CC-92480 Enhances Cell-Autonomous Cytotoxicity through Blockade of G ₂/M Transition When Combined with Bortezomib/Dexamethasone in Pre-Clinical Multiple Myeloma

Background: Pomalidomide (POM) is an established agent in relapsed/refractory (R/R) multiple myeloma (MM). CC-92480, a novel cereblon E3 ligase modulator (CELMoD ^®) agent, is being investigated in R/R MM patients in combination with the proteasome inhibitor (PI) bortezomib (BTZ) and steroid dexamethasone (DEX) (NCT03374085/NCT03989414). Previously, we showed mechanistic synergy of POM/BTZ/DEX in MM cell line models (Bjorklund et al). Here we analyzed the cell autonomous cytotoxic activities of CC-92480 or POM alone and in combination with BTZ/DEX to compare and differentiate their mechanisms of action (MOA).

Results:

Comparative analysis of the anti-proliferative activity against H929 and MM1.S cell lines revealed that CC-92480 demonstrated a more potent inhibition of proliferation by 100-fold lower dose compared to POM. Combination experiments utilizing a titration of POM or CC-92480 in combination with a 1 hr BTZ pulse, to mimic the clinical pharmacokinetics (+/- DEX co-treatment) showed an enhancement of antiproliferative capacity in both doublet and triplet combinations compared to single agents. Combination indices for POM/BTZ/DEX or CC-92480/BTZ/DEX resulted in values <1 for most combinations indicating a synergistic effect. Additionally, POM or CC-92480 in combination with BTZ or DEX, or in triplet combinations increased induction of apoptosis (>90% for each triplet compared to POM (20%) and CC-92480 (40%). Flow cytometric analysis of Aiolos and Ikaros protein level in MM cells treated with POM/BTZ/DEX or CC-92480/BTZ/DEX resulted in a slight kinetic delay in substrate depletion at early time points (1-4 hr), where the effect is less apparent with CC-92480, and indistinguishable at 24 hr compared to single agent POM or CC-92480 in the clinically relevant concentrations.

We performed transcriptomic analyses of H929 cells treated with POM/BTZ/DEX or CC-92480/BTZ/DEX for 24 hrs to identify key pathways responsible for the observed synergistic combination effect. Common pathways dysregulated by POM or CC-92480 included previously identified interferon, protein homeostasis and proliferation gene sets. Gene set enrichment analysis (GSEA) showed many significant pathway differences when comparing the triplets, including general cell cycle progression, cell division and chromatin segregation. Interestingly, genes involved in negative regulation of G ₂/M transition were identified as one of the most significant differences between POM/BTZ/DEX and CC-92480/BTZ/DEX.

To understand how these pathways contributed to cell cycle effects and apoptosis, we assessed DNA fragmentation by TUNEL in conjunction with cell cycle flow cytometry to examine cell cycle specific apoptotic induction. Temporal assessment (6, 12, 18, 24, and 48 hr treatments) demonstrated accumulation of BrdU incorporation in all cell cycle phases when treated with POM/BTZ/DEX or CC-92480/BTZ/DEX indicating cell death was occurring within all phases. However, there was a marked enhancement of G ₂/M BrdU incorporation (80% vs. 40% of G ₂/M population) at 18-24 hr when treated with CC-92480/BTZ/DEX compared to POM/BTZ/DEX, or other single agent treatments. Additionally, G ₂/M transition-dependent cyclins A and B were shown to be dysregulated by CC-92480. These data indicate that CC-92480 potentiates a G ₂/M arrest in combination with BTZ in MM cells.

Conclusions: These results demonstrate that CC-92480 alone or in combination with BTZ/DEX elicits a more potent cytotoxic effect on MM cells compared to POM. Importantly, the combination of either POM or CC-92480 with a PI, like BTZ, does not appreciatively affect single agent MOA. We have also identified a key differentiating mechanism of cell autonomous activity for CC-92480 in combination with BTZ/DEX where MM cells enhance apoptotic induction at the G ₂/M stage compared to POM. Clinically, this added mechanistic difference suggests a more cytotoxic response in patients treated with CC-92480/BTZ/DEX compared to POM/BTZ/DEX.