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Perurena N, Situ L, Cichowski K. Combinatorial strategies to target RAS-driven cancers. Nat Rev Cancer 2024; 24:316-337. [PMID: 38627557 DOI: 10.1038/s41568-024-00679-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 05/01/2024]
Abstract
Although RAS was formerly considered undruggable, various agents that inhibit RAS or specific RAS oncoproteins have now been developed. Indeed, the importance of directly targeting RAS has recently been illustrated by the clinical success of mutant-selective KRAS inhibitors. Nevertheless, responses to these agents are typically incomplete and restricted to a subset of patients, highlighting the need to develop more effective treatments, which will likely require a combinatorial approach. Vertical strategies that target multiple nodes within the RAS pathway to achieve deeper suppression are being investigated and have precedence in other contexts. However, alternative strategies that co-target RAS and other therapeutic vulnerabilities have been identified, which may mitigate the requirement for profound pathway suppression. Regardless, the efficacy of any given approach will likely be dictated by genetic, epigenetic and tumour-specific variables. Here we discuss various combinatorial strategies to treat KRAS-driven cancers, highlighting mechanistic concepts that may extend to tumours harbouring other RAS mutations. Although many promising combinations have been identified, clinical responses will ultimately depend on whether a therapeutic window can be achieved and our ability to prospectively select responsive patients. Therefore, we must continue to develop and understand biologically diverse strategies to maximize our likelihood of success.
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Affiliation(s)
- Naiara Perurena
- Genetics Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lisa Situ
- Genetics Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Karen Cichowski
- Genetics Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Department of Medicine, Harvard Medical School, Boston, MA, USA.
- Ludwig Center, Harvard Medical School, Boston, MA, USA.
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Boumelha J, Molina-Arcas M, Downward J. Facts and Hopes on RAS Inhibitors and Cancer Immunotherapy. Clin Cancer Res 2023; 29:5012-5020. [PMID: 37581538 PMCID: PMC10722141 DOI: 10.1158/1078-0432.ccr-22-3655] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 06/19/2023] [Accepted: 08/01/2023] [Indexed: 08/16/2023]
Abstract
Although the past decade has seen great strides in the development of immunotherapies that reactivate the immune system against tumors, there have also been major advances in the discovery of drugs blocking oncogenic drivers of cancer growth. However, there has been very little progress in combining immunotherapies with drugs that target oncogenic driver pathways. Some of the most important oncogenes in human cancer encode RAS family proteins, although these have proven challenging to target. Recently drugs have been approved that inhibit a specific mutant form of KRAS: G12C. These have improved the treatment of patients with lung cancer harboring this mutation, but development of acquired drug resistance after initial responses has limited the impact on overall survival. Because of the immunosuppressive nature of the signaling network controlled by oncogenic KRAS, targeted KRAS G12C inhibition can indirectly affect antitumor immunity, and does so without compromising the critical role of normal RAS proteins in immune cells. This serves as a rationale for combination with immune checkpoint blockade, which can provide additional combinatorial therapeutic benefit in some preclinical cancer models. However, in clinical trials, combination of KRAS G12C inhibitors with PD-(L)1 blockade has yet to show improved outcome, in part due to treatment toxicities. A greater understanding of how oncogenic KRAS drives immune evasion and how mutant-specific KRAS inhibition impacts the tumor microenvironment can lead to novel approaches to combining RAS inhibition with immunotherapies.
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Saltos AN, Creelan BC, Tanvetyanon T, Chiappori AA, Antonia SJ, Shafique MR, Ugrenovic-Petrovic M, Sansil S, Neuger A, Ozakinci H, Boyle TA, Kim J, Haura EB, Gray JE. A phase I/IB trial of binimetinib in combination with erlotinib in NSCLC harboring activating KRAS or EGFR mutations. Lung Cancer 2023; 183:107313. [PMID: 37499521 DOI: 10.1016/j.lungcan.2023.107313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 07/17/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Activating mutations in EGFR or KRAS are highly prevalent in NSCLC, share activation of the MAPK pathway and may be amenable to combination therapy to prevent negative feedback activation. METHODS In this phase 1/1B trial, we tested the combination of binimetinib and erlotinib in patients with advanced NSCLC with at least 1 prior line of treatment (unless with activating EGFR mutation which could be treatment-naïve). A subsequent phase 1B expansion accrued patients with either EGFR- or KRAS-mutation using the recommended phase 2 dose (RP2D) from Phase 1. The primary objective was to evaluate the safety of binimetinib plus erlotinib and establish the RP2D. RESULTS 43 patients enrolled (dose-escalation = 23; expansion = 20). 17 harbored EGFR mutation and 22 had KRAS mutation. The RP2D was erlotinib 100 mg daily and binimetinib 15 mg BID × 5 days/week. Common AEs across all doses included diarrhea (69.8%), rash (44.2%), fatigue (32.6%), and nausea (32.6%), and were primarily grade 1/2. Among KRAS mutant patients, 1 (5%) had confirmed partial response and 8 (36%) achieved stable disease as best overall response. Among EGFR mutant patients, 9 were TKI-naïve with 8 (89%) having partial response, and 8 were TKI-pretreated with no partial responses and 1 (13%) stable disease as best overall response. CONCLUSIONS Binimetinib plus erlotinib demonstrated a manageable safety profile and modest efficacy including one confirmed objective response in a KRAS mutant patient. While clinical utility of this specific combination was limited, these results support development of combinations using novel small molecule inhibitors of RAS, selective EGFR- and other MAPK pathway inhibitors, many of which have improved therapeutic indices. CLINICAL TRIAL REGISTRATION NCT01859026.
