Dissertations / Theses on the topic 'EGFR TKI'

Responsable d'environ 30000 décès/an en France, le cancer du poumon est un problème de santé publique majeur. Un des enjeux actuels est d'adapter le traitement du cancer du poumon pour proposer des thérapeutiques ciblées plus efficaces et moins agressives. Les inhibiteurs de l'activité tyrosine kinase du récepteur de l'EGF (EGFR-TKI, gefitinib et erlotinib) constituent un réel progrès pour le traitement des cancers du poumon. Cependant, des mécanismes de résistance ont été décrits et des traitements combinés de thérapies ciblées avec des EGFR-TKI pourraient permettre de surmonter les résistances dans les cancers du poumon.Dans ce contexte, nous avons étudié les mécanismes impliqués dans la résistance à ces traitements. Nous montrons que l'activation de la voie de signalisation PI3K/AKT joue un rôle majeur dans la résistance aux EGFR-TKI, en inhibant l'apoptose par des mécanismes dépendant de l'acétylation. Les histones déacétylases (HDACs) et les sirtuines interviennent dans ces mécanismes de résistance, en modulant l'activation de la voie PI3K/AKT et l'apoptose. Ainsi l'utilisation d'inhibiteurs des HDACs (HDACi) et des sirtuines permettent de restaurer la sensibilité aux EGFR-TKI. Ces résultats confirment l'intérêt thérapeutique de l'association EGFR-TKI/HDACi et montrent le potentiel thérapeutique d'associer des inhibiteurs de l'EGFR et de la voie PI3K/AKT pour contourner la résistance aux EGFR-TKI.Les molécules thérapeutiques doivent atteindre spécifiquement le site tumoral, nécessitant parfois de les protéger contre leur dégradation, de réduire leurs effets indésirables, et de contrôler leur libération dans le temps et l'espace, à l'aide de transporteurs. Ainsi dans la deuxième partie de cette thèse, nous avons évalué les capacités de ciblage des tumeurs pulmonaires de nanoparticules à base de copolymère amphiphile, contenant une partie polysaccharidique hydrophile (le hyaluronane) et une partie polypeptidique hydrophobe (le poly(γ‐benzyl L‐glutamate, PBLG). Nos travaux mettent en évidence la capacité de ciblage tumoral de ces nanoparticules injectées par voie intraveineuse, ouvrant ainsi de nouvelles perspectives thérapeutiques. Notre objectif est de charger les combinaisons de traitements EGFR-TKI/HDACi que nous avons identifiées dans ces vecteurs, afin de traiter les tumeurs pulmonaires résistantes aux EGFR-TKI
Responsible of 30000 deaths each year in France, lung cancer is a major public health problem. One of the current challenges is to adapt the treatment of lung cancer to offer more effective and less aggressive targeted therapies. EGFR tyrosine kinase inhibitors (EGFR-TKI, gefitinib and erlotinib) represent a real progress in lung cancer therapy. However resistance mechanisms have been described and combination of targeted therapy with EGFR-TKI could overcome resistance in lung cancer.In this context, we studied mechanisms involved in resistance to EGFR-TKI. We show that PI3K/AKT activation is a major pathway leading to EGFR-TKI resistance leading to apoptosis inhibition through acetylation-dependent mechanisms. Histone deacetylase (HADCs) and sirtuin are involved in these mechanisms and modulate PI3K/AKT activation and apoptosis. The use of HDACs inhibitors (HDACi) and sirtuins inhibitors thus restores the sensitivity to EGFR-TKI. Altogether these results confirm the therapeutic effect of the EGFR-TKI/HDACi combination and show the therapeutic potential of the association of EGFR and PI3K/AKT inhibitors to overcome EGFR-TKI resistance.Therapeutic molecules must specifically reach the tumor site, sometimes requiring to protect them against degradation, to reduce their side effects, and to control their release in time and space, using transporters. In the second part of this thesis, we have thus evaluated the lung tumors targeting capabilities of amphiphilic copolymer-based nanoparticles, containing an hydrophilic polysaccharidic block (hyaluronan) and an hydrophobic polypeptidic block (the poly(γ‐benzyl L‐glutamate PBLG). Our work highlights the tumor targeting capability of these nanoparticles injected intravenously, offering new lung cancer therapy perspectives. Our aim is to load the drugs combination (EGFR-TKI/HDACi) in these vectors, to treat the lung tumors resistant to EGFR-TKI

