Treatment Of Multiple Myeloma Research Articles

Lenalidomide‐induced posterior reversible encephalopathy syndrome: A case report

AbstractPosterior reversible encephalopathy syndrome (PRES) is a disorder of cerebrovascular dysregulation. To our knowledge, we present the first case of lenalidomide‐induced PRES in English. A 59‐year‐old woman with history of multiple myeloma status post stem cell transplant and induction triple therapy 6 months ago with partial remission and subsequent high‐dose melphalan 1 month ago presented with progressive vision loss for 1 week. Her systolic blood pressure was >180 mmHg, and neurological examination demonstrated decreased vision bilaterally. Brain MRI revealed significant T2 hyperintensity restricted to temporal and occipital lobes and left occipital parenchymal hemorrhage and diffuse leptomeningeal enhancement. She had a witnessed generalized tonic–clonic seizure and EEG that captured an electrographic seizure originating from the occipital lobe. Her vision improved rapidly after discontinuing the lenalidomide. She was discharged to rehab with a normal neurological examination. We report the first English case of presumed lenalidomide induced PRES in a patient undergoing multiple myeloma treatment.

Comparison of two autologous hematopoietic stem cell mobilization strategies in patients with multiple myeloma: CE plus G-CSF versus G-CSF only: A single-center retrospective analysis.

Despite recent advances in the treatment of multiple myeloma, high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (ASCT) remains an essential therapeutic keystone. As for the stem cell mobilization procedure, different regimens have been established, usually consisting of a cycle of chemotherapy followed by application of granulocyte-colony stimulating factor (G-CSF), although febrile neutropenia is a common complication. Following national guidelines, our institution decided to primarily use G-CSF only mobilization during the COVID-19 pandemic to minimize the patients' risk of infection and to reduce the burden on the health system. In this retrospective single-center analysis, the efficacy and safety of G-CSF only mobilization was evaluated and compared to a historic control cohort undergoing chemotherapy-based mobilization by cyclophosphamide and etoposide (CE) plus G-CSF. Although G-CSF only was associated with a higher need for plerixafor administration (p < .0001) and a higher number of apheresis sessions per patient (p = .0002), we were able to collect the target dose of hematopoietic stem cells in the majority of our patients. CE mobilization achieved higher hematopoietic stem cell yields (p = .0015) and shorter apheresis sessions (p < .0001) yet was accompanied by an increased risk of febrile neutropenia (p < .0001). There was no difference in engraftment after ASCT. G-CSF only mobilization is a useful option in selected patients with comorbidities and an increased risk of serious infections, especially in the wintertime or in future pandemics.

Abstract LB128: A novel tri-specific T cell engager targeting BCMA and GPRC5D for treatment of multiple myeloma

Abstract Introduction Multiple myeloma (MM) accounts for 10% of all hematologic cancers. Recent advances in MM therapy have greatly increased the overall response and survival rate. However, almost all patients eventually relapse. The prognosis still remains poor. BCMA and GPRC5D are overexpressed in myeloma cells. Although CAR-T and T cell engager (TCE) targeting BCMA or GPRC5D have been efficacious in MM patients, resistance does occur. Since the expression of BCMA and GPRC5D in MM are heterogeneous, to further improve the overall response and survival, we have recently generated a novel tri-specific T-cell engager, GBD218, targeting both BCMA and GPRC5D. GBD218 has demonstrated potent in vitro and in vivo activity against myeloma cells. Methods Anti-BCMA and GPRC5D nanobodies were screened from alpaca immune libraries, and anti-CD3 antibody was engineered from mouse hybridoma clone. The tri-specific antibodies were constructed in a “1+1+1” format through “knob into hole” technology fused with silenced IgG1 Fc. The format of the tri-specific antibodies was optimized by multiple rounds of in vitro activity and druggability evaluation. The in vivo tumor growth inhibition effects were evaluated in PBMC-humanized xenograft mouse models. Results GBD218 has been designed to potently bind hBCMA (KD=0.4nM) and hGPRC5D (cell binding EC50 ~ 2nM). To reduce CRS and other potential AEs associated with TCEs, a low affinity of anti-CD3 Fab was used. In cell-based functional assays, GBD218 showed efficient cytotoxicity against single and double positive MM cell lines with various expression levels of BCMA and GPRC5D. T cell activation and cytokine release induced by GBD218, in the presence or absence of MM cancer cells, is nicely balanced for great killing efficacy and the low risk of CRS. Importantly, the results showed that GBD218 exhibited superior in vitro killing activity compared to benchmarks, including teclistamab, talquetamab, the combination of teclistamab and talquetamab, suggesting a synergistic effect of GBD218 by targeting BCMA and GPRC5D. In xenograft models, GBD218 showed excellent anti-tumor activity, indicating great potential for GBD218 as a promising therapeutics for MM. Conclusion GBD218 is a novel tri-specific antibody that showed potent in vitro and in vivo anti-tumor activity. GBD218 efficiently kills both BCMA and/or GPRC5D expressing MM cells, which may hold promise to increase response rate and improve survival in MM patients in clinic. Citation Format: Yongcong Tan, Xuezhen Li, Fan Yu, Juehua Xu, Zhen Qian, Yiqi Cao, Xueyan Yang, Qinglin Du, Fei Peng, Shuhua Han, Qian Ding. A novel tri-specific T cell engager targeting BCMA and GPRC5D for treatment of multiple myeloma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 2 (Late-Breaking, Clinical Trial, and Invited Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(7_Suppl):Abstract nr LB128.

Sequence not salvage.

