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Tumor proliferation measured as Ki67 index in (A) mSEP-CR(-)RTBDNb and (B) mCPC treated with the indicated dose and route of administration of gemcitabine.

information on drugs used in preclinical studies

mouse models of supratentorial ependymoma and CPC and the number of cells implanted as allografts

Purpose: Curing all children with brain tumors will require an understanding of how each subtype responds to conventional treatments and how best to combine existing and novel therapies. It is extremely challenging to acquire this knowledge in the clinic alone, especially among patients with rare tumors. Therefore, we developed a preclinical brain tumor platform to test combinations of conventional and novel therapies in a manner that closely recapitulates clinic trials.Experimental Design: A multidisciplinary team was established to design and conduct neurosurgical, fractionated radiotherapy and chemotherapy studies, alone or in combination, in accurate mouse models of supratentorial ependymoma (SEP) subtypes and choroid plexus carcinoma (CPC). Extensive drug repurposing screens, pharmacokinetic, pharmacodynamic, and efficacy studies were used to triage active compounds for combination preclinical trials with “standard-of-care” surgery and radiotherapy.Results: Mouse models displayed distinct patterns of response to surgery, irradiation, and chemotherapy that varied with tumor subtype. Repurposing screens identified 3-hour infusions of gemcitabine as a relatively nontoxic and efficacious treatment of SEP and CPC. Combination neurosurgery, fractionated irradiation, and gemcitabine proved significantly more effective than surgery and irradiation alone, curing one half of all animals with aggressive forms of SEP.Conclusions: We report a comprehensive preclinical trial platform to assess the therapeutic activity of conventional and novel treatments among rare brain tumor subtypes. It also enables the development of complex, combination treatment regimens that should deliver optimal trial designs for clinical testing. Postirradiation gemcitabine infusion should be tested as new treatments of SEP and CPC. Clin Cancer Res; 24(7); 1654–66. ©2018 AACR.

Individuals with monogenic disorders can experience variable phenotypes that are influenced by genetic variation. To investigate this in sickle cell disease (SCD), we performed whole-genome sequencing (WGS) of 722 individuals with hemoglobin HbSS or HbSβ0-thalassemia from Baylor College of Medicine and from the St. Jude Children’s Research Hospital Sickle Cell Clinical Research and Intervention Program (SCCRIP) longitudinal cohort study. We developed pipelines to identify genetic variants that modulate sickle hemoglobin polymerization in red blood cells and combined these with pain-associated variants to build a polygenic score (PGS) for acute vaso-occlusive pain (VOP). Overall, we interrogated the α-thalassemia deletion −α3.7 and 133 candidate single-nucleotide polymorphisms (SNPs) across 66 genes for associations with VOP in 327 SCCRIP participants followed longitudinally over 6 years. Twenty-one SNPs in 9 loci were associated with VOP, including 3 (BCL11A, MYB, and the β-like globin gene cluster) that regulate erythrocyte fetal hemoglobin (HbF) levels and 6 (COMT, TBC1D1, KCNJ6, FAAH, NR3C1, and IL1A) that were associated previously with various pain syndromes. An unweighted PGS integrating all 21 SNPs was associated with the VOP event rate (estimate, 0.35; standard error, 0.04; P = 5.9 × 10−14) and VOP event occurrence (estimate, 0.42; standard error, 0.06; P = 4.1 × 10−13). These associations were stronger than those of any single locus. Our findings provide insights into the genetic modulation of VOP in children with SCD. More generally, we demonstrate the utility of WGS for investigating genetic contributions to the variable expression of SCD-associated morbidities.

Purpose: Curing all children with brain tumors will require an understanding of how each subtype responds to conventional treatments and how best to combine existing and novel therapies. It is extremely challenging to acquire this knowledge in the clinic alone, especially among patients with rare tumors. Therefore, we developed a preclinical brain tumor platform to test combinations of conventional and novel therapies in a manner that closely recapitulates clinic trials. Experimental Design: A multidisciplinary team was established to design and conduct neurosurgical, fractionated radiotherapy and chemotherapy studies, alone or in combination, in accurate mouse models of supratentorial ependymoma (SEP) subtypes and choroid plexus carcinoma (CPC). Extensive drug repurposing screens, pharmacokinetic, pharmacodynamic, and efficacy studies were used to triage active compounds for combination preclinical trials with “standard-of-care” surgery and radiotherapy. Results: Mouse models displayed distinct patterns of response to surgery, irradiation, and chemotherapy that varied with tumor subtype. Repurposing screens identified 3-hour infusions of gemcitabine as a relatively nontoxic and efficacious treatment of SEP and CPC. Combination neurosurgery, fractionated irradiation, and gemcitabine proved significantly more effective than surgery and irradiation alone, curing one half of all animals with aggressive forms of SEP. Conclusions: We report a comprehensive preclinical trial platform to assess the therapeutic activity of conventional and novel treatments among rare brain tumor subtypes. It also enables the development of complex, combination treatment regimens that should deliver optimal trial designs for clinical testing. Postirradiation gemcitabine infusion should be tested as new treatments of SEP and CPC. Clin Cancer Res; 24(7); 1654–66. ©2018 AACR.