Responsable de 1,6 million de décès par an dans le monde, le cancer du poumon constitue aujourd’hui la première cause de mortalité par cancer. Les cancers bronchiques non-à-petites cellules représentent 85% des cancers du poumon et ont un pronostic vital très mauvais. Les EGFR-TKI (inhibiteurs de l’activité tyrosine kinase de l’EGFR, gefitinib) constituent un réel progrès thérapeutique pour le traitement des cancers du poumon. Cependant, ces traitements ne sont efficaces que dans un petit sous-groupe de patients. Un des enjeux actuels est donc d’identifier les mécanismes de résistance primaire mis en jeu par les tumeurs.Les récepteurs à activité tyrosine kinase (RTK) activent des voies de signalisation intracellulaires depuis la membrane plasmique. Ces dernières années, une translocation nucléaire des RTK a également été mise en évidence. Ces travaux récents suggèrent que la signalisation nucléaire des RTK pourrait contribuer à la résistance des tumeurs en réponse aux thérapies anti-cancéreuses.Dans l’équipe, il a été montré que l’activation de l’IGF-1R est associée à la progression tumorale des adénocarcinomes pulmonaires et que le gefitinib induit une accumulation nucléaire de l’IGF-1R dans un modèle d’adénocarcinome mucineux. Sur la base de ces résultats, nous avons émis l’hypothèse que l’IGF-1R nucléaire pourrait jouer un rôle dans la résistance aux EGFR-TKI des adénocarcinomes pulmonaires mucineux.Nos résultats indiquent que plus de 70% des adénocarcinomes pulmonaires présentent un marquage nucléaire de l’IGF-1R. A l’aide de différents modèles cellulaires résistants aux EGFR-TKI, nous montrons que le gefitinib induit l’accumulation nucléaire de l’IGF-1R dans les adénocarcinomes pulmonaires mucineux. Cette translocation nucléaire implique l’endocytose clathrines-dépendante de l’IGF-1R et la formation d’un complexe entre l’IGF-1R, l’importine β1 et la pro-amphiréguline. La neutralisation de l’amphiréguline prévient le transport nucléaire de l’IGF-1R et resensibilise les cellules à l’apoptose induite par le gefitinib in vitro et in vivo. L’ensemble de ces résultats identifient le trafic intracellulaire de l’IGF-1R comme un nouveau composant de la réponse aux EGFR-TKI et suggèrent que la signalisation nucléaire IGF-1R/Areg contribue à la progression des adénocarcinomes mucineux sous EGFR-TKI
Responsible of 1.6 million deaths each year worldwide, lung cancer is today the leading cause of cancer mortality in the world. Non-small-cell lung cancers account for about 85% of lung cancer and have a very bad prognosis (5-year survival rate inferior to 10%). EGFR-TKI (EGFR tyrosine kinase inhibitors, gefitinib) are a real medical advance for lung cancers treatment. However, these treatments are efficient in a small subgroup of patients. So, one of the current issues is to identify primary resistance mechanisms involved in tumors.Tyrosine kinase receptors (RTK) activate intracellular signaling pathways from the plasma membrane. These last years, a nuclear translocation of the RTK was shown. Recent works suggest that RTK nuclear signaling could contribute to tumors resistance in response to anti-cancerous therapies.In our team, it was shown that activation of IGF-1R signaling is associated with lung adenocarcinoma progression and that gefitinib induces IGF-1R nuclear accumulation in a mucinous adenocarcinoma cell line. On the basis of these results, we hypothesize that nuclear IGF-1R could play a role in the resistance of mucinous lung adenocarcinoma to EGFR-TKI.Our results indicate that more than 70% lung adenocarcinoma tumors present a positive IGF-1R nuclear staining. Thanks to EGFR-TKI-resistant cell lines, we show that gefitinib induces the nuclear accumulation of IGF-1R in mucinous adenocarcinoma. This nuclear translocation involves clathrin-mediated endocytosis and a complex between IGF-1R, importin β1 and pro-amphiregulin. Amphiregulin silencing prevents IGF-1R nuclear translocation in response to gefitinib and restores gefitinib-induced apoptosis in vitro and in vivo. Our whole results identify that IGF-1R intracellular trafficking is a new component of response to EGFR-TKI and strongly suggest that a nuclear IGF-1R/amphiregulin signaling contributes to mucinous lung adenocarcinoma progression in response to EGFR-TKI

Background: Lung cancer is the leading cause of cancer-related death and one of the most common cancer types worldwide. Epidermal growth factor receptor (EGFR) has been shown to be an important therapeutic target in non-small cell lung cancer. Kirsten rat sarcoma viral oncogene homologue (KRAS) is a downstream signalling molecule in the EGFR pathway. Lung cancer patients with EGFR mutations respond to tyrosine EGFR inhibitor therapy, in contrast, patients with KRAS mutations do not benefit of such treatment. Methods: This study investigates the frequency of EGFR and KRAS mutations in non-small cell lung cancer patients. Fifty-one lung cancer patients with primary non-small cell lung cancer diagnosed between 1995 and 2005 in the Uppsala-Örebro region were analysed by Sanger sequencing and Pyrosequencing to determine the mutation status of these genes. Results: Five EGFR mutations were found in four patients (8%), two deletions in exon 19, one point mutation in exon 20 and two point mutations in exon 21. KRAS mutations were found in 12 patients (24%), ten codon 12 mutations and two codon 61 mutations. Conclusions: This study confirms previous observations regarding the frequency of EGFR and KRAS mutations in non-small cell lung cancer. Mutations in EGFR and KRAS were mutually exclusive, indicating that both mutations present relevant tumorigenic genomic aberrations.

Il gene EGFR e' un marcatore molecolare fondamentale per determinare la sensibilita' o meno ai farmaci inibitori delle tirosin-chinasi (TKI) in pazienti affetti da adenocarcinoma polmonare. Lo scopo del lavoro e' di determinare se la percentuale di cellule neoplastiche mutate in EGFR correli con la risposta ai farmaci TKI. Sono stati analizzati 18 casi; di ogni caso e' stato analizzato il gene EGFR (esoni 18, 19, 20 e 21) mediante Next Generation Sequencing (NGS). La quantita' di cellule neoplastiche presenti nell'area analizzata e' stata valutata da un patologo, su un vetrino colorato con Ematossilina-Eosina, e tale quantita' e' stata normalizzata alla percentuale di alleli mutati rilevata mediante NGS. E' stata rilevata una correlazione fra la percentuale di cellule neoplastiche mutate in EGFR e la risposta ai TKI, ed e' stato osservato che pazienti con una percentuale di cellule neoplastiche mutate al di sopra del 56% presentano una migliore "overall survival" rispetto ai pazienti con una percentuale inferiore. I dati suggeriscono che, oltre al valore predittivo, la definizione della percentuale di cellule neoplastiche mutate in EGFR potrebbe avere un valore prognostico.

