<i>KEAP1/NFE2L2</i> Mutations Predict Lung Cancer Radiation Resistance That Can Be Targeted by Glutaminase Inhibition

Abstract

Tumor genotyping is not routinely performed in localized non-small cell lung cancer (NSCLC) due to lack of associations of mutations with outcome. Here, we analyze 232 consecutive patients with localized NSCLC and demonstrate that <i>KEAP1</i> and <i>NFE2L2</i> mutations are predictive of high rates of local recurrence (LR) after radiotherapy but not surgery. Half of LRs occurred in tumors with <i>KEAP1/NFE2L2</i> mutations, indicating that they are major molecular drivers of clinical radioresistance. Next, we functionally evaluate <i>KEAP1/NFE2L2</i> mutations in our radiotherapy cohort and demonstrate that only pathogenic mutations are associated with radioresistance. Furthermore, expression of NFE2L2 target genes does not predict LR, underscoring the utility of tumor genotyping. Finally, we show that glutaminase inhibition preferentially radiosensitizes <i>KEAP1</i>-mutant cells via depletion of glutathione and increased radiation-induced DNA damage. Our findings suggest that genotyping for <i>KEAP1/NFE2L2</i> mutations could facilitate treatment personalization and provide a potential strategy for overcoming radioresistance conferred by these mutations. SIGNIFICANCE: This study shows that mutations in <i>KEAP1</i> and <i>NFE2L2</i> predict for LR after radiotherapy but not surgery in patients with NSCLC. Approximately half of all LRs are associated with these mutations and glutaminase inhibition may allow personalized radiosensitization of <i>KEAP1/NFE2L2</i>-mutant tumors.<i>This article is highlighted in the In This Issue feature, p. 1775</i>.