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Del Giudice I, Della Starza I, De Falco F, Gaidano G, Sportoletti P. Monitoring Response and Resistance to Treatment in Chronic Lymphocytic Leukemia. Cancers (Basel) 2024; 16:2049. [PMID: 38893168 PMCID: PMC11171231 DOI: 10.3390/cancers16112049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/09/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
The recent evolution in chronic lymphocytic leukemia (CLL) targeted therapies led to a progressive change in the way clinicians manage the goals of treatment and evaluate the response to treatment in respect to the paradigm of the chemoimmunotherapy era. Continuous therapies with BTK inhibitors achieve prolonged and sustained control of the disease. On the other hand, venetoclax and anti-CD20 monoclonal antibodies or, more recently, ibrutinib plus venetoclax combinations, given for a fixed duration, achieve undetectable measurable residual disease (uMRD) in the vast majority of patients. On these grounds, a time-limited MRD-driven strategy, a previously unexplored scenario in CLL, is being attempted. On the other side of the spectrum, novel genetic and non-genetic mechanisms of resistance to targeted treatments are emerging. Here we review the response assessment criteria, the evolution and clinical application of MRD analysis and the mechanisms of resistance according to the novel treatment strategies within clinical trials. The extent to which this novel evidence will translate in the real-life management of CLL patients remains an open issue to be addressed.
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Affiliation(s)
- Ilaria Del Giudice
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00161 Rome, Italy;
| | - Irene Della Starza
- Hematology, Department of Translational and Precision Medicine, Sapienza University, 00161 Rome, Italy;
- AIL Roma, ODV, 00161 Rome, Italy
| | - Filomena De Falco
- Department of Medicine and Surgery, Institute of Hematology and Center for Hemato-Oncological Research, University of Perugia, 06129 Perugia, Italy;
| | - Gianluca Gaidano
- Division of Hematology, Department of Translational Medicine, Università del Piemonte Orientale, 28100 Novara, Italy;
| | - Paolo Sportoletti
- Department of Medicine and Surgery, Institute of Hematology and Center for Hemato-Oncological Research, University of Perugia, 06129 Perugia, Italy;
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2
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Vom Stein AF, Hallek M, Nguyen PH. Role of the tumor microenvironment in CLL pathogenesis. Semin Hematol 2023:S0037-1963(23)00098-7. [PMID: 38220499 DOI: 10.1053/j.seminhematol.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/02/2023] [Accepted: 12/23/2023] [Indexed: 01/16/2024]
Abstract
Chronic lymphocytic leukemia (CLL) cells extensively interact with and depend on their surrounding tumor microenvironment (TME). The TME encompasses a heterogeneous array of cell types, soluble signals, and extracellular vesicles, which contribute significantly to CLL pathogenesis. CLL cells and the TME cooperatively generate a chronic inflammatory milieu, which reciprocally reprograms the TME and activates a signaling network within CLL cells, promoting their survival and proliferation. Additionally, the inflammatory milieu exerts chemotactic effects, attracting CLL cells and other immune cells to the lymphoid tissues. The intricate CLL-TME interactions also facilitate immune evasion and compromise leukemic cell surveillance. We also review recent advances that have shed light on additional aspects that are substantially influenced by the CLL-TME interplay.
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Affiliation(s)
- Alexander F Vom Stein
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; Center for Molecular Medicine Cologne; CECAD Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany
| | - Michael Hallek
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; Center for Molecular Medicine Cologne; CECAD Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany
| | - Phuong-Hien Nguyen
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf; Center for Molecular Medicine Cologne; CECAD Center of Excellence on Cellular Stress Responses in Aging-Associated Diseases, Cologne, Germany.
