Myelodysplastic Syndromes Bone Marrow Research Articles

Toll-Like Receptor 4, 2, and Interleukin 1 Receptor Associated Kinase4: Possible Diagnostic Biomarkers in Myelodysplastic Syndrome Patients.

Myelodysplastic syndrome (MDS) is a clonal hematologic disorder that requires the integration of morphologic, cytogenetic, hematologic, and clinical findings for a successful diagnosis. Trying to find ancillary tests such as biomarkers improve the diagnosis process. Several studies showed that a disordered immune system is associated with MDS. The chronic activated innate immune system, particularly the Toll-like receptors (TLRs) pathway could be involved in the induction of the inflammation. In the present study, we investigated the expression of TLR2, TLR4, and IRAK4 in bone marrow (BM) of MDS patients, the leukemia group, and the healthy group. For this purpose, we assessed the expression of TLR2, TLR4, and IRAK4 by real time-PCR. In line with new findings, we demonstrated that the expression of TLR2, TLR4, and IRAK4 significantly increased in MDS BM compared with the healthy group. Moreover, IRAK4 expression raised significantly in MDS patients compared with other studied hematologic neoplasms. Also, the expression levels of TLR2 and TLR4 significantly increased in MDS in comparison to some studied non-MDS malignancies (P ˂ 0.05). Receiver operating characteristics (ROC) analysis and area under the curve (AUC) suggested that the expression of TLR2, TLR4, and IRAK4 (AUC = 0.702, AUC = 0.75, and AUC = 0.682, respectively) had acceptable diagnostic values to identify MDS from the other understudied leukemias. Overall, the expression of TLR2, TLR4, and IRAK4 could be potential biomarkers for discriminating MDS from some hematologic disorders.

Bone marrow macrophages are involved in the ineffective hematopoiesis of myelodysplastic syndromes.

Myelodysplastic syndromes (MDS) are a group of heterogeneous myeloid clonal disorders characterized by ineffective hematopoiesis. Accumulating evidence has shown that macrophages (MΦs) are important components in the regulation of tumor progression and hematopoietic stem cells (HSCs). However, the roles of bone marrow (BM) MΦsin regulating normal and malignant hematopoiesis in different clinical stages of MDS are largely unknown. Age-paired patients with lower-risk MDS (N = 15), higher-risk MDS (N = 15), de novo acute myeloid leukemia (AML) (N = 15), and healthy donors (HDs) (N = 15) were enrolled. Flow cytometry analysis showed increased pro-inflammatory monocyte subsets and a decreased classically activated (M1) MΦs/alternatively activated (M2) MΦs ratio in the BM of patients with higher-risk MDS compared to lower-risk MDS. BM MФs from patients with higher-risk MDS and AML showed impaired phagocytosis activity but increased migration compared with lower-risk MDS group. AML BM MΦs showed markedly higher S100A8/A9 levels than lower-risk MDS BM MΦs. More importantly, coculture experiments suggested that the HSC supporting abilities of BM MΦs from patients with higher-risk MDS decreased, whereas the malignant cell supporting abilities increased compared with lower-risk MDS. Gene Ontology enrichment comparing BM MΦs from lower-risk MDS and higher-risk MDS for genes was involved in hematopoiesis- and immunity-related pathways. Our results suggest that BM MΦs are involved in ineffective hematopoiesis in patients with MDS, which indicates that repairing aberrant BM MΦs may represent a promising therapeutic approach for patients with MDS.

KPT-8602 Induced Hematopoietic Differentiation in U2AF1 S34F Mutant Cells and Myelodysplastic Syndromes Bone Marrow Stem and Progenitor Cells

Myelodysplastic syndromes (MDS) are a group of clonal bone marrow (BM) neoplasms characterized by ineffective hematopoiesis, cytopenia's, and a high risk of progression to acute myeloid leukemia. Current standard therapies include erythropoiesis stimulating agents for lower risk disease and DNMTi for higher risk MDS; however, less than half of patients respond and even the best responses are transient and non-curative. The majority of MDS patients harbor at least one of ~40 commonly found somatic gene mutations, most of which occur in splicing factor genes such as U2AF1, which also have non-canonical roles in nuclear export. KPT-8602 (Eltanexor) is a novel selective inhibitor of nuclear export (SINE) that acts by disrupting nuclear export of cargo relevant in MDS. We hypothesized that U2AF1 S34 F mutant cells would be selectively sensitive to treatment with KPT-8602. We created immortalized murine hematopoietic progenitor cells by retroviral transduction of stimulated bone marrow (BM) cells isolated from U2AF1 WT or U2AF1 S34F mice with a HOXB8_ER vector. Estrogen drives the hematopoietic transcription factor immortalizing the cells in a progenitor state, however, upon estrogen withdrawal the cells will differentiate and eventually die. This differentiation can be driven by treatment with specific growth factors such as erythropoietin (EPO) for erythroid differentiation or granulocyte macrophage colony stimulating factor (GM-CSF) for myeloid differentiation. KPT-8602 exposure induced differentiation and increased hematopoiesis in murine cell models and primary MDS samples. U2AF1 WT and U2AF1 S34F cells were plated in medium lacking estrogen and treated with GM-CSF (10nM) or EPO (1nM) with or without KPT-8602 (10nM) for 72h, then stained with Ly6C, CD11b, Ter119, and CD71 for flow cytometry analysis. In addition, we performed colony forming capacity assays in both the murine cells and primary MDS BM stem and progenitor cells and age-comparable healthy donors, with 14 day KPT-8602 exposure. Treatment with GM-CSF significantly increased the expression of Ly6C in both U2AF1 WT and U2AF1 S34F cells (WT fold change untreated vs GMCSF =1.9, p=0.03; S34F fold change untreated vs GMCSF =2.3, p<0.01). However, addition of KPT-8602 caused significantly more Ly6C expression than GM-CSF alone in the mutant cells (WT fold change GMCSF vs combination =3.1, p=0.06; S34F fold change GMCSF vs combination =4.0, p<0.01). There were no significant changes in CD11b expression with KPT-8602 treatment. We did not find a statistically significant increase in erythroid markers assessed by Ter-119 and CD71 after EPO treatment, however, KPT-8602 treatment alone showed a trend of increased expression of Ter-119 and CD71 in the mutant cells that fell just below statistical significance (Ter119 p=0.08 for WT, p=0.09 for S34F; CD71 p=0.21 for WT, p=0.06 for S34F). Additionally, we looked at selective toxicity of U2AF1 S34Fby WST-1 reagent and found no differences in toxicity between the WT or mutant cells with KPT-8602. However, U2AF1 WT and U2AF1 S34F progenitor cells showed an increase in colony forming capacity (n=1 with technical duplicates) when plated in the presence of KPT-8602 showing an average fold change in colony growth of 1.4 for U2AF1 WT and 1.3 for U2AF1 S34F underscoring the ability of KPT-8602 to induce differentiation. To confirm these results were not cell line artifacts, we next treated primary BM stem and progenitor cells from MDS patients (n=2) and healthy donors (n=4). MDS patient 1 (age 73y) was diagnosed with MDS-MLD-EB1 and harbored mutations in TP53, ASXL1, BCOR, TET2 and PPM1D. MDS patient 2 (age 79y) was diagnosed with MDS/MPN and harbored an SF3B1 mutation. Healthy donors (n=4) were all male and had a median age of 65y. Treatment with KPT-8602 (10nM) significantly increased burst and colony forming unit-erythroid (BFU-E/CFU-E) in MDS primary cells (p=0.02) with no significant increase in the healthy donors (p=0.57) (BFU-E/CFU-E fold increase was 1.1 for healthy donors and 3.5 for MDS). Collectively, these findings suggest that KPT-8602 promotes myeloid and erythroid differentiation and further validates the use of KPT-8602 as a therapeutic strategy for MDS. Future studies will fully elucidate the specific mechanisms by which KPT-8602 acts in the context of splicing factor mutations, and other commonly found MDS mutation types.

