TSC2-deficiency potentiates a catabolic signaling switch that differentiates neural and neural crest lineage development and progressive disease manifestations
Lymphangioleiomyomatosis (LAM) is a rare lung disease marked by cystic destruction caused by invasive LAM cells harboring loss-of-function mutations in TSC2 that exhibit dysregulated mTORC1 signaling. Rapamycin, the only approved treatment, is not curative. Therapeutic discovery has been limited by inadequate cell and animal models due to the unknown LAM cell of origin. We report a novel TSC2--/-- human pluripotent stem cell (hPSC)-derived neural crest cell (NCC) model, which replicates key LAM features. Leveraging this model, temporal RNA sequencing and genome-wide CRISPR knockout screens identified synthetic lethal genes including TWIST1 and SUN4. Antisense oligonucleotides (ASOs) targeting TWIST1 and SUN4 demonstrated selective TSC2 mutant NCC cytotoxicity and inhibited invasion. Using a "test-withdraw-monitor" clinical trial paradigm, TWIST1 and SUN4 ASOs profoundly suppressed tumor viability in a Tsc2--/-- mouse allograft model and eradicated 40% of tumors, outperforming standard of care rapamycin and highlighting their promise as novel cytoablative LAM therapeutics.