Abstract 1703: The HDAC6 inhibitor Nexturastat A improves in vivo PD-1 immune blockade

The role of HDACs in cell biology, initially limited to their effects upon histones, now encompasses more complex regulatory functions that vary with their tissue expression, cellular compartmentalization and stage of cellular differentiation. Several recent studies have shown that selective HDAC inhibitors (HDACi) are able to impair in vivo tumor growth. Therefore, there is an emerging interest in the understanding of the molecular mechanisms mediating these anti-tumor properties. In this context, a number of recent publications have demonstrated that the selective inhibition of specific HDACs enhances tumor immunogenicity in a wide variety of tumors, thereby preventing tumor escape and improving immune surveillance. Our group has focused on HDAC6, and shown that both the genetic abrogation and pharmacological inhibition of this HDAC modulates the expression of a variety of immune-regulatory proteins in the tumor microenvironment, including PD-L1, PD-L2, MHC class I, B7-H4 and TRAIL-R1. In particular, we have previously demonstrated that both pharmacological inhibition and/or genetic abrogation of HDAC6 plays a critical role in the immune check point blockade by down-regulating the expression of PD-L1. Moreover, we have also shown that in vivo inhibition of HDAC6 reduces tumor growth in B16 and SM1 murine melanoma models within syngeneic immunocompetent hosts. Additionally, we have found that the combination of the HDAC6i Nexturastat A (NextA) and checkpoint PD-1 immune blockade therapy results in an important improvement in anti-tumor immune responses as evidenced by the reduction of tumor growth when compared to treatment with individual stand-alone agents. Moreover, our data has shown an increase in CD8+, NK+ cell infiltration of tumors treated with the combination therapy versus either standalone treatment. Further analysis of in vivo immune tumor infiltration evidenced that the treatment with NextA importantly diminished the macrophage M2 phenotype in the tumor microenvironment. An outcome that was also observed in combination with PD-1 immune blockade. Lastly, we have found that the anti-PD-1/NextA in vivo combination therapy reduces the expression of PD-L1, PD-L2 and other negative check-point pathways. However, the HDAC6 inhibition has a minimal effect over the expression of their respective counterparts in T cells (i.e. PD-1). Overall, we have found that HDAC6i could be used as a potential adjuvant in ongoing therapeutic options involving immune check-point blockade.

Citation Format: Tessa Knox, Eva Sahakian, Debarati Banik, Melissa Hadley, Erica Palmer, Jennifer Kim, John Powers, Sarthak Shah, Alexa Lowe, Javier Pinilla, Eduardo Sotomayor, Norman Lee, Alan Kozikowski, Alejandro V. Villagra. The HDAC6 inhibitor Nexturastat A improves in vivo PD-1 immune blockade [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1703.

Abstract 4967: HDAC11 function as a transcriptional regulator in immature myeloid cells to myeloid-derived suppressor cells transition

In normal myelopoiesis, immature myeloid cells (IMCs) differentiate into macrophages, neutrophils or dendritic cells, a process that is tightly controlled by transcription factors and epigenetic regulators. However, under tumor burden, IMCs differentiate into myeloid derived suppressor cells (MDSCs) and with subsequent up-regulation of immune suppressive factors and a pro-tumor effect. In prior studies, we found that MDSCs from HDAC11 KO mice displayed an increased T-cell suppressive activity that was associated with a more aggressive tumor growth as compared to MDSCs from wild type control mice. Unlike MDSC's in which absence of HDAC11 is associated with a suppressive phenotype, T-cell lacking HDAC11 are hyper-reactive and endowed with strong antitumor activity. To assess which phenotype will be the dominant one in vivo, we performed adoptive immune cell transfer experiments of MDSC and/or T-cells from HDAC11 KO mice into C57BL/6 tumor-bearing mice. The transfer of HDAC11KO MDSCs was able to eliminate, at least partially, the anti-tumor effect elicited by the adoptive transfer of HDAC11KO T cells.

Mechanistically we have found that MDSCs lacking HDAC11 displayed up-regulation of expression and enzymatic activity of arginase 1 and Nos2, two enzymes that are crucial in regulating MDSCs suppressive function. The aberrant enzymatic activities of Arg1 and Nos2 in HDAC11KO MDSCs correlate with over-expression of the lineage-specific transcription factor C/EBPβ, which has been shown to be essential for the differentiation of functional MDSCs. Furthermore, ChIP analysis confirmed that HDAC11 is recruited to the C/EBPβ gene promoter where exerts a negative regulatory effect upon gene transcription.

