Acute Leukemia Blasts Research Articles

Asparagine transport through SLC1A5/ASCT2 and SLC38A5/SNAT5 is essential for BCP-ALL cell survival and a potential therapeutic target.

B-cell precursor acute lymphoblastic leukaemia (BCP-ALL) blasts strictly depend on the transport of extra-cellular asparagine (Asn), yielding a rationale for L-asparaginase (ASNase) therapy. However, the carriers used by ALL blasts for Asn transport have not been identified yet. Exploiting RS4;11 cells as BCP-ALL model, we have found that cell Asn is lowered by either silencing or inhibition of the transporters ASCT2 or SNAT5. The inhibitors V-9302 (for ASCT2) and GluγHA (for SNAT5) markedly lower cell proliferation and, when used together, suppress mTOR activity, induce autophagy and cause a severe nutritional stress, leading to a proliferative arrest and a massive cell death in both the ASNase-sensitive RS4;11 cells and the relatively ASNase-insensitive NALM-6 cells. The cytotoxic effect is not prevented by coculturing leukaemic cells with primary mesenchymal stromal cells. Leukaemic blasts of paediatric ALL patients express ASCT2 and SNAT5 at diagnosis and undergo marked cytotoxicity when exposed to the inhibitors. ASCT2 expression is positively correlated with the minimal residual disease at the end of the induction therapy. In conclusion, ASCT2 and SNAT5 are the carriers exploited by ALL cells to transport Asn, and ASCT2 expression is associated with a lower therapeutic response. ASCT2 may thus represent a novel therapeutic target in BCP-ALL.

Abstract 264: Differentiation therapy: Esculetin as a potent agent to alter cellular plasticity of leukemic & solid tumor stem cells

Abstract Background The “Differentiation therapy” has been emerging as a promising and more effective strategy against acute leukemia relapses. Objective In extension to the revolutionising therapeutic outcomes of All Trans Retinoic Acid (ATRA) to induce terminal differentiation of Acute Promyelocytic Leukemic (APL) blast cells, we decipher the potential effect of a natural compound “Esculetin” to serve as a differentiating agent in Acute Myeloid Leukemia (AML) as well as solid tumour cells. Underlaying role of Wnt signaling pathways in esculetin mediated blast cell differentiation was also evaluated. Methods Human acute myeloid leukemic cells (Kasumi-1) with t(8;21/AML-ETO) translocation were used as a model system. Growth inhibitory and cytotoxic activity of esculetin were analysed using growth kinetics and MTT assay. Morphological alterations, cell scatter characteristics, NBT reduction assay and cell surface marker expression pat- terns were analysed to detect terminally differentiated phenotypes. We employed RT2profiler PCR array system for the analysis of transcriptome profile of Wnt signaling components. Calcium inhibitors (TMB8 and Amlodipine) and Transforming growth factor beta (TGF-β) were used to modulate the Wnt signaling axes. To investigate whether esculetin exerts the similar effects on the invasive solid tumour cancer stem cells subset, we used a cellular model system of colon carcinoma HCT116 cells reflecting EMT phenotype. Results We illustrate cytotoxic as well as blast cell differentiation potential of esculetin on Kasumi-1 cells. Morphological alterations akin to neutrophilic differentiation as well as the corresponding acquisition of myeloid lineage markers indicate terminal differentiation potential of esculetin in leukemic blast cells. Exposure to esculetin also resulted in downregulation of canonical Wnt axis while upto ~ 21 fold upregulation of non-canonical axis associated genes. Esculetin also showed potential to revert the CSC marker expressions and concurrent EMT consistent with reduced functional aggressiveness in colon cancer cells. Conclusions Our study highlights the importance of selective use of calcium pools as well as “axis shift” of the canonical to non-canonical Wnt signaling upon esculetin treatment which might abrogate the inherent proliferation to release maturation arrest and induce the differentiation in leukemic blast cells as well as CSC stem cells. The current findings provide further therapeutic interventions to consider esculetin as a potent differentiating agent to counteract relapses. Citation Format: Ankit Mathur, Daman Saluja. Differentiation therapy: Esculetin as a potent agent to alter cellular plasticity of leukemic & solid tumor stem cells [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 264.

Tagraxofusp in Combination with Azacitidine and Venetoclax in Newly Diagnosed CD123+ Acute Myeloid Leukemia, Expansion Cohort of a Phase 1b Multicenter Trial

