Trametinib as a promising therapeutic option in alleviating vascular defects in an endothelial KRAS-induced mouse model

Single-cell and spatial transcriptomic analyses reveal transcriptional cell lineage heterogeneity in extracranial arteriovenous malformation

BACKGROUND

Extracranial arteriovenous malformations (eAVMs) are rare congenital vascular anomalies consisting of abnormal artery-vein bypass with no intervening capillary network, and can lead to disability and death. The critical genetic determination factors and key transcriptional pathways of the eAVMs genesis process are still unclear.

OBJECTIVE

To generate an overview of the molecular information within eAVMs at the single-cell level.

METHODS

We performed single-cell RNA sequencing (scRNA-seq) on nine samples of eAVMs receiving a confirmatory histopathologic evaluation from a board-certified dermatopathologist and two nonlesional tissue sample controls. 10x Visium spatial transcriptomics (ST) was performed on one eAVM to spatially localize heterogeneous cells and profile the gene expression dynamics of the cells in their morphological context. The scRNA-seq and ST data were integrated and analyzed to further query for spatially restricted mapping of intrapopulation heterogeneous cells.

RESULTS

We identified different cell states of endothelial cells (ECs), perivascular cells and immune cells in eAVMs, uncovered the presence of MAFB+ nidus ECs, characterized mesenchymal activation in ECs, and identified transcriptional variation within perivascular cells and the presence of smooth muscle-like pericytes in eAVMs. Dysregulated cell to cell interactions among ECs, perivascular cells and immune cells that are associated with eAVMs, including those involving MDK, VEGF, ANGPT, SEMA3 and GALECTIN-9 were cataloged. Together, our results depicted the heterogeneity underlying cell function and interaction of eAVMs at a single-cell resolution.

CONCLUSION

We present a comprehensive picture of the cell-resolution atlas that describes the transcriptomic heterogeneity underlying cell function and interaction in eAVMs.

Advances in sporadic brain arteriovenous malformations: Novel genetic insights, innovative animal models and emerging therapeutic approaches

Brain arteriovenous malformations (bAVMs) are a notable cause of intracranial hemorrhage, strongly associated with severe morbidity and mortality. Contemporary treatment options include surgery, stereotactic radiosurgery, and endovascular embolization, each of which has limitations. Hence, development of pharmacological interventions is urgently needed. The recent discovery of the presence of activating Kirsten rat sarcoma (KRAS) viral oncogene homologue mutations in most sporadic bAVMs has opened the door for a more comprehensive understanding of the pathogenesis of bAVMs and has pointed to entirely novel possible therapeutic targets. Herein, we review the status quo of genetics, animal models, and therapeutic approaches in bAVMs.

MAPK Signaling and Angiopoietin-2 Contribute to Endothelial Permeability in Capillary Malformations

Capillary malformations (CM) are slow-flow vascular abnormalities present at birth and predominantly manifest as cutaneous lesions. In the rare neurocutaneous disorder known as Sturge Weber Syndrome (SWS), individuals exhibit CM not only on the skin but also within the leptomeninges of the brain and the choroid of the eye. >90% of CM are caused by a somatic R183Q mutation in GNAQ, the gene encoding Gαq - a heterotrimeric G-protein subunit. The somatic GNAQ mutation is notably enriched in endothelial cells (ECs) isolated from CM-affected regions. Here we show blood vessels in cutaneous and leptomeningeal SWS lesions exhibit extravascular fibrin indicating a compromised endothelial barrier. Longitudinal MRI of the brain in one SWS patient further suggests vascular permeability. To explore this pathological phenotype, we employed the trans-endothelial electrical resistance (TEER) assay to measure permeability of the EC-EC barrier in vitro . Human EC CRISPR edited to create a GNAQ R183Q allele (EC-R183Q) exhibited a reduced barrier compared to mock edited EC (EC-WT). We sought to identify signaling molecules needed for EC barrier formation. Knockdown of angiopoietin-2 (ANGPT2), known to be significantly increased in EC-R183Q and in CM, partially yet significantly restored the barrier, while an anti-ANGPT2 function blocking antibody did not. We next tested the MEK1,2 inhibitor (Trametinib) because MAPK signaling is increased by GNAQ mutation. MEK1,2 inhibitors partially restored the EC barrier, implicating involvement of MAPK/ERK signaling. The combination of ANGPT2 knockdown and Trametinib significantly restored the EC barrier to near EC-WT levels. The additive impacts of ANGPT knockdown and MEK1,2 inhibition indicate the two operate in separate pathways. In summary, we discovered that GNAQ p.R183Q ECs exhibit compromised endothelial barrier formation, reflecting the compromised EC barrier in CM lesions, and that ANGPT2 knockdown combined with Trametinib effectively restores the EC-EC barrier.

