The Efficacy of CB-103, a First-in-Class Transcriptional Notch Inhibitor, in Preclinical Models of Breast Cancer

BACKGROUND

The efficacy of CB-103 was evaluated in preclinical models of both ER+ and TNBC. Furthermore, the therapeutic efficacy of combining CB-103 with fulvestrant in ER+ BC and paclitaxel in TNBC was determined.

METHODS

CB-103 was screened in combination with a panel of anti-neoplastic drugs. We evaluated the anti-tumor activity of CB-103 with fulvestrant in ESR1-mutant (Y537S), endocrine-resistant BC xenografts. In the same model, we examined anti-CSC activity in mammosphere formation assays for CB-103 alone or in combination with fulvestrant or palbociclib. We also evaluated the effect of CB-103 plus paclitaxel on primary tumors and CSC in a GSI-resistant TNBC model HCC1187. Comparisons between groups were performed with a two-sided unpaired Students' t-test. A one-way or two-way ANOVA followed by Tukey's post-analysis was performed to analyze the in vivo efficacy study results.

THE RESULTS

CB-103 showed synergism with fulvestrant in ER+ cells and paclitaxel in TNBC cells. CB-103 combined with fulvestrant or paclitaxel potently inhibited mammosphere formation in both models. Combination of CB-103 and fulvestrant significantly reduced tumor volume in an ESR1-mutant, the endocrine-resistant BC model. In a GSI-resistant TNBC model, CB-103 plus paclitaxel significantly delayed tumor growth compared to paclitaxel alone.

CONCLUSION

our data indicate that CB-103 is an attractive candidate for clinical investigation in endocrine-resistant, recurrent breast cancers with biomarker-confirmed Notch activity in combination with SERDs and/or CDKis and in TNBCs with biomarker-confirmed Notch activity in combination with taxane-containing chemotherapy regimens.

CB‐103: A novel CSL‐NICD inhibitor for the treatment of NOTCH‐driven T‐cell acute lymphoblastic leukemia: A case report of complete clinical response in a patient with relapsed and refractory T‐ALL

Relapsed T cell acute lymphoblastic leukaemia (T‐ALL) has a very poor prognosis. A 24‐year‐old patient with relapsed high‐risk T‐ALL (PTEN gene deletion; NOTCH1 mutation), was treated with the NOTCH inhibitor CB‐103. Within 1 week of starting CB‐103, the bone marrow was free of T‐ALL blast infiltration (MRD+) and successfully underwent allogeneic hematopoietic stem cell transplantation (allo‐HSCT). Sequential samples of ctDNA to monitor the disease after allo‐HSCT showed a decrease of circulating Notch1 and PTEN alterations. This is the first T‐ALL patient treated with CB‐103. The observed clinical response encourages further exploration of CB‐103 in ALL.

Abstract 408: Development of a first-in-class notch transcription factor inhibitor CB-103 to overcome resistance to chemotherapy and targeted therapies

Human cancers possess striking ability to develop resistance to Standard of Care (SoC) designed to target specific hallmarks of cancer. This capability to develop resistance is in part due to cancer cell’s ability to activate alternative pathways and modulate tumor microenvironment to enhance cell survival, evade cell death and immunosurveillance. One such mechanism of developing resistance to SoC is the activation of the NOTCH pathway. NOTCH signaling is a developmental pathway which is known to be activated in several human cancers as a key oncogenic hit. In addition to its role as an oncogenic driver, activation of NOTCH is also known to induce resistance to several anti-cancer therapeutics in breast cancer and colorectal cancer. NOTCH signaling is known to cooperate with parallel oncogenic signals to impede activity of several drugs as a single agent. Previous agents targeting the NOTCH pathway upstream of the transcription complex were halted early in clinical development due to dose-limiting toxicities.Here we report activity of a novel first-in-class clinical stage CSL-NICD inhibitor in a panel of cell lines, xenograft and PDX models of human cancers in combination with several chemo and targeted therapies. Guided by in vitro and in vivo studies pre-clinical studies, CB-103 is currently being investigated in clinical trials as a single agent and in combination with SoC. Preliminary pre-clinical and clinical data shows desirable safety and efficacy profile of CB-103 enabling clinical development in combination with several therapeutic agents.

