The SOS1 Inhibitor MRTX0902 Blocks KRAS Activation and Demonstrates Antitumor Activity in Cancers Dependent on KRAS Nucleotide Loading

KRAS is the most frequently mutated oncogene in human cancer and facilitates uncontrolled growth through hyperactivation of the RTK/MAPK pathway. The Son of Sevenless homolog 1 (SOS1) protein functions as a guanine nucleotide exchange factor (GEF) for the RAS subfamily of small GTPases and represents a druggable target in the pathway. Using a structure-based drug discovery approach, MRTX0902 was identified as a selective and potent SOS1 inhibitor that disrupts the KRAS:SOS1 protein-protein interaction to prevent SOS1-mediated nucleotide exchange on KRAS and translates into an anti-proliferative effect in cancer cell lines with genetic alterations of the KRAS-MAPK pathway. MRTX0902 augmented the antitumor activity of the KRAS G12C inhibitor adagrasib when dosed in combination in eight out of twelve KRAS G12C-mutant human non-small cell lung cancer (NSCLC) and colorectal cancer (CRC) xenograft models. Pharmacogenomic profiling in preclinical models identified cell cycle genes and the SOS2 homolog as genetic co-dependencies and implicated tumor suppressor genes (NF1, PTEN) in resistance following combination treatment. Lastly, combined vertical inhibition of RTK/MAPK pathway signaling by MRTX0902 with inhibitors of EGFR or RAF/MEK led to greater downregulation of pathway signaling and improved antitumor responses in KRAS-MAPK pathway-mutant models. These studies demonstrate the potential clinical application of dual inhibition of SOS1 and KRAS G12C and additional SOS1 combination strategies that will aide in the understanding of SOS1 and RTK/MAPK biology in targeted cancer therapy.

MRTX1719 Is an MTA-Cooperative PRMT5 Inhibitor That Exhibits Synthetic Lethality in Preclinical Models and Patients with MTAP-Deleted Cancer

Previous studies implicated protein arginine methyltransferase 5 (PRMT5) as a synthetic lethal target for MTAP-deleted (MTAP del) cancers; however, the pharmacologic characterization of small-molecule inhibitors that recapitulate the synthetic lethal phenotype has not been described. MRTX1719 selectively inhibited PRMT5 in the presence of MTA, which is elevated in MTAP del cancers, and inhibited PRMT5-dependent activity and cell viability with >70-fold selecti-vity in HCT116 MTAP del compared with HCT116 MTAP wild-type (WT) cells. MRTX1719 demonstrated dose-dependent antitumor activity and inhibition of PRMT5-dependent SDMA modification in MTAP del tumors. In contrast, MRTX1719 demonstrated minimal effects on SDMA and viability in MTAP WT tumor xenografts or hematopoietic cells. MRTX1719 demonstrated marked antitumor activity across a panel of xenograft models at well-tolerated doses. Early signs of clinical activity were observed including objective responses in patients with MTAP del melanoma, gallbladder adenocarcinoma, mesothelioma, non-small cell lung cancer, and malignant peripheral nerve sheath tumors from the phase I/II study.

SIGNIFICANCE

PRMT5 was identified as a synthetic lethal target for MTAP del cancers; however, previous PRMT5 inhibitors do not selectively target this genotype. The differentiated binding mode of MRTX1719 leverages the elevated MTA in MTAP del cancers and represents a promising therapy for the ∼10% of patients with cancer with this biomarker. See related commentary by Mulvaney, p. 2310. This article is featured in Selected Articles from This Issue, p. 2293.

Abstract 2778: A novel MTA-cooperative PRMT5 inhibitor, MRTX1719, stabilizes the ternary MTA-PRMT5 complex and leads to synthetic lethality in MTAP deleted cancers

