Preclinical efficacy of azacitidine and venetoclax for infant KMT2A-rearranged acute lymphoblastic leukemia reveals a new therapeutic strategy.

Infants with KMT2A-rearranged B-cell acute lymphoblastic leukemia (ALL) have a dismal prognosis. Survival outcomes have remained static in recent decades despite treatment intensification and novel therapies are urgently required. KMT2A-rearranged infant ALL cells are characterized by an abundance of promoter hypermethylation and exhibit high BCL-2 expression, highlighting potential for therapeutic targeting. Here, we show that hypomethylating agents exhibit in vitro additivity when combined with most conventional chemotherapeutic agents. However, in a subset of samples an antagonistic effect was seen between several agents. This was most evident when hypomethylating agents were combined with methotrexate, with upregulation of ATP-binding cassette transporters identified as a potential mechanism. Single agent treatment with azacitidine and decitabine significantly prolonged in vivo survival in KMT2A-rearranged infant ALL xenografts. Treatment of KMT2A-rearranged infant ALL cell lines with azacitidine and decitabine led to differential genome-wide DNA methylation, changes in gene expression and thermal proteome profiling revealed the target protein-binding landscape of these agents. The selective BCL-2 inhibitor, venetoclax, exhibited in vitro additivity in combination with hypomethylating or conventional chemotherapeutic agents. The addition of venetoclax to azacitidine resulted in a significant in vivo survival advantage indicating the therapeutic potential of this combination to improve outcome for infants with KMT2A-rearranged ALL.

Preclinical Evaluation of Carfilzomib for Infant KMT2A-Rearranged Acute Lymphoblastic Leukemia.

BACKGROUND: Infants with KMT2A-rearranged B-cell precursor acute lymphoblastic leukemia (ALL) have poor outcomes. There is an urgent need to identify novel agents to improve survival. Proteasome inhibition has emerged as a promising therapeutic strategy for several hematological malignancies. The aim of this study was to determine the preclinical efficacy of the selective proteasome inhibitor carfilzomib, for infants with KMT2A-rearranged ALL. METHODS: Eight infant ALL cell lines were extensively characterized for immunophenotypic and cytogenetic features. In vitro cytotoxicity to carfilzomib was assessed using a modified Alamar Blue assay with cells in logarithmic growth. The Bliss Independence model was applied to determine synergy between carfilzomib and the nine conventional chemotherapeutic agents used to treat infants with ALL. Established xenograft models were used to identify the maximal tolerated dose of carfilzomib and determine in vivo efficacy. RESULTS: Carfilzomib demonstrated low IC50 concentrations within the nanomolar range (6.0-15.8 nm) across the panel of cell lines. Combination drug testing indicated in vitro synergy between carfilzomib and several conventional chemotherapeutic agents including vincristine, daunorubicin, dexamethasone, L-asparaginase, and 4-hydroperoxycyclophosphamide. In vivo assessment did not lead to a survival advantage for either carfilzomib monotherapy, when used to treat both low or high disease burden, or for carfilzomib in combination with multi-agent induction chemotherapy comprising of vincristine, dexamethasone, and L-asparaginase. CONCLUSIONS: Our study highlights that in vitro efficacy does not necessarily translate to benefit in vivo and emphasizes the importance of in vivo validation prior to suggesting an agent for clinical use. Whilst proteasome inhibitors have an important role to play in several hematological malignancies, our findings guard against prioritization of carfilzomib for treatment of KMT2A-rearranged infant ALL in the clinical setting.

Changes in vasotocin immunoreactivity of paraventricular nuclei and adrenal function of Japanese quail in relation to different phases of sexual development.

In relevance to osmoregulatory and reproductive functions, activity of hypothalamic neurosecretory neurons may also vary seasonally. The current study was performed to determine annual changes in ir-AVT neurons of hypothalamus and adrenal gland function. We examined changes in ir-AVT neuron by immunohistochemical method and plasma testosterone was measured by enzyme immunoassay. The steroidogenic interrenal activity was studied by histological and biochemical methods. Birds were sampled in February (quiescent), April (recrudescent), June (breeding) and November (regressive). A significant and gradual increase in the number of ir-AVT neurons was observed from quiescent to breeding phase which decreased during regressive phase of annual gonadal cycle. The gradual increase in ir-AVT neurons along with annual gonadal activity of quail were accompanied by increase in plasma levels of testosterone. These results indicate a functional interaction between sex steroid and AVT synthesizing neurons. Adrenal activity (as judged by weight, ascorbic acid content, cortical cord width and cortico-medullary ratio) was also maximum during breeding phase. It is thus postulated that domesticated quail when exposed to natural day length (NDL), exhibits seasonal/annual cyclicity in vastocinergic activity and adrenal function which may be due to difference in sex steroid hormone.