Background: CD123 is a subunit of the interleukin 3 (IL3) receptor expressed on the surface of blasts in most acute myeloid leukemias (AMLs). Tagraxofusp (TAG), a CD123-directed therapy, is a recombinant protein drug consisting of IL3 fused to a truncated diphtheria toxin payload approved for treatment of blastic plasmacytoid dendritic cell neoplasm. We found TAG resistance in AML cells was mediated by DNA methylation and silencing of diphthamide genes (e.g., DPH1), which causes resistance to diphtheria toxin (Togami, JCI 2019). The hypomethylating agent azacitidine (AZA) reversed TAG resistance, and TAG plus AZA prolonged survival vs. either alone in xenograft models. TAG-exposed AML cells were also sensitized to the BCL2 inhibitor venetoclax (VEN). We performed a phase 1b trial combining these agents in myeloid malignancies and reported acceptable safety in dose escalation of TAG with AZA-VEN (ASH 2021). Here, we report an expansion cohort in newly diagnosed AML treated with TAG-AZA-VEN. Methods: Patients (pts) were adults with AML ineligible or declining intensive induction chemotherapy. CD123+ blasts were required (tested locally by flow or IHC, any level). Eligibility included albumin >3.2 g/dL and normal cardiac ejection fraction. Pts were treated on 28-day cycles with AZA 75 mg/m2 d1-7, VEN 400 mg d1-21 with ramp up in cycle 1, and TAG 12 µg/kg d4-6 ( Fig A), with cycle 1 hospitalization to mitigate risks of capillary leak syndrome (CLS). Also included are 3 pts who received TAG 7 µg/kg (n=2) or 9 µg/kg (n=1) in escalation. TAG was given on d4 to avoid VEN ramp up overlap and because preclinical data showed AZA pretreatment can sensitize AML cells to TAG. Results: 26 pts with AML were treated; median age 71 (range 60-81). All were adverse risk per ELN 2022 criteria, including 13 (50%) with a mutation in TP53 and others with 1 or more of ASXL1, BCOR, EZH2, RUNX1, SF3B1, SRSF2, STAG2, or U2AF1. Eight (31%) had complex karyotype, 8 (31%) secondary AML, and 5 (19%) therapy-related AML. Adverse events (AEs) were like those seen with TAG or AZA/VEN, without evidence of exacerbation by combination. Grade 3+ AEs occurring in >15% of pts regardless of attribution included thrombocytopenia (54%), leukopenia (54%), febrile neutropenia (35%), and anemia (31%). CLS, a known TAG side effect, occurred in 19% (n=5; three grade 2, one gr 3, one gr 4; all in cycle 1) and was manageable by albumin supplementation and diuresis. Mortality at 30 days was 11.5%, with causes of death of sepsis (n=2), multiorgan system failure (n=1). 18 of 26 pts (69%) achieved a best response of CR (10; 39%), CRi (5; 19%), or MLFS (3; 12%). Of the 13 with TP53 mutation, 7 (54%) achieved CR/CRi/MLFS (CR=4, CRi=2, or MLFS=1). Bone marrow blasts decreased in all pts who had a biopsy after starting treatment ( Fig A). For the 18 achieving CR/CRi/MLFS, the median duration of response was 12.4 months (mo) (95% CI, 6.1-NA). 13 of 26 (50%) proceeded to allogeneic stem cell transplantation, which included 6/13 (46%) with TP53 mutation. The median number of cycles was 3 for both pts who did (range 1-15) and did not (range 2-4) proceed to transplant. The median follow-up was 10.7 mo, including post-transplant timepoints. Median overall survival (OS) was 14 mo (95% CI, 9.5-NA) and progression-free survival (PFS) was 8.5 mo (95% CI, 5.1-NA). In pts with TP53 mutation, median OS was 9.5 mo (95% CI, 1.8-NA); and not reached (NR) without ( Fig B). PFS for pts with TP53 mutation was 5.1 mo (95% CI, 1.8-NA), and 13.3 mo (95% CI, 8.6-NA) without. Measurable residual disease (MRD) was assessed by flow cytometry in 17 pts who achieved CR/CRi/MLFS; 12/17 (71%) were MRD negative (<0.1%). 4/7 (57%) with TP53 mutation achieving CR/CRi/MLFS were MRD negative. Median OS for pts who became MRD negative was NR. Median OS for the 13 pts who received allogeneic transplant was 18.2 mo (95% CI, 14.0-NA). Median PFS for the transplanted pts was 13.3 mo (95% CI, 8.2-NA). Conclusions: Treatment of AML with triplet TAG-AZA-VEN is feasible and shows encouraging activity as up-front therapy in adverse risk AML, including in pts with TP53 mutation. These data (OS 14 mo; TP53 mutant OS 9.5 mo) compare favorably to HMA/VEN in ELN adverse risk (OS 12 mo; Lachowiez, BloodAdv 2023) or TP53 mutant AML with poor risk cytogenetics (OS 5.2 mo; Pollyea, CCR 2022), albeit with some differences between populations. No new safety signals were observed. Further development of this combination is warranted, including directly compared to AZA-VEN.

RISK FACTORS AND EARLY SIGNS OF CRITICAL CONDITIONS IN CHILDREN WITH ACUTE LYMPHOBLASTIC LEUKEMIA ADMITTED TO THE INTENSIVE CARE UNIT

Relevance: Acute lymphoblastic leukemia (ALL) is the most common cancer among children, accounting for nearly a quarter of all childhood cancers.
 The study aimed to determine the risk factors and signs of critical conditions in children with acute lymphoblastic leukemia admitted to an intensive care unit (ICU).
 Methods: The approach used was a systematic review. Data was collected from sources published in 2019-2023. Four cohort studies, four retrospective analyses, two literature reviews, one case-control study, and one case study were included in this systematic review.
 Results: The prognosis in pediatric ALL depends on the initial number of blast cells in the peripheral blood. Patients with B-cell precursor acute lymphoblastic leukemia (BCP ALL) and low blast cell numbers survived better than patients with T-cell acute lymphoblastic leukemia (T-ALL) and low cell count. IL1B and NLRP1 genetic polymorphisms enhanced ALL risk and reduced infectious comorbidity. However, these gene polymorphisms must be confirmed in juvenile leukemia. KRAS, FLT3, NRAS, PTPN11, KMT2D, PTEN, and NOTCH1 gene mutations affected pediatric ALL patient features and treatment results. These mutations demonstrate the relevance of genetic profiling in risk classification and tailored management. Gene variations and availability of effective medication contributed. Pediatric BCP-ALL patients with the PAX5P80R mutation had worse 5-year overall survival, higher white blood cell counts, male preponderance, and more genetic abnormalities. Pediatric BCP-ALL focused on genetic analysis and risk stratification. Children of African American and European American ancestry showed varied incidence, recurrence, and outcome rates for ALL. African American children exhibited lower incidence but greater recurrence rates and poorer prognosis than European American children.
 Conclusion: Risk factors for these patients’ admission to ICU include comorbidities, infectious diseases, hypoxia, and hemodynamic instability, as well as age and baseline white blood cell count at diagnosis.