Chimeric antigen receptor T-cell (CAR-T) therapy for the treatment of multiple myeloma (MM) has fundamentally changed the relapsed and refractory therapeutic landscape, but the disease remains incurable. Two CAR-T products, idecabtagene vicleucel (ide-cel; Abecma) and ciltacabtagene autoleucel (cilta-cel, Carvykti), have been FDA- and EMA-approved for the treatment of relapsed/refractory MM (RRMM); both target B-cell maturation antigen (BCMA), a surface glycoprotein highly expressed on MM cells. Despite deep and durable responses following CAR-T therapy, most patients will need subsequent treatment, and the optimal next-line therapy is presently unclear. Commentary on: Liu etal. Outcomes in patients with multiple myeloma receiving salvage treatment after BCMA-specific CAR-T therapy: A retrospective analysis of LEGEND-2. Br J Haematol 2024;204:1780-1789.

Allogeneic CAR T Cells: Complex Cellular Therapy Designs Test the Limits of Our Preclinical Models.

All chimeric antigen receptor (CAR) T-cell products currently approved by the FDA are autologous, which poses several challenges for widespread use. In this issue, Degagné and colleagues present their preclinical research on creating off-the-shelf CAR T cells for multiple myeloma. They utilized the CRISPR/Cas12a genome editing platform and gene knock-in techniques to eliminate alloreactivity and decrease susceptibility to natural killer (NK)-cell elimination. This work has led to an ongoing phase I trial of off-the-shelf CAR T cells for multiple myeloma treatment. See related article by Degagné et al., p. 462 (2).

Genetic Risk Factors for Bortezomib-induced Neuropathic Pain in an Asian Population: A Genome-wide Association Study in South Korea

Bortezomib-induced neuropathic pain (BINP) poses a challenge in multiple myeloma (MM) treatment. Genetic factors play a key role in BINP susceptibility, but research has predominantly focused on Caucasian populations. This research explored novel genetic risk loci and pathways associated with BINP development in Korean MM patients while evaluating the reproducibility of variants from Caucasians. Clinical data and buffy coat samples from 185 MM patients on bortezomib were collected. The cohort was split into discovery and validation cohorts through random stratification of clinical risk factors for BINP. Genome-wide association study was performed on the discovery cohort (n = 74) with Infinium Global Screening Array-24 v3.0 BeadChip (654,027 single nucleotide polymorphism [SNPs]). Relevant biological pathways were identified using the pathway scoring algorithm. The top 20 SNPs were validated in the validation cohort (n = 111). Previously reported SNPs were validated in the entire cohort (n = 185). Pathway analysis of the genome-wide association study results identified 31 relevant pathways, including immune systems and endosomal vacuolar pathways. Among the top 20 SNPs from the discovery cohort, 16 were replicated, which included intronic variants in ASIC2 and SMOC2, recently implicated in nociception, as well as intergenic variants or long noncoding RNAs. None of the 17 previously reported SNPs remained significant in our cohort (rs2274578, P = .085). This study represents the first investigation of novel genetic loci and biological pathways associated with BINP occurrence. Our findings, in conjunction with existing Caucasian studies, expand the understanding of personalized risk prediction and disease mechanisms. PerspectiveThis article is the first to explore novel genetic loci and pathways linked to BINP in Korean MM patients, offering novel insights beyond the existing research focused on Caucasian populations into personalized risk assessment and therapeutic strategies of BINP.

In silico Identification of HDAC Inhibitors for Multiple Myeloma: A Structure-based Virtual Screening, Drug Likeness, ADMET Profiling, Molecular Docking, and Molecular Dynamics Simulation Study

Background: Multiple myeloma (MM) is a hematological malignancy of plasma cells that produce a monoclonal immunoglobulin protein. Despite significant advances in the treatment of MM, currently available therapies are associated with toxicity and resistance. As a result, there is an increasing demand for novel, effective therapeutics. Inhibition of histone deacetylases (HDACs) is emerging as a potential method for treating cancer. HDAC6 is one of 18 different HDAC isoforms that regulate tubulin lysine 40 and function in the microtubule network. HDAC6 participates in tumorigenesis and metastasis through protein ubiquitination, tubulin, and Hsp90. Several studies have found that inhibiting HDAC6 causes AKT and ERK dephosphorylation, which leads to decreased cell proliferation and promotes cancer cell death via the PI3K/AKT and MAPK/ERK signaling pathways. Objective: The objective of this study is to target HDAC6 and identify potent inhibitors for the treatment of multiple myeloma by employing computer-aided drug design. Materials and Methods: A total of 199,611,439 molecules from five different chemical databases, such as CHEMBL25, ChemSpace, Mcule, MolPort, and ZINC, have been screened against HDAC6 by structure- based virtual screening, followed by filtering for various drug-likeness, ADME, toxicity, consensus molecular docking, and 100 ns MD simulation. Results: Our research work resulted in three molecules that have shown strong binding affinity (CHEMBL2425964 -9.99 kcal/mol, CHEMBL2425966 -9.89 kcal/mol, and CSC067477144 -9.86 kcal/mol) at the active site HDAC6, along with effective ADME properties, low toxicity, and high stability. Inhibiting HDAC6 with these identified molecules will induce AKT and ERK dephosphorylation linked to reduced cell proliferation and promote cancer cell death. Conclusion: CHEMBL2425964, CHEMBL2425966, and CSC067477144 could be effective against multiple myeloma.

