Amplification of MYCN is a poor prognostic feature in neuroblastoma (NBL) indicating aggressive disease. We and others have shown BET bromodomain inhibitors (BETi) target MYCN indirectly by downregulating its transcription. Here we sought to identify agents that synergize with BETi and to identify biomarkers of resistance. We previously performed a viability screen of ∼1,900 oncology-focused compounds combined with BET bromodomain inhibitors against MYCN -amplified NBL cell lines. Reanalysis of our screening results prominently identified inhibitors of aurora kinase A (AURKAi) to be highly synergistic with BETi. We confirmed the anti-proliferative effects of several BETi+AURKAi combinations in MYCN -amplified NBL cell lines. Compared to single agents, these combinations cooperated to decrease levels of N-myc. We treated both TP53 -wild type and mutant, MYCN -amplified cell lines with the BETi JQ1 and the AURKAi Alisertib. The combination had improved efficacy in the TP53 -WT context, notably driving apoptosis in both genetic backgrounds. JQ1+Alisertib combination treatment of a MYCN -amplified, TP53 -null or TP53 -restored genetically engineered mouse model of NBL prolonged survival better than either single agent. This was most profound with TP53 restored, with marked tumor shrinkage and apoptosis induction in response to combination JQ1+Alisertib. BETi+AURKAi in MYCN -amplified NBL, particularly in the context of functional TP53 , provided anti-tumor benefits in preclinical models. This combination should be studied more closely in a pediatric clinical trial.

Genome-wide association studies (GWAS) have discovered thousands of risk loci for common, complex diseases, each of which could point to genes and gene programs that influence disease. For some diseases, it has been observed that GWAS signals converge on a smaller number of biological programs, and that this convergence can help to identify causal genes. However, identifying such convergence remains challenging: each GWAS locus can have many candidate genes, each gene might act in one or more possible programs, and it remains unclear which programs might influence disease risk. Here, we developed a new approach to address this challenge, by creating unbiased maps to link disease variants to genes to programs (V2G2P) in a given cell type. We applied this approach to study the role of endothelial cells in the genetics of coronary artery disease (CAD). To link variants to genes, we constructed enhancer-gene maps using the Activity-by-Contact model. To link genes to programs, we applied CRISPRi-Perturb-seq to knock down all expressed genes within +/-500 Kb of 306 CAD GWAS signals and identify their effects on gene expression programs using single-cell RNA-sequencing. By combining these variant-to-gene and gene-to-program maps, we find that 43 of 306 CAD GWAS signals converge onto 5 gene programs linked to the cerebral cavernous malformations (CCM) pathway, which is known to coordinate transcriptional responses in endothelial cells, but has not been previously linked to CAD risk. The strongest regulator of these programs is TLNRD1, which we show is a new CAD gene and novel regulator of the CCM pathway. TLNRD1 loss-of-function alters actin organization and barrier function in endothelial cells in vitro, and heart development in zebrafish in vivo. Together, our study identifies convergence of CAD risk loci into prioritized gene programs in endothelial cells, nominates new genes of potential therapeutic relevance for CAD, and demonstrates a generalizable strategy to connect disease variants to functions.

Somatic mutations are rare in pediatric AML (pAML), indicating alternate strategies are needed to identify targetable dependencies. We performed the first enhancer mapping of 3 pAML in 22 patient samples. Generally, pAML samples were distinct from adult AML 4 samples, and MLL (KMT2A)-rearranged samples were also distinct from non-KMT2A-5 rearranged samples. Focusing specifically on super-enhancers (SEs), we identified SEs 6 associated with many known leukemia regulators. The retinoic acid receptor alpha 7 (RARA) gene was differentially regulated in our cohort, and a RARA associated SE was 8 detected in 64% our cohort across all cyto/molecular subtypes tested. RARA SE-positive 9 pAML cell lines and samples demonstrated high RARA mRNA levels. These samples 10 were specifically sensitive to the synthetic RARA agonist tamibarotene in vitro, with 11 slowed proliferation, apoptosis induction, differentiation, and upregulated retinoid target 12 gene expression, compared to RARA SE-negative samples. Tamibarotene prolonged 13 survival and suppressed the leukemia burden of a RARA SE-positive pAML patient-14 derived xenograft (PDX) mouse model compared to a RARA SE-negative PDX. Our work 15 demonstrates that examining chromatin regulation can identify new, druggable 16 dependencies in pAML and provides rationale for a pediatric tamibarotene trial in children 17 with RARA-high AML.