Abstract Melanoma accounts for over 85% of all skin cancer deaths. Current therapies including drugs targeting BRAF and MEK significantly improve the prognosis of metastatic melanoma patients, yet innate or acquired resistance challenges long-term responses. We have shown previously that fatty acid beta-oxidation (FAO) is up-regulated during the acquisition of BRAF-inhibitor (BRAFi) resistance and that the FDA approved drug ranolazine, by targeting FAO attenuates the development of acquired resistance. However, how ranolazine-induced metabolic rewiring increases cell death is unclear. Here we identify ranolazine as a ferroptosis inducer in BRAFi-resistant melanoma, in which FAO serves as a ferroptosis surveillance mechanism. Accordingly, in progressed tumours of BRAFi treated patients up-regulation of FAO regulators correlates with increased expression of ferroptosis markers. BRAFi resistant cells are heavily poised for execution of ferroptosis; they display reduced glutathione levels, higher levels of long-chain polyunsaturated fatty acid (PUFA) membrane-incorporation, and increased membrane-resident phospholipid oxidation, all of which is amplified by ranolazine. Counteracting ranolazine action is MBOAT1/2 mediated phospholipid remodelling, which initiates reduced PUFA membrane-incorporation as ferroptosis surveillance mechanism. We show that the androgen receptor (AR), which is a determinant of BRAFi resistance, controls MBOAT1/2 expression, thereby contributing to ferroptosis resistance. In BRAFi resistant tumours and cell lines, we confirm AR upregulation predominantly in the MITF low /AXL high undifferentiated/neural-crest like state, but it also occurs in the MITF high /AXL low differentiated melanocytic state. The AR antagonist enzalutamide sensitises AR expressing melanoma cells to RSL3 and erastin independent of phenotype state, but in FAO high BRAFi relapsed tumours AR up-regulation correlates with the undifferentiated/neural-crest like (UD/NC) state, and enzalutamide synergises with ranolazine in ferroptosis-induction in UD/NC cells. Thus, therapeutically combining ranolazine with the AR inhibitor enzalutamide to induce ferroptosis can circumvent dedifferentiation related BRAFi resistance and could increase therapeutic activity and long-term efficacy.
Redondo-Muñoz et al. (Mon,) studied this question.