LKB1 mutations, especially when combined with KRAS mutations, may define a specific and more aggressive NSCLC subtype. Metformin synergizes with cisplatin against KRAS/LKB1 co-mutated tumors, and may prevent or delay the onset of resistance to cisplatin by targeting CD133 + cancer stem cells. This study lays the foundations for combining metformin with standard platinum-based chemotherapy in the treatment of KRAS/LKB1 co-mutated NSCLC.

We found a trend towards worse overall survival in patients with KRAS/LKB1 co-mutated tumors as compared to KRAS-mutated ones (hazard ratio: 2.02, 95% confidence interval: 0.94–4.35, p = 0.072). In preclinical experiments, metformin produced pro-apoptotic effects and enhanced cisplatin anticancer activity specifically in KRAS/LKB1 co-mutated patient-derived xenografts. Moreover, metformin prevented the development of acquired tumor resistance to 5 consecutive cycles of cisplatin treatment (75% response rate with metformin-cisplatin as compared to 0% response rate with cisplatin), while reducing CD133 + cells.

We retrospectively determined the frequency and prognostic value of KRAS/LKB1 co-mutations in tissue specimens from NSCLC patients enrolled in the TAILOR trial. We generated stable LKB1 knockdown and LKB1-overexpressing isogenic H1299 and A549 cell variants, respectively, to test the in vitro efficacy of metformin. We also investigated the effect of metformin on cisplatin-resistant CD133 + cells in NSCLC patient-derived xenografts.

We hypothesized that activating KRAS mutations and inactivation of the liver kinase B1 (LKB1) oncosuppressor can cooperate to sustain NSCLC aggressiveness. We also hypothesized that the growth advantage of KRAS/LKB1 co-mutated tumors could be balanced by higher sensitivity to metabolic stress conditions, such as metformin treatment, thus revealing new strategies to target this aggressive NSCLC subtype.

By taking advantage of the outcome data obtained in the TAILOR trial, we retrospectively assessed frequency and prognostic value of KRAS/LKB1 co-mutation in advanced NSCLC. Moreover, we evaluated the efficacy of metformin to induce energetic crisis in NSCLC cell lines with different KRAS/LKB1 mutational status. We generated stable LKB1 knockdown and LKB1 overexpressing isogenic H1299 and A549 cells variants, respectively, and tested the hypothesis that KRAS/LKB1 co-mutated tumors are not able to counteract metformin-induced energy crisis, thus undergoing enhanced apoptosis after in vitro treatment. Finally, we exploited NSCLC patient-derived xenografts (PDXs), which closely mimic patients tumors, to investigate therapeutic activity of metformin plus cisplatin combination in the context of LKB1/KRAS co-mutated tumors.

In this study, we hypothesized that the metabolic frailty of KRAS/LKB1 co-mutated NSCLC cells could be exploited pharmacologically by combining drugs that affect cell metabolism with compounds that increase intracellular stress by interfering with DNA replication and repair, such as platinum compounds. To induce metabolic stress, we used the antidiabetic drug metformin, which has revealed interesting antitumor activity in both in vitro and in vivo preclinical studies. Metformin has been reported to be active against ChT-resistant cancer stem cells (CSCs) in different cancer types.Moreover, metformin use in diabetic patients has been associated with reduced risk of several cancers, as well as a better prognosis in patients with advanced malignancies, including NSCLC. The proposed direct anticancer mechanism of metformin likely relies on the inhibition of complex I of the electron transport chain, with the consequent reduction of intracellular adenosine triphosphate levels and the induction of an energetic crisis in tumor cells.However, the antitumor in vitro effects of metformin vary across different cancer types.

Another frequently altered gene in NSCLC is KRAS, whose mutations are usually mutually exclusive with EGFR, ALK and ROS1 mutations, and are found in approximately 25% of all NSCLCs.Decades of intense research to effectively inhibit constitutively active KRAS, or to target its major downstream effectors, led to unsatisfactory clinical results in NSCLC patients.So far, no predictive or prognostic role for KRAS mutations have been consistently documented.Some evidences suggest that specific subgroups of KRAS-mutated tumors with co-mutations in other crucial genes may display specific clinical behavior, such an intrinsically aggressive clinical course or exquisite response/resistance to therapies.NSCLCs with activating KRAS mutations frequently harbor other concurrent mutations in liver kinase B1 (LKB1), long non-coding RNAs (p53), cyclin dependent kinase 4/6 (CDK4/6) genes. In particular, approximately 10% of all NSCLC are co-mutated for both KRAS and LKB1.LKB1 is a tumor suppressor kinase that is involved in regulating cell growth, metabolism, and survival. Its major direct target is the protein kinase AMP-activated catalytic subunit alpha 1 (AMPK), which is activated in conditions of metabolic stress and orchestrates an adaptive metabolic response that aims to spare energy units and nutrients.For example, AMPK phosphorylates and inhibits acetyl-CoA carboxylase alpha (ACC1) and 3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) enzymes, which are involved in fatty acid and cholesterol biosynthesis, two energy-consuming processes. Moreover, by phosphorylating TSC complex subunit 2 (TSC2), AMPK inhibits the mammalian target of rapamycin (mTOR) kinase, with the consequent inhibition of protein synthesis ( Supplementary Fig. 1 ).Recent studies have revealed that KRAS/LKB1 co-mutated pancreatic cancer cells display a “hypermetabolic state” characterized by enhanced glycolysis and serine-glycine-one carbon metabolism.Another preclinical study published by Shackelford et al.has shown that the biguanide phenformin produces meaningful in vitro and in vivo antitumor effects in KRAS/LKB1 co-mutated NSCLC. In particular, the authors of this paper suggested that LKB1 inactivation makes NSCLC cells unable to halt energy and anabolite-consuming processes even in conditions of metabolic stress caused by phenformin, while constitutively active KRAS forces cells to duplicate their DNA and other intracellular structures, thus accelerating energy depletion, damage to intracellular components, and induction of cell apoptosis.

