Death Receptor Agonists Research Articles

Tetravalent death receptor 5 (DR5) agonist ozekibart (INBRX-109) + FOLFIRI in 2L+ colorectal adenocarcinoma (CRC): Preliminary results from a phase 1 study.

129 Background: DR5, a proapoptotic receptor, is selectively expressed on tumor vs normal cells, making it an attractive target. DR5 binds to its ligand, TRAIL, resulting in DR5 multimerization and apoptosis; greater DR5 clustering enhances downstream effects. Ozekibart is a next-generation, recombinant, humanized, tetravalent DR5 agonist that is based on a single-domain antibody platform and precisely engineered to balance agonism and safety. Ozekibart previously demonstrated an acceptable safety profile and clinical benefit in chondrosarcoma (1), prompting a phase 2, randomized trial (ChonDRAgon; NCT04950075). An ongoing phase 1 study (NCT03715933) is evaluating ozekibart in various solid tumors, including 2L+ CRC, for which effective therapies are lacking. We present preliminary results of ozekibart + FOLFIRI in 2L+ CRC (data cutoff: Aug 9, 2024). Methods: Parts 1 (single-agent dose escalation) and 2 (single-agent dose expansion; recommended phase 2 dose [RP2D] ozekibart 3 mg/kg IV Q3W) of this 3-part, open-label trial are complete. Part 3 (combination dose expansion with chemo) is ongoing in pts with CRC, Ewing sarcoma, or SDH-deficient GIST. Pts with locally advanced or metastatic, unresectable CRC who received oxaliplatin-based chemo were eligible for part 3. Pts with chronic liver disease were ineligible. Pts in the part 3 CRC cohorts (N=13; enrollment complete) received ozekibart 1 mg/kg (n=5) or 3 mg/kg (n=8) IV Q28D (1 cycle) + FOLFIRI Q14D (FOLFIRI could be stopped after ≥6 cycles); in 4/5 pts, ozekibart dose was escalated to 3 mg/kg (RP2D). The primary endpoint is safety; clinical response is an exploratory endpoint. Results: In total, 13 pts with CRC (male, 62%) received ozekibart + FOLFIRI. Median age was 60. All pts had metastatic disease; median number of prior lines of therapy was 2 (range, 1-6). At data cutoff, 2 pts remained on treatment. Ozekibart-related adverse events (AEs) were reported in 85% of pts (grade ≥3, 31%) and led to ozekibart interruption in 3 pts and discontinuation in 1 pt. One combo-related AE (neutropenic sepsis) led to death. The most common ozekibart-related AEs were nausea (n=5) and diarrhea, fatigue, and increased alanine aminotransferase (each n=4). Four pts (31%) had responses (all partial). Disease control rate (response + stable disease) was 77% (10/13) and durable (>180 days) in 46% (6/13) of pts. Most pts had tumor shrinkage. Median PFS was 7.85 mo. Conclusions: Ozekibart + FOLFIRI showed encouraging preliminary efficacy, including PRs and durable disease control, as 2L+ therapy in pts with CRC. Given these promising data, a new expansion cohort (C4d) is open to validate these findings in a more homogeneous population. Eligible pts will have had 2 or 3 prior lines of systemic therapy (irinotecan allowed but not in the immediately prior line) and must have archival or fresh biopsy tissue. 1. Subbiah. Clin Cancer Res. 2023. Clinical trial information: NCT03715933 .

TRAIL agonists rescue mice from radiation-induced lung, skin or esophageal injury.

Radiotherapy can be limited by pneumonitis which is impacted by innate immunity, including pathways regulated by TRAIL death receptor DR5. We investigated whether DR5 agonists could rescue mice from toxic effects of radiation and found two different agonists, parenteral PEGylated trimeric-TRAIL (TLY012) and oral TRAIL-Inducing Compound (TIC10/ONC201) could reduce pneumonitis, alveolar-wall thickness, and oxygen desaturation. Lung protection extended to late effects of radiation including less fibrosis at 22-weeks in TLY012-rescued survivors versus un-rescued surviving irradiated-mice. Wild-type orthotopic breast tumor-bearing mice receiving 20-Gy thoracic radiation were protected from pneumonitis with disappearance of tumors. At the molecular level, radioprotection appeared due to inhibition of CCL22, a macrophage-derived chemokine previously associated with radiation pneumonitis and pulmonary fibrosis. Treatment with anti-CCL22 reduced lung injury in vivo but less so than TLY012. Pneumonitis severity was worse in female versus male mice, and this was associated with increased expression of X-linked TLR7. Irradiated mice had reduced esophagitis characterized by reduced epithelial disruption and muscularis externa thickness following treatment with ONC201 analogue ONC212. The discovery that short-term treatment with TRAIL pathway agonists effectively rescues animals from pneumonitis, dermatitis and esophagitis following high doses of thoracic radiation exposure has important translational implications.

