antibodies Antibodies Antibodies Antibodies 2079-6382 MDPI 10.3390/antib2010082 antibodies-02-00082 Review An Old Idea Tackling a New Problem: Targeted Toxins Specific for Cancer Stem Cells Waldron Nate N. 1 Vallera Daniel A. 2 * Department of Pharmacology, University of Minnesota, 210 Delaware Street Southeast Minneapolis, MN 55455, USA Department of Therapeutic Radiology-Radiation Oncology, Section on Molecular Cancer Therapeutics, University of Minnesota Masonic Cancer Center, 425 East River Parkway Minneapolis, MN 55455, USA Author to whom correspondence should be addressed; E-Mail: valle001@umn.edu; Fax: +1-612-626-4842. 28 01 2013 03 2013 2 1 82 92 06 12 2012 19 01 2013 22 01 2013 © 2013 by the authors; licensee MDPI, Basel, Switzerland. 2013

This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license (http://creativecommons.org/licenses/by/3.0/).

Targeting and killing specific cells discriminately has been the goal of targeted therapy dating back to the era of Paul Ehrlich. The discovery of cancer stem cells has caused a paradigm shift within the cancer field and provided an opportunity to use targeted therapies such as targeted toxins to bind and kill these cells selectively. A number of targeted toxins have been developed against recently identified cancer stem cell markers. In this review we discuss the development and current status of these exciting novel drugs and their potential use to combat drug-refractory relapse.

 cancer stem cells targeted toxins immunotoxins CD133 EpCAM CD123 CD44 Abbreviations dCD133KDEL

deimmunized pseudomonas exotoxin fused to anti-CD133 scFv with a KDEL terminus

 KDEL

amino acid sequence Lys-Asp-Glu-Leu

 mAb

monoclonal antibody

 TT

Targeted toxin

 PE

pseudomonas exotoxin

 scFv

recombinant single chain VH and VL domain

 1. Introduction

The idea of specifically targeting and killing cells responsible for disease is not a new one. Paul Ehrlich discovered the first targeted therapy, Arsphenamine, in 1909. This work inspired scientists in a range of disciplines over the next 100 years to continue working and developing new therapeutics that specifically destroy target cells. Immunotoxins, hereafter referred to more generally as targeted toxins, descended from this early work and have been used in cancer therapy for decades [1,2].

Targeted toxins (TTs) are biological drugs consisting of a ligand linked to a protein toxin. Some of the most commonly used toxins are pseudomonas exotoxin (PE), diptheria toxin (DT), ricin, saporin, bouganin, and gelonin. These toxins act catalytically on target cells to induce apoptosis using a range of mechanisms from inhibiting protein translation via ADP-ribosylation of EF-2 (PE and DT) to inactivating ribosomes (ricin, saporin, bouganin, gelonin) [3]. While the mechanism of action may vary, the one constant is that the TT must reach the target cells and the ligand portion of the molecule must bind its specific receptor and then be internalized before it is able to induce apoptosis. These ligands are typically antibodies, antibody fragments, cytokines, or growth factors, all specific to their target receptor [3,4].

The past decade has witnessed a paradigm shift within the cancer field. There has been overwhelming evidence recently presented in a wide range of tumor types that there exists a typically small subpopulation of cells within the cancer that have been termed cancer stem cells (CSCs). These cells can enhance tumor initiation, self-propagation, and differentiation into all the phenotypically diverse cells found within the tumor population. Furthermore, CSCs have been shown to be more chemotherapy and radiation resistant than non-CSCs [5,6]. This explains the single most difficult problem in treating cancer patients, drug-refractory relapse. Thus, new therapeutic agents are necessary to target these cells in particular in order to prevent drug-resistant relapse. A logical approach to eliminate CSCs is to target their unique cell surface markers.

A number of markers have been identified that allow for the separation and ultimately targeting of CSCs. In 1997, Bonnet and Dick reported the first CSCs in acute myeloid leukemia. These cells were characterized as being CD34+/CD38− [7]. Since then a number of markers have been used to successfully identify CSCs in a broad range of tumor types. However, only cell surface markers, not intracellular markers, are useful when it comes to treatment using TTs. Thus, this review will focus only on TTs specific for these markers. Table 1 shows the CSC TTs discussed herein and their phase of development.

