Effect of surfactant dose on outcomes in preterm infants with respiratory distress syndrome: the OPTI-SURF study protocol.

INTRODUCTION: Respiratory distress syndrome is a condition seen in preterm infants primarily due to surfactant insufficiency. European guidelines recommend the dose and method of surfactant administration. However, in routine practice, clinicians often use a 'whole vial' approach to surfactant dosing. The aim of this study is to assess whether in preterm infants of gestational age 36+6 weeks+days or less, a low first dose of surfactant (100-130 mg/kg) compared with a high first dose (170-200 mg/kg) affects survival with no mechanical ventilation on either on postnatal days 3 and 4, and other outcomes. METHODS AND ANALYSIS: In this prospective, observational study, we will use the National Neonatal Research Database as the main data source. We will obtain additional information describing the dose and method of surfactant administration through the neonatal EPR system. We will use propensity scores to form matched groups with low first dose and high first dose for comparison. ETHICS AND DISSEMINATION: This study was approved by the West Midlands-Black Country Research Ethics Committee (REC reference: 18/WM/0132; IRAS project ID: 237111). The results of the research will be made publicly available through presentations at local, national or international conferences and will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT03808402; Pre-results.

Vandetanib inhibits both VEGFR-2 and EGFR signalling at clinically relevant drug levels in preclinical models of human cancer.

Vandetanib is a multi-targeted receptor tyrosine kinase inhibitor that is in clinical development for the treatment of solid tumours. This preclinical study examined the inhibition of two key signalling pathways (VEGFR-2, EGFR) at drug concentrations similar to those achieved in the clinic, and their contribution to direct and indirect antitumour effects of vandetanib. For in vitro studies, receptor phosphorylation was assessed by Western blotting and ELISA, cell proliferation was assessed using a cell viability endpoint, and effects on cell cycle determined using flow cytometry. For in vivo studies, Western blotting, ELISA and immunohistochemistry (IHC) were used to assess receptor phosphorylation. Cell culture experiments demonstrated that anti-proliferative effects of vandetanib resulted from inhibition of either EGFR or VEGFR-2 signalling in endothelial cells, but were associated with inhibition of EGFR signalling in tumour cells. Vandetanib inhibited both EGFR and VEGFR-2 signalling in normal lung tissue and in tumour xenografts. In a lung cancer model expressing an activating EGFR mutation, the activity of vandetanib was similar to that of a highly selective EGFR inhibitor (gefitinib), and markedly greater than that of a highly selective VEGFR inhibitor (vatalanib). These data suggest that at the plasma exposures achieved in the clinic, vandetanib will significantly inhibit both VEGFR-2 and EGFR signalling, and that both inhibition of angiogenesis and direct inhibition of tumour cell growth can contribute to treatment response.

Assessing the activity of cediranib, a VEGFR-2/3 tyrosine kinase inhibitor, against VEGFR-1 and members of the structurally related PDGFR family.

Cediranib is a potent inhibitor of the VEGF receptor (VEGFR)-2 and VEGFR-3 tyrosine kinases. This study assessed the activity of cediranib against the VEGFR-1 tyrosine kinase and the platelet-derived growth factor receptor (PDGFR)-associated kinases c-Kit, PDGFR-α, and PDGFR-ß. Cediranib inhibited VEGF-A-stimulated VEGFR-1 activation in AG1-G1-Flt1 cells (IC(50) = 1.2 nmol/L). VEGF-A induced greatest phosphorylation of VEGFR-1 at tyrosine residues Y1048 and Y1053; this was reversed by cediranib. Potency against VEGFR-1 was comparable with that previously observed versus VEGFR-2 and VEGFR-3. Cediranib also showed significant activity against wild-type c-Kit in cellular phosphorylation assays (IC(50) = 1-3 nmol/L) and in a stem cell factor-induced proliferation assay (IC(50) = 13 nmol/L). Furthermore, phosphorylation of wild-type c-Kit in NCI-H526 tumor xenografts was reduced markedly following oral administration of cediranib (≥1.5 mg/kg/d) to tumor-bearing nude mice. The activity of cediranib against PDGFR-ß and PDGFR-α was studied in tumor cell lines, vascular smooth muscle cells (VSMC), and a fibroblast line using PDGF-AA and PDGF-BB ligands. Both receptor phosphorylation (IC(50) = 12-32 nmol/L) and PDGF-BB-stimulated cellular proliferation (IC(50) = 32 nmol/L in human VSMCs; 64 nmol/L in osteosarcoma cells) were inhibited. In vivo, ligand-induced PDGFR-ß phosphorylation in murine lung tissue was inhibited by 55% following treatment with cediranib at 6 mg/kg but not at 3 mg/kg or less. In contrast, in C6 rat glial tumor xenografts in mice, ligand-induced phosphorylation of both PDGFR-α and PDGFR-ß was reduced by 46% to 61% with 0.75 mg/kg cediranib. Additional selectivity was showed versus Flt-3, CSF-1R, EGFR, FGFR1, and FGFR4. Collectively, these data indicate that cediranib is a potent pan-VEGFR kinase inhibitor with similar activity against c-Kit but is significantly less potent than PDGFR-α and PDGFR-ß.