Intra-nucleus mosaic pattern (InMop) and whole-cell Haralick combined-descriptor for identifying and characterizing acute leukemia blasts on single cell peripheral blood images.

Acute leukemia is usually diagnosed when a test of peripheral blood shows at least 20% of abnormal immature cells (blasts), a figure even lower in case of recurrent cytogenetic abnormalities. Blast identification is crucial for white blood cell (WBC) counting, which depends on both identifying the cell type and characterizing the cellular morphology, processes susceptible of inter- and intraobserver variability. The present work introduces an image combined-descriptor to detect blasts and determine their probable lineage. This strategy uses an intra-nucleus mosaic pattern (InMop) descriptor that captures subtle nuclei differences within WBCs, and Haralick's statistics which quantify the local structure of both nucleus and cytoplasm. The InMop captures WBC inner-nucleus structure by applying a multiscale Shearlet decomposition over a repetitive pattern (mosaic) of automatically-segmented nuclei. As a complement, Haralick's statistics characterize the local structure of the whole cell from an intensity co-occurrence matrix representation. Both InMoP and Haralick-based descriptors are calculated using the b-channel from Lab color-space. The combined-descriptor is assessed by differentiating blasts from nonleukemic cells with support vector machine (SVM) classifiers and different transformation kernels, in two public and independent databases. The first database-D1 (n = 260) is composed of healthy and acute lymphoid leukemia (ALL) single cell images, and second database-D2 contains acute myeloid leukemia (AML) blasts (n = 3294) and nonblast (n = 15,071) cell images. In a first experiment, blasts versus nonblast differentiation is performed by training with a subset of D2 (n = 6588) and testing in D1 (n = 260), obtaining a training AUC of 0.991 ± 0.002 and AUC = 0.782 for the independent validation. A second experiment automatically differentiates AML blasts (260 images from D2) from ALL blasts (260 images from D1), with an AUC of 0.93. In a third experiment, state-of-the-art strategies, VGG16 and RESNEXT convolutional neural networks (CNN), separate blast from nonblast cells in both databases. The VGG16 showed an AUC of 0.673 and the RESNEXT of 0.75. Reported metrics for all the experiments are area under the ROC curve (AUC), accuracy and F1-score.

Pediatric T-cell acute lymphoblastic leukemia blast signature and MRD associated immune environment changes defined by single cell transcriptomics analysis

Different driver mutations and/or chromosomal aberrations and dysregulated signaling interactions between leukemia cells and the immune microenvironment have been implicated in the development of T-cell acute lymphoblastic leukemia (T-ALL). To better understand changes in the bone marrow microenvironment and signaling pathways in pediatric T-ALL, bone marrows collected at diagnosis (Dx) and end of induction therapy (EOI) from 11 patients at a single center were profiled by single cell transcriptomics (10 Dx, 5 paired EOI, 1 relapse). T-ALL blasts were identified by comparison with healthy bone marrow cells. T-ALL blast-associated gene signature included SOX4, STMN1, JUN, HES4, CDK6, ARMH1 among the most significantly overexpressed genes, some of which are associated with poor prognosis in children with T-ALL. Transcriptome profiles of the blast cells exhibited significant inter-patient heterogeneity. Post induction therapy expression profiles of the immune cells revealed significant changes. Residual blast cells in MRD+ EOI samples exhibited significant upregulation (P < 0.01) of PD-1 and RhoGDI signaling pathways. Differences in cellular communication were noted in the presence of residual disease in T cell and hematopoietic stem cell compartments in the bone marrow. Together, these studies generate new insights and expand our understanding of the bone marrow landscape in pediatric T-ALL.

CD38-Specific CAR Integrated into CD38 Locus Driven by Different Promoters Causes Distinct Antitumor Activities of T and NK Cells.

The robust and stable expression of CD38 in T-cell acute lymphoblastic leukemia (T-ALL) blasts makes CD38 chimeric antigen receptor (CAR)-T/natural killer (NK) a potential therapy for T-ALL. However, CD38 expression in normal T/NK cells causes fratricide of CD38 CAR-T/NK cells. Here a "2-in-1" gene editing strategy is developed to generate fratricide-resistant locus-specific CAR-T/NK cells. CD38-specific CAR is integrated into the disrupted CD38 locus by CRISPR/Cas9, and CAR is placed under the control of either endogenous CD38 promoter (CD38KO/KI ) or exogenous EF1α promoter (CD38KO/KI EF1α). CD38 knockout reduces fratricide and allows the expansion of CAR-T cells. Meanwhile, CD38KO/KI EF1α results in higher CAR expression than CD38KO/KI in both CAR-T and CAR-NK cells. In a mouse T-ALL model, CD38KO/KI EF1α CAR-T cells eradicate tumors better than CD38KO/KI CAR-T cells. Surprisingly, CD38KO/KI CAR-NK cells show superior tumor control than CD38KO/KI EF1α CAR-NK cells. Further investigation reveals that endogenous regulatory elements in NK cells lead to higher expression of CD38 CAR than in T cells, and the expression levels of CAR affect the therapeutic outcome of CAR-T and CAR-NK cells differently. Therefore, these results support the efficacy of CD38 CAR-T/NK against T-ALL and demonstrate that the "2-in-1" strategy can resolve fratricide and enhance tumor eradication, paving the way for clinical translation.