 2. Cancer Stem Cell Targeted Toxins 2.1. CD123

CD123, also known as IL-3Rα, is the alpha subunit of interleukin-3 and is expressed on leukemic stem cells (LSCs) in Acute Myeloid Leukemia (AML), Chronic Myeloid Leukemia (CML), Myelodysplastic Syndrome (MDS), and Systemic Mastocytosis [8]. An anti-IL3 Diphtheria toxin fusion protein (DT388IL3) recently completed a phase I clinical trial [9]. Out of 45 patients, three had complete or partial responses with four more having minimal responses. Transaminasemia, vascular leak syndrome, and fever were the main toxicities in this study. These toxicities point to the need to improve selectivity and potency in order to increase efficacy.

antibodies-02-00082-t001_Table 1

Targeted Toxins directed against CSC markers currently under investigation.

Target Name Toxin Cancer Phase of Development Reference
IL3 DT388IL3 Diphtheria Toxin AML Phase I [9]
CD123 26292(Fv)-PE38-KDEL Pseudomonas Exotoxin A AML Preclinical [10]
CD44 Bivatusumab Mertansine Maytansine HNSCC Phase I [16,17]
Derivitive
EpCAM chiHEA125-Ama α-Amanitin Pancreas Preclinical [24]
EpCAM Ec4-ETA Pseudomonas Exotoxin A Colon Preclinical [26]
EpCAM Opportuzumab Monatox Pseudomonas Exotoxin A Bladder Phase II [27,28]
HNSCC Phase I [29]
EpCAM VB6-845 deBouganin Breast Preclinical [30]
EpCAM/Her2 DTEpCAM23 Diphtheria Toxin Colon Preclinical [23]
CD133 CdtAC149A, C178ABC-CD133MAb Cytolethal Distending Toxin HNSCC Preclinical [35]
CD133 dCD133KDEL Deimmunized Pseudomonas Exotoxin A HNSCC Preclinical [36]
Breast Preclinical [38]

Notes: Several laboratories are now investigating a range of different approaches and toxins targeting cancer stem cell associated markers. In several of the preclinical studies, more than one cancer type was investigated.

A TT called 26292(Fv)-PE38-KDEL was developed to target LSCs that shows a promising increase in selectivity and potency compared to DT388IL3. This TT combines a single chain variable fragment (scFv) with a truncated form of pseudomonas exotoxin, which was mutated to increase activity and has shown good activity against several leukemia lines [10]. The activity appears to be dependent on a threshold level of CD123 expression on the leukemia cells, which can vary greatly from patient-to-patient. Additional studies are needed to further assess efficacy and toxicity of this TT.

 2.2. CD44

CD44 has become a useful marker for identifying CSCs in AML, colon, head and neck squamous cell carcinoma (HNSCC), and other cancers as well [11,12]. CD44 is a member of a cell adhesion molecule (CAM) family of proteins involved with regulating growth, differentiation, survival, and migration. Bivatuzumab is a humanized monoclonal antibody specific for the anti-CD44v6 isoform of CD44. This isoform in particular correlates with poor prognosis in a number of cancers, including gastric, breast, and colorectal cancer [13,14].

Researchers have recently tried targeting CD44 with Bivatuzumab conjugates with some promising results [15,16,17]. One of these conjugates is a targeted toxin named Bivatusumab mertansine (or BIWI 1), and it has recently been tested clinically to treat head and neck squamous cell carcinoma (HNSCC). BIWI 1 consists of a monoclonal antibody conjugated to a potent maytansine derivitive. In the phase 1 study of patients with advanced multi-drug-refractory HNSCC, three patients out of 31 showed significant improvement in the study with visible tumor regression [16,17]. However, the study was terminated prior to completion following the death of a patient in a parallel study due to toxic epidermal necrolysis. While this study’s objective was to determine toxicity and safety, the fact that some efficacy was observed suggests potential of targeting CD44. However, more work is needed to reduce the limiting toxicities.

