Accumulating evidence has suggested that tumors may arise and grow as a result of the formation of a subset cell population termed cancer stem cells (CSC) or tumor initiating cells. Several research reports have indicated that CSCs are relatively resistant to conventional therapies. Thus, therapeutic strategies that specifically target cancer stem cells could have a major impact on cancer patient survival. Patient-derived tumor xenografts (PDX) have played a major role in the development of new cancer therapies. The advantage of PDX over standard cell-line xenograft models is that PDX retain much of the molecular, genetic, and histological heterogeneity of the original tumor and are minimally passed. In addition, self-renewal and lineage differentiation, the hallmarks of cancer stem cells, can be demonstrated through serial transplantation in immunodeficient mice. Our therapeutic approach in cancer stem cell drug discovery has been to target key developmental pathways that have been strongly implicated in cancer including the Notch pathway.

We carried out tumorigenicity studies in three SCLC PDX models utilizing naïve cells positively enriched for either Notch2 or Notch3 expression. In two of the three models, Notch2+ and/or Notch3+ cell populations resulted in enhanced tumor formation. In a SCLC tumor that expressed low levels of Notch3, the Notch2+ population resulted in 70% tumor formation compared to CD44+ (10%) or CD133+ (45%) enriched populations.

We have developed a monoclonal antibody, tarextumab (OMP-59R5), which selectively inhibits the function of both Notch2 and Notch3. Our preclinical data in PDX models demonstrate that tarextumab was efficacious in inhibiting the growth of various indications with minimal intestinal toxicity. Notably, the sensitivity of tarextumab in combination with gemcitabine or gemcitabine plus nab-paclitaxel in pancreatic tumors was associated with higher levels of Notch3 gene expression. Interference with Notch2/3 signaling by tarextumab delays tumor recurrence, decreases cancer stem cell frequency (as determined by in vivo LDA studies) and modulates the function of tumor vasculature.

Our ALPINE Phase 1b clinical trial indicates that tarextumab is generally well-tolerated and shows signs of anti-tumor efficacy and modulation of Notch pathway signaling in the clinic. Furthermore, we observe a higher response rate and longer survival in patients with Notch3 high tumors receiving gemcitabine/nab-paclitaxel/tarextumab combination therapy. Analysis of pre- and post-treatment tumor biopsies showed an inhibition of Notch pathway and CSC gene signatures. Ongoing Phase 2 clinical trials evaluate first-line treatment with tarextumab in metastatic pancreatic cancer (ALPINE) and small cell lung cancer (PINNACLE). Collectively, these results demonstrate the utility of PDX models for discovery and development of anti-cancer stem cell therapeutics, identifying pharmacodynamic endpoints of drug actions, identifying predictive biomarkers for patient stratification, and translating these preclinical findings into clinical trials.

Citation Format: Marcus M. Fischer, Wan-Ching Yen, Fumiko Axelrod, Christopher Bond, Jennifer Cain, Belinda Cancilla, Randall Henner, Rene Meisner, Aaron Sato, Jalpa Shaw, Tracy Tang, Breanna Wallace, Min Wang, Chun Zhang, Ann Kapoun, Lei Zhou, Jakob Dupont, John Lewicki, Austin Gurney, Tim Hoey. Use of patient-derived tumor xenografts (PDX) for discovery and development of an anti-Notch2/3 monoclonal antibody targeting cancer stem cells. [abstract]. In: Proceedings of the AACR Special Conference: Patient-Derived Cancer Models: Present and Future Applications from Basic Science to the Clinic; Feb 11-14, 2016; New Orleans, LA. Philadelphia (PA): AACR; Clin Cancer Res 2016;22(16_Suppl):Abstract nr A41.