The 2024 IUPAC-Richter Award Goes to Craig M. Crews

Abstract Craig M. Crews has been awarded the 2024 IUPAC-Richter Prize in Medicinal Chemistry. Crews is a Professor in the Department of Molecular, Cellular and Developmental Biology and Professor of Chemistry and Pharmacology at Yale University. His discovery and implementation of the PROteolysis TArgeting Chimeras (PROTACs) technology for removing specific unwanted proteins revolutionized the field by identifying a new method for affecting protein function. The fact that this technology has been widely adapted and investigated not only within the pharmaceutical industry, but also in academia, demonstrates the significance and impact of this work. While no drugs have yet been approved, several are in development and these molecules are progressing, because they are effective and safe. He also played a key role in the discovery of carfilzomib, an approved proteasome inhibitor for the treatment of multiple myeloma. The acceptance lecture will be held in Rome, Italy (1-5 September 2024) at the XXVIII EFMC International Symposium on Medicinal Chemistry.

Proteasome inhibitor-associated histiocytoid Sweet's syndrome: Clinical and histological similarities to Nakajo-Nishimura syndrome suggest a potential mechanism.

Histiocytoid Sweet's syndrome (HSS) is a variant of Sweet's syndrome (SS) that clinically resembles SS but differs histologically by infiltrates, predominantly composed of immature cells of the myeloid lineage. Medications such as proteasome inhibitors have been reported to cause HSS but there has been little discussion on the underlying mechanism. Here we report two cases of HSS associated with a proteasome inhibitor. Both patients were on ixazomib for the treatment of multiple myeloma and presented with acute erythematous plaques on the upper half of the body. Pathological findings were consistent with HSS. Similarities between proteasome inhibitor-induced HSS and Nakajo-Nishimura syndrome, an inherited inflammatory disease, can be identified both clinically and histologically, suggesting a potential explanation of the mechanism behind proteasome inhibitor-associated HSS.

Role of Immune Cells and Immunotherapy in Multiple Myeloma.

The clinical signs of multiple myeloma, a plasma cell (PC) dyscrasia, include bone loss, renal damage, and paraproteinemia. It can be defined as the uncontrolled growth of malignant PCs within the bone marrow. The distinctive bone marrow milieu that regulates the progression of myeloma disease involves interactions between plasma and stromal cells, and myeloid and lymphoid cells. These cells affect the immune system independently or because of a complicated web of interconnections, which promotes disease development and immune evasion. Due to the importance of these factors in the onset of disease, various therapeutic strategies have been created that either target or improve the immunological processes that influence disease progression. The immune system has a role in the mechanism of action of multiple myeloma treatments. The main contributions of immune cells to the bone marrow microenvironment, as well as how they interact and how immune regulation might lead to therapeutic effects, are covered in this study.

Synergy between BRD9- and IKZF3-Targeting as a Therapeutic Strategy for Multiple Myeloma.

Progress in the treatment of multiple myeloma (MM) has resulted in improvement in the survival rate. However, there is still a need for more efficacious and tolerated therapies. We and others have shown that bromodomain-containing protein 9 (BRD9), a member of the non-canonical SWI/SNF chromatin remodeling complex, plays a role in MM cell survival, and targeting BRD9 selectively blocks MM cell proliferation and synergizes with IMiDs. We found that synergy in vitro is associated with the downregulation of MYC and Ikaros proteins, including IKZF3, and overexpression of IKZF3 or MYC could partially reverse synergy. RNA-seq analysis revealed synergy to be associated with the suppression of pathways associated with MYC and E2F target genes and pathways, including cell cycle, cell division, and DNA replication. Stimulated pathways included cell adhesion and immune and inflammatory response. Importantly, combining IMiD treatment and BRD9 targeting, which leads to the downregulation of MYC protein and upregulation of CRBN protein, was able to override IMiD resistance of cells exposed to iberdomide in long-term culture. Taken together, our results support the notion that combination therapy based on agents targeting BRD9 and IKZF3, two established dependencies in MM, represents a promising novel therapeutic strategy for MM and IMiD-resistant disease.

Abstract 3618: High-avidity BCMA CAR and high-affinity, non-cleavable CD16 Fc receptor incorporated in off-the-shelf CAR T cells promote multi-antigen targeting and durable anti-tumor cytotoxicity in the treatment of multiple myeloma