A pooled exploratory analysis of the effect of tumor size and KRAS mutations on survival benefit from adjuvant platinum-based chemotherapy in node-negative non–small cell lung cancer.

Lung cancer is the most frequent cause of cancer-related death worldwide, accounting for more than 1.4 million deaths per year.NSCLC accounts for approximately 85% of all lung cancers, and is poorly sensitive to most of available treatment options, with response rates ranging between 10% and 25% with standard therapies.For the majority of patients with advanced NSCLC, cytotoxic chemotherapy (ChT) remains the cornerstone treatment. In recent years, inhibitors of constitutively active EGFR, ALK receptor tyrosine kinase (ALK) or ROS1 kinases dramatically improved tumor responses and clinical outcomes of patients with mutated tumors.Furthermore, pembrolizumab has recently replaced platinum-containing ChT as the first-line treatment for tumors expressing programmed death ligand 1 in more than 50% of cancer cells.When considered together, targeted therapies and pembrolizumab represent approximately 30% of all first-line treatments, whereas platinum-based ChT remains the preferred first-line option for the remaining patients.

Patient-derived xenografts (PDXs) were established as previously described.The experimental protocol was approved by the C.E.S.A. (Ethical Committee for Animal Experimentation, of the National Cancer Institute Foundation), and animal experimentation was performed following guidelines drawn-up by C.E.S.A. according to the guidelines for the welfare and use of animals in cancer research.PDXs were implanted, starting from a previously established NSCLC PDXs platform in 5-week-old severe combined immune deficiency (SCID) mice.Groups of four mice, bearing a PDX sample in each flank for a total of n = 8 tumors per group were treated once a week for 3 weeks with intraperitoneal injection of 5 mg/kg cisplatin (Teva, Petah Tikva, Israel) and/or daily with 100 mg/kg or 800 mg/kg metformin (per gavage, 2 doses of 50 mg/kg or 400 mg/kg every 10 to 14 hours). Tumor growth was followed by caliper once a week and results were analyzed using GraphPad Prism software (La Jolla, California). Response rate was calculated as previously decribed.Mice were weighed twice a week and no weight loss was observed ( Supplementary Fig. 2 ). Serial transplantation experiment was performed as previously reported.

Patient-derived xenografts of non small cell lung cancer: resurgence of an old model for investigation of modern concepts of tailored therapy and cancer stem cells.

The human NSCLC cell lines A549 (KRAS/LKB1) and H1299 (KRAS/LKB1) were obtained from the American Type Culture Collection. Cells were cultured in Roswell Park Memorial Institute (RPMI)–1640 medium (Lonza, Basel, Switzerland), supplemented with 10% (volume/volume) fetal bovine serum (Lonza) and a solution of 100 U/mL penicillin and 100 U/mL streptomycin (Lonza). For cellular assays see Supplementary Material and Methods

Only KRAS-mutated tumors were considered for the present analysis. The chi-squared test was used to analyze the associations between LKB1 status and different clinical variables. PFS was defined as the time from the randomization up to the date of progression or death from any cause, whichever came first. OS was defined as the time from randomization up to the date of death from any cause. Subjects who had not progressed or died while on study were censored at the last disease assessment date. Survival curves were estimated with the Kaplan-Meier method, and statistical significance between survival curves was assessed through the log-rank test. Cox proportional hazards models were used to assess at univariate and multivariable (adjusted for Eastern Cooperative Oncology Group performance status [ECOG-PS], sex, histotype, smoking history, and treatment arm) analysis the association of specific mutational profiles with patient PFS and OS. Results were expressed as hazard ratios (HRs) and their corresponding 95% confidence intervals (95% CIs). All statistical tests were two-sided and a p < 0.05 was considered statistically significant. Statistical analyses were performed using SAS version 9.4 (SAS Institute, Cary, North Carolina).

TAILOR ( ClinicalTrials.gov , trial number NCT00637910 ) was a nonprofit multicenter, open label, randomized trial, funded by the Italian Regulatory Agency AIFA and conducted by 52 Italian hospitals. The clinical results of the TAILOR trial have been published.Patients with EGFR wild-type (WT) and known KRAS mutational status progressing after platinum-based chemotherapy were randomized in a phase 3 trial to receive either docetaxel or erlotinib as their second-line therapy. The primary endpoint of the trial was overall survival (OS) after second-line treatment. Secondary endpoints included progression-free survival (PFS) and objective response rate. A pre-specified analysis was conducted also for the first-line outcomes.The protocol was approved by the human investigational review board at each participating site, and voluntary written informed consent was obtained from each patient. All experiments were performed in accordance with the Declaration of Helsinki. The remaining fractions of tissue samples collected at patient enrollment in the TAILOR study were used for the present one.

Value of KRAS as prognostic or predictive marker in NSCLC: results from the TAILOR trial.

Altogether, these data suggest that the MC combination can specifically target CD133 + cells in KRAS/LKB1 co-mutated NSCLC PDXs, thus preventing or delaying resistance to cisplatin.