Previous studies have shown that cancer cell lines with homozygous deletion of the MTAP gene (MTAP del), are selectively sensitive to shRNA-mediated PRMT5 inhibition or MTA-cooperative PRMT5 inhibitors. PRMT5 is a methyltransferase that adds symmetric dimethyl arginine marks to various proteins essential for cell viability whereas MTAP is responsible for metabolizing MTA as part of the methionine salvage pathway. In MTAP del cells, MTA accumulates and partially inhibits PRMT5 activity by directly competing with SAM, the universal methyl donor and PRMT5 substrate. Thus, the deletion of MTAP leads to the formation of the PRMT5-MTA complex and functions as a synthetic lethal target. In this capacity, MTA-cooperative PRMT5 inhibitors are hypothesized to exhibit an increased therapeutic index compared to first generation PRMT5 inhibitors by preferentially inhibiting PRMT5 in MTAP del cancer cells while sparing normal cells. First generation PRMT5 inhibitors target either apo-PRMT5 or the PMRT5-SAM complex, while MRTX1719 preferentially binds the PRMT5-MTA complex, stabilizing the complex in an inactive state. Thermal shift analysis demonstrated rapid and complete binding of MRTX1719 to MTA-bound PRMT5 whereas binding to SAM-bound PRMT5 was delayed and incomplete after prolonged incubation. First generation clinical-stage PRMT5 inhibitors showed either preferential binding to the PRMT5-SAM complex or no selectivity between the PRMT5-MTA complex, the PMRT5-SAM complex, or apo-PRMT5 in the thermal shift assay, suggesting first generation inhibitors do not recapitulate the synthetic lethal phenotype in MTAP del cancers. In vitro, MRTX1719 exhibits a durable pharmacodynamic effect in MTAP del cells or MTAP WT cells incubated with MTA following drug washout in agreement with the long target residence time suggested by the thermal shift data. Moreover, in vivo time course studies confirm MRTX1719 exhibits potent and durable inhibition of PRMT5-dependent symmetric dimethyl arginine (SDMA) in MTAP del tumor xenografts. HemaTox™ viability assays were used to determine potency against human MTAP WT erythroid and myeloid cells where MRTX1719 was ~45-fold less potent compared to the MTAP del HCT116 cancer cell line. In contrast, first generation PRMT5 inhibitors were similarly potent against the HCT116 isogenic cell lines and human hematopoietic cells, irrespective of MTAP status. These data demonstrate MRTX1719 preferentially and potently binds PRMT5 in the presence of MTA and selectively inhibits MTAP del cancer cell lines. Moreover, the kinetic properties and selectivity profile suggest MRTX1719 will exhibit a significantly improved therapeutic window for the treatment of MTAP del cancer patients.

Citation Format: Laura Vegar, Ruth Aranda, Laura Waters, Krystal Moya, Allan Hebbert, Christopher S. Smith, Jill Hallin, Briere M. David, Lars D. Engstrom, Darin Vanderpool, Matthew M. Marx, James G. Christensen, Peter A. Olson. A novel MTA-cooperative PRMT5 inhibitor, MRTX1719, stabilizes the ternary MTA-PRMT5 complex and leads to synthetic lethality in MTAP deleted cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 2778.

Anti-tumor efficacy of a potent and selective non-covalent KRASG12D inhibitor

Recent progress in targeting KRAS^G12C has provided both insight and inspiration for targeting alternative KRAS mutants. In this study, we evaluated the mechanism of action and anti-tumor efficacy of MRTX1133, a potent, selective and non-covalent KRAS^G12D inhibitor. MRTX1133 demonstrated a high-affinity interaction with GDP-loaded KRAS^G12D with K_D and IC₅₀ values of ~0.2 pM and <2 nM, respectively, and ~700-fold selectivity for binding to KRAS^G12D as compared to KRAS^WT. MRTX1133 also demonstrated potent inhibition of activated KRAS^G12D based on biochemical and co-crystal structural analyses. MRTX1133 inhibited ERK1/2 phosphorylation and cell viability in KRAS^G12D-mutant cell lines, with median IC₅₀ values of ~5 nM, and demonstrated >1,000-fold selectivity compared to KRAS^WT cell lines. MRTX1133 exhibited dose-dependent inhibition of KRAS-mediated signal transduction and marked tumor regression (≥30%) in a subset of KRAS^G12D-mutant cell-line-derived and patient-derived xenograft models, including eight of 11 (73%) pancreatic ductal adenocarcinoma (PDAC) models. Pharmacological and CRISPR-based screens demonstrated that co-targeting KRAS^G12D with putative feedback or bypass pathways, including EGFR or PI3Kα, led to enhanced anti-tumor activity. Together, these data indicate the feasibility of selectively targeting KRAS mutants with non-covalent, high-affinity small molecules and illustrate the therapeutic susceptibility and broad dependence of KRAS^G12D mutation-positive tumors on mutant KRAS for tumor cell growth and survival.