Abstract Immune cell therapy has proven highly effective for the treatment of multiple myeloma (MM). However, key challenges remain that include disease relapse, limited patient access, and inability to effectively combine with existing standard-of-care therapies. Rapid progress in the development of off-the-shelf, multiplexed-engineered, induced pluripotent stem cell (iPSC)-derived cell therapies enables large-scale manufacture of immune cells incorporating multiple novel synthetic controls of cell function to improve cell fitness, enhance cell function, and enable synergistic combination with existing effective therapies such as CD38-targeted antibody (mAb) therapy. We have developed an iPSC-derived chimeric antigen receptor T (CAR-iT) cell therapy that uniquely leverages elements of both adaptive and innate immunity by incorporating a BCMA-targeted CAR (BCMA-CAR) derived from a scFv domain exhibiting high-binding affinity in the low nanomolar range, and a high-affinity, non-cleavable CD16 (hnCD16) Fc receptor to enable antibody-dependent cellular cytotoxicity with mAb therapy. The genetic deletion of CD38 gene was also incorporated to eliminate the possibility for CD38-mediated fratricide, and genetic deletion of TRAC gene was introduced to remove the potential risk of graft-versus-host disease in an allogeneic setting. These CAR iT cells, which were generated from a clonally-derived iPSC line, demonstrated homogenous expression of each genetic edit (&amp;gt;95% BCMA-CAR and hnCD16; &amp;lt;1% CD38 and TCR surface expression). Using a stringent, disseminated xenograft mouse model of multiple myeloma, MM.1S, which was allowed to achieve complete systemic engraftment during the initial 4 days, treatment with BCMA-CAR iT cells demonstrated comparable tumor cell clearance (p=0.0024 vs. vehicle at Day 17) to primary BCMA-CAR T cells (p=0.002 vs. vehicle). In combination with a CD38-targeted mAb to exploit hnCD16 and biallelic CD38 KO, BCMA-CAR iT cells are capable of dual-antigen targeting to address antigen escape and promote durable tumor control. To this end, a single dose of BCMA-CAR iT cells combined with daratumumab exhibited near complete TGI for the duration of the study (p&amp;lt;0.0001 vs. vehicle at Day 37). Together, these studies demonstrate CAR iT cells incorporating a high-avidity BCMA CAR and high-affinity, non-cleavable CD16 Fc receptor can uniquely leverage elements of both adaptive and innate immunity and can be combined with CD38-targeted mAb to potentially outcompete primary BCMA CAR T cells. As these CAR iT cells can be administered off-the-shelf, key challenges associated with current immune cell therapy, such as patient access and inability to synergize with standard-of-care therapies, can be addressed for the treatment of relapsed/refractory MM. Citation Format: John Reiser, Alison O'Connor, Bryan Hancock, Spas Markov, Brian Groff, Alma Gutierrez, Miguel Meza, Mark Jelcik, Yijia Pan, Alex Garcia, Bobby Goulding, Matthew Denholtz, Tom Lee, Ramzey Abujarour, Ryan Bjordahl, Armin Rehm, Raedun Clarke, Jode Goodridge, Bahram Valamehr. High-avidity BCMA CAR and high-affinity, non-cleavable CD16 Fc receptor incorporated in off-the-shelf CAR T cells promote multi-antigen targeting and durable anti-tumor cytotoxicity in the treatment of multiple myeloma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3618.

Abstract 1890: HMA800067, a novel CD38-targeting antibody-drug conjugate (ADC), demonstrated superior anti-tumor activity to daratumumab in preclinical B-cell malignancies models

Abstract Introduction: Daratumumab (Dara), an anti-CD38 monoclonal antibody, has been widely used in the treatment of multiple myeloma (MM). However, some of MM patients exhibit primary or acquired resistance to Dara therapy. A CD38 targeting antibody-drug conjugate (ADC) HMA800067 is developed, in which Dara was conjugated with cytotoxic payload via a novel linker, aiming to have superior anti-tumor efficacy to Dara, even in the subjects with resistance to Dara treatment. Methods: HMA800067 was characterized by ELISA-based binding assay, cell internalization assay, antibody-dependent cell-mediated cytotoxicity (ADCC) and antibody-dependent cellular phagocytosis (ADCP) assays. The in vitro anti-tumor potency was assessed against a panel of 24 MM and B cell lymphoma cell lines with various CD38 expressions. Bystander effect of HMA800067 was evaluated in co-culture of CD38− SU-DHL-2 cells with CD38+ Ramos cells. In vivo anti-tumor efficacy was investigated in the multiple MM and Diffuse Large B-cell Lymphoma (DLBCL) subcutaneous xenograft models, including some non-responsive to Dara. Results: HMA800067 displayed comparable binding affinity and internalization capability to Dara in CD38+ Ramos cells. And HMA800067 maintained the ability of Dara to induce the death of CD38+ Daudi cells by ADCC and ADCP, which indicated that conjugation did not change the property of Dara in the ADC upon antigen binding. HMA800067 exhibited a CD38-dependent cytotoxic activity with median IC50 of 0.46 nM against a panel of tumor cell lines, with a trend that the higher CD38 expression, the stronger potency could be seen. Bystander killing effect of HMA800067 was observed in CD38− cells when co-cultured with CD38+ cells in vitro. Furthermore, with the low release of payload in plasma and sustainable high exposure of payload in the tumor, HMA800067 demonstrated dose-dependent and superior anti-tumor efficacy to Dara in all tested models, and 10 mg/kg induced complete tumor regression in MM RPMI-8226, DLBCL SU-DHL-6 and SU-DHL-10 models. For example, in SU-DHL-6 xenograft model, the treatment of intravenous injection of HMA800067 at 10 mg/kg single dose induced complete tumor regression in all the animals within 10 days of administration, which was maintained until the end of study (day 49), while 10 mg/kg Dara twice a week for 2 weeks inhibited tumor growth within 20%-40% without any tumor regression during a four-week observation post initial dosing. Conclusion: HMA800067 demonstrated potent anti-tumor activities in vitro and in vivo in multiple B-cell malignant tumor lines, including those with poor response to Dara. These results supported further development of HMA800067, as a superior therapeutic option for treatment of patients with CD38+ B cell malignancies. Citation Format: Yan Xu, Junqing Liang, Shuwen Jiang, Haibin Yang, Hui Zhang, Fangfang Mao, Jiahuan Zhu, Jianlin He, Na Yang, Jian Wang, WeiHan Zhang, Yongxin Ren, Weiguo Su. HMA800067, a novel CD38-targeting antibody-drug conjugate (ADC), demonstrated superior anti-tumor activity to daratumumab in preclinical B-cell malignancies models [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1890.