NONSTANDARD ABBREVIATIONS AND ACRONYMS

NOVELTY AND SIGNIFICANCE

What is known?: The mutant Gαq-R183Q in endothelial cells activates phospholipase β3, contributing to increased angiopoietin-2, a pro-angiogenic, proinflammatory molecule that contributes to vascular permeability.Endothelial Gαq-R183Q is sufficient to drive formation of enlarged blood vessels akin to what is observed in CM. ANGPT2 shRNA knockdown prevented the enlarged vessel phenotype in a xenograft model.An EC-specific GNAQ p.R183Q mouse model showed permeability in brain vessels, detected by perfusion of Evans Blue dye, indicating reduced vascular integrity.What New Information Does This Article Contribute?: Reduced vascular integrity in CM is confirmed by Martius Scarlet Blue staining and longitudinal MRI imaging of SWS brain. GNAQ p.R183Q EC form a weaker endothelial barrier in vitro compared to control ECs. The weakened endothelial barrier in the mutant ECscan be rescued by Gαq inhibitor, YM254890, confirming the compromised barrier is a consequence of the mutant Gαq. Titration experiments modeling the mosaic nature of the GNAQ p.R183Q in CMshow that 5- 10% GNAQ p.R183Q EC in the monolayer is sufficient to reduce endothelial barrier formation. Knockdown of ANGPT2 or MEK1,2 inhibition partially restored the endothelial barrier in GNAQ p.R183Q EC. Combining knockdown of ANGPT2 and addition of a MEK inhibitor, Trametinib, restored the endothelial barrier to near what is seen in wild type ECs.What is the translational message?: Sturge Weber Syndrome (SWS) is a neurocutaneous disorder that involves atypical blood vessel overgrowth in the skin, brain and eye. It is associated with facial CM (aka port wine birthmark), leptomeningeal CM in the brain visible with MRI, and glaucoma. Theneurological sequalae involve seizures, cerebral atrophies and calcification, and intellectual disorders. Currently there are no molecularly targeted therapies for non-syndromic CM or SWS. Our study shows the involvement of MAPK pathway and the proinflammatory molecule ANGPT2 in endothelial permeability and suggests a path to target GNAQ p.R183Q driven CM.

Association of Somatic KRAS Variants with Osteolysis in Arteriovenous Malformations

The genetic study of vascular anomalies provides a better understanding of their etiopathogenesis and allows the use of targeted therapies. Activating KRAS pathogenic variants promote cell proliferation by activating MAPK and PI3K signalling pathways, which have been associated with the pathogenesis of vascular anomalies, especially high-flow ones such as arteriovenous malformations (AVMs). AVMs' genomic landscape is extensive, and a genotype-phenotype correlation has not been shown. In this study, we aimed to prove an association between KRAS gene mutations and the presence of osteolysis in patients with AVMs. Herein, we present a clinical-molecular retrospective study of patients with AVMs, bone involvement, and KRAS pathogenic variants.A retrospective review of patients with AVMs and KRAS somatic variants followed by the Vascular Anomalies Unit at our institution was performed. All patients present bone involvement. We analyzed demographics, clinical features (AVMs location, phenotype), treatment received, and response to treatment. Previous imaging studies were used to assess bone involvement. Genetic studies were performed by high-throughput sequencing using a custom-designed panel.Of the 77 patients with AVMs currently followed in our clinic, 60 (77.9%) had genetic testing, and 19 (31.6%) presented a KRAS somatic activating variant and were therefore included in the study. There were 12 women and 7 men aged 10 to 79 years. When studying radiographies or CT scans, we found that all 19 patients associated osteolysis adjacent to the AVMs. Regarding the KRAS variants, the most frequent one was p.Gly12Asp, followed by p.Gln61His and p.Gly13Arg. Additionally, we reviewed imaging studies from the other 41 patients with AVMs and different pathogenic variants such as MAP2K1, RASA1, and BRAF, and did not find osteolysis.We have described for the first time the relationship between somatic, activating KRAS pathogenic variants and osteolysis in patients with AVMs. Early detection of these KRAS alterations in this type of patient should lead us to rule out bone involvement. Moreover, identifying these mutations may help guide targeted therapies, potentially preventing the development of osteolysis and improving patient outcomes.

