Background
Breast cancer is a heterogeneous disease, characterized by different clinical outcomes and response to therapy depending on the molecular subtypes [
1]. Triple negative breast cancer (TNBC) accounting for about 10% to 15% of all breast cancers, is characterized by an aggressive phenotype, high genomic instability, tendency to develop metastases [
2,
3] and chemoresistance [
4‐
7]. Taxanes-based chemotherapy is still the standard of care for the majority of early and advanced TNBCs but clinical outcome is still poor compared to other subtypes, with high risk of relapse relapse and poor survival in the metastatic setting [
8]. There is, therefore, an urgent need to identify new molecular targeted treatments for TNBC.
The PI3K/AKT/mTOR pathway plays a major role in human cancers, being involved in the regulation of critical processes such as cell cycle, proliferation, metastatic progression and resistance to antitumor treatments [
9,
10]. This pathway comprises a family of intracellular signal transducer enzymes with three key regulatory nodes: PI3K, AKT and mammalian target of rapamycin (mTOR) [
1,
11]. PI3K/AKT/mTOR hyperactivation is common finding in cancer, and somatic mutations in PIK3CA/AKT/mTOR axis, like gain-of-function mutations of
PIK3CA gene and loss/low expression of the regulatory molecule PTEN, have been identified as responsible of resistance to conventional therapeutical regimens in different tumours, including breast cancer [
12]. Thus, several agents acting on the PI3K/AKT/mTOR pathway, have been developed and tested in clinical trials in combination with standard therapies [
8,
13]. Taselisib, a selective inhibitor of mutant PI3K, and ipatasertib, a selective ATP-competitive pan-Akt inhibitor, have been studied in clinical trials in combination with endocrine agents (NCT02340221, NCT02273973, NCT01296555) or taxanes (NCT02301988, NCT01862081, NCT02162719, NCT03337724), showing conflicting results in patients harboring PI3K/AKT/PTEN-altered tumours [
14‐
18]. Several evidences have showed that common PI3K-AKT/mTOR inhibitors could induce autophagy in different preclinical models, promoting the escape from their antitumor effect. Mechanistically this effect is mediated by the inhibition of mTOR complex 1 (mTORC1)- including mTOR, RAPTOR, PRAS40, DEPTOR, mLST8, Tti1 and Tel2 proteins- that represent the main negative regulator of autophagy induction [
19‐
24].
Autophagy is a complex catabolic process in which cells destroy defective cellular components and recycle their constituting elements to sustain cellular metabolism [
25]. The role of autophagy in cancers is controversial as it seems to promote both anti-tumour or pro-tumour pathways, depending on tumor types and stages [
26‐
30]. For example during early carcinogenesis, autophagy might exert an antitumor effect by preventing the genomic instability due to accumulation of damaged proteins and organelles [
31‐
33]. However, during tumour progression, autophagy is able to increase stress tolerance, drug-resistance and tumor cell survival in hostile conditions [
34].
Indeed, aggressive tumours, like TNBC, show higher level of autophagy to better tolerate cellular stress occurring during the metastatic process [
8,
35]. Therefore, autophagy inhibitors like chloroquine (CQ) and hydroxychloroquine (HCQ) have been largely tested as antitumor agents in preclinical studies, and are currently in development in clinical trials for different cancer types, alone or in combination with standard therapies [
36,
37].
The aim of this study was to evaluate the antitumor activity of PI3K or AKT inhibitors plus CQ, in order to prevent authophagy -mediated mechanism of resistance, in combination with taxanes. In details, we showed that, both ipatasertib and taselisib, can induce autophagy in several breast cancer cell lines, characterized by different genetic background, including variable expression of ER/HER2 receptors or mutations of PI3K/AKT pathway. This effect was particularly evident in TNBC where we observed strong potentiation of antitumor activity by combining PI3K/AKT pathway inhibitors plus CQ, and more importantly, where a clear synergistic antitumor effect was observed both in vitro and in vivo in triple combination with paclitaxel.