Abstract 14: Identification of tumor-reactive T cell receptors through functional single cell interaction analyses for personalized T cell therapy

Abstract Innovative immunotherapy approaches such as adoptive transfer of chimeric antigen receptor (CAR) T cells or tumor infiltrating lymphocytes (TILs) have shown great success in the treatment of solid tumors and hematological malignancies. Although treatment of multiple myeloma with CAR T cells can induce deep responses, relapses frequently occur due to antigen escape and limited CAR T cell persistence. TCR-engineered T cells may show prolonged persistence in vivo and could mediate sustained antitumor effects. A further benefit of TCR transgenic T cells is the ability to target intracellular antigens that are inaccessible to CAR T cells, expanding the range of potential targets for immunotherapy. In our project, we propose to identify T cell receptors (TCRs) specifically targeting autologous myeloma cells. Tumor-reactive T cells were identified using the Bruker Cellular Analysis Lightning® platform, allowing simultaneous functional analysis of up to 1500 individual T cell/target cell interactions on a chip. Reactive T cells were identified upon detection of secreted cytokines (IFNγ, TNFα, IL2) and measurement of 4-1BB (CD137) surface expression. Tumor-reactive T cells showing various cytokine secretion patterns and 4-1BB expression profiles were detected in each myeloma patient (on average 11.9 T cells out of 1243 cells tested per assay run). Individual tumor-reactive T cells have been isolated and their TCRs were sequenced. TCR sequences of tumor-reactive T cells were mapped to single-cell RNA sequencing data of T cells from the same patiens to reveal a gene expression signature of myeloma-reactive T cells. TCR genes of reactive T cells were cloned and overexpressed in autologous T cells for functional validation and analysis of tumor derived neoepitope specificity. In summary, we present a pipeline allowing identification of myeloma-recognizing T cells and recovery of bona fide tumor-reactive TCRs eligible for patient-individualized T cell therapy. Citation Format: Tim Robin Wagner, Niklas Kehl, Simon Steiger, Michael Kilian, Bruno Schönfelder, Tamara Boschert, Katharina Lindner, Patrick Schmidt, Karsten Rippe, Hartmut Goldschmidt, Marc-Steffen Raab, Michael Platten, Mirco Friedrich, Stefan B. Eichmüller. Identification of tumor-reactive T cell receptors through functional single cell interaction analyses for personalized T cell therapy [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 14.

Abstract 1233: Novel inhibitor targeting triple integrated stress response kinase HRI, PERK, and GCN2 provides new insights into overcoming resistance to proteasome inhibitors in multiple myeloma

Abstract The introduction of novel treatments for Multiple myeloma (MM), particularly proteasome inhibitors (PI) such as bortezomib (BTZ), has greatly improved outcomes. However, many patients eventually experience relapse. Therefore, new approaches for managing patients with resistance to PI should be explored. The integrated stress response (ISR) is an evolutionarily conserved intracellular signaling network that is activated in response to both intrinsic and extrinsic stresses. Stresses are sensed by four specialized kinases: HRI, PERK, PKR, and GCN2, which converge on the phosphorylation of eIF2α. This phosphorylation triggers the translation of ATF4, thus promoting cell survival and homeostasis. Recent studies investigating the contribution of the four ISR kinases in overcoming resistance to PI treatment, have revealed the potential of a selective GCN2 inhibitor to overcome this resistance. Here, we observed that PI simultaneously induced mitochondrial stress, ER stress, and amino acid starvation, leading to the activation of HRI, PERK, and GCN2, respectively. However, the contribution of crosstalk among ISR kinases has not been considered thus far. To gain a comprehensive understanding of ISR kinases in BTZ resistance, we generated single or combination patterns of double and triple KO of the four ISR kinases and reevaluated their contribution to BTZ treatment. Sensitivity screening using the HAP1 single, double, and triple KO cell library showed that HRI primarily, and to a lesser extent, PERK and GCN2, contribute to BTZ resistance. Consistent with the HAP1 KO screening, MM cell line-derived KO cells revealed a similar dependency on these three kinases. Building upon our observation of the significance of the HRI/PERK/GCN2 triple kinase, we developed a novel and orally available small molecule, CRD-1367799, which inhibits these triple kinases in cells. CRD-1367799 effectively dampened the activity of these ISR kinases, leading to a complete inhibition of eIF2α phosphorylation and ATF4 activation. Additionally, we observed a distinct anti-growth effect when combined with BTZ in vitro and in vivo, which was not replicated by the GCN2 or PERK-selective inhibitor. Furthermore, we uncovered the mechanism of cell death induction in combination with proteasome inhibitors. Notably, the apoptosis inducers NOXA and CHOP were upregulated, but the mechanism did not seem to rely on previously known processes such as ATF4-mediated transcriptional induction. In summary, our novel findings on the contribution of the triple ISR kinase provides us with new insights for overcoming resistance to proteasome inhibitors with HRI/PERK/GCN2 inhibitor. To the best of our knowledge, the use of a triple kinase inhibitor in this context has not been reported thus far, making CRD-1367799 a new therapeutic strategy for MM with PI. Citation Format: Yasumichi Inoue, Koki Hikami, Shunsuke Ebara, Midori Sugiyama, Robert Oda, Akio Mizutani, Misaki Yoshida, Hiroko Yamakawa, Shigehiro Yagishita, Akinobu Hamada, Hidetoshi Hayashi, Masaki Ri, Shinsuke Iida, Daisuke Morishita. Novel inhibitor targeting triple integrated stress response kinase HRI, PERK, and GCN2 provides new insights into overcoming resistance to proteasome inhibitors in multiple myeloma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1233.