 2.3. EpCAM

Epithelial cell adhesion molecule (EpCAM, also known as CD326 and ESA) is a well-known overexpressed marker on many carcinomas. Initially thought to simply be a cell-cell adhesion molecule, more recently it has been discovered that EpCAM has diverse roles within cancer cells that range from cell signaling and migration to proliferation and differentiation [18]. Even more interesting are the findings that EpCAM is expressed at an even higher level on CSCs and correlates with increased tumorigenesis versus non-EpCAM positive cells in breast, pancreatic, hepatocellular, HNSCC, and other carcinomas as well [19,20,21]. This finding may not be completely surprising based on the recent evidence showing EpCAM is a direct target in the Wnt/β-catenin signaling pathway, which is a critical pathway in both normal adult stem cells and CSCs [6,22]. Furthermore, EpCAM is an attractive receptor for TTs because it efficiently internalizes when bound by an antibody or an scFv enabling toxin bearing molecules easy access to the interior of the target cells where they can act to induce apoptosis [23]. Recently, a number of anti-EpCAM TTs have been developed and show great promise in both pre-clinical testing and in recent clinical trials.

One of these EpCAM TTs was created by conjugating α-amanitin (a mushroom toxin) to the anti-EpCAM chimerized monoclonal antibody chiHEA125. This targeted toxin called chiHEA125-Ama was then tested against pancreatic carcinoma in vitro and in a mouse xenograft model with significant efficacy. Six of ten and nine of ten in the highest concentration groups (50 and 100 µg/kg) showed no visible tumors at day 16 after only two injections of chiHEA125-Ama. It was also found to be potently active against other EpCAM positive carcinoma lines in vitro as well. At the doses tested, no observable toxicity was detected in an analysis of blood liver enzymes levels [24]. Pancreatic cancer is the fourth leading cause of death in the United States and with extremely limited therapeutic options available chiHEA125-Ama warrants further development as a potential anticancer agent for pancreatic (and other EpCAM expressing) cancer [25].

An interesting TT was recently developed that combines the same truncated form of pseudomonas exotoxin with an anti-EpCAM DARPin and is named Ec4-ETA [26]. DARPins, or designed ankyrin repeat proteins, are a new class of binding molecules that can be engineered to be highly specific and have very high affinity for a given receptor. They are very stable, easily manipulated, and produce high yields when expressed in Escherichia coli. Ec4-ETA is the first known example of a DARPin targeted toxin. Ec4-ETA was tested in vitro against a number of EpCAM positive carcinomas and showed IC50 values in the sub-picomolar range. It also efficiently localized to colon carcinoma xenografts when given systemically and significantly inhibited tumor growth. Furthermore, Ec4-ETA was well tolerated and showed no detectable liver toxicity in the mice. This study shows that DARPins could be used in place of antibodies or antibody fragments in TTs as successful, high affinity targeting ligands.

Oportuzumab Monatox, also known as VB4-485, is an anti-EpCAM TT produced by Viventia Biotechnologies that has recently completed three clinical trials [27,28,29]. Oportuzumab Monatox (OM) was produced by fusing a truncated form of Pseudomonas exotoxin A (ETA) to an scFv of the humanized anti-EpCAM antibody MOC31. The first two clinical trials were in patients with grade 2 or 3 stage drug-refractory transitional cell carcinoma of the bladder. In the phase one study, 64 patients were enrolled in dose escalating cohorts where the highest dose given was 30.16 mg. Patients received intravesically administered OM once a week for six consecutive weeks, and were followed for an additional 4–6 weeks and then reassessed. During the study no dose-limiting toxicity was identified and so a maximum tolerated dose (MTD) was not determined. They did find that 77% of the patients did develop human anti-toxin antibodies by the end of the study, with 16% developing human anti-human antibodies. However, upon reassessment at the 12-week time point 24 of the patients (39%) achieved a complete response defined as a nonpositive urinary cytology with either a normal cystoscopy or an abnormal cystoscopy with a negative biopsy [27]. This is impressive especially since the doses in this study were not optimized for efficacy. In the phase two study 46 patients received either 6 or 12 weekly 30 mg treatments. At the end of the study 20 patients (44%) achieved a complete response and 7 patients (16%) were still disease free 18–25 months following the end of the study. Furthermore, no patients had to discontinue treatment due to an adverse affect [28]. OM may prove to be a valuable agent for bladder carcinoma in monotherapy or possibly in combination with other therapies.

