LAUSR

Synthetic lethal dependencies have recently emerged as tumor-specific vulnerabilities which provide broad therapeutic windows and have successfully been used for rational therapeutic target discovery. Despite intense international efforts over many decades, cure rates for patients with high-risk rhabdomyosarcoma remain dismal. Resistance to intensive chemotherapy is common, and targets for molecular therapies are largely undefined. Telomere maintenance is a hallmark of cancer and requires either activation of telomerase (TERT) or alternative lengthening of telomeres (ALT). ALT is active in a large subset of rhabdomyosarcomas and not active in healthy tissues suggesting it is a unique, tumor-specific process. ALT has recently been shown to depend on DNA damage response activation through the ATR kinase, and studies in osteosarcoma have revealed that ALT renders cancer cells hypersensitive to ATR inhibition. This defines ALT as a tumor-specific synthetic lethal determinant for susceptibility to ATR inhibition. Consistent with previous reports, we observed that ALT-dependent rhabdomyosarcoma cells are hypersensitive to ATR inhibition via AZD6738, a small molecule ATR inhibitor currently being tested in clinical trials. Intriguingly, we found that treatment with ATR inhibitors not only induced DNA damage but also resulted in aneuploidy and subsequent apoptosis in ALT-dependent rhabdomyosarcoma cells, suggesting loss of telomere protection and inadequate chromosomal segregation occur during mitosis upon ATR inhibition. To test this, we measured unrepaired DNA double-strand break formation using TUNEL. ALT-dependent cells, but not TERT-dependent cells, showed increased TUNEL labeling, consistent with an increase in double-stranded DNA breaks and unprotected DNA ends. Consistent with reduced telomere maintenance, ATR inhibition significantly reduced the number of C-circles in rhabdomyosarcoma cells relying on ALT. Furthermore, AZD6738 treatment reduced phosphorylation of known ATR targets, and differentially phosphorylated peptides were enriched for proteins involved in alternative lengthening of telomeres as measured using SILAC labeling and LC-MS/MS phospho-proteomic analysis. Finally, treatment with AZD6738 reduced tumor burden in patient-derived primary rhabdomyosarcoma xenografts, which was potentiated by combined treatment with cisplatin. Our findings delineate a therapeutically actionable DNA repair dependency induced at least in part by ALT and may lead directly to clinical translation of ATR inhibitors for therapy of refractory rhabdomyosarcoma. Citation Format: Heathcliff Dorado Garcia, Jennifer von Stebut, Ian MacArthur, Koshi Imami, Natalie Timme, Kerstin Schoenbeck, Annabell Szymansky, Georg Seifert, Patrick Hundsdoerfer, Andrej Lissat, Matthias Selbach, Angelika Eggert, Johannes Schulte, Anton Henssen. Synthetic lethal targeting of ATR in alternative lengthening of telomeres-dependent rhabdomyosarcoma [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 2628.