Achieving synergism in combination chemotherapy for gastric cancer treatment

Gastric cancer is the fifth most prevalent malignancy and the fourth-leading cause of cancer-associated deaths worldwide. Combination chemotherapy in adjunct to surgery is the mainstay of treatment in gastric cancer. However, survival rates are still very low, despite the administration of potent chemotherapeutics with different mechanisms of action in combination regimens, due to dose-limiting toxicities and chemoresistance. Endeavors in the molecular characterization of cancer enabled the incorporation of molecular-targeted agents into combination regimens and improved treatment outcomes in several cancers. However, the number of approved targeted therapies and the benefit they provide is still limited in gastric cancer. In this thesis study, we aimed to identify the molecular-targeted agent and conventional chemotherapeutic combinations with synergistic action in gastric cancer cell models and dissect the mechanisms of synergism employing powerful functional genomic approaches. Screening the dual combinations of small molecule inhibitors that target EGFR, mTOR, and cMET with five conventional chemotherapeutics with diverse mechanisms of action revealed erlotinib (EGFR inhibitor) and SN38 (topoisomerase I poison) as the most synergistic combination in all four cell models we tested. The synergism was much more robust in the gastric cancer cell model resistant to chemotherapy and stronger than that for combination regimens used in the clinic. Assessment of growth rate and cell death kinetics with FLICK assay validated that the synergism was due to increased cell death and a significant decrease in population size. With a genome-wide perturbation screen and an RNAi-based signature assay, we revealed that the synergism was mainly due to the inhibition of the ABCG2 efflux pump by erlotinib, which enhanced the action of SN38. Hence this study marks the first discovery that functional genomics methodologies identify ABCG2 as an off-target of erlotinib and a potential mechanism of drug resistance against topoisomerase I poisons in gastric cancer. Based on the insights provided by this thesis study, we propose that ABCG2 inhibition by erlotinib in the presence of topoisomerase I poisons represents a promising strategy for the treatment of both naïve and chemoresistant gastric tumors.