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Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiographic syndrome that presents with neurological manifestations, including seizures, headache, or confusion, and is associated with posterior cerebral white matter edema on imaging. PRES is typically a benign and reversible condition. However, PRES can be fatal or associated with permanent deficits. Numerous conditions are associated with PRES, including hypertensive encephalopathy, renal diseases, and cytotoxic or immunosuppressant drugs. Recently, many case reports described the association between PRES and chemotherapeutic agents. However, trastuzumab-associated PRES is rarely reported. Herein, we report a case of a 51-year-old female with a history of metastatic gastric cancer who developed seizures while being treated with trastuzumab, and neuroimaging confirmed the diagnosis of PRES.

Les résultats des projets actuels apportent une information, sur différents aspects des rôles de la voie PI3K, dans le développement du cancer du sein, et la réponse au traitement. Les projets particuliers couvrent des sujets liés à la voie aux niveaux concernant les récepteurs de la famille HER, activant la voie PI3K, ainsi que PI3K et les effecteurs en découlant. Les effets pronostic et prédictif de la dérégulation de PI3K sont les sujets centraux de la recherche décrite ici. Une baisse d’expression de PI3KR1 est associée à une survie réduite dans notre cohorte de patients. Une attention particulière a été portée aux mutations de PIK3CA communes dans le cancer du sein. Tandis que les mutations de PIK3CA agissent comme des marqueurs de bon pronostic chez les patients anti-HER2-naïfs, ces mutations agissent au contraire comme prédicteurs négatifs de la réponse au traitement par trastuzumab. Les résultats décrits mènent un peu plus vers l’implication de plusieurs voies moléculaires altérées, en particulier la voie de signalisation Wnt, dans la tumorigénèse des cancers du sein PIK3CA mutés. De plus, nous avons testé les taux de lapatinib plasmatique montrant une augmentation pertinente dans les périodes d’état d’équilibre du traitement. Par ailleurs, nous avons démontré des incohérences dans l’évaluation de l’EGFR et proposé des approches pour l’interprétation des comptages d’immunohistochimie et de FISH. Tous ces sujets sont connectés par la 170 voie PI3K, et le besoin d’approfondir les connaissances actuelles, et d’apporter de nouvelles informations utiles applicables dans le futur dans les pratiques cliniques / Results of the presented research projects bring information about several aspects of the PI3K signaling pathway roles in breast cancer development and treatment response. The particular projects covered the subjects connected with the signaling pathway, ranging from the HER family receptors activating the pathway, and PI3K to the downstream levels of signalisation. The prognostic and predictive effect of PI3K deregulation was the central subject of the described research. The decreased expression of PIK3R1 associated with reduced survival of our patients. A special focus was put on the PIK3CA mutations which are common in breast cancer. Whereas the PIK3CA mutations act as a good prognostic marker in patients non-treated with the HER2 inhibitors, these mutations predict a negative response to trastuzumab treatment. The described results, furthermore, draw attention to the role of several altered molecular signaling pathways in breast cancer development, especially to the Wnt signaling pathway. The lapatinib plasma levels showing the relevant increase in comparison with the already described efficient steady-state levels were also described in one of the projects. Moreover, various modifications to EGFR status assessment were compared and showed that EGFR FISH and IHC count interpretation depended significantly on method and thresholds used. All these subjects are connected by the PI3K pathway, the need to deepen current knowledge and bring new useful information applicable in future clinical practice.

HER2overexpression is associated with poor breast cancer prognosis and increased risk of metastasis. Current HER2targeted therapies include monoclonal antibody based strategies which work by reducing HER2 levels at the cell surface (trastuzumab), by preventing HER2 dimerization (pertuzumab), or via targeted delivery of a cytotoxic payload (trastuzumab emtansine). Although these therapies are successful in some cases, acquired and inherent resistance to these therapeutics remain a treatment hurdle. Oncolytic viruses (OVs) specifically target and lyse cancer cells while leaving normal cells unharmed. One such OV, VSVΔ51, replicates in interferon (IFN) defective cells, a characteristic of approximately 70% of tumours. We hypothesized that the combination of HER2 targeting therapies with VSVΔ51 could improve therapeutic efficacy. We found that HER2 overexpression was associated with increased virus sensitivity and that modulation of HER2 signaling through a subset of activating ligands and inhibitory drugs could influence infection. We further established that the HER2 monoclonal antibodies trastuzumab and pertuzumab mediate an anti-viral effect on VSVΔ51 spread. Finally, we demonstrate that conjugation of a microtubule targeting agent to trastuzumab can overcome the induced anti-viral state and enhance VSVΔ51 spread specifically in cancer cells. Overall, this work highlights the importance of HER2 signaling and activation on VSVΔ51 spread and shows that conjugation of microtubule destabilizing agents to monoclonal antibodies can enhance VSVΔ51 efficacy.