Taken together, we have uncovered a previously unknown role for HDAC11 as a transcriptional regulator of MDSCs function. A better understanding of this novel role of HDAC11 in myeloid biology will lead to targeted epigenetic therapies to manipulate the suppressive effect of these immunoregulatory cells.

Citation Format: Jie Chen, Fengdong Cheng, Eva Sahakian, John Powers, Zi Wang, Alejandro Villagra, Javier Pinilla-Ibarz, Eduardo M. Sotomayor. HDAC11 function as a transcriptional regulator in immature myeloid cells to myeloid-derived suppressor cells transition [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4967.

Abstract 4055: Enhancing anti-PD-1 immune blockade in melanoma through selective inhibition of histone deacetylase 6

Histone deacetylases (HDACs), were originally described in a limited context as histone modifiers. New evidence has demonstrated that HDACs are also involved in a diverse range of cellular processes that are not restricted to the chromatin environment, such as the regulation of the cell cycle/apoptosis and, more recently, a modulator of immune response. However, much remains unknown about the mechanism of action of HDACs and their roles in the immune-biology of cancer. The non-specific nature of pan-HDAC inhibitors results in a narrow therapeutic window of use, limiting the dose and duration due to toxicity. Our group has focused in one specific HDAC, HDAC6, and shown that both the genetic abrogation and pharmacological inhibition of this HDAC modulates the expression of a variety of immune-regulatory proteins in the tumor microenvironment, including PD-L1, PD-L2, MHC class I, B7-H4 and TRAIL-R1. In particular, we have previously demonstrated that both pharmacological inhibition and/or genetic abrogation of HDAC6 plays a critical role in the immune check point blockade by down-regulating the expression of PD-L1 and other check-point modulators such as PD-L2, B7-H4, etc. Moreover, we have also observed that in vivo inhibition of HDAC6 reduces tumor growth in B16 and SM1 murine melanoma models within syngeneic immunocompetent hosts. Additionally, we have found that the combination of low doses of the HDAC6i Nexturastat A and checkpoint immune blockade, including anti-PD-1 and anti-CTLA4, results in an important improvement in anti-tumor immune responses as evidenced by the reduction of tumor growth when compared to treatment with individual stand-alone agents. In these studies we also evidenced an increased production of IFNγ and IL-2 in the stand-alone check-point inhibitor treatments, which leads to an upregulation of PD-L1 and PD-L2. Similar levels of IFNγ and IL-2 were found in the combination groups. However, the expression level of PD-L1 and PD-L2 were comparable to the non-treated group. Taking all together, we have found that HDAC6i could be used as a potential adjuvant in ongoing therapeutic options involving immune check-point blockade.

Citation Format: Tessa Knox, Eva Sahakian, Jayakumar Nair, Jennifer Kim, Debarati Banik, Melissa Hadley, John Powers, Fengdong Cheng, Sida Shen, Javier Pinilla, Jeffrey Weber, Alan Kozikowski, Eduardo Sotomayor, Alejandro Villagra. Enhancing anti-PD-1 immune blockade in melanoma through selective inhibition of histone deacetylase 6 [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4055. doi:10.1158/1538-7445.AM2017-4055

Evaluation of a "walk-through" ladder top design during ladder-roof transitioning tasks

This study evaluated the effect of an extension ladder "walk-through" top design on kinetic and kinematic behaviors and the outward destabilizing forces induced on the ladder during transitioning at elevation. Thirty-two male participants performed stepping tasks between a ladder top and a roof at simulated elevation in a surround-screen virtual-reality system. The experimental conditions included a "walk-through" and a standard ladder top section supported on flat and sloped roof surfaces. Three force platforms were placed under the ladder section and in the roof to measure propulsion forces during transitions. A motion measurement system was used to record trunk kinematics. The frictional demand at the virtual ladder base was also calculated. The results indicate that under optimal ladder setup (angle 75.5 °), the frictional demand at the ladder base remains relatively small for all experimental conditions. Also, the "walk through" ladder top eased the ladder-to-roof transitions but not the roof-to-ladder transitions.

Evaluating Anti-Infective Drugs in the Resistant Pathogen Setting: Can we Use External Controls?