Chronic endothelial dopamine receptor stimulation improves endothelial function and hemodynamics in autosomal dominant polycystic kidney disease

Altered polycystin-mediated endothelial flow mechanosensitivity contributes to the development of hypertension and cardiovascular complications in patients with autosomal dominant polycystic kidney disease (ADPKD). Stimulation of endothelial type 5 dopamine receptors (DR5) can acutely compensate for the endothelial consequences of polycystin deficiency, but the chronic impact of this approach must be evaluated in ADPKD. Nineteen patients with ADPKD on standard of care therapy were randomized to receive a 2-month treatment with the DR agonist rotigotine using transdermal patches, nine at 2 mg/24hours and ten at 4 mg/24hours or while ten were untreated. Rotigotine at the dose of 4 mg/24hours significantly increased nitric oxide release (nitrite levels from 10±30 to 46±34 nmol/L) and radial artery endothelium-dependent flow-mediated dilatation (from 16.4±6.3 to 22.5±7.3%) in response to hand skin heating. Systemic hemodynamics were not significantly modified but aplanation tonometry showed that rotigotine at 4 mg/24hours reduced aortic augmentation index and pulse pressure without affecting carotid-to femoral pulse wave velocity. Plasma creatinine and urea, urinary cyclic AMP, which contributes to cyst growth in ADPKD and copeptin, a surrogate marker of vasopressin, were not affected by rotigotine. In mice with a specific deletion of polycystin-1 in endothelial cells, chronic infusion of the peripheral DR5 agonist fenoldopam also improved mesenteric artery flow-mediated dilatation and reduced blood pressure. Thus, our study demonstrates that in patients with ADPKD, chronic administration of rotigotine improves conduit artery endothelial function through the restoration of flow-induced nitric oxide release as well as hemodynamics suggesting that endothelial DR5 activation may represent a promising pharmacological approach to prevent cardiovascular complications of ADPKD.

Abstract 1899: Novel combinations of aplitabart, a DR5 agonist IgM antibody, with ADCs or chemotherapeutic agents lead to robust anti-tumor responses in solid tumor models

Abstract Agonism of death receptor 5 (DR5), a tumor necrosis factor receptor superfamily member, induces the killing of tumor cells via the extrinsic apoptotic pathway upon receptor multimerization. We have engineered a multivalent IgM DR5 agonist antibody, aplitabart (IGM-8444), that induces robust anti-tumor activity in both in vitro and in vivo preclinical models. We also demonstrated potent synergistic in vitro activity of aplitabart with different classes of chemotherapeutic agents including microtubule inhibitors, nucleoside analogs and topoisomerase inhibitors in a range of solid cancer cell lines. Preliminary results from an ongoing phase 1a/ab clinical study show that aplitabart has an encouraging safety profile and promising activity in combination with FOLFIRI ± bevacizumab in heavily pretreated metastatic colorectal cancer patients. To further explore the combination therapies for aplitabart in lung and breast cancers, we evaluated standard of care chemotherapies, such as paclitaxel, carboplatin, and antibody drug conjugates (ADCs) in vitro on a range of human lung and breast cancer cell lines. We observed dose-dependent synergistic cytotoxic effects of aplitabart on tumor cells when combined with these agents. Additionally, these agents increased the expression of DR5 on tumor cells and could explain their synergistic combinatorial activity with aplitabart. Representative cancer cell lines were selected to evaluate these combinations in vivo using xenograft mouse models where robust anti-tumor responses were demonstrated in the xenograft lung and breast cancer models, resulting in enhanced tumor growth inhibition and extended survival. Our findings demonstrate potent in vitro synergistic cytotoxicity and enhanced anti-tumor response in preclinical models in vivo by combining aplitabart with ADCs, or carboplatin and paclitaxel. These results support the combination of DR5 agonist IgM antibodies with agents known to upregulate DR5 expression on solid tumors. Aplitabart is currently under evaluation in a randomized clinical study in combination with FOLFIRI + bevacizumab in comparison with FOLFIRI + bevacizumab in patients with colorectal cancer (NCT04553692). Citation Format: Mélanie Desbois, Susan E. Calhoun, Kevin C. Hart, Carolyn R. Denson, Poonam Yakkundi, Thomas J. Matthew, Maya K. Leabman, Sanela Bilic, Genevive Hernandez, Eric W. Humke, Albert F. Candia, Bruce Keyt, Angus M. Sinclair, Maya F. Kotturi, Beatrice T. Wang. Novel combinations of aplitabart, a DR5 agonist IgM antibody, with ADCs or chemotherapeutic agents lead to robust anti-tumor responses in solid tumor 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 1899.

Abstract C031: A randomized Phase 1b study of IGM-8444 in combination with FOLFIRI + bevacizumab compared to FOLFIRI + bevacizumab alone in second line metastatic colorectal cancer

