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Description, RGX-202, a small-molecule creatine transporter SLC6A8 inhibitor, suppresses colorectal cancer and modulates human creatine levels., Colorectal cancer (CRC) is a leading cause of cancer mortality. Creatine metabolism was previously shown to critically regulate colon cancer progression. We report that RGX-202, an oral small-molecule SLC6A8 transporter inhibitor, robustly inhibits creatine import in vitro and in vivo, reduces intracellular phosphocreatine and ATP levels, and induces tumor apoptosis. RGX-202 suppressed CRC growth across KRAS wild-type and KRAS mutant xenograft, syngeneic, and patient-derived xenograft (PDX) tumors. Antitumor efficacy correlated with tumoral expression of creatine kinase B. Combining RGX-202 with 5-fluorouracil or the DHODH inhibitor leflunomide caused regressions of multiple colorectal xenograft and PDX tumors of distinct mutational backgrounds. RGX-202 also perturbed creatine metabolism in patients with metastatic CRC in a phase 1 trial, mirroring pharmacodynamic effects on creatine metabolism observed in mice. This is, to our knowledge, the first demonstration of preclinical and human pharmacodynamic activity for creatine metabolism targeting in oncology, thus revealing a critical therapeutic target.

Colorectal cancer (CRC) is a leading cause of cancer mortality. Creatine metabolism was previously shown to critically regulate colon cancer progression. We report that RGX-202, an oral small-molecule SLC6A8 creatine transporter inhibitor, robustly inhibits creatine import in vitro and in vivo, reduces intracellular phosphocreatine and ATP levels and induces tumor cell apoptosis in CRC. RGX-202 suppressed tumor growth across KRAS wild-type and KRAS mutant xenograft, syngeneic and patient-derived xenograft colorectal cancers. Anti-tumor efficacy correlated with tumoral expression of creatine kinase B. Combining RGX-202 with 5- fluorouracil or the DHODH inhibitor leflunomide caused regressions of multiple colorectal xenograft and PDX tumors of distinct mutational backgrounds. RGX-202 also perturbed creatine metabolism in metastatic CRC patients enrolled in a Phase-1 trial, mirroring pharmacodynamic effects on creatine metabolism observed in mice. This is, to our knowledge, the first demonstration of pre-clinical and human pharmacodynamic activity for creatine metabolism targeting in oncology, revealing a critical target for CRC.

Prostate cancer (PC) progressed to castration resistance (CRPC) is a fatal disease. CRPC tumors develop resistance to new-generation antiandrogen enzalutamide through lineage plasticity, characterized by epithelial-mesenchymal transition (EMT) and a basal-like phenotype. FOXA1 is a transcription factor essential for epithelial lineage differentiation. Here, we demonstrate that FOXA1 loss leads to remarkable upregulation of transforming growth factor beta 3 (TGFB3), which encodes a ligand of the TGF-β pathway. Mechanistically, this is due to genomic occupancy of FOXA1 on an upstream enhancer of the TGFB3 gene to directly inhibit its transcription. Functionally, FOXA1 downregulation induces TGF-β signaling, EMT, and cell motility, which is effectively blocked by the TGF-β receptor I inhibitor galunisertib (LY2157299). Tissue microarray analysis confirmed reduced levels of FOXA1 protein and a concordant increase in TGF-β signaling, indicated by SMAD2 phosphorylation, in CRPC as compared with primary tumors. Importantly, combinatorial LY2157299 treatment sensitized PC cells to enzalutamide, leading to synergistic effects in inhibiting cell invasion in vitro and xenograft CRPC tumor growth and metastasis in vivo. Therefore, our study establishes FOXA1 as an important regulator of lineage plasticity mediated in part by TGF-β signaling, and supports a novel therapeutic strategy to control lineage switching and potentially extend clinical response to antiandrogen therapies.

