METHOD FOR MONITORING EARLY TREATMENT RESPONSE

FIELD OF THE INVENTION

[0001] This invention pertains to a method for monitoring early response to cancer treatment, particularly in cytotoxic treatment involving radiation and chemotherapy, each alone or in combination. The method involves the use of Magnetic Resonance Spectroscopy (MRS).

BACKGROUND OF THE INVENTION

[0002] Some of the common approaches to cancer treatment include surgery, radiation therapy, and chemotherapy. Radiation therapy and chemotherapy are effective if they are capable of killing the tumor cells; i.e., when they act as cytotoxic agents. Typically, the response to radiation therapy or chemotherapy is monitored by magnetic resonance imaging (MRI) of the tumor, wherein a decrease in tumor size is indicative of positive response to treatment.

[0003] Cytotoxic therapies rely on disrupting the DNA and RNA of malignant cells. Radiation creates DNA strand breaks and aberrations. Examples of lethal aberrations are the ring and dicentric chromosomal aberrations, and the anaphase bridge chromatid aberration. Hall, E. J., Ch 2 in Radiobiology for the Radiologist. 5 ^th ed., Lippincott, Williams and Wilkins (2000). Cytotoxic agents or drugs generally alter DNA and RNA synthesis or functions, e.g., forming cross links between DNA strands (alkylating agents and platinum analogs); inhibiting DNA - dependent RNA polymerase (streptomycin drugs); blocking production of mitotic spindles (vinca alkaloids); and preventing disassociation of drug treated spindles (taxans). Hall, E. J., Ch 27, supra. [0004] Cytotoxic agents induce apoptosis, a programmed cell death. Apoptosis is under the control of two signaling pathways. One pathway utilizes "death receptors" on the cancer cell membrane. Fas and tumor necrosis factor (TNF) receptors can be activated by cytotoxic drugs, such as adriamycin, forming caspase-8 thereby initiaing a protease cascade that cleaves cellular targets and results in apoptosis cell death. The second pathway is initiated by cellular stress, such as DNA damage from either radiation or chemotherapeutic agents. The DNA strand breaks are sensed by kinases that activate p53 (a tumor suppressor protein) resulting in the box gene releasing cytochrome c from the mitochondria. Cytochrome c activates caspase-9 and downstream caspases causing apoptosis. Apoptosis links programmed cell death to DNA damage. Schmitt, CA, et al, J. Path. 187, 127-137 (1999). [0005] Unfortunately, tumors can be resistant to a class of chemotherapeutic agents, or develop resistance during the prolong exposure to a cytotoxic drug. Untreated tumors

may have a mutation in p53, a tumor suppressor protein, preventing the release of cytochrome c from the mitochondria and thereby blocking apoptosis. Schmitt, et al., supra, and Bunz, F., et al., J. Clin. Invest. 104, 263-269 (1999). Drug resistance may develop during treatment by up-regulating the multiple drug resistance (mdr) gene that extrudes the drug out of the cell. Drug resistance may also develop the malignant cells increase intraceullular glutathione. Hall, E. J., Ch 27, supra.

[0006] Radiation resistance develops in hypoxic tumors because some DNA strand breaks are repaired. Radiation sensitivity is maintained in oxygenated tumors with oxygen forming peroxides that react with the DNA strand breaks preventing their repair. Hall, E. J., Ch 6 supra.

[0007] Cytotoxic resistance is now monitored by obtaining sequential contrast CT/MR studies at 3-12 month intervals. Resistance to treatment is identified by an increase in tumor size and an increase in enhancement (angiogenesis) of the tumor following the treatment. Therapeutic response is documented by decrease in tumor size and decrease in tumor enhancement. The decrease in size documents apoptosis with loss of cellularity. In many cases, a detectable change in tumor size is observed only after a significant long period of time, for example after treatment for a period of 3 months or more. Such long periods of time could be harmful to the patient for during this long period of time, tumor cells could multiply and/or metastasize, and lead to worsening the patient's condition.

[0008] The foregoing shows that there exists a need for a method where an early cytotoxic treatment response can be monitored. Accordingly, the present invention provides such a method. This and other advantages of the invention, as well as additional inventive features, will be apparent from the description of the invention provided herein.

