Cell Chronic Lymphocytic Leukemia Patients Research Articles

Ibrutinib modulates the immunosuppressive CLL microenvironment through STAT3-mediated suppression of regulatory B-cell function and inhibition of the PD-1/PD-L1 pathway.

Ibrutinib, a covalent inhibitor of Bruton Tyrosine Kinase (BTK), is approved for treatment of patients with relapsed/refractory or treatment-naïve chronic lymphocytic leukemia (CLL). Besides directly inhibiting BTK, ibrutinib possesses immunomodulatory properties through targeting multiple signaling pathways. Understanding how this ancillary property of ibrutinib modifies the CLL microenvironment is crucial for further exploration of immune responses in this disease and devising future combination therapies. Here, we investigated the mechanisms underlying the immunomodulatory properties of ibrutinib. In peripheral blood samples collected prospectively from CLL patients treated with ibrutinib monotherapy, we observed selective and durable downregulation of PD-L1 on CLL cells by 3 months post-treatment. Further analysis showed that this effect was mediated through inhibition of the constitutively active signal transducer and activator of transcription 3 (STAT3) in CLL cells. Similar downregulation of PD-1 was observed in CD4+ and CD8+ T cells. We also demonstrated reduced interleukin (IL)-10 production by CLL cells in patients receiving ibrutinib, which was also linked to suppression of STAT3 phosphorylation. Taken together, these findings provide a mechanistic basis for immunomodulation by ibrutinib through inhibition of the STAT3 pathway, critical in inducing and sustaining tumor immune tolerance. The data also merit testing of combination treatments combining ibrutinib with agents capable of augmenting its immunomodulatory effects.

Abstract 1207: SNS-062 demonstrates efficacy in chronic lymphocytic leukemia in vitro and inhibits C481S mutated Bruton tyrosine kinase

Abstract Introduction: In order to address the issue of acquired resistance to ibrutinib, we sought to characterize the Bruton agammaglobulinemia tyrosine kinase (BTK) inhibitor SNS-062 in preclinical models of chronic lymphocytic leukemia (CLL). Methods: Primary CLL B cells were isolated from the whole blood of consented patients by ficoll density centrifugation and Rosette-Sep negative selection. Annexin V and propidium iodide flow cytometry was used to measure patient CLL cell viability and 7-AAD was used to measure viability in stromal co-culture. CD40 and CD86 expression was evaluated via flow cytometry subsequent to sustained 3.2uM CpG stimulation. BCR signaling in primary CLL cells was investigated by immunoblot following 1 hour treatment and following 1 hour or 24 hours of incubation with SNS-062 in XLA cell lines. ITK inhibition was investigated via immunoblot after stimulation with anti-CD3 and anti-CD28 and incubation with SNS-062 for 1 hour. SNS-062 was used at a concentration of 1uM in preclinical studies unless otherwise noted. Measurement of kinase activity in human recombinant WT BTK or C481S BTK was performed in a FRET kinase assay. Results: Immunoblots of BTK and ERK phosphorylation of XLA cells transfected with WT or C481S BTK demonstrated that SNS-062 inhibition is comparable to that of ibrutinib in WT BTK and greater than that of ibrutinib in C481S BTK. Using a recombinant kinase assay, we found the IC50 of SNS-062 against WT BTK to be 4.6nM and C481S BTK to be 1.1nM, suggesting that SNS-062 retains activity against the mutated BTK variant. Additionally, SNS-062 was found to be six times more potent than ibrutinib and greater than 640 times more potent than acalabrutinib against C481S BTK. SNS-062 demonstrates dose-dependent inhibition of BTK in primary patient CLL cells comparable to ibrutinib via immunoblot for BTK phosphorylation. The viability of primary patient cells treated with 0.1uM, 1.0uM, and 10.0uM SNS-062 for 48 hours was measured to be 96.7%, 96.1%, and 88.1%, respectively, that of the untreated condition. At 48 hours, SNS-062 decreased viability of primary CLL cells in the presence of HS5 stromal protection by 5.5%. SNS-062 was found to decrease CpG induced CD40 and CD86 expression by 8.7% and 15.7%, respectively. Using an in vitro kinase assay, SNS-062 inhibited ITK with an IC50 value of 24nM. An immunoblot of anti-CD3/CD28 stimulated Jurkat cells revealed that SNS-062 decreased the phosphorylation of ERK, implying inhibition of ITK. Conclusion: Unlike ibrutinib, SNS-062 inhibits BTK signaling in the presence of the C481S mutation and may address acquired resistance to covalent BTK inhibitors. SNS-062 decreases B cell activation markers, viability, and stromal cell protection in primary patient CLL cells and was shown to inhibit ITK, suggesting support of T cell mediated antitumor activities. These data support further investigation of this molecule and advancement into clinical trials. Citation Format: Catherine A. Fabian, Sean D. Reiff, Daphne Guinn, Linda Neuman, Judith A. Fox, Wendy Wilson, John C. Byrd, Jennifer A. Woyach, Amy J. Johnson. SNS-062 demonstrates efficacy in chronic lymphocytic leukemia in vitro and inhibits C481S mutated Bruton tyrosine kinase [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 1207. doi:10.1158/1538-7445.AM2017-1207

ADP-Ribosylation Reactions in Animals, Plants, and Bacteria

PARP2017, a meeting on ADP-ribosylation reactions, was held in Budapest (17–19 May 2017).[...]

NK cell dysfunction in chronic lymphocytic leukemia is associated with loss of the mature cells expressing inhibitory killer cell Ig-like receptors

ABSTRACTA prospective analysis of natural killer (NK) cell phenotype and function was performed on fresh peripheral blood samples from untreated patients with B-cell chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL). Compared to healthy controls, CD56dim NK cells in CLL patients displayed reduced expression of the NKG2D activating receptor and increased CD27 expression, which indicates declines in mature cells. In addition, NK cells from CLL patients showed reduced degranulation responses toward transformed B cells alone or with rituximab and were more sensitive to activation-induced cell death. We further noted a striking reduction in the frequency and viability of NK cells expressing the inhibitory killer cell Ig-like receptors (KIR)2DL1 and/or KIR3DL1, which progressed over time in most patients. Comparisons between a CLL patient and healthy monozygotic twin were consistent with our results in the larger cohorts. Functional and biomarker alterations were less pronounced on NK cells from SLL patients, which have lower tumor burden in peripheral blood than CLL, but significant reduction in degranulation under ADCC conditions and lower frequency and viability of KIR-expressing NK cells were still evident in SLL. We conclude that mature KIR-expressing NK cells respond to the high circulating B cell tumor burden in CLL, but undergo activation-induced apoptosis. Consequently, CLL patients may benefit from therapies that augment NK cell survival and function.