In another phase one clinical trial in twenty patients with advanced recurrent HNSCC, OM was administered intratumorally weekly for four weeks. The MTD was determined to be 930 µg with elevated liver enzymes being the dose limiting toxicity. All patients at the end of the study had detectable anti-toxin antibodies and neutralizing antibodies developed in seven of the patients. However, there was a positive response in 87.5% of EpCAM-positive patients. Four patients showed tumor growth stabilization, while 10 others had a notable regression. Another four patients exhibited complete responses to the treatment [29].

Because neutralizing antibodies are a problem for OM, Viventia has developed a new variation of this drug with reduced immunogenicity. This new variant, VB6-845 uses the same anti-EpCAM scFv, but the pseudomonas exotoxin fragment is swapped out for a deimmunized version of Bouganin, a plant toxin that acts through deadenylation of rRNA thus blocking protein translation. Preclinical testing has shown good efficacy and safety and it will be interesting to see how this drug performs in upcoming clinical trials [30]. Overall, OM has exhibited very promising results and may be an effective therapeutic in the treatment of HNSCC as well as transitional cell carcinoma of the bladder.

Our laboratory has developed a bispecific TT that targets both EpCAM and erbB2, the gene product of Her2 that is overexpressed on 30–40% of ovarian and breast cancers [23]. This bispecific, called DTEpCAM23, showed potent picomolar activity in vitro against a range of carcinomas including breast, colon, ovarian, lung, and prostate cancer. DTEpCAM was more effective than either monospecific TT alone or in combination. Furthermore, in two tumor models of colon cancer, DTEpCAM23 significantly inhibited tumor growth. Bispecific TTs may prove to be very useful moving forward because they can target both CSC and the more differentiated tumor cell populations as well.

 2.4. CD133

Another major cancer stem cell marker that has been targeted is CD133, also known as Prominin-1. CD133 is a pentaspan membrane glycoprotein and has been shown to be a marker of the CSC populations in many carcinomas including breast, colon, prostate, liver, pancreatic, lung and HNSCC [11,31]. It is known to be associated with the Wnt signaling pathway because down-regulation of CD133 results in corresponding degradation of β-catenin and decreased proliferation in vitro and in vivo [32,33,34]. However, the specific function of this cell surface receptor is still unknown.

The first known TT that selectively inhibits the CD133+ cell population is called CdtAC149A, C178ABC-CD133MAb. This TT uses the anti-CD133 antibody AC133 conjugated to cytolethal distending toxin (Cdt). Cdt acts as a nuclease and damages host DNA leading to growth arrest and subsequent cell death. In this study, the proliferation of CD133+ HNSCC cells was arrested thus providing a necessary proof of concept showing that CD133 is internalized (a necessary step in TT function) and can be specifically targeted to inhibit cell growth [35].

Our group has recently developed a deimmunized anti-CD133 TT called dCD133KDEL. It combines an scFv from a novel monoclonal antibody (clone 7) with a deimmunized truncated form of pseudomonas exotoxin A [36]. This new monoclonal antibody is unique in that it binds all isoforms of CD133 thus avoiding the controversy surrounding AC133 resulting from its binding to only some undifferentiated epitopes and restricting its use [37]. By mutating immunogenic epitopes on the pseudomonas exotoxin, we significantly reduced the risk of dCD133KDEL having the same problem many other TTs have had in the clinic: that is the development of neutralizing antibodies against the toxin portion of the protein. In our first paper on dCD133KDEL, we showed its ability to inhibit the proliferation of two HNSCC cell lines in vitro, suppress tumor initiation, and cause significant tumor regression in vivo while only killing the small subpopulation of CD133+ cells. A therapeutic window was demonstrated between dCD133KDEL’s killing of CD133+ cancer stem cells in our time course viability assay and killing of normal CD133+ hematopoietic stem cells in a colony formation assay [36]. In a second paper we showed dCD133KDEL is effective against breast carcinoma in vitro and in a systemic mouse model as well [38]. We have also tested this TT against the ovarian cancer line OVCAR5 in vitro and in vivo with very good preliminary results [39]. It also has an excellent safety profile that makes it possible to give multiple courses of 20 µg injection per nude mouse, where one course is 3 weekly injections given Monday, Wednesday, and Friday. The MTD in athymic nude mice was determined to be 2.0 mg/kg (5 times the dose used in vivo) and the limiting toxicity at this dose is liver toxicity indicated by elevated Alanine Transaminase levels (unpublished data). Table 2 summarizes the various tumors and model systems we have investigated to date using dCD133KDEL. This new CSC specific TT shows significant potential as a possible therapeutic for carcinomas where CD133 has been shown to be a marker for CSCs.

