First-in-human phase I trial of the oral first-in-class ubiquitin specific peptidase 1 (USP1) inhibitor KSQ-4279 (KSQi), given as single agent (SA) and in combination with olaparib (OLA) or carboplatin (CARBO) in patients (pts) with advanced solid tumors, enriched for deleterious homologous recombination repair (HRR) mutations.
Authors: Yap Timothy A. , Lakhani Nehal J. , Patnaik Amita , Lee Elizabeth Katherine , Gutierrez Martin , Moore Kathleen N. , Carneiro Benedito A. , Hays John L. , Huang Marilyn , LoRusso Patricia , Wylie Andrew , Cadzow Louise , Goulet Matthew , Tobin Erica , Krieter Oliver , Schmid Daniela , Blake Sophia M. , Dieterich Max , Jamois Candice , Harris Patricia M. 
Published: June 2024

3005 Background: USP1 is a deubiquitinase that regulates DNA damage response pathways, such as Translesion Synthesis and Fanconi Anemia pathways. KSQi is a potent, selective small molecule inhibitor of USP1 with anti-proliferative activity in tumors with HRR mutations. The combination of KSQi and PARP inhibitors (PARPi) showed strong synergy in Ovarian and TNBC PDX models, supporting this clinical trial. Methods: This is a 2-part study: Part 1 dose escalation using a BOIN design explored safety, pharmacokinetics (PK), pharmacodynamics (PD) and preliminary anti-tumor activity of KSQi as SA (Arm 1) and in combination with OLA at 200 mg BID (Arm 2) or CARBO at AUC 4 (Arm 3) to determine the MTD and/or recommended dose for expansion (RDE). Part 2 will assess efficacy and safety of the combinations in expansion cohorts. Results: As of Jan 4, 2024, 64 pts (19m/45f; median age 63 y) received KSQi 100 - 1250 mg; Arm 1: 100 mg (3 pts), 150 (3), 200 (4), 300 (6), 450 (5), 650 (9), 900 (7) and 1250 (5); Arm 2: 200 (5), 450 (5) and 900 (5); Arm 3: 200 (3) and 450 (4). Median number of prior therapies was 5, 4 and 3 for Arm 1, 2 and 3, respectively. 29% had prior PARPi in Arm 1, 53% in Arm 2, and 71% in Arm 3. All pts in Arms 2 and 3 had tumors with deleterious HRR mutations. Most common treatment-emergent adverse events (TEAE) were anemia (36%), increased creatinine (33%) as SA, and anemia in combination with OLA (87%) and CARBO (71%). The most common G3+ TEAEs were hyponatremia (12%) as SA and anemia in combination with OLA (73%) and CARBO (29%). DLTs (n = 3) were G3 maculopapular rash at 1250 mg (Arm 1) and G3 WBC decrease at 200 mg, G3 anemia at 450 mg (Arm 2). 30% (19/64) of pts had an interruption in KSQi dosing and 1 (1.6%) discontinued treatment. PK AUC and Cmax increased almost dose-proportionally up to 650 mg. A preliminary review of OLA concentrations following co-administration with KSQi showed no significant impact of OLA at C2D1. Ubiquitinated PCNA induction was observed in paired tumor biopsies from pts receiving KSQi, supporting intra-tumoral USP1 inhibition. A RECIST PR was observed in a fallopian tube cancer pt lasting 7 weeks and SD in 9 pts treated with SA KSQi; best response in combination with OLA was SD in 6 pts and 2 SD with CARBO. Disease control rate at 16 weeks was 28% (Arm 1), 40% (Arm 2) and 29% (Arm 3). Conclusions: KSQi is a first-in-class USP1 inhibitor with an acceptable safety profile as SA and in combination. An MTD was not reached in any Arms. PD results support the mechanism of action of USP1 inhibition. The RDE will be determined in additional back-fill cohorts. Clinical trial information: NCT05240898 .