• To evaluate if RAD001 can decrease the size and/or number of intestinal polyps in patients with Peutz-Jeghers Syndrome. [ Time Frame: 2011 ] [ Designated as safety issue: No ]
  

• To evaluate if increased glucose uptake by hamartomas in Peutz-Jeghers syndrome patients due to mutations in STK11, which is involved in glucose homeostasis, renders them FDG avid [ Time Frame: 2011 ] [ Designated as safety issue: No ]
  
• To evaluate if RAD001 decreases mTOR signaling in intestinal polyps of Peutz-Jeghers syndrome patients. [ Time Frame: 2011 ] [ Designated as safety issue: No ]
  
• To evaluate if RAD001 increases apoptosis of intestinal polyps of Peutz-Jeghers syndrome patients. [ Time Frame: 2011 ] [ Designated as safety issue: Yes ]
  
• To evaluate FDG-PET as a tool for detecting intestinal polyps [ Time Frame: 2011 ] [ Designated as safety issue: Yes ]
  

Drug: RAD001

RAD001 (everolimus) is a novel derivative of rapamycin. RAD001 has been in clinical development since 1996 as an immunosuppressant in solid organ transplantation. Since 2003, RAD001 is approved in Europe (trade name: Certican) via the Mutual Recognition Procedure (MRP) for the prevention of organ rejection in patients with renal and cardiac transplantation. Certican is also approved in Australia, South Africa, the Middle East, Central and South America, the Caribbean and some Asian countries.

RAD001 is being investigated as an anticancer agent based on its potential to act

• directly on the tumor cells by inhibiting tumor cell growth and proliferation
• indirectly by inhibiting angiogenesis leading to reduced tumor vascularity (via potent inhibition of tumor cell VEGF production and VEGF-induced proliferation of endothelial cells)

Peutz-Jeghers Syndrome is a hereditary polyposis condition in which hamartomatous tumors develop in many tissues of the body. These tumors are benign but frequently cause gastrointestinal obstruction and bleeding beginning in the 2nd-3rd decades of life necessitating surgical intervention. Unfortunately, a recent study showed that the lifetime risk of cancers that arise in Peutz-Jeghers Syndrome is 85% by age 70 years and is 60% by age 60 years (Hearle et al., 2006).

A working definition of PJS has been suggested by Giardiello et al ,1987(www.genetests.com):

• For individuals with a histopathologically confirmed hamartoma, a definite diagnosis of PJS requires two of the following three findings:

  • Family history consistent with autosomal dominant inheritance
  • Mucocutaneous hyperpigmentation (although this can fade with age)
  • Small-bowel polyposis
• For individuals without histopathologic verification of hamartomatous polyps, a probable diagnosis of PJS can be made based on the presence of two of the three clinical criteria above.
• For individuals without a family history of PJS, diagnosis depends upon the presence of two or more histologically verified Peutz-Jeghers-type hamartomatous polyps (Tomlinson & Houlston 1997).
• For individuals with a first-degree relative with PJS, presence of mucocutaneous hyperpigmentation is sufficient for presumptive diagnosis.

Recently, rapamycin (Rapamune, Wyeth), an FDA-approved drug for use in orthotopic transplant recipients, was successfully used in an off-label study of 5 individuals with a related condition called tuberous sclerosis in which the patients had subependymal giant cell astrocytomas that caused significant and insidious neurological problems such as hydrocephalus and seizures (Franz, et al. 2006). All astrocytoma lesions exhibited regression with treatment of oral rapamycin and in one case, necrosis. Treatment was well tolerated and may offer an alternative to operative therapy in tuberous sclerosis. Tuberous sclerosis is caused by germline mutations in the tuberous sclerosis 1 or 2 genes. These genes encode proteins that function downstream of STK11, the gene that is mutated in Peutz-Jeghers Syndrome. Mutations of STK11 or TSC1/2 leads to activation of mTOR (mammalian target of rapamycin). Dysregulation of mTOR has been demonstrated in several types of cancers and clinical trials are underway to see if inhibition of mTOR will be of benefit to a variety of cancer patients. A recent trial showed efficacy of RAD001 in advanced renal cancer (Hudes, et al. 2007).

All of these studies will be performed on an outpatient basis.