Les inhibiteurs de BRAFV600-, dont le vemurafenib, sont efficaces contre les tumeurs présentant cette mutation activatrice de la voie des MAPK, ce qui est le cas d’un mélanome sur deux. Mais la plupart des malades traités rechutent dans l’année, et développent des tumeurs paradoxales secondaires.Divers mécanismes de résistance aux inhibiteurs de BRAF ont été décrits, cette résistance passant soit par réactivation de la voie des MAPK, soit par activation de la voie parallèle Akt/mTor, soit par anomalie de régulation de l’apoptose. Dans le cadre de cette thèse, nous avons mis en évidence une nouvelle cible thérapeutique: l’initiation de la traduction cap-dépendante. L’augmentation de la traduction de certains ARNm en protéines est une étape capitale de l’expression des gènes dans les processus oncogènes. Une étape limitante de cette traduction est son initiation. La protéine eIF4E (eukaryotic Initiation Factor 4E) se lie à la coiffe m7GTP des ARNm et régule la synthèse protéique en fonction de ses partenaires 4EBP1 et eIF4G. Quand eIF4E est assemblé à eIF4G et eIF4A, on parle du complexe « eIF4F », situé au point de convergence de la voie des MAPK et de la voie Akt/mTor via 4EBP1. Ce complexe est nécessaire à la traduction des protéines de survie et de prolifération cellulaire ayant une structure secondaire complexe en 5’UTR. Pour déterminer le statut d’activation du complexe eIF4F dans des lignées cellulaires, nous avons réalisé une immunoprécipitation des protéines liées au cap (« cap-binding assay »). Nous avons observé que le vemurafenib entraînait une diminution d’eIF4G fixé à eIF4E dans les cellules sensibles mais aucune modification dans les lignées résistantes. Parallèlement, la fixation de 4EBP1 à eIF4E augmente sous vemurafenib pour les lignées sensibles. Pour confirmer ces résultats, nous avons utilisé la technique de « Proximity Ligation Assay » (PLA), qui nous a permis de visualiser les complexes eIF4E-eIF4G et eIF4E-4EBP1 sous forme de points fluorescents observables en microscopie. Le nombre de complexes eIF4E-eF4G était bien diminué dans les cellules sensibles sous vemurafenib ce qui n’était pas le cas dans les cellules résistantes. Parallèlement, le nombre d’interactions eIF4E-4EBP1 augmentait dans les cellules sensibles et restait stable dans les cellules résistantes. De même, dans les tumeurs de patients, le rapport des complexes eIF4E-eIF4G sur eIF4E-4EBP1 diminuait dans les métastases en réponse au vemurafenib puis réaugmentait lors des récidives tumorales. De plus, nous avons testé des composés ciblant la traduction cap-dépendante et plus particulièrement eIF4A : les flavaglines. Nous avons montré que leur capacité à cibler l’initiation de la traduction était corrélée à l’inhibition de la prolifération des lignées cellulaires résistantes. Enfin, nous avons testé l’une d’elles in vivo. Les résultats montrent un effet synergique de cette drogue combinée au vemurafenib et une inhibition de la croissance tumorale.Concernant l’autre inconvénient majeur des anti-BRAF, l’induction fréquente de tumeurs secondaires, nous avons visualisé, aussi par PLA, les dimères BRAF-CRAF pour la première fois dans une série de tumeurs paradoxales de patients, cutanées et extra-cutanées. Ces dimères sont significativement plus nombreux dans les tumeurs cutanées apparaissant sous anti-BRAF que dans une série tumeurs contrôles de même type.En conclusion, nous avons identifié un nouveau biomarqueur de résistance aux anti-BRAF, visualisable par PLA. Pour optimiser la réponse tumorale à ces thérapies ciblées, qui constituent le traitement de choix des mélanomes métastatiques mutés, nous proposons d’y associer un inhibiteur de l’initiation de la traduction. Nous avons en parallèle mis au point le PLA BRAF-CRAF dans les tumeurs paradoxales induites par les anti-BRAF, et nous avons identifié des sous-populations plus à risque de développer ce type de tumeurs. / BRAFV600- inhibitors, including vemurafenib, are efficient against tumors harboring this MAPK pathway activating mutation, which is the case of ~50% of melanomas. But most of the patients under treatment progress within a year, and develop paradoxical secondary tumors. Most resistance mechanisms to drugs that target the BRAF and/or MEK kinases in cancer rely on