Common Mechanism Of Resistance Research Articles

Abstract IA018: Metastatic bladder cancer: The expanding role of antibody drug conjugates

Abstract Antibody drug conjugates (ADCs) consist of an antibody, a cytotoxic payload, and a linker between the two. ADCs are becoming increasingly used in metastatic bladder cancer. Enfortumab vedotin (EV) in combination with pembrolizumab recently demonstrated impressive improvements in survival and overall responses compared to chemotherapy in the frontline metastatic setting. Sacituzumab govitecan (SG) and single agent EV are also effective, later line options for patients who have progressed on prior chemotherapy and/or immunotherapy. New ADCs, including those targeting HER2, have also displayed promising results in bladder cancer patients. Trials are exploring the use of ADCs in combination with each other as well as with immunotherapy. Novel ADCs with dual targets, dual payloads, and other augmentations are being developed and may represent new options for patients moving forward. However, these advances raise many questions. How to best manage the differing toxicities seen with ADCs? What is best sequencing of ADCs? What are the common resistance mechanisms to ADCs? How do these resistance mechanisms affect subsequent use of ADCs? And how effective are these agents in bladder cancer variants and divergent histologies? This talk with cover the expanding role of ADCs in metastatic bladder cancer. Citation Format: Nicholas Simon. Metastatic bladder cancer: The expanding role of antibody drug conjugates [abstract]. In: Proceedings of the AACR Special Conference on Bladder Cancer: Transforming the Field; 2024 May 17-20; Charlotte, NC. Philadelphia (PA): AACR; Clin Cancer Res 2024;30(10_Suppl):Abstract nr IA018.

Impact of Antimicrobial Resistance in Health and Economic Outcomes: A Review

Background: Antimicrobial resistance (AMR) observed when microorganism adapt and multiply in the presence of drugs to which they are exposed. Antibiotic resistance is a global health problem, with the current trend of inappropriate and overuse of antibiotics predicted to cause 10 million deaths by 2050. However, resistant bacteria are multiplying worldwide, infecting healthy people, animals, and human environment, affecting countries with low- and middle-income countries. Although the discovery of antibiotics has saved many lives in recent years, increasing bacterial resistance to antibiotics threatens clinical and agricultural progress, and even treatable bacterial infections can be life-threatening. Strategies: In the present review we discuss the global burden of social and economic impact of antibiotic resistance, common mechanisms of antibiotic resistance, microbiological health and treatment resistance, patient attitudes, hospital and cancer outcomes. Summarize the impact of AMR. Potential strategies to overcome AMR such as Targeting antimicrobial-resistant enzymes, Targeting antimicrobial-resistant bacteria, Drug delivery systems, Physiochemical methods, Unconventional strategies. Conclusion: The devastating effect of antibiotic resistance is clear by way of the sudden boom inside the quantity of cases in which microorganism are immune to typically prescribed antibiotics in clinical practice. Although the superiority of bacterial resistance is growing, there is limited statistics at the impact of this hassle on the fitness and economic consequences of the clinical network.

Genomic epidemiology reveals multiple mechanisms of linezolid resistance in clinical enterococci in China

BackgroundInfections caused by linezolid-resistant enterococci (LRE) are clinically difficult to treat and threaten patient health. However, there is a lack of studies on long time-span LRE strains in China. For this reason, our study comprehensively revealed the resistance mechanisms of LRE strains collected in a Chinese tertiary care hospital from 2011 to 2022.MethodsEnterococcal strains were screened and verified after retrospective analysis of microbial data. Subsequently, 65 LRE strains (61 Enterococcus faecalis and 4 Enterococcus faecium, MIC ≥ 8 µg/ml), 1 linezolid-intermediate Enterococcus faecium (MIC = 4 µg/ml) and 1 linezolid-susceptible Enterococcus faecium (MIC = 1.5 µg/ml) were submitted for whole-genome sequencing (WGS) analysis and bioinformatics analysis.ResultsThe optrA gene was found to be the most common linezolid resistance mechanism in our study. We identified the wild-type OptrA and various OptrA variants in 98.5% of LRE strains (61 Enterococcus faecalis and 3 Enterococcus faecium). We also found one linezolid-resistant Enterococcus faecium strain carried both optrA and cfr(D) gene, while one linezolid-resistant Enterococcus faecium only harbored the poxtA gene. Most optrA genes (55/64) were located on plasmids, with impB-fexA-optrA, impB-fexA-optrA-erm(A), fexA-optrA-erm(A), and fexA-optrA segments. A minority of optrA genes (9/64) were found on chromosomes with the Tn6674-like platform. Besides, other possible linezolid resistance-associated mechanisms (mutations in the rplC and rplD genes) were also found in 26 enterococcal strains.ConclusionsOur study suggested that multiple mechanisms of linezolid resistance exist among clinical LRE strains in China.

Abstract PO4-04-12: A Phase 1b/2 study of palazestrant (OP-1250) in combination with ribociclib or alpelisib in patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative, advanced and/or metastatic breast cancer