antibodies-02-00082-t002_Table 2

A summary of the cancer and model types used to date by our group in evaluating the efficacy of dCD133KDEL.

Cell Line Cancer Type Model Type Response Obtained Reference
UMSCC-11B HNSCC Flank Regression [36]
MDA-MB-231 Breast Systemic Partial Regression [38]
OVCAR-5 Ovarian Intraperitoneal Regression [39]

Notes: Our group has published independent reports using 3 different xenograft models to assess the efficacy of dCD133KDEL in immunodeficient mice.

 3. Conclusions

CSCs have been shown to be more resistant to chemotherapy and irradiation than more differentiated cancer cells that make up the bulk of the tumor. CSC then may be at the root of our most serious problem in cancer, drug refractory tumor relapse. Thus, it would be perilous to ignore them as therapeutic targets. TTs may prove to be uniquely qualified to fill this role because of their extremely high potency and exquisite selectivity.

A major concern of drugs that target CSC surface markers is that they would also kill normal adult progenitor cells that also express these same markers. In our work on dCD133KDEL, we partially addressed this concern by testing umbilical cord blood cells that were 76% CD133+. At a concentration 100 times greater than used to inhibit the proliferation of HNSCC cells in vitro, the normal human hematopoietic stem cells were not inhibited [36]. There are several hypotheses that could explain this therapeutic window. First, the CD133+ cells could have been killed and then replaced by the CD133- cell population. Two different groups have demonstrated this type of plasticity in progenitor cells recently [40,41]. Second, normal hematopoietic progenitors may be more quiescent and have a slower endocytic uptake than CSC and thus not be as effected by the toxin. Finally, the CSC may express CD133 at a higher level then the normal progenitor cells, which is true in colorectal, pancreatic, gastric, and hepatocellular carcinomas [42]. Each of these separately or in combination could explain the ability for dCD133KDEL to specifically kill CSC and not normal hematopoietic progenitors.

In the broader picture, each target will have a different therapeutic window, but our work shows significant promise that CSCs can be selectively eliminated. However, several strategies exist to limit the toxicity of systemically administered drugs. We described a method called ToxBloc where an intraperitoneal pre-dose of the ligand without toxin was given prior to injection with the targeted toxin. This allowed us to give doses 15-fold higher than the maximal tolerated dose [43]. Other possible methods include photochemical internalization and ultrasound triggered drug delivery via microbubbles [44,45].

Since many tumors are phenotypically diverse, the use of multiple drugs in combination may be necessary to successfully increase the percentage of tumor regressions in patients. It is already established that TTs work synergistically with chemotherapy [46,47]. So, new TTs that selectively attack CSCs could be an important weapon to combat drug refractory relapse.

Acknowledgements

We would like to acknowledge Drs Jayanth Panyam and John Ohlfest for the help in the development and investigation of dCD133KDEL. This work was supported in part by the US Public Health Service Grants RO1-CA36725, R01 HL077923 awarded by the NCI and the NIAID, DHHS, the Randy Shaver Foundation, the Lion’s Children’s Cancer Fund, and the William Lawrence and Blanche Hughes Fund.

Supplementary Materials

Supplementary materials can be accessed at: http://www.mdpi.com/2073-4468/2/1/82/s1.