Decreased efficacy of antibiotics due to resistant pathogens has created a need for the development of more effective medical interventions. Despite the increasing prevalence of pathogens resistant to one or more drugs, identifying and enrolling participants into clinical trials that evaluate new interventions for the treatment of some diseases can be challenging given the low prevalence of disease in which there are no effective treatments. Thus researchers might be tempted to consider externally-controlled trials that may allow for a reduction of the necessary number of prospectively-identified trial participants, thus easing recruitment burden and resulting in more timely trial completion relative to randomized controlled trials. We discuss advantages and disadvantages in externally controlled trials and review requirements for a valid externally-controlled trial. As ECTs are subject to the bias of observational studies, the criteria for a valid ECT should be carefully evaluated before these designs are implemented. Given considerable variation in study results in the resistant pathogen setting, the lack of information on important patient characteristics that may confound estimates of treatment effects, as well as the improvements in medical practice and evolving antibiotic resistance, the use of ECTs in the resistant pathogen setting, is not recommended. ECTs should be should be limited to specific situations where superiority of the effect of the new intervention is dramatic, the usual course of the disease highly predictable, the endpoints are objective (e.g., all-cause mortality) and the impact of baseline and treatment variables on outcomes is well characterized. Given that the resistant pathogen setting does not satisfy these criteria, we conclude that that randomized clinical trials are needed to evaluate new treatments for resistant pathogens. Innovative approaches to trial design that may ease recruitment burden while evaluating the benefits and harms of new treatments are being developed and utilized.

Abstract 2331: HDAC6, new role as master regulator of PD-L1 and immune-related pathways

Histone deacetylases (HDACs), originally described as histone modifiers, have more recently been demonstrated to modify a variety of other proteins involved in diverse cellular processes unrelated to the chromatin environment, including the modulation of proteins related to cell cycle/apoptosis and immune regulation. In contrast to the well-documented effects of HDAC inhibitors (HDACi) in the control of cell cycle and apoptosis, their role in immunobiology is still not completely understood, and the reported immunological outcomes when using HDACi are heterogeneous. Our group recently reported that the pharmacological or genetic abrogation of a single HDAC, HDAC6, modulates the expression of immuno-regulatory proteins, including PD-L1, PD-L2, MHC class I, B7-H4 and TRAIL-R1. We primarily focused in PD-L1, which is an important negative regulator of T-cell function and often over-expressed in cancer cells. In a mechanistic point of view, we have found that the pharmacological inhibition and genetic abrogation of HDAC6 inactivates the STAT3 pathway, impairs the nuclear translocation and the recruitment of STAT3 to the PD-L1 promoter and subsequently down-regulates the expression of PD-L1. Moreover, the in vivo abrogation of HDAC6 reduces tumor growth in melanoma models, effect that is enhanced in the presence of the immune check-point blocking antibodies anti-PD-1 and anti-CTLA4. These results provide a key pre-clinical rationale and justification to further study isotype selective HDAC6 inhibitors as potential immunomodulatory agents in cancer.

Citation Format: Tessa Knox, Maritza Lienlaf, Patricio Perez, Mibel Pabon, Calvin Lee, Fengdong Cheng, Eva Sahakian, John Powers, Susan Deng, Smalley Keiran, Alan Kozikowski, Javier Pinilla, Amod Sarnaik, Ed Seto, Jeffrey Weber, Eduardo Sotomayor, Alejandro Villagra. HDAC6, new role as master regulator of PD-L1 and immune-related pathways. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2331.

Abstract 4485: Regulation of chronic lymphocytic leukemia (CLL) immunobiology by histone deacetylase 6 (HDAC6)

In CLL, an immunosuppressive phenotype enables the malignant B cell to evade immune detection leading to immune suppression. In recent years, epigenetic changes prompted by proteins known as histone deacetylases (HDACs) have gained special attention predominantly because of their active role in the regulation of pathogenesis and immune-related pathways in CLL; though the precise mechanism by which these regulatory events take place has yet to be elucidated. In addition to the well-recognized role of histone deacetylase inhibitors (HDACi) in the control of cell cycle and apoptosis, HDACi have a potential role in modulating the immunobiology of CLL. Remarkably, HDACi alter the inflammatory status of immune cells and tumor cells themselves. Among the family of HDACs, we have recently demonstrated that HDAC6 has a regulatory role in transcriptional regulation of IL-10, and is responsible for T cell anergy in murine and human antigen presenting cells.