Abstract Background: Endocrine therapy (ET) when administered with cyclin-dependent kinase 4/6 (CDK4/6) inhibitors has improved outcomes in patients (pts) with estrogen receptor (ER)-positive, human epidermal growth factor receptor 2 (HER2)-negative advanced breast cancer (BC) or metastatic breast cancer (MBC) and is the current standard of care for first-line treatment. Addition of the PIK3 inhibitor alpelisib to ET significantly improved progression-free survival in pts with PIK3CA-mutated, ER-positive, HER2-negative MBC, and alpelisib + fulvestrant is the standard of care for second or later-line treatment. Most pts will acquire resistance to ET, with mutations in ESR1 constituting the most common mechanism of resistance. Palazestrant (OP-1250) is a small molecule oral complete ER antagonist (CERAN) and selective ER degrader (SERD) that binds the ligand binding domain of ER and completely blocks ER-driven transcriptional activity in both wild-type (ESR1-wt) and mutant (ESR1-mut) forms of ER. In preclinical studies, palazestrant in combination with ribociclib demonstrated activity in both ESR1-wt and ESR1-mut xenograft models and showed efficacy in brain metastasis xenograft models. In a Phase 1/2 monotherapy study in pts with ER-positive, HER2-negative MBC, palazestrant was well tolerated with demonstrated antitumor efficacy and favorable pharmacokinetics (PK) supporting once a day (qd) dosing at the recommended Phase 2 dose (RP2D) of 120 mg. The aim of this study is to evaluate the safety, PK, and antitumor activity of palazestrant + ribociclib or alpelisib in pts with ER-positive, HER2-negative advanced BC or MBC. Methods: Eligible pts have evaluable ER-positive, HER2-negative advanced BC or MBC; ≤2 prior ETs (prior CDK4/6 inhibitors allowed); and ≤1 prior line of chemotherapy. In the alpelisib arm, pts must have a PIK3CA mutation in the tumor or ctDNA. Patients are administered oral palazestrant at escalating doses of 30, 60, and 120 mg qd in combination with the approved dose of oral ribociclib (600 mg qd; days 1–21 of 28-day cycle) or approved dose of oral alpelisib (300 mg qd) in a 3+3 design to identify the RP2D. The dose-expansion part will assess additional safety and PK parameters and the antitumor activity of palazestrant in combination with ribociclib or alpelisib (NCT05508906). Results: As of June 15, 2023, 10 pts have received 30 mg and 60 mg doses of palazestrant in combination with ribociclib (n=6) or alpelisib (n=4). No dose-limiting toxicities have been observed. After administration in the first two combination dose levels of 30 and 60 mg, palazestrant exposure was consistent with monotherapy administration; exposure data show no drug–drug interactions (DDI) when compared to published exposure parameters. Most reported treatment-emergent adverse events (TEAEs) were grade 1 or 2 and consistent with the known safety profiles of all 3 drugs. In the ribociclib arm, the TEAEs occurring in ≥2 pts included grade 1 nausea (n=4), grade 1 constipation (n=2), and neutropenia (grade 2, n=1; grade 3, n=3). For the 3 pts in the 30 mg palazestrant + alpelisib cohort, the only TEAE occurring in ≥2 pts was grade 1 diarrhea. One pt had grade 1 hyperglycemia. Conclusions: In this ongoing study, palazestrant in combination with ribociclib or alpelisib was well tolerated, and enrollment to the palazestrant 120 mg dose with ribociclib or alpelisib is ongoing. No new safety signals were observed for the 3 drugs, and no clinically significant DDIs were observed between palazestrant and ribociclib or alpelisib at the doses evaluated. Exposure of each drug was consistent with observed monotherapy exposure levels. Updated data will be presented. Citation Format: Virginia Borges, Carlos Alemany, Nancy Lin, Sara Nunnery, Cynthia Ma, Margaret Tonda, Morena Shaw, Arlene Chan. A Phase 1b/2 study of palazestrant (OP-1250) in combination with ribociclib or alpelisib in patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative, advanced and/or metastatic breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-04-12.

Abstract PO2-19-08: INAVO121: Phase III study of inavolisib + fulvestrant vs alpelisib + fulvestrant in patients with hormone receptor-positive, HER2-negative, PIK3CA-mutated locally advanced or metastatic breast cancer

Abstract BACKGROUND Standard-of-care (SoC) endocrine therapy (ET) for patients (pts) with hormone receptor-positive, HER2-negative, PIK3CA-mutated locally advanced or metastatic breast cancer (HR+, HER2–, PIK3CA-mut LA/mBC) was transformed by combinations with cyclin-dependent kinase 4/6 inhibitors (CDK4/6is); a CDK4/6i-based combination is approved in high-risk early BC. However, in most pts, mechanisms of resistance that emerge during or after treatment with a CDK4/6i and ET combination lead to relapse/disease progression. Dysregulating mutations in PIK3CA, occurring in ~40% of HR+, HER2– BCs, represent a common mechanism of resistance to CDK4/6is and ET combinations. Alpelisib (ALP; a selective PI3Kα inhibitor; PI3Kαi) + fulvestrant (FUL) is approved for pts with HR+, HER2–, PIK3CA-mut LA/mBC, but its widespread implementation in clinical practice has been challenging. As such, there is a significant need to develop PI3Kαis with a better therapeutic index. Inavolisib (INAVO) is a highly potent and selective PI3Kαi that also facilitates the degradation of mutated PI3Kα isoform. INAVO has demonstrated manageable safety/tolerability, alone and in combination with SoC treatments in HR+, HER2–, PIK3CA-mut LA/mBC. Moreover, an ongoing Phase I trial showed that INAVO + FUL elicited encouraging preliminary antitumor activity in heavily pretreated pts, including a CDK4/6i-based regimen. TRIAL DESIGN INAVO121 is a Phase III, randomized, open-label study. Pts are randomized 1:1 to receive INAVO (9 mg oral daily; PO QD) + FUL (500 mg intramuscularly on Days [D] 1 and 15 of Cycle 1, then D1 of subsequent cycles), or ALP (300 mg PO QD) + FUL. Randomization is stratified by visceral disease (yes vs no) and prior CDK4/6i therapy (adjuvant vs metastatic setting). Pts will receive treatment until disease progression or unacceptable toxicity. ELIGIBILITY CRITERIA Pts have HR+, HER2–, PIK3CA-mut LA/mBC (confirmed by circulating-tumor DNA or tumor tissue), adequate hematologic and organ function, and disease progression after or during treatment with a CDK4/6i-based regimen. Up to two prior lines of systemic therapy in LA/mBC, including one line of chemotherapy, are allowed. AIMS The primary endpoint is progression-free survival (PFS) by blinded independent central review (BICR). Secondary endpoints include overall survival, BICR-objective response rate, BICR-best overall response, BICR-duration of response, BICR-clinical benefit rate, safety, tolerability, pt-reported outcomes, and pharmacokinetics. STATISTICAL METHODS A stratified log-rank test at an overall 0.05 significance level (two-sided) will be used for the primary endpoint analysis. Median PFS will be estimated using Kaplan–Meier methodology. An independent data monitoring committee will be in place for safety and efficacy. ACCRUAL The study is open for enrollment and has randomized four pts; the study is targeting 400 pts at ~200 sites globally. CONTACT INFORMATION For more information or to refer a patient, email global.rochegenentechtrials@roche.com or call 1-888-662-6728 (USA only). Clinicaltrials.gov number NCT05646862. This abstract was originally presented at ASCO 2023 (TPS1123). Citation Format: Dejan Juric, Kevin Kalinsky, Seock-Ah Im, Eva Ciruelos, Giampaolo Bianchini, Carlos Barrios, William Jacot, Peter Schmid, Sherene Loi, Hope Rugo, Veronica Craine, Katherine Hutchinson, Aulde Flechais, Eirini Thanopoulou, Nadia Harbeck. INAVO121: Phase III study of inavolisib + fulvestrant vs alpelisib + fulvestrant in patients with hormone receptor-positive, HER2-negative, PIK3CA-mutated locally advanced or metastatic breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-19-08.

