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A PRECLINICAL STUDY OF FLAVOPIRIDOL IN THE TREATMENT OF ACUTE
KELLY MARIE JACKMAN
A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY
UNIVERSITY OF FLORIDA
O 2007 Kelly Marie Jackman
To those whose lives have been touched by cancer; especially women who have lost their
fathers. Even though our loved ones have moved on, a small part of them is still here in us.
I would first like to thank my mentor, Dr. Hunger. I appreciate the time that he has given to
assist me in my writing and scientific development. Because of his patient guidance and honesty,
my ability to communicate in a more sophisticated and organized manner has matured
tremendously. My professional demeanor has also changed a great deal during my graduate
career; part of which I owe to the example set by Dr. Hunger. I will always be grateful for his
I would also like to thank the members of my committee, Drs. Rowe, Kilberg, and Fletcher
for their input into this work and their contribution to making sure that it progressed in a timely
My appreciation also goes to the past and present members of the Hunger laboratory.
Through discussions of various topics, both professional and non-scientific, Dr. Victor Prima has
helped me to learn how to articulate and defend my ideas; skills which are integral to the
graduate experience. Dr. Mi Zhou was and still is a wonderful friend and an important source of
personal support. Both of these individuals have taught me so much about the cultures of
Ukraine and China, respectively, which has made my time in the lab a truly unique experience. I
would also like to thank Carole Frye for her valuable advice and technical assistance with my
experiments. My thanks also go to Amanda Rice, who became a great friend in the short time
that she worked in the lab.
Without the tireless help of the individuals in the Flow Cytometry Core Lab, this work
would not have been possible. I would like to thank Neil Benson, Bhavna Bhardwaj, and Steve
McClellan for assisting me with my experiments. Bhavna and Steve were willing spirits as they
performed most of the raw data analyses contained in this dissertation, for which I was always
grateful. I would also like to thank Linda Young in the Department of Statistics for patiently
helping me through all of the statistics required to properly analyze my data.
Other members of the College of Medicine that I wish to thank are Judy Adams, my
graduate secretary, as well as Cathy Hymon, secretary for Pediatric Hematology/Oncology.
Without these ladies I would not have been able to navigate the huge system that is UF. I would
also like to remember my fellow students and members of GSO.
Finally, and most importantly, I would like to thank my mom. She has been there through
everything; so many events that it becomes difficult to list them all. She has held my hand
literally and figuratively when it was time for many of the special people in my life, and hers, to
leave us. She has been there through the frustrations and triumphs of my life and academic career
and has always supported me. My mom is truly my best friend and I know that without her I
would not have gotten as far as I have. I hope that my achievement brings to her a sense of
satisfaction that a small part of the plan that she and my father set into motion many years ago
TABLE OF CONTENTS
ACKNOWLEDGMENTS .............. ...............4.....
LIST OF TABLES ............ ...... ._._ ...............8....
LIST OF FIGURES .............. ...............10....
AB S TRAC T ........._._ ............ ..............._ 12...
1 BACKGROUND .............. ...............14....
General Treatment of Acute Lymphoblastic Leukemia (ALL) ................. ......................14
Relapsed ALL: The Clinical Problem .............. ...............15....
Important Regulators of Cell Cycle ................. ...............16........... ...
Cell Cycle Regulators in Cancer and ALL ................ ...............17........... ..
Flavopiridol (FP) .............. ..... .. .. .. ..... ... ...................2
In Vitro Testing of Flavopiridol in Combination with Other Agents: Sequence of
Administration and Synergy ............... ...............22....
Efficacy of Flavopiridol in Clinical Trials............... ...............23.
Biological Correlates of Clinical Activity .............. .... ........... .... ...... .......2
Clinical Trials of Paclitaxel (PAC) and Combining Flavopiridol with Paclitaxel .................28
Proj ect Rationale. ................. ...............29..............
2 FLAVOPIRIDOL DISPLAYS PRECLINICAL ACTIVITY IN ACUTE
LYMPHOBLASTIC LEUKEMIA ............ ..... ._ ...............36....
Introducti on ............ ..... ._ ...............36....
M ethods .............. .. ... .... ..................3
In Vitro Drug Sensitivity Testing .............. ...............37....
Western Blot Analyses .............. ...............38....
Measurement of Cell Death ............ ..... ._ ...............39...
Cell Cycle Analysis .............. ...............40....
R e sults............ _... ... .. .._ ...... .. .._... .. ... .... ... ............4
ALL Cell Lines Used for in Vitro Testing Lack pl6 Protein Expression ................... ....40
In Vitro Drug Sensitivity in ALL Cell Lines................ ...............41.
FP Induces Apoptosis in ALL Cell Lines.............. .. .........................4
FP Induces Cell Cycle Arrest in ALL Cell Lines which Correlates with Effects on
pp-Rb Protein Expression .............. ...............42....
Apoptotic Effects of FP in Human Serum ................. ....___ .......... .........4
Discussion ................. ...............44........ ......
3 PRECLINICAL STUDIES OF FLAVOPIRIDOL COMBINED WITH PACLITAXEL
INT ACUTE LYMPHOBLASTIC LEUKEMIA .................... ...............5
Introducti on ................. ...............52.................
M ethods .............. ...............53....
M materials .................. .. .. .... ...... .... ....... .............5
Single Agent in Vitro Sensitivity Assays .............. ...............53....
Drug Combination Studies .............. ...............54....
Treatment Sequence .............. ...............54....
Statistical Analysis .............. ...............55....
R e sults................... ... .. ....... .. ........ .............5
Single Agent FP Treatment .............. ...............55....
Single Agent PAC Treatment ................... .......... ...............56......
Combination Treatment with FP and PAC ................. ...............56...............
Determination of Optimal Schedule for PAC+FP ................. .............................57
Activity of PAC in Human Serum. ................ ........... ......... ........ ..........57
Combination Studies in Human Serum .............. ...............58....
Discussion ........._._._..... ..... ...............58....
4 C ONCLU SIONS AND DI SCU SSION .............. ...............67....
FP Single Agent Studies .........._.... .. ......_._... ............_ ............6
Establishing an in Vitro Treatment Model of ALL ......____ ..... ... ................67
Drug Sensitivity Testing via Cell Proliferation Assays............... ...............67.
The Mechanism of Cell Death Induced by FP in ALL Cell Lines .............. ...............68
FP Activity in Human Serum .............. ...............69....
PAC+FP Combination Studies .............. ...............70....
Note about Statistical Analysis............... ...............70
Enhancement of PAC Activity by FP ......__....._.__._ ......._._. ...........7
Methods of Determining Synergy .................... ...............7
FP Combined with PAC .............. ...............75...
Sequence Dependent Enhancement. ...._ ......_____ .......___ ............7
Drug Sensitivity in Human Serum .............. ...............78....
Placing Perspective on this Proj ect..........._...._ ....... ...___ .... .....___ ...........7
Potential Side Effects of Single Agent and Combination Therapy ................ ...............79
Where Does FP Fit into the Treatment Scheme of ALL? ............__.. ...___...........79
Future Directions ................. ...............80.................
LI ST OF REFERENCE S ................. ...............96................
BIOGRAPHICAL SKETCH ................. ...............108......... ......
LIST OF TABLES
4-1. Mixed model analysis for FP treatment duration in Nalm-6 ................ .......___...........87
4-2. Mixed model analysis for FP treatment duration in RCH-ACV............__ ..........__ .....87
4-3. Differences between treatment duration at a given FP concentration in Nalm-6 .................87
4-4. Differences between treatment duration at a given FP concentration in RCH-ACV..........87
4-5. Mixed model analysis of PAC single agent treatment in Nalm-6 ................... ...............8
4-6. Mixed model analysis of PAC single agent treatment in RCH-ACV .............. ..................88
4-7. Differences in cell death based on incubation time after 6 or 24 hours PAC treatment in
N alm -6 .............. ...............89....
4-8. Differences in cell death based on incubation time after 6 or 24 hours PAC treatment in
RCH-ACV. ........... ..... .._ ...............90....
4-9. Combination Index (CI) values for drug combination studies using a variety of ratios .......90
4-10. Mixed model analysis of Nalm-6 and RCH-ACV combination data ........._...... ........._.....90
4-11. Mixed model analysis of Molt-4 and Jurkat combination data ................... ...............9
4-12. Significant differences in treatment for a given cell line and drug concentration ...............91
4-13. Significant differences in treatment for a given cell line and drug concentration ...............91
4-14. Combination Index (CI) values for drug combination studies .............. ....................9
4-15. One-Way Analysis of Variance of treatment sequence in Nalm-6 ........._.._. ........._.._.....92
4-16. Weighted One-Way Analysis of Variance of treatment sequence in RCH-ACV ..............92
4-17. Significant differences between standard treatment sequence, reverse treatment
sequence, and single agent controls in Nalm-6 ................. ...............92..............
4-18. Significant differences between standard treatment sequence, reverse treatment
sequence, and single agent controls in RCH-ACV ....__ ................. ................ ...93
4-19. Mixed model analysis for comparison of cell death induced by PAC in FBS vs. HS ........93
4-20. Comparison of cell death induced by PAC in FBS vs. HS............... ...................9
4-21. Mixed model analysis of cell viability FBS vs. HS............... ...............94...
4-22. Mixed model analysis s of combination studies in human serum ................. ............... ....94
4-23. Significant differences in treatment for combination studies in human serum..................95
LIST OF FIGURES
1-1. Treatment of Childhood Acute Lymphoblastic Leukemia (ALL) ................. ................ ...32
1-2. Cyclin dependent kinase (CDK) inhibitors function in the transition from G1 (Gap 1) to
S (DNA synthesis) phase of the cell cycle............... ...............33.
1-3. pl6 works in concert with pRb to regulate the G1-S transition. .............. ....................3
1-4. Flavopiridol is a pan-CDK inhibitor. ................. ...............35........ ..
2-1. Fifty percent inhibitory concentration (ICso) determinations via WST-1 in cell lines that
lack pl6 protein expression. ............. ...............47.....
2-2. Flavopiridol induces apoptosis in ALL cell lines in a concentration dependent manner......48
2-3. Flavopiridol induces G1-S and G2-M (Gap 2-mitotic) arrest in RCH-ACV with reduced
phosphorylation of pRb ............. ...............49.....
2-4. Flavopiridol induces transient G1-S arrest in Nalm-6. ........... ...............50......
2-5. Efficacy of FP in human serum. ............. ...............51.....
3-1. Experimental design for PAC single agent treatment. ............. ...............60.....
3-2. Cell death induced by treatment with FP or PAC in Nalm-6 and RCH-ACV. ...................61
3 -3. Flavopiridol enhances the efficacy of PAC in ALL cell lines. ........... _... ...._._...........62
3-4. PAC+FP is a more efficacious treatment sequence than FP&PAC or concurrent
exposure in Nalm-6. ........... ..... .._ ...............63...
3-5. PAC+FP is a more efficacious treatment sequence than FP&PAC or concurrent
exposure in RCH-ACV. .............. ...............64....
3-6. Efficacy of PAC in Nalm-6 in the presence of human serum. .........___ ...... .._. ...........65
3-7. Flavopiridol enhances the efficacy of PAC in human serum. ..........__..... ._ ..............66
4-1. Growth curves used to establish cell concentration for proliferation assays.........................82
4-2. Representative dose-response curves generated from cell proliferation assays. ...................83
4-3. Illustration of isobologram analysis of combined drug effects.. ............... ............. .......84
4-4. Preliminary combination data at a variety of ratios in Nalm-6. ........._._ .... ...._.._........85
4-5. Preliminary combination data at a variety of ratios in the presence of human serum...........86
Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy
A PRECLINICAL STUDY OF FLAVOPIRIDOL IN THE TREATMENT OF ACUTE
Kelly Marie Jackman
Chair: Stephen P. Hunger
Major: Medical Sciences--Physiology and Pharmacology
Approximately 80% of children with acute lymphoblastic leukemia (ALL) will be cured;
however, it is essential to study novel agents and new combinations of existing therapies for their
potential use in relapsed patients. Loss of pl6 function might play a part in the progression of
ALL, which makes this pathway an interesting target for novel therapeutics. I have chosen to
study flavopiridol (FP), a semi-synthetic flavonoid that targets the pl6 pathway. FP acts as a
pan-cyclin dependent kinase inhibitor with the ability to induce apoptosis and cell cycle arrest in
human cancer cells. My studies have shown that at a concentration approximately equal to the
IC5o, FP induces a transient G1-S arrest and a low percentage of apoptosis in ALL cell lines. At
approximately twice the ICso, FP induces a sustained G1-S and G2-M arrest with a high
percentage of apoptosis. My work has also shown that FP treatment decreases the
phosphorylation of retinoblastoma protein on specific serine residues; an indication of a
reduction in endogenous CDK activity. Further, despite a high level of binding by FP to proteins
present human serum and subsequent reduction in its in vitro activity reported by others, I show
that there is not a substantial difference in FP activity in the presence of human serum when
compared to fetal bovine serum.
Based on disappointing results from early clinical studies of FP by others, I chose to test
FP in combination with paclitaxel. PAC has a mechanism of action which is complementary to
that of FP. PAC enhances the activity of CDK 1, inhibits microtubule depolymerization, and
induces G2-M arrest. Others have reported that FP enhances the efficacy of PAC in a sequence-
dependent manner in cell types other than ALL. My results show that FP enhances the efficacy
of PAC in ALL cell lines and that this enhancement is dependent on the sequence of
administration. In this study I established optimal times of exposure for each of the agents when
used in combination and confirmed that the enhancement of PAC activity by FP is present both
in fetal bovine serum and human serum.
General Treatment of Acute Lymphoblastic Leukemia (ALL)
Acute lymphoblastic leukemia (ALL) is the most common form of childhood cancer,
accounting for approximately 30% of pediatric malignancies (1). With current multi-agent
chemotherapy regimens, approximately 80% of patients are cured of their disease; however,
relapse remains a significant clinical problem (2). Treatment of children with ALL consists of
three phases: induction, consolidation and maintenance (Figure 1-1) (2, 3). The total length of
treatment lasts 2-3 yrs. The purpose of the first phase of treatment, which lasts approximately
one month, is to induce a complete remission or an absence of morphologically detectable
leukemic blast cells in the blood or bone marrow. This is successfully achieved in 99% of
patients with three or four drugs (2, 3). The consolidation phase of therapy lasts 4-8 months and
is designed to reduce the number of remaining leukemic blast cells using the agents listed in
Figure 1-1 (3). Maintenance therapy (1.5 to 2.5 years) consists of methotrexate and 6-
mercaptopurine; in addition to vincristine and either prednisone or dexamethasone.
Patients with recurrent ALL receive more intensive therapy involving any or all of the
agents previously outlined in other phases with other active agents such as ifosfamide, etoposide
or teniposide often added. Stem cell transplant is also frequently performed for patients whose
disease recurs during treatment or within 6 months of completing therapy. In the case of relapse
outside of the bone marrow, such as leukemic blasts found in the central nervous system or
testes, radiation can be administered at that site if it has not been previously administered.
There are agents which are currently used on an experimental basis in children with ALL.
These include newer cytotoxic agents such as clofarabine, a nucleoside analog, agents which
target tyrosine kinases and those that target histone deacetylases (2). Imatinib mesylate (Gleevec)
targets the tyrosine kinase formed by the BCR-ABL fusion protein resulting from a translocation
between chromosome number 9 and chromosome number 22 (Philadelphia chromosome) as well
as other tyrosine kinases. Use of this agent has induced remissions in BCR-ABL positive ALL
(4-6). Other therapies under investigation include the use of RNA interference technology, gene
therapy and immunotherapy (2).
Relapsed ALL: The Clinical Problem
Relapse can occur in a number of sites, including but not limited to the bone marrow,
central nervous system, and testes. Survival rates after bone marrow relapse range from 5% to
57% and are especially poor for those with a relapse within 36 months of initial diagnosis (7-11).
