Search

Outcome in childhood acute lymphoblastic leukemia is prognosticated from levels of minimal residual disease after remission induction therapy. Higher levels of minimal residual disease are associated with inferior results even with intensification of therapy, thus suggesting that identification and targeting of minimal residual disease cells could be a therapeutic strategy. Here we identify high expression of 5T4 in subclonal populations of patient-derived xenografts from patients with high, post-induction levels of minimal residual disease. 5T4-positive cells showed preferential ability to overcome the NOD-scidIL2Rγnull mouse xenograft barrier, migrated in vitro on a CXCL12 gradient, preferentially localized to bone marrow in vivo and displayed the ability to reconstitute the original clonal composition on limited dilution engraftment. Treatment with A1mcMMAF (a 5T4-antibody drug conjugate) significantly improved survival without overt toxicity in mice engrafted with a 5T4-positive acute lymphoblastic leukemia cell line. Mice engrafted with 5T4-positive patient-derived xenograft cells were treated with combination chemotherapy or dexamethasone alone and then given A1mcMMAF in the minimal residual disease setting. Combination chemotherapy was toxic to NOD-scidIL2Rγnull mice. While dexamethasone or A1mcMMAF alone improved outcomes, the sequential administration of dexamethasone and A1mcMMAF significantly improved survival (P=0.0006) over either monotherapy. These data show that specifically targeting minimal residual disease cells improved outcomes and support further investigation of A1mcMMAF in patients with high-risk B-cell precursor acute lymphoblastic leukemia identified by 5T4 expression at diagnosis.

We developed a murine model of CNS disease to obtain a better understanding of the pathogenesis of CNS involvement in pre-B-cell acute lymphoblastic leukemia (ALL). Semiquantitative proteomic discovery–based approaches identified unique expression of asparaginyl endopeptidase (AEP), intercellular adhesion molecule 1 (ICAM1), and ras-related C3 botulinum toxin substrate 2 (RAC2), among others, in an invasive pre-B-cell line that produced CNS leukemia in NOD-SCID mice. Targeting RAC2 significantly inhibited in vitro invasion and delayed disease onset in mice. Induced expression of RAC2 in cell lines with low/absent expression of AEP and ICAM1 did not result in an invasive phenotype or murine CNS disease. Flow cytometric analysis identified an enriched population of blast cells expressing ICAM1/lymphocyte function associated antigen-1 (LFA-1)/CD70 in the CD10+/CD19+ fraction of bone marrow aspirates obtained from relapsed compared with normal controls and those with primary disease. CD10+/CD19+ fractions obtained from relapsed patients also express RAC2 and give rise to CNS disease in mice. Our data suggest that combinations of processes are involved in the pathogenesis of CNS disease in pre-B-cell ALL, support a model in which CNS disease occurs as a result of external invasion, and suggest that targeting the processes of adhesion and invasion unique to pre-B cells may prevent recurrences within the CNS.

Despite the high cure rates in childhood acute lymphoblastic leukemia (ALL), relapsed ALL remains a significant clinical problem. Genetic heterogeneity does not adequately explain variations in response to therapy. The chemoprotective tumor microenvironment may additionally contribute to disease recurrence. This study identifies metabolic reprogramming of leukemic cells by bone marrow stromal cells (BMSC) as a putative mechanism of drug resistance. In a BMSC-extracellular matrix culture model, BMSC produced chemoprotective soluble factors and facilitated the emergence of a reversible multidrug resistant phenotype in ALL cells. BMSC environment induced a mitochondrial calcium influx leading to increased reactive oxygen species (ROS) levels in ALL cells. In response to this oxidative stress, drug resistant cells underwent a redox adaptation process, characterized by a decrease in ROS levels and mitochondrial membrane potential with an upregulation of antioxidant production and MCL-1 expression. Similar expanded subpopulations of low ROS expressing and drug resistant cells were identified in pre-treatment bone marrow samples from ALL patients with slower response to therapy. This suggests that the bone marrow microenvironment induces a redox adaptation in ALL subclones that protects against cytotoxic stress and potentially gives rise to minimal residual disease. Targeting metabolic remodeling by inhibiting antioxidant production and antiapoptosis was able to overcome drug resistance. Thus metabolic plasticity in leukemic cell response to environmental factors contributes to chemoresistance and disease recurrence. Adjunctive strategies targeting such processes have the potential to overcome therapeutic failure in ALL.