The regulation of tumor‐suppressive microRNA, miR‐126, in chronic lymphocytic leukemia

The introduction of miR profiling of chronic lymphocytic leukemia (CLL) patients with different cytogenetic profiles and responses to therapy has allowed incorporation of important miR‐mRNA interactions into the understanding of disease biology. In this study, we performed miR expression analysis using NanoString nCounter to discover differentially regulated miRs after therapy with the Bruton tyrosine kinase inhibitor ibrutinib. Of the differentially regulated miRs in the discovery set, miR‐29c and miR‐126 were confirmed using real‐time PCR to be upregulated in CLL patient cells with ibrutinib therapy. In the validation set, an inverse correlation was observed between miR‐126 levels and expression of its putative target p85β, an isoform of the phosphoinositide 3‐kinase p85 regulatory subunit. We found that mRNA for the host gene EGFL7, primary unprocessed miR‐126, and mature miR‐126 are all downregulated in CLL cells compared to normal B cells. Patients in later stages of disease have a greater decrease in miR‐126 expression compared to treatment‐naive patients, indicating that lower miR‐126 levels may associate with disease progression. Overexpression of miR‐126 in leukemia cell lines significantly downregulates p85β expression and decreases activation of prosurvival mitogen‐activated protein kinase (MAPK) signaling. These results implicate miR‐126 in the pathology of CLL.

Biomarkers of Response to Anti-CD19 Chimeric Antigen Receptor (CAR) T-Cell Therapy in Patients with Chronic Lymphocytic Leukemia

The adoptive transfer of autologous T cells genetically modified to express a CD19-specific, 4-1BB/CD3z-signaling CAR (CTL019) has shown remarkable activity and induce long-term remissions in a subset of patients with relapsed/refractory chronic lymphocytic leukemia (CLL). To date, little is known about predictive indicators of efficacy. This study was designed to evaluate biomarkers of clinical response to CTL019 in CLL. We studied forty-one patients with advanced, heavily pre-treated and high-risk CLL who received at least one dose of CTL019 cells. We show that in vivo expansion and persistence are key quality attributes of CTL019 cells in CLL patients who have complete responses to therapy; in 2 patients responses are sustained beyond five years and accompanied by the persistence of functional CTL019 cells. Furthermore, durable remissions were associated with transcriptomic signatures of early memory T cells, while T cells from non-responding patients were enriched in genes belonging to known pathways of terminal differentiation and exhaustion. Polychromatic flow cytometry also demonstrated a significantly higher level of T cell exhaustion markers on the infused CAR T cells and reduced CD27 expression in non-responding patients. Accordingly, the combined assessment of PD1 and CD27 expression on CD8+ CTL019 cells in the infusion product accurately predicted response to treatment. Restimulation of the infusion product through the CAR further demonstrated that CTL019 cells from complete responders secreted significantly higher levels of several cytokines, including CCL20, IL-21, IL-22, IL-17, and IL-6, suggesting that the STAT3 signaling pathway may play a role in potentiating the enhanced potency of CTL019 cells. To identify a phenotype of T cells that is predictive of response prior to CTL019 manufacturing, we initially retrospectively evaluated the proportions of naïve, stem cell memory, central memory, effector memory and effector cells at the time of leukapheresis and observed either marginally significant or no significant correlations with clinical outcome. A systematic, unbiased analysis of the same biomarker panel revealed that the frequency of CD27+CD45RO- cells in the CD8+ T cell population correlated significantly with complete and durable responses to this therapy. Analysis of the infusion products using the same flow cytometric panel showed that most (>95%) of T cells expressed CD45RO at the end of the manufacturing run; CD27 expression frequencies, however, were maintained at the same level as in the leukapheresis. Together, these findings suggest that intrinsic T cell fitness dictates both response and resistance to highly active engineered CAR T cells. Thus, enrichment of T cells with optimal differentiation potential and proliferative capacity by timing of collection or culture modification might potentiate the generation of maximally efficacious infusion products. These data and additional immunological biomarkers may be used to identify which patients are most likely to respond to adoptive transfer strategies, leading to an enhanced personalized approach to cellular therapy. DisclosuresFraietta:Novartis: Patents & Royalties: Novartis, Research Funding. Lacey:Novartis: Research Funding. Wilcox:Novartis: Research Funding. Bedoya:Novartis: Research Funding. Chen:Novartis: Research Funding. Orlando:Novartis: Employment. Brogdon:Novartis: Employment. Hwang:Novartis: Research Funding. Frey:Novartis: Research Funding; Amgen: Consultancy. Pequignot:Novartis: Research Funding. Ambrose:Novartis: Research Funding. Levine:Novartis: Patents & Royalties, Research Funding; GE Healthcare Bio-Sciences: Consultancy. Bitter:Novartis: Employment. Porter:Genentech: Employment; Novartis: Patents & Royalties, Research Funding. Xu:Novartis: Research Funding. June:Immune Design: Consultancy, Equity Ownership; University of Pennsylvania: Patents & Royalties; Celldex: Consultancy, Equity Ownership; Novartis: Honoraria, Patents & Royalties: Immunology, Research Funding; Tmunity: Equity Ownership, Other: Founder, stockholder ; Pfizer: Honoraria; Johnson & Johnson: Research Funding. Melenhorst:Novartis: Patents & Royalties: Novartis, Research Funding.