reactivation of the RAS-RAF-MEK-ERK signal transduction pathway (ERK-dependent), on activation of the alternative PI3K-AKT-mTOR pathway (ERK-independent) or on modulation of the caspase-dependent apoptotic cascade. All three pathways converge to regulate the formation of the eIF4F translation initiation complex that binds to the 7-methyl-guanine cap at the 5’ end of mRNAs, thereby modulating mRNA translation of specific mRNAs. We show here that persistent formation of the eIF4F complex, comprising the eIF4E cap binding protein, the eIF4G scaffolding protein and the eIF4A RNA helicase, is associated with resistance to anti-BRAF, anti-MEK and to anti-BRAF + anti-MEK combinations in BRAFV600- mutant melanoma, colon and thyroid cell lines. Unresponsiveness to treatment and maintenance of eIF4F complex formation is associated with either reactivation of MAPK signaling or absence of ERK-independent decreased phosphorylation of the inhibitory eiF4E binding protein 4EBP1 or increased pro-apoptotic Bcl-2 modifying factor (BMF)-dependent degradation of eIF4G. Development of an in situ method shows by proximity ligation assay (PLA) that the formation of the eIF4F complex is decreased in tumors responding to anti-BRAF therapy and increased in resistant metastases. Strikingly, inhibiting the eIF4F complex, either by blocking the eIF4E-eIF4G interaction or by targeting eIF4A with small compounds is synergistic with BRAFV600- inhibition. The other main problem arising during anti-BRAF treatment is the frequent induction of secondary cutaneous and extra-cutaneous tumors, through the formation of BRAF-CRAF dimers that we visualized in vivo for the first time. In conclusion, we have identified by PLA a novel biomarker of resistance against BRAF inhibitors, which is also a promising therapeutic target. Combinations of drugs targeting BRAF (and/or MEK) and eIF4F may overcome most of the resistance mechanisms arising in BRAFV600- cancers. In parallel, we established a BRAF-CRAF PLA method in paradoxical secondary tumors induced by BRAF inhibitors, leading to the identification of several subpopulations more at risk of developing this type of tumors.

Metastatic melanoma is unusually lethal with a ten year survival rate of less than 10%. Conventional DNA-damaging agents produce little improvement in patient survival. Vemurafenib (Zelboraf), a targeted therapeutic that inhibits the oncogenic BRAF demonstrates significant survival benefit. Unfortunately, it is now evident that there is both intrinsic and acquired resistance. Consequently, new strategies for sensitizing melanomas to vemurafenib are needed. Melanoma resistance to therapy is fueled in part by the integrins, the major cell surface adhesion receptors which are highly over-expressed in melanoma. Both integrin antagonists and agents that engage defective integrins increase the sensitivity of melanomas to chemotherapy. Our laboratory has identified a novel peptide, denoted vinculin activating peptide or VAP that targets integrins from within the cell and brings aberrant integrin function intact. VAP sensitizes melanoma to dacarbazine in vitro and in vivo. The effect VAP has on overcoming resistance to targeted therapies like vemurafenib, as well as the mechanism for its effects are not well understood. The goals of this project are to determine if VAP can be employed to improve sensitivity and/or overcome resistance to vemurafenib and to identify the cell surface target of VAP. Our results show that VAP not only improves melanoma sensitivity to vemurafenib but also decreases intrinsic resistance to this promising drug. In addition, we present evidence that β1 and β3 integrins are the target of VAP's effects. Since peptide-based therapies are not stable in the clinic, we explored another integrin binding partner, kindlin-2. We found that kindlin-2 is over expressed in resistant melanomas. The inhibition of kindlin-2 increases β1 integrin activation and decreases β3 integrin functions. Agents that bring aberrant β1 and β3 integrin function intact can be employed to improve sensitivity and overcome resistance to vemurafenib suggesting that combinatorial therapies that employ vemurafenib and integrin-based agents might be efficacious in combatting resistance in melanoma patients.

