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Supplementary Figures, Tables, Methods

Supplementary Figure S1. AMG 510 demonstrates cooperativity with SHP2 and RTK inhibition

Supplementary Figure S9. Combined SHP2 and KRASG12C inhibition improves efficacy in vivo.

Purpose:Although KRAS represents the most commonly mutated oncogene, it has long been considered an “undruggable” target. Novel covalent inhibitors selective for the KRASG12C mutation offer the unprecedented opportunity to target KRAS directly. However, prior efforts to target the RAS–MAPK pathway have been hampered by adaptive feedback, which drives pathway reactivation and resistance.Experimental Design:A panel of KRASG12C cell lines were treated with the KRASG12C inhibitors ARS-1620 and AMG 510 to assess effects on signaling and viability. Isoform-specific pulldown of activated GTP-bound RAS was performed to evaluate effects on the activity of specific RAS isoforms over time following treatment. RTK inhibitors, SHP2 inhibitors, and MEK/ERK inhibitors were assessed in combination with KRASG12C inhibitors in vitro and in vivo as potential strategies to overcome resistance and enhance efficacy.Results:We observed rapid adaptive RAS pathway feedback reactivation following KRASG12C inhibition in the majority of KRASG12C models, driven by RTK-mediated activation of wild-type RAS, which cannot be inhibited by G12C-specific inhibitors. Importantly, multiple RTKs can mediate feedback, with no single RTK appearing critical across all KRASG12C models. However, coinhibition of SHP2, which mediates signaling from multiple RTKs to RAS, abrogated feedback reactivation more universally, and combined KRASG12C/SHP2 inhibition drove sustained RAS pathway suppression and improved efficacy in vitro and in vivo.Conclusions:These data identify feedback reactivation of wild-type RAS as a key mechanism of adaptive resistance to KRASG12C inhibitors and highlight the potential importance of vertical inhibition strategies to enhance the clinical efficacy of KRASG12C inhibitors.See related commentary by Yaeger and Solit, p. 1538

Supplementary Figure S7. SHP2 inhibition enhances the efficacy of KRASG12C inhibition.

Supplementary Figure S8. KRASG12C and SHP2 inhibition does not inhibit the growth of signaling of a non-KRASG12C mutant cell line.

Supplementary Figure S3. RTK inhibitors display variable cooperative effects with KRASG12C inhibitors across models.

Supplementary Figure S4. Combined KRASG12C and RTK inhibition improves efficacy in vivo.

Supplementary Figure S6. SHP2 inhibition enhances suppression of MAPK signaling in the presence of KRASG12C inhibition.

Supplementary Figure S2. KRASG12C inhibitors are subject to adaptive feedback through activation of RTKs.

Supplementary Figure S5. Combined KRASG12C and SHP2 or MAPK inhibition improves in vitro efficacy

Clonal heterogeneity associated with acquired resistance presents a critical therapeutic challenge. Whole-exome sequencing of paired tumor biopsies and targeted sequencing of cell-free DNA (cfDNA) from patients with BRAFV600E colorectal cancer receiving BRAF inhibitor combinations identified 14 distinct alterations in MAPK pathway components driving acquired resistance, with as many as eight alterations in a single patient. We developed a pooled clone system to study clonal outgrowth during acquired resistance, in vitro and in vivo. In vitro, the dynamics of individual resistant clones could be monitored in real time in cfDNA isolated from culture media during therapy. Outgrowth of multiple resistant clones was observed during therapy with BRAF, EGFR, and MEK inhibitor combinations. However, ERK inhibition, particularly in combination with BRAF and EGFR inhibition, markedly abrogated clonal outgrowth in vitro and in vivo. Thus, convergent, up-front therapy may suppress outgrowth of heterogeneous clones harboring clinically observed resistance alterations, which may improve clinical outcome. Significance: We observed heterogeneous, recurrent alterations in the MAPK pathway as key drivers of acquired resistance in BRAFV600E colorectal cancer, with multiple concurrent resistance alterations detectable in individual patients. Using a novel pooled clone system, we identify convergent up-front therapeutic strategies capable of intercepting multiple resistance mechanisms as potential approaches to suppress emergence of acquired resistance. Cancer Discov; 8(4); 417–27. ©2018 AACR. See related commentary by Janku, p. 389. See related article by Corcoran et al., p. 428. This article is highlighted in the In This Issue feature, p. 371

