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. Author manuscript; available in PMC: 2017 May 24.
Published in final edited form as: Crit Rev Oncog. 2016;21(1-2):115–124. doi: 10.1615/CritRevOncog.2016016084

Gene Therapy for Lung Cancer

Humberto Lara-Guerra 1, Jack Roth 1,*
PMCID: PMC5443620  NIHMSID: NIHMS859784  PMID: 27481008

Abstract

Gene therapy was originally conceived to treat monogenic diseases. The replacement of a defective gene with a functional gene can theoretically cure the disease. In cancer, multiple genetic defects are present and the molecular profile changes during the course of the disease, making the replacement of all defective genes impossible. To overcome these difficulties, various gene therapy strategies have been adopted, including immune stimulation, transfer of suicide genes, inhibition of driver oncogenes, replacement of tumor-suppressor genes that could mediate apoptosis or anti-angiogenesis, and transfer of genes that enhance conventional treatments such as radiotherapy and chemotherapy. Some of these strategies have been tested successfully in non-small-cell lung cancer patients and the results of laboratory studies and clinical trials are reviewed herein.

Keywords: lung cancer, gene therapy

I. INTRODUCTION

In 1973, I was completing my first year of general surgery residency at the Johns Hopkins Hospital and contemplating a future career in academia. The chief of surgery, Dr. George Zuidema, suggested that I take time for a research fellowship and recommended a new program in oncology recently established by Dr. Donald Morton at University of California, Los Angeles (UCLA). Intrigued, I read several recent publications from Dr. Morton’s group at the National Cancer Institute published prior to his move to UCLA and my interest and excitement escalated. Their studies showed that human immune responses to cancer could be detected and, in mice, that the immune response could eradicate tumors. I interviewed with Dr. Morton and was fortunate to be offered a fellowship. When I arrived at UCLA, I found a clinical department unlike any I had previously encountered. This was a multidisciplinary group with basic scientists, medical oncologists, and surgeons all dedicated to treating cancer in a single administrative unit. This was an exciting time in oncology and the Morton group was leading the way. Clinical trials with novel drugs, immunotherapy, adjuvant therapy, and limb-sparing surgery for sarcoma were initiated. As a fellow, I undertook laboratory research and saw oncology patients in the clinic. Dr. Morton stressed the importance of understanding the biology of cancer and pursuing translational research that would benefit patients. The research briefly reviewed here reflects a lifelong application of these concepts that Dr. Morton followed and taught throughout his career.

Non-small-cell lung cancer (NSCLC) is the leading cause of cancer deaths in the United States and in the world. Targeted agents directed against specific genetic abnormalities related to driving the proliferation and survival of NSCLC cells have been developed. However, the prevalence of specific molecular alterations against which clinically approved targeted agents are directed is less than 10% in NSCLC patients.1 Furthermore, even with an initial response, it is common that patients develop resistance, revealing the complex regulatory networks present in NSCLC cells.

Genetic alterations are usually present in two major classes of genes, oncogenes and tumor-suppressor genes. These genetic alterations regulate malignant growth, including self-sufficiency in growth signals; insensitivity to growth-inhibitory signals; evasion of programmed cell death; limitless replicative potential; induced angiogenesis, invasion, and metastasis; reprogrammed cell metabolism; and evasion of immune destruction.2 Due to their essential role for the survival of cancer cells, specific targeted agents blocking activated oncogenes are able to induce tumor regression. However, these responses are usually short-lived. The most common genetic alterations present in NSCLC are located in tumor-suppressor genes against which no targeted agents have been developed.3

II. RESTORING TUMOR-SUPPRESSOR GENE FUNCTION

The most common gene mutations detected by recent whole-genome sequencing are in tumor-suppressor genes.3 In most situations, tumor-suppressor genes require both alleles of a gene to be deleted or inactivated to lead to tumor growth. The replacement of just one functional allele may therefore be enough to restore normal growth regulation and to induce tumor apoptosis. The most frequently mutated gene in NSCLC is the tumor-suppressor p53.3–5