Introduction: The European Union (EU) is a political and economic confederation <p>composed by 27 member states (EU-27). The EU implemented several standardizations in laws, <p>justice and home affairs and shares the consensus that health care should be regulated by the <p>state. A high level of human protection should be ensured in all its member states. European <p>health systems are funded and managed by each national government and for historical <p>reasons health policy and health expenditure are not homogeneous. <p>Whereas cancer incidence is dependent on factors such as population age, life-style and <p>genetic predisposition, cancer mortality in general is dependent on the efficacy of health <p>systems in providing cancer prevention, efficient screening methods and treatments. <p>Around 20% of the breast cancers show amplification/overexpression of HER2 that is <p>associated with a more aggressive disease and worse clinical outcome. By targeting the HER2 <p>receptor trastuzumab has significantly improved overall survival and changed the natural <p>course of this disease. <p>Objectives: This study aims to evaluate (1) the association of health expenditure with <p>breast cancer outcome, (2) to explore to which degree the differences in breast cancer survival <p>are related to the speed of uptake of trastuzumab and its determinants and (3) to evaluate the <p>real usage of trastuzumab and its relation to breast cancer survival in the EU. <p>Results: Breast cancer survival was found strongly correlated with health expenditure. A <p>clear cutoff divides Western and Eastern Europe in that regard, with western countries showing <p>higher health expenditure and higher breast cancer survival than Eastern Europe. Trastuzumab <p>reimbursement was faster in Western European countries, a factor associated with higher <p>health expenditure and better health policy performance. Trastuzumab uptake is increasing all <p>over Europe in the last 12 years, however it is still being under used in Eastern countries while <p>in Western Europe the uptake is sufficient to treat virtually all patients in need of the drug. <p>Conclusion: Important discrepancies in breast cancer survival exist in the EU. Western <p>Europe has higher breast cancer survival and higher health expenditure than Eastern Europe. <p>This can be partially explained by the faster approval and increased uptake of trastuzumab in <p>Western countries. Higher health expenditure and better health policy performance were <p>factors linked to faster reimbursement and uptake of trastuzumab. / Doctorat en sciences médicales / info:eu-repo/semantics/nonPublished