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3
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Concurrent Inhibition of Akt and ERK Using TIC-10 Can Overcome Venetoclax Resistance in Mantle Cell Lymphoma. Cancers (Basel) 2023; 15:cancers15020510. [PMID: 36672458 PMCID: PMC9856512 DOI: 10.3390/cancers15020510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/11/2023] [Accepted: 01/11/2023] [Indexed: 01/18/2023] Open
Abstract
Venetoclax, a BCL-2 inhibitor, has proven to be effective in several hematological malignancies, including mantle cell lymphoma (MCL). However, development of venetoclax resistance is inevitable and understanding its underlying molecular mechanisms can optimize treatment response. We performed a thorough genetic, epigenetic and transcriptomic analysis of venetoclax-sensitive and resistant MCL cell lines, also evaluating the role of the stromal microenvironment using human and murine co-cultures. In our model, venetoclax resistance was associated with abrogated TP53 activity through an acquired mutation and transcriptional downregulation leading to a diminished apoptotic response. Venetoclax-resistant cells also exhibited an upregulation of the PI3K/Akt pathway, and pharmacological inhibition of Akt and ERK with TIC-10 led to cell death in all venetoclax-resistant cell lines. Overall, we highlight the importance of targeted therapies, such as TIC-10, against venetoclax resistance-related pathways, which might represent future therapeutic prospects.
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4
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Sarapura Martinez VJ, Buonincontro B, Cassarino C, Bernatowiez J, Colado A, Cordini G, Custidiano MDR, Mahuad C, Pavlovsky MA, Bezares RF, Favale NO, Vermeulen M, Borge M, Giordano M, Gamberale R. Venetoclax resistance induced by activated T cells can be counteracted by sphingosine kinase inhibitors in chronic lymphocytic leukemia. Front Oncol 2023; 13:1143881. [PMID: 37020867 PMCID: PMC10067719 DOI: 10.3389/fonc.2023.1143881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Accepted: 03/07/2023] [Indexed: 04/07/2023] Open
Abstract
The treatment of chronic lymphocytic leukemia (CLL) patients with venetoclax-based regimens has demonstrated efficacy and a safety profile, but the emergence of resistant cells and disease progression is a current complication. Therapeutic target of sphingosine kinases (SPHK) 1 and 2 has opened new opportunities in the treatment combinations of cancer patients. We previously reported that the dual SPHK1/2 inhibitor, SKI-II enhanced the in vitro cell death triggered by fludarabine, bendamustine or ibrutinib and reduced the activation and proliferation of chronic lymphocytic leukemia (CLL) cells. Since we previously showed that autologous activated T cells from CLL patients favor the activation of CLL cells and the generation of venetoclax resistance due to the upregulation of BCL-XL and MCL-1, we here aim to determine whether SPHK inhibitors affect this process. To this aim we employed the dual SPHK1/2 inhibitor SKI-II and opaganib, a SPHK2 inhibitor that is being studied in clinical trials. We found that SPHK inhibitors reduce the activation of CLL cells and the generation of venetoclax resistance induced by activated T cells mainly due to a reduced upregulation of BCL-XL. We also found that SPHK2 expression was enhanced in CLL cells by activated T cells of the same patient and the presence of venetoclax selects resistant cells with high levels of SPHK2. Of note, SPHK inhibitors were able to re-sensitize already resistant CLL cells to a second venetoclax treatment. Our results highlight the therapeutic potential of SPHK inhibitors in combination with venetoclax as a promising treatment option for the patients.
