Bradford Graves

Effect of the MDM2 antagonist RG7112 on the P53 pathway in patients with MDM2-amplified, well-differentiated or dedifferentiated liposarcoma: an exploratory proof-of-mechanism study

BACKGROUNDnWe report a proof-of-mechanism study of RG7112, a small-molecule MDM2 antagonist, in patients with chemotherapy-naive primary or relapsed well-differentiated or dedifferentiated MDM2-amplified liposarcoma who were eligible for resection.nnnMETHODSnPatients with well-differentiated or dedifferentiated liposarcoma were enrolled at four centres in France. Patients received up to three 28-day neoadjuvant treatment cycles of RG7112 1440 mg/m(2) per day for 10 days. If a patient progressed at any point after the first cycle, the lesion was resected or, if unresectable, an end-of-study biopsy was done. The primary endpoint was to assess markers of RG7112-dependent MDM2 inhibition and P53 pathway activation (P53, P21, MDM2, Ki-67, macrophage inhibitory cytokine-1 [MIC-1], and apoptosis). All analyses were per protocol. This trial is registered with EudraCT, number 2009-015522-10.nnnRESULTSnBetween June 3, and Dec 14, 2010, 20 patients were enrolled and completed pretreatment and day 8 biopsies. 18 of 20 patients had TP53 wild-type tumours and two carried missense TP53 mutations. 14 of 17 assessed patients had MDM2 gene amplification. Compared with baseline, P53 and P21 concentrations, assessed by immunohistochemistry, had increased by a median of 4·86 times (IQR 4·38-7·97; p=0·0001) and 3·48 times (2·05-4·09; p=0·0001), respectively, at day 8 (give or take 2 days). At the same timepoint, relative MDM2 mRNA expression had increased by a median of 3·03 times (1·23-4·93; p=0·003) that at baseline. The median change from baseline for Ki-67-positive tumour cells was -5·05% (IQR -12·55 to 0·05; p=0·01). Drug exposure correlated with blood concentrations of MIC-1 (p<0·0001) and haematological toxicity. One patient had a confirmed partial response and 14 had stable disease. All patients experienced at least one adverse event, mostly nausea (14 patients), vomiting (11 patients), asthenia (nine patients), diarrhoea (nine patients), and thrombocytopenia (eight patients). There were 12 serious adverse events in eight patients, the most common of which were neutropenia (six patients) and thrombocytopenia (three patients).nnnDISCUSSIONnMDM2 inhibition activates the P53 pathway and decreases cell proliferation in MDM2-amplified liposarcoma. This study suggests that it is feasible to undertake neoadjuvant biopsy-driven biomarker studies in liposarcoma.nnnFUNDINGnF Hoffmann-La Roche.

MDM2 Small-Molecule Antagonist RG7112 Activates p53 Signaling and Regresses Human Tumors in Preclinical Cancer Models

MDM2 negatively regulates p53 stability and many human tumors overproduce MDM2 as a mechanism to restrict p53 function. Thus, inhibitors of p53-MDM2 binding that can reactivate p53 in cancer cells may offer an effective approach for cancer therapy. RG7112 is a potent and selective member of the nutlin family of MDM2 antagonists currently in phase I clinical studies. RG7112 binds MDM2 with high affinity (K(D) ~ 11 nmol/L), blocking its interactions with p53 in vitro. A crystal structure of the RG7112-MDM2 complex revealed that the small molecule binds in the p53 pocket of MDM2, mimicking the interactions of critical p53 amino acid residues. Treatment of cancer cells expressing wild-type p53 with RG7112 activated the p53 pathway, leading to cell-cycle arrest and apoptosis. RG7112 showed potent antitumor activity against a panel of solid tumor cell lines. However, its apoptotic activity varied widely with the best response observed in osteosarcoma cells with MDM2 gene amplification. Interestingly, inhibition of caspase activity did not change the kinetics of p53-induced cell death. Oral administration of RG7112 to human xenograft-bearing mice at nontoxic concentrations caused dose-dependent changes in proliferation/apoptosis biomarkers as well as tumor inhibition and regression. Notably, RG7112 was highly synergistic with androgen deprivation in LNCaP xenograft tumors. Our findings offer a preclinical proof-of-concept that RG7112 is effective in treatment of solid tumors expressing wild-type p53.