Methods
Cell cultures
Human breast cancer cells MDAMB231, MDAMB468, MCF-7, SKBR3 and MDAMB361 were purchased from American Type Culture Collection (Rockville, MD, USA). All cell lines were genotyped to confirm their origin. MDAMB231, MCF7 and SKBR3 cells were maintained in DMEM high glucose (Lonza) complemented with 10% fetal bovine serum (FBS; Lonza). MDAMB468 and MDAMB361 were maintained in DMEM-F12 complemented with 10% FBS. All media were supplemented with 10000 U/ml penicillin and 10 mg/ml streptomycin (Lonza) and 4 mM L-glutamine in a humidified atmosphere composed of 95% air and 5% CO2 at 37 °C. Cell lines were regularly inspected for mycoplasma.
Drugs and Reagents
Paclitaxel was purchased from Selleck Chemicals (Selleckchem, Houston, TX, USA) and Chloroquine diphosphate salt from Sigma Aldrich. Taselisib (GDC0032) and ipatasertib (GDC-0068) were supplied by Genentech (Research proposal nr. OR-215703). They were dissolved in sterile dimethylsulfoxide (DMSO) and a 500 mM and 100 mM stock solutions, respectively, were prepared and stored in aliquots at −20 °C. Working concentrations were diluted in appropriate medium.
Cell proliferation assay and drugs combination studies
Cell proliferation was measured in 96-well plates in cells untreated and treated with ipatasertib, taselisib, paclitaxel and CQ as single agent or in combination. Cell proliferation was measured using a spectrophotometric dye incorporation assay Sulforhodamine B [
38] after 48 or 72 h of treatment. IC50 were determined by interpolation from dose-response curves.
Clonogenic assay
Single cell suspensions were plated at 50–100 cells/well in 12 wells plate. After 24 h, the cells were treated with single or combinations of drugs, daily for 10 days. Colonies were visualized by incubation with 0.5% crystal violet dissolved in 20% methanol for 30 min, and photographed. Then, colonies were dissolved in 100% methanol and quantified by spectrophotometry.
Spheroids were cultured as described before [
39] in appropriate Sphere Medium. The cells (40,000 cells/ml) were plated in low attachment multiwell plates and treated with indicated drugs. Spheroids have been treated as reported in figures. Spheroids were scored with CellTiter- Glo
® 3D Cell Viability Assay (Promega, Madison, WI, USA).
Protein extraction and Western blotting
Cells, grown and treated as indicated in results, were washed once with ice-cold PBS and centrifuged. The cell pellet was lysed by Nonidet P40 plus protease inhibitors (Thermo Fisher Scientific, Waltham, MA USA) and clarified by centrifugation. Equal amount of protein, monitored by Bradford assay, was separated on 8–10% Sodium Dodecyl Phosphate (SDS) polyacrylamide gel electrophoresis (PAGE) Enhanced chemiluminescence (ECL) immunodetection reagents were from GE Healthcare. Image Quant LAS 500, and ImageQuantTL image software (GE Healthcare) were used to detect chemiluminescence and quantify signal, respectevely. Image J was used to quantify protein bands from western blot images. The quantification reflects the relative amounts as a ratio of each protein band relative to loading control (β-actin). The following antibodies were used: polyclonal LC3B Antibody #2775 (1:1000) Cell Signaling, polyclonal anti PARP#9532S (1:1000) Cell Signaling, polyclonal anti p62/SQSTM1 #J PM045 MBL international (1:1000), polyclonal anti ATG5 PM050 MBL International (1:1000), monoclonal Anti-β-Actin A5316 (1:1000) Sigma Aldrich.
