EXOSOMES AND CANCER EDWIN LEE MD, FACE INSTITUTE FOR HORMONAL BALANCE ORLANDO, FL

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1 EXOSOMES AND CANCER EDWIN LEE MD, FACE INSTITUTE FOR HORMONAL BALANCE ORLANDO, FL

2 DISCLOSURE THE FOLLOWING POTENTIAL CONFLICT OF INTEREST RELATIONSHIPS ARE GERMANE TO MY PRESENTATION. EQUIPMENT: N/A SPEAKERS BUREAU: N/A STOCK SHAREHOLDER: N/A GRANT/RESEARCH SUPPORT N/A CO FOUNDER : CLINICAL PEPTIDE SOCIETY STATUS OF FDA DEVICES USED FOR THE MATERIAL BEING PRESENTED: N/A STATUS OF OFF LABEL USE OF DEVICES, DRUGS OR OTHER MATERIALS THAT CONSTITUTE THE SUBJECT OF THIS PRESENTATION: N/A

3 2016

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5 CANCER GENES FALL INTO 2 CATEGORIES 1). Tumor Suppressor Genes p53, BRAC-1, BRAC-2 2). Proto-oncogenes HER2, BRAF, KRAS

6 TUMOR SUPPRESSOR GENES Example p53 gene

7 PROTO-ONCOGENES GENES Example HER2 HUMAN EPIDERMAL GROWTH FACTOR RECEPTOR 2. THIS PROTEIN RECEPTOR IS INVOLVED IN THE GROWTH, REPAIR AND DIVISION OF CELLS IN THE BREAST

8 DNA DAMAGE

9 OUTCOME OF DNA DAMAGE

10 ENVIRONMENTAL CAUSES OF DNA DAMAGE

11 Mutated Cancer Genes

12 Mutated Cancer Genes

13 Mutated Proto Oncogenes- HER2

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15 EXOSOMES are nm sized vesicles WHITESIDE TL. TUMOR-DERIVED EXOSOMES AND THEIR ROLE IN CANCER PROGRESSION. ADV CLIN CHEM. 2016;74: Tiny vesicles shuttle proteins and genetic information between both neighboring and distant cells Exosomes are representatives of the parental cell phenotype and genotype Cells differ greatly not only in the quantity but also the quality of exosomes they secrete.

16 EXTRACELLULAR VESICLES VERSUS EXOSOME Debate among scientists what the definition of a exosome. Extracellular vesicles includes exosomes, microvesicles, apoptotic vesicles, oncosomes nanovesicles

17 CARGO OF EXOSOMES TAYLOR DD, GERCEL-TAYLOR C. MICRORNA SIGNATURES OF TUMOR-DERIVED EXOSOMES AS DIAGNOSTIC BIOMARKERS OF OVARIAN CANCER. GYNECOL ONCOL (2008) 110(10):13 21 over 4,000 different proteins Heat shock proteins (HSP70, HSP90) cell-surface proteins CD9, CD63, CD81 antigens mrna, mirna, longrna, DNA

18 EXOSOMES IN THE ROLE OF TUMOR GROWTH TAYLOR DD, GERCEL-TAYLOR C. MICRORNA SIGNATURES OF TUMOR-DERIVED EXO- SOMES AS DIAGNOSTIC BIOMARKERS OF OVARIAN CANCER. GYNECOL ONCOL (2008) 110(10):13 21 CARADEC J, ET AL. REPRODUCIBILITY AND EFFICIENCY OF SERUM-DERIVED EXOSOME EXTRACTION METHODS. CLIN BIOCHEM. 2014;47(13 14): Normal human blood has approx 2,000 trillion exosomes, and the blood of cancer patients is approx 4,000 trillion exosomes Exosomes from cancer have a higher concentration of microrna

19 MICRO RNA OLIVETO S, MANCINO M, MANFRINI N, BIFFO S. ROLE OF MICRORNAS IN TRANSLATION REGULATION AND CANCER. WORLD J BIOL CHEM 2017; 8(1): Particular mirna may be oncogenic in one type of cancer, and in other cancer may be tumor suppressor Example is mir-29 act as a tumoursuppressor in lung tumor whereas in breast cancer this mirna has oncogenic functions

20 Cancer cells secrete exosomes via: Lobb RJ et al. EXOSOMES: KEY MEDIATORS OF METASTASIS AND PRE-METASTATIC NICHE FORMATION SEMİN CELL DEV BİOL JUL;67:3-10. Paracrine mode: Releasing micro RNA on neighboring cells, that induce post transcriptional repression or activate membrane surface receptors to favor growth and invasiveness Endocrine mode Autocrine mode

