AML-027: Menin Inhibition Decreases Bcl-2 and Bcl-xL and Enhances Venetoclax Activity in NPM1/FLT3-Mutated AML

Abstract

<h3>Context:</h3> MLL1-menin interaction in NPM1-mutated (NPM1c) AML shares a common HOX gene signature and dependencies as that of MLL-rearrangements (MLL1-r) with menin. Menin inhibition has demonstrated anti-leukemia activity in both NPM1c and MLL-r AML. NPM1c frequently occurs in AML with FLT3-ITD/FLT3-TKD mutations. Co-inhibition of menin and FLT3 has shown enhanced anti-leukemia activity in MLL-r/FLT3- and NPM1c/FLT3-mutated AML. Targeting Bcl-2 has emerged as a promising therapeutic option for AML patients. However, despite the major improvement of combining the Bcl-2 inhibitor venetoclax with hypomethylating agents, most patients develop resistance and ultimately relapse. <h3>Objective:</h3> Investigate anti-leukemic activities, potential synergism, and mechanisms of menin-MLL1 inhibitor SDNX-50469, an equipotent surrogate of the clinical compound SNDX-5613 and venetoclax combination <i>in vivo</i> in an NPM1c/FLT3-ITD/TKD PDX model. <h3>Design:</h3> The PDX cell-engrafted NSG mice were treated with 0.05 or 0.1% SNDX-50469-spiked chow, venetoclax (50 mg/kg), or 0.1% SNDX-50469 plus venetoclax (one month). Engraftment and disease progression were assessed by flow cytometric measurement of circulating human CD45+ cells. The treatment effects on leukemia cell populations and protein levels were determined by CyTOF mass cytometry. <h3>Results:</h3> Menin inhibition exhibited strong anti-leukemia activity, which was enhanced by venetoclax, while venetoclax alone had minimal effects. The combination most effectively extended survival (143 d for 0.1% SNDX-50469 plus venetoclax, P=0.0003; 131 and 125 d for 0.1% or 0.05% SNDX-50469, respectively, both P=0.0001; 69 d for venetoclax, P=0.025; <i>vs</i> 61 d for controls). At the end of treatment, CyTOF analysis of bone marrow cells demonstrated that menin inhibition preferentially targeted CD34+CD38+ cells, while venetoclax targeted CD34+CD38- cells. Only the combination effectively eliminated bulk and CD34+CD38+/CD34+CD38-stem/progenitor cells. Menin inhibition increased the percentage of CD11b+ myeloid cells. Mechanistically, menin inhibition decreased Bcl-2 and Bcl-xL and concomitantly increased Bax and Bim, which seemingly enhanced venetoclax activity. However, we observed increased p-FLT3 in the surviving leukemia cells, particularly in the combination group, which may contribute to the regrowth of leukemia cells. <h3>Conclusions:</h3> Our study validated menin as a therapeutic target and demonstrated that its inhibition synergizes with venetoclax in NPM1/FLT3-mutated AML, which warrants clinical evaluation. Inhibition of FLT3 may further enhance menin and Bcl-2 co-targeting efficacy in NPM1- and FLT3-mutated AML.