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Affiliation(s)
- Andreas N Saltos
- Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA.
| | - Ben C Creelan
- Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Tawee Tanvetyanon
- Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Alberto A Chiappori
- Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Scott J Antonia
- Center for Cancer Immunotherapy, Duke Cancer Institute, 20 Duke Medicine Cir., Durham, NC 27710, USA
| | - Michael R Shafique
- Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | | | - Samer Sansil
- Cancer Pharmacokinetics & Pharmacodynamics Core, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Anthony Neuger
- Cancer Pharmacokinetics & Pharmacodynamics Core, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Hilal Ozakinci
- Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Theresa A Boyle
- Department of Pathology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Jongphil Kim
- Department of Biostatistics and Bioinformatics, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Eric B Haura
- Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Jhanelle E Gray
- Department of Thoracic Oncology, Moffitt Cancer Center, 12902 Magnolia Dr., Tampa, FL 33612, USA
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Flietner E, Wen Z, Rajagopalan A, Jung O, Watkins L, Wiesner J, You X, Zhou Y, Sun Y, Kingstad-Bakke B, Callander NS, Rapraeger A, Suresh M, Asimakopoulos F, Zhang J. Ponatinib sensitizes myeloma cells to MEK inhibition in the high-risk VQ model. Sci Rep 2022; 12:10616. [PMID: 35739276 PMCID: PMC9226136 DOI: 10.1038/s41598-022-14114-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/01/2022] [Indexed: 11/08/2022] Open
Abstract
Multiple myeloma (MM) is a malignant plasma cell cancer. Mutations in RAS pathway genes are prevalent in advanced and proteasome inhibitor (PI) refractory MM. As such, we recently developed a VQ MM mouse model recapitulating human advanced/high-risk MM. Using VQ MM cell lines we conducted a repurposing screen of 147 FDA-approved anti-cancer drugs with or without trametinib (Tra), a MEK inhibitor. Consistent with its high-risk molecular feature, VQ MM displayed reduced responses to PIs and de novo resistance to the BCL2 inhibitor, venetoclax. Ponatinib (Pon) is the only tyrosine kinase inhibitor that showed moderate MM killing activity as a single agent and strong synergism with Tra in vitro. Combined Tra and Pon treatment significantly prolonged the survival of VQ MM mice regardless of treatment schemes. However, this survival benefit was moderate compared to that of Tra alone. Further testing of Tra and Pon on cytotoxic CD8+ T cells showed that Pon, but not Tra, blocked T cell function in vitro, suggesting that the negative impact of Pon on T cells may partially counteract its MM-killing synergism with Tra in vivo. Our study provides strong rational to comprehensively evaluate agents on both MM cells and anti-MM immune cells during therapy development.
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Affiliation(s)
- Evan Flietner
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Room 7453, WIMR II, 1111 Highland Avenue, Madison, WI, 53705, USA
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, 53705, USA
| | - Zhi Wen
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Room 7453, WIMR II, 1111 Highland Avenue, Madison, WI, 53705, USA
- Center for Precision Medicine Research and Integrated Research and Development Laboratories, Marshfield Clinic Research Institute, Marshfield, WI, 54449, USA
| | - Adhithi Rajagopalan
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Room 7453, WIMR II, 1111 Highland Avenue, Madison, WI, 53705, USA
| | - Oisun Jung
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, 1111 Highland Avenue, Madison, WI, 53705, USA
| | - Lyndsay Watkins
- Center for Precision Medicine Research and Integrated Research and Development Laboratories, Marshfield Clinic Research Institute, Marshfield, WI, 54449, USA
| | - Joshua Wiesner
- Department of Biochemistry, University of Wisconsin-Madison, Madison, WI, 53706, USA
| | - Xiaona You
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Room 7453, WIMR II, 1111 Highland Avenue, Madison, WI, 53705, USA
| | - Yun Zhou
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Room 7453, WIMR II, 1111 Highland Avenue, Madison, WI, 53705, USA
| | - Yuqian Sun
- Department of Biology, College of Agricultural and Life Sciences, University of Wisconsin-Madison, Madison, WI, 53706, USA
| | - Brock Kingstad-Bakke
- Department of Pathobiological Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Natalie S Callander
- Division of Hematology/Oncology, Department of Medicine, UW Comprehensive Cancer Center, University of Wisconsin-Madison, Madison, WI, 53705, USA
| | - Alan Rapraeger
- Department of Human Oncology, School of Medicine and Public Health, University of Wisconsin-Madison, 1111 Highland Avenue, Madison, WI, 53705, USA
| | - M Suresh
- Department of Pathobiological Sciences, University of Wisconsin-Madison, Madison, WI, USA
| | - Fotis Asimakopoulos
- Division of Hematology/Oncology, Department of Medicine, UW Comprehensive Cancer Center, University of Wisconsin-Madison, Madison, WI, 53705, USA
- Division of Blood and Marrow Transplantation, Department of Medicine, University of California-San Diego, La Jolla, CA, 92093, USA
| | - Jing Zhang
- McArdle Laboratory for Cancer Research, University of Wisconsin-Madison, Room 7453, WIMR II, 1111 Highland Avenue, Madison, WI, 53705, USA.
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