Inhibitors of Bruton's tyrosine kinase (BTKi) and phosphatidylinositol 3-kinase delta (PI3Kδi) that target the B cell receptor (BCR) signaling pathway have revolutionized the treatment of chronic lymphocytic leukemia (CLL). While mutations associated with resistance to BTK inhibitors have been identified, limited data are available on mechanisms of resistance to PI3Kδi. Here we present findings from longitudinal whole-exome sequencing of multiply relapsed CLL patients (Ncases=28) enrolled in PI3Ki trials. The non-responder subgroup was characterized by baseline activating mutations in MAP2K1, BRAF and KRAS in 60% of patients. PI3Kδ inhibition failed to inhibit ERK phosphorylation (pERK) in non-responder CLL cells with and without mutations, while treatment with MEKi rescued ERK inhibition. Overexpression of MAP2K1 mutants in vitro led to increased basal and inducible pERK and resistance to idelalisib. These data demonstrate that MAPK/ERK activation plays a key role in resistance to PI3Kδi in CLL and provide rationale for combination therapy with PI3Kδ and ERK inhibitors.
The damage to liver mitochondria is universally observed in both humans and animal models after excessive alcohol consumption. Acute alcohol treatment has been shown to stimulate calcium (Ca) release from internal stores in hepatocytes. The resultant increase in cytosolic Ca is expected to be accumulated by neighboring mitochondria, which could potentially lead to mitochondrial Ca overload and injury. Our data indicate that total and free mitochondrial matrix Ca levels are, indeed, elevated in hepatocytes isolated from alcohol-fed rats compared with their pair-fed control littermates. In permeabilized hepatocytes, the rates of mitochondrial Ca uptake were substantially increased after chronic alcohol feeding, whereas those of mitochondrial Ca efflux were decreased. The changes in mitochondrial Ca handling could be explained by an up-regulation of the mitochondrial Ca uniporter and loss of a cyclosporin A-sensitive Ca transport pathway. In intact cells, hormone-induced increases in mitochondrial Ca declined at slower rates leading to more prolonged elevations of matrix Ca in the alcohol-fed group compared with controls. Moreover, treatment with submaximal concentrations of Ca-mobilizing hormones markedly increased the levels of mitochondrial reactive oxygen species (ROS) in hepatocytes from alcohol-fed rats, but did not affect ROS levels in controls. The changes in mitochondrial Ca handling are expected to buffer and attenuate cytosolic Ca increases induced by acute alcohol exposure or hormone stimulation. However, these alterations in mitochondrial Ca handling may also lead to Ca overload during cytosolic Ca increases, which may stimulate the production of mitochondrial ROS, and thus contribute to alcohol-induced liver injury.
Purpose: Phosphatidylinositol 3-kinase inhibitors (PI3Ki) are approved for relapsed chronic lymphocytic leukemia (CLL). While patients may show an initial response to these therapies, development of treatment intolerance or resistance remains clinical challenges. To overcome these, prediction of individual treatment responses based on actionable biomarkers is needed. Here, we characterized the activity and cellular effects of ten PI3Ki and investigated whether functional analyses can identify treatment vulnerabilities in PI3Ki-refractory/intolerant CLL and stratify responders to PI3Ki. Experimental design: Peripheral blood mononuclear cell (PBMC) samples (n=51 in total) from treatment naïve and PI3Ki-treated CLL patients were studied. Cells were profiled against ten PI3Ki and the Bcl-2 antagonist venetoclax. Cell signaling and immune phenotypes were analyzed by flow cytometry. Cell viability was monitored by detection of cleaved caspase-3 and the CellTiter-Glo assay. Results: pan-PI3Ki were most effective at inhibiting PI3K signaling and cell viability, and showed activity in CLL cells from both treatment-naïve and idelalisib-refractory/intolerant patients. CLL cells from idelalisib-refractory/intolerant patients showed overall reduced protein phosphorylation levels. The pan-PI3Ki copanlisib, but not the p110d inhibitor idelalisib, inhibited PI3K signaling in CD4+ and CD8+ T cells in addition to CD19+ B cells, but did not significantly affect T cell numbers. Combination treatment with a PI3Ki and venetoclax resulted in synergistic induction of apoptosis. Analysis of drug sensitivities to 73 drug combinations and profiling of 31 proteins stratified responders to idelalisib and umbralisib, respectively. Conclusions: Our findings suggest novel treatment vulnerabilities in idelalisib-refractory/intolerant CLL, and indicate that ex vivo functional profiling may stratify PI3Ki responders.