Abstract Background: Death receptor 5 (DR5), a member of the tumor necrosis factor (TNF) receptor superfamily that binds to TNF-related apoptosis-inducing ligand and activates the extrinsic apoptotic pathway, is an attractive target for cancer therapies given its upregulated expression in multiple cancers and ability to induce apoptosis. However, key limitations of therapies targeting DR5 are a lack of potency due to an inability to multimerize DR5, and/or clinically significant hepatoxicity. IGM-8444 is an IgM-based DR5 agonist with 10 binding sites that allow multimerization and subsequent activation of DR5. Preclinical studies demonstrate IGM-8444 cytotoxicity as a single agent and in combination in a range of tumors. We discuss our ongoing randomized study of IGM-8444 in combination with FOLFIRI + bevacizumab compared to FOLFIRI + bevacizumab alone in second line metastatic colorectal cancer (mCRC) (NCT04553692). Methods: This study is a Phase 1b, multicenter, randomized, open-label clinical trial of IGM-8444 in combination with FOLFIRI + bevacizumab compared to FOLFIRI + bevacizumab alone in patients with second line mCRC who have not received prior irinotecan in either the adjuvant, locally advanced, or metastatic setting. Patients will be randomized 1:1 either to Treatment Arm 1: IGM-8444 in combination with FOLFIRI + bevacizumab or Treatment Arm 2: FOLFIRI + bevacizumab. Patients will be stratified by the presence of liver metastases and KRAS mutational status. Patients randomized in Treatment Arm 2 will have the opportunity to crossover to Treatment Arm 1 after confirmed radiographic progression. Patients will receive IGM-8444 on Days 1 and 15 of each 28-day cycle at a dose level of 3 mg/kg. IGM-8444 will be dosed prior to administering FOLFIRI + bevacizumab in Treatment Arm 1. FOLFIRI + bevacizumab will be administered in accordance with prescribing guidelines and institutional standards. Patients will continue this regimen until disease progression or unacceptable toxicity. The primary endpoint will be progression-free survival as determined by study investigators. Secondary endpoints include frequency and severity of adverse events, overall response rate, duration of response, and overall survival as determined by study investigators. The randomized study is currently open with patients actively enrolling. The planned study size is 110 patients. Clinical Trial Registry Number NCT04553692 Citation Format: Susanna Ulahannan, Meredith Pelster, Patricia LoRusso, Gerald Falchook, Judy Wang, Minal Barve, Jaspreet Grewal, Warren Chow, Jason Henry, Michael Cecchini, Vivek Subbiah, Maya Leabman, Genevive Hernandez, Yao Li, Angus Sinclair, Beatrice Wang, Maya Kotturi, Eric Humke, Sean Ahern, Leslie Ennis, Melaine Caruano, Sapeck Agrawal. A randomized Phase 1b study of IGM-8444 in combination with FOLFIRI + bevacizumab compared to FOLFIRI + bevacizumab alone in second line metastatic colorectal cancer [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr C031.

Abstract A137: Pharmacokinetics and pharmacodynamics of IGM-8444, a first-in-class engineered pentameric DR5-targeting agonist IgM monoclonal antibody, in patients with R/R and newly diagnosed cancers

Abstract Introduction: IGM-8444 is an engineered DR5 agonist IgM antibody with 10 binding sites that efficiently multimerizes DR5 to induce tumor cell apoptosis. The first-in-human Phase 1a/1b study of IGM-8444 (NCT04553692) is ongoing, and preliminary results show that IGM-8444 is well-tolerated as a single agent (SA) and in combination with chemotherapeutic and targeted agents. Encouraging efficacy is also observed with IGM-8444 combined with FOLFIRI +/- bevacizumab (bev) in patients with relapsed/refractory mCRC. Here we present pharmacokinetic (PK) and pharmacodynamic biomarker data from Phase 1a participants treated with IGM-8444 as SA or in combination at doses of 0.15 to 5 mg/kg given weekly (QW) or 0.3 to 10 mg/kg given every 2 weeks (Q2W). Methods: Blood samples for PK and biomarker analysis were collected at multiple timepoints during cycles 1 and 2. Sparse sampling was utilized at later cycles. Plasma biomarker evaluation included measurement of M30 by ELISA and total caspase-3 (casp-3) by MSD. Tumor biomarkers were assessed in baseline and on-treatment tissue through immunohistochemistry for DR5 and cleaved caspase-3 (CC3). Initial population PK modeling was conducted to assess the PK characteristics of IGM-8444 as SA and in combination, and to enable simulations of different doses and dosing regimen scenarios. Results: Treatment-related increases in plasma levels of apoptotic markers casp-3 (up to 25-fold) and M30 (up to 6-fold) were observed across dose levels. These changes occurred independently of any ALT or AST fluctuations, suggesting tumor-specific apoptosis induction. Dose-dependent increases in casp-3 and CC3 were observed in blood and tumor, respectively, indicating activation of DR5 pathway. At 3 mg/kg, on-treatment tumor CC3 levels were up to 10-fold higher in FOLFIRI combo, signifying enhanced apoptosis when IGM-8444 is combined with chemotherapy. Population PK analysis indicates that IGM-8444 PK is best described by a two-compartment model with parallel linear and nonlinear clearance. Terminal half-life at 10 mg/kg Q2W was >2 days. PK simulations suggest that IGM-8444 administered at 3 or 10 mg/kg Q2W sustains average concentrations within the range as those observed at efficacious doses of IGM-8444 in preclinical mouse tumor models, where SA IGM-8444 exhibits dose-dependent efficacy with no evidence of a bell-shaped response. To date, ADAs have been detected in ~25% of participants. ADA titers in confirmed ADA-positive participants remain relatively low and the available data do not indicate a significant effect of ADAs on the PK of IGM-8444. Conclusions: Pharmacodynamic changes in blood and tissue confirm the biologic activity of IGM-8444 and demonstrates that targeted therapy with an engineered IgM antibody can result in tumor penetration and target engagement within tumor tissue. Taken together, the biomarker and PK data support the use of IGM-8444 at a dose of 3 mg/kg or above for combination studies. The randomized Phase 1b is underway and evaluates the activity of FOLFIRI+bev +/- IGM-8444 in 2L mCRC. Citation Format: Genevive Hernandez, Sanela Bilic, Yinghui Guan, John So, Sabya Bhattacharya, Beatrice Wang, Maya Kotturi, Miho Oyasu, Melanie Desbois, Yuan Cao, Eric Humke, Sean Ahern, Angus Sinclair, Susanna Ulahannan, Vivek Subbiah, Merideth Pelster, Patricia Lorusso, Gerald Falchook, Judy Wang, Minal Barve, Jaspreet Grewal, Warren Chow, Jason Henry, Michael Cecchini, Chris Takimoto, Maya Leabman. Pharmacokinetics and pharmacodynamics of IGM-8444, a first-in-class engineered pentameric DR5-targeting agonist IgM monoclonal antibody, in patients with R/R and newly diagnosed cancers [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2023 Oct 11-15; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2023;22(12 Suppl):Abstract nr A137.