Abstract 6890: 2D Tumor cell culture based Ex vivo drug sensitivity screening platform for South African patient samples (leukemia, multiple myeloma, ovarian and uterine cancer) demonstrate potential for targeted cancer therapies

Abstract Resistance to standard chemotherapy is a major challenge with Leukemia (Leuk), Multiple Myeloma (MM), Ovarian Cancer (OvCa) and Uterine Cancer (UtCa) treatments, which ultimately leads to relapse. Our study objective is to establish a robust drug sensitivity screening platform that can identify drugs and drug combinations that are effective in precision medicine for individual South African patient samples (Leuk, MM, OvCa and UtCa). Given that resistance to chemotherapy treatment accounts for high mortality and morbidity, we focus on the hypothesis that several drug combinations will be required for patients to achieve better response for drug regimens beyond first line of chemotherapy. Therefore, our defined objectives were to 1) establish 2D ex vivo tumour cell culturing using South African patient samples; 2) develop a drug sensitivity screening platform through which selected single and drug combinations will be identified; 3) to provide South African cancer (OvCa, Ut Ca, CLL, MM) patients with individualized treatment options with effective drug combinations for targeted therapies. Through collaboration with, Steve Biko Hospital Pretoria, Chris Hani Baragwanath Hospital and Wits Donald Gordon Medical Centre, Johannesburg, South Africa, we performed 100 patient sample collections including Acute myeloid leukaemia (AML) (n=7), Chronic lymphocytic leukaemia (CLL) (n=4), Chronic myeloid leukaemia (CML) (n= 30), MM (n=40), OvCa (n=10), UtCa (n=4) and healthy donors (n=5). Culture setting for all patient-derived tumor cells were established through the 2D cancer cell culturing in 96 well plates. This was followed by functional drug sensitivity testing using a panel of FDA approved chemotherapy drugs. The average turnaround time from biopsy to drug sensitivity test results is currently at 14 days. We have completed ex vivo drug sensitivity screening to perform analysis on patient samples (n=80) using 30 drugs with a concentration range of 1-1000 nm. Our preliminary drug sensitivity screening studies show good response to proteosome inhibitors, melphalan, doxorubicin and kinase inhibitors. We have established a wound healing assay for OvCa and UtCa samples and demonstrated sustained cell growth for the period of 2 weeks with tumor cells growing faster than twin normal tissue. We are now at stage of performing drug sensitivity screening for OvCa and UtCa patient samples for both twin normal and tumor tissues. We have established a drug sensitivity screening platform and wound healing assay with primary patient derived cells that utilizes South African Patient samples to select effective drugs for monotherapy and also drug combinations. Citation Format: Mutsa Takundwa, Vanelle Kenmogne, Thudzelani Malise, Bernice Monchusi, Phumuzile Dube, Ekene Nweke, June Fabian, Heather Maher, Justin du Toit, Vinitha Philip-Cherian, Pascaline Fru, Adekunle Sajo, Arnold (Arrie) Mouton, Matthys C. van Aardt, Cathy Visser, Greta Dreyer, Deepak Govindaraj. 2D Tumor cell culture based Ex vivo drug sensitivity screening platform for South African patient samples (leukemia, multiple myeloma, ovarian and uterine cancer) demonstrate potential for targeted cancer therapies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6890.

Abstract 1906: UNO-A001 (A001), a clinical candidate CD38 x CD3 bispecific with a novel structure, potently kills multiple myeloma cells in vitro and is highly effective in vivo

Abstract CD38 is a validated target for the treatment of multiple myeloma (MM) as evidenced by the important clinical activity of CD38 targeting monoclonal antibodies. Bispecific T Cell Engagers (TCEs) kill cancer cells by distinct mechanisms as compared to standard format antibody therapeutics and several TCEs have demonstrated impressive clinical activity, and have been approved for clinical use, in hematologic malignancies. Here we describe a novel bispecific leveraging the potent killing mechanism of TCEs to target CD38 bearing cancer cells. UNO-A001 is a TCE binding the cell surface receptor CD38 on target human cancer cells and CD3 on T cells. The molecule has a differentiated format, binding CD38 with a high affinity humanized camelid VHH moiety and CD3 on T cells through a unique antibody Fab arm. The affinities of each arm were optimized so that the CD38 arm bound with high affinity and the CD3 arm with much lower relative binding affinity. This configuration was designed to engage CD38 bearing target cells with multiple TCE molecules at lower doses and concentrations while minimizing T cell binding in the periphery, and in the absence of cell surface CD38. A001 potently and specifically killed human CD38 bearing multiple myeloma cell lines in T cell killing assays in vitro with EC50s in the 2.7-6.6 pM range. This potency, despite the designed lower affinity to CD3, may be due to the unique structure of A001 enabling a productive immunologic synapse between T cells and the target cancer cells, and an optimal TAA/CD3 binding affinity ratio. A001 was also highly effective in inhibiting tumor growth in H929 xenograft models. In a flank model of H929 tumor growth A001 dose dependently inhibited tumor growth with complete growth inhibition of established tumors at the highest dose level tested. In a systemic disease model with NCI-H929-luc cells A001 was also highly effective and improved survival relative to control treated animals. In preparation for clinical studies a robust and high yield production cell line was created and characterized. It achieved high expression levels of quality monodisperse UNO-A001 product that was stable in all relevant storage conditions. A001 has similar affinities for human and cynomolgus macaque CD38 and CD3. Dose ranging studies in cynomolgus macaques demonstrated tolerability consistent with clinically approved TCEs, and the expected dose dependent pharmacodynamic effects on CD38 expressing myeloid and lymphoid cell populations. These data support planned clinical testing of A001 in multiple myeloma and other CD38 bearing hematologic malignancies, including mantle cell lymphoma, T cell lymphoma, and acute myelogenous leukemia. Citation Format: Mark Anderson, Yan Ling, Mark L. Chiu, Peter Cheung. UNO-A001 (A001), a clinical candidate CD38 x CD3 bispecific with a novel structure, potently kills multiple myeloma cells in vitro and is highly effective in vivo [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 1906.