Citation Format: Michele Vigolo, Charlotte Urech, Sebastien Lamy, Samarpan Majumder, Lucio Miele, Rajwinder Lehal. Development of a first-in-class notch transcription factor inhibitor CB-103 to overcome resistance to chemotherapy and targeted therapies [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 408.

Targeting Notch inhibitors to the myeloma bone marrow niche decreases tumor growth and bone destruction without gut toxicity

Systemic inhibition of Notch with γ-secretase inhibitors (GSI) decreases multiple myeloma (MM) tumor growth, but the clinical use of GSI is limited due to its severe gastrointestinal toxicity. In this study, we generated a GSI Notch inhibitor specifically directed to the bone (BT-GSI). BT-GSI administration decreased Notch target gene expression in the bone marrow, but it did not alter Notch signaling in intestinal tissue or induce gut toxicity. In mice with established human or murine MM, treatment with BT-GSI decreased tumor burden and prevented the progression of MM-induced osteolytic disease by inhibiting bone resorption more effectively than unconjugated GSI at equimolar doses. These findings show that BT-GSI has dual anti-myeloma and anti-restorative properties, supporting the therapeutic approach of bone-targeted Notch inhibition for the treatment of MM and associated bone disease.

Phase 1 study of CB-103, a novel first-in-class inhibitor of the CSL-NICD gene transcription factor complex in human cancers

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Background: CB-103 selectively inhibits the CSL-NICD interaction leading to down-regulation of CSL-NICD mediated oncogenic pathway activation downstream of NOTCH receptor/ligand signaling, and has shown potent anti-cancer activity as single agent and in combination with targeted/chemotherapies in preclinical models. The aim of this dose escalation/expansion phase 1/2a study is to assess safety, maximum tolerated dose (MTD) and recommended phase 2 dose (RP2D), preliminary activity, pharmacokinetics and pharmacodynamics of CB-103. Methods: Eligible were adult patients (pts) with advanced or recurrent selected solid tumors. Tumor tissue, where available, was retrospectively tested for NOTCH pathway activating mutations and surrogate tissues were evaluated for gene expression of related target genes. CB-103 was given orally in 28 days cycles at escalating doses until disease progression or toxicity. In a dose confirmatory cohort, NOTCH activation will be prospectively assessed to determine eligibility. Results: Forty-one pts (19 adenoid cystic carcinoma (ACC), 16 colorectal and 4 breast cancer, 2 prostate cancer) were assigned to increasing dose levels starting from 15mg once daily (OD). Median age was 55 years (range 25-76). Median number of prior lines of therapy was 2 (range 0-7). Thirty-two pts in 8 escalation groups completed the 28-day DLT window. One DLT (asymptomatic grade (G) 3 GGT increase) was observed at the highest dose (600mg). Related treatment emergent adverse events (AE) occurring in >10% of pts were nausea (24%), diarrhea (20%), dyspepsia (15%), fatigue (12%) and vision blurred (12%), all G 1/2. No discontinuations occurred due to treatment-related AEs. The MTD has not been reached. Several pts reported vision changes that improved over time and were fully reversible after stopping the drug. Median time on treatment for all pts was 52 days (range 5-249). Best response was stable disease (SD). For ACC pts, preliminary median PFS was 21.7 weeks (95% confidence interval (CI) 13.7-22.4 weeks) and disease control rate (DCR) was 79% at week 8 and 58 % at week 20. Three pts with ACC harboring activating NOTCH alterations had radiologically confirmed stable disease (SD) > 6 months. Importantly, in 3 pts with NOTCH positive disease a temporary stop of tumor growth was observed. One pt showed a reduction in size of a liver lesion up to 25% before progression due to new lesions. Mechanistically, strong on-treatment downregulation of NOTCH target genes was observed. The dose of 600mg CB-103 OD was declared the RP2D. Conclusions: CB-103 is the first drug to effectively control the CSL-NICD transcription complex. CB-103 is well tolerated in pts with advanced tumors and, as expected on the basis of mechanistic studies, in the absence of the typical toxicities associated with Notch targeting GSIs or mABs. The RP2D has been established for advancing clinical development into phase 2. Clinical trial information: NCT03422679.

