Sarkaria, Jann N.

Abstract Purpose: Navtemadlin is a potent small-molecule inhibitor of MDM2, which has completed a phase 0 window-of-opportunity study in glioblastoma (GBM). To optimally interpret the clinical data, a detailed analysis of navtemadlin pharmacokinetics (PK), pharmacodynamics, and efficacy was performed in GBM patient-derived xenografts (PDX). Experimental Design: Response to navtemadlin was characterized in vitro and in vivo in GBM PDXs with and without MDM2 amplification. Efficacy in vivo was integrated with measured plasma and intra-tumoral drug levels to develop a translational PK/efficacy model comparing exposure effective in PDX to exposure achieved in phase 0 patient samples. Results: In vitro, navtemadlin showed robust on-target activity in TP53–wild-type GBM. In vivo efficacy strongly correlated with MDM2 amplification status. In subcutaneous PDXs, navtemadlin significantly extended survival when dosed at 25 mg/kg in an MDM2-amplified PDX compared with 100 mg/kg in a non-amplified PDX. Central nervous system distribution was limited by blood–brain barrier efflux (Kp_brain = 0.009). In an MDM2-amplified orthotopic PDX model, navtemadlin was ineffective at 100 mg/kg; when established in mice with deficient blood–brain barrier efflux (Rag−/−Abcb1a−/−Abcg2−/−), 25 mg/kg doubled survival. A tumor PK/efficacy model was built to define target exposure for efficacy in GBM, using the effective 25 mg/kg dose. Modeled exposures exceeded this threshold in three (of 16) tumor samples from phase 0 study patients at the 240 mg dose level. Conclusions: Navtemadlin efficacy was highly dependent on adequate brain penetration. Our translational PK/efficacy model suggests that the minimum effective tumor exposures were achieved only in a minority of patients with GBM.

Abstract Background Dasatinib is an oral inhibitor of the Src kinase family, with preclinical data indicating impact on gliomagenesis, tumor invasion, and radiosensitivity. Methods North Central Cancer Treatment Group N0877 is a phase 1 dose escalation and phase II randomized study evaluating the maximum tolerated dose (MTD), safety, and efficacy of dasatinib with radiation and temozolomide (TMZ) for glioblastoma. Following identification of the MTD, adult patients with a histologic diagnosis of glioblastoma were randomized 2:1 between dasatinib given with standard concurrent and adjuvant TMZ, versus placebo with standard concurrent and adjuvant TMZ. Radiation dose was 60 Gy in 30 fractions. The primary endpoint was overall survival (OS). Secondary endpoints included progression-free survival (PFS), toxicity, and quality of life. Results Thirteen patients were enrolled in the phase I component and established the MTD and phase II dose of 150 mg given daily. A total of 204 patients were enrolled in the phase II component. OS was not different between arms (median OS 15.6 months for dasatinib compared to 19.3 months for placebo, hazard ratio:1.21 favoring placebo, 95% CI: 0.88–1.65, log-rank P-value: .238). Similarly, PFS was not significantly different between the dasatinib and placebo arms. There was a significant increase in anemia, nausea, and creatinine elevation with dasatinib, but significantly more grade 3 lymphopenia with placebo. Conclusions The addition of dasatinib to standard chemoradiation did not improve outcomes for patients with glioblastoma. Clinical Trial Identifier NCT00869401.