Abstract 3616: In vivo expansion patterns of anti-BCMA CAR T-cell in relapsed/refractory multiple myeloma: Comparative immunomonitoring of idecabtagene vicleucel and ciltacabtagene autoleucel

Abstract Introduction: Chimeric antigen receptor (CAR) T cell (CAR-T) treatments have revolutionized the treatment of multiple myeloma (MM). Two CAR-T cell products targeting B cell maturation antigen (BCMA) have received approval for the treatment of MM: idecabtagene vicleucel (idecel) and ciltacabtagene autoleucel (ciltacel). A comparative analysis of in vivo CAR-T responses in patients receiving these novel cellular therapies has not been performed, especially not in the real-world setting. Methods: We prospectively enrolled 23 MM patients treated with idecel or ciltacel in our study GCCC2043. Blood samples were obtained at apheresis, pre-lymphodepleting (LD) chemotherapy, on days 0, +7, +14, +21, +28 and at +3 months post CAR-T. Samples were stained using BCMA or control CAR detection reagents, monoclonal antibodies against T cell surface antigens, and analyzed using flow cytometry. Results: Baseline clinical characteristics, pre-apheresis and pre-LD absolute lymphocyte counts were comparable between groups. There were no G3 cytokine release syndrome (CRS) events whereas G1/2 CRS and all-grade Immune Effector Cell-Associated Neurotoxicity Syndrome (ICANS) events were not significantly different between cohorts. The global overall response rate (ORR) was 78.3% (n=18) and 60.9% (n=14) at days 30 and 90, respectively. At +1 month, 72.7% (8/11) of idecel and 83.3% (10/12) of ciltacel cohort had an objective response (p=0.625). There was no statistical ORR difference between idecel and ciltacel cohorts at 3, 6, and 9 months. Two-way ANOVA of CAR-T expansion studies revealed a trend towards an effect of treatment type (p=0.0595). Time to peak CAR-T numbers was significantly shorter for idecel (p=0.0127), however, ciltacel showed a significantly more pronounced CAR-T expansion (p=0.043) and longer persistence. Peak CAR-T expansion was associated with clinical responses across cohorts at +1 (p=0.034) and +3 months (p=0.050). Day +30 responses were indicative of Day +90 and Day +180 responses (p&amp;lt;0.001, p=0.011). There was no difference in CD8+ CAR T cell peak levels, however, CD4+ CAR T cell peak levels were much higher (p=0.019) for ciltacel vs. idecel. Similarly, there were significantly higher (p=0.002) CD4+/CD8+ double-positive CAR-T peak levels in ciltacel vs. idecel patients. There was no significant difference in the distribution of T cell memory subtypes at peak level. Conclusions: We demonstrate here for the first time significant differences in CAR T cell expansion and persistence patterns following infusion of either idacel or ciltacel. Studies are underway at our institution investigating anti-BCMA CAR T cell responses in more detail and larger numbers of patients. Such studies have the potential to identify predictive/prognostic biomarkers and/or lead to further optimization of myeloma-targeting CAR-T. Citation Format: Mehmet Kocoglu, Aaron P. Rapoport, Etse Gebru, Destiny Omili, Daniel Yamoah, Rediet Mulatu, Jean Yared, Nancy M. Hardy, Michael Kallen, Ashraf Z. Badros, Djordje Atanackovic. In vivo expansion patterns of anti-BCMA CAR T-cell in relapsed/refractory multiple myeloma: Comparative immunomonitoring of idecabtagene vicleucel and ciltacabtagene autoleucel [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3616.

Abstract 7191: Targeting IGF1R/INSR pathway with approved ALK inhibitors inhibits AKT signaling and overcomes proteasome inhibitor resistance in multiple myeloma