BRIEF SUMMARY OF THE INVENTION

[0009] The invention provides a method for monitoring early treatment response of a cancer treatment comprising measuring by MRS, the amount of Choline present in the cancerous tissue, particularly in the internal cell membranes or endomembranes, before and after cytotoxic treatment; the treatment comprises radiation and/or chemotherapy, whereby a decrease in the amount of Choline after treatment is indicative of a positive response. In accordance with the invention, diagnosed cancers can be monitored by following cell membrane metabolism utilizing the Choline peak on ¹ H MR spectroscopy. The Choline peak represents the visible mobile Choline forming the plasma and organelle cell membranes. A decrease in the Choline identifies treatment response; an increase in the Choline peak identifies treatment failure.

[0010] The present invention provides one or more of several advantages, for example, the amount of Choline changes prior to classical imaging findings, and the MRS peak corresponding to Choline changes with a cytotoxic treatment based on radiation and/or chemotherapy. The present invention offers the combined advantages of MRI and MRS and provides a method to monitor early treatment response. The present invention also provides a method for monitoring cancer treatment. Further, the present invention also provides for a method for monitoring protein translation comprising administering an amount of the molecule or radiation to an animal having a cancerous tissue and measuring, by Magnetic Resonance Spectroscopy, the amount of Choline present in the endomembranes of the cancerous tissue before and after administering the molecule or radiation.

DETAILED DESCRIPTION OF THE INVENTION

[0011] The present invention is predicated on monitoring changes in the amount of one or more metabolites occurring in an internal cell membrane (endomembrane), for example, changes induced by the down regulation of one or more of the intracellular organelles and their secretory granules and transport vesicles. The internal cell membranes, which constitute nearly 90% of the total cell membranes, form the membranes of the nucleus, the mitochondria, the lysosomes, the peroxisomes, the endoplasmic reticulums, the Golgi apparatus, the secretory granules, and the transport vesicles. Cytotoxic agents down-regulate the intracellular organelles and their secretory granules and transport vesicles.

[0012] Following the endomembranes (intracellular organelles) correlates with Francis Crick's "Central Dogma of Molecular Biology". The central dogma involves DNA replication, transcription of information carried by DNA into the form of RNA, and translation of the information encoded in the RNA into proteins. Genetic alterations in tumors amplify the protein synthesis utilizes intracellular organelles, subcellular membrane-bounded compartments. The organelles include the nucleus, endoplasmic reticulum (ER), Golgi complex (GC), lyosomes, peroxisomes, and mitochondria. Protein synthesis is initiated in the nucleus by transcription of the appropriate DNA genes to form messenger, ribosomal and transfer RNA. Ribosomes are the "work benches" of protein synthesis linking amino acids into a polypeptide. Ribosomes adhere to the ER forming the rough ER (rER). The polypeptides enter rER for processing. Following protein processing in the rER, the proteins are packaged into transport vesicle and moved to the GC where further protein processing takes place. Other transport vesicles are generated to carry the proteins between the cisternae of the Golgi stack. Lysosomes are derived from cell membranes of the rER and GC and contain digestive

enzymes needed to re-cycle membranes and proteins. The peroxisomes and mitochondria are multiplied to handle the increased production of hydrogen peroxide, and the increased demand for energy in protein synthesis. Secretory granules package and move the completed proteins from the Golgi complex to the plasma membrane where the proteins are either bound or secreted. While the cell membranes for the transport vesicles and secretory granules are generated by budding off the rER and GC cell membranes, the cell membranes for peroxisomes and mitochondria are generated by division of pre-existing peroxisomes and mitochondria. The continued budding of vesicles and granules off the rER and GC requires continued regeneration of rER and GC cell membranes. Therefore, in cancer, the uncontrolled protein synthesis is coupled to the increase in the intracellular cell membranes.

