Therapeutic targeting of EP300/CBP by bromodomain inhibition in hematologic malignancies

CCS1477 (inobrodib) is a potent, selective EP300/CBP bromodomain inhibitor which induces cell-cycle arrest and differentiation in hematologic malignancy model systems. In myeloid leukemia cells, it promotes rapid eviction of EP300/CBP from an enhancer subset marked by strong MYB occupancy and high H3K27 acetylation, with downregulation of the subordinate oncogenic network and redistribution to sites close to differentiation genes. In myeloma cells, CCS1477 induces eviction of EP300/CBP from FGFR3, the target of the common (4; 14) translocation, with redistribution away from IRF4-occupied sites to TCF3/E2A-occupied sites. In a subset of patients with relapsed or refractory disease, CCS1477 monotherapy induces differentiation responses in AML and objective responses in heavily pre-treated multiple myeloma. In vivo preclinical combination studies reveal synergistic responses to treatment with standard-of-care agents. Thus, CCS1477 exhibits encouraging preclinical and early-phase clinical activity by disrupting recruitment of EP300/CBP to enhancer networks occupied by critical transcription factors.

EVI1 phosphorylation at S436 regulates interactions with CtBP1 and DNMT3A and promotes self-renewal

The transcriptional regulator EVI1 has an essential role in early development and haematopoiesis. However, acute myeloid leukaemia (AML) driven by aberrantly high EVI1 expression has very poor prognosis. To investigate the effects of post-translational modifications on EVI1 function, we carried out a mass spectrometry (MS) analysis of EVI1 in AML and detected dynamic phosphorylation at serine 436 (S436). Wild-type EVI1 (EVI1-WT) with S436 available for phosphorylation, but not non-phosphorylatable EVI1-S436A, conferred haematopoietic progenitor cell self-renewal and was associated with significantly higher organised transcriptional patterns. In silico modelling of EVI1-S436 phosphorylation showed reduced affinity to CtBP1, and CtBP1 showed reduced interaction with EVI1-WT compared with EVI1-S436A. The motif harbouring S436 is a target of CDK2 and CDK3 kinases, which interacted with EVI1-WT. The methyltransferase DNMT3A bound preferentially to EVI1-WT compared with EVI1-S436A, and a hypomethylated cell population associated by EVI1-WT expression in murine haematopoietic progenitors is not maintained with EVI1-S436A. These data point to EVI1-S436 phosphorylation directing functional protein interactions for haematopoietic self-renewal. Targeting EVI1-S436 phosphorylation may be of therapeutic benefit when treating EVI1-driven leukaemia.

Pre-clinical activity of combined LSD1 and mTORC1 inhibition in MLL-translocated acute myeloid leukaemia

The histone demethylase lysine-specific demethylase 1 (LSD1 or KDM1A) has emerged as a candidate therapeutic target in acute myeloid leukaemia (AML); tranylcypromine-derivative inhibitors induce loss of clonogenic activity and promote differentiation, in particular in the MLL-translocated molecular subtype of AML. In AML, the use of drugs in combination often delivers superior clinical activity. To identify genes and cellular pathways that collaborate with LSD1 to maintain the leukaemic phenotype, and which could be targeted by combination therapies, we performed a genome-wide CRISPR-Cas9 dropout screen. We identified multiple components of the amino acid sensing arm of mTORC1 signalling-RRAGA, MLST8, WDR24 and LAMTOR2-as cellular sensitizers to LSD1 inhibition. Knockdown of mTORC1 components, or mTORC1 pharmacologic inhibition, in combination with LSD1 inhibition enhanced differentiation in both cell line and primary cell settings, in vitro and in vivo, and substantially reduced the frequency of clonogenic primary human AML cells in a modelled minimal residual disease setting. Synergistic upregulation of a set of transcription factor genes associated with terminal monocytic lineage differentiation was observed. Thus, dual mTORC1 and LSD1 inhibition represents a candidate combination approach for enhanced differentiation in MLL-translocated AML which could be evaluated in early phase clinical trials.