Abstract Background: Resistance to proteasome inhibitors (PI) bortezomib (BTZ) and carfilzomib (CFZ) is a major obstacle to the successful treatment of multiple myeloma (MM); thus, identification of novel therapeutic options is an unmet medical need. ALK inhibitors have been shown to exhibit anti-MM activity in monotherapy or in combination with CFZ. Our data showed that MM cells were negative for ALK; thus, we aimed to identify the mechanism of action of the ALK inhibitor ceritinib in MM cells and the mechanism of synergy between ceritinib and CFZ. Methods: A set of PI-naïve and PI-resistant MM cells was used in this study. Genome-wide CRISPR/Cas9-based screening using the Brunello library was performed in the AMO-1 cell line. Kinase inhibitor selectivity data were retrieved from ChEMBL, v30 database. RNA sequencing was used to determine expression changes after treatment, and RNA-seq data from patients included in the CoMMpass study were analyzed. Western blotting was performed to assess the levels of total and phosphorylated protein. Unbiased LC-MS/MS was performed to determine the effects of ceritinib and CFZ on the intracellular metabolites. An in vivo mouse model based on the orthotopic injection of AMO-BTZ cells into the femur of NSG mice was used to determine the effect of the drug combination in vivo. Results: Among approved ALK inhibitors, ceritinib has been identified as the most synergistic cytotoxic combination with CFZ in PI-naïve and PI-resistant MM cells. An in silico search of the ChEMBL database identified InsR and IGF1R as receptor tyrosine kinase that are inhibited by ceritinib. PI-naïve, PI-resistant cell lines, as well as MM patients were negative for ALK, but positive for InsR and IGF1R expression. CRISPR/Cas9-screening identified genes involved in the negative regulation of mTORC signaling (DDIT4, NPRL2/3, TSC1/2) and the transcription factor FOXO1 as the major resistance candidates to ceritinib. Subsequently, FOXO1 inhibition using a selective chemical inhibitor protected the cells from ceritinib-induced cytotoxicity. Next, ceritinib inhibited mTORC signaling and induced the expression of genes related to cell cycle arrest, which are downstream of FOXO1. Likewise, ceritinib, by targeting the InsR/IGF1R, impaired purine-pyrimidine and amino acid homeostasis, suggesting metabolic and proliferation shut-down and amino acid starvation due to downstream mTORC and Akt inhibition and FOXO1 induction. The combination of ceritinib and CFZ was superior to CFZ in PI-resistant MM in vivo and showed strong synergistic cytotoxicity in primary cells from MM patients progressing under or after PI-containing therapy. Conclusion: Ceritinib, an FDA-approved drug, overcomes PI resistance in MM by inhibiting InsR/IGF1R and downstream Akt signaling. Therefore, ceritinib is a promising treatment option for PI-resistant MM. Supported by the project National Institute for Cancer Research (Programme EXCELES, ID Project No. LX22NPO5102) - Funded by the European Union - Next Generation EU. Citation Format: Andrej Besse, Tiberiu Totu, Marianne Kraus, Anthonius P. Janssen, Jana Veprkova, Max Mendez Lopez, Ondrej Slaby, Marija Buljan, Mario van der Stelt, Christoph Driessen, Lenka Besse. Targeting IGF1R/INSR pathway with approved ALK inhibitors inhibits AKT signaling and overcomes proteasome inhibitor resistance in multiple myeloma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 7191.

Abstract 6602: Targeting the SWI/SNF complex in POU2F-POU2AF transcription factor-driven malignancies

Abstract Background: Small cell lung cancer (SCLC) is a rapidly progressing subtype of lung cancer with a high growth rate and early metastasis propensity, often resulting in a more advanced disease stage at diagnosis. A recent transcriptome analysis of human SCLC tumors revealed that SCLC could be characterized by the expression pattern of certain transcription factors (TFs), including ASCL1 (achaete-scute family bHLH transcription factor 1) and POU2F3 (POU domain class 2 transcription factor 3), exemplifying SCLC as a TF-driven malignancy. ASCL1-driven SCLC (SCLC-A) manifests a neuroendocrine phenotype, while POU2F3-driven SCLC (SCLC-P) is characterized as a tuft-cell-like variant. Recent studies revealed that POU domain class 2 transcription factors uniquely rely on coactivators to achieve their lineage-defining functions in the tuft cell and B cell lineages. In tuft-cell-like SCLC cells, the coactivators of POU2F3 (POU2AF2 and POU2AF3) endow POU2F3 with a critical transactivation domain by forming a master regulator complex, which supports enhancer-mediated cancer-promoting gene activation in SCLC-P cells. This indicates a potential therapeutic vulnerability of tuft-cell-like SCLC whereby strategies aimed at blocking POU2F3-POU2AF2/3 function may lead to clinical benefit. Methods: We conducted a domain-targeted CRISPR screen to identify druggable targets for SCLC-P, followed by pharmacological validation in preclinical SCLC models. Multi-omics techniques, including ATAC-seq, ChIP-seq, RNA-seq, and RIME, were employed to elucidate the SWI/SNF complex's regulatory influence on the POU2F-POU2AF axis. Results: Here we identified that the POU2F3 molecular subtype of SCLC (SCLC-P) exhibits an exquisite dependence on the activity of the SWI/SNF epigenetic complex. SCLC-P cell lines were sensitive to low nanomolar levels of a SWI/SNF ATPase degrader when compared to other molecular subtypes of SCLC. Co-factors of POU2F were found to interact with components of the SWI/SNF complex. The POU2F3 transcription factor complex is evicted from chromatin upon SWI/SNF ATPase degradation. A novel, orally bioavailable SWI/SNF ATPase PROTAC degrader demonstrated preferential efficacy in SCLC-P relative to the SCLC-A subtype. The SWI/SNF ATPase PROTAC degrader did not alter normal tuft cell numbers in lung or colon, nor did it exhibit toxicity in mice. B cell malignancies which displayed a dependency on the POU2F co-factor, POU2AF1, were also remarkably sensitive to SWI/SNF ATPase degradation. In a POU2AF1-dependent, disseminated murine model of multiple myeloma, AU-24118 had an enhanced survival benefit as compared to pomalidomide, an approved treatment for multiple myeloma. Conclusions: Taken together, our studies suggest that POU2F-POU2AF driven malignancies have an intrinsic dependence on the SWI/SNF complex representing a striking therapeutic vulnerability. Citation Format: Lanbo Xiao, Tongchen He, Olaf Klingbeil, Young Eleanor, Xiaoli Wu, Yuanyuan Qiao, Abhijit Parolia, Sanjana Eyunni, Rahul Mannan, Somnath Mahapatra, NamHoon Kim, Heng Zheng, Fengyun Su, Xuhong Cao, Susanta Samajdar, Murali Ramachandra, Christopher R. Vakoc, Arul M. Chinnaiyan. Targeting the SWI/SNF complex in POU2F-POU2AF transcription factor-driven malignancies [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 6602.