Based on our in vitro findings in A549 and H1299 cells, we hypothesized that metformin synergizes with cisplatin to kill the population of chemoresistant CSCs, which can repopulate the tumor by progressively increasing the number of chemoresistant cells. To test this hypothesis, we analyzed the content of CD133cells in PDX73 LKB1/KRAS co-mutated tumors during serial transplantation experiments. Fluorescence-activated cell sorting analysis of tumors after the first cycle of treatment showed enrichment of CD133cells in cisplatin-treated as compared to vehicle-treated tumors. This enrichment was partially reverted by metformin-cisplatin (MC) combination (0.94%, 1.95%, and 1.25% CD133cells in vehicle-, cisplatin-, and MC-treated tumors, respectively). CSC enrichment in cisplatin-treated tumors, as well as CSC decrease in MC-treated ones, was also observed after the second treatment cycle (0.84%, 2.22%, and 0.47% CD133cells in vehicle-, cisplatin-, and MC-treated tumors, respectively). After four treatment cycles, that is, when tumors treated with cisplatin alone had become almost completely cisplatin-resistant, we no longer detected any CD133enrichment in cisplatin-treated tumors, whereas a decrease in CD133CSCs was still appreciable in MC-treated ones (0.91%, 0.78%, and 0.38% CD133cells in vehicle-, cisplatin-, and MC-treated tumors, respectively) ( Figs. 4 A and B). Moreover, the time needed by tumors to reach the target volume of 150 mm(lag time) progressively increased in tumors treated with the MC combination compared to the lag time of vehicle- or cisplatin-treated tumors ( Fig. 4 C). A similar effect of metformin in reducing CSCs was also appreciable in LKB1PDX111, although it was less pronounced (33.7% decrease of the 2,2-fold cisplatin-induced CSCs enrichment and 69.3% decrease of the 2.1-fold CSCs enrichment observed in PDX111 and PDX73, respectively) ( Fig. 4 D).

Fluorescence-activated cell sorting (FACS) analysis of tumor samples from KRAS/LKB1 co-mutated PDX73 tumors treated with cisplatin or cisplatin and metformin during the serial transplantation experiment. (A, B) CD133 + CSCs percentage increases at each passage in the cisplatin-treated tumors and this CSCs enrichment is counteracted in the cisplatin-and-metformin– treated tumors. In the last serial passage, when tumors became completely resistant to treatment, cisplatin effects are no more appreciable in terms of CSCs enrichment, whereas in the cisplatin-and-metformin–treated tumors a decrease of CSCs percentage is appreciable. (C) Tumors lag time (time tumors need to reach 150 mm 3 volume after implant) gradually increases in cisplatin-and-metformin–treated tumors compared to both controls and cisplatin-treated tumors. (D) A similar effect on counteracting cisplatin-induced CSCs enrichment is appreciable also in KRAS G12V /LKB1 WT PDX111. LKB1, liver kinase B1.

Figure 4 Fluorescence-activated cell sorting (FACS) analysis of tumor samples from KRAS/LKB1 co-mutated PDX73 tumors treated with cisplatin or cisplatin and metformin during the serial transplantation experiment. (A, B) CD133 + CSCs percentage increases at each passage in the cisplatin-treated tumors and this CSCs enrichment is counteracted in the cisplatin-and-metformin– treated tumors. In the last serial passage, when tumors became completely resistant to treatment, cisplatin effects are no more appreciable in terms of CSCs enrichment, whereas in the cisplatin-and-metformin–treated tumors a decrease of CSCs percentage is appreciable. (C) Tumors lag time (time tumors need to reach 150 mm 3 volume after implant) gradually increases in cisplatin-and-metformin–treated tumors compared to both controls and cisplatin-treated tumors. (D) A similar effect on counteracting cisplatin-induced CSCs enrichment is appreciable also in KRAS G12V /LKB1 WT PDX111. LKB1, liver kinase B1.

These data suggest that metformin is able not only to acutely boost the anticancer effects of cisplatin, but also to progressively reduce the occurrence of chemoresistance in a KRAS/LKB1 co-mutated preclinical model.

Primary or acquired resistance to cytotoxic ChT is a common and apparently insurmountable problem for patients with advanced NSCLC. To investigate if metformin affects tumor sensitivity throughout subsequent cycles of cisplatin treatment, we performed a serial transplantation experiment. After five serial transplantations and 5 cycles of cisplatin treatment, PDX73 (LKB1/KRAS) became almost completely resistant to ChT. On the contrary, 5 cycles of metformin and cisplatin combination produced long-lasting effects in terms of tumor volume shrinkage ( Fig. 3 E and Supplementary Table 4 ). The response rate of tumors treated with cisplatin progressively decreased after each serial transplantation cycle (50% of cases underwent progression of disease (PD) and 50% partial response at first cycle, whereas 100% of tumors showed PD at the fifth cycle). Conversely, the metformin-cisplatin combination progressively increased tumor response rate across subsequent treatment cycles (50% PD and 50% partial response at first cycle versus 12.5% PD and 37.5% PR; 12.5% complete response and 37.5% maintained complete response at fifth cycle) ( Fig. 3 F).

Altogether, these data suggest that metformin differentially affects NSCLC cell growth and survival in a way that depends on LKB1 and KRAS mutational status: in particular, high-dose metformin halts tumor growth by inhibiting cancer cell proliferation in KRAS-mutated LKB1-WT NSCLC, while it promotes apoptosis of LKB1/KRAS co-mutated NSCLC cells. Moreover, LKB1/KRAS co-mutated tumors are specifically sensitive to the cisplatin-metformin combination.

When we increased metformin dosage to 800 mg/kg daily, tumor growth was inhibited comparably to the 100 mg/kg dosage in PDX111 (49.0 ± 25.5% MGI), whereas dose-dependent decrease in tumor volume was appreciable in PDX73 (41.1 ± 11.7% MGI) ( Fig. 3 C). Increasing metformin dosages was associated with progressive and dose-dependent decrease in Ki67 expression in PDX111, and a dramatic increase in cleaved caspase 3 positivity in PDX73 model ( Fig. 3 B). Moreover, a more intense expression of pAMPK in PDX111 compared with PDX73 tumors after 800 mg/kg metformin treatment was appreciable ( Supplementary Fig. 5 ), suggesting the involvement of AMPK in the response of tumors to the biguanide. Finally, metformin synergized with cisplatin to reduce tumor size specifically in the PDX73 model ( Fig. 3 D and Supplementary Table 3 ), thus recapitulating results obtained with in vitro experiments.