Une transition épithélio-mésenchymateuse (TEM) et une expression élevée de la sphingosine kinase 1 (SPHK1) sont souvent observées dans les cancers. Notre étude du génome et du transcriptome d'adénocarcinomes pulmonaires (AP) montre que l'expression élevée de SPHK1 est en rapport, d'une part, avec des gains de la région incluant le locus SPHK1 et, d'autre part, avec une signature d'expression génique de TEM dans des tumeurs invasives. L'expression de SPHK1 est restreinte aux cellules tumorales. La surexpression de SPHK1 dans des cellules d'AP et l'exposition à son produit, la sphingosine-1-phosphate (S1P), entraînent une TEM, de manière réversible pour la S1P. La surexpression de SPHK1 active aussi NF-kB. La surexpression du facteur anti-apoptotique FLIP active NF-kB, induit une TEM et augmente l'expression de SPHK1, suggérant une boucle d'amplification entre NF-kB et SPHK1. Une TEM et la surexpression de FLIP ont été impliquées dans la résistance primaire aux inhibiteurs pharmacologiques de l'EGFR (EGFR TKI). Nous montrons que la surexpression de SPHK1 dans des cellules A549 diminue modestement la sensibilité au gefitinib, alors que l'inhibition de SPHK1 ou la déplétion du sérum en S1P l'augmentent modestement. L'invalidation de SPHK1 entraîne l'apoptose d'A549 y compris quand FLIP est surexprimé. L'activation et le maintien d'une TEM sont généralement attribués à des signaux contextuels du stroma. Cette thèse montre que les cellules tumorales elles-mêmes favorisent la surexpression de SPHK1 qui peut induire une TEM de façon autonome. De plus, la surexpression de FLIP impliquée dans la résistance aux EGFR TKI, n'empêche pas l'apoptose induite par l'invalidation de SPHK1
Epithelial-mesenchymal transition (EMT) and sphingosine kinase 1 (SPHK1) high expression are often seen in cancers. Our study of genomic and gene expression data in pulmonary adenocarcinomas (AP) shows that SPHK1 high expression correlates with both gains in the region encompassing the SPHK1 locus, and an EMT gene expression signature in invasive tumors. SPHK1 expression is restricted to tumors cells. SPHK1 overexpression in AP cells, as well as exposure to its productsphingosine-1-phosphate (S1P),induce an EMT -in a reversible manner for S1P. SPHK1 overexpression also activates NF-kB. Overexpression of FLIP – an antiapoptotic factor - activates NF-kB, induces an EMT, and increases SPHK1 expression, suggesting an amplification loop between NF-kB and SPHK1. EMT and FLIP overexpression are known to favor primary resistance to EGFR pharmacological inhibitors (EGFR TKI). We show that SPHK1 overexpression in A549 cells slightly decreases cell sensitivity to gefitinib, while pharmacologic inhibition of SPHK1 or serum S1P depletionincrease it. Downregulation of SPHK1 expression induces apoptosis of A549 cells even when FLIP is overexpressed. Activation and maintenance of EMT are generally attributed to contextual signals from the stroma. Here, we show that tumor cells themselves favor SPHK1 overexpression, which can led to EMT in cell-autonomous manner. In addition, FLIP overexpression which is implicated in EGFR TKI resistance, cannot prevent apoptosis that is induced by SPHK1 invalidation

This thesis defined a unique role for the protein cell division cycle associated protein-3 (CDCA3) in epidermal growth factor receptor (EGFR) mutant non-small cell lung cancer (NSCLC). This thesis has established an association between the levels of CDCA3 expression and the tumour response to tyrosine kinase inhibitors (TKI), which are the front-line therapy for EGFR-mutant NSCLC. In this disease, CDCA3 functions to modulate cellular growth pathways to impact sensitivity towards TKI therapy. Future work might enable development of a clinical stratification tool to discern TKI responsive from non-responsive EGFR-mutant NSCLC tumours.

Orientador: Lair Zambon
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciencias Medicas
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Resumo: A maioria dos carcinomas de pulmão não pequenas células (CPNPC) em estádios avançados com mutações ativadoras (deleções do exon 19 ou a mutação L858R do exon 21) do receptor do fator de crescimento epidérmico (EGFR) respondem inicialmente, aos medicamentos gefitinib e erlotinib, que são inibidores da tirosina quinase (TKIs) do EGFR. Porém em uma média de 6-12, meses esses tumores desenvolvem resistência adquirida aos TKIs do EGFR. Dois mecanismos de resistência ao gefitinib/erlotinib explicam porque os CPNPC com mutações do EGFR se tornam resistentes aos TKIs: mutações de resistência secundária e um sistema de "troca de oncogenes". A mutação T790M-EGFR secundária ocorre em 50% dos pacientes com mutação no EGFR com resistência adquirida aos TKIs do EGFR, e em in vitro esta mutação T790M-EGFR inativa a hipersensitividade das mutações ativadoras do EGFR ao gefitnib ou erlotinib. Outras mutações de resistência secundárias (D761Y, L747S, A854T) são raras. Um outro mecanismo de resistência é a amplificação adquirida do oncogene MET, que ocorre em mais ou menos 20% do pacientes resistentes ao gefitinib/erlotinib e, em metade destes casos, em conjunção com T790M. O MET ativa sinais de sinalização que contornam o EGFR inibido, gerando um sistema de "troca de oncogenes" nesses tumores. Esses dados pré-clinicos relevantes aos CPNPCs com o EGFR mutado e resistência ao gefitinib ou erlotinib levaram ao desenvolvimento de experimentos clínicos com novos inibidores do EGFR que inibem "in vitro" a mutação T790M-EGFR (HKI-272, XL-647, BIBW-2992 e PF00299804), e inibidores de MET mais TKIs do EGFR em combinação. Neste trabalho: 1) Agrupamos e resumimos os dados dos experimentos clínicos prospectivos com o gefinitib em pacientes com o EGFR mutado. Mais de 80% dos pacientes com deleções do exon 19 ou a mutação L858R do EGFR tiveram resposta radiográfica, com sobrevivência livre de progressão de 7,7 a 12,9 meses nos estudos identificados, e sobrevivência geral acima de 15 meses; 2) Usamos células CPNPC com mutações do EGFR para identificarmos a molécula pró-apoptótica BIM como o efetor principal da apoptose induzida pelos TKIs do EGFR; 3) Caracterizamos a mutação resistente ao gefinitib EGFR-L858R-L747S, e determinamos que L858R-L747S apresenta um padrão de resistência menos acentuado ao gefitinib do que o observado com L858R-T790M; e 4) Avaliamos os efeitos do erlotinib em pacientes com CPNPC EGFR mutado e resistência ao gefitinib, caracterizando a correlação da resposta radiográfica e clínica com os mecanismos conhecidos de resistência ao TKIs do EGFR (as mutações de resistência secundárias T790M e L747S, e a amplificação do MET). A maioria (mais de 83%) dos pacientes resistentes ao gefitinib tiveram progressões radiográficas nos primeiros 2 a 4 meses de exposição ao erlotinib 150 mg/dia. Isto é consistente com nossas observações pré-clínicas, indicativas de que a maioria dos tumores resistentes ao gefitinib possui predominantemente T790M e/ou amplificações do MET, que são resistentes tanto ao gefitinib quanto erlotinib. Pesquisas pré-clínicas e experimentos clínicos futuros do CPNPC com EGFR mutado têm o potencial de melhorar os resultados do tratamento clínico de pacientes com essas mutações somáticas.
Abstract: Most advanced non-small cell lung cancers (NSCLCs) with activating epidermal growth factor receptor (EGFR) mutations (exon 19 deletions or L858R) initially respond to the EGFR tyrosine kinase inhibitors (TKIs) gefitinib and erlotinib. However, over time (median of 6-12 months) most tumors develop acquired resistance to EGFR TKIs. Intense research in these NSCLCs has identified two major mechanisms of resistance to gefitinib/erlotinib: secondary resistance mutations and "oncogene kinase switch" systems. The secondary T790M mutation occurs in 50% of EGFR mutated patients with TKI resistance, and in vitro this mutation negates the hypersensitivity of activating EGFR mutations. Other secondary resistance mutations (D761Y, L747S, A854T) seem to be rare. The amplification of the MET oncogene is present in 20% of TKI-resistant tumors; however in half of the cases with this "oncogene kinase switch" mechanism the T790M is co-existent. The growing pre-clinical data in EGFR mutated NSCLCs with acquired resistance to gefitinib or erlotinib has spawned the initiation or conception of clinical trials testing novel EGFR inhibitors that in vitro inhibit T790M (HKI-272, XL-647, BIBW-2992 and PF00299804), and MET inhibitors in combination with EGFR TKIs. In this work we: 1) Pooled and summarized data from prospective clinical trials of gefitinib for EGFR mutated patients. More than 80% of patients with exon 19 deletions or the L858R EGFR mutation attained a radiographic response with progression-free survival of 7.7 to 12.9 months in the identified studies, and overall survival exceeding 15 months; 2) Identified the pro-apoptotic molecule BIM as the main effector of EGFR TKI-induced apoptosis using NSCLC cell lines with EGFR mutations; 3) Characterized the L858R-L747S gefitinib-resistant mutation, and demonstrated that L858R-L747S has a partial resistance pattern when compared to L858R-T790M; and 4) Evaluated the effects of erlotinib in EGFR mutated NSCLC with resistance to gefitinib while characterizing the correlation of response and resistance to this approach to the known mechanisms of resistance to EGFR TKIs (the secondary mutations T790M and L747S, and the amplification of MET). Our clinical observation was that the majority (over 83%) of the gefitinib-resistant patients given erlotinib 150 mg/day had radiographic progression within the first 2 to 4 months of exposure. This is consistent with our pre-clinical observations, since we expected gefitinib-resistant tumors to predominantly harbor T790M and/or MET amplification, which are cross-resistant to both gefitinib and erlotinib. Ongoing pre-clinical and clinical research in EGFR mutated NSCLC has the potential to significantly improve the outcomes of patients with these somatic mutations.
Doutorado
Clinica Medica
Doutor em Clínica Médica

