A Phase 1 Proof of Concept Study Evaluating the Addition of an LSD1 Inhibitor to Nab-Paclitaxel in Advanced or Metastatic Breast Cancer (EPI-PRIMED)

Thiru Prasanna, Laeeq Malik, Robert D McCuaig, Wen Juan Tu, Fan Wu, Pek Siew Lim, Abel H Y Tan, Jane E Dahlstrom, Philip Clingan, Eugene Moylan, Jeremy Chrisp, David Fuller, Sudha Rao, Desmond Yip, Thiru Prasanna, Laeeq Malik, Robert D McCuaig, Wen Juan Tu, Fan Wu, Pek Siew Lim, Abel H Y Tan, Jane E Dahlstrom, Philip Clingan, Eugene Moylan, Jeremy Chrisp, David Fuller, Sudha Rao, Desmond Yip

Abstract

Objective: Lysine-Specific Demethylase-1 (LSD1) is overexpressed in breast cancer cells and facilitate mesenchymal properties which may contribute to therapeutic resistance and cancer progression. The purpose of this study was to investigate the safety of combination, nab-paclitaxel and phenelzine, an irreversible LSD1 inhibitor in patients with metastatic breast cancer (mBC).

Methods: Eligible patients with mBC were treated with nab-paclitaxel (100mg/m2) weekly for 3 weeks with one week break in a 28-day cycle. Dose escalation of phenelzine followed the Cumulative Cohort Design and phenelzine treatment commenced from day 2 of first cycle. Eleven patients were screened, and eligible patients were enrolled in cohorts with the dose of phenelzine ranging from 45mg to 90mg.

Results: The Optimum Biological Dose was established at 60mg of phenelzine daily in combination with nab-paclitaxel and considered as the recommended phase 2 dose. Most (95%) of adverse events were grade 1 or 2 with two grade 3 events being diarrhea and neutropenia at 45mg and 60mg phenelzine respectively, with no unexpected toxicity/deaths. Commonly reported toxicities were fatigue (n=4,50%), dizziness (n=6,75%), neutropenia (n=3,37.5%), peripheral neuropathy (n=3,37.5%), diarrhea (n=2,25%), and hallucination (n=2,25%). After a median follow up of 113 weeks, all patients showed disease progression on trial with 4 patients being alive at the time of data cut off, including one patient with triple negative breast cancer. Median progression-free survival was 34 weeks. Significant inhibition of LSD1 and suppression of mesenchymal markers in circulating tumor cells were noted.

Conclusion: Phenelzine in combination with nab-paclitaxel was well tolerated, without any unexpected toxicities in patients with mBC and demonstrated evidence of antitumor activity. For the first time, this proof-of-concept study showed in-vivo inhibition of LSD1 suppressed mesenchymal markers, which are known to facilitate generation of cancer stem cells with metastatic potential. Clinical Trial Registration: ClinicalTrials.Gov NCT03505528, UTN of U1111-1197-5518.

Keywords: breast cancer; cancer stem cells; circulating tumor cells; lysine-specific demethylase 1; metastasis.

Conflict of interest statement

In accordance with NHMRC policy and our ethical obligations as researchers, we report that SR, WT, RM, AT, PL, JED, and FW have equity in EpiAxis Therapeutics Pty Ltd. DY has been an Advisory Board member for Specialised Therapeutics. JC is the CEO of EpiAxis Therapeutics. DF is the Chair of EpiAxis Therapeutics. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The authors declare that this study received funding from EpiAxis Therapeutics. The funder had the following involvement with the study: the company instigated the study protocol, data collection, analysis, and interpretation.

Copyright © 2022 Prasanna, Malik, McCuaig, Tu, Wu, Lim, Tan, Dahlstrom, Clingan, Moylan, Chrisp, Fuller, Rao and Yip.

Figures

Figure 1
Figure 1
Study design.
Figure 2
Figure 2
Analysis of CTC mesenchymal markers during the study. Analysis of CTC mesenchymal marker and LSD1 in metastatic breast cancer patient derived CTCs. Figure shows differential changes between phenelzine 45mg (blue) and 60mg (Red). CTCs were isolated at baseline, cycle 1 (Day 29), 2 (Day 57) or cycle 3 (Day 85 end of study). (A) Shows changes in mean cytoplasmic intensity of CSV, LSD1s111p (LSD1p), EGFR, FOXQ1, PD-L1 or SNAI1 during the course of trial. (B) Shows changes in nuclear intensity of H3K9me2, H3K4me2, LSD1s111p, EGFR, FOX1Q, or SNAI1. (C) Phenotypic index, measuring the phenotypic change in the patients CTCs was calculated as described in the methods for the cytoplasmic, nuclear and whole cell scores. This score was then plotted for cycle 1 to 3 compared to baseline readings. Significant differences were determined with a two-way ANOVA with multiple comparisons to baseline and are indicated, *<0.05, **<0.01, ***<0.001, ****<0.001, ns, not significant.
Figure 3
Figure 3
CTC analysis of the patient with triple negative breast cancer with longest survival. The mean cytoplasmic fluorescent intensity (CFI) or the mean nuclear fluorescent intensity (NFI) of mesenchymal markers and PD-L1 were measured in CTC of the patients with triple negative breast cancer with longest survival was. Graphs plot the CFI or NFI mean for Cycle 1 to 3 compared to baseline readings. Significant differences were determined with a two-way ANOVA with multiple comparisons to baseline and are indicated, *

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