P53 is a transcription factor able to up-regulate apoptotic genes and down-regulate prosurvival genes.6,7 P53 functions as a transcriptional gatekeeper, monitoring for DNA damage or oncogene activation, halting the progression of the cell cycle at the G1 stage to facilitate DNA repair or, if changes are irreversible, to induce self-destruction via apoptosis.6,7

Because conventional chemotherapy and radiotherapy act by inducing DNA damage, it is expected that cancer cells with mutated or absent P53 protein might show resistance to therapy. However, because neoplastic cells have multiple somatic mutations, it was not intuitively obvious that the single correction of P53 protein by the addition of a wild-type p53 into the cancer cell genome would be sufficient to induce apoptosis. Nevertheless, experiments in different types of neoplastic cells have shown that the single correction of defective/absent p53 with wild-type p53 induces apoptosis.8,9 In NSCLC, the observation that reintroduction of wild-type p53 in NSCLC cell lines carrying mutated or deleted p53 is able to trigger apoptosis provided the justification of exploring its therapeutic use.8 Some p53 mutations may impart oncogenic potential to p53 and are considered gain-of-function mutations. However, in most cases, overexpression of wtp53 protein will overcome this and trigger apoptosis.

III. PRECLINICAL STUDIES OF P53 GENE REPLACEMENT

The first of p53 gene replacement used a retroviral vector and showed that restoration of functional p53 suppressed the growth of some, but not all, human NSCLC cell lines in vitro.10–12 With this retroviral vector, intratumoral p53 gene therapy showed suppression of tumor growth in an orthotropic human NSCLC model with absent or mutant p53.13 This was the first study demonstrating that the restoration of a single tumor-suppressor gene could induce tumor regression in vivo. Subsequent studies, including clinical trials, have used an adenoviral vector (Ad-p53) of a serotype 5 replication-defective vector with a deleted E1 region.14 Ad-p53 was able to induce apoptosis and to suppress proliferation in NSCLC cell lines, to increase sensitivity to chemotherapeutic agents regardless of cellular p53 status, and to inhibit tumor growth in NSCLC orthotropic mouse models.15–17 In addition, killing of non-transduced tumor cells through a bystander effect initiated by Ad-p53-transduced tumor cells has been reported, potentially induced via regulation of proapoptotic signals, angiogenesis, and immune response.18–22

IV. CLINICAL TRIALS OF P53 GENE REPLACEMENT

The first clinical trial implementing p53 gene replacement utilized an intratumoral therapy of a replication-defective retroviral vector expressing wild-type p53 driven by a beta-actin promotor.23 The therapeutic agent was provided via intratumoral injection in nine unresectable NSCLC patients progressing after conventional therapy. Three of the nine patients showed evidence of tumor regression with no vector-related toxicity, demonstrating the feasibility and safety of p53 gene therapy. A dose-escalation trial in 28 NSCLC patients who had not responded to conventional therapy showed successful gene transfer via intratumoral injection in 80% of evaluable patients, with expression of p53 detected in 46%.24 With no significant toxicities detected, apoptosis was observed in all but one of the patients expressing p53. More than 50% tumor reduction was observed in two patients, with one experiencing a disease-free survival of more than a year and another experiencing a nearly complete response (CR).

In a subset analysis of patients with tumors causing airway obstruction, the degree of toxicity and antitumor activity of the delivery of Ad-p53 gene therapy via bronchoscopy were assessed.25 Twelve patients (median age, 60 years) with advanced endobronchial NSCLC were evaluated. The median tumor area was 5 cm x 3.2 cm. All patient tumors contained a p53 gene mutation. Ad-p53 was administered via bronchoscopic intratumoral injection once every 28 days. Toxicity attributed to the Ad-p53 vector was minimal. Six of the 12 patients had significant improvement in airway obstruction, with three patients meeting the criteria for partial response (PR). In addition, a phase I trial evaluated the safety of Ad-p53 gene transfer via bronchoalveolar lavage.26 In 23 assessable patients with bronchioloalveolar carcinoma, 16 experienced stabilization of their disease, but limited distribution of vector was observed.