P10 Blastic plasmacytoid dendritic cell neoplasm: two representative cases

Abstract Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a malignant proliferation of plasmacytoid dendritic cells, representing &amp;lt; 1% of primary cutaneous lymphomas. It most commonly presents in the skin and has a poor prognosis with median survival of 1 year. The fifth World Health Organization classification of haematolymphoid tumours encompasses two entities in plasmacytoid dendritic cell neoplasms: BPDCN and ‘mature plasmacytoid dendritic cell neoplasm associated with myeloid neoplasm’. We present two cases, one representing each subset. Our first case was a 58-year-old man who presented with an asymptomatic, rapidly progressive, skin coloured-to-ery­thematous and hyperpigmented firm papules, nodules and plaques over the trunk, upper limbs and face of 2.5 months’ duration. This was associated with loss of appetite, loss of weight and leucopenia (2180 cells μL−1). Skin biopsy revealed a grenz zone with pandermal infiltration by large cells with high nuclear : cytoplasmic ratio, vesicular nuclei and prominent nucleoli, and frequent mitotic figures. Immunohistochemistry (IHC) was leucocyte common antigen (LCA)+ but CD3–, CD20–, myeloperoxidase (MPO)– and CD117–. Bone marrow biopsy showed a similar infiltrate of cells, but the peripheral blood smear and flow cytometry was within normal limits. Further IHC was CD4+, CD56+, CD43+ and CD123+, establishing a diagnosis of BPDCN, and the patient was initiated on the Hoelzer protocol with 80% clearance of lesions after two cycles of chemotherapy. The second case was a 60-year-old woman who presented with asymptomatic firm skin-coloured nodules on her scalp, trunk, extremities and oral mucosa, associated with a low-grade fever, fatigability, weight loss, generalized lymphadenopathy and hepatosplenomegaly of 4 months’ duration. Histopathology showed similar features to the first case, with IHC being negative for CD3, CD20, CD138 and MPO. However, cells were LCA+, CD4+, CD56+ and CD43+. Bone marrow showed 77% acute leukaemia blasts with a MPO+ result, establishing diagnosis of acute myeloid leukaemia, suggestive of a mature plasmacytoid dendritic cell neoplasm associated with myeloid neoplasm. To conclude, BPDCN is an aggressive neoplasm that commonly presents in the skin and should be suspected by dermatologists when screening IHC for lymphoid and myeloid cell lines is negative in a suspected case of leukaemia cutis. A panel of CD4/CD56/CD43/CD123 may be used to establish the diagnosis.

DP06 (P10) Blastic plasmacytoid dendritic cell neoplasm: two representative cases

Abstract Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a malignant proliferation of plasmacytoid dendritic cells, representing &amp;lt;1% of primary cutaneous lymphomas. It most commonly presents in the skin and has a poor prognosis with median survival of 1 year. The fifth World Health Organization classification of haematolymphoid tumours encompasses two entities in plasmacytoid dendritic cell neoplasms: BPDCN and ‘mature plasmacytoid dendritic cell neoplasm associated with myeloid neoplasm’. We present two cases, one representing each subset. Our first case was a 58-year-old man who presented with an asymptomatic, rapidly progressive, skin coloured-to-ery­thematous and hyperpigmented firm papules, nodules and plaques over the trunk, upper limbs and face of 2.5 months’ duration. This was associated with loss of appetite, loss of weight and leucopenia (2180 cells μL–1). Skin biopsy revealed a grenz zone with pandermal infiltration by large cells with high nuclear:cytoplasmic ratio, vesicular nuclei and prominent nucleoli and frequent mitotic figures. Immunohistochemistry (IHC) was leucocyte common antigen (LCA)+ but CD3–, CD20–, myeloperoxidase (MPO)– and CD117–. Bone marrow biopsy showed a similar infiltrate of cells, but the peripheral blood smear and flow cytometry was within normal limits. Further IHC was CD4+, CD56+, CD43+ and CD123+, establishing a diagnosis of BPDCN, and the patient was initiated on the Hoelzer protocol with 80% clearance of lesions after two cycles of chemotherapy. The second case was a 60-year-old woman who presented with asymptomatic firm skin-coloured nodules on her scalp, trunk, extremities and oral mucosa, associated with a low-grade fever, fatigability, weight loss, generalized lymphadenopathy and hepatosplenomegaly of 4 months’ duration. Histopathology showed similar features to the first case, with IHC being negative for CD3, CD20, CD138 and MPO. However, cells were LCA+, CD4+, CD56+ and CD43+. Bone marrow showed 77% acute leukaemia blasts with a MPO+ result, establishing diagnosis of acute myeloid leukaemia, suggestive of a mature plasmacytoid dendritic cell neoplasm associated with myeloid neoplasm. To conclude, BPDCN is an aggressive neoplasm that commonly presents in the skin and should be suspected by dermatologists when screening IHC for lymphoid and myeloid cell lines is negative in a suspected case of leukaemia cutis. A panel of CD4/CD56/CD43/CD123 may be used to establish the diagnosis.

