets toward the ultimate goal of targeted therapies for patients aimed directly at the disordered regulatory biology of their individual tumors.

    IGF-I Induces Migration and Invasion of Multiple Myeloma Cells

    Multiple myeloma (MM) is an incurable form of cancer characterized by accumulation of malignant plasma cells in the bone marrow. During the course of this disease, tumor cells cross endothelial barriers and home to the bone marrow. In later stages, myeloma cells extravasate through blood vessels and may seed a variety of organs. Insulin-like growth factor I (IGF-I) is one of several growth factors shown to promote the growth of MM cells. In this study, NCI researchers have assessed the ability of IGF-I to serve additionally as a chemotactic factor affecting the mobility and invasive properties of these cells. Results indicate that IGF-I promotes transmigration through vascular endothelial cells and bone marrow stromal cell lines. The identification of IGF-I as both a proliferative and migratory factor provides a rational basis for the development of targeted therapeutic strategies directed at IGF-I in the treatment of MM.

    Novel Therapeutic Strategies for Lymphoma Assessed in Clinical Trials

    In vitro, overexpression of the mdr-1 gene product, P-glycoprotein (Pgp), in tumor cells can confer high-level resistance to natural product-derived cytotoxics. It has been reported that Pgp was detectable by immunohistochemistry in 1/49 (2 percent) of untreated but was detectable in 6/8 (75 percent) of treated lymphomas, suggesting that Pgp conferred drug resistance. To test this hypothesis, NCI scientists developed and tested an mdr-1 reversal strategy in relapsed lymphomas using EPOCH (doxorubicin/vincristine/etoposide, prednisone, cyclophosphamide) and dexverapamil. Based on results showing EPOCH to be effective and well tolerated, they began a phase II study of EPOCH in previously untreated patients with aggressive lymphomas. In this study, EPOCH doses are escalated within patients to the maximum tolerated dose (MTD). End points are dose-intensity, efficacy, toxicity, and molecular markers of drug resistance. Early results show a high complete response rate of 89 percent with an EFS of 77 percent at 2 years median follow-up. Accrual to this trial continues.

    NCI staff have recently developed and tested a "second-generation" EPOCH regimen (EPOCH II) to replace stem cell transplant for lymphomas requiring high-dose intensity including poor-prognosis untreated aggressive lymphomas, potentially curable relapsed lymphomas, and low-grade lymphomas. This regimen is based on experimental/clinical observations that suggest infusion schedules may improve the therapeutic index of natural product-derived cytotoxics and that high-dose alkylator therapy can overcome drug resistance in lymphoma. Preliminary results show EPOCH II to have a response rate of 90 percent with 66 percent complete.

    Examination of tumor tissues to assess potential mechanisms of drug resistance is an ongoing effort. Researchers have demonstrated the association of clinical drug resistance with p53 mutation and low proliferation rate in relapsed lymphomas. Currently, they are studying other novel cell cycle proteins such as p27 in lymphomas. Recently, we have been interested in testing novel protein kinase inhibitors in lymphomas. One such inhibitor, UCN-01, has shown marked synergy with fludarabine in a variety of human cell lines. To further assess this drug, the NCI will soon begin a phase I study of UCN-01 and fludarabine in patients with relapsed and refractory indolent lymphomas.

    Gynecologic Surgery Reduces Risk of Ovarian Cancer in BRCA Mutation Carriers

    Women with BRCA1 and BRCA2 mutations are reported to have a low risk of peritoneal carcinoma in the first years after bilateral oophorectomy (BO). To assess the level and persistence of reduction of ovarian and peritoneal cancer risk after gynecologic surgeries, 847 Israeli women with incident ovarian cancer or primary peritoneal cancer were tested for the three Ashkenazi founder mutations. A comparison of gynecologic surgery history among all case patients, BRCA1 (n = 187) and BRCA2 (n = 64) carrier case patients, and the noncarrier case patients (n = 598) to control subjects drawn from a population registry (n = 2,396) found that 8 women with primary peritoneal cancer and 128 control subjects reported a previous BO. Other gynecologic surgeries were associated with a 30–50-percent reduced risk of ovarian cancer, with the removal of some ovarian tissue associated with the most risk reduction. Reduced risks were seen in BRCA1/2 carriers and in noncarriers. Age at surgery and years since surgery did not affect risk reductions, but type and extent of surgery did. J Natl Cancer Inst 2003; 95:1072–1078.

    Ovarian Cancer Risk after Use of Ovulation-Stimulating Drugs

    A retrospective cohort study of 12,193 eligible study subjects (median age 30 years), who were evaluated for infertility during the period of 1965 to 1988 at 5 clinical sites, identified 45 subsequent ovarian cancers. The infertility patients had a significantly elevated ovarian cancer risk compared with the general population (standardized incidence ratio = 1.98).When patient characteristics were taken into account and risks assessed in the infertile women, the rate ratios (RR) associated with ever use were 0.82 for clomiphene and 1.09 for gonadotropins. There were higher but nonsignificant risks with follow-up time. Although drug effects did not vary by causes of infertility, a slightly higher risk was associated with clomiphene use among women who remained nulligravid, based on six exposed patients (RR = 1.75). These results do not confirm the strong link reported in some studies between ovulation-stimulating drugs and ovarian cancer. Slight but nonsignificant elevations in risk associated with drug use among certain subgroups of users, however, support the need for continued monitoring of long-term risks. Obstet Gynecol 2004; 103:1194–1203

    Tamoxifen and Risk of Rare Endometrial Cancers

    Recent studies suggest that the tamoxifen-related risk of uterine corpus cancer may be especially high for some uncommon cell types, although the magnitude of risk has not been quantified. Data from 39,451 breast cancer patients initially treated with tamoxifen were evaluated. The overall risk of subsequent uterine corpus cancer was increased more than 2-fold (observed-to-expected ratio [O/E] = 2.17) relative to the general SEER population. Relative risk was substantially higher for malignant mixed mullerian tumors (MMMTs) (O/E = 4.62) than for endometrial adenocarcinomas (O/E = 2.07), although excess absolute risk was another 1.4 versus 8.4 cancers per 10,000 women per year, respectively. Among women who survived for 5 years or longer, there was an 8-fold relative risk for MMMTs and a 2.3-fold risk for endometrial adenocarcinomas, with those developing MMMTs having a worse prognosis. These findings indicate that tamoxifen may have delayed effects, such as the increased risk of MMMTs, rare but aggressive tumors of unclear pathogenesis. J Natl Cancer Inst 2004; 96:70–74.

    Fumarate Hydratase Gene Mutations Cause Hereditary Leiomyomatosis and Renal Cell Cancer

    Hereditary leiomyomatosis and renal cell cancer (HLRCC) is an autosomal-dominant disorder characterized by smooth-muscle tumors of the skin and uterus and/or renal cancer. FH gene sequence analysis among 35 North American families with cutaneous leiomyomas revealed germline mutations in 31 families (89 percent). Twenty different mutations in FH were identified, of which 18 were novel. Of these 20 mutations, 2 were insertions, 5 were small deletions that caused frameshifts leading to premature truncation of the protein, and 13 were missense mutations. Eleven unrelated families shared a common mutation: R190H. Ninety-eight percent (46/47) of women with cutaneous leiomyomas also had uterine leiomyomas, and 89 percent (41/46) had a prior total hysterectomy, 44 percent at age = 30 years. Unilateral and solitary renal tumors were identified in 13 individuals from 5 families. Seven individuals from four families had papillary type II renal cell carcinoma, and another individual from one of these families had collecting duct carcinoma of the kidney. HLRCC is associated with FH mutations and clinically significant uterine fibroids and aggressive renal tumors. Am J Hum Genet 2003; 73: 95–106.

    Hepatitis C Virus Infection and Non-Hodgkin Lymphoma

    Several studies have noted elevated hepatitis C virus (HCV) prevalence among patients with non-Hodgkin lymphoma (NHL), suggesting that HCV infection increases NHL risk through chronic immune stimulation. In a population-based case-control study of NHL in the United States, HCV infection was identified using an enzyme immunoassay and confirmed by recombinant immunoblot assay or HCV RNA detection. The association between HCV and NHL was assessed using logistic regression, adjusting for demographic factors, illicit drug use, or medical history. Thirty-two of 813 (3.9 percent) NHL cases and 14 of 684 (2.1 percent) controls were HCV infected. Positive associations were noted for follicular, marginal zone and mucosa-associated lymphoid tissue NHLs. The study demonstrates an association between HCV infection and NHL in the United States and suggests that HCV infection may be a cause of NHL. Int. J. Cancer 2004; 111, 76–80.

    Obesity-related Cancer Increases among Black and White Men

    Obesity has been linked to excess risk for many cancers, but the evidence remains tenuous for some uncommon types and few studies have included nonwhite subjects. The risk for all cancer sites and subsites was examined among a cohort of male U.S. veterans (3,668,486 whites; 832,214 blacks) hospitalized with a diagnosis of obesity. Among white veterans, risk was significantly elevated for several cancers, including cancers of the lower esophagus, gastric cardia, small intestine, colon, rectum, gallbladder and ampulla of vater, male breast, prostate, bladder, thyroid, and connective tissue and for malignant melanoma, multiple myeloma, chronic lymphocytic leukemia (CLL), and acute myeloid leukemia (AML). Excess risks initially observed for cancers of the liver and pancreas persisted among men without a history of diabetes or alcoholism. Among black veterans, risks were significantly elevated for cancers of the colon, extrahepatic bile ducts, prostate, and thyroid and for malignant melanoma, multiple myeloma, CLL, and AML. Cancer Causes Control 2004; 15:35–43.

