The development of resistance to anti-cancer therapeutics remains one of the core issues preventing the improvement of survival rates in cancer. Therapy resistance can arise in a multitude of ways, including the accumulation of epigenetic alterations in cancer cells. By remodeling DNA methylation patterns or modifying histone proteins during oncogenesis, cancer cells reorient their epigenomic landscapes in order to aggressively resist anti-cancer therapy. To combat these chemoresistant effects, epigenetic modifiers such as DNA hypomethylating agents, histone deacetylase inhibitors, histone demethylase inhibitors, along with others have been used. While these modifiers have achieved moderate success when used either alone or in combination with one another, the most positive outcomes were achieved when they were used in conjunction with conventional anti-cancer therapies. Epigenome modifying drugs have succeeded in sensitizing cancer cells to anti-cancer therapy via a variety of mechanisms: disrupting pro-survival/anti-apoptotic signaling, restoring cell cycle control and preventing DNA damage repair, suppressing immune system evasion, regulating altered metabolism, disengaging pro-survival microenvironmental interactions and increasing protein expression for targeted therapies. In this review, we explore different mechanisms by which epigenetic modifiers induce sensitivity to anti-cancer therapies and encourage the further identification of the specific genes involved with sensitization to facilitate development of clinical trials.

Relapse remains a major obstacle to achieving 100% overall survival rate in pediatric hematologic malignancies like acute lymphoblastic leukemia (ALL). Relapse often results from the development of chemoresistance. One of the mechanisms of chemoresistance involves ALL cell interactions with the bone marrow (BM) microenvironment, providing a sanctuary. This phenomenon is known as BM microenvironment-induced chemoprotection. Members of the transmembrane 4 superfamily (tetraspanins; TSPANs) are known to mediate microenvironmental interactions and have been extensively studied in solid tumors. Although the TSPAN family member CD81 is a minimal residual disease marker, its biological role in ALL is not well characterized. We show for the first time that CD81 knockout induces chemosensitivity, reduces cellular adhesion, and disrupts in vivo BM homing and engraftment in B-ALL. This chemosensitization is mediated through control of Bruton tyrosine kinase signaling and induction of p53-mediated cell death. We then show how CD81-related signaling can be disrupted by treatment with the epigenetic drug combination of DNA hypomethylating agent azacitidine (aza) and histone deacetylase inhibitor panobinostat (pano), which we previously used to sensitize ALL cells to chemotherapy under conditions that promote BM microenvironment-induced chemoprotection. Aza/pano-mediated modulation of CD81 surface expression is involved in decreasing BM load by promoting ALL cell mobilization from BM to peripheral blood and increasing response to chemotherapy in disseminated patient-derived xenograft models. This study identifies the novel role of CD81 in BM microenvironment-induced chemoprotection and delineates the mechanism by which aza/pano successfully sensitizes ALL cells via modulation of CD81.

Although there has been much progress in the treatment of acute lymphoblastic leukemia (ALL), decreased sensitivity to chemotherapy remains a significant issue. Recent studies have shown how interactions with the bone marrow microenvironment can protect ALL cells from chemotherapy and allow for the persistence of the disease. Epigenetic drugs have been used for the treatment of ALL, but there are no reports on whether these drugs can overcome bone marrow-induced chemoprotection. Our study investigates the ability of the DNA methyltransferase inhibitor azacitidine and the histone deacetylase inhibitor panobinostat to overcome chemoprotective effects mediated by osteoblasts. We show that the combination of azacitidine and panobinostat has a synergistic killing effect and that this combination is more effective than cytarabine in inducing ALL cell death in co-culture with osteoblasts. We also show that this combination can be used to sensitize ALL cells to chemotherapeutics in the presence of osteoblasts. Finally, we demonstrate that these effects can be replicated ex vivo in a number of mouse passaged xenograft lines from both B-ALL and T-ALL patients with varying cytogenetics. Thus, our data provides evidence that azacitidine and panobinostat can successfully overcome osteoblast-induced chemoprotection in vitro and ex vivo in both B-ALL and T-ALL cells.