Resistance to PI3K inhibitors including idelalisib remains poorly understood. The present study was designed to identify mechanisms underlying PI3K inhibitor resistance in CLL through WES, RNAseq and biochemical confirmation. We performed WES on matched tumor and germline samples from 28 relapsed CLL patients treated with PI3K inhibitors (idelalisib, 79% (22/28), pilaralisib 10.7% (3/28), voxtalisib 10.7% (3/28)). The median number of prior therapies was 4.5 and the adverse cytogenetic aberrations del(17p) and del(11q) were seen in 21% and 32% respectively. A median of two longitudinal tumor samples were sequenced per patient (Nsamples= 68). An average of 23 ± 12 (range = 4-58) non-silent somatic mutations were identified in the initial sample. The non-silent mutation rate was 0.64 ± 0.32 per MB (range = 0.11-1.61) and typical of CLL. Significantly mutated genes (based on MutSig2CV) included SF3B1 36%, TP53 21%, DDX3X 14% and BRAF 11%. The cohort was sub-divided into responders (R) (Ncases= 18, Nsamples= 47) and non-responders (NR) (Ncases= 10, Nsamples= 21). Among the 10 NR, 7 had been treated with idelalisib and 3 with voxtalisib. Comparison of the mutational landscape between R and NR showed that, notably, mutations in BRAF(N=5), MAP2K1(N=2), KRAS(N=2),XPO1(N=1), PLEKHA1(N=1), INPPL1(N=1) and NXF1(N=1) were exclusively found in NR. Moreover, MAPK pathway genes (KRAS, BRAF and MAP2K1) were the only recurrent somatic mutations present exclusively in NR. We inferred the cancer cell fraction (ccf) for each somatic mutation using ABSOLUTE and found that the ccf values for MAP2K1 (p=0.01), XPO1 and PLEKHA1 mutations increased with time, indicating a positive selection pressure. Phylogic analysis of 6 R and 4 NR with at least 3 serial samples identified a median of 2 dynamic subclones (change of at least 10% between any two timepoints) and showed enrichment of the "Reactome_RAF_MAP_Kinase_Cascade" pathway in NR (p=3x10-4, q=0.04). In addition, Gene Set Enrichment Analysis comparing RNAseq samples drawn prior to or after PI3K therapy in five of the patients from our cohort (1 primary NR and 4 progressors after response) demonstrated activation of the "Reactome_Prolonged_ERK_Activation_Events" pathway at the later time-points (p=2.3x10-4, q= 0.03). Given these findings, we further investigated the role of the ERK/MAPK pathway in idelalisib resistance. Western blot analysis of ERK1/2 phosphorylation in ex vivo idelalisib treated PBMCs from an initially responding patient who acquired resistance later showed that idelalisib failed to inhibit ERK1/2 phosphorylation only at the resistant timepoint. This persistent ERK1/2 activation was inhibited by combination treatment with the MAP2K1 inhibitor CI-1040. We then profiled pAKT and pERK relative to total, by western blot on ex vivo idelalisib-treated samples (5 R, 5 NR). Idelalisib treatment ex vivo inhibited AKT phosphorylation in both R and NR, but no reduction in ERK phosphorylation was seen in NR, in contrast to R. Based on these findings we hypothesized that increased or persistent ERK activity confers resistance to PI3K inhibitors and tested the impact of MAP2K1 mutations on ERK activity. Among NR, we identified two different mutations in MAP2K1, E203K and Q56P (2/10 NR vs 0/18 R), both previously described as activating in solid tumors. In a separate cohort of multiply relapsed CLL patients, we found 4 cases of MAP2K1 F53L mutations, also previously reported in solid tumors. We studied the functional significance of these MAP2K1 mutations by generating stable MEC1 CLL cell lines expressing HA tagged E203K, F53L or Q56P MAP2K1 mutants. We found that all mutant cell lines had elevated basal ERK1/2 phosphorylation (E203K p<0.001; F53L p<0.001; Q56P p<0.001). Moreover, idelalisib did not inhibit IgM-induced ERK1/2 phosphorylation in the mutants when compared to the controls expressing wild type MAP2K1 (E203K p<0.001; F53L p<0.001; Q56P p<0.001). Preliminary results using the ERK1/2 inhibitor SCH772984 showed that the combination of SCH772984 along with idelalisib effectively decreased ERK1/2 phosphorylation in the mutant cell lines compared to idelalisib alone. Taken together, these data implicate the ERK pathway in idelalisib resistance and suggest that ERK1/2 inhibitors either combined with idelalisib at therapy start or added to idelalisib at early progression might sensitize patients to PI3K delta therapy. Disclosures Brown: Acerta / Astra-Zeneca: Membership on an entity's Board of Directors or advisory committees; Invectys: Membership on an entity's Board of Directors or advisory committees; Sunesis: Consultancy; TG Therapeutics: Consultancy; Morphosys: Membership on an entity's Board of Directors or advisory committees; Roche/Genentech: Consultancy; Gilead: Consultancy, Research Funding; Celgene: Consultancy; Genentech: Consultancy; Pharmacyclics: Consultancy; Abbvie: Consultancy; Verastem: Consultancy, Research Funding; Beigene: Membership on an entity's Board of Directors or advisory committees; Janssen: Consultancy; Sun Pharmaceutical Industries: Research Funding; Loxo: Consultancy; Boehringer: Consultancy.