    Risk of Head and Neck Squamous Cell Cancer and Death in Transplanted and Untransplanted Patients with Fanconi Anemia

    Hematopoietic stem cell transplant (SCT) is currently the only therapy that can restore normal hematopoiesis in patients with Fanconi anemia (FA). FA patients have a high baseline risk of squamous cell cancers (SCC) of the head, neck, and esophagus, and SCT conditioning may increase SCC incidence. The risks of SCC and death in 145 untransplanted FA patients in the North American Survey (NAS) cohort were compared to 117 transplanted FA patients in a separate cohort. The age-specific hazard of SCC was 4.4-fold higher in transplanted versus untransplanted FA patients, and SCC occurred at significantly younger ages in the former. Survival after SCC was similarly poor in both cohorts. The hazard of SCC increased at a greater than linear rate by 10 years after transplant. Acute and chronic graft versus host diseases were significant SCC risk factors. Adverse event rates in these cohorts provide historical control rates to assess emerging therapies for FA. Blood First Edition Paper, prepublished online August 26, 2004; DOI 10.1182/blood-2004-04-1652

    Alachlor Exposure May Increase Risk of Lymphohematopoietic Cancers

    Cancer incidence during 1993 to 2000 was evaluated among pesticide applicators exposed to alachlor in the Agricultural Health Study, a prospective cohort study of licensed pesticide applicators in Iowa and North Carolina. A total of 49,980 pesticide applicators were included in this analysis, including 26,510 applicators (53 percent) who reported alachlor use. Among alachlor-exposed applicators, a significant increasing trend for incidence of all lymphohematopoietic cancers was associated with lifetime exposure-days and intensity-weighted exposure-days to alachlor. The risks of leukemia (rate ratio [RR] = 2.8) and multiple myeloma (RR = 5.7) were increased among applicators in the highest alachlor-exposure category. Am J Epidemiol 2004; 159:373–80

    Formaldehyde Exposure May Increase Leukemia Risk

    Extended follow-up of a cohort of 25,619 U.S. industrial workers evaluated the association between measures of formaldehyde exposure (peak exposure, average exposure intensity, cumulative exposure, and exposure duration) and mortality from lymphohematopoietic cancers (n = 178). Compared with workers exposed to low peak levels of formaldehyde (0.1–1.9 ppm), workers exposed to peak levels of 2.0–3.9 ppm were two and a half times (RR= 2.43) more likely to develop myeloid leukemia. Workers exposed to peak levels of 4.0 ppm were three and a half times more likely (RR = 3.46) to develop myeloid leukemia. Compared with workers exposed to low levels of average exposure intensity of formaldehyde (0.1–0.4 ppm), relative risk for myeloid leukemia was slightly elevated (RR = 1.15) for workers exposed to 0.5–0.9 ppm and two and a half times more prevalent for workers exposed to 1.0 ppm average intensity (RR = 2.49). J Natl Cancer Inst 2003; 95:1615–1623

    Significant Ongoing Rare Diseases Research Initiatives

    Cohort Consortium

    NCI has launched the Cohort Consortium, in which parallel and pooled studies of large population cohorts utilize advances in genomic technology to identify inherited susceptibility genes and gene-environment interactions in nonfamilial cancers. The Consortium is a unique public-private partnership that currently includes 23 population cohorts; epidemiologists for each cohort are collaborating not only with genomicists at their own institutions but also are working formally with three major genome centers: the Whitehead/MIT Center for Genome Research, the Centre d'Etude du Polymorphisme Humain (CEPH) in Paris, and the NCI Core Genotyping Facility.

    The Cohort Consortium represents a coordinated, interdisciplinary approach that will greatly accelerate the research process and allow scientists to perform subset analyses and confirmatory studies to examine gene-environment and gene-gene interactions. The approach provides "instantaneous parallel replication" of findings across cohorts. The Cohort Consortium presents the cancer research community with an extraordinary opportunity to advance research on genes and the environment and to do so economically by using already existing resources. The unique epidemiologic infrastructure also provides an opportunity to partner with other NIH Institutes to investigate a series of complex diseases, including diabetes and cardiovascular and neurological diseases. By involving both the intramural and extramural research communities, the opportunity exists for NIH to cost effectively leverage its resources and ensure that the dramatic advances in genomics and other emerging technologies are incorporated into rigorous population-based studies to unravel the determinants and mechanisms underlying cancer and other diseases.

    Non-Hodgkin Lymphoma Case-control Consortium

    NCI intramural and extramural investigators have joined forces in a coordinated series of ongoing case-control studies focused on non-Hodgkin lymphoma (NHL). The NHL collaboration, known as InterLymph, represents a new generation of large-scale molecular epidemiology, with investigators pooling data from North America, Europe, and Australia to identify reasons for the increasing incidence of this tumor around the world. Each case-control study includes a detailed review of the pathological and genetic characteristics of the NHL cases. The investigators are sharing data in order to test for genetic and environmental causes that cannot be addressed in individual studies with smaller sample sizes. Because the consortium involves essentially all major ongoing epidemiologic studies of NHL, it represents a model for the study of many malignancies.

    The first breakthrough finding from the consortium was the demonstration that the TNF-alpha gene plays a key role in diffuse large B-cell lymphoma, the most common form of the disease. A recent meta-analysis of 13 single nucleotide polymorphisms (SNPs) in genes that play a role in regulating the immune system revealed a statistically significant association between a gene variant of TNF-alpha and increased risk of developing diffuse large B-cell lymphoma. Individuals heterozygous for this SNP were at 30-percent increased risk, while homozygous individuals were at 60-percent increased risk of developing the disease. Other genes are now under investigation.

    Human Papilloma Virus Vaccine Trial

    A wealth of scientific evidence has led to the conclusion that virtually all cases of cervical cancer are attributable to cervical infection by a subset of human papilloma viruses (HPV). About one-half of cervical cancer is attributable to HPV-16 infection. The second most frequent type, HPV-18, accounts for another 10–20percent of these cancers. HPV infection, predominantly HPV-16, also appears to cause most anal cancers as well as a proportion of vulvar, penile, and head-and-neck cancers. An effective HPV vaccine should be able to reduce the incidence of the cancers attributable to HPV infection.

    Investigators at the National Cancer Institute, with long-term support from the Office of Research on Women's Health (ORWH), have developed a method for producing an HPV vaccine composed of a single noninfectious protein from the virus. The scientists found: (1) multiple copies of the viral protein spontaneously assemble into empty shells (called virus-like particles or VLP) to which the immune system responds as though encountering the authentic virus; (2) the VLP vaccine is highly protective in animal papilloma virus models; and (3) an HPV-16 VLP vaccine is safe and induces a strong, durable immune response in women and men. Two pharmaceutical companies (Merck and GlaxoSmithKline) are currently carrying out international phase III vaccine trials, having found that the VLP vaccine can protect women from infection by the HPVs targeted by the vaccine. The NCI, with continued support from ORWH, is conducting an independent trial of the vaccine produced by GSK. The trial is being carried out in Costa Rica, where cervical cancer is the most common cancer of women, in close collaboration with Costa Rican investigators and the Government of Costa Rica. The experimental HPV vaccine, or a hepatitis A vaccine, is given in a blinded manner to all healthy young women who ask to participate. The women are followed for a period of 4 years for the development of HPV infection and cervical lesions, which are treated according to accepted standard of care guidelines. Thus, all women in the trial benefit from excellent cervical cancer screening, the control group has the benefit of receiving a vaccine that will protect them against hepatitis A, and the experimental group may benefit from the experimental vaccine. Cross-over vaccination and vaccination against hepatitis B will also be offered to all participants at the end of the trial, as an added benefit.

    The prevention of cervical cancer is the main public health goal of the vaccine, which may become available to the public in 3–5 years, if the ongoing trials when completed are deemed successful by the FDA. The current vaccines target HPV-16 and -18, which together account for about 60–70 percent of cervical cancer worldwide. If a vaccine is 90-percent effective against these HPV types, it will have the potential of reducing the incidence of cervical cancer by more than 60 percent. An effect of this magnitude would translate to a reduction of about 150,000 deaths per year worldwide from cervical cancer. In addition, the vaccine would be expected to reduce by about one-half the number of precancerous cervical lesions that require treatment (currently about 1 million cases per year in the United States), leading to a substantial reduction in morbidity, anxiety, and cost. In theory, the vaccine could also reduce the incidence of the other cancers attributable to the targeted HPVs. These other cancers may represent an additional 75,000 deaths per year worldwide that might be prevented by the current vaccine.

    Ovarian Cancer Prevention and Early Detection Study

    NCI, in collaboration with the Gynecologic Oncology Group and the Cancer Genetics Network, is funding a new, 5-year prospective study to identify ways to lower the risk of developing ovarian cancer as well as improve the ability to detect this cancer at an earlier, more readily curable, stage. This study targets women at elevated risk of developing ovarian cancer, either because they have a strong family history of breast and/or ovarian cancer or because they have tested positive for changes in genes that increase the risk of developing ovarian cancer. The study is evaluating two interventions: (1) risk-reducing removal of the ovaries and fallopian tubes; and (2) a novel ovarian cancer screening strategy. All study participants will complete the same set of questionnaires, receive an ultrasound examination of the ovaries, and provide blood samples. The latter will be used for biomarker development and validation. Women in each study group will be closely monitored for the occurrence of breast and ovarian cancer as well as other outcomes of interest. In addition, the protocol includes a detailed assessment of quality-of-life, medical decision-making, and the management of nononcologic complications of premature menopause. At present, this study is open at 90 sites across the United States, and it has accrued 460 (of a planned 1,800) subjects.

    Kidney Cancer Case-control Study

    In the years from 1973–1977 to 1988–1992, incidence rates of U.S. and international kidney cancer rose among men and women in all regions and ethnic groups, with a few exceptions, mostly in Scandinavian countries. The largest percentage increases were for men in Japan (171 percent) and for women in Italy (107 percent). In the years 1988–1992, kidney cancer incidence rates were highest in France and lowest in India. Rates for renal pelvis cancer were less than 1/100,000 person-years in almost all regions in both sexes, and the temporal trends were inconsistent.

    In the United States, more rapid increases in the incidence and mortality rates for renal cell cancer have been noted among African Americans than Caucasians. However, the reasons behind the upward trend and the ethnic differences remain unclear. In April 2002, NCI scientists launched the "Case-control Study of Renal Cell Cancer Among Caucasians and African Americans in the U.S." This population-based study will strive to identify environmental and genetic determinants that underlie the demographic patterns. In particular, the investigators hope to clarify the role of smoking, obesity, hypertension, medications, susceptibility genes, and other factors in the etiology of renal cancer. The investigators plan to recruit 1,400 Caucasian and 700 African-American cases and 2,800 controls from the Detroit and Chicago metropolitan regions over a 4-year period. Participants will complete a 90-minute interview and provide samples of saliva and blood.

