Maximal activation of apoptosis signaling by co-targeting anti-apoptotic proteins in BH3 mimetic-resistant AML and AML stem cells

MCL-1 is known to play a major role in resistance to BCL-2 inhibition, but the contribution of other BCL-2 family proteins has not been fully explored. We here demonstrate ineffectiveness of MCL-1 inhibitor AMG176 in venetoclax-resistant, and conversely, of venetoclax in AMG176-resistant AML. Like cells with acquired resistance to venetoclax, cells with acquired resistance to AMG176 express increased MCL-1. Both cells with acquired resistance to venetoclax and to AMG176 express increased levels of BCL-2 and BCL-2A1, decreased BAX, and/or altered levels of other BCL-2 proteins. Co-targeting BCL-2 and MCL-1 was highly synergistic in AML cell lines with intrinsic or acquired resistance to BH3 mimetics or engineered to genetically-overexpress BCL-2 or BCL-2A1 or downregulate BAX. The combination effectively eliminated primary AML blasts and stem/progenitor cells resistant to or relapsed after venetoclax-based therapy irrespective of mutations and cytogenetic abnormalities. Venetoclax and AMG176 combination markedly suppressed anti-apoptotic BCL-2 proteins and AML stem/progenitor cells and dramatically extended mouse survival (median 336 vs control 126 d, P<0.0001) in a PDX model developed from a venetoclax/hypomethylating agent therapy-resistant AML patient. However, decreased BAX levels in the bone marrow residual leukemia cells after 4-wk combination treatment may represent a resistance mechanism that contributed to their survival. Enhanced anti-leukemia activity was also observed in a PDX model of monocytic AML, known to be resistant to venetoclax therapy. Our results support co-dependence on multiple anti-apoptotic BCL-2 proteins and suppression of BAX as mechanisms of AML resistance to individual BH3 mimetics. Co-targeting of MCL-1 and BCL-2 eliminates otherwise apoptosis-resistant cells.

Activation of RAS/MAPK pathway confers MCL-1 mediated acquired resistance to BCL-2 inhibitor venetoclax in acute myeloid leukemia

Despite high initial response rates, acute myeloid leukemia (AML) treated with the BCL-2-selective inhibitor venetoclax (VEN) alone or in combinations commonly acquires resistance. We performed gene/protein expression, metabolomic and methylation analyses of isogenic AML cell lines sensitive or resistant to VEN, and identified the activation of RAS/MAPK pathway, leading to increased stability and higher levels of MCL-1 protein, as a major acquired mechanism of VEN resistance. MCL-1 sustained survival and maintained mitochondrial respiration in VEN-RE cells, which had impaired electron transport chain (ETC) complex II activity, and MCL-1 silencing or pharmacologic inhibition restored VEN sensitivity. In support of the importance of RAS/MAPK activation, we found by single-cell DNA sequencing rapid clonal selection of RAS-mutated clones in AML patients treated with VEN-containing regimens. In summary, these findings establish RAS/MAPK/MCL-1 and mitochondrial fitness as key survival mechanisms of VEN-RE AML and provide the rationale for combinatorial strategies effectively targeting these pathways.

Abstract P2-06-22: PEA15-AA, an unphosphorylatable mutant of PEA15, as a novel therapeutic gene for triple-negative breast cancer

Background: Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer characterized by a high rate of metastatic recurrence and poor prognosis. Molecular mechanism underlying the metastatic behavior of TNBC has not been well elucidated, and newer approaches addressing drivers of metastasis are crucial to improving patient outcomes. PEA15 (Phosphoprotein enriched in astrocytes-15) regulates cell proliferation, apoptosis, and autophagy. In breast cancer, PEA15 expression inhibits invasion by binding to ERK and preventing its nuclear translocation. The biological function of PEA15 is tightly regulated by its phosphorylation at Ser104 and Ser116. However, the effect of PEA15 phosphorylation status on TNBC remains unknown. In this study, we tested the hypothesis that unphosphorylated PEA15 will prevent metastasis in TNBC through inhibition of the epithelial-to-mesenchymal transition (EMT).

Method: We established stable cells overexpressing unphosphorylatable (PEA15-AA) and phospho-mimetic (PEA15-DD) PEA15 mutants in MDA-MB-468 cells. To dissect specific Cellular Mechanisms regulated by PEA15 phosphorylation, we performed RT-PCR immune and metastasis arrays. In vivo mouse models were used to see effects of PEA15 phosphorylation on tumor growth.