Esculetin releases maturation arrest and induces terminal differentiation in leukemic blast cells by altering the Wnt signaling axes

BackgroundThe “Differentiation therapy” has been emerging as a promising and more effective strategy against acute leukemia relapses.ObjectiveIn extension to the revolutionising therapeutic outcomes of All Trans Retinoic Acid (ATRA) to induce terminal differentiation of Acute Promyelocytic Leukemic (APL) blast cells, we decipher the potential effect of a natural compound “Esculetin” to serve as a differentiating agent in Acute Myeloid Leukemia (AML). Underlaying role of Wnt signaling pathways in esculetin mediated blast cell differentiation was also evaluated.MethodsHuman acute myeloid leukemic cells (Kasumi-1) with t(8;21/AML-ETO) translocation were used as a model system. Growth inhibitory and cytotoxic activity of esculetin were analysed using growth kinetics and MTT assay. Morphological alterations, cell scatter characteristics, NBT reduction assay and cell surface marker expression patterns were analysed to detect terminally differentiated phenotypes. We employed RT2profiler PCR array system for the analysis of transcriptome profile of Wnt signaling components. Calcium inhibitors (TMB8 and Amlodipine) and Transforming growth factor beta (TGF-β) were used to modulate the Wnt signaling axes.ResultsWe illustrate cytotoxic as well as blast cell differentiation potential of esculetin on Kasumi-1 cells. Morphological alterations akin to neutrophilic differentiation as well as the corresponding acquisition of myeloid lineage markers indicate terminal differentiation potential of esculetin in leukemic blast cells. Exposure to esculetin also resulted in downregulation of canonical Wnt axis while upto ~ 21 fold upregulation of non-canonical axis associated genes.ConclusionsOur study highlights the importance of selective use of calcium pools as well as “axis shift” of the canonical to non-canonical Wnt signaling upon esculetin treatment which might abrogate the inherent proliferation to release maturation arrest and induce the differentiation in leukemic blast cells. The current findings provide further therapeutic interventions to consider esculetin as a potent differentiating agent to counteract AML relapses.

Ex vivo Drug Sensitivity Imaging-based Platform for Primary Acute Lymphoblastic Leukemia Cells.

Resistance of acute lymphoblastic leukemia (ALL) cells to chemotherapy, whether present at diagnosis or acquired during treatment, is a major cause of treatment failure. Primary ALL cells are accessible for drug sensitivity testing at the time of new diagnosis or at relapse, but there are major limitations with current methods for determining drug sensitivity ex vivo. Here, we describe a functional precision medicine method using a fluorescence imaging platform to test drug sensitivity profiles of primary ALL cells. Leukemia cells are co-cultured with mesenchymal stromal cells and tested with a panel of 40 anti-leukemia drugs to determine individual patterns of drug resistance and sensitivity ("pharmacotype"). This imaging-based pharmacotyping assay addresses the limitations of prior ex vivo drug sensitivity methods by automating data analysis to produce high-throughput data while requiring fewer cells and significantly decreasing the labor-intensive time required to conduct the assay. The integration of drug sensitivity data with genomic profiling provides a basis for rational genomics-guided precision medicine. Key features Analysis of primary acute lymphoblastic leukemia (ALL) blasts obtained at diagnosis from bone marrow aspirate or peripheral blood. Experiments are performed ex vivo with mesenchymal stromal cell co-culture and require four days to complete. This fluorescence imaging-based protocol enhances previous ex vivo drug sensitivity assays and improves efficiency by requiring fewer primary cells while increasing the number of drugs tested to 40. It takes approximately 2-3 h for sample preparation and processing and a 1.5-hour imaging time. Graphical overview.

Downregulation of the Mutated WT1 Alleles in Malignant Hematopoietic Cells Via Nonsense-Mediated mRNA Decay Contradicts Their Prognostic Impact

Background The Wilms Tumor 1 (WT1) gene is highly expressed in almost all types of malignancies including acute myeloid leukemia (AML). It is also mutated in up to 20% of AML blasts in pediatric and adult patients. Both, the increased expression and also the presence of mutations are correlated negatively with chance of survival in different AML patient cohorts. We and others have previously showed devastating survival outcomes in children with AML blasts harboring WT1 mutations in combination FLT3-ITD and NUP98-NSD1 (Niktoreh et al., 2019). As WT1 can act as both, oncogene and tumor suppressor gene, this study was designed to analyze the WT1 genomic locus mutations in acute leukemia blasts. Methods and Results Screening for WT1 sequence alterations. Using the TruSight Myeloid Sequencing PanelTM (Illumina), we initially screened 35 leukemia and lymphoma cell lines for genomic alterations in 54 genes. This panel allowed us to detect even low variant-allele-frequency (VAF) alterations in the mutational hotspots of WT1, exons 7 and 9. In addition to a known WT1 mutation in CTS cells (AML M1), we discovered novel alterations in three other malignant cell lines. KASUMI-6 cells (AML M2) harbored the identical mutation as CTS cells, a 2-bp deletion in WT1 exon 7 leading to frameshift with a premature termination codon (c.1202_1203delGA, p.Arg401IlefsTer3). The U937 histiocytic lymphoma cells carried the known TP53 mutation and also an unknown heterozygous nonsense mutation in WT1 exon 7, changing the arginine 369 into a premature stop codon (c.1105C>T, p.Arg369Ter). Interestingly, MOLM-1 cells (CML in blast crisis) harbored a p.Arg462Gln alteration. Next, we performed Sanger sequencing for the complete coding region of WT1, including the upstream promoter as well as the 5'UTR and 3'UTR regions, all 10 exons and the adjacent 150 bp intronic sequences at the exon-intron boundaries. Sanger sequencing confirmed the mutations discovered via NGS and revealed single bp alterations in the WT1 promoter region of CTS cells and in the 5'UTR of K-562 cells. We also detected a recurring variation in intron 3 of WT1 (c.872+16G>A) in the cell lines K-562, NB-4, M07e and UOC-M1; the functional implications of the alterations are yet to be determined. Functional impact of WT1 mutations. To understand the potential impact of the WT1 sequence alterations, we studied the WT1 mRNA expression in these cells in the presence of cycloheximide (CHX), an inhibitor of the nonsense-mediated mRNA decay (NMD) machinery. As shown in figure 1A, U937 cells were used as negative control cells, as they are known to have no expression of the WT1 mRNA. Despite the presence of mutations in CTS, KASUMI-6 and MOLM-1 cells, all three cell lines expressed elevated levels of WT1, well within the range of 30 other malignant cell lines without any alterations/mutations in the WT1 locus (data not shown). To differentiate the WT1 expression between the mutated and the wildtype allele, we performed a fragment length analysis on a capillary electrophoresis system using the complimentary DNA of CHX-treated cell lines. For these analyses, we employed a multiplex PCR strategy using ABL1 as housekeeping gene and a primer pair binding in exons 4 and 10 of WT1. As delineated in figure 1B, the mutated alleles in CTS and KASUMI-6 cells, which are 2-bps shorter, could be easily separated from the wildtypes (data for KASUMI-6 not shown). Additionally, since our primer pair also amplified the alternatively spliced exon 5 and the alternative splice donor at the end of exon 9, leading to inclusion or exclusion of three amino acids (KTS), we were able to separately analyze the four major WT1 isoforms from both alleles. As shown in figure 1B, the expression levels of the WT1 mutated alleles of CHX-treated cells increased 2- to 3-fold compared to DMSO-treated cells in CTS and 3- to 4-fold in KASUMI-6 (data not shown). Conclusion Careful analyses of the WT1 genomic locus in 35 malignant hematological cell lines revealed previously unknown heterozygous loss-of-function WT1 mutations in KASUMI-6, MOLM-1 and U-937 cells. mRNA expression analysis demonstrated that these mutations are strongly regulated by NMD machinery, leading to (almost) complete downregulation of the mutated WT1 allele. These results strongly question any direct effect of WT1 mutations in the leukemic blasts and therefore cannot explain the role of mutations in WT1 as a prognostic factor in AML. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

