Survival of chronic lymphocytic leukemia (CLL) cells is triggered by several stimuli, such as the B-cell receptor (BCR), CD40 ligand (CD40L), or interleukin-4 (IL-4).We identified that these stimuli regulate apoptosis resistance by modulating sphingolipid metabolism. Applying liquid chromatography electrospray ionization tandem mass spectrometry, we revealed a significant decrease of proapoptotic ceramide in BCR/IL-4/CD40L-stimulated primary CLL cells compared with untreated controls. Antiapoptotic glucosylceramide levels were significantly increased after BCR cross-linking. We identified BCR engagement to catalyze the crucial modification of ceramide to glucosylceramide via UDPglucose ceramide glucosyltransferase (UGCG). Besides specific UGCG inhibitors, our data demonstrate that IgMmediated UGCG expression was inhibited by the novel and highly effective PI3K␦ and BTK inhibitors CAL-101 and PCI-32765, which reverted IgM-induced resistance toward apoptosis of CLL cells. Sphingolipids were recently shown to be crucial for mediation of apoptosis via mitochondria. Our data reveal ABT-737, a mitochondria-targeting drug, as interesting candidate partner for PI3K␦ and BTK inhibition, resulting in synergistic apoptosis, even under protection by the BCR. In summary, we identified the mode of action of novel kinase inhibitors CAL-101 and PCI-32765 by controlling the UGCGmediated ceramide/glucosylceramide equilibrium as a downstream molecular switch of BCR signaling, also providing novel targeted treatment options beyond current chemotherapy-based regimens. (Blood. 2012;120(19):3978-3985)
IntroductionDespite recent advances in the treatment of chronic lymphocytic leukemia (CLL) by use of modern chemoimmunotherapies, 1,2 the disease remains incurable for most patients with the exception of those who have the option of an allogeneic transplantation. 3 Moreover, most chemotherapeutic regimens require a certain physical fitness of the patient. Because CLL is a disease of the elderly, there is a need for novel therapeutic concepts, which are able to disrupt resistance to cytostatic drugs. Chemoresistance is thought to be partially the result of malignant cell clones that find a niche within the microenvironment. Resistance might be mediated at least by 3 major stimuli: (1) by engagement of the B-cell receptor (BCR), (2) by CD40 ligand (CD40L)-CD40 interaction, and (3) by stimulation via interleukin-4 (IL-4). 4 Those signals lead via downstream pathways to reduced susceptibility of CLL cells toward chemotherapy within the microenvironment. To some extent, these stimuli share common pathways to mediate survival. 5 As a consequence, the balance between proapoptotic and antiapoptotic signals is disrupted toward pro-survival signals. BCR signaling has been identified as the central and determining factor in CLL. Therefore, novel compounds, which target this pathway, have been developed: CAL-101 as PI3K␦ inhibitor and PCI-32765 as inhibitor of Bruton tyrosine kinase (BTK).Recent data from first trials using CAL-101 and PCI-32765 ind...