Increased dosage, the use of other existing chemotherapy agents not typically used in primary
treatment (etoposide, ifosfamide, and others) and widespread use of stem cell transplantation
have not significantly improved outcome for these patients. In addition, while complete
remission rates for children who relapse more than 3 years after diagnosis are similar to those
seen at initial diagnosis (>95%), patients who relapse less than 3 years after diagnosis often fail
to attain a second remission (12).
Thus, there is a need to develop novel agents and/or new combinations of existing agents
in order to improve the outcome of relapsed pediatric ALL patients. Many new agents have been
developed that have novel modes of action. Some of these include the cyclin-dependent kinase
inhibitors (CDKIs), examples being flavopiridol and UCN-01 (13, 14). Other drugs which are
typically used in other types of cancers, such as the microtubule depolymerization inhibitors
paclitaxel and docetaxel, have been used experimentally in ALL with mixed results (15-17). It
becomes essential to study the biology that makes relapsed ALL different from ALL at initial
diagnosis so that priority can be given to the study of the most promising agents.
Important Regulators of Cell Cycle
Gene expression profiling reveals that several key pathways are altered at the time of ALL
relapse vs. at initial diagnosis, including cell cycle regulation, DNA repair and apoptosis (18).
This proj ect has focused on preclinical testing of agents that target the aberrations in cell cycle
regulation present in relapsed ALL. Regulatory proteins can be broadly separated into those
which regulate the transition from G1 (Gap 1) to S (DNA synthesis) phase and from G2 (Gap 2)
to M (mitosis) phase. CDK 2, CDK 4, and CDK 6 regulate the transition from G1 to S and CDK
1 (cdc2) regulates the transition from G2 to M (Figure 1-2) (19). Most molecules of interest in
this proj ect function in the restriction point from G1 to S or the point at which the cell is
committed to divide with or without the presence of growth factors (20), as beyond this point the
cell is less likely to respond to external stimuli such as a drug. CDK 4 and CDK 6 become
functional after cyclin DI, cyclin D2, or cyclin D3 binding (19). These kinases phosphorylate
retinoblastoma protein (pRb) at specific serine and/or threonine residues. This phosphorylation is
normally prevented by pl6 (cyclin-dependent kinase 4 inhibitor A; INK4A), which binds to
CDK 4 and CDK 6 in the place of the cyclin (21). pl6 is part of the INK4 family of proteins,
including pl5 (INK4B), pl8(INK4C), and pl9(INK4D), which work to inhibit CDK 4 and CDK
6, along with members of the CIP/KIP family, including p27 (cyclin dependent kinase inhibitor
IB; KIPl), p57 (cyclin dependent kinase inhibitor IC; KIP2) and p21 (cyclin dependent kinase
inhibitor 1A; WAFl/CIPl) (Figure 1-2) (22). When pl6 is present, the hypophosphorylated form
of pRb acts as a tumor suppressor by binding to E2F transcription factor, making E2F unable to
bind to DP-1 and 2 (Figure 1-3). These molecules function as transcription factors that act in
DNA synthesis and nucleotide metabolism (22).
pl6 has been a maj or interest in this proj ect; however, other molecules such as pl5, p21,
and p27 have been studied by the Hunger lab and others for their possible roles in the
progression of ALL (see below). pl5 shares great homology with pl6, is found within 25kb of
the pl6 gene on chromosome 9 (23), and acts as a TGF-P (transforming growth factor-p) induced
inhibitor of CDK 4 and CDK 6 (24). p21 and p27 regulate not only CDK 4 and CDK 6, but also
CDK 2, which functions in concert with CDK 4 and CDK 6 to phosphorylate pRb (19). It is
CDK 2 that actually completes the hyperphosphorylation of pRb. This inhibits the tumor
suppressive nature of pRb and allows progression of the cell cycle through S-phase. p21 is
activated by the p53 transcription factor (22). P53 is regulated by MDM-2 (mouse double minute
2; HDM-2 in humans) which inactivates the transcriptional activity of p53, flags it for
ubiquitylation, and ensures its transport from the nucleus into the cytoplasm. An alternate
reading frame of the pl6 locus produces pl4 (alternate reading frame; ARF) which acts as a
tumor suppressor by preventing the p53 suppression activity of MDM-2.
Cell Cycle Regulators in Cancer and ALL
Deletion of pl6 is the most common form of genetic alteration in cancer among cell cycle
regulators (25). Studies have shown that greater than 30% of ALL cases have pl5 and pl6
deletions, with that percentage increasing to greater than 50% in T-cell ALL and remaining
greater than 20% in B-precursor ALL (26). It has been found by the Hunger lab and others that a
substantial number of patients develop pl5 and/or pl6 deletions in the bone marrow between the
time of initial diagnosis and relapse of ALL (27, 28). The pl5 promoter has also been studied
and has been found to undergo methylation between diagnosis and relapse, much more
commonly than the pl6 promoter (29-3 1). This pl5 methylation takes place in CpG islands at the
5' end of the gene, which results in loss of transcription in the promoter region (32). A study
from the Hunger laboratory used 18 matched specimen pairs from children with ALL at initial
diagnosis and first relapse to determine if pl5/pl6 deletions or hypermethylation of the pl5
promoter occurred between diagnosis and relapse (27). Results showed that out of 14 pairs that
were germline at diagnosis, three developed homozygous deletions of both pl5 and pl6 and two
developed homozygous pl6 deletions and retained germline pl5 status between the time of
initial diagnosis and relapse. pl5 promoter hypermethylation developed in two patients between
diagnosis and relapse. Out of the eighteen total cases, seven had homozygous pl5 deletions, nine
had homozygous pl6 deletions, and two of eight cases tested had pl5 promoter
hypermethylation at relapse. Similar findings have been reported by Carter, et al., showing that
out of a group of 25 pediatric ALL patients, at diagnosis 32% and 20% had homozygous and
hemizygous pl6 (exon 2) deletions respectively (28). The incidence of homozygous pl6 deletion
at relapse increased to 64%, illustrating the potential importance of the loss pl6 in the
progression of ALL.
The prevalence of pl5 and pl6 alterations is much higher than the level of p21 and p2 7
alterations found in ALL (33, 34). Both p21 and p27 function to inhibit CDK 2 and CDK 4 (35-
37). p21 is regulated by p53 in order to control cell growth (38). Hayette, et al. performed a study
of alterations of molecules which inhibit CDKs in leukemia, using bone marrow or peripheral
blood from 121 newly diagnosed ALL cases, 85 newly diagnosed acute myeloid leukemia cases,
and 42 newly diagnosed B-cell chronic lymphocytic leukemia cases (34). Via Southern blot this
group found that pl6 was inactivated in 25 of 38 T-cell ALL cases and 28 of 83 B-lineage ALLs.
After testing 40 ALL samples with a pl6 aberration, it was found that 22 cases (55%) had
biallelic pl5 deletions and 11 cases (28%) had monoallelic deletions. All cases with a pl5
deletion also had an anomaly in the pl6 gene. There were no alterations found in p21 and
monoallelic deletion of p2 7 was present in 4 of 85 acute myeloid leukemia cases tested. These
data show that p21 and p2 7 alterations are much less prevalent in leukemia than deletions of pl5
and pl6. Another study by Kawamura, et al. further illustrates this point by analyzing 71 primary
T-ALL samples and 18 T-ALL cell lines for alterations in pl5, pl6, p21, p53, and RAS via
polymerase chain reaction-single strand conformation polymorphism analysis (33). They found
that none had alterations in p21. In contrast, 18 of 47 (3 8%) newly diagnosed patients had pl6
alterations and 7 of 14 (50%) patients had pl6 alterations at relapse.
Gene deletion is not the only cause of loss of functional pl6. Many samples have been
found to have an intact pl6 gene, but no protein expression. An interesting study by Nakamura,
et al. notes that when pl6 expression was investigated in childhood ALL samples via Western
blot, 18 of 22 samples with an intact pl6 gene did not express pl6 protein; however, protein
expression was able to be induced after treatment with a demethylating agent, indicating that the
loss of pl6 protein expression was due to gene hypermethylation (39). Others have reported
similar results in T-cell ALL and/or AML (40-42). A separate study of pediatric T-cell ALL
patients reported that only 9 of the 45 samples with intact pl6 expressed pl6 protein (43). This
study found that pl6 was altered at the DNA, RNA or protein level in 1 15 of the 124 (93%)
samples tested and concluded that alteration in both pl6 and pl5 were essential to the
progression of T-cell ALL. Most recently a study of adults with untreated ALL found that not
one of the samples tested (n=91) expressed pl6 protein (44).
A study performed by Carter, et al. on 45 patient samples via quantitative PCR techniques
found that ALL patients with a hemizygous deletion of pl6 at diagnosis were 6.5 times more
likely (P=0.00687) to relapse and those with a homozygous deletion had an even higher risk ratio
of 1 1.5 (P=0.000539) (45). In contrast to the findings of Carter et al., Einsiedel et al. found that
there was no association between pl6 deletions and event free survival in ALL (46). pl5 and pl6
status could be correlated to two maj or prognostic indicators: T-cell immunophenotype and first
remission duration. This study did not assess for hemizygous deletions, as Carter did, because of
theoretic and methodologic considerations. Another group compared wildtype pl6 to
hemizygous deletions and found no difference in potential for event free survival (47).
Given this information it becomes apparent that despite the fact that its prognostic value is
still somewhat controversial, pl6 alterations occur commonly in relapsed ALL and are often
acquired during disease progression. Deletion of pl6 and hypermethylation of the pl5 promoter
region occur much more frequently in ALL than alterations in other cell cycle regulatory
molecules such as p21 or p27. Therefore the pl5/pl6 pathway is an attractive target for
therapeutic intervention in relapsed ALL. Several agents exist that modulate cell cycle
progression and are logical candidates to test in relapsed ALL. One such agent is flavopiridol, a
description of which follows.
Flavopiridol (FP) is a semisynthetic flavonoid derived from rohitukine, an alkaloid isolated
from a plant indigenous to India (48). Flavopiridol has a variety of mechanisms of action;
however, most relevant to my studies is the ability of FP to decrease the activity of CDKs and
induce cell cycle arrest (Figure 1-4). Cell cycle regulatory elements such as the CDK inhibitors
pl5 and pl6 are altered in ALL between diagnosis and relapse, indicating that this loss of
checkpoint control in the cell cycle could be a critical factor in the progression of the disease and
an attractive target for novel therapeutic agents. FP competitively binds to the ATP binding cleft
of the CDK (14) and is capable of reducing the activity of CDK 1, CDK 2, CDK 4, CDK 6, and
CDK 7 with IC5o values in the range of 20-400 nM (49). FP also reduces the activity of CDK 9
FP induces cell cycle arrest at the G1-S phase border as well as during G2-M. Inhibition of
CDK 2 and CDK 4 has been correlated to G1 arrest in MCF-7 breast carcinoma cells (14).
Another group had similar findings using MDA-468 breast carcinoma cells that were
synchronized either in G1 phase with aphidicolin or synchronized in M phase with nocodazole
(53). MDA-468 cells treated with 200 nM FP after release from aphidicolin G1 block arrested in
G2-M after 24 hours. Cultures released from nocodazole M phase block and treated with 200 nM
FP showed a G1-S arrest when compared to control cultures not treated with FP.
The ability of FP to induce cell death has been tested in vitro in a variety of cancer cell
types, including adult leukemia. An early study in a variety of solid tumor cell types and HL-60
leukemia cells found that FP was cytotoxic as measured by trypan blue exclusion and colony
formation assays (54). Previous studies had only shown that FP was cytostatic (53). The former
study also found that 90% cell death was induced 72 hours following a 24 hour exposure to 250-
300 nM FP compared to 50% cell death induced immediately following the 24 hour drug
exposure, thus showing that more time was needed to achieve a maximum cell death response.
This group also showed that both logarithmically growing and cytostatic cell lines were affected
by FP treatment. Similar results have been found by others testing non-small cell lung carcinoma
cell lines (55). It was found that seven different cell lines were sensitive to FP at concentrations
ranging from 100-500 nM; regardless of whether the cell lines were in logarithmic growth phase
or cytostatic. This group also showed that cell cycle arrest preceded cell death in most cases and
that maximal cell death occurred 72 hours post-treatment with concentrations of FP 500 nM or
below. These data illustrate the cytotoxic action of FP during a prolonged exposure. This activity
combined with the ability of FP to inhibit CDK activity and induce cell cycle arrest contribute to
this proj ect' s focus on testing the efficacy of FP as a potential treatment for ALL.
In Vitro Testing of Flavopiridol in Combination with Other Agents: Sequence of
Administration and Synergy
It has been found that administering FP with traditional antineoplastic agents can improve
the efficacy of those agents and that in some cases this interaction is synergistic. The
enhancement of a traditional agent by FP has been shown to be dependent on the sequence in
which the drugs are given, such as the enhancement of paclitaxel (PAC) activity by FP (56).
Paclitaxel (trade name Taxol) prevents microtubule depolymerization (57) and induces G2-M
phase arrest (58). An example of the enhancement of PAC activity by FP can be found in work
by Motwani, et al. in which MKN-74 human gastric carcinoma cells and MCF-7 human breast
carcinoma cells were exposed to PAC, FP, or both agents either sequentially or simultaneously
(56). When MKN-74 cells were exposed to PAC and FP for 24 hours, the level of apoptosis
increased from 3 +/- 1% with FP alone to 8 +/- 1%. A significant increase was then seen when
the drugs were used sequentially. MKN-74 cells were exposed to PAC for 18 hours followed by
FP for 24 hours and the level of apoptosis was 40 +/- 2%; however, when using FP followed by
PAC the level was 8 +/- 1%, which was not significantly different from the amount of apoptosis
found after exposing the cells to FP for 24 hours followed by no drug for 18 hours. Caspase-3,
the final activator of the apoptotic cascade was activated when MKN-74 and MCF-7 were treated
with PAC followed by FP. Without FP, PAC only minimally activated caspase-3. If the sequence
of administration was reversed, FP inhibited the function of PAC by preventing mitosis and
CDK 1 activity. Similar results in regard to cytotoxicity have been achieved when using FP in
conjunction with docetaxel in vitro and in xenograft tumor models (59).
When testing eight agents against a human non-small cell lung carcinoma cell line (A549),
Bible and Kaufmann found that seven of the eight agents had synergy with FP that was sequence
specific (60). These authors extensively studied the possibility that treatment with PAC and FP
could show sequence dependent synergy. Their finding that the effects of PAC were more
pronounced when administered before FP treatment as opposed to after or concomitantly was
particularly intriguing. A marked decrease in clonigenic cell survival over PAC alone and FP
alone was seen when PAC treatment was followed by FP. Synergy was assessed through the use
of combination index or CI. A CI of 1.0 indicates that the relationship between the drugs being
studied is nearly additive, while a CI of <1.0 indicates synergy and a CI of >1.0 indicates
antagonism (61). At the concentration at which cell proliferation was inhibited by 75% (IC75)
and 95% (IC95), COmbination indices of 0.49 +/- 0.21 and 0.20 +/- 0. 14 were found, respectively,
indicating synergy if PAC was given before FP in the treatment sequence (60). Antagonism was
found if PAC followed FP.
Others have tested many agents in conjunction with FP in myeloid leukemia cell lines.
These agents have included phorbol 12-myristate 13-acetate (PMA), imatinib mesylate
(Gleevec), bryostatin 1, bortezomib (Velcade) and suberoylanilide hydroxamic acid (SAHA)
(62-66). All have shown promising results for the ability of FP to enhance the activity of other
Efficacy of Flavopiridol in Clinical Trials
Based on its action as a CDK inhibitor and promising preclinical activity, FP was tested in
phase I human trials. Studies designed to obtain clinical pharmacology data after giving FP as a
72 hour infusion readily achieved plasma concentrations that were comparable to that found to
be effective in vitro (67, 68). However, most clinical trials involving cancer patients gave FP as a
72 hour infusion every 2-3 weeks and found that it had limited efficacy as a single agent (69-75).
