Preclinical evaluation of a novel triple-acting PIM/PI3K/mTOR inhibitor, IBL-302, in breast cancer.


Journal

Oncogene
ISSN: 1476-5594
Titre abrégé: Oncogene
Pays: England
ID NLM: 8711562

Informations de publication

Date de publication:
04 2020
Historique:
received: 28 03 2019
accepted: 30 01 2020
revised: 20 01 2020
pubmed: 12 2 2020
medline: 21 11 2020
entrez: 12 2 2020
Statut: ppublish

Résumé

The proviral integration of Moloney virus (PIM) family of protein kinases are overexpressed in many haematological and solid tumours. PIM kinase expression is elevated in PI3K inhibitor-treated breast cancer samples, suggesting a major resistance pathway for PI3K inhibitors in breast cancer, potentially limiting their clinical utility. IBL-302 is a novel molecule that inhibits both PIM and PI3K/AKT/mTOR signalling. We thus evaluated the preclinical activity of IBL-302, in a range of breast cancer models. Our results demonstrate in vitro efficacy of IBL-302 in a range of breast cancer cell lines, including lines with acquired resistance to trastuzumab and lapatinib. IBL-302 demonstrated single-agent, anti-tumour efficacy in suppression of pAKT, pmTOR and pBAD in the SKBR-3, BT-474 and HCC-1954 HER2+/PIK3CA-mutated cell lines. We have also shown the in vivo single-agent efficacy of IBL-302 in the subcutaneous BT-474 and HCC-1954 xenograft model in BALB/c nude mice. The combination of trastuzumab and IBL-302 significantly increased the anti-proliferative effect in HER2+ breast cancer cell line, and matched trastuzumab-resistant line, relative to testing either drug alone. We thus believe that the novel PIM and PI3K/mTOR inhibitor, IBL-302, represents an exciting new potential treatment option for breast cancer, and that it should be considered for clinical investigation.

Identifiants

pubmed: 32042115
doi: 10.1038/s41388-020-1202-y
pii: 10.1038/s41388-020-1202-y
pmc: PMC7118022
doi:

Substances chimiques

IBL-302 0
Protein Kinase Inhibitors 0
Pyridines 0
Pyrimidines 0
Thiophenes 0
Lapatinib 0VUA21238F
MTOR protein, human EC 2.7.1.1
Protein Serine-Threonine Kinases EC 2.7.11.1
TOR Serine-Threonine Kinases EC 2.7.11.1
Trastuzumab P188ANX8CK