    Bladder Cancer in the Northeastern United States

    Data from the new cancer atlas covering the period 1970–1994 indicate that bladder cancer mortality rates among white men and women are elevated in the northeastern United States, particularly in the northern parts of New England including Maine, New Hampshire, and Vermont. The reasons for these high mortality rates are unclear. The persistent elevations in mortality and incidence for bladder cancer among both men and women suggest the possible role of environmental factors. A leading suspect exposure is inorganic arsenic in drinking water, which is elevated in private wells in parts of New England. The purpose of this study is to determine the risk factors that explain the high mortality and incidence rates for bladder cancer in men and women in northern New England. The study will be a population-based case-control study of carcinoma of the urinary bladder in 3 states: New Hampshire, Vermont, and Maine. All histologically confirmed incident cases of carcinoma of the bladder occurring within a 3-year period among residents of the study areas between the ages of 30 and 79 years will be eligible for the study. Controls will be selected randomly from the general population of each study area, frequency matched to the age-, race-, and gender-specific distributions of incidence cases of bladder cancer in each state. We expect to interview 1,200 cases and 1,200 controls. Several data collection activities will be incorporated in this study: a self-administered residential/occupational history calendar; a self-administered diet questionnaire; in-person interviews with subjects using a computer-assisted personal interview (CAPI); collection of drinking water to determine levels of arsenic and other contaminants in drinking water; and collection of buccal cells, toenails, spot urine, 4-day urinary habits diary, overnight urine (from a sample of 240 cases and 240 controls), and blood (from a sample of 180 cases and 180 controls). Tumor tissue samples will be obtained for cases. We are examining associations between bladder cancer and environmental exposures in efforts to explain the elevated mortality and incidence in northern New England.

    Testicular Cancer among U.S. Servicemen

    The incidence of testicular germ cell tumors (TGCT) has increased during the better part of the twentieth century and is of particular concern as it primarily affects young men. Though the tumor is relatively infrequent in the population as a whole, TGCT is the most common cancer among U.S. males in the age group 25–34 years. Despite the increases in TGCT rates, the etiology is still poorly understood. The only well-described risk factors for TGCT are cryptorchism, family history of TGCT, and prior history of TGCT. Therefore, in order to understand better the environmental and genetic determinants of TGCT risk, NCI scientists are conducting a case-control study among members of the U.S. Armed Forces. The study includes men who have donated a blood sample to the Department of Defense Serum Repository (DoDSR) between the years 1989 and 2002. All DoDSR donors who have developed GCT are matched to DoDSR donors who have not developed TGCT. The DoDSR serum sample will be tested for levels of organochlorines, gonadotropin levels, and viral antibody titres. In addition, each participant is donating a current buccal cell specimen that will be used to examine genetic susceptibility. Physical activity, medical history, medication history, and other risk factors of the participants will also be analyzed. In addition, the mothers of all participants are being invited to complete a questionnaire concerning a variety of possible risk factors such as physical activity, medical history, medication history, perinatal exposures, and other risk factors. The mothers are also being asked to donate a buccal cell specimen. As of November 2004, the study had enrolled 736 cases; 838 controls; and 1,048 mothers of the case and control men. The study is scheduled to cease field activities in February 2005.

    Breast/Ovarian Cancer Family Registries

    The Breast/Ovarian and Colon Cancer Family Registries (CFR) studies support research to identify genetic changes that predispose to breast, ovarian, and colon cancers, and to explore gene-gene and gene-environment interactions that may contribute to the development of cancer among families with these cancers. These registries provide the tools and resources needed to clarify gene-environment interactions in cancer risk. They have identified thousands of families at high risk for breast, ovarian, and colorectal cancers who have agreed to be part of this research. Of particular interest are potential collaborations aimed at identification and characterization of cancer susceptibility genes; definition of gene-gene and gene-environment interaction in cancer etiology; and cooperative research on the translational, preventive, and behavioral aspects of such findings. The outcome will be a clearer understanding of the genes that affect the development of cancer, and how environmental factors may modify these genes.

    Academic Public Private Partnership Program

    A new initiative, called the Academic Public Private Partnership Program (AP4), has been created to support the discovery of new cancer agents and their rapid translation to human clinical trials. With this program, the NCI will support collaborations between universities, pharmaceutical companies, biotech companies, and nonprofit organizations. A new funding mechanism that would accomplish this goal was called for by several Progress Review Groups. The effort began in July 2003 with the announcement of an RFA for a 1-year planning grant, which will be utilized by the proposed AP4 directors to bring together potential partners and to compose the center application. In July 2004, 14 planning grants were awarded, descriptions of which can be found at <http://dtp.nci.nih.gov/docs/ap4/ap4-index.jsp>. The AP4 initiative represents a new paradigm in drug discovery, development, and delivery for the NCI.

    At the suggestion of the Leukemia, Lymphoma, and Myeloma Progress Review Group, NCI is supporting the formation of partnerships among academia, industry, nonprofit institutions, and government entities. These AP4s will research novel cancer therapeutic, prevention, diagnostic, and imaging interventions. The overall goal of the partnerships will be to speed the translation of newly discovered cancer interventions to clinical trials. The NCI is assisting the formation of these partnerships by funding 1-year planning grants.

    The planning grants will be utilized by the principal investigators to study the feasibility of developing the pharmaceutical/nonprofit/academic interaction necessary to establish and support a partnership, to hold a meeting of potential partners, and to select research projects for the potential AP4 center. This effort is a two-step application process: only awardees of the planning grant are eligible to apply for the AP4 Center grant.

    The principal investigators and institutions are recognized leaders in the field of anticancer intervention, discovery, and development and have assembled excellent teams to plan and organize the AP4 centers. The AP4 center grant applications, which will be the end product of these planning grants, will afford NCI an optimal opportunity to fund top-caliber, results-oriented research. Of the 14 potential partnerships currently being planned, two are focused on blood cancers.

    Dr. Kit S. Lam, University of California, Davis Cancer Center, Davis, CA, is the codirector of a cancer therapeutics team consisting of 50 researchers who work collaboratively on three main themes: drug discovery, drug development, and clinical investigations. The potential AP4 center will concentrate on orphan cancers including acute myelocytic leukemia (AML), acute lymphocytic leukemia (ALL), and ovarian cancer. The team resides in an area abundant in institutes and corporations in fields relevant to drug discovery and development.

    The AP4 center at Northwestern University proposed by Dr. Thomas O'Halloran focuses on the development of improved diagnostics and therapeutic for two rare and generally fatal malignancies, pancreatic cancer and multiple myeloma. Most pancreatic cancer patients have metastatic disease at the time of diagnosis and succumb to the disease within a year. While new therapies have extended survival times for multiple myeloma patients, the disease is still invariably fatal. Dr. O'Halloran plans to utilize the existing research strengths in the Northwestern University Chemistry of Life Processes Institute and in the Robert H. Lurie Comprehensive Cancer as the foundation for the new AP4 center. The research environment includes excellent chemistry, materials science, engineering, biology, and medicine disciplines. Investigators from clinical oncology, molecular biology, diagnostics, imaging, nanotechnology, and drug development will be brought together in this center. This potential AP4 center has an excellent opportunity to bring together institutional strengths, the expertise and resources of its pharmaceutical and biotechnology partners, and the support and input of patient advocacy organizations.

    Drug Development for Cancer, Including Rare Cancers

    NCI continues to screen new synthetic and natural compounds for antitumor activity using the automated cancer cell line screen. Over 87,000 defined chemical structures have been evaluated since the screen became operational in April 1990. More than 9,200 compounds have demonstrated in vitro antitumor activity, of which more than 5,200 agents have been selected for in vivo evaluation for assessment of therapeutic activity. Obviously, there are more compounds to test/develop than current resources would allow. The Drug Development Group (DDG) oversees the decision-making process regarding the development of new drugs and relies on extramural review of proposed activities. A complete description of this process is available on the Developmental Therapeutics Program Web site (dtp.nci.nih.gov). Including vaccines and other biologicals, as well as chemotherapeutic agents, 4 agents are in DDG level 1B (early preclinical testing), 9 are in DDG level 2A (GMP production and late preclinical testing), 6 agents are in DDG level 2B (IND-directed toxicology), and (need count from CTEP) are in DDG level 3 (ready for human testing subject to obtaining an IND). Table 1 lists the agents in the DDG process. As the agents move through the different levels of the decision process, the level of NCI’s financial commitment increases.

    To expedite the movement of academic discoveries from the laboratory to proof-of-principle clinical trials, NCI initiated the program Rapid Access to Intervention Development (RAID) in 1998. RAID makes resources available, on a competitive basis, to the academic research community that are necessary to convert a new molecule into a drug candidate suitable for clinical testing and are generally not available to academic investigators who lack a corporate partner. These resources include: (1) GMP synthesis, formulation, range finding, and IND-directed toxicology and pharmacology; (2) clinical trial planning; and (3) regulatory assistance so that FDA requirements may be satisfied by any investigator who seeks to put a new molecule into the clinic.

    As of December 2004, 288 applications have been received, 104 of which were approved for NCI support. A description of the successful applicants and the projects can be found at http://dtp.nci.nih.gov/docs/raid/raid_index.html. Table 4 lists current RAID projects pertaining to rare diseases.

    Table 1. Compounds That Passed Drug Development Group (as of December 2004)

    Drug Development Group 1B

    NSC Number
    719239 Discreet
    725088 Discreet
    728930 Discreet
    733269 JMP

    Drug Development Group 2A
    NSC Number
    680410 Adaphostin
    656240 Dithiophene and derivatives
    682994 Dithiophene and derivatives
    703939 RFB4-onconase
    711516 Chimeric antiamyloidosis MAb
    722333 Transferrin-doxorubicin conjugate
    724910 Discreet
    721782 1-methyltryptophan
    722134 Discreet

    Drug Development Group 2B
    NSC Number
    281612 Dimethane sulfonate
    309132 Zebularine
    710464 Aminoflavone
    711193 CDDO
    713205 Halofuginone
    729746 HA22

    Drug Development Group 3
    NSC Number
    716976 BNP7787
    371331+112907 Cytochlor + Tetrahydrouridine
    724770 VEGF-Trap
    724636 Biricodar (VX-710)
    724772 BAY 43-9006
    663249 Triapine
    726292 MLN 518
    727990 SB-715992
    727989 GW-572016
    707545 17-DMAG
    701852 SAHA
    728876 90Y-DOTA-Hpam4
    729968 Reolysin
    694501 Pyrrolobenzodiazepine (SJG136)
    720735 Discreet (PPI-2458-[Fumagillin Analog]
    703813 CC-5013
    732208 AZD2171
    733606 ABT472
    732517 BMS 354825
    710464 Aminoflavone
    733504 RAD001
    731636 SGN-30
    711193 CDDO

    Table 2: Active Research and Development Agreements (as of December 21, 2004)

    The NCI cooperates on the development of novel anticancer therapies with commercial as well as institutional entities ranging from fresh startups to the multinational biopharmaceutical firms. NCI currently holds 36 Cooperative Research and Development Agreements (CRADAs), 52 Clinical Trials Agreements (CTAs), 12 Clinical Supply Agreements (CSAs), and 203 Material Transfer Agreements (MTAs) with its collaborators.

