Breast cancer mutations HER2V777L and PIK3CAH1047R activate the p21-CDK4/6 –Cyclin D1 axis driving tumorigenesis and drug resistance

In metastatic breast cancer, HER2 activating mutations frequently co-occur with mutations in the PIK3CA , TP53 , or E-cadherin genes. Of these co-occurring mutations, HER2 and PIK3CA mutations are the most prevalent gene pair, with approximately 40% of HER2 mutated breast cancers also having activating mutations in PIK3CA . To study the effects of co-occurring HER2 and PIK3CA mutations, we bred genetically engineered mice with the HER2V777L ; PIK3CAH1047R transgenes (HP mice) and studied the resulting breast cancers both in vivo as well as ex vivo using cancer organoids. HP breast cancers show accelerated tumor formation in vivo and increased invasion and migration in in vitro assays. HP breast cancers have resistance to the pan-HER tyrosine kinase inhibitor, neratinib, but are effectively treated by neratinib plus trastuzumab deruxtecan. Proteomic and RNA-Seq analysis of HP breast cancers showed increased gene expression of Cyclin D1 and p21WAF1/Cip1 and changes in cell cycle markers. Combining neratinib with CDK4/6 inhibitors was another effective strategy for HP breast cancers with neratinib plus palbociclib showing a statistically significant reduction in mouse HP tumors as compared to either drug alone. We validated both the neratinib plus trastuzumab deruxtecan and neratinib plus palbociclib combinations using a human breast cancer patient-derived xenograft that has very similar HER2 and PIK3CA mutations. Both of these drug combinations are being tested in phase 1 clinical trials and this study provides valuable preclinical evidence for them. ### Competing Interest Statement Ron Bose receives a research grant from Puma Biotechnology, Inc. and has performed consulting on a HER2 clinical trial for Genentech. Neratinib used in this study was provided by Puma Biotechnology, Inc. Anton Iliuk is a principal at Tymora Analytical Operations, which developed and commercialized the PolyMAC enrichment kit. * Abbreviations : EGFR : Epidermal Growth Factor Receptor HER2 : Human Epidermal Growth Factor Receptor 2 PIK3CA : Phosphatidylinositol-4,5-Bisphosphate 3-Kinase Catalytic Subunit Alpha TCGA : The Cancer Genome Atlas ADCs : Antibody-drug conjugates T-DXd : Trastuzumab deruxtecan CDK4/6i : Cyclin-dependent kinase 4 and 6 inhibitors.