KIT gain of function mutations play an important role in the pathogenesis of gastrointestinal stromal tumors (GISTs). Imatinib is a selective tyrosine kinase inhibitor of ABL, platelet-derived growth factor receptor (PDGFR), and KIT and represents a new paradigm of targeted therapy against GISTs. Here we report for the first time that, after imatinib treatment, an additional specific and novel KIT mutation occurs in GISTs as they develop resistance to the drug. We studied 12 GIST patients with initial near-complete response to imatinib. Seven harbored mutations in KIT exon 11, and 5 harbored mutations in exon 9. Within 31 months, six imatinib-resistant rapidly progressive peritoneal implants (metastatic foci) developed in five patients. Quiescent residual GISTs persisted in seven patients. All six rapidly progressive imatinib-resistant implants from five patients show an identical novel KIT missense mutation, 1982T3 C, that resulted in Val654Ala in KIT tyrosine kinase domain 1. This novel mutation has never been reported before, is not present in pre-imatinib or post-imatinib residual quiescent GISTs, and is strongly correlated with imatinib resistance. Allelic-specific sequencing data show that this new mutation occurs in the allele that harbors original activation mutation of KIT.

We report a new mechanism of aberrant pre-mRNA splicing resulting in constitutive activation of a mis-spliced oncoprotein (KIT) leading to malignancy (gastrointestinal stromal tumor) in contrast to loss of function of misspliced proteins resulting in diverse human diseases in the literature. The mechanisms of three consecutive molecular events, deletion of noncoding and coding regions encompassing the 3 0 authentic splice site, creation of a novel intra-exonic pre-mRNA 3 0 splice acceptor site leading to in-frame loss of 27 nucleotides (nine amino acids; Lys550-Lys558), and the mechanism of constitutive activation of the mis-spliced KIT are elucidated. Loss of a peptide in a critical location unleashed the protein from autoinhibition (as evidenced by three-dimensional structural analysis), causing KIT to become constitutively activated and resulting in the GIST phenotype. We also demonstrated that only one of the following two exonic splicing enhancers is sufficient for inclusion of the KIT exon 11 in vivo: AACCCATGT (nucleotides 2-10 from the 5 0 end, which are recognized by SC35, SRp55, and SF2/ASF) or GGTTGTTGAGG (nucleotides 27-37 from the 5 0 end, which are recognized by SC35 and SRp55), suggestive of exonic enhancer redundancy.

Activating mutation in KIT or platelet-derived growth factor-a can lead to gastrointestinal stromal tumors (GISTs). Eighty-four cases from two institutes were analyzed. Of them, 62 (74%) harbored KIT mutations, 7 of which are previously unreported. One exhibited duplication from both intron 11 and exon 11, which has not been reported in KIT in human cancer. A homozygous/hemizygous KIT-activating mutation was found in 9 of the 62 cases (15%). We identified three GIST patients with heterozygous KIT-activating mutations at initial presentation, who later recurred with highly aggressive clinical courses. Molecular analysis at recurrence showed total dominance of homozygous (diploid) KIT-activating mutation within a short period of 6-13 months, suggesting an important role of oncogene homozygosity in tumor progression. Topoisomerase II is active in the S-and G 2 phases of cell cycle and is a direct and accurate proliferative indicator. Cellular and molecular analysis of serial tumor specimens obtained from consecutive surgeries or biopsy within the same patient revealed that these clones that acquired the homozygous KIT mutation exhibited an increased mitotic count and a striking fourfold increase in topoisomerase II proliferative index (percentage cells show positive topoisomerase II nuclear staining compared to the heterozygous counterpart within the same patient. KIT forms a homodimer as the initial step in signal transduction and this may account for the quadruple increase in proliferation. Using SNPs for allelotyping on the serial tumor specimens, we demonstrate that the mechanism of the second hit resulting in homozygous KIT-activating mutation and loss of heterozygosity is achieved by mitotic nondisjunction, contrary to the commonly reported mechanism of mitotic recombination. Keywords: homozygous KIT mutation; GIST; SNP Gastrointestinal stromal tumors (GISTs) originate from the interstitial cells of Cajal and are driven by a proliferative signal resulting from dominant activating mutations of KIT or platelet-derived growth factor receptor-a (PDGFRA).

