Therapeutic Targeting of Oncogene-Induced Transcription-Replication Conflicts in Pancreatic Ductal Adenocarcinoma

Transcription-replication conflicts (TRCs) are a key source of replication stress in cancer, with pancreatic ductal adenocarcinoma (PDAC) showing uniquely high levels. This study investigated the mechanism, oncogene dependency, subtype specificity, and preclinical activity of the TRC-targeting molecule AOH1996 in PDAC models. Initial clinical evidence of AOH1996 activity in patients with PDAC is also provided.

The oncogene-dependent toxicity of AOH1996 was studied in KRAS(G12D)-inducible systems. Its effects on replication fork progression, TRCs, DNA damage, cell cycle, and apoptosis were assessed in PDAC cell lines. Subtype-specific responses were tested in organoids, and in vivo efficacy was evaluated using murine and patient-derived xenografts. Clinical activity was measured through radiographic response and progression-free survival in patients.

AOH1996 exhibited dose-dependent cytotoxicity reliant on KRAS(G12D) induction (average half maximal inhibitory concentration: 0.93 μM). It inhibited replication fork progression and induced TRCs by enhancing interactions between RNA Polymerase II and proliferating cell nuclear antigen, causing transcription-dependent DNA damage and transcription shutdown. Organoids with high replication stress were most sensitive (half maximal inhibitory concentration: 406 nM-2 μM). In mouse models, AOH1996 reduced tumor growth, induced tumor-selective DNA damage, and prolonged survival (median 14 vs 21 days, P = .04) without toxicity. Two patients with chemotherapy-refractory PDAC treated with AOH1996 showed up to 49% tumor shrinkage in hepatic metastases.

AOH1996 safely and effectively targets TRCs in preclinical PDAC models, with initial clinical evidence supporting its potential for treating chemotherapy-refractory PDAC. Further clinical development is warranted.