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors were potent hits against a mouse ependymoma cell line, but their effectiveness against central nervous system tumors will depend on their ability to cross the blood–brain barrier and attain a sufficient exposure at the tumor. Among 3-hydroxy-3-methylglutaryl coenzyme A inhibitors that had activity in vitro, we prioritized simvastatin (SV) as the lead compound for preclinical pharmacokinetic studies based on its potential for central nervous system penetration as determined from in silico models. Furthermore, we performed systemic plasma disposition and cerebral microdialysis studies of SV (100 mg/kg, p.o.) in a murine model of ependymoma to characterize plasma and tumor extracellular fluid (tECF) pharmacokinetic properties. The murine dosage of SV (100 mg/kg, p.o.) was equivalent to the maximum tolerated dose in patients (7.5 mg/kg, p.o.) based on equivalent plasma exposure of simvastatin acid (SVA) between the two species. SV is rapidly metabolized in murine plasma with 15 times lower exposure compared with human plasma. SVA exposure in tECF was

Background We report a phase I study to examine the pharmacokinetics, safety, and recommended dosage of weekly intravenous bolus 5-fluorouracil (5-FU) in children and young adults with recurrent ependymoma. Methods Patients 22 years of age or less with recurrent ependymoma were treated with bolus dosage 5-FU weekly for 4 weeks followed by a 2-week rest period, defining one cycle. Patients could continue on therapy for 16 cycles. The starting 5-FU dosage was 500 mg/m(2). Dose-limiting toxicity was determined after one cycle. Patients were initially enrolled according to a rolling-6 design; subsequent dose re-escalation phase was based on a 3 + 3 design. Results We treated patients at 400 (n = 6), 500 (n = 15), and 650 (n = 5) mg/m(2), with de-escalation due to toxicity. Twenty-three of twenty-six patients enrolled were evaluable. Five patients experienced grade 4 neutropenia (n = 2: 650 mg/m(2); n = 3: 500 mg/m(2)). One patient experienced grade 3 diarrhea. At 500 mg/m(2), the median 5-FU maximal concentration, AUC0-∞, and alpha half-life were 825 µM, 205 µM × h, and 9.9 min, respectively. Interim analysis revealed an association between hematologic toxicity and prior number of chemotherapeutic regimens (P = .03). The study was amended to re-escalate the dosage in a less heavily pretreated cohort of patients. Conclusions These phase I clinical data provide initial pharmacokinetic parameters to describe i.v. bolus 5-FU disposition in children with recurrent ependymoma. Tumor exposures effective in preclinical testing can be achieved with tolerable bolus dosages in patients. Bolus 5-FU is well tolerated and possesses antitumor activity.

Cancers are characterized by non-random chromosome copy number alterations that presumably contain oncogenes and tumor-suppressor genes (TSGs). The affected loci are often large, making it difficult to pinpoint which genes are driving the cancer. Here we report a cross-species in vivo screen of 84 candidate oncogenes and 39 candidate TSGs, located within 28 recurrent chromosomal alterations in ependymoma. Through a series of mouse models, we validate eight new ependymoma oncogenes and ten new ependymoma TSGs that converge on a small number of cell functions, including vesicle trafficking, DNA modification and cholesterol biosynthesis, identifying these as potential new therapeutic targets.

The treatment of children with primary central nervous system (CNS) tumors continues to be a challenge despite recent advances in technology and diagnostics. In this overview, we describe our approach for identifying and evaluating active anticancer drugs through a process that enables rational translation from the lab to the clinic. The preclinical approach we discuss uses tumor subgroup-specific models of pediatric CNS tumors, cerebral microdialysis sampling of tumor extracellular fluid (tECF), and pharmacokinetic modeling and simulation to overcome challenges that currently hinder researchers in this field. This approach involves performing extensive systemic (plasma) and target site (CNS tumor) pharmacokinetic studies. Pharmacokinetic modeling and simulation of the data derived from these studies are then used to inform future decisions regarding drug administration, including dosage and schedule. Here, we also present how our approach was used to examine two FDA approved drugs, simvastatin and pemetrexed, as candidates for new therapies for pediatric CNS tumors. We determined that due to unfavorable pharmacokinetic characteristics and insufficient concentrations in tumor tissue in a mouse model of ependymoma, simvastatin would not be efficacious in further preclinical trials. In contrast to simvastatin, pemetrexed was advanced to preclinical efficacy studies after our studies determined that plasma exposures were similar to those in humans treated at similar tolerable dosages and adequate unbound concentrations were found in tumor tissue of medulloblastoma-bearing mice. Generally speaking, the high clinical failure rates for CNS drug candidates can be partially explained by the fact that therapies are often moved into clinical trials without extensive and rational preclinical studies to optimize the transition. Our approach addresses this limitation by using pharmacokinetic and pharmacodynamic modeling of data generated from appropriate in vivo models to support the rational testing and usage of innovative therapies in children with CNS tumors.

High-throughput screens (HTS) of compound toxicity against cancer cells can identify thousands of potential new drug-leads. But only limited numbers of these compounds can progress to expensive and labor intensive efficacy studies in mice, creating a ‘bottle-neck’ in the drug development pipeline. Approaches that triage drug-leads for further study are greatly needed. Here, we provide an intermediary platform between HTS and mice by adapting mouse models of pediatric brain tumors to grow as orthotopic xenografts in the brains of zebrafish. Freshly isolated mouse ependymoma, glioma and choroid plexus carcinoma cells expressing red fluorescence protein (RFP) were conditioned to grow at 34°C. Conditioned tumor cells were then transplanted orthotopically into the brains of zebrafish acclimatized to ambient temperatures of 34°C. Live in vivo fluorescence imaging identified robust, quantifiable and reproducible brain tumor growth as well as spinal metastasis in zebrafish. All tumor xenografts in zebrafish retained the histological characteristics of the corresponding parent mouse tumor and efficiently recruited fish endothelial cells to form a tumor vasculature. Finally, by treating zebrafish harboring ERBB2-driven gliomas with an appropriate cytotoxic chemotherapy (5-fluorouracil) or tyrosine kinase inhibitor (Erlotinib), we show that these models can effectively assess drug efficacy. Our data demonstrate, for the first time, that mouse brain tumors can grow orthtopically in fish and serve as a platform to study drug efficacy. Since large cohorts of brain tumor bearing zebrafish can be generated rapidly and inexpensively, these models may serve as a powerful tool to triage drug-leads from HTS for formal efficacy testing in mice.