V. P53 GENE REPLACEMENT IN COMBINATION WITH CHEMOTHERAPY

In vitro and xenograft NSCLC models have shown that sequential therapy of cisplatin and p53 gene therapy enhances p53 expression.27,28 In a phase I study of intratumoral delivery of Ad5CMV-p53, 15 patients with histologically confirmed NSCLC and p53 mutations were enrolled.29 Nine patients received escalating dose levels of Ad5CMV-p53 as monotherapy once every 4 weeks. Six patients were treated on a 28-day schedule with Ad5CMV-p53 in combination with intravenous administration of cisplatin (80 mg/m2). There were no dose-limiting toxicities. The most common treatment-related toxicity was transient fever. Specific p53 transgene expression was detected in tumor tissues despite the presence of neutralizing anti-adenovirus antibody. Thirteen of 15 patients were evaluated for efficacy. One patient had a PR, 10 had stable disease with three lasting at least 9 months, and two patients had progressive disease.

Another phase I trial of NSCLC patients resistant to cisplatin-based therapy tested the addition of Ad-p53 to these regimens.30 Intratumoral Ad-p53 gene therapy injection in sequence after six monthly courses of cisplatin resulted in two of 24 patients achieving PR and 17 achieving stable disease for at least 2 months with a safe toxicity profile. Seventy-nine percent of tumor biopsies showed an increase in the number of apoptotic cells.

VI. P53 GENE THERAPY IN COMBINATION WITH RADIATION THERAPY

Ad-p53 gene transfer increases the sensitivity of p53-deficient tumor cells to radiation.31

The combination of three intratumoral injections of Ad-p53 with concomitant radiotherapy (60 Gy over 6 weeks) showed 5% and 58% of patients with a CR or PR, respectively.32 In biopsies obtained 3 months after therapy, no viable tumor was observed in 63% of cases. Among 13 evaluable patients after 1 year, 39% had a CR and 23% had a PR or disease stabilization. The 1-year progression-free survival rate was 45.5%. Most treatment failures were caused by metastatic disease without local progression.

In that study, paired biopsies (days 18 and 19) before and after Ad-p53 gene therapy were obtained. Ad-p53 vector-specific DNA was detected in nine of 12 patients. From 11 patients with adequate samples for both vector DNA and mRNA analysis, eight showed an increase in mRNA expression associated with detectable vector DNA. Post-injection increases in p53 mRNA were detected in 11 of 12 paired biopsies, with 10 of 11 increasing threefold or more. Before Ad-p53 gene therapy, biopsies were negative for p53 expression by immunohistochemistry. After Ad-p53 injection, staining confirmed nuclear p53 expression in the posttreatment biopsies. The expression of genes that are targets of p53 was also modified, with p21 (CDKN1A), MDM2, and BAK showing an up-regulation 24 hours after Ad-p53 injection.

The most frequently reported adverse events related to Ad-p53 treatment were fever and chills, asthenia, injection site pain, nausea, and vomiting. The vast majority of these events were mild to moderate. To date, no maximum tolerated dose for Ad-p53 injection has been established. Beginning in 1998, a similar adenovirus-p53-expressing vector was tested in China in clinical trials under the name Gendicine. A multicenter, randomized clinical trial was conducted in which Ad-p53 was administered to 135 patients with head and neck squamous cell carcinoma.33 One group received gene therapy in combination with radiotherapy (GTRT) and the other group received radiotherapy alone (RT). In the GTRT group, the CR rate determined by computed tomography was 64% with 29% PR. The response rate in the RT group was 19% of the patients showing CR and 60% PR. There was a significant difference between the two groups in both the CR rate and the PR rate. This study served as the basis for the approval of Ad-p53 (Gendicine) by the Chinese Food and Drug Administration and Gendicine thus became the first gene therapy agent approved for human use.