The Dual Inflammasome/Myddosome Inhibitor HT-6184 Restores Erythropoiesis in MDS/AML

Background: The NLRP3 inflammasome is one of the key biological drivers of ineffective hematopoiesis and inflammation in myelodysplastic syndrome (MDS). Inflammasome activation arises from both cell-extrinsic (e.g., Toll-like receptors) and cell-intrinsic signals (e.g., somatic mutations) that direct caspase-1 maturation leading to GATA-1 degradation, myeloid skewing, and pyroptotic cell death. HT-6184 is a potent allosteric inhibitor of the inflammasome scaffold protein NEK7 that blocks inflammasome assembly, promotes ASC speck dissolution, and inhibits myddosome activation of NFκβ. To investigate preclinical activity in MDS, we evaluated HT-6184 in MDS and acute myeloid leukemia (AML) models, including patient-derived sample cultures. Results: Expression of inflammasome pathway components was first assessed by gene expression profiling in a large cohort of MDS bone marrow CD34+-selected cells and healthy age-matched controls. Cellular expression of the inflammasome components, caspase-1, gasdermin D, IL-18 and Pycard was significantly upregulated in MDS specimens compared to healthy controls. Furthermore, cases with the highest expression of inflammasome effectors had significantly inferior overall survival (Log Rank P <0.05). The novel inflammasome inhibitor, HT-6184, was designed to prevent NEK7 from mediating the oligomerization of NLRP3 monomers following an activation signal, ultimately preventing inflammasome assembly. Thus, the structure of HT-6184 was tailored to maximize its interactions with NEK7, rigidifying the protein, and locking it in a conformation that prevents interaction with NLRP3. The allosteric activity of HT-6184 was examined using nano differential scanning fluorimetry and confirmed with limited proteolysis assays, which demonstrated that HT-6184 disrupts NEK7 conformations at single-digit nanomolar concentrations. This was confirmed in cell-based assays showing its ability to inhibit IL-1β release with a 50% inhibitory concentration (IC) of 46 nM in THP-1 cells. These data further correlate with HT-6184 blocking of ASC speck formation with an IC90 of 100 nM in THP-1 cells as well as speck dissolution. HT-6184 also affects the NF-κΒ pathway, by blocking myddosome function and resulting in a decreased expression of an NF-κΒ driven reporter gene, with an IC50 of 10.2 nM in transfected cells. HT-6184 exerts its pharmacological activity by inhibiting the priming and activation steps of the NLRP3 inflammasome. It is pharmacologically active in a human whole blood assay, strongly downregulating the production of pro-inflammatory cytokines. Anti-inflammatory efficacy was also observed in vivo in a murine inflammation model of inflammatory bowel disease. HT-6184 incubation with human monocytes abrogated production of IL-1β and IL-6, reverting human monocytes to a less inflamed state as demonstrated by single cell proteomic studies (isoplexis platform). It similarly decreased IL-1β production from monocytes derived from a TET2 -/+ mouse model that preferentially develops monocytic expansion. Finally, treatment initiation of primary MDS/AML bone marrow specimens (N=10) with HT-6184 in methylcellulose cultures markedly increased erythroid differentiation and reduced myelomonocytic colonies in the majority of samples. This was evidenced by the change in total number of colonies and by fluorescence activated cell sorting (FACS) assessment of differentiation markers (Glycophorin A, CD71, CD11b, CD14) after 14 days of incubation. Inflammasome-directed IL-1β secretion in primary MDS samples was also abrogated by HT-6184 treatment. Conclusions: These findings demonstrate that the novel dual inflammasome/myddosome inhibitor, HT-6184 effectively suppresses myeloid skewing, restores erythroid commitment in MDS/AML specimens, and provides a rationale for clinical development in myeloid malignancies.