Activation of T-cells is predominantly dependent on both co-stimulatory and co-inhibitory molecules, including PD-1/PD-L1 as well as CTLA4-B7, OX40-OX40L, CD40-CD154, GAL9-TIM3, and 41BBL/41BB. Furthermore, most of these molecules have been identified to have epigenetically induced changes in expression.

Previously we had reported that expression of HDAC6 is increased in CLL patient samples. Recent studies from our lab show that selective HDAC6 inhibitors modify the expression of immunomodulatory molecules, which may ultimately lead to increases in the immunogenicity of CLL. Thus far, findings from our lab reveal that CLL cells treated with HDAC6i show 1) a dose dependent cell kill, 2) a reduction of IL-10—an important cytokine in the regulation of cell proliferation in CLL, and 3) synergistic reduction of viability when combined with the BTK inhibitor ibrutinib. Subsequently, we have also demonstrated that MEC2-HDAC6KD cells exhibit an increase in MHCII and a decrease in PD-L1 expression. Interestingly, we also observed a decrease in the expression of PD-L1 and other immune checkpoint markers in CLL cell lines treated with low-doses of HDAC6i. Additionally, malignant B cells isolated from euTCL1 mice and treated ex vivo with HDAC6i become more immunogenic and elicit greater type I allogeneic T cell immune response. Lastly, utilizing our in vivo CLL murine models (euTCL1, and euTCL1-HDAC6KO), we have been able to demonstrate a reduction in circulating lymphocytes in euTCL1-HDAC6KO, as well as euTCL1 mice receiving systemic administration of HDAC6i.

In conclusion, selective inhibition of HDAC6 in CLL results in the reduction of co-inhibitory molecules, dose dependent increases in cell killing as single treatment as well as strong synergy when combined with ibrutinib. These findings could provide a successful combination immunotherapeutic strategy for the treatment of CLL.

Citation Format: Eva Sahakian, Kamira Maharaj, John Powers, Renee M. Fonesca, Susan Deng, Javier Pinilla-Ibraz, Steven N. Quayle, Simon S. Jones. Regulation of chronic lymphocytic leukemia (CLL) immunobiology by histone deacetylase 6 (HDAC6). [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 4485.

Results of a phase II study of lenalidomide and rituximab for refractory/relapsed chronic lymphocytic leukemia

Chronic lymphocytic leukemia (CLL) is an incurable disease in need of new therapeutic strategies. The immunomodulatory agent, lenalidomide, has shown activity as salvage therapy for CLL. In this phase II trial, we combined lenalidomide with rituximab in 25 patients (range, 41-79) with refractory/relapsed CLL. Lenalidomide was administered orally on escalating doses, with cycle 1 doses of 2.5mg daily on days 1-7, 5mg on days 8-14, and 10mg on days 15-21 followed by 7days off. On cycle 2 and beyond, lenalidomide was administered at 20mg daily on days 1-21. Rituximab was administered at 375mg/m(2) intravenously on a weekly basis for the first cycle starting on day 15 for 4 doses, with each cycle being 28days. Treatment was continued until disease progression or toxicity. Overall response rate was 45.8% on intent-to-treat and 61.1% in evaluable patients (all partial responses). Median time to treatment failure was 14.3 months for evaluable patients, and median overall survival was not reached. The most common grade 3/4 toxicity was neutropenia (72% of patients). The most common nonhematologic toxicity was infection (29% of patients). Lenalidomide combined with rituximab showed activity in heavily treated refractory CLL with an acceptable toxicity profile.

Abstract P2-09-01: Patient reported outcomes of multiplex breast cancer susceptibility testing utilizing a tiered-binned counseling and informed consent model in BRCA1/2 negative patients