VII. SYSTEMIC GENE THERAPY

Most NSCLC patients die from systemic metastases. Nanovesicles capable of encapsulating plasmid DNA allow the delivery of gene therapeutic agents intravenously to distant metastases.34,35 Allele losses and genetic alterations on the short arm of chromosome 3 (3p25, 3p21–22, 3p14, and 3p12–13) are among the most frequent and earliest genomic abnormalities involved in lung cancer and many other human cancers.36–38 Multiple overlapping homozygous deletions have also been found in the 3p21.3 region spanning a 120 kb genomic locus in human lung cancer cell lines.39,40 In addition, chromosomal abnormalities in the 3p21.3 region have been detected frequently in smoke-damaged respiratory epithelium and preneoplasic lesions.39,41,42 These findings suggest that one or more putative tumor-suppressor genes are present in the 3p21.3 region and that they function as “gatekeepers” in the molecular pathogenesis of lung cancer.39,41,43 When re-expressed in NSCLC cell lines, 3p21.3 genes show various degrees of tumor suppression in vitro and xenograft models with the Tumor Suppressor Candidate 2 gene (TUSC2) showing the greatest suppressor activity. 42,44 The TUSC2 protein is absent in the majority of NSCLC cell lines.38,44–46 Loss or reduction of TUSC2 expression was associated with significantly worse overall survival. Premalignant lesions also expressed significantly lower levels of TUSC2 compared with normal and hyperplastic bronchial epithelia. Expression of TUSC2 showed the most potent pro-apoptotic activity in human NSCLC cells among the candidate 3p21.3 tumor-suppressor genes.44 The apoptotic protease-activating factor 1 (Apaf-1) was identified as a potential cellular target of TUSC2 protein by its direct protein–protein interaction. 47 Apaf-1 plays an important role in the mitochondria- dependent apoptotic pathway, but a relatively high level of endogenous Apaf-1 protein was detected in NSCLC cells.48–50 These Apaf-1 proteins appeared to be functionally inactive, as indicated by their lack of intrinsic ATPase activity. Forced expression of TUSC2 in TUSC2-deficient tumor cells can trigger cytochrome c release from the mitochondria into the cytosol and cause TUSC2 binding to Apaf-1, thus recruiting it to critical cellular locations, activating Apaf-1, initiating Apaf-1-mediated caspase activation, and inducing apoptosis.51

VIII. PRECLINICAL STUDIES OF TUSC2 GENE REPLACEMENT

A TUSC2-expressing plasmid vector was packaged in N-[1-(2,3-dioleoyloxy)propyl]-N,N,N-trimethylammonium chloride (DOTAP):cholesterol (DOTAP:chol) nanovesicles to create a gene delivery agent that can be delivered intravenously. The nanovesicles are taken up selectively by both cultured and fresh tumor cells with 10-fold more than normal cells, thus imparting a passive targeting property without the need to attach ligands.52 Intratumoral TUSC2 nanovesicle delivery in subcutaneous xenografts inhibits tumor growth. Intravenous delivery in an NSCLC metastasis mouse model significantly decreased the number of metastatic nodules and prolonged survival.35 Analysis of TUSC2 expression showed distribution of TUSC2 throughout the tumor in a high percentage of the tumor cells.

IX. CLINICAL TRIAL OF TUSC2 GENE THERAPY

A phase I clinical trial using TUSC2 nanovesicles was performed in stage IV NSCLC patients.53 Patients with recurrent or metastatic NSCLC previously treated with platinum-based chemotherapy were treated with escalating doses of intravenous DOTAP:chol nanovesicles encapsulating a TUSC2 expression plasmid (DOTAP:chol-TUSC2) every 3 weeks for a maximum of six doses. Thirty-one patients were treated at six dose levels ranging from 0.01 to 0.09 milligrams per kilogram. Seventy-percent had received two or more prior chemotherapy regimens. The only dose-limiting toxicities were two episodes of transient grade 3 hypophosphatemia, resulting in an MTD of 0.06 mg/kg. Twenty-three patients received two or more doses. Five patients achieved stable disease (range, 2.6–10.8 months, 95% confidence interval [CI] 2.0–7.6) and all other patients progressed. Two patients had reductions in primary tumor size of 14% and 26%. One patient with stable disease had evidence of a durable metabolic response on positron emission tomography imaging and received 12 cycles of therapy. This patient remains alive on subsequent therapy 14 months after the final treatment with DOTAP:chol-TUSC2. Median survival for all patients was 8.3 months (95% CI 6.0–10.5 months).