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Affiliation(s)
- Valeria J. Sarapura Martinez
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)- Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Brenda Buonincontro
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)- Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Chiara Cassarino
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)- Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Juliana Bernatowiez
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)- Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Ana Colado
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)- Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
| | - Gregorio Cordini
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)- Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
- Servicio de Hematología, Hospital de Clínicas, José de San Martín, Universidad de Buenos Aires (UBA), Buenos Aires, Argentina
| | - Maria del Rosario Custidiano
- Departamento de Hematología y Unidad de Trasplante Hematopoyético, Instituto Alexander Fleming, Buenos Aires, Argentina
| | - Carolina Mahuad
- Servicio de Hematología, Hospital Alemán, Buenos Aires, Argentina
| | | | | | - Nicolás O. Favale
- Cátedra de Biología Celular y Molecular, Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires (UBA), Buenos Aires, Argentina
- Instituto de Química y Fisicoquímica Biológicas “Profesor Dr. Alejandro C. Paladini” (IQUIFIB), Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET) - Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Mónica Vermeulen
- Laboratorio de Células Presentadoras de Antígeno y Respuesta Inflamatoria, IMEX-CONICET-ANM, Buenos Aires, Argentina
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, UBA, Buenos Aires, Argentina
| | - Mercedes Borge
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)- Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, UBA, Buenos Aires, Argentina
| | - Mirta Giordano
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)- Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, UBA, Buenos Aires, Argentina
| | - Romina Gamberale
- Laboratorio de Inmunología Oncológica, Instituto de Medicina Experimental (IMEX)-Consejo Nacional de Investigaciones Científicas y Técnicas (CONICET)- Academia Nacional de Medicina (ANM), Buenos Aires, Argentina
- Departamento de Microbiología, Parasitología e Inmunología, Facultad de Medicina, UBA, Buenos Aires, Argentina
- *Correspondence: Romina Gamberale,
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Thijssen R, Tian L, Anderson MA, Flensburg C, Jarratt A, Garnham AL, Jabbari JS, Peng H, Lew TE, Teh CE, Gouil Q, Georgiou A, Tan T, Djajawi TM, Tam CS, Seymour JF, Blombery P, Gray DH, Majewski IJ, Ritchie ME, Roberts AW, Huang DC. Single-cell multiomics reveal the scale of multilayered adaptations enabling CLL relapse during venetoclax therapy. Blood 2022; 140:2127-2141. [PMID: 35709339 PMCID: PMC10653037 DOI: 10.1182/blood.2022016040] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 06/06/2022] [Indexed: 11/20/2022] Open
Abstract
Venetoclax (VEN) inhibits the prosurvival protein BCL2 to induce apoptosis and is a standard therapy for chronic lymphocytic leukemia (CLL), delivering high complete remission rates and prolonged progression-free survival in relapsed CLL but with eventual loss of efficacy. A spectrum of subclonal genetic changes associated with VEN resistance has now been described. To fully understand clinical resistance to VEN, we combined single-cell short- and long-read RNA-sequencing to reveal the previously unappreciated scale of genetic and epigenetic changes underpinning acquired VEN resistance. These appear to be multilayered. One layer comprises changes in the BCL2 family of apoptosis regulators, especially the prosurvival family members. This includes previously described mutations in BCL2 and amplification of the MCL1 gene but is heterogeneous across and within individual patient leukemias. Changes in the proapoptotic genes are notably uncommon, except for single cases with subclonal losses of BAX or NOXA. Much more prominent was universal MCL1 gene upregulation. This was driven by an overlying layer of emergent NF-κB (nuclear factor kappa B) activation, which persisted in circulating cells during VEN therapy. We discovered that MCL1 could be a direct transcriptional target of NF-κB. Both the switch to alternative prosurvival factors and NF-κB activation largely dissipate following VEN discontinuation. Our studies reveal the extent of plasticity of CLL cells in their ability to evade VEN-induced apoptosis. Importantly, these findings pinpoint new approaches to circumvent VEN resistance and provide a specific biological justification for the strategy of VEN discontinuation once a maximal response is achieved rather than maintaining long-term selective pressure with the drug.