Le trastuzumab est le traitement de référence des cancers du sein « HER2 amplifié ». Outre les limitations inhérentes à toute IgG, cet anticorps est inefficace pour traiter les tumeurs exprimant que modérément (cancers hormonaux) ou faiblement (triple négatif) HER2. L'objectif de ces travaux de thèse est de concevoir de nouveaux anticorps bispécifiques destinés au traitement de cancers du sein échappant à l'action du trastuzumab. Nous nous sommes appuyés sur des formats innovants, basés sur l'utilisation d'anticorps simple domaine de lama (sdAb) comme unité de reconnaissance antigénique. Deux anticorps bispécifiques Fab-like (bsFab) ont été développés, l'un dirigé contre HER2 (HER2bsFab) et l'autre ciblant la mésothéline (MesobsFab), un antigène surexprimé dans 30 à 70% des cancers du sein « triple négatif ». En liant spécifiquement et de façon efficace FcγRIII, ces deux bsFabs ne compètent pas avec les IgG endogènes, ne fixent pas FcγRIIB et activent fortement les NKs. In vitro, HER2bsFab induit de fortes sécrétions de cytokines pro-inflammatoires et de puissantes ADCCs contre des lignées de cancer du sein indépendamment du niveau d'expression d'HER2 et du polymorphisme FcγRIIIA-158. In vivo, HER2bsFab montre une nette supériorité comparé au trastuzumab contre des tumeurs ne surexprimant que modérément HER2. HER2bsFab et MesobsFab induisent in vitro de fortes cytotoxicités contre deux lignées de cancer du sein « triple négatif » et des résultats préliminaires réalisés chez la souris semblent confirmer ces observations. A termes, l'utilisation de ces anticorps permettrait d'étendre la proportion de patientes traitables de façon efficace par immunothérapie. / Trastuzumab is established as standard of care for the treatment of HER2high breast cancers. However, in addition to Fc-related limitations inherent to IgG antibodies, trastuzumab is inefficient to treat low- (triple-negative) or moderate-HER2-overexpressing (hormone-receptor-positive) breast cancers. Based on the unique structural and functional properties of llama single domain antibodies (sdAbs), we report the design of two Fab-like bispecific antibodies targeted to HER2 (HER2bsFab) and mesothelin (MesobsFab), an antigen overexpressed in several human tumors, including triple-negative breast cancers. The two bsFabs display a unique, specific and high affinity for FcγRIII. As a consequence, they do not bind the FcγRIIB inhibitor receptor and bypass competition with endogenous IgGs. HER2bsFab mediated ADCC at picomolar concentration against HER2high as well as HER2moderate cell lines. In vivo HER2bsFab potently inhibited HER2high tumor growth and more importantly, exhibited a net superiority over trastuzumab at inhibiting HER2moderate tumor growth. Moreover, FcγRIIIA-engagement by HER2bsFab was independent of FcγRIIIA-158 polymorphism and induced a stronger NK cells activation in response to target cell recognition. Such findings led us to investigating the efficacy of bsFabs in a context of low-HER2-overexpression displays by triple-negative breast cancers. In vitro characterization showed that both HER2bsFab and MesobsFab trigger efficient lysis of two different triple-negative breast cancer cell lines. Altogether, these findings would enable the treatment of a broader population of patients than that eligible with current HER2-targeted therapies.

BACKGROUND:In breast cancer endocrine therapy, post-therapy Ki-67 assay of biopsy material predicts recurrence-free survival but is invasive and prone to sampling error. 18F]Fluorodeoxyglucose (FDG) positron emission tomography (PET) has shown an early agonist or 'flare' response to tamoxifen and estradiol, but has not been tested in response to estrogen-lowering aromatase inhibitors (AIs). We hypothesized that decreased agonistic response to AIs would result in early FDG uptake decline. We also measured early response to trastuzumab (T), another targeted agent for breast cancer with differing mechanisms of action. Our study was designed to test for an early decline in FDG uptake in response to AI or T and to examine association with Ki-67 measures of early response.METHODS:Patients with any stage of newly diagnosed or recurrent breast cancer were eligible and enrolled prior to initiation (or resumption) of AI or T therapy. FDG PET and tissue biopsy were planned before and after 2 weeks of AI or T therapy, with pretreatment archival tissue permitted. Cutoffs of greater than or equal to]20% decline in standardized uptake value (SUV) as FDG PET early response and less than or equal to]5% post-treatment expression as Ki-67 early response were defined prior to analysis.RESULTS:Forty-two patients enrolled, and 40 (28 AI, 12 T) completed serial FDG-PET imaging. Twenty-two patients (17 AI, 5 T) had newly diagnosed disease, and 23 (14 AI, 9 T) had metastatic disease (5 newly diagnosed). Post-treatment biopsy was performed in 25 patients (63%) and was either refused or not feasible in 15. Post-treatment biopsy yielded tumor in only 17/25 cases (14 AI, 3 T). Eleven of 14 AI patients with post-therapy tissue showed FDG PET early response, and there was 100% concordance of PET and post-therapy Ki-67 early response. For the T group, 6/12 showed an FDG PET early response, including 2/3 patients with post-therapy biopsy, all with Ki-67 >5%.CONCLUSIONS:Substantial changes in FDG PET SUV occurred over 2 weeks of AI therapy and were associated with low post-therapy proliferation. SUV decline was seen in response to T, but few tissue samples were available to test association with Ki-67. Our results support further investigation of FDG PET as a biomarker for early response to AI therapy.