Cirmtuzumab Targets ROR1 to Inhibit Ibrutinib-Resistant, Wnt5a-Induced Rac1 Activation in Chronic Lymphocytic Leukemia

Signaling via the B cell receptor (BCR) plays an important role in the pathogenesis and progression of chronic lymphocytic leukemia (CLL). This is underscored by the clinical effectiveness of an inhibitor of Bruton's tyrosine kinase (BTK), ibrutinib, which can block BCR-signaling. However, ibrutinib cannot induce complete responses (CR) or durable remissions without continued therapy, suggesting that ancillary pathways contribute to CLL growth/survival that are independent of BCR-signaling. ROR1 is a receptor for Wnt5a, which can promote activation of Rac1 to enhance CLL-cell proliferation and survival. We hypothesized that the effects of ibrutinib on blocking BCR-signaling might be offset by non-canonical Wnt-signaling via ROR1. If so, then inhibition of both ROR1- and BCR-signaling might have an enhanced anti-tumor effect.We examined the CLL cells of patients who were taking ibrutinib at the standard dose of 420 mg per day. Freshly isolated CLL cells had activated Rac1, which diminished over time upon culture in serum-free media, unless treated with exogenous Wnt5a, as noted for CLL cells of patients not taking ibrutinib. Moreover, Wnt5a could induce Rac1 activation and enhance proliferation of CLL cells treated in vitro with ibrutinib, even at concentrations that exceeded those required to completely inhibit BTK and BCR-signaling. On the other hand, Wnt5a-induced activation of Rac1 was blocked by treatment of the CLL cells with cirmtuzumab (UC-961), a first-in-class humanized mAb specific for a functional extracellular epitope of ROR1; this mAb is being evaluated in a phase I clinical trial in patients with CLL. To examine the activity of ibrutinib and/or cirmtuzumab, alone or in combination, we transferred human CLL cells into the peritoneal cavity of immune-deficient Rag2−/−γc−/− mice, which subsequently were treated with ibrutinib via oral gavage and/or cirmtuzumab administered iv. Although either agent alone resulted in some leukemia-cell clearance, cirmtuzumab and ibrutinib had apparent synergistic activity when used together in clearing human leukemia cells. We also examined the activity of each agent, alone or in combination, against a ROR1+ mouse leukemia, which we had engrafted in Rag2−/−γc−/− mice. While the engrafted mice treated with cirmtuzumab or ibrutinib alone had significantly smaller spleens and lower proportions of leukemia cells than the engrafted animals that did not receive any treatment, the mice treated with the combination of cirmtuzumab and ibrutinib had significantly smaller spleens and synergistic clearance of leukemia cells. Collectively, this study demonstrates that cirmtuzumab and ibrutinib may have synergistic activity in the treatment of patients with CLL, providing the rationale for clinical trials using cirmtuzumab in combination with ibrutinib, or another inhibitor of BTK, such as acalabrutinib, for treatment of patients with CLL or other B-cell malignancies dependent on non-canonical Wnt5a/ROR1 signaling. DisclosuresKipps:Celgene: Consultancy, Honoraria, Research Funding; Pharmacyclics, LLC, an AbbVie Company: Consultancy, Honoraria; Gilead: Consultancy, Honoraria, Speakers Bureau; Roche: Consultancy, Honoraria; AbbVie: Consultancy, Honoraria, Research Funding.

TLR9-Regulated IL10 Mediates Immune Inhibitory Activity of Chronic Lymphocytic Leukemia B-Cells

Introduction: Chronic lymphocytic leukemia (CLL) cells exhibit inhibitory features of regulatory B-cells (Bregs), which are suspected to modulate cancer immune evasion on the one hand, and to promote immunosuppression leading to opportunistic infections on the other. One of the major mechanisms through which Bregs restrain the immune system is production of the anti-inflammatory cytokine interleukin 10 (IL10). Our previous study has demonstrated that CLL cells generate IL10, inhibit autologous CD4+ T-cell proliferation and induce regulatory T-cells (Tregs) from autologous CD4+ T-cells. All these abilities were found to be triggered by activation of toll like receptor 9 (TLR9) with the agonist CpG-ODN (ODN). Of note, Treg induction was also observed following CD40 activation with CD40 ligand (CD40L), while intracellular IL10 levels and proliferation inhibition were unaffected by this stimulant. Given the magnitude of the regulatory effects induced by ODN, the current study aimed to explore the contribution of TLR9 activation to the control of IL10 generation by CLL cells and to assess the role of this inhibitory cytokine in mediating the above Breg abilities of these cells.Methods: B-cells were isolated from peripheral blood mononuclear cells (PBMCs) of untreated CLL patients (Rai stages 0-IV). B-CLL cells were stimulated with ODN or CD40L and either examined directly, or co-cultured with isolated autologous CD4+ T-cells. A cytokine array was used to detect and estimate the concentration of a variety of cytokines (n = 42) secreted to the medium. FACS analysis was employed to examine intracellular IL10 levels in CLL cells, either untreated or treated with an IRAK1/4 inhibitor, obstructing upstream TLR signaling, at doses of 2µM or 5µM. For co-culture experiments, CLL cells were transfected with IL10 siRNA or scramble RNA (control), using the nucleofector technology by Amaxa. T-cell proliferation was evaluated using carboxyfluorescein succinimidyl ester (CFSE) staining for cell tracking after stimulation with anti-CD3/CD28 antibodies and interleukin 2 (IL2). Percentage of cells retained in G0 (non-proliferating pool) was assessed for each condition.Results: The cytokine array showed IL10 to be the only cytokine secreted by CLL cells to the medium under baseline conditions. The secretion was significantly enhanced following ODN stimulation [fold induction >1.65 (N=3)], but not after CD40L activation. Since in our studies, ODN emerged as the sole activator of IL10 generation, levels of this cytokine were assessed following IRAK1/4 inhibition. The results showed a dose-dependent attenuation of intracellular IL10 levels, with percentage of IL10 expression being 5.88 (±2.01) at baseline, 5.18 (±2.01) for low-dose and 4.83 (±1.93) for high-dose IRAK1/4 inhibition (N=5, p<0.05 for 2µM and p<0.01 for 5µM). To define the contribution of IL10 to Breg functions of CLL cells, the impact of IL10 RNA interference was examined. CLL cell transfection with IL10 siRNA diminished the inhibitory effect of these cells on proliferation of co-cultured autologous T-cells, demonstrating a 21% reduction in T-cell inhibition. In the control co-culture, 12.4 (±2.3)% of stimulated CD4+ T-cells remained in G0, whereas in the presence of IL10-depleted CLL cells, only 9.8 (±1.87)% of CD4+ T-cells remained in the non-proliferating pool (N=8, p<0.05).Conclusions: In the current study, IL10 emerges as the only inhibitory cytokine secreted at biologically relevant levels by CLL cells, and the only one whose quantity significantly increases following ODN-activation. The TLR9 signaling pathway directly controls IL10 generation, which in turn contributes to the inhibition of T-cell proliferation. While normal B-cells are known to respond to TLR9 activation by secreting a variety of cytokines, the exclusive generation of IL10 by activated CLL cells, resulting in T-cell inhibition, may represent a unique clonal quality promoting disease progression. DisclosuresAvivi:Tel Aviv Sourasky Medical center: Consultancy, Other: consultancy to :BMS Roche.