One of these trials found that FP had antitumor activity in certain patients with renal, prostate,
and colon cancer, and non-Hodgkin's lymphoma (69). The two maximum tolerated doses
(MTDs) found in this phase I study gave peak plasma concentrations of 271 nM and 344 nM, the
second after antidiarrheal prophylaxis. The concentrations of FP needed to inhibit cyclin
dependent kinase function (200 to 400 nM) were safely achieved in this study. Despite both in
vitro and in vivo data showing that FP was cytostatic and cytotoxic in non-small cell lung
carcinoma cells, Shapiro and colleagues stopped a phase II study after only 20 of 45 patients
proj ected to be in the study were treated, as no responses were observed in these individuals (72).
This study also noted that a mean steady-state plasma concentration of 200+89.9nM was
achieved, which was well within the FP concentration range found to be effective in vitro.
Questions regarding dose and length of treatment have been the main focus of many
clinical trials involving FP. In addition to the traditional 72 hour infusion schedule, FP has also
been tested as a 24 hour continuous infusion given every two weeks and a 1 hour bolus
administered over a range of schedules. Flinn, et al. found that FP had no clinical activity in
patients with fludarabine refractory chronic lymphocytic leukemia (CLL) when given as a 24
hour infusion (76). A study from the same group compared FP activity in CLL when the agent
was administered as a 72 hour infusion to a 1 hour bolus and found that the 72 hour schedule did
not result in any patient responses; however, the bolus dose did result in slight clinical activity
(75). A separate phase I study using FP as a single agent in patients with advanced neoplasms
tested FP at varying 1 hour infusion doses over 5-days, 3-days and 1-day every 3 weeks (77).
During the trial, median peak total concentrations at the MTD of 1.7 CIM (range 1.3 to 4.2 CIM)
for 5-day administration, 3.2 CIM (range 1.7 to 4.8 CIM) for 3-day administration, and 3.9 CIM
(range 1.8 to 5.1 CIM) for 1-day administration were found. Twelve of the 55 patients studied had
stable disease for greater than or equal to three months with a median duration of six months
(range, three to eleven months). A similar study was conducted by the National Cancer Institute
of Canada using FP as a bolus infusion over 3 days in patients with untreated or relapsed mantle-
cell lymphoma (78). No complete responses were observed; however, 1 1% of patients had a
partial response and 71% had stable disease. Similar results for the 1 hour bolus have also been
reported in malignant melanoma and multiple myleoma (79, 80). The only study of FP in
pediatric patients also used this schedule and was performed by Whitlock, et al. in patients with
solid tumors (81). No responses were observed despite achieving mean peak plasma
concentrations of 3.71 and 9. 11 CIM after doses of 37.5 mg/m2 and 80 mg/m2 TOSpectively.
Shorter infusion schedules for FP as outlined above were pursued by clinicians with the
intention of increasing the peak plasma concentration of the agent. Early trials of FP given as a
72 hour infusion were based on drug activity data generated from in vitro studies of FP that were
performed in media supplemented with fetal bovine serum (FBS). Later studies showed that FP
is highly bound to human plasma proteins (68, 82). Approximately 92-95% of FP is human
plasma protein bound compared to 0-37% bound in FBS (82). This difference in protein binding
results in a decrease in the in vitro cytotoxicity of FP. Studies of primary CLL cells have shown
1 hour and 24 hour LCso values in FBS of 670 nM and 120 nM respectively, compared to 3,510
nM and 470 nM in human plasma or human serum (HS) (82). Based on these data and clinical
pharmacology data, a pivotal study of the use of FP as a short infusion was performed (83). FP
was given as a 30 minute bolus infusion followed by a 4 hour continuous infusion in patients
with CLL with the goal of achieving a peak plasma concentration of 1.5 CIM. Patients were
divided into cohorts, with the first receiving a 30 mg/m2 bolus dose followed by a 30 mg/m2
infusion. The second cohort received a 40 mg/m2 bolus followed by a 40 mg/m2 infuSion. The
maximum plasma FP concentrations achieved at these dose levels were 2,080 nM after 30
minutes and 960 nM after 4.5 hrs (84). A third cohort was given a 30 mg/m2 bolus followed by a
50 mg/m2 infuSion. These dosages achieved peak plasma levels of 1,950 nM after 30 minutes
and 1,540 nM after 4.5 hours This study had to be temporarily discontinued, as this schedule had
high clinical activity that resulted in tumor lysis so severe that one patient died (85). The group
implemented procedures for monitoring patients for tumor lysis syndrome and continued the
study which resulted in a 45% overall response rate in CLL patients.
Biological Correlates of Clinical Activity
Several clinical trials have included studies to determine if the same mechanisms of action
for FP observed in vitro could be achieved in vivo. Previous in vitro studies have shown that FP
inhibits CDK activity (14, 49-52, 86, 87), induces apoptosis (54, 55, 87-96), reduces the
transcription and/or expression of anti-apoptotic proteins Bcl-2 (B-cell leukemia/1ymphoma 2)
and Mcl-1 myeloidd cell leukemia sequence 1) (49, 87, 96-100), and binds to DNA (101). In a
phase I study by Thomas, et al. FP was tested as a single agent given as a 72 hour infusion every
two weeks in patients with a variety of tumor types (67). Peripheral blood lymphocytes were
collected during treatment and analyzed via flow cytometry for evidence of apoptosis or changes
in cell cycle kinetics. No evidence of changes in these measurements was found; however, the
authors noted that there were early signs of clinical activity.
During a phase I trial of FP combined with docetaxel in patients with metastatic breast
cancer, Tan and colleagues examined Ki67, p53, and phosphorylated pRb in paired patient tumor
and buccal mucosa samples (102). Ki67 was used as an indication of cell proliferation and
phosphorylated pRb was used as an indirect measurement of CDK activity. The buccal mucosa
biopsies of ten of the eleven patients enrolled in the study showed increased nuclear expression
of p53 and decreased expression of phosphorylated pRb after treatment with FP as a single agent.
The authors postulated that the increase in p53 expression could have been due to the ability of
FP to bind to DNA (101) or the ability of FP to reduce transcription or down regulate MDM-2,
based on the activity of other CDK inhibitors (50, 103). Six paired tumor samples showed no
changes in p53, Ki67, or phosphorylated pRb. The authors concluded that the biological effect of
FP was achieved in the buccal mucosa; however, the treatments tested were not feasible due to
dose limiting toxicities.
A similar phase I study used FP in combination with cisplatin or carboplatin in patients
with advanced tumors (104). Peripheral blood mononuclear cells were analyzed before and after
FP treatment and found to have increased p53 expression and increased phosphorylated STAT3
(signal transducer and activator of transcription 3) levels. Treatment had no effect on cyclin DI,
phosphorylated RNA polymerase II (indicator of CDK activity), or Mcl-1. The authors felt that
there was a possibility that the increased p53 and pSTAT3 levels were due binding of FP to
DNA and that the lack of an effect by FP on cyclin Dl expression, the phosphorylation of RNA
polymerase II, or Mcl-1 expression might have been due to the inability of FP to inhibit P-TEFb
(CDK 9) in vivo. There was a lack of clinical activity observed during the trial and it was further
postulated that the lack of an effect on Mcl-1 expression by FP could have been an explanation
for this low clinical response. Alternatively, the authors could not definitively say that the same
effects that were observed in non-cycling peripheral blood cells could be observed in tumor cells,
as these were not tested.
Finally, a phase II trial of relapsed or refractory melanoma patients had disappointing
clinical results that the authors partially attributed to a lack of biological activity in vivo (80).
Western blot analyses very similar to those performed in the studies cited above found that only
one patient out of eight tested had the expected results of decreased Mcl-1 with increased p53
expression and increased expression of phosphorylated STAT3 as a result of FP treatment. Two
additional patients had decreased Mcl-1 in combination with lower levels of p53 and
phosphorylated STAT3. It was noted that the former patient progressed after one cycle of FP
All of the trials cited above used FP as either a 1, 24, or 72 hour infusion. This is contrary
to the most recent use of FP as a 30 minute bolus followed by a 4 hour infusion found to be
highly effective in CLL (85). Most of the in vitro studies to which the above authors were
attempting to correlate biological activity in vivo were performed in FBS. As previously cited,
the newer infusion schedule takes the high percentage of protein binding of FP that occurs in HS
into account by achieving a higher plasma FP concentration in a shorter time than that achieved
in previous trials. Studies have been conducted in vitro in CLL cells grown in the presence of HS
that show that FP is biologically active under these conditions when used at concentrations
higher than those previously utilized in FB S (100).
Clinical Trials of Paclitaxel (PAC) and Combining Flavopiridol with Paclitaxel
With the exception of recent studies in CLL, FP has had limited efficacy in clinical trials
when used as a single agent. However, as outlined previously, there have been promising
preclinical results showing synergy between PAC and FP. Early clinical trials have also tested
FP in combination with PAC in cancer types other than ALL.
PAC has been found to be effective as a single agent in the treatment of several types of
cancer including breast, ovarian, and lung cancer, and melanoma (105, 106). PAC also has
considerable in vitro activity against ALL (107) and has been tested in both adults (15, 108) and
children (16) with leukemia. Studies in adults used 3 doses of 100 minutes each repeated every
three weeks (15) and a 24 hour infusion repeated every 3-4 weeks (108). A trial in pediatric
leukemia patients used a 24 hour PAC infusion; achieving peak plasma concentrations of
approximately 1,000 nM. Unfortunately, these studies did not report any substantial clinical
responses. Minimal responses have been reported using PAC as a single agent in children with
solid tumors (109). This trial used varying doses of PAC as a 24 hour infusion repeated every
three weeks. Peak plasma concentrations were dose-dependent and ranged from approximately
1,000 nM to 7,000 nM. Two out of 31 total patients treated reported significant toxicity. PAC is
89-98% bound to plasma proteins in vivo (110). Perhaps similar to FP, a shorter infusion
schedule with the goal of obtaining a high peak PAC plasma concentration might prove
beneficial in the treatment of ALL.
Promising results have been achieved when FP was combined with PAC in patients with a
variety of solid tumor types (111). Clinical responses were observed in patients with esophagus,
lung and prostate cancer, some of whom had progressed on PAC single agent treatment. It
should be noted that the agents were given in the specific sequence of PAC followed by FP
Preclinical in vitro studies or clinical studies using FP have never been conducted in
relation to childhood ALL. Relapsed ALL patients become increasingly refractory to agents
typically used in the treatment of ALL, thus creating a need to investigate new drugs. I examined
FP because of the high frequency of pl5/pl6 abnormalities and altered expression of other cell
cycle regulatory proteins in relapsed ALL. Results from preclinical studies suggest that FP can
act similarly to these molecules in that it inhibits CDK activity and induces cell cycle arrest. FP
can also induce apoptosis in human cancer cells. Based on these findings, I performed in vitro
studies of FP at different times of exposure to mimic prolonged infusion and newer bolus
schedules. During these studies I examined the cell death and alterations in cell cycle progression
induced by FP.
Clinical responses measured during trials of FP as a single agent have shown that it has
limited efficacy when used in a 72-, 24- or 1 hour dosing schedule. Recent data from studies in
CLL have suggested that prolonged FP infusions have a low overall response rate due to failure
to achieve an effective free FP concentration as a result of secondary protein binding in human
plasma. A shorter infusion of a higher dose of FP was found to be very promising. In order to
model this new infusion strategy, this proj ect includes experiments using cultures that were
grown in medium supplemented with human serum in place of fetal bovine serum. A higher
concentration of FP is also administered over a shorter period of time when compared to
This proj ect has not only served as a means to determine the potential efficacy of FP when
used as a single agent in ALL cell lines, but has also served as a study to determine the effects of
combining FP with PAC. In vitro studies and clinical trials in patients with types of cancer other
than ALL have shown that FP can enhance the activity of PAC. In some cases using FP in
combination with PAC can have a synergistic effect on in vitro treatment. This enhancement is
dependent on the sequence in which the drugs are administered. In the case of FP combination
treatment with PAC, this sequence dependence has been reported to be due to the ability of PAC
to activate CDK 1 activity coupled to the inhibitory action of FP against this same CDK (56).
Because PAC is not typically used in the treatment of ALL, I first established that ALL cell lines
were sensitive to PAC treatment. I also tested whether FP enhances the efficacy of PAC in vitro
and if this enhancement was dependent on the sequence in which the two drugs were
administered. This drug combination could offer a treatment regimen to children with relapsed
ALL that would utilize two agents to which the patients will not have been previously exposed.
In the future, data from this proj ect could be used to develop a clinical trial which would
utilize either FP as a single agent or PAC in combination with FP, both in the schedule that I
have found to be most efficacious. This proj ect also provides data to indicate the mechanism of
action behind the efficacy of FP in ALL in order to provide a biological basis for the clinical
Induction: 1 month; Results in complete remission in 99% of patients
Treatments can include the following:
--anthracycline for high-risk patients (daunorubicin)
Intrathecal therapy-2 doses in the first month since diagnosis and 4-6 doses during the next 1 or 2
months. Agents utilized include
--hydrocortisone and cytosine arabinoside (ara-C) added for high-risk patients
Patients with high white blood cell (WBC) count (high risk) or WBC in the cerebral spinal fluid
receive radiation to the brain and possibly the spinal cord. May also administer high dose
intrathecal methotrexate with leucovorin to treat side effects.
Consolidation: 4-8 months; Reduces the remaining number of leukemic blasts
Standard risk patients receive
--6-mercaptopurine or 6-thioguanine
--optional: vincristine and prednisone
High risk patients receive:
--L-asparaginase, doxorubicin, etoposide, cyclophosphamide, ara-C and dexamethasone
substituted for prednisone (possibly two rounds)
Maintenance: 1.5 to 2.5 yrs
--vincristine; prednisone or dexamethasone (every 4-8 weeks)
Figure 1-1. Treatment of Childhood Acute Lymphoblastic Leukemia (ALL): 2-3 yrs. total (3)
\ + Cdo2
Figure 1-2. Cyclin dependent kinase (CDK) inhibitors function in the transition from G1 (Gap 1)
to S (DNA synthesis) phase of the cell cycle. pl5 and pl6 inhibit CDK 4 and CDK 6,
as do p21 and p27. The restriction point of the cell cycle is located at the transition
from Go to G1 and marks the point at which the cell is no longer sensitive to external
agents such as growth factors or a drug. Pursuing permission from American
Association for Cancer Research: [Clinical Cancer Research] Shah MA, Schwartz
GK. Cell cycle mediated drug resistance: an emerging concept in cancer therapy.
Clinical Cancer Research 2001; 7:2168-2181., copyright 2001, originally published at
Figure 1, p. 2169.
Fiue -.pl orsi cner ih ~ t eult teG-Staniin.p6 niit h
Figur genes1 inolved in prgesonetwt ~ th rogugh the G 1-S transition. Rpr6intedbyt p heriso
from Macmillan Publishers Ltd: [Nature Reviews Cancer] Classon M, Harlow E. The
retinoblastoma tumour suppressor in development and cancer. Nature Reviews
Cancer 2002; 2:910-917, copyright 2002, originally published as Figure 1, p.911.
Figure 1-4. Flavopiridol is a pan-CDK inhibitor. FP inhibits CDK 4, CDK 6 and CDK 2, thus
inducing a G1-S arrest. FP can also inhibit CDK 1 (cdc2) and induce G2-M arrest
Reprinted by permission from Meniscus Ltd: [Horizons in Cancer Therapeutics: From
Bench to Bedside] Shah MA, Schwartz GK. Cell cycle modulation: an emerging
target for cancer therapy. Horizons in Cancer Therapeutics: From Bench to Bedside
2004; 4(3):3-21., copyright 2004, originally published as Figure 5, p.7.