Abstract CT251: Savolitinib (savo) + osimertinib (osi) vs savo + placebo (PBO) in patients (pts) with EGFR-mutated (EGFRm), MET-amplified advanced NSCLC with progression on osi

Abstract Background Osi, an EGFR-TKI, is the preferred 1L treatment (tx) for EGFRm aNSCLC; however, resistance eventually develops in most pts. MET amplification is the most common known resistance mechanism to osi. Combining osi with savo, a MET-TKI, has shown antitumor activity in EGFRm, MET-amplified aNSCLC. We conducted a Phase II, double-blind, randomized study (NCT04606771) to assess the individual contribution of savo to the combination. Methods Pts with EGFRm (Ex19del, L858R), MET-amplified (MET gene copy ≥5 or MET/CEP7 ratio ≥2; central confirmation by FISH), aNSCLC with progression on ≥1 tx, including osi, were randomized (1:1) to savo 300 mg QD + osi 80 mg QD or savo 300 mg QD + PBO. Tx continued until PD, unacceptable AEs, or other discontinuation criterion. Primary endpoint: ORR per RECIST 1.1 (investigator-assessed). Efficacy was also assessed by exploratory, higher MET cutoffs (determined retrospectively): 3+ staining ≥90% tumor cells (IHC90+) and/or MET gene copy ≥10 (FISH10+). Plasma was collected for exploratory analyses. Results 30 pts were randomized (savo + osi n=14; savo + PBO n=16). Table shows efficacy data. Grade ≥3 AEs and sAEs occurred in: 3 (21%) and 4 (29%) pts receiving savo + osi; 5 (31%) and 3 (19%) pts receiving savo + PBO, respectively. Most common any-grade AEs with savo + osi vs savo + PBO were nausea (50% vs 19%), peripheral edema (36% vs 25%) and vomiting (21% vs 31%). Conclusion Savo + osi demonstrated clinical activity, with savo + PBO showing lower clinical activity. Clinical activity was observed in pts with higher MET cutoffs (FISH10+ and/or IHC90+). Due to small sample sizes, these data need to be interpreted with caution. Safety was consistent with known AE profiles of each tx. This study was terminated early as the contribution of savo to the savo + osi combination is being further assessed in SAVANNAH (NCT03778229), which uses a different savo dosing regimen and higher MET-amplification cutoffs. TABLE 1. NAND Savolitinib + osimertinib Savolitinib + placebo FISH10+ and/or IHC90+a (n=8) All patients(n=14) FISH10+ and/or IHC90+ a (n=7) All patients (n=16) ORR, % (95% CI)b 63 (24, 91) 57 (29, 82) 29 (4, 71) 13 (2, 38) Complete response, n (%)b 0 0 0 0 Partial response, n (%)b 5 (63) 8 (57) 2 (29) 2 (13) Median duration of response, weeks (95% CI) 30.6 (23.0, NC) 30.6 (18.9, NC) NR (12.4, NC) NR (12.4, NC) PFS events, n (%)c 4 (50) 9 (64) 5 (71) 13 (81) Median PFS, months (95% CI) 8.2 (4.1, NC) 7.4 (5.6, NC) 4.0 (1.3, NC) 1.6 (1.3, 4.1) aAs IHC was not used to determine pt eligibility, this subgroup does not comprise all randomized pts due to limited sample availability; bResponses included unconfirmed responses; cOnly included events that occurred within 2 missed visits of the last evaluable assessment. CI, confidence interval; FISH10+, FISH (MET copy number ≥10); IHC90+, immunohistochemistry overexpression (3+ staining intensity) in ≥90% of tumor cells; NC, not calculable; NR, not reached; ORR, objective response rate; PFS, progression-free survival. Citation Format: James Chih-Hsin Yang, Yuh-Min Chen, Ullas Batra, Kien Do, Piyada Sitthideatphaiboon, Pongwut Danchaivijitr, Kang-Yun Lee, Jarin Chindaprasirt, Cheng-Ta Yang, Gee-Chen Chang, Chaiyut Charoentum, Teerapat Ungtrakul, Juan Ignacio Hernandez Moran, Ryan Hartmaier, Matthew Haskins, Wanning Xu, Jonathan W. Riess. Savolitinib (savo) + osimertinib (osi) vs savo + placebo (PBO) in patients (pts) with EGFR-mutated (EGFRm), MET-amplified advanced NSCLC with progression on osi [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr CT251.

Abstract 6506: SOS1 inhibition in combination with HER2 inhibition in models of HER2-driven cancer

Abstract Cancers driven by amplifications or mutations of the gene ERBB2 (coding for the receptor tyrosine kinase (RTK) HER2) have been the focus of HER2-targeting antibodies as well as small molecule inhibitors. Despite initial efficacy, resistance to these HER2-targeted therapies inevitably develops. One strategy to tackle this resistance is to identify rational combinations to address common pathways/factors that contribute to resistance. One such common mechanism of resistance is reactivation of the Mitogen-activated protein kinase (MAPK) pathway. SOS1 is a guanine nucleotide exchange factor (GEF) which regulates the MAPK pathway by catalyzing the exchange of RAS-GDP (inactive) to RAS-GTP (active). SOS1 is activated by multiple different RTKs - upon RTK-ligand binding, autophosphorylation of the RTK recruits the GRB2-SOS1 protein complex to the plasma membrane, enabling the complex to bind and activate RAS-GDP. Given SOS1’s role downstream of RTKs and upstream of the MAPK pathway, we sought to investigate the potential of a SOS1 inhibitor (SOS1i) in combination with a HER2 inhibitor (HER2i) in preclinical models of cancer driven by HER2 mutation or gene amplification. Using in vitro and in vivo models we found evidence of added benefit of SOS1i in combination with HER2i, as well as enhanced inhibition of MAPK signaling, as seen by decrease in ERK activation and expression of MAPK effector genes such as DUSP6. Taken together, we propose that SOS1 inhibition combined with HER2 inhibition may be a rational strategy for deeper and more prolonged responses to HER2 inhibitor treatment by preventing resistance via the MAPK pathway. Citation Format: Robyn L. Schenk, Kaja Kostyrko, Johannes Popow, Christina Gewinner, Anke Baum, Christoph Albrecht, Melanie Hinkel, Robin Jacob, Tom Madensky, Regina Ruzicka, Eva Strauss, Hengyu Lyu, Anastasia M. Lopez, Ningping Feng, Christopher P. Vellano, Joseph R. Marszalek, Timothy P. Heffernan, Mark Pearson, Marco H. Hofmann. SOS1 inhibition in combination with HER2 inhibition in models of HER2-driven cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6506.