MAP kinase ERK5 modulates cancer cell sensitivity to extrinsic apoptosis induced by death-receptor agonists

Death receptor ligand TRAIL is a promising cancer therapy due to its ability to selectively trigger extrinsic apoptosis in cancer cells. However, TRAIL–based therapies in humans have shown limitations, mainly due inherent or acquired resistance of tumor cells. To address this issue, current efforts are focussed on dissecting the intracellular signaling pathways involved in resistance to TRAIL, to identify strategies that sensitize cancer cells to TRAIL-induced cytotoxicity. In this work, we describe the oncogenic MEK5-ERK5 pathway as a critical regulator of cancer cell resistance to the apoptosis induced by death receptor ligands. Using 2D and 3D cell cultures and transcriptomic analyses, we show that ERK5 controls the proteostasis of TP53INP2, a protein necessary for full activation of caspase-8 in response to TNFα, FasL or TRAIL. Mechanistically, ERK5 phosphorylates and induces ubiquitylation and proteasomal degradation of TP53INP2, resulting in cancer cell resistance to TRAIL. Concordantly, ERK5 inhibition or genetic deletion, by stabilizing TP53INP2, sensitizes cancer cells to the apoptosis induced by recombinant TRAIL and TRAIL/FasL expressed by Natural Killer cells. The MEK5-ERK5 pathway regulates cancer cell proliferation and survival, and ERK5 inhibitors have shown anticancer activity in preclinical models of solid tumors. Using endometrial cancer patient-derived xenograft organoids, we propose ERK5 inhibition as an effective strategy to sensitize cancer cells to TRAIL-based therapies.

Tetrandrine synergizes with MAPK inhibitors in treating KRAS-mutant pancreatic ductal adenocarcinoma via collaboratively modulating the TRAIL-death receptor axis

Pancreatic ductal adenocarcinoma (PDAC) is one of the most aggressive and lethal malignancies lacking effective therapies. KRAS mutations that occur in over 90% of PDAC are major oncogenic drivers of PDAC. The MAPK signaling pathway plays a central role in KRAS-driven oncogenic signaling. However, pharmacological inhibitors of the MAPK pathway are poorly responded in KRAS-mutant PDAC, raising a compelling need to understand the mechanism behind and to seek new therapeutic solutions. Herein, we perform a screen utilizing a library composed of 800 naturally-derived bioactive compounds to identify natural products that are able to sensitize KRAS-mutant PDAC cells to the MAPK inhibition. We discover that tetrandrine, a natural bisbenzylisoquinoline alkaloid, shows a synergistic effect with MAPK inhibitors in PDAC cells and xenograft models. Mechanistically, pharmacological inhibition of the MAPK pathway exhibits a double-edged impact on the TRAIL-death receptor axis, transcriptionally upregulating TRAIL yet downregulating its agonistic receptors DR4 and DR5, which may explain the limited therapeutic outcomes of MAPK inhibitors in KRAS-mutant PDAC. Of great interest, tetrandrine stabilizes DR4/DR5 protein via impairing ubiquitination-mediated protein degradation, thereby allowing a synergy with MAPK inhibition in inducing apoptosis in KRAS-mutant PDAC. Our findings identify a new combinatorial approach for treating KRAS-mutant PDAC and highlight the role of TRAIL-DR4/DR5 axis in dictating the therapeutic outcome in KRAS-mutant PDAC.

Preclinical Characterization and Phase 1 Trial Results of INBRX-109, a Third-Generation, Recombinant, Humanized, Death Receptor 5 Agonist Antibody, in Chondrosarcoma.

Patients with unresectable/metastatic chondrosarcoma have poor prognoses; conventional chondrosarcoma is associated with a median progression-free survival (PFS) of <4 months after first-line chemotherapy. No standard targeted therapies are available. We present the preclinical characterization of INBRX-109, a third-generation death receptor 5 (DR5) agonist, and clinical findings from a phase 1 trial of INBRX-109 in unresectable/metastatic chondrosarcoma (NCT03715933). INBRX-109 was first characterized preclinically as a DR5 agonist, with binding specificity and hepatotoxicity evaluated in vitro and antitumor activity evaluated both in vitro and in vivo. INBRX-109 (3 mg/kg every 3 weeks) was then evaluated in a phase 1 study of solid tumors that included a cohort with any subtype of chondrosarcoma and a cohort with IDH1/IDH2-mutant conventional chondrosarcoma. The primary endpoint was safety. Efficacy was an exploratory endpoint, with measures including objective response, disease control rate, and PFS. In preclinical studies, INBRX-109 led to antitumor activity in vitro and in patient-derived xenograft models, with minimal hepatotoxicity. In the phase 1 study, INBRX-109 was well tolerated and demonstrated antitumor activity in unresectable/metastatic chondrosarcoma. INBRX-109 led to a disease control rate of 87.1% (27/31; durable clinical benefit, 40.7% [11/27]), including 2 partial responses, and median PFS of 7.6 months. Most treatment-related adverse events, including liver-related events, were low grade (grade ≥3 events in chondrosarcoma cohorts, 5.7%). INBRX-109 demonstrated encouraging antitumor activity with a favorable safety profile in patients with unresectable/metastatic chondrosarcoma. A randomized, placebo-controlled, phase 2 trial (ChonDRAgon, NCT04950075) will further evaluate INBRX-109 in conventional chondrosarcoma.