FLAVOPIRIDOL DISPLAYS PRECLINICAL ACTIVITY IN ACUTE LYMPHOBLASTIC
One of the most commonly used methods of evaluating the potential efficacy of
chemotherapeutic agents prior to their use in patients is to determine the ability of the agent to
prevent growth of cancer cells in vitro. Results from methyl-thiazol-tetrazolium (MTT) assays
have shown a correlation between in vitro sensitivity of leukemia cells taken from peripheral
blood and bone marrow of patients and clinical outcome (1 12-1 19). Hongo et al. (1 12) found that
using agents determined to be efficacious in MTT assays resulted in better outcome for patients
with ALL or acute nonlymphoblastic leukemia when compared with patients whose treatment
regimens were determined via conventional methods of the time. Approximately 82% (n=1 1) of
patients treated with agents determined to be efficacious in MTT assays had complete or partial
remissions as compared with 40% (n=15) of patients treated by conventional means. I have
chosen to use a modified MTT assay as my initial means of determining the sensitivity of ALL
cell lines to FP. I have expanded my studies by testing the ability of FP to induce apoptosis and
cell cycle arrest in ALL cell lines, as cell proliferation assays merely measure an increase or
decrease in viable cell number.
The mechanism of action of a chemotherapeutic agent is an integral part of determining
how the agent will be used as well as what side effects might occur as a result of its use.
Knowing the mechanism of action can also help to target cancer cells without affecting non-
cancerous tissue. The ultimate fate of a cell, ie. cell death or senescence as a result of cell cycle
arrest can have an effect on the progression of the cancer. Cells which senesce might have the
ability to secrete signaling molecules which promote the growth of other cancer cells in the
surrounding area (120). For some researchers, this possibility makes apoptosis a preferred
mechanism of action for anti-neoplastic agents. I have determined that FP has the ability to
reduce ALL cell proliferation via a modified MTT assay and have further investigated the ability
of FP to induce cell cycle arrest and apoptosis. Through Western blot analysis I have observed a
correlation between the concentration dependent effects of FP on cell proliferation and the
endogenous phosphorylation of pRb. Correlating these mechanisms with drug concentration and
the effect that FP has on cell cycle regulatory elements will serve as important information when
deciding the use of FP as a single agent or in combination with other agents in the treatment of
In Vitro Drug Sensitivity Testing
In vitro drug sensitivity assays were modeled after those described originally by Pieters
and colleagues (113). Cell lines were grown in RPMI 1640 (Mediatech, Inc. Herndon, VA) with
10% fetal bovine serum (FBS, Mediatech) or 10% human AB serum (HS, Mediatech) and 1%
penicillin/streptomycin (Mediatech) at 370C with 5% CO2. Nalm-6 (B-precursor ALL) was
originated by Minowada, et al. (121). Molt-4 and Jurkat (both T-cell ALL) were obtained from
the American Type Culture Collection (ATCC, Rockville, MD). RCH-ACV is a B-precursor
ALL cell line provided by Dr. Seshadri (122). K562 (ATCC) is a chronic myelogenous leukemia
(CML) cell line commonly used for in vitro testing in the NCI 60 cell line test set and was
included in this study as a control. Exponentially growing cell cultures were plated in flat
bottomed 96-well dishes in 100 CIL of cell culture medium with a dilution of drug in vehicle
appropriate for each agent. Vehicles included ethanol for dexamethasone (Sigma, St. Louis,
MO), water for doxorubicin (Sigma), and dimethyl sulfoxide (DMSO) for FP (Sanofi-Aventis,
Bridgewater, NJ). All were further diluted in RPMI 1640. Samples for each drug concentration
were tested in quadruplicate for each experiment. Also tested in parallel were appropriate
dilutions of vehicle without drug, which functioned as an untreated control for calculation of
ICso. For the purpose of my study IC5o was defined as the concentration of drug at which cell
proliferation was inhibited by 50% as compared to an untreated control. Cell lines were plated at
a concentration of 1X105 cells/mL in 100 CIL for RCH-ACV, Molt-4, and Jurkat. Nalm-6 and
K562 were plated at a concentration of 5X104 CellS/mL in 100 CL. Different cell concentrations
were used in order to maintain the cultures in log phase growth throughout the period of the
experiments. Cell lines were incubated with drug for 96 hours, at which time WST-1 (4-[3-(4-
lodophenyl)-2-(4-nitrophenyl)-2H-5-tetrazoi]1,3-benzene disulfonate) reagent (Roche,
Indianapolis, IN) was directly added to each well according to manufacturer' s instructions.
WST-1 is a modified version of the MTT (methyl-thiazol-tetrazolium) reagent. Absorbance was
measured on a Molecular Devices (Sunnyvale, CA) Vmax kinetic microplate reader at 450nm,
subtracting a reference wavelength of 650nm. ICso was calculated by plotting leukemic cell
survival (LCS) against drug concentration. The drug concentration at which LCS equaled 50%
was defined as the ICso. LCS was calculated as follows:
X 100%. (2-1)
Results are the mean of at least two independent experiments.
Western Blot Analyses
ALL cell lines were tested for pl6 protein expression with HeLa cells used as a positive
control. HeLa extract was diluted into extract from Nalm-6 (previously found to be pl6 deleted
via Southern blot (40)) in order to simulate a low level or variable amount of pl6 protein
express si on. Protein extracts were prepared using Radi o-Immunoprecipitati on As say (RIPA)
Buffer (Sigma) with sodium orthovanadate (Santa Cruz, Santa Cruz, CA), phenylmethylsulfonyl
fluoride (PMSF, Santa Cruz), and a protease inhibitor cocktail (Sigma). Fifty micrograms of
protein was loaded onto a 4-20% gradient polyacrylimide gel (Biorad, Hercules, CA) and
subjected to sodium dodecyl sulfate-polyacrylimide gel electrophoresis (SDS-PAGE). Proteins
were transferred to a 0.2 CIM pore nitrocellulose membrane (Biorad). After transfer, the
membrane was blocked with 5% dry non-fat milk in TBS with 0.1% Tween-20 (TBS-T) for one
hour with gentle agitation. Following blocking, the membrane was incubated at room
temperature (RT) with mouse monoclonal IgG1 antibody to full length pl6 protein (50.1, catalog
number sc-9968, Santa Cruz) at a dilution of 1:375 in 5% non-fat milk for one hour. The
membrane was then washed 3 X 15 minutes in TB S-T and incubated for one hour in goat anti-
mouse IgG secondary antibody conjugated with horseradish peroxidase in 5% milk.
Retinoblastoma protein phosphorylated on serine 795 (pp-Rbser795) and retinoblastoma protein
phosphorylated on series 807 and 811 (pp-Rb""ser/sovi) were resolved via SDS-PAGE after
loading 25 Clg protein lysate. The proteins were transferred to a nitrocellulose membrane which
was blocked as described and incubated with rabbit polyclonal antibodies to pp-Rbser795 and pp-
Rbserso7isll (product numbers 9301 and 9308, Cell Signaling Technology, Danvers, MA) 1:1000
in 5% bovine serum albumin (B SA) overnight and treated as previously described. Detection of
total p-Rb expression was performed using mouse monoclonal IgG1 antibody (IF8, catalog
number sc-102, Santa Cruz) 1:200 in 1% BSA after blocking for 1 hour at RT with 1% BSA.
Detection of actin (isoform non-specific) (C2, catalog number sc-8432, Santa Cruz) was used as
a loading control on all membranes. After washing 3 X 15 minutes, proteins were visualized on
radiographic film via ECL or ECL Plus reagent (Amersham, Piscataway, NJ). Results from
Western analyses were obtained from at least two separate experiments.
Measurement of Cell Death
Two methods were utilized to detect cell death and/or apoptosis in drug treated samples.
Samples were stained with Annexin V (Pharmingen, San Diego, CA) and Propidium Iodide (PI)
(Roche) as recommended by Pharmingen. Direct TUNEL (terminal deoxynucleoti dyltransferase
dUTP nick end labeling) staining was also performed according to manufacturer' s instructions
(Apo-Direct Kit, Pharmingen). Samples were analyzed via flow cytometry using a Becton
Dickinson (San Jose, CA) FACSort flow cytometer. Percentages of cell death/apoptosis were
measured by obtaining the sum of the upper right and lower right quadrants of the scatterplot
generated by analysis of samples stained with AnnexinV/PI. Percentages of apoptotic cells were
measured via TUNEL by obtaining the percentage of the cell population staining positive for
FITC-dUTP. Results were obtained from at least three independent experiments.
Cell Cycle Analysis
To determine cell cycle kinetics as a result of FP treatment, cell lines were analyzed for
DNA content using PI staining and flow cytometric analysis essentially as described by Ormerod
(123). Data were generated using ModFit LT for Mac version 3.1 software (Verity Software
House, Topsham, ME). Results are representative of at least three independent experiments.
ALL Cell Lines Used for in Vitro Testing Lack pl6 Protein Expression
I determined pl6 protein expression in the cell lines used for in vitro drug sensitivity
testing via Western blot. Nalm-6, REH, Molt-4, and Jurkat have been reported previously to have
homozygous pl6 deletions (33, 40, 124, 125), while the Hunger laboratory has found RCH-ACV
to have intact pl6 via Southern blot (126). HeLa cells were used as a positive control. HeLa
lysate was diluted into Nalm-6 (pl6 deleted) lysate in order to simulate 10% and 1% pl6
expression. I found that none of the ALL cell lines tested expressed a detectable amount of pl6
protein, including RCH-ACV (Figure 2-la).
In Vitro Drug Sensitivity in ALL Cell Lines
I determined the sensitivity (IC5o) of Nalm-6, Molt-4, Jurkat, RCH-ACV and K562 to a
continuous 96 hour exposure to dexamethasone (Dex) and doxorubicin (Dox), two agents
commonly used in the treatment of childhood ALL, and FP. Each of the four ALL cell lines and
K562 were highly resistant to dexamethasone and variably sensitive to doxorubicin (Figure 2-
lb). Each of the cell lines tested showed sensitivity to FP, with ICSOs ranging from 99~111.5 nM
in Molt-4 to 312.51159.1 nM in K562. These values are similar to concentrations achieved in
vivo in phase I/II trials of FP administered both as a 1 hour and a 72 hour infusion (67-69, 72, 77,
FP Induces Apoptosis in ALL Cell Lines
WST-1 assays measure the numbers of viable cells present following exposure to drug.
Decreased numbers of viable cells could be due to apoptosis, decreased cell proliferation, or
both. I performed Annexin V/PI staining and subsequent flow cytometric analysis on cell lines
which were exposed to drug for 72 hours to determine whether FP induced apoptosis. First, I
compared the cell death induced by FP and Dox in Nalm-6 and RCH-ACV at concentrations
approximating the ICso of each drug (FP: 150nM; Dox: 10ng/mL). At these concentrations, FP
induced a substantially lower percentage of cell death than Dox in both Nalm-6 and RCH-ACV
(Figure 2-2a). I then examined apoptosis induced by 300 nM FP and observed much higher rates
of apoptotic cell death, 93% and 83% in Nalm-6 and RCH-ACV respectively. I expanded these
studies and confirmed that FP induces apoptosis by performing parallel Annexin V/PI and
TUNEL analysis in Nalm-6, RCH-ACV, Molt-4 and Jurkat following 72 hours exposure to FP at
various concentrations (Figure 2-2b and 2-2c). For each cell line tested, modest levels (<25%) of
apoptosis were induced by 72 hours exposure to 150 nM FP and high levels (>80%) were
observed following exposure to 300 nM FP. Similar results were seen via Annexin V/PI and
TUNEL assays, confirming the apoptotic nature of the observed cell death. Taken together, these
data establish that FP treatment induces modest apoptotic cell death in B-precursor and T-cell
ALL lines at lower concentrations and is a potent inducer of apoptosis at higher concentrations.
FP Induces Cell Cycle Arrest in ALL Cell Lines which Correlates with Effects on pp-Rb
My results demonstrated that the inhibition of cell proliferation observed with WST-1
assays can only partially be attributed to apoptosis when cell lines are treated with 150 nM FP;
however, 300 nM FP fully induces apoptosis. I hypothesized that the remaining inhibition at 150
nM FP could be due to cell cycle arrest. In order to test this hypothesis I performed cell cycle
analysis of samples treated with 0, 50, 150 and 300 nM FP for 24 and 48 hours. Treatment with
50 nM FP did not induce arrest when compared to an untreated control in RCH-ACV (Figure 2-
3a) and Nalm-6 (Figure 2-4). I observed a transient G1-S arrest after 150 nM treatment that was
present at 24 hours, but resolved by 48 hours. Sustained G1-S and G2-M arrest were induced after
treatment with 300 nM FP; which was apparent at 24 hours and more pronounced at 48 hours. In
order to address the possibility that the transient nature of the arrest induced by 150 nM
treatment was due loss of drug potency over time, I performed experiments in which treated cells
were exposed to FP for 24 hours, at which time the growth medium and drug were replaced
(Figure 2-3b). Cultures were allowed to incubate in parallel with those established 24 hours prior
for an additional 24 hours. Following incubation all cultures were evaluated for cell cycle
kinetics. Data showed similar cell cycle phase distributions between cultures treated with FP for
48 hours and those which had medium and drug replaced after 24 hours.
To investigate the mechanism of the observed cell cycle arrest, I determined expression of
total pRb and specific phospho-pRb forms (pp-Rbser795 and pp-Rbserso7/sll) in parallel to cell cycle
analysis (Figure 2-3c). Phosphorylation of pRb on ser 795 has been largely linked to CDK 4
activity and regulation of the G1-S transition by pRb (128). Phosphorylation of ser 807/811 has
also been linked to CDK 4 activity (129). Treatment of ALL cell lines with 300 nM FP resulted
in a sustained decrease in pp-Rbser795 and pp-Rbserso7/sll protein expression, which correlates with
the G1-S arrest observed at this drug concentration. Total pRb protein levels indicate stable levels
of total protein and a decrease in the expression of the hyperphosphorylated form of pRb (upper
band) that is dependent on drug concentration and time of exposure to FP. Treatment with a low
level of FP (50 nM) did not result in a decrease in the phosphorylation of pRb; however,
treatment with 150 nM and 300 nM FP did result in a decrease in the expression of the
phosphorylated form of pRb after 48 hours treatment.
Apoptotic Effects of FP in Human Serum
Others have shown that FP is 92-95% protein bound in human plasma and that there is a
decrease in the activity of FP in CLL cells when grown in human plasma or serum vs. FBS (82).
In order to determine if supplementation with human serum (HS) would have a similar effect on
FP efficacy in ALL cell lines, I tested the ability of FP to induce apoptosis in Nalm-6, RCH-
ACV, Jurkat, and Molt-4 grown in medium supplemented with FBS and compared this to cell
death of cell lines grown in HS. In order to mimic the peak drug levels that occur with FP
infusion schedules with high activity against CLL cells (30 minute bolus followed by a 4 hour
infusion), I measured cell death at 4.5 hrs (Figure 2-5a). For measurement of cell death at a sub-
peak level, I analyzed after 24 hours drug exposure (Figure 2-5b). Varying concentrations of FP
were used in keeping with those found to be achieved in CLL patients treated with the above
schedule at approximately these time points (85). After 4.5 hours, a modest percentage of cell
death is induced in Nalm-6 and RCH-ACV (15-20% and 10%, respectively). In contrast,
approximately 55-60% cell death is induced in Jurkat and Molt-4 at 4.5 hours. When comparing
the cell death induced in cultures supplemented with FB S to that of HS, I show that the
differences in the percentage of apoptosis induced in media containing FB S vs. HS are not
substantial for Nalm-6, RCH-ACV, and Molt-4; however, more cell death was induced by FP in
Jurkat cells grown in media containing FBS vs. HS. The percentage of apoptosis observed after
24 hours FP treatment was higher than that at 4.5 hours in all four cell lines tested. When
comparing the cell death achieved in cultures supplemented with FBS to that of HS at the 24
hour timepoint, I observed substantial differences between media containing FB S and HS for
RCH-ACV at all FP concentrations tested and at the lowest FP concentration (300 nM) in Nalm-
6 and Jurkat. My results show no differences between FBS and HS for Molt-4.