Abstract Glioblastoma (GBM) remains the most common and lethal adult malignant primary brain cancer with few treatment options. A significant issue hindering GBM therapeutic development is intratumor heterogeneity. GBM tumors contain neoplastic cells within a spectrum of different transcriptional states. Identifying effective therapeutics requires a platform that predicts the differential sensitivity and resistance of these states to various treatments. Here, we developed a novel framework, ISOSCELES ( I nferred cell S ensitivity O perating on the integration of S ingle- C ell E xpression and L 1000 E xpression S ignatures), to quantify the cellular drug sensitivity and resistance landscape. Using single-cell RNA sequencing of newly diagnosed and recurrent GBM tumors, we identified compounds from the LINCS L1000 database with transcriptional response signatures selectively discordant with distinct GBM cell states. We validated the significance of these findings in vitro, ex vivo, and in vivo , and identified a novel combination of an OLIG2 inhibitor and Depatux-M for GBM. Our studies suggest that ISOSCELES identifies cell states sensitive and resistant to targeted therapies in GBM and that it can be applied to identify new synergistic combinations. Highlights Integration of GBM single-cell RNA sequencing data with L1000-derived drug response signatures facilitates clustering of tumor cells and small molecules on cell-drug connectivity. Cell-drug connectivity predicts the identities of drug-sensitive and resistant cell states. In silico perturbation analysis using cell-drug connectivity predicts drug-induced changes in the cell-drug connectivity landscape in vivo. In silico perturbation analysis to predict drug-induced changes in the tumor cell-drug connectivity landscape predicts drug combinations that synergize in vivo to extend survival.

Abstract Glioblastoma Multiforme (GBM) is a highly aggressive malignant brain tumor. Despite decades of research, the tumor is essentially incurable, primarily due to the failure of small molecule drugs to pass the blood-brain barrier (BBB). This molecular "pump" within the brain's blood vessel linings restricts effective drug delivery to the tumor. To address this challenge, we have developed an antibody targeted nanoparticle therapeutic platform, NV103. NV103 employs liposomal nanoparticles with tumor antigen targeted antibodies specifically engineered to deliver otherwise ineffective drugs like irinotecan directly to tumor. GBMs are heterogeneous, characterized by diverse genomic profiles and tumor antigen expression patterns. EGFR is a well-known example. Here we identified a novel GBM tumor antigen, CD99. CD99 is not a commonly recognized GBM biomarker, but we find that GBMs consistently express CD99. We evaluated nearly 100 GBM PDXs in the Mayo Clinic repository and found that nearly all express CD99. We then evaluated NV103's efficacy across multiple GBM tumors with varying levels of CD99 cell surface expression. Importantly, NV103 demonstrated exceptional BBB penetration in an in vitro transwell system utilizing brain endothelial cells derived from human stem cells. NV103 also exhibits prolonged plasma persistence with detectable levels present at 24 hours, compared to free drug which is undetectable within hours. This prolonged drug availability combined with the ability to penetrate the BBB and preferentially bind to tumor cells results in dramatically enhanced anti-GBM activity. In GBM mouse studies, NV103 and its payload exhibited at least 5-fold enhanced delivery to tumor vs. brain. In preclinical animal studies, NV103 extended the survival of orthotopically implanted human PDX glioblastoma (GBMPDX43)-bearing mice by at least three-fold compared to free-drug treatments. We also showed that NV103 effectively induces cytotoxicity across a broad spectrum of CD99-expressing GBMs. NV103 showed significantly enhanced anti-tumor activity, even in low CD99-expressing tumors, such as GBMPDX43. Moreover, dose-response trends in GBM-bearing animals suggest that escalating doses of CD99-targeted nanoparticles could further improve survival outcomes. This targeted approach minimizes drug exposure to normal tissues, including brain. We found no dose limiting toxicity at 50mg/kg, five times higher than the 10mg/kg used for most of the tumor bearing animal studies. These findings underscore NV103's potential to effectively target heterogeneous GBMs, including those with variable CD99 expression levels, not unlike HER2-low tumors treated with HER2-directed ADCs. Further, preclinical data suggest that NV103 dose escalation will amplify its therapeutic impact, positioning this platform as a potential groundbreaking approach to overcome treatment resistant GBM. Citation Format: HyungGyoo Kang, Bryon Upton, Jon Nagy, Jann N. Sarkaria, Timothy J. Triche. Enhancing GBM therapy with tumor-targeted nanoparticles [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_2):Abstract nr LB183.