Results: The clonogenic growth of PEA15-AA–expressing cells was significantly reduced by 80% compared with empty vector-transfected cells (PEA15-V). Anchorage-independent growth, an indicator of in vivo tumorigenicity, was inhibited in cells expressing PEA15-AA by 60% compared with PEA15-V. PEA15-AA upregulated the expression of E-cadherin and decreased the expression of mesenchymal markers, suggesting that PEA15-AA reverses EMT. Compared with PEA15-V, migration and invasion of cells expressing PEA15-AA were reduced by 65% and 72%, respectively. In contrast, PEA15-DD promoted migration, invasion, and expression of mesenchymal markers. To determine the in vivo effect of PEA15-AA, we injected stable PEA15 transfectants of MDA-MB-468 cells into the mammary fat pad of NOD/SCID mice. The PEA15-DD–injected group showed greater tumor volumes than PEA15-V and PEA15-AA groups, suggesting that PEA15-AA has antitumor effects both in vitro and in vivo. From the immune and metastasis arrays, we found that expression level of IL-8, which is known to induce EMT, was greatly decreased by PEA15-AA, while IL-8 was highly expressed in PEA15-DD cells. Addition of recombinant IL-8 to the cells expressing PEA15-AA partially rescued mesenchymal characteristics, increasing migration and expression of mesenchymal markers. By contrast, IL-8 knockdown in PEA15-DD–expressing cells decreased the mesenchymal phenotype. These findings indicate that IL-8 may play an important role as a mediator of phosphorylation of PEA-15 in breast cancer cell migration and invasion and suggest that PEA15-AA inhibits the expression of IL-8, thereby reversing EMT.

Conclusion: Taken together, our results show that PEA15 phosphorylation serves as an important regulator, having a dual role as an oncogene or tumor suppressor. Further studies are warranted to evaluate the impact of PEA15 phosphorylation status on metastasis in vivo. These findings support the development of PEA15-AA as a potential therapeutic strategy for TNBC.

Citation Format: Park J, Chauhan G, Cohen EN, Ueno NT, Battula VL, Tripathy D, Reuben JM, Bartholomeusz C. PEA15-AA, an unphosphorylatable mutant of PEA15, as a novel therapeutic gene for triple-negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-06-22.

Abstract P5-07-03: GD2-mediated FAK signaling regulates breast cancer stem cell function in triple negative breast cancer

Ganglioside GD2 identifies breast cancer stem cells (BCSCs, Battula et al., JCI, 2012) and expression of GD2 is tightly regulated by GD3 synthase (GD3S). GD3S is highly expressed in GD2+ cells and inhibition of GD3S inhibits tumor formation and metastasis of breast cancer cells. However, the mechanism of GD2-mediated regulation of BCSC function is not known. Here we hypothesize that GD2 regulates signaling pathways involved in cell adhesion, migration and invasion of breast cancer cells. To identify these signaling pathways, antibody micro-arrays were used with 850 validated antibodies specific to total or phosphorylated proteins. Interestingly, focal adhesion kinase (FAK) was the most significantly phosphorylated protein in GD2+ compared to GD2- cells (S910 and S722). In addition, expression of FAK downstream mediators including Csk, PKCq, PKCl/I, Pyk2, and p38MAPK, was up-regulated in GD2+ compared to GD2- cells. Western blot analysis of FACS sorted SUM159 cells also revealed increased phosphorylation of FAK >80% at Y397 and >25% at Y861 in GD2+ compared to GD2- cells. FAK downstream targets including paxillin, p130 Cas, pERK were also up-regulated in GD2+ cells compared to GD2- cells indicating definitive activation of FAK signaling in GD2+ BCSCs. To investigate the functional role of GD2 in FAK mediated functions, we genetically deleted GD3S using the CRISPR knock-out system in SUM159 cells. only <1% GD2expression compared to >20% in parental cells was observed. GD3S-KO cells grew 5-10% slower in cell culture mostly because of the reduction (15±5%) in adherence. Trans-well assays revealed 3-5 fold reduction in migration and invasion of GD3S-KO compared to parental cells. These data indicate that GD2 and GD3S are not only the markers of BCSCs but also regulators of their function. Finally, we tested the effect of FAK inhibitor (PF-573228) against GD2+ BCSCs and GD3S-KO SUM159 cells. PF-573228 treatment decreased the number of mammospheres generated by GD2+ cells 3-4 fold in a dose dependent manner (100nM-1µm). In addition, treatment of PF-573228, inhibited migration and invasion of GD2+ cells 2 and 3 fold, respectively. However, treatment with PF-573228 on GD3S-KO cells further reduced their ability to migrate and invade by over 70% compared to untreated cells. In addition, GD3S-KO cells failed to form any mammospheres when cultured under low adherence conditions (p<0.00001), whereas the parental cells formed 15-20 mammospheres per 1,000 cells plated. In conclusion, our data demonstrate that FAK signaling is activated in GD2+ cells but that FAK inhibition alone may not be sufficient to inhibit BCSC function. Combined FAK and GD3S inhibition may exert highly synergistic effects against BCSCs.