The generation of natural product libraries containing column fractions, each with only a few small molecules, using a high-throughput, automated fractionation system, has made it possible to implement an improved dereplication strategy for selection and prioritization of leads in a natural product discovery program. Analysis of databased UPLC-MS-ELSD-PDA information of three leads from a biological screen employing the ependymoma cell line EphB2-EPD generated details on the possible structures of active compounds present. The procedure allows the rapid identification of known compounds and guides the isolation of unknown compounds of interest. Three previously known flavanone-type compounds, homoeriodictyol (1), hesperetin (2), and sterubin (3), were identified in a selected fraction derived from the leaves of Eriodictyon angustifolium. The lignan compound deoxypodophyllotoxin (8) was confirmed to be an active constituent in two lead fractions derived from the bark and leaves of Thuja occidentalis. In addition, two new but inactive labdane-type diterpenoids with an uncommon triol side chain were also identified as coexisting with deoxypodophyllotoxin in a lead fraction from the bark of T. occidentalis. Both diterpenoids were isolated in acetylated form, and their structures were determined as 14S,15-diacetoxy-13R-hydroxylabd-8(17)-en-19-oic acid (9) and 14R,15-diacetoxy-13S-hydroxylabd-8(17)-en-19-oic acid (10), respectively, by spectroscopic data interpretation and X-ray crystallography. This work demonstrates that a UPLC-MS-ELSD-PDA database produced during fractionation may be used as a powerful dereplication tool to facilitate compound identification from chromatographically tractable small-molecule natural product libraries.

To better understand neuroblastoma differentiation, we used microarray analysis to identify common gene expression changes from three differentiation models. This revealed STMN4 and ROBO2 to be consistently up-regulated in differentiated neuroblastoma cells induced by chromosome 1 transfer, MYCN knockdown, and 9-cis retinoic acid (9cRA). Furthermore, stable expression of transfected STMN4 or ROBO2 induced differentiation in IMR-32 cells. STMN4 and ROBO2 expression also increased in other 9cRA-induced differentiated neuroblastoma cell lines. Of clinical importance is that neuroblastoma patients with higher tumour mRNA expression of STMN4 and ROBO2 had better progression-free survival. This study highlights the importance of STMN4 and ROBO2 during neuroblastoma differentiation.

Summary Using a mouse model of ependymoma—a chemoresistant brain tumor—we combined multicell high-throughput screening (HTS), kinome-wide binding assays, and in vivo efficacy studies, to identify potential treatments with predicted toxicity against neural stem cells (NSC). We identified kinases within the insulin signaling pathway and centrosome cycle as regulators of ependymoma cell proliferation, and their corresponding inhibitors as potential therapies. FDA approved drugs not currently used to treat ependymoma were also identified that posses selective toxicity against ependymoma cells relative to normal NSCs both in vitro and in vivo, e.g., 5-fluorouracil. Our comprehensive approach advances understanding of the biology and treatment of ependymoma including the discovery of several treatment leads for immediate clinical translation.

The introduction of cultured p185BCR-ABL-expressing (p185+) Arf−/− pre-B cells into healthy syngeneic mice induces aggressive acute lymphoblastic leukemia (ALL) that genetically and phenotypically mimics the human disease. We adapted this high-throughput Philadelphia chromosome–positive (Ph+) ALL animal model for in vivo luminescent imaging to investigate disease progression, targeted therapeutic response, and ALL relapse in living mice. Mice bearing high leukemic burdens (simulating human Ph+ ALL at diagnosis) entered remission on maximally intensive, twice-daily dasatinib therapy, but invariably relapsed with disseminated and/or central nervous system disease. Although relapse was frequently accompanied by the eventual appearance of leukemic clones harboring BCR-ABL kinase domain (KD) mutations that confer drug resistance, their clonal emergence required prolonged dasatinib exposure. KD P-loop mutations predominated in mice receiving less intensive therapy, whereas high-dose treatment selected for T315I “gatekeeper” mutations resistant to all 3 Food and Drug Administration–approved BCR-ABL kinase inhibitors. The addition of dexamethasone and/or L-asparaginase to reduced-intensity dasatinib therapy improved long-term survival of the majority of mice that received all 3 drugs. Although non–tumor-cell–autonomous mechanisms can prevent full eradication of dasatinib-refractory ALL in this clinically relevant model, the emergence of resistance to BCR-ABL kinase inhibitors can be effectively circumvented by the addition of “conventional” chemotherapeutic agents with alternate antileukemic mechanisms of action.

