Pancreatic Ductal Adenocarcinoma is a Disease of Excessive Autophagy. Pancreatic ductal adenocarcinoma (PDA) is a highly lethal disease characterized by early systemic dissemination, perturbation in bioenergetics, inflammation, coagulation, and resistance to chemotherapy. A common link to explain these tumor associated derangements has eluded clinicians and scientists. In genetically engineered murine models of human pancreatic cancer, we have demonstrated that IL-6 mediated autophagy induced by damage associated molecular pattern proteins (DAMPs) is a critical final pro-survival pathway in the tumor microenvironment promoting carcinogenesis, tumor progression and resistance to therapy. Unexpectedly we have now observed excessive autophagic flux is also present within multiple sites/organ systems in both murine models and patients with PDA. We hypothesize that PDA is a systemic disorder of DAMP induced excessive autophagy. Successful treatment will be associated with a return to homeostatic basal autophagy. Here we propose to directly address this hypothesis in patients by performing a randomized clinical trial of preoperative gemcitabine and nab-paclitaxel with or without the autophagy inhibitor hydroxychloroquine. We have recently completed two 'proof of principle' pilot trials of preoperative gemcitabine/hydroxychloroquine and gemcitabine/nab-paclitaxel; demonstrating the feasibility, safety and the potential for improved efficacy with this approach. We will utilize the clinical outcomes and biologic materials from these three clinical trials to investigate the following specific aims:
Specific Aim I : Demonstrate that addition of the autophagy inhibitor hydroxychloroquine improves response to pre-operative gemcitabine and nab-paclitaxel.
Specific Aim 2 : Demonstrate that addition of the autophagy inhibitor hydroxychloroquine will decrease pro-survival pathways in treated tumors.
Specific Aim 3 : Demonstrate that PDA is associated with a state of DAMP induced excessive systemic autophagy.
Adenocarcinoma of the pancreas is expected to be the fourth leading cause of cancer deaths in the United States in 2013. Five year survival is less than 5% and mortality rates are nearly identical to its incidence. We hypothesize that progression and resistance to therapeutic intervention in adenocarcinoma of the pancreas is promoted by HMGB1/RAGE signaling leading to a perpetual state of increased autophagy and resistance to apoptosis. In this proposal we will validate targeting this novel molecular pathway (HMGB1/RAGE) neo- adjuvant clinical trial. The results of this project will provide important preclinical and clinical information that will directly drive future bench-top and bedside studies.
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