Early Enhancement of IgM Expression and Signaling Capacity during Ibrutinib Therapy in CLL Patients

In chronic lymphocytic leukemia (CLL), B-cell receptor (BCR) signaling is key to survival and proliferation, and can be effectively targeted by the Bruton's tyrosine kinase (BTK) inhibitor ibrutinib. BCR surface IgM (sIgM) levels and signaling capacity are low but variable in CLL. The variability has clinical consequences and relatively high sIgM in circulating cells is associated with aggressive disease, a higher proliferative component and higher levels of adhesion and migration receptors (D'Avola, Drennan et al, Blood 2016).The aim of this study was to investigate the expression and function of sIgM and other surface markers on the circulating tumor cells of CLL patients following one week of ibrutinib therapy. Expression of markers associated with the BCR complex (IgM, IgD, CD19), and with adhesion or migration (CD38, CD49d, CXCR4) was assessed by flow cytometry in 13 CLL patients prior to and following one week of therapy. Signaling capacity was measured by immunoblotting following sIgM or CXCR4 stimulation. N-glycosylation status of the µ-heavy chains was measured by immunoblotting after biotinylation of cell surface proteins to determine IgM maturation (Krysov et al, Blood 2010).Following one week of treatment basal activity of BTK was significantly reduced compared with pre-treatment (P=0.002), and anti-IgM induced BTK auto-phosphorylation was completely suppressed, confirming full inhibition of BTK in vivo. Expression of sIgM, but not of sIgD, increased dramatically (P=0.005), with little change in the other receptors. The increase was similar in the tissue-egressed CXCR4dimCD5hi cells and in the CXCR4brightCD5low long-resting cells of the circulation. Increased sIgM expression associated with the fully N-glycosylated form of sIgM, characteristic of the absence of antigen engagement. Also, it correlated with increased capacity to phosphorylate SYK following anti-IgM stimulation (r=0.91, P<0.0001). Conversely, CXCL12-induced CXCR4 signaling, measured by ERK phosphorylation, was fully suppressed.Whilst ibrutinib induces a rapid and persistent redistribution of CLL cells into the blood, early suspension is typically associated with reduction of the lymphocytosis, nodal progression and short survival. These data reveal a dangerous early phenomenon during ibrutinib in which IgM expression has increased in the circulating cells, resulting in enhanced IgM-mediated signaling capacity through SYK. CXCR4 inhibition may prevent migration into tissue during ibrutinib and avoid (super)antigen encounter, but cells could be at risk of increased IgM mediated proliferation and disease progression if ibrutinib is withdrawn at this stage. DisclosuresPackham:Aquinox Pharmaceuticals: Research Funding; Karus Therapeutics: Other: Share Holder & Founder. Steele:Portola Pharmaceuticals: Honoraria.

High Aurora Kinase and Low Dido Levels Characterizes a Sub-Group of Chronic Lymphocytic Leukemia with Chromosomal Gains and High White Blood Cell Counts: Potential Inter-Regulatory Role of E2F1 and Mir-17-92 Cluster

During cell cycle division Aurora kinases (AURKA and AURKB) participate in the formation and control of mitotic spindle fibers, while, protein isoforms (DIDO1, DIDO2 and DIDO3), derived by alternative splicing of the DIDO gene, assist at the junction of microtubules to kinetochores. Thus, both are relevant to cell cycle maintenance. Interestingly, overexpression (or gain of function) of AURKs or low expression (or loss of function of DIDO) are both associated with centrosomal amplification and chromosomal instability (CIN), leading to aneuploidy. Among hematological diseases with CIN records, chronic lymphocytic leukemia (CLL) can display centrosome amplification and changes in AURKs expression levels leading to aneuploidy. The Despite this, there are no studies evaluating the potential association of these genes with CIN in CLL. By evaluating their gene expression levels in CLL samples from patients with or without chromosomal aberrations, we show that increased levels of AURKA and AURKB and, conversely, reduced levels of DIDO variants, are both significantly associated with chromosomal gains and with increased white blood cell (WBC) counts. Clearly, CLL samples without any cytogenetic abnormality had expression levels similar to samples mostly harboring non-numerical aberrations. The finding that the expression levels of AURKs and DIDO variants are completely opposed, showing a discrete inter-related pattern, led us to investigate the potential regulatory mechanism behind this. Given that other have previously shown that the oncogenic miR-17-92 cluster is significantly upregulated in purified CLL patient cells expressing unmutated IGHV genes (as compared to mutated patient cells), and that miR-17 is expressed at significantly higher levels in unmutated or ZAP-70 high cases (bad prognostic cases generally associated with chromosomal instability), we investigated the potential negative regulation of DIDO variants by microRNAs from this cluster. In addition, based on the already described regulatory mechanism by which AURKA overexpression induces the E2F1-mediated transcription upregulation of the miR-17-92 cluster (with an observed expression correlation of both proteins in cancer specimens); we decided to investigate this regulatory axis in CLL. Notably, we found that all DIDO variants are predicted to be heavily targeted by several miRs of this oncogenic cluster. We show that CLL samples with low DIDO expression, in addition to the already mentioned AURK high levels, displayed significant higher levels of the transcription factor E2F1 and of its transcriptional target, the miR-17-92 primary transcript (MIR17HG). Moreover, by using the NTERA-2 cell line as a model, we show that siRNA knockdown of AURKA (at the transcript and protein level, as confirmed by qPCR and western blot) is accompanied by a striking significant reduction of E2F1 and also of MIR17HG. Furthermore, transfection of NTERA-2 cells with synthetic mimics of the miR-17~92 cluster (namely, miR-19a, miR-20a and miR-92a) results in a clear and significant reduction in the transcript levels of all DIDO variants. Finally, specific siRNA inhibition of the DIDO3 variant (but not the others) led to a significant reduction in the transcript levels of all DIDO variants, indicating an additional mechanism contributing to the downregulation of DIDO transcripts. Altogether, our results demonstrate the existence of a potential interconnected regulatory mechanism between AURK and DIDO, associated with CIN and higher WBC counts in CLL. More importantly, the high expression levels of AURKs and the associated low levels of DIDO variants are specifically associated with cytogenetic abnormalities presenting chromosomal gains, highlighting the specific cellular mechanism underlying the CIN observed in this distinct CLL group. Given the central role of CIN in cancer genesis and progression, these findings will likely have an important impact on prognosis or treatment of CLL. Funded by: FAPESP, CNPq and CAPES. DisclosuresNo relevant conflicts of interest to declare.