Breast cancers with overexpression or amplification of the HER2 tyrosine kinase receptor are more aggressive, resistant to chemotherapy, and associated with a worse prognosis. Currently, these breast cancers are treated with the monoclonal antibody trastuzumab (Herceptin®). Unfortunately, not all patients respond to trastuzumab drug therapy; some patients show de novo resistance, while others acquire resistance during treatment. This thesis describes our RNAi studies to identify novel regulators of the HER2 signaling pathway in breast cancer. Three kinome-wide siRNA screens were performed on five HER2 amplified and seven HER2 non-amplified breast cancer cell lines, two normal breast cell lines, as well as two HER2-positive breast cancer cell lines with acquired trastuzumab resistance and their isogenic trastuzumab-sensitive controls. To understand the main kinase drivers of HER2 signaling, we performed a comprehensive screen that selected against growth inhibitors of the non-HER2 amplified breast cancer cell lines. This screen identified the loss of the HER2/HER3 heterodimer as the most prominent selective inhibitor of HER2-amplified breast cancers. In a trastuzumab sensitization screen on five trastuzumab-treated breast cancer cell lines, we identified several siRNA against the PI3K pathway as well as various other signaling pathways that inhibited proliferation. Finally, in a screen for acquired trastuzumab resistance, PKCη and its downstream targets were identified. Loss of PKCη resulted in a decrease in G1/S transition and upregulation of the cyclin dependent kinase inhibitor p27. Initial data suggest that PKCη promotes p27 ubiquitination and degradation. Taken together, these studies provide novel insight into the complex signaling of HER2-positive breast cancers and the mechanisms of resistance to trastuzumab therapy. This work describes how various kinases can modulate cell proliferation, and points to possible novel drug targets for the treatment of HER2-positive breast cancers.

Background Trastuzumab resistance imposes a major limitation to the successful treatment of HER2 positive breast cancer. The expression of HER4 and its prognostic value is controversial in breast cancer. Furthermore, its role in trastuzumab treatment and resistance in HER2 positive breast cancer has not been reported. Methods The effects of trastuzumab on HER4 cleavage and its localisation were studied in both parental and trastuzumab-resistant SKBR3 and BT474 cells using western blot, RT-PCR, nuclear fractionation and confocal microscopy. Tissue microarrays consisting of a cohort of HER2 positive breast cancer patients were stained for HER4 by immunohistochemistry and the results were correlated with patients’ outcome. This study also assessed HER4 expression in the tumor samples from a window study of trastuzumab alone or in combination with neoadjuvant chemotherapy in HER2 positive breast cancer patients. Results Trastuzumab treatment upregulated HER4 mRNA, and increased expression of both 80 and 180 kDa HER4 protein isoforms, and induced nuclear translocation of 80kDa HER4 protein isoforms, which the results similar to heregulin stimulation. This was also seen in trastuzumab resistant cells although HER4_80kDa and nuclear HER4 decreased upon overnight withdrawal of trastuzumab in resistant cell lines. In addition, knockdown of HER4 protein expression by specific siRNAs increased trastuzumab sensitivity and reversed trastuzumab resistance in SKBR3 and BT474 cells, confirming the importance of HER4 in trastuzumab response. This study also showed that trastuzumab-induced HER4 nuclear translocation is due to HER4 activation and cleavage since &gamma;-secretase inhibitor (GSi) and neratinib prevented the process when combined with trastuzumab treatment, correlating with an increased apoptosis and decreased cell viability. There was also increased nuclear HER4 expression in tumors from both BT474 xenografts and from patients with breast cancer treated with trastuzumab monotherapy. Furthermore, nuclear HER4 predicted poor clinical response to trastuzumab monotherapy in patients undergoing a window study and was a poor prognostic factor in HER2 positive breast cancer. Conclusions This study suggests HER4 activation, cleavage and nuclear translocation play a key role in trastuzumab resistance in HER2 positive breast cancer. Nuclear HER4 could be a novel predictive and prognostic biomarker in HER2 positive breast cancer patients.