Background: The majority of pancreatic ductal adenocarcinoma (PDAC) patients experience disease progression after Gemcitabine-nab-Paclitaxel (GemPac) treatment indicating the need for more effective combination therapies for this highly recalcitrant disease. Earlier we showed that nuclear exporter protein exportin 1 (XPO1) is a valid therapeutic target in PDAC and selective inhibitor of nuclear export (SINE) selinexor (Sel), synergistically enhances the efficacy of GemPac in pancreatic cancer cells, spheroids, patient derived tumors and showed evaluable response in PDAC patients in a Phase I study. Here we investigated the mechanisms of this synergy utilizing PDAC cellular models in vitro and LSL-Kras G12D/+; Trp53 fl/+; Pdx1-Cre (KPC) mouse model.

Methods: We used single-nuclei RNA sequencing in KPC tumors, and poly A RNA sequencing in PDAC cells post sel-Gem-Pac treatment. Prioritized sn-seq and RNA-seq identified molecules were validated in in vitro or in the PDAC patient samples through siRNA mediated silencing, quantitative gene expression, cytotoxicity and related assays.

Results: In KPC model, selinexor-GemPac caused statistically significant enhancement in survival compared to controls (p less than 0.05). Molecular analysis of residual KPC tumors showed re-organization of tumor stromal architecture, suppression of proliferation and nuclear retention of tumor suppressors. Histopathological analysis for Ki67 suggests comparatively lower rate of proliferation and enhanced nuclear accumulation of FOXO3a in the treated mice. Loosening of stroma and lowering of collagen fiber is also evident in treated mice from Picrosirius and Masson’s trichrome staining. Additionally, the KPC derived primary tumor cells showed reduced colony formation upon combination treatment. Sn-seq showed reduction in tumor cell heterogeneity (less cell clusters based on gene expression), CDK8, CD44 and Camk1d stem cell and EMT related genes alongside significant alterations in mitochondrial signaling after combination treatment. In cellular models, GO and GSEA analyses of RNA-seq data predicted DNA templated regulation of transcription and DNA replication associated genes in Sel or Sel-GemPac mediated growth inhibition. The top downregulated genes including drug resistant related gene PFN1 and HSP90 identified in Sel or Sel-GemPac treated PDAC cells from RNA-seq data were validated using RNAi and confirmed their role in synergy.

Conclusions: Taken together Selinexor in combination with Gemcitabine-nab-Paclitaxel enhanced the survival of KPC mice through inhibition of well-connected tumor promoting molecules resulting in broad penetration in PDAC supporting signaling. A phase II study involving selinexor-gemcitabine combination in patients with metastatic PDAC is ongoing.

Citation Format: Md. Hafiz Uddin, Sahar Bannoura, Yiwei Li, Husain Y. Khan, Amro Aboukameel, Mohammed N. Al-Hallak, Rafic Beydoun, Steve Kim, Yosef Landesman, Ramzi M. Mohammad, Anthony Shields, Asfar S. Azmi. Nuclear protein export inhibitor selinexor chemotherapy combination for pancreatic cancer therapy [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 5330.