Une transition épithélio-mésenchymateuse (TEM) et une expression élevée de la sphingosine kinase 1 (SPHK1) sont souvent observées dans les cancers. Notre étude du génome et du transcriptome d'adénocarcinomes pulmonaires (AP) montre que l'expression élevée de SPHK1 est en rapport, d'une part, avec des gains de la région incluant le locus SPHK1 et, d'autre part, avec une signature d'expression génique de TEM dans des tumeurs invasives. L'expression de SPHK1 est restreinte aux cellules tumorales. La surexpression de SPHK1 dans des cellules d'AP et l'exposition à son produit, la sphingosine-1-phosphate (S1P), entraînent une TEM, de manière réversible pour la S1P. La surexpression de SPHK1 active aussi NF-kB. La surexpression du facteur anti-apoptotique FLIP active NF-kB, induit une TEM et augmente l'expression de SPHK1, suggérant une boucle d'amplification entre NF-kB et SPHK1. Une TEM et la surexpression de FLIP ont été impliquées dans la résistance primaire aux inhibiteurs pharmacologiques de l'EGFR (EGFR TKI). Nous montrons que la surexpression de SPHK1 dans des cellules A549 diminue modestement la sensibilité au gefitinib, alors que l'inhibition de SPHK1 ou la déplétion du sérum en S1P l'augmentent modestement. L'invalidation de SPHK1 entraîne l'apoptose d'A549 y compris quand FLIP est surexprimé. L'activation et le maintien d'une TEM sont généralement attribués à des signaux contextuels du stroma. Cette thèse montre que les cellules tumorales elles-mêmes favorisent la surexpression de SPHK1 qui peut induire une TEM de façon autonome. De plus, la surexpression de FLIP impliquée dans la résistance aux EGFR TKI, n'empêche pas l'apoptose induite par l'invalidation de SPHK1
Epithelial-mesenchymal transition (EMT) and sphingosine kinase 1 (SPHK1) high expression are often seen in cancers. Our study of genomic and gene expression data in pulmonary adenocarcinomas (AP) shows that SPHK1 high expression correlates with both gains in the region encompassing the SPHK1 locus, and an EMT gene expression signature in invasive tumors. SPHK1 expression is restricted to tumors cells. SPHK1 overexpression in AP cells, as well as exposure to its productsphingosine-1-phosphate (S1P),induce an EMT -in a reversible manner for S1P. SPHK1 overexpression also activates NF-kB. Overexpression of FLIP – an antiapoptotic factor - activates NF-kB, induces an EMT, and increases SPHK1 expression, suggesting an amplification loop between NF-kB and SPHK1. EMT and FLIP overexpression are known to favor primary resistance to EGFR pharmacological inhibitors (EGFR TKI). We show that SPHK1 overexpression in A549 cells slightly decreases cell sensitivity to gefitinib, while pharmacologic inhibition of SPHK1 or serum S1P depletionincrease it. Downregulation of SPHK1 expression induces apoptosis of A549 cells even when FLIP is overexpressed. Activation and maintenance of EMT are generally attributed to contextual signals from the stroma. Here, we show that tumor cells themselves favor SPHK1 overexpression, which can led to EMT in cell-autonomous manner. In addition, FLIP overexpression which is implicated in EGFR TKI resistance, cannot prevent apoptosis that is induced by SPHK1 invalidation