310 - Total Marrow Lymphoid Irradiation [TMLI] in Combination with Cyclophosphamide Is Associated with Good Early Outcomes in Patients Undergoing Stem Cell Transplantation for Acute Lymphoblastic Leukemia and Lymphoid Blast Crises in CML

310 - Total Marrow Lymphoid Irradiation [TMLI] in Combination with Cyclophosphamide Is Associated with Good Early Outcomes in Patients Undergoing Stem Cell Transplantation for Acute Lymphoblastic Leukemia and Lymphoid Blast Crises in CML

CRISPR-based gene disruption and integration of high-avidity, WT1-specific T cell receptors improve antitumor T cell function.

T cell receptor (TCR)-based therapy has the potential to induce durable clinical responses in patients with cancer by targeting intracellular tumor antigens with high sensitivity and by promoting T cell survival. However, the need for TCRs specific for shared oncogenic antigens and the need for manufacturing protocols able to redirect T cell specificity while preserving T cell fitness remain limiting factors. By longitudinal monitoring of T cell functionality and dynamics in 15 healthy donors, we isolated 19 TCRs specific for Wilms' tumor antigen 1 (WT1), which is overexpressed by several tumor types. TCRs recognized several peptides restricted by common human leukocyte antigen (HLA) alleles and displayed a wide range of functional avidities. We selected five high-avidity HLA-A*02:01-restricted TCRs, three that were specific to the less explored immunodominant WT137-45 and two that were specific to the noncanonical WT1-78-64 epitopes, both naturally processed by primary acute myeloid leukemia (AML) blasts. With CRISPR-Cas9 genome editing tools, we combined TCR-targeted integration into the TCR α constant (TRAC) locus with TCR β constant (TRBC) knockout, thus avoiding TCRαβ mispairing and maximizing TCR expression and function. The engineered lymphocytes were enriched in memory stem T cells. A unique WT137-45-specific TCR showed antigen-specific responses and efficiently killed AML blasts, acute lymphoblastic leukemia blasts, and glioblastoma cells in vitro and in vivo in the absence of off-tumor toxicity. T cells engineered to express this receptor are being advanced into clinical development for AML immunotherapy and represent a candidate therapy for other WT1-expressing tumors.

A Novel Anti-CD19 Chimeric Antigen Receptor T Cell Product Targeting a Membrane-Proximal Domain of CD19

