KRAS-driven Tumorigenesis and KRAS-driven Therapy in Pancreatic Adenocarcinoma.

Pancreatic ductal adenocarcinoma (PDAC) is associated with significant morbidity and mortality and is projected to be the second leading cause of cancer-related deaths by 2030. Mutations in KRAS are found in the vast majority of PDAC cases and plays an important role in the development of the disease. KRAS drives tumor cell proliferation and survival through activating the MAPK pathway to drive cell cycle progression and to lead to MYC-driven cellular programs. Moreover, activated KRAS promotes a pro-tumorigenic microenvironment through forming a desmoplastic stroma and by impairing anti-tumor immunity. Secretion of GM-CSF and recruitment of myeloid-derived suppressor cells and pro-tumorigenic macrophages results in an immunosuppressive environment while secretion of SHH and TGF-beta drive fibroblastic features characteristic of PDAC. Recent development of several small molecules to directly target KRAS mark an important milestone in precision medicine. Many molecules show promise in preclinical models of PDAC and in early phase clinical trials. In this review, we discuss the underlying cell intrinsic and extrinsic roles of KRAS in PDAC tumorigenesis, the pharmacologic development of KRAS inhibition, and therapeutic strategies to target KRAS in PDAC.