Extracranial arteriovenous malformations: towards etiology-based therapeutic management

Anomalies during angiogenesis can initiate the formation of arteriovenous malformations (AVMs), characterized by aberrant connections between arteries and veins and fast lesional blood flow. These anomalies can manifest anywhere in the body, including the brain, and they typically appear at birth and evolve alongside growth of the individual. Depending on their location and size, AVMs can induce progressive deformation, chronic pain, functional impairment, and ulceration and pose life-threatening risks such as hemorrhage and organ dysfunction. The primary treatment modalities entail surgical intervention or embolization followed by surgery. However, these approaches are often challenging and seldom offer definitive resolution. In addition, inadequately performed surgery may trigger angiogenic rebound, fostering AVM recurrence. Advancements in comprehending the molecular pathways underlying AVMs have sparked interest in repurposing targeted therapies initially devised for cancer treatment. The first results are promising, giving new hope to the patients affected with these often devastating and debilitating lesions, the management of which presents major clinical challenges.

From bench to bedside: murine models of inherited and sporadic brain arteriovenous malformations

Brain arteriovenous malformations are abnormal vascular structures in which an artery shunts high pressure blood directly to a vein without an intervening capillary bed. These lesions become highly remodeled over time and are prone to rupture. Historically, brain arteriovenous malformations have been challenging to treat, using primarily surgical approaches. Over the past few decades, the genetic causes of these malformations have been uncovered. These can be divided into (1) familial forms, such as loss of function mutations in TGF-β (BMP9/10) components in hereditary hemorrhagic telangiectasia, or (2) sporadic forms, resulting from somatic gain of function mutations in genes involved in the RAS-MAPK signaling pathway. Leveraging these genetic discoveries, preclinical mouse models have been developed to uncover the mechanisms underlying abnormal vessel formation, and thus revealing potential therapeutic targets. Impressively, initial preclinical studies suggest that pharmacological treatments disrupting these aberrant pathways may ameliorate the abnormal pathologic vessel remodeling and inflammatory and hemorrhagic nature of these high-flow vascular anomalies. Intriguingly, these studies also suggest uncontrolled angiogenic signaling may be a major driver in bAVM pathogenesis. This comprehensive review describes the genetics underlying both inherited and sporadic bAVM and details the state of the field regarding murine models of bAVM, highlighting emerging therapeutic targets that may transform our approach to treating these devastating lesions.

Molecular landscape and classification of vascular anomalies

Vascular malformations, which result from anomalies in angiogenesis, include capillary, lymphatic, venous, arteriovenous, and mixed malformations and affect specific vessel types. Historically, treatments such as sclerotherapy and surgery have shown limited efficacy in complicated cases. Most vascular malformations occur sporadically, but some can be inherited. They result from mutations similar to oncogenic alterations, activating pathways such as PI3K-AKT-mTOR or Ras-MAPK-ERK. Recognizing these parallels, we highlight the potential of targeted molecular inhibitors, repurposing anticancer drugs for the treatment of vascular malformations. This case-based review explores recent developments in precision medicine for slow-flow and fast-flow vascular malformation.