Background. AXL receptor tyrosine kinase (AXL) is a transmembrane protein that is overexpressed in a variety of tumors and correlates with poor prognosis in cancer patients. AXL is expressed in cancer and stromal cells and has been implicated in the development of resistance to chemotherapy, targeted therapies & immunotherapies. Activation of AXL by its ligand, growth arrest specific protein 6 (Gas6), or ligand-independent dimerization facilitates AXL phosphorylation, initiates signaling cascades that promote cancer cell proliferation, survival, and an immunosuppressive microenvironment. Here we present the discovery and characterization of a novel, highly potent and selective novel AXL inhibitor. Materials and Methods. The potency and specificity of the novel Arcus inhibitor against AXL and other kinases was determined using a panel of HTRF KinEASE-TK assays. Intracellular target engagement was evaluated by monitoring displacement of a competitive fluorescent tracer using an AXL NanoBRETTM intracellular kinase assay. To further assess the inhibitory effect of the novel Arcus inhibitor on AXL kinase activity, AXL autophosphorylation induced SH2 domain translocation was measured in cells using a PathHunterÒ U2OS AXL Functional assay system. Inhibition of AXL phosphorylation in cancer cells was evaluated by Western blot and levels of soluble and surface AXL were assessed by ELISA and flow cytometry, respectively. Pharmacokinetics (PK), pharmacodynamics (PD) and anti-tumor efficacy were evaluated in murine models. Results. A novel, potent, reversible, and highly selective AXL kinase inhibitor has been generated by Arcus. The novel inhibitor exhibits single-digit nanomolar potency in both biochemical and cell-based assays, retains significant activity in 100% human serum and does not show significant inhibition of the major CYP450 isoforms nor the hERG potassium channel. The novel Arcus molecule inhibits AXL phosphorylation mediated by both ligand-dependent Gas6 stimulation as well as ligand-independent autophosphorylation. AXL phosphorylation and subsequent signaling leads to receptor internalization, thereby decreasing both surface AXL expression and soluble AXL levels. AXL activity is inhibited in a concentration dependent manner significantly increasing both surface AXL expression and soluble AXL levels. More importantly, significant anti-tumor efficacy is observed in combination with targeted therapies in several in vivo models. Furthermore, AXL inhibition significantly reduces tumor growth after relapse to single-agent targeted therapy. Conclusions. A novel selective inhibitor of AXL tyrosine kinase activity has been developed that demonstrates single-digit nanomolar potency and inhibition of both ligand-dependent and ligand-independent AXL phosphorylation. Significant anti-tumor activity is observed in combination with targeted therapy and upon acquired resistance in xenograft models. Selective AXL inhibition is a promising therapeutic strategy to overcome resistance to chemotherapy, targeted therapy, and/or immunotherapy. Citation Format: Susan L. Paprcka, Subhasree Sridhar, Irene M. Luu, Salema Jafri, Dillon H. Miles, Suan Liu, Ruben Flores, Shiwei Qu, Manjunath Lamani, Sriivas Paladugu, Cesar Meleza, James Wu, Hema Singh, Yu Chen, Sean Cho, Akshata Udyavar, Angelo Kaplan, Enzo Stargnaro, Xiaoning Zhao, Lixia Jin, Manmohan R. Leleti, Stephen W. Young, Jay P. Powers, Matthew J. Walters, Ester Fernandez-Salas. Potent and selective AXL tyrosine kinase inhibition demonstrates significant anti-tumor efficacy in combination with standard of care therapeutics in preclinical models [abstract]. In: Proceedings of the AACR-NCI-EORTC Virtual International Conference on Molecular Targets and Cancer Therapeutics; 2021 Oct 7-10. Philadelphia (PA): AACR; Mol Cancer Ther 2021;20(12 Suppl):Abstract nr P253.

