Targeting AhR suppresses the generation of amivantamab-lazertinib-induced drug-tolerant persisters in EGFR-mutant lung cancer

Introduction: In 2024, the U.S. FDA approved first-line amivantamab-lazertinib based on the MARIPOSA trial, which showed superior overall survival compared with osimertinib. However, mechanisms of resistance to this dual-target therapy remain poorly understood. Using multi-omics analyses of patient-derived and preclinical models, we identified the aryl hydrocarbon receptor (AhR) as a potential target to overcome amivantamab-lazertinib resistance. Methods: Fresh tumor samples from a treatment-naïve EGFR exon 19 deletion patient were transplanted into athymic nude mice to establish patient-derived xenograft (PDX) models. Mice were treated with amivantamab-lazertinib for 10 days, followed by single-cell and bulk RNA sequencing, whole-exome sequencing, and immunohistochemistry to assess early-phase responses. In vitro, flow cytometry measured lazertinib-induced AhR expression, and HepG2 AhR-luciferase reporter assays evaluated lazertinib-AhR binding. In silico docking (SAMSON) assessed binding affinity. CellTiter-Glo and colony-formation assays tested combinatorial effects of amivantamab, lazertinib, and DA-4505, an investigational AhR antagonist. Results: Single-cell RNA-seq identified AhR among the most upregulated genes in drug-tolerant persister (DTP) cells after amivantamab-lazertinib exposure. Docking analysis suggested lazertinib acts as an AhR agonist. FACS confirmed that the combination markedly increased AhR expression across NSCLC cell lines. Adding DA-4505 enhanced growth inhibition in H1975 and YU-1185 patient-derived cells, with colony assays confirming additive effects. Transcriptomic and phospho-flow analyses indicated that cell lines with activated Src signaling were most sensitive to triple-drug treatment. Early clinical data from a phase I trial showed DA-4505 monotherapy was well tolerated up to 400 mg. Conclusion: Targeting AhR with DA-4505 augments the efficacy of amivantamab-lazertinib and may mitigate resistance in EGFR-mutant NSCLC. Ongoing clinical evaluation will determine its translational potential.