Although BCL2 mutations are reported as later occurring events leading to venetoclax resistance, many other mechanisms of progression have been reported but remain poorly understood. Here we analyze longitudinal tumor samples from eleven patients with disease progression on venetoclax to characterize the clonal evolution of resistance. All patients tested showed increased in vitro resistance to venetoclax at their post-treatment timepoint. We found the previously described acquired BCL2-G101V mutation in only 4/11 patients with 2 patients showing very low variant allele fraction (VAF; 0.03-4.68%). Whole exome sequencing (WES) revealed acquired loss(8p) in 4/11 patients of which 2 patients also have gain (1q21.2-21.3) in the same cells, affecting the MCL-1 gene. In vitro experiments showed that CLL cells from the four patients with loss(8p) were more resistant to venetoclax than those without it, while the cells from two patients also carrying gain (1q21.2-21.3) showed increased sensitivity to MCL-1 inhibition. Progression samples with gain (1q21.2-21.3) were more susceptible to combination MCL-1 inhibitor with venetoclax. Differential gene expression analysis comparing bulk RNAseq data from pre-treatment and progression time points of all patients showed upregulation of proliferation, BCR and NFKB gene sets including MAPK genes. Cells from progression timepoints demonstrated upregulation of surface immunoglobulin M (sIgM) and higher pERK levels compared to the pre-timepoint, suggesting an upregulation of BCR signaling that activates the MAPK pathway. Overall, our data suggest several mechanisms of acquired resistance to venetoclax in CLL that could pave the way for rationally designed combination treatments for venetoclax resistant CLL patients.
PurposePhosphatidylinositol 3-kinase inhibitors (PI3Ki) are approved for relapsed chronic lymphocytic leukemia (CLL). While patients may show an initial response, development of treatment intolerance or resistance remains a clinically challenging. Prediction of individual treatment responses based on clinically actionable biomarkers is needed to overcome these challenges. Here, we investigated whether ex vivo functional responses to targeted therapies can stratify responders to idelalisib and guide precision medicine in CLL.Experimental designCLL cells from treatment naïve, idelalisib-responding, and idelalisib-refractory/intolerant patients (n=33 in total) were profiled against ten PI3Ki and the Bcl-2 antagonist venetoclax. Cell signaling and immune phenotypes were analyzed by flow cytometry. Cell viability was monitored by detection of cleaved caspase-3 and the CellTiter-Glo assay.ResultsAmong the ten PI3Ki studied, pan-PI3Ki were most effective at inhibiting PI3K signaling and cell viability, and they showed activity also in CLL cells from idelalisib-refractory/intolerant patients. The pan-PI3Ki copanlisib, but not the p110δ inhibitor idelalisib, inhibited PI3K signaling in CD4+ and CD8+ T cells in addition to CD19+ B cells, while it did not significantly affect T cell numbers. Combination treatment with a PI3Ki and venetoclax resulted in synergistic induction of apoptosis. Based on ex vivo drug sensitivity testing, a relapsed CLL patient was treated with idelalisib plus venetoclax, and the patient achieved a partial response. A more systematic analysis revealed that CLL cells from patients with a long-term response to idelalisib showed significantly higher drug sensitivities to 73 drug combinations at baseline compared to short-term responders.ConclusionsOur findings suggest novel treatment vulnerabilities in idelalisib-refractory/intolerant CLL, and demonstrate that ex vivo functional profiling may guide precision medicine and predict treatment responses of individual CLL patients.TRANSLATIONAL RELEVANCEThe phosphatidylinositol 3-kinase inhibitors (PI3Ki) idelalisib and duvelisib are approved for relapsed chronic lymphocytic leukemia (CLL), but their use has been limited by severe toxicity and acquired resistance. Identification of biomarkers that predict individual treatment responses, as well as alternative treatment vulnerabilities in PI3Ki refractory/intolerant patients, is needed to optimally tailor CLL therapy. We performed functional analyses of CLL cells from treatment naïve, idelalisib-responding and idelalisib-refractory/intolerant patients to identify clinically actionable biomarkers. We show that CLL cells from idelalisib-refractory/intolerant patients remain sensitive to pan-PI3Ki and PI3Ki plus venetoclax combinations. Ex vivo drug sensitivity testing was used to guide treatment of a relapsed CLL patient who obtained a partial response after idelalisib plus venetoclax therapy. A systematic analysis of drug sensitivities to 73 drug combinations stratified responders to idelalisib using baseline samples from short-term and long-term responders to idelalisib. Our study demonstrates the power of functional precision medicine in relapsed CLL.
