Abstract A03: Several rational combination kinase inhibitor treatments identified by synthetic lethality screens are efficacious in intracranial triple negative breast cancer models
Authors: Swearingen Amanda E.D. Van , Sambade Maria J. , Siegel Marni B. , Sud Shivani , Bevill Samantha M. , Golitz Brian T. , Bash Ryan E. , Santos Charlene M. , Darr David B. , Parker Joel S. , Miller C. Ryan , Johnson Gary L. , Anders Carey K. 
Published: December 2017

Abstract
Introduction: Nearly half of metastatic triple negative breast cancer (TNBC) patients develop brain metastases (BMs) and face a poor prognosis. There are no FDA-approved systemic therapies to treat TNBC BM, due in part to the blood-brain barrier. TNBC and breast cancer BMs exhibit both activation of the PI3K and MEK pathways, but attempts to target them in preclinical models have shown limited efficacy due to innate and acquired resistance to kinase inhibition in TNBC. In this study, we identify several clinically relevant rational combination therapies based on synthetic lethality and evaluate the efficacy of combined brain-penetrant, clinically-available kinase inhibitors in intracranial TNBC models.
Methods: An siRNA screen against 720 kinase genes was used to identify synthetic enhancers of lethality with pan-PI3K inhibitor (BKM120) or MEK1/2 inhibitor (AZD6244) treatment in vitro using TNBC models capable of growing in mouse brain (SUM149, MDA-MB-231Br). The efficacy of these and other brain-penetrant drugs of interest based on the screen were assessed for efficacy in vitro, alone (IC50s) and combined (synergy). Some combinations were evaluated in vivo in mice bearing intracranial TNBC tumors for their effects on survival and tumor burden. Tumor burden was monitored via bioluminescence. IC tumors from treated mice were extracted, fresh frozen, and analyzed for the activation state of the kinome using multiplexed kinase inhibitor bead (MIB) enriched mass spectrometry (MS).
Results: The screen identified the following combinations as synthetic lethal pairs: PI3K+MEK, MEK+PDGFR, PI3K+AURKA, MEK+BRAF. Pharmacological synergy of combined treatments was confirmed in vitro between PI3K(/mTOR)+MEK, MEK+PDGFR, and PI3K+AURKA, in TNBC cells (SUM149, 231Br) using brain-penetrant drugs in clinical development (mTOR inhibitor Everolimus, dual PI3K/mTOR inhibitor GNE317, PDGFR inhibitor Pazopanib, AURKA inhibitor MLN8237, BRAF inhibitor Dabrafenib). For some combinations, particularly PI3K+AURKA inhibition, sequencing of the drugs significantly altered the combined effects and synergy.
Combinations which were synthetically lethal and synergistic at physiologically relevant doses in vitro demonstrated enhanced efficacy in vivo, including PI3K+MEK, MEK+PDGFR, and PI3K+AURKA. In contrast, other combinations (i.e. PI3K+mTOR) did not significantly improve survival or tumor burden in vivo. Despite improved survival with some combination treatments, mice eventually succumbed to tumor burden as tumors eventually grew. Kinome analysis of IC tumors treated with PI3K (BKM120) and/or MEK1/2 (AZD6244) inhibitors for 2 weeks identified several potential resistance markers, including INSR, IGF1R, and FGFR2, which may be targetable clinically.
Conclusions: Synthetic lethality screens identified multiple rational combination therapies based on PI3K and/or MEK inhibition in TNBC cells, particularly PI3K+MEK, MEK+PDGFR, and PI3K+AURKA. Combined use of brain-penetrant, clinically available inhibitors against these targets showed promising efficacy in intracranial TNBC mouse models. Rational combinations of brain-penetrant kinase inhibitors are promising strategies for a patient population with few options. In vivo studies assessing the efficacy of other identified combinations, as well as more extensive characterization of potential resistance mechanisms, in intracranial TNBC mouse models are warranted to provide the translational foundation for future clinical studies.
Citation Format: Amanda E.D. Van Swearingen, Maria J. Sambade, Marni B. Siegel, Shivani Sud, Samantha M. Bevill, Brian T. Golitz, Ryan E. Bash, Charlene M. Santos, David B. Darr, Joel S. Parker, C. Ryan Miller, Gary L. Johnson, Carey K. Anders. Several rational combination kinase inhibitor treatments identified by synthetic lethality screens are efficacious in intracranial triple negative breast cancer models [abstract]. In: Proceedings of the AACR Precision Medicine Series: Opportunities and Challenges of Exploiting Synthetic Lethality in Cancer; Jan 4-7, 2017; San Diego, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2017;16(10 Suppl):Abstract nr A03.