 Supplementary Files References Kornek G. Selzer E. Targeted therapies in solid tumours: pinpointing the tumour’s Achilles heel Curr. Pharm. Des. 2009 15 207 242 10.2174/138161209787002906 Strom T.B. Anderson P.L. Rubin-Kelley V.E. Williams D.P. Kiyokawa T. Murphy J.R. Immunotoxins and cytokine toxin fusion proteins Semin. Immunol. 1990 2 467 479 Madhumathi J. Verma R.S. Therapeutic targets and recent advances in protein immunotoxins Curr. Opin. Microbiol. 2012 15 300 309 Choudhary S. Mathew M. Verma R.S. Therapeutic potential of anticancer immunotoxins Drug Discov. Today 2011 16 495 503 10.1016/j.drudis.2011.04.003 Eyler C.E. Rich J.N. Survival of the fittest: Cancer stem cells in therapeutic resistance and angiogenesis J. Clin. Oncol. 2008 26 2839 2845 10.1200/JCO.2007.15.1829 Moncharmont C. Levy A. Gilormini M. Bertrand G. Chargari C. Alphonse G. Ardail D. Rodriguez-Lafrasse C. Magne N. Targeting a cornerstone of radiation resistance: Cancer stem cell Cancer Lett. 2012 322 139 147 10.1016/j.canlet.2012.03.024 Bonnet D. Dick J.E. Human acute myeloid leukemia is organized as a hierarchy that originates from a primitive hematopoietic cell Nat. Med. 1997 3 730 737 10.1038/nm0797-730 Ten Cate B. de Bruyn M. Wei Y. Bremer E. Helfrich W. Targeted elimination of leukemia stem cells; a new therapeutic approach in hemato-oncology Curr. Drug Targets 2010 11 95 110 10.2174/138945010790031063 Frankel A. Liu J.S. Rizzieri D. Hogge D. Phase I clinical study of diphtheria toxin-interleukin 3 fusion protein in patients with acute myeloid leukemia and myelodysplasia Leuk. Lymphoma 2008 49 543 553 10.1080/10428190701799035 Du X. Ho M. Pastan I. New immunotoxins targeting CD123, a stem cell antigen on acute myeloid leukemia cells J. Immunother. 2007 30 607 613 10.1097/CJI.0b013e318053ed8e Boman B.M. Wicha M.S. Cancer stem cells: A step toward the cure J. Clin. Oncol. 2008 26 2795 2799 Sales K.M. Winslet M.C. Seifalian A.M. Stem cells and cancer: An overview Stem Cell Rev. 2007 3 249 255 10.1007/s12015-007-9002-0 Zollar M. CD44: Can a cancer-initiating cell profit from an abundantly expressed molecule? Nat. Rev. Cancer 2011 11 254 267 10.1038/nrc3023 Orian-Rousseau V. CD44, a therapeutic target for metastasising tumours Eur. J. Cancer 2010 46 1271 1277 10.1016/j.ejca.2010.02.024 Börjesson P.K. Postema E.J. Roos J.C. Colnot D.R. Marres H.A. van Schie M.H. Stehle G. de Bree R. Snow G.B. Oyen W.J. Phase I therapy study with (186)Re-labeled humanized monoclonal antibody BIWA 4 (bivatuzumab) in patients with head and neck squamous cell carcinoma Clin. Cancer Res. 2003 9 3961S 3972S Sauter A. Kloft C. Gronau S. Bogeschdorfer F. Erhardt T. Golze W. Schroen C. Pharmacokinetics, immunogenicity and safety of bivatuzumab mertansine, a novel CD44v6-targeting immunoconjugate, in patients with squamous cell carcinoma of the head and neck Int. J. Oncol. 2007 30 927 935 Riechelmann H. Sauter A. Golze W. Hanft G. Schroen C. Hoermann K. Erhardt T. Gronau S. Phase I trial with the CD44v6-targeting immunoconjugate bivatuzumab mertansine in head and neck squamous cell carcinoma Oral Oncol. 2008 44 823 829 10.1016/j.oraloncology.2007.10.009 Trzpis M. McLaughlin P.M. de Leij L.M. Harmsen M.C. Epithelial cell adhesion molecule: More than a carcinoma marker and adhesion molecule Am. J. Pathol. 