The Role of TRAIL in Apoptosis and Immunosurveillance in Cancer

Tumor necrosis factor (TNF)-related apoptosis-inducing ligand (TRAIL) is a member of the TNF superfamily that selectively induces apoptosis in tumor cells without harming normal cells, making it an attractive agent for cancer therapy. TRAIL induces apoptosis by binding to and activating its death receptors DR4 and DR5. Several TRAIL-based treatments have been developed, including recombinant forms of TRAIL and its death receptor agonist antibodies, but the efficacy of TRAIL-based therapies in clinical trials is modest. In addition to inducing cancer cell apoptosis, TRAIL is expressed in immune cells and plays a critical role in tumor surveillance. Emerging evidence indicates that the TRAIL pathway may interact with immune checkpoint proteins, including programmed death-ligand 1 (PD-L1), to modulate PD-L1-based tumor immunotherapies. Therefore, understanding the interaction between TRAIL and the immune checkpoint PD-L1 will lead to the development of new strategies to improve TRAIL- and PD-L1-based therapies. This review discusses recent findings on TRAIL-based therapy, resistance, and its involvement in tumor immunosurveillance.

Abstract 1066: PARP inhibitor rucaparib in combination with imipridones ONC201 or ONC212 demonstrates preclinical synergy against BRCA1/2-deficient breast, ovarian, and prostate cancer cells

Abstract BRCA1/2 genes encode proteins that mediate homologous recombination and repair (HRR). BRCA1/2 mutations increase risk of breast, ovarian, prostate and other cancers. BRCA1/2 mutated tumor cells are sensitive to PARP inhibitors (PARPi), that cause DNA replication fork to collapse. Approximately 40% of patients develop PARPi resistance through different mechanisms. One of the mechanisms of PARPi resistance is through P13k/Akt pathway activation. Imipridones are TRAIL-inducing compounds which are PERK-independent activators of the integrated stress response, and dual inhibitors of Akt/ERK. We hypothesized that combining imipridones with PARPi would overcome PARPi resistance due to Akt activation. PARPi also sensitize various solid tumors to recombinant TRAIL and DR5 agonist antibodies thereby further suggesting possible synergies between imipridones and PARPi. Our lab previously showed efficacy of imipridone ONC201 in BRCA-deficient cancer cells and potential synergy with olaparib (2017 AACR annual meeting abstract), without further investigating potential synergistic mechanisms. We explored combination drug synergy of rucaparib (PARP inhibitor) and imipridones (ONC212 and ONC201) in BRCA1/2-deficient breast, ovarian and prostate cancer cell lines. CellTiterGLO viability assays were performed after 72 hours to demonstrate synergistic effects of combination treatment. Western blots were performed to investigate the effect of combination treatment on the Akt pathway, as well as expression of cellular metabolic stress protein ATF4. Cytokine profiling using the Luminex 200 technology was used to study the effect of treatment on the tumor microenvironment. Combination treatment (rucaparib and ONC212, rucaparib and ONC201) in BRCA–deficient cell lines (HCC1937, PEO1, KURAMOCHI, 22RV1, LNCAP) showed synergistic reduction in cell viability. In the HCC 1937 cell line, combination studies of rucaparib-ONC212 and rucaparib-ONC201 showed a synergystic effect, as calculated by Compusyn software, combination indexes below one were observed at concentration of 0.29-37.5 of µM rucaparib with ONC201 at 1.25-5 µM and ONC212 6.25-50 nM with the best combination index of 0.7 for rucaparib-ONC201 combination and 0.31 for rucaparib-ONC212. We similarly observed synergy in other cell lines with combination treatment. Western blot analysis of rucaparib-ONC212 combination showed total Akt protein reduction and an increase in ATF4 consistent with the synergistic effects. Further studies are ongoing to characterize possible mechanisms and effects of PARP inhibitor-imipridone combination treatment on immune-mediated killing. Our findings identify novel PARP inhibitor-imipridone therapy combinations that can be further developed for treatment of BRCA1/2 deficient cancers. Citation Format: Maryam Ghandali, Kelsey E. Huntington, praveen Srinivasan, Don S. Dizon, Stephanie L. Graff, Benedito A. Carneiro, Wafik S. El-Deiry. PARP inhibitor rucaparib in combination with imipridones ONC201 or ONC212 demonstrates preclinical synergy against BRCA1/2-deficient breast, ovarian, and prostate cancer cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1066.

Abstract 6148: Disulfide isomerases AGR2, ERp44, and PDIA1 maintain death receptor 5 in an auto-inhibited, monomeric form