EVI1 carboxy-terminal phosphorylation is ATM-mediated and sustains transcriptional modulation and self-renewal via enhanced CtBP1 association

The transcriptional regulator EVI1 has an essential role in early hematopoiesis and development. However, aberrantly high expression of EVI1 has potent oncogenic properties and confers poor prognosis and chemo-resistance in leukemia and solid tumors. To investigate to what extent EVI1 function might be regulated by post-translational modifications we carried out mass spectrometry- and antibody-based analyses and uncovered an ATM-mediated double phosphorylation of EVI1 at the carboxy-terminal S858/S860 SQS motif. In the presence of genotoxic stress EVI1-WT (SQS), but not site mutated EVI1-AQA was able to maintain transcriptional patterns and transformation potency, while under standard conditions carboxy-terminal mutation had no effect. Maintenance of hematopoietic progenitor cell clonogenic potential was profoundly impaired with EVI1-AQA compared with EVI1-WT, in particular in the presence of genotoxic stress. Exploring mechanistic events underlying these observations, we showed that after genotoxic stress EVI1-WT, but not EVI1-AQA increased its level of association with its functionally essential interaction partner CtBP1, implying a role for ATM in regulating EVI1 protein interactions via phosphorylation. This aspect of EVI1 regulation is therapeutically relevant, as chemotherapy-induced genotoxicity might detrimentally sustain EVI1 function via stress response mediated phosphorylation, and ATM-inhibition might be of specific targeted benefit in EVI1-overexpressing malignancies.

Derepression of the Iroquois Homeodomain Transcription Factor Gene IRX3 Confers Differentiation Block in Acute Leukemia

The Iroquois homeodomain transcription factor gene IRX3 is expressed in the developing nervous system, limb buds, and heart, and transcript levels specify obesity risk in humans. We now report a functional role for IRX3 in human acute leukemia. Although transcript levels are very low in normal human bone marrow cells, high IRX3 expression is found in ∼30% of patients with acute myeloid leukemia (AML), ∼50% with T-acute lymphoblastic leukemia, and ∼20% with B-acute lymphoblastic leukemia, frequently in association with high-level HOXA gene expression. Expression of IRX3 alone was sufficient to immortalize hematopoietic stem and progenitor cells (HSPCs) in myeloid culture and induce lymphoid leukemias in vivo. IRX3 knockdown induced terminal differentiation of AML cells. Combined IRX3 and Hoxa9 expression in murine HSPCs impeded normal T-progenitor differentiation in lymphoid culture and substantially enhanced the morphologic and phenotypic differentiation block of AML in myeloid leukemia transplantation experiments through suppression of a terminal myelomonocytic program. Likewise, in cases of primary human AML, high IRX3 expression is strongly associated with reduced myelomonocytic differentiation. Thus, tissue-inappropriate derepression of IRX3 contributes significantly to the block in differentiation, which is the pathognomonic feature of human acute leukemias.

Secondary syphilis presenting with aortitis and coronary ostial occlusion

Aortitis is an established manifestation of tertiary syphilis. We report a rare case of aortitis with ostial occlusion and left ventricular failure in secondary syphilis. Her management required a true multidisciplinary approach from multiple specialities due to complications of concomitant psychosis and a history of anaphylaxis to penicillin. This case illustrates the complexities of diagnosing and managing a rare presentation of this increasingly prevalent infection.

Inhibition of intracellular pH control and relationship to cytotoxicity of chlorambucil and vinblastine