Acute lymphoblastic leukemia (ALL) is a malignant hematological disease afflicting hematopoiesis in the bone marrow. While 80-90% of patients diagnosed with ALL will achieve complete remission at some point during treatment, ALL is associated with high relapse rate, with the 5-year overall survival rate of 68%. The initial remission failure and the high rate of relapse can be attributed to intrinsic chemoprotective mechanisms that allow persistence of ALL cells despite therapy. These mechanisms are mediated, at least in part, through the engagement of cell adhesion molecules (CAMs) within the bone marrow microenvironment. This review assembles CAMs implicated in protection of leukemic cells from chemotherapy. Such studies are limited in ALL. Therefore, CAMs that are associated with poor outcomes or are over-expressed in ALL and have been shown to be involved in chemoprotection in other hematological cancers are also included. It is likely that these molecules play parallel roles in ALL because the CAMs identified to be a factor in ALL chemoresistance also work similarly in other hematological malignancies. We review the signaling mechanisms activated by the engagement of CAMs that provide protection from chemotherapy. Development of targeted therapies against CAMs could improve outcome and raise the overall cure rate in ALL.

β-hemoglobinopathies like sickle cell disease (SCD) and β-thalassemia are characterized by differing mutations in the hemoglobin subunit beta gene (HBB). These disorders vary in phenotypic presentation and severity, with more severe manifestations leading to transfusion dependence along with associated complications such as infection and iron overload. β-hemoglobinopathies symptoms rapidly worsen after birth as the levels of fetal hemoglobin (HbF) begin to decline. To reverse this decline, current treatment plans typically involve the use of pharmacological agents such as hydroxyurea to raise expression levels of HbF. However, these treatments only result in transient effects and must be consistently administered. Gene editing technologies such as CRISPR/Cas9 (Clustered Regularly Interspaced Short Palindromic Repeats- CRISPR associated protein) offer the opportunity to create novel treatments which can raise HbF expression with potential permanent effects. Two gene targets, B-cell lymphoma/leukemia 11A gene (BCL11A) and the promoter regions of gamma globin genes (HBG1/2), have been identified to significantly increase HbF protein expression. In order to differentiate the effectiveness of BCL11A and HBG1/2 editing, a meta-analysis was performed by first identifying 119 studies for inclusion based on the search terms terms “β-Thalassemia,” “beta-thal” “sickle cell disease,” “SCD,” and “CRISPR.” Following application of exclusion and inclusion criteria, we performed analysis on 8 peer-reviewed published studies from 2018 to 2021 were included in the study. Forest plots were generated using R (version 4.1.2). Primary comparative analysis shows HBG1/2 had a significantly (p < 0.01)greater impact on induction of HbF expression compared to BCL11A. This analysis leads us to conclude that HBG1/2 merits further investigation as a possible gene editing target for treatment of SCD and β-thalassemia.