Although sickle cell disease (SCD) is a monogenic disorder, the severity and specific organ dysfunction and failure are strongly influenced by genetic modifiers. Rapid identification of all modifiers in patients and well-phenotyped cohorts will better define the impact of relevant variants on clinical status, inform disease biology, and identify new therapeutic strategies. We created the Sickle Genome Project (SGP), a whole genome sequencing (WGS) strategy, to define genomic variation and modifiers of SCD. We performed WGS on 871 African American SCD patients from St. Jude Children's Research Hospital who participated in the Sickle Cell Clinical Research and Intervention Program (SCCRIP, Hankins et al. Pediatr Blood Cancer, 2018) and Texas Children's Hospital Hematology Center (TCHC). We developed robust pipelines for accurate detection of single nucleotide polymorphisms (SNPs), identification of structural variants and data retrieval/sharing via the St. Jude Cloud platform (to be described elsewhere). Notable findings include: 1) Confirmed associations of common genetic modifiers with SCD phenotypes, including levels of fetal hemoglobin (BCL11A, HBS1L-MYB, HBB), bilirubin (UGT1A1), and microalbuminuria (APOL1). Additional associations approaching genome-wide significance require further investigation, including replication in independent samples. 2) Improved determination of the SCD modifier α-thalassemia. The most common α-thalassemia mutations in SCD are 3.7 kb or 4.2 kb deletions (-α3.7 and -α4.2 alleles), which arose from recombination between homologous HBA1 and HBA2 genes and are difficult to map using standard WGS reads. Three independent crossover events are described for -α3.7 and one for -α4.2 in SCD cohorts. We developed a novel approach to identify α-globin gene deletions by local de novo assembly of WGS data and coverage depth analysis. We identified 5 -α3.7 alleles (frequencies 0.77-32.12%) and 7 -α4.2 alleles (frequencies 0.19-5.77%). Collectively, the frequency of all -α alleles was 57%, reflecting at least 12 distinct recombination events, greatly exceeding previously published counts. These findings better define the evolution of α-globin genes to allow improved understanding of their regulation and influence on SCD. 3) Characterization of β0-thalassemia alleles. Mutations in the extended β-globin locus influence SCD phenotypes. Five SGP patients had large β-globin (HBB) deletions associated with elevated fetal hemoglobin, which ameliorates symptoms of SCD. Twenty-three patients had HbSβ0-thalassemia, which reduces the severity of some SCD phenotypes. Overall, 48.6% (18/37) of patients clinically designated as HbSβ0 -thalassemia had no identified β-thalassemia mutation. Moreover, 4/680 patients (0.6%) designated HbSS were identified to be β0-thalassemia heterozygotes. The MCV, RBC and %HbA2 distributions overlapped substantially in correct vs. incorrect genotype assignments. Improved discrimination of HbSβ0 vs HbSS genotypes by WGS will better define associated phenotype differences to impact clinical care. 4) Determination of a genetic variant linked to vaso-occlusive crisis (VOC). Previously, a single GWAS study linked rs3115229, located 63.7 kb 5′ upstream of the KIAA1109 gene, with VOC at borderline significance (P = 5.63 × 10−8) (Chaturvedi et al, Blood 130, 2017). Using WGS data for 327 SGP participants (HbSS or HbSβ0-thalassemia) enrolled in the SCCRIPP study, we found strong association (p = 7 x 10-5) between the onset of VOC and a 4-SNP diplotype within an adjacent LD block of the KIAA1109-TENR-IL2-IL21 region (chr4: 122.8Mb - 123.8Mb) which has been previously associated with numerous inflammatory disorders. We validated this association using imputed genome-wide array data in an independent group of SCD patients (Sleep and Asthma Cohort, n= 181 patients, p = 0.05) (Cohen et al, Ann Am Thorac Soc, 2016). This works provides confirmation that the region surrounding KIAA1109 is associated with pain crisis in SCD. Our studies provide new information on the genomic architecture of SCD patients and delineate a consolidated approach for future applications of precision medicine. Disclosures Hankins: Novartis: Research Funding; Global Blood Therapeutics: Research Funding; NCQA: Consultancy; bluebird bio: Consultancy. Estepp:Global Blood Therapeutics: Consultancy, Research Funding; ASH Scholar: Research Funding; NHLBI: Research Funding; Daiichi Sankyo: Consultancy.

SummaryThe mammalian PCP pathway regulates diverse developmental processes requiring coordinated cellular movement, including neural tube closure and cochlear stereociliary orientation. Here, we show that epidermal wound repair is regulated by PCP signaling. Mice carrying mutant alleles of PCP genes Vangl2, Celsr1, PTK7, and Scrb1, and the transcription factor Grhl3, interact genetically, exhibiting failed wound healing, neural tube defects, and disordered cochlear polarity. Using phylogenetic analysis, ChIP, and gene expression in Grhl3−/− mice, we identified RhoGEF19, a homolog of a RhoA activator involved in PCP signaling in Xenopus, as a direct target of GRHL3. Knockdown of Grhl3 or RhoGEF19 in keratinocytes induced defects in actin polymerization, cellular polarity, and wound healing, and re-expression of RhoGEF19 rescued these defects in Grhl3-kd cells. These results define a role for Grhl3 in PCP signaling and broadly implicate this pathway in epidermal repair.

The childhood brain tumor, medulloblastoma, includes four subtypes with very different prognoses. Here, we show that paracrine signals driven by mutant β-catenin in WNT-medulloblastoma, an essentially curable form of the disease, induce an aberrant fenestrated vasculature that permits the accumulation of high levels of intra-tumoral chemotherapy and a robust therapeutic response. In contrast, SHH-medulloblastoma, a less curable disease subtype, contains an intact blood brain barrier, rendering this tumor impermeable and resistant to chemotherapy. The medulloblastoma-endothelial cell paracrine axis can be manipulated in vivo, altering chemotherapy permeability and clinical response. Thus, medulloblastoma genotype dictates tumor vessel phenotype, explaining in part the disparate prognoses among medulloblastoma subtypes and suggesting an approach to enhance the chemoresponsiveness of other brain tumors.

Clofarabine, a deoxyadenosine analog, was an active anticancer drug in our in vitro high-throughput screening against mouse ependymoma neurospheres. To characterize the clofarabine disposition in mice for further preclinical efficacy studies, we evaluated the plasma and central nervous system disposition in a mouse model of ependymoma. A plasma pharmacokinetic study of clofarabine (45 mg/kg, IP) was performed in CD1 nude mice bearing ependymoma to obtain initial plasma pharmacokinetic parameters. These estimates were used to derive D-optimal plasma sampling time points for cerebral microdialysis studies. A simulation of clofarabine pharmacokinetics in mice and pediatric patients suggested that a dosage of 30 mg/kg IP in mice would give exposures comparable to that in children at a dosage of 148 mg/m2. Cerebral microdialysis was performed to study the tumor extracellular fluid (ECF) disposition of clofarabine (30 mg/kg, IP) in the ependymoma cortical allografts. Plasma and tumor ECF concentration–time data were analyzed using a nonlinear mixed effects modeling approach. The median unbound fraction of clofarabine in mouse plasma was 0.79. The unbound tumor to plasma partition coefficient (K pt,uu: ratio of tumor to plasma AUCu,0–inf) of clofarabine was 0.12 ± 0.05. The model-predicted mean tumor ECF clofarabine concentrations were below the in vitro 1-h IC50 (407 ng/mL) for ependymoma neurospheres. Thus, our results show the clofarabine exposure reached in the tumor ECF was below that associated with an antitumor effect in our in vitro washout study. Therefore, clofarabine was de-prioritized as an agent to treat ependymoma, and further preclinical studies were not pursued.