New therapeutic opportunities from dissecting the pre-B leukemia bone marrow microenvironment.

The microenvironments of leukemia and cancer are critical for multiple stages of malignancies, and they are an attractive therapeutic target. While skeletal abnormalities are commonly seen in children with acute lymphoblastic leukemia (ALL) prior to initiating osteotoxic therapy, little is known about the alterations to the bone marrow microenvironment during leukemogenesis. Therefore, in this study, we focused on the development of precursor-B cell ALL (pre-B ALL) in an immunocompetent BCR-ABL1+ model. Here we show that hematopoiesis was perturbed, B lymphopoiesis was impaired, collagen production was reduced, and the number of osteoblastic cells was decreased in the bone marrow microenvironment. As previously found in children with ALL, the leukemia-bearing mice exhibited severe bone loss during leukemogenesis. Leukemia cells produced high levels of receptor activator of nuclear factor κB ligand (RANKL), sufficient to cause osteoclast-mediated bone resorption. In vivo administration of zoledronic acid rescued leukemia-induced bone loss, reduced disease burden and prolonged survival in leukemia-bearing mice. Taken together, we provide evidence that targeting leukemia-induced bone loss is a therapeutic strategy for pre-B ALL.

APOE genotype results in differential effects on the peripheral clearance of amyloid-beta42 in APOE knock-in and knock-out mice.

The epsilon4 allele of apolipoprotein E (APOE) is currently the major genetic risk factor identified for Alzheimer's disease (AD). Previous in vivo data from our laboratory has demonstrated that amyloid-beta (Abeta) is rapidly removed from the plasma by the liver and kidney and that the rate of its clearance is affected by ApoE in C57BL/6J and APOE-/- mice. To expand upon these findings, we assessed the peripheral clearance of human synthetic Abeta42 in APOE epsilon2, epsilon3, and epsilon4 knock-in and APOE knock-out mice injected with lipidated recombinant apoE2, E3, and E4 protein. Our results show that APOE does influence the rate at which the mice are able to clear Abeta42 from their bloodstream. Both APOE epsilon4 mice and APOE knock-out mice treated with lipidated recombinant apoE4 demonstrated increased retention of plasma Abeta42 over time compared to APOE epsilon2/APOE knock-out rE2 and APOE epsilon3/APOE knock-out rE3 mice. These findings suggest that the peripheral clearance of Abeta42 is significantly altered by APOE genotype. Given that APOE epsilon4 is a risk factor for AD, then these novel findings provide some insight into the role of ApoE isoforms on the peripheral clearance of Abeta which may impact on clearance from the brain.

Effect of long and short photoperiod on vasotocin neurons of paraventricular nuclei and adrenal function of water deprived Japanese quail.

The responses of magnocellular neurons of paraventricular nuclei (PVN) and changes to adrenal activity to water deprivation in Japanese quail maintained under gonado-inhibitory and stimulatory photoperiods were examined. Water deprivation of 4 days resulted in a 12% decrease in body weight of sexually regressed short day (SD, 6L:18D) quail, while the decrease was more (18%) in sexually stimulated long day (LD, 16L:8D) quail. The increase in plasma osmolality following water deprivation was also more (47%) in LD than to SD quail (36%). Under the LD condition, quail had increased numbers, sizes and immunostaining of ir-AVT neurons of PVN compared to SD condition. A significant increase in the number of ir-AVT neurons was observed following 4 days of water deprivation in both SD and LD quail compared to their respective fully hydrated controls. However, the degree of response was more under the LD compared to the SD condition suggesting that gonado-stimulatory long days increase the activity/response of the AVT system. Increased adrenal ascorbic acid content (i.e., activity) was also observed to quail of LD when compared to SD treatment. However, osmotic stress led to adrenal hypertrophy and hyperactivity of quail of both of the photoperiodic regimes. Our findings indicate that not only osmotic stress but also photo-gonadal stimulation upregulates the expression of hypothalamic AVT genes and increases the localization of ir-AVT in many neurons of PVN. The above results support the existence of a parallel adrenal-gonad relationship and increase in adrenal function during osmotic stress, which also leads to simultaneous increase in AVT system. We conclude that photo-sexual conditions alter hypothalamic vasotocinergic and adrenal activity in Japanese quail and the degree of stimulation of the two systems following osmotic stress is higher under gonado-stimulatory LD conditions.