To assess the in vivo effects of LKB1 inactivation on metformin-induced apoptosis in KRAS-mutated NSCLC, we treated the following two PDXs models: PDX111 (KRAS/LKB1) and PDX73 (KRAS/ LKB1). Low metformin dosages (100 mg/kg daily) partially inhibited tumor growth in LKB1PDX111 (50.5 ± 14.8% maximal growth inhibition [MGI]), but not in LKB1-mutated PDX73 (MGI of 21.8 ± 19.9%) ( Fig. 3 A). No apoptosis induction was appreciable in PDX111 tumors, whereas metformin increased the levels of cleaved caspase 3 in the LKB1/KRAS co-mutated PDX73 model ( Fig. 3 B) despite the lack of meaningful tumor shrinkage. Moreover, loss of LKB1 in PDX73 was associated with increased tumor necrosis following metformin treatment, suggesting an impaired capacity of LKB1-deficient tumor to adapt to the metabolic stress caused by biguanide therapy ( Fig. 3 B).

In vivo treatments of PDX111 (KRAS G12V /LKB1 WT ) and PDX73 (KRAS G12V /LKB1 K287X ). (A) Metformin induces a slight decrease in tumor growth at 100 mg/kg daily dosage in PDX111, and has no effects on tumor growth at 100 mg/kg daily dosage in PDX73. (B) Immunohistochemistry analysis cleaved caspase 3 and Ki-67 expression of treated PDXs. Cleaved caspase 3 expression in PDX111 remains stable upon metformin treatments both at 100 mg/kg (average of 600 positive cells/quadrant) and at 800 mg/kg (750 positive cell/quadrant). On the contrary, Ki-67 expression gradually decreases with increasing metformin doses (920, 615, 550 positive cells/quadrant in untreated, 100 mg/kg and 800 mg/kg metformin-treated tumors, respectively). In the KRAS/LKB1 co-mutated PDX73, metformin induces an increase of apoptosis, as shown by a gradual increase in cleaved caspase 3 with increasing metformin dosage (80, 150, 750 positive cells/quadrant in untreated, 100 mg/kg and 800 mg/kg metformin-treated tumors, respectively); whereas Ki-67 expression remains at levels comparable with those of untreated tumors (950, 950, 1000 positive cells/quadrant in untreated, 100 mg/kg and 800 mg/kg metformin- treated tumors, respectively). Hematoxylin-eosin staining shows necrotic areas (highlighted with an asterisk [*]) only in double-mutated PDX73 upon metformin treatment. (C) Increasing metformin dosage to 800 mg/kg daily, a dose-dependent effect of biguanide treatment on PDX growth is appreciable only in KRAS/LKB1 co-mutated PDX73. (D) Metformin treatment (800 mg/kg) ameliorates cisplatin effects only in KRAS/LKB1 co-mutated PDX73, whereas no differences between metformin alone, cisplatin alone, or a combination of the two are appreciable in LKB1 wild-type PDX111. (E) Serial transplantation and serial treatment cycles of cisplatin or cisplatin and metformin combination in KRAS/LKB1 co-mutated PDX73. Cisplatin-treated tumors progressively become resistant to treatments, whereas effects of the combination of cisplatin and metformin last for 5 cycles with a progressive increase in the response rate (F). LKB1, liver kinase B1.

Figure 3 In vivo treatments of PDX111 (KRAS G12V /LKB1 WT ) and PDX73 (KRAS G12V /LKB1 K287X ). (A) Metformin induces a slight decrease in tumor growth at 100 mg/kg daily dosage in PDX111, and has no effects on tumor growth at 100 mg/kg daily dosage in PDX73. (B) Immunohistochemistry analysis cleaved caspase 3 and Ki-67 expression of treated PDXs. Cleaved caspase 3 expression in PDX111 remains stable upon metformin treatments both at 100 mg/kg (average of 600 positive cells/quadrant) and at 800 mg/kg (750 positive cell/quadrant). On the contrary, Ki-67 expression gradually decreases with increasing metformin doses (920, 615, 550 positive cells/quadrant in untreated, 100 mg/kg and 800 mg/kg metformin-treated tumors, respectively). In the KRAS/LKB1 co-mutated PDX73, metformin induces an increase of apoptosis, as shown by a gradual increase in cleaved caspase 3 with increasing metformin dosage (80, 150, 750 positive cells/quadrant in untreated, 100 mg/kg and 800 mg/kg metformin-treated tumors, respectively); whereas Ki-67 expression remains at levels comparable with those of untreated tumors (950, 950, 1000 positive cells/quadrant in untreated, 100 mg/kg and 800 mg/kg metformin- treated tumors, respectively). Hematoxylin-eosin staining shows necrotic areas (highlighted with an asterisk [*]) only in double-mutated PDX73 upon metformin treatment. (C) Increasing metformin dosage to 800 mg/kg daily, a dose-dependent effect of biguanide treatment on PDX growth is appreciable only in KRAS/LKB1 co-mutated PDX73. (D) Metformin treatment (800 mg/kg) ameliorates cisplatin effects only in KRAS/LKB1 co-mutated PDX73, whereas no differences between metformin alone, cisplatin alone, or a combination of the two are appreciable in LKB1 wild-type PDX111. (E) Serial transplantation and serial treatment cycles of cisplatin or cisplatin and metformin combination in KRAS/LKB1 co-mutated PDX73. Cisplatin-treated tumors progressively become resistant to treatments, whereas effects of the combination of cisplatin and metformin last for 5 cycles with a progressive increase in the response rate (F). LKB1, liver kinase B1.

Role of LKB1 in the In Vivo Response to Cisplatin and Metformin Cotreatment in NSCLC PDXs

Altogether, these data indicate a role for functional LKB1 in preventing metformin-induced apoptosis and enhancement of cisplatin cytotoxic effects, especially in a KRAS-mutated background.