Non-small-cell lung cancer (NSCLC) accounts for 80–85% of all lung cancers and is associated with significant mortality. As epidermal-growth-factor receptor (EGFR) is over-expressed in 80-90% of NSCLC, its inhibition via EGFR-Tyrosine Kinase inhibitors (EGFR-TKIs) is a main therapeutic strategy. However, patients with mutations in KRAS are resistant to EGFR-TKIs. A study in mutant KRAS-driven lung cancer in transgenic mice showed that tumor growth was dependent on the activity of focal adhesion kinase (FAK). Therefore, we hypothesized that KRAS-mutant NSCLC will be sensitive to FAK-TKIs and, given known FAK-EGFR cross-talk, FAK inhibition will sensitize KRAS-mutant NSCLC to EGFR-TKIs. We performed cell viability assays of WT versus mutant KRAS NSCLC cell lines following treatment with FAK-TKI alone or in combination with a clinically relevant EGFR-TKI. We found that KRAS-mutant cells were more sensitive to FAK-TKI than KRAS-WT NSCLC. In addition, we found that the combination treatment including FAK and EGFR TKIs resulted in reduced tumor cell viability as compared to treatment with either drug alone. This enhanced anti-tumor response could be due to FAK-TKI’s ability to down-regulate EGFR downstream targets. Our preliminary data suggests that in KRAS-mutant cells the drug combination appears to more effectively inhibit Akt activity than single drug treatment alone. This suggests an enhanced ability to impair cell survival following treatment with the drug combination. We also found that treatment with FAK TKI in KRAS mutant NSCLC cells resulted in increased activation of EGFR which was due in part to modulation of EGFR recycling and production of endogenous EGFR ligands. Thus, the combination of FAK- and EGFR-TKIs may be more effective in KRAS mutant NSCLC as treatment with EGFR-TKI overcomes the unexpected ‘side effect’ of treatment with FAK-TKI, namely activation of the EGFR pathway by this drug. The findings of our study are novel and have uncovered previously unrecognized outcomes of FAK inhibition on EGFR activity. Moreover, our data support the notion that the combination of FAK- and EGFR-TKIs could be an effective treatment for KRAS mutant NSCLC patients.

Il cancro ai polmoni è la patologia neoplastica con il tasso di mortalità più elevato. L’adenocarcinoma (AC), che rappresenta il 60% dei tumori polmonari non a piccole cellule (NSCLC), è l’istotipo più diffuso e attaualmente viene trattato mediante resezione chirurgica combinata con un regime chemioterapico basato su platino (Pt) abbinato ad una coppia di molecole citotossiche. Con lo scopo di risolvere gli svantaggi del trattamento chemioterapico, negli ultimi anni sono stati sviluppati farmaci a bersaglio molecolare. Le terapie molecolari maggiormente utilizzate per gli AC polmonari sono gli inibitori tirosin-chinasici (TKIs) diretti contro il recettore del fattore di crescita dell’epidermide (EGFR) e contro la chinasi del linfoma anaplastico (ALK). Lo scopo del mio progetto è stato quello di migliorare la cura dei pazienti affetti da AC polmonare sia tramite l’implementazione dei saggi per analizzare EGFR in campioni tissutali e biopsie liquide sia tramite la valutazione dell’espressione di un nuovo possibile bersaglio di farmaci molecolari: il recettore tirosin-chinasico orfano da ligando-1 (ROR1). I nuovi saggi (SensiScreen®) sono stati validati su due coorti retrospettive di pazienti affetti da AC polmonare: la prima rappresentata da 471 campioni di tessuto e la seconda rappresentata da 61 campioni di plasma, 5 di siero e 39 di tessuto dagli stessi pazienti. SensiScreen® conferma le mutazioni trovate con DS e con le altre metodologie, ma soprattutto permette di analizzare alcuni casi risultati non valutabili con gli altri saggi e consente di trovare nuovi casi mutati. L’espressione di ROR1 e di miR-382 (un microRNA, miRNA, coinvolto nell’inibizione di ROR1) è stata valutata con TaqMan real-time PCR in una terza coorte retrospettiva costituita da 102 pazienti affetti da AC polmonare. Le nostre analisi dimostrano un’overespressione di ROR1 e di miR-382 nel 28.6% e nel 48.1% dei casi rispettivamente.

博士
國防醫學院
生命科學研究所
104
ABSTRACT Several nature or synthetic small compounds can be helpful in improving the symptoms of diseases and treating patients. Post-translational modification (PTM) plays a vital role in various biological processes and disease progression such as cellular differentiation, signaling transduction, and protein stability and localization. Aberrant epidermal growth factor receptor (EGFR) signaling is one of the most critical oncogenic pathways in non-small-cell lung carcinoma (NSCLC) that triggers the tumor progression. However, suppression of the EGFR downstream signaling cascade has been considered a main therapeutic approach of intervention for cancer patients. In this thesis, we report that a therapeutically regulatory mechanism utilizing a new small compound T315-mediated EGFR degradation. Exposure to T315 induces apoptosis in lung cancer cell lines, including EGFR wild-type A549 as well as EGFR mutant PC9 and H1975 cells. T315 dose-dependently decreases the EGFR protein level and facilitates dephosphorylation of its downstream targets (AKT and ERK), and both of them play critical roles for lung cancer cell survival. We further demonstrate that T315 induces autophosphorylation at Tyr-1045 in the autophosphorylation domain of EGFR and boosts EGFR degradation through the ubiquitin proteasome pathway by increasing the interaction between the ubiquitin E3 ligase, Casitas B-lineage Lymphoma (CBL), and EGFR. The mass spectrometry implies that T315 may be bound to the extracellular domain of EGFR and subsequent triggers Tyr-1045 autophosphorylation. Finally, the combination of T315 with a commercial tyrosine kinase inhibitor of BIBW2992 additively suppresses in vitro NSCLC cell growth and the mouse xenograft model. Our evidences suggest that T315 is a next-generation of anticancer drug to inhibit the growth of EGFR TKI-resistant lung adenocarcinoma cells via EGFR degradation.