Results of the Phase I Trial of RG7112, a Small-Molecule MDM2 Antagonist in Leukemia.

Purpose: RG7112 is a small-molecule MDM2 antagonist. MDM2 is a negative regulator of the tumor suppressor p53 and frequently overexpressed in leukemias. Thus, a phase I study of RG7112 in patients with hematologic malignancies was conducted. Experimental Design: Primary study objectives included determination of the dose and safety profile of RG7112. Secondary objectives included evaluation of pharmacokinetics; pharmacodynamics, such as TP53-mutation status and MDM2 expression; and preliminary clinical activity. Patients were divided into two cohorts: Stratum A [relapsed/refractory acute myeloid leukemia (AML; except acute promyelocytic leukemia), acute lymphoblastic leukemia, and chronic myelogenous leukemia] and Stratum B (relapsed/refractory chronic lymphocytic leukemia/small cell lymphocytic leukemia; CLL/sCLL). Some Stratum A patients were treated at the MTD to assess clinical activity. Results: RG7112 was administered to 116 patients (96 patients in Stratum A and 20 patients in Stratum B). All patients experienced at least 1 adverse event, and 3 dose-limiting toxicities were reported. Pharmacokinetic analysis indicated that twice-daily dosing enhanced daily exposure. Antileukemia activity was observed in the 30 patients with AML assessed at the MTD, including 5 patients who met International Working Group (IWG) criteria for response. Exploratory analysis revealed TP53 mutations in 14% of Stratum A patients and in 40% of Stratum B patients. Two patients with TP53 mutations exhibited clinical activity. p53 target genes were induced only in TP53 wild-type leukemic cells. Baseline expression levels of MDM2 correlated positively with clinical response. Conclusions: RG7112 demonstrated clinical activity against relapsed/refractory AML and CLL/sCLL. MDM2 inhibition resulted in p53 stabilization and transcriptional activation of p53-target genes. We provide proof-of-concept that MDM2 inhibition restores p53 function and generates clinical responses in hematologic malignancies. Clin Cancer Res; 22(4); 868–76. ©2015 AACR.

Small Molecule Inhibitors of p53/MDM2 Interaction

The discovery of the key negative regulator MDM2 (mouse double minute 2, also termed HDM2 for its human equivalent) provided a great opportunity to manipulate the levels of the tumor suppressor p53 in cancer cells. Activation of p53 in tumor cells by inhibiting the interaction of MDM2 with p53 has therefore been the focus of a large effort in drug discovery. The modulation of protein-protein interactions, however, has historically been very difficult to achieve owing to the large surface area of interaction. In this article, we review the recent accomplishments in this area and our quest for a clinically viable MDM2 inhibitor.

Discovery of potent and selective spiroindolinone MDM2 inhibitor, RO8994, for cancer therapy

The field of small-molecule inhibitors of protein-protein interactions is rapidly advancing and the specific area of inhibitors of the p53/MDM2 interaction is a prime example. Several groups have published on this topic and multiple compounds are in various stages of clinical development. Building on the strength of the discovery of RG7112, a Nutlin imidazoline-based compound, and RG7388, a pyrrolidine-based compound, we have developed additional scaffolds that provide opportunities for future development. Here, we report the discovery and optimization of a highly potent and selective series of spiroindolinone small-molecule MDM2 inhibitors, culminating in RO8994.

Optimization of small molecule drugs binding to highly polar target sites: lessons from the discovery and development of neuraminidase inhibitors.

Binding affinity optimization of small molecules interacting with polar binding sites on target proteins is a formidable, but not uncommon challenge in drug discovery. The challenge relates to the difficulty of integrating favourable and unfavourable polar, non-polar and conformation contributions into overall favourable binding energies. This review describes the surprising breakthrough findings leading to the development of Tamiflu, a clinically efficacious orally bioavailable drug targeting the active site of influenza neuraminidase (NA). The NA active site is highly polar and formed mostly by arginine, aspartate and glutamate residues. This active site structure evolved for efficient interaction with charged sialic acid moieties on glycoproteins and stabilization of an oxocarbonium ion in the transition state of the neuraminidase reaction. The initial strategy of optimizing polar interactions in transition state analogs led to NA inhibitors (NAIs) with sub-nanomolar binding affinities, but such compounds were highly polar and lacked oral bioavailability. The realization of the possibility to achieve high affinity binding in a highly polar active site through optimization of non-polar and van-der-Waals interactions initially appeared counterintuitive and required a few serendipitous findings, but was key to reduce the polarity of drug candidates, avoid large desolvation penalties and achieve oral bioavailability.