We previously demonstrated that a combination of epigenetic drugs azacitidine (DNA hypomethylating agent) and panobinostat (HDACi) can sensitize acute lymphoblastic leukemia (ALL) cell lines and a variety of patient-derived xenograft (PDX) lines to chemotherapy under conditions that mimic bone marrow microenvironment-induced chemoprotection (Quagliano et al., 2017, Leuk Res). Using disseminated PDX models, we observed that mice pre-treated with azacitidine and panobinostat combination (aza/pano) prior to receiving chemotherapy survived longer than mice treated with chemotherapy alone, indicating that epigenetic drugs chemo-sensitized ALL to chemotherapy in vivo (Fig. 1A). However, the mechanism by which this sensitization occurs was unknown. Direct cell-cell contact was required for the chemoprotection of ALL cells in co-culture with osteoblast-like cells (Saos-2). Furthermore, adhesion of various ALL PDX lines to Saos-2 monolayers was reduced significantly (Fig. 1B) following treatment with aza/pano, indicating that aza/pano induced chemosensitization may be mediated by modulation of cell surface molecules. Therefore, we performed a high throughput flow cytometry assay using the BD LyoplateTM to investigate alterations in the expression of cell surface molecules following aza/pano treatment. This assay identified tetraspanin (TSPAN) protein CD81 as one of the candidate molecules downregulated on the cell surface by aza/pano. Aza/pano treatment also reduced surface expression of CD49d (integrin α4) and CD29 (integrin β1), which together form the VLA-4 receptor (Figure 1C). TSPANs like CD81 have previously been shown to interact with VLA-4; and regulate VLA-4 adhesion to VCAM-1 on bone marrow cells. To determine if the interaction between CD81 and VLA-4 was perturbed by aza/pano, surface co-localization of CD81 and CD49d was analyzed in immunofluorescence images using Volocity image analysis software. Following treatment with aza/pano, CD49d showed a significant reduction of co-localization with CD81 (Fig. 1D), suggesting aza/pano can disturb CD81/VLA-4 interaction. Previous differential gene expression analyses showed that CD81 transcript levels were higher in ALL in comparison to healthy bone marrow samples. Consistent with transcript data, we observed a significant increase in cell surface expression of CD81 in B-ALL PDX lines compared to immortalized B-cells by flow cytometry. Taken together, these data imply that aza/pano induced chemo-sensitization may be mediated through CD81. To determine the specific role of CD81, we generated Nalm6 cells with homozygous CD81 knockout (KO) by CRISPR/Cas9 mutagenesis. CD81 KO was confirmed by Sanger sequencing and flow cytometry. CD81 KO cells had 60% reduction in their drug resistance index compared to wild-type cells (Fig. 1E), validating the role of CD81 in inducing chemo-resistance. Because of the role of CD81 in the regulation of cell adhesion by modulation of integrins, we evaluated the significance of CD81 in leukemia engraftment and progression. CD81 KO and WT cells were transplanted into NSG-SGM3 mice via tail-vein injection. Flow cytometry on flushed bone marrows after 96 h post cell injection revealed a reduced presence of CD81 KO cells, indicating that CD81 plays a role in ALL homing and engraftment in the bone marrow. Periodic analysis of peripheral blood in a long-term engraftment assay revealed a significant increase in leukemic percentage in mice transplanted with CD81 WT cells at 14 days post injection (Fig. 1F). These observations suggest that CD81 mediates chemoprotection by enhanced adhesion. Conclusion This study provides evidence for the possible role of CD81 in inducing chemoprotection by promoting adhesion between ALL cells and cells within the bone marrow microenvironment. Due to aza/pano's modulation of CD81 surface expression, it is possible that aza/pano induced chemo-sensitization is mediated by down regulation of CD81. Figure 1. Figure 1. Disclosures Kolb: Roche- Genentech: Membership on an entity's Board of Directors or advisory committees; Servier: Membership on an entity's Board of Directors or advisory committees.