The impact of erythroblast enucleation efficiency on the severity of anemia in patients with myelodysplastic syndrome

Anemia is the most common manifestation in myelodysplastic syndrome (MDS) patients, but the cause of ineffective hematopoiesis is not fully understood. Enucleation is an important event in the maturation process of erythroblasts. According to a series of morphological phenotypes of the pathological development of MDS erythroblasts, we speculate that there may be enucleation disorders. To verify this hypothesis, we cultured MDS bone marrow CD34+ cells in vitro and induced erythroblast development. The results showed that erythroblast enucleation in MDS was significantly lower than that in the normal group, and the rate of enucleation was positively correlated with hemoglobin concentration. Risk stratification of MDS was performed to further analyze the differences in enucleation among the normal group, low-middle risk group and high-risk group. The results showed that the enucleation rate of the high risk group was higher than that of the low-middle risk group but still lower than that of the normal group. Moreover, the expression of pERK and pAKT in MDS erythroblasts in the high risk group was higher than that in the normal group, while the expression of pERK and pAKT in the low-middle risk group was lower than that in the normal group. Furthermore, the enucleation of MDS was positively correlated with the phosphorylation degree of ERK and AKT. In conclusion, this study reveals that the enucleation of erythroblasts is one of the possible causes of anemia in MDS.-kLsQ5yxZq6YLTXHvFfPKmVideo

Using Next Generation Sequencing of Flow Cytometry CD Markers and Machine Learning As a Replacement to Flow Cytometry Analysis for the Diagnosis of Hematologic Neoplasms

Introduction: Flow cytometry performs multi-parameter analysis of cells and analyzes surface and intracellular markers for accurate phenotypic characterization of a cell population. Flow cytometry is used extensively in the diagnosis and classification of various hematologic neoplasms. However, analysis of the generated data is time consuming and remains subjective, requiring special skill and experience. Furthermore, some diagnostic classes, such as myeloproliferative neoplasms (MPN) and myelodysplastic syndrome (MDS), are difficult to diagnose using flow cytometry. The RNA levels of the CD markers used in flow cytometry can be reliably quantified using next generation sequencing (NGS). However, when all cells are jointly sequenced, studying subpopulation of cells is lost, which hinders accurate diagnosis. However, machine learning algorithms are capable of multi-marker normalizing and compensate for the loss of subclonal analysis. To validate this assumption, we explored the potential of using the RNA levels of 30 CD markers along with a machine learning algorithm in the differential diagnosis between various types of hematologic neoplasms. Methods: RNA was extracted from fresh bone marrow and peripheral blood samples from 172 acute myeloid leukemia (AML), 369 normal control, 68 MPN, 218 MDS, 93 acute lymphoblastic leukemia (ALL), 74 chronic lymphocytic leukemia (CLL), 38 mantle cell lymphoma, and 83 multiple myeloma cases. The samples were consecutive and collected without selection. RNA sequencing was performed using a targeted hybrid capture panel that included CD1A, CD2, CD3D, CD3E, CD3G, CD4, CD5, CD7, CD8A, CD8B, CD10, CD14, CD19, CD20, CD22, CD33, CD34, CD38, CD40, CD44, CD47, CD68, CD70, CD74, CD79A, CD79B, CD81, CD138, CD200, and CD274 genes. Salmon v1.4.0 software was used for expression quantification (TPM). Machine learning algorithm (random forest) was used for classifying diseases. Two thirds of samples were used for training the random forest algorithm and one third was used for testing. Results: While frequently a diagnosis can be made by simply inspecting the RNA levels of various CD markers, machine learning is needed when the fraction of the neoplastic cells is low. Using machine learning (random forest), diagnosis of most hematologic neoplasms was achieved with high sensitivity and specificity in the testing set. Area under the curve (AUC) was at 0.972 (95% CI: 0.950-0.994) for AML vs. normal, 0.936 (95% CI: 0.898-0.974) for normal vs. MM, 0.965 (95% CI: 0.909-1.00) for mantle vs. CLL, 0.962 (95% CI: 0.907-1.00) for CLL vs. ALL, 0.935 (95% CI: 0.866-1.00) for CLL vs. normal, and 0.964 (95% CI: 0.927-1.00) for AML vs. ALL. Diseases that are difficult to diagnose by routine flow cytometry were diagnosed by RNA expression and machine learning at acceptable accuracy. For example, AUC was at 0.761 (95% CI: 0.689-0.834) for MDS vs. normal, 0.831 (95% CI: 0.762-0.901) for MDS vs. AML, 0.888 (95% CI: 0.822-0.954) for MDS vs. MPN, and 0.785 (95% CI: 0.698-0.872) for MPN vs. normal. Conclusions: This data demonstrates that NGS quantification of RNA from 30 CD markers when combined with machine learning is adequate for reliable diagnosis of various types of hematologic neoplasms. This approach can provide valuable information to distinguish between MPN, MDS, and normal bone marrow that flow cytometry cannot provide. Furthermore, this technology can be automated and less susceptible to human error and practically can be used as a replacement to routine flow cytometry analysis.

CAR virus receptor mediates erythroid differentiation and migration and is downregulated in MDS.

Myelodysplastic syndromes (MDS) are myeloid neoplasms presenting with dysplasia in the bone marrow (BM) and peripheral cytopenia. In most patients anemia develops. We screened for genes that are expressed abnormally in erythroid progenitor cells (EP) and contribute to the pathogenesis of MDS. We found that the Coxsackie-Adenovirus receptor (CAR = CXADR) is markedly downregulated in CD45low/CD105+ EP in MDS patients compared to control EP. Correspondingly, the erythroblast cell lines HEL, K562, and KU812 stained negative for CAR. Lentiviral transduction of the full-length CXADR gene into these cells resulted in an increased expression of early erythroid antigens, including CD36, CD71, and glycophorin A. In addition, CXADR-transduction resulted in an increased migration against a serum protein gradient, whereas truncated CXADR variants did not induce expression of erythroid antigens or migration. Furthermore, conditional knock-out of Cxadr in C57BL/6 mice resulted in anemia and erythroid dysplasia. Finally, decreased CAR expression on EP was found to correlate with high-risk MDS and decreased survival. Together, CAR is a functionally relevant marker that is down-regulated on EP in MDS and is of prognostic significance. Decreased CAR expression may contribute to the maturation defect and altered migration of EP and thus their pathologic accumulation in the BM in MDS.