The poor outcome of children with ALL who experience a bone marrow relapse despite
intensive chemotherapy and/or stem cell transplant, makes it imperative to identify agents with
novel mechanisms of action. Based on the frequent acquisition of pl6 deletions at relapse (27)
and alterations in expression of genes that encode for cell cycle regulatory proteins at relapse
(18), I performed preclinical studies of FP in ALL cell lines. My results support the use of these
cell lines as a model of relapsed ALL in that none of the lines expressed pl6 protein and all were
resistant to dexamethasone and variably sensitive to doxorubicin, two agents commonly used in
the treatment of ALL and to which relapsed patients frequently become resistant (130). I report
that childhood ALL cell lines are sensitive to FP, providing a biological rationale for clinical
trials of FP in relapsed ALL.
I found that FP was active in a concentration dependent manner against ALL cell lines. At
a concentration approximating the ICso determined in WST-1 assays (150 nM), FP induced
transient cell cycle arrest with a limited percentage of apoptosis. At approximately twice this
concentration, FP was a potent inducer of cell death. This information provides a dual
mechanistic explanation for the decrease in viable cell number that I observed in WST-1 assays.
CDKs phosphorylate pRb and therefore regulate its ability to sequester transcription
factors involved in cell proliferation during the G1-S phase transition. Phosphorylation of pRb on
approximately 16 different serine and/or threonine residues can be attributed to the activity of
specific CDKs (13 1). My Western blot analysis shows that expression of pp-Rbser795 and pp-
Rbserso7isll is reduced after 24 and 48 hours treatment with 300nM FP. These data correlate with
the sustained G1-S arrest observed after 300 nM FP treatment and show that FP treatment results
in a reduction of endogenous CDK activity. Evaluation of total pRb protein expression showed
consistent expression across all treatment levels, indicating that the decrease in phospho-specific
pRb was not due to loss of total pRb. Treatment with 150 and 300 nM FP resulted in a decrease
in the hyperphosphorylated form of total protein after 48 hours drug exposure. This decrease
further illustrates the reduction in CDK activity as a result of FP treatment in ALL cell lines.
This also suggests a mechanism for the transient G1-S arrest observed after 150 nM FP treatment
and the G2-M arrest I observed after 300 nM treatment. The apoptosis and cell cycle arrest
induced by FP treatment in ALL cell lines provide two potential modes of treatment in ALL. FP
could be used as a single agent to induce a cytotoxic effect or be utilized in combination with
another chemotherapeutic agent that would complement the ability of FP to induce cell cycle
arrest. My observation that FP inhibits CDK activity and induces cell cycle arrest in ALL cells
suggests that there may be schedule dependent differences in activity if FP is combined with
other agents, particularly those with cell cycle specific activity.
Initial phase I/II trials of FP in many human cancers were disappointing. While in vitro
studies showed that FP was efficaceous against a diverse variety of tumors at concentrations of
100-300 nM, no significant clinical activity was seen with prolonged infusion regimens, despite
achievement of similar FP concentrations in vivo (69-73). Shinn and colleagues hypothesized
that the disparity between in vitro and in vivo activity might be due to differences in binding of
FP to plasma proteins present in FBS used in vitro vs. those present in human plasma (82). They
confirmed that for CLL cells the FP ICso was significantly (approximately 10-fold) higher in
vitro when experiments were performed in human plasma rather than bovine serum. This
suggested that infusion schedules that produced high peak FP concentrations might be more
effective than prolonged lower dose infusion schedules. Early phase clinical trials confirmed this
hypothesis in CLL using a 30 minute bolus dose followed by a 4 hour infusion (85). Expanded
studies are ongoing. Based on these observations, I also examined the relative efficacy of FP in
vitro in experiments using human serum compared to bovine serum. In my experiments I
observed fewer differences between ALL cell line sensitivity to FP in HS vs. FBS than observed
by Shinn and colleagues. Importantly, despite some differences among the cell lines tested,
substantial amounts of apoptosis were induced by FP in all cell lines under conditions that are
very similar to what might be observed clinically, particularly at the 1000 nM and 2000 nM
levels at 4.5 hours and 300 nM level at 24 hours. These data suggest that the newer FP infusion
schedules found to be very promising in CLL should be utilized to test FP against relapsed ALL.
Dmianerlhsluone Doxorubida Flnlopirido~l inlM
RCH-ACV >10 1318.6 131.3+33.8
Naint-6 >10 10.612.9 142.5246.0
Muolt-4l >10 9.7+3.8 89911.5
Jurkat >10 771.3142.1 300135.4
IEW2 >10 39.2t28.7 312.50 59.1
acti~ -C ~L
p15 ~ ~ I--
6 78 9
Figure 2-1. Fifty percent inhibitory concentration (ICso) determinations via WST-1 in cell lines
that lack pl6 protein expression. A) Western blot for pl6 protein expression; Lane 1)
100% HeLa (positive control), 2) empty lane, 3)10% HeLa, 4) 1% HeLa, 5) Nalm-6,
6) RCH-ACV, 7) REH, 8) Molt-4, 9) Jurkat B) IC50 values+1SD for Dex, Dox and
FP after 96 hours drug exposure measured via WST-1 cell proliferation assays.
measured via measured via
Untreated 2.47 0.51
150 nM FP 19.72 22 22
300 nM FP 81.45 89.02
Untmeated I < 0.58
150 nM FP 23 46 22.33
300 nM FP 8 16 80,04
Untr~ence i.91 1 81
300 nMF 905116 51 0
Untrated 4.948 0.541
150 nM FP 11.12 3.07
300 nM FP 79.28 82.03
Figure 2-2. Flavopiridol induces apoptosis in ALL cell lines in a concentration dependent
manner. A) Scatter plots from flow cytometric analysis of Annexin V/PI stained
samples of Nalm-6 and RCH-ACV comparing cell death induced by 72 hours
exposure to 150 nM and 300 nM FP to the cell death induced by 72 hours exposure to
10 ng/mL Dox, an agent known to induce apoptosis. Percentage to right of each plot
represents the sum of the lower right quadrant (cells in the early stage of apoptosis)
and upper right quadrant (late stage apoptosis) of each plot B) Scatterplots generated
using two different staining methods after 72 hours continuous exposure to 300 nM
FP show similar results; AnnexinV/PI (left) and TUNEL staining (right) C)
Comparison of results from AnnexinV/PI to TUNEL in cell lines treated with 0, 150,
and 300 nM FP respectively.
A rr.lm-a RcH-ncv
vhi*rar~ slftraa wa~o~a~ 'P~mD~
renurr ~arruw lur~rr ~oc~rr
''it~J n~n r~l ,, ~E~ ,,
Nth-6 3MI rM FP REH-nn, 3W *n FP
..,,, ifl ,,
~olr-r 3W nl~ FP Illrtiat 300 nbl FP
A. Untre.aed 50 nN FP 150 nMl FP 3001 aMF
14 has*~ j 850 4.6 a5.6% 41
Untreated 50 nN FP 150 nN FP 200 mM FP
48du to.Drg Rpl re
D M IM 3@ 0 2 150 3MrMF
24 rs, 40
Figure 2-3. Flavopridol induces Gi-SandG- Gp -ioi) reti RHAVwt
reucd hsporltin fp~ A el cce at ftr 4an 4 ous xosret
0,5,10 n 0 n P ratmen wih5 MF hsn fet nclyl
kinetics when compared to untrureatead cnrl aaso rnin Sars fe
24 our exosue t 10 n FPanda sstine GiS ares ater24 nd 8 hur
treamen wih 30 nMFP.Als shwn s a ustine G2M arestfolowig 30 n
Figre2-. lcomparable tosampes without adrug2 reaplacement.C) Wrestern blot showing
seustied decphrelasei xrsion of p p-Rbsel yer9 dandp-beroai after a 4 or exposure to
0,5,10ad300 nM FP. TotlpR xressin emiscntnt with 5 F as doeecrs in thel ye
hyperhous ephosryaed for (uppe band)assand 1Sars after 150 and 300 nMretmnt
5 11strpated S LnLifR 15 L~r hif2
Figre -4.Flvopridl idues raniet.19 Gi-S 1 ares in Nal-6.Cl ccedtaatr24ad4
hour exosue t 0,50, and 50 M F. Tramn ih5 M Phsn feto
cell ccle knetic when ompard to ntreatd conrol. ataso G- res fe
24 ous retmntwih 50nM Cllcylekietcsreur t bsein ate 4 hur
0g 300 10 29 30 100 2
0 300 1000 2000I 0 300 1000 2000
orHS DA) More24n c rrelldeth a i ndce in Jurat cells o~ t ~reatdfr 45husandi I
suplm ene wihFSta hs n S oeeteclldahidcdih
remaining_ cel lie a proiaeyeua ewe h totpso sr.B fe
24! hor ramn fRHAV oecl eahwsidcdb Pteteta l
cocetrtin tete incll uplmnedwt F Sthntos uplmnedwt
HS Difeene in celdahbtentetotps fsr eeas bevdi
Nlm- n uktafe ramn wt 0 MF.Nodfeecsbewe eawr
obsre in Molt-4.I~
Cel Death Post-4.5 hrs. Treatment in HS
PRECLINICAL STUDIES OF FLAVOPIRIDOL COMBINED WITH PACLITAXEL IN
ACUTE LYMPHOBLASTIC LEUKEMIA
Clinical trials of FP involving cancer types other than ALL have shown that FP has limited
efficacy when used as a single agent. As outlined in Chapter 1, several in vitro studies have
shown that the efficacy of traditional chemotherapy agents can be increased when used in
combination with FP. One such traditional agent is paclitaxel (PAC). Few clinical trials
involving FP combination therapy have been performed; however, promising results have been
obtained in a variety of solid tumor patients using FP in combination with PAC (111). PAC has
shown in vitro toxicity in leukemia cell lines; however, has had limited efficacy in clinical trials
in children and adults with leukemia (15, 16). PAC and FP represent two drugs to which ALL
patients will not have been previously exposed. This fact as well as in vitro data showing
synergy between FP and PAC in other cell types lead me to question if PAC/FP combination
therapy could hold promise in the treatment of ALL.
It has been previously found that the interaction between PAC and FP is dependent on the
sequence in which the two drugs are administered in vitro. Combination therapy is most
efficacious when PAC precedes FP in the treatment sequence (PAC+FP), as opposed to the
reverse or concurrent therapy (56, 60). I have confirmed these Eindings in ALL cell lines as well
as determined optimal treatment duration for each agent prior to testing combination therapy. In
an effort to maintain the clinical relevance of my findings I have also taken the currently
accepted in vivo infusion schedule for each drug into account when designing my experiments.
The recommended schedule for PAC administration is either 3 hour or 24 hour infusion (110). I
have tested 6 and 24 hours exposure to PAC. Early trials involving FP used a 72 hour continuous
infusion schedule. My experiments reflect this, as in experiments in which PAC was combined
with FP, cell lines were exposed to FP for 72 hours. Later studies by others have shown that FP
is highly protein bound and that supplementing cell culture medium with human serum (HS) in
place of fetal bovine serum (FB S) decreases the sensitivity of CLL cells to FP (82). In order to
address this I have conducted experiments in media supplemented with both FBS and HS.
ALL cell lines were obtained and cultured as described previously (132). PAC (Sigma, St.
Louis, MO) was dissolved in dimethyl sulfoxide (DMSO) and freshly diluted in RPMI 1640
prior to each experiment. FP (Sanofi-Aventis, Bridgewater, NJ) was dissolved in DMSO and
further diluted in RPMI 1640 no more than 30 days prior to each experiment.
Single Agent Inz Vitro Sensitivity Assays
Nalm-6 and RCH-ACV were exposed to 0-300 nM FP in RPMI 1640 with 10% fetal
bovine serum (FBS; Mediatech, Inc. Herndon, VA) continuously for 72 hours. Cell death was
measured every 24 hours via flow cytometric analysis of Annexin V (Pharmingen, San Diego,
CA)/Propidium Iodide (PI, Roche, Indianapolis, IN) as described previously (132). Treatment
duration and sensitivity to PAC were determined by exposing Nalm-6 and RCH-ACV to 0-100
nM PAC for 6 hours and 24 hours in parallel followed by cell death measurements every 24
hours for a total of 72 hrs (Figure 3-1). In a separate experiment, Nalm-6 was exposed to 0-
1,000 nM PAC in RPMI 1640 supplemented with 10% human serum (HS; Mediatech) for a
period of 6 hours in parallel to samples treated in media supplemented with 10% FBS with cell
death measured every 24 hours. In order to determine the effect of HS on untreated cell
proliferation and viability, growth curves were generated using trypan blue staining (Sigma) of
samples grown with HS compared to FBS.
Drug Combination Studies
FP was combined with PAC using a drug concentration ratio of 1:10 (PAC:FP) in Nalm-6
and RCH-ACV. Due to greater sensitivity to PAC, Molt-4 and Jurkat were treated at a ratio of
1:20 to allow for a lower concentration of PAC to be utilized. Cell lines were exposed to PAC in
cell culture medium supplemented with 10% FBS for approximately six hours, washed, and then
treated with FP for an additional 72 hours. Treatment duration was selected based on PAC and
FP single agent experiments. Single drug controls for PAC consisted of six hours incubation with
PAC followed by incubation in drug free medium for approximately 72 hours. Cell lines used for
single drug treatment with FP were incubated in drug free RPMI 1640 for approximately six
hours; after which the cell lines were incubated with FP for an additional 72 hours. At the
completion of the 72 hour incubation, cell death was evaluated for all samples. In order to
confirm that results similar to that found in medium supplemented with FBS could be achieved
in cultures supplemented with HS, Nalm-6 was exposed to PAC for 6 hours followed by FP for
72 hours at a concentration ratio of 1:3. Control samples were treated and cell death was
evaluated in the same manner as described for combination studies in FBS.
Nalm-6 and RCH-ACV were used to determine the optimal treatment sequence. One 1:10
combination was chosen from the drug combination studies in FBS in order to confirm that PAC
followed by FP (20nM PAC+200nM FP) was indeed the most efficacious treatment sequence.
Briefly, for the samples in which FP treatment followed PAC treatment (PAC+FP), cell lines
were cultured in RPMI 1640 with and without 20 nM PAC for 6 hours, then washed and
transferred to RPMI 1640 with and without 200 nM FP. In sample sets in which FP treatment
preceded PAC treatment (FP&PAC), cell lines were treated similarly, with the sequence of drug
exposure reversed. Cell death measurements were taken immediately after FP treatment for
PAC+FP and its controls. For FP&PAC and its controls, cell death was determined
approximately 18 hours following completion of PAC treatment. Concurrent exposure
experiments were performed separately; during which cell lines were treated with both agents for
a total of 72 hours. Cell death was measured at 24 hour intervals via flow cytometry as
All experiments, excluding concurrent exposure to PAC and FP, were performed with
three independent replicates. A mixed model was used to analyze each experiment. The
replicates for each experiment were considered a random factor. If there was a significant
interaction (p<0.05) between the variables in each experiment, mainly cell line, treatment, time
of exposure, and drug concentration depending on the type of experiment, then Least Squares
Means of the treatment combinations were compared using a Student' s t-test or F test.
Single Agent FP Treatment
In order to determine the time of exposure to FP that resulted in the maximum cell death
response in ALL cell lines, I incubated Nalm-6 and RCH-ACV with 0-300 nM FP with cell
death measured at 24, 48, and 72 hours. There was a significant concentration dependent
response in both cell lines (p<0.0001; Figure 3-2 a). I compared the cell death induced after 24
hours treatment to the cell death induced after 72 hours. There were no significant differences in
cell death based on time of exposure at the 50 nM concentration in either Nalm-6 or RCH-ACV.