Current evidence suggests that carbonic anhydrase I1 (CA 11) is produced by pancreatic duct cells but not by pancreatic acinar or islet cells. The aim of this study was to determine whether CA I1 homologous RNA and CA I1 immunoreactive protein are produced by cell lines established from human pancreatic adenocarcinomas. A 1.7-Kb CA I1 homologous RNA was detected in poly(A+) RNA isolated from normal human pancreas, normal human liver, and to varying degrees in the cell lines examined. The CA I1 immunoreactivity corresponding to approximately 30 kD (consistent with the established molecular mass of CA 11) was also detected by immunoblotting in normal human pancreas, normal human liver, and some of the cell lines. We also found that the levels of CA I1 homologous RNA increase in the pancreatic adenocarcinoma cell lines following treatment with the differentiating agent, retinoic acid.

Conventional chemotherapeutic drugs are ineffective in treatment of gastrointestinal stromal tumors (GISTs). Imatinib (STI571, Gleevec, Glivec; Novartis Pharmaceuticals, East Hanover, NJ), a selective inhibitor of KIT, ABL, BCR-ABL, PDGFRA, and PDGFRB, represents a new paradigm of targeted cancer therapy and has revolutionized the treatment of patients with chronic myelogenous leukemia and GISTs. Unfortunately, imatinib resistance has emerged. The reported mechanism of imatinib resistance in GISTs involves missense mutation in the kinase domain of KIT, including Thr670Ile, Tyr823Asp, and Val654Ala. The established mechanisms and potential mechanisms of imatinib resistance in GISTs, the imaging studies indicative of early development of imatinib resistance, and the management of imatinib-resistant GISTs are discussed.

Elongation factor-1 (EF-1) gamma is overexpressed in a high proportion of gastrointestinal cancers. The mechanism of overexpression has not been determined. The purpose of this study was to examine cDNA specimens from pancreatic and colorectal cancer for mutation in this gene, which would allow us to determine whether gene mutations are responsible for overexpression of EF-1gamma. In one colorectal carcinoma, we detected an A-->G transition at amino-acid codon 158 (T-->C in the sense strand) resulting in a change from a leucine to a serine. The base change was not detected in cDNA isolated from normal-appearing tissue from the same patient. We did not find mutations in another five colorectal carcinoma and five pancreatic cancer samples. Thus, although we detected a mutation in one tumor, the frequency of mutations was too low to account for the high frequency of overexpression of the EF-1gamma RNA in colorectal cancer. We also investigated other possible mechanisms of overexpression of the EF-1gamma RNA in this study. Slot-blot analysis of DNA isolated from colorectal cancers showed that the overexpression was not due to gene amplification. Using serum starvation to synchronize cultured cells, we showed that the overexpression was also not due to an increase in the number of cycling cells, as occurs in cancer. Using Southern blot analysis, we were unable to detect genome rearrangements that could have been responsible for the overexpression. In conclusion, the mechanism for overexpression of the EF-1gamma gene in colorectal and pancreatic cancer remains unknown. However, mutations in the coding sequence of the gene, gene amplification, and gene rearrangement do not account for the high frequency of overexpression of this gene, and the overexpression is not due to an increase in the number of cycling cells.

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Elongation factor-1 (EF-1) gamma is overexpressed in a high proportion of gastrointestinal cancers. The mechanism of overexpression has not been determined. The purpose of this study was to examine cDNA specimens from pancreatic and colorectal cancer for mutation in this gene, which would allow us to determine whether gene mutations are responsible for overexpression of EF-1gamma. In one colorectal carcinoma, we detected an A-->G transition at amino-acid codon 158 (T-->C in the sense strand) resulting in a change from a leucine to a serine. The base change was not detected in cDNA isolated from normal-appearing tissue from the same patient. We did not find mutations in another five colorectal carcinoma and five pancreatic cancer samples. Thus, although we detected a mutation in one tumor, the frequency of mutations was too low to account for the high frequency of overexpression of the EF-1gamma RNA in colorectal cancer. We also investigated other possible mechanisms of overexpression of the EF-1gamma RNA in this study. Slot-blot analysis of DNA isolated from colorectal cancers showed that the overexpression was not due to gene amplification. Using serum starvation to synchronize cultured cells, we showed that the overexpression was also not due to an increase in the number of cycling cells, as occurs in cancer. Using Southern blot analysis, we were unable to detect genome rearrangements that could have been responsible for the overexpression. In conclusion, the mechanism for overexpression of the EF-1gamma gene in colorectal and pancreatic cancer remains unknown. However, mutations in the coding sequence of the gene, gene amplification, and gene rearrangement do not account for the high frequency of overexpression of this gene, and the overexpression is not due to an increase in the number of cycling cells.