Ample preclinical data suggests that grape seed procyanidin extract (GSE) possesses multi-faceted anticancer properties. GSE has been shown to favorably modulate carcinogenic mechanisms, including 1) major eicosanoids pathways, such as inhibitions of cyclocoxygenase (COX)-2/prostaglandin (PG)E2, induction of prostacyclin synthase (PTGIS)/PGI2 and increase production of 15(S)-hydroxy-eicosatetraenoic acid (15-HETE); 2) downregulation of oncomirs microRNA (miR)-19a, -19b and up-regulations of their downstream targets - tumor suppressors insulin-like growth factor II receptor (IGF-2R) and phosphatase and tensin homolog (PTEN), resulting in reduction of phosphorylated (P)-AKT, as well as downregulation of oncomir miR-106b and upregulation of its target – the tumor suppressor P21. Recently, we have found that oral leucoselect phytosome (LP), a standardized GSE complexed with soy phospholipid to enhance bioavailability, significantly inhibited human lung cancer xenograft growth, reduced bronchial Ki-67 labeling index (a marker of proliferation), favorably modulated major eicosanoids pathways, and downregulated serum miR-19a, -19b, and -106b in heavy current/former smokers. We therefore hypothesize that oral administration of LP is safe, can favorably modulate mechanisms associated with lung cancerization, and be useful for lung cancer treatment. To test these hypotheses, a single arm, phase IIa neoadjuvant lung cancer treatment study using LP, will be conducted in 30 patients with newly diagnosed, stage I and II resectable lung cancer. Aim #1: will determine the safety, feasibility and pharmacokinetics (PK)/pharmacodynamics (PD) of 2-3 weeks of oral LP in stage I or II nonsmall cell lung cancer (NSCLC) patients prior to resection. Subjects will consent to study participation and archive of specimens for research, including blood, urine, and from diagnostic procedures, such as bronchoscopy [bronchoalveolar lavage (BAL) fluid and cells, lesion biopsies and lymph node (LN) sampling] and/or transthoracic needle aspiration (TTNA) as clinically indicated, to be used as pre- treatment samples. Qualified subjects who are diagnosed with resectable lung cancer will be enrolled and treated for ~2-3 weeks until surgical resection. At the time of surgery, serial clinical specimens, including BAL, LN, lung tumor/adjacent tissue, blood and urine will be collected as post-treatment samples for assessing PK/bioavailability, PD and mechanism of actions when applicable. The safety of oral LP will be monitored weekly with the NCI common terminology criteria for adverse events Version 5.0 and adverse reaction questionnaires. Aim #2: To determine the antineoplastic and mechanistic effects of oral LP in stage I/ II lung cancer patients. The anticancer effects of LP will be assessed by comparing its bioactivity pre- vs. post-treatment, as measured by modulations of tumor pathological response, downstaging, Ki-67 labeling index, activated caspase 3 (apoptosis marker), COX-2, PTGIS, 15-LOX, PTEN, P-AKT, IGF2R; 2) markers of inflammation and antitumor immunity: PGE2, PGI2, 15-HETE, interleukin (IL)-6, -10, -12, C reactive protein (CRP) In BAL, plasma, and/or tumors; 3) cancer-relevant, pathway specific gene expression profile in BAL cells and tumors; 4) epigenetic miRNA profile in BAL cells and tumors; 5) miR-19a, -19b, and -106b in serum and tumors. Aim #3: will validate the roles of miR-19a, miR-19b, and miR-106b in mediating the anti-neoplastic effects of GSE and the utility of serum miR-19a, -19b, and -106b as surrogate endpoint biomarkers (SEBM) for therapeutic monitoring. In our previous studies, we found that GSE significantly down-regulated well-known lung cancer oncomirs miR-19a, -19b, and -106b in human lung neoplastic cells and A549 xenograft tumors in nude mice, as well as in the serum of heavy current/former smokers. Findings will provide important insights into the feasibility and mechanistic effects of GSE/LP against lung cancer, help identify SEBM and set the stage for future confirmatory clinical trials.

Lung cancer is the leading cause of cancer death in the country, surpassing deaths caused by colorectal, prostate and breast cancers combined. Veterans are at higher risk of lung cancer due to the higher rate of smoking and environmental toxin exposures. The lack of effective therapy provides the impetus to search for alternative, safe, and efficacious anticancer agents to improve treatment strategy against lung cancer, enhance the probability of a cure and reduce recurrence. Based on encouraging preclinical and clinical findings in a lung cancer chemoprevention pilot study, the purpose of this new CSR&D Merit Review proposal is to evaluate the feasibility of a standardized grape seed procyanidin extract with enhanced bioavailabilities, leucoselect phytosome, for neoadjuvant treatment of resectable stage I and II lung cancer in a phase IIa clinical trial, to establish safety, feasibility, define and validate mechanisms of action, identify suitable surrogate endpoint biomarkers and set the stage for larger, confirmatory trials in the near future.