Abstract B56: Insights into the role of Epithelial to Mesenchymal transition (EMT) as an important mechanism of drug-resistance to molecular targeted therapies
Authors: Thomson Stuart , Buck Elizabeth , Ullman Erica , Chau Andrew , Mercado Peter , Bean James , Miglarese Mark , Epstein David , Haley John D. 
Published: March 2013

Abstract
Resistance to targeted therapies is emerging as a major theme in cancer research. As more therapies become used routinely in the clinic it is apparent that although significant responses are observed the majority of patients progress while on therapy. Drug resistance can occur through a number of distinct mechanisms and no single mechanism can account for all the resistance that occurs in response to a particular therapy. These mechanisms include acquisition of secondary drug-resistant mutations within the target and activation of alternate prosurvival signaling pathways through compensatory signaling or epithelial to mesenchymal transitions (EMT).
The ability of cancer cells to undergo an EMT has been implicated as a major factor driving metastasis, through the acquisition of enhanced migratory and invasive properties. However it is also clear that by undergoing this process the cancer cells become resistant to a number of targeted therapies. Recent retrospective analysis of phase 3 clinical trial samples has revealed that a poorer response to Erlotinib in the 2/3rd line setting in NSCLC was associated with a loss of E-cadherin (an epithelial tumor marker), suggesting that tumors that had undergone EMT were less responsive to EGFR-directed therapy. In addition an EMT phenotype has been reported in a number of EGFR-mutant NSCLC patients who have progressed while on erlotinib therapy. These clinical observations suggest that EMT plays an important role in mediating response to targeted therapy.
In order to understand the full impact of these clinical observations and identify mechanisms of resistance in mesenchymal tumor cells we have modeled EMT in a number of different ways in vitro. We have used panels of NSCLC cell lines that are in a fixed epithelial or mesenchymal state, induced an EMT with TGFβ, or driven an EMT through prolonged exposure to EGFR-TKi targeted therapy (erlotinib). Using large-scale phosphoproteomic and transcriptomic datasets we used a systems biology approach to uncover important observations relating to the role of EMT as a drug-resistance mechanism. Firstly, these models confirm the clinical observations and show that tumor cells that have undergone EMT are less responsive to a number of targeted agents including EGFR and IGF1R-IR directed agents. Secondly, they reveal the plasticity of the EMT process where three distinct stages of EMT: epithelial, ‘metastable’ mesenchymal and ‘epigenetically-fixed’ mesenchymal are observed. Thirdly, upon undergoing EMT tumor cells acquire novel mechanisms of cellular signaling not apparent in their epithelial counterparts. These include receptor tyrosine kinase (RTK) autocrine and paracrine loops, such as PDGFR, FGFR, AXL and integrin α5β1 and up regulation of IL-6 and IL-11 mediated JAK-STAT signaling. Reciprocal activation of PDGFR signaling through EGFR inhibition was observed in the mesenchymal state. Lastly, these models indicate that as part of the EMT process the tumor cells display a CD44high/CD24low cancer stem cell phenotype and show enhanced colony formation.
These observations reinforce the important role that EMT can have in driving drug resistance in tumor cells and highlight the wide diversity of mechanisms that can be used by tumor cells to evade targeted drug therapy. An understanding of these mechanisms and the contexts in which they are most likely to arise will have important implications in driving combinatorial drug therapy in cancer patients in the future.