Multi-combination therapy for temozolomide-resistant GBM: identification of temozolomide/small molecule inhibitor combinations that target the MDM2/p53 and PI3K-AKT/mTOR networks
Introduction: Glioblastoma (GBM) is the most aggressive malignant brain cancer in adults. Induction of the DNA damage response pathway by Temozolomide (TMZ), a DNA alkylating agent, activates p53 resulting in apoptosis. GBM can adapt by upregulatingthe pro-survival pathway regulator Protein Kinase B (AKT), which phosphorylates murine double minute 2 (MDM2) resulting in increased MDM2-mediated p53 ubiquitination. We hypothesize that a combination treatment of blood-brain-barrier penetrant small molecule inhibitors (SMIs) to AKT (GDC-0068) and MDM2 protein-protein interaction inhibitor (RG7388), will stabilize p53 expression and potentiate TMZ-mediated effects in a recurrent p53wt GBM xenoline.
Methods: Dose response assays followed by Calcusyn statistical analysis determined optimal combination dose ratios. Incucyte imaging analyzedconfluence throughout a treatment cycle. Cellular response was characterized by: 1) Western blotting 2) Flow cytometry with SPiDER β-Gal and FITC Annexin V/ Propidium Iodide to quantify senescent and apoptotic cells, respectively 3) p53 siRNA knockdown to examine p53 dependency in treated cells.
Results: Combination index identified synergismof TMZ in the presence of AKT and MDM2 inhibitors at clinically achievable concentrations. Incucyte confirmed a low-dose triple combination significantly inhibited tumor growth. Western blots detected low expression of cleaved PARP and elevated expression of p53 and p21 in RG7388-treated cells compared to vehicle, suggesting senescence-related growth inhibition. SPiDER β-Gal and FITC Annexin V/PI assays confirmed a high percentage of senescent cells and minimal apoptosis following combination treatment compared to vehicle or single SMI-treated cells. P53 siRNA knockdown confirmed that cell growth inhibition is p53 dependent in treated cells.
Conclusion: This study provides rationale for targeting p53 in recurrent p53wt GBM and reveals that senescence could function as a potential therapeutic resistance mechanism. In future studies, targeting of the MDM2-p53 network in the presence of a SM senescence inhibitor will be evaluated to determine if this increases GBM cell death.
Copyright (c) 2021 Anthony Alfonso, Barbara J. Bailey, Erika A. Dobrota, Nuri Damayanti, M. Courtney Young, Pankita H. Pandya, Aaron Cohen-Gadol, Reza Saadatzadeh, Harlan E. Shannon, Karen E. Pollok, PhD
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