Purpose: Although KRAS represents the most commonly mutated oncogene, it has long been considered an “undruggable” target. Novel covalent inhibitors selective for the KRASG12C mutation offer the unprecedented opportunity to target KRAS directly. However, prior efforts to target the RAS–MAPK pathway have been hampered by adaptive feedback, which drives pathway reactivation and resistance. Experimental Design: A panel of KRASG12C cell lines were treated with the KRASG12C inhibitors ARS-1620 and AMG 510 to assess effects on signaling and viability. Isoform-specific pulldown of activated GTP-bound RAS was performed to evaluate effects on the activity of specific RAS isoforms over time following treatment. RTK inhibitors, SHP2 inhibitors, and MEK/ERK inhibitors were assessed in combination with KRASG12C inhibitors in vitro and in vivo as potential strategies to overcome resistance and enhance efficacy. Results: We observed rapid adaptive RAS pathway feedback reactivation following KRASG12C inhibition in the majority of KRASG12C models, driven by RTK-mediated activation of wild-type RAS, which cannot be inhibited by G12C-specific inhibitors. Importantly, multiple RTKs can mediate feedback, with no single RTK appearing critical across all KRASG12C models. However, coinhibition of SHP2, which mediates signaling from multiple RTKs to RAS, abrogated feedback reactivation more universally, and combined KRASG12C/SHP2 inhibition drove sustained RAS pathway suppression and improved efficacy in vitro and in vivo. Conclusions: These data identify feedback reactivation of wild-type RAS as a key mechanism of adaptive resistance to KRASG12C inhibitors and highlight the potential importance of vertical inhibition strategies to enhance the clinical efficacy of KRASG12C inhibitors. See related commentary by Yaeger and Solit, p. 1538

The three RAS genes are the most commonly mutated oncogenes in cancer and are refractory to conventional therapies. Oncogenic mutation of KRAS in 44% of colorectal cancers (CRC) leads to aberrant activation of downstream effector pathways, including the ERK MAPK signaling cascade, which can lead to an immunosuppressive tumor microenvironment. Single-agent therapies targeting the ERK MAPK cascade or immune checkpoint (PD-1/PD-L1) have been mostly unsuccessful in KRAS-mutant CRC, and efforts are under way to identify effective combination strategies. We employed an unbiased RNA-seq approach to identify gene signatures significantly upregulated upon ERK MAPK pathway inhibition in a panel of KRAS-mutant CRC cell lines. We found that treatment with either the MEK inhibitor trametinib or ERK inhibitor Vx-11e induced upregulation of interferon gene signatures and JAK/STAT pathway signaling components. Inhibition of MEK or ERK also transcriptionally increased levels of MHC Class I and antigen presentation machinery. Upregulation of MHC Class I was reversed with either pharmacologic inhibition of JAK/STAT signaling or genetic knockdown of the transcription factor IRF1. We propose that combining MAPK inhibition with checkpoint immunotherapy may provide an effective treatment in KRAS-mutant CRC tumors in vivo and that potential synergy may be due to enhancing the immunogenicity of tumors through priming of interferon response pathways and antigen presentation machinery. Citation Format: Meagan B. Ryan, Ferran Fece de la Cruz, Leanne G. Ahronian, Sarah Phat, David T. Myers, Heather A. Shahzade, Catriona Hong, Ryan B. Corcoran. ERK MAPK inhibition enhances the immunogenicity of KRAS-mutant 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 B50.

Clonal heterogeneity associated with acquired resistance presents a critical therapeutic challenge. Whole-exome sequencing of paired tumor biopsies and targeted sequencing of cell-free DNA (cfDNA) from BRAF(V600E) colorectal cancer patients receiving BRAF inhibitor combinations identified 14 distinct alterations in MAPK pathway components driving acquired resistance, with as many as eight alterations in a single patient. We developed a novel pooled clone system to study clonal outgrowth during acquired resistance, in vitro and in vivo. In vitro, the dynamics of individual resistant clones could be monitored in real-time in cfDNA isolated from culture media during therapy. Outgrowth of multiple resistant clones was observed during therapy with BRAF, EGFR, and MEK inhibitor combinations. However, ERK inhibition, particularly in combination with BRAF and EGFR inhibition, markedly abrogated clonal outgrowth in vitro and in vivo. Thus, convergent, upfront therapy may suppress outgrowth of heterogeneous clones harboring clinically observed resistance alterations, which may improve clinical outcome.