Introduction: CD19-directed chimeric antigen receptor T (CART19) cell therapies have shown impressive clinical outcomes in CD19+ B-cell malignancies. All the FDA-approved CART19, including tisagenlecleucel, axicabtagene ciloleucel, brexucabtagene autoleucel, and lisocabtagene maraucel use an anti-CD19 single-chain variable fragments (scFv) derived from the FMC63 antibody that binds to a CD19 epitope that is located in the membrane-distal portion of CD19. While this CART19 products are very effective in the clinic, the majority of patients still fails treatment or eventually relapses due to several mechanisms of resistance, including CAR T cell dysfunction in the immunosuppressive microenvironment. Novel strategies to enhance the activity of CART cells are critically needed. We and others recently demonstrated that modifications of the binding region of the CAR (scFv) (Singh N., Nat Med, 2021) can drastically change the interaction between the CAR T cell and the cancer cells, potentially improving the anti-tumor effect. In this study, we aimed to develop a novel anti-CD19 CAR that binds to a membrane-proximal domain of CD19 with the goal of improving CART functions. Moreover, we hypothesized that such a CART product would be active against B-cell acute lymphoblastic leukemia (B-ALL) blasts that present aberrant expression of the CAR19(FMC63) on the surface as we described in two pediatric B-ALL patients relapsed after CART19 (CTL019) at our Institution (Ruella M., Nat Med, 2018).Methods and Results: To these goals, we screened a chicken immune scFv library against the CD19 extracellular domain. We selected an scFv clone (1218) that was not competing with FMC63 for CD19 binding in competition enzyme immunoassays and real-time interaction analysis. The chicken 1218 scFv was humanized by CDR-grafting to human germline genes and backmutations (h1218 scFv) and was confirmed to be specific for CD19 in cell microarray assays and flow cytometry analyses. In order to define the epitope that was recognized by the 1218 scFv, we performed mutagenesis assays replacing several residues of human CD19 with monkey CD19 residues showed that, as compared to FMC63, the epitope of the h1218 scFv is localized in a membrane-proximal location shown by three-dimensional modeling (Teplyakov A., Proteins, 2018) (Fig. 1A). Key residues needed for the binding of the h1218 scFv were identified as T51, S53, E55, K59 and K63, while the membrane-distal amino acid H218 is recognized as a key residue for FMC63 binding.Therefore, we designed a novel CAR construct using the h1218 scFv, a 4-1BB costimulatory and CD3z signaling domains, using a lentiviral backbone. This CAR(h1218) construct was very active in vitro in human T cells demonstrating cytotoxicity, cytokine release, and proliferation upon encounter with CD19+ leukemic and lymphoma cells (NALM6, RAJI, and OCI-Ly18) (data not shown). Moreover, CART19(h1218) showed enhanced long-term (12 days) tumor control as compared to CART19(FMC63) against wild type NALM6 (data not shown). In vivo, CART19(h1218) cells (1.5x10 6 CAR+ cells/mouse) demonstrated tumor clearance against both Raji (CD19+ B-cell lymphoma) and Nalm6 (CD19+ B-cell leukemia) xenografts (Fig. 1B). Remarkably, in a more challenging stress- test model with lower CART doses (0.75x10 6 CAR+ cells/mouse) CART19(h1218) demonstrated stronger tumor control against Nalm6 cells as compared to CART19(FMC63) (Fig. 1C). Furthermore, our group recently described the occurrence of a B-ALL relapse characterized by the expression of the CAR19 itself on the cell surface due to accidental transduction of leukemic cells during manufacturing. The CART19(h1218) product but not CART19(FMC63) was able to recognize and kill CAR19(FMC63)-expressing leukemic cells in vitro at varying E:T ratios. Of note, in a long-term (12 days) in vitro killing assay using a low, challenging E:T ratio of 0.125:1 we observed potent and prolonged tumor control (Fig. 1D).Conclusions: These results indicate that the development of a CAR binder able to recognize an alternative and membrane-proximal epitope of CD19 might lead to improved anti-leukemia and lymphoma activity and can recognize CAR19(FMC63)+ blasts that are not recognized by CART19(FMC63). This novel CART19(h1218) product will be tested in phase I-II clinical trials for patients with B-cell malignancies. [Display omitted] DisclosuresPatel: AbClon Inc.: Research Funding. Kim: Abclon Inc.: Current Employment. Lee: AbClon Inc.: Research Funding. Guruprasad: AbClon Inc.: Research Funding. Kim: AbClon Inc.: Current Employment. Choi: AbClon Inc.: Current Employment. Kim: AbClon Inc.: Current Employment. Kim: AbClon Inc.: Current Employment. Lee: AbClon Inc.: Current Employment. Lee: AbClon Inc.: Current Employment. Park: AbClon Inc.: Current Employment. Lee: AbClon Inc.: Current Employment. Cui: AbClon Inc.: Current Employment. Yoon: AbClon Inc.: Current Employment. Kim: AbClon Inc.: Research Funding. Kim: AbClon Inc.: Research Funding. Hwang: AbClon Inc.: Current Employment. Lee: AbClon Inc.: Current Employment. Lee: AbClon Inc.: Current Employment. Chung: AbClon Inc.: Membership on an entity's Board of Directors or advisory committees, Research Funding. Ruella: Novartis: Patents & Royalties; BMS, BAYER, GSK: Consultancy; AbClon: Consultancy, Research Funding; Tmunity: Patents & Royalties; viTToria biotherapeutics: Research Funding.

ALL blasts drive primary mesenchymal stromal cells to increase asparagine availability during asparaginase treatment

AbstractMechanisms underlying the resistance of acute lymphoblastic leukemia (ALL) blasts to l-asparaginase are still incompletely known. Here we demonstrate that human primary bone marrow mesenchymal stromal cells (MSCs) successfully adapt to l-asparaginase and markedly protect leukemic blasts from the enzyme-dependent cytotoxicity through an amino acid trade-off. ALL blasts synthesize and secrete glutamine, thus increasing extracellular glutamine availability for stromal cells. In turn, MSCs use glutamine, either synthesized through glutamine synthetase (GS) or imported, to produce asparagine, which is then extruded to sustain asparagine-auxotroph leukemic cells. GS inhibition prevents mesenchymal cells adaptation to l-asparaginase, lowers glutamine secretion by ALL blasts, and markedly hinders the protection exerted by MSCs on leukemic cells. The pro-survival amino acid exchange is hindered by the inhibition or silencing of the asparagine efflux transporter SNAT5, which is induced in mesenchymal cells by ALL blasts. Consistently, primary MSCs from ALL patients express higher levels of SNAT5 (P < .05), secrete more asparagine (P < .05), and protect leukemic blasts (P < .05) better than MSCs isolated from healthy donors. In conclusion, ALL blasts arrange a pro-leukemic amino acid trade-off with bone marrow mesenchymal cells, which depends on GS and SNAT5 and promotes leukemic cell survival during l-asparaginase treatment.

Antibody-Drug Conjugates for the Treatment of Acute Pediatric Leukemia.