Having established that LKB1/KRAS co-mutation has no significant prognostic value in advanced NSCLC patients, we investigated the ability of metformin to selectively target LKB1/KRAS co-mutated NSCLC cells in vitro. To this aim, we treated A549 (a model of LKB1/KRAS co-mutated NSCLC) and H1299 (a model of LKB1/KRASNSCLC) cells with increasing metformin concentrations and assessed cell growth rate. Metformin inhibited growth to a similar extent in both cell lines, irrespective of the mutational status of KRAS and LKB1. At high metformin concentration (250 mmol/L), growth was almost completely inhibited, and the lowest concentration that showed a partially inhibitory effect was 50 mmol/L ( Fig. 2 A). Metformin also reduced mitochondrial membrane potential in both cell lines ( Supplementary Fig. 4 A). We then investigated if metformin induced differential pro-apoptotic effects depending on KRAS and LKB1 mutational status. To do so, we determined the percentage of annexin V positivity in untreated and in metformin-treated cells. Interestingly, 50 mmol/L metformin caused higher apoptosis rates in A549 cells (10-fold increase in metformin-treated cells compared to control cells) than in H1299 cells (7.6-fold increase) ( Fig. 2 B), whereas cell cycle arrest in the G1 phase was only induced in H1299 cells ( Supplementary Fig. 4 B). This difference in the apoptotic rate among the two cell lines was further exacerbated with a metformin concentration of 250 mmol/L (46.2-fold increase and 18.5-fold increase in A549 and H1299, respectively) ( Fig. 2 B). To investigate if this differential sensitivity to metformin-induced apoptosis actually depends on the mutation status of KRAS and LKB1 genes, we generated A549 LKB1cells and H1299 cells with different KRAS and LKB1 status (KRAS/LKB1, KRAS/LKB1, KRAS/LKB1, or KRAS/LKB1). However, because metformin concentrations used in previous experiments are highly super-physiological and cannot be reached in vivo without causing potentially lethal toxicities, we explored lower metformin concentrations in combination with cisplatin, the reference compound for the first-line treatment of advanced NSCLC. In parental A549 cells, relatively low metformin concentration (5 mmol/L) significantly enhanced cisplatin-induced apoptosis (9-fold and 17-fold annexin V positivity increase compared to controls in cisplatin-treated and cisplatin plus metformin-treated cells, respectively), whereas this effect was absent in A549 LKB1cells ( Fig. 2 C). Similar results were obtained with H1299 isogenic cell lines, where 5 mmol/L metformin enhanced cisplatin-induced apoptosis specifically in double mutated H1299-KRAS/LKB1cells (1.2-fold and 12.1-fold annexin V positivity increase compared to controls in cisplatin treated and cisplatin and metformin treated cells, respectively). Noticeably, A549 LKB1cells showed a fold change in annexin V positive cells similar to that observed in H1299cells (2- and 1.2-fold increase, respectively) and A549 cells showed a fold change comparable to that of H1299cells (17- and 12.1-fold increase, respectively) ( Fig. 2 D) when treated with the combination of cisplatin and metformin. Moreover, metformin was able to counteract cisplatin-induced increase of CD133CSCs in both A549 and H1299 cell lines (48% and 44% average prevention of cisplatin-induced enrichment, respectively ( Supplementary Fig. 4 C).

Effects of metformin on A549 (KRAS G12S /LKB1 del ) and H1299 (KRAS WT /LKB1 WT ) NSCLC cell line. (A) Dose-effect curve shows that both cell lines are affected by biguanide treatment in a similar way in terms of number of live cells after 24 hours of treatment. (B) Annexin V staining shows that 50 mmol/L metformin treatment for 24 hours induces a 10-fold increase and 7.6-fold increase of apoptosis induction in A549 and H1299 cells, respectively. These differences are exacerbated with 250 mmol/L metformin treatment for 24 hours where the biguanide induces a 46.2-fold increase and 18.5-fold increase in A549 and H1299 cells, respectively. *p < 0.05; **p < 0.01 compared to controls; #p < 0.05; ##p < 0.01 compared to 50 mM metformin. (C) Metformin increases apoptosis induced by cisplatin in A549 transfected with control plasmid (pBABE) but not in A549 cells with ectopic expression of wild-type LKB1 (LKB1 WT ) *p < 0.05; **p < 0.01; compared to untreated control. §§§p < 0.001 LKB1 WT compared to pBABE cells. ###p < 0.001 cisplatin-treated compared to cisplatin and metformin treated. (D) Metformin increases apoptosis induced by cisplatin treatment only in isogenic H1299 KRAS G12C /LKB1 del cell line. *p < 0.05; compared to control cells #p < 0.01; cisplatin-treated compared to cisplatin-and-metformin treated cells. pBABE, control plasmid; LKB1, liver kinase B1.

Figure 2 Effects of metformin on A549 (KRAS G12S /LKB1 del ) and H1299 (KRAS WT /LKB1 WT ) NSCLC cell line. (A) Dose-effect curve shows that both cell lines are affected by biguanide treatment in a similar way in terms of number of live cells after 24 hours of treatment. (B) Annexin V staining shows that 50 mmol/L metformin treatment for 24 hours induces a 10-fold increase and 7.6-fold increase of apoptosis induction in A549 and H1299 cells, respectively. These differences are exacerbated with 250 mmol/L metformin treatment for 24 hours where the biguanide induces a 46.2-fold increase and 18.5-fold increase in A549 and H1299 cells, respectively. *p < 0.05; **p < 0.01 compared to controls; #p < 0.05; ##p < 0.01 compared to 50 mM metformin. (C) Metformin increases apoptosis induced by cisplatin in A549 transfected with control plasmid (pBABE) but not in A549 cells with ectopic expression of wild-type LKB1 (LKB1 WT ) *p < 0.05; **p < 0.01; compared to untreated control. §§§p < 0.001 LKB1 WT compared to pBABE cells. ###p < 0.001 cisplatin-treated compared to cisplatin and metformin treated. (D) Metformin increases apoptosis induced by cisplatin treatment only in isogenic H1299 KRAS G12C /LKB1 del cell line. *p < 0.05; compared to control cells #p < 0.01; cisplatin-treated compared to cisplatin-and-metformin treated cells. pBABE, control plasmid; LKB1, liver kinase B1.