Abstract 5150: Improvement of hematopoiesis in primary low risk MDS with the TGFBR1 investigational inhibitor TP-6379

Abstract Background: The inflammaging modulator, S100A9, mediates immunosuppression and plays a key role in the pathogenesis of low-risk myelodysplastic syndrome (MDS). Specifically, S100A9’s feedforward activation in the bone marrow (BM) induces pyroptotic cell death of hematopoietic stem and progenitor cells (HSPC) and the activation and accumulation of myeloid-derived suppressor cells (MDSC). This process creates a suppressive microenvironment including the secretion of transforming growth factor β (TGFβ) that signals through the TGFβ receptor 1 (TGFBR1) to induce inhibitory processes that contribute to this phenotype. We hypothesize that targeting with an investigational TGFBR1 inhibitor, TP-6379, reduces immune suppression and restores hematopoiesis in MDS. Methods: Primary low risk MDS BM mononuclear cells (BMMNC) were obtained from the Moffitt Total Cancer Care Protocol and cultured in vitro with TP-6379. Healthy BMMNC were purchased, treated with or without recombinant S100A9 and TP-6379. Results: Treatment of primary MDS BMMNC (n=15) and S100A9-treated healthy BMMNC (n=5) with TP-6379 for 48 hours was observed to significantly improve proliferation of hematopoietic progenitor cells as measured by colony forming capacity. Total colonies, and BFU-E specific colonies, showed significant increase. This expansion of progenitors with treatment was validated by flow cytometric analysis of Lineage−HLA-DR−CD34+ HSPC and showed a reduction in genomic instability, measured by γH2AX. In addition, TP-6379 was observed to reduce the numbers of suppressive mediators; MDSC, T regs and senescent lymphocytes and increase the number of cytotoxic cells, including NK cells. Our analysis revealed that BMMNC with spliceosomal mutations, including SF3B1, have elevated sensitivity to TP-6379 treatment. Therefore, we tested wild type and SF3B1 K700E CRISPR knock-in K562 cells in the presence of TP-6379 for 48 hours. K562 is a well-established cell line model for study of MDS. The SF3B1 mutant expressing cells have significantly reduced BFU-E colony forming capacity, compared to wild type cells, concordant with higher pyroptosis activation and consistent with the BMMNC results. Hence, we measured phospho-SMAD activity, as a direct measure of TGFBR1 inhibition. SF3B1 mutant expressing cells were shown to be highly sensitive to TP-6379, with a significant loss of SMAD activation. Expression analysis of primary MDS, S100A9-treated healthy BMMNC cells and K562 SF3B1 mutant cells revealed elevated expression of SERPINE1 which was rescued by TP-6379 treatment. Conclusions: TP-6379 restores healthy hematopoiesis in low-risk MDS, which may translate into a strong therapeutic option in a disease with few clinical options. Importantly, our work also suggests a specific role for spliceosome dysfunction in bone marrow failure and a novel role for SERPINE1 in MDS and S100A9-induced suppression. Citation Format: Erika A. Eksioglu, Gabriela M. Wright, Jason M. Foulks, Matthew Lalonde, Steven L. Warner, Kenneth L. Wright. Improvement of hematopoiesis in primary low risk MDS with the TGFBR1 investigational inhibitor TP-6379. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 5150.

Oxidized Mitochondrial DNA Engages TLR9 to Activate the NLRP3 Inflammasome in Myelodysplastic Syndromes.

Myelodysplastic Syndromes (MDSs) are bone marrow (BM) failure malignancies characterized by constitutive innate immune activation, including NLRP3 inflammasome driven pyroptotic cell death. We recently reported that the danger-associated molecular pattern (DAMP) oxidized mitochondrial DNA (ox-mtDNA) is diagnostically increased in MDS plasma although the functional consequences remain poorly defined. We hypothesized that ox-mtDNA is released into the cytosol, upon NLRP3 inflammasome pyroptotic lysis, where it propagates and further enhances the inflammatory cell death feed-forward loop onto healthy tissues. This activation can be mediated via ox-mtDNA engagement of Toll-like receptor 9 (TLR9), an endosomal DNA sensing pattern recognition receptor known to prime and activate the inflammasome propagating the IFN-induced inflammatory response in neighboring healthy hematopoietic stem and progenitor cells (HSPCs), which presents a potentially targetable axis for the reduction in inflammasome activation in MDS. We found that extracellular ox-mtDNA activates the TLR9-MyD88-inflammasome pathway, demonstrated by increased lysosome formation, IRF7 translocation, and interferon-stimulated gene (ISG) production. Extracellular ox-mtDNA also induces TLR9 redistribution in MDS HSPCs to the cell surface. The effects on NLRP3 inflammasome activation were validated by blocking TLR9 activation via chemical inhibition and CRISPR knockout, demonstrating that TLR9 was necessary for ox-mtDNA-mediated inflammasome activation. Conversely, lentiviral overexpression of TLR9 sensitized cells to ox-mtDNA. Lastly, inhibiting TLR9 restored hematopoietic colony formation in MDS BM. We conclude that MDS HSPCs are primed for inflammasome activation via ox-mtDNA released by pyroptotic cells. Blocking the TLR9/ox-mtDNA axis may prove to be a novel therapeutic strategy for MDS.

TLR9-Selective Therapeutic Targeting of MDS Clones with a CpG Payload-Delivery Strategy

Inflammatory molecules and their receptors serve as regulatory cues driving the proliferation of hematopoietic stem and progenitors (HSPC) in myelodysplastic syndromes (MDS). Recent studies indicate that inflammaging (inflammation in aging) in the bone marrow (BM) microenvironment contributes to hematopoietic impairment and MDS clone expansion. However, attempts to develop therapeutics targeting these processes have been hampered by potential off target effects due to the lack of identification of selective biomarkers to specifically target the MDS malignant clone. Therefore, a better understanding of the mechanisms of MDS inflammaging processes for selection and target of malignant clones remains a key goal. Several groups, including ours, have found that innate immune receptors are over expressed in MDS BM HSPC, including Toll-like receptors (TLRs). Overexpression of these receptors was associated with secretion of inflammatory cytokines and mediators including S100A9. S100A9, a Damage-Associated Molecular Pattern (DAMPs) molecule, causes pyroptosis of HSPC and induces genomic instability leading to MDS clonal expansion in an autocrine amplification loop. However, most of the TLRs and associated factors are hard to target due to their wide expression on healthy immune cells. We found that TLR9, usually an intracellular receptor, is upregulated and translocated to the surface of MDS progenitors, which thereby presents an opportunity for disease-specific targeting through its natural ligand, CpG oligonucleotides. TLR9 is one of the main pathogen recognition receptors expressed intracellularly in innate immune cells and recognizes bacterial nucleic acid moieties. Its gene expression has been previously found to be upregulated in MDS and now our work demonstrates a functional upregulation and translocation in low-risk disease. Flow cytometric sorting of low risk MDS BM cells with labeled CpG separated cells based on mutational burden suggesting that surface TLR9 is specific to malignant clones. Furthermore, pyroptotic release of nucleic acid DAMPs, such as RNA:DNA hybrids and our recently published biomarker oxidized mitochondrial DNA, is linked to the translocation of TLR9 from intracellular endosomes to the surface of these cells. This overexpression was validated in our unique inflammaging animal model, the S100A9 transgenic (Tg) mice, that phenocopies human MDS. Moreover, treatment of human BM mononuclear cells (MNC) with recombinant human S100A9 induced surface expression of TLR9, through the accumulation of S100A9-induced RNA:DNA hybrids and oxidized mitochondrial DNA. Therefore, this paradoxical surface expression of TLR9 in MDS BM HSPCs provides an opportunity to selectively target malignant cells through the targeted delivery of cytotoxins using our newly developed CpG-linked payload deliver strategy. CpG has been used safely in phase I and Phase II clinical trials where it has been shown to be well tolerated, although not effective as a stand-alone therapy. Therefore, we linked CpG to dendrimer particles (CpG-Den) providing a cationic lipid surface structure capable of disrupting cells only after internalization through TLR9. The CpG-Den linkage ratio can be manipulated to modify cytotoxicity strength and the particle size avoids leukocyte engulfment. Using both primary MDS BM MNC and BM MNC from S100A9Tg mice we demonstrate that treatment in vitro and in vivo with CpG-Den selectively targets surface TLR9+ HSPC, increasing healthy hematopoiesis in colony forming assays, and BM expression of HSPC, as well ameliorating anemia in vivo in the S100A9Tg mice. Use of this therapy also led to a decrease in suppressive myeloid cells likely aiding in the reduction of the inflammaging cycle. Localized targeting was confirmed in vivo by labeling CpG-Den with IR800 revealing specific accumulation in the mice BM. Our data supports TLR9-targeting potential in a proof-of-concept strategy to selectively target primary MDS malignant cells to restore and enhance hematopoiesis while avoiding toxicities.