Notch Inhibition in Cancer: Challenges and Opportunities

Notch is a key oncogenic pathway in several human cancers and to date, no targeted treatment of Notch activated cancers is available to patients. Therapeutic targeting of Notch has been an unresolved challenge due to severe on-target dose limiting toxicities associated with pan-Notch inhibition by either γ-secretase inhibitors or receptor/ligand targeting MAbs. At Cellestia Biotech, we have identified novel series of small molecule inhibitors of the Notch transcription complex. These molecules act as pan-Notch inhibitors and do not cause toxicities commonly associated with first- and second-generation Notch inhibitors currently tested in the clinic, thus providing a novel and unique opportunity to address a high unmet medical need. Our lead molecule, CB-103 is currently being investigated in Phase-1 dose escalation in cancer patients. Cellestia Biothech is further expanding its medicinal chemistry activities advancing the development of novel molecules for targeting transcription factors in cancer as well as non-cancer indications.

Abstract P4-07-05: A novel, first in class Notch transcriptional inhibitor, CB-103 has activity on luminal breast cancer stem cells in combination with fulvestrant

The Notch signaling pathway plays a central role in cellular differentiation, growth and stem cell maintenance. Expression and activation of Notch pathway receptors and ligands have differential outcomes depending on the tissue, localization and cell type. When Notch pathway is aberrantly activated by genetic lesions, it can be a major driver for Notch-dependent cancers and can cause resistance to standard of care treatment. We and others have shown that in Estrogen Receptor (ER)-positive breast cancers, estrogen deprivation caused by endocrine therapy results in Notch1 and Notch4 activation. In turn, Notch1 stimulated ER-dependent transcription in the absence of estrogen, causing endocrine resistance. Combinations of Notch inhibitors and endocrine therapy are effective in preclinical models of ER-positive breast cancer and have shown promising signals in early clinical trials.

Cellestia's lead development candidate CB-103 is a small molecule, first-in-class, oral pan-Notch inhibitor. CB-103 selectively blocks Notch pathway activation-related gene transcription through binding to a Notch specific protein in the transcription factor complex. The blockade occurs by protein-protein interaction inhibition with a binding site critical for the assembly of the Notch transcription complex. This is a unique mode of action, which allows blocking Notch signaling regardless of the genetic lesions which have activated the pathway.

We have performed mammosphere assays to test the potency and efficacy of this compound on stem cell ability to form sphere. We used two different doses of CB-103; either alone or in combination with a fixed dose of Fulvestrant (30nM), a SERD, in our mammosphere assays. Two different ER+ luminal,endocrine resistant cell lines were tested and compared with their parental controls. From our data, it's apparent that there is a synergistic effect when using CB-103 in combination with Fulvestrant. It's also evident that the efficacy of CB-103 is maximal maximizes at the lowest concentration tested in our assays. The combination was effective in 3 out of 4 models. However, the effect of CB-103 on MCF7-TAMR either as a single agent or in combination was not statistically significant.

Cellestia has received regulatory approval to start clinical development with CB-103 in a first-in-human study Phase l – lla study investigating safety (Ph l) and preliminary single agent efficacy (Ph lla) of CB-103 in patients with advanced solid cancers and haematological malignancies. Our data support the notion of testing this agent in ER-positive breast cancer in combination with SERDs.

Citation Format: Majumder S, Crabtree J, Hossain F, Murone M, Lehal R, Miele L. A novel, first in class Notch transcriptional inhibitor, CB-103 has activity on luminal breast cancer stem cells in combination with fulvestrant [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P4-07-05.

