Low dose AKT inhibitor miransertib cures PI3K-related vascular malformations in preclinical models of human disease

Low-flow vascular malformations are congenital overgrowths composed by abnormal blood vessels potentially causing pain, bleeding, and obstruction of different organs. These diseases are caused by oncogenic mutations in the endothelium which result in overactivation of the PI3K/AKT pathway. Lack of robust in vivo preclinical data has prevented the development and translation into clinical trials of specific molecular therapies for these diseases. Here, we describe a new reproducible preclinical in vivo model of PI3K-driven vascular malformations using the postnatal mouse retina. This model reproduces human disease with Pik3ca activating mutations expressed in a mosaic pattern and vascular malformations formed in veins and capillaries. We show that active angiogenesis is required for the pathogenesis of vascular malformations caused by activating Pik3ca mutations. Using this model, we demonstrate that low doses of the AKT inhibitor miransertib both prevents and induces the regression of PI3K-driven vascular malformations. We confirmed miransertib efficacy in isolated human endothelial cells with genotypes spanning most of human low-flow vascular malformations. Graphical abstract O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=69 SRC="FIGDIR/small/452617v1_ufig1.gif" ALT="Figure 1"> View larger version (31K): org.highwire.dtl.DTLVardef@15b29b6org.highwire.dtl.DTLVardef@fa9f8org.highwire.dtl.DTLVardef@6001d8org.highwire.dtl.DTLVardef@11926c5_HPS_FORMAT_FIGEXP M_FIG C_FIG Low-flow vascular malformations are caused by PI3K signalling overactivation in endothelial cells. We have generated an optimised and robust preclinical system of PI3K-driven vascular malformations by inducing the mosaic expression of Pik3caH1047R in the retinal angiogenic endothelium. This preclinical model displays traits constituting the main hallmarks of the pathogenesis of low-flow blood vascular malformations: overactivation of PI3K signalling (high phospho-S6), vascular compartment specificity, loss of pericyte coverage, and endothelial cell hyperproliferation. Using this preclinical model we report that low dose AKT inhibitor miransertib prevents and regress PI3K-driven vascular malformations.