Characterize Biomarkers and Mechanisms of Resistance for MDM2 Inhibitors in AML

Acute myeloid leukemia (AML) is a molecularly and clinically heterogeneous disease with an aggressive phenotype and poor prognosis. Inactivation of the wild-type p53, through upregulation of the TP53 negative regulator MDM2, is observed in around 50% of AML patients, providing a rationale for targeting MDM2 for the treatment of AML. Small molecule inhibitors of MDM2, including Idasanutlin, have shown efficacy as monotherapy and in combinations. However, patients exhibit heterogeneous responses with frequent drug resistance.

We integrated ex vivo drug sensitivity assay, clinical parameters, whole exome sequence (WES), RNAseq, cytokine stimulation, and CRISPR/Cas9 dropout screening data to identify biomarkers that predict idasanutlin response and to elucidate the underlying drug-resistant mechanisms. Surprisingly, besides TP53 itself, we did not find an essential role in losing any of the major TP53 downstream targets alone leading to Idasanutlin resistance from Idasanutlin treated resistant cell lines, CRISPR screening, or individually targeted knockout experiments. Besides TP53 mutations, other major AML mutations, including RAS pathway mutations do not drive Idasanutlin resistance indicated by the patient sample functional screening data and in vitro mutation overexpression models. We observed instead that AML with a high differentiation or mature myeloid signature: including low blast, a high percentage of monocytes/granulocytes/T cells, AML FAB M4/M5 morphology, and a high expression of a myeloid immune signature gene are relatively resistant to Idasanutlin.

We further characterized that both healthy/leukemia-associated T cells, granulocytes, and monocytes are intrinsically resistant to idasnutlin due to low expression levels of MDM2 and/or TP53. To examine whether the presence of differentiated cells protects leukemia blast cells from Idasanutlin, we performed a co-culture drug treatment experiment. Strikingly, only leukemia-associated monocytes, but not healthy monocytes, healthy/leukemia T cells or granulocytes, or leukemia blast cells protected leukemia blast cells from apoptosis in the presence or absence of Idasanutlin. Similar results were obtained for the other two MDM2 inhibitors, AMG232 and DS-3032b, and a BCL2 inhibitor, venetoclax. To further uncover which cytokines secreted from the leukemia-associated monocytes confer MDM2 inhibitor resistance, we tested 11 common cytokines, including IL-1a, IL-1b, IL-3, IL-6, IL-8, M-CSF GM-CSF, FLT3, MCP-1, TNFa, and SCF. We observed that IL-1α, IL-1β, IL-3, and GM-CSF markedly induced idasanutlin treatment resistance for AML, but not ALL or CLL patient cells. Interestingly, IL-1α and IL-1β only protect leukemia blasts, but not healthy CD34 hematopoietic stem and progenitor cells from Idasanutlin-induced apoptosis. We further performed RNAseq and immunoblots on IL-1α and IL-1β treated AML, CLL, and ALL cells. We observed the major TP53 downstream pathways remain activated by idasanutlin in the presence of IL-1α and IL-1β. Interestingly, GATA2 is significantly upregulated in IL-1α and IL-1β treated AML, but not CLL or ALL cells in the presence or absence of Idasanutlin. Furthermore, overexpressing GATA2 conferred Idasanutlin resistance at high concentrations. Finally, we observed that combining a FLT3/IRAK dual inhibitor, pacritinib, or an IRAK1 /IL-1 receptor antagonist, anakinra, partially rescued IL-1α and IL-1β mediated drug resistance of MDM2 inhibitors. As such, we uncovered the role of leukemia-associated monocyte in driving intrinsic and extrinsic MDM2 inhibitor resistance and the potential underlying mechanisms.

Tyner:Aptose: Research Funding; Acerta: Research Funding; Agios: Research Funding; Array: Research Funding; Astra-Zeneca: Research Funding; Constellation: Research Funding; Genentech: Research Funding; Gilead: Research Funding; Incyte: Research Funding; Janssen: Research Funding; Kronos: Research Funding; Meryx: Research Funding; Petra: Research Funding; Schrodinger: Research Funding; Seattle Genetics: Research Funding; Syros: Research Funding; Takeda: Research Funding; Tolero: Research Funding; Recludix Pharma: Membership on an entity's Board of Directors or advisory committees.