Temozolomide (TMZ) is the main chemotherapy for GBM, but resistance develops in most patients, highlighting the need for sensitizing strategies. PARP inhibitors (PARPi), which disrupt DNA repair, are being investigated as TMZ-sensitizing agents. Here we evaluated the efficacy and explored molecular mechanisms of pamiparib-mediated TMZ sensitization. In vitro, low concentrations of pamiparib (0.1-1.0 μM) synergized with TMZ and enhanced DNA damage, particularly during the S- and G2/M phases. In vivo, pamiparib monotherapy (0.75 or 3 mg/kg, twice daily) was ineffective, however, TMZ afforded survival benefit in orthotopic patient-derived xenograft (PDX) models (GBM12, GBM22, and GBM84) of MGMT-methylated primary GBM. Pamiparib combined with TMZ (25 or 50 mg/kg daily) prolonged survival in GBM12 [median survival 272 vs. 114 days with TMZ (P=0.02), 30 days with placebo (P<0.001)] and GBM22 (median survival 88 vs. 60 days with TMZ (P=0.05), 26 days with placebo, (P<0.001)] but not in GBM84 [median survival 355 vs. 404 days with TMZ (P=0.44), 37 days with placebo (P<0.001)]. These findings align with prior studies indicating that PARPi can potentiate TMZ efficacy in a subset of primary GBM models sensitive to TMZ. TMZ induces cytotoxic DNA adducts, N7MeG, N3MeA, and O6MeG. While N7MeG and N3MeA are repaired by base-excision repair (BER), MGMT removes O6MeG. Suppressed MGMT expression, due to promoter methylation, drives TMZ sensitivity in ∼40% of primary GBM cases. In MGMT-methylated tumors, O6MeG-thymine mispairs trigger futile mismatch repair, causing replication stress. Although BER is PARP-dependent, BER inhibition did not replicate the TMZ-sensitizing effects of pamiparib. Beyond DNA repair, PARP regulates replication stress by recruiting translocases like SMARCAL1 and controlling endonucleases such as MRE11 and EXO1, protecting stressed forks and nascent DNA. We targeted these components using siRNA and small-molecule inhibitors to elucidate their roles in TMZ sensitization. Unexpectedly, silencing SMARCAL1 or MRE11, or inhibiting MRE11 with mirin, did not affect pamiparib-mediated sensitization in U251 cells. While EXO1 silencing attenuated DNA damage signaling, it had minimal impact on TMZ sensitivity or pamiparib-mediated sensitization. These results suggest that fork protection mechanisms may be epistatic to PARP but redundant for TMZ sensitivity. Alternatively, replication stress may be mitigated by lesion bypass via translesion synthesis (TLS), where replicative polymerases are replaced with low-fidelity polymerases. Consistent with this, silencing RAD18, involved in TLS, enhanced sensitivity to both TMZ and pamiparib, with the combination being more effective than either drug alone. In conclusion, pamiparib enhances TMZ efficacy in a subset of primary GBM. While further in vivo validation is needed, TLS deficiency may be a key determinant of pamiparib-mediated sensitization. Citation Format: Shiv K. Gupta, Ann C. Mladek, Sonia Jain, Katrina K. Bakken, Zeng HU, Brett L. Carlson, Danielle M. Burgenske, Jann N. Sarkaria. Pamiparib-induced replication stress augments the efficacy of temozolomide in GBM PDX models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 1 (Regular Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_1):Abstract nr 2910.

