Abstract B43: A systems biology approach to elucidate the mechanism of EGFR inhibitor sensitivity in mutant KRAS-driven colorectal cancer
Authors: McFall Thomas , Diedrich Jolene , Littlechild Stacy L. , Sisk-Hackworth Laura , Moresco James , Mengistu Meron , Shaw Andrey , Stites Ed 
Published: June 2021

Abstract
Standard protocol to treat colorectal cancer (CRC) includes surgery, chemotherapy and radiotherapy as first-line treatment options. When applicable, targeting agents such as anti-EGFR therapies (i.e., cetuximab and panitumumab) have become important long-term neoadjuvant therapies that increase survival in some patients. In recent years it has become common practice to sequence patients and their tumor specimens’ DNA. This recent push in genomic medicine has led to the identification that 30-40% of CRC patient harbor an activating KRAS mutation. These mutations are thought to be an early driver in the cancer’s progression. KRAS is also considered to be the key player in conferring resistance to the anti-EGFR treatments cetuximab and panitumumab. That Ras mutations confer resistance to EGFR inhibitors is intuitive. In recent years, clinical guidelines have extended the list of contraindicated genotypes to many mutations in both the KRAS and NRAS genes. In contrast with the current guidelines for managing CRC with EGFR inhibitors, it has been shown that patients harboring a KRAS G13D mutation are sensitive to cetuximab. This has been reproducibly shown in both in vitro and in vivo model systems and is supported by retrospective analysis of initial clinical trial data. The current mutant-RAS restrictive guidelines are supported by a method that relied upon the grouping of all common Ras mutations as “equal,” which potentially washes out less common yet sensitive mutations. Whether KRAS G13D mutations are sensitive to cetuximab has remained a controversial topic for many years due to the lack of understanding of a mechanism, as it is counterintuitive to the current understanding of EGFR signaling cascade. We here identify a novel mechanism by which G13D RAS mutant is sensitive to EGFR inhibition by a nonintuitive process of reliance upon WT RAS molecules. We utilized a computational model of RAS signaling previously developed by our laboratory to explore mutant Ras signaling and thereby investigated the controversial response of KRAS G13D to anti-EGFR agents. Our computational studies of the historically reported biochemical processes that regulate Ras signals reveal a nonintuitive, mutant-specific dependency of wild-type RAS activation on EGFR. The model also reveals this dependency is determined by the interaction strength between a KRAS mutant and tumor suppressor neurofibromin. Our prospective experiments confirm this mechanism that arises from the systems-level regulation of Ras pathway signaling. Overall, our work demonstrates how systems approaches enable mechanism-based inference in genomic medicine.
Citation Format: Thomas McFall, Jolene Diedrich, Stacy L. Littlechild, Laura Sisk-Hackworth, James Moresco, Meron Mengistu1, Andrey Shaw, Ed Stites. A systems biology approach to elucidate the mechanism of EGFR inhibitor sensitivity in mutant KRAS-driven colorectal cancer [abstract]. In: Proceedings of the AACR Special Conference on Targeting RAS-Driven Cancers; 2018 Dec 9-12; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Res 2020;18(5_Suppl):Abstract nr B43.