Phase 2 Study of Fingolimod in Lung Cancers

Lung cancer is the second most common cancer and the leading cause of cancer death in the United States. There were approximately 237,000 new cases of lung cancer that were diagnosed in 2022 . The past decade has seen a revolution of new advances in the management of both non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) with remarkable progress in screening, diagnosis, and treatment. The advances in systemic treatment have been driven primarily by the development of molecularly targeted therapeutics, immune-checkpoint inhibitors, and anti-angiogenic agents, all of which have transformed this field with significantly improved patient outcomes. Despite these advances, the prognosis for patients with advanced NSCLC and SCLC is poor, particularly after the failure of a platinum-based chemotherapy regimen and check point inhibitors with limited options available for patients. Therefore, new methods of targeting these malignancies are crucial. Fingolimod is a sphingosine analog that has demonstrated strong tumor suppressive activity in preclinical models of lung cancers and warrants further study. This proposed study is a single institution Phase II clinical trial to investigate the safety and efficacy of fingolimod in patients with NSCLC and SCLC. Fingolimod is a small molecule derived from myriocin that acts as a sphingosine analog. It is currently FDA-approved to treat patients with relapsing forms of multiple sclerosis (MS), including clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease by binding to sphingosine-1-phosphate (S1P) receptors 1, 3, 4, and 5 causing T lymphocyte egression and retention in peripheral lymphoid organs leading to immunosuppression. However, it can act as an antagonist for the S1P receptor promoting tumor suppression in multiple cancer cell lines and mouse models inhibiting cell proliferation, and inducing cancer cell death. There are multiple studies demonstrating its activity in preclinical models of lung cancer. Fingolimod induces a type of programmed cell death called necroptosis in lung cancer cells. This is mediated by activation of the tumor suppressor protein phosphatase 2A (PP2A) through interaction with the PP2A inhibitor (I2PP2A). Specifically, work done using the adenocarcinoma cell line A549 and small cell carcinoma cell line H1341 showed that fingolimod-mediated stress induced the formation of ceramidosomes leading to plasma membrane blebbing, compromised membrane integrity, and necroptosis. This study will evaluate the safety, tolerability, and response rate in patients with NCSLC and SCLC who have progressed on front-line therapy including chemotherapy, immune checkpoint inhibitors, and targeted agents. It will contribute to the development of new methods for targeting these malignancies and provide insights into the potential use of fingolimod as a treatment option for these patients.