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Mechanisms underlying gemcitabine resistance in pancreatic cancer and sensitisation by the iMiD™ lenalidomide.

Gemcitabine is currently the leading therapeutic for pancreatic cancer treatment, despite growing resistance. Studying the mechanisms that underlie gemcitabine resistance and discovery of agents that increase the tumour sensitivity to gemcitabine, is therefore desirable. The thalidomide analogue lenalidomide has been approved for use in multiple myeloma in combination with dexamethasone. Although it is primarily immunomodulatory, it also has direct effects on tumours. We investigated the sensitivity of three pancreatic cell lines PANC-1, MIA-PaCa-2 and BxPC-3 to gemcitabine. We observed that PANC-1 cells display most resistance to gemcitabine and MIA-PaCa-2 are most sensitive. Western blot analysis revealed that PANC-1 exhibits high phosphorylated extracellular signal-regulated kinase (pERK) expression, whereas MIA-PaCa-2 displays low expression. Combining gemcitabine and lenalidomide reduced the IC(50) of gemcitabine up to 40% (p<0.05). Western blot analysis showed lenalidomide significantly reduced pERK expression in all cell lines (p<0.05). It was hypothesised that gemcitabine sensitivity could be increased through combination with a pERK-reducing agent. The mitogen-activated kinase (MEK) specific inhibitor U0126 was used on PANC-1 cells to restore gemcitabine sensitivity. U0126 significantly increased cell killing by gemcitabine from 30% to 60% (p<0.001). Sensitive MIA-PaCa-2 cells were transfected with a constitutively active MEK mutant to reduce gemcitabine sensitivity. Transfection resulted in a significant reduction in cell killing by gemcitabine from 54-16% (p<0.05). These results provide evidence that ERK activity underlies sensitivity to gemcitabine and that addition of an agent that reduces this activity, such as lenalidomide, enhances gemcitabine efficacy. In conclusion, these results provide an understanding of gemcitabine resistance and could be used to predict successful combination therapies.