<h3>Purpose/Objective(s)</h3> Novel radiotherapy, such as Peptide Radionuclide Receptor Therapy, is becoming a milestone treatment for advanced Gastroenteropancreatic neuroendocrine tumors (GEP-NETs). Ribonucleotide Reductase (RnR) subunit M2 (RRM2) activates RnR, the rate-limiting enzyme of DNA synthesis and repair. The purpose of this study was to determine the therapeutic rationale of RnR-targeted therapy and to evaluate 3-aminopyridine-2-carboxaldehyde thiosemicarbazone (3-AP) as a radiosensitizer in treating GEP-NETs <i>in vitro</i> and <i>in vivo.</i> <h3>Materials/Methods</h3> (1) RRM2 inhibition was achieved by siRNA knockdown or a RRM2 specific inhibitor, 3-AP, in three GEP-NET cell lines (QGP-1, BON and NT-3) and patient-derived spheroids. Radiation (XRT) was delivered via an X-ray irradiator. Immunohistochemistry confirmed RRM2 expression in cell lines and spheroids, and western immunoblotting was used to examine phosphorylation of DNA repair pathways (DNA-PK, ATM, ATR), cell cycle arrest markers (Rb, Chk1, Chk2) and apoptotic protein (cleaved PARP). Proliferation assays and cell cycle analyses were used to evaluate cytostatic cellular response. Colorimetric survival and DNA fragmentation assays were used to investigate radiosensitization of RRM2 inhibition. (2) For <i>in vivo</i> studies<i>,</i> we utilized an athymic nude mouse GEP-NET xenograft model to assess tumor growth using a combination of 3-AP and XRT. <h3>Results</h3> (1) RRM2 receptor expression, predominantly in the cytoplasm, was noted in all GEP-NET cell lines and spheroids. Knockdown of RRM2 significantly inhibited cellular proliferation at 48 and 72h. Similarly, 3-AP inhibited cellular proliferation with an absolute IC-50 of 1240nM and 1297nM for QGP-1 and BON cells, respectively. Induction of ATM and DNA-PK phosphorylation, but not ATR, was detected with RRM2 inhibition. Importantly, siRNA RRM2 knockdown and 3-AP increased expression of cell cycle arrest markers (pRb, pChk1, and pChk2), and 3-AP (2500nM) arrested cells before entering the G2/M phase, significantly reducing the percentage of G2/M cells from 8.4% to 0.5% at 72h. Combination of RRM2 inhibition with XRT increased apoptosis as noted by increased expression of cleaved PARP. RRM2 inhibition by 3-AP potentiated XRT by reducing 14d cellular survival and inducing DNA fragmentation at 96h post-XRT. (2) We observed a significant decrease in tumor size in mice treated with XRT (2Gy) alone compared to control (146 mm<sup>2</sup> vs. 280 mm<sup>2</sup>, respectively); combination treatment (2Gy XRT, followed by immediate 3-AP [10mg/kg] i.p. injection) demonstrated a further 48% decrease in tumor size compared to XRT alone. <h3>Conclusion</h3> Our studies demonstrate that inhibition of RRM2 potentiates XRT and results in a significant increase in apoptosis <i>in vitro</i> and a decrease in tumor size <i>in vivo</i>, suggesting enhanced cytotoxicity and radiosensitization. Selective RRM2 inhibition by 3-AP provides a potent therapeutic strategy as a radiosensitizer and offers a novel approach in treating advanced GEP-NETs.
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