Ibrutinib Disrupts the Metabolic Program of CLL Cells in-Vivo

Introduction: Unlike their normal resting B cell counterparts, chronic lymphocytic leukemia (CLL) cells proliferate. Approximately 1% of the total CLL cell clone expands daily. To adjust for the increase in energetic demands imposed by continuous proliferation, CLL cells undergo metabolic reprogramming and, as recently shown (Rozovski U, et al. Mol Cancer Res. 2015; 13:944-53), CLL cells utilize fat in a manner similar to that of adipocytes. The recent introduction of the oral Bruton tyrosine kinase inhibitor (BTK) ibrutinib revolutionized the treatment of CLL. Because the proliferation of CLL cells is driven by lipid metabolism and ibrutinib inhibits the B cell receptor-induced proliferation of CLL cells, we sought to determine whether ibrutinib also disrupts the metabolic program that provides CLL cells with their unique energy requirements.Methods: We prospectively studied serial peripheral blood samples from 16 patients with CLL. The patients’ peripheral blood CLL cells were analyzed prior to and during treatment with ibrutinib. All patients received a daily dose of 420 mg ibrutinib. In addition, we performed in vitro studies using CLL cells from 3 ibrutinib-naïve patients. CLL cells were analyzed for free-fatty acids (FFA) consumption and for the rate of cellular apoptosis using propiduim iodide (PI) and annexin V staining analyzed by flow cytometry.Results: To study lipid metabolism of CLL cells we incubated peripheral blood CLL cells from 3 randomly selected ibrutinib-naïve patients in the presence or absence of FFA and measured the concentration of culture media-dissolved O2 (dO2). Like in our previous study (Rozovski U, et al. Mol Cancer Res. 2015; 13:944-53), we found that CLL cells metabolized FFA and, as a result, the levels of dO2 decreased. However when the cells were co-cultured with FFA and ibrutinib, the delta dO2 (dO2 with FFA minus dO2 without FFA) remained unchanged, suggesting that ibrutinib blocked FFA metabolism in CLL cells.Then, to determine whether ibrutinib also inhibited CLL-cell lipid metabolism in patients treated with ibrutinib, we collected 2 to 5 consecutive PB samples (median: 5) from 16 CLL patients prior to and during treatment with ibrutinib. Unlike the 12% reduction in delta dO2 detected in untreated patients’ CLL cells incubated with FFA in vitro, a 6% reduction in delta dO2 was detected in CLL cells of patients treated with ibrutinib 4 days into treatment and after a median of 147 days of ibrutinib treatment a change in delta dO2 was no longer detected. These data suggest that ibrutinib-treated cells lost their capacity to utilize FFA or that the number of FFA consuming circulating CLL cells declined until they were no longer detected. In addition, whereas ibrutinib induced apoptosis of CLL cells in a dose-dependent manner in vitro, ibrutinib did not induce apoptosis at the same time points in vivo, suggesting that interruption of FFA metabolism does not lead to apoptotic cell death and that the metabolic and proapoptotic pathways are not linearly intertwined in CLL cells.In conclusion: Treatment with ibrutinib changes the metabolic profile CLL cells. Even after short exposure to the drug the cells were less capable of utilizing FFA, and after longer exposure, the cells could no longer utilize FFA. Whether ibrutinib induced reduction in FFA metabolism decreases the proliferation capacity of CLL cells remains to be determined. DisclosuresBurger:Pharmacyclics: Research Funding. O'Brien:Janssen: Consultancy, Honoraria; Pharmacyclics, LLC, an AbbVie Company: Consultancy, Honoraria, Research Funding. Jain:Pfizer: Consultancy, Honoraria, Research Funding; Celgene: Research Funding; Abbvie: Research Funding; Novimmune: Consultancy, Honoraria; Servier: Consultancy, Honoraria; Incyte: Research Funding; ADC Therapeutics: Consultancy, Honoraria, Research Funding; Seattle Genetics: Research Funding; Genentech: Research Funding; BMS: Research Funding; Pharmacyclics: Consultancy, Honoraria, Research Funding; Infinity: Research Funding; Novartis: Consultancy, Honoraria. Wierda:Novartis: Research Funding; Abbvie: Research Funding; Acerta: Research Funding; Gilead: Research Funding; Genentech: Research Funding.

Cirmtuzumab inhibits Wnt5a-induced Rac1 activation in chronic lymphocytic leukemia treated with ibrutinib

Signaling via the B cell receptor (BCR) plays an important role in the pathogenesis and progression of chronic lymphocytic leukemia (CLL). This is underscored by the clinical effectiveness of ibrutinib, an inhibitor of Bruton’s tyrosine kinase (BTK) that can block BCR-signaling. However, ibrutinib cannot induce complete responses (CR) or durable remissions without continued therapy, suggesting alternative pathways also contribute to CLL growth/survival that are independent of BCR-signaling. ROR1 is a receptor for Wnt5a, which can promote activation of Rac1 to enhance CLL-cell proliferation and survival. In this study, we found that CLL cells of patients treated with ibrutinib had activated Rac1. Moreover, Wnt5a could induce Rac1 activation and enhance proliferation of CLL cells treated with ibrutinib at concentrations that were effective in completely inhibiting BTK and BCR-signaling. Wnt5a-induced Rac1 activation could be blocked by cirmtuzumab (UC-961), an anti-ROR1 mAb. We found that treatment with cirmtuzumab and ibrutinib was significantly more effective than treatment with either agent alone in clearing leukemia cells in vivo. This study indicates that cirmtuzumab may enhance the activity of ibrutinib in the treatment of patients with CLL or other ROR1+ B-cell malignancies.