Abstract Previous studies indicated that compounds termed Disulfide bond Disrupting Agents (DDAs) exhibit anti-cancer activity that is associated with downregulation of EGFR/HER1, HER2, and HER3, and activation of Death Receptors 4 and 5 (DR4/5). DDA-induced HER1-3 downregulation is preceded by disulfide-mediated oligomerization. In contrast, DDA-mediated DR4/5 oligomerization results in DR5 upregulation, and activation of DR4/5 pro-apoptotic signaling through Caspases 8 and 3. However, the precise mechanisms by which altered disulfide bonding stabilizes and activates DR5 are unknown. A recent report indicated that the extracellular domain of DR5 acts in an auto-inhibitory manner to prevent DR5 oligomerization and pro-apoptotic signaling in the absence of its ligand, TRAIL. A subsequent paper showed that the DR5 auto-inhibitory domain is a positive patch consisting of three basic residues. Importantly, the structure of the auto-inhibitory loop is formed by two disulfide bonds. We hypothesize that DDAs disrupt the disulfide bonds that make up the auto-inhibitory loop, resulting in DR5 oligomerization, and activation of Caspase 8/3-driven apoptosis in a TRAIL-independent manner. Due to their novel mechanisms of action, DDAs may overcome the pharmacological liabilities that have limited the efficacy of TRAIL analogs and DR5 agonist antibodies. Another unanswered question is how precisely DDAs alter DR5 and EGFR disulfide bonding. The direct targets of DDA action were revealed through affinity purification studies with biotinylated-DDA analogs. These studies identified the protein disulfide isomerases AGR2, ERp44, and PDIA1 as DDA target proteins, explaining how DDAs alter DR5 and EGFR disulfide bonding patterns. Consistent with this interpretation, knockdown of AGR2 or ERp44, or expression of catalytically null AGR2 or ERp44 mutants, mimicked DDAs in inducing disulfide-mediated DR5 oligomerization and Caspase 8 activation. Together, these results demonstrate a fundamentally novel, ligand-independent mechanism for activation of DR5 through DDA-mediated inhibition of the PDIs AGR2, ERp44, and PDIA1. Significantly, DDAs are the first identified active site inhibitors of AGR2 and ERp44. Citation Format: Brian K. Law, Mary E. Law, Elham Yaaghubi, Amanda Ghilardi, Brad J. Davis, Renan Ferreira, Samantha Eggleston, Jade Nguyen, Grace Alexandrow, Jin Koh, Sixue Chen, Chi-Wu Chiang, Coy Heldermon, Peter Norgaard, Ronald K. Castallano, Zaafir M. Dulloo. Disulfide isomerases AGR2, ERp44, and PDIA1 maintain death receptor 5 in an auto-inhibited, monomeric form. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6148.

Abstract 6123: Characterization of the synergistic tumor cytotoxicity of agonistic DR5 IgM antibody IGM-8444 with chemotherapeutic agents

Abstract Death receptor 5 (DR5) is a tumor necrosis factor receptor (TNF) superfamily member that requires multimerization to activate the extrinsic apoptotic pathway and is broadly expressed on solid and hematologic cancers. IGM-8444 is a multivalent IgM DR5 agonist that efficiently multimerizes DR5 to induce tumor cell apoptosis while maintaining a favorable in vitro and in vivo safety profile. The universal mechanism of apoptotic cell death and the safety profile of IGM-8444 makes it an attractive combination partner with standard of care treatment regimens. Here we describe the characterization of single agent and combinatorial cytotoxicity with different classes of chemotherapeutic agents. IGM-8444 was first evaluated as a monotherapy across a panel of human solid tumor cell lines in vitro and xenograft tumor models in vivo. IGM-8444 responses ranged from highly sensitive to resistant. In a sensitive Colo205 model IGM-8444 additionally showed rapid intratumoral pharmacodynamic (PD) activity, inducing maximal caspase-3 cleavage at 6 hours post-dose. Next a panel of solid tumor (including colorectal, gastric, non-small cell lung cancer, and pancreatic) cell lines were selected to evaluate IGM-8444 in combination with standard of care chemotherapeutic agents. Synergistic cytotoxicity was observed when IGM-8444 was used in combination with certain classes of chemotherapeutic agents including topoisomerase inhibitors, microtubule inhibitors, nucleoside analogs, and platinum-based agents. Enhanced anti-tumor activity was also observed in xenograft mouse models where IGM-8444 was dosed in combination with these classes of chemotherapeutic compounds. Mechanistically, this synergistic combinatorial cytotoxicity may be explained by the reported increase in DR5 expression on tumor cells following treatment with many of these classes of chemotherapeutic agents. In summary, IGM-8444 shows in vitro cytotoxicity and in vivo PD and anti-tumor efficacy responses in preclinical models, with enhanced activity in combination with several classes of chemotherapies reported to upregulate DR5 expression. IGM-8444 combination with FOLFIRI standard of care is currently under evaluation in a Phase 1 study in patients with metastatic colorectal cancer (NCT04553692). Citation Format: Beatrice T. Wang, Thomas J. Matthew, Poonam Yakkundi, Miho Oyasu, Mélanie Desbois, Susan E. Calhoun, Ling Wang, Tasnim Kothambawala, Devinder K. Ubhi, Marvin S. Peterson, Eric W. Humke, Maya F. Kotturi, Bruce A. Keyt, Angus M. Sinclair. Characterization of the synergistic tumor cytotoxicity of agonistic DR5 IgM antibody IGM-8444 with chemotherapeutic agents [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6123.

Molecular superglue-mediated higher-order assembly of TRAIL variants with superior apoptosis induction and antitumor activity

Prompting higher-order death receptor (DR) clustering by increasing the valency of DR agonist is efficient to induce apoptosis of tumor cells. As an attractive DR agonist with superior biosafety, the trimeric tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) exerts limited antitumor effect in patients, which is predominantly attributed to its low DR clustering ability and short serum half-life. Previous antibody scaffolds-based engineering strategies to increase the valency and/or prolong the serum half-life of TRAIL improve apoptosis induction, however, often produce large proteins with poor tumor penetration. Covalent protein ligation mediated by small molecular superglues such as SpyTag/SpyCatcher might be a novel strategy to assemble higher-order TRAIL variants. Upon fusion to TRAIL promotor, SpyTag/SpyCatcher molecular superglue preferentially ligated two trimeric TRAIL to produce a hexameric TRAIL variant, HexaTR, exhibiting a significantly increased apoptosis induction. In addition, an albumin-binding HexaTR, ABD-HexaTR, with a prolonged serum half-life by binding to endogenous albumin was also produced using the same strategy. Compared to the trimeric TRAIL, the hexameric HexaTR and ABD-HexaTR showed 20–50 times greater in vivo antitumor effect, resulting in eradication of several types of large (150–300 mm3) tumor xenografts. Combination with bortezomib carried by liposome further improved the antitumor effects of the hexavalent HexaTR and ABD-HexaTR in refractory cancer. Our results indicate that the superglue-mediated higher-order assembly is promising to improve the DR clustering and proapoptotic signaling of TRAIL, showing great advantages in constructing the next generation of DR agonists for cancer therapy.