    Agent Company Type
    17-AAG KOSAN BIOSCIENCES CRADA
    17-DMAG KOSAN BIOSCIENCES CRADA
    280-446 NOVARTIS CTA
    2-METHOXYESTRADIOL (Panzem) ENTREMED, INC. CRADA
    506U78 (Nelarabine) GLAXOSMITHKLINE CTA
    5-AZACYTIDINE PHARMION CORPORATION CTA
    ABT 472 ABBOTT LABORATORIES CTA
    AE-941 AETERNA CTA
    ALL-TRANS RETINOIC ACID HOFFMANN-LAROCHE CTA
    ANTI-CTLA4 ANTIBODY MEDAREX CTA
    Antigen genes formulated for delivery in a dermal powderject xr gene delivery device POWDERJECT CTA
    ARSENIC TRIOXIDE (Trisenox) CELL THERAPEUTICS, INC. CRADA
    ARTEMISININ ELSOHLY LABORATORIES M-CRADA
    AZD2171 ASTRAZENECA PHARMACEUTICALS LP CRADA
    BAY 43-9006 (Sorafenib) BAYER CORPORATION CTA
    BENZOYLPHENYLUREA ISHIHARA SANGYO KAISHA CTA
    BEVACIZUMAB (Avastin) GENENTECH CRADA
    BMS 214662 BRISTOL-MYERS SQUIBB CTA
    BMS 247550 (Ixabepilone) BRISTOL-MYERS SQUIBB CTA
    BMS 275291 (MMPI) BRISTOL-MYERS SQUIBB CTA
    BMS 354825 BRISTOL-MYERS SQUIBB CTA
    BNP7787 BIONUMERIK PHARMACEUTICALS CTA
    CAMPATH 1H (Alemtuzumab) BERLEX LABORATORIES CTA
    CARBOXYPEPTIDASE G2 PROTHERICS INC. CTA
    CCI-779 (Temsirolimus) WYETH PHARMACEUTICALS, INC. CRADA
    CDDO REATA DISCOVERY, INC. CRADA-LOI
    CILENGITIDE (EMD 121974) MERCK KGAA CRADA
    CLODRONATE SCHERING OY M-CRADA
    COL-3 (Medastat) COLLAGENEX CRADA
    CYTOCHLOR, THU HALOGENETICS, INC CTA
    DECITABINE SUPERGEN, INC. CRADA
    E7389 EISAI RESEARCH INSTITUTE CRADA
    EMD 273063 EMD PHARMACEUTICALS M-CRADA
    EXEMESTANE PFIZER M-CRADA
    FK228 (Depsipeptide) GLOUCESTER PHARMACEUTICALS CRADA
    FLAVOPIRIDOL (Alvocidib) SANOFI-AVENTIS CRADA
    G3139 (Oblimersen sodium) GENTA CRADA
    GADOLINIUM TEXAPHYRIN (Gd-Tex) PHARMACYCLICS CRADA
    GM-CSF (Sargramostim) BERLEX LABORATORIES CTA
    GTI-2040 LORUS THERAPEUTICS CTA
    GW572016 (Lapatinib ditosylate) GLAXOSMITHKLINE CTA
    HALOFUGINONE (Cebegine) COLLGARD PHARMACEUTICALS CRADA
    HERCEPTIN (Trastuzumab) GENENTECH CRADA
    HSP-E7 STRESSGEN BIOTECHNOLOGIES CTA
    ID-KLH LYMPHOMA VACCINE BIOVEST INTERNATIONAL CRADA
    IL-2 CHIRON CORPORATION CTA
    ING201 INTROGEN CTA
    IRESSA (ZD1839) ASTRAZENECA PHARMACEUTICALS LP CTA
    IRINOTECAN (Camptosar) PFIZER CTA
    KRN5500 KIRIN CTA
    LUTETIUM TEXAPHYRIN (Lu-Tex) PHARMACYCLICS CRADA
    MEDI-522 (Vitaxin) MEDIMMUNE CRADA
    MGI 114 (Irofulven) MGI PHARMA CTA
    MLN 518 MILLENNIUM PHARMACEUTICALS CRADA
    MS-275 SCHERING AG CRADA
    O6-BENZYLGUANINE AOI PHARMACEUTICALS CRADA
    OSI-774 (Tarceva; erlotinib) OSI PHARMACEUTICALS, INC. CTA
    OXALIPLATIN (Eloxatin) SANOFI-SYNTHELABO CRADA
    PERIFOSINE AOI PHARMACEUTICALS CRADA
    PPI 2458 (Fumagillin Analog) PRAECIS PHARMACEUTICALS CTA
    PR-1 VACCINE VACCINE COMPANY CTA
    PS-341 (Bortezomib; Velcade) MILLENNIUM PHARMACEUTICALS CRADA
    PSC-833 (Cyclosporin) NOVARTIS CTA
    PV701 WELLSTAT CRADA
    PXD-101 CURAGEN CTA
    PYRAZOLOACRIDINE PARKE-DAVIS CTA
    R115777 (Tipifarnib, Zarnestra) JOHNSON & JOHNSON R&D CTA
    RAD001 NOVARTIS CTA
    REBECCAMYCIN ANALOG (Becatecarin) EXELIXIS CTA
    REOLYSIN ONCOLYTICS BIOTECH CTA
    REVLIMID (lenalidomide) CELGENE CORPORATION CTA
    rF-TRICOM, rF-CEA-TRICOM THERION IntMurl-CRADA
    RITUXIMAB BIOGEN IDEC CRADA
    rV-B7.1 THERION IntMurl-CRADA
    SAHA MERCK & CO. CTA
    SB-715992 GLAXOSMITHKLINE CTA
    SC-55494 SEARLE CTA
    SGN-30 SEATTLE GENETICS CTA
    SJG-136 IPSEN CRADA
    SMART 1D10 (HU1D10, Apolizumab) PROTEIN DESIGN LABS, INC. CTA
    STI571 (Gleevec, Imatinib mesylate) NOVARTIS CRADA
    THALIDOMIDE (Thalomid) CELGENE CORPORATION CTA
    TIRAPAZAMINE (Tirazone) SANOFI-SYNTHELABO CTA
    TOPOTECAN (Hycamptamine) GLAXOSMITHKLINE CTA
    TRIAPINE VION PHARMACEUTICALS CTA
    Tumor Necrosis Factor-alpha (Tasonermin) BOEHRINGER INGELHEIM CTA
    UCN-01 KYOWA HAKKO KOGYO CTA
    VEGF TRAP SANOFI-AVENTIS CTA
    VX710 (Biricodar) VERTEX PHARMACEUTICALS CTA
    XK469 BRISTOL-MYERS SQUIBB CTA
    ZEVALIN (Ibritumomab tiuxetan) BIOGEN IDEC CTA

    Table 3: Investigational New Anticancer Agents in Early Clinical Trials (as of January 2005)

    Phase I Phase II
    Biologic Agents
    Advexin® (adenovirus p53) Advexin® (adenovirus p53)
    Anti-idiotype-KLH Myeloma Vaccine Anti-idiotype-KLH Myeloma Vaccine
    Antisense GTI-2040 Antisense GTI-2040
    Apolizumab (MoAb: Hu1D10) Apolizumab (MoAb: Hu1D10)
    Apolizumab + Rituxan® Avastin™ (bevacizumab, MoAb: anti-VEGF)
    Autologous T cells + rF-gp100P209 Avastin™ PAP-pulsed Dendritic Cells
    Avastin™ (bevacizumab, MoAb: anti-VEGF) BL22 Immunotoxin
    BL22 Immunotoxin Campath® [MoAb: CAMPATH-1H (Anti-CD52)]
    Campath® [MoAb: CAMPATH-1H (Anti-CD52)] CAP-1 peptide vaccine
    gp 100 IVS Cells Vaccine Expanded activated T cells + IL-2
    gp100TCR-transduced PBL + TIL ESO-1 Peptides
    gp100 Protein (184V) Vaccine FGF-5:172-176/217-220 peptides
    Genasense® (G3139 ASO) Genasense® (G3139 ASO)
    IL-2 transduced cells (retroviral vector) gp100 IVS Cells Vaccine
    IL-12 gp100 Peptides A,C,F Vaccine
    IL-12 + IL-2 Herceptin® (trastuzumab; MoAb: humanized Her2)
    LBM-2 Immunotoxin IL-12
    MDX-010 (Human Anti-CTLA4 MoAb) IL-12 + IL-2
    MoAb: 3A1, 95-5-49, 95-6-22 (Anti-T cell) LMB-2 Immunotoxin
    MoAb: HeFi-1 (Anti-CD30) MDX-010 (Human Anti-CTLA4 mAb)
    MoAb: I-131 HuCC49 Delta CH2 MoAb: 3A1, 95-5-49, 95-6-22 (Anti-T cell)
    MS275 MSGV1AIB(anti-MART-1 TCR) Retroviral Vector-Transduced Autologous TIL/PBL
    PANVAC™-V and PANVAC™-F Mutated VHL Peptides Vaccine
    PR-1 Peptide Vaccine PAX3/FKHR/EWS/FLI1&2 Vaccine
    Prosvac® (PSA-TRICOM vaccine) PG13/LNc8 RetrovirusTransduced T cells
    ras/p53 Vaccine PR-1 Peptide Vaccine
    Recombinant Fowlpox- CEA(6D)/TRICOM + Vaccinia- CEA(6D)/TRICOM Vaccine Prosvac® (PSA-TRICOM vaccine)
    Recombinant Fowlpox-TRICOM and Vaccinia-TRICOM Vaccine ras/p53 Vaccine
    Rituxan® (rituximab, MoAb: IDEC-C2B8)/Chemotherapy Recombinant Fowlpox- CEA(6D)/TRICOM + Vaccinia- CEA(6D)/TRICOM Vaccine
    SS1(dsFv)PE38 Recombinant Fowlpox-PSA Vaccine
    Sodium Phenylbutyrate (IV) Recombinant Fowlpox-TRICOM and Vaccinia-TRICOM Vaccine
    Vitaxin® (MEDI-522) Rituxan® (rituximab, MoAb: IDEC-C2B8)/Chemotherapy
    Zevalin® (MoAb: Y2B8) SGN-00101 (HspE7) Vaccine
      Sodium Phenylbutyrate (IV)
      Thalidomid® (thalidomide)
      Zevalin® (MoAb: Y2B8)
    Chemotherapeutic Agents
    17-AAG 17-AAG
    17-DMAG BAY 43-9006
    BAY 43-9006 BMS 247550 (epothilone B analog)
    BMS 214662 (FTI) Bryostatin 1
    BMS 247550 (epothilone B analog) CAI
    BPU CCI-779 (rapamycin analog)
    Bryostatin 1 COL-3
    CAI Decitibine
    Camptosar® (irinotecan, CPT-11) Depsipeptide
    CCI-779 (rapamycin analog) EF5
    CC-5013 Eloxatin® (oxaliplatin)
    COL-3 EMD 121974
    Cytochlor + Tetrahydrouridine Fenretinide (4-HPR)
    Decitibine Flavopiridol
    Depsipeptide Gleevec® (imatinib mesylate, STI571)
    E7389 (halichondrin B analog) GW572016
    EF5 Halofuginone (topical)
    Eloxatin® (oxaliplatin) Hycamtin® (topotecan)
    EMD 121974 Iressa® (ZD1839)
    Fenretinide (4-HPR) Irofulven (MGI-114)
    Flavopiridol MMPI (BMS 275291)
    Gadolinium Texaphyrin Nelarabine® (compound 506U78)
    Gleevec® (imatinib mesylate, STI571) O6-Benzylguanine (O6-BG)
    Hycamtin® (topotecan) Perifosine
    Iressa® (ZD1839) Pyrazoloacridine
    Irofulven (MGI-114) Rebeccamycin Analog
    KRN5500 SB-715992
    Lutetium Texaphyrin Suramin
    O6-Benzylguanine (O6-BG) Tarceva® (OSI-774)
    Panzem® [methoxyestradiol (2ME2)] Taxotere® (docetaxel)
    Pyrazoloacridine Tirapazamine
    Rebeccamycin Analog Triapine®
    SarCNU Trisenox® (arsenic trioxide)
    SB-715992 UCN-01
    SJG136 Velcade® (bortezomib, PS341)
    Suramin Zarnestra® (R115777)
    Tarceva® (OSI-774)  
    Taxol® (paclitaxel)  
    Tirapazamine  
    Triapine®  
    Trisenox® (arsenic trioxide)  
    UCN-01  
    Velcade® (Bortezomib, PS341)  
    XK469  
    Zarnestra® (R115777)  