[0013] Following the changes in the endomembranes (organelle membranes) by MRS has several advantages over following apoptosis (loss of cellularity) by MRI. The changes in the total choline peak (MRS) occur before changes in size and enhancement (MRI) Norfray, J. F., et al., supra. MRS allows earlier determination of sensitivity or resistance to cytotoxic drugs than MRI. Norfray, J. F., et al., supra. The earlier changes seen by MRS are related to interruption of protein synthesis (translation) occurring within the organelles. The later changes seen by MRI are related to downstream programmed cell death (apoptosis) occurring with loss of tumor cells. [0014] Accordingly, the present invention provides a method for monitoring early treatment response of a cancer treatment comprising measuring, by Magnetic Resonance Spectroscopy (MRS), the amount of Choline present in the endomembranes of the cancerous tissue before and after treatment; the treatment comprises administration of a cytotoxic agents, whereby a decrease in the amount of Choline after treatment is indicative of a positive response. MRS can be based on the resonance of any suitable nuclei; for example, nuclei selected from the group consisting Of ³¹ P ₅ ¹ H, ¹³ C, and ²³ Na, and any combination thereof; preferably, ¹ H.

[0015] The choline peak frequency is amplified during ¹ H MRS, thereby becoming a valuable marker for cell membranes. ¹ H MRS amplifies the Choline peak frequency, 10,000 times by removing the hydrogen signal from water leaving the hydrogen signal from detectable metabolites, including Choline. The choline signal is amplified another- nine-fold with the choline containing nine hydrogens per molecule (as trimethylamines or trimethylammonium salts). Further amplification occurs from the endomembranes that constitute 90% of the cell membranes, while the plasma membranes equal the remaining 10%.

[0016] The present invention also provides for a method for monitoring protein translation comprising administering an amount of the molecule or radiation to an

animal having a cancerous tissue and measuring, by Magnetic Resonance Spectroscopy, the amount of Choline present in the endomembranes of the cancerous tissue before and after administering the molecule or radiation. The present invention can be used for monitoring protein translation. Choline visualizes cellular membranes. The quantity of choline directly correlates with the amount of intracellular organelles and intracellular organelles make up 90% of cell membranes. Some organelles, such as rER, are the site of protein synthesis. Some of the proteins synthesized in the cell's organelles are inserted into cellular membranes, while other proteins synthesized in the cell's organelles are secreted as part of a coordinated cellular process. An increase in protein synthesis increases mass of these organelles and a decrease in protein synthesis decreases the mass of these organelles. Thus, the cellular Choline level also reflects cellular protein synthesis. Accordingly, drugs up-regulating or down-regulating protein translation can be monitored by following an increase in Choline (resulting from an increase in organelles). Therefore, the current invention can monitor early treatment response by quantifying Choline of intracellular organelles linked to protein synthesis (translation). Further, the effect of drugs that can interrupt or up-regulate DNA replication (which requires protein translation) or RNA transcription (which results in protein translation), can be monitored by the current invention with protein translation visualized by decreases or increases in Choline.

[0017] The term "Choline" herein is used to denote choline ((CHg) ₃ N ⁺ CH ₂ CH ₂ OH), a derivative of choline, or a combination of choline and/or one or more derivatives of choline. Examples of choline derivatives include lysophosphatidylcholine, or glycerophosphocholine, phosphomonoesters of choline (e.g., phosphocholine), phosphodiesters of choline (e.g., phosphatidylcholine), sphingomyelin, phosphoethanolamine, glycerophosphoethanolamine, or any combination thereof. In an embodiment of the invention, the term "Choline" represents the sum of choline and all choline derivatives (or total choline), for example, the sum of choline and phosphocholine. Phosphoserine and glycerophosphoserine also can be monitored Ruiz-Cabello, J. et al., NMR in Biomedicine, 5, 223-233 (1992); Podo, F., NMR in Biomedicine, 12, 413-439 (1999); and Blums, S. et al., Magn. Reson. Med., 42, 643-654 (1999).

