Data from Cancer-Associated Fibroblasts Promote Imatinib Resistance in Gastrointestinal Stromal Tumors through PGK1-Mediated Metabolic Reprogramming

Abstract Gastrointestinal stromal tumors (GIST), the most common sarcomas of the gastrointestinal tract, are primarily driven by c-KIT or PDGFRA mutations that activate downstream signaling pathways, including PI3K/AKT/mTOR. Whereas imatinib (IM), a first-line tyrosine kinase inhibitor (TKI), is initially effective, resistance develops in ∼50% of patients within 20 months. Second- and third-line TKIs, such as sunitinib and regorafenib, provide limited benefits, highlighting the urgent need to address resistance mechanisms. Previous research has predominantly focused on genetic drivers of resistance and overlooked the role of the tumor microenvironment. In this study, we identified a role for cancer-associated fibroblasts (CAF) in driving IM resistance. Specifically, TGFβ1 secreted by CAFs amplified cellular communication network factor 2 (CCN2)/receptor for activated C kinase 1 (Rack1) signaling. The CCN2/Rack1 axis activated PI3K/AKT signaling to induce phosphorylation and mitochondrial translation of phosphoglycerate kinase 1 (PGK1), promoting metabolic reprogramming that supported tumor survival and drug resistance. Coculture models and single-cell RNA sequencing revealed distinct CAF subtypes and showed that CAF-secreted TGFβ1 enhanced glycolysis and inhibited the tricarboxylic acid cycle, fueling GIST progression and secondary resistance. Inversely, CCN2 secreted by GIST cells promoted TGFβ1 production in CAFs. These findings uncover a TGFβ1/CCN2/Rack1/PGK1 mechanism linking CAF-mediated metabolic reprogramming to IM resistance in GISTs. Targeting CAF–GIST interactions and key metabolic pathways presents a promising therapeutic strategy. Significance: Cross-talk between cancer-associated fibroblasts and cancer cells promotes metabolic and tumor microenvironmental reprogramming that drives imatinib resistance in gastrointestinal stromal tumors, providing potential targets to overcome resistance and improve therapeutic outcomes.