Co-targeting of both de novo and salvage pathways for dCTP biosynthesis shows efficacy in T-ALL and B-ALL., Pharmacological targeting of metabolic processes in cancer must overcome redundancy in biosynthetic pathways. Deoxycytidine (dC) triphosphate (dCTP) can be produced both by the de novo pathway (DNP) and by the nucleoside salvage pathway (NSP). However, the role of the NSP in dCTP production and DNA synthesis in cancer cells is currently not well understood. We show that acute lymphoblastic leukemia (ALL) cells avoid lethal replication stress after thymidine (dT)-induced inhibition of DNP dCTP synthesis by switching to NSP-mediated dCTP production. The metabolic switch in dCTP production triggered by DNP inhibition is accompanied by NSP up-regulation and can be prevented using DI-39, a new high-affinity small-molecule inhibitor of the NSP rate-limiting enzyme dC kinase (dCK). Positron emission tomography (PET) imaging was useful for following both the duration and degree of dCK inhibition by DI-39 treatment in vivo, thus providing a companion pharmacodynamic biomarker. Pharmacological co-targeting of the DNP with dT and the NSP with DI-39 was efficacious against ALL models in mice, without detectable host toxicity. These findings advance our understanding of nucleotide metabolism in leukemic cells, and identify dCTP biosynthesis as a potential new therapeutic target for metabolic interventions in ALL and possibly other hematological malignancies.

Signaling by the BCR-ABL fusion kinase drives Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph+ ALL) and chronic myelogenous leukemia (CML). Despite their clinical activity in many patients with CML, the BCR-ABL kinase inhibitors (BCR-ABL-KIs) imatinib, dasatinib, and nilotinib provide only transient leukemia reduction in patients with Ph+ ALL. While host-derived growth factors in the leukemia microenvironment have been invoked to explain this drug resistance, their relative contribution remains uncertain. Using genetically defined murine Ph+ ALL cells, we identified interleukin 7 (IL-7) as the dominant host factor that attenuates response to BCR-ABL-KIs. To identify potential combination drugs that could overcome this IL-7-dependent BCR-ABL-KI-resistant phenotype, we screened a small-molecule library including Food and Drug Administration-approved drugs. Among the validated hits, the well-tolerated antimalarial drug dihydroartemisinin (DHA) displayed potent activity in vitro and modest in vivo monotherapy activity against engineered murine BCR-ABL-KI-resistant Ph+ ALL. Strikingly, cotreatment with DHA and dasatinib in vivo strongly reduced primary leukemia burden and improved long-term survival in a murine model that faithfully captures the BCR-ABL-KI-resistant phenotype of human Ph+ ALL. This cotreatment protocol durably cured 90% of treated animals, suggesting that this cell-based screening approach efficiently identified drugs that could be rapidly moved to human clinical testing.

This work was supported by grants from the NIH (R.J.G., P01CA96832 and P30CA021765), the American Lebanese Syrian Associated Charities and Cancer Research UK.

Nutlin-3a is an MDM2 inhibitor that is under investigation in preclinical models for a variety of pediatric malignancies, including retinoblastoma, rhabdomyosarcoma, neuroblastoma, and leukemia. We used physiologically based pharmacokinetic (PBPK) modeling to characterize the disposition of nutlin-3a in the mouse. Plasma protein binding and blood partitioning were assessed by in vitro studies. After intravenous (10 and 20 mg/kg) and oral (50, 100, and 200 mg/kg) dosing, tissue concentrations of nutlin-3a were determined in plasma, liver, spleen, intestine, muscle, lung, adipose, bone marrow, adrenal gland, brain, retina, and vitreous fluid. The PBPK model was simultaneously fit to all pharmacokinetic data using NONMEM. Nutlin-3a exhibited nonlinear binding to murine plasma proteins, with the unbound fraction ranging from 0.7 to 11.8%. Nutlin-3a disposition was characterized by rapid absorption with peak plasma concentrations at approximately 2 h and biphasic elimination consistent with a saturable clearance process. The final PBPK model successfully described the plasma and tissue disposition of nutlin-3a. Simulations suggested high bioavailability, rapid attainment of steady state, and little accumulation when administered once or twice daily at dosages up to 400 mg/kg. The final model was used to perform simulations of unbound tissue concentrations to determine which dosing regimens are appropriate for preclinical models of several pediatric malignancies.

stroma content and vascularization. At the transcriptomic level, we identified several PDX clusters similar to Goblet-like, Enterocyte, Transit-Amplifying, Inflammatory and Stem-like subtypes recently reported in CRC patients. In addition, well and moderately differentiated PDX showed a different gene expression profile than poorly and undifferentiated models. At the genomic level, the colon PDX models exhibited alteration profiles comparable to those reported for patient tumors regarding signatures of mutational processes (patient-age related or associated to mismatch repair gene deficiencies), chromosomal rearrangement and mutated genes (e.g. APC, TP53, KRAS and TP53). Moreover, we identified 6 PDX models with microsatellite instability (MSI), 5 of them being hyper-mutant with a loss of MLH1 expression. Interestingly, colon PDX displaying the MSI phenotype showed gene expression patterns of the Globlet-like or Inflammatory subtypes. To demonstrate the potential of our approach, we searched for molecular determinants of cetuximab sensitivity in colon PDX by combining in vivo drug sensitivity and molecular data. The study identified the Transit Amplifying subtype, AREG/EREG expression and KRAS mutation among the best predictors of response. Similarly, predictive biomarkers for oxaliplatin and irinotecan were found, and their associations with particular PDX subtypes are under investigation. The accuracy in predicting patient outcome following treatment with FOLFOX and FOLFIRI will be evaluated by assessing publicly available datasets. The comprehensive characterization of our colon PDX models confirmed their similarities with patient tumors and their inter-tumoral diversity. The combined use of PDX molecular and drug sensitivity data represents a promising approach for biomarker identification and tumor response prediction at a preclinical stage.