Untangling sporadic brain arteriovenous malformations: towards targeting the KRAS/MAPK pathway

Brain arteriovenous malformations (AVMs) are vascular lesions characterized by abnormal connections between parenchymal arteries and veins, bypassing a capillary bed, and forming a nidus. Brain AVMs are consequential as they are prone to rupture and associated with significant morbidity. They can broadly be subdivided into hereditary vs. sporadic lesions with sporadic brain AVMs representing the majority of all brain AVMs. However, little had been known about the pathogenesis of sporadic brain AVMs until the landmark discovery in 2018 that the majority of sporadic brain AVMs carry somatic activating mutations of the oncogene, Kirsten rat sarcoma viral oncogene homologue (KRAS), in their endothelial cells. Here, we review the history of brain AVMs, their treatments, and recent advances in uncovering the pathogenesis of sporadic brain AVMs. We specifically focus on the latest studies suggesting that pharmacologically targeting the KRAS/MEK pathway may be a potentially efficacious treatment for sporadic brain AVMs.

CRISPR/CasRx suppresses KRAS-induced brain arteriovenous malformation developed in postnatal brain endothelial cells in mice

Brain arteriovenous malformations (bAVMs) are anomalies forming vascular tangles connecting the arteries and veins, which cause hemorrhagic stroke in young adults. Current surgical approaches are highly invasive, and alternative therapeutic methods are warranted. Recent genetic studies identified KRAS mutations in endothelial cells of bAVMs; however, the underlying process leading to malformation in the postnatal stage remains unknown. Here we established a mouse model of bAVM developing during the early postnatal stage. Among 4 methods tested, mutant KRAS specifically introduced in brain endothelial cells by brain endothelial cell-directed adeno-associated virus (AAV) and endothelial cell-specific Cdh5-CreERT2 mice successfully induced bAVMs in the postnatal period. Mutant KRAS led to the development of multiple vascular tangles and hemorrhage in the brain with increased MAPK/ERK signaling and growth in endothelial cells. Three-dimensional analyses in cleared tissue revealed dilated vascular networks connecting arteries and veins, similar to human bAVMs. Single-cell RNA-Seq revealed dysregulated gene expressions in endothelial cells and multiple cell types involved in the pathological process. Finally, we employed CRISPR/CasRx to knock down mutant KRAS expression, which efficiently suppressed bAVM development. The present model reveals pathological processes that lead to postnatal bAVMs and demonstrates the efficacy of therapeutic strategies with CRISPR/CasRx.

[Management of pediatric vascular malformations]

BACKGROUND

Vascular malformations belong to the group of vascular anomalies. They are rare congenital diseases resulting from abnormal development of vessels and can arise in any location, often in the head and neck region. Clinical symptoms are variable, functional handicaps and esthetic problems may result.

MATERIALS AND METHODS

One differentiates between arteriovenous, lymphatic, venous, and capillary malformations and combinations thereof. Their classification, symptoms, diagnostics, and treatment options are discussed.

RESULTS

The different types of vascular malformations as well as their clinical presentation, diagnostic workup, and therapeutic options are presented, supported by clinical examples.

CONCLUSION

Interdisciplinary care of pediatric patients with vascular malformations is essential in order to generate a treatment concept after correct diagnosis and improve symptoms and quality of life.

Microsecond Molecular Dynamics Simulation to Gain Insight Into the Binding of MRTX1133 and Trametinib With KRASG12D Mutant Protein for Drug Repurposing

