Targeting RET in Brain Metastases from Estrogen Receptor Positive Breast Cancer

Brain metastases (BrM) occur in 10-15% of patients with estrogen receptor (ER)-positive breast cancer, and remain a significant clinical challenge. While current therapeutic paradigms, including surgical resection and systemic therapy, have efficacy in the management of BrM from ER+BC, median overall survival following the diagnosis of BrM is approximately 18 months. The limited efficacy of current therapies, along with a relative paucity of therapeutic options, highlight the urgent clinical need to identify druggable targets for BrM from ER+BC.

We previously identified recurrent overexpression of the receptor tyrosine kinase RET in breast cancer BrM relative to patient-matched primary tumors. The principal ligand for RET, Glial Cell-Derived Neurotrophic Factor (GDNF), is predominately expressed in the brain, where it functions in the maintenance of neurons and multiple glial cell types. Here, we show that increased RET expression and activation correlates with brain metastasis in breast cancer patients. Further, we confirm the role of RET signaling in the promotion of metastatic properties in vitro, including tumor spheroid formation, migration, invasion, and transformation. Using RET-overexpressing and RET-deficient models in four ER+BC cell lines, we demonstrate that RET overexpression enhances activation of RET downstream targets, such as ERK and AKT, and promotes metastatic phenotypes in in vitro , ex vivo and in vivo assays. Importantly, we demonstrate that the phenotypic effects of GDNF-mediated RET signaling can be abrogated by administration of Pralsetinib, a highly potent RET-selective kinase inhibitor. Using an ex vivo mouse brain slice co-culture model, we further demonstrate that RET overexpression in breast cancer cell lines potentiates their colonization and invasion into the brain tissues, which are reduced in RET-knockdown cell lines. RET overexpression facilitates brain colonization of breast cancer cells in vivo and is associated with reduced survival. Using proteomic analyses, we identify novel GDNF-mediated signaling pathways in breast cancer cell line models, including PLCγ, P70S6K, STAT3 and CREB. RET-mediated activation of this range of downstream targets is sensitive to inhibition by Pralsetinib. In sum, this study identifies and characterizes RET as a targetable driver of breast cancer brain metastasis, and further describes the action of Pralsetinib in ER-positive breast cancer cell lines, providing insights to improve current targeted therapies for patients with breast cancer brain metastasis.