Circulating microRNA-192 as a diagnostic biomarker in human chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is known as the most common lymphoid malignancy in the Western world. MicroRNAs (miRNAs) are a class of small noncoding RNAs with pivotal roles in cellular and molecular processes related to different malignancies including CLL. Recently, some studies have shown that miR-192 plays a key role in CLL pathogenesis through increasing CDKN1A/p21 levels, suppression of Bcl-2 and enhancement of wild-type P53 and cell cycle arrest. Forty samples, including 20 patients with CLL, diagnosed in Omid hospital (Isfahan, Iran) and 20 healthy controls were sampled during a period of 4 months. Using real-time PCR method, expression of miR-192 was analyzed in peripheral blood mononuclear cells (PBMCs) of CLL patients in comparison with healthy subjects. In silico molecular signaling pathway enrichment analysis was also performed on validated and predicted targets (targetome) of miR-192 in DAVID database to explore possible role of miR-192 in some pathways. The expression of miR-192 was found to be significantly reduced (~2.5-folds) in CLL patients compared with healthy subjects (P=0.002). In silico molecular signaling pathway enrichment analysis detected cell indicated signaling pathway as one of the most statistically relevant pathway with miR-192 targetome. Our findings showed that miR-192 could be a biomarker for early diagnosis of CLL.

Assessment of the influence of peripheral blood mononuclear cell stimulation with Streptococcus pneumoniae polysaccharides on expression of selected Toll-like receptors, activation markers and Fas antigen in patients with chronic lymphocytic leukemia.

Since 2012, both the 13-valent pneumococcal conjugate vaccine (PCV13) and the 23-valent pneumococcal polysaccharide vaccine (PPV23) have been recommended for pneumococcal infection prevention in patients with chronic lymphocytic leukemia (CLL). Available literature data indicate that leukemic cells may respond to the presence of pathogens through specific Toll-like receptors (TLR). The aim of the study was to assess the effect of in vitro PPV23 stimulation of peripheral blood mononuclear cells (PBMCs) on expression of TLR-2, TLR-4, CD25, CD69, and CD95 on the surface of CD3+ T cells and CD19+ B cells in CLL patients. A total of 30 previously untreated patients with CLL, stage 0 according to the Rai classification, were included in the study. PBMCs obtained from each patient were cultured with and without PPV23 antigens. After 24-, 48-, and 72 h cultures, the viable cells underwent labeling with fluorochrome-conjugated monoclonal antibodies, and were analyzed using a flow cytometer. Between 24 h and 72 h (p=0.002) stimulation with PPV23 and between 48 h and 72 h (p=0.034) stimulation with PPV23 the frequencies of CD3+TLR-2+ cells were diminished. Increase of the value of the percentage of CD19+CD69+ cells was observed after 24 h (p=0.003), 48 h (p=0.025) and 72 h (p=0.012) of stimulation with PPV23. Stimulation with PPV23 led to an increase of the percentage of CD19+CD95+ cells after 24 h (p=0.003), 48 h (p=0.015), and 72 h (p=0.006). We found that both T and B cells respond to antigens of PPV23 by inducing TLR-dependent pathways, lymphocyte activation and CD95 expression.

Cytokine Contents in Chronic Lymphocytic Leukemia: Association with ZAP70 Expression.

Objective:Chronic lymphocytic leukemia (CLL) is a disease that shows varying clinical progression, and expression of the protein tyrosine kinase ZAP70 has been described as a very valuable prognostic factor. Patients with ZAP70 positivity are characterized by worse clinical course and significantly shorter progression-free and overall survival. In this study, intracytoplasmic interferon gamma (IFN-γ) and interleukin-4 (IL-4) content of T, B, and CLL cells in CLL patients and their correlations with Rai staging and ZAP70 positivity were investigated.Materials and Methods:CLL patients newly diagnosed or in follow-up at the İstanbul University İstanbul Medical Faculty Hematology Department were included in this study. These patients were classified according to Rai staging and ZAP70 expression. IL-4, IFN-γ, and ZAP70 expressions in peripheral blood T, B, and CLL cells were measured by four-color flow cytometry.Results:There was a statistically significant correlation between advanced disease and ZAP70 positivity. IL-4-secreting T cells were significantly increased; however, IFN-γ secretion was significantly decreased in CLL patients compared to healthy individuals, whereas IL-4-secreting B cells were significantly diminished in contrast to T cells.Conclusion:These findings suggest damage in the cellular immunity and that IL-4 might lead to many complications and may be important in disease progression.

The BCL2 selective inhibitor venetoclax induces rapid onset apoptosis of CLL cells in patients via a TP53-independent mechanism

AbstractBCL2 blunts activation of the mitochondrial pathway to apoptosis, and high-level expression is required for chronic lymphocytic leukemia (CLL) survival. Venetoclax (ABT-199) is a small-molecule selective inhibitor of BCL2 currently in clinical trials for CLL and other malignancies. In conjunction with the phase 1 first-in-human clinical trial of venetoclax in patients with relapsed or refractory CLL (M12-175), we investigated the mechanism of action of venetoclax in vivo, explored whether in vitro sensitivity assays or BH3 profiling correlated with in vivo responses in patients, and determined whether loss of TP53 function affected responses in vitro and in vivo. In all samples tested, venetoclax induced death of CLL cells in vitro at concentrations achievable in vivo, with cell death evident within 4 hours. Apoptotic CLL cells were detected in vivo 6 or 24 hours after a single 20-mg or 50-mg dose in some patients. The extent of mitochondrial depolarization by a BIM BH3 peptide in vitro was correlated with percentage reduction of CLL in the blood and bone marrow in vivo, whereas the half lethal concentration derived from standard cytotoxicity assays was not. CLL cell death in vitro and the depth of clinical responses were independent of deletion of chromosome 17p, TP53 mutation, and TP53 function. These data provide direct evidence that venetoclax kills CLL cells in a TP53-independent fashion by inhibition of BCL2 in patients and support further assessment of BH3 profiling as a predictive biomarker for this drug.