Clofarabine, a deoxyadenosine analog, was a potent hit in our in vitro high-throughput screening against murine ependymoma neurospheres. To prioritize clofarabine for further preclinical efficacy studies, we evaluated the plasma pharmacokinetic (PK) disposition and central nervous system penetration in a murine model of ependymoma. A plasma PK study of clofarabine (45 mg/kg IP) was performed using CD1 nude mice bearing ependymoma cortical allographs (Ink4a/Arf-null + RTBDN) to obtain initial plasma PK parameters. These estimates were used to derive D-optimal plasma sampling time-points (e.g., 0.25, 2.5, and 5 hr) for cerebral microdialysis studies. Comparison of the clofarabine systemic exposure obtained from the plasma PK study and that simulated from pediatric patients using a published population PK model (Bonate, Cancer Chemotherap Pharmacol, 2011) suggested a dosage of 30 mg/kg in mice would be equivalent to a pediatric dosage of 180 mg/m2 given as a 2 hr infusion. Cerebral microdialysis was applied in CD1 nude mice bearing ependymoma cortical allographs (Ink4a/Arf-null + RTBDN), which permitted repeated in situ sampling of clofarabine tumor extracellular fluid (tECF). A microdialysis probe (BASi; 1 mm membrane) was introduced into the tumor through a cannula inserted during tumor cell implantation. After microdialysis probe equilibration, 7 mice were dosed with 30 mg/kg of clofarabine IP. In each mouse, serial plasma samples were collected at 0.25, 2.5, and 5 h post-dose, and tECF dialysate fractions were collected over 60 min intervals for up to 5 h post-dose. To measure clofarabine in both plasma and tECF, a robust, sensitive LC-MS/MS method was developed and validated. Both within-day and between-day precision (%CV) were ≤ 5.1% and accuracy ranged from 86% to 109%. A two-compartment model with absorption and tumor compartments linked to a central compartment was fitted to plasma and tECF concentration-time data using a nonlinear mixed effects modeling approach (NONMEM 7.2.0). For modeling purposes, the volume of the tECF compartment was fixed to published values. Unbound fraction of clofarabine in murine plasma was 0.82 ± 0.14. The model derived area under unbound concentration-time curve (AUCu,0-8) values for 30 and 45 mg/kg dosages were 5185 ± 550 µg/L*hr and 7677 ± 699 µg/L*hr, respectively. Clofarabine was absorbed rapidly from the peritoneal cavity with Tmax (time to reach maximum concentration) value of 0.33 ± 0.17 hr. Tumor to plasma partition coefficient (Kpt,uu: ratio of tumor to plasma AUCu,0-inf) of clofarabine was 0.12 ± 0.05. The model predicted mean tECF clofarabine concentrations were below the in vitro 1-hr IC50 (1.34 µM) for ependymoma neurospheres. In summary, we have shown the tECF clofarabine concentrations were below that required for antitumor effect in our in vitro washout studies, thus we have not pursued clofarabine for detailed efficacy studies in our preclinical pipeline. Citation Format: Yogesh T. Patel, Megan O. Jacus, Abigail D. Davis, Pradeep Vuppala, Jason D. Dapper, Burgess B. Freeman, Nidal Boulos, Stacy L. Throm, Richard J. Gilbertson, Clinton F. Stewart. Clofarabine, a potent anticancer compound with limited penetration in an orthotopic murine model of ependymoma. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4645. doi:10.1158/1538-7445.AM2014-4645

Abstract 540 Expression of the constitutively active tyrosine kinase BCR-ABL1 is the hallmark of two diseases with distinct pathologic and clinical features: chronic myeloid leukemia (CML), an expansion of relatively mature granulocytes that typically responds well to kinase inhibition, and pre-B cell acute lymphoblastic leukemia (ALL), an aggressive malignancy of lymphoid progenitors that has a dismal prognosis. The basis for this dichotomy has been poorly understood. Recent studies profiling genome-wide DNA copy number alterations in CML and ALL have identified common deletions of IKZF1 (encoding the lymphoid transcription factor IKAROS) in de novo BCR-ABL1 positive ALL, and at the progression of CML to lymphoid blast crisis, suggesting that perturbation of IKAROS activity is a key event in the pathogenesis of BCR-ABL1 lymphoid leukemia. The IKAROS alterations commonly involve coding exons 3–6, resulting in expression of a dominant negative IKAROS isoform, IK6. Moreover, the presence of IKZF1 alterations is associated with poor outcome in BCR-ABL1 ALL. We have previously shown in a retroviral bone marrow transplant model of BCR-ABL1 ALL that Ikzf1 loss results in increased penetrance of leukemia, but the role of IK6 in the pathogenesis of ALL has not been studied. Here, we have examined the effect of the expression of Ik6 in a retroviral bone marrow transplant model of murine BCR-ABL1 B-progenitor ALL. Unmanipulated marrow from C57BL/6 Arf null mice was transduced with MSCV retrovirus coexpressing p185 BCR-ABL1 and luciferase, plated for 8 days to derive pre-B cells, then transduced with MSCV retrovirus expressing either wildtype Ikaros (Ik1-RFP), Ik6-RFP, or empty vector. Expression of Ik1 was not tolerated and resulted in cell death and apoptosis. IK6 expression led to increased proliferation of p185+Arf null cells with reduced sensitivity to the BCR-ABL1 kinase inhibitor dasatinib compared to cells transduced with empty vector. Intracellular phosphosignaling analysis of Crkl phosphorylation demonstrated that this reduced sensitivity to dasatinib was independent of ABL1 inhibition. Gene expression profiling of p185+Arf null-Ik6 cells revealed a gene expression signature similar to that of human BCR-ABL1+ ALL with enrichment of hematopoietic stem cells genes as well as genes involved in B-cell receptor, Notch, and Jak-Stat signaling pathways. To test the role of Ik6 in leukemogenesis and treatment responsiveness in vivo, p185 BCR-ABL1-luciferase Arf null cells were transduced with MSCV retrovirus expressing GFP alone, Ik1-GFP, or Ik6-GFP then transplanted into lethally irradiated C57BL/6 recipients. Expression of Ik6 in vivo led to accelerated tumorigenesis and decreased survival with tumors uniformly of pre-B immunophenotype. Moreover, mice transplanted with Ik6-expressing marrow were less sensitive to dasatinib therapy (10mg/kg QD initiated 7 days post-BMT) compared to control mice (19d vs. 31.5d, p Disclosures: No relevant conflicts of interest to declare.

