Modulation of HER2 internalization enhances single-dose antibody-drug potency in HER2⁺ gastric cancer

HER2 is a membrane receptor tyrosine kinase overexpressed in 18-20% of gastric tumors. Trastuzumab emtansine (T-DM1) is an antibody-drug conjugate (ADC) that targets HER2-positive (HER2⁺) cancer cells with a chemotherapeutic agent, emtansine. T-DM1 has low efficacy in HER2⁺ gastric cancer. This study explored the efficacy of combining drugs known to modulate HER2 internalization to enhance T-DM1 efficacy in gastric cancer. We used cholesterol-depleting drugs (lovastatin) to enhance HER2 membrane density. The irreversible pan-HER tyrosine kinase inhibitor neratinib was used to enhance the internalization of HER2-bound T-DM1. Therapy, pre-treatment and post-treatment positron emission tomography/computed tomography (PET/CT) were performed in both male and female mice. An enhancement of cell surface and internalized HER2 was observed after lovastatin and neratinib incubations, respectively. The combination of lovastatin with neratinib enhanced T-DM1 internalization in cancer cells. A decrease in HER2 protein levels and HER2 phosphorylation was detected in cells treated with T-DM1/lovastatin/neratinib when compared to control and T-DM1-only groups. PET/CT imaging of mice in the T-DM1/lovastatin/neratinib group showed a decrease in HER2 tumoral expression, which was associated with a decrease in tumor volume and sustained treatment efficacy in the T-DM1/lovastatin/neratinib group. This work demonstrates the therapeutic enhancement of T-DM1 using combination therapy with lovastatin/neratinib in gastric cancer. The treatment can be successfully monitored through PET/CT imaging.