The Three-Dimensional X-Ray Crystal Structure of HIV-1 Protease Complexed with a Hydroxyethylene Inhibitor

The aspartyl proteinase encoded within the genome of the type I human immunodeficiency virus (HIV-1 PR) is a valid and important target for the development of a therapeutic to treat HIV infections. Progress in this area has been rapid due to 1) the wealth of previous experience with other aspartyl proteinases and 2) the massive commitment by a large number of research groups worldwide. In this chapter we would like to discuss some of our efforts to develop a PR inhibitor by describing the structure of a complex between HIV-1 PR and a hydroxyethylene inhibitor. As a final note before continuing, we would like to acknowledge the significant contributions that Alex Wlodawer and his group have made to this field which have been important to the progress made not only by our group but by many others as well.

Abstract 4727: Antitumor activity of the MDM2 antagonist, RG7112

The p53 tumor suppressor is a transcription factor which plays a central role in prevention of tumor development by inducing cell cycle arrest or apoptosis in response to diverse stresses. In unstressed cells, p53 level is tightly controlled by MDM2 which binds p53 and negatively regulates its activity and stability. MDM2 is overproduced in many human cancers as a mechanism to impair p53 function. Antagonists of p53-MDM2 interaction could reactivate p53 and may offer a novel approach to cancer therapy. The first potent and selective small-molecule inhibitors of p53-MDM2 binding, the Nutlins, provided preclinical proof-of-concept for MDM2 antagonists as a new therapeutic option for patients with tumors expressing wild-type p53. RG7112 is a member of the Nutlin family of MDM2 antagonists with improved potency, selectivity and pharmacological properties which is currently in Ph1 clinical evaluation. Here, we describe its biological activity in models of human cancer in vitro and in vivo. RG7112 binds to MDM2 with high affinity in vitro (KD ∼11 nM) and effectively blocks its interaction with p53. Crystal structures of RG7112-MDM2 complexes revealed that this imidazoline molecule interact with the p53-binding pocket of MDM2 by projecting functional groups that mimic critical amino acid residues from the p53 molecule. Treatment of cancer cells expressing wild-type p53 with RG7112 stabilized p53 and activated the p53 pathway as revealed by the induction of multiple p53-regulated genes. This led to cell cycle arrest in G1 and G2 phases followed by apoptosis. It showed potent antitumor activity in vitro against a panel of solid tumor and leukemia cells expressing wild-type p53 with EC50 in the 0.2 - 2.2 µM range. The overall selectivity between the panels of seven mutant and fifteen wild-type p53 lines, expressed as fold difference in the average EC 50 values was 14-fold. As previously shown with nutlin-3, RG7112 demonstrated variable apoptotic activity in a panel of solid tumor cells with the best apoptotic response in cells with mdm2 gene amplification. Interestingly, inhibition of caspase activity did not change the kinetics of p53-induced cell death. Oral administration of RG7112 to nude mice bearing established human tumor xenografts caused dose-dependent tumor inhibition and tumor regression at non-toxic concentration. The in vivo mode of action was confirmed by pharmacodynamic markers, indicating p53 pathway activation and induction of growth arrest and apoptosis in tumor tissues. Our results showed that RG7112 is a potent p53 activator and antitumor agent in vitro and in vivo that may have therapeutic utility in the treatment of solid tumors and leukemia with wild-type p53. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4727. doi:1538-7445.AM2012-4727

Abstract B55: Antitumor activity of the MDM2 antagonist RG7388.

