A Preclinical Study to Repurpose Spironolactone for Enhancing Chemotherapy Response in Bladder Cancer.

Dongbo Xu, Qiang Cao, Li Wang, Jianmin Wang, Bo Xu, Kristopher Attwood, Lei Wei, Yue Wu, Gary J Smith, Eriko Katsuta, Kazuaki Takabe, Gurkamal Chatta, Khurshid A Guru, David W Goodrich, Qiang J Li

Neoadjuvant chemotherapy (NAC) followed by radical cystectomy is the standard of care for patients with muscle-invasive bladder cancer (MIBC). Defects in nucleotide excision repair (NER) are associated with improved responses to NAC. Excision Repair Cross-Complementation group 3 (ERCC3) is a key component of NER process. No NER inhibitors are available for treating bladder cancer patients. We have developed an ex vivo cell-based assay of 6-4 pyrimidine-pyrimidinone (6-4PP) removal as a surrogate measure of NER capacity in human bladder cancer cell lines. The protein expression of ERCC3 was examined in human MIBC specimens and cell lines. Small molecule inhibitors were screened for NER inhibition in bladder cancer cell lines. Spironolactone (SP) was identified as a potent NER inhibitor. Combined effects of SP with chemo-drugs were evaluated in vitro and in vivo. The efficacy between platinum and SP on cytotoxicity was determined by combination index. A correlation between NER capacity and cisplatin sensitivity was demonstrated in a series of bladder cancer cell lines. Further, siRNA-mediated knockdown of ERCC3 abrogated NER capacity and enhanced cisplatin cytotoxicity. SP inhibited ERCC3 protein expression, abrogated NER capacity, and increased platinum-induced cytotoxicity in bladder cancer cells in vivo and in patient-derived organoids. Moreover, SP exhibited the potential synergism effects with other clinical chemotherapy regimens in bladder cancer cell lines. Our data support the notion of re-purposing SP for improving the chemotherapy response of NAC in MIBC patients. Further clinical trials are warranted to determine the safety and efficacy of SP in combination with chemotherapy.