Immunofluorescence assay
Cells, plated on slides in 24-wells plate at 25000-50000 cells/well, were treated with drugs as indicated in figure legends. Then cells were fixed in 4% paraformaldehyde (20 min at RT), blocked by 0.2% PBS/BSA solution (1h at RT) and incubated with primary (1:100) anti-LC3 or anti-p62/SQSTM1 antibodies overnigh at 4°. After washes, cells were incubated with (1:200) anti-rabbit Alexa Fluor-488 or Alexa Fluor-594 for 1h at RT, mounted on slide holder using mountant medium (Life technologies, Gaitherburg, MD, USA). Confocal images were obtained using Zeiss inverted 700 confocal laser scanning microscopy and a ×63 oil immersion objective.
Flow cytometry analysis of apoptosis
Cells were treated with the drug combinations as indicated in relative legends. Apoptosis was measured after staining with annexin V-fluorescein isothiocyanate (annexin V-FITC). Annexin positive cells were quantified with FACS calibur flow cytometer (Becton Dickinson), analysed using CellQuestPro software (Becton Dickinson). Data were acquired after analysis of at least 10,000 events [
40].
Flow cytometry analysis of cell cycle
Analysis of cell cycle kinetic was performed after treatment as indicated in the relative legend. Briefly, cells were fixed in 70% ethanol, stained with propidium iodide and evaluated by a FACScalibur flow cytometer (Becton Dickinson). For each sample, 20,000 events were collected. Cell cycle analysis was performed with ModFit LT software (Verity Software House, Inc., Topsham, ME). FL2 area versus FL2 width gating was done to exclude doublets from the G2-M region.
In vivo experiments
Female NOD/SCID athymic mice (Charles River, Wilmington, MA, USA) were acclimatized in the Animal Care Facility of “Fondazione G.Pascale-IRCCS-CROM Laboratories, in accordance with ”Directive 2010/63/EU on the protection of animals used for scientific purpose” and made effective in Italy by the legislative DLGS 26/2014. The study was approved by the Italian Ministry of Health. MDAMB231 cells (7 × 10
6) diluted in 200 μl [PBS/Matrigel GF (Becton Dickinson) 1/1] were injected subcutaneously (s.c) in the flank regions of the mice. After tumors reached approximately 100 mm
3, mice were randomized into treatment arms with 5–7 tumors per group. Taselisib (5 mg/kg) was dissolved in a vehicle containing 0.5% methylcellulose with 0.2% TWEEN-80 and was administered via daily oral gavage [
41]. Paclitaxel were diluted in physiological solution and administrated intraperitoneally (i.p.) weekly. CQ were dissolved in physiological solution and administered daily via oral gavage. In particular, taselisib 5 mg/kg was administrated x os/daily (5 days/week) by gavage, CQ (30 mg/kg) was administrated x os/daily (5 days/week) by gavage and paclitaxel 10mg/Kg was administrated once a week intraperitoneally (IP). Treatment lasted 2 weeks followed by 1 week of follow-up.
Mice in the control groups were treated with relative vehicles via daily oral gavage and weekly IP. Tumor volume (TV) (mm3), Tumor growth delay (TGD) and the percent change in the experimental groups was compared with that of the vehicle control groups as described before [
42]. Tumor incidence curves to analyze tumor engraftment (first appearance of a palpable mass) was performed taking advantage of Kaplan-Meier approach. Tumor size was measured twice a week and calculated as: ½ × width2 × length. Animals were monitored for abnormal tissue growth and euthanized if excessive health deterioration was observed.
Plasmid transfection
MDAMB231 cells were plated on slides in 24-wells plate at 25000 cells/well. Then they were transfected with EGFP-LC3 plasmid using Lipofectamine 2000 Reagents (Invitrogen, Carlsbad, CA, USA), according to the manufacturers recommendation [
43]. 12h after the transfection, cells were treated with ipatasertib, taselisib or CQ at concentrations and time indicating in the relative legend and processed for immunofluorescent experiments as described before. EGFP-LC3 plasmid was purchased by Addgene plasmid #11546 (
http://n2t.net/addgene:11546; RRID: Addgene_11546).