Combined Inhibition of MCL1 By AZD5991 and BCL2/Bclxl By AZD4320 As Promising Strategies to Overcome Acute Leukemia Tumor Burden and Niche Chemoresistance

Background. Abnormal regulation of anti-apoptotic proteins belonging to the BCL2 family contributes to therapeutic resistance of many hematological neoplasms. Although Venetoclax, a selective inhibitor of the BCL2 protein, has proven to exert beneficial effects in acute leukemias, the activation of another anti-apoptotic protein, MCL1, a key factor to Venetoclax acquired resistance, frequently reduces its benefits. Additionally, it is known that BCL-xL plays an important pro-survival role in cancer cells by interacting with BCL-2 Hence, we hypothesize that the co-inhibition of MCL1, Bcl-2 and BCL-xL would represent an improved strategy for the treatment of patients with acute leukemia. Thus, in this study, we assessed the efficacy of specific inhibitors of MCL1, BCL2 and BCLxL antiapoptotic proteins. Aims. To investigate the in vitro, ex vivo and in vivo effects of AZD5991 (AstraZeneca), a novel MCL1 inhibitor compound, alone or in combination with AZD4320 (BCL-2/BCL-XL inhibitor compound), venetoclax, cytarabine and doxorubicin. Methods.MCL1 mRNA expression data were obtained from TCGA AML study, performed in mononuclear cells isolated from 163 AML patients (median age 57.5 years [range: 18-88]). Bone marrow (BM) aspirates (25) from healthy donors (HD), Myelodysplastic syndrome (MDS), de novo AML, and acute lymphoblastic leukemia (ALL) patients at diagnosis were submitted to analysis of MCL1 protein levels by flow cytometry and immunofluorescence (IF). A panel of myeloid (OCI-AML3, MOLM13, U937, HL60, KG1a, K562) and lymphoblastic (RS4;11, Jurkat) leukemia cell lines were treated with increasing concentrations of AZD5991 for 48h and the 50% inhibiting concentration and apoptosis (annexin-V stain) rates were determined. Mononuclear and hematopoietic stem (CD34+) cells from HD were submitted to cytotoxic assays. Leukemia cell lines were also tested for reactive oxygen species (ROS) and nitric oxide (NO) production (DAF dye), mitochondrial membrane potential (DilC1 probe) and protein expression (flow cytometry, Western blot) in a time course of 0 to 48h, alone or in combination. Moreover, we tested the AZD5991/AZD4320 action in malignant cells cultured in a 3D-system (in the presence of the mesenchymal cells) and in a monocyte monolayer (2D) in order to evaluate tumor microenvironment (TME) participation. We also developed a xenograft mouse model using U937 leukemia cell line. Statistical analyzes were performed using Kruskal Wallis, ANOVA or Mann-Whitney tests (p<.05). Results. The TCGA study (CBIO Portal) analysis showed high MCL1 gene expression in AML patients was observed (p<.0001). Immunofluorescence and flow cytometry showed that MCL1, BCL-2 and BCL-xL protein levels higher in MDS, AML and ALL BM cells compared to normal cells. All leukemia cell lines were dose-dependent sensitive to AZD5991. Growth inhibiting concentrations were OCI-AML3/0.04μM, U937/4.3μM, RS4;11/3.5μM, Jurkat/0.3μM. Apoptosis was increased in a time and concentration-dependent manner, with greater intensity in OCI-AML3 cells. AZD5991 was able to impair mitochondrial membrane potential with reduced mitochondrial ROS and NO production (p<.01) and decreased MCL1, Bax and Bak but increased Bim protein levels. Coculture in a 3D-system showed that AZD5991 treatment reduced patients’ cell growth, without modulating HD cells. In the 2D-coculture, programmed monocytes intensified apoptosis with synergistic effect between AZD5991 and AZD4320. In vitro experiments demonstrated an additive effect between AZD5991 and AZD4320, venetoclax, cytarabine or doxorubicin. In addition, xenotransplanted mice confirmed the efficacy of AZD5991 compound alone or in combination with AZD4320 due to reduction of tumor weight (fold decrease (FD): 3.8; 2.8) and tumor volume (FD: 6.5; 2.8) compared to vehicle-treated group, respectively. Conclusion. MCL1 overexpression in mononuclear cells from patients with acute leukemia and that present or not resistance to venetoclax treatment, is associated with poor prognosis and relapse disease. Our results demonstrated that co-targeting MCL-1, BCL-2 and BCL-xL, through the AZD5991 and AZD4320 compounds in the treatment of acute leukemias, may enhance therapeutic specificity, overcome chemoresistance and contribute with the cure of these aggressive malignant disorders. Funding: FAPESP grants #2017/21801-2, #2019/25247-5, #2021/05320-0.