Very few cancer patients are cured through drug therapy alone, with the majority exhibiting acquired resistance. To date, most studies of therapeutic escape have focused upon tumor-intrinsic mechanisms of drug resistance with little attention paid to the role of normal host cells in preventing complete tumor eradication. In the present study we implicate co-operative bi-directional signaling between melanoma cells and fibroblasts in the generation of a pro-survival niche that mediates drug resistance. Mass-spectrometry based phosphoproteomics was used to show that BRAF inhibition and chemotherapy drugs enhanced the survival of both melanoma cells and fibroblasts through the induction of fibronectin (FN)/integrin α5β1 signaling. Immunohistochemical staining confirmed the induction of FN in mouse xenografts and human melanoma specimens following BRAF inhibitor treatment. Adhesion to FN amplified the adaptive EGFR, HER3 and c-MET receptor tyrosine kinase (RTK) signals required for PI3K/AKT/Mcl-1-mediated melanoma cell survival when BRAF was inhibited. At the same time, BRAF inhibition led, directly and indirectly, to the paracrine release of HGF and neuregulin from fibroblasts, with TGF-β release from the melanoma cells increasing both fibroblast differentiation and survival. Although dual inhibition of RTKs and BRAF did not reverse host-mediated resistance, therapeutic escape was overcome through combined BRAF/PI3K inhibition, suggesting the PI3K/AKT pathway to be a common signaling vulnerability in microenvironment-mediated drug resistance. Our work suggests that durable responses to targeted therapies will only be achieved through dual targeting of the tumor and the adaptive host responses to therapy. These findings are especially important for a cancer such as melanoma, where as few as one cell can repopulate the entire tumor in vivo.

No description available.

Neste estudo foram avaliados os efeitos farmacológicos do vemurafenibe (inibidor BRAFV600E) e da cloroquina (inibidor de autofagia) na viabilidade celular e crescimento tumoral das sublinhagens de melanoma:G361 pLKO que expressa dermicidina e G361 IBC I com silenciamento da expressão. As células G-361 responderam a vemurafenibe (2 μM) e cloroquina (100 μM), isoladamente ou combinadas, com aumento apoptose, e redução das taxas de senescência. Vemurafenibe (50 mg/kg / 21 dias) inibiu o crescimento tumoral em camundongos imunodeficientes independente da expressão da DCD. A combinação com Cloroquina (30 mg/kg) a cada 24 horas, acelerou, enquanto a cada 72 horas, reduziu o crescimento tumoral. Os tumores apresentaram alterações morfológicas e núcleos atípicos; e não expressaram os marcadores S100, HMB-45, Mela-A ou citoqueratinas. Este trabalho confirmar a eficácia do vemurafenibe e sugere o potencial adjuvante da cloroquina no tratamento de melanomas. O estudo também confirma o papel da dermcidina como oncogne e fator de crescimento de células de melanoma maligno. / In this study we evaluated the pharmacological effects of vemurafenib ( inhibitor BRAFV600E) and chloroquine (autophagy inhibitor) in cell viability and tumor growth of two melanoma cell lines identified as G-361 pLKO, which expresses dermcidin, and G361 IBC I which silenced DCD expression. G-361 melanoma cells responded to vemurafenib (1-2 μM) and chloroquine (50-100 μM) alone or combined, with increased apoptosis rates, while decreasing senescent cells. Vemurafenib (50 mg/kg / 21 days) inhibited melanoma growth in immunodeficient mice independent of dermicidin. Chloroquine (30 mg/kg) in combination with vemurafenib, accelerated (at 24 hour interval), and reduced (at 72 hours interval), melanoma growth. Tumor tissues showed atypical cell morphology and nuclear histological patterns and melanocytic differentiation biomarkers S100, HMB-45, Melan-A or pancytokeratins were not. This work confirms the efficacy of vemurafenib and suggests potential adjuvant effect of chloroquine. It also confirms the role of dermcidin as growth factor and oncogene for melanoma cells.