Design and Discovery of MRTX0902, a Potent, Selective, Brain-Penetrant, and Orally Bioavailable Inhibitor of the SOS1:KRAS Protein-Protein Interaction

SOS1 is one of the major guanine nucleotide exchange factors that regulates the ability of KRAS to cycle through its “on” and “off” states. Disrupting the SOS1:KRAS^G12C protein–protein interaction (PPI) can increase the proportion of GDP-loaded KRAS^G12C, providing a strong mechanistic rationale for combining inhibitors of the SOS1:KRAS complex with inhibitors like MRTX849 that target GDP-loaded KRAS^G12C. In this report, we detail the design and discovery of MRTX0902—a potent, selective, brain-penetrant, and orally bioavailable SOS1 binder that disrupts the SOS1:KRAS^G12C PPI. Oral administration of MRTX0902 in combination with MRTX849 results in a significant increase in antitumor activity relative to that of either single agent, including tumor regressions in a subset of animals in the MIA PaCa-2 tumor mouse xenograft model.

Abstract LB505: Design and discovery of MRTX0902, a potent, selective, and orally bioavailable SOS1 inhibitor

KRAS mutations are the most common activating mutations in human cancer that ultimately lead to hyperactivation of the MAPK pathway and uncontrolled growth. KRAS functions as a small GTPase that cycles through its GTP-loaded “on” state and its GDP-loaded “off” state, a highly regulated process that is crucial for normal cell proliferation and survival. The guanine nucleotide exchange factor (GEF) SOS1 plays a critical role in this process by regulating the “on/off” state of KRAS. The protein-protein interaction between SOS1 and KRAS facilitates turnover of KRAS from the GDP-loaded inactive state to its activated and GTP-loaded state, a critical step to enable productive KRAS effector binding and activation of downstream signaling. The KRASG12C inhibitor, adagrasib (MRTX849), irreversibly binds to the GDP-loaded inactive conformation of KRASG12C and has recently shown encouraging clinical activity across several cancer types. As adagrasib binds preferentially to the inactive state of KRAS, blockade of SOS1 is anticipated to shift KRASG12C into the adagrasib-susceptible GDP-loaded state. Furthermore, this combination strategy could be used to target other mutant-driven cancers within the MAPK pathway using the appropriate KRASmut inhibitors and/or inhibitors of other targets within the MAPK pathway including MEK or EGFR. MRTX0902 was identified using iterative structure-based design as a selective inhibitor of SOS1 that demonstrates an IC50 value of 2 nM in a SOS1 HTRF binding assay and 30 nM in an MKN1 cellular assay. In pharmacokinetic evaluation across species, MRTX0902 demonstrated low extraction ratios and moderate to high bioavailability in mice, rats, and dogs. In preclinical models, MRTX0902 augmented the antitumor activity of adagrasib and other selected therapies. The design, discovery, and preclinical characterization of the potential best-in-class candidate MRTX0902 will be described.

Citation Format: John M. Ketcham, David M. Briere, Aaron C. Burns, James G. Christensen, Robin J. Gunn, Jacob Haling, Anthony Ivetac, Shilpi Khare, Jon Kuehler, Svitlana Kulyk, Jade Laguer, John D. Lawson, Krystal Moya, Natalie Nguyen, Peter Olson, Lisa Rahbaek, Christopher R. Smith, Niranjan Sudhakar, Nicole C. Thomas, Darin Vanderpool, Xiaolun Wang, Matthew A. Marx. Design and discovery of MRTX0902, a potent, selective, and orally bioavailable SOS1 inhibitor [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB505.

