Multimetric MRI Captures Early Response and Acquired Resistance of Pancreatic Cancer to KRAS Inhibitor Therapy

Abstract

PurposeIn pancreatic ductal adenocarcinoma (PDAC), KRAS mutations drive both cancer cell growth and formation of a dense stroma. Small molecule KRAS inhibitors (KRASi) represent a promising new treatment hence clinical tools that can assess early response, detect resistance and/or predict prolonged survival are desirable to understand clinical biology of KRASi. We hypothesized that diffusion-weighted MRI (DWI) can detect cell death while dynamic contrast enhanced MRI (DCE) and magnetization transfer ratio (MTR) imaging are sensitive to tumor microenvironment changes, and these metrics shed insights into tumor size change induced by KRASi treatment. Experimental DesignMultiple preclinical PDAC models including a genetically engineered mouse model (KPC) received MRTX1133, a KRASi specific for KRASG12D mutation. Quantitative imaging markers were corroborated with immunohistochemistry (IHC) analyses. ResultsSignificant increase of tumor apparent diffusion coefficient (a DWI metric) was detected as early as 48h and persisted to Day7 after initiation of KRASi treatment and was strongly correlated with cell death and reduced cellularity, resulting in greatly prolonged median survival in treated mice. Capillary perfusion/permeability (a DCE metric) exhibited an inverse relationship with microvascular density. Distinct responses of KRASG12C versus KRASG12D tumors to MRTX1133 were captured by the MRI metrics corroborated with IHC. When tumors developed resistance to MRTX1133, the imaging marker values exhibited a reversal from those of responding tumors. ConclusionsMultiparametric MRI provides early biological insights of cancer and stromal response to KRASi treatment and sets the stage for testing the utility of these clinically ready MRI methods in patients receiving KRASi therapy. Translational relevanceEmerging small molecule KRAS inhibitors (KRASi) represent a new class of therapy for PDAC. Clinical tools that can provide early biological insights of KRASi therapy are desirable. In PDAC models, we examined a clinically ready imaging protocol that combines MRI-based tumor size, diffusion-weighted MRI (DWI), dynamic contrast enhanced MRI (DCE), and magnetization transfer ratio (MTR) for detection of early response as well as acquired resistance to MRTX1133, a KRASi being evaluated in clinical trials. Our data show that DWI and DCE metrics provided key insights of significant cell death and tumor microenvironment changes underlying tumor size regression as early as 48 hours after KRASi treatment initiation. These MRI metrics also captured resistance to KRASi developed over prolonged treatment. This study has high translational relevance by employing clinically applied MRI methods, an investigational new drug and a genetically engineered mouse model that recapitulates salient features of human PDAC.