Statistical analysis
All experiments were performed at least three times. Statistical significance was determined by the one-way ANOVA, Tukey’s multiple comparison test, Dunn’s multiple comparisons test and Log Rank test; a p<0.05 was considered to be statistically significant and the specific values are reported or indicated in legends to figures as *, p< 0.05; **, p< 0.01; ***, p< 0.001. All statistical evaluations were performed with GraphPad Prism 8.
Discussion
TNBC have a very poor clinical outcome and taxanes-based chemotherapy still represent the main standard of care option for this disease. Only recently the checkpoint inhibitor atezolizumab was approved, in combination with nab-paclitaxel in the treatment of PD-L1+ metastatic TNBC patients [
56]. PI3K/AKT/mTOR pathway is frequently activated in TNBC, through gain of function mutation of PI3KCA and of loss of function of PTEN [
8,
57], and, therefore, the pharmacological inhibition of PI3K/AKT pathway can, in theory, represent a successful treatment strategy in these tumours [
58]. In agreement with this hypothesis, in a phase II trial, the TBCRC 032 IB/II trial, taselisib combined with enzalutamide, increased clinical benefit of AR+ TNBC patients [
17]. Furthermore, two randomized phase II studies, namely, the Lotus trial [
16] and the PAKT trial [
59] have showed that adding an AKT inhibitor, ipatasertib or capivasertib, respectively, to paclitaxel, improves progression free survival (PFS) in TNBC patients harbouring activating mutations of PI3K/AKT1/PTEN axis. However, these promising results have not been confirmed in phase III trials [
18]. A possible explanation of these conflicting results is that the efficacy of PI3K/AKT inhibitors may be limited by the autoinduction of autophagy, which, in turn, may mediate the development of resistance [
25]. Based on this, we speculated that the pharmacological inhibition of autophagy, obtained with CQ administration, could potentiate antitumor effects of ipatasertib/taselisib in combination with conventional chemotherapy. We investigated this hypothesis in breast cancer models characterized by different ER+ HER2+ receptors profile and mutations of PI3KCA/PTEN or KRAS/B-RAF.
Sensitivity to both ipatasertib and taselisib was more evident in HER2+ cell lines and in PI3KCA mutated cell lines, thus confirming previous preclinical studies [
48,
56,
60‐
62], while TNBC cell lines resulted, overall, less sensitive to both drugs, in keeping with previous findings that TNBC tumours are associated with resistance to PI3K/AKT inhibitors [
13]. However, as expected, this effect was less evident in PTEN-null and EGFR overexpressing MDAMB468 cell line, compared to KRAS/BRAF-mutated MDAMB231 [
46,
47]. These results are consistent with the results of phase Ib clinical trial NCT01791478 showing that a small number of patients (~10%) with KRAS mutations do not derive clinical benefit by alpelisib, an α-selective PI3K inhibitor, in combination with letrozole in ER+/HER2- metastatic breast cancer [
62], and of Poseidon phase 1b trial [
45], in which mutations of KRAS in circulating tumor (ct) DNA identified patients with clinical resistance to taselisib [
63].
In agreement with our hypothesis, we observed that the antitumor effect of both ipatasertib and taselisib was paralleled by the induction of autophagy signaling in all breast cancer cell lines. Recently, Zhai et al. have shown that ipatasertib is able to induce autophagic cell death in hepatocellular carcinoma [
64], while, Zorea et al showed that an ovarian cancer cell line undergoes autophagy, after taselisib treatment, to avoid cell death [
65]. To our knowledge, our study is the first to show that ipatasertib and taselisib are able to induce autophagy in different breast cancer models. Of note, the increase of autophagy signaling was more evident in the most resistant TNBC KRAS/BRAF-mutated MDAMB231 cell line. This is consistent with other evidences showing that KRAS mutations could drive increased autophagy flux making KRAS mutant models highly sensitive to autophagy inhibition [
66‐
68]. Indeed, in this cell line, the pharmacological inhibition of autophagy, exerted by CQ, significantly increased the efficacy of PI3K/AKT inhibitors, suggesting that the activation of autophagy in this highly aggressive tumours, could represent a mechanism of escape to drug therapy. On the opposite, in the more sensitive breast cancer cell lines, the synergistic antitumor interaction between CQ and the two PI3K/AKT inhibitors was less evident. Overall, in our models, TNBC cell lines appeared strongly autophagy-addicted, indeed the addition of chloroquine to ipatasertib or taselisib caused a strong growth reduction, with a significant increase of apoptosis. The proliferation rate was dramatically reduced with low doses of CQ, while higher doses were requested to achieve a significant reduction of proliferation in the other cell lines.