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MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/genetics
- Leukemia, Lymphocytic, Chronic, B-Cell/metabolism
- Myeloid Cell Leukemia Sequence 1 Protein/metabolism
- Proto-Oncogene Proteins c-bcl-2/metabolism
- NF-kappa B
- Drug Resistance, Neoplasm/genetics
- Bridged Bicyclo Compounds, Heterocyclic/pharmacology
- Bridged Bicyclo Compounds, Heterocyclic/therapeutic use
- Recurrence
- Antineoplastic Agents/therapeutic use
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Affiliation(s)
- Rachel Thijssen
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Luyi Tian
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Mary Ann Anderson
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
| | - Christoffer Flensburg
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Andrew Jarratt
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Alexandra L. Garnham
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Jafar S. Jabbari
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Hongke Peng
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Thomas E. Lew
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
| | - Charis E. Teh
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Quentin Gouil
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Angela Georgiou
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Tania Tan
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Tirta M. Djajawi
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Constantine S. Tam
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - John F. Seymour
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Piers Blombery
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Daniel H.D. Gray
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Ian J. Majewski
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Matthew E. Ritchie
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
| | - Andrew W. Roberts
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
- Department of Clinical Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, Australia
- Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Melbourne, Australia
| | - David C.S. Huang
- The Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Department of Medical Biology, University of Melbourne, Melbourne, Australia
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6
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Yi X, Jain N, Iles LR, Ayres ML, Wierda WG, Gandhi V. Targeting Mcl-1 by AMG-176 During Ibrutinib and Venetoclax Therapy in Chronic Lymphocytic Leukemia. Front Oncol 2022; 12:833714. [PMID: 35273915 PMCID: PMC8901605 DOI: 10.3389/fonc.2022.833714] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
B-cell receptor (BCR) signaling pathway and Bcl-2 family prosurvival proteins, specifically Bcl-2 and Mcl-1, are functional in the pathobiology of chronic lymphocytic leukemia (CLL). A pivotal and apical molecule in the BCR pathway is Bruton’s tyrosine kinase (BTK). Together, BTK, Bcl-2, and Mcl-1 participate in the maintenance, migration, proliferation, and survival of CLL cells. Several ongoing and published clinical trials in CLL reported high rates of remission, namely, undetectable measurable residual disease (u-MRD) status with combined BTK inhibitor ibrutinib and Bcl-2 antagonist, venetoclax. While the majority of patients achieve complete remission with undetectable-measurable residual disease, at least one third of patients do not achieve this milestone. We hypothesized that cells persistent during ibrutinib and venetoclax therapy may be sensitive to combined venetoclax and Mcl-1 inhibitor, AMG-176. To test this hypothesis, we took peripheral blood samples at baseline, after Cycle 1 and Cycle 3 of ibrutinib monotherapy, after one week and 1 cycle of ibrutinib plus venetoclax therapy. These serial samples were tested for pharmacodynamic changes and treated in vitro with AMG-176 or in combination with venetoclax. Compared to C1D1 cells, residual cells during ibrutinib and venetoclax treatment were inherently resistant to endogenous cell death. Single agent exposure induced some apoptosis but combination of 100 nM venetoclax and 100 or 300 nM of AMG-176 resulted in 40–100% cell death in baseline samples. Cells obtained after four cycles of ibrutinib and one cycle of venetoclax, when treated with such concentration of venetoclax and AMG-176, showed 10–80% cell death. BCR signaling pathway, measured as autophosphorylation of BTK was inhibited throughout therapy in all post-therapy samples. Among four anti-apoptotic proteins, Mcl-1 and Bfl-1 decreased during therapy in most samples. Proapoptotic proteins decreased during therapy. Collectively, these data provide a rationale to test Mcl-1 antagonists alone or in combination in CLL during treatment with ibrutinib and venetoclax.
