Therapeutic Effects of Inhibition of Sphingosine-1-Phosphate Signaling in HIF-2 alpha Inhibitor-Resistant Clear Cell Renal Cell Carcinoma

Simple Summary: Clear cell renal cell carcinoma is a common malignancy that represents 80% of all kidney tumors. Most tumors harbor an inactivation of the VHL gene, leading to the accumulation of HIF-1 alpha and HIF-2 alpha. Promising clinical results of specific HIF-2 alpha inhibitors will soon lead to new treatment options for advanced cancer patients, although primary and acquired resistance to these agents are common. We here show that Acriflavine, which inhibits both HIF-1 alpha and HIF-2 alpha, and Fingolimod (FTY720), which inhibits sphingosine-1-phosphate signaling, show therapeutic activities in several experimental ccRCC models that are resistant to HIF-2 alpha-inhibitor treatment. Additionally, we show that specific HIF-2 alpha-inhibition suppresses the tumor immune microenvironment, which will be important to consider for future combination studies with immune checkpoint inhibitors. Specific inhibitors of HIF-2 alpha have recently been approved for the treatment of ccRCC in VHL disease patients and have shown encouraging results in clinical trials for metastatic sporadic ccRCC. However, not all patients respond to therapy and pre-clinical and clinical studies indicate that intrinsic as well as acquired resistance mechanisms to HIF-2 alpha inhibitors are likely to represent upcoming clinical challenges. It would be desirable to have additional therapeutic options for the treatment of HIF-2 alpha inhibitor resistant ccRCCs. Here we investigated the effects on tumor growth and on the tumor microenvironment of three different direct and indirect HIF-alpha inhibitors, namely the HIF-2 alpha-specific inhibitor PT2399, the dual HIF-1 alpha/HIF-2 alpha inhibitor Acriflavine, and the S1P signaling pathway inhibitor FTY720, in the autochthonous Vhl/Trp53/Rb1 mutant ccRCC mouse model and validated these findings in human ccRCC cell culture models. We show that FTY720 and Acriflavine exhibit therapeutic activity in several different settings of HIF-2 alpha inhibitor resistance. We also identify that HIF-2 alpha inhibition strongly suppresses T cell activation in ccRCC. These findings suggest prioritization of sphingosine pathway inhibitors for clinical testing in ccRCC patients and also suggest that HIF-2 alpha inhibitors may inhibit anti-tumor immunity and might therefore be contraindicated for combination therapies with immune checkpoint inhibitors.