博士
國立臺灣海洋大學
生命科學暨生物科技學系
107
Epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) are effective therapies for patients with non-small cell lung cancer (NSCLC) bearing EGFR mutations. It is reported that the response rate is 60-80% in Taiwan. Despite bearing EGFR active mutations, 20-40% of patients did not respond to TKIs. Moreover, in certain patients responding to TKIs initially, drug resistance will develop in 8-12 months after treatment. An acquired T790M mutation was detected in half of TKI-resistant tumors and the third-generation EGFR inhibitors, osimertinib, was demonstrated to show activity against this mutation. Nevertheless, the resistant mechanisms are still not fully understood. We have successfully cultivated an NSCLC cell line, JLR10, bearing L858R mutation and exhibiting resistance to gefitinib. JLR10 expressed wild type in KRAS and BRAF genes; no mutation in EGFR other than TK domain was found, but a variant of exon 13 (R521K) was observed. JLR10 expressed MET gene amplification, accompanied with constitutive activation of both PI3K and MAPK pathways. This cell line could serve as a good model to explore novel resistant genes in NSCLC. In searching for potential genes relevant to EGFR-TKI resistance, the genetic profiles of JLR10 (L858R, gefitinib-resistant) and H3255 (L858R, gefitinib-sensitive) were analyzed with Affymetrix CytoScan HD/750k array and compared. The results showed that while both miR221 and miR222 were highly expressed in JLR10, they were negligible in the latter, a good correlation with MET expression in these 2 cell lines. Upregulation of miR221/222 has been reported to be associated with TRAIL resistance. Our drug sensitivity experiments, however, demonstrated that while H3255 was completely resistant to TRAIL, it induced a moderate cell death in JLR10, suggesting the existence of differential resistant mechanisms in these two cell models. The antitumor activity of combining TRAIL with available small molecular inhibitors was then evaluated. MET inhibitor PHA665257 significantly inhibited autophosphorylation of MET, AKT and ERK1/2 in JLR10 but did not synergize with TRAIL to induce tumor cell death. Unexpectedly, sorafenib, a multikinase inhibitor, although not exhibiting tumor inhibitory activity alone, demonstrated a high synergistic effect with TRAIL to induce cell apoptosis in JLR10; whereas, all available EGFR mutated NSCLC cell lines were resistant to this combined treatment. The synergistic effect can even be observed shortly (6-h) after treatment. These results suggest that combined sorafenib and TRAIL treatment could represent a potential therapeutic in NSCLC. Previously we have reported that a four-gene signature (LCN2, PTHLH, FJX1, and RAB38) was associated with survival among patients with early-stage NSCLC. Our subsequent studies showed that higher RAB38 expression in tumor specimens was associated with higher frequency of tumor recurrence in these patients; RAB expression was also inversely correlated with disease-free survival and overall patient survival, suggesting that it may serve as a prognostic factor in NSCLC. Using NSCLC cell lines, we further demonstrated that tumor cells with EGFR mutations expressed higher levels of RAB38 compared with those of wild-type. Furthermore, following specific knockdown of RAB38 by shRNA transfection, substantially reduced Matrigel invasiveness was detected in HCC827 cells (Exon 19 deletion) compared to those transfected with empty vector. These results indicate that RAB38 may be associated with EGFR status and could be targeted to reduce tumor metastasis in NSCLC. Using clinical specimens and in vitro cell models, we have shown that RAB38 could serve as a potential target in NSCLC and combination of sorafenib and TRAIL treatment induced a rapid and substantial cell apoptosis in NSCLC cell line. Although the mechanisms associated with these observations remain to be explored, these studies may pave the way toward effective treatment for this deadly disease.

博士
國立臺灣大學
醫學檢驗暨生物技術學研究所
104
Metastasis is a major cause of cancer-related death. Here, we identify a novel tumor suppressor gene, FAM198B, which has never been characterized in humans previously, by comparing the transcriptional profiles of a high metastatic lung adenocarcinoma cell line and its isogenic low metastatic cell line. The high expression of FAM198B was associated with favorable survival in lung adenocarcinoma patients. Enforced expression of FAM198B suppressed cell invasion, migration, mobility, proliferation and anchorage-independent growth in vitro and reduced tumor growth and metastasis in in vivo mouse models. Additionally, we found that FAM198B is an N-glycosylated protein with two extracellular N-linked glycosylation sites (Asn98 and Asn289). Deglycosylation nearly eliminated the metastasis suppression activity of FAM198B due to a decrease in stability. A microarray analysis was used to examine the underlying mechanism of FAM198B in metastasis suppression and identified MMP1 as a critical downstream target of FAM198B. The FAM198B-mediated MMP-1 downregulation was via inhibition of the phosphorylation of extracellular signal-regulated kinase (ERK). Taken together, these results indicate that FAM198B acts as a tumor suppressor to inhibit cancer cell invasion and metastasis via the ERK/MMP1 signaling pathways and may serve as a potential therapeutic target for lung adenocarcinoma.

碩士
國立臺灣大學
藥理學研究所
106
Lung cancer is the leading cause of cancer deaths worldwide, and EGFR-TKI is the first-line treatment for non-small cell lung cancer (NSCLC) harbouring EGFR activation mutation. However, most patients develop acquired resistance within 9–14 months. Therefore, it is critical to explore the mechanisms of drug resistance to improve treatment efficacy. Two resistant cells, HCC827/IR (IRESSA resistance) and H1975/AR (AZD9291 resistance) exhibiting EMT phenotypes were generated to investigate the molecular and cellular characteristics of the EGFR-TKI acquired resistance. The expression and activation of EGFR were reduced in both resistant cells. Upregulation of AXL and FGFR1 were found in HCC827/IR but not H1975/AR cells. HCC827/IR (without T790M) and H1975/AR (without C797S) showed “off target resistance”. Activation of AKT (p-AKT) in both parental cells was more sensitive to EGFR-TKI than that in resistant cells. RNA-seq revealed that AKT3 was upregulated in both resistant cells. High expression of AKT3 was predicted to correlate with the poor survival of lung adenocarcinoma patients. Knockdown of AKT3 in HCC827/IR cells inhibited cell migration and increased the protein expression of E-cadherin, as well as inhibited S phase population to reduce cell proliferation. Knockdown of AKT3 in H1975/AR cells enhanced AZD9291-induced inhibition on AKT activation (p-AKT). Immunoprecipitation of AKT3 in both resistant cells demonstrated its involvement in AKT activation, and AKT3 activation (p-AKT3) was not sensitive to gefitinib and AZD9291 inhibition in resistant cells. We also found that protein but not mRNA of AKT3 was upregulated in gefitinib-treated HCC827/IR cells and AZD9291-treated H1975/AR cells. Therefore, AKT3 might serve as a predictive biomarker for EGFR-TKIs therapy, and its upregulation might be one of the mechanisms for EGFR-TKIs acquired resistance. Besides, combination of AZD9291 with AKT inhibitor elicited synergistic inhibition on cell viability of H1975/AR cells.