Thirteen patients (9.7% of all patients and 27.7% of KRAS-mutated patients) harbored mutations in both KRAS and LKB1 genes. Among different variables explored, we only found a positive association between double KRAS/LKB1 co-mutations and low-grade tumors (p = 0.004) ( Table 1 ). At a median follow-up of 63 months, 46 patients had progressed (44 died and 2 experienced disease progression without death). Among patients with KRAS-mutated tumors, median PFS for LKB1-mutated and LKB1-WT patients was 2.7 and 3.4 months, respectively ( Fig. 1 A). LKB1 status was nonsignificantly associated with PFS at both univariable analysis (HR: 1.62, 95% CI: 0.82–3.19, p = 0.163) and multivariate analysis, which adjusted for ECOG-PS, sex, histotype, smoking history, and treatment arm (HR: 1.77, 95% CI: 0.85–3.68, p = 0.125) ( Table 2 ). Differences in median OS were more discernible: 4.4 and 10.5 months for KRAS/LKB1 co-mutated and KRAS-mutated LKB1-WT patients, respectively ( Fig. 1 B). As in the case of PFS, the association between LKB1 status and patient OS was non-statistically significant at both univariable and multivariable analysis (HR: 1.78, 95% CI: 0.90–3.52, p = 0.095; HR: 2.02, 95% CI: 0.94–4.35, p = 0.072 for univariate and multivariate analysis, respectively) ( Table 2 ). Kaplan Meier curves for PFS and OS are depicted in Figures 1 A and B, respectively.

Kaplan Meier curves for progression-free survival (A) and overall survival (B) in KRAS MUT /LKB1 WT versus KRAS MUT /LKB1 MUT patients enrolled within the TAILOR trial. Hazard ratio: univariate (unadjusted) and multivariate (adjusted for ECOG-PS, sex, histotype, smoking history and treatment arm). WT, wild-type; LKB1, liver kinase B1; HR, hazard ratio; Chi2, chi squared; CI, confidence interval; ECOG-PS, Eastern Cooperative Oncology Group performance status.

Figure 1 Kaplan Meier curves for progression-free survival (A) and overall survival (B) in KRAS MUT /LKB1 WT versus KRAS MUT /LKB1 MUT patients enrolled within the TAILOR trial. Hazard ratio: univariate (unadjusted) and multivariate (adjusted for ECOG-PS, sex, histotype, smoking history and treatment arm). WT, wild-type; LKB1, liver kinase B1; HR, hazard ratio; Chi2, chi squared; CI, confidence interval; ECOG-PS, Eastern Cooperative Oncology Group performance status.

To investigate if KRAS/LKB1 co-mutated tumors represent a distinct subgroup of NSCLC endowed with higher clinical aggressiveness, we retrospectively analyzed data from 222 patients enrolled in the TAILOR trial between October 2007 and March 2012. Of these, 134 tumor tissue specimens were available for further molecular analyses ( Supplementary Fig. 3 ). The main characteristics of our cohort of patients are summarized in Table 1 . In particular, 47 patients (35.1%) had KRAS-mutated tumors, whereas LKB1 mutations were found in 21 (15.7%) patients ( Supplementary Tables 1 and 2 ).

Discussion

5 Herbst R.S.

Heymach J.V.

Lippman S.M. Lung cancer. , 29 Brunelli L.

Caiola E.

Marabese M.

Broggini M.

Pastorelli R. Comparative metabolomics profiling of isogenic KRAS wild type and mutant NSCLC cells in vitro and in vivo. 6 Jänne P.A.

Shaw A.T.

Pereira J.R.

et al. Selumetinib plus docetaxel for KRAS-mutant advanced non–small-cell lung cancer: a randomised, multicentre, placebo-controlled, phase 2 study. , 7 Heavey S.

O’Byrne K.J.

Gately K. Strategies for co-targeting the PI3K/AKT/mTOR pathway in NSCLC. 8 Meng D.

Yuan M.

Li X.

et al. Prognostic value of K-RAS mutations in patients with non–small cell lung cancer: a systematic review with meta-analysis. , 9 Cuffe S.

Bourredjem A.

Graziano S.

et al. A pooled exploratory analysis of the effect of tumor size and KRAS mutations on survival benefit from adjuvant platinum-based chemotherapy in node-negative non–small cell lung cancer. , 10 Garassino M.C.

Martelli O.

Broggini M.

et al. Erlotinib versus docetaxel as second-line treatment of patients with advanced non–small-cell lung cancer and wild-type EGFR tumours (TAILOR): a randomised controlled trial. , 30 Marabese M.

Ganzinelli M.

Garassino M.C.

et al. KRAS mutations affect prognosis of non–small-cell lung cancer patients treated with first-line platinum containing chemotherapy. , 31 Piva S.

Ganzinelli M.

Garassino M.C.

et al. Across the universe of K-RAS mutations in non–small-cell-lung cancer. KRAS oncogenic mutations are found in approximately 20% to 25% of NSCLCs, and are implicated in the stimulation of cancer cell growth, proliferation, and metabolic reprogramming.However, despite decades of intense research, no truly active therapies to target constitutively active KRAS have been found yet.The prognostic role of KRAS mutations remains debatable, and the different genetic variants described so far are not clearly associated with specific clinical behaviors.