21 EXOSOMES IN THE ROLE OF TUMOR GROWTH PSAILA B, LYDEN D. THE METASTATIC NICHE: ADAPTING THE FOREIGN SOIL. NAT REV CANCER (2009) 9(4): ZHANG H-G, GRIZZLE WE. EXOSOMES AND CANCER: A NEWLY DESCRIBED PATHWAY OF IMMUNE SUPPRESSION. CLIN CANCER RES (2011) 17(5): Major Roles in cancer formation 1) Inducing the environment for cancer to start 2) Disarming anti-tumor immune response

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24 DIAGNOSING CANCER WITH EXOSOMES Pancreatic cancer can be detected with exosomes Multiple methods from Antigen based, Ultracentrifugation and Ultrafiltration, sucrose gradient centrifugation and etc. Nuzhat Z, et al. Tumour-derived exosomes as a signature of pancreatic cancer - liquid biopsies as indicators of tumour progression. Oncotarget. 2016;8(10): Ovarian cancer can be detected with exosomes expressing CD24 and EpCAM (Epithelial Cell Adhesion Molecule) Obtained ascites samples N = 20 Able to monitor clinical response during therapy Im H, Shao H, Park YI, et al. Label-free detection and molecular profiling of exosomes with a nanoplasmonic sensor. Nat Biotechnol. 2014;32(5):490-5.

25 DIAGNOSING CANCER WITH EXOSOMES Non small cell lung cancer can be diagnosed with exosomes Plasma from 109 patients w/ stage 3a -4 Was capable of detecting and phenotyping exosomes in all samples from only 10 µl of unpurified plasma Jakobsen K.R. et al.. Exosomal proteins as potential diagnostic markers in advanced non-small cell lung carcinoma. J Extracell Vesicles. 2015;4: Published 2015 Mar 2 Rectal cancer can be diagnosed with exosomes N= 24 of advanced rectal cancer Exosomes containing mirnas 486-5p, 181a-5p and 30d-5p Bjørnetrø T et al. An experimental strategy unveiling exosomal micrornas 486-5p, 181a-5p and 30d-5p from hypoxic tumour cells as circulating indicators of high-risk rectal cancer. J Extracell Vesicles. 2019;8(1):

26 DIAGNOSING CANCER WITH URINARY EXOSOMES ØVERBYE, ANDERS ET AL. IDENTIFICATION OF PROSTATE CANCER BIOMARKERS IN URINARY EXOSOMES ONCOTARGET VOL. 6,30 (2015): Study of 15 healthy versus 16 with prostate cancer looking at the urinary exosomes 221 proteins were up regulated in exosomes from prostate cancer The highest sensitivity, 94%, was observed for transmembrane protein 256 (TM256) TM256 and LAMTOR1 protein could be used to augment the sensitivity to 100%.

27 FORGOING PROSTATE BIOPSY? SANDA, MARTIN G ET AL. ASSOCIATION BETWEEN COMBINED TMPRSS2:ERG AND PCA3 RNA URINARY TESTING AND DETECTION OF AGGRESSIVE PROSTATE CANCER JAMONCOLOGY VOL. 3,8 (2017): N= 516 and 561 in placebo group. Urinary exosomes of PCA3 and T2:ERG RNA were measured before prostate biopsy. First-catch urine was collected after Digital rectal exam 95 percent sensitivity for detecting aggressive prostate cancer, combining testing of urinary T2:ERG and PCA3 (Prostate cancer antigen 3, Transmembrane Protease Serine 2 fused with ERG- 50% of all prostate cancer has T2:ERG)

28 MICHIGAN PROSTATE SCORE SALAMI SS, SCHMIDT F, LAXMAN B, ET AL. COMBINING URINARY DETECTION OF TMPRSS2:ERG AND PCA3 WITH SERUM PSA TO PREDICT DIAGNOSIS OF PROSTATE CANCER. UROL ONCOL 2013;31: Urinary exosomes of PCA3 and T2:ERG RNA are measured after prostate exam. Algorithm developed at the University of Michigan that combines urine T2:ERG, prostate cancer antigen 3 (PCA3), and serum PSA to predict the risk of detecting PCa on biopsy. specificity of 90% and an 80% sensitivity

29 DIAGNOSING CANCER WITH EXOSOMES FUJITA K, ET AL. URINARY BIOMARKERS OF PROSTATE CANCER, INT J UROL SEP;25(9): MCKIERNAN J. ET AL, A NOVEL URINE EXOSOME GENE EXPRESSION ASSAY TO PREDICT HIGH-GRADE PROSTATE CANCER AT INITIAL BIOPSY AMA ONCOL JUL 1;2(7): Exosome company that is FDA approved Urine test to rule out prostate cancer Exosomes looking at 3 RNA markers ERG, PCA3, SPDEF (SAM-pointed domain-containing ETS transcription factor) If level is less than 15.6 then high grade prostate cancer is ruled out Lung cancer test with exosomes but only available for research only