Abstract 4668: Characterization of fourth-generation EGFR inhibitors in binding experiments with C797S mutant EGFR and cell-based assays with osimertinib-resistant non-small cell lung cancer cell lines

Abstract Osimertinib is a third-generation epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor that inhibits the EGFR kinase domain by irreversible binding of the cysteine-797 residue (C797). Osimertinib was originally designed to target the T790M mutation, which is clinically the most frequently observed resistance mechanism to treatment with first- or second-generation EGFR inhibitors. Osimertinib has a high selectivity for the classical EGFR driver mutations (exon 19 deletion and L858R) compared to wild-type EGFR. Due to this favorable selectivity profile, osimertinib has become the standard first-line therapy for non-small cell lung cancer (NSCLC). Common resistance mechanisms following osimertinib treatment are MET oncogene amplification, and cysteine-to-serine substitution at position 797 (C797S) of EGFR, which precludes binding of osimertinib. Fourth-generation EGFR inhibitors and combinations with other targeted agents are potential strategies to overcome osimertinib resistance or to increase its efficacy. Three fourth-generation EGFR inhibitors were profiled in biochemical and cell-based assays: BDTX-1535, BLU-945, and JBJ-09-063. The binding kinetics for wild-type and C797S mutant EGFR were determined in surface plasmon resonance binding experiments on a Biacore 1S+ (Cytiva). The effect on osimertinib-resistant cells, generated using two different approaches, was studied in cell viability assays. In the first model, subclones of the NSCLC cell line PC-9, harboring an exon 19 deletion activating EGFR mutation, were selected for osimertinib resistance by in vitro drug selection [1]. In the second model, the EGFR C797S mutation was introduced into the NSCLC cell line NCI-H1975, which expresses both the L858R activating mutation and the T790M resistance mutation, by gene-editing with CRISPR-Cas9. Synergies with fourth-generation EGFR inhibitors were determined by profiling combinations in a 6-by-6 matrix, and quantifying synergistic effects using the Excess over Bliss score. We will present a detailed comparison of the binding kinetics of the three fourth-generation EGFR inhibitors on wild-type and C797S-mutant EGFR, and their ability to compete with osimertinib for binding to the kinase domain of EGFR. The different fourth-generation inhibitors show various selectivities for the various EGFR mutants and differences in their ability to spare wild-type EGFR. Profiling results of the three fourth-generation EGFR inhibitors in the osimertinib-resistant cell lines and on a panel of more than one hundred human cancer cell lines will be presented. Reference: [1] Bertran-Alamillo et al. Nature Communications 10, 1812; 2019 Citation Format: Janneke J. Melis, Kirsten Kevenaar, Jeffrey J. Kooijman, Yvonne Grobben, Jacob Ytsma, Jordi Bertran-Alamillo, Miguel-Angel Molina-Vila, Nicole Willemsen-Seegers, Guido J. Zaman. Characterization of fourth-generation EGFR inhibitors in binding experiments with C797S mutant EGFR and cell-based assays with osimertinib-resistant non-small cell lung cancer cell lines [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4668.

Abstract 2666: Genetic ablation of B2M leads to resistance to PD-1/PD-L1 blockade in vivo

Abstract Immune checkpoint inhibitors (ICIs) has revolutionized the treatment landscape of various cancers by reinvigorating the exhausted T cells in patients. However, the therapeutic efficacy is largely confined due to the primary or acquired resistance to anti-PD-1 (L1) therapy in many patients. Recently, the mechanisms of resistance to ICIs has been extensively elucidated from different aspects and emerging sequencing data from clinical samples has pointed to IFN-γ signaling defects and antigen presentation loss in patients who are resistant to PD-1(L1) blockade. The loss-of-function mutations in JAK1 and JAK2 results in lack of response to IFN-γ signaling and incapacity to upregulate PD-L1 and MHC-I, which subsequently leads to noninflammatory TMEs and resistance to anti-PD-1/PD-L1. The loss-of-function of B2M is likely a common resistance mechanism that the intratumoral cytotoxic CD8+ T cells are failed to be boosted owing to antigen presentation loss. In order to obtain higher clinical benefits in various cancers, it’s appealing and urgent to develop mechanism-based strategies to overcome resistance to ICI-based immunotherapy. To this end, we developed a genetically acquired resistant tumor model with B2M mutations in syngenic MC38 tumor cells using CRISPR/Cas9 technology, which is ‘hot’ tumor to PD-1/PD-L1 blockade. The expression of B2M was detected by western blotting and flow cytometry. Mouse B2M-knockout MC38 tumors became resistant to PD-1/PD-L1 blockade in vivo. Notably, we found a remarkable increase of CD8+ T cell infiltration in B2m-KO MC38 tumors in comparison to parental MC38 tumors upon anti-PD-1 treatment, which further explains that antigen presentation loss results in inactivation of cytotoxic CD8+ T cells within the tumor microenvironments (TMEs), subsequently leading to resistance and poor survival to ICI therapy.In summary, our data consistently indicated the importance of MHC-I expression in T cell activation in the TMEs and the possibility to dig out the pathway involved in MHC-I expression independent of IFN-γ signaling by CRISPR-based screening to overcome MHC-I deficiency-induced resistance in the future. In addition, it’s possible to leverage the cytotoxic NK cells and CD4+ T cells in antitumor immunity against MHC-II+ tumors even with the loss of MHC-I molecules. For example, high dose of IL-2RB-biased IL-2 agonist preferentially binding to the dimeric IL-2R can stimulate Teff and NK cells independent of immune checkpoint expression. Likewise, cytokine modified anti-PD-1 fusion formulation like anti-PD-1-IL-2 mutein and anti-PD-1-IL-15 mutein are promising to overcome the resistance. Furthermore, it has been suggested that the resistance due to genetic mutations of MHC-I could be overcome by combining NF-B targeted therapies. Citation Format: Yanlei Zhang, Hechun Ma, Boang Han, Yi Li, Ping Yang, Zhen Li, Dongxiao Feng, Lei Ci, Ruilin Sun, Daniel X. He. Genetic ablation of B2M leads to resistance to PD-1/PD-L1 blockade in vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2666.

