Insulin-like growth factor-1 receptor (IGF1R) inhibitors are effective in preclinical studies, but so far, no convincing benefit in clinical studies has been observed, except in some rare cases of sustained response in Ewing sarcoma patients. The mechanism of resistance is unknown, but several hypotheses are proposed. In this review, multiple possible mechanisms of resistance to IGF-targeted therapies are discussed, including activated insulin signaling, pituitary-driven feedback loops through growth hormone (GH) secretion and autocrine loops. Additionally, the outcomes of clinical trials of IGF1-targeted therapies are discussed, as well as strategies to overcome the possible resistance mechanisms. In conclusion, lowering the plasma insulin levels or blocking its activity could provide an additional target in cancer therapy in combination with IGF1 inhibition. Furthermore, because Ewing sarcoma cells predominantly express the insulin receptor A (IRA) and healthy tissue insulin receptor B (IRB), it may be possible to synthesize a specific IRA inhibitor.

Insulin-like growth factor 2 (IGF2) is a strong mitogenic peptide with an imprinted gene that is primarily involved in fetal development. It is highly expressed in the fetus where it is involved in fetal growth and tissue differentiation. However, postnatally, the expression of IGF2 decreases despite higher expression levels in the blood as compared with that of IGF1. In adults, the physiological function of IGF2 is poorly understood; however, the possibility of a metabolic function exists. Although the expression of IGF2 normally decreases in adults, it is overexpressed in a variety of cancers and associated with increased insulin-like growth factor 1 (IGF1R) receptor and insulin receptor (IR) activity. This subsequently increases the activity of downstream genes such as AKT, FOXO, and MAPK, resulting in enhanced proliferation, survival, and overall worse prognosis in patients overexpressing IGF2. As IGF1R activation has been found in several types of cancers, many different IGF1R-targeted therapies have been clinically evaluated, however, with only limited anti-cancer efficacy. In the present review, the physiological function of IGF2 will be outlined in relation to gene expression, imprinting, and signaling. Additionally, differences in physiological and aberrant signaling of IGF2 in cancer will be summarized.

Polyglutamine (polyQ) diseases are monogenic fatal neurodegenerative disorders caused by a CAG repeat expansion that is translated into a toxic polyQ tract. There are nine polyQ diseases: Huntington’s disease (HD), spinocerebellar ataxias 1, 2, 3, 6, 7 and 17 (SCA1, 2, 3, 6, 7, 17), dentatorubral-pallidoluysian atrophy (DRPLA) and spinal and bulbar muscular atrophy (SBMA). Although no disease-modifying therapies are available, lowering levels of the causative mutant polyQ protein is a promising potential treatment. Preclinically, the efficacy of polyQ protein-lowering compounds is often assessed using time-consuming Western blots (WB), which can produce variable results. Therefore, to improve throughput and accuracy of polyQ protein level quantification, Simple Western (SW) capillary immunoassays were developed. A panel of antibodies was screened for reactivity to the polyQ proteins on SW. The most promising antibodies were selected for further assay development. This resulted in optimised SW immunoassays for huntingtin (HTT), ataxin 1, 2 and 3 (ATXN1, 2, 3), atrophin 1 (ATN1) and androgen receptor (AR). Additionally, size-separation of the wild-type and polyQ-expanded mutant protein isoforms on SW was shown for ATXN1, ATXN3 and ATN1, allowing for their separate quantification. To facilitate size-separation of the larger HTT protein (≥ 348 kDa), a novel caspase 3-based assay was developed to generate N-terminal wild-type and mutant HTT fragments that could be separately quantified on SW in contrast to full-length HTT. In conclusion, SW capillary immunoassays were developed for polyQ proteins to improve preclinical research and aid the development of polyQ-lowering therapies for polyQ diseases.

Huntington’s disease (HD) is caused by a CAG repeat expansion in the huntingtin ( HTT ) gene, encoding an elongated polyglutamine stretch in the corresponding mutant HTT (mHTT) protein. HD pathogenesis is driven by multiple neurotoxic mHTT protein species, including HTT1a and repeat-associated non-AUG translation (RAN) proteins, which increase in expression as mutant CAG repeats lengthen due to somatic expansion. VO659 is an investigational CAG repeat-targeting antisense oligonucleotide (ASO) that lowers mHTT protein levels by blocking translation. Here, we show that VO659 allele-preferentially lowers levels of multiple neurotoxic mHTT protein species in a CAG repeat length-dependent manner, relatively sparing wild-type HTT, while becoming more efficacious as somatic expansion occurs. VO659 reduced HTT1a mRNA levels in HD fibroblasts with an ultra-long CAG repeat, blocked the translation of HTT1a and polyalanine-containing RAN proteins derived from HTT exon 1 overexpression constructs, and displayed a long tissue half-life in mouse brain, supporting an infrequent dosing regimen. A first-in-human, open-label phase 1/2a clinical trial ( NCT05822908 ) is currently ongoing in HD patients. VO659’s unique CAG repeat-dependent and allele-preferential mechanism of action holds promise for its therapeutic effect in HD patients by targeting multiple core neurotoxic proteins derived from (somatically) expanded mHTT CAG repeats, while sparing wild-type HTT expression.