Types de publication

Journal Article Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

IM

Pagination

3028-3040

Références

Bachmann M, Möröy T, The serine/threonine kinase Pim-1. Int J Biochem Cell Biol. 2005;37:726–30.
Tursynbay Y, Zhang J, Li Z, Tokay T, Zhumadilov Z, Wu D, et al. Pim-1 kinase as cancer drug target: an update. Biomed Rep. 2016;4:140–6.
doi: 10.3892/br.2015.561 pubmed: 26893828
Aziz AUR, Farid S, Qin K, Wang H, Liu B. Pim kinases and their relevance to the PI3K/AKT/mTOR pathway in the regulation of ovarian cancer. Biomolecules. 2018;8:7.
doi: 10.3390/biom8010007 pmcid: 5871976
Nawijn MC, Alendar A, Berns A. For better or for worse: the role of Pim oncogenes in tumorigenesis. Nat Rev Cancer. 2011;11:23–34.
doi: 10.1038/nrc2986 pubmed: 21150935
Zhao B, Liu L, Mao J, Zhang Z, Wang Q, Li Q. PIM1 mediates epithelial-mesenchymal transition by targeting Smads and c-Myc in the nucleus and potentiates clear-cell renal-cell carcinoma oncogenesis article. Cell Death Dis. 2018;9:307–21.
Beier UH, Weise JB, Laudien M, Sauerwein H, Görögh T. Overexpression of Pim-1 in head and neck squamous cell carcinomas. Int J Oncol. 2007;30:1381–7.
pubmed: 17487358
Roh M, Gary B, Song C, Said-Al-Naief N, Tousson A, Kraft A, et al. Overexpression of the oncogenic kinase Pim-1 leads to genomic instability. Cancer Res. 2003;63:8079–84.
Narlik-Grassow M, Blanco-Aparicio C, Carnero A. The PIM family of serine/threonine kinases in cancer. Med Res Rev. 2014;34:136–59.
doi: 10.1002/med.21284 pubmed: 23576269
Warfel NA, Kraft AS. PIM kinase (and Akt) biology and signaling in tumors. Pharm Ther. 2015;151:41–9.
doi: 10.1016/j.pharmthera.2015.03.001
White E. The pims and outs of survival signaling: role for the Pim-2 protein kinase in the suppression of apoptosis by cytokines. Genes Dev. 2003;17:1813–6.
doi: 10.1101/gad.1123103 pubmed: 12897050
Isaac M, Siu A, Jongstra J. The oncogenic PIM kinase family regulates drug resistance through multiple mechanisms. Drug Resist Updates. 2011;14:203–11.
doi: 10.1016/j.drup.2011.04.002
Brasó-Maristany F, Filosto S, Catchpole S, Marlow R, Quist J, Francesch-Domenech E, et al. PIM1 kinase regulates cell death, tumor growth and chemotherapy response in triple-negative breast cancer. Nat Med. 2016;22:1303–13.
doi: 10.1038/nm.4198 pubmed: 27775704 pmcid: 5552044
Malinen M, Jääskeläinen T, Pelkonen M, Heikkinen S, Väisänen S, Kosma VM, et al. Proto-oncogene PIM-1 is a novel estrogen receptor target associating with high grade breast tumors. Mol Cell Endocrinol. 2013;365:270–6.
doi: 10.1016/j.mce.2012.10.028 pubmed: 23142699
Horiuchi D, Camarda R, Zhou AY, Yau C, Momcilovic O, Balakrishnan S, et al. PIM1 kinase inhibition as a targeted therapy against triple-negative breast tumors with elevated MYC expression. Nat Med. 2016;22:1321–9.
doi: 10.1038/nm.4213 pubmed: 27775705 pmcid: 5341692
Rebello RJ, Huglo AV, Furic L. PIM activity in tumours: a key node of therapy resistance. Adv Biol Regul. 2018;67:163–9.
doi: 10.1016/j.jbior.2017.10.010 pubmed: 29111105
Wong PM, Feng Y, Wang J, Shi R, Jiang X. Regulation of autophagy by coordinated action of mTORC1 and protein phosphatase 2A. Nat Commun. 2015;6:8048.
doi: 10.1038/ncomms9048 pubmed: 26310906
Elster N, Cremona M, Morgan C, Toomey S, Carr A, O’Grady A, et al. A preclinical evaluation of the PI3K alpha/delta dominant inhibitor BAY 80-6946 in HER2-positive breast cancer models with acquired resistance to the HER2-targeted therapies trastuzumab and lapatinib. Breast Cancer Res Treat. 2015;149:373–83.
doi: 10.1007/s10549-014-3239-5 pubmed: 25528022
Le X, Antony R, Razavi P, Treacy DJ, Luo F, Ghandi M, et al. Systematic functional characterization of resistance to PI3K inhibition in breast cancer. Cancer Discov. 2016;6:1134–47.
Zhang F, Beharry ZM, Harris TE, Lilly MB, Smith CD, Mahajan S, et al. PIM1 protein kinase regulates PRAS40 phosphorylation and mTOR activity in FDCP1 cells. Cancer Biol Ther. 2009;8:846–53.