    Table 4. Current RAID Projects for the Treatment of Rare Diseases (As of 12/04)

    Compound NSC Name Disease Investigator Pediatric Use
    710296 C-myb Antisense Oligodeoxynucleotide Acute Myelocytic Leukemia Dr. Alan Gewirtz; University of Pennsylvania, School of Medicine Yes
    710292 Lipopeptide Cytomegalovirus Dr. Don Diamond; City of Hope Medical Center Yes
    711518 Allogenic Pancreatic Tumor Vaccine Pancreas Dr. Elizabeth M. Jaffee; Johns Hopkins University  
    711519 IGF-1R Antisense Oligodeoxynucleotide Glioma Dr. Robert Aiken; Thomas Jefferson Medical College Yes
    714597 Imexon Multiple Myeloma Dr. Robert Dorr; University of Arizona, Arizona Cancer Center
    113090 Betulinic Acid Multiple Myeloma Dr. Tapas Das Gupta; University of Illinois at Chicago  
    734551
    714503
    Fenretinide plus Safingnol Neuroblastoma, Pancreas, Acute Leukemias Dr. C. Patrick Reynolds; University of Southern California School of Medicine Yes
    715815 Chimeric Anti-CD54 monoclonal Antibody (UV3) Multiple Myeloma Dr. Ellen Vitetta; University of Texas, Southwestern Medical Center  
    715816 Tropism-Modified Adenoviral Vector Ovary Dr. Glenn Peters; University of Alabama, Comprehensive Cancer Center  
    71887 Psuedomonas Exotoxin Construct Glioblastoma Multiforme, Neoplastic Meningitis Dr. Darrell Bigner; Duke University Comprehensive Cancer Center Yes
    719277 Nonpathogenic Oncolytic Poliovirus Chimeras Glioma Dr. Matthias Gromeier; Duke University Medical Center Yes
    720454 vac-mTag Recombinant Vaccinia Construct Mesothelioma Dr. Harvey Pass; Barbara Ann Karmanos Cancer Institute  
    720836 IL-6 plus Interferon Multiple Myeloma Dr. Richard Jones; Johns Hopkins University  
    722667 Folate receptor-targeted liposomal daunorubicin (F-L-DAU) Acute myelocytic leukemia Dr. Robert Lee; Ohio State University  
    723253 Allogeneic multiple myeloma vaccine Multiple myeloma Ivan Borrello; Johns Hopkins University  
    723256 d-24-RGD oncolytic virus Chronic lymphocytic leukemia Alfred Yung; University of Texas, M.D. Anderson Cancer Center  
    725178 Targeted CRAd Pancreatic adenocarcinoma Selwyn Vickers; University of Alabama  
    726189 SHetA2 Ovary Doris Benbrook; University of Oklahoma
    326231 BSO Neuroblastoma Patrick Reynolds, Children's Hospital LA Yes
    374551 Oral formulation of fenretinide Neuroblastoma Barry Maurer; Children's Hospital LA Yes
    723254 hsp70-targeted E7 recombinant DNA vaccine Cervical Connie Trimble; Johns Hopkins University  
    731413 Ad5/3-delta24 Ovary Akseli Hemminki; Helsinki University Hospital  
    731414 MV-NIS virus Refractory multiple myeloma Stephen Russell; Mayo Clinic  
    731442 KSR antisense oligonucleotide Pancreatic Richard Kolesnick; MSK Cancer Center  
    733624 Frondoside A Pancreatic Thomas Adrian, Northwestern School of Medicine  

    Initiatives Planned for the Future

    Case-control Consortia

    By 2008, consortial studies of the several major cancers will be completed or under way. The breast and prostate cohort consortia have already been created and funded, while consortial studies of brain cancers and lymphoma will be conducted and analyzed in the short term. Cancers of high lethality (e.g., pancreas, liver, and esophagus) will also be studied through consortia, and a proposed Request for Application for these ongoing consortia will be initiated in 2005. In the short term, all of these consortia will be developed and the studies initiated, and these studies will be conducted and analyzed by the end of the mid term. Consortia to study other cancers, including childhood cancers, will be initiated in 4–6 years and conducted and analyzed in 7–10 years. The order and priority will depend on emerging hypotheses from population and laboratory research. The established consortia will be utilized to initiate both etiologic studies and early detection biomarkers of cancer precursors to identify carcinogenic mechanisms and preventive interventions. These studies may be expanded based on outcomes from the integrated cancer biology initiative. Linking the consortia through standardized platforms developed by the bioinformatics strategic initiative will accelerate accurate data collection and analysis. Factors that significantly influence the risk of developing cancer will be essential elements for other strategic initiatives including clinical interventions; cancer health disparities; and prevention, early detection, and prediction.

    Trans-NCI R21 Pancreatic Cancer Program Announcement

    Pancreatic cancer is a highly lethal disease marked by pain, anorexia, sleep problems, and weight loss. It has the worst prognosis among all of the major malignancies. Despite efforts over the past century, conventional treatment approaches such as chemotherapy, radiation, surgery, or combinations of these modalities have had little impact on the course of this disease. It is clear that a better understanding of the molecular biology and biochemistry of pancreatic cancer is urgently needed to effectively diagnose, prevent, and treat this malignancy. Estimates by the American Cancer Society (ACS) indicate 31,860 new cases and 31,270 deaths from pancreatic cancer for 2004. The Trans-NCI Pancreatic Cancer Program Announcement would support a variety of research areas across multiple disciplines. Brief descriptions of extramural research across the cancer continuum identified by NCI division are provided here.

    Cancer Biology—NCI is interested in expanding research in the biology of pancreatic cancer. Examples of appropriate research areas include, but are not limited to, how variations in cells combine with the microenvironment in the development of pancreatic cancer, development of experimental models for human pancreatic cancer, and exploration of molecular pathways important in cancer biology, particularly those that could lead to novel targets for therapeutic development.

    Clinical Chemoprevention Trials—NCI is interested in smaller phase II trials involving persons at risk for familial pancreatic cancer or patients with pancreatic intraepithelial neoplasia (PANIN) lesions. Such cohorts could be treated with a COXIB, FTI, statin, etc., and then be followed with endoscopic ultrasound. These smaller exploratory clinical trials could be complemented by additional epidemiological or preclinical studies, designed to identify candidate surrogate biomarkers and/or candidate chemopreventive or dietary compounds.

    Candidate Biomarkers—Biomarkers are needed to assess: (1) pancreatic cancer risk, i.e., factors modifying pancreatic etiologic events and/or exposures, (2) response modification, i.e., response to a putative chemopreventive drug or dietary factor, and (3) pancreatic cancer advancement or stage, i.e., ability to predict pancreatic cancer outcome.

    Cancer Control and Population Sciences—Identify genetic combinations that lead to pancreatic cancer, identify 'new' environmental exposures that contribute to pancreatic cancer, determine the relationship between inflammation and pancreatic cancer, develop a biofluid-based test for pancreatic cancer, and determine what combination of 'two hits'—genetic and/ or environmental—are needed for pancreatic cancer to develop.

    Cancer Treatment and Diagnosis—The Clinical Grants and Contracts Branch as well as the clinical trials sponsored by the Investigational Drug Branch and the Clinical Investigations Branch at CTEP would benefit greatly from grant support specifically directed toward: Development of early stage clinical trials in pancreatic cancer, translational research associated with early stage clinical trials in pancreatic cancer, imaging studies associated with clinical trials in pancreatic cancer, exploratory studies to identify and evaluate biomarkers (with associated assay development) to determine prognosis and predict response to therapy in pancreatic cancer, and correlative studies using specimens from multi-institutional prevention and treatment trials.

    Workshop to Explore Public-private Partnerships for Childhood Cancers

    To help assure that children do receive timely benefit from advances in cancer biology, NCI will sponsor a workshop in FY2005 to address opportunities for public-private partnerships to identify childhood cancer molecular targets and to exploit this new knowledge for therapeutic benefit. The recommendations from this workshop will guide NCI efforts in establishing appropriate partnerships and in defining the most efficient and effective ways to support research that will identify effective molecular therapeutics for children with cancer.