In Nalm-6, there was a significant difference in cell death between 24 and 72 hours exposure to
300 nM FP (p<0.0001), while in RCH-ACV these differences were observed between 24 and 72
hours exposure to 150 nM (p=0.0034) as well as between 24 and 72 hours exposure to 300 nM
Single Agent PAC Treatment
I exposed Nalm-6 and RCH-ACV to PAC for 6 or 24 hours and measured apoptosis at 24,
48, and 72 hours following initial exposure. I observed concentration dependent cell killing in
Nalm-6 and RCH-ACV samples treated for both 6 and 24 hours with a greater percentage of cell
death observed after 24 hours vs. 6 hours drug exposure (Figure 3-2 b). Further, I show that cell
lines treated for 6 hours then transferred to drug-free medium show a greater gradation in
response between 10 nM PAC and 100 nM PAC than those treated for 24 hours, particularly in
Nalm-6. Cell death peaked 48 hours post-treatment and remained consistent with no substantial
change at 72 hours post-treatment in both cell lines. Statistical analysis showed that time of
exposure (6 or 24 hours) to PAC was a significant factor in the percentage of cell death observed
in both Nalm-6 (p=0.0001) and RCH-ACV (p=0.0138). The post-treatment time at which cell
death measurements were taken was also a significant factor in both Nalm-6 (p<0.0001) and
RCH-ACV (p=0.0008). The interaction between the factors of time of exposure and sample time
was significant in Nalm-6 (p=0.0427); however, this interaction was not significant in RCH-
ACV (p=0.6812). My results indicate that even though a 24 hour drug exposure time resulted in
a greater percentage of cell death, a shorter exposure period of 6 hours still resulted in a
substantial amount of cell death. Importantly, incubation for 48-72 hours post-treatment was
needed in order to achieve a maximum response.
Combination Treatment with FP and PAC
Based on my single agent studies I treated four cell lines with PAC for 6 hours; then
transferred the cultures to media containing FP for 72 hours and measured cell death at the end
of this period. Nalm-6 and RCH-ACV were treated with a drug concentration ratio of 1:10
(PAC:FP) and Molt-4 and Jurkat at a ratio of 1:20. I observed a concentration dependent cell
death response for both the single agent treatments as well as each combination (Figure 3-3). My
results demonstrate that when PAC is combined with FP the cell death that results is significantly
higher than when either of the two agents is utilized by itself. I found a statistically significant
difference (p<0.05 or p<0.0001) between single agent and combination treatment in the range of
10-30 nM PAC and 100-300 nM FP in Nalm-6. In RCH-ACV these differences were present for
treatments in the range of 15-25 nM PAC and 100-250 nM FP. Significant differences
(p<0.0001) were present at 5-10 nM PAC and 100-150 nM FP in Molt-4 and Jurkat.
Determination of Optimal Schedule for PAC+FP
I tested PAC+FP, the reverse sequence, and each of the single agent controls to confirm
that the former was the most effective treatment sequence. The most promising dose level (20
nM PAC+200 nM FP) was selected for more detailed analysis. Combining PAC with FP in the
sequence PAC+FP results in significantly greater cell death in Nalm-6 than FP&PAC or single
agent treatment (Figure 3-4 a). The cell death resulting from the PAC+FP was significantly
higher than the other treatments with p values ranging from p<0.0001 to p=0.001. I observed a
similar response in RCH-ACV with p values ranging from p<0.0001 to p<0.01 (Figure 3-5).
I also examined concurrent exposure to 20 nM PAC and 200 nM FP and observed no
enhancement (Figure 3-4 b) in activity. Indeed, the cell death induced after treatment with both
agents is less than that observed with FP alone across three days of testing.
Activity of PAC in Human Serum
Studies have found that 89-98% of PAC is protein bound in human serum (110). This
prompted us to investigate how the efficacy of PAC in ALL cell lines would be affected if
culture medium was supplemented with human AB serum (HS) in place of fetal bovine serum
(FB S). I show that Nalm-6 cells exposed to 10, 100, and 1,000 nM PAC for 6 hours in media
supplemented with HS underwent significantly less apoptosis than observed when experiments
were performed using media supplemented with FBS (Figure 3-6). These differences in PAC
sensitivity were not due to intrinsic differences in cell growth in media supplemented with FBS
vs. HS (Figure 3-6 d).
Combination Studies in Human Serum
Shinn and colleagues have reported that 63-100% of FP is free (non-protein bound) in
FBS, as compared to only 4.7-7.9% free in human plasma in vitro (82). Based on this
information and the high level of protein binding by PAC to plasma proteins, I treated Nalm-6
with PAC combined with FP at a concentration ratio (PAC:FP) of 1:3 in medium supplemented
with HS in order to confirm that the enhancement of PAC activity by FP that I observed in FB S
could also be achieved under these culture conditions (Figure 3-7). Higher concentrations of
PAC were used in order to compensate for the lower sensitivity of ALL cell lines to PAC in the
presence of HS. I show that FP significantly enhances the efficacy of PAC at all concentrations
tested (p<0.0001). Combination treatment was significantly different from FP single agent
treatment at the lowest concentration tested (p<0.05); however, significant differences did not
exist at higher concentrations of FP most probably due to a high percentage of cell death induced
from single agent FP treatment using this prolonged exposure schedule.
There is a significant need to identify novel agents and new combination treatments for
relapsed ALL. Others have shown that PAC and FP have limited efficacy when utilized as single
agents in leukemia patients (16, 75, 133); however, together these drugs have mechanisms of
action that complement each other and might effectively target aberrations in cell cycle
regulation that are commonly present in ALL cells at relapse. My studies demonstrate that ALL
cell lines are sensitive to both PAC and FP in vitro, and that FP enhances the efficacy of PAC in
a sequence specific manner.
My observation that the cell death induced after treatment with 1,000 nM PAC in HS is
comparable to cell death achieved by treatment with 100 nM PAC in FBS is consistent with prior
studies by others showing a high degree of PAC binding by proteins present in HS. In contrast to
data of Shinn and colleagues in CLL (82), my previous studies showed relatively little difference
between the in vitro activity of FP when experiments are performed in HS vs. FBS. My current
observations confirm that despite a decrease in sensitivity to PAC in the presence of HS, FP
enhances the efficacy of PAC under these treatment conditions.
The time of actual drug exposure utilized for PAC treatment (6 hours) in my experiments
was in keeping with the recommended clinical administration of 3 or 24 hours infusion (1 10).
My findings show that 48-72 hours of incubation are needed to achieve a maximum cell death
response to PAC treatment. I also found that the amount of cell death induced by FP in the
concentration ranges studied was dependent upon the duration of exposure, with 72 hours
inducing a peak response. Based on these two factors, I studied a 72 hour FP exposure in the
combination studies. This schedule of FP exposure is different than newer FP dosing strategies
that administer a 30 minute FP bolus followed by a 4 hour infusion to produce much high peak
FP concentrations than those achieved with other infusion schedules, which have yielded
promising early results in patients with refractory chronic lymphocytic leukemia (CLL) (83). In
other studies, I have found that shorter in vitro exposure of the same ALL cell lines, cultured in
media containing either FBS or HS, to high FP concentrations similar to those attained in CLL
clinical trials induced substantial amounts of apoptosis. Based on the results attained in the
current studies, I anticipate that administration of PAC prior to the FP bolus should enhance ALL
cell death and suggest that this combination should be investigated in clinical trials for relapsed
Sample and stain
with Annexin VIPI
(Dayl1) Sample and stain
with Annexin V/PI
Sanpl~nd 8dn ~(DaIys 2 and 3)
with Annexln VIPI
Spin 5 min. 18 hrs.
6 hours 1,000 RPM
r Replace medium
Set-up flasks with PAC
Sample and stain
wvith Annexin VIPI (Day 0)
Spin 5 min.
Figure 3-1. Experimental design for PAC single agent treatment.
Cll Drth Inducld ~ Inenarins Cenerntraolonr ef
PP [n ~Ulln4
m II ~I I ri
041 041 D43
Cll Drth Inducd by Inc nalnp Conf Nmrdonl at
FP In RCH~C\I
r o;r ~
Dsyl Ogl D43
B. I NRCH CTreatedwnmhPadharr ala Hoer .ACVTnreal th Padkanel24 hts.
100 100It IP
A) Perce to- cel det indcedaferll 72hustetetwt 0 5,20 n 0
nMFPmesuedevry24hor via~n flow ctoercalyiofAnxnVP
stie smlsofN l-. eut arth menotreidpnet
expriensi SD. Sinfcn ifrncsi ieo xour tietcld
hours or 24 IVTI* horstramentLrll wih 0 .0 10,C~r 100 n PACllnl mesrd vr 2 or
thrafe oratt alof7 hou lrs.Rslts ar hema o heeidpedn
exeimnsi D Sinfcn diferece at idniacoetrinsbwenhe2
andl 72r horsml ie r nictd ausrne r m0.1t<.01foal
symbols.I~p ~ n
Sequential Treatment with Paciltaxel and Flavoplrldol In
PAC (nM) FP (nl@
Sequential Treatment with Padiltaxel and Flavoplrldol
Sequential Treatment with Paelitaxel and Flavopiridol
2.5, SO 5, 100 7.5, 150) 10, 200
PAC (nl@,FP (n) ap~o.Dool
2.5. 50 5, 100 7.5, 150
PAC (nl@, FP (nM)
Figure 3-3. Flavopiridol enhances the efficacy of PAC in ALL cell lines. FP was combined with
PAC in the sequence PAC+FP at a concentration ratio of 1:10 in Nalm-6 and RCH-ACV
and 1:20 in Molt-4 and Jurkat. Cell lines were treated with PAC for 6 hours immediately
followed by FP for 72 hours. Cell death was measured at the conclusion of treatment via
flow cytometric analysis of Annexin V/PI stained samples. Results represent averages
from at least three independent experiments+1SD.
Nalm-6 Sequence Experiment
PPACa2>FP200 PAC2&tO >FP200 FP2D~aPAC20 FP20M)O &PAC2 urstraded
Nalm-6 Concurrent Excposure
Treatment Day D Day 1 Day 2 Day 3
untreated 3.19 4.13 2.683 1.64
200 3.19 31 66~.63 53.63
PAC 20 3.19 44.33 40.69 41.58
FP 200 3.19 65.46 66~.77 67.45
Figure 3-4. PAC+FP is a more efficacious treatment sequence than FP&PAC or concurrent
exposure in Nalm-6. A) Nalm-6 was treated for 6 hours with 20 nM PAC followed
by 200 nM FP for 72 hours or the reverse sequence. Both sequences included
appropriate single agent controls and an untreated control. Cell death was measured
via flow cytometric analysis of Annexin V/PI stained samples immediately following
FP treatment for PAC+FP and approximately 18 hours after PAC treatment for
FP&PAC. Results are the mean of three independent experiments+1SD. Statistical
significance was measured by comparing PAC20+FP200 to the remaining treatment
sequences. *p<0.0001; #p=0.001. B) Concurrent exposure to PAC and FP in Nalm-
6. Cell lines were simultaneously exposed to 20 nM PAC and 200 nM FP for a total
of 72 hours with cell death measured every 24 hours.
RCH-ACV Sequence Experiment
PrAC2>P0 AE SPm F2>ACD P2> >A2 rra
so RC-C ocretEpsr
PACAC 20crrn 4.51661 2.2 4.1
FP 200 4.5 15.23 18.7 19.52
Figure 3-5. PAC+FP is a more efficacious treatment sequence than FP&PAC or concurrent
exposure in RCH-ACV. A) RCH-ACV was treated for 6 hours with 20 nM PAC
followed by 200 nM FP for 72 hours or the reverse sequence. Both sequences
included appropriate single agent controls and an untreated control. Cell death was
measured via flow cytometric analysis of Annexin V/PI stained samples immediately
following FP treatment for PAC+FP and approximately 18 hours after PAC
treatment for FP&PAC. Results are the mean of three independent experiments SD.
Statistical significance was measured comparing PAC20+FP200 to the remaining
treatment sequences. *p<0.01. B) Concurrent exposure to PAC and FP in RCH-ACV.
Cell lines were simultaneously exposed to 20 nM PAC and 200 nM FP for a total of
72 hours with cell death measured every 24 hours
Treatment with 10 nM PAC MBS v. HS
Day0 Day1 DaY2 Day3
Treatment with 1000 nM PAC FBS v. HS
OayD 041 DWZ D y3
Averagen Growt F00n A BS v. HS
C 0 00E+0
Day Da1 Dy
Figure 3-6. Efficacy of PAC in Nalm-6 in the presence of human serum. Cell death resulting
from 6 hours exposure to PAC in the concentrations shown in medium supplemented
with HS compared to that in FBS measured every 24 hours for a total of 72 hours.
a) 10 nM PAC b) 100 nM PAC c) 1000 nM PAC d) growth curve from untreated cell
cultures comparing HS and FB S supplements. All results are the mean of three
independent experiments+1SD; *p<0.05, #p<0.0002.
Sequential Treatment with Paditaxel and Flavopiridol
B3 450- 6FP
100, 300 125. 375 150. 450 200. 600 "p<0.0
PAC (nM), FP (nM) p000
Figure 3-7. Flavopiridol enhances the efficacy of PAC in human serum. PAC was combined
with FP at a concentration ratio of 1:3 in Nalm-6 cultured in the presence of HS.
Nalm-6 was treated and sampled as in previous assays in FBS. Results are the mean
of three independent experiments SD.
CONCLUSIONS AND DISCUSSION
FP Single Agent Studies
Establishing an in Vitro Treatment Model of ALL
In this proj ect I have focused on determining the potential efficacy of FP both as a single
agent and in combination with PAC in ALL cell lines. I tested these agents based on their
mechanisms of action. FP could target defects in cell cycle regulation produced by mutations in
human cancer, such as pl6; which is frequently altered at the gene and/or protein expression
level in relapsed ALL (124). The action of PAC as an inducer of CDK1 and microtubule
depolymerization inhibitor complements this activity. Following the first chapter of background,
the second chapter of this dissertation details the results that I obtained when testing FP as a
single agent. As part of my initial studies, I established that the cell lines to be used for
sensitivity testing were an accurate model of relapsed ALL by determining their level of pl 6
expression and their sensitivity to dexamethasone and doxorubicin, agents typically used to treat
ALL (3). I found that despite the fact that one of the cell lines had an intact pl6 gene, none of the
cell lines expressed pl6 (Figure 2-1). I also showed that the cell lines were highly resistant to
dexamethasone and variably sensitive to doxorubicin; findings not unlike what would be
obtained in a patient (2). Importantly, the cell lines were sensitive to FP at concentrations similar
to those found to be effective in vitro by others.
Drug Sensitivity Testing via Cell Proliferation Assays
Results for drug sensitivity were obtained using WST-1; a modified version of the MTT
cell proliferation assay. As introduced in the second chapter, in vitro sensitivity to
chemotherapeutic agents measured via this type of assay has been found to correlate to in vivo
efficacy (112-119). In order to use these assays, I first needed to establish that the cell lines could
be maintained untreated in log phase growth over the standard time course of four days. I found
that using a cell concentration of 1X104 CellS/well in 96 well plates gave the best exponential
growth over time (Figure 4-1 a, b). Nalm-6 was later established at a lower concentration due its
lower doubling time (Chapters 2 and 3). In addition, as part of my preliminary studies I showed
that measuring cell proliferation over time via a cell proliferation assay resulted in the same type
of exponential growth curve as when the number of viable cells over time was measured by
trypan blue exclusion (Figure 4-1 c); thus validating the assay. Cell proliferation assays were
used to generate growth curves to establish the ICso concentrations reported in Chapter 2 (Figure
2-1). Examples of these growth curves may be found in Figure 4-2.