Abstract ND02: MRTX0902: A SOS1 inhibitor for therapeutic intervention of KRAS-driven cancers

KRAS is the most frequently mutated oncogene in cancer and drives uncontrolled growth through hyperactivation of the MAPK pathway. Significant progress has been made in the past several years to directly target KRASG12C with the FDA approval of sotorasib and the reported clinical activity of adagrasib (MRTX849). Despite these remarkable breakthroughs, additional therapies that enhance the depth and duration of response to KRASG12C inhibitors provide the opportunity to build upon the initial progress. SOS proteins are guanine nucleotide exchange factors (GEFs) that transduce receptor tyrosine kinase (RTK) signaling from the cell surface and facilitate the activation of RAS family proteins. In addition, SOS1 is a target of negative feedback signaling following RAS-mediated activation of the RAF-MEK-ERK cascade. Thus, SOS proteins represent a significant therapeutic node that maintains RAS pathway equilibrium as well as oncogenic signaling dynamics. Here we highlight the discovery and preclinical evaluation of MRTX0902, a potent, selective, and orally bioavailable inhibitor of SOS1 presently in IND-enabling studies. A structure-based approach was used to identify a novel chemical series that disrupts the protein-protein interaction between SOS1 and KRAS, thereby preventing SOS1-mediated GTP-exchange on GDP-bound KRAS. Considering MRTX849 preferentially binds to inactive GDP-bound KRASG12C, targeting SOS1 in this genetic context increases the ability of MRTX849 to bind and inhibit KRASG12C. The combination of MRTX0902 with MRTX849 enhances the depth and durability of an anti-tumor response when compared to MRTX849 alone in pre-clinical KRASG12C tumor models. MRTX0902 augments additional targeted therapies across a variety of RAS-addicted tumors, indicating that SOS1 inhibition is effective against a broad spectrum of mutations within the MAPK pathway. Furthermore, drug-anchored CRISPR experiments with MRTX0902 and MRTX849 uncovered a previously underappreciated functional role of the SOS1 paralog, SOS2, in KRAS-addicted tumors. In addition to aiding in the understanding of SOS and RAS family signaling dynamics, these studies implicate SOS2 as a potential cancer drug target in the context of SOS1/KRASG12C inhibition. In summary, we have used a structure-based approach to discover a SOS1 inhibitor that augments the anti-tumor activity of MRTX849 and additional targeted MAPK pathway inhibitors. We anticipate our findings to translate into the clinic and make an impact in patients with RAS-addicted tumors.

Citation Format: John M. Ketcham, Shilpi Khare, Niranjan Sudhakar, David M. Briere, Larry Yan, Jade Laguer, Laura Vegar, Darin Vanderpool, Jill Hallin, Lauren Hargis, Vickie Bowcut, David Lawson, Robin J. Gunn, Anthony Ivetac, Nicole C. Thomas, Barbara Saechao, Natalie Nguyen, Jeffrey Clarine, Lisa Rahbaek, Christopher R. Smith, Aaron C. Burns, Matthew A. Marx, James G. Christensen, Peter Olson, Jacob R. Haling. MRTX0902: A SOS1 inhibitor for therapeutic intervention of KRAS-driven cancers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr ND02.

Abstract 1131: Pharmacogenomic insight into targetable vulnerabilities and modifiers of response to MRTX1133 in KRASG12D-mutant models