Reduced expression of pro-apoptotic Bcl-2 family proteins has been described in many gastrointestinal cancers, and may play a role in tumourigenesis. The human homologue of the pro-apoptotic Bcl-2 protein, Bfk, is predominantly expressed in tissues of the gastrointestinal tract. In colon, four alternatively spliced isoforms were identified; of which two are pro-apoptotic when overexpressed. In the transition from normal tissue to tumour, pro-apoptotic Bfk isoform expression is substantially reduced in up to 80% of tumours isolated from the human gastrointestinal tract (8/10 colonic tumours and 26/37 of all gastrointestinal tumours) compared to 3/117 tumours from outside the gastrointestinal tract. These data suggest that pro-apoptotic isoforms of Bfk may help to protect against the development of human gastrointestinal malignancy.

PUBLISHED, Control of mitogen-activated protein kinase (MAPK) cascades is central to regulation of many cellular responses. We describe here human tribbles homologues (Htrbs) that control MAPK activity. MAPK kinases interact with Trbs and regulate their steady state levels. Further, Trbs selectively regulate the activation of extracellular signal-regulated kinases, c-Jun NH2-terminal kinases, and p38 MAPK with different relative levels of activity for the three classes of MAPK observed depending on the level of Trb expression. These results suggest that Trbs control both the extent and the specificity of MAPK kinase activation of MAPK.

Bid, a BH3-only Bcl-2 protein, is activated by proteolytic cleavage exposing the BH3 domain, which then induces apoptosis by interacting with pro-apoptotic Bcl-2 family proteins (e.g. Bax and Bak) at the mitochondrial surface. The arrangement of domains within Bid suggested that Bid function might be regulated in part by alternative splicing. We have determined the gene structure of human Bid and identified a number of novel exons. We have also demonstrated endogenous mRNA and protein expression for three novel isoforms of Bid, generated using these exons. Bid(S) contains the N-terminal regulatory domains of Bid without the BH3 domain; Bid(EL) corresponds to full-length Bid with additional N-terminal sequence; and Bid(ES) contains only the Bid sequence downstream of the BH3 domain. Expression of these isoforms is regulated during granulocyte maturation. In functional studies Bid(EL) induces apoptosis, whereas Bid(S) abrogates the pro-apoptotic effects of truncated Bid and inhibits Fas-mediated apoptosis. Bid(ES) induces apoptosis but is also able to partially inhibit the pro-apoptotic effects of truncated Bid. These three novel endogenously expressed isoforms of Bid are distinct in their expression, their cellular localization, and their effects upon cellular apoptosis. Differential expression of these novel Bid isoforms may regulate the function of Bid following cleavage and thus influence the fate of cells exposed to a range of pro-apoptotic stimuli.

Extracellular vesicles have been described in non-paracrine cellular interactions in cancer. We report a similar phenomenon in B-cell precursor (BCP) acute lymphoblastic leukaemia (ALL). Using advanced microscopy and high throughput screening, we further characterise a subset of large vesicles (LEVs) identified in cell lines, murine models of human BCP-ALL and clinical samples. Primary ALL blasts and cell lines released heterogeneous anucleate vesicles

We have identified a fourth splice variant of the TGFβ-activated kinase (TAK1), called TAK1-d, and identified an error in the previously published TAK1-c sequence. Our data shows that the c and d variants encode proteins whose carboxyl ends differ markedly from those of variants a and b. Analysis of the human TAK1 gene sequence, located at 6q16.1–q16.3, shows that the coding sequence is organised in 17 exons. The four splice variants result from alternative splicing of exons 12 and 16, the reading frame of exon 17 being determined by the presence or absence of exon 16. Study of the relative levels of expression of the four splice variants showed significant variations between tissues. Our evidence suggests that the alternative splicing of the TAK1 mRNA may have important functional implications.