Other authors have found that TNBC show higher level of autophagy than other breast cancer subtypes. Autophagy proteins, such as Beclin-1 and LC3A/B were found over-expressed in TNBC cells compared to the other breast cancer subtypes [
7], and this expression appeared correlated with tumour progression and poor outcome in TNBC [
69]. Claude-Taupin et al. found high expression of ATG9 protein in TNBC breast cancer tissues, while the inhibition of ATG9 by shRNA- and CRISPR/Cas9-driven of ATG9A was associated with a regression of pro-cancer phenotypes in a TNBC in vitro model [
70]. Hamurcu et al. highlighted that silencing of LC3 and Beclin-1 genes, thereby inhibiting autophagy, significantly suppressed cell proliferation, colony formation, migration and invasion of TNBC models, and induced increase of apoptosis [
71]. Accordly, Maycotte et al. showed that silencing of ATG5, ATG7 and Beclin1 reduced the proliferation of different TNBC cell lines (basal and claudin-low) [
72]. Finally, Chen et al. showed that the activation of autophagy signaling, was associated with metastatic progression in TNBC models [
73]. These data strongly suggest a pro-survival role of autophagy in TNBC tumors.
Based on these findings, in last years, several studies focused on modulation of autophagy in cancer, through the use of well-know molecules such as CQ and HCQ [
54]. Preclinical evidences support CQ and HCQ use as anti-cancer therapies, especially in combination with conventional anti-cancer treatments, since they seem to be able to sensitize tumour cells to a variety of drugs, potentiating their therapeutic activity [
37]. It has been fully described that CQ and HCQ exert anticancer effects due to their anti-autophagy activities, although other anti-cancer activities, such as modulation of inflammatory pathway and apoptosis, have been highlighted [
74,
75].
Several clinical trials are investigating the use of CQ or HCQ, alone or in combination with standard therapies, in different cancer types including breast cancer [
25,
37]. Recently, Arnaout et al. published results from a randomized, double-blind clinical trial evaluating treatment with single-agent CQ 500 mg daily for 2–6-weeks prior to breast surgery. The treatment was not associated with any significant effects on breast cancer cellular proliferation, however, it was associated with toxicity that may affect its broader use in oncology [
76]. These disappointing results, however, could be in part ascribed to the choose of the wrong target population and the wrong dose [
55,
77]. In our study, because of the potential toxicity of CQ, we decided to use low doses of CQ. In particular, in the acute administration the maximum concentration of 10 µM was used while in the chronic administration we used lower concentrations such as 1 µM or 58nM, resembling concentrations that are normally used in clinical practice to treat diseases other than cancer [
54,
55]. Interestingly, these concentrations were sufficient to synergize with either taselisib or ipatasertib in TNBC models. Finally, we translated our in vitro observations in a proof-of-concept preclinical
in vivo study by evaluating CQ plus taselisib in combination with paclitaxel, the standard first line chemotherapy backbone in TNBC. Interestingly, in MDAMB231 cells, the triple combination of low doses of taselisib, CQ and paclitaxel strongly synergized in short and long term exposure, achieving surprising results in in vivo models, where tumor growth was deeply inhibited both during the treatment and the follow-up period, suggesting a carry-over effect lasting even without drug-pressure.
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