Acute myeloid leukemia (AML) has a very poor 5-year survival of ~20% in Europe. The internal tandem duplication (ITD) mutation of the Fms-like receptor tyrosine kinase 3 (FLT3) (FLT3-ITD) is the most frequent mutation (~25%) in normal karyotype AML. In recent clinical studies, few patients display prolonged remissions with receptor tyrosine kinase (RTK) inhibitors, such as FLT3 inhibitors (FLT3i) therapy, highlighting a substantial unmet need for novel effective treatment. Persistence of leukemia stem cells (LSC) drive AML leukemogenesis, responsible for drug resistance and disease relapse following conventional chemotherapy. Growing evidence recognizes that FLT3-ITD mutation leads to the constitutive activation of FLT3 kinase and its downstream pathways, including PI3K/AKT/mTOR signaling, strongly associated with LSC survival and crosstalk between LSC and stromal cells associated bone marrow (BM) tumor environment (TME). The TME provides protection of FLT3-ITD AML cells against FLT3 inhibitors. Thus, the PI3K/AKT/mTOR pathway may represent as a putative target for FLT3-ITD AML. This study aims to test the hypothesis that PI3K/AKT/mTOR inhibition could sensitize FLT3-ITD AML cells to RTKi-lead targeted therapy using human AML cell lines and primary patient blasts. First, I uncover the phenotypic profile of FLT3-ITD versus FLT3 wildtype cell lines following treatment with selected FLT3i or PI3K/AKT/mTORi that have failed treatment of AML as monotherapy in clinical studies. More specifically, I determine the drug efficacy by means of cell growth measurement and assessment of cell cycle status and apoptosis. I was able to demonstrate that BAY-806946 (pan PI3Ki) and PF-04691502 (dual PI3K/mTORi) exerted growth inhibitory activity caused by G1 cell cycle arrest and apoptosis, and this effect was irrespective of FLT3 status. Quizartinib (FLT3i) selectively inhibited cell growth in FLT3-ITD AML and this effect was mainly caused by apoptosis. The observed drug-induced apoptotic effect was however not as efficient as chemotherapy. Next, I provide proof-of-concept for the combination of quizartinib and BAY-806946 using both FLT3-ITD AML cell lines and primary patient blasts. When evaluating on primary patient blasts, I take into consideration the protective role of mesenchymal stromal cells and physiological growth factors to mimic the BM microenvironment. Hereby, I co-cultured FLT3-ITD AML blasts with stromal cell line MS-5 and added growth factors essential for AML survival and differentiation such as IL-3, TPO and G-CSF at physiological concentration. As expected, treatment with BAY-806946 enhanced both cytostatic and cytotoxic effect of quizartinib in FLT3-ITD AML cell line MOLM-13 as well as primary patient blasts in co-culture. More importantly, enhanced apoptosis was measured in the stem cell like CD34+CD38- population. Lastly, I elucidate the cytokine profile and persistent phosphoproteins as putative targets following combination treatment. Ultimately, this study demonstrates the potential of PI3K/AKT/mTORi to enhance the efficacy of RTKi quizartinib for the treatment of FLT3-ITD AML.
In Europa, la sopravvivenza a 5 anni dei pazienti affetti da leucemia mieloide acuta (LMA) è solo del 20%. La duplicazione interna in tandem del gene FLT3 (FLT3-ITD), che codifica per il recettore della tirosina chinasi FLT3, è la mutazione più frequente (~ 25%) nella LMA con cariotipo normale, dove porta all'attivazione costitutiva della chinasi FLT3. Nonostante risultati iniziali molto promettenti con inibitori di FLT3 (FLT3i) nei pazienti con questa mutazione, pochi pazienti hanno remissioni prolungate, evidenziando la necessità di nuove e più efficaci terapie. La persistenza delle cellule staminali leucemiche guida la leucemogenesi della LMA ed è responsabile della resistenza ai farmaci e della ricaduta dopo chemioterapia convenzionale. L'attivazione costitutiva di FLT3 porta all’attivazione del signaling a valle, e in particolare della via PI3K/AKT/mTOR, una cascata di segnale fortemente associata alla sopravvivenza delle cellule staminali leucemiche e al crosstalk tra le cellule staminali leucemiche e le cellule stromali associate al microambiente tumorale midollare. La nicchia midollare fornisce protezione alle cellule leucemiche FLT3-ITD nei confronti degli inibitori FLT3. Pertanto, la via PI3K/AKT/mTOR può rappresentare un bersaglio terapeutico nella AML FLT3-ITD. Questo studio mira a verificare l'ipotesi che l'inibizione di PI3K/AKT/mTOR sensibilizzi le cellule AML FLT3-ITD alla terapia mirata con RTKi utilizzando linee cellulari AML umane e blasti di pazienti primari. In particolare, ho definito il profilo fenotipico delle linee cellulari FLT3-ITD rispetto a quelle FLT3 wildtype dopo trattamento con un pannello di FLT3i o PI3K/AKT/mTORi che non hanno dimostrato sufficiente efficacia clinica se utilizzato come monoterapia. Successivamente, ho valutato l’effetto del farmaco sulla crescita cellulare e sul ciclo cellulare e l'apoptosi. I risultati ottenuti dimostrano che BAY-806946 (pan PI3Ki) e PF-04691502 (inibitore duale PI3K/mTORi) sono in grado di inibire la crescita poiché causano arresto del ciclo cellular in fase G1 e apoptosi, un effetto che appare indipendente dallo stato mutazionale di FLT3. Dimostrano inoltre che l’arresto della crescita cellulare indotto dall’inibitore di FLT3 (FLT3i) quizartinib è causato principalmente dall’induzione di apoptosi. Tuttavia l’efficacia rimane inferiore rispetto al trattamento con chemioterpia convenzionale (AraC). Inoltre, la proof of concept per l’utilizzo della combinazione del quizartinib con BAY-806946 è stata ottenuta in linee cellulari AML FLT3-ITD e blasti primari da paziente. Nel valutare i blasti primari da paziente, è stato considerato il ruolo protettivo delle cellule stromali mesenchimali in co-coltura, e dei fattori di crescita per riprodurre le condizioni del microambiente midollare. Pertanto, blasti primari da paziente LAM sono stati mantenuti in co-coltura con cellule stromali MS5 in presenza di concentrazioni fisiologiche di fattori di crescita quali IL-3, TPO e GM-CSF. Come atteso, il BAY-806946 potenzia l’effetto citostatico e citotossico del quizartinib nelle cellule MOLM-13 e nei blasti primari da paziente con mutazione FLT3-ITD in condizione di co-coltura. E’ importante sottolineare l’incremento di apoptosi osservato anche nella sottopopolazione staminale leucemica CD34+CD38-. Infine, ho valutato il profilo delle citochine e delle fosfoproteine persistenti come bersagli putativi dopo il trattamento di combinazione. Complessivamente, questo studio dimostra il potenziale di PI3Ki per migliorare l'efficacia di RTKi quizartinib nel trattamento della LMA FLT3-ITD.
