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959 “Triple” Combination of Targeting Methyltransferase, BCL-2 and PD-1 Facilitates Therapeutic Responses in Acute Myeloid Leukemia (AML)

Program: Oral and Poster Abstracts
Session: 604. Molecular Pharmacology and Drug Resistance in Myeloid Diseases: Poster I
Hematology Disease Topics & Pathways:
AML, Diseases, Therapies, Combinations, Myeloid Malignancies
Saturday, December 5, 2020, 7:00 AM-3:30 PM

Zhihong Zeng, MD1*, Shelley Herbrich, PhD1, Tianyu Cai, PhD1*, Antonio Cavazos, MSc1*, Taylor Manzella1*, Helen Ma, MS1*, Vinitha Mary Kuruvilla, MSc1*, Kala Hayes1*, Jairo A. Matthews1*, Courtney D. DiNardo, MD, MSc2, Naval Daver, MD1 and Marina Konopleva, MD, PhD3

1Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
2Department of Leukemia, UT MD Anderson Cancer Center, Houston, TX
3Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, TX

Background

The long-term survival of AML, especially of older AML patients, under the established therapies remains poor. A recent breakthrough therapy of selective BCL-2 inhibitor venetoclax with hypomethylating agents (HMA) azacitidine or decitabine is approved to treat older and unfit patients with AML (DiNardo et.al. EHA 2020). This combination induces responses in > 65% of older AML patients, but the responses in relapsed/refractory AML patients are sub-optimal. Upregulation of programmed death-1 (PD-1) in T-cells is associated with AML immune-suppression, and combination of anti-PD-1 with azacitidine has activity in relapsed/refractory AML (Daver et. al. Cancer Discovery 2019). Recent pre-clinical findings indicate that venetoclax preserved T-cells immunity by sparing central memory T-cells and enhanced activity of anti-PD-1 antibodies in immune-competent mouse models in vivo (Mathew et.al. Blood 2018). In this study, we tested the hypothesis that PD-1 inhibition facilitates the depth and duration of response to venetoclax and HMA combination by reactivating T-cells mediated immunity against AML.

Results

We collected peripheral blood (PB) samples from trial patients before and after receiving the treatment of decitabine and venetoclax (Dec_Ven) (NCT03404193) and examined the percentage of AML blasts and T-cells by multi-parameter flow cytometry. The combination of Dec_Ven effectively reduced PB CD33+/CD34+ cells from 46 ± 15% at baseline (BL) to 27 ± 16% at 2.3 days (Day 1 – 3) (time point 1, or T1), and 15 ± 13% at 5.5 days (Day 3 – 8) (T2), and increased CD3+ T-cells: 28 ± 10% (BL), 54 ± 13% (T1) and 59 ± 19 % (T2), (BL vs.T1, CD33/CD34+, p = 0.001; CD3+, p = 0.02, n = 6). The reduction of CD33+/CD34+ positively correlated with the depletion of circulating blasts (R = 0.64, p = 0.0001).

Further analyzing the T-cells subsets among CD4 helper cells and CD8 cytotoxic cells, we found that Dec_Ven therapy promoted an activated T-cells phenotype by upregulating CD69 and PD-1 in both CD4 and CD8 cells in early time point samples, and led to T-cells exhaustion, as indicated by persistent expression of PD-1 at later time-point when CD69 was undetectable (PD-1 in CD3+CD4+ cells: 13 ± 2%, n = 6 (BL), 15 ± 3%, n = 6 (T1) and 22 ± 7%, n = 5 (T2); PD-1 in CD3+CD8+ cells: 14 ± 3%, n = 6 (BL), 27 ± 5%, n = 6, (T1), 29 ± 9%, n =5 (T2), BL vs. T1, p = 0.05). The persistent expression of PD-1 is a hallmark of T-cells exhaustion and immunosuppression (Jia et.al. Blood Cancer J 2018). Mass cytometry CyTOF immune-profiling of various compartments of CD4 and CD8 cells on PB uncovered that Dec_Ven reduced naïve T-cells (CD45RA+CCR7+) but spared or even increased frequencies of the central (CD45RA-CCR7+) and effector memory (CD45RA-CCR7-) CD4 or CD8 cells.

