Abstract 1632: MDM2 inhibitor alrizomadlin (APG-115) promotes antitumor activity of mitogen-activated protein kinase (MAPK) inhibitors in uveal melanoma

Abstract Uveal melanoma (UM) is the commonest primary intraocular malignancy, yet its molecular pathogenesis is poorly understood. Most UM cases have activating mutations in genes encoding G protein subunits alpha Q or 11, leading to activation of downstream effectors. These include protein kinase C, mitogen-activated protein kinases (MAPK1/3; also termed extracellular signal-regulated kinase 2/1 [ERK2⁄ERK1], respectively), and yes-associated protein, suggesting a rationale for therapeutically targeting these related pathways. Genetic analyses show that TP53 is infrequently mutated in UM, but associated pathways may be functionally inactivated. Ubiquitination-mediated degradation of p53 activates MAPK signaling, such that, active p53 may promote suppression of MAPK signaling. Alrizomadlin (APG-115) is a small molecule targeting p53/MDM2 that is in clinical development for solid and hematologic cancers. This study evaluated the antitumor effect of alrizomadlin, alone or combined with other targeted therapies, in preclinical models of UM. In cell-based antiproliferation assays of many UM cell lines, alrizomadlin exerted moderate growth inhibitory effects (IC50 = 0.151-1.857μM). When combined with inhibitors against mitogen-activated protein kinase kinase (MEK) [trametinib and selumetinib], mammalian target of rapamycin (mTOR) [rapamycin], focal adhesion kinase (FAK) [defactinib and Ascentage’s APG-2449, which targets FAK/ALK/ROS1], and MEK/rapidly accelerated fibrosarcoma [RAF] [VS-6766], alrizomadlin demonstrated enhanced antiproliferative activity. In a UM xenograft model (MP41), alrizomadlin showed dose-dependent antitumor activity when administered at 25, 50, and 100 mg/kg, with tumor growth inhibition (TGI) rates of 24.8%, 38%, and 39.1%, respectively. In this model, synergistic antitumor effects were observed when alrizomadlin was combined with selumetinib or APG-2449, with TGI rates of 65.4% and 47.5%, respectively. Mechanistically, alrizomadlin likely increased p53, MDM2, and downstream p21 in MP41 cells. Importantly, alrizomadlin inhibited ERK phosphorylation and enhanced selumetinib inhibition in a dose- and time-dependent manner. Prior studies indicated that FAK can suppress p53 by enhancing MDM2-dependent p53 ubiquitination. In this study, APG-2449 showed dose-dependent inhibition of FAK phosphorylation and upregulation of p53. Alrizomadlin also inhibited phosphorylation of FAK and downstream ERK. Therefore, the combination of alrizomadlin and APG-2449 was synergistic. Combining MEK and FAK inhibitors also markedly augmented caspase-3 and poly (ADP-ribose) polymerase 1 (PARP-1) cleavage (apoptosis hallmarks) and enhanced observed antitumor effects. In conclusion, our results demonstrate the potential utility of combining alrizomadlin with MAPK pathway inhibitors to treat patients with UM. Citation Format: Guangfeng Wang, Eric Liang, Ping Min, Dajun Yang, Yifan Zhai. MDM2 inhibitor alrizomadlin (APG-115) promotes antitumor activity of mitogen-activated protein kinase (MAPK) inhibitors in uveal melanoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 1632.