LEUCEMIA MIELOIDE ACUTA CON MUTAZIONE FLT3-ITD: razionale per l'uso combinato di inibitori di fosfoinositide 3-chinasi e recettori tirosin chinasici / Saliha Nur Darici , 2022 May 27. 34. ciclo, Anno Accademico 2020/2021.
LEUCEMIA MIELOIDE ACUTA CON MUTAZIONE FLT3-ITD: razionale per l'uso combinato di inibitori di fosfoinositide 3-chinasi e recettori tirosin chinasici
DARICI, SALIHA NUR
2022
Abstract
Acute myeloid leukemia (AML) has a very poor 5-year survival of ~20% in Europe. The internal tandem duplication (ITD) mutation of the Fms-like receptor tyrosine kinase 3 (FLT3) (FLT3-ITD) is the most frequent mutation (~25%) in normal karyotype AML. In recent clinical studies, few patients display prolonged remissions with receptor tyrosine kinase (RTK) inhibitors, such as FLT3 inhibitors (FLT3i) therapy, highlighting a substantial unmet need for novel effective treatment. Persistence of leukemia stem cells (LSC) drive AML leukemogenesis, responsible for drug resistance and disease relapse following conventional chemotherapy. Growing evidence recognizes that FLT3-ITD mutation leads to the constitutive activation of FLT3 kinase and its downstream pathways, including PI3K/AKT/mTOR signaling, strongly associated with LSC survival and crosstalk between LSC and stromal cells associated bone marrow (BM) tumor environment (TME). The TME provides protection of FLT3-ITD AML cells against FLT3 inhibitors. Thus, the PI3K/AKT/mTOR pathway may represent as a putative target for FLT3-ITD AML. This study aims to test the hypothesis that PI3K/AKT/mTOR inhibition could sensitize FLT3-ITD AML cells to RTKi-lead targeted therapy using human AML cell lines and primary patient blasts. First, I uncover the phenotypic profile of FLT3-ITD versus FLT3 wildtype cell lines following treatment with selected FLT3i or PI3K/AKT/mTORi that have failed treatment of AML as monotherapy in clinical studies. More specifically, I determine the drug efficacy by means of cell growth measurement and assessment of cell cycle status and apoptosis. I was able to demonstrate that BAY-806946 (pan PI3Ki) and PF-04691502 (dual PI3K/mTORi) exerted growth inhibitory activity caused by G1 cell cycle arrest and apoptosis, and this effect was irrespective of FLT3 status. Quizartinib (FLT3i) selectively inhibited cell growth in FLT3-ITD AML and this effect was mainly caused by apoptosis. The observed drug-induced apoptotic effect was however not as efficient as chemotherapy. Next, I provide proof-of-concept for the combination of quizartinib and BAY-806946 using both FLT3-ITD AML cell lines and primary patient blasts. When evaluating on primary patient blasts, I take into consideration the protective role of mesenchymal stromal cells and physiological growth factors to mimic the BM microenvironment. Hereby, I co-cultured FLT3-ITD AML blasts with stromal cell line MS-5 and added growth factors essential for AML survival and differentiation such as IL-3, TPO and G-CSF at physiological concentration. As expected, treatment with BAY-806946 enhanced both cytostatic and cytotoxic effect of quizartinib in FLT3-ITD AML cell line MOLM-13 as well as primary patient blasts in co-culture. More importantly, enhanced apoptosis was measured in the stem cell like CD34+CD38- population. Lastly, I elucidate the cytokine profile and persistent phosphoproteins as putative targets following combination treatment. Ultimately, this study demonstrates the potential of PI3K/AKT/mTORi to enhance the efficacy of RTKi quizartinib for the treatment of FLT3-ITD AML.File | Dimensione | Formato | |
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SDarici_PhD-thesis_revised.pdf
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Descrizione: Tesi definitiva Darici Salihanur
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