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31 MICRO RNA VS SMALL INTERFERING RNA

32 DILEMMA of getting sirna into the cancer cells OHNO S, DRUMMEN GP, KURODA M. FOCUS ON EXTRACELLULAR VESICLES: DEVELOPMENT OF EXTRACELLULAR VESICLE-BASED THERAPEUTIC SYSTEMS. INT J MOL SCI. 2016;17(2):172. PUBLISHED 2016 FEB 6. DOI: /IJMS Problem scientists have wrestled with for over a decade: getting sirna into the right cells. Synthetic lipid nanoparticles have been the mainstay delivery device for sirna, but they can cause a toxic immune response in humans Lipid nanoparticles are notorious for congregating in the liver

33 EXOSOMES THE RISING STAR IN DRUG DELIVERY KIM M.S., HANEY M.J., ZHAO Y., YUAN D., DEYGEN I., KLYACHKO N.L., KABANOV A.V., BATRAKOVA E.V. ENGINEERING FOR TARGETED PACLITAXEL DELIVERY TO PULMONARY METASTASES: IN VITRO AND IN VIVO EVALUATIONS. NANOMEDICINE. 2018;14: Exosomes has recently emerged as a promising drug delivery system non immunogenic, high biocompatibility, and high efficacy of delivery

34 EXOSOMES CROSSES THE BLOOD BRAIN BARRIER ALVAREZ-ERVIL L, ET AL. DELIVERY OF SIRNA TO THE MOUSE BRAIN BY SYSTEMIC INJECTION OF TARGETED EXOSOMES. NAT BIOTECHNOL APR;29(4): In 2011 a study done at University of Oxford demonstrated that exosomes stuffed full of small interfering RNA (sirna) reached cells inside the brains of mice Lowered production of BACE1, a protein involved in Alzheimer s disease.

35 EXOSOMES - Specific to oncogenic KRAS in pancreatic cancer KAMERKAR S, LEBLEU VS, SUGIMOTO H, ET AL. EXOSOMES FACILITATE THERAPEUTIC TARGETING OF ONCOGENIC KRAS IN PANCREATIC CANCER. NATURE. 2017;546(7659): In 2017 intravenous injections of small interfering RNA-loaded exosomes suppressed pancreatic cancer in mice better than similar injections of sirna-loaded lipid nanoparticles, and without any obvious immune reactions

36 EXOSOMES - Specific to oncogenic KRAS in pancreatic cancer KAMERKAR S, LEBLEU VS, SUGIMOTO H, ET AL. EXOSOMES FACILITATE THERAPEUTIC TARGETING OF ONCOGENIC KRAS IN PANCREATIC CANCER. NATURE. 2017;546(7659): Treatment with small interfering RNA-loaded exosomes suppressed cancer in multiple mouse models of pancreatic cancer and significantly increased their overall survival

37 EXOSOMES LUNG CANCER Study done in mice KIM M.S., HANEY M.J., ZHAO Y., YUAN D., DEYGEN I., KLYACHKO N.L., KABANOV A.V., BATRAKOVA E.V. ENGINEERING FOR TARGETED PACLITAXEL DELIVERY TO PULMONARY METASTASES: IN VITRO AND IN VIVO EVALUATIONS. NANOMEDICINE. 2018;14: Macrophage-derived exosomes loaded with a potent anticancer agent paclitaxel (PTX) and attach on their surface a PEGconjugated ligand targeting the Sigma receptor, which is overexpressed by lung cancer cells.

38 Comparative study with different exosomes carrying doxorubicin (DOX) for pancreatic cancer KANCHANAPALLY R. ET AL, INT J NANOMEDICINE JAN 11;14: Macrophage -derived Exosomes loaded with DOX showed the highest anti tumor activity Versus pancreatic cancer cells derived exosomes and pancreatic stellate cells derived exosomes loaded with DOX

39 STUDY OF EXOSOMES ON PROSTATE CANCER IN VIVO Cancer cell derived Exosomes can deliver Paclitaxel to the prostate cancer cells through endocytosis and showed increased cytotoxic effect Saari H, et al. J Control Release Dec 28;220(Pt B):727-37

40 Phase 1 clinical trials with exosomes Ohno Shin-ichiro, et al. Extracellular vesicle based therapeutic systmes. INT. J. MOL. SCI. 2016, 17, 172; Using tumor peptide/drug loaded exosomes in patients with metastatic melanoma, advanced non-small cell lung cancer, colorectal cancer, and malignant glioma