Trabalho final de mestrado integrado em Medicina, apresentado à Faculdade de Medicina da Universidade de Coimbra.
OBJECTIVE: Clinical characterization and therapeutic follow-up after histological typing and molecular pathology of Bronchial-Pulmonary Carcinoma MATERIAL AND METHODS: This retrospective study is supported by information collected from a 2011-2013 data basis provided by Instituto de Anatomia Patológica e Patologia Molecular of Faculty of Medicine of Coimbra, concerning histological typing and EGFR, KRAS and ALK mutation status in biopsies, and subsequent follow up of patients, treated at University Hospital of Coimbra, Instituto Português de Oncologia of Coimbra and Hospital of Guarda. RESULTS: Data corresponds to 56 patients with bronchial-pulmonary carcinoma, most (64.3%) of whom were male. Adenocarcinoma was the most common histological type (66.1%), followed by pleomorphic (8.9%), epidermoid (7.1%), adenosquamous (7.1%), large cell (5.4%), sarcomatoid (3.6%) and mucoepidermoid (1.8%) carcinomas. In men, the most common histological type was adenocarcinoma (66.7%), as well as in women (65%). The mean age at diagnosis was 66 years old. About 62.5% had prior history of smoking. 64.3% presented stage IV at diagnosis, 14.3 % IIIB, 7.1 % IIIA and the remaining 14.3% was classified as stage I or II. In 29 cases patients showed mutated epidermal growth factor receptor, comparing with 27 biopsies wild type. About 39.3% received tyrosine kinase inhibitors and 32.1% were treated with chemotherapy combined with radiotherapy. CONCLUSIONS: The study showed higher incidence of bronchial pulmonary carcinoma in men. Adenocarcinoma was the most frequent histological type either in men and women. Smoking habit was prevalent. The majority of patients with mutated status for epidermal growth factor receptor received tyrosine kinase inhibitors (19). For patients wild type, conventional chemotherapy was applied in most cases (19) .The overall survival for patients carrying mutated epidermal growth factor receptor is higher, comparing with the ones wild type, and this result has statistical significance. Radiotherapy was used in association with chemotherapy or alone in palliative therapeutic measures. Most patients presented advanced stages at diagnosis and so curative options were applied only in few cases (11).

博士
國立交通大學
分子醫學與生物工程研究所
105
The increasing incidence of cancer attracts more and more attention in medical research. In recent years, targeting therapeutics have shown promising efficacy in a variety of cancers. Lung cancer is the leading cause of cancer death in the world, and approximate 85% is of non-small cell lung cancer (NSCLC). The epidermal growth factor receptor (EGFR)-targeting tyrosine kinase inhibitors (TKIs) such as gefitinib, afatinib, and osimertinib have shown remarkable benefits in all stages of NSCLC patients harboring drug-sensitive mutations in the EGFR gene. In East Asian population, more than 50% NSCLC patients have such mutations. Unfortunately, almost all patients who initially responded to the EGFR-TKIs treatment eventually developed resistance to these target therapeutics. Several in vitro cell culture methods have been developed to study drug resistance mechanisms using cells obtained by prolonged drug treatment. However, relatively little is known how cancer cells would respond immediately upon EGFR targeting drugs. From the standpoints of cancer cells, striving to survive is the first priority when encountering anti-cancer drugs; and, we may hypothesis that cancer cell would use the cell emergency responses to defend drugs in some manners. This study focused on how the lung cancer cells respond upon EGFR-TKIs treatment and the consequence of interfering these cellular responses. There are two major findings in this study. First, emergency adhesion response occurred in NSCLC cells upon EGFR-TKI drug treatment, and the drug efficacy could be increased by interfering the cell emergency adhesion response. Second, an EGFR-TKI-induced downregulation of steroid biosynthesis pathway was identified. After this steroid biosynthesis pathway was reversed by glucocorticoids, the EGFR-TKI drug-induced cell apoptosis was totally abolished in cell-based and in vivo animal tests. These laboratory studies were translated into clinical application and a surprisingly increased risk of disease progression was observed in lung cancer patients receiving concomitant use of gefetinib and glucocorticoids (GCs) from a retrospective study employing Taiwan National Health Insurance Research Database. In conclusion, we found that drug induced cell responses were important to the application of EGFR-targeting therapy. Findings from this study may be translated into clinical applications to enhance the efficacy of EGFR-TKI therapy by simultaneously interfering cell emergency adhesion response. In addition, the unnecessary compromising effects caused by GCs use in TKI therapy may be minimized by awareness of such a potential effect.

碩士
國立陽明大學
微生物及免疫學研究所
102
Hedgehog stemness pathway plays an important role both in development and in cancer progression. Aberrant activation of Hedgehog pathway has been identified in several cancers, but its importance in lung adenocarcinoma remains unclear. We investigated the gene expressions of a series of Hedgehog component and found that only HHIP, the negative regulator of Hedgehog pathway, was significantly repressed in lung tumors. In contrast, GLI1, the main transcription factor of Hedgehog pathway, showed similar expression level between tumor and paired normal adjacent tissue. We then found that the gene expression of GLI1 can be induced in specific conditions such as serum-starvation or EGFR-TKI treatment, while the overexpression of HHIP can block such induction.　The induction of GLI1 then activated HGF expression and AKT phosphorylation, and improved cell survival and clonogenicity in the presence of EGFR-TKI treatment. Accordingly, the combined treatment of EGFR-TKI with the inhibitors of GLI1 or MET showed a synergistic inhibitor effect on clonogenicity of lung cancer cells. In summary, our results suggested that Hedgehog pathway is a survival signaling in lung cancer that can be induced in response to drug treatment, and the suppression of HHIP is necessary for such induction. The activation of Hedgehog pathway then induced HGF expression and the phosphorylation of MET and AKT, a novel cross-talk that has not been described in literatures. Our data also implied that the combined treatment of EGFR-TKI and GLI1 inhibitor can overcome the primary resistance, which may be applied in clinic for the treatment of lung adenocarcinoma with EGFR mutations.

EGFR TKIs are standard therapy for advanced NSCLC. In order to define their role in early disease, we implemented a phase II trial of neoadjuvant gefitinib in clinical stage I NSCLC. Tumour shrinkage was seen in 43% of patients, with 11% achieving RECIST partial response (PR). Analysis of molecular markers showed EGFR TKD mutations in 17% of cases, being the only associated with PR. For the first time we defined the histopathological response of NSCLC to these agents, characterized by reduction in tumour cellularity and proliferative index as well as presence of non-mucinous BAC histology. Clinical PR tumours also presented large areas of stromal fibrosis with presence of focal residual tumour. In a characterization of intracellular signalling response, EGFR dephosphorylation in the residues Y1068 and Y1173 was not concordant and only the former was significantly reduced. pAkt Ser473/Akt and Thr308/Akt ratios were significantly reduced but observed among both, clinical responders and resistant patients. Interestingly, reduction in pEGFR Y1068 was significantly associated with increase in tumour cellularity (p=0.047), Ki-67 index (p=0.018) and tumour growth (p=0.019) with a residual perinuclear localization been detected, suggesting a novel mechanism of resistance involving receptor internalization. Finally, we determined that the EGFR protein remains stable up to one hour of post resection ischemia but two to three tumour samples are necessary for an adequate tumour representation. Furthermore, EGFR cytoplasmic compartment presented the best association with clinical response in our cohort. Taking all together, we were able to generate the first clinical trial exploring the use of an EGFR TKI in early NSCLC, characterizing for the first time the histopathological and signalling responses to these agents with an evidence of a potential novel mechanism of resistance. Finally, we observed that multiple samples collection for an adequate tumour representation, and assessment of the cytoplasmic compartment, are warrant.