doi: 10.4161/cbt.8.9.8210 pubmed: 19276681
Cen B, Mahajan S, Wang W, Kraft AS. Elevation of receptor tyrosine kinases by small molecule AKT inhibitors in prostate cancer is mediated by Pim-1. Cancer Res. 2013;73:3402–11.
doi: 10.1158/0008-5472.CAN-12-4619 pubmed: 23585456 pmcid: 3680595
Koblish H, Li Y long, Shin N, Hall L, Wang Q, Wang K, et al. Preclinical characterization of INCB053914, a novel pan-PIM kinase inhibitor, alone and in combination with anticancer agents, in models of hematologic malignancies. PLoS ONE. 2018;13:e0199108.
doi: 10.1371/journal.pone.0199108 pubmed: 29927999 pmcid: 6013247
Cen B, Xiong Y, Song JH, Mahajan S, DuPont R, McEachern K, et al. The Pim-1 protein kinase is an important regulator of MET receptor tyrosine kinase levels and signaling. Mol Cell Biol. 2014;34:2517–32.
doi: 10.1128/MCB.00147-14 pubmed: 24777602 pmcid: 4054323
Xia Z, Knaak C, Ma J, Beharry ZM, McInnes C, Wang W, et al. Synthesis and evaluation of novel inhibitors of Pim-1 and Pim-2 protein kinases. J Med Chem. 2009;52:74–86.
Chen LS, Redkar S, Bearss D, Wierda WG, Gandhi V. Pim kinase inhibitor, SGI-1776, induces apoptosis in chronic lymphocytic leukemia cells. Blood. 2009;114:4150–7.
doi: 10.1182/blood-2009-03-212852 pubmed: 19734450 pmcid: 2774551
Haddach M, Michaux J, Schwaebe MK, Pierre F, O’Brien SE, Borsan C, et al. Discovery of CX-6258. A potent, selective, and orally efficacious pan-pim kinases inhibitor. ACS Med Chem Lett. 2012;3:135–9.
doi: 10.1021/ml200259q pubmed: 24900437
Keeton EK, McEachern K, Dillman KS, Palakurthi S, Cao Y, Grondine MR, et al. AZD1208, a potent and selective pan-Pim kinase inhibitor, demonstrates efficacy in preclinical models of acute myeloid leukemia. Blood. 2014;123:905–13.
doi: 10.1182/blood-2013-04-495366 pubmed: 24363397 pmcid: 3916880
Garcia PD, Langowski JL, Wang Y, Chen M, Castillo J, Fanton C, et al. Pan-PIM kinase inhibition provides a novel therapy for treating hematologic cancers. Clin Cancer Res. 2014;20:1834–45.
Burger MT, Nishiguchi G, Han W, Lan J, Simmons R, Atallah G, et al. Identification of N-(4-((1R,3S,5S)-3-amino-5-methylcyclohexyl)pyridin-3-yl)-6-(2,6-difluorophenyl)-5-fluoropicolinamide (PIM447), a potent and selective proviral insertion site of Moloney murine leukemia (PIM) 1, 2, and 3 kinase inhibitor in clinical tria. J Med Chem. 2015;58:8373–86.
Païno T, Garcia-Gomez A, González-Méndez L, San-Segundo L, Hernández-García S, López-Iglesias AA, et al. The novel pan-PIM kinase inhibitor, PIM447, displays dual antimyeloma and bone-protective effects, and potently synergizes with current standards of care. Clin. Cancer Res. 2017;23:225–38.
doi: 10.1158/1078-0432.CCR-16-0230 pubmed: 27440267
Cortes J, Tamura K, Deangelo DJ, De Bono J, Lorente D, Minden M, et al. Phase I studies of AZD1208, a proviral integration Moloney virus kinase inhibitor in solid and haematological cancers. Br J Cancer. 2018;118:1425–33.
Dakin LA, Block MH, Chen H, Code E, Dowling JE, Feng X, et al. Discovery of novel benzylidene-1,3-thiazolidine-2,4-diones as potent and selective inhibitors of the PIM-1, PIM-2, and PIM-3 protein kinases. Bioorg Med Chem Lett. 2012;22:4599–604.
doi: 10.1016/j.bmcl.2012.05.098 pubmed: 22727640
Meja K, Stengel C, Sellar R, Huszar D, Davies BR, Gale RE, et al. PIM and AKT kinase inhibitors show synergistic cytotoxicity in acute myeloid leukaemia that is associated with convergence on mTOR and MCL1 pathways. Br J Haematol. 2014;167:69–79.
doi: 10.1111/bjh.13013 pubmed: 24975213
Neil M, Aparicio CB, Jiang S, Martinez S, McKenzie A, Page M, et al. Abstract 4524: Combined inhibition of PIM and PI3 kinases shows an enhanced efficacy in a number of solid tumour cell lines. Cancer Res. 2014;74:4524.