Targeting TRAIL Death Receptors in Triple-Negative Breast Cancers: Challenges and Strategies for Cancer Therapy

The tumor necrosis factor (TNF) superfamily member TNF-related apoptosis-inducing ligand (TRAIL) induces apoptosis in cancer cells via death receptor (DR) activation with little toxicity to normal cells or tissues. The selectivity for activating apoptosis in cancer cells confers an ideal therapeutic characteristic to TRAIL, which has led to the development and clinical testing of many DR agonists. However, TRAIL/DR targeting therapies have been widely ineffective in clinical trials of various malignancies for reasons that remain poorly understood. Triple negative breast cancer (TNBC) has the worst prognosis among breast cancers. Targeting the TRAIL DR pathway has shown notable efficacy in a subset of TNBC in preclinical models but again has not shown appreciable activity in clinical trials. In this review, we will discuss the signaling components and mechanisms governing TRAIL pathway activation and clinical trial findings discussed with a focus on TNBC. Challenges and potential solutions for using DR agonists in the clinic are also discussed, including consideration of the pharmacokinetic and pharmacodynamic properties of DR agonists, patient selection by predictive biomarkers, and potential combination therapies. Moreover, recent findings on the impact of TRAIL treatment on the immune response, as well as novel strategies to address those challenges, are discussed.

CFLIP suppression and DR5 activation sensitize senescent cancer cells to senolysis.

Senolytics, drugs that kill senescent cells, have been proposed to improve the response to pro-senescence cancer therapies; however, this remains challenging due to a lack of broadly acting senolytic drugs. Using CRISPR/Cas9-based genetic screens in different senescent cancer cell models, we identify loss of the death receptor inhibitor cFLIP as a common vulnerability of senescent cancer cells. Senescent cells are primed for apoptotic death by NF-κB-mediated upregulation of death receptor 5 (DR5) and its ligand TRAIL, but are protected from death by increased cFLIP expression. Activation of DR5 signaling by agonistic antibody, which can be enhanced further by suppression of cFLIP by BRD2 inhibition, leads to efficient killing of a variety of senescent cancer cells. Moreover, senescent cells sensitize adjacent non-senescent cells to killing by DR5 agonist through a bystander effect mediated by secretion of cytokines. We validate this 'one-two punch' cancer therapy by combining pro-senescence therapy with DR5 activation in different animal models.

TRAIL-Based Therapies Efficacy in Pediatric Bone Tumors Models Is Modulated by TRAIL Non-Apoptotic Pathway Activation via RIPK1 Recruitment.

Despite advances in clinical management, osteosarcoma and Ewing sarcoma, the two most frequent malignant primary bone tumors at pediatric age, still have a poor prognosis for high-risk patients (i.e., relapsed or metastatic disease). Triggering a TRAIL pro-apoptotic pathway represents a promising therapeutic approach, but previous studies have described resistance mechanisms that could explain the declining interest of such an approach in clinical trials. In this study, eight relevant human cell lines were used to represent the heterogeneity of the response to the TRAIL pro-apoptotic effect in pediatric bone tumors and two cell-derived xenograft models were developed, originating from a sensitive and a resistant cell line. The DR5 agonist antibody AMG655 (Conatumumab) was selected as an example of TRAIL-based therapy. In both TRAIL-sensitive and TRAIL-resistant cell lines, two signaling pathways were activated following AMG655 treatment, the canonical extrinsic apoptotic pathway and a non-apoptotic pathway, involving the recruitment of RIPK1 on the DR5 protein complex, activating both pro-survival and pro-proliferative effectors. However, the resulting balance of these two pathways was different, leading to apoptosis only in sensitive cells. In vivo, AMG655 treatment reduced tumor development of the sensitive model but accelerated tumor growth of the resistant one. We proposed two independent strategies to overcome this issue: (1) a proof-of-concept targeting of RIPK1 by shRNA approach and (2) the use of a novel highly-potent TRAIL-receptor agonist; both shifting the balance in favor of apoptosis. These observations are paving the way to resurrect TRAIL-based therapies in pediatric bone tumors to help predict the response to treatment, and propose a relevant adjuvant strategy for future therapeutic development.

Bioymifi suppresses Burkitt’s lymphoma cell line proliferation via cell cycle arrest and apoptosis

Purpose: To find a new treatment alternative for Burkitt’s lymphoma, one of the B cell-derived non-Hodgkin's lymphomas that has an extremely aggressive growth profile with a high mortality rate.&#x0D; Methods: Bioymifi (death receptor agonist) was administered at various doses to Human Burkitt's Lymphoma Raji cell lines, and cell proliferation was evaluated using XTT analysis. Apoptosis induction and cell cycle analysis were assessed using flow cytometry.&#x0D; Results: Bioymifi exhibited good cytotoxicity in Raji cell lines with IC50 value of 29.5 μM. Furthermore, results of apoptosis induction and cell cycle analysis indicated that Bioymifi had potent anti-proliferative activity through sub-S cell cycle arrest and stimulation of apoptosis (p &lt; 0.05).&#x0D; Conclusion: Bioymifi has anticancer potentials against Human Burkitt's Lymphoma Raji cell lines. Further pharmacological studies will be required to establish the mechanism of action.