Abstract 5799: Characterization and profiling of CB-103, a novel small-molecule protein-protein interaction inhibitor targeting the NOTCH transcription complex

NOTCH signalling is a key development pathway whose aberrant activation is known to play a role in multiple human cancers. In human tumors the NOTCH pathway can be activated by various genetic lesions such over expression of ligands/receptors, GOF mutations in NOTCH receptors, including protein stabilizing mutations in the PEST domain of NOTCH, chromosomal translocations, or loss-of-function mutations in the E3 ubiquitin ligase FBXW7 and other negative regulators of the pathway (SPEN, NUMB). Activation of signalling due to above mentioned mechanisms can be addressed in part using blocking antibodies against NOTCH ligands/receptors or small molecule inhibitors of the gamma secretase enzyme (GSIs). However, in human tumors where NOTCH signalling is constitutively activated due to chromosomal translocations in the NOTCH receptors (NOTCH1 and 2), none of the above-mentioned strategies will be effective. Moreover, due to on-target and off-target toxicities associated with blocking antibodies and GSIs, these anti-NOTCH agents failed to advance in clinical trials, although some of them showed signs of clinical efficacy. Given the role of NOTCH signalling in human tumors, there is a need to identify novel targets in the NOTCH pathway and develop new and more selective anti-NOTCH agents. To inhibit pan-NOTCH signalling in human tumors independently of the mechanisms of NOTCH activation, and in the most downstream part of the pathway, we have previously reported the discovery of a new class of small molecules able to target the NOTCH transcription complex enabling the specific inhibition of NOTCH target gene expression (e.g. cMYC, HES1, DTX1, CCND1). These small molecules act as protein-protein interaction inhibitors, and thereby compromise the assembly of functional NOTCH transcription complex.

Here we present further in vitro and in vivo characterization of the lead molecule CB-103. The anti-cancer activity of CB-103 was extensively profiled in several human cancer cell lines representing NOTCH positive solid tumors, leukemias and lymphomas. Moreover, CB-103 responsiveness of these cell lines correlates with a downregulation of the NOTCH signature following treatment with CB-103. Specifically, we will present data outlining the in vivo pharmacokinetic and pharmacodynamic properties of CB-103.

Citation Format: Rajwinder Lehal, Charlotte Urech, Michele Vigolo, Maximilien Murone, Freddy Radtke. Characterization and profiling of CB-103, a novel small-molecule protein-protein interaction inhibitor targeting the NOTCH transcription complex [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5799.

Abstract B061: Targeting lymphomas with the novel first-in-class pan-NOTCH transcription inhibitor CB-103

Background: NOTCH pathway is recurrently activated in human cancers, including lymphomas, and overactivation of the pathway has been correlated to a worse prognosis in patients with solid tumors, leukemias, and lymphomas, making it an attractive target for treatment (Rossi et al, JEM 2012; Rossi et al, Blood 2012; Kridel et al, Blood 2012). However, so far, pharmacologic approaches to inhibit its activity are limited to the use of nonspecific gamma secretase inhibitors and blocking antibodies with limited application. None of these therapeutic agents have been approved yet for cancer treatment. CB-103 is a novel first-in-class pan-NOTCH inhibitor that blocks signaling by directly and specifically targeting the NOTCH transcription complex, and it has shown preclinical activity in a variety of solid tumor and leukemia models (Lehal et al, AACR 2017). Here, we present the very first results with CB-103 in a large panel of B and T cell lymphoma cell lines. Methods: 58 human lymphoma cell lines [27 diffuse large B cell lymphomas (DLBCL); 9 mantle cell lymphomas; 6 marginal zone lymphomas; 9 T-cell lymphomas; 7 others], 2 murine and 1 canine, were exposed to increasing doses of CB-103 for 72h. Cell proliferation was measured by using the MTT assay. Transcriptome analysis was performed using the Illumina HumanHT 12 Expression BeadChips and with the HTG EdgeSeq Oncology Biomarker Panel, a targeted RNA-Seq investigating over 2500 genes, followed by a limma moderate t-test, and GSEA. Results: CB-103 presented a median IC50 above 20 μM across the whole panel of 61 lymphoma cell lines (range from 400 nM to > 20 μM), without significant differences among lymphoma subtypes. Importantly, 13/58 cell lines had an IC50 <10 μM and were defined as sensitive. These cell lines were derived from ABC DLBCL (3/7, 43%), GCB DLBCL (5/20, 25%), MCL (3/9, 33%), marginal zone lymphoma (1/6, 17%), and canine DLBCL (1/1, 100%). The sensitive cell lines, when compared with those presenting IC50 >10 μM, presented a gene expression signature significantly enriched with genes involved in the epithelial-mesenchymal transition (FDR 0.0014), a Notch-related process. Indeed, the transcripts higher in the sensitive cell lines included, among others, DLL1 (P 0.010; Log Fold Change 2.39), BAMBI (P 0.046; Log Fold Change 0.92), MCM7 (P 0.015; Log Fold Change 1), and ULK1 (P 0.045; Log Fold Change 2.39), all connected to NOTCH pathway. Finally, 10 of the CB-103 sensitive human cell lines were also exposed to another NOTCH inhibitor, the gamma secretase inhibitor LY-3039187, which resulted active only in one MCL cell line, while it had IC50 >20 μM in the other cell lines tested. Conclusions: CB-103 presented in vitro antilymphoma activity in a restricted number of B cell lymphoma cell lines, which were characterized by a NOTCH-related gene expression signature. Further studies with the compound are ongoing and a phase I is planned to start in Q3 2017 (EUDRACT Number 2017-001491-35).

