APR-246 overcomes resistance to cisplatin and doxorubicin in ovarian cancer cells

Two main causes of platinum resistance are mutation in the tumor suppressor gene TP53 and drug-induced increase in intracellular glutathione concentration. Mutations in TP53 occur in about 50% of human tumors. APR-246 (PRIMA-1^MET) is the first clinical-stage compound that reactivates mutant p53 and induces apoptosis. APR-246 is a prodrug that is converted to the active compound methylene quinuclidinone (MQ), a Michael acceptor that binds to cysteine residues in mutant p53 and restores its wild-type conformation. Here, we show that MQ also binds to cysteine in glutathione, thus decreasing intracellular free glutathione concentration. We also show that treatment with APR-246 completely restores the cisplatin and doxorubicin sensitivity to p53-mutant drug-resistant ovarian cancer cells. We propose that this unique ability of APR-246/MQ to bind to cysteines in both mutant p53 and glutathione has a key role in the resensitization as well as in the outstanding synergistic effects observed with APR-246 in combination with platinum compounds in ovarian cancer cell lines and primary cancer cells. However, MQ binding to cysteines in other targets, for example, thioredoxin reductase, may contribute as well. Strong synergy was also observed with the DNA-damaging drugs doxorubicin and gemcitabine, while additive effects were found with the taxane docetaxel. Our results provide a strong rationale for the ongoing clinical study with APR-246 in combination with platinum-based therapy in patients with p53-mutant recurrent high-grade serous (HGS) ovarian cancer. More than 96% of these patients carry TP53 mutations. Combined treatment with APR-246 and platinum or other DNA-damaging drugs could allow dramatically improved therapy of a wide range of therapy refractory p53 mutant tumors.APR-246 (also called PRIMA-1^MET) is the first compound in clinical development that reactivates mutant p53 in cancer cells by promoting its correct wild-type (wt) folding, thus triggering apoptosis.^{1, 2} The lead compound of APR-246, PRIMA-1, was originally discovered by Bykov et al.³ APR-246 showed a good safety profile in a Phase I/II clinical dose-finding study on hematological malignancies and prostate cancer and both clinical and p53-dependent biological responses were observed.⁴ A Phase Ib/II Proof of Concept study with APR-246 in combination with platinum-based therapy, in patients with recurrent p53-mutant high-grade serous (HGS) ovarian cancer, is ongoing. More than 96% of patients with HGS ovarian carcinoma carry TP53 mutations.⁵Platinum-based drugs have an important role in the treatment of many solid tumors including ovarian cancer. Cisplatin, the first drug of this class, has had a major impact in treatment of cancer but is also associated with severe adverse effects like nephrotoxicity. This prompted the development of the less toxic analog carboplatin.⁶ The primary mechanism of action of platinum compounds is adduct formation with nucleophilic groups in tumor cell DNA. This triggers the DNA damage response pathway, in which p53 has a key role, leading to cell-cycle arrest, senescence and/or apoptosis.⁷Patients with ovarian cancer often respond well to the first-line platinum-based chemotherapy, but the majority of the patients with advanced stage tumors relapse and eventually die of chemotherapy-refractory disease. Platinum resistance is most often associated with decreased platinum levels at the site of action (i.e., DNA) and/or failure to trigger the DNA damage response after adduct formation.^{6, 7} The underlying molecular mechanisms of resistance to platinum compounds are multifactorial, involving drug-induced increase in cellular glutathione (GSH) levels leading to enhanced efflux of platinum compounds, reduced drug uptake, increased drug inactivation and DNA adduct repair, as well as inactivation of the tumor suppressor protein p53.^{7, 8, 9, 10} Mutation in p53 is one of the main mechanisms for inhibiting propagation of the DNA damage signal to the apoptotic machinery. About 50% of all tumors carry mutant p53 (see p53.free.fr, 2015) and cancer cells with defects in p53 are in general more resistant to conventional chemotherapy. In many tumors, including ovarian cancer, p53 mutations are correlated to shortened time to progression and decreased patient survival time.^{11, 12} Thus, restoration of wt function of p53 is a promising strategy for cancer therapy.^{13, 14}Here, we describe a new aspect of therapeutic activity of APR-246. APR-246 not only reactivates p53 but also decreases intracellular glutathione levels in a dose-dependent manner. Moreover, APR-246 completely restored cisplatin and doxorubicin sensitivity to mutant p53-carrying resistant ovarian cancer cells. Our results may open possibilities for greatly improved treatment of a wide range of platinum-resistant tumors.