The clinical development of antibody–drug conjugates (ADCs) has gained momentum in recent years and these agents are gradually moving into frontline regimens for pediatric acute leukemias. ADCs consist of a monoclonal antibody attached to a cytotoxic payload by a cleavable linker. This structure allows for highly cytotoxic agents to be directly delivered to leukemia cells leading to cell death and avoids excessive off-tumor toxicity. Near universal expression on B-cell acute lymphoblastic leukemia (ALL) blasts and the ability of rapid internalization has rendered CD22 an ideal target for ADC in B-ALL. Inotuzumab ozogamicin, the anti-CD22 antibody linked to calicheamicin led to complete remission rates of 60–80% in patients with relapsed/refractory B-ALL. In acute myeloid leukemia (AML), the CD33 targeting gemtuzumab ozogamicin has demonstrated modest improvements in survival and is the only ADC currently licensed in the United States for pediatric patients with de novo AML. Several other ADCs have been developed and tested clinically for leukemia but have achieved limited success to date. The search for additional leukemia-specific targets and optimization of ADC structure and specificity are ongoing efforts to improve their therapeutic window. This review provides a comprehensive overview of ADCs in acute leukemias, with a focus on pediatric ALL and AML.

Notch Signaling in the Bone Marrow Lymphopoietic Niche.

Lifelong mammalian hematopoiesis requires continuous generation of mature blood cells that originate from Hematopoietic Stem and Progenitor Cells (HSPCs) situated in the post-natal Bone Marrow (BM). The BM microenvironment is inherently complex and extensive studies have been devoted to identifying the niche that maintains HSPC homeostasis and supports hematopoietic potential. The Notch signaling pathway is required for the emergence of the definitive Hematopoietic Stem Cell (HSC) during embryonic development, but its role in BM HSC homeostasis is convoluted. Recent work has begun to explore novel roles for the Notch signaling pathway in downstream progenitor populations. In this review, we will focus an important role for Notch signaling in the establishment of a T cell primed sub-population of Common Lymphoid Progenitors (CLPs). Given that its activation mechanism relies primarily on cell-to-cell contact, Notch signaling is an ideal means to investigate and define a novel BM lymphopoietic niche. We will discuss how new genetic model systems indicate a pre-thymic, BM-specific role for Notch activation in early T cell development and what this means to the paradigm of lymphoid lineage commitment. Lastly, we will examine how leukemic T-cell acute lymphoblastic leukemia (T-ALL) blasts take advantage of Notch and downstream lymphoid signals in the pathological BM niche.

Metabolically controlled histone H4K5 acylation/acetylation ratio drives BRD4 genomic distribution.

In addition to acetylation, histones are modified by a series of competing longer-chain acylations. Most of these acylation marks are enriched and co-exist with acetylation on active gene regulatory elements. Their seemingly redundant functions hinder our understanding of histone acylations' specific roles. Here, by using an acute lymphoblastic leukemia (ALL) cell model and blasts from individuals with B-precusor ALL (B-ALL), we demonstrate a role of mitochondrial activity in controlling the histone acylation/acetylation ratio, especially at histone H4 lysine 5 (H4K5). An increase in the ratio of non-acetyl acylations (crotonylation or butyrylation) over acetylation on H4K5 weakens bromodomain containing protein 4 (BRD4) bromodomain-dependent chromatin interaction and enhances BRD4 nuclear mobility and availability for binding transcription start site regions of active genes. Our data suggest that the metabolism-driven control of the histone acetylation/longer-chain acylation(s) ratio could be a common mechanism regulating the bromodomain factors' functional genomic distribution.

Cell-Stage Dependent Outcomes of the NAMPT/SIRT2-Mediated Activation of LMO2 By Deacetylation in Normal Hematopoiesis and in T-ALL

NAMPT (nicotinamide phosphoribosyltransferase) regulates cellular functions through the protein deacetylation activity of NAD+-dependent sirtuins (SIRT). Here we demonstrated that NAMPT is indispensable for hematopoiesis and leukemogenesis through SIRT2-mediated deacetylation and activation of the hematopoietic transcription factor, LMO2 (LIM domain only 2). LMO2 is essential for the blood cell formation through the interaction with LIM Domain Binding 1 (LDB1) protein and activation of the TAL1 transcriptional complex. We found that NAMPT/SIRT2-mediated deacetylation of LMO2 on two evolutionary highly conserved lysines (K74 and K78) enables its interaction with LDB1 protein, activation of the TAL1 complex target genes (e.g. GATA1, KDR, KLF1) and hematopoietic differentiation. NAMPT- or SIRT2 inhibition abrogated LMO2 deacetylation and early hematopoietic differentiation of the induced pluripotent stem cells (iPSCs) in vitro as well as blood cell formation in zebrafish embryos in vivo on 24 hours post fertilization. Intriguingly, transfection of NAMPT- compromised zebrafish embryos with the deacetylation-mimic LMO2 mutant restore defective hematopoiesis, demonstrating the essential role of LMO2 deacetylation on K74 and K78 in NAMPT-mediated early hematopoiesis. Intriguingly, LMO2 is also known as an oncogene, which hyper-activation transforms lymphoid progenitor cells into T-cell acute lymphoblastic leukemia (T-ALL) blasts. We found, that NAMPT- or SIRT2 inhibition markedly suppressed proliferation of LMO2-expressing T-ALL cells in vitro and in zebrafish xenograft model in vivo . It was in line with impaired LMO2:LDB1 interaction and downregulation of T-ALL-specific LMO2 target genes such as HHEX.Taken together, we identified a new molecular mechanism of LMO2 activation by NAMPT/SIRT2-mediated deacetylation, which may explain the pathogenesis of hematopoietic diseases, involving disturbed TAL1 complex functions. Moreover, we found, that targeting of LMO2 deacetylation by NAMPT/SIRT2 inhibition may be a potential novel therapy for LMO2-related T-ALL. DisclosuresNo relevant conflicts of interest to declare.