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Affiliation(s)
- Xue Yi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Nitin Jain
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - LaKesla R Iles
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Mary L Ayres
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - William G Wierda
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Varsha Gandhi
- Department of Experimental Therapeutics, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.,Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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7
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Fiorcari S, Maffei R, Atene CG, Mesini N, Maccaferri M, Leonardi G, Martinelli S, Paolini A, Nasillo V, Debbia G, Potenza L, Luppi M, Marasca R. Notch2 Increases the Resistance to Venetoclax-Induced Apoptosis in Chronic Lymphocytic Leukemia B Cells by Inducing Mcl-1. Front Oncol 2022; 11:777587. [PMID: 35070982 PMCID: PMC8770925 DOI: 10.3389/fonc.2021.777587] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/23/2021] [Indexed: 12/24/2022] Open
Abstract
Chronic lymphocytic leukemia (CLL) has experienced a clinical revolution—thanks to the discovery of crucial pathogenic mechanisms. CLL is still an incurable disease due to intrinsic or acquired resistance of the leukemic clone. Venetoclax is a Bcl-2 inhibitor with a marked activity in CLL, but emerging patterns of resistance are being described. We hypothesize that intrinsic features of CLL cells may contribute to drive mechanisms of resistance to venetoclax. We analyzed the expression of Interferon Regulatory Factor 4 (IRF4), Notch2, and Mcl-1 in a cohort of CLL patients. We evaluated CLL cell viability after genetic and pharmaceutical modulation of Notch2 expression in patients harboring trisomy 12. We tested venetoclax in trisomy 12 CLL cells either silenced or not for Notch2 expression or in combination with an inhibitor of Mcl-1, AMG-176. Trisomy 12 CLL cells were characterized by low expression of IRF4 associated with high levels of Notch2 and Mcl-1. Notch2 and Mcl-1 expression determined protection of CLL cells from spontaneous and drug-induced apoptosis. Considering the involvement of Mcl-1 in venetoclax resistance, our data demonstrated a contribution of high levels of Notch2 and Mcl-1 in a reduced response to venetoclax in CLL cells carrying trisomy 12. Furthermore, reduction of Mcl-1 expression by silencing Notch2 or by treatment with AMG-176 was able to restore the response of CLL cells to venetoclax. The expression of Notch2 identifies a subset of CLL patients, mainly harboring trisomy 12, characterized by high levels of Mcl-1. This biological mechanism may compromise an effective response to venetoclax.
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Affiliation(s)
- Stefania Fiorcari
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | - Rossana Maffei
- Hematology Unit, Department of Oncology and Hematology, Azienda-Ospedaliero Universitaria (AOU) of Modena, Policlinico, Modena, Italy
| | - Claudio Giacinto Atene
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | - Nicolò Mesini
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | - Monica Maccaferri
- Hematology Unit, Department of Oncology and Hematology, Azienda-Ospedaliero Universitaria (AOU) of Modena, Policlinico, Modena, Italy
| | - Giovanna Leonardi
- Hematology Unit, Department of Oncology and Hematology, Azienda-Ospedaliero Universitaria (AOU) of Modena, Policlinico, Modena, Italy
| | - Silvia Martinelli
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | - Ambra Paolini
- Hematology Unit, Department of Oncology and Hematology, Azienda-Ospedaliero Universitaria (AOU) of Modena, Policlinico, Modena, Italy
| | - Vincenzo Nasillo
- Diagnostic Hematology and Clinical Genomics Laboratory, Department of Laboratory Medicine and Pathology, Azienda Unità Sanitaria Locale di Modena (AUSL)/Azienda Ospedaliero-Universitaria di Modena (AOU) Policlinico, Policlinico, Modena, Italy
| | - Giulia Debbia
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | - Leonardo Potenza
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy.,Hematology Unit, Department of Oncology and Hematology, Azienda-Ospedaliero Universitaria (AOU) of Modena, Policlinico, Modena, Italy
| | - Mario Luppi
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy.,Hematology Unit, Department of Oncology and Hematology, Azienda-Ospedaliero Universitaria (AOU) of Modena, Policlinico, Modena, Italy
| | - Roberto Marasca
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy.,Hematology Unit, Department of Oncology and Hematology, Azienda-Ospedaliero Universitaria (AOU) of Modena, Policlinico, Modena, Italy
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