Gemcitabine Overcomes Erlotinib Resistance in EGFR-Overexpressing Cancer Cells through Downregulation of Akt

A phase III clinical trial showed gemcitabine chemotherapy combined with epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor erlotinib significantly improved overall survival in patients with advanced pancreatic cancer. Therefore, we studied whether addition of gemcitabine to erlotinib in cancer cells having intrinsic or acquired erlotinib resistance could restore chemosensitization in these cells. We studied the synergistic effect of erlotinib and gemcitabine in EGFR-overexpressing A-431 cells with acquired erlotinib resistance and in intrinsic erlotinib-resistant triple negative breast cancer (TNBC) BT-549, MDA-MB-231 and MDA-MB-468 cell lines. Erlotinib and gemcitabine were synergistic in both parental intrinsically erlotinib-sensitive A-431 cells (combination index = 0.69 at the effective dose [ED50]) and in two A-431 cell pools that had acquired erlotinib resistance (combination indices = 0.63 and 0.49 at ED50). The synergistic effect of erlotinib and gemcitabine on cancer cells did not require sensitivity to erlotinib provided that erlotinib can inhibit EGFR. The restoration of sensitivity by gemcitabine occurred through downregulation of phosphorylated Akt (p-Akt), which suggests that PI3K-PTEN-Akt activity is important to the synergism between the two agents. In A-431 parental cells, treatment with gemcitabine followed by erlotinib - but not the reverse sequence - was superior to erlotinib alone. The importance of the order of administration maybe due to the downregulation of p-Akt by gemcitabine in a dose- and time-dependent manner in cells with intrinsic or acquired erlotinib resistance. Our data show that gemcitabine increased the cytotoxic effect of erlotinib by downregulating p-Akt in EGFR-overexpressing cells with either intrinsic or acquired erlotinib resistance.