Abstract 964: Updated results of a prospective observational multicenter study on resistance mechanisms to osimertinib using circulating tumor DNA analyses in EGFR-mutated non-small cell lung cancer patients (ELUCIDATOR study)

Abstract Background: Although osimertinib (Osi) is the key standard therapy for patients (pts) with advanced non-small cell lung cancer (NSCLC) harboring sensitizing epidermal growth factor receptor (EGFR) mutations, most of cases experience the progressive disease (PD) after initial response to the treatment. Therefore, understanding the Osi resistance mechanisms and identifying the poor responders are essential to develop better treatment strategies. Thus, we conducted a prospective observational multicenter study and analyzed serially collected circulating tumor DNA (ctDNA). Here we report the results from updated analyses focusing on the association between genetic information from ctDNA and clinical outcome. Methods: Patient eligibility criteria were as follows: a definitive diagnosis of non-squamous NSCLC confirmed through biopsy or cytology, EGFR exon 19 deletion (19del) or L858R mutation, Osi planned as first-line treatment, and pts who could provide blood specimens. Paired plasma DNA samples were collected before starting Osi as baseline (BL) and at PD and analyzed to investigate Osi resistance by next-generation sequencing (NGS). Correlations between genetic information obtained from ctDNA and clinical outcome such as progression free survival (PFS) and overall survival (OS) were evaluated. The median follow-up time was 33.1 months. Results: One hundred eighty-eight pts were enrolled between May 2019 and January 2021, and 125 (66%) were female, 96 (51%) were EGFR 19del mutation, and 109 (58%) were never smoker. Among those, 178 pts were included in the analyses, and 111 experienced PD. In consistent with previous reports, median PFS (mPFS) and median OS (mOS) were 19.1 months and 36.0 months, respectively. The efficacy of Osi differed between 19del and L858R in both PFS and OS, with 19del being longer outcome [mPFS, 23.3 months vs. 17.2 months, HR: 1.56 (95%CI: 1.08-2.26), mOS, 40.3 months vs. 30.4 months, HR: 1.54 (95%CI: 0.98-2.45)]. Univariate analysis revealed that the presence of TP53 mutations and MET amplification (amp) at BL was a predictive factor of shorter PFS and OS. Multivariate analysis also revealed that the TP53 mutations at BL was a predictive factor of shorter PFS and OS. Plasma samples from 85 pts were available for ctDNA analysis. New adaptive mutations or amp at PD were detected in genes such as PIK3CA in 3 cases, MET amp in 4, TP53 in 4, BRIMP3 in 2, APC in 1, and BRAF in 2. Secondary EGFR C797S resistance mutation was detected in 1 case. Conclusions: TP53 mutation at BL could be predictive of poor response to Osi. MET amp and PIK3CA mutations were detected as the most common resistance mechanisms, and secondary EGFR resistance mutations were observed less frequently than previous reports. Citation Format: Mitsuo Osuga, Akihiro Tamiya, Daijiro Harada, Yasuyuki Mizumori, Shun-ichi Isa, Yoshihiko Taniguchi, Keiichi Nakamura, Tsutomu Shinohara, Hidetoshi Yanai, Katsumi Nakatomi, Masahide Oki, Masahide Mori, Tomohito Kuwako, Koji Yamazaki, Atsuhisa Tamura, Masahiko Ando, Yasuhiro Koh. Updated results of a prospective observational multicenter study on resistance mechanisms to osimertinib using circulating tumor DNA analyses in EGFR-mutated non-small cell lung cancer patients (ELUCIDATOR study) [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 964.

Abstract 5871: Unveiling mechanisms of CDK4/6 inhibitor resistance in ER+ breast cancer models with acquired resistance

Abstract Introduction: Cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors, including palbociclib, ribociclib, and abemaciclib, have revolutionized the treatment of estrogen receptor-positive (ER+) breast cancer. However, the development of resistance to these inhibitors poses a formidable challenge in the clinical management of ER+ breast cancer. This study aims to explore the common resistance mechanisms in three CDK4/6 inhibitor-resistant models induced by chronic exposure to these agents. Methods: We developed models of resistance to palbociclib, ribociclib, and abemaciclib by repeatedly exposing murine xenografts to these CDK4/6 inhibitors. Resistance was confirmed through cell viability assays and in vivo tumorigenesis studies. The tumors were sequenced using NGS analyses, and genes of interest were validated through Western blotting and qPCR. Results: In all resistant models, we identified a common resistant mechanism via NGS analyses, which was characterized by the overexpression of the FAT1, CCNE1, and AR genes. The upregulation of these genes at mRNA and protein levels was confirmed by qPCR analyses and western blotting, respectively. Our data indicate that upregulation of FAT1, CCNE1, and AR genes may play a critical role in mediating resistance to CDK4/6 inhibitors, namely palbociclib, ribociclib, and abemaciclib. Conclusion: Our investigation uncovered a shared mechanism, characterized by the overexpression of FAT1, CCNE1, and AR genes, that underlay CDK4/6 inhibitors-induced drug resistance in ER+ breast cancer. These findings shed light on the shared pathways that drive CDK4/6 inhibitor resistance and provide insights into potential therapeutic targets for overcoming this resistance in breast cancer patients. Understanding these mechanisms is crucial for the development of more effective treatment strategies for CDK4/6 inhibitor-resistant cancers. Citation Format: Bin Li, Gaoxiang Liu, Ting Ni, Wenting Shi, Qingyang Gu. Unveiling mechanisms of CDK4/6 inhibitor resistance in ER+ breast cancer models with acquired resistance [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 5871.