The ability to effectively target mutated KRAS has remained elusive despite decades of research. Recently, the identification of selective KRASG12C inhibitors has provided an effective treatment option for patients harboring this particular mutation and has also provided insight toward targeting other KRAS mutants, including KRASG12D. MRTX1133 was identified via a structure-based drug design strategy as a potent, selective, and non-covalent KRASG12D inhibitor directed at the switch II binding pocket. MRTX1133 exhibited dose dependent KRAS pathway and tumor growth inhibition and demonstrated marked anti-tumor activity across a panel of models in vivo, including tumor regression &gt;30% in 8 out of 11 pancreatic ductal adenocarcinoma (PDAC) models. While evaluation of MRTX1133 across a panel of cell and patient-derived xenograft models demonstrated strong single agent activity in the majority of models tested, a subset of models were less responsive. Focused sgRNA libraries targeting ~5,000 genes were tested in MRTX1133-anchored CRISPR/Cas9 screens in vitro and in vivo in PDAC and colorectal KRASG12D-mutant cell lines. Similar to what was seen in a targeted genetic screen with our selective KRASG12C inhibitor MRTX849, several genes that act either upstream or downstream of KRAS were depleted with MRTX1133 treatment which illuminate specific targetable vulnerabilities in the context of KRASG12D inhibition. sgRNAs targeting EGFR, PIK3CA, PTPN11, mTOR, and CDK2/4/6 were depleted in MRTX1133-treated (or vehicle-treated) cell lines or xenograft models, while hallmark tumor suppressor genes RB1, KEAP1, NF1 and PTEN were enriched. The enrichment of KEAP1 sgRNAs in PDAC models parallels findings with MRTX849 in preclinical models and is in line with emerging clinical data suggesting increased capacity to scavenge reactive oxygen species (ROS) may represent a mechanism of partial resistance to a non-covalent, non-electrophilic warhead-containing KRASG12D-selective inhibitor in PDAC. Treatment using small molecules targeting selected vulnerabilities in vitro and in vivo confirmed these genetic findings. Further evaluation of dependencies utilizing an integrated analysis of RNAseq data also revealed KRAS regulates and is critically dependent on pro-survival and cell cycle genes for cancer cell viability. These data lend further insight into tumor response to KRASG12D inhibition and provide key insight into the genes that mediate the mechanism of action of, as well as confer partial resistance to MRTX1133, and identify combination targets that can augment the anti-tumor effect of MRTX1133.

Citation Format: Vickie Bowcut, Andrew Calinisan, David M. Briere, Lauren Hargis, Lars D. Engstrom, Jade Laguer, Darin Vanderpool, Xiaolun Wang, J David Lawson, Nicole Thomas, Robin Gunn, Christopher R. Smith, Julio Fernandez-Banet, Leo He, Adam Pavlicek, Lisa Rahbaek, Matthew A. Marx, Peter Olson, James G. Christensen, Jill Hallin. Pharmacogenomic insight into targetable vulnerabilities and modifiers of response to MRTX1133 in KRASG12D-mutant models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 1131.

Abstract LB193: Chemical genomics identify novel druggable nodes and resistance pathways in the presence of concomitant SOS1 and KRAS inhibition

KRAS is the most frequently mutated oncogene in human cancer and facilitates uncontrolled growth through hyperactivation of the MAPK pathway. Recent data has consistently demonstrated co-dependencies of mutant-KRAS with extrinsic proteins that augment GTP-loading. Son of Sevenless homolog 1 (SOS1) is the most proximal of these proteins to KRAS and functions as a guanine nucleotide exchange factor (GEF) for the RAS subfamily of small GTPases, thus representing a highly sought-after druggable target. Utilizing a structure-based drug discovery approach, we identified a selective and potent SOS1 inhibitor, MRTX0902, that functions by disrupting the KRAS/SOS1 protein-protein interaction, ultimately preventing SOS1-mediated nucleotide exchange on KRAS. MRTX0902 enhances the anti-tumor activity of the KRASG12C inhibitor adagrasib across multiple KRASG12C-mutant preclinical models; however, it is anticipated that deeper pharmacological inhibition of KRAS signaling may give rise to novel combination targets and additional adaptive resistance mechanisms. To identify additional vulnerabilities and combination strategies, we conducted drug-anchored CRISPR screens in two KRASG12C xenograft models in the presence of MRTX0902 and adagrasib in vitro and in vivo. Interestingly, we found that the SOS1 homolog, SOS2, only emerges as a co-dependency under selective pressure of combination treatment and likely compensates for the inhibition of SOS1. Furthermore, multiple components from the PIK3CA/mTOR signaling pathway, PRMT5, and other non-vertical signal transduction pathways were uncovered and identified as genetic co-dependencies that emerged under selective pressure. Conversely, tumor suppressor genes including TSC1/2, PTEN, NF1, KEAP1 and TP53 along with phosphatases PTPN12 and PTPN14 enhanced tumor growth when knocked out providing a catalogue of putative resistance genes and mechanisms. Lastly, we utilized small molecule inhibitors of putative therapeutic targets identified from our CRISPR screens to validate genetic co-dependencies across in vitro and in vivo translational models. These studies uncover the potential utility of additional drug partners for the MRTX0902 and adagrasib combination and aide in the understanding of SOS and RAS biology in targeted cancer therapy.