The three RAS genes are the most commonly mutated oncogenes in cancer and have long been considered an “undruggable” target. Alterations in KRAS occur at the highest frequency, with G12D, G12V, and G12C mutations being the most common. The recent development of novel covalent inhibitors selective for the KRASG12C mutation offers the unprecedented opportunity to target KRAS directly. However, prior efforts to target the RAS-MAPK pathway in have been hampered by adaptive feedback, which drives pathway reactivation and resistance. We find evidence of rapid adaptive RAS-MAPK pathway feedback reactivation following KRASG12C inhibition in the majority of KRASG12C models, including lung, colon, and pancreatic lines. Reactivation of the RAS-MAPK pathway correlates with activation of multiple upstream RTKs and subsequent increase of wild-type RAS activity. We find that co-inhibition of SHP2, a common node downstream of RTKs, or co-inhibition of individual RTKs such as EGFR or FGFR enhances the efficacy of KRASG12C inhibition both in vitro and in vivo by overcoming adaptive reactivation of the RAS-MAPK pathway. Notably, only the combination of KRASG12C and SHP2 inhibitor treatment displays tumor regressions in vivo in multiple models when compared to either inhibitor alone. We also see evidence that combining KRASG12C inhibitors with MEK or ERK inhibitors as an additional potential vertical inhibition strategy in KRASG12C models. We propose a vertical inhibition strategy anchored with KRASG12C inhibitors with either RTK or SHP2 inhibitors as a potential strategy for the treatment of KRASG12C mutant tumors. Citation Format: Meagan B Ryan, Ferran Fece de la Cruz, Sarah Phat, David T Myers, Heather A Shahzade, Catriona B Hong, Ryan B Corcoran. Vertical inhibition overcomes adaptive resistance to KRASG12C inhibition [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference on Molecular Targets and Cancer Therapeutics; 2019 Oct 26-30; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2019;18(12 Suppl):Abstract nr A129. doi:10.1158/1535-7163.TARG-19-A129

Clonal heterogeneity associated with the emergence of acquired resistance to therapy presents a critical challenge for therapeutic strategies to overcome resistance. We investigated the molecular landscape of acquired resistance in BRAF-mutant colorectal patients treated with BRAF inhibitor combinations. Through whole-exome sequencing of paired pre-treatment and post-progression tumor biopsies and targeted sequencing of pre-treatment and post-progression plasma circulating tumor DNA (ctDNA), we identified 14 unique alterations in MAPK pathway components driving acquired resistance, affecting KRAS, NRAS, BRAF, MEK1 and MEK2. Analysis of ctDNA at the time of disease progression revealed profound tumor heterogeneity associated with acquired resistance, with multiple concurrent resistance alterations detectable in ctDNA in individual patients, with one patient harboring as many as 8 co-existing resistance alterations. These findings necessitate development of a strategy capable of simultaneously overcoming multiple heterogeneous resistance mechanisms. To evaluate potential strategies for convergent targeting of multiple concurrent resistance alterations, we generated individual resistant models harboring the full spectrum of clinically observed mutations driving acquired resistance. Individually, these alterations drove resistance to BRAF inhibitor combinations currently in clinical trials by maintaining MAPK signaling. However, since acquired resistance is thought to arise from pre-existing clones that emerge during treatment, we developed a novel pooled clone model system to study clonal outgrowth under the selective pressure of therapy. In this system, each resistant clone was pooled at an abundance of 1% in a background of the sensitive parental cells and exposed to an array of potential therapies, both in vitro, and in vivo as xenografts. The change in clonal abundance from baseline to the completion of therapy was assessed for each clone by digital PCR to measure the degree of clonal outgrowth. Moreover, in vitro, we were able to monitor clonal dynamics in real-time by isolating cell-free DNA (cfDNA) from the cell culture media every 3-4 days during therapy. We observed rapid outgrowth of resistant clones during BRAF-EGFR and BRAF-MEK therapy, and delayed, but robust outgrowth during BRAF-MEK-EGFR therapy, all of which are therapies that have been evaluated in recent clinical trials. However, ERK inhibitor alone, and to a greater degree BRAF-ERK and BRAF-ERK-EGFR combinations markedly abrogated the clonal outgrowth of resistant clones. Moreover, in xenograft tumors derived from clonal pools, BRAF-ERK-EGFR triple combination resulted in profound tumor regressions and completely prevented the outgrowth of all resistant clones. In conclusion, we observed the potential for profound heterogeneity of acquired resistance mechanisms in BRAF-mutant colorectal cancer patients, with multiple alterations observed in ctDNA from individual patients. Our data suggest that convergent, upfront therapy with RAF-ERK or RAF-ERK-EGFR inhibitor combinations may suppress outgrowth of clones harboring clinically observed resistant alterations, offering the potential for improved clinical outcome. Citation Format: Mehlika Hazar-Rethinam, Marianna Kleyman, G. Celine Han, David Liu, Leanne G. Ahronian, Heather A. Shahzade, Lifeng Chen, Aparna R. Parikh, Jill N. Allen, Jeffrey W. Clark, Eunice L. Kwak, Jason E. Faris, Janet E. Murphy, Theodore S. Hong, Emily E. Van Seventer, Brandon Nadres, Catriona B. Hong, Joseph M. Gurski Jr., Nicholas A. Jessop, Dora Dias-Santagata, A. John Iafrate, Eli M. Van Allen, Ryan B. Corcoran. Modeling convergent therapeutic strategies to overcome the heterogeneity of acquired resistance in BRAF-mutant colorectal cancer [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr LB-A34.