Neste estudo foram avaliados os efeitos farmacológicos do vemurafenibe (inibidor BRAFV600E) e da cloroquina (inibidor de autofagia) na viabilidade celular e crescimento tumoral das sublinhagens de melanoma:G361 pLKO que expressa dermicidina e G361 IBC I com silenciamento da expressão. As células G-361 responderam a vemurafenibe (2 μM) e cloroquina (100 μM), isoladamente ou combinadas, com aumento apoptose, e redução das taxas de senescência. Vemurafenibe (50 mg/kg / 21 dias) inibiu o crescimento tumoral em camundongos imunodeficientes independente da expressão da DCD. A combinação com Cloroquina (30 mg/kg) a cada 24 horas, acelerou, enquanto a cada 72 horas, reduziu o crescimento tumoral. Os tumores apresentaram alterações morfológicas e núcleos atípicos; e não expressaram os marcadores S100, HMB-45, Mela-A ou citoqueratinas. Este trabalho confirmar a eficácia do vemurafenibe e sugere o potencial adjuvante da cloroquina no tratamento de melanomas. O estudo também confirma o papel da dermcidina como oncogne e fator de crescimento de células de melanoma maligno. / In this study we evaluated the pharmacological effects of vemurafenib ( inhibitor BRAFV600E) and chloroquine (autophagy inhibitor) in cell viability and tumor growth of two melanoma cell lines identified as G-361 pLKO, which expresses dermcidin, and G361 IBC I which silenced DCD expression. G-361 melanoma cells responded to vemurafenib (1-2 μM) and chloroquine (50-100 μM) alone or combined, with increased apoptosis rates, while decreasing senescent cells. Vemurafenib (50 mg/kg / 21 days) inhibited melanoma growth in immunodeficient mice independent of dermicidin. Chloroquine (30 mg/kg) in combination with vemurafenib, accelerated (at 24 hour interval), and reduced (at 72 hours interval), melanoma growth. Tumor tissues showed atypical cell morphology and nuclear histological patterns and melanocytic differentiation biomarkers S100, HMB-45, Melan-A or pancytokeratins were not. This work confirms the efficacy of vemurafenib and suggests potential adjuvant effect of chloroquine. It also confirms the role of dermcidin as growth factor and oncogene for melanoma cells.

Vemurafenib is a potent serine/threonine kinase inhibitor and is registered as Zelboraf® for the treatment of metastatic melanomas harboring BRAFV600E mutations. There is a large individual variation in drug response and the side effects observed among patients treated with Zelboraf® has proven to be severe.  LC-MS/MS methods were developed to measure vemurafenib and its metabolites in human plasma for prediction of treatment outcome and side effects in order to individualize treatment with Zelboraf®.  A novel, rapid quantification method was developed for vemurafenib using a stable isotope labeled internal standard. The method was validated according to international guidelines with regard to calibration range, accuracy, precision, carry-over, dilution integrity, selectivity, matrix effects, recovery and stability. All parameters met the set acceptance criteria.  The first method suitable for quantifying vemurafenib metabolites in human plasma is presented. Lacking commercially available reference substances, human liver microsomes were used to produce the metabolites. In patient samples at steady-state five previously in vitro identified metabolites were quantified for the first time.

Os pacientes com melanomas, em geral, apresentam extrema quimiorresistência e prognóstico ruim, com taxa de sobrevida de aproximadamente seis meses; portanto, novas estratégias terapêuticas são necessárias. As células deste tipo de tumor acumulam alterações na expressão gênica que contribuem para a proliferação descontrolada, evasão de senescência e inibição de morte celular em múltiplas rotas intracelulares. No Capítulo 1, foi explorado o controle epigenético do supressor tumoral RECK. Esse gene é largamente expresso em tecidos normais, com correlação de sua expressão com melhor prognóstico. Em tumores, RECK é inibido, incluindo em melanoma. Neste estudo, sua inibição por hipermetilação do promotor e remodelamento da cromatina por HDACs não foi o único fator inibitório nas linhagens de melanoma analisadas. Mesmo após a utilização a remoção de marcas epigenéticas associadas ao silenciamento gênico, a expressão proteica não pôde ser recuperada nas linhagens utilizadas neste trabalho. No Capítulo 2, isolou-se subpopulações clonais ao acaso a fim de modelar a heterogeneidade tumoral intrínseca. Neste modelo experimental, caracterizamos a presença de dois perfis tumorais subclonais: uma mais proliferativa, invasiva e sensível a vemurafenibe; e outra menos proliferativa, mais resistente e com maior expressão de