KIR genotype distribution among patients with chronic lymphocytic leukemia: Is there a role for KIR 2DS4 and KIR 2DS5 genes?

IntroductionThe function of natural killer (NK) cells is regulated by different antigen receptors including killer immunoglobulin-like receptors (KIR). In addition to their important role in fighting infection, natural killer cells produce cytotoxicity against some cancer cells. Studies demonstrated that NK cells have a reduced function in chronic lymphocytic leukemia (CLL). AimThe aim of this study is to investigate KIR expression of NK cells in CLL patients to check for any association between KIR genotypes and this disease. MethodsKIR genotype was analyzed for 120 healthy Lebanese patients and 56 CLL patients using the KIR Genotyping SSP kit. ResultsAmong the 56 CLL patients, the AA, AB, and BB genotypes frequencies were, respectively, 38%, 46%, and 16% with an A:B ratio of 1.55:1. As for the controls, the AA, AB, and BB genotypes frequencies were, respectively, 39.17%, 50%, and 10.83% with an A:B ratio of 1.79:1. KIR 2DS4*001/002 and KIR 2DS5 were found to be significantly more prevalent among CLL patients as compared to controls. ConclusionThis is the first study that reports such an interesting prevalence of KIR genes in CLL necessitating further clinical and translational research pertaining to the pathophysiology of this disease.

Chronic Lymphocytic Leukemia (CLL) Cells Are Susceptible to γδ-T Cell Mediated Killing, Provided CLL-Derived γδ-T Cell Dysfunction Can be Reversed

Background:Although T cell immunotherapy is considered a promising therapeutic approach in B cell malignancies, autologous T cell based therapy proved to be far less effective in CLL than in more aggressive B cell malignancies. This has been attributed to an acquired state of T cell dysfunction. Disturbances in conventional (αβ-)T cells include expansion of CD4+ and CD8+ T cells, increased expression of exhaustion markers and impaired cytotoxicity and cytokine production. Vγ9Vδ2-T cells are a conserved subset of cytotoxic T lymphocytes with potent antitumor activity, due to recognition of phosphoantigen-induced changes in CD277 in tumor cells. Aminobisphosphonate (ABP) treatment leads to intracellular accumulation of phosphoantigens and increased Vγ9Vδ2 antitumor responses. Vγ9Vδ2-T cells have been shown to effectively kill malignant B cell lines in vitro. Moreover, in clinical trials Vγ9Vδ2-T cells have been shown to recognize and kill B cell lymphomas. Whether Vγ9Vδ2-T cells could be exploited for CLL immunotherapy has not yet been explored. The aim of this study is to investigate the phenotype and function of Vγ9Vδ2-T cells in CLL patients, in order to determine whether Vγ9Vδ2-T cells can effectively kill CLL cells.Results:Frequencies of Vγ9Vδ2-T cells do not differ between untreated CLL patients (n=46) and age-matched healthy controls (HC) (n=20) as assessed by flow cytometry. Vγ9Vδ2-T cell subpopulations are skewed towards effector type (CD27- CD45RA-) in CLL patients, while numbers of naïve (CD27+ CD45RA+) Vγ9Vδ2-T cells are decreased. Expression of exhaustion markers PD-1 and BTLA is comparable between CLL and HC, as is expression of CD16, mediating antibody-dependent cellular cytotoxicity. Next, we compared the functionality of Vγ9Vδ2-T cells from CLL patients and HC. We first examined cytokine production and CD107a expression, a marker of degranulation. Production of TNFα and IFNγ upon PMA/ionomycin stimulation was significantly diminished in CLL Vγ9Vδ2-T cells as compared to HC Vγ9Vδ2-T cells. Similarly, CD107a expression was significantly reduced. Overnight coculture with primary CLL cells or the Vγ9Vδ2-T cell sensitive Daudi lymphoma cell line also induced expression of TNFα, IFNγ and CD107a. However, upon co-culture, HC Vγ9Vδ2-T cells expressed significantly more TNFα, IFNγ and CD107 than CLL Vγ9Vδ2-T cells. Subsequently, we compared cytotoxicity of Vγ9Vδ2-T cells towards Daudi cells. HC-derived Vγ9Vδ2-T cells killed Daudi cells 3-4 times more effectively at 1:5 and 1:2.5 effector:target ratios. Although ABP pretreatment of Daudi cells increased both CLL-derived and HC-derived Vγ9Vδ2-mediated killing, differences between CLL and HC could not be overcome. We then looked at Vγ9Vδ2-T cell cytotoxicity towards CLL cells. Vγ9Vδ2-T cells from HCs effectively recognized and killed primary CLL cells, irrespective of ABP pretreatment. CLL-derived Vγ9Vδ2-T cells killed allogeneic CLL cells significantly less efficiently.Finally, we investigated whether the Vγ9Vδ2-T cell dysfunction in CLL patients was reversible upon ex vivo activation without the presence of leukemic B cells. Purified Vγ9Vδ2-T cells were cocultured with mature monocytic-derived dendritic cells in the presence of ABP for 8 days. Following these culture conditions, no difference was observed in production of TNFα, IFNγ and IL-4 upon PMA/ionomycin stimulation between HC- and CLL-derived activated Vγ9Vδ2-T cells. Likewise, there was no difference in CD107a expression. The activated Vγ9Vδ2-T cells of HCs and CLL patients were equally effective at killing Daudi cells.Conclusion:Vγ9Vδ2-T cells are capable of recognizing and killing CLL cells. Yet, CLL-derived Vγ9Vδ2-T cells are functionally impaired in terms of cytokine production and cytotoxic capacity in comparison to age-matched HCs. Functional impairments of Vγ9Vδ2-T cells are reversible upon ex vivo activation. If dysfunction can be overcome effectively, the antileukemic properties of autologous Vγ9Vδ2-T cells can be efficiently employed. DisclosuresNo relevant conflicts of interest to declare.