13 Calles A.

Sholl L.M.

Rodig S.J.

et al. Immunohistochemical Loss of LKB1 is a biomarker for more aggressive biology inKRAS-mutant lung adenocarcinoma. , 14 Skoulidis F.

Byers L.A.

Diao L.

et al. Co-occurring genomic alterations define major subsets of KRAS-mutant lung adenocarcinoma with distinct biology, immune profiles, and therapeutic vulnerabilities. , 15 Sanchez-Cespedes M.

Parrella P.

Esteller M.

et al. Inactivation of LKB1 / STK11 is a common event in adenocarcinomas of the lung. 10 Garassino M.C.

Martelli O.

Broggini M.

et al. Erlotinib versus docetaxel as second-line treatment of patients with advanced non–small-cell lung cancer and wild-type EGFR tumours (TAILOR): a randomised controlled trial. 32 Shen Z.

Wen X.F.

Lan F.

Shen Z.Z.

Shao Z.M. The tumor suppressor gene LKB1 is associated with prognosis in human breast carcinoma. , 33 Bonanno L.

De Paoli A.

Zulato E.

et al. LKB1 expression correlates with increased survival in patients with advanced non–small cell lung cancer treated with chemotherapy and bevacizumab. 17 Garcia D.

Shaw R.J. AMPK: Mechanisms of cellular energy sensing and restoration of metabolic balance. Our working hypothesis is that genetic alterations co-occurring with KRAS activating mutations may define NSCLC subgroups characterized by different prognosis and/or response to specific treatments, possibly opening up new possibilities of therapies targeted to specific populations of KRAS-mutated NSCLC patients. For instance, mutations in LKB1, p53, and CDK4/6 co-occur with KRAS mutations in a clinically meaningful percentage of NSCLCs, and a negative prognostic role of KRAS/LKB1 co-mutations in NSCLC has been recently reported.Consistently with these findings, we found that NSCLC patients with tumors bearing KRAS/LKB1 co-mutations, and receiving second-line treatment within the TAILOR trial, had a trend towards poorer PFS and OS when compared to patients with KRAS-only mutated tumors.Based on our results, LKB1 mutations may define a more aggressive subset of KRAS-mutated NSCLC, as previously reported.Higher aggressiveness of LKB1-mutated tumors could result from the loss of LKB1 oncosuppressive function, which is involved in regulating cancer cell growth and proliferation on the basis of nutrient availability.LKB1 loss, as caused by inactivating mutations or deletions of the LKB1 gene, could make cancer cells unresponsive to nutrient starvation and energetic stress, thus accelerating their growth even when nutrients (e.g., glucose, amino acid) are scarce. When combined with activating mutations in oncogenes, such as KRAS, which stimulates unrestrained cell growth, proliferation and energy-requiring anabolic processes, LKB1 inactivation may confer a particularly aggressive clinical phenotype associated with reduced patient survival.

WT/LKB1WT cells (H1299) or in the KRASMUT/LKB1WT PDX (PDX111), where the activation of the LKB1/AMPK signaling pathway reduces cell proliferation, thus reducing metabolic requirements and preventing metabolic crisis in cancer cells. 21 Owen M.R.

Doran E.

Halestrap A.P. Complex 1 of the mitochondrial respiratory chain. 11 Shackelford D.B.

Abt E.

Gerken L.

et al. LKB1 inactivation dictates therapeutic response of non-small cell lung cancer to the metabolism drug phenformin. 11 Shackelford D.B.

Abt E.

Gerken L.

et al. LKB1 inactivation dictates therapeutic response of non-small cell lung cancer to the metabolism drug phenformin. In our preclinical experiments, we tested the hypothesis that LKB1 mutations, which are associated with aggressive growth phenotype in the absence of an effective anticancer treatment, may confer metabolic frailty to tumors with KRAS-induced deregulation of cell growth and proliferation. We showed that supra-physiological dosages of metformin, which causes energetic stress in cancer cells by interfering with mitochondrial activity, selectively induce apoptosis in KRAS/LKB1 co-mutated models (A549 cells and PDX73), but not in KRAS/LKB1cells (H1299) or in the KRAS/LKB1PDX (PDX111), where the activation of the LKB1/AMPK signaling pathway reduces cell proliferation, thus reducing metabolic requirements and preventing metabolic crisis in cancer cells.This result was not surprising because recently published data have shown a meaningful pro-apoptotic effect of the biguanide phenformin, a more potent analog of metformin, specifically in KRAS/LKB1 co-mutated NSCLC cells.However, both in Shackelford et al.and in our study, the biguanide dosages used are by far too high to be reached in the plasma of cancer patients.

In the perspective of future clinical applications, our main finding is that metformin is capable of enhancing cisplatin-induced in vitro pro-apoptotic and in vivo antitumor effects specifically in KRAS/LKB1 co-mutated tumors. Moreover, metformin prevented secondary resistance to cisplatin and actually progressively enhanced cisplatin-induced antitumor effects specifically against KRASG12V/LKB1K287X NSCLC in vivo models.

+ cells, which we previously reported to represent a highly tumorigenic, cisplatin-resistant cell subpopulation enriched of cancer initiating cells with high disseminating potential. 28 Moro M.

Bertolini G.

Pastorino U.

Roz L.

Sozzi G. Combination treatment with all-trans retinoic acid prevents cisplatin-induced enrichment of CD133+ tumor-initiating cells and reveals heterogeneity of cancer stem cell compartment in lung cancer. , 34 Bertolini G.

Roz L.