RECK e fatores ligados a EMT. Nossos resultados, em conjunto, mostraram que as linhagens celulares parentais utilizadas apresentam diferenças entre si quanto à viabilidade celular, indução de apoptose e fosforilação de ERK após o tratamento com vemurafenibe. Segundo o nosso modelo, a resistência intrínseca ao vemurafenibe está presente e reflete a heterogeneidade do tumor inicial. Com estes resultados, pretendemos contribuir para o conhecimento sobre a composição clonal presente na heterogeneidade tumoral, além de contribuir para a função de RECK na biologia do melanoma. / Patients with melanoma often present extreme chemoresistance and poor prognosis, with survival rates of approximately six months; therefore, new therapeutic strategies are necessary. Melanoma cells accumulate genotypic changes that contribute to uncontrolled proliferation, evasion of senescence and cell death inhibition in multiple cellular pathways. In Chapter 1, we have explored the epigenetic control of the tumor suppressor RECK. This gene is widely expressed in normal tissues, with correlation of its expression with better prognosis. In tumors, RECK is inhibited, including melanoma. Here, RECK inhibition by promoter hypermethylation and chromatin remodeling by HDACs was not the only inhibiting factor in the melanoma cell lines analyzed. Even after removing the epigenetic marks associated to gene expression silencing, the protein expression could not be recovered in the cell lines used in this study. In Chapter 2, it has been isolated several tumor clonal subpopulations in order to modulate the intrinsic tumor heterogeneity. In this experimental model, we have characterized the presence of two tumor subclonal profiles: a more proliferative, invasive and sensitive to Vemurafenib; and other less proliferative, less sensitive to Vemurafenib and presenting more expression of RECK and factors associated to EMT. Our results together have showed the parental cell lines used here differed from each other in terms of cell viability, induction of apoptosis, and ERK phosphorylation after treatment with Vemurafenib. According to our model, the intrinsic resistance to Vemurafenib is present and reflects the heterogeneity of the initial tumor. With these results, we intend to contribute to the knowledge of the tumor clonal subpopulations composition in tumor heterogeneity, and contributes to the RECK function in melanoma biology.

Os pacientes com melanomas, em geral, apresentam extrema quimiorresistência e prognóstico ruim, com taxa de sobrevida de aproximadamente seis meses; portanto, novas estratégias terapêuticas são necessárias. As células deste tipo de tumor acumulam alterações na expressão gênica que contribuem para a proliferação descontrolada, evasão de senescência e inibição de morte celular em múltiplas rotas intracelulares. No Capítulo 1, foi explorado o controle epigenético do supressor tumoral RECK. Esse gene é largamente expresso em tecidos normais, com correlação de sua expressão com melhor prognóstico. Em tumores, RECK é inibido, incluindo em melanoma. Neste estudo, sua inibição por hipermetilação do promotor e remodelamento da cromatina por HDACs não foi o único fator inibitório nas linhagens de melanoma analisadas. Mesmo após a utilização a remoção de marcas epigenéticas associadas ao silenciamento gênico, a expressão proteica não pôde ser recuperada nas linhagens utilizadas neste trabalho. No Capítulo 2, isolou-se subpopulações clonais ao acaso a fim de modelar a heterogeneidade tumoral intrínseca. Neste modelo experimental, caracterizamos a presença de dois perfis tumorais subclonais: uma mais proliferativa, invasiva e sensível a vemurafenibe; e outra menos proliferativa, mais resistente e com maior expressão de RECK e fatores ligados a EMT. Nossos resultados, em conjunto, mostraram que as linhagens celulares parentais utilizadas apresentam diferenças entre si quanto à viabilidade celular, indução de apoptose e fosforilação de ERK após o tratamento com vemurafenibe. Segundo o nosso modelo, a resistência intrínseca ao vemurafenibe está presente e reflete a heterogeneidade do tumor inicial. Com estes resultados, pretendemos contribuir para o conhecimento sobre a composição clonal presente na heterogeneidade tumoral, além de contribuir para a função de RECK na biologia do melanoma. / Patients with melanoma often present extreme chemoresistance and poor prognosis, with survival rates of approximately six months; therefore, new therapeutic strategies are necessary. Melanoma cells accumulate genotypic changes that contribute to uncontrolled proliferation, evasion of senescence and cell death inhibition in multiple cellular pathways. In