<div>AbstractPurpose:<p>PI3K inhibitors (PI3Ki) are approved for relapsed chronic lymphocytic leukemia (CLL). Although patients may show an initial response to these therapies, development of treatment intolerance or resistance remain clinical challenges. To overcome these, prediction of individual treatment responses based on actionable biomarkers is needed. Here, we characterized the activity and cellular effects of 10 PI3Ki and investigated whether functional analyses can identify treatment vulnerabilities in PI3Ki-refractory/intolerant CLL and stratify responders to PI3Ki.</p>Experimental Design:<p>Peripheral blood mononuclear cell samples (<i>n</i> = 51 in total) from treatment-naïve and PI3Ki-treated patients with CLL were studied. Cells were profiled against 10 PI3Ki and the Bcl-2 antagonist venetoclax. Cell signaling and immune phenotypes were analyzed by flow cytometry. Cell viability was monitored by detection of cleaved caspase-3 and the CellTiter-Glo assay.</p>Results:<p>pan-PI3Kis were most effective at inhibiting PI3K signaling and cell viability, and showed activity in CLL cells from both treatment-naïve and idelalisib-refractory/intolerant patients. CLL cells from idelalisib-refractory/intolerant patients showed overall reduced protein phosphorylation levels. The pan-PI3Ki copanlisib, but not the p110δ inhibitor idelalisib, inhibited PI3K signaling in CD4<sup>+</sup> and CD8<sup>+</sup> T cells in addition to CD19<sup>+</sup> B cells, but did not significantly affect T-cell numbers. Combination treatment with a PI3Ki and venetoclax resulted in synergistic induction of apoptosis. Analysis of drug sensitivities to 73 drug combinations and profiling of 31 proteins stratified responders to idelalisib and umbralisib, respectively.</p>Conclusions:<p>Our findings suggest novel treatment vulnerabilities in idelalisib-refractory/intolerant CLL, and indicate that <i>ex vivo</i> functional profiling may stratify PI3Ki responders.</p></div>
<div>AbstractPurpose:<p>PI3K inhibitors (PI3Ki) are approved for relapsed chronic lymphocytic leukemia (CLL). Although patients may show an initial response to these therapies, development of treatment intolerance or resistance remain clinical challenges. To overcome these, prediction of individual treatment responses based on actionable biomarkers is needed. Here, we characterized the activity and cellular effects of 10 PI3Ki and investigated whether functional analyses can identify treatment vulnerabilities in PI3Ki-refractory/intolerant CLL and stratify responders to PI3Ki.</p>Experimental Design:<p>Peripheral blood mononuclear cell samples (<i>n</i> = 51 in total) from treatment-naïve and PI3Ki-treated patients with CLL were studied. Cells were profiled against 10 PI3Ki and the Bcl-2 antagonist venetoclax. Cell signaling and immune phenotypes were analyzed by flow cytometry. Cell viability was monitored by detection of cleaved caspase-3 and the CellTiter-Glo assay.</p>Results:<p>pan-PI3Kis were most effective at inhibiting PI3K signaling and cell viability, and showed activity in CLL cells from both treatment-naïve and idelalisib-refractory/intolerant patients. CLL cells from idelalisib-refractory/intolerant patients showed overall reduced protein phosphorylation levels. The pan-PI3Ki copanlisib, but not the p110δ inhibitor idelalisib, inhibited PI3K signaling in CD4<sup>+</sup> and CD8<sup>+</sup> T cells in addition to CD19<sup>+</sup> B cells, but did not significantly affect T-cell numbers. Combination treatment with a PI3Ki and venetoclax resulted in synergistic induction of apoptosis. Analysis of drug sensitivities to 73 drug combinations and profiling of 31 proteins stratified responders to idelalisib and umbralisib, respectively.</p>Conclusions:<p>Our findings suggest novel treatment vulnerabilities in idelalisib-refractory/intolerant CLL, and indicate that <i>ex vivo</i> functional profiling may stratify PI3Ki responders.</p></div>
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