Moore G, Heavey S, Lightner C, Brady L, O’Byrne K, Finn S, et al. P1.02-065 elucidating the role of PIM kinase and its therapeutic potential in NSCLC. J Thorac Oncol. 2017;12:S527–8. https://doi.org/10.1016/j.jtho.2016.11.649 .
doi: 10.1016/j.jtho.2016.11.649
Reidy M, et al. Initial evaluation of novel dual PIM/PI3K and triple PIM/PI3K/mTOR inhibitors in multiple myeloma. Blood. 2014;124:5713. LP–5713. http://www.bloodjournal.org/content/124/21/5713.abstract .
Moody SE, Schinzel AC, Singh S, Izzo F, Strickland MR, Luo L, et al. PRKACA mediates resistance to HER2-targeted therapy in breast cancer cells and restores anti-apoptotic signaling. Oncogene. 2014;34:2061–71.
Bian C, Liu Z, Li D, Zhen L. PI3K/AKT inhibition induces compensatory activation of the MET/STAT3 pathway in non-small cell lung cancer. Oncol Lett. 2018;15:9655–62.
pubmed: 29928341 pmcid: 6004714
Sourbier C, Lindner V, Lang H, Agouni A, Schordan E, Danilin S, et al. The phosphoinositide 3-kinase/Akt pathway: A new target in human renal cell carcinoma therapy. Cancer Res. 2006;66:5130–42.
doi: 10.1158/0008-5472.CAN-05-1469 pubmed: 16707436
Simioni C, Cani A, Martelli AM, Zauli G, Tabellini G, McCubrey J, et al. Activity of the novel mTOR inhibitor Torin-2 in B-precursor acute lymphoblastic leukemia and its therapeutic potential to prevent Akt reactivation. Oncotarget. 2014;5:10034–47.
doi: 10.18632/oncotarget.2490 pubmed: 25296981 pmcid: 4259403
Herzog A, Bian Y, Vander BroekR, Hall B, Coupar J, Cheng H, et al. PI3K/mTOR inhibitor PF-04691502 antitumor activity is enhanced with induction of wild-type TP53 in human xenograft and murine knockout models of head and neck cancer. Clin Cancer Res. 2013;19:3808–19.
doi: 10.1158/1078-0432.CCR-12-2716 pubmed: 23640975 pmcid: 3715575
Hua H, Zhu Y, Song YH. Ruscogenin suppressed the hepatocellular carcinoma metastasis via PI3K/Akt/mTOR signaling pathway. Biomed Pharmacother. 2018;101:115–22.
doi: 10.1016/j.biopha.2018.02.031 pubmed: 29477471
Chapuis N, Tamburini J, Green AS, Vignon C, Bardet V, Neyret A, et al. Dual inhibition of PI3K and mTORC1/2 signaling by NVP-BEZ235 as a new therapeutic strategy for acute myeloid leukemia. Clin Cancer Res. 2010;16:5424–35.
doi: 10.1158/1078-0432.CCR-10-1102 pubmed: 20884625
Macdonald A, Campbell DG, Toth R, McLauchlan H, Hastie CJ, Arthur JSC. Pim kinases phosphorylate multiple sites in Bad and promote 14-3-3 binding and dissociation from Bcl-XL. BMC Cell Biol. 2006;7:1.
doi: 10.1186/1471-2121-7-1 pubmed: 16403219 pmcid: 1368972
Bhattacharya N, Wang Z, Davitt C, McKenzie IFC, Xing PX, Magnuson NS. Pim-1 associates with protein complexes necessary for mitosis. Chromosoma. 2002;111:80–95.
doi: 10.1007/s00412-002-0192-6 pubmed: 12111331
Wang Z, Bhattacharya N, Mixter PF, Wei W, Sedivy J, Magnuson NS. Phosphorylation of the cell cycle inhibitor p21Cip1/WAF1by Pim-1 kinase. Biochim Biophys Acta. 2002;1593:45–55.
Zhang Y, Wang Z, Magnuson NS. Pim-1 kinase-dependent phosphorylation of p21Cip1/WAF1 regulates its stability and cellular localization in H1299 cells. Mol Cancer Res. 2007;5:909–22.
doi: 10.1158/1541-7786.MCR-06-0388 pubmed: 17855660
Jin B, Wang Y, Wu CL, Liu KY, Chen H, Mao Z Bin. PIM-1 modulates cellular senescence and links IL-6 signaling to heterochromatin formation. Aging Cell. 2014;13:879–89.
doi: 10.1111/acel.12249 pubmed: 25040935 pmcid: 4331745
Yang J, Liu K, Yang J, Jin B, Chen H, Zhan X, et al. PIM1 induces cellular senescence through phosphorylation of UHRF1 at Ser311. Oncogene. 2017;36:4828–42.
Hogan C, Hutchison C, Marcar L, Milne D, Saville M, Goodlad J, et al. Elevated levels of oncogenic protein kinase Pim-1 induce the p53 pathway in cultured cells and correlate with increased Mdm2 in mantle cell lymphoma. J Biol Chem. 2008;283:18012–23.
doi: 10.1074/jbc.M709695200 pubmed: 18467333