Citation Format: Filippo Spriano, Chiara Tarantelli, Alberto Arribas, Eugenio Gaudio, Luciano Cascione, Luca Aresu, Emanuele Zucca, Davide Rossi, Anastasios Stathis, Maximilien Murone, Dirk Weber, Rajwinder Lehal, Freddy Radtke, Francesco Bertoni. Targeting lymphomas with the novel first-in-class pan-NOTCH transcription inhibitor CB-103 [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2017 Oct 26-30; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Ther 2018;17(1 Suppl):Abstract nr B061.

Abstract 338: A novel small molecule inhibitor of the Notch transcription activation complex

NOTCH signaling is a developmental pathway known to play critical roles during embryonic development as well as for the regulation of self-renewing tissues. Aberrant activation of NOTCH signaling leads to deregulation of the self-renewal process resulting in sustained proliferation, evasion of cell death, loss of differentiation capacity, invasion and metastasis, all of which are hallmarks of cancer. Over activation of NOTCH in human cancers can be a consequence of over expression of NOTCH ligands/receptors, GOF mutations in NOTCH receptors as well as chromosomal translocations leading to constitutive activation of the pathway. Given the importance of Notch signaling in human cancers, several therapeutic approaches have been utilized to block NOTCH signaling. Two of these strategies are; a) the use of monoclonal blocking antibodies (Mabs) against NOTCH ligands and receptors and b) the use of small molecule γ-secretase inhibitors (GSIs). However, these approaches can only be effective if tumor cells express full-length ligand or receptor molecules. On the contrary, in human cancers harbouring NOTCH gene fusion due to chromosomal translocations, the use of Mabs and GSIs will have very limited clinical benefits. A third, yet not fully explored approach could be the blockage of NOTCH signalling by targeting the most downstream event in the NOTCH cascade i,e NOTCH transcriptional activation complex using small molecule inhibitors.

Here we report discovery and identification of a novel, orally-active small molecule inhibitor, named CB-103, of the NOTCH pathway that blocks NOTCH signaling by targeting the NOTCH transcriptional activation complex in the nucleus. CB-103 has shown the ability to block NOTCH signalling in human cancer cell lines, induce neurogenic phenotype in drosophila, induce muscle cell differentiation and inhibit NOTCH dependent cellular processes in mice. In addition, CB-103 exhibit anti-tumor efficacy in a xenograft model of human triple negative breast cancer resistant to GSIs and Mabs against NOTCH ligands/receptors. Furthermore, CB-103 has shown a remarkable activity in PDX models of human T-ALL harbouring activation of the NOTCH pathway. Additional studies are underway on several analogs of CB-103 to determine ADME/PK/PD profile and nominate a development candidate for further clinical development of this novel inhibitor of the NOTCH pathway.

Citation Format: Rajwinder Lehal, Viktoras Frismantas, Sylvain Loubéry, Viktoria Reinmuller, Gerardo Turcatti, Marcos Gonzalez-Gaitan, Jean-Pierre Bourquin, Freddy Radtke. A novel small molecule inhibitor of the Notch transcription activation complex. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 338.