PD-1 Inhibitors Can be the First-Line Therapy for Myelodysplastic Syndrome (MDS) --Study on the Bone Marrow Immune Microenvironment of MDS By Multispectral Imaging of Multiplex Immunofluorescence

Objective: Myelodysplastic Syndrome (MDS) is a special myeloid neoplasm with still limited treatment choices and poor survival. Although current therapies including HMAs have been shown to prolong survival, only 40-50% of patients respond to therapy, and responses are universally transient, with loss of response within 2 years. With the increasing understanding of the pathogenesis of MDS in recent years, MDS was found closely associated with the bone marrow microenvironment, including immune microenvironment (IME). More and more evidences show that the immune microenvironment of MDS is related with its disease characteristics and prognosis. Knowing more of the IME of MDS may facilitate the diagnose and treatment on MDS. However, till now little was known about the bone marrow immune microenvironment of MDS. Previous studies mostly applied multiparameter flow cytometry and based on the PB samples or frozen bone marrow fluid samples, less was known about the immune landscape of MDS bone marrow biopsies. Methods: We use multispectral imaging of multiplex immunofluorescence (mIF) to analyze the bone marrow biopsy slides and explore the bone marrow immune microenvironment of MDS patients. A total of 20 de novo MDS patients, 20 post-treatment MDS patients and 20 normal controls were included in this study. In HMAs treated group, 10 patients were response to HMA and another 10 patients were not response. HMAs were either decitabine with a dose at 20mg/m2 d1-5 or 5-Azacytidine with a dose at 75mg/m2 d1-7. The multiplex staining panel could differentiate the distinct cell subpopulations into CD34+CD117+ cells, CD8+ cells, PD1+ cells, CTLA4+ cells, CD8+PD1+ cells and CD8+CTLA4+ cells, CD8-PD1+ cells and CD8-CTLA4+ cells, respectively. We analyzed the proportion of these cells in MDS patients and normal controls, and analyzed the proportion of these cells in MDS patients with different IPSS risk stratifications, and we also assessed the degree of myelofibrosis in MDS patients and analyzed the relationship between myelofibrosis and immune cells. Results: We found that compared with the normal control, the proportion of CD8+ cells in de novo MDS patients increased, and CD8+PD1+ T cells increased too, but the CD8+CTLA4+ T cells decreased. Compared with the lower-risk groups, CD8+ T cells as well as CD8+PD1+ T cells increased in higher-risk groups, while CD8+CTLA4+ T cells decreased. We also found a higher CD8+ T cells as well as CD8+/PD1+ T cells in MDS-F patients, especially in MDS-F patients with higher IPSS risk levels. We also found that compared with the normal control, the proportion of CD8+ T cells per CD34+CD117+ cell reduced, and was lower in IPSS int-2 risk/high-risk group than that in low-risk/int-1 risk group. But the proportion of CD8+PD1+/CD34+CD117+ increased compared with normal control. To analyze the bone marrow immune microenvironment after HMAs treatment, CD8+PD1+ T cells decreased in patients who are effective to HMAs, but still remain high in patients who had no response to HMAs, so did the proportion of CD8+PD1+/CD8+ and CD8+PD1+/CD34+CD117+. However, such findings were not found on CD8+/CTLA4+ T cells. Conclusions: Our research findings provide a new insight on the bone marrow IME of MDS. The results confirmed that the immune checkpoint molecule PD-1 positive CD8+ T cells are abundant in MDS IME and associated with the risk. However, CTLA4 may not be a major molecule interfere with the IME of MDS. Our result also suggest that PD-1 inhibitor combines with HMAs might be used as a first-line therapy for de novo MDS patients to cover those patients who may not have response to HMAs. Also, PD-1 inhibitor may cover higher risk MDS and MDS-F, the latter is a high-risk subtype of MDS. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Deep learning application of the discrimination of bone marrow aspiration cells in patients with myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are a group of hematologic neoplasms accompanied by dysplasia of the bone marrow hematopoietic cells with cytopenia. Detecting dysplasia is important in the diagnosis of MDS, but it takes considerable time and effort. Also, since the assessment of dysplasia is subjective and difficult to quantify, a more efficient tool is needed for quality control and standardization of bone marrow aspiration smear interpretation. In this study, we developed and evaluated an algorithm to automatically discriminate hematopoietic cell lineages and detect dysplastic cells in bone marrow aspiration smears using deep learning technology. Bone marrow aspiration images were acquired from 34 patients diagnosed with MDS and from 24 normal bone marrow slides. In total, 8065 cells were classified into eight categories: normal erythrocytes, normal granulocytes, normal megakaryocytes, dysplastic erythrocytes, dysplastic granulocytes, dysplastic megakaryocytes, blasts, and others. The algorithm demonstrated acceptable performance in classifying dysplastic cells, with an AUC of 0.945–0.996 and accuracy of 0.912–0.993. The algorithm developed in this study could be used as an auxiliary tool for diagnosing patients with MDS and is expected to contribute to shortening the time required for MDS bone marrow aspiration diagnosis and standardizing visual reading.