Vascular endothelial growth factor receptors VEGFR-2 and VEGFR-3 are localized primarily to the vasculature in human primary solid cancers.

PURPOSE: Vascular endothelial growth factor (VEGF) signaling is key to tumor angiogenesis and is an important target in the development of anticancer drugs. However, VEGF receptor (VEGFR) expression in human cancers, particularly the relative expression of VEGFR-2 and VEGFR-3 in tumor vasculature versus tumor cells, is poorly defined. EXPERIMENTAL DESIGN: VEGFR-2- and VEGFR-3-specific antibodies were identified and used in the immunohistochemical analysis of human primary cancers and normal tissue. The relative vascular localization of both receptors in colorectal and breast cancers was determined by coimmunofluorescence with vascular markers. RESULTS: VEGFR-2 and VEGFR-3 were expressed on vascular endothelium but not on malignant cells in 13 common human solid tumor types (n > 400, bladder, breast, colorectal, head and neck, liver, lung, skin, ovarian, pancreatic, prostate, renal, stomach, and thyroid). The signal intensity of both receptors was significantly greater in vessels associated with malignant colorectal, lung, and breast than adjacent nontumor tissue. In colorectal cancers, VEGFR-2 was expressed on both intratumoral blood and lymphatic vessels, whereas VEGFR-3 was found predominantly on lymphatic vessels. In breast cancers, both receptors were localized to and upregulated on blood vessels. CONCLUSIONS: VEGFR-2 and VEGFR-3 are primarily localized to, and significantly upregulated on, tumor vasculature (blood and/or lymphatic) supporting the majority of solid cancers. The primary clinical mechanism of action of VEGF signaling inhibitors is likely to be through the targeting of tumor vessels rather than tumor cells. The upregulation of VEGFR-3 on tumor blood vessels indicates a potential additional antiangiogenic effect for dual VEGFR-2/VEGFR-3-targeted therapy.

Sck is expressed in endothelial cells and participates in vascular endothelial growth factor-induced signaling.

Sck, a member of the Shc family of cell signaling proteins, has only been studied in neuronal cells, though previous studies have demonstrated its expression in tissues other than brain. Using RT-PCR and RNase protection assays, we detected Sck mRNA expression in endothelial cells, and Sck protein was detected by Western blotting using polyclonal and monoclonal antibodies targeting the Sck CH1 domain. Immunohistochemistry protocols demonstrate that Sck is expressed in KDR and PECAM positive cells found in the mouse retina, mouse heart and human umbilical chord. Treatment of human umbilical vein endothelial (HUVE) cells with vascular endothelial growth factor (VEGF) leads to the recruitment of Sck to the KDR VEGF receptor and an enhanced Sck tyrosine phosphorylation. Sck is recruited to KDR tyrosine 1175, as co-immunoprecipitation of KDR and Sck is not observed in VEGF-treated porcine aortic endothelial cells expressing a receptor mutated at this autophosphorylation site. The Sck and Shc SH2 domains, and not the PTB domain, mediates its interactions with KDR, as recombinant Sck SH2 domain binds to a tyrosine phosphorylated KDR 1175-derived synthetic peptide, but not to a peptide synthesized without tyrosine phosphate. Recombinant PLCgamma SH2 domain also interacts with the phosphotyrosine 1175 containing peptide. VEGF-induced MAPK activation is dependent upon PLCgamma activity, and chimeric proteins consisting of the Shc or Sck SH2 domains fused with a cellular internalization sequence attenuated this activation. Taken together, these results demonstrate that Sck is expressed in vascular endothelial cells, and participates in VEGF-induced signal transduction.

Fibroblast growth factor receptor substrate 2 participates in vascular endothelial growth factor-induced signaling.

Vascular endothelial growth factor (VEGF) activates endothelial cells, in part, by interacting with the kinase insert domain-containing receptor (KDR) receptor tyrosine kinase. Although progress has been made in the identification of cell-signaling proteins that participate in the VEGF-induced response, questions remain concerning the molecular interactions that allow coupling of receptor activation with an increased cellular response. Evidence is provided in this manuscript that indicates a role for the fibroblast growth factor receptor substrate 2 (FRS2) in VEGF-induced signal transduction. VEGF treatment of human umbilical vein endothelial cells (HUVECs) and KDR-transfected porcine aortic endothelial cells leads to the rapid tyrosine phosphorylation of FRS2. FRS2 is associated constitutively with KDR, and VEGF treatment has no effect on this interaction. VEGF treatment of KDR-expressing cells leads to the recruitment of Nck, p21-activated kinase, Crk, Grb2, and protein kinase C l to FRS2. The ability of FRS2 to recruit cell-signaling proteins to the cell is significant because it provides a mechanism for enhancing the repertoire of VEGF-induced signaling pathways.