41 Phase 1 study MESENCHYMAL STEM CELL-DERIVED EXOSOMES with sirna -pancreatic cancer CLINICALTRIALS.GOV IDENTIFIER: NCT Mesenchymal stromal cellsderived exosomes with KrasG12D sirna in treating participants with pancreatic cancer with KrasG12D mutation that has spread to other places in the body. Stage 4 pancreatic cancer cells with KrasG12D mutation Estimated enrollment of 28 Estimated completion date is Feb 2019 No results posted

42 Dexosomes as a therapeutic cancer vaccine: from bench to bedside. LE PECQ JB. BLOOD CELLS MOL DIS SEP-OCT;35(2): Exosomes released from dendritic cells, now referred as dexosomes Vaccination with dexosomes, designed to express tumor antigens, is a potent strategy to elicit anti-tumor immune response

43 Phase 1 study with dexosomes melanoma ESCUDIER, B.; DORVAL, T.; CHAPUT, N.; ANDRE, F.; CABY, M.P.; NOVAULT, S.; FLAMENT, C.; LEBOULAIRE, C.; BORG, C.; AMIGORENA, S.; ET AL. VACCINATION OF METASTATIC MELANOMA PATIENTS WITH AUTOLOGOUS DENDRITIC CELL (DC) DERIVED-EXOSOMES: RESULTS OF THEFIRST PHASE I CLINICAL TRIAL. J. TRANSL. MED. 2005, 3, 10. Advanced stage III/IV melanoma expressing the MAGE-3 antigen was treated with MAGE-3 peptides loaded dexosomes from autologous dendritic cell 5 out of the 15 enrolled patients experienced some measure of clinical benefit with respect to the primary tumor or lymph node lesions.

44 Phase 1 study dexosomes NON-SMALL CELL LUNG CANCER MORSE MA, ET AL. A PHASE I STUDY OF DEXOSOME IMMUNOTHERAPY IN PATIENTS WITH ADVANCED NON-SMALL CELL LUNG CANCER. J. TRANSL. MED. 2005, 3, 9 9 completed the therapy, but overall no significant induction of MAGE peptide-specific T-cell responses

45 Phase 2 study dexosomes NON-SMALL CELL LUNG CANCER VIAUD S, ET AL. UPDATED TECHNOLOGY TO PRODUCE HIGHLY IMMUNOGENIC DENDRITIC CELL-DERIVED EXOSOMES OF CLINICAL GRADE: A CRITICAL ROLE OF INTERFERON-GAMMA. J. IMMUNOTHER. 2011, 34, Second generation dexosomes cancer vaccination with improved immune stimulatory capacities A phase II with 41 patients enrolled non-operable NSCLC is completed but no results posted (NCT )

46 Antisense oligonucleotides vs small interfering RNA

47 Phase 1 study exosomes on Glioma CLINICALTRIALS.GOV IDENTIFIER: NCT Exosomes derived from autologous glioma loaded with antisense oligodeoxynucleotide targeting the insulin-like growth factor receptor-1 N = 13 No data reported

48 FUTURE EXOSOMES TO DELIVER CANCER DRUGS Looking for new kinds of exosomes from bacteria, fungi, plants, animals and fruit. Roche agreed to pay PureTech Health up to $36 million for access to its exosomes extracted from dairy cow milk.

49 PHASE 1 PLANT EXOSOMES COLON CANCER CLINICALTRIALS.GOV IDENTIFIER: NCT Study investigating the ability of plant exosomes to deliver curcumin to normal and colon cancer tissue Not recruiting yet

50 PHASE 1 GRAPE EXOSOMES Head and neck cancer CLINICALTRIALS.GOV IDENTIFIER: NCT Grape exosomes to prevent oral mucositis associated with chemo radiation treatment of head and neck cancer. Also the effect of grape exosomes on the production of cytokines and immune responses to tumor exosomal antigens

51 GOOD VERSUS BAD EXOSOMES Exosomes from cancer is very different from exosomes from mesenchymal stem cell

52 VEXOSOMES : EXOSOMES Packaged with virus- GYÖRGY B, SAGE C, INDZHYKULIAN AA, ET AL. RESCUE OF HEARING BY GENE DELIVERY TO INNER-EAR HAIR CELLS USING EXOSOME-ASSOCIATED AAV. MOL THER. 2017;25(2): At Massachusetts General Hospital has packaged an adeno-associated virus gene therapy inside an exosome Showed benefits in hearing in a mouse with hereditary deafness

53 CONCLUSION Exosomes can be used to diagnosis cancer Treatment of cancer can be personalized with engineered exosomes loaded with drugs, mirna, sirna, peptides or others Using exosomes in cancer is a game changer.