    Future Research in Blood Cancers

    NCI has reissued two Program Announcements, Quick Trials for Novel Cancer Therapies: Exploratory Grants (PAR-04-155) and Clinical Cancer Therapy and Prevention Research (PA-04-046). These initiatives currently have many projects related to different types of blood cancers and addressed the PRG’s recommendations to provide for molecular characterization of hematological malignancies and new and novel treatment and prevention strategies.

    New Myeloproliferative Disorders Initiative

    NCI cosponsored with the NHLBI the RFA (HL-04-034) titled “Cellular and Genetic Discovery toward Curative Therapy in Myeloproliferative Disorders (MPD).” This initiative will fund up to 12 new grants in FY2005.

    C. Rare Disease-specific Scientific Conferences, Symposia, or Workshops with Outcomes

    D. Activities Rare Diseases Patient Advocacy Groups to Stimulate Research

    E. Education Activities on Rare Diseases for the Researcher, Public, and the Health Care Provider Community

    (These three sections are combined since most meetings now include investigators, advocates, interested members of the public, and health care providers.)

    Cancer Survivorship: Genetic Susceptibility and Second Primary Cancers: Dr. Lois Travis, held November 8–9, 2004

    Given the increasing survival of cancer survivors, it becomes imperative to characterize the late effects of successful cancer treatment. Second primary cancers are now the number one cause of death among long-term survivors of selected cancers. Although the research community has made great strides in describing the risk and temporal patterns of second primary cancers, the identification of susceptible patient subgroups has not been systematically addressed. If genetically susceptible subsets of populations can be identified, the opportunity to tailor cancer therapy in order to minimize serious late toxicity would result. Susceptibility can be conferred because of numerous inter-individual differences in carcinogen processing and elimination, including polymorphisms in DNA repair pathways, cell cycle regulation, and genetic variation in drug metabolism and response. The study of cancer survivors provides a special opportunity to investigate the mechanisms of carcinogenesis, since it is the only setting in which humans are deliberately exposed to carefully measured amounts of known carcinogens (chemotherapy and radiation).

    The goal of the meeting was to comprehensively review the current state of knowledge in this area and to identify important areas for future research. When complete, the final workshop summary will be presented to the NCI Executive Committee, the Prevention Committee of ASCO, and the Outcomes Group of ASTRO.

    Global Increases in Esophageal Adenocarcinoma: Current Epidemiologic Research and Future Directions: Dr. Wong Ho Chow, to be held May 9–10, 2005, in Rockville, MD

    Esophageal cancer overall is a rare malignancy. However, incidence rates of esophageal adenocarcinoma have been increasing rapidly worldwide for the past three decades, while rates for esophageal squamous cell carcinoma have declined. In the United States, the increases in esophageal adenocarcinoma among white men have outpaced all other cancers, and the rates have surpassed those of squamous cell carcinoma of the esophagus since 1994. Substantial increases of esophageal adenocarcinoma also are observed among women and minorities.

    In the 1990s, several epidemiologic studies were launched in the United States and other countries to examine reasons for the upward trends of esophageal adenocarcinoma. These studies have provided convincing evidence linking risk of this cancer to smoking, obesity, and gastroesophageal reflux disease. However, the role of other potential environmental and genetic risk factors is still unclear. Major limitations were the relatively small number of cases that each study was able to recruit and the even fewer numbers of patients who provided biological samples for molecular studies. The opportunities for more in-depth analyses of potential risk factors, particularly for exposures of relatively low prevalence and analyses of genetic and tumor markers, will be enhanced by pooling data from these investigations. NCI can play a valuable role by facilitating scientific dialogue, promoting the sharing of resources, and mapping future directions of interdisciplinary research in the etiology of this emerging cancer.

    Proposed content/scientific issues: The proposed workshop will review current research, including data and type of biological samples collected in each study and findings to date, and discuss the feasibility and logistics for pooling the questionnaire data and biological samples. Participants will also discuss the future directions and type of epidemiologic studies needed to further elucidate the etiology and biological mechanisms leading to esophageal adenocarcinoma. To this end, the workshop will include presentations on state of the science laboratory technology that can be applied in epidemiologic investigations, including high-throughput genotyping, microarray, and proteomic analyses.

    Anticipated goals: It is anticipated that the workshop will result in a preliminary plan for sharing data and resources among the existing studies and initiation of one to two proof-of principle analytical projects using the shared data. It is also anticipated that the workshop will stimulate ideas for future research.

    CLL Research Consortium Annual Meeting:

    The CLL Research Consortium had its annual meeting in Bethesda, MD, in April 2004. Members of the public, professional societies, and advocacy groups as well as staff of NCI and NHLBI were invited to attend.

    Natural History and Treatment of Peritoneal Mesothelioma:

    This meeting held September 13–14, 2004, in Bethesda included almost 200 participants including representatives from the Office of Rare Diseases and NCI faculty. Extramural faculty included U.S. and international investigators. Meeting sections included laboratory investigation, epidemiology, treatment, and outcomes.

    Other Meetings Include the Following:

    • 19th International Pigment Cell Conference "A Focus on Human Pigmentary Disorders"
    • Linking Haplotypes and Genetic Variation with Cancer Risk Assessment, Prevention, Detection, and Treatment Workshop
    • Sarcoma and Mesenchymal Stem Cell Biology Workshop
    • Collaborative Approaches to Discovering Genes in African Americans and Hispanics
    • Utilizing Mapping by Admixture Linkage Disequilibrium
    • Lymphangiogenesis and Cancer: Research Directions and Therapeutic Opportunities
    • Childhood Cancer Survivorship: Improving Care After Treatment
    • RNA Interference-Target Validation and Potential Therapeutic Applications for Childhood Cancers
    • Bloom Syndrome: Molecular Basis of Genomic Instability
    • Genetic Diseases Caused by ABC Transporters
    • Workshop on Chronic Graft-Versus-Host Disease
    • FASEB Conference on Modulatory Adhesion Molecules in Tissue Organization

    Rare Diseases Research Activities and Advances

    Center for Cancer Research, 2004

    Molecular Signature Identified for Liver Cancer

      A molecular signature has been identified that can be used to predict metastatic hepatocellular cancer (HCC) and patient prognosis. This signature can separate HCC patients into metastatic and nonmetastatic groups and may be useful for diagnosing HCC patients with metastatic potential. Currently, we are conducting a cross-validation study with a larger number of independent HCC patients to refine this signature. A serum profile has been established by determining the serum concentration of osteopontin and matrix metalloproteinase 9 to predict HCC patient survival and metastasis. Both microarray and serum profiling may provide a cross-validation of the metastasis prediction model in preparation for whether it should be recommended for aiding future clinical diagnosis.

    Clinical Trials in Pediatric Sarcoma and Leukemia Patients

    • The Pediatric Oncology Branch (POB) emphasizes clinical trials in high-risk sarcoma and leukemia patients and new drug development studies for pediatric cancer patients. Current efforts in high-risk sarcoma patients include development of effective immunotherapeutic strategies and utilization of allogeneic bone marrow transplant to generate graft-versus-tumor effects. Similar strategies are being used for recurrent leukemia patients. In addition, we are currently evaluating specific immunotoxin therapy for recurrent leukemias.
    • The value of dynamic MRI imaging in predicting response to neoadjuvant chemotherapy is being studied in newly diagnosed osteosarcoma. The predictive value appears to be promising. Preliminary analysis of gene expression profiling on these tumors suggests that profiles may cluster patients into “good” and “poor” prognosis prospectively.
    • IRB approval was recently received for a new salvage therapy for recurrent osteosarcoma and Ewing’s sarcoma using a combination of sequential gemcitabine/docetaxel based on preliminary in vitro synergy and previous activity of the single agents. This study will be performed through a newly formed sarcoma consortium and is supported by Aventis and Lilly.
    • Current research efforts in the POB include clinical trials of novel, nonmyeloablative allogeneic stem cell transplant regimens for childhood hematopoietic malignancies. Biologic correlative studies conducted as part of these trials include valuation of chemotherapy-induced immunosuppression, immune recovery after allogeneic transplantation, and the pathophysiology of graft-versus-host disease. Additional clinical trial activities include phase I development of immunotoxins for refractory leukemias and lymphomas. In an effort to improve understanding of the molecular mechanisms of leukemogenesis and identify potential new therapeutic targets, collaborative investigations of gene expression profiles of pediatric leukemias are also being conducted.

    Molecular Markers of Ewing’s Sarcoma and Rhabdomyosarcoma Aid Diagnosis

    • Many pediatric solid tumors exhibit fundamental cytogenetic abnormalities that have implications in their pathogenesis. The Ewing's sarcoma family of tumors (ESFT) and alveolar rhabdomyosarcoma (RMS) are characterized by consistent chromosomal translocations that result in the fusion of genes and subsequent formation of novel chimeric genes. These molecular markers can be detected by RT-PCR or fluorescence in situ hybridization (FISH) and can be used not only to establish the diagnosis in difficult cases but also to understand the pathogenesis of these tumors. Recently, the products of these fusion genes have become the target of vaccine therapies in newly established protocols in the POB at the NCI.

    Novel Therapies Devised for Brain and Spinal Cord Tumors

    • Novel experimental therapeutics are being developed for children and adults with tumors of the brain and spinal cord. Toward this end, the translational laboratory efforts of the Neuro-Oncology Branch are focusing on new strategies for selective tumor targeting through gene transfer using neural and endothelial stem cells and novel genetic vectors, through the identification of tumor-selective processes such as angiogenesis, and through the identification of tumor-specific markers.
    • Angiogenesis inhibition is being explored as a novel therapeutic strategy for the treatment of malignant gliomas. Selective delivery of genes of choice to tumor-associated angiogenesis can result in subsequent destruction of the tumor vascular bed. This novel strategy will be brought to the clinic soon.
    • We are also in the process of identifying unique proteins expressed on infiltrating glioma cells and on endothelium, associated with the angiogenic response of tumors, for the purpose of identifying novel peptides and single chain antibody molecules. These molecules will be tagged with radioisotopes for diagnostic purposes and conjugated with immunotoxins.

    Gene Expression Profiling Predicts Outcome in Rhabdomyosarcoma and Neuroblastoma

    • The POB has developed substantial efforts in both proteomic and genomic characterization of pediatric tumors. The POB has carried out reverse-phase protein arrays on a set of 34 rhabdomyosarcomas. Expression of several proteins was highly associated with a high risk for relapse. Gene expression profiling is being performed on a series of neuroblastomas of different stages and prognosis to identify tumor-specific expression patterns or "fingerprints." The analysis has identified patterns of gene expression that accurately predicted outcome. These studies are also continuing in an attempt to identify new potential targets for therapy in poor-outcome patients.

