6546 Background: MEK/MAPK and PI3K/Akt pathways have been demonstrated to be constitutively activated in the majority of AML patients and associated with poor prognosis, but inhibition of single pathway has only demonstrated modest clinical activity. Methods: The current study evaluated the efficacy of combination of orally available inhibitors to MEK (AZD6244, Astra Zeneca), PI3K/mTOR (NVP-BEZ235, Novartis), Akt (MK 2206, Merck) and Bcl-2 family members (ABT263, Abbott) in human AML cell lines and primary AML patient samples. Results: In MV 4;11 cells (harboring both MLL re-arrangement and FLT3-ITD mutation), AZD6244 or BEZ235 alone moderately decreased viable cells by 30-40%, but combination of these two had dramatic additive effect of cell killing by 70-80%. ABT263 plus AZD6244 or BEZ235 resulted in further additive cell killing effects. While MK2206 alone had little effect, combination of MK2206 with AZD6244 resulted in excellent synergy. Similar effects were observed in HL60 cells with complex karyotype, KG-1 cells with del (5q), and in leukemia cells from 3 AML patients with different cytogenetic abnormalities. Combination therapy induced apoptotic cell death. To evaluate the mechanisms of apoptosis, flow cytometry was used to detect phospho-protein and apoptosis-associated proteins. Interestingly, inhibition of MEK/MAPK with AZD6244 increased pmTOR and Mcl-1 levels, suggesting feedback activation of PI3K/Akt/mTOR pathway, which could be abrogated by BEZ235. AZD6244 also resulted in increased expression of Bim and Bcl-2 in AML cell lines, which could not be abrogated by BEZ235, suggesting that the modulation of these two proteins is independent of the PI3K/Akt/mTOR pathway. This could explain why ABT263 could further sensitize the cell killing by AZD6244 and BEZ235. Conclusions: Our data provide a strong rationale for combinational targeting of PI3K/Akt/mTOR and MEK pathways for the treatment of AML. Furthermore, inhibition of BCl-2 family members by ABT263 may provide additional therapeutic benefit. Based on our pre-clinical findings, a phase I clinical trial to combine AZD6244 with MK2206 through NCI has been proposed to treat patients with refractory or relapsed AML.
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