[0018] The amount of Choline can be measured by MRS in any suitable manner. For example, the amount of Choline can be measured by measuring the height of apeak or peaks corresponding to Choline. In another embodiment, the amount of Choline can be measured by measuring the area under a peak or peaks corresponding to Choline. In yet another embodiment, the amount of Choline can be measured by measuring the ratio of the height of a peak or peaks corresponding to Choline relative to the height of a peak

or peaks of an internal standard. In a further embodiment, the amount of Choline can be measured by measuring the ratio of the area under a peak or peaks corresponding to Choline relative to the area under a peak or peaks of an internal standard. [0019] Any suitable internal standard can be used. For example, the internal standard is total creatine when the MRS is based on ¹ H resonance, or internal standard is adenosine triphosphate (ATP) when the MRS is based on ³¹ P resonance. The term "total creatine" refers to the combination of creatine and phosphocreatine. Creatine is buffered in cell systems; accordingly, the amount of creatine remains substantially constant. In accordance with this invention, the change in the amount of Choline measured as part of the early treatment response, e.g., within 168 hours or less, relates mainly, preferably only, to the change in the endomembranes. [0020] It is contemplated that the present inventive method is applicable to monitoring early treatment response wherein the treatment involves any cytotoxic therapy.

[0021] In accordance with an embodiment of the present invention, inhibition of replication, transcription and/or translation causes an interruption in an up-regulated intracellular organelle; for example, an interruption in the function of the secretory granules and/or the transporting vesicles. In accordance with another embodiment of the invention, inhibition of the replication, transcription and/or translation causes an interruption in the function of the Golgi apparatus. In further embodiments of the invention, inhibition of the replication, transcription and/or translation causes an interruption in the function of the lysosomes, the endoplasmic reticulum, the mitochondrion, the nucleus, and/or the peroxisomes.

[0022] In accordance with the present invention, any suitable cancer or tumor can be treated, for example, a cancer selected from the group consisting of brain cancer, colorectal cancer, breast cancer, acute leukemia, lung cancer, kidney cancer, squamous cell cancer, testicular cancer, stomach cancer, melanoma, sarcomas, ovarian cancer, non-small cell lung cancer, esophageal cancer, pancreatic cancer, neuroblastoma, mesothelioma, prostate cancer, bone cancer, kidney cancer, and hepatocellular cancer. [0023] In accordance with the present inventive method, early treatment response can be measured within a period of about 168 hours, preferably about 24 hours, and more preferably about 12 hours, of the treatment. For example, the response can be monitored every 12, 24, 36, 48, 60, 72, 84, 96, 108, 120, 132, 144, 156, or 168 hours, or any combination thereof, after administration of cytotoxic therapy. [0024] Treatment response can also be documented using the current invention within 24 to 168 hours by monitoring protein translation. This embodiment utilizes a magnetic resonance magnet, equal to or greater than 1.5 Tesla, uses existing software

and coils which are commercially available, has high spatial resolution, lacks radiation, employs user- friendly automatic sequences, allows non-invasive sequential analysis of drug doses/combinations, provides quantification from multi-sites, and can be employed with a plurality of drugs for trials. This embodiment can monitor treatment responses in vivo and in vitro, in humans and laboratory animals, as well as, in tissues and perfused cell extracts. This embodiment quantifies normal protein translation, as well as the amplified protein translation seen in cancer and cancer-related inflammation. Since protein translation occurs in all cells, all cancer histologies can be studied. This embodiment is applicable to cytostatic and cytotoxic drugs. Further, drugs augmenting protein translation can be monitored. Potential uses of this embodiment include, but are not limited to, drug development, detecting early cell kill and documenting the interruption of signaling pathways.

[0025] The present invention also provides a method for monitoring cancer treatment comprising: (a) localizing a tumor in a patient; (b) selecting a region of interest (ROI) of the tumor; (c) obtaining magnetic resonance spectra (MRS) of the ROI; (d) measuring the amount of Choline in the endomembranes from the MRS spectra; (e) initiating treatment comprising administering a cytotoxic therapy; (f) obtaining MR spectra of the tumor at the same ROI within a period of 7 days, preferably 3 days, and more preferably within 1 day, of initiating treatment; (g) measuring the amount of Choline in the endomembranes from the MR spectra; and (h) comparing the amount of Choline I obtained before treatment with the amount of Choline obtained after treatment; whereby a decrease in the amount of Choline after treatment is indicative of a positive response to treatment.