    Microarray for Neurofibromatosis Developed to Identify Molecular Targets

    • The NCI POB is developing a tissue microarray for pediatric solid tumors and neurofibromatosis type 1 (NF1)-associated tumors with the goal of analyzing these tumors for the presence of targets of new molecularly targeted agents. The microarray will be used to make rational decisions in the drug development for pediatric cancers and NF1.

    Molecular Signature of Malignant Gliomas Sought

    • We are in the process of constructing a glioma-specific cDNA microarray chip to develop a molecular classification scheme of malignant gliomas. Through the identification of signature gene expression profiles, we hope to be able to group pediatric and adult gliomas into tumors that are biologically more related. This will allow us to offer more accurate prognoses and begin to address the issue of individualized therapies.

    Metastasis and Therapy Studied in New Mouse Models of Metastatic Osteosarcoma

    • The POB has a major focus on osteosarcoma. We have recently developed mouse models of metastatic osteosarcoma and identified novel proteins that appear to play a major role in metastatic behavior in this model and, hopefully, in human osteosarcoma as well. Work is ongoing to determine what signaling pathways mediate these effects on metastatic behavior with the hope that novel therapeutic interventions can be identified and tested for patients with metastatic osteosarcoma. We are also testing novel anti-metastatic agents using this mouse model.

    Artificial Neural Networks Predict Clinical Outcomes in Neuroblastoma

    • Researchers at the National Cancer Institute have used artificial neural networks (ANNs) and DNA microarrays to successfully predict the clinical outcome of patients diagnosed with neuroblastoma (NB). The ANNs also identified a minimal set of 19 genes whose expression levels were closely associated with this clinical outcome.
    • Using the 19 predictor genes, the ANNs were also able to partition the subset of patients classified as high risk into good and poor outcome groups as well as predict which of the high-risk patients would fail conventional therapy. This has major clinical implications since we are now able to distinguish a group of ultra-high-risk patients who will not respond to conventional therapy and therefore require alternative treatment strategies. We may also be able to reduce the intensity and thereby reduce the toxicity of treatment regime to those predicted to survive based on their gene expression profile.
    • We can translate our findings to the clinic because simple prognostic assays can be developed based on this small number of genes. In fact, three of the genes found to be overexpressed in poor-outcome tumors encode proteins secreted into the blood, meaning they could be used as serum prognosis markers in a simple blood test. In collaboration with industry, we are now developing clinical assays based on these 19 genes and planning to test for the presence of these serum markers in other patients with NB for prognostic prediction.

    Targeted Treatment Agents for Neurofibromatosis Tested in Clinical Trials

    • The ras family of G-proteins plays an important role in the transduction of signals that trigger cell proliferation, and mutations in ras genes are found in 30 percent of all human cancers. Ras proteins undergo post-translational farnesylation, which is required for activity of wild-type and mutant ras proteins, and this step can be inhibited by farnesyltransferase inhibitors such as R115777. The evaluation of R115777 in children with refractory solid tumors and neurofibromatosis type I (NF1) is therefore a rational choice. A phase I trial of R115777 for children with these tumors was recently completed, and based on the results of this phase I trial, a multi-institutional, randomized, double-blinded, placebo-controlled, cross-over phase II trial of R115777 for patients with NF1 and progressive plexiform neurofibromas was developed and is open for patient accrual.
    • A phase I trial of the antifibrotic agent pirfenidone is coordinated by the NCI, POB in collaboration with Children's National Medical Center, Washington, DC, and the Mayo Clinic, Rochester, MN, and just completed accrual. Subsequently a phase II trial of pirfenidone for children and young adults with NF1 and progressive plexiform neurofibromas was developed at the NCI, POB, and this trial just opened for accrual.

    Gene Expression Profiling Diagnoses Benign versus Malignant Thyroid Tumors

    • Classification of human cancers into distinct groups based on their molecular profile rather than their histological appearance may prove to be more relevant to specific cancer diagnoses and cancer treatment regimes. Therefore, in this study, we developed a gene expression approach to diagnose benign versus malignant thyroid lesions in 73 patients with thyroid tumors. We successfully built a 10- and 6-gene model able to differentiate benign versus malignant thyroid tumors. Our results support the premise that a molecular classification system for thyroid tumors is possible, and this in turn may provide a more accurate diagnostic tool for the clinician managing patients with suspicious thyroid lesions.

    A Functional Polymorphism in RGS6 Modulates Bladder Cancer Risk

    • RGS proteins negatively regulate G protein signaling. Recent reports have shown that RGS proteins modulate neuronal, cardiovascular, and lymphocytic activity, yet their role in carcinogenesis has not been explored. In an epidemiologic study of 477 bladder cancer patients and 446 matched controls, three noncoding single-nucleotide polymorphisms (SNPs) in RGS2 and RGS6 were each associated with a statistically significant reduction in bladder cancer risk. The risk of bladder cancer was reduced by 74 percent in those individuals with the variant genotype at all three SNPs. In addition, we demonstrated that RGS2 transcripts and several splice variants of RGS6 are expressed in bladder cancer cells. These data provide the first evidence that RGS proteins may be important modulators of cancer risk and validate RGS6 as a target for further study.
    • In an ongoing hospital-based case-control study, we explored the association between 12 noncoding SNPs in five RGS genes identified in the National Center for Biotechnology Information (NCBI) database (dbSNP) and the risk of bladder carcinoma, a cause of over 12,000 deaths per annum in the United States. Our results suggest that selected RGS variant SNPs may be important modifiers of cancer risk. To validate the biological significance of these SNPs, we also sought to identify functional changes in transcript levels, alternative splicing events, and protein translation efficiency that may result from the presence of the variant alleles.

    Novel RNA-based Antiviral Therapies Devised for Cervical Cancer

    • The papillomaviruses are epitheliotropic small DNA tumor viruses that cause both benign and malignant lesions in humans and animals. An oncogenic subset of the human papillomaviruses (including HPV-16, -18, -31, and -33) is associated with the vast majority of cervical cancers as well as squamous cell carcinomas in other locations. Expression of papillomavirus genes is regulated at both transcriptional and post-transcriptional levels. We are currently exploiting HPV alternative splicing to develop novel RNA-based antiviral and anticancer therapies. In addition, we have been involved in several collaborations on HPV transcriptional and post-transcriptional regulation. Some of the techniques we have developed, such as isoform-specific real-time quantitative RT-PCR (QRT-PCR), are also being used in other collaborations both within and outside the papillomavirus field.
    • Targeting HPV-infected cells using specific trans-splicing: The ideal cancer therapy would kill cancer cells and have no effect on normal cells. The expression of spliced human papillomavirus E6/E7 pre-mRNAs by the vast majority of cervical cancers provides an absolute difference between cancer cells and normal cells that can be exploited for the specific targeting of these cells. Through a CRADA between NCI and Intronn, Inc., we are investigating the use of Intronn’s Spliceosome Mediated RNA Trans-splicing (SMaRT) Technology to develop a novel RNA-based suicide gene therapy for cervical cancer.

    Vaccines Developed Against HPV Virion Proteins

    • There is a strong association between malignant progression of human genital lesions and certain human papillomavirus (HPV) types, most frequently HPV-16. Our research is concerned with development of vaccines against HPV and other targets and elucidation of the PV life cycle. We have generated virus-like particles (VLPs) for HPV-16 and other PVs that consist of the L1 major capsid protein or L1 plus L2, the minor capsid protein. Parenteral injection of purified VLPs induced high titers of neutralizing antibodies and protection from experimental challenge in animal models. Based upon these results, we have validated GMP grade VLPs and have completed phase I and phase II clinical trials of an HPV-16 L1 VLP vaccine. Vaccines, even those vaccinated in the absence of adjuvant, consistently produced high titers of HPV-16 psuedovirion-neutralizing antibodies and reported only minor side effects. We are also developing alternative vaccine candidates, some for use in disease induced by HPV and others for use in diseases unlinked to HPV infection.

    Molecular Genetics of Gynecologic Cancers Characterized

    • Gynecologic cancer remains a major health problem for women in this country with approximately 25,000 deaths annually attributed to this problem. The purpose of this project is to characterize the molecular genetics of this group of tumors and ultimately use that information for clinical application in rationally designing therapeutic and prevention trials. We have characterized endometrial, cervical, and ovarian specimens that span the histiologic spectrum from benign to malignant for mutations in the ras, p53, cyclin dependent kinase inhibitors, FHIT and Rb genes, and microsatellite instability. These studies should help to identify the molecular genetic events that are important in the genesis of endometrial and cervical cancers and their use for their early detection.
    • Evaluation of ovarian tumors revealed that activated ras genes are found in benign (10 percent) and low malignant potential (LMP) (30 percent) tumors but not ovarian carcinomas (5–10 percent). In addition, mutations in the tumor suppressor genes p53 and Rb occur in ovarian carcinomas (48 and 14 percent respectively) but are not present in LMP tumors. This suggests that ovarian carcinoma and LMP tumors are discrete biologic entities.
    • To identify potential new markers of ovarian cancer and genes important in its pathogenesis, malignant ovarian epithelium is being compared to its benign counterpart using differential display technology, representational display, and microarrays. As part of the Director's Challenge collaborative grant between this laboratory and MSK, 400 ovarian cancer specimens will be profiled utilizing cDNA microarrays and patterns will be correlated with clinical characteristics such as survival, histology, and stage. Genes that are differentially expressed will be isolated, cloned, and characterized for their roles in the development of ovarian cancer.

    Genome Expression Profiling of Ovarian Cancer Reveals Activated Pathways

    • Ovarian cancer is the most lethal type of gynecologic cancer in the Western world. The high case fatality rate is due in part because most ovarian cancer patients present with advanced stage disease that is essentially incurable. In order to obtain a whole genome assessment of aberrant gene expression in advanced ovarian cancer, we used oligonucleotide microarrays comprising over 40,000 features to profile 37 advanced stage papillary serous primary carcinomas. We identified 1,191 genes that were significantly (P < 0.001) differentially regulated between the ovarian cancer specimens and normal ovarian surface epithelium. The list of differentially expressed genes includes ones that are involved in cell growth, differentiation, adhesion, apoptosis, and migration. Based on our expression results, a signaling pathway associated with tumor cell migration, spread, and invasion was identified as being activated in advanced ovarian cancer.

