Department of Translational Oncology, Genentech, Inc., South San Francisco, CA, USA.
Department of Leukemia, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA.
Haematologica. 2021 Apr 1;106(4):1034-1046. doi: 10.3324/haematol.2019.244020.
FLT3 internal tandem duplication (FLT3-ITD) mutations account for ~25% of adult acute myeloid leukemia cases and are associated with poor prognosis. Venetoclax, a selective BCL-2 inhibitor, has limited monotherapy activity in relapsed/refractory acute myeloid leukemia with no responses observed in a small subset of FLT3-ITD+ patients. Further, FLT3-ITD mutations emerged at relapse following venetoclax monotherapy and combination therapy suggesting a potential mechanism of resistance. Therefore, we investigated the convergence of FLT3-ITD signaling on the BCL-2 family proteins and determined combination activity of venetoclax and FLT3-ITD inhibition in preclinical models. In vivo, venetoclax combined with quizartinib, a potent FLT3 inhibitor, showed greater anti-tumor efficacy and prolonged survival compared to monotherapies. In a patient-derived FLT3-ITD+ xenograft model, cotreatment with venetoclax and quizartinib at clinically relevant doses had greater anti-tumor activity in the tumor microenvironment compared to quizartinib or venetoclax alone. Use of selective BCL-2 family inhibitors further identified a role for BCL-2, BCL-XL and MCL-1 in mediating survival in FLT3-ITD+ cells in vivo and highlighted the need to target all three proteins for greatest anti-tumor activity. Assessment of these combinations in vitro revealed synergistic combination activity for quizartinib and venetoclax but not for quizartinib combined with BCL-XL or MCL-1 inhibition. FLT3-ITD inhibition was shown to indirectly target both BCL-XL and MCL-1 through modulation of protein expression, thereby priming cells toward BCL-2 dependence for survival. These data demonstrate that FLT3-ITD inhibition combined with venetoclax has impressive anti-tumor activity in FLT3-ITD+ acute myeloid leukemia preclinical models and provides strong mechanistic rational for clinical studies.
FLT3 内部串联重复(FLT3-ITD)突变占成人急性髓系白血病病例的约 25%,与预后不良相关。维奈托克(一种选择性 BCL-2 抑制剂)在复发/难治性急性髓系白血病中的单药活性有限,在一小部分 FLT3-ITD+患者中观察到无反应。此外,FLT3-ITD 突变在维奈托克单药治疗和联合治疗后复发时出现,表明存在潜在的耐药机制。因此,我们研究了 FLT3-ITD 信号在 BCL-2 家族蛋白上的汇聚,并确定了维奈托克和 FLT3-ITD 抑制在临床前模型中的联合活性。在体内,维奈托克与强效 FLT3 抑制剂 quizartinib 联合使用,与单药治疗相比,具有更强的抗肿瘤疗效和更长的生存时间。在源自患者的 FLT3-ITD+异种移植模型中,与单独使用 quizartinib 或维奈托克相比,维奈托克和 quizartinib 的联合治疗在肿瘤微环境中具有更强的抗肿瘤活性,在临床相关剂量下使用选择性 BCL-2 家族抑制剂进一步确定了 BCL-2、BCL-XL 和 MCL-1 在介导 FLT3-ITD+细胞体内存活中的作用,并强调需要针对这三种蛋白进行最大程度的抗肿瘤活性。这些组合在体外的评估显示,quizartinib 和维奈托克具有协同组合活性,但 quizartinib 与 BCL-XL 或 MCL-1 抑制联合使用则没有。FLT3-ITD 抑制通过调节蛋白表达间接靶向 BCL-XL 和 MCL-1,从而使细胞向 BCL-2 依赖性存活方向发展。这些数据表明,FLT3-ITD 抑制联合维奈托克在 FLT3-ITD+急性髓系白血病临床前模型中具有显著的抗肿瘤活性,并为临床研究提供了强有力的机制合理性。