Abstract 1989: Intratumor heterogeneity in EGFR-mutant lung tumors mediates targeted therapy resistance and formation of drug tolerant microenvironment

Abstract Introduction: Non-small cell lung cancers (NSCLC) harboring EGFR mutations are commonly treated with EGFR tyrosine kinase inhibitors (TKIs), but the emergence of drug resistance often leads to treatment failure. While various acquired resistance mechanisms have been identified, they are not always actionable. Furthermore, since drug resistance is typically studied after cancer relapse, little is known about the cellular or microenvironmental taking place during the formation of resistance at the stage of minimal residual disease (MRD). Therefore, it is necessary to understand the mechanisms leading to resistance during MRD and develop new ways to prevent drug resistance in EGFR-mutant cancers. Methods: In this study, we discovered pre-existing intratumor heterogeneity in EGFR expression within EGFR-mutant NSCLCs and found that patient tumors contain clones with low mutant EGFR expression. To study the effect of this intratumor heterogeneity on drug response, we isolated low and high expressing cells and conducted longitudinal drug challenge assays in ex vivo and in vivo models. To dissect how the observed heterogeneity affects drug resistance and the tumor microenvironment during MRD, we employed patient-derived tumor cells and used novel tumor-on-a-chip co-culture approaches. Results: Our findings reveal that EGFR-low cells are more tolerant to drug treatment and can survive the initial TKI insult, making them more likely to contribute to drug resistance in EGFR-mutant NSCLCs. Additionally, the surviving EGFR-low cells were able to modify the tumor microenvironment leading to fibroblast accumulation and immune suppression, contributing to the drug-tolerant tumor microenvironment. Importantly, we found that pharmacological induction of EGFR using epigenetic inhibitors was able to sensitize the drug tolerant cells to EGFR inhibition, suggesting a potential strategy to overcome TKI resistance in NSCLC patients. Conclusions: In conclusion, our study sheds light on the critical role of intratumoral heterogeneity in treatment resistance and offers valuable insights into potential strategies to overcome this challenge. Our findings suggest that combination therapies that can alter the cellular phenotype during MRD have the potential to prevent intrinsic drug resistance. This underscores the importance of gaining a better understanding of the mechanisms underlying drug-tolerant microenvironment and developing more effective treatment strategies for patients with EGFR-mutant NSCLCs. Citation Format: Heidi M. Haikala, Bassel Alsaed, Jieun Son, Linh Lin, Prafulla Gokhale, Pasi Jänne. Intratumor heterogeneity in EGFR-mutant lung tumors mediates targeted therapy resistance and formation of drug tolerant microenvironment abstract. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts) ; 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84 (6Suppl): Abstract nr 1989.