Abstract 1068: Anti-DR5 agonist IgM antibody IGM-8444 combined with SMAC mimetic birinapant induces strong synergistic tumor cytotoxicity

Abstract Apoptosis is induced through extrinsic and intrinsic signaling pathways. Extrinsic apoptosis can be activated through multimerization of death receptor 5 (DR5), a tumor necrosis factor (TNF) receptor family member highly expressed in many cancers. However, cellular resistance mechanisms within the intrinsic pathway may limit DR5 activity, including inhibitor of apoptosis proteins (IAPs) that block caspase activity or promote pro-survival NFκB signaling. Second mitochondria-derived activator of caspases (SMAC) is an endogenous bivalent IAP antagonist. Birinapant, a bivalent SMAC mimetic that binds and degrades IAPs, has been evaluated through Phase 2, demonstrating good safety and on target activity but minimal efficacy as a monotherapy. We hypothesized that simultaneously targeting the extrinsic apoptotic pathway with IGM-8444, an anti-DR5 multivalent IgM agonist, and the intrinsic apoptotic pathway with birinapant could enhance tumor cell apoptosis. Human cancer cell lines including triple negative breast cancer (TNBC), head and neck, ovarian, colorectal, lung, and sarcomas, were screened for sensitivity to IGM-8444 and birinapant combination. Strong synergistic cytotoxicity was observed in vitro in 36/45 (80%) cancer cell lines, as measured by both Bliss synergy score and maximal killing. IGM-8444 and birinapant combination also induced synergistic cytotoxicity in cells with acquired resistance to DR5 agonist antibodies. By contrast, IGM-8444 and birinapant did not kill primary human hepatocytes in vitro, demonstrating the potential clinical safety for this combination. In vivo, the IGM-8444 and birinapant combination dose-dependently reduced tumor growth in a MDA-MB-231 TNBC model, with 8/10 tumor-free mice at the highest dose of birinapant tested. By comparison, birinapant combination with an anti-DR5 IgG agonist showed a modest response. IGM-8444 and birinapant also showed significant anti-tumor responses in additional cell line and patient-derived xenograft models, including 7/9 tumor-free animals in a HT-1080 fibrosarcoma model and 9/10 complete responses in a EBC-1 lung squamous cell lung carcinoma model. Lastly, pharmacodynamic biomarkers including cIAP1 degradation, caspase activation, and caspase-cleaved cytokeratin 18 in tumor and serum correlated with anti-tumor response. In summary, combined targeting of the extrinsic and intrinsic apoptotic pathways with IGM-8444 and birinapant respectively enhances tumor cytotoxicity in multiple preclinical models. The combination of IGM-8444 with birinapant is currently under evaluation in a Phase 1 study in patients with relapsed and/or refractory solid cancers (NCT04553692). Citation Format: Beatrice T. Wang, Melanie Desbois, Susan E. Calhoun, Thomas J. Matthew, Poonam Yakkundi, Ling Wang, Xingjie Chen, Tasnim Kothambawala, Miho Oyasu, Maya F. Kotturi, Genevive Hernandez, Xiaohan Liu, Marvin S. Peterson, Eric W. Humke, Bruce A. Keyt, Angus M. Sinclair. Anti-DR5 agonist IgM antibody IGM-8444 combined with SMAC mimetic birinapant induces strong synergistic tumor cytotoxicity [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1068.

Bioymifi, a novel mimetic of TNF-related apoptosis-induced ligand (TRAIL), stimulates eryptosis.

Tumor necrosis factor-related apoptosis-induced ligand (TRAIL) is a cytokine that initiates apoptosis upon binding to death receptor 5 (DR5) on cancer cells. Small molecule TRAIL mimetics have therefore been investigated as promising chemotherapeutic agents. Since anemia of chemotherapy is common, our goal is to investigate the hemolytic and eryptotic properties of novel DR5 agonist bioymifi (BMF) and identify the underlying molecular mechanisms. Whole blood (WB) was stimulated with 100μM of BMF, whereas red blood cells (RBCs) were treated with 10-100μM of BMF for 24h at 37°C. WB was analyzed for RBC, leukocyte, and platelet indices, while RBCs were examined for hemolysis by light absorbance of free hemoglobin, membrane scrambling by Annexin V-FITC, calcium by Fluo4/AM, cellular morphology by light scatter, and oxidative stress by 2',7'-dichlorodihydrofluorescein diacetate (H2DCFDA) using flow cytometry. Caspase inhibitor Z-VAD-FMK, p38 inhibitor SB203580, casein kinase 1α inhibitor D4476, receptor-interacting protein 1 inhibitor necrostatin-2, reduced glutathione, or cyclooxygenase (COX) inhibitor aspirin were added accordingly. BMF exerted dose-responsive, calcium-independent hemolysis, reduced RBC hemoglobin, significantly increased Annexin V-, Fluo4-, and DCF-positive cells, along with a dual effect on forward and side light scatter. Notably, the cytotoxic potential of BMF was significantly mitigated upon pharmacological inhibition of p38. Furthermore, BMF exhibited selective toxicity to eosinophils and significantly diminished reticulocyte hemoglobin content. Altogether, these novel findings highlight the adverse outcomes of BMF exposure on RBC physiology and provide the first toxicological assessment of BMF as an antitumor agent.