CDK4/6 inhibitors upregulate cIAP1/2, and Smac mimetic LCL161 enhances their antitumor effects in cholangiocarcinoma cells.

Cholangiocarcinoma (CCA) is a highly aggressive bile duct cancer with a poor prognosis and high mortality rates, primarily due to the lack of early diagnosis and effective treatments. We have shown that cyclin D and CDK4/6, key regulators of cell cycle progression, are highly expressed in CCA patients. Moreover, high levels of cyclin D, CDK4, and CDK6 are associated with shorter survival in CCA patients, suggesting that cyclin D and CDK4/6 might be potential targets for CCA therapy. However, we have demonstrated that CDK4/6 inhibitor palbociclib monotherapy is less effective in CCA cells. We have identified Cellular Inhibitor of Apoptosis Proteins 1 and 2 (cIAP1/2), NF-κB target genes that their expression is associated with shorter survival in CCA patients, as potential key regulators of the CDK4/6 inhibitor response. We showed that palbociclib, a CDK4/6 inhibitor, increases phosphorylated p65 and its nuclear translocation, resulting in cIAP1/2 upregulation in CCA cells. Therefore, we hypothesized that the combination of a cIAP1/2 antagonist and a CDK4/6 inhibitor might enhance the CDK4/6 inhibitor response. Interestingly, combined treatment with the Smac mimetic LCL161, a cIAP1/2 antagonist, and palbociclib synergistically inhibits cell proliferation and induces cell death in both 2D monolayer and 3D spheroid CCA cultures. We further showed that this combination treatment has less effect on non-tumor cholangiocytes and human peripheral blood mononuclear cells (PBMCs). Our findings demonstrate for the first time that the combined treatment of Smac mimetics and CDK4/6 inhibitors is a promising novel targeted therapy for CCA patients.