2007 171 386 395 10.2353/ajpath.2007.070152 Imrich S. Hachmeister M. Gires O. EpCAM and its potential role in tumor-initiating cells Cell Adh. Migr. 2012 6 30 38 10.4161/cam.18953 Van der Gun B.T. Melchers L.J. Ruiters M.H. de Leij L.F. McLaughlin P.M. Rots M.G. EpCAM in carcinogenesis: The good, the bad or the ugly Carcinogenesis 2010 31 1913 1921 10.1093/carcin/bgq187 Yamashita T. Ji J. Budhu A. Forgues M. Yang W. Wang H.Y. Jia H. Ye Q. Qin L. Wauthier E. EpCAM-positive hepatocellular carcinoma cells are tumor-initiating cells with stem/progenitor cell features Gastroenterology 2009 136 1012 1024 Takahashi-Yanaga F. Kahn M. Targeting Wnt signaling: Can we safely eradicate cancer stem cells? Clin. Cancer Res. 2010 16 3153 3162 10.1158/1078-0432.CCR-09-2943 Stish B.J. Chen H. Shu Y. Panoskaltsis-Mortari A. Vallera D.A. Increasing anticarcinoma activity of an anti-erbB2 recombinant immunotoxin by the addition of an anti-EpCAM sFv Clin. Cancer Res. 2007 13 3058 3067 10.1158/1078-0432.CCR-06-2454 Moldenhauer G. Salnikov A.V. Lüttgau S. Herr I. Anderl J. Faulstich H. Therapeutic potential of amanitin-conjugated anti-epithelial cell adhesion molecule monoclonal antibody against pancreatic carcinoma J. Natl. Cancer Inst. 2012 104 622 634 10.1093/jnci/djs140 Hidalgo M. Pancreatic cancer N. Engl. J. Med. 2010 362 1605 1617 Martin-Killias P. Stefan N. Rothschild S. Plückthun A. Zangemeister-Wittke U. A novel fusion toxin derived from an EpCAM-specific designed ankyrin repeat protein has potent antitumor activity Clin. Cancer Res. 2011 17 100 110 10.1158/1078-0432.CCR-10-1303 Kowalski M. Entwistle J. Cizeau J. Niforos D. Loewen S. Chapman W. MacDonald G.C. A Phase I study of an intravesically administered immunotoxin targeting EpCAM for the treatment of nonmuscle-invasive bladder cancer in BCG-refractory and BCG-intolerant patients Drug Des. Devel. Ther. 2010 4 313 320 Kowalski M. Guindon J. Brazas L. Moore C. Entwistle J. Cizeau J. Jewett M.A. MacDonald G.C. A phase II study of oportuzumab monatox: An immunotoxin therapy for patients with noninvasive urothelial carcinoma in situ previously treated with bacillus Calmette-Guérin J. Urol. 2012 188 1712 1718 MacDonald G.C. Rasamoelisolo M. Entwistle J. Cizeau J. Bosc D. Cuthbert W. Kowalski M. Spearman M. Glover N. A phase I clinical study of VB4-845: Weekly intratumoral administration of an anti-EpCAM recombinant fusion protein in patients with squamous cell carcinoma of the head and neck Drug Des. Devel. Ther. 2009 2 105 114 Entwistle J. Brown J.G. Chooniedass S. Cizeau J. Macdonald G.C. Preclinical Evaluation of VB6-845: An Anti-EpCAM Immunotoxin with Reduced Immunogenic Potential Cancer Biother. Radiopharm. 2012 27 582 592 10.1089/cbr.2012.1200.271 Ferrandina G. Petrillo M. Bonanno G. Scambia G. Targeting CD133 antigen in cancer Expert Opin. Ther. Targets 2009 13 823 837 10.1517/14728220903005616 Rappa G. Fodstad O. Lorico A. The stem cell-associated antigen CD133 (Prominin-1) is a molecular therapeutic target for metastatic melanoma Stem Cells 2008 26 3008 3017 10.1634/stemcells.2008-0601 Mak A.B. Nixon A.M. Kittanakom S. Stewart J.M. Chen G.I. Curak J. Gingras A.C. Mazitschek R. Neel B.G. Stagljar I. Regulation of CD133 by HDAC6 Promotes β-Catenin Signaling to Suppress Cancer Cell Differentiation Cell Rep. 2012 2 951 963 10.1016/j.celrep.2012.09.016 Takenobu H. Shimozato O. Nakamura