[0026] The basis for clinical MR studies (e.g., MRS or MRI) is the one of the nuclei, for example, the hydrogen nucleus - the proton. The same machinery is used for these studies. They differ in the software manipulation of the emitted radiofrequency (RF) from the H nuclei. In MRI, the signal is used to create the image; in MRS, the signal is used to create the spectrum. Fourier Transform principle is the basis of the computer that allows the MRS software to separate the individual RFs within the signal. The spectrum therefore represents the different RFs being emitted within the selected region of interest (ROI). The points along the horizontal axis of the spectrum represent specific RFs emitted from each metabolite. The vertical axis of the spectrum is proportional to the amount of each metabolite forming the area beneath the RF peaks. Spectra can be obtained on 0.5 to 2.0T MR scanners, although high-field strength scanners provide better definition of the spectra. Spectra obtained with different-strength scanners can be compared on a scale in parts per million (ppm) along the horizontal axis because metabolites always reside at one or more specific sites, for example, alanine resides at

1.47, N-acetylaspartate resides at 2.0 and 2.6 ppm, creatine resides at 3.0 and 3.9 ppm, Choline resides at 3.2 ppm, and water resides at 5.0 ppm.

[0027] Any suitable MR spectrometer can be used in the practice of the present invention. Clinical MR spectra can be obtained on MR scanners, for example, utilizing the clinical spectroscopy package called proton brain exam/single voxel (PROBE/S V) developed by General Electric Medical Systems (Milwaukee, WI) for use with GE' s 1.5 Tesla (T) MR scanner. See Norfray, J. et al., supra, and Norfray, J.F. et al., supra, for procedures for obtaining MR spectra, identification of the peaks corresponding to metabolites such as Choline, creatine, and others, and ratio of the peaks. See also Danielsen and Ross, Magnetic Resonance Spectroscopy Diagnosis of Neurological Diseases, Marcel Dekker, Inc. (1999); Ross, B. et al., Magnetic Resonance Quarterly, 10, 191-247 (1994); and Ross et al., U.S. Patent 5,617,861. Based on the information in the above publications, as well as information available in the art, those of skill in the art should be able to practice the invention on all types of tumors in accordance with the present invention.

[0028] The present invention can be carried out in any suitable manner, for example, as follows. Prior to initiating a therapy on a patient, the tumor is localized. Thus, for example, magnetic resonance images (MRI' s) of the tumor, e.g., brain metastasis, breast malignancy, or bone tumor, with axial, sagittal, and coronal Tl and T2 images are obtained with and without contrast. A region of interest (ROI) of tumor is selected. This can be carried out based on the MRI findings to determine the tumor volume and location to be studied. MR spectra of the ROI are obtained within the tumor utilizing short and/or long TE (echo time) pulse sequences. The spectra obtained are interpreted. The peak corresponding to Choline is identified, e.g., at a chemical shift of 3.22 ppm. Based on the Choline peak, the amount of total cellular membranes is determined from either the height of the peak or the area under the peak. An internal or external standard is identified in the ROI. An example of an internal standard is creatine or total creatine. An example of an external standard is 100% 2-(trimethylsilyl)ethanol (TSE), which may be taped to the head coil of the MR spectrometer. Kreis, R. et al., J. Magnetic Resonance, Series B 102, 9-19 (1993). The ratio of the Choline to the standard is calculated. The Choline to creatine ratio represents a measure of the total cell membranes within the ROI of the tumor prior to treatment.

[0029] The treatment of the tumor is initiated by administering an effective amount of cytotoxic agent starting from time zero. The early treatment response can be monitored, for example, at 24 hours (day 1) to 168 hours (day 7), as follows. The tumor is localized utilizing the same MRI pulse sequences as prior to the treatment. The same ROI is selected within the tumor. MR spectra of the tumor are obtained utilizing the

same pulse sequences, the same TR (relaxation time), TE (echo time), phases, and frequency averages. The MR spectra are interpreted as before and the Choline to creatine ratios (e.g., height or area ratios) are calculated.

[0030] If the observed decrease in the Choline to creatine ratio is 15% or more, preferably 20% or more, and more preferably 25% or more relative to pre-treatment condition, then it can be concluded that an early response is positive and tumor regression is achieved. The early decrease in the Choline to creatine ratio identifies a decrease in the intracellular cell membranes, for example, a decrease in the organelles and their granules and/or vesicles. If the ratio of Choline to creatine increases, e.g., a 15% or more, preferably 20% or more, and more preferably 25% or more, of an early increase in the ratio-is observed, the increase identifies an increase in the intracellular membranes, for example, an increase in the organelles and their granules and/or vesicles.