The Kirsten Rat Sarcoma (KRAS) G12D mutant protein is a primary driver of pancreatic ductal adenocarcinoma, necessitating the identification of targeted drug molecules. Repurposing of drugs quickly finds new uses, speeding treatment development. This study employs microsecond molecular dynamics simulations to unveil the binding mechanisms of the FDA-approved MEK inhibitor trametinib with KRASG12D, providing insights for potential drug repurposing. The binding of trametinib was compared with clinical trial drug MRTX1133, which demonstrates exceptional activity against KRASG12D, for better understanding of interaction mechanism of trametinib with KRASG12D. The resulting stable MRTX1133-KRASG12D complex reduces root mean square deviation (RMSD) values, in Switch I and II domains, highlighting its potential for inhibiting KRASG12D. MRTX1133's robust interaction with Tyr64 and disruption of Tyr96-Tyr71-Arg68 network showcase its ability to mitigate the effects of the G12D mutation. In contrast, trametinib employs a distinctive binding mechanism involving P-loop, Switch I and II residues. Extended simulations to 1 μs reveal sustained network interactions with Tyr32, Thr58, and GDP, suggesting a role of trametinib in maintaining KRASG12D in an inactive state and impede the further cell signaling. The decomposition binding free energy values illustrate amino acids' contributions to binding energy, elucidating ligand-protein interactions and molecular stability. The machine learning approach reveals that van der Waals interactions among the residues play vital role in complex stability and the potential amino acids involved in drug-receptor interactions of each complex. These details provide a molecular-level understanding of drug binding mechanisms, offering essential knowledge for further drug repurposing and potential drug discovery.

Targeted treatments for vascular malformations: current state of the art

Vascular malformations, which arise from anomalies in angiogenesis, encompass capillary, lymphatic, venous, arteriovenous, and mixed malformations, each affecting specific vessel types. Historically, therapeutic options such as sclerotherapy and surgery have shown limited efficacy in complicated malformations. Most vascular malformations stem from hereditary or somatic mutations akin to oncogenic alterations, activating the PI3K-AKT-mTOR, RAS-MAPK-ERK, and G-protein coupled receptor pathways. Recognizing the parallels with oncogenic mutations, we emphasize the potential of targeted molecular inhibitors in the treatment of vascular malformations by repurposing anticancer drugs. This review delves into the recent development and future use of such agents for the management of slow- and fast-flow vascular malformations, including in more specific situations, such as prenatal treatment and the management of associated coagulopathies.

Pathophysiology in Brain Arteriovenous Malformations: Focus on Endothelial Dysfunctions and Endothelial-to-Mesenchymal Transition

Brain arteriovenous malformations (bAVMs) substantially increase the risk for intracerebral hemorrhage (ICH), which is associated with significant morbidity and mortality. However, the treatment options for bAVMs are severely limited, primarily relying on invasive methods that carry their own risks for intraoperative hemorrhage or even death. Currently, there are no pharmaceutical agents shown to treat this condition, primarily due to a poor understanding of bAVM pathophysiology. For the last decade, bAVM research has made significant advances, including the identification of novel genetic mutations and relevant signaling in bAVM development. However, bAVM pathophysiology is still largely unclear. Further investigation is required to understand the detailed cellular and molecular mechanisms involved, which will enable the development of safer and more effective treatment options. Endothelial cells (ECs), the cells that line the vascular lumen, are integral to the pathogenesis of bAVMs. Understanding the fundamental role of ECs in pathological conditions is crucial to unraveling bAVM pathophysiology. This review focuses on the current knowledge of bAVM-relevant signaling pathways and dysfunctions in ECs, particularly the endothelial-to-mesenchymal transition (EndMT).

Sotorasib for Vascular Malformations Associated with KRAS G12C Mutation

KRAS gain-of-function mutations are frequently observed in sporadic arteriovenous malformations. The mechanisms underlying the progression of such KRAS-driven malformations are still incompletely understood, and no treatments for the condition are approved. Here, we show the effectiveness of sotorasib, a specific KRAS G12C inhibitor, in reducing the volume of vascular malformations and improving survival in two mouse models carrying a mosaic Kras G12C mutation. We then administered sotorasib to two adult patients with severe KRAS G12C-related arteriovenous malformations. Both patients had rapid reductions in symptoms and arteriovenous malformation size. Targeting KRAS G12C appears to be a promising therapeutic approach for patients with KRAS G12C-related vascular malformations. (Funded by the European Research Council and others.).