Abstract IA10: Notch signaling and cancer

Cancer can be seen as disease of perturbed self-renewal. In the last decades it became clear that many of the signaling pathways known to be important during embryonic development also play important roles in regulating self-renewing tissues. Deregulation of the self-renewal process results in sustained proliferation, evasion of cell death, loss of differentiation capacity, invasion and metastasis all of which are hallmarks of cancer. The major question is how do these deregulated signaling cascades mechanistically contribute to cancer and are they suitable for targeting therapy?

The Notch pathway is one such cascade required for normal stem cell maintenance and development of different organs. Over activation of this pathway due to mutations in the Notch receptor are found in more than 50% of human T-cell leukemia and deregulated Notch signaling has been shown to promote tumor progression of various organs. The oncogenic mediators of aberrant Notch function in T-ALL and other Notch-driven cancers appear to be manifold and complex. The modulatory function of individual miRNAs in Notch driven T-ALLs has recently been established. However, whether Dicer1-processed miRNAs are essential for Notch-driven T-ALL is currently unknown. We used conditional and inducible genetic loss of function approaches to show that development and maintenance of Notch-driven T-ALL is dependent on Dicer1 function. Lineage tracing experiments revealed that Dicer1 deficiency led to the induction of apoptosis in T-ALL cells whereas cell cycle progression remained unaltered. Through microarray-based miRNA profiling, we identified miR-21 as a previously unrecognized miRNA deregulated in both mouse and human T-ALL. Herein, we demonstrate that miR-21 regulates T-ALL cell survival via repression of the tumor suppressor Pdcd4.

Moreover, we will report on the identification of a novel small molecule inhibitor (CB103) that blocks Notch signaling by interfering with the transcriptional activation complex. The compound CB103 has shown remarkable ability to block Notch signaling in human cancer cell lines as well as primary human T-ALL cells, thus abrogating their proliferative properties. In addition, compound CB103 exhibit in vivo activity as demonstrated by its ability to impinge upon Notch dependent developmental processes and by impeding tumor growth in xenograft models of human leukemia and breast cancer.

Citation Format: Fabian Junker, Rajwinder Lehal, Viktoras Frimantas, Beat C. Bornhauser, Jean-Pierre Bourquin, Ute Koch, Freddy Radtke. Notch signaling and cancer. [abstract]. In: Proceedings of the AACR Special Conference: Developmental Biology and Cancer; Nov 30-Dec 3, 2015; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Res 2016;14(4_Suppl):Abstract nr IA10.

Alzheimer's disease mutations in APP but not γ-secretase modulators affect epsilon-cleavage-dependent AICD production

Pathological amino-acid substitutions in the amyloid precursor protein (APP) and chemical γ-secretase modulators affect the processing of APP by the γ-secretase complex and the production of the amyloid-beta peptide Aβ42, the accumulation of which is considered causative of Alzheimer's disease. Here we demonstrate that mutations in the transmembrane domain of APP causing aggressive early-onset familial Alzheimer's disease affect both γ- and ε-cleavage sites, by raising the Aβ42/40 ratio and inhibiting the production of AICD50-99, one of the two physiological APP intracellular domains (ICDs). This is in sharp contrast to γ-secretase modulators, which shift Aβ42 production towards the shorter Aβ38, but unequivocally spare the ε-site and APP- and Notch-ICDs production. Molecular simulations suggest that familial Alzheimer's disease mutations modulate the flexibility of the APP transmembrane domain and the presentation of its γ-site, modifying at the same time, the solvation of the ε-site.

Stem cells living with a Notch

Notch signaling has been shown over the past few decades to play fundamental roles in a plethora of developmental processes in an evolutionarily conserved fashion. Notch-mediated cell-to-cell signaling is involved in many aspects of embryonic development and control of tissue homeostasis in a variety of adult tissues, and regulates stem cell maintenance, cell differentiation and cellular homeostasis. The focus of this Review is the role of Notch signaling in stem cells, comparing insights from flies, fish and mice to highlight similarities, as well as differences, between species, tissues and stem cell compartments.