Abstract 563: Targeting PDE4D reinstates toxic PARP trapping via cAMP-ROS-DNA damage axis and restores the efficacy of standard of care in treatment-refractory ER+ breast cancer

Abstract Endocrine therapies, modulating ER level and/or activity, and the CDK4/6 inhibitors are among the standard-of-care (SOC) therapies used in estrogen receptor-positive (ER+) breast cancer. However, most ER+ breast cancer patients eventually develop resistance to SOC, representing a major clinical challenge that reduces clinical outcome. Therefore, elucidating the common mechanisms of sensitivity and resistance to SOC therapies, and identifying novel actionable targets are urgently needed. Here, we demonstrated that cell death induced by endocrine therapies and CDK4/6 inhibitors involves toxic PARP1 trapping and generation of a functional BRCAness (i.e., BRCA1/2 deficiency) phenotype, leading to transcriptional blockage. We showed that this is achieved by activation of the cAMP/reactive oxygen species (ROS)/DNA damage axis upon downregulation of phosphodiesterase 4D (PDE4D). Importantly, we identified PDE4D as a novel ER target gene that in turn stimulates ER activity in a feedforward loop in endocrine-responsive models. However, during SOC resistance, an ER-to-EGFR switch induces PDE4D overexpression via c-Jun. Inhibition of PDE4D using BPN14770, the first-in-class PDE4D allosteric inhibitor that has successfully completed Phase II trials in Fragile X syndrome, reinstates PARP1 trapping and BRCAness, leading to drug sensitization in vitro and in vivo. Furthermore, inhibition of EGFR or PARP1 recapitulates the effects of PDE4D targeting and overcomes SOC resistance irrespective of the BRCA1/2 status in cell line models, primary cultures and organoids of endocrine resistant ER+ PDXs. Notably, we demonstrated that high PDE4D mRNA and protein expression is associated with dramatically worse disease-free survival and overall survival in endocrine therapy-treated ER+ breast cancer. Given the availability of potent and non-toxic PDE4D inhibitors, and clinically approved EGFR and PARP1 inhibitors, our findings have great translational potential to improve the clinical outcome of refractory ER+ breast cancers. Citation Format: Ozge Saatci, Metin Cetin, Meral Uner, Unal M. Tokat, Ioulia Chatzistamou, Elodie Montaudon, Aytekin Akyol, Sercan Aksoy, Aysegul Uner, Elisabetta Marangoni, Mathew Sajish, Ozgur Sahin. Targeting PDE4D reinstates toxic PARP trapping via cAMP-ROS-DNA damage axis and restores the efficacy of standard of care in treatment-refractory ER+ breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 563.

Abstract 4571: Combination of FOLFIRI (5-FU, Leucovorin, and Irinotecan) and ProAgio on colon cancer growth and metastasis

Abstract Background/Objective: One of the common mechanisms of resistance of solid tumors, including colon cancers, is activation of integrins on endothelial cells (ECs) and cancer-associated fibroblasts (CAFs). ProAgio is a small molecule developed to target integrin alpha V beta 3 (αvβ3), located on surface of abnormal ECs and CAFs. ProAgio enhances apoptosis and inhibits angiogenesis via targeting αvβ3. The aim of the current study is to evaluate the ProAgio combination with FOLFIRI on the immune profile and tumor growth of colon cancer. Material and Methods: Female BALB/CJ and male NSG (NOD.Cg-Prkdcscid Il2rgtm1Wjl/SzJ) mice were acquired from the Jackson Laboratory, and experiments were performed under the approval of The University of Alabama at Birmingham-Institutional Animal Care and Use Committee. For orthotropic tumor efficacy studies, BALB/CJ mice were injected with 2×105 CT-26 wild type and CT26.CL25 cells in 30ul 1:1 Matrigel Matrix and PBS into the Cecum. PDX (10mg) was orthotopically implanted into the NSG mice cecum. At Day five, mice were divided into four treatment groups: including 1) sterile water (vehicle), 2) ProAgio (15mg/kg; IP; once daily for nine days), 3) FOLFIRI (5-FU: 30mg/kg; Leucovorin 50mg/kg; Irinotecan; 20mg/kg - once every three days intraperitoneal) or 4) combination of ProAgio and FOLFIRI. The study completed on day 15, tumor weight was noted, and tumors were processed for histology and flow cytometry. Results: ProAgio plus FOLFIRI significantly (p<0.001) reduced tumor weight in both models compared to individual treatments and vehicles. Combination-treated mice showed a significant (p<0.001) reduction in T-cell exhaustion (CD8+ T cells that are positive for PD-1, TIM-3, and CTLA-4). Analysis of the myeloid compartment showed a significant (p<0.001) increase in the M1 macrophages that express F4/80 as well as CD86, MHC-II and a decrease in the M2 macrophage in the mice treated with ProAgio plus FOLFIRI. The combination therapy exhibited a significant (p<0.001) increase in the dendritic cell infiltration into the tumor microenvironment. Histology analysis showed that ProAgio treatment reduced the incidence of organ site metastasis (disseminated and locoregional spread) such as liver, pancreas, and diaphragm. Conclusion: Our study offers encouraging observations that ProAgio plus FOLFIRI can suppress colon cancer growth and metastasis by inhibiting αvβ3 preclinically and may provide a novel therapeutic combination for the management of colon cancers. Citation Format: Purnachandra Nagaraju Ganji, Jeremy B. Foote, Madhu Sudhana Saddala, Falguni Mishra, Sujith Sarvesh, Midhun Malla, Ashiq Masood, Zhi-Ren Liu, Bassel F. El-Rayes. Combination of FOLFIRI (5-FU, Leucovorin, and Irinotecan) and ProAgio on colon cancer growth and metastasis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4571.

Abstract 2619: A novel EGFR × HER3-targeting bispecific antibody drug-conjugate, BCG019, demonstrates robust anti-tumor efficacy in preclinical evaluation

