Abstract:X-linked Inhibitor of Apoptosis Protein (XIAP), the most potent mammalian caspase inhibitor, has been associated with acquired therapeutic resistance in inflammatory breast cancer (IBC), an aggressive subset of breast cancer with an extremely poor survival rate. The second mitochondria-derived activator of caspases (Smac) protein is a potent antagonist of IAP proteins and the basis for the development of Smac mimetic drugs. Here, we report for the first time that bivalent Smac mimetic Birinapant induces cell death as a single agent in TRAIL-insensitive SUM190 (ErbB2-overexpressing) cells and significantly increases potency of TRAIL-induced apoptosis in TRAILsensitive SUM149 (triple negative, EGFR-activated) cells, two patient tumor-derived IBC models. Birinapant has high binding affinity (nM range) for cIAP1/2 and XIAP. Using isogenic SUM149-and SUM190-derived cells with differential XIAP expression (SUM149 wtXIAP, SUM190 shXIAP) and another bivalent Smac mimetic (GT13402) with high cIAP1/2 but low XIAP binding affinity (Kd >1 µM), we show that XIAP inhibition is necessary for increasing TRAIL potency. In contrast, single agent efficacy of Birinapant is due to pan-IAP antagonism. Birinapant caused rapid cIAP1 degradation, caspase activation, PARP cleavage, and NF-κB activation. A modest increase in TNF-α production was seen in SUM190 cells following Birinapant treatment, but no increase occurred in SUM149 cells. Exogenous TNF-α addition did not increase Birinapant efficacy. Neutralizing antibodies against TNF-α or TNFR1 knockdown did not reverse cell death. However, pan-caspase inhibitor Q-VD-OPh reversed Birinapant-mediated cell death. In addition, Birinapant in combination or as a single agent decreased colony formation and anchorage-independent growth potential of IBC cells. The above manuscript was initially submitted to Breast Cancer Research and Treatment and the authors received the reviews along with the decision of 'could be accepted for publication should you be prepared to incorporate major revisions'.We thank the reviewer for his recommendations that were indeed helpful in revising this manuscript. We have included a detailed author response and revision status of each of the reviewer's comments.In response to the reviewer's concerns, we have undertaken the following experiments: 1.Measurement of clonogenic growth potential as a means of assessing viability effects of the Smac mimetic treatments 2.Annexin-V/7-AAD flow cytometric staining of cells treated with the Smac mimetics as a direct means of evaluating apoptosis 3.An in-depth time course analysis of NF-kB activation in SUM190 cells following treatment with the Smac mimetic 4.Assessment of anchorage independent growth potential as a preliminary predictor of in vivo activity of the Smac mimeticWe sincerely hope that all the reviewers' concerns have been adequately addressed and the manuscript is acceptable for publication in the present revised form.Disclosure Statement: The authors are aware of and agree to the content of the paper and ...