The uptake and cytotoxicity of weakly acidic or basic chemotherapeutic agents is determined in part by passive diffusion along the pH gradient between the intracellular and extracellular compartments. In vivo it is known that tumour extracellular pH is more acidic than intracellular pH. Using CaNT murine tumour cells in vitro, we found the cytotoxicity of chlorambucil (a weak acid) increased as the extracellular pH of the culture medium (pHmed) was acidified. The cytotoxicity of vinblastine shows a reverse pH relationship with reduced cytotoxicity as pHmed was acidified. Chlorambucil cytotoxicity increased at acidic pHmed because the weak acidic function is ionised to a lesser extent at acidic pH and, therefore, favours drug uptake into the relatively neutral intracellular compartment. Vinblastine cytotoxicity decreased at acidic pHmed because the weak basic function is ionised to a greater extent at acidic pH and therefore does not favour drug uptake into the relatively neutral intracellular compartment. Using a combination of an inhibitor of the cell membrane proton pump, amiloride, and the ionophore, nigericin, the intracellular compartment can be acidified. This results in a time-dependent increase in sensitivity of the cells to low pHmed with significant cytotoxicity after 6 h exposure to pHmed = 6.2 and suggests that there is potential for direct tumour cytotoxicity in vivo if the tumour extracellular pH were equally acidic. An indirect effect of intracellular acidification is to alter the distribution of drugs between the extra- and intracellular compartment by reducing the pH gradient across the cell membrane. In response to intracellular acidification, the cytotoxicity of chlorambucil was reduced and that for vinblastine was increased. Inhibition of cellular pH control may result in direct cytotoxicity by acidification due to inhibition of proton efflux or indirectly by resulting in differential uptake of chemotherapeutic agents with weak acidic or basic functions.

Enhancement of chlorambucil cytotoxicity by combination with flavone acetic acid in a murine tumour

Previous studies using murine tumours have shown enhanced action of certain chemotherapeutic compounds when combined with agents that reduce tumour blood flow. In the majority of cases the compounds used were cytotoxic to the induced hypoxic cells but in this study we have investigated the relative importance of changes in tumour pH following blood flow reductions. The role of tumour pH was investigated by using combinations of the cytotoxic alkylating agent Chlorambucil (CHL) with the vascular occluding agent Flavone Acetic Acid (FAA). Chlorambucil is a weak acid (pKa = 3.7) and is concentrated within cells exposed to culture media at low pH or to the acidic microenvironment in vivo. In vitro incubations showed that greater cytotoxicity was obtained when cells were incubated at low pH and that the cytotoxicity was independent of the level of oxygenation at the time of the drug incubation. Combination of both CHL and FAA in vivo resulted in greater reductions in cell survival and growth delay than when either agent was given alone. Simultaneous administration of the two agents were very effective, potentially due to two factors; firstly, that the pH of the tumour changes during ischaemia and secondly, that the reduced blood flow potentially alters the pharmacokinetic distribution of CHL resulting in 'drug-trapping' within the tumour. Since the action of CHL is independent of the induced hypoxia which results from blood flow reduction it is suggested that the increased in vivo action is due in part to the changes in tumour pH.

Ischaemia induced cell death in tumors: importance of temperature and pH

PURPOSE

Increasing attention has focussed on the therapeutic potential of agents which can reduce tumor blood flow and induce ischaemia for long enough to result in tumor cell death. A confounding factor in this approach is the fact that the core temperature of superficial tumors reduces when the supplying blood flow is occluded and therefore protects the tumor cells from "metabolic" death. Consequently, we have tested the importance of tumor temperature on the relationship between vascular occlusion and cell death.

METHODS AND MATERIALS

The murine tumor CaNT used in this study was implanted subcutaneously in the dorsum. Total vascular occlusion was achieved by physically occluding the blood supply to the tumors for periods between 1 and 20 h. The mouse temperature was controlled by placing the whole body in a thermostatically controlled incubator maintained at 35 degrees C. Tumor cell survival was assessed using an excision assay and by measuring the delay in growth of treated tumors. Measurement of tumor pH was achieved using microelectrodes.

RESULTS

The core temperature of unclamped tumors was approximately 33 degrees C, but fell by about 5 degrees C during vascular occlusion at room temperature. Tumor cell survival was decreased with increasing periods of vascular occlusion at room temperature, but a greater reduction in cell survival and correspondingly increased regrowth delay was observed when the tumor temperature was prevented from cooling below preocclusion values. The extracellular pH (pHe) fell during vascular occlusion and this reduction was greater when the tumor temperature was maintained at preocclusion values. This extracellular acidosis is expected to partly explain the observation of greater tumor cell death in those tumors whose temperature does not reduce during occlusion.

CONCLUSION

The temperature of superficial tumors reduces in response to vascular occlusion. This may result in an underestimation of the cytotoxicity of agents which reduce tumor blood flow as the tumor cooling protects the cells from the acidosis that accumulates within the occluded tumor.