Citation Format: Shilpi Khare, Niranjan Sudhakar, David M. Briere, Larry Yan, Lars D. Engstrom, Jade Laguer, James Medwid, Laura Vegar, Darin Vanderpool, Matthew A. Marx, John M. Ketcham, James G. Christensen, Peter Olson, Jacob R. Haling. Chemical genomics identify novel druggable nodes and resistance pathways in the presence of concomitant SOS1 and KRAS inhibition [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr LB193.

Identification of MRTX1133, a Noncovalent, Potent, and Selective KRASG12D Inhibitor

KRAS^G12D, the most common oncogenic KRAS mutation, is a promising target for the treatment of solid tumors. However, when compared to KRAS^G12C, selective inhibition of KRAS^G12D presents a significant challenge due to the requirement of inhibitors to bind KRAS^G12D with high enough affinity to obviate the need for covalent interactions with the mutant KRAS protein. Here, we report the discovery and characterization of the first noncovalent, potent, and selective KRAS^G12D inhibitor, MRTX1133, which was discovered through an extensive structure-based activity improvement and shown to be efficacious in a KRAS^G12D mutant xenograft mouse tumor model.

Cascading speciation among mutualists and antagonists in a tree-beetle-fungi interaction

Cascading speciation is predicted to occur when multiple interacting species diverge in parallel as a result of divergence in one species promoting adaptive differentiation in other species. However, there are few examples where ecological interactions among taxa have been shown to result in speciation that cascades across multiple trophic levels. Here, we test for cascading speciation occurring among the western pine beetle (Dendroctonus brevicomis), its primary host tree (Pinus ponderosa), and the beetle's fungal mutualists (Ceratocystiopsis brevicomi and Entomocorticium sp. B). We assembled genomes for the beetle and a fungal symbiont and then generated reduced representation genomic data (RADseq) from range-wide samples of these three interacting species. Combined with published data for the host tree, we present clear evidence that the tree, the beetle, and the fungal symbionts are all genetically structured into at least two distinct groups that have strongly codiverged with geographical isolation. We then combine our genomic results with diverse population and laboratory-based data to show evidence for reproductive isolation at each level of the cascade and for coevolution of both antagonistic and mutualistic species interactions within this complex network.

Discovery of potent, reversible MetAP2 inhibitors via fragment based drug discovery and structure based drug design-Part 2

Methionine aminopeptidase-2 (MetAP2) is an enzyme that cleaves an N-terminal methionine residue from a number of newly synthesized proteins. This step is required before they will fold or function correctly. Pre-clinical and clinical studies with a MetAP2 inhibitor suggest that they could be used as a novel treatment for obesity. Herein we describe the discovery of a series of pyrazolo[4,3-b]indoles as reversible MetAP2 inhibitors. A fragment-based drug discovery (FBDD) approach was used, beginning with the screening of fragment libraries to generate hits with high ligand-efficiency (LE). An indazole core was selected for further elaboration, guided by structural information. SAR from the indazole series led to the design of a pyrazolo[4,3-b]indole core and accelerated knowledge-based fragment growth resulted in potent and efficient MetAP2 inhibitors, which have shown robust and sustainable body weight loss in DIO mice when dosed orally.

Discovery of potent, reversible MetAP2 inhibitors via fragment based drug discovery and structure based drug design-Part 1

Methionine aminopeptidase 2 (MetAP2) is an enzyme that cleaves an N-terminal methionine residue from a number of newly synthesized proteins. Pre-clinical and clinical studies suggest that MetAP2 inhibitors could be used as a novel treatment for obesity. Herein we describe our use of fragment screening methods and structural biology to quickly identify and elaborate an indazole fragment into a series of reversible MetAP2 inhibitors with <10nM potency, excellent selectivity, and favorable in vitro safety profiles.