In parallel, we measured the serum cytokines levels, and found that treatment of Dec_Ven increased IL2, IL6 and INFg secretion in PB. IL2 and IL6 are two cytokines that regulate the proliferation and differentiation of effector memory T-cells; and INFg is a critical mediator of treatment-induced immune response.

To further test if targeting PD-1 induced anti-leukemia effect and amplified the effect of Dec_Ven, we treated leukemia cells collected before and after Dec_Ven therapy with anti-CD3 and anti-PD-1 antibodies in vitro. Treatment reduced CD33+/CD34+ cells in 2 of 3 pre-treatment samples (untreated vs. anti-CD3_PD-1: 55% vs. 15%, pt #6; 70% vs. 52%, pt #7) and synergistically reduced/eliminated the residual CD33+/CD34+ cells in AML samples obtained after Dec_Ven therapy (untreated vs. anti-CD3_PD-1: 84% vs. 66% Day 3, pt #3; 18% vs. 8% Day 3, pt #6; 44% vs. 35% Day 1, 5% vs. 2% Day 4, pt #7) (Fig.1).

Conclusions

Our data indicate that Dec_Ven therapy induces PD-1 expression on T-cells but selectively preserves potentially important anti-tumor T-cells immune subsets. The “triple” combination therapy of HMA with BCL-2 and PD-1 antagonists may facilitate anti-leukemia responses by enhancing T-cells function. Clinical trial to test this hypothesis is ongoing in relapsed/refractory AML patients (NCT02397720).

Disclosures: DiNardo: Agios: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Research Funding; Calithera: Research Funding; Celgene: Consultancy, Honoraria, Research Funding; Daiichi Sankyo: Consultancy, Honoraria, Research Funding; ImmuneOnc: Honoraria, Research Funding; Jazz: Honoraria; Takeda: Honoraria; Notable Labs: Membership on an entity's Board of Directors or advisory committees; MedImmune: Honoraria; Novartis: Consultancy. Daver: Bristol-Myers Squibb: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Karyopharm: Research Funding; Servier: Research Funding; Genentech: Research Funding; AbbVie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Astellas: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novimmune: Research Funding; Gilead: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding; Trovagene: Research Funding; Fate Therapeutics: Research Funding; ImmunoGen: Research Funding; Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Jazz: Consultancy, Membership on an entity's Board of Directors or advisory committees; Trillium: Consultancy, Membership on an entity's Board of Directors or advisory committees; Syndax: Consultancy, Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy, Membership on an entity's Board of Directors or advisory committees; KITE: Consultancy, Membership on an entity's Board of Directors or advisory committees; Agios: Consultancy, Membership on an entity's Board of Directors or advisory committees; Daiichi Sankyo: Consultancy, Membership on an entity's Board of Directors or advisory committees, Research Funding. Konopleva: Agios: Research Funding; Ascentage: Research Funding; AstraZeneca: Research Funding; Sanofi: Research Funding; Reata Pharmaceutical Inc.;: Patents & Royalties: patents and royalties with patent US 7,795,305 B2 on CDDO-compounds and combination therapies, licensed to Reata Pharmaceutical; Eli Lilly: Research Funding; Calithera: Research Funding; Kisoji: Consultancy; Stemline Therapeutics: Consultancy, Research Funding; Amgen: Consultancy; F. Hoffmann La-Roche: Consultancy, Research Funding; Cellectis: Research Funding; Ablynx: Research Funding; AbbVie: Consultancy, Research Funding; Forty-Seven: Consultancy, Research Funding; Rafael Pharmaceutical: Research Funding; Genentech: Consultancy, Research Funding.

*signifies non-member of ASH