Citation Format: Nguyen K, Sun JC, Hortobagyi GN, Andreeff M, Battula VL. GD2-mediated FAK signaling regulates breast cancer stem cell function in triple negative breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-07-03.

Abstract P5-07-02: ST8SIA1 regulates tumorigenesis in triple negative breast cancer

Recurrence in breast cancer is mainly due to metastases and drug resistance in a fraction of primary tumors cells which are also known as cancer stem cells or tumor initiating cells. We found that Ganglioside GD2 identifies breast cancer stem cell (BCSCs) in triple negative breast cancer (TNBC) and that GD2 biosynthesis is tightly regulated by enzyme ST8SIA1 (GD3 synthase) in GD2+ cells. We have reported that ST8SIA1 is highly expressed in TNBC and its expression is highly correlated with p53 mutations primary tumors (Yan et al, SABCS abstract 2016). Here we hypothesize that ST8SIA1 has a functional role in BCSC mediated tumorigenesis in TNBC. To test the hypothesis, we deleted ST8SIA1 in SUM159 cells using CRISPR-Cas9 technology. As expected, deletion of ST8SIA1 in SUM159 cells reduced GD2+ cells from 17±1.5% to 0.3±0.1%. However, cell proliferation assay revealed no significant difference between ST8SIA1-KO and Cas9 control cells. In contrast, in-vitro tumorigenesis by soft-agar assays revealed a complete loss of colony formation in ST8SIA1-KO cells, whereas Cas9 control cells produced 30±10 colonies out of 1000 cells plated. To investigate tumor initiation potential, ST8SIA1-KO- or Cas9 control- SUM159 cells were transplanted in mammary fat pad of NSG mice. Cas9 control cells produced tumors within 1-2 weeks and reached the maximum allowed size by IACUC (1.5cm) within 3-4 weeks. In contrast, ST8SIA1-KO cells failed to produce any tumors even 15 weeks after injections. In addition, survival analysis by log-rank test revealed that most of the cas9 control cell injected mice died within 4 weeks after cell implantation whereas no deaths were observed in ST8SIA1-KO cells injected mice even 100 days after tumor implantation. These data indicate that loss of ST8SIA1 in TNBC cells depletes GD2+ BCSCs and inhibits in-vitro and in-vivo tumorigenesis.

To investigate gene expression changes due to loss of ST8SIA1 in CRISPR knockout cells, we analyzed mRNA expression in ST8SIA1-KO- and Cas9 control- SUM159 cells by RNAseq analysis (done in triplicates for each cell type). At p<0.05 and fold change >2, we found 1502 genes down-regulated and 842 genes up-regulated in ST8SIA1-KO- compared to cas9 control- cells. Ingenuity pathway analysis revealed that several stem cell associated signaling pathway including, wnt, stat3, NFκB, nanog and IL8 whereas tumor suppressor PTEN and p38 MAPK signaling were activated in ST8SIA1-KO- compared to cas9 control- cells. In specific, proteins associated with stem cell function including NOTCH3, PDGFRB, PDGFRA, VCAM1, CXCR4, CXCL12, SOX2, wnt5a were down regulated in ST8SIA1-KO cells whereas DKK1 which acts as an antagonist for wnt-β-catenin signaling, was up-regulated in ST8SIA1-KO cells. These findings were validated by flow cytometry and western blot analysis using specific antibodies. In conclusion, our data suggests that deletion of ST8SIA1 in TNBC cells depletes BCSCs and inhibits tumorigenesis in-vitro and in-vivo. Development of specific inhibitors of ST8SIA1 could be of potential therapeutic value for patients with TNBC.

Citation Format: Battula VL, Nguyen K, Sun JC, Dasgupta A, Bartholomeusz C, Andreeff M. ST8SIA1 regulates tumorigenesis in triple negative breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-07-02.

Abstract P6-02-01: Metabolic stress induces GD2 expression and cancer stem cell phenotype in triple negative breast cancer

Breast cancer stem cells (BCSCs) have been characterized as a fraction of cells in primary tumors that are drug resistant and have metastatic potential. Ganglioside GD2 has been shown by us and others as a marker for