Design, Synthesis, and Biological Activity of Novel Polycyclic Aza-Amide FKBP12 Ligands

Since the discovery that FK-506 promotes neurite outgrowth, considerable attention has been focused on the development of potent nonimmunosuppressive ligands for FK-506 binding proteins (FKBPs). Such neuroimmunophilin agents have been reported to show neuroregenerative activity in a variety of cell and animal models including neurite outgrowth, age-related cognitive decline, Parkinson's disease, peripheral nerve injury, optic nerve degeneration, and diabetic neuropathy. We have designed and synthesized a unique series of tetracyclic aza-amides that have been shown to be potent FKBP12 rotamase inhibitors. The structure-activity relationships established in this study have demonstrated diverse structural modifications that result in potent rotamase inhibitory activity.

Crystal structure of human ABAD/HSD10 with a bound inhibitor: implications for design of Alzheimer's disease therapeutics

The enzyme 17beta-hydroxysteroid dehydrogenase type 10 (HSD10), also known as amyloid beta-peptide-binding alcohol dehydrogenase (ABAD), has been implicated in the development of Alzheimer's disease. This protein, a member of the short-chain dehydrogenase/reductase family of enzymes, has been shown to bind beta-amyloid and to participate in beta-amyloid neurotoxicity. We have determined the crystal structure of human ABAD/HSD10 complexed with NAD(+) and an inhibitory small molecule. The inhibitor occupies the substrate-binding site and forms a covalent adduct with the NAD(+) cofactor. The crystal structure provides a basis for the design of potent, highly specific ABAD/HSD10 inhibitors with potential application in the treatment of Alzheimer's disease.

Laparoscopically assisted colon surgery

Laparoscopy has been used in surgical procedures more frequently in the past decade because it reduces postoperative pain, decreases the length of hospitalization, decreases the duration of disability, and provides a better cosmetic result. We retrospectively reviewed our experience with laparoscopic colon surgery at Baylor University Medical Center. Since 1995, we have done 17 procedures, including 10 colon resections and 7 colostomies. The results in these patients have been quite good: only 1 patient was converted to an open procedure, and the remaining 16 patients experienced no mortality, major morbidity, or wound infection.

Laparoscopic Nissen fundoplication for gastroesophageal reflux disease

BACKGROUND

This is a retrospective review from March 1994 through October 1996 of 78 patients who underwent laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD). The purpose of this study was to evaluate the postoperative results and complications.

METHODS

The patient profile included 38 men and 40 women with a mean age of 46 years (range 11 to 81). The main preoperative symptoms included heartburn (92%), respiratory problems (42%), and dysphagia (32%). Preoperative assessment included esophagogastroduodenoscopy, upper gastrointestinal series, esophageal manometry, and 24-hour pH monitoring. Essential indications for surgery included esophagitis (83%), Barrett's esophagus without dysplasia (22%), and esophageal stricture (23%). All patients underwent a 360-degree wrap with a Maloney dilator and division of the short gastric vessels.

RESULTS

The mean operative time was 206 minutes (range 90 to 455). The average time for patients to tolerate a full liquid diet was 1.2 days, and the mean hospital stay was 2.4 days. Current follow-up, from 3 to 36 months, showed complete resolution of heartburn without medications in 67 patients (86%), occasional heartburn in 8 patients (10%), and slight improvement of heartburn in 3 patients (4%). Five patients with preoperative Barrett's metaplasia showed no evidence of it postoperatively (n = 2) or marked regression (n = 3).

CONCLUSION

Laparoscopic Nissen fundoplication is the procedure of choice for patients with complicated GERD.

Single-chain recombinant human cytomegalovirus protease. Activity against its natural protein substrate and fluorogenic peptide substrates

We report here the production of active recombinant single-chain human cytomegalovirus protease in Escherichia coli and development of a continuous assay for this protease. In order to produce the human cytomegalovirus (HCMV) protease for structural studies and accurate kinetic analysis, mutation of alanine 143 at an internal cleavage site was introduced to prevent auto-proteolysis. The resulting soluble 29-kDa A143Q protease was purified to homogeneity as a stable single-chain protein by hydrophobic interaction and ionic-exchange chromatography. The in vivo protein substrate, assembly protein precursor, was also expressed and purified for activity studies. To develop a continuous protease assay, fluorescent synthetic peptide substrates similar to the cleavage sequence P5 to P5' of the maturation site containing anthranilic acid and nitrotyrosine as a resonance energy transfer donor-acceptor pair were designed. Purified HCMV A143Q protease cleaved the recombinant assembly protein precursor with Km and kcat values of 3.0 +/- 1.0 microM and 13.3 +/- 1.6 min-1. The Km for peptide substrates is at least 45-fold higher than for the natural protein substrate, but the kcat values are similar. A sensitive assay was developed using fluorescent peptide substrates, which can detect nM HCMV protease activity.