Reverse repurposing: Potential utility of cancer drugs in nonmalignant illnesses

Growth and immune process dysregulation can result in both cancer and nonmalignant disease (hereditary or acquired, with and without predisposition to malignancy). Moreover, perhaps unexpectedly, many nonmalignant illnesses harbor genomic alterations indistinguishable from druggable oncogenic drivers. Therefore, targeted compounds used successfully to treat cancer may have therapeutic potential for nonmalignant conditions harboring the same target. MEK, PI3K/AKT/mTOR, fibroblast growth factor receptor (FGFR), and NRG1/ERBB pathway genes have all been implicated in both cancer and noncancerous conditions, and several cognate antagonists, as well as Bruton's tyrosine kinase inhibitors, JAK inhibitors, and CD20-directed antibodies, have established or theoretical therapeutic potential to bridge cancer and benign diseases. Intriguingly, pharmacologically tractable cancer drivers characterize a wide spectrum of disorders without malignant potential, including but not limited to Alzheimer's disease and a variety of other neurodegenerative conditions, rheumatoid arthritis, achondroplastic dwarfism, and endometriosis. Expanded repositioning of oncology agents in order to benefit benign but serious medical illnesses is warranted.

MEK signaling represents a viable therapeutic vulnerability of KRAS-driven somatic brain arteriovenous malformations

Brain arteriovenous malformations (bAVMs) are direct connections between arteries and veins that remodel into a complex nidus susceptible to rupture and hemorrhage. Most sporadic bAVMs feature somatic activating mutations within KRAS, and endothelial-specific expression of the constitutively active variant KRASG12D models sporadic bAVM in mice. By leveraging 3D-based micro-CT imaging, we demonstrate that KRASG12D-driven bAVMs arise in stereotypical anatomical locations within the murine brain, which coincide with high endogenous Kras expression. We extend these analyses to show that a distinct variant, KRASG12C, also generates bAVMs in predictable locations. Analysis of 15,000 human patients revealed that, similar to murine models, bAVMs preferentially occur in distinct regions of the adult brain. Furthermore, bAVM location correlates with hemorrhagic frequency. Quantification of 3D imaging revealed that G12D and G12C alter vessel density, tortuosity, and diameter within the mouse brain. Notably, aged G12D mice feature increased lethality, as well as impaired cognition and motor function. Critically, we show that pharmacological blockade of the downstream kinase, MEK, after lesion formation ameliorates KRASG12D-driven changes in the murine cerebrovasculature and may also impede bAVM progression in human pediatric patients. Collectively, these data show that distinct KRAS variants drive bAVMs in similar patterns and suggest MEK inhibition represents a non-surgical alternative therapy for sporadic bAVM.

The Role and Therapeutic Implications of Inflammation in the Pathogenesis of Brain Arteriovenous Malformations

Brain arteriovenous malformations (bAVMs) are focal vascular lesions composed of abnormal vascular channels without an intervening capillary network. As a result, high-pressure arterial blood shunts directly into the venous outflow system. These high-flow, low-resistance shunts are composed of dilated, tortuous, and fragile vessels, which are prone to rupture. BAVMs are a leading cause of hemorrhagic stroke in children and young adults. Current treatments for bAVMs are limited to surgery, embolization, and radiosurgery, although even these options are not viable for ~20% of AVM patients due to excessive risk. Critically, inflammation has been suggested to contribute to lesion progression. Here we summarize the current literature discussing the role of the immune system in bAVM pathogenesis and lesion progression, as well as the potential for targeting inflammation to prevent bAVM rupture and intracranial hemorrhage. We conclude by proposing that a dysfunctional endothelium, which harbors the somatic mutations that have been shown to give rise to sporadic bAVMs, may drive disease development and progression by altering the immune status of the brain.

Contemporary management of extracranial vascular malformations

Vascular malformations are congenital vascular anomalies that originate because of disorganized angiogenesis, most commonly from spontaneous somatic genetic mutations. The modern management of vascular malformations requires a multidisciplinary team that offers patients the gamut of medical, surgical, and percutaneous treatment options with supportive care. This manuscript discusses the standard and contemporary management strategies surrounding extracranial vascular malformations and overgrowth syndromes.