P727: NK-CELL IMMUNOEDITING BY MESENCHYMAL STROMAL CELLS IN MDS

Background: Disorders of the immune system contribute to the pathophysiology and progression of myelodysplastic syndrome (MDS). Cytotoxic Natural Killer (NK) lymphocytes have been extensively studied for their anti-leukemic activity. However, whether the dysplastic bone marrow (BM) in MDS can directly imprint NK cells and hence alter immunosurveillance is still controversial. Extensive characterizations of MDS patients uncovered deep perturbations in the phenotype and function of cytotoxic lymphocyte subsets and of the stromal compartment, in particular mesenchymal stromal cells (MSC), linked with disease predisposition, initiation and progression. However, few studies have been undertaken to characterize the interactions established within the MDS immune microenvironment between immune and stromal cells. Aims: Recent studies on MDS BM ecosystem suggest a possible symbiotic relationship between cancer, immune and stromal cells. Our project thus aims to underpin the influence of the pathological MSC from MDS BM over NK cells to create a leukemia-permissive microenvironment allowing disease development and progression. Methods: We performed an extensive in vitro characterization of the NK and MSC interactions by co-culture system. Healthy donor (HD) NK cells were co-cultured either with MSC isolated from HD or MDS patient BM samples and were analyzed by high-parametric flow-cytometry, qRT-PCR, secretome and imaging assays. Results: Analyses of supernatants from MSC/NK co-cultures unveiled altered secretion of soluble factors related to inflammation and BM homing such as IL6, CCL2 and CXCL10 in the pathologic condition compared to the healthy one. MDS MSC did not support efficiently NK-cell viability. Moreover, NK cells cultured with MDS MSC were less efficient at eliminating cancer cells compared to NK cells cultured with HD MSC. Finally, metabolic analyses uncovered an altered NK cell energetic profile dictated by the different MSC that could contribute to their poor survival and reduced cytolytic function. Summary/Conclusion: Altogether, our results suggest that MSC from MDS BM edit NK cells to promote an immunosuppressive environment facilitating MDS escape and progression. Further analyses are ongoing to underpin the pivotal role of immune-microenvironment interactions in the treatment response. We expect this study to identify new biomarkers to forecast disease progression and open an avenue for new combination therapies targeting the tumour microenvironment.

PB2206: FULL SPECTRAL FLOW CYTOMETRY ANALYSIS OF THE BONE MARROW IMMUNE MICROENVIRONMENT IN PATIENTS WITH MYELODYSPLASTIC SYNDROME

Background: The bone marrow (BM) microenvironment is actively studied in patients with myelodysplastic syndrome (MDS). Full-spectral flow cytometry (FSFCM) is a novel technique that makes it possible to simultaneously study the immune system and malignant cells. Aims: to study the microenvironment and immune checkpoint of MDS by FSFCM. Methods: Retrospective analysis of BM samples from 22 MDS patients and 22 healthy donors who received treatment at the Hebei Yanda Lu Daopei Hospital between January 2020 and September 2020 using 26 parameter FSFCM in a single tube. Multiple immune subsets, myeloblasts and their expression of CD96 and CD200 were also analyzed. Results: The percentage of multiple lymphocytic subsets and number of plasmacytoid dendritic cells (PDCs) were significantly significantly lower in the samples from MDS patients compared to the samples from non-malignant controls.Additionally, expression of the CD96 surface marker were significantly lower on T-cell subsets and CD56bri NK cells,and was significantly higher levels on PDCs in the MDS patient samples compared to the healthy control samples. in the MDS samples CD200 expression on immune cells and myeloblasts were significantly higher in the MDS samples compared to those from healthy controls. The overexpression of CD200 on CD56dim natural killer (NK) cells was an independent risk factor for MDS. Image:Summary/Conclusion: The percentage of immune cells and expression of immune checkpoint proteins on immune cells from BMs of MDS were distinct from that of healthy control samples.

P747: LR-MDS IS CHARACTERIZED BY DIFFERENTIAL EXPRESSION OF INFLAMMASOME-RELATED GENES IN SPECIFIC CELL POPULATIONS

Background: Myelodysplastic Syndromes (MDS) are a group of hematopoietic neoplasms characterized by clonal expansion of hematopoietic stem and progenitor cells (HSPC) and peripheral blood cytopenia. MDS can develop from clonal hematopoiesis of indeterminate potential (CHIP) and progress through low-risk (LR) to high-risk (HR)-MDS and further to acute myeloid leukemia (AML). Recent findings emphasize the role of sterile inflammation in the bone marrow (BM) as a driver of neoplastic progression. Our previous analysis of whole BM mononuclear cells (BM-MNC) has revealed distinct expression patterns of inflammasome-related genes, including IL1B and IL18, to be associated with LR-MDS subgroups and clinical features. This raises the prospect of interrupting disease evolution at an early stage by targeted, personalized anti-inflammatory therapy. The development and stratification of such therapies will ultimately require more detailed knowledge of the variety and consequences of inflammation networks in MDS bone marrow. Aims: Our objective was to assess inflammasome-related gene expression levels in individual cell types in the BM of CHIP, LR-MDS and HR-MDS individuals as well as non-CHIP controls in order to determine a) which cell types contribute to the expression of inflammasome-related genes and b) whether specific disease states are associated with consistent patterns of cell-specific gene expression. Methods: Cryopreserved BM-MNC from 3 non-CHIP controls, 3 CHIP individuals, 14 LR-MDS and 5 HR-MDS patients were obtained from the MDS registry and the BoHemE Study (NCT02867085) at the University Hospitals in Dresden and Leipzig. Hematopoietic stem and progenitor cells (HSPC), monocytes, monocytic myeloid-derived suppressor cells (M-MDSC), polymorphonuclear MDSC (PMN-MDSC), B lymphocytes, T lymphocytes and CD45- cells (control) were sorted from thawed BM-MNC on a BD FACS Jazz. RNA was isolated and the gene expression of IL1B, IL18, S100A9, IRAK4, NLRP3, PYCARD, CASP1 and NLRC4 was assessed by RT-qPCR. Results: The majority of the inflammasome-related genes, including IL1B, NLRP3, NLRC4 and S100A9 were expressed in all disease states predominantly by monocytes and M-MDSC (p<0.001). However, IL18 was expressed at the highest level in HSPC. Consistent to our previous analysis of whole BM-MNC, we found an association between cell-specific gene expression and LR-MDS genetics, with HSPC-derived IL18 mRNA being highest in SF3B1-mutated LR-MDS, while monocytic IL1B mRNA was highest in del(5q) LR-MDS. Furthermore, an apparent progression in expression from non-CHIP through to LR-MDS was detected, with mRNA levels of IL1B and NLRP3 in monocytic cells and PYCARD and CASP1 in HSPC increasing from non-CHIP to CHIP between 1.5- and 7.9-fold. From CHIP to LR-MDS, mRNA levels of CASP1 and NLRC4 in monocytic cells and PYCARD both in HPSC and in monocytic cells increased by 1.8- to 2.1-fold. Summary/Conclusion: We identify features of inflammasome-related gene expression in individual cell populations and disease states reflecting the progression from non-CHIP through CHIP to MDS. Our analysis suggests strongly that high resolution studies of gene expression in specific populations or single cells will resolve a spectrum of MDS-related inflammation states relevant to prognosis and personalized therapy. Therefore, we are currently performing RNA-Seq from sorted cell populations in order to extend our analysis beyond the core inflammasome reported here.