Background:The risks, benefits and utilities of multiplex panels for breast cancer susceptibility are unknown and new counseling and informed consent models are needed. We sought to obtain patient reported outcomes of multiplex testing in BRCA1/2 negative patients utilizing a novel, previously piloted tiered-binned counseling model for multiplex testing. Methods:BRCA1/2 negative participants completed pre(V1) and post-test counseling(V2) and surveys evaluating cognitive, affective and behavioral responses to a 25-gene multiplex testing panel. We used linear regressions with estimation by GEE where appropriate. Results:376 patients have been approached. To date, 124 participants(33%) have consented to the study, 21(6%) declined and 231(61%) are considering. Of 95 who have completed pre-test counseling(V1), 88(93%) elected to proceed with 25-gene panel testing and (81%) were classified as making an informed choice after tiered-binned counseling. 6/53(11%) participants received a positive result, including 1 mutation in MSH2 and 5 in moderate penetrance genes (2 ATM, 1 BARD1, 1 CHEK2, 1 PALB2). 22/53(42%) participants received a variant of unknown significance(VUS). General anxiety and perceived utility decreased significantly with pre-test counseling and after results (Table 1). Knowledge increased with pre-test counseling; cancer worry increased after receipt of multiplex results. Higher cancer worry was associated only with lower income (2.6 points/income category, p<0.01). Those with a VUS had greater decreases in perceived utility compared to negative (p=0.01) or positive (p=0.003) results. To date, there are no other significant differences in knowledge, distress or uncertainty by test result. Medical management recommendations for the proband changed in 3/6 with a positive result. Cascade testing in the family was discussed as an option in 3/6 with a positive result. Conclusions:Many BRCA1/2-negative patients proceed with 25-gene cancer susceptibility testing if offered and most make informed choices utilizing a tiered-binned genetic counseling model. The tiered-binned counseling model is associated with increased knowledge, decreases in general anxiety and uncertainty after pre-test counseling and disclosure of results, but an increase in cancer worry after result disclosure. The clinical utility, long-term outcomes and differences in patient reported outcomes by test result remain unknown.

Table 1 Baseline, Mean(SD)After V1, Mean(SD)After V2, Mean(SD) N=75ˆ;N=49ˆˆN=75ˆ;N=49ˆˆN=49ˆˆGeneral Anxiety (range 0-21)6.4(3.9)*;6.9(3.9)**6.0(4.3)*;6.6(4.2)**5.8(4.5)**General Depression (range 0-212.8(2.9);3.1(3.2)3.0(3.5);3.1(3.6)3.0(3.7)State Anxiety (range 20-80)35.5(11.2);36.6(11.9)35.5(11.8);36.8(11.9)36.1(12.2)Cancer Worry (range 0-75)18.2(13.5);20.1(13.8)**16.7(12.5);17.2(11.9)**21.0(13.9)**Knowledge (range 17-82)65.7(5.0)**;66.5(5.0)**68.0(5.7)**;68.4(5.6)**67.3(4.9)**Uncertainty (range 0-15)5.8(3.9);6.2(4.3)5.6(3.7);5.4(3.2)5.6(3.5)Perceived Utility (range 24-120)75.2(14.0)*;75.9(14.0)**73.0(14.1)*;74.1(13.4)**68.4(16.9)***p≤0.05 **p≤0.01. ˆcompleted V1. ˆˆcompleted V1 & V2. To date, 53 have received results and 49 have completed post-disclosure surveys.

Citation Format: Bradbury AR, Patrick-Miller L, Egleston BE, Maxwell KN, Brandt A, Brower J, DiGiovanni L, Long JM, Powers J, Stopfer J, Nathanson KL, Domchek SM. Patient reported outcomes of multiplex breast cancer susceptibility testing utilizing a tiered-binned counseling and informed consent model in BRCA1/2 negative patients. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-09-01.

Functional Analysis of Histone Deacetylase 11 (HDAC11)

The physiological role of histone deacetylase 11 (HDAC11), the newest member of the HDAC family, remained largely unknown until the discovery of its regulatory function in immune cells. Among them, the regulation of cytokine production by antigen-presenting cells and the modulation of the suppressive ability of myeloid-derived suppressor cells (MDSCs) (Sahakian et al. Mol Immunol 63: 579-585, 2015; Wang et al. J Immunol 186: 3986-3996, 2011; Villagra et al. Nat Immunol 10: 92-100, 2009). Our earlier data has demonstrated that HDAC11, by interacting at the chromatin level with the IL-10 promoter, downregulates il-10 transcription in both murine and human APCs in vitro and ex vivo models (Villagra et al. Nat Immunol 10: 92-100, 2009). However the role of HDAC11 in other cell types still remains unknown. Here we present several methods that can potentially be used to identify the functional role of HDAC11, assigning special attention to the evaluation of immunological parameters.