Abstract EGFR and HER3 are receptor tyrosine kinases that are highly expressed in multiple epithelial tumors. EGFR point mutations and small insertions within the kinase domain are common in lung cancer. HER3 is overexpressed in patients who are resistant to EGFR-TKI therapy, and is one of the common resistance mechanisms of EGFR and HER2-targeted therapy. We hypothesize that simultaneous targeting of EGFR and HER3 with a bispecific ADC will have the potential to overcome the resistance caused by HER3 after EGFR-targeted therapy and obtain better efficacy than the combination of EGFR monotherapy and HER3 monotherapy. We first generated fully human bispecific antibodies (bsAbs) targeting EGFR and HER3 using RenLite® mice, which contain the full human heavy chain variable domain with a common human kappa light chain to facilitate bispecific antibody assembly. The anti-EGFR × HER3 bsAb demonstrated reactivity to human and cynomolgus monkey antigens and binding to multiple cancer cell lines, including NSCLC, gastric, pancreatic, colorectal, and breast cancer cell lines. The anti-EGFR × HER3 bsAb also showed high internalization activity in cell lines expressing EGFR and HER3. The anti-EGFR × HER3 bsAb was then conjugated with vc-MMAE (valine-citrulline-monomethyl auristatin E) for proof-of-concept studies, as well as BLD1102, Biocytogen’s novel, proprietary linker/payload system composed of a DNA Topo I inhibitor payload (BCPT02) and highly hydrophilic protease-cleavable linker, to generate EGFR- and HER3-targeting bispecific ADC candidates BCG019. In vivo efficacy of the bsADC candidates were evaluated in cell-derived NSCLC and gastric cancer xenografts and in patient-derived gastric and colorectal xenograft models. Both bsADCs showed superior anti-tumor activity when compared to benchmark ADCs. Collectively, these results suggest that our novel anti-EGFR × HER3 bsADC has therapeutic potential for EGFR and HER3 co-expressing tumors. Citation Format: Zhuolin Li, Chengzhang Shang, Gao An, Chaoshe Guo, W. Frank An, Yi Yang. A novel EGFR × HER3-targeting bispecific antibody drug-conjugate, BCG019, demonstrates robust anti-tumor efficacy in preclinical evaluation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 2619.

Abstract 1216: Pan-RAS inhibition by a tumor-targeted biotherapeutic

Abstract Oncogenic RAS signaling drives tumor growth in about 30% of human malignancies. In recent years the first mutant-specific inhibitors of KRAS G12C (sotorasib and adagrasib) entered the clinic. While some durable responses were noted in KRAS-mutant non-small cell lung cancer, the clinical experience of KRAS G12C inhibitors is marked by rapid drug resistance, either intrinsic or acquired, causing re-activation of the MAPK pathway. Common resistance mechanisms include compensatory signaling through the related RAS isoforms NRAS and HRAS, as well as the selection of non-G12C KRAS mutations, among others. The bacterial peptidase RRSP potently cleaves all RAS mutants and isoforms in the conserved Switch I region. We have shown that receptor-mediated intracellular delivery of RRSP using an engineered protein delivery system (RASx) can inactivate all RAS signaling in a cell, causing apoptosis in RAS-addicted tumor cells in vitro and in vivo. Since systemic pan-RAS inhibition is not likely to be tolerated therapeutically, precise tumor targeting is a necessary feature of a true pan-RAS inhibitor. Here, we describe the unique ability of the RASx system to specify the cell surface receptor used by RRSP to enter cells, allowing exquisite targeting and killing of KRAS, NRAS and HRAS-driven tumor cells while sparing healthy tissues. We screened a panel of patient-derived tumor organoids (PDOs), to demonstrate broad tumor cell killing across pancreatic and colorectal cancer-derived PDOs. 97% of KRAS mutant organoids were sensitive to RASx, independent of the specific mutation. Intriguingly, 46% of wildtype RAS PDOs were sensitive to RASx, including organoids with activating mutations in EGFR. In contrast, PDOs with mutations downstream of RAS such as BRAF V600E were resistant to RASx. Indeed, RASx is effective not only against RAS-addicted tumors, but also wildtype RAS tumors driven by upstream receptor tyrosine kinases, potentially expanding the clinical utility of this platform. RASx is a first-in-class, tumor-targeted pan-RAS inhibitor that represents a unique entry into the growing armamentarium against oncogenic RAS. Citation Format: Greg L. Beilhartz, Huazhu Liang, Molly Udaskin, Christine Ng, Nikolina Radulovich, Roman A. Melnyk. Pan-RAS inhibition by a tumor-targeted biotherapeutic [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1216.

Abstract 4127: Combined inhibition of RAF, MEK, and FAK attenuates melanoma brain metastases and prolongs survival in preclinical models

Abstract Despite promising results from recent FDA-approved therapies, many advanced melanoma patients develop resistance to both immunotherapy and targeted therapy. A common resistance mechanism to targeted therapy is upregulation of the PI3K/AKT signaling pathway, which has also been shown to promote the development of melanoma brain metastases. Historically, AKT inhibitors have failed in the clinic due to their limited efficacy or intolerable toxicity. Proteomic analysis comparing non-metastatic vs brain metastatic primary tumors in mice revealed focal adhesion kinase (FAK) as an AKT1 specific effector and a potential alternative therapeutic target. FAK is a non-receptor tyrosine kinase that localizes primarily to focal adhesions to regulate cell migration. To determine whether targeting FAK alone or in combination with the RAF/MEK inhibitor avutometinib reduces brain metastases and prolongs survival, we utilized both autochthonous and syngeneic melanoma mouse models. Mice with either subcutaneous tumors or established brain metastases were treated with FAK inhibitor, RAF/MEK inhibitor, or the combination of FAK and RAF/MEK inhibitors. Each cohort was assessed for tumor onset, growth, metastasis, and survival. Our results show that combined RAF/MEK/FAK inhibition significantly delays tumor onset, causes regression of established tumors, prevents the development of brain metastases, promotes the regression of established brain metastases, and prolongs survival. In addition, patient-derived BRAF V600E melanoma xenograft mouse models resistant to the BRAF inhibitor dabrafenib and the MEK inhibitor trametinib, were sensitive to combined RAF/MEK/FAK blockade. The addition of the BRAF inhibitor encorafenib to these models further enhanced the effect on tumor growth. These results support the initiation of a clinical trial evaluating the efficacy of the RAF/MEK inhibitor avutometinib in combination with the FAK inhibitor defactinib in patients with brain metastases from cutaneous melanoma. Additionally, we are assessing non-canonical roles of FAK in modulating the tumor microenvironment to determine whether avutometinib and defactinib also enhance the efficacy of immune checkpoint inhibition in this disease. Citation Format: Karly A. Stanley, Jared D. Almazan, Tursun Turapov, David A. Kircher, Gennie L. Parkman, MiKaela N. Field, Katie M. Culver, Christopher M. Stehn, Silvia Coma, Jonathan A. Pachter, Howard Colman, Sheri L. Holmen. Combined inhibition of RAF, MEK, and FAK attenuates melanoma brain metastases and prolongs survival in preclinical models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4127.

Inter-phylum circulation of a beta-lactamase-encoding gene: a rare but observable event.