Chapter 1, we have explored the epigenetic control of the tumor suppressor RECK. This gene is widely expressed in normal tissues, with correlation of its expression with better prognosis. In tumors, RECK is inhibited, including melanoma. Here, RECK inhibition by promoter hypermethylation and chromatin remodeling by HDACs was not the only inhibiting factor in the melanoma cell lines analyzed. Even after removing the epigenetic marks associated to gene expression silencing, the protein expression could not be recovered in the cell lines used in this study. In Chapter 2, it has been isolated several tumor clonal subpopulations in order to modulate the intrinsic tumor heterogeneity. In this experimental model, we have characterized the presence of two tumor subclonal profiles: a more proliferative, invasive and sensitive to Vemurafenib; and other less proliferative, less sensitive to Vemurafenib and presenting more expression of RECK and factors associated to EMT. Our results together have showed the parental cell lines used here differed from each other in terms of cell viability, induction of apoptosis, and ERK phosphorylation after treatment with Vemurafenib. According to our model, the intrinsic resistance to Vemurafenib is present and reflects the heterogeneity of the initial tumor. With these results, we intend to contribute to the knowledge of the tumor clonal subpopulations composition in tumor heterogeneity, and contributes to the RECK function in melanoma biology.

Malignant melanoma (MM) is the deadliest skin cancer with an ever-increasing incidence. New treatments have improved the prognosis for patients with advanced MM. Still, most patients do not respond, and the side effects can be severe, underlining the need for better therapies. The overall aim of this thesis was to evaluate new means to improve the treatment for patients with advanced MM. Immunostimulatory gene therapy (AdCD40L) was evaluated in a clinical study and BRAF-inhibitory treatment in rare cases of BRAF-mutated MM. Due to its immunogenicity, MM is an attractive target for immunostimulatory gene therapy. AdCD40L is an adenovirus carrying the human gene for CD40 ligand, which in different ways can stimulate the immune system to combat cancer. We conducted a Phase I/IIa study with AdCD40L in patients with metastatic MM having received established treatments. In cohort 1 (n=6), four weekly, intratumoural AdCD40L injections were given. In cohort 2 (n=9), low dose cyclophosphamide was added to increase the immune response. Since irradiation may act synergistically with immunotherapy, patients in cohort 3 (n=9) also received a single fraction of radiotherapy (8 Gy). This fraction was given towards the lesion selected for injections. The primary objectives were to assess the feasibility and safety of AdCD40L-treatment and secondarily its anti-tumour effects. Patients were thoroughly assessed for toxicity. The anti-tumour response was evaluated by imaging techniques (FDG-PET/CT, DW-MRI scans), tumour biopsies and blood tests. Plasma protein markers were measured with a multiplex platform. Another objective was to evaluate the potential of DW-MRI and FDG-PET/CT for prediction of AdCD40L treatment response, in terms of overall survival (OS). AdCD40L was well tolerated with mild transient reactions. Local and distant responses in PET/CT scans along with a significantly better 6-month survival in the cohorts that received cyclophosphamide conditioning were observed. Effector lymphocyte responses were elicited. All patients had an increased T effector/T regulatory-cell ratio and death receptors were significantly up-regulated post therapy. Inflammatory cytokines and other plasma proteins were altered in favourable ways by the AdCD40L treatment. The analyses support that the functional DWI parameters may be better early predictors of OS than the established metabolic and morphologic criteria of FDG-PET/CT and CT/MRI, respectively. In conclusion, the stimulation of the CD40 pathway to initiate anti-tumour immunity is a promising treatment alternative for MM patients. However, further studies with developed treatment schemes are warranted. In the first report ever on treatment of a pregnant patient with a BRAF-inhibitor, the therapy was initiated in the second trimester. The treatment with vemurafenib enabled prolonged gestation, hence reducing the risk of immaturity-related complications. Further, we report the first case worldwide of a patient with metastatic conjunctival melanoma who benefitted from treatment with vemurafenib. Additional studies are needed to assess the efficacy of BRAF -inhibitors in the different subtypes of ocular melanoma.