Cheong, Hio Teng.
Thesis M.Phil. Chinese University of Hong Kong 2015.
Includes bibliographical references (leaves 127-139).
Abstracts also in Chinese.
Title from PDF title page (viewed on 16, November, 2016).

碩士
國立臺灣海洋大學
生物科技研究所
96
Epidermal growth factor receptor (EGFR) is highly expressed in numerous malignancies functioning to promote tumor progression. Gefitinib is a tyrosine kinase inhibitor of EGFR (EGFR-TKI) efficient for the treatment of non-small cell lung cancer (NSCLC) expressing mutated EGFR. Prolonged treatment with gefitinib, however, may develop acquired resistance to all EGFR-TKIs currently available. Recent evidence from preclinical research disclosed that bisphosphonates originally designed for treating bone disease also exhibited anti-tumor activity. The purpose of this study was to evaluate the combinatory effects of EGFR-TKI gefitinib and bisphosphonate zoledronic acid on NSCLC in vitro and in vivo in order to develop a novel therapy for NSCLC. Human NSCLC lines, HCC827 (EGFR mutant type) and A549 (EGFR wild type) were utilized. To find out the optimal dosage, serial diluted drugs were added to cell culture and cell viability was evaluated by MTT method. Cell cycle distribution and apoptosis analysis were evaluated by flow cytometry method. Cytokine contents in the culture supernatants were determined by ELISA method. Levels of phospho-AKT and phospho-ERK1/ERK2 were measured by a two-site sandwich ELISA in cell lysates as well as western blot method. Athymic nude mice were s.c injected with NSCLCs. Tumor-bearing mice were treated with gefitinib and zoledronic acid, either alone or in combination. The inhibitory effects of both drugs on HCC827 cells were dose-dependent; an additive effect was observed when both drugs were applied simultaneously. Gefitinib induced an increase in G0/G1 arrest and zoledronic acid induced an increase in G1/S on HCC827 cells; when applied together, a further increase in G0/G1 arrest and a significant reduction in IL-8, VEGF and GM-CSF production were demonstrated. Gefitinib-suppressed the phosphorylation of ERK1/ERK2 and AKT on HCC827 cells was also enhanced by co-treatment with zoledronic acid. Animal studies showed that the combinatory treatment resulted in an additive effect on HCC827 xenograft, as compared to either drug alone. Although zoledronic acid did not enhanced the effect of gefitinib on A549 cells in vitro, growth inhibition of A549 xenograft by combination therapy was observed. Zoledronic acid enhanced the anti-tumor activity of gefitinib on NSCLC with EGFR mutation, including growth inhibition, cell cycle arrest, and reduction of angiogenic cytokines in vitro and in vivo. It will provide a basis for the novel therapy in patients with NSCLC.

碩士
中山醫學大學
醫學研究所
102
Objective: To evaluate the effectiveness of target therapy on the survival of patients with lung cancer by using longitudinal National Health Insurance (NHI) databases. Methods: Data source of this study came from the NHI research databases published by the National Health Research Institutes. Patients from year 2002 to 2010 were included. After excluding subjects with missing cancer staging, or other important variables such as age and sex, this study included 87320 subjects in the analysis. According to the inclusion time of target therapies by the NHI, this study classified all of the subjects into 3 groups: year 2002-2004 (chemotherapy only), year 2005-2010 without target therapy and year 2005-2010 with target therapy. The newly diagnosed lung cancer patients were then assigned to the above 3 groups to examine whether the availability of target therapy as well the patient’s gender, cancer cell type and stage affect the 5-year survival of the patients. Results: First of all, we analyzed the 1-year and 5-year cumulative survival of the patients with lung cancer. The 1-year cumulative survival probability was 0.799 for the target therapy group which was higher than 0.363 for the year 2002-2004 chemotherapy group and 0.358 for the year 2005-2010 without target therapy group. However, the 5-year cumulative survival probability was 0.084 for the target therapy group which was lower than 0.093 for the year 2002-2004 chemotherapy group and 0.118 for the year 2005-2010 without target therapy group. Second, we analyzed the patients with squamous cell carcinoma. The 1-year cumulative survival probability was 0.791 for the target therapy group which was higher than 0.360 for the year 2002-2004 chemotherapy group and 0.344 for the year 2005-2010 without target therapy group. However, the 5-year cumulative survival probability was 0.049 for the target therapy group which was lower than 0.096 for the year 2002-2004 chemotherapy group and 0.102 for the year 2005-2010 without target therapy group. Third, we analyzed the patients with adenocarcinoma. The 1-year cumulative survival probability was 0.808 for the target therapy group which was higher than 0.434 for the year 2002-2004 chemotherapy group and 0.438 for the year 2005-2010 without target therapy group. However, the 5-year cumulative survival probability was 0.092 for the target therapy group which was lower than 0.109 for the year 2002-2004 chemotherapy group and 0.169 for the year 2005-2010 without target therapy group. The results also showed that lung cancer patients diagnosed in year 2005-2010 had 10% lower mortality risk (hazard ratio = 0.90 with 95% CI = 0.874 - 0.926) compared with those diagnosed in year 2002-2004. Among the patients diagnosed in year 2005-2010, those received target therapy had much lower mortality risk with HR = 0.512 (95% CI = 0.498 – 0.527) compared with those did not received target therapy. In addition, female patients receiving target therapy had lower mortality risk than male patients receiving target therapy. Conclusion: The target therapies can prolong the length of survival for female and patients with adenocarcinoma but not those with squamous cell carcinoma. However, there was no difference in the 5-year survival between target therapy and chemotherapy groups.