Mohlin S, Hansson K, Radke K, Martinez S, Blanco‐Apiricio C, Garcia‐Ruiz C, et al. Anti‐tumor effects of PIM / PI 3K/ mTOR triple kinase inhibitor IBL ‐302 in neuroblastoma. EMBO Mol Med. 2019;11:10058.
Cobb M, Hunter L, Carlson D, Darr D, Haystead T, Baines AT. Abstract 524: Characterizing the in-vitro and in-vivo effects of the PIM kinase inhibitor HS140 in triple-negative human breast cancer. Cancer Res. 2017;77:524.
Liu WT, Jing YY, Yu GF, Chen H, Han ZP, Yu DD, et al. Hepatic stellate cell promoted hepatoma cell invasion via the HGF/c-Met signaling pathway regulated by p53. Cell Cycle. 2016;15:886–94.
doi: 10.1080/15384101.2016.1152428 pubmed: 27077227 pmcid: 4889302
Zhang R, Zhou Z, Lu S, Lu Z, Wan D, Pan Z, et al. Pim-3 as a potential predictor of chemoradiotherapy resistance in locally advanced rectal cancer patients. Sci Rep Am Soc Clin Oncol. 2017;7:16043.
Chandarlapaty S, Sawai A, Scaltriti M, Rodrik-Outmezguine V, Grbovic-Huezo O, Serra V, et al. AKT inhibition relieves feedback suppression of receptor tyrosine kinase expression and activity. Cancer Cell. 2011;19:58–71.
doi: 10.1016/j.ccr.2010.10.031 pubmed: 21215704 pmcid: 3025058
Liu P, Cheng H, Santiago S, Raeder M, Zhang F, Isabella A, et al. Oncogenic PIK3CA-driven mammary tumors frequently recur via PI3K pathway-dependent and PI3K pathway-independent mechanisms. Nat Med. 2011;17:1116–20.
Ilic N, Utermark T, Widlund HR, Roberts TM. PI3K-targeted therapy can be evaded by gene amplification along the MYC-eukaryotic translation initiation factor 4E (eIF4E) axis. Proc Natl Acad Sci. 2011;108:E699–708.
doi: 10.1073/pnas.1108237108 pubmed: 21876152 pmcid: 3174675
Doshi KA, Natarajan K, Wolfson B, Huszar D, Baer MR. The Pim kinase inhibitor AZD1208 sensitizes acute myeloid leukemia cells with fms-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) to cytotoxic effects of chemotherapy drugs. Cancer Res. 2015;75:5332.
Song JH, Kraft AS. Pim kinase inhibitors sensitize prostate cancer cells to apoptosis triggered by Bcl-2 family inhibitor ABT-737. Cancer Res. 2012;72:294–303.
doi: 10.1158/0008-5472.CAN-11-3240 pubmed: 22080570
Musiani D, Hammond DE, Cirillo L, Erriquez J, Olivero M, Clague MJ, et al. PIM2 kinase is induced by cisplatin in ovarian cancer cells and limits drug efficacy. J Proteome Res. 2014;13:4970–82.
doi: 10.1021/pr500651n pubmed: 25099161
Tursynbay Y, Zhang J, Li Z, Tokay T, Zhumadilov Z, Wu D, et al. Pim-1 kinase as cancer drug target: an update. Biomed Rep. 2016;4:140–6.
Keegan NM, Walshe JM, Toomey S, Gullo G, Kennedy MJ, Bulger KN, et al. A phase Ib trial of copanlisib and tratuzumab in pretreated recurrent or metastatic HER2-positive breast cancer “PantHER”. J Clin Oncol. 2018;36:1036.
Elster N, Toomey S, Fan Y, Cremona M, Morgan C, Weiner Gorzel K. et al. Frequency, impact and a preclinical study of novel ERBB gene family mutations in HER2-positive breast cancer. Ther Adv Med Oncol. 2018;10:1758835918778297. https://doi.org/10.1177/1758835918778297 .
doi: 10.1177/1758835918778297 pubmed: 30023006 pmcid: 6047239
Rampal RK, Maria P-O, Amritha Varshini HS, Levine RL, Cao A. Synergistic therapeutic efficacy of combined JAK1/2, Pan-PIM, and CDK4/6 inhibition in myeloproliferative neoplasms. Blood.2016;128:634.
doi: 10.1182/blood.V128.22.634.634
McDermott MSJ, Browne BC, Conlon NT, O’Brien NA, Slamon DJ, Henry M, et al. PP2A inhibition overcomes acquired resistance to HER2 targeted therapy. Mol Cancer. 2014;13:157.
doi: 10.1186/1476-4598-13-157 pubmed: 24958351 pmcid: 4230643
McDermott MSJ, Canonici A, Ivers L, Browne BC, Madden SF, O’Brien NA, et al. Dual inhibition of IGF1R and ER enhances response to trastuzumab in HER2 positive breast cancer cells. Int J Oncol. 2017;50:2221–8.
Eustace AJ, Crown J, Clynes M, O’Donovan N. Preclinical evaluation of dasatinib, a potent Src kinase inhibitor, in melanoma cell lines. J Transl Med. 2008;6:53.
doi: 10.1186/1479-5876-6-53 pubmed: 18823558 pmcid: 2569026