Despite the dramatic efficacies of imatinib and second-generation BCR-ABL kinase inhibitors (dasatinib and nilotinib) in chronic myelogenous leukemia (CML), these drugs fail to provide durable therapeutic benefit in patients with Philadelphia-chromosome positive (Ph+) BCR-ABL-induced acute lymphoblastic leukemias (ALLs). In contrast to chronic-phase CML, deletion of the CDKN2A (INK4A-ARF) tumor suppressor locus occurs in 65% of Ph+ ALL cases. Accordingly, introduction of cultured Arf−/− p185BCR-ABL-expressing (p185+) pre-B cells, but not their Arf+/+ counterparts, into healthy syngeneic recipient mice induces fulminant B cell leukemia; virtually every p185+, Arf−/− cell is a leukemia-initiating cell (LIC). We have now monitored disease progression and dasatinib-responsiveness in vivo by following the fate of p185+ Arf−/− luciferase-expressing LICs. In animals bearing high leukemic burdens (simulating the human clinical condition at diagnosis), two weeks of dasatinib therapy induced dramatic reductions in luminescent signals, but all animals harbored persistent, measurable deposits of drug-refractory cells. The vast majority of BCR-ABL alleles from these residual cells were free of kinase domain (KD) mutations, but rare leukemic clones harboring the T315I KD mutation, known to confer near-complete drug resistance to imatinib, dasatinib and nilotinib, were detectable in a subset of recipients. Following several weeks of continued dasatinib therapy, all mice developed clinical relapse preceded by dramatic increases in luminescent signals, both in the hematopoietic compartment and central nervous system. Many of these drug-resistant leukemic cells now harbored the T315I KD mutation. Animals that had been maintained in remission with 4 weeks of continuous dasatinib therapy quickly relapsed upon therapy discontinuation, almost always without evidence of KD mutations. In this clinically-relevant Ph+ ALL model, several factors including Arf loss-of-function, disease burden, intensity of therapy, and length of drug exposure interact to determine therapeutic outcome and to trigger confluent mechanisms of drug resistance. Critically, while continuous dasatinib therapy efficiently selects for and maintains cells harboring drug-resistant KD mutations that mediate eventual clinical relapse, most drug-refractory leukemic cells survive in hematopoietic tissues in the absence of KD mutations during maintenance therapy, implying that mutation-independent factors sustain LIC survival. We propose that Arf inactivation in Ph+ ALL (but not in CML) enhances the biological ‘fitness’ of leukemic cells and diminishes the efficiency with which targeted therapy can successfully eradicate drug-refractory disease. This facilitates the subsequent emergence of cell-intrinsic drug resistance, most frequently manifested as BCR-ABL KD mutations. Citation Information: Mol Cancer Ther 2009;8(12 Suppl):A253.

Despite the dramatic efficacy of imatinib and second-generation BCR-ABL kinase inhibitors (dasatinib and nilotinib) in chronic myelogenous leukemia (CML), these drugs fail to provide durable therapeutic benefit in patients with Philadelphia-chromosome positive (Ph+) BCR-ABL-induced acute lymphoblastic leukemias (ALL). In contrast to chronic-phase CML, deletion of the CDKN2A (INK4A-ARF) tumor suppressor locus occurs in diagnostic blast samples from 65% of Ph+ ALL patients. Introduction of cultured Arf−/− p185BCR-ABL-expressing (p185+) pre-B cells, but not their Arf+/+ counterparts, into healthy syngeneic recipient mice induces fulminant B cell leukemia. Virtually every p185+, Arf−/− cell has leukemia-initiating cell capacity. We have now monitored disease progression and dasatinib-responsiveness in vivo by following the fate of leukemogenic p185+ Arf−/− donor cells engineered to express luciferase. When dasatinib therapy is initiated in recipients with low leukemic burdens, most animals remain in remission for many weeks, but some ultimately relapse on therapy or soon after drug discontinuation. Most resistant leukemias sustained kinase domain (KD) mutations, most frequently in the ATP-binding (‘P’) loop, that only modestly impact drug sensitivity. In contrast, in animals bearing high leukemic burdens (simulating the human clinical condition at diagnosis), dasatinib therapy induced dramatic reductions in luminescent signals, but all animals harbored persistent, measurable deposits of drug-resistant cells. Residual drug-refractory ALL cells recovered from these otherwise healthy animals contained rare clones expressing the T315I mutation known to confer drug resistance to imatinib, dasatinib and nilotinib, and most frequently associated with clinical resistance in Ph+ ALL. However, the vast majority of BCR-ABL alleles were mutation-free, implying that KD mutations could not be solely responsible for drug resistance. Following continued therapy, these mice underwent clinical relapse preceded by dramatic increases in luminescent signals, both in the hematopoietic compartment and central nervous system. Many of these drug-resistant leukemias now harbored the T315I KD mutation. Animals that had been maintained in remission with 4 weeks of continuous dasatinib therapy quickly relapsed upon therapy discontinuation, almost always without evidence of BCR-ABL KD mutations. Together, these studies indicate that in this clinically-relevant Ph+ ALL model, several factors including Arf lossof- function, disease burden, intensity of therapy, and length of drug exposure interact to determine therapeutic outcome and to trigger confluent mechanisms of drug resistance. Critically, while continuous dasatinib therapy efficiently selects for and maintains cells harboring drug-resistant KD mutations that mediate eventual clinical relapse, most drugrefractory leukemic cells survive in the absence of KD mutations during maintenance therapy, implying that mutation-independent factors facilitate persistence of residual leukemic disease. We propose that Arf inactivation in Ph+ ALL (but not in CML) enhances the biological ‘fitness’ of leukemic cells and diminishes the efficiency with which targeted therapy can successfully eradicate drug-refractory disease. This facilitates the subsequent emergence of cell-intrinsic drug resistance, most frequently manifested as BCR-ABL KD mutations.