IL-1β expression in bone marrow dendritic cells is induced by TLR2 agonists and regulates HSC function

AbstractHematopoietic stem/progenitor cells (HSPCs) reside in localized microenvironments, or niches, in the bone marrow that provide key signals regulating their activity. A fundamental property of hematopoiesis is the ability to respond to environmental cues such as inflammation. How these cues are transmitted to HSPCs within hematopoietic niches is not well established. Here, we show that perivascular bone marrow dendritic cells (DCs) express a high basal level of Toll-like receptor-1 (TLR1) and TLR2. Systemic treatment with a TLR1/2 agonist induces HSPC expansion and mobilization. It also induces marked alterations in the bone marrow microenvironment, including a decrease in osteoblast activity and sinusoidal endothelial cell numbers. TLR1/2 agonist treatment of mice in which Myd88 is deleted specifically in DCs using Zbtb46-Cre show that the TLR1/2-induced expansion of multipotent HPSCs, but not HSPC mobilization or alterations in the bone marrow microenvironment, is dependent on TLR1/2 signaling in DCs. Interleukin-1β (IL-1β) is constitutively expressed in both murine and human DCs and is further induced after TLR1/2 stimulation. Systemic TLR1/2 agonist treatment of Il1r1−/− mice show that TLR1/2-induced HSPC expansion is dependent on IL-1β signaling. Single-cell RNA-sequencing of low-risk myelodysplastic syndrome bone marrow revealed that IL1B and TLR1 expression is increased in DCs. Collectively, these data suggest a model in which TLR1/2 stimulation of DCs induces secretion of IL-1β and other inflammatory cytokines into the perivascular niche, which in turn, regulates multipotent HSPCs. Increased DC TLR1/2 signaling may contribute to altered HSPC function in myelodysplastic syndrome by increasing local IL-1β expression.

TIM3/CEACAM1 pathway involves in myeloid-derived suppressor cells induced CD8+ T cells exhaustion and bone marrow inflammatory microenvironment in myelodysplastic syndrome.

Myeloid-derived suppressor cells (MDSC) induced cellular immune deficiency and bone marrow inflammatory microenvironment play an important role in the pathogenesis and progression of myelodysplastic syndrome (MDS), but the underlying mechanism remains unclear. Here, we revealed that immune checkpoint protein TIM3 and CEACAM1 were highly demonstrated on MDSC and CD8+ T cells in MDS patients. CD8+ T cells were reduced in number and function and presented a exhaustion state. The levels of pro-inflammatory cytokines (IL-1β, IL-18) and CEACAM1 were raised in bone marrow supernatants and MDSC culture supernatants. Blocking or neutralizing TIM3/CEACAM1 and IL-1β/IL-18 partially reversed exhaustion of CD8+ T cells. Moreover, TIM3 correlated with NF-κB /NLRP3 inflammatory pathway. The levels of NF-κB/NLRP3/Caspase-1/IL-1β and IL-18 were all increased in MDSC of MDS. Co-culturing MDSC from MDS patients with rhCEACAM1 enhanced NF-κB/NLRP3/Caspase-1/IL-1β and IL-18 levels, whereas blocking TIM3 could partially reverse the above manifestations. These results indicated that TIM3/CEACAM1 pathway involved in CD8+ T cells exhaustion and might activate the NF-κB/NLRP3/Caspase-1 pathway in MDSC, increasing pro-inflammatory cytokines secretion in MDS bone marrow microenvironment. This study provided a basis for applying immune checkpoint inhibitors that could simultaneously modulate pro-inflammatory cytokine secretion and enhance anti-tumour immune function in the treatment of MDS.

Toll-like receptor and cytokine expression throughout the bone marrow differs between patients with low- and high-risk myelodysplastic syndromes

Myelodysplastic syndromes (MDS) are hematopoietic stem cell disorders, the pathogenesis of which involves enhanced immune signaling that promotes or selects for mutant hematopoietic stem and progenitor cells (HSPCs). In particular, toll-like receptor (TLR) expression and signaling are enhanced in MDS, and their inhibition is an attractive therapeutic strategy. Although prior studies have reported increased expression of TLR2 and its binding partners TLR1 and TLR6 in the CD34+ cells of patients with MDS (especially those with low-risk disease), TLR expression in other cell types throughout the bone marrow is largely unknown. To address this, we used mass cytometry to assess the expression of TLR1, TLR2, and TLR6 and cytokines in the bone marrow hematopoietic cells of six low/intermediate-risk and six high-risk unmatched MDS bone marrow samples, as well as healthy controls, both at baseline and in response to TLR agonists. We observed several consistent differences between the groups. Most notably, TLR expression was upregulated in multiple cell populations in the low/intermediate-risk, but not high-risk, patients. In addition, many cytokines, including interleukin-6, interleukin-8, tumor necrosis factor α, transforming growth factor β, macrophage inflammatory protein 1β, and granzyme B, were highly expressed from various cell types in low/intermediate-risk patients. However, these same cytokines, with the exception of transforming growth factor β, were expressed at lower levels in high-risk MDS. Together, these findings highlight the differential role of inflammation, and specifically TLR expression, in low/intermediate- versus high-risk MDS, and suggest that elevated TLR expression and cytokine production in multiple cell types likely influences the pathogenesis of MDS in lower-risk patients.

Immunodepletion of MDSC by AMV564, a novel bivalent, bispecific CD33/CD3 T cell engager, ex vivo in MDS and melanoma

We have reported previously that CD33hi myeloid-derived suppressor cells (MDSCs) play a direct role in the pathogenesis of myelodysplastic syndromes (MDSs) and that their sustained activation contributes to hematopoietic and immune impairment, including modulation of PD1/PDL1. MDSCs can also limit the clinical activity of immune checkpoint inhibition in solid malignancies. We hypothesized that depletion of MDSCs may ameliorate resistance to checkpoint inhibitors and, hence, targeted them with AMV564 combined with anti-PD1 in MDS bone marrow (BM) mononuclear cells (MNCs) enhanced activation of cytotoxic Tcells. AMV564 was active invivo in a leukemia xenograft model when co-administered with healthy donor peripheral blood MNCs (PBMCs). Our findings provide a strong rationale for clinical investigation of AMV564 as a single agent or in combination with an anti-PD1 antibody and in particular for treatment of cancers resistant to checkpoint inhibitors.