Synergy between preactivated photofrin-II and tamoxifen in killing retrofibroma, pseudomyxoma and breast cancer cells

Exposure of photoactive compounds to light prior to their use in biological systems (preactivation) results in the generation of tumour cell specific metastable cytotoxic species that are no longer dependent on the light energy. Thus, preactivation renders the photoactive compounds suitable for systemic use. We have examined the in vitro effect of preactivated photofrin-II and tamoxifen in retroperitoneal fibroma, pseudomyxoma and male breast carcinoma cell lines. These cells were found to be non-responsive to tamoxifen and were negative for oestrogen receptors. Incubation of these cells with 0.5 microgram/ml preactivated photofrin-II and tamoxifen (less than 10(-6) mol/l) resulted in a significantly enhanced (P less than 0.001) inhibition of DNA synthesis compared with either agent alone. This synergistic effect between tamoxifen and preactivated photofrin-II was determined by multiple drug effect analysis. Treatment of cells with preactivated photofrin-II did not cause the increased expression of oestrogen receptors. These observations suggest that a combination of antihormonal drugs with preactivated compounds may be of clinical value.

The response of retroperitoneal fibrosis to tamoxifen

Although retroperitoneal fibrosis is uncommon and histologically benign, it is a progressive and potentially fatal tumor. As the fibroblasts proliferate, they encase and may obstruct important retroperitoneal structures. Medical therapy in the past has been ineffectual, and since the tumor usually cannot be resected, surgery consists of lysis or bypass of the involved structures. Tamoxifen is effective in the treatment of desmoid tumors, and we report its use in two patients with retroperitoneal fibrosis with excellent results. The simplicity and safety of this treatment make tamoxifen an attractive choice of therapy.

Biliary lithotripsy

At Baylor University Medical Center in Dallas, we began performing lithotripsy with the Medstone STS lithotripter for gallstones in January 1988 and in the first year treated 81 patients. Fifty-five of these patients were available for 4-month follow-up. We randomized half of the patients to receive ursodeoxycholic acid for 7 days prior to lithotripsy and gave all of the patients ursodeoxycholic acid after lithotripsy. Only 10.4 percent of the patients who contacted us ultimately proved to be candidates for lithotripsy. Gallstone fragmentation occurred in 95 percent of all patients and in 97 percent of those patients with solitary stones under 20 mm in size. The rate of clearance for solitary stones less than 20 mm in size was 50 percent. Unfavorable effects ascribable to lithotripsy were infrequent. All of the patients had pain before treatment, and one-third complained of biliary colic after treatment. Minor skin bruising which resolved in 1 to 5 days was found in 20 percent of the patients. This study lends credence to the findings of previous studies and demonstrates that lithotripsy combined with bile acid therapy is a useful therapy for cholelithiasis.

Biliary lithotripsy in the United States

We have reported the case of a patient whose gallstone was completely fragmented by lithotripsy; all demonstrable particles passed completely within 36 hours. The patient required no analgesics and had no complications from the procedure. This is the first case of gallstones successfully treated solely by a combination of lithotripsy and bile acid therapy in the United States under an FDA-approved IDE protocol.

Cholecystectomy

We retrospectively reviewed 360 consecutive cholecystectomies done by the four surgeons in our private group practice. No patient had dehiscence of the wound or evisceration. One patient had a seroma, which was opened in the office, but the fluid contained no white blood cells or bacteria on smear, and the culture was negative. No deaths occurred during the hospitalization or within 30 days after the operation. Routine perioperative antibiotics were used, and most wounds were drained with closed suction drainage. Routine intraoperative cholangiography was also done. On the basis of the favorable morbidity and mortality in this large group of patients and a review of the literature, we recommend the routine use of antibiotics and cholecystectomy for most patients with gallstones.