Natalie Thielen1, Chaoyuan Kuang2, Ning Wei3, Seiya Kitamura1, Emiko Nagai1
1Albert Einstein College of Medicine, Bronx, NY,2Albert Einstein Cancer Ctr., Bronx, NY,3Montefiore Comprehensive Cancer Center, Bronx, New York, NY
摘要 Abstract
Background: Colorectal cancer (CRC) is the second leading cause of cancer-related mortality. KRAS mutations, present in approximately 40% of CRC cases. FDA-approved inhibitors exist for KRAS G12C , but this mutation represents only a small subset of CRC, and resistance frequently develops through canonical or alternative survival pathways. KRAS G12D is the most prevalent allele in CRC; however, there are currently no FDA-approved inhibitors and few agents in advanced development. To address KRAS resistance, we developed a high-throughput combinatorial screening platform using both cell lines and patient-derived organoids (PDOs) with fully annotated molecular profiles to identify synergistic drug combinations capable of overcoming resistance.
Method: To demonstrate the utility of this platform for identifying G12D inhibitor (G12Di) resistance mechanisms and synergistic partners, we performed a large-scale combinatorial drug screen in both parental and resistant KRAS G12D mutant CRC cell lines. The screening library consisted of approximately 2,600 kinase inhibitors and 3,500 FDA-approved or clinical-stage compounds, tested both as single agents and in combination with a preclinical KRAS G12D inhibitor. Viability was assessed using the ATP-based luminescence assay CellTiter-Glo. Compounds demonstrating robust synergy were prioritized for secondary validation using 8×8 dose-response matrices. The most promising compounds were validated in KRAS G12D PDOs to confirm translational potential.
Result: Multiple compounds displayed synergistic activity with KRASi. Notably, "NT-1," a novel analog of the FDA-approved EGFR inhibitor osimertinib, demonstrated significant synergy (synergy score >10) at nanomolar concentrations across both sensitive and resistant CRC models. Compared with other EGFR inhibitors (osimertinib, erlotinib, afatinib), NT-1 achieved greater inhibitory effects at lower doses. These findings were extended to combinations with emerging pan-KRAS inhibitors, where NT-1 consistently outperformed approved EGFR inhibitors and cetuximab, producing deeper suppression of p-EGFR and p-ERK, and stronger induction of apoptosis. Ex vivo validation using KRAS G12D PDOs confirmed the translational potential of these combinations, demonstrating that NT-1 can mitigate both intrinsic and acquired resistance to G12Di. Ongoing in vivo studies are assessing NT-1 in combination with G12D selective and pan-KRAS inhibitors to delineate mutation-specific versus pathway-level vulnerabilities.
Conclusion: Our combinatorial screening platform provides novel biological insights into KRAS G12D resistance mechanisms in CRC and effectively identifies drug combinations with immediate clinical utility. The combination of NT-1 with G12D selective or pan-KRAS inhibitors represents a promising therapeutic strategy to overcome KRAS G12D resistance.