Solid tumors contain hypoxic regions in which cancer cells are often resistant to chemotherapy-induced apoptotic cell death. Therapeutic strategies that specifically target hypoxic cells and promote apoptosis are particularly appealing, as few normal tissues experience hypoxia. We have found that the compound ABT-737, a Bcl-2 homology domain 3 (BH-3) mimetic, promotes apoptotic cell death in human colorectal carcinoma and small cell lung cancer cell lines exposed to hypoxia. This hypoxic induction of apoptosis was mediated through downregulation of myeloid cell leukemia sequence 1 (Mcl-1), a Bcl-2 family protein that serves as a biomarker for ABT-737 resistance. Downregulation of Mcl-1 in hypoxia was independent of hypoxia-inducible factor 1 (HIF-1) activity and was consistent with decreased global protein translation. In addition, ABT-737 induced apoptosis deep within tumor spheroids, consistent with an optimal hypoxic oxygen tension being necessary to promote ABT-737–induced cell death. Tumor xenografts in ABT-737–treated mice also displayed significantly more apoptotic cells within hypoxic regions relative to normoxic regions. Synergies between ABT-737 and other cytotoxic drugs were maintained in hypoxia, suggesting that this drug may be useful in combination with chemotherapeutic agents. Taken together, these findings suggest that Mcl-1–sparing BH-3 mimetics may induce apoptosis in hypoxic tumor cells that are resistant to other chemotherapeutic agents and may have a role in combinatorial chemotherapeutic regimens for treatment of solid tumors.

l-Asparaginase is a key therapeutic agent for treatment of childhood acute lymphoblastic leukemia (ALL). There is wide individual variation in pharmacokinetics, and little is known about its metabolism. The mechanisms of therapeutic failure with l-asparaginase remain speculative. Here, we now report that 2 lysosomal cysteine proteases present in lymphoblasts are able to degrade l-asparaginase. Cathepsin B (CTSB), which is produced constitutively by normal and leukemic cells, degraded asparaginase produced by Escherichia coli (ASNase) and Erwinia chrysanthemi. Asparaginyl endopeptidase (AEP), which is overexpressed predominantly in high-risk subsets of ALL, specifically degraded ASNase. AEP thereby destroys ASNase activity and may also potentiate antigen processing, leading to allergic reactions. Using AEP-mediated cleavage sequences, we modeled the effects of the protease on ASNase and created a number of recombinant ASNase products. The N24 residue on the flexible active loop was identified as the primary AEP cleavage site. Sole modification at this site rendered ASNase resistant to AEP cleavage and suggested a key role for the flexible active loop in determining ASNase activity. We therefore propose what we believe to be a novel mechanism of drug resistance to ASNase. Our results may help to identify alternative therapeutic strategies with the potential of further improving outcome in childhood ALL.

In ALL, leukemic cells have been shown to modulate the bone marrow microenvironment through aberrant cytokine production favoring leukemic cell survival. Extracellular vesicles have also been recognised as key mediators of non-paracrine cellular interactions in cancer. This mechanism of tumor-stromal interaction has been described in chronic lymphocytic leukemia where recipient stromal cells undergo phenotypic changes. We now report a similar phenomenon in ALL. Light microscopy showed that primary ALL blasts and cell lines, released anucleate extracellular vesicles into extracellular fluids. On transmission electron microscopy, leukemic extracellular vesicles (LEVs) were observed to be heterogeneous, ranging from 100nm exosome-like particles to large 6µm particles. Larger LEVs were enclosed in lipid-rich membranes and contained several organelles including ribosomes, lysosomes, golgi bodies and mitochondria. On fluorescent immunostaining, LEVs demonstrated an organized cytoskeleton with expression of actin, vinculin and talin. On imaging flow cytometry, a relative excess of circulating CD19-positive LEVs were observed in patient samples at diagnosis compared to post-treatment; these were readily distinguished from CD61-expressing platelets. On time-lapse microscopy, LEVs generated by green fluorescent labeled ALL cells, appeared as dynamic particles and were internalized by both leukemic and bone marrow stromal cells. Confocal microscopy revealed internalized labeled LEVs located in the perinuclear region of recipient cells for up to a week. Lipophilic tracer labeled LEVs, ALL cell lines and primary cells were transplanted intrafemorally in NSG mice as independent experiments. Transplanted LEVs were observed in peripheral blood at day 9 of transplantation and in marrow stromal cells in contralateral femurs at day 14 of injection. Bilateral femoral flushes at day 14 in both LEV and ALL xenografts, showed free LEVs in extracellular spaces as well as internalization of LEVs by murine mesenchymal cells. While internalization of LEVs by heterogeneous leukemic cell lines led to phenotypic transformation to the cell of origin, recipient marrow stromal cells did not demonstrate change in phenotype, viability or proliferation. In keeping with this, both control and LEV internalized stromal cells had similar ATP levels. Instead, metabolic analyses using an extracellular flux analyzer indicated that recipient stromal cells demonstrated altered normoxic metabolism, with decreased mitochondrial respiration, and increased extracellular acidification associated with raised lactate production. Thus indicating aerobic glycolysis as the main source of energy. In concordance with this, megakaryocytes, granulocytes and endothelial cells but not lymphoblasts in leukemic murine and human bone marrow demonstrated perimembranous expression of the lactate export protein MCT4 (monocarboxylate transporter 4). In contrast, in normal and remission marrow, while granulocytes express membranous MCT4, endothelial cells do not express MCT4 and megakaryocytes showed a predominant cytoplasmic expression. Thus internalized LEVs triggered a metabolic switch from oxidative phosphorylation to aerobic glycolysis in recipient stromal cells resulting in extracellular lactate generation. We speculate that extracellular lactate in the microenvironment serves as the preferred energy substrate for ALL cells, a phenomenon reported in other cancers and termed the reverse Warburg effect. Targeting lactate-dependent metabolism may therefore represent a novel common therapeutic strategy in ALL and other cancers. Disclosures No relevant conflicts of interest to declare.

