Abstract
BackgroundAcquired drug resistance is the greatest obstacle to the successful treatment of multiple myeloma (MM). Despite recent advanced treatment options such as liposomal formulations, proteasome inhibitors, immunomodulatory drugs, myeloma-targeted antibodies, and histone deacetylase inhibitors, MM is still considered an incurable disease.MethodsWe investigated whether the clinical exportin 1 (XPO1) inhibitor selinexor (KPT-330), when combined with pegylated liposomal doxorubicin (PLD) or doxorubicin hydrochloride, could overcome acquired drug resistance in multidrug-resistant human MM xenograft tumors, four different multidrug-resistant MM cell lines, or ex vivo MM biopsies from relapsed/refractory patients. Mechanistic studies were performed to assess co-localization of topoisomerase II alpha (TOP2A), DNA damage, and siRNA knockdown of drug targets.ResultsSelinexor was found to restore sensitivity of multidrug-resistant 8226B25, 8226Dox6, 8226Dox40, and U266PSR human MM cells to doxorubicin to levels found in parental myeloma cell lines. NOD/SCID-γ mice challenged with drug-resistant or parental U266 human MM and treated with selinexor/PLD had significantly decreased tumor growth and increased survival with minimal toxicity. Selinexor/doxorubicin treatment selectively induced apoptosis in CD138/light-chain-positive MM cells without affecting non-myeloma cells in ex vivo-treated bone marrow aspirates from newly diagnosed or relapsed/refractory MM patients. Selinexor inhibited XPO1-TOP2A protein complexes (proximity ligation assay), preventing nuclear export of TOP2A in both parental and multidrug-resistant MM cell lines. Selinexor/doxorubicin treatment significantly increased DNA damage (comet assay/γ-H2AX) in both parental and drug-resistant MM cells. TOP2A knockdown reversed both the anti-tumor effect and significantly reduced DNA damage induced by selinexor/doxorubicin treatment.ConclusionsThe combination of an XPO1 inhibitor and liposomal doxorubicin was highly effective against acquired drug resistance in in vitro MM models, in in vivo xenograft studies, and in ex vivo samples obtained from patients with relapsed/refractory myeloma. This drug combination synergistically induced TOP2A-mediated DNA damage and subsequent apoptosis. In addition, based on our preclinical data, we have initiated a phase I/II study with the XPO1 inhibitor selinexor and PLD (ClinicalTrials.gov NCT02186834). Initial results from both preclinical and clinical trials have shown significant promise for this drug combination for the treatment of MM.
Highlights
Acquired drug resistance is the greatest obstacle to the successful treatment of multiple myeloma (MM)
We have shown that knockdown of exportin 1 (XPO1) protein by siRNA or inhibition with an Exportin 1 (XPO1) inhibitor will sensitize drug-resistant myeloma cells to the topoisomerase II (TOP2) inhibitor doxorubicin [3, 5]
We show that XPO1 inhibition sensitized drug-resistant MM cells to liposomal doxorubicin in in vitro and in vivo models and ex vivo in relapsed/refractory patient MM cells, demonstrating that this combination may provide the means for overcoming acquired drug resistance in MM
Summary
Acquired drug resistance is the greatest obstacle to the successful treatment of multiple myeloma (MM). We have shown that knockdown of exportin 1 (XPO1) protein by siRNA or inhibition with an XPO1 inhibitor will sensitize drug-resistant myeloma cells to the topoisomerase II (TOP2) inhibitor doxorubicin [3, 5]. We have shown that XPO1 inhibitors are able to prevent nuclear export and promote nuclear accumulation of the tumor suppressor protein p53, and prevent the export of the drug target TOP2A [3, 5]. Recent publications have indicated that XPO1 inhibitors, the orally available clinical compound selinexor (KPT-330), may be effective against various malignancies, including breast cancer [6, 7], glioblastoma [8], hepatocellular carcinoma [9], kidney cancer [10, 11], leukemia [12,13,14,15,16], lung cancer [17], mantle cell lymphoma [18, 19], melanoma [20, 21], mesothelioma [22], nonHodgkin lymphoma [23], ovarian cancer [7], pancreatic cancer [24, 25], prostate cancer [25, 26], and MM [5, 13, 27]
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