T. Ochiai H. Yamaguchi Y. Ohira M. Nakagawara A. Kamijo T. CD133 suppresses neuroblastoma cell differentiation via signal pathway modification Oncogene 2011 30 97 105 10.1038/onc.2010.383 Damek-Poprawa M. Volgina A. Korostoff J. Sollecito T.P. Brose M.S. O’Malley B.W. Jr. Akintoye S.O. DiRienzo J.M. Targeted inhibition of CD133+ cells in oral cancer cell lines J. Dent. Res. 2011 90 638 645 Waldron N.N. Kaufman D.S. Oh S. Inde Z. Hexum M.K. Ohlfest J.R. Vallera D.A. Targeting tumor-initiating cancer cells with dCD133KDEL shows impressive tumor reductions in a xenotransplant model of human head and neck cancer Mol. Cancer Ther. 2011 10 1829 1838 10.1158/1535-7163.MCT-11-0206 Swaminathan S.K. Olin M.R. Forster C.L. Cruz K.S. Panyam J. Ohlfest J.R. Identification of a novel monoclonal antibody recognizing CD133 J. Immunol. Methods 2010 361 110 115 10.1016/j.jim.2010.07.007 Ohlfest J.R. Zellmer D. Panyam J. Swaminathan S.K. Oh S. Waldron N.N. Toma S. Vallera D.A. Immunotoxin targeting CD133+ breast carcinoma cells Drug Deliv. Transl. Res. 2012 10.1007/s13346-012-0066-2 Skubitz A.P.N. Taras E.P. Boylan K.L.M. Waldron N.N. Oh S. Panoskaltsis-Mortari A. Vallera D.A. Targeting CD133 in an in vivo ovarian cancer model reduces ovarian cancer progression Gynecol. Oncol. 2013 submitted Rutella S. Bonanno G. Marone M. De Ritis D. Mariotti A. Voso M.T. Scambia G. Mancuso S. Leone G. Pierelli L. Identification of a novel subpopulation of human cord blood CD34- CD133- CD7- CD45þ lineage-cells capable of lymphoid/NK cell differentiation after in vitro exposure to IL-15 J. Immunol. 2003 171 2977 2988 Suuronen E.J. Wong S. Kapila V. Waghray G. Whitman S.C. Mesana T.G. Ruel M. Generation of CD133+ cells from CD133- peripheral blood mononuclear cells and their properties Cardiovasc. Res. 2006 70 126 135 10.1016/j.cardiores.2006.01.014 Smith L.M. Nesterova A. Ryan M.C. Duniho S. Jonas M. Anderson M. Zabinski R.F. Sutherland M.K. Gerber H.P. Van Orden K.L. CD133/prominin-1 is a potential therapeutic target for antibody-drug conjugates in hepatocellular and gastric cancers Br. J. Cancer 2008 99 100 109 10.1038/sj.bjc.6604437 Oh S. Stish B.J. Vickers S.M. Buchsbaum D.J. Saluja A.K. Vallera D.A. A new drug delivery method of bispecific ligand-directed toxins, which reduces toxicity and promotes efficacy in a model of orthotopic pancreatic cancer Pancreas 2010 39 913 922 10.1097/MPA.0b013e3181cbd908 Weyergang A. Selbo P.K. Berstad M.E. Bostad M. Berg K. Photochemical internalization of tumor-targeted protein toxins Lasers Surg. Med. 2011 43 721 733 Escoffre J.M. Mannaris C. Geers B. Novell A. Lentacker I. Averkiou M. Bouakaz A. Doxorubicin liposome-loaded microbubbles for contrast imaging and ultrasound triggered drug delivery IEEE Trans. Ultrason. Ferroelectr. Freq. Control. 2013 60 78 87 10.1109/TUFFC.2013.2539 Hassan R. Broaddus V.C. Wilson S. Liewehr D.J. Zhang J. Anti-Mesothelin Immunotoxin SS1P in combination with gemcitabine results in increased activity against mesothelin-expressing tumor xenografts Clin. Cancer Res. 2007 13 7166 7171 10.1158/1078-0432.CCR-07-1592 Pearson J.W. Sivam G. Manger R. Wiltrout R.H. Morgan A.C. Jr. Longo D.L. Enhanced therapeutic efficacy of an immunotoxin in combination with chemotherapy against an intraperitoneal human tumor xenograft in athymic mice Cancer Res. 1989 49 4990 4995