Auteurs

Sean P Kennedy (SP)

Medical Oncology Group, Department of Molecular Medicine, Royal College of Surgeons Ireland, Smurfit Building Beaumont Hospital, Beaumont, Dublin, Ireland. Seanpkennedy@rcsi.ie.

Michael O'Neill (M)

Inflection Biosciences, Anglesea House, Blackrock, Dublin, Ireland.

Darren Cunningham (D)

Inflection Biosciences, Anglesea House, Blackrock, Dublin, Ireland.

Patrick G Morris (PG)

Medical Oncology Group, Department of Molecular Medicine, Royal College of Surgeons Ireland, Smurfit Building Beaumont Hospital, Beaumont, Dublin, Ireland.
Cancer Clinical Trials and Research Unit, Beaumont Hospital, Dublin, Ireland.

Sinead Toomey (S)

Medical Oncology Group, Department of Molecular Medicine, Royal College of Surgeons Ireland, Smurfit Building Beaumont Hospital, Beaumont, Dublin, Ireland.

Carmen Blanco-Aparicio (C)

Experimental Therapeutics Programme, Spanish National Cancer Research Centre (CNIO), Madrid, Spain.

Sonia Martinez (S)

Experimental Therapeutics Programme, Spanish National Cancer Research Centre (CNIO), Madrid, Spain.

Joaquin Pastor (J)

Experimental Therapeutics Programme, Spanish National Cancer Research Centre (CNIO), Madrid, Spain.

Alex J Eustace (AJ)

Molecular Therapeutics for Cancer in Ireland, National Institute for Cellular Biotechnology, Dublin City University, Dublin, Ireland.

Bryan T Hennessy (BT)

Medical Oncology Group, Department of Molecular Medicine, Royal College of Surgeons Ireland, Smurfit Building Beaumont Hospital, Beaumont, Dublin, Ireland.
Cancer Clinical Trials and Research Unit, Beaumont Hospital, Dublin, Ireland.
Cancer Trials Ireland, Innovation House, Old Finglas Road, Botanic, Dublin, Ireland.

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