Netrin1 blockade alleviates resistance to chemotherapy in pancreatic cancer

Netrin1, a developmental cue, is a master regulator of tumour epithelial-to-mesenchymal transition (EMT)¹, a mechanism that is known to drive resistance to chemotherapy². A netrin1 antibody (NP137)³ has been shown to inhibit tumour EMT in preclinical¹ and clinical⁴ settings. In animal models of pancreatic cancer, netrin1 and its receptor neogenin have been shown to promote tumour progression⁵, EMT⁵ and metastasis⁶. Here we report the results of a phase 1b study that assesses the combination of NP137 with modified FOLFIRINOX (mFOLFIRINOX) in first line patients with locally advanced pancreatic cancer (ClinicalTrials.gov: NCT05546853 ). Forty-three patients were enrolled and received mFOLFIRINOX plus NP137 every other week for up to 12 cycles. NP137 was well tolerated. Median progression-free survival (PFS) was 10.85 months (95% confidence interval, 10.03-15.61) and median overall survival was 16.43 months (95% confidence interval, 12.75-non-reached), with 21 patients remaining alive at the time of data cut-off. Post-therapy conversion surgery occurred in 23% of patients. Laser capture microdissection was performed on pre-therapeutic biopsies and surgical specimens. Microbulk RNA sequencing confirmed that the main pathway that was down-regulated with the combination of mFOLFIRINOX plus NP137 was EMT. Moreover, survival outcomes were extended for patients with tumour cells that expressed high levels of the netrin1 receptor neogenin-median PFS 15.65 months in neogenin-high versus 10.22 months in neogenin low. Our results support the idea that netrin1 blockade alleviates resistance to chemotherapy by inhibiting EMT, particularly in neogenin-high pancreatic cancer.