Lung and bladder cancers are mostly incurable because of the early development of drug resistance and metastatic dissemination. Hence, improved therapies that tackle these two processes are urgently needed to improve clinical outcome. We have identified RSK4 as a promoter of drug resistance and metastasis in lung and bladder cancer cells. Silencing this kinase, through either RNA interference or CRISPR, sensitized tumor cells to chemotherapy and hindered metastasis in vitro and in vivo in a tail vein injection model. Drug screening revealed several floxacin antibiotics as potent RSK4 activation inhibitors, and trovafloxacin reproduced all effects of RSK4 silencing in vitro and in/ex vivo using lung cancer xenograft and genetically engineered mouse models and bladder tumor explants. Through x-ray structure determination and Markov transient and Deuterium exchange analyses, we identified the allosteric binding site and revealed how this compound blocks RSK4 kinase activation through binding to an allosteric site and mimicking a kinase autoinhibitory mechanism involving the RSK4’s hydrophobic motif. Last, we show that patients undergoing chemotherapy and adhering to prophylactic levofloxacin in the large placebo-controlled randomized phase 3 SIGNIFICANT trial had significantly increased (P = 0.048) long-term overall survival times. Hence, we suggest that RSK4 inhibition may represent an effective therapeutic strategy for treating lung and bladder cancer.

First-line therapy for most pediatric sarcoma is based on chemotherapy in combination with radiotherapy and surgery. A significant number of patients experience drug resistance and development of relapsed tumors. Drugs that have the potential to re-sensitize relapsed tumor cells toward chemotherapy treatment are therefore of great clinical interest. Here, we used a drug profiling platform with PDX-derived primary rhabdomyosarcoma cells to screen a large drug library for compounds re-sensitizing relapse tumor cells toward standard chemotherapeutics used in rhabdomyosarcoma therapy. We identified ABT-263 (navitoclax) as most potent compound enhancing general chemosensitivity and used different pharmacologic and genetic approaches in vitro and in vivo to detect the NOXA-BCL-XL/MCL-1 balance to be involved in modulating drug response. Our data therefore suggests that players of the intrinsic mitochondrial apoptotic cascade are major targets for stimulation of response toward first-line therapies in rhabdomyosarcoma.

Rhabdomyosarcoma (RMS) is an aggressive pediatric soft tissue sarcoma, which constitutes of two main histological subtypes. Alveolar Rhabdomyosarcoma (FP-RMS) is characterized by a fusion protein PAX3-FKHR, whereas embryonal Rhabdomyosarcoma (FN-RMS), which is the focus of this project, is more genetically heterogeneous. The prognosis for RMS has improved over the years, however the cure rates for recurrent or relapse disease remains dismal, warranting further identification of novel therapeutic interventions, which is the aim of this project. To this end, we performed two CRISPR knockout screens, using a kinome sgRNA library and a whole genome sgRNA library in combination with etoposide at a concentration of IC10, in order to identify genes that might confer resistance to chemotherapeutic drugs. In addition, the kinome screen was also designed to identify essential genes by using the treatment control samples as further time points. For treatment associated genes, we identified components of the JNK/P38 and Hippo signaling pathways among the top hits. We also found enrichment of a novel pathway involving HIFα stabilization via the genes LRRK2 and PTK6. Further and as expected, many DNA damage repair pathways were enriched. Finally in this category, players of the Wnt signaling pathway including JNK1, which is involved in non-canonical Wnt signaling were found to be enriched. As for essential gene identification, many cell cycle genes such as CDK6, PLK3 and PLK4 were among the top hits, as well as WEE1, which has been implicated in the context of RMS, were common between all the time points. Taken together, the CRISPR screens identified potential pathways that might be involved in resistance of FN-RMS cells towards etoposide. Selected candidates are being validated via an in vitro competition assay and drug screening is being performed to identify inhibitors that could be used to re-sensitize cells to treatment with standard chemotherapy. Citation Format: Devmini C. Moonamale, Marco Wachtel, Beat W. Schäfer. Mechanisms of tumor recurrence and drug resistance in rhabdomyosarcoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3962.