Beta-lactamase-mediated degradation of beta-lactams is the most common mechanism of beta-lactam resistance in Gram-negative bacteria. Beta-lactamase-encoding genes can be transferred between closely related bacteria, but spontaneous inter-phylum transfers (between distantly related bacteria) have never been reported. Here, we describe an extended-spectrum beta-lactamase (ESBL)-encoding gene (blaMUN-1) shared between the Pseudomonadota and Bacteroidota phyla. An Escherichia coli strain was isolated from a patient in Münster (Germany). Its genome was sequenced. The ESBL-encoding gene (named blaMUN-1) was cloned, and the corresponding enzyme was characterized. The distribution of the gene among bacteria was investigated using the RefSeq Genomes database. The frequency and relative abundance of its closest homolog in the global microbial gene catalog (GMGC) were analyzed. The E. coli strain exhibited two distinct morphotypes. Each morphotype possessed two chromosomal copies of the blaMUN-1 gene, with one morphotype having two additional copies located on a phage-plasmid p0111. Each copy was located within a 7.6-kb genomic island associated with mobility. blaMUN-1 encoded for an extended-spectrum Ambler subclass A2 beta-lactamase with 43.0% amino acid identity to TLA-1. blaMUN-1 was found in species among the Bacteroidales order and in Sutterella wadsworthensis (Pseudomonadota). Its closest homolog in GMGC was detected frequently in human fecal samples. This is, to our knowledge, the first reported instance of inter-phylum transfer of an ESBL-encoding gene, between the Bacteroidota and Pseudomonadota phyla. Although the gene was frequently detected in the human gut, inter-phylum transfer was rare, indicating that inter-phylum barriers are effective in impeding the spread of ESBL-encoding genes, but not entirely impenetrable.

Abstract B007: NAD+ metabolism drives PARPi resistance in ovarian cancer cells

Abstract NAD+ is a coenzyme for redox reactions and a cofactor for enzymes such as PARPs and Sirtuins. The nuclear enzyme PARP1 is a major consumer of NAD+, which is cleaved during the catalytic activation of PARP1 in response to DNA damage. PARP1 inhibitors compete with NAD+ for the catalytic site of PARP1 and reduce the catalytic activity of PARP1 and impair DNA damage repair. Recently PARP inhibitors (PARPi) have shown efficacy in the treatment of ovarian cancers and most patients with defects in homologous repair of DNA damage are now on PARPi maintenance. But, heterogeneous responses to PARPi is limiting their clinical efficacy. To identify the mechanisms of PARPi resistance, we generated a panel of ovarian cancer cells with acquired resistance to niraparib (PARPiR), an FDA approved PARP inhibitor. We demonstrated that the PARPiR cells are also resistant to other FDA approved PARP inhibitors rucaparib and olaparib. This data suggested that a common mechanism of resistance underlies poor response to the FDA approved PARP inhibitors. Since PARP1 activity is tightly controlled by the cellular NAD+ levels, we next investigated the role of NAD+ biosynthesis in PARPi resistance. Metabolomic profiling of the parental and PARPiR cells demonstrated that PARPiR cells have elevated levels of NAD+ metabolism. Indeed, treating the PARPiR cells with inhibitors of NAD+ synthesis restored the sensitivity to PARP inhibitors. Moreover, culturing the previously sensitive parental ovarian cancer cells in NAD+ precursors decreased their sensitivity to PARP inhibitors. These data collectively demonstrated that high levels of NAD+ metabolism causes PARP inhibitor resistance in ovarian cancer cells. Complementary to the metabolomic analysis, results from phenotypic assays in PARPiR cells revealed that high levels of NAD+ maintain cellular quiescence in PARPiR cells. In summary, our results demonstrated that high levels of NAD+ biosynthesis causes PARPi resistance by maintaining cellular quiescence. There is an urgent need to identify the mechanisms of resistance to PARP inhibitors to increase their clinical efficacy. Our study identified that maintenance of quiescence is a fundamental mechanism of PARPi resistance. We also demonstrated that inhibiting NAD+ biosynthesis reverses PARP inhibitor resistance. Citation Format: Subin Myong, Hardik Shah, Benedikt Nagele, Reshma Rajesh, Sridevi Challa. NAD+ metabolism drives PARPi resistance in ovarian cancer cells [abstract]. In: Proceedings of the AACR Special Conference on Ovarian Cancer; 2023 Oct 5-7; Boston, Massachusetts. Philadelphia (PA): AACR; Cancer Res 2024;84(5 Suppl_2):Abstract nr B007.

Functional Heterogeneity in MET Pathway Activation in PDX Models of Osimertinib-resistant EGFR-driven Lung Cancer.

Using a novel cohort of in vivo PDX models of MET pathway activation with acquired resistance to osimertinib in EGFR-mutant lung cancer, we demonstrate that phospho-MET may be a clinically relevant assay to guide treatment selection with osimertinib and savolitinib combination. In addition, our work shows that patients with MET polysomy tumors may have subclonal MET amplification and therefore require close follow up for the use of osimertinib and savolitinib combination.

PI3K/mTOR is a therapeutically targetable genetic dependency in diffuse intrinsic pontine glioma.

Diffuse midline glioma (DMG), including tumors diagnosed in the brainstem (diffuse intrinsic pontine glioma - DIPG), are uniformly fatal brain tumors that lack effective treatment. Analysis of CRISPR-Cas9 loss-of-function gene deletion screens identified PIK3CA and MTOR as targetable molecular dependencies across DIPG patient models, highlighting the therapeutic potential of the blood-brain barrier penetrant PI3K/Akt/mTOR inhibitor, paxalisib. At the human equivalent maximum tolerated dose, mice treated with paxalisib experienced systemic glucose feedback and increased insulin levels commensurate with patients using PI3K inhibitors. To exploit genetic dependence and overcome resistance whilst maintaining compliance and therapeutic benefit, we combined paxalisib with the anti-hyperglycemic drug, metformin. Metformin restored glucose homeostasis and decreased phosphorylation of the insulin receptor in vivo, a common mechanism of PI3K-inhibitor resistance, extending survival of orthotopic models. DIPG models treated with paxalisib increased calcium-activated PKC signaling. The brain penetrant PKC inhibitor enzastaurin in combination with paxalisib, synergistically extended the survival of multiple orthotopic patient-derived and immunocompetent syngeneic allograft models; benefits potentiated in combination with metformin and standard-of-care radiotherapy. Therapeutic adaptation was assessed using spatial transcriptomics and ATAC-sequencing, identifying changes in myelination and tumor immune microenvironment crosstalk. Together, we have identified a clinically relevant DIPG therapeutic combinatorial approach.