Therapeutic Targeting of BET Proteins in Osteosarcoma

Abstract

Osteosarcoma (OS) is an aggressive bone cancer in pediatric, adolescent, and young adult patients with an exceedingly poor prognosis. An area of therapeutic opportunity is that OS exhibits increased oncogenic replication stress (RS), augmenting genome instability and tumor progression. Exploiting RS provides a treatment intervention. Bromodomain and extra-terminal (BET) proteins regulate DNA transcription, replication, and repair. BET inhibitors create an imbalance between transcription and replication kinetics, exacerbating oncogenic RS and increasing cell death. We hypothesized that BET inhibition would decrease OS tumor growth via modulation of gene expression and increased RS. Bivalent BET inhibitor AZD5153 monotherapy significantly suppressed the growth of patient-derived xenografts (PDXs) established from treatment-naïve male and female OS patients. AZD5153-mediated anti-tumor effect correlated with increased γ-H2AX levels, indicative of elevated RS. RNA-sequencing and kinome profiling revealed intra- and inter-tumoral molecular response mechanisms attributable to therapeutic response and potential resistance in BET inhibitor-treated PDX and OS cell lines. Reprogramming of signaling networks involved in DNA damage response, apoptosis, invasion, and Wnt signaling were identified. Combining AZD5153 with salvage agents demonstrated additive-to-synergistic cell growth inhibition in vitro with drug combinations inducing apoptosis. AZD5153 increased DNA-strand breaks that was further enhanced by salvage therapy. In a PDX established from a metastatic lesion of a patient treated with frontline and salvage therapy, a combination of AZD5153 and topotecan was well tolerated and increased survival probability compared to each agent alone. These data suggest that AZD5153 alone or in combination with low-dose salvage therapy holds promise as an efficacious treatment strategy in OS.