Perego P.

et al. Highly tumorigenic lung cancer CD133+ cells display stem-like features and are spared by cisplatin treatment. The possibility that the safe and low-cost drug metformin prevents or substantially delays the onset of secondary resistance to platinum-based ChT is highly relevant from a clinical point of view and is worth being explored in the clinical setting. In the clinical setting, cisplatin-based combinations (with pemetrexed or gemcitabine) are the standard first-line options to treat NSCLCs lacking specific oncogenic addiction or strong programmed death ligand 1 expression. Although in this study we did not explore the effects of metformin in combination with platinum-based doublet chemotherapy, our findings are significant because cisplatin represents the compounds with the most relevant anticancer activity, and is actually the backbone of these combinations. Based on our findings, metformin could prevent cisplatin-induced increase of CD133cells, which we previously reported to represent a highly tumorigenic, cisplatin-resistant cell subpopulation enriched of cancer initiating cells with high disseminating potential.These findings suggest a potential mechanism by which metformin could prevent acquired resistance to cisplatin in KRAS/LKB1 co-mutated NSCLC.

35 Reagan-Shaw S.

Nihal M.

Ahmad N. Dose translation from animal to human studies revisited. 36 Morgillo F.

Sasso F.C.

Della Corte C.M.

et al. Synergistic effects of metformin treatment in combination with gefitinib, a selective EGFR tyrosine kinase inhibitor, in LKB1 wild-type NSCLC cell lines. WT NSCLCs, which are typically poorly responsive to erlotinib monotherapy. 37 Morgillo F.

Fasano M.

Della Corte C.M.

et al. Results of the safety run-in part of the METAL (METformin in Advanced Lung cancer) study: a multicentre, open-label phase I–II study of metformin with erlotinib in second-line therapy of patients with stage IV non–small-cell lung cancer. 36 Morgillo F.

Sasso F.C.

Della Corte C.M.

et al. Synergistic effects of metformin treatment in combination with gefitinib, a selective EGFR tyrosine kinase inhibitor, in LKB1 wild-type NSCLC cell lines. WT NSCLC. Conversely, metformin-induced metabolic stress does not result in AMPK activation and mTOR inhibition when LKB1 is inactive (LKB1MUT). If KRAS mutations are contemporarily present, cells go on proliferating even in conditions of metformin-induced energetic and anabolic stress, which can expose them to increased cisplatin-induced DNA damage and less efficient DNA repair, an energy- and anabolite-requiring process. A limitation of these in vivo experiments consists in the high metformin dosages used. Indeed, 800 mg/kg metformin/d approximately correspond to a daily dosage of 3891 mg for a 60-kg patient, whereas the maximum safe dose of metformin is 2550 mg/d in diabetic patients, and could be lower in combination with cisplatin in NSCLC patients.Thus, to envisage a clinical application of metformin for cancer treatment, further studies will be needed to assess either efficacy of lower dosages or safety of short periods of higher dosage treatment. In one preclinical study, Morgillo et al.showed that metformin sensitizes NSCLC cells to gefitinib independently from EGFR and KRAS mutational status, and recently published preliminary clinical data have shown acceptable tolerability and promising anticancer activity with the metformin-erlotinib combination in EGFRNSCLCs, which are typically poorly responsive to erlotinib monotherapy.The synergistic antiproliferative and pro-apoptotic effects of metformin and gefitinib are limited to NSCLC cells with active LKB1, whereas LKB1-mutated models do not benefit from this combination.Although these data seem to contradict our findings of an exquisite sensitivity of LKB1-mutated cells to the MC combination, they could be reconciled by considering the different mechanism of action of gefitinib/erlotinib, which specifically inhibit EGFR, and cisplatin, which induces DNA intra-strand and inter-strand links that result in single- and double-strand DNA breaks. The combination of metformin and gefitinib/erlotinib could inhibit two crucial signal transduction pathways, namely the MAPK (via EGFR inhibition by gefitinib/erlotinib) and mTOR (via metformin-induced activation of AMPK, which requires the presence of active LKB1) cascade, thus resulting in synergistic antiproliferative and pro-apoptotic effects in LKB1NSCLC. Conversely, metformin-induced metabolic stress does not result in AMPK activation and mTOR inhibition when LKB1 is inactive (LKB1). If KRAS mutations are contemporarily present, cells go on proliferating even in conditions of metformin-induced energetic and anabolic stress, which can expose them to increased cisplatin-induced DNA damage and less efficient DNA repair, an energy- and anabolite-requiring process.

In addition to the ongoing study on erlotinib-metformin combination in EGFR WT NSCLC, metformin is being tested in combination with first-line, platinum-based ChT in unselected NSCLC patient populations (NCT 00637910). On the basis of our findings, as well as of results from other groups, only specific NSCLC subgroups may benefit from adding metformin to standard ChT. We therefore expect that the ongoing studies could fail to show any improvement from adding metformin to cytotoxic ChT, and that careful patient selection on biomarker expression will be essential to optimize clinical results in future studies.

In conclusion, LKB1 mutations may define more aggressive NSCLC subtypes even in the absence of other common oncogene mutations, such as KRAS mutations. However, the co-occurrence of LKB1/KRAS mutations could define a specific subgroup of NSCLCs characterized by exquisite sensitivity to the combination of metformin-induced metabolic stress and cisplatin-induced replication stress and DNA damage. In particular, the MC combination could specifically target the population of CD133+ cells that are involved in the development of secondary resistance to cisplatin. Despite some limitations of our study, including the relatively small number of patients analyzed and the high metformin dosage needed to produce meaningful biological effects in both in vitro and in vivo experiments, targeting LKB1/KRAS co-mutated tumors with the MC combination may represent a novel therapeutic strategy for the treatment of this aggressive subgroup of NSCLC. Based on excellent safety profile and low costs of metformin, we believe that our results provide sufficient evidence to encourage the conduction of clinical trials to assess the antitumor activity of cisplatin-pemetrexed-metformin triple therapy as first-line treatment of patients with LKB1/KRAS co-mutated NSCLCs who are not candidate to receive pembrolizumab.