Ibrutinib Treatment Reduces Both T-Regulatory Cells and B-Regulatory Cell Phenotype in Malignant B Cells in Chronic Lymphocytic Leukemia Patients

Introduction: Chronic lymphocytic leukemia (CLL) has multiple mechanisms of active immune suppression including expansion of T-regulatory cells which increases with progression of the disease. In addition, the malignant CLL cells were found to produce IL-10 in vitro and functionally recapitulate the phenotype of regulatory B cells. These regulatory "B10" (capable of producing IL10 after hours in vitro stimulation) or "B10 pro" (capable of producing IL10 after 2 days in vitro conditioning) are generally rare in healthy individuals, and play an important role in regulating inflammatory and autoimmune process. Similarly, CLL cells can exert tumor specific as well as global immune suppressive effect via IL-10 production. Ibrutinib, the first in class irreversible BTK inhibitor has been proved to be a safe and effective therapy for CLL. Recently we and others have demonstrated favorable cellular immune modulatory effects of ibrutinib through inhibition of an alternative target interleukin-2 induced T-cell kinase (ITK) that promotes Th1 CD4 polarization. Herein, we explore influence of ibrutinib on other immune suppressive features including T-regulatory cells and the B-regulatory phenotype associated with CLL cells.Methods: PBMCs were collected from nine previously treated CLL patients treated with 420mg of ibrutinib daily per clinical trial OSU-11133 (NCT01589302) at the time of pretreatment, cycle 3 day 1 and cycle 6 day 1. For Brief stimulation (B10 condition), cryopreserved PBMCs were thawed and stimulated with PMA/Ionomycin/Golgi-stop plus CpG for 5 hours. For prolonged stimulation (B10-Pro condition), PBMCs were stimulated with CpG plus CD40L for 48 hours, PMA / Ionomycin / Golgi-stop were added for final 5 hours. The cells were then fixed / permeabilized and stained for intracellular IL-10. For FOXP3 staining, PBMCs were permeabilized and fixed with Foxp3 Buffer Set from eBioscience, and were stained with stained with PE conjugated anti-human Foxp3 antibody (clone 259D/C7).Results: Significant IL-10 production was detected in 8 out 9 patient's CLL cells after 48 hours in vitro stimulation. Interestingly, CLL cells collected from patients treated with ibrutinib in vivo were significantly impaired in their capacity to make IL-10 in 7 out of the 8 patients whose CLL cells were capable of producing IL-10. On average, there is more than 4 fold reduction( P< 0.01) in the frequency of cells producing IL-10 by cycle 3, more than 5 fold reduction (P< 0.01) by cycle 6. (Figure 1 A, upper panel). IL-10 production after a brief 5 hour in vitro stimulation was observed in 4 out of the 9 patients studied, though the frequencies of IL-10 producing cells were low (Figure 1 A, lower panel). Samples collected post-ibrutinib treatment showed a trend towards reduced frequency of IL-10 producing CLL cells after 5 hour stimulation. We have also shown that during the first two cycles of ibrutinib, patients' plasma levels of IL-10 decreased. Analysis of potential immunosuppressive molecules revealed a dramatic reduction in surface expression of CD200, BTLA and PD-1 in CLL cells collected post ibrutinib treatment compared to pre-treatment samples (Figure 1B). We also found that for all the patients analyzed, the percentage of CD4+/Foxp3+ and CD4+/CD25+/Foxp3+ regulatory T cells were significantly reduced in samples collected after ibrutinib treatment. The difference is more dramatic for CD25+Foxp3+ cells (figure 1C).Conclusion: Here we demonstrate a significant decrease in the frequency of T-regulatory cells and IL-10 competent "B-reg" like leukemia cells in CLL patients after ibrutinib treatment. Ability of CLL cells to produce IL-10 and their regulatory B cell like features are considered to play a major role in mediating both global and tumor specific immunosuppression in CLL patients. Ibrutinib has been reported to enhance the immune response against B cell lymphoma in a mouse model. Our findings provide potential mechanisms by which ibrutinib treatment relieve the immunosuppressive effect of malignant B cells, thus enhancing global as well as tumor specific immunity. The main mechanisms likely include impaired IL-10 production capability and reduced surface expression of immunosuppressive molecules by CLL cells, as well as reduced frequency of regulatory T cells and IL-10 producing T cells. [Display omitted] [Display omitted] [Display omitted] DisclosuresMaddocks:Novartis: Research Funding; Janssen: Research Funding; Pharmacyclics: Consultancy, Research Funding. Byrd:Acerta Pharma BV: Research Funding; Acerta Pharma BV: Research Funding.

Identification and characterization of distinct IL-17F expression patterns and signaling pathways in chronic lymphocytic leukemia and normal B lymphocytes.

Chronic lymphocytic leukemia (CLL) is characterized by a progressive accumulation of B lymphocytes. T cell abnormalities are a common feature of CLL and contribute to impaired immune function in these patients. T cells are ineffective in eliminating the leukemic clone and may actually promote tumor growth and survival. Previous work from our laboratory documented elevated circulating levels of IL-17A-producing Th17 cells in CLL patients as compared to healthy age-matched control subjects. These high circulating Th17 levels associated with better prognostic markers and significantly longer overall survival, even among patients whose clones used unmutated IGHVs (U-CLL). Recent studies suggest that Th17 cells are heterogeneous, expressing different profiles of cytokines, and that different subsets of Th17s mediate different biological functions. In the present study, we found significantly higher levels of IL-17F-expressing CD4+ T cells in CLL versus healthy peripheral blood mononuclear cells following in vitro stimulation in the presence of Th17-promoting cytokines. Furthermore, the differentiation of IL-17F-expressing Th17 cells was significantly enhanced when purified CD4+ T cells from CLL patients were cultured in the presence of autologous CLL B cells. Lastly, single-cell network profiling revealed that IL-17F triggers NFκB phosphorylation in T and B cells from patients with CLL, but not age-matched healthy controls. Taken together, our data suggest that the phenotype of Th17 cells in CLL patients is distinct from healthy individuals, expressing higher levels of IL-17F, and that B and T cells from CLL patients are particularly responsive to IL-17F, as compared to healthy age-matched control individuals.Electronic supplementary materialThe online version of this article (doi:10.1007/s12026-015-8722-5) contains supplementary material, which is available to authorized users.