The p53 tumor suppressor is a transcription factor that inhibits tumor development by inducing cell cycle arrest or apoptosis in response to diverse stresses. In normal cells, p53 levels are tightly controlled by MDM2 which binds p53 and negatively regulates its activity and stability. MDM2 is overproduced in many human cancers, thereby impairing p53 function. Antagonists of p53-MDM2 interaction can reactivate p53 and offer a novel approach to cancer therapy. The first potent and selective small-molecule inhibitors of p53-MDM2 binding, the nutlins, provided preclinical proof-of-concept for MDM2 antagonists as therapeutics for patients with tumors expressing wild-type p53. Subsequently, a member of the nutlin family, RG7112, was the first small molecule inhibitor of MDM2 to be tested clinically. Here we describe, RG7388, a highly optimized agent with analogous mechanism of action representing an entirely new branch of the nutlin family of MDM2 antagonists. Like RG7112, RG7388 binds selectively to the p53 site on the surface of the MDM2 molecule, effectively displacing p53 from MDM2, and leading to p53 stabilization and activation of the p53 pathway. However, RG7388 is derived from a distinct chemical series that binds with higher potency and selectivity to the MDM2 protein. RG7388 has substantially improved pharmacological properties, resulting in superior preclinical efficacy at lower doses and exposures as compared with its predecessor, RG7112. RG7388 elicits growth arrest and apoptosis at approximately 10-fold lower concentrations in vitro and in vivo, has an improved CYP inhibition profile, and a 2.5- to 20-fold lower projected human efficacious dose as compared with RG7112. Tumors with functional p53 signaling and MDM2 over-expression or amplification are likely to be the most sensitive to RG7388, however preclinical studies indicate that tumors with normal MDM2 levels may also respond to this novel therapeutic strategy. Results from preclinical safety and toxicology studies support further exploration of this compound in cancer patients. RG7388 is a promising agent that may offer a new therapeutic option and is currently in clinical testing in both solid and hematologic malignancies. Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B55. Citation Format: Brian Higgins, Christian Tovar, Kelli Glenn, Antje Walz, Zoran Filipovic, Yu-E Zhang, Markus Dangl, Bradford Graves, Lyubomir Vassilev, Kathryn Packman. Antitumor activity of the MDM2 antagonist RG7388. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B55.

Abstract C128: Small-molecule antagonists of MDM2 and MDMX.

The p53 tumor suppressor is controlled by MDM2 and MDMX that negatively modulate its activity. Both proteins possess p53-binding sites within their N-terminal domains and can inhibit the transcriptional activity of p53. However, only MDM2 can serve as E3 ubiquitin ligase for p53 and is thus responsible for its stability. MDMX does not have intrinsic ligase activity but can modulate the ligase activity of MDM2. Many human tumors overproduce MDM2 or MDMX to impair p53 function. Small-molecule MDM2 antagonists, the nutlins, interact specifically with the p53-binding pocket of MDM2 and can release p53 from negative control. Treatment of cancer cells expressing wild-type p53 with nutlins stabilizes p53 and activates the p53 pathway, leading to cell cycle arrest and apoptosis in vitro and in vivo. However, nutlins and other published MDM2 antagonists do not inhibit the p53-MDMX interaction and their effectiveness can be compromised in tumors overexpressing MDMX. We identify the first small molecules that potently block p53 interaction with both MDM2 and MDMX (in vitro IC50 of 17 nM and 24 nM, respectively) by inhibitor-driven homo- and/or hetero-dimerization of MDM2 and MDMX proteins. Structural studies revealed that these idole-hydantoin compounds bind into and occlude p53 pockets of MDM2 and/or MDMX by inducing the formation of dimeric protein complexes kept together by a dimeric small-molecule core. This novel mode of inhibiting protein-protein interactions effectively stabilized p53 and activated p53 signaling in cancer cells, leading to cell cycle arrest and apoptosis. MDM2/MDMX antagonist, RO-5963, restored p53 apoptotic activity in cultured osteosarcoma cells in the presence of high levels of MDMX. RO-5963 showed a significantly better apoptotic activity against MCF7 and other solid tumor cell lines with higher MDMX levels than the MDM2-specific inhibitor, nutlin-3a, suggesting that dual antagonists may offer a more effective therapeutic modality for MDMX-overexpressing cancers. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2011 Nov 12-16; San Francisco, CA. Philadelphia (PA): AACR; Mol Cancer Ther 2011;10(11 Suppl):Abstract nr C128.