    Recombinant Immunotoxins Developed for Ovarian and Pancreatic Cancer Therapy

    • Mesothelin is a differentiation antigen present on normal mesothelial cells and overexpressed in several human tumors, including mesothelioma and ovarian and pancreatic adenocarcinoma. Mesothelin is a promising candidate for tumor-specific therapy, given its limited expression in normal tissues and high expression in several cancers. We have developed a recombinant anti-mesothelin immunotoxin (SS1P) that targets ovarian cancers, mesotheliomas, and pancreatic cancers and is currently in clinical trials. Recombinant immunotoxin SS1P shows significant activity in preclinical models including complete regression of mesothelin-expressing tumor xenografts in mice as well as cytotoxic activity in vitro against tumor cells obtained directly from patients with ovarian cancer and peritoneal mesothelioma.

      We are using animal models to evaluate therapies that could enhance antibody delivery, with the goal of translating these findings to the clinic. Two phase I trials with immunotoxin SS1P are now open.

    Targeted Systemic Radiotherapeutics Evaluated for Intraperitoneal Cancers

    • Evaluations are being performed of the therapeutic efficacy of targeted systemic radiotherapeutics for treating metastatic intraperitoneal cancer, such as pancreatic cancer, while simultaneously optimizing their value in conjunction with chemotherapeutics. The majority of targeted ratation therapies have employed a single administration of a single isotope, while in fact, dose fractionation and combination therapies with other modalities clearly provide superior results. Studies combining the use of targeted α-emitters with chemotherapeutics are novel and unique to the NCI.

    Cytogenetic Signature of Vaginal Squamous Cell Carcinoma Identified

    • We used comparative genomic hybridization to establish a pattern of genomic imbalances in vaginal squamous cell carcinomas. Analysis of 16 tumors revealed that 70 percent of vaginal carcinomas carry relative copy number increases that map to chromosome arm 3q. Other recurring gains were observed on chromosome arms 5p and 19p. Chromosomal losses were infrequent. The cytogenetic data were related to the presence of human papillomavirus genomes, expression of laminin-5 as a marker for invasiveness, and expression levels of markers for proliferative activity and mutated TP53. The results suggest that vaginal carcinomas are defined by a specific distribution of chromosomal aneuploidies and that the pattern of genomic imbalances is strikingly similar to that observed in squamous cell carcinomas of the uterine cervix. Age at diagnosis, tumor size, and increased laminin-5 expression have a significant influence on the survival time. As in other malignant diseases, early detection greatly affects survival rates. It is therefore a perceived goal to analyze and understand the genetic mechanisms leading to vaginal tumorigenesis.

    Techniques Evaluated for Early Detection of Esophageal Cancer

    • Esophageal cancer has a very poor prognosis, primarily because most tumors produce symptoms only after they have spread beyond the esophageal wall and are unresectable. Significant improvement in survival will require successful strategies to diagnose and treat more cases at earlier, more curable stages of the disease. A project is being carried out in Linxian, China, a county with very high rates of esophageal cancer, to evaluate techniques that may be useful in a practical early detection and treatment program.
    • The project includes five studies: the Cytology Sampling Study, the Mucosal Staining Study, the Endoscopic Staging Study, the Endoscopic Therapy Pilot Study, and the Chemoregression Study.

    Molecular Genetics of Kidney Cancer Studied

    • In order to identify the genes that cause kidney cancer and develop molecular therapeutics for this disease, we have studied the inherited forms of cancer of the kidney. Individuals with the inherited form of kidney cancer associated with von Hippel Lindau (VHL) are predisposed to develop tumors in the brain, spine, eyes, pancreas, adrenal gland, and inner ear. By studying VHL families we were able to perform genetic linkage analysis to localize and subsequently identify the VHL gene on chromosome 3. We have identified the VHL gene mutation in the germline of 246/246 VHL kindreds and are currently studying genotype/phenotype relationships as well as evaluating minimally invasive forms of therapy for kidney and adrenal tumors in VHL. The VHL gene has been shown to be the gene for the hereditary form of renal carcinoma associated with VHL as well as the common form of sporadic (nonhereditary) kidney cancer (clear cell renal carcinoma)

    Angiogenesis in Renal Cell Cancer Targeted in Laboratory and Clinical Studies

    • Renal cell cancer (RCC) is a highly vascular tumor that contains a mutation in the VHL tumor suppressor gene in over 80 percent of clear cell carcinomas. This mutation is linked to deregulation of vascular endothelial growth factor (VEGF), a potent angiogenic agent. We are currently beginning a new initiative directed at identifying the mediators of angiogenesis and growth of RCC and neutralizing these biological activities in preclinical tumor models and in patients with RCC. In preclinical models of RCC xenografts in nude mice, we are evaluating neutralizing antibodies to FGF-5. RCC was found to express FGF-5 when expression screening of a cDNA library from an RCC line revealed FGF-5 as the targeted RCC-associated tumor antigen. This molecule, originally identified by its ability to transform 3T3, is expressed in approximately 60 percent of RCC lines and some prostate and breast cancer lines. We have not found it expressed by normal adult tissues by RT-PCR, and it therefore represents an excellent therapeutic target for multiple adenocarcinomas including RCC.
    • Parallel to these laboratory studies, we are conducting clinical protocols of anti-angiogenic agents. In a new, accruing clinical protocol, we are evaluating the efficacy of a humanized neutralizing antibody to hVEGF (Genentech, Inc.) in a randomized, double-blind, placebo-controlled format in patients with progressive, metastatic RCC. In this 150-patient trial, we are also evaluating the use of novel noninvasive imaging techniques to evaluate anti-angiogenic agents in clinical trials. The next generation of clinical studies will be combinations of agents if the anti-VEGF monoclonal antibody demonstrates any significant clinical activity.

    Gene Expression Profiles Provide Diagnosis and Prognosis of Lymphoid Malignancies

    • To provide a molecular basis for the diagnosis of human lymphoid malignancies, we are exploiting DNA microarray technology to profile gene expression in these cancers on a genomic scale. The laboratory created a novel DNA microarray, the "Lymphochip," which is enriched in genes that are expressed in and/or function in lymphocytes.
    • We have used Lymphochip and Affymetrix microarrays to profile gene expression in diffuse large B-cell lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma, follicular lymphoma, multiple myeloma, and in a wide variety of normal lymphoid subsets.
    • One central goal of these studies is to relate gene expression to clinical outcome, thereby establishing a quantitative, reproducible, and informative molecular diagnosis of the lymphoid malignancies. Our studies have revealed previously unknown types of diffuse large B-cell lymphoma that are indistinguishable by current diagnostic methods but have strikingly distinct gene expression profiles, originate from different stages of B-cell differentiation, utilize distinct oncogenic mechanisms, and differ in their ability to be cured by current chemotherapy. For several lymphoid malignancies, we have identified molecular profiles that predict the length of survival or the ability to be cured by chemotherapy, thereby providing clinically useful prognostic indicators. Our laboratory has mounted a major effort to create a diagnostic microarray that could provide these molecular diagnoses and prognoses to patients with lymphoid malignancies.
    • Importantly, the genes that are associated with clinical prognosis have provided new targets for therapy of the lymphoid malignancies. Our laboratory uses functional genomics, chemical genetics, and molecular biological techniques to validate these and other molecular targets toward the ultimate goal of targeted therapies for patients aimed directly at the disordered regulatory biology of their individual tumors.

    IGF-I Induces Migration and Invasion of Multiple Myeloma Cells

    • Multiple myeloma (MM) is an incurable form of cancer characterized by accumulation of malignant plasma cells in the bone marrow. During the course of this disease, tumor cells cross endothelial barriers and home to the bone marrow. In later stages, myeloma cells extravasate through blood vessels and may seed a variety of organs. Insulin-like growth factor I (IGF-I) is one of several growth factors shown to promote the growth of MM cells. In the current study, we have assessed the ability of IGF-I to serve additionally as a chemotactic factor affecting the mobility and invasive properties of these cells. Results indicate that IGF-I promotes transmigration through vascular endothelial cells and bone marrow stromal cell lines. The identification of IGF-I as both a proliferative and migratory factor provides a rational basis for the development of targeted therapeutic strategies directed at IGF-I in the treatment of MM.

    Novel Therapeutic Strategies for Lymphoma Assessed in Clinical Trials

    • In vitro, overexpression of the mdr-1 gene product, P-glycoprotein (Pgp), in tumor cells can confer high-level resistance to natural product-derived cytotoxics. It has been reported that Pgp was detectable by immunohistochemistry in 1/49 (2 percent) of untreated but was detectable in 6/8 (75 percent) treated lymphomas, suggesting that Pgp conferred drug resistance. To test this hypothesis, we developed and tested a mdr-1 reversal strategy in relapsed lymphomas using EPOCH (doxorubicin/vincristine/etoposide, prednisone, cyclophosphamide) and dexverapamil. Based on our results showing EPOCH to be effective and well tolerated, we began a phase II study of EPOCH in previously untreated patients with aggressive lymphomas. In this study, EPOCH doses are escalated within patients to the maximum tolerated dose (MTD). End points are dose intensity, efficacy, toxicity, and molecular markers of drug resistance. Early results show a high complete response rate of 89 percent with an EFS of 77 percent at 2 years median follow-up. Accrual continues to this trial.
    • We have recently developed and tested a “second generation” EPOCH regimen (EPOCH II) to replace stem cell transplant for lymphomas requiring high-dose intensity including poor prognosis untreated aggressive lymphomas, potentially curable relapsed lymphomas, and low-grade lymphomas. This regimen is based on experimental/clinical observations that suggest infusion schedules may improve the therapeutic index of natural product-derived cytotoxics and that high-dose alkylator therapy can overcome drug resistance in lymphoma. Preliminary results show EPOCH II to have a response rate of 90 percent with 66 percent complete.
    • Examination of tumor tissues to assess potential mechanisms of drug resistance is an ongoing effort in our group. We have demonstrated the association of clinical drug resistance with p53 mutation and low proliferation rate in relapsed lymphomas. Currently, we are studying other novel cell-cycle proteins such as p27 in lymphomas. Recently, we have been interested in testing novel protein kinase inhibitors in lymphomas. One such inhibitor, UCN-01, has shown marked synergy with fludarabine in a variety of human cell lines. To further assess this drug, we will soon begin a phase I study of UCN-01 and fludarabine in patients with relapsed and refractory indolent lymphomas.
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    Last Reviewed: July 22, 2005