The Mechanism of Cell Death Induced by FP in ALL Cell Lines
Also in Chapter 2, I established that FP induces apoptosis in ALL cell lines. FP induced
less apoptosis at its IC5o than a similar concentration of doxorubicin, a known cytotoxic agent
(Figure 2-2). I also showed that FP treatment resulted in apoptosis consistently across four ALL
cell lines (Figure 2-2). Results were obtained after 72 hours treatment to reflect treatment
strategies current at the time. These measurements were taken using flow cytometric analysis of
both Annexin V/PI and TUNEL stained samples in order to confirm that the level of cell death
measured using Annexin V/PI assays was consistent with another method.
Based on the ability of FP to induce cell cycle arrest in cancer cell types other than ALL
(14, 53) and the apparent disparity in cell death at the ICsos for doxorubicin and FP, I conducted
a study of cell cycle kinetics after treatment with both low and high concentrations of FP. I found
that at the ICso, FP induced a transient G1-S block that appeared after 24 hours treatment; with
cell cycle kinetics returning to baseline by 48 hours treatment (Figure 2-3). This arrest gave an
explanation for the decrease in cell proliferation observed at this FP concentration despite a lack
of apoptosis. Treatment with a concentration of FP twice the ICso resulted in a sustained G1-S
and G2-M arrest over the course of 48 hours. Drug replacement studies showed that the transient
nature of the G1-S arrest at the ICso was not due to loss of drug potency over time. Further, I
established that FP prevents the phosphorylation of specific serine residues on pRb, an indication
of a decrease in endogenous CDK activity.
FP Activity in Human Serum
Recent findings have shown that FP is highly protein bound in human plasma and that this
low drug availability can decrease in vitro efficacy (82). Researchers hypothesized that this could
explain the disappointing results obtained in clinical trials using FP as a 72, 24 or 1 hour
infusion, despite obtaining plasma concentrations similar to that found to be effective in vitro
(20-400 nM) (69-81, 124). As explained in Chapters 2 and 3, Byrd and colleagues from Ohio
State University (OSU) designed a clinical trial for patients with refractory CLL with the goal of
obtaining a plasma FP concentration of 1.5 CIM after a 30 minute bolus dose followed by a 4
hour infusion (83). The trial was quite successful despite issues with tumor lysis syndrome, with
an overall response rate of 45%. In order to determine if protein binding would have an effect on
the cell death induced by FP treatment in ALL cell lines, I tested in vitro sensitivity in the
presence of HS and compared it to FBS. Cell death measurements were taken after 4.5 hours and
24 hours continuous exposure to mimic peak and trough concentrations in the OSU infusion
schedule (Figure 2-5). I found that despite the high level of protein binding in human serum
reported by others, it is possible to achieve a high percentage of cell death in ALL cell lines in
vitro with concentrations that mimic those expected to be produced by the treatment schedule
utilized by Byrd and colleagues.
PAC+FP Combination Studies
Note about Statistical Analysis
Chapter 3 details my studies of FP in combination with PAC. To make meaningful
comparisons between treatments, statistical analysis was applied to the data. The analyses of
each data set followed the same basic pattern; beginning with a mixed model analysis of variance
(ANOVA) followed by post-tests to determine if there were significant differences between
treatments, times of exposure, or treatment sequences depending on the variables of the
individual experiment. ANOVA was chosen as the method of analysis based on the fact that each
type of experiment involved multiple comparisons. If a Student' s t-test had been applied to each
individual measurement within each data set, the probability of obtaining significant p values
would have been artificially high (134).
By definition ANOVA compares the actual results to the data that would have been
obtained if the null hypothesis were correct. ANOVA was used to test the significance of the
interaction between the variables for each experiment. If the null hypothesis were correct, there
would be no interaction between any of the variables in the experiment. Each p value given from
the mixed model analysis assigns a percentage to the probability that the interaction present was
due to chance. If significant interactions between variables were present, results based on one
variable could not be analyzed for significance without taking the other variables into account.
The "mixed model" designation to the ANOVA simply states that there were fixed and random
factors in each of the experiments. The variables tested in each experiment were defined as being
fixed effects and the number of replicates was taken as a random effect. The mixed model
analyses are given in tables which are discussed throughout the text that follows.
If the interaction between the factors in each experiment was significant, then the Least
Squares Means of the replicates from each experiment were compared using a Student' s t-test or
an F-test. These analyses are also included in the discussion that follows.
Enhancement of PAC Activity by FP
PAC and FP have complementary modes of action in that PAC enhances CDK 1 activity
while FP is a pan-CDK inhibitor. This is the hypothesis behind why the enhancement of PAC by
FP is dependent on the order in which the drugs are administered (56). As summarized in
Chapter 3, others have shown that FP can enhance the activity of PAC in vitro in cancer types
other than ALL (56, 60). Promising results have also been obtained during a clinical trial using
patients with various types of cancer (1 11). I chose to test PAC in combination with FP due to
the aberrations in cell cycle regulatory proteins frequently found in relapsed ALL patients and
because this treatment regimen would offer a new possibility to children with relapsed ALL
using two agents to which they would not have been previously exposed.
In order to conduct these experiments I first needed to establish whether ALL cell lines
were sensitive to PAC and determine a treatment schedule for each of the drugs as single agents.
After testing FP in two cell lines over 72 hours, I was able to determine that the time of exposure
had a significant effect on the percentage of cell death induced by FP. Statistical analysis was
conducted by first determining if there was a significant interaction between the factors of FP
concentration and time of exposure (Tables 4-1 and 4-2). When it was determined that a
significant interaction existed, the data were further analyzed by determining if there were
significant differences in cell death at different times of exposure for a given FP concentration
(Tables 4-3 and 4-4). With the results given in Chapter 3 (Figure 3-2), I was able to conclude that
72 hours FP treatment gave a peak cell death response.
Through single agent PAC studies I established that ALL cell lines were sensitive to this
agent. I chose to measure cell death as a result of 6 hours and 24 hours treatment based on earlier
pharmacokinetic studies by others (110, 135, 136). Following drug exposure, apoptosis was
measured every 24 hours for a total of 72 hours. Statistical analysis of my data showed that there
was a significant interaction between PAC concentration, time of exposure, and sample time in
Nalm-6 but not RCH-ACV (Tables 4-5 and 4-6). I chose to use a 6 hour exposure to PAC for my
combination studies, as this resulted in a better range of choices for drug concentrations to test
given the gradation in response between 10 nM and 100 nM when compared to 1.0 and 10 nM
after 24 hours exposure. Also, as detailed in Chapter 3, my data showed that 48-72 hours
incubation were required to achieve maximum cell death after treatment (Figure 3-2). Statistical
analysis of PAC single agent treatment may be reviewed in Tables 4-7 and 4-8.
Methods of Determining Synergy
I combined FP with PAC to determine if the combination would increase the efficacy of
the single agents. Synergy can be defined as when the effect of a combination of agents is greater
than the sum of the effects of each of the single agents (137). There are various methods to
determine if the effect of treatment with multiple agents is synergistic, including isobologram
analysis, fractional effect, and median-effect analysis (138). Isobologram analysis begins by
measuring the dose of each drug required to produce the same effect, e.g. 50% cell death. These
doses are plotted against each other and a line is drawn connecting the two doses (Figure 4-3)
(139). The line is said to represent the doses of the two drugs which are equipotent. If a dose
combination produces the designated effect and is plotted far below the line, this combination is
considered synergistic, e.g. point Q in Figure 4-3. If the drug combination is plotted far above the
line, it is considered to be antagonistic (point R). Points very close to the line represent additivity
(point P). The isolobolgram method requires a large number of measurements, applies only if the
drugs have similar modes of action (mutually exclusive) and can only be used for combinations
of two drugs (138).
The fractional product method is very intuitive in that one simply multiplies the
percentages represented by the unaffected fraction (e.g. percent viable cells post-treatment) for
each single agent (13 8). If the combination of drugs results in a percentage that is equal to the
product of the two single agents, then the two agents are additive. The requirements of this
method are that the drugs must have different modes of action (mutually non-exclusive) and that
the dose-effect curves for the agents are hyperbolic.
The most common method in current literature used to evaluate for synergy between
agents is based on the median-effect principle authored by Chou and Talalay (61). One uses
median-effect analysis to determine a Combination Index (CI) value for each drug combination.
According to median effect analysis, if CI=1.0 this indicates an additive relationship between the
two drugs. If CI<1.0, synergy is present and if CI>1.0 antagonism is indicated. This method has
the advantage of allowing the researcher to evaluate a minimal number of drug concentrations
and determine the relationship between greater than two drugs if desired. In addition, one is not
limited to evaluating agents with only the same or different modes of action. Both mutually
exclusive and mutually non-exclusive agents can be analyzed.
To understand median-effect analysis, let us first examine the median effect principle. This
principle is based on the ICso for each individual agent. Consider statement 4-1:
+ + (4-1)
().( i)l ( i)l (Dml), (Dmz)
The term (fa)x is the fraction affected by drug (percent cell death after treatment with drug), ft~ is
the fraction unaffected by drug (percent viable cells), D is the dose of a single drug in the
combination and Dm is the ICso for that drug if it were used as a single agent. If drugs 1 and 2
were combined at their ICsos,
+ -0.5+0.5=1.0. (4-2)
Now consider two examples from PAC combined with FP in Nalm-6 at a ratio of 1:10. In the
first, 10 nM PAC was combined with 100 nM FP. The ICso for PAC was 28.95 nM based on the
single agent controls in the experiment and the ICso for FP was 279.1 nM. Thus, according to
(D)l (D)Z 10 100
+ = + 0.703 (4-3)
(Dmz), (Dmz) 28.95 279.1
In the second example, 15 nM PAC was combined with 150 nM FP with the same ICsos as in the
first example for a sum equaling 1.055. Comparatively, the sum in the first example is 30%
below 1.0, whereas the sum in the second example is 6% above 1.0. Through the use of the
median-effect principle, one can conclude that the combination in the first example is synergistic
and the second combination is additive, providing that both agents have the same mode of action.
From this information one understands how CI values based on 1.0 were derived. From
statement 1, median effect analysis defines CI as:
CI- + (4-4)
D is the dose of each drug used in the combination and Dx is the dose of each single agent that
would be required to induce the same percentage of cell death caused by the drug combination.
In the case of two or more agents having different modes of action, Equation 4-4 is modified to:
(D), (D)Z (D), (D)2
CI= + + (4-5)
(Dx), (Dx), (Dx), (Dx),
FP Combined with PAC
Combination studies were initiated by first establishing a concentration ratio for PAC and
FP. Under median-effect analysis, it is suggested that agents are combined using a set drug
concentration ratio (137), in this case PAC:FP. Several ratios were tested in Nalm-6 including
1:5, 1:10, 1:12, and 1:15 (Figure 4-4). I found that FP enhanced the activity of PAC most
dramatically when the two agents were used in the ratios of 1:10 and 1:12. I performed median-
effect analysis to generate Combination Index (CI) values for the four ratios tested. A CI<1.0
indicated synergy, while CI>1.0 indicated antagonism and CI=1.0 indicated an additive
relationship between PAC and FP (61). Table 4-9 shows CI values at the 50% effective dose for
the drug combination (ED5o), ED75, and ED90 for each ratio. When evaluating combination data
using median-effect analysis, two sets of CI values are generated based on the modes of action of
the two drugs tested: mutually exclusive and mutually non-exclusive CI values. I chose to utilize
the mutually non-exclusive CI values, as PAC and FP have different modes of action. Though
the CI results were <1.0 when PAC was combined with FP at a ratio of 1:12, the actual cell death
measurements were more compelling when the two agents were combined at a ratio of 1:10 (see
Figure 4-4). This ratio also allowed for the use of lower concentrations of both agents.
Nalm-6 and RCH-ACV were tested using a ratio of 1:10. When testing Molt-4 and Jurkat,
I used a ratio of 1:20 to account for the fact that these cell lines were exquisitely sensitive to
PAC. This allowed for the use of a lower PAC concentration. Results from cell death
measurements shown in Chapter 3 indicated a significant difference in the cell death induced by
single agent controls when compared to each combination in all four cell lines tested (Figure 3-
3). A mixed model analysis similar to what was employed for FP and PAC single agent studies
was utilized to evaluate the overall significance of the results (Tables 4-10 and 4-1 1). Nalm-6
and RCH-ACV were evaluated under the same analysis, as these cell lines were treated with the
same concentration ratio (1:10). Molt-4 and Jurkat were subj ected to a separate analysis, as both
were treated with a drug concentration ratio of 1:20. It was found that there was a significant
interaction between the factors cell line, treatment (PAC, FP, or PAC+FP) and drug
concentration in all four cell lines tested. Based on the overall significance of the results, the cell
death induced by each single agent control was compared to its respective combination. The
results for which there were significant differences are reported in Tables 4-12 and 4-13.
Representative CI values for the ED5o, ED75, and ED90 for each cell line are reported in Table 4-
14. The data ranged from being slightly synergistic (Nalm-6 ED90 CI=0.939) to antagonistic
(Jurkat ED5o CI=1.59), with half of the drug combinations showing near additivity to slight
The CI values reported in this chapter represent those obtained based on PAC and FP
having different modes of action and clearly show that the degree of synergy between PAC and
FP is very slight where it is present. In Chapter 3 I show that FP enhances PAC activity and vise
versa by measuring the simple effects of the drugs. In order for this enhancement to be
considered synergistic via median-effect analysis, the differences between single agent treatment
and combination therapy would need to be several orders of magnitude higher than the data that I
obtained (61). This can be explained by the median-effect plot which graphs log (D) vs. log
and ultimately connects to the median-effect equation from which all of the above equations are
derived. Stated more simply, analysis of combined drug effects through median-effect analysis
requires log order differences between single agent and combination treatment. For example, if
instead of obtaining the data reported in Chapter 3 at a drug concentration ratio of 1:10, I had
found similar results using a ratio of 1:100 or 1:1000, my CI values would have been much lower
and therefore more synergistic.
Sequence Dependent Enhancement
Results reported previously by others show that enhancement of PAC activity by FP is
dependent on the sequence in which the agents are administered (56). In order to confirm this in
ALL cell lines, I chose the most promising treatment from my combination studies to determine
if PAC+FP, FP&PAC or concurrent exposure would result in the highest percentage of cell
death. As reported in Chapter 3, the percentage of cell death resulting from standard treatment
(PAC+FP) was compared to the reverse sequence and single agent controls. An ANOVA was
utilized to analyze the statistical significance of treatment sequence prior to comparing the
individual effects of treatment. A one-way analysis of variance was used for Nalm-6 and a
weighted one-way analysis was used for RCH-ACV (Tables 4-15 and 4-16) to make this
determination. The weighted analysis was used due to an inconsistent sample size for some of
the treatment conditions for this cell line. The term "one-way" connotes that the experiments
were categorized in one way: by treatment sequence instead of by treatment sequence and cell
line. Treatment sequence was a significant factor in the percentage of cell death resulting from
the various treatments tested. Statistics were not applied to the data from concurrent exposure
experiments, as these data were generated from one experiment. I confirmed that PAC+FP was
the most efficacious treatment sequence in Nalm-6 (Figure 3-4 a). The statistical analysis
comparing 20 nM PAC+200 nM FP to the reverse sequence and single agent controls can be
found in Table 4-17. I also confirmed the proper treatment sequence in RCH-ACV (Figure 3-5 a,
Table 4-18). I showed in Figure 3-4 b and Figure 3-5 b that concurrent exposure is not a feasible
option for this drug combination, as it resulted in less cell death than the sum of the two single
Drug Sensitivity in Human Serum
Due to the reported difference in binding by FP to human plasma proteins vs. proteins in
FBS and the resulting decrease in sensitivity in CLL cells, I compared the sensitivity of ALL cell
lines to FP in FBS and HS and found that there was not a substantial difference in sensitivity
between the two sera (Figure 2-5). PAC is also highly plasma protein bound and I report in
Chapter 3 that there is a 10-fold decrease in the sensitivity of ALL cell lines to PAC in the
presence of HS when compared to FBS (Figure 3-6). Statistical analysis showed that the type of
serum used had a significant impact on the results (p=0.0370; Table 4-19). Statistical
comparisons between the two types of sera at specific PAC concentrations were performed to
supplement the data shown in Chapter 3 (Table 4-20). I reported that the difference in sensitivity
between FBS and HS was not due to a significant difference in cell proliferation in the two sera.