Total body irradiation for bone marrow transplantation (BMT) conditioning is commonly used in immunologic research. Historically, cesium-137 (137Cs) irradiators were predominantly used as a radiation source for these studies. However, 137Cs has a moderate half-life (30 years), is highly water soluble, and poses significant environmental and radiological safety concerns. As a result, the Department of Energy is promoting the replacement of 137Cs irradiation systems with orthovoltage x-ray cabinet systems, which pose no such concerns. Because the physical characteristics of x-ray and 137Cs photon beams have slightly different energy deposition characteristics, the relatively biological effectiveness (RBE) for x-rays is slightly higher than 137Cs in cell survival studies. This study aims to compare the RBE of orthovoltage and 137Cs irradiators with regards to BMT efficiency. Total body irradiation was performed on C57BL6 mice using 137Cs or 320 kVp x-rays across six dose levels to establish a RBE for lethality. Cohorts of five mice were irradiated using split-dose radiation delivered four hours apart. Daily observations and body weights were captured over a 30-day period. Mice with poor body condition scores or weight loss ≥20% were euthanized. With x-rays, 50% lethality was observed ∼750 cGy while 137Cs required ∼850 cGy, which results in an RBE of 750 cGy/850 cGy = 0.88. Bone marrow ablation and subsequent engraftment efficacy was compared in a parallel study. Cohorts of five C57BL6 CD45.1 recipient mice received total body irradiation with an established single dose 1000 cGy 137Cs regimen or a range of x-ray doses (910-1030 cGy single-dose) and then were infused with CD45.2 donor bone marrow. Ten weeks after BMT, bone marrow, spleen, thymus, and peripheral blood were analyzed via multi-color flow cytometry and the percentage of CD45.1 and CD45.2-positive cells were analyzed to determine marrow engraftment efficiency across various immune compartments. A clear dose-response relationship with bone marrow ablation and engraftment was observed in the stem cell and progenitor compartments. LSK (Lineage- Sca-1+ c-Kit+) cells and other hematopoietic progenitors in the bone marrow were efficiently engrafted (>99%) except for the lowest dose of 910 cGy (around 98%). Similarly, in the spleen, B cells, myeloid, megakaryocyte/erythrocyte, and granulocyte/macrophage lineages were also efficiently engrafted similar to that of 137Cs. Developing thymocytes were efficiently replaced by all radiation regimens, while replacement of peripheral T cell populations varied but were similar to traditional 137Cs at the highest doses. Taken together, these data demonstrate comparable BMT efficiencies with orthovoltage irradiation after appropriate dose-optimization. Citation Format: Danielle M. Burgenske, Brett L. Carlson, Matthew J. Rajcula, Michael J. Shapiro, Virginia M. Shapiro, Jann N. Sarkaria. An in vivo comparison of 137Cs and orthovoltage irradiation for murine bone marrow transplantation [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 1 (Regular Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_1):Abstract nr 4684.

Abstract Background and Objective: Glioblastoma (GBM) is most common primary brain tumor with dire need of novel therapeutics. Studies with intracranial tumors are required for robust characterization and development of novel drugs for brain cancer. Tumor harvest and processing is an important aspect to study pharmacokinetics, pharmacodynamics, drug delivery, and tumor evolution. Typically, delineating and dissecting tumor from surrounding brain for varied downstream processes is dependent on the distinct morphology of the tumor and/or expression of fluorescent marker. However, genetic modification of the tumor cells for the expression of fluorescent protein is not always possible, especially for patient-derived xenograft (PDX) tumor models. Thus, we have developed a dye-based staining method to confidently visualize tumor in the brain and assessed usability of isolated tumors for drug and DNA analysis. Methodology: Whole brains were harvested from mice with intracranial Mayo GBM PDX tumors and stored at -80oC freezer. Few days prior to staining, brains were transferred to -20oC freezer. Brain was cut into 1 mm thick coronal sections and transferred onto glass slides. Slices were covered with toluidine blue (TB) solution (0.05 to 10 mg/mL) for 45 s. Excess stain solution was removed, and slices were observed under white light. Regions of tumor became more transparent, while normal brain remained opaque. This enabled dissection of tumor from normal brain for downstream analyses. Results: TB concentration (0.05 to 10 mg/mL) was optimized to stain 1 mm thick sections of fresh frozen brain, and the best contrast between tumor to normal brain was observed at 0.1-0.3 mg/mL. TB aided differential visualization of tumors in several PDX models - GBM12, GBM43, GBM39 and GBM108 - suggesting broad applicability. To evaluate the accuracy of TB staining, brain with PDX tumor transduced with pSINeGFP/fLuc2 was observed by both TB staining and eGFP fluorescence. This analysis demonstrated excellent concordance across 6 animals with three distinct PDX models. Genomic DNA was isolated from tumor dissected under TB guidance and analyzed by PCR for primers specific for murine vs human PTGER2. 50-70% of the DNA in tumor samples was detected to be of human origin while normal brain tissue had 90-95% of the mouse DNA highlighting the specificity of TB stain for tumor detection. Tumors from drug treated GBM108 PDX were isolated under TB guidance and comparable drug levels were detected by LC-MS/MS as analyzed in GFP-assisted tumor samples. Conclusion: Staining fresh frozen thick brain sections with toluidine blue enables visualization of tumor from normal brain regions that is compatible with varied downstream processes. Development of such staining assays can help faster and easier tumor processing and is not dependent on genetic modification of tumor cells prior to experimentation. Citation Format: Sonia Jain, Anders Herfindahl-Quint, Caroline D. Doherty, Wenjuan Zhang, Danielle M. Burgenske, Jann N. Sarkaria. Novel staining method for visualization, isolation and processing of intracranial brain tumors [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2025; Part 1 (Regular Abstracts); 2025 Apr 25-30; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2025;85(8_Suppl_1):Abstract nr 2531.