Background We previously discovered that the epigenetic drug combination - azacitidine (aza, DNMTi) and panobinostat (pano, HDACi) can sensitize ALL cells to chemotherapy (Quagliano et al., Leuk Res, 44:101, 2017). This sensitization occurred through a decrease in cellular adhesion and a modulation of the cell surface expression of the tetraspanin protein CD81 (Quagliano et al., Blood, 132:3957, 2018). This study aims to elucidate the molecular mechanism by which CD81 surface modulation by pre-treatment with aza/pano leads to chemosensitization. Methods CD81 knockout Nalm6 (CD81KO) cells were generated by CRISPR/Cas9 mutagenesis. IHC was performed using anti-human mitochondria antibody on femurs harvested from NSG-SGM3 mice at 72 h post transplantation with WT or CD81KO cells. For adhesion assay, ALL cells stained with VPD450 were co-cultured with Saos-2 cells for 24 h. Unbound cells were washed, and bound cells were collected for flow cytometry analysis. CD19 surface expression was determined after 48 h treatment with aza/pano (500 nM/1.5 nM) using flow cytometry. For western blot analysis, aza/pano treated cells were transferred on to Saos-2 monolayers and treated with Ara-C (30 nM) for 16 h. Results CD81KO cells not only had decreased homing and engraftment visualized by reduced ALL cell presence in bone marrow (Fig. 1A), but also had 45% reduction in cellular adhesion to osteoblasts compared to WT Nalm6 cells (Fig. 1B), indicating that CD81 downregulation results in reduced bone marrow interactions. To investigate the signaling effects downstream of aza/pano-mediated CD81 modulation, we first tested if CD19 was affected due to its prominent role in the formation of the B-cell co-receptor and because CD19 requires CD81 for proper membrane trafficking (Cherukuri et al., J Immunol, 172:370, 2004). CD19 surface expression was reduced in aza/pano-treated cells and completely knocked out in CD81KO cells (Fig. 1C). CD19 is known to prolong and amplify the activation of Bruton's tyrosine kinase (BTK), so we also analyzed the phosphorylation of BTK in aza/pano-treated cells and found it to be reduced by 63% (Fig. 1D). This reduction in BTK phosphorylation may be responsible for the decrease in cell adhesion following treatment with aza/pano because prior studies observed reduced adhesion following BTK inhibition (Herman et al., Clin Cancer Res, 21:4642, 2015). Taken together, these data suggest that aza/pano induced reduction in cell adhesion was mediated by downregulation of CD81 and BTK dephosphorylation. We studied how the expression of p53 and its target BCL2 associated X protein (BAX), which are known to be induced by Ara-C, were affected following pre-treatment with aza/pano. Cells with Ara-C treatment alone or the aza/pano pre-treatment both had minor induction of p53 expression compared to control, while aza/pano pre-treated cells that received Ara-C had further increase in p53 protein (1.7-fold increase compared to Ara-C alone, Fig. 1E). Bax mRNA and protein were increased 4.2-fold in aza/pano-treated cells following Ara-C treatment compared to Ara-C alone. Increased Bax expression following Ara-C treatment in aza/pano pre-treated cells was accompanied by a 3.9-fold increase in cleavage of caspase-3 compared to cells treated with Ara-C alone, which in turn causes cleavage of Poly-ADP Ribose Polymerase (PARP) (Fig. 1E). Both p53 and Bax protein levels were higher in CD81KO cells than in WT cells (Fig. 1E), suggesting that aza/pano-mediated reduction of CD81 is involved in inducing the expression of p53. CD81KO cells that were treated with Ara-C also had further increase in p53 and Bax expression compared to Ara-C treated WT cells (Fig. 1E), consistent with an increased sensitivity to chemotherapy. To confirm the role of BTK inhibition in the induction of p53, Nalm6 cells were treated with the BTK inhibitor fenebrutinib for 24 h (10 nM). Following treatment, expression of p53 was induced and Bax expression was 2.6-fold higher in treated cells compared to untreated cells (Fig. 1E). Taken together, these data suggest that modulation of the surface expression of CD81 and the phosphorylation of BTK by aza/pano induces sensitization via upregulation of p53 and overexpression of Bax. Conclusion We identify a novel mechanism by which aza/pano treatment induces chemosensitization by reducing cell adhesion via modulating CD81 surface expression, reducing BTK phosphorylation, and inducing p53. Figure 1 Disclosures No relevant conflicts of interest to declare.

Despite recent advances in the treatment of hematologic malignancies, relapse still remains a consistent issue. One of the primary contributors to relapse is the bone marrow microenvironment providing a sanctuary to malignant cells. These cells interact with bone marrow components such as osteoblasts and stromal cells, extracellular matrix proteins, and soluble factors. These interactions, mediated by the cell surface proteins like cellular adhesion molecules (CAMs), induce intracellular signaling that leads to the development of bone marrow microenvironment–induced chemoprotection (BMC). Although extensive study has gone into these CAMs, including the development of targeted therapies, very little focus in hematologic malignancies has been put on a family of cell surface proteins that are just as important for mediating bone marrow interactions: the transmembrane 4 superfamily (tetraspanins; TSPANs). TSPANs are known to be important mediators of microenvironmental interactions and metastasis based on numerous studies in solid tumors. Recently, evidence of their possible role in hematologic malignancies, specifically in the regulation of cellular adhesion, bone marrow homing, intracellular signaling, and stem cell dynamics in malignant hematologic cells has come to light. Many of these effects are facilitated by associations with CAMs and other receptors on the cell surface in TSPAN-enriched microdomains. This could suggest that TSPANs play an important role in mediating BMC in hematologic malignancies and could be used as therapeutic targets. In this review, we discuss TSPAN structure and function in hematologic cells, their interactions with different cell surface and signaling proteins, and possible ways to target/inhibit their effects.