Pretreatment and 24 hour posttreatment tumor biopsies were obtained from seven patients by percutaneous computed tomographic guidance from a central tumor location. RT-PCR analysis detected high levels of TUSC2 plasmid expression in six of seven posttreatment tumor specimens, but not in pretreatment specimens or negative controls. Proximity ligation assay performed on paired biopsies from three patients demonstrated no TUSC2 protein staining in pretreatment tissues compared with intense TUSC2 protein staining in posttreatment tissues. RT-PCR gene expression profiling analysis of apoptotic pathway genes in one paired specimen with high posttreatment levels of TUSC2 mRNA and protein showed significant up-regulation and down-regulation of genes involved in both the intrinsic and extrinsic apoptotic pathways. Antibodies to single- and double-stranded DNA were not detected 14 months after completion of 12 cycles of therapy in one patient. We concluded that DOTAP:chol-TUSC2 nanovesicles can be safely administrated intravenously in lung cancer patients with demonstrable gene delivery to tumors with protein expression and evidence of antitumor activity.

X. FUTURE DIRECTIONS

TUSC2 interaction down-regulates different tyrosine kinases.51 Forced TUSC2 expression in NSCLC cell lines lacking activated c-Abl kinase leads to decreased levels of c-Abl’s tyrosine kinase activity, diminishing the size and number of colonies in soft agar. Furthermore, re-expression of wild-type TUSC2 into wild-type EGFR, gefitinib-resistant NSCLC cell lines sensitized their response to gefitinib by enhancing growth inhibition and synergistically inducing apoptosis in vitro and in an orthotropic mouse model at concentrations of gefitinib similar to steady-state serum concentrations achievable with oral dosing. TUSC2 nanovesicle treatment alone or with gefitinib inactivated EGFR and Akt. Finally, a combination of TUSC2 nanovesicles and erlotinib induced higher levels of cell growth inhibition, apoptosis induction, and inactivation of EGFR and Akt than those observed with erlotinib alone. TUSC2 nanovesicle and erlotinib treatment showed cooperative growth inhibition in different colony formation assays, including in cell lines resistant to erlotinib. Cooperative antitumor interaction of TUSC2 nanovesicles and erlotinib treatment were confirmed in vivo using a lung colony formation metastatic model, with the greatest reduction in colonies occurring with the TUSC2 nanovesicle and erlotinib combination. This new evidence supporting a cooperative effect of TUSC2 re-expression in combination with erlotinib supports a phase I/II trial assessing the combination of TUSC2-nanovesicles with erlotinib in stage IV or recurrent NSCLC patients with absence of EGFR TK-activating mutations or showing progression after erlotinib treatment.54

Finally, the Cancer Genome Atlas Network has reported the first NSCLC comprehensive characterization.55 This comprehensive genomic sequence of lung squamous cell carcinomas confirmed the importance of p53 and also identified novel or previously underestimated tumor-suppressor genes such as CDKN2A, which was found to be inactivated in 72% of cases, resulting in different patterns of expression of its encoded proteins ARF and INK4A. RB1 was also found to be frequently mutated. These studies can guide the development of future gene therapies against NSCLC.

XI. CONCLUSIONS

Contrary to initial beliefs, the body of work on p53 has demonstrated that gene replacement targeting a single tumor-suppressor gene can cause cancer regression. In addition, DOTAP:chol-TUSC2 confirmed that gene therapy could be administrated systemically. With both gene therapeutic options showing clinical response with a safe toxicity profile, combinations with other NSCLC therapies, including targeted agents, deserve to be explored. With other promising gene therapeutic options currently in laboratory development in addition to new potential targets discovered by genomic sequencing, the matching of a targeted gene therapy with specific molecular profiles or therapeutic regimens has a promising future.

Acknowledgments

This work was supported in part by the National Institutes of Health/National Cancer Institute through The University of Texas M.D. Anderson Cancer Center’s Cancer Center Support Grant CA-016672; Lung Program and Shared Core Facilities Specialized Program of Research Excellence (SPORE) Grant CA-070907 (J. Minna and J.A Roth); R01 Grant CA-116322 (L. Ji); and Tobacco Settlement Funds as appropriated by the Texas Legislature and by a sponsored research agreement from Genprex, Inc. (R. Mehran). H.L.G. was supported by the Cancer Prevention Research Institute of Texas (Institutional Training Grants RP101502 and RP140106).

ABBREVIATIONS

NSCLC

non-small-cell lung cancer

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