Abstract Background The ataxia-telangiectasia mutated (ATM) protein coordinates the cellular response to therapeutic radiation, and ATM inhibitors can potentially enhance the efficacy of radiation in otherwise radiation-resistant tumors. Methods The small molecule ATM kinase inhibitor WSD0628 was specifically designed for enhanced distribution across the blood-brain barrier to more effectively treat glioblastoma (GBM) and brain metastases in combination with radiation therapy (RT). GBM and brain metastasis patient-derived xenograft models were used to understand target inhibition, radiosensitization, inhibition of the DNA damage response, and in vivo efficacy. Results Initial in vitro characterization of WSD0628 demonstrates a high level of selectivity across kinase families, limited aldehyde oxidase liability, and low risk of hERG interactions. Consistent with a central role for ATM in radiation response, WSD0628 blocked radiation-induced signaling and enhanced radiosensitivity in U251 glioma cells and brain tumor PDXs GBM120 and M12. In comparison to control or RT alone in orthotopic PDXs, the combination of WSD0628 with RT markedly prolonged median survival—GBM12 (19, 55, and 408 days, respectively); GBM43 (26, 44, and 143 days, respectively); GBM120 (51, 89, and 231 days, respectively); M12 (17, 39, and 190 days, respectively). Pharmacokinetic and pharmacodynamic testing after treatment in orthotopic GBM43 tumors showed inhibitory levels of WSD0628 and a reduction of γH2AX foci in the combination-treated tumors. Conclusions Collectively, these results suggest a promising role for WSD0628 in combination with RT in brain tumors and provide the rationale for an ongoing Phase 0/1A clinical trial testing this combination in recurrent GBM.

Abstract Background Most oncology therapeutics have limited distribution into the brain, and developing strategies to overcome this limitation would be clinically impactful. While therapeutic radiation is often cited as a strategy to accomplish this, there are no published studies demonstrating the effect of radiation on drug distribution into the brain or brain tumors. Methods Mice were treated with brain radiation (6 Gy × 5, 4 Gy × 10; 40 Gy × 1) and dosed with drugs (levetiracetam, cefazolin, nedisertib, brigimadlin, apitolisib, or GNE-317) at times ranging from just prior to months after radiation. Plasma and tissue drug concentrations were measured by LC-MS/MS. Results Radiation did not significantly enhance drug delivery into brain tissue for levetiracetam, cefazolin, GNE-317, apitolisib, or nedisertib at any time post-radiation. Even a single, supra-therapeutic dose of radiation (40 Gy) did not significantly affect brain distribution of GNE-317 or apitolisib (P ≥ .07) from 16 to 160 hours post-radiation. For brigimadlin, radiation (6 Gy × 5) was associated with a modest but significant increase in drug accumulation only at 72 hours post-radiation (brain-to-plasma ratio 0.014 ± 0.006 vs. 0.025 ± 0.010, respectively; P = .04), but not at any other timepoint (24 hours, 15, 28, 94, 133, 183 days; P > .05). Similarly, radiation (6 Gy × 5) of orthotopic tumors did not increase levels of brigimadlin in GBM10 or GBM108 or nedisertib in GBM108 (P > .05). Conclusions Radiation had no meaningful impact on drug delivery into brain or brain tumors for the drugs tested.