Elacridar improves sunitinib efficacy in colorectal cancer models

To improve treatment outcome for unresectable metastatic colorectal cancer (mCRC), many small molecule kinase inhibitors (KIs) have been tested. Most fail in early-phase clinical trials due to intrinsic resistance. As ATP Binding Cassette transporters are known to cause treatment resistance in mCRC, as well as to obtain higher intracellular drug concentrations, we evaluated whether inhibition of these transporters could potentiate KI efficacy. In patient-derived tumour organoids (PDTOs) from mCRC biopsies, preincubation with potent transporter inhibitor elacridar significantly improved sunitinib efficacy. Contrasting expectations, this was accompanied by reduced intracellular sunitinib accumulation. Mechanistically, confocal fluorescence imaging revealed reduced lysosomal sequestration of sunitinib in cells preincubated with elacridar. Storage of drugs-that are lysosomotropic and substrates of ABC-transporters-in subcellular compartments reduces the active pool and potentially contributes to intrinsic drug resistance in mCRC. Combination strategies that target ABC-transporters or lysosomes might be considered to potentiate drug efficacy.