Abstract An increased rate of cellular proliferation is a hallmark of cancer and may be accompanied by increase in ribosome biogenesis and dysregulation in rRNA synthesis. In this regard CX-5461 has been developed as a novel RNA POL1 inhibitor and is currently in Phase I/II clinical trials. We have set out to explore the use of this agent in combination with radiation therapy and to understand the associated molecular mechanisms using this approach. A panel of human tumour cell lines treated with CX-5461 indicated a broad spectrum of sensitivity (MTT assay) with IC50 values varying from 25nM - >2µM. No clear relationship between p53 status and sensitivity to CX-5461 was indicated and the mode of cell death was cell context dependent - either via autophagy (LC3I→ LC3II conversion, with P62 sequestosome decrease), sometimes via apoptosis (annexinV staining, caspase-3 activation), also in the presence of increased senescence (β-galactosidase activity). Combination treatment experiments involving CX-5461 alongside radiation therapy (0-16Gy) showed marked synergistic effects for some cancer cell lines, particularly the cervical cancer CASKI line (HPV16+ve). Highly significant effects were seen when low dose radiation and low dose CX-5461 were used together in CASKI cells: combination index CI=< 0.2 with 6nM CX-5461 and 2Gy (isobologram analysis). Cell cycle analysis of CASKI cells treated in combination indicated cell cycle disruption with prolonged S-phase, giving some insight into some of the associated mechanisms involved. In addition, we have found that BRCA-mutant PEO1 ovarian cancer cells were sensitive to CX-5461, IC50 approx. 100nM, whereas carboplatin-resistant PEO1CarbR (with reversed BRCA mutant status) cells gave an IC50 value >3µM In addition, proteomic studies have shown that PEO1CarbR cells overexpress a number of nucleolar proteins and we are investigating the relevance of this in relation to CX-5461 sensitivity. Our further studies aim to identify potential biomarkers of response to CX-5461 and may also inform the design of clinical trials of this novel agent. Citation Format: Mohammed Ismael, Roger Webb, Mazhur Ajaz, Helen Coley. CX5461 in combination with radiotherapy I effective against gynecological tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1862.