The statistical analysis on which this conclusion was based is reported in Table 4-21.
Based on these results I wanted to confirm that the enhancement in PAC activity by FP
that I had observed in FBS could also be achieved in the presence of HS. I chose to use a
concentration ratio of 1:3 based on preliminary experiments using a variety of ratios (Figure 4-
5). This concentration ratio allowed for the use of higher concentrations of PAC to compensate
for lower sensitivity in HS. However, these concentrations are still substantially lower than the
plasma concentrations reported during clinical trials of PAC in children with leukemia or solid
tumors (16, 109). I found that FP enhances the efficacy of PAC in a manner similar to the
enhancement found in FB S using a ratio of 1:10 or 1:20. Statistical analysis showed that despite
a lack of significance in the interaction between treatment and drug concentration, there was an
enhancement of PAC activity by FP (Tables 4-22 and 4-23).
Placing Perspective on this Project
Potential Side Effects of Single Agent and Combination Therapy
As previously discussed in Chapters 2 and 3, severe tumor lysis syndrome (TLS) resulted
during the initial clinical studies of the currently used administration schedule for FP (83).
Though this was a clear sign of the efficacy of FP in CLL, the toxicity that resulted caused the
death of one patient enrolled in the study. Steps have since been taken to prevent TLS through
the use of prophylactic therapy prior to the administration of FP and monitoring of patients while
on therapy. An algorithm for monitoring for hyperkalemia has also been instituted as part of the
study (140). According to official monitoring criteria from the NCI, the level of hyperkalemia
that has resulted has been low in both inpatients and outpatients; however, pre-treatment,
potassium chelation therapy, and dialysis have still been required in some cases.
Concern might be raised about the potential side effects of combining PAC with FP. Any
dose limiting toxicities reported during trials of PAC in patients with leukemia have occurred at
concentrations in the micromolar range; much higher than the concentrations used in my
experiments. It should also be noted that these concentrations were achieved after a 24 hour
infusion. I am proposing a shorter infusion time for PAC in my combination studies.
Where Does FP Fit into the Treatment Scheme of ALL?
When a novel agent becomes available as a possible addition to the regimen used to treat
ALL, researchers and clinicians must determine for what stage of therapy the new agent is best
suited. Because childhood ALL has such a high cure rate, it is difficult to measure a significant
improvement as a result of the addition of a new agent to the initial stages of therapy. Some feel
that novel agents should replace current therapies with the goal of decreasing toxic side effects
rather than increasing the cure rate; particularly when the drug is a targeted agent that would be
used in a subgroup that already has a positive prognosis (141). While it might be somewhat
beyond the scope of this dissertation, considering whether FP would have a place in the
treatment of ALL is relevant to proposing a clinical trial. Some might question whether a pan-
CDK inhibitor has a place in an age of cancer drug discovery characterized by targeted therapies.
FP has been used with success in trials of CLL patients. Others have shown that the biological
mechanism behind the capability of FP to kill CLL cells is its ability to decrease the transcription
and protein expression levels of short-lived anti-apoptotic molecules such as Bcl-2 and Mcl-1
(100). These molecules were targeted based on the need of CLL cells, which are non-cycling, to
express them continuously in order to remain in a state of senescence.
While ALL is characterized by many types of chromosomal translocations and other
genetic aberrations, there is not one specific molecule that can be targeted across subgroups of
patients, such as the BCR-ABL tyrosine kinase produced by the 9;22 translocation that has made
imatinib mesylate (Gleevec) so successful in patients with chronic myelogenous leukemia. As
previously discussed in Chapters 2 and 3, more modern studies using microarray technology
have found significant differences in the expression of genes that regulate cell cycle, DNA repair
and apoptosis between the times of diagnosis and relapse in ALL; however, more work is
necessary to discern a clear pattern in gene expression that would reveal which aberrations lead
to relapse (18). Several studies remain that show that pl6 is altered at the gene and/or protein
expression level in up to 50% of ALL cases. Because FP can function in the pl6 pathway and
there is a lack of available targets that affect a comparable percentage of ALL patients, the fact
that FP is not a precisely targeted therapy should not be a hindrance to its possible use in ALL.
This work represents an initial study of the efficacy of FP as a single agent and combined
with PAC in ALL cell lines. It might be beneficial to expand these studies into patient samples,
in order to determine if the treatments would be efficacious in samples which are far less
removed from a patient than immortalized cell lines. I would also propose testing the biological
basis of the apoptosis induced by FP as a single agent by determining the activation of caspases
and downregulation of antiapoptotic molecules such as Bcl-2 and Mcl-1 as result of treatment.
Importantly, and perhaps in contrast to the work performed by others, I would only propose the
further biological studies after FP had been successfully tested in a patient population. The
studies of FP contained herein, perhaps with the addition of single agent studies in patient
samples, provide a biological justification for a clinical trial of FP in children with ALL. I have
shown that FP can induce apoptosis and cell cycle arrest, both mechanisms that inhibit
proliferation of cancer cells. If FP was found to be successful in treating children with ALL, then
further studies into its mechanism of action in vivo would be warranted. These studies could hold
the possibility of assisting researchers in discovery of new targets for more potent agents on the
horizon. Also, this information would provide a basis for using FP in combination with other
agents such as PAC.
A RMl-AGVI Cal Gumih in SSWall Plate
B. REN CdlGrowh in 8HhIB Plate
c- Abrsorbance ovrer TlrnelX10^4 cerlls/ell
iR, + ROACV
Figure 4-1. Growth curves used to establish cell concentration for proliferation assays. Trypan
blue exclusion and WST-1 were utilized to measure the number of viable cells per
well in a 96-well plate over a 4 day time period. a)growth curves generated from
RCH-ACV; b)REH; c)growth curves generated using WST-1 for comparison to
trypan blue exclusion.
0 50 100 19) 200 250
FP (n M)
0 50 100 190 200 250
F P (n M)
Figure 4-2. Representative dose-response curves generated from cell proliferation assays.
Figure 4-3. Illustration of isobologram analysis of combined drug effects. Given the
combination of drugs A and B at equipotent concentrations, possible responses from
the drug mixture are shown. Point "Q" represents a synergistic effect, point "P" an
additive effect and point "R" represents antagonism Reprinted by permission from
American Society for Pharmacology and Experimental Therapeutics: [Journal of
Pharmacology and Experimental Therapeutics] Tallarida RJ. Drug synergism: its
detection and applications. Journal of Pharmacology and Experimental Therapeutics
2001; 298(3):865-872, copyright 2001, originally published as Figure 1, p.866.
Sequential Treatment wkth PaalItXel and Flavopiridel Sequential T reament with Paditaxel and FlavopirIdo
in Nalm M in Nalm4 1:10
PA (n .F FP( A n P(M
Figure 4-4. Preliminary combination data at a variety of ratios in Nalm-6. Cell death
measurements after treatment with PAC for 6 hours followed by FP for 72 hours at
concentration ratios (PAC:FP) of 1:5, 1:10, 1:12, and 1:15.
Figure 4-5. Preliminary combination data at a variety of ratios in the presence of human serum.
Cell death measurements after treatment with PAC for 6 hours followed by FP for 72
hours at concentration ratios (PAC:FP) of 1:2, 1:3, 1:4, and 1:5. The 1:3 ratio was
chosen for further study.
Table 4-1. Mixed model analysis for FP treatment duration in Nalm-6
Numerator DF Denominator DF F value P value
FP Concentration 4 10 20.04 <0.0001
Day 2 20 25.93 <0.0001
Day*FP 8 20 26.25 <0.0001
Table 4-2. Mixed model analysis for FP treatment duration in RCH-ACV
Numerator DF Denominator DF F value P value
FP concentration 4 10 7.90 0.0038
Day 2 20 67.28 <0.0001
Day*FP 8 20 19.42 <0.0001
Table 4-3. Differences between treatment duration at a given FP concentration in Nalm-6
Sample time- FP Sample time- FP Difference in T value P value
concentration (nM) concentration mean cell death
Day 1 FP 150 Day 2 FP 150 0.3033 0.26 0.7978
Day 1 FP 150 Day 3 FP 150 0.6033 0.52 0.6113
Day 1 FP 200 Day 2 FP 200 0.2533 0.22 0.8305
Day 1 FP 200 Day 3 FP 200 1.6367 1.40 0. 1766
Day 1 FP 300 Day 2 FP 300 -11.8500 -10.14 <0.0001
Day 1 FP 300 Day 3 FP 300 -18.5167 -15.85 <0.0001
Day 1 FP 50 Day 2 FP 50 0.4200 0.36 0.7230
Day 1 FP 50 Day 3 FP 50 0.8667 0.74 0.4669
Day 2 FP 150 Day 3 FP 150 0.3000 0.26 0.8000
Day 2 FP 200 Day 3 FP 200 1.3833 1.18 0.2503
Day 2 FP 300 Day 3 FP 300 6.6667 5.71 <0.0001
Day 2 FP 50 Day 3 FP 50 0.4467 0.38 0.7063
Table 4-4. Differences between treatment duration at a given FP concentration in RCH-ACV
Sample time-FP concentration (nM) Sample time- Difference T value P value
FP in mean cell
Day 2 FP 150
Day 3 FP 150
Day 2 FP 200
Day 2 FP 300
Day 3 FP 300
Day 2 FP 50
Day 3 FP 50
Day 3 FP 150
Day 3 FP 300
Day 3 FP 50
Day 1 FP 150
Day 1 FP 150
Day 1 FP 200
Day 1 FP 300
Day 1 FP 300
Day 1 FP 50
Day 1 FP 50
Day 2 FP 150
Day 2 FP 300
Day 2 FP 50
Table 4-6. Mixed model analysis of PAC single agent treatment in RCH-ACV
Numerator DF Denominator F value P value
PAC concentration 3 14 108.48 <0.0001
Time of Exposure (6 1 14 7.91 0.0138
hours or 24 hours)
PAC*Time 3 14 5.90 0.0081
Sample Time (Day) 2 32 9.08 0.0008
Day*PAC 6 32 6.12 0.0002
Day*Time 2 32 0.39 0.6812
Day*PAC*Time 6 32 0.71 0.6454
Table 4-5. Mixed model analysis of PAC single agent treatment in Nalm-6
Numerator DF Denominator DF F value P value
PAC concentration 3 14 174.68 <0.0001
Time of exposure (6 1 14 27.77 0.0001
hours or 24 hours)`
Sample time (Day)
rs PAC treatment
Table 4-7. Differences in cell death based on incubation time after 6 or 24 hou
Day PAC (nM) Time (hours) Day P value
mean cell death
Table 4-8. Differences in cell death based on incubation time after 6 or 24 hours PAC treatment
Difference in mean cell
Table 4-9. Combination Index (CI) values for drug
Nalm-6 PAC:FP EDso El
combination studies using a variety of ratios
Table 4-10. Mixed model analysis of Nalm-6 and RCH-ACV combination data
Numerator Denominator F value
Cell Line 1
Cell Line*Treatment 2
Drug concentration 4
Treatment* Concentrati on 8
Cell Line*"Treatment* Concentrati on 9
Table 4-11i. Mixed model analysis of Molt-4 and Jurkat combination data
Numerator DF Denominator F value P value
Cell line 1
Cell line*Treatment 2
Treatment* Concentrati on 8
Cell line*Treatment* Concentration 12
Table 4-12. Significant differences in treatment for a given cell line and drug concentration
Combo treatment PAC
100 nM FP
10 nM PAC
150 nM FP
15 nM PAC
200 nM FP
20 nM PAC
250 nM FP
25 nM PAC
300 nM FP
30 nM PAC
100 nM FP
150 nM FP
15 nM PAC
200 nM FP
20 nM PAC
250 nM FP
25 nM PAC
SE T value P value
Table 4-13. Significant differences in treatment for a given cell line and drug concentration
Cell Combo treatment PAC (nM):FP Single agent SE T P value
line (nM) control value
100 nM FP
5 nM PAC
150 nM FP
7.5 nM PAC
200 nM FP
10 nM PAC
100 nM FP
5 nM PAC
150 nM FP
7.5 nM PAC
10 nM PAC
ED5o ED75 ED90
Nalm-6 1.25 1.08 0.939
RCH-ACV 1.18 1.15 1.15
Molt-4 1.58 1.34 1.14
Jurkat 1.59 1.33 1.11
Table 4-15. One-Way Analysis of Variance of treatment sequence in Nalm-6
Numerator DF Denominator DF F value P value
Treatment 6 14 46.29 <0.0001
Table 4-16. Weighted One-Way Analysis of Variance of treatment sequence in RCH-ACV
Numerator DF Denominator DF F value P value
Treatment 6 14 16.86 <0.0001
Table 4-17. Significant differences between standard treatment sequence, reverse treatment
sequence, and single agent controls in Nalm-6
Combination Index (CI) values for drug combination studies
Treatment 1 SE
Table 4-18. Significant differences between standard treatment sequence, reverse treatment
sequence, and single
Treatment 1 Treatment 2
0+FP 200 PAC 20+FP
0+PAC 20 PAC 20+FP
FP 20000 PAC 20+FP
FP PAC 20+FP
200+PAC 20 200
PAC 20+FP untreated
agent controls in RCH-ACV
Treatment 1 SE
Table 4-19. Mixed model analysis for comparison of cell death induced by PAC in FBS vs. HS
Numerator DF Denominator DF F value P value
Type of serum 1 2 25.57 0.0370
PAC (nM) 4 14 62.75 <0.0001
Type*PAC 4 14 5.08 0.0097
Day 3 54 69.74 <0.0001
Day*Type 3 54 8.75 <0.0001
Day*PAC 12 54 18.85 <0.0001
Day*Type*PAC 12 54 1.69 0.0941
Table 4-21. Mixed model analysis of cell viability FBS vs. HS
Numerator DF Denominator DF F value P value
Day 3 12 16.07 0.0002
Type of serum 1 2 1.09 0.4055
Day*Type 3 12 1.27 0.3294
Table 4-22. Mixed model analysis of combination studies in human serum
Table 4-20. Comparison of cell
Day Type of PAC
0 FBS 0
0 FBS 1
0 FBS 10
death induced by PAC in FBS vs. HS
Day Type of PAC
0 HS 0
0 HS 1
0 HS 10
0 HS 100
0 HS 1000
1 HS 0
1 HS 1
1 HS 10
1 HS 100
1 HS 1000
2 HS 0
2 HS 1
2 HS 10
2 HS 100
2 HS 1000
3 HS 0
3 HS 1
3 HS 10
3 HS 100
3 HS 1000
P value Difference
in mean cell
Numerator DF Denominator F value
Treatment* Concentrati on
Table 4-23. Significant differences in treatment for combination studies in human serum
Treatment 1 Treatment 2 P value Difference in mean
300 nM FP 100 nM PAC, 300 nM 0.0112 -24.4877
100 nM PAC, 300 nM 100 nM PAC <0.0001 37.8793
375 nM FP 125 nM PAC, 375 nM 0.061 -32.0078
125 nM PAC, 375 nM 125 nM PAC <0.0001 63.9835
450 nM 150 nM PAC, 450 nM 0.4802 -16.7949
150 nM PAC, 450 nM PAC 150 <0.0001 78.2333
600 nM FP 200 nM PAC, 0.8746 4.2426
600 nM FP
200 nM PAC 200 nM PAC, 600 nM <0.0001 23.6096
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