Clinical and laboratory studies in childhood acute lymphoblastic leukemia (ALL) suggest that the bone marrow microenvironment protects blast cells, thus influencing disease relapse. This study was designed to identify the mechanisms by which bone marrow stromal cells could mediate chemoresistance in ALL cells. An in vitro organotypic extracellular matrix-bone marrow stromal cells (ECM-BMSC) culture system, that sustained primary cells without the addition of exogenous factors, was created. ECM-BMSC derived conditioned medium (CM) conferred broad-spectrum chemoprotection to ALL and other cancer cells. Multi drug resistant sub-clones (MDRS), derived by exposing ALL cells in CM to Mitoxantrone, retained chemoresistance even beyond 50 passages in normal medium. Chemoprotective effect was retained in the Proteinase K, RNase and heat resistant, < 3kDa fraction of CM; transmission electron microscopy demonstrated the presence of stromal cell derived exosomes in this fraction. Confocal microscopy confirmed the uptake of ultra-centrifuged fluorescently labelled (PKH 67) stromal exosomes by ALL cells which then developed a resistant phenotype. Stromal derived exosomes and MDRS were enriched in miRNA expression (TaqMan Human miRNA array V3), compared to parent cells, with 92% concordance. Ingenuity™ pathway-based analysis of the unique miRNA pattern predicted dysregulation of mitochondrial function and oxidative phosphorylation. SILAC based phosphoproteomics and U133A V2 gene expression array analysis revealed aberrant PI3K/AKT and oxidative phosphorylation activity. A kinase inhibitor screen showed that PI3K/AKT inhibitors were most potent in reversing CM mediated chemoresistance. Exposure to CM initially (24 hours), pAKT activity and ROS level decreased to lower than the basal level, with upregulation of CDKN1B and MCL-1, and a decreased mitochondrial membrane potential. shRNA knockdown of CDKN1B restored normal growth rate but not chemosensitivity. MDRS that were resistant to exogenous H2O2 induced apoptosis, regained sensitivity after MCL-1 knockdown. Upregulation of ROS and downregulation of MCL-1 using PEITC lead to cell death in chemo sensitive and resistant cells. Our study identifies that the microenvironment produces soluble factors that induces a redox adaptation in ALL cells leading to chemoresistance. This can be overcome by the simultaneous inhibition of the antioxidant system (to increase ROS) and suppressing antiapoptic proteins (to eliminate the mitochondrial membrane safeguard). Tumour protection by the microenvironment is likely to be common to other cancers. Future therapeutic strategies need to consider targeting the host-tumor interactions in adjunct to conventional chemotherapy. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 1506. doi:1538-7445.AM2012-1506

To the editor: Cancer cells produce unique heterogeneous vesicles[1][1] capable of transferring oncogenic material[2][2],[3][3] to other cells,[4][4],[5][5] with the potential of modulating a tumor-supportive environment.[6][6][⇓][7]-[8][8] We have previously reported the presence of lipid