[0031] The use of MRS to follow cytotoxic therapy has one or more advantages. Coupling the amount endomembranes to the amount of protein synthesis provides a biomarker depicting meaningful biological activity. Membranes are composed of Choline molecules that can be visualized and quantified by MRS using any suitable nuclei, e.g., ³¹ P, ¹ H, and ¹³ C, preferably ¹ H. MRS measures the total choline. A decrease in the total choline documents failure of a cytotoxic therapy. Monitoring total choline is reproducible and allows quantification. The same pulse sequence by different manufacturers produces the same results allowing multi-site trials. The total choline biomarker end-point is more sensitive, and can be quantified compared to clinical end- points and MRI. It is believed that monitoring cytotoxic therapies by following endomembrane protein synthesis would have one or more of the following advantages improve patient outcome; change therapeutic choice; impact or diagnostic thinking; and impact on society.

[0032] The present invention further provides a method for determining effectiveness of cytotoxic therapy (a drug molecule or radiation) for treating cancer comprising administering the therapy (an amount of the molecule or radiation) to an animal having a cancerous tissue and measuring, by Magnetic Resonance Spectroscopy, the amount of Choline present in the cancerous tissue, particularly of the endomembranes, before and after administering the molecule, wherein the therapy comprises administration of a drug molecule or radiation cytotoxic therapy, whereby a decrease in the amount of Choline after administering the therapy is indicative of its effectiveness. The animals to be used in the present method can be, for example, mammals such as mice, rats, horses, guinea pigs, rabbits, dogs, cats, cows, pig, and monkeys. The amount of cytotoxic therapy will vary with a number of factors, e.g.,

weight of the animal, type of cancer, and severity of cancer, and is within the skill of the artisan. The potential cytotoxic drug can be administered by any suitable route of administration, e.g., oral, aerosol, parenteral, subcutaneous, intravenous, intraarterial, intramuscular, interperitoneal, rectal, and vaginal routes radiation can be hyperfractionated and/or accelerated. The cancer can be natural or induced. Thus, effectiveness of a cytotoxic therapy can be determined within a relatively short period of time, for example, within 12-168 hours, preferably 12-24 hours.

[0033] AU references, including publications, patent applications, and patents, cited herein are hereby incorporated by reference to the same extent as if each reference were individually and specifically indicated to be incorporated by reference and were set forth in its entirety herein.

[0034] The use of the terms "a" and "an" and "the" and similar referents in the context of describing the invention (especially in the context of the following claims) are to be construed to cover both the singular and the plural, unless otherwise indicated herein or clearly contradicted by context. The terms "comprising," "having," "including," and "containing" are to be construed as open-ended terms (i.e., meaning "including, but not limited to,") unless otherwise noted. Recitation of ranges of values herein are merely intended to serve as a shorthand method of referring individually to each separate value falling within the range, unless otherwise indicated herein, and each separate value is incorporated into the specification as if it were individually recited herein. All methods described herein can be performed in any suitable order unless otherwise indicated herein or otherwise clearly contradicted by context. The use of any and all examples, or exemplary language (e.g., "such as") provided herein, is intended merely to better illuminate the invention and does not pose a limitation on the scope of the invention unless otherwise claimed. No language in the specification should be construed as indicating any non-claimed element as essential to the practice of the invention.

[0035] Preferred embodiments of this invention are described herein, including the best mode known to the inventors for carrying out the invention. Variations of those preferred embodiments may become apparent to those of ordinary skill in the art upon reading the foregoing description. The inventors expect skilled artisans to employ such variations as appropriate, and the inventors intend for the invention to be practiced otherwise than as specifically described herein. Accordingly, this invention includes all modifications and equivalents of the subject matter recited in the claims appended hereto as permitted by applicable law. Moreover, any combination of the above- described elements in all possible variations thereof is encompassed by the invention unless otherwise indicated herein or otherwise clearly contradicted by context.