Retroviral vector-mediated transduction of the BCR-ABL tyrosine kinase into Arf-deficient mouse bone marrow progenitors allows rapid ex vivo outgrowth of pure pre-B cell populations that induce a highly aggressive form of ALL when inoculated intravenously into healthy syngeneic mice. These leukemias resist therapy with the BCR-ABL kinase inhibitor imatinib, and surprisingly, drug resistance is non-tumor-cell autonomous. We now demonstrate that expression of the p185 BCR-ABL isoform (hereafter p185) in Arf-null pre-B cells is sufficient to generate polyclonal populations of leukemia-initiating cells (LICs), only 20 of which induce fatal, imatinib-resistant disease within one month after infusion. These p185+ Arf-null LICs are pre-B cells by immunophenotypic criteria, lack evidence of myeloid and stem cells markers, exhibit immunoglobulin heavy chain gene rearrangements and random proviral insertions, and are almost universally capable of initiating lethal, transplantable leukemias in healthy syngeneic recipient mice. Therefore, these LICs do not represent rare ‘cancer stem cells’. Resistance to targeted therapy with imatinib in this model system is not dependent upon mutations within the BCR-ABL kinase domain, but, rather, is mediated through interactions between the LICs and the host environment. While cytokines like IL-7 are dispensable for the efficient generation of p185+, Arf-null cells, these LICs remain IL-7-responsive and are significantly protected from imatinib-induced cytostasis by IL-7 in vitro. Introduction of p185 into Arf-null hematopoietic progenitors that also lack the common gamma chain (γc) for cytokine receptors bypasses their cytokine requirements and permits pre-B cell development. These p185+, Arf-null, γc-null LICs also initiate ALL but exhibit much greater sensitivity to imatinib in vivo, allowing a significant fraction of treated mice to sustain long term remissions even when therapy is discontinued. Therefore, salutary cytokines expressed in the hematopoietic microenvironment facilitate leukemic proliferation and confer resistance to targeted therapy. Not surprisingly, single agent therapy with dasatinib, a second generation BCR-ABL kinase inhibitor, is dramatically more efficacious in this pre-clinical Ph+ ALL model, although some recipient mice still succumb to disease despite continuous drug treatment. Using vectors co-expressing p185 and luciferase, we are now initiating dasatinib therapy when recipient animals have detectable disease burdens, thereby permitting a more dynamic assessment of therapeutic response and subsequent failure. We speculate that in human Ph+ ALL, the frequent deletion of the INK4A-ARF locus (∼50% of cases at diagnosis) might help to maintain LIC survival in the face of targeted therapy and so facilitate the emergence of drug-resistant BCR-ABL variants. As such, INK4A-ARF deletion might prove to be a poor prognostic indicator.

Chemotherapies active in preclinical studies frequently fail in the clinic due to lack of efficacy, which limits progress for rare cancers since only small numbers of patients are available for clinical trials. Thus, a preclinical drug development pipeline was developed to prioritize potentially active regimens for pediatric brain tumors spanning from in vitro drug screening, through intracranial and intra-tumoral pharmacokinetics to in vivo efficacy studies. Here, as an example of the pipeline, data are presented for the combination of 5-fluoro-2′-deoxycytidine and tetrahydrouridine in three pediatric brain tumor models. The in vitro activity of nine novel therapies was tested against tumor spheres derived from faithful mouse models of Group 3 medulloblastoma, ependymoma, and choroid plexus carcinoma. Agents with the greatest in vitro potency were then subjected to a comprehensive series of in vivo pharmacokinetic (PK) and pharmacodynamic (PD) studies culminating in preclinical efficacy trials in mice harboring brain tumors. The nucleoside analog 5-fluoro-2′-deoxycytidine (FdCyd) markedly reduced the proliferation in vitro of all three brain tumor cell types at nanomolar concentrations. Detailed intracranial PK studies confirmed that systemically administered FdCyd exceeded concentrations in brain tumors necessary to inhibit tumor cell proliferation, but no tumor displayed a significant in vivo therapeutic response. Despite promising in vitro activity and in vivo PK properties, FdCyd is unlikely to be an effective treatment of pediatric brain tumors, and therefore was deprioritized for the clinic. Our comprehensive and integrated preclinical drug development pipeline should reduce the attrition of drugs in clinical trials. Electronic supplementary material The online version of this article (doi:10.1007/s11060-015-1965-0) contains supplementary material, which is available to authorized users.