1. Novel radio-therapeutic deliveries to induce apoptosis in epithelial and endothelial compartment of solid tumors : A Pre- Clinical and Clinical Perspective Mansoor M. Ahmed PhD Staff Scientist http://www.biologyofcancer.org Weis Center for Research, Geisinger Clinic, Danville, PA 17822

2. Low-dose fractionated radiation as a chemo-potentiator

3. This is how the idea started!!!! When paclitaxel and radiation were combined, an enhanced radiosensitizing effect (P < 0.05) was observed in HCT-116 cells (SF(2) = 0.138; D(0) = 103 cGy), whereas in HT-29 cells no significant radiosensitization of paclitaxel was observed (SF(2) = 0.608; D(0) = 306 cGy). However, pretreatment with paclitaxel followed by multifractionated low dose radiation (0.5- or 1-Gy fractions for a total dose of 2 Gy) significantly enhanced the radiosensitizing effect in both HCT-116 and HT-29 cells. The results of the current study suggested that multifractionated radiation given at very low doses after exposure of cells to paclitaxel conferred a potent radiation sensitizing effect irrespective of p53 status.

4. Radiation Cell Survival Curve: Redefining ‘the shoulder’ Radiation Cell Survival Curve: Redefining ‘the shoulder’ Preclinical data suggest that LDFRT ( <1 Gy) potentiates the effectiveness of various chemoRx agents including Taxol, Cisplatin, and Gemcitabine

5. HYPER-RADIATION SENSITIVITY HRS was documented in more than 40 tumor cell lines in response to single low dose radiation HRS occurs after fractionated low-doses in in-vitro Increased HRS is observed in G2M cell cycle phase HRS does not exhibit cellular repair mechanisms

6. Traditional Dose Time Fractionation (2 Gy/ day) Low Dose/fraction (0.5 Gy b.i.d/day) M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F M T W T F USE OF HRS INDUCING DOSE IN CLINIC?

7. Can HRS-inducing low-dose radiation potentiate the effect chemotherapy?

8. LDFRT, potentiator of Taxanes

9. LDFRT, potentiator of Gemcitabine

10. LDFRT, potentiator of Cisplatin

11. LDFRT impede the activation of NF  B, NFY1 and ERE function SCC-61

12. LDFRT impede the activation of NF  B, NFY1 and ERE function SQ20B

13. LDFRT impede the activation of NF  B, NFY1 and ERE function SQ20B

14. LDFRT impede the activation of NF  B, NFY1 and ERE function BG1

15. Targets of NF  B and NFY1 (mdr-1 and bcl-2) are not up-regulated in response to LDFRT

16. T-167 TACT GGGAATTCT CAATG------GAGG CTGATTGGCT GGGC-- hMDR1 NF  B NF-YANF-YB NF-YC -6092-6083 -82 -72 LUC +1 +162 MDR-1 and LDFRT : NF-Y link

17. Bcl-2 and LDFRT : NF  B link SQ20B SCC-61

18. Chemopotentiating effect of LDFRT in in-vivo

20. LDFRT in the clinic

21. Low-dose Fractionated Radiation (LDFRT) as a potentiator of neoadjuvant Paclitaxel (P) and Carboplatin (C) in Locally Advanced Squamous Cell Carcinoma of the Head and Neck (SCCHN). S. Arnold, M. Kudrimoti, J. Valentino, P. Spring, M. Ahmed, W. Regine, D. Kenady, C. Given, M. Mohiuddin Supported in part by an unrestricted research grant from Bristol-Myers Squibb

22. Treatment Schema: Trial 1 Response assessment 2 cycles q 21d Taxol 225 mg/m2 Carboplatin AUC=6 80 cGy Day 1 Day 2 Definitive surgery or radiation 80 cGy Arnold, et al. Abstract #1112

23. Treatment Schema: Trial 2 Response assessment Day 8 Taxol 75 mg/m2 Carboplatin AUC=6 Days 1, 2 Taxol 75 mg/m2 Definitive surgery or radiation Day 1550 cGy Taxol 75 mg/m2 2 cycles q 21d 50 cGy Arnold, et al. Abstract #1112

24. Grade 3 and 4 Toxicities ToxicityTrial 1 (n=39)Trial 2 (n=16) Neutropenia50%25% Infection13%5% Dermatitis8%0% Pulmonary3%0% Allergic3%0% Diarrhea0%6% Arthralgias/Myalgias3%0% Allergic3%0% Arnold, et al. Abstract #1112

25. TrialResponsenCR (%)PR (%)SD (%)PD (%)RR (%) Trial 1Primary Site3911 (28%)24 (62%)4 (10%)035 (90%) Overall395 (13%)27 (69%)6 (15%)1 (3%)32 (82%) Trial 2Primary Site1610 (63%)5 (31%)1 (6%)015 (94%) Overall166 (38%)8 (50%)2 (12%)014 (88%) Arnold, et al. Abstract #1112 Results: Trials 1 & 2

26. Conclusions Chemopotentiating LDFRT combined with Paclitaxel and Carboplatin is effective in SCCHN and has a similar toxicity to chemotherapy alone RR was 82% in Trial 1 and 88% in Trial 2 Primary site CR rate improved from 28% in Trial 1 to 63% in Trial 2 This primary site CR rate is comparable to the highest reported CR rate in induction therapy with considerably less side effects, and may have a significant impact on long-term outcome Arnold, et al. Abstract #1112

27. PANCREAS CANCER

28. STRATA A – Locally advanced/metastatic (Liver) GI Tumors without Peritoneal Carcinomatosis: LD-UART off GEMCITABINE off Repeat q 21 days [4 cycles total] DAY 1,2 8,9 15 LD-UART - Low dose Upper Abdominal Radiation Therapy - 60 cGy (initial), 70, 80, 90 (bid x 2 days) Gemcitabine: 1250 mg/m 2 over 2 hours. STRATA B - As above but with Peritoneal Carcinomatosis: LD-WART off GEMCITABINE off Repeat q 21 days [4 cycles total] DAY 1,2 8.9 15 LD-WART - Low dose Whole Abdominal Radiation Therapy – 60cGy (initial), 70, 80, 90 (bid x 2 days) Gemcitabine: 1250 mg/m 2 over 2 hours.

29. Patient Characteristics (n=10) Median Age:60 years (49 - 82) Tumor Type/Number: Unresectable Pancreas5 patients Metastatic Pancreas (Liver)4 patients Unresectable Small Bowel1 patient Prior Therapy:1 patient Median Age:60 years (49 - 82) Tumor Type/Number: Unresectable Pancreas5 patients Metastatic Pancreas (Liver)4 patients Unresectable Small Bowel1 patient Prior Therapy:1 patient

30. Radiographic Responses (n=10) Radiographic Response by RECIST Criteria: 1 CR (10%) 2 PR (20%) 5 SD (50%) 2 PD (20%) * Median survival for all 10 patients is 10 months (range 4 - 37). Radiographic Response by RECIST Criteria: 1 CR (10%) 2 PR (20%) 5 SD (50%) 2 PD (20%) * Median survival for all 10 patients is 10 months (range 4 - 37).

31. Pre Treatment Post Treatment

33. Conclusions LD-UART is well tolerated at 60cGy per fraction when combined with gemcitabine Given the encouraging radiographic responses and median survival of 10 months in this poor prognostic group of patients, a phase II evaluation is warranted and ongoing LD-UART is well tolerated at 60cGy per fraction when combined with gemcitabine Given the encouraging radiographic responses and median survival of 10 months in this poor prognostic group of patients, a phase II evaluation is warranted and ongoing

34. Future Considerations There are many questions yet to be answered and a great deal of opportunity for LDFRT ?? mechanism, sequence, timing, etc. In the meantime… LDFRT = “r” Sites of Opportunity Colorectal CA (FOLFOX) rFOLFOX Hodgkins Lymphoma (ABVD) rABVD NHL (CHOP) rRCHOP Breast Cancer (CMF) rAC-T Ovarian (Taxotere) rTaxotere H&N (CarboTaxol) rCarboTaxol Etc.. There are many questions yet to be answered and a great deal of opportunity for LDFRT ?? mechanism, sequence, timing, etc. In the meantime… LDFRT = “r” Sites of Opportunity Colorectal CA (FOLFOX) rFOLFOX Hodgkins Lymphoma (ABVD) rABVD NHL (CHOP) rRCHOP Breast Cancer (CMF) rAC-T Ovarian (Taxotere) rTaxotere H&N (CarboTaxol) rCarboTaxol Etc..

35. Ionizing radiation ATM Autophosphorylation Chromatin changes Reactive Oxygen Species Bax Cell Death Activation Caspases EGR-1 Ras AKT/PI3-K NF  B Bcl-2 TNF-  MDR1 Chemo- Resistance Survival Proliferation ATM P P P p53 P Substrate phosphorylation ATM P Nbs1 P ATM P Brca1 P p21 waf1/cip1 G1 Arrest DNA Repair Focus Formation DNA repair process is not activated by LDFRT

36. Ionizing radiation ATM Autophosphorylation Chromatin changes Reactive Oxygen Species Bax Ras AKT/PI3-K NF  B Bcl-2 TNF-  MDR1 Chemo- Resistance Survival Proliferation ATM P P Mutant p53 Substrate phosphorylation ATM P Nbs1 P ATM P Brca1 P p21 waf1/cip1 DNA Repair Focus Formation Induced Radiation Resistance LDFRT directly activates

37. Collaborators and the Lab Dr Mohiuddin, Director, Geisinger-Fox Chase Cancer Center, Wilkes-Barre, PA Dr Paul Spring, Associate Professor, Department of Otolaryngology, University of Arkansas Medical Center, Little Rock, AR Dr Susanne Arnold, Associate Professor, Department of Internal Medicine (Hem -Onc), University of Kentucky Medical Center, Lexington, KY