RGX-104, a first-in-class small-molecule LXR agonist modulates innate immunity and cancer progression via transcriptional activation of ApoE. ApoE protein suppresses tumor cell invasion and angiogenesis, and also depletes circulating and tumoral myeloid derived suppressor cells (MDSC), leading to T cell activation.A multivariate approach was used to address pharmacokinetic (PK) and pharmacodynamic relationships of RGX-104 in a phase 1 dose escalation study in patients with relapsed/refractory solid tumors. The study entailed multiple escalation arms with RGX-104 as monotherapy and in combination with nivolumab, ipilimumab, or docetaxel. Various markers including intratumoral ApoE and its receptor LRP1 in biopsy specimens, gene expression of LXR-targets in whole blood, serum markers including cytokines and lipids, as well as immune cell types such as MDSC, CD8 T-cells, and neutrophils in peripheral blood from patients were monitored at several time points. PK metrics were tracked to assess dose response relationships. Clinical outcomes such as objective response, time to disease progression, and duration on therapy were used for exploratory correlative analyses. A generally dose dependent increase in steady state exposure to RGX-104 was observed among all cohorts; the lowest efficacious exposure among patients with partial response was ~14,000 ng*h/mL. Treatment with RGX-104 at doses ranging from 120 mg BID to 240 mg BID induced expression of LXR targets, ApoE [2.7X (p=0.008) to 7.1X (p=0.007)] and ABCA1 [ 6.3X (p=1.20E-03) to 7X (p=8.1E-04] over baseline in a generally dose-dependent manner as assessed in whole blood. Similarly, MDSC depletion, ranging from 70%-90% relative to baseline, was observed in patients treated with RGX-104 along with concomitant CD8 T-cell activation; similar effects were noted in patients in combination cohorts. A model to explore dose dependency of change in immune cell types suggested that baseline levels of MDSC were most predictive of the magnitude of MDSC reduction after treatment, and that favorable clinical outcomes correlate with the extent of MDSC reduction and T cell activation. Low baseline levels of tumoral ApoE were associated with greater clinical benefit, with almost all patients with stable disease or partial response exhibiting ApoE tumor positive score of ≤20%; these patients also exhibited low/negative PD-L1 ( Citation Format: Monica Mita, Alan Mita, Erika Hamilton, Gerald S. Falchook, Michael Postow, Bartosz Chmielowski, Russell J. Schilder, James Strauss, Emerson Lim, Shubham Pant, Angela Jain, Oliver Rixe, Rebecca Redman, Kevin B. Kim, Tomislav Dragovich, R. Donald Harvey, Igor Puzanov, Nimisha Schneider, Renee Deehan, Tobi Guennel, Joe Lin, Sohail Tavazoie, Roger Waltzman, Eric Rowinsky, Michael Szarek, Subhasree Sridhar, Robert Busby, Narayan Lebaka, Celia Andreu, Isabel Kurth, David Darst, Masoud Tavazoie, Syed Raza, Robert Wasserman, Foster C. Gonsalves. Correlative analysis of pharmacokinetics and pharmacodynamics of RGX-104, a first-in-class Liver-X-Receptor (LXR) agonist, and clinical outcomes in patients with advanced solid tumors [abstract]. In: Proceedings of the Annual Meeting of the American Association for Cancer Research 2020; 2020 Apr 27-28 and Jun 22-24. Philadelphia (PA): AACR; Cancer Res 2020;80(16 Suppl):Abstract nr LB-133.

MERTK, a receptor tyrosine kinase of the TYRO3/AXL/MERTK (TAM) family, is expressed in innate immune cells including macrophages, dendritic cells and NK cells and is overexpressed in a wide variety of cancers, including leukemia and many solid cancers. Activation of MERTK on cancer cells via ligand binding results in activation of several tumor-promoting signaling pathways, which stimulate proliferation, migration and angiogenesis, and decrease apoptosis and chemosensitivity. Furthermore, activation of MERTK on macrophages drives immune evasion through the promotion of an immune-suppressive M2 phenotype. Pre-clinical and clinical studies have shown promising emerging evidence of anti-tumor efficacy upon modulation of TAM receptor signaling. Herein, we report the pre-clinical characterization of RGX-019, a humanized IgG1 antibody with high affinity and specificity for human MERTK. Surface Plasmon Resonance, cell-based binding assays and competition ELISA demonstrate high affinity/avidity binding for RGX-019 to human MERTK. In contrast, binding to human AXL, human TYRO3, or murine MERTK was not detected. Binding of RGX-019 to the MERTK receptor triggered its rapid internalization and degradation from the surface of human cancer cells within 4 hours and prevented Gas6 induced phosphorylation of AKT, a downstream signal transduction pathway that promotes cell growth and survival. RGX-019 treatment of SKMel5 melanoma cells effectively inhibited colony formation. RGX-019-induced degradation of MERTK in in vitro differentiated human M2 macrophages reduced AKT activation and promoted a pro-inflammatory cytokine signature. Furthermore, a related surrogate murine MERTK antibody significantly inhibited growth of MDA-MB-231 breast cancer tumors, demonstrating single agent anti-tumor efficacy in vivo. These findings demonstrate that RGX-019 is a potent and selective inhibitor of MERTK signaling with a unique mechanism-of-action that potently disrupts MERTK signaling in both cancer cells and immune-suppressive macrophages via MERTK receptor degradation. This activity results in robust repression of cancer cell growth both in vitro and in vivo. Overall, these data support further development of RGX-019 as a cancer therapeutic. Citation Format: Shugaku Takeda, Celia Andreu-Agullo, Subhasree Sridhar, Nils Halberg, Ivo C. Lorenz, Sohail Tavazoie, Isabel Kurth, Masoud Tavazoie. Characterization of the anti-cancer and immunologic activity of RGX-019, a novel pre-clinical stage humanized monoclonal antibody targeting the MERTK receptor [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr LB-277.

Background: Colorectal cancer (CRC) is one of the leading causes of cancer deaths worldwide with more than 140,000 patients diagnosed and nearly 50,000 deaths annually in the U.S. alone. Roughly 60% of patients present with locally advanced or distant metastatic disease, with the liver being a primary site of metastatic colonization. Creatine metabolism has been implicated in colon cancer progression and metastatic colonization of the liver. Metastatic colon cancer cells upregulate and release creatine kinase-B (CKB) into the extracellular space, where it phosphorylates creatine to generate the high-energy metabolite phosphocreatine. Phosphocreatine is imported via the creatine transporter SLC6a8. Intracellular phosphocreatine can be converted to ATP to fuel the survival of metastatic cancer cells within the hypoxic hepatic microenvironment. Consistent with this finding, genetic depletion of SLC6a8 in colon and pancreatic cancer cell lines significantly reduced liver colonization in mouse xenograft models. Results: We herein demonstrate that the novel small molecule RGX-202 is a robust inhibitor of creatine uptake in cancer cells, both in vitro and in vivo. Oral administration of RGX-202 induced apoptosis of colon cancer cells in vivo, and significantly suppressed colon cancer liver metastatic colonization and primary tumor growth, both in KRAS wild-type and KRAS mutant colon cancer cell lines as well as in human PDX mouse models. Using genetic studies, these effects were found to be dependent on tumoral expression of SLC6a8. In addition, combination treatment of the CT26 syngeneic colon cancer mouse model with 5-FU resulted in synergistic antitumor activity, with complete tumor regressions observed in more than 40% of treated mice. Similarly, combination treatment of the KPC syngeneic mouse model with gemcitabine significantly reduced the growth of primary pancreatic tumors. Definitive 28-day GLP toxicology and pharmacokinetics studies of RGX-202 are currently ongoing. Preliminary observations suggest good tolerability in several animal species with a favorable pharmacokinetic profile, including bioavailability. Conclusion: These results strongly support clinical development of RGX-202 in patients with gastrointestinal cancers, including colorectal and pancreatic cancer, both as monotherapy and in combination with standard-of-care treatment. Citation Format: Isabel Kurth, Celia Andreu, Shugaku Takeda, Helen Tian, Foster Gonsalves, Katya Leites, Subhasree Sridhar, Jia Min Loo, Rob Busby, Sohail Tavazoie, Masoud Tavazoie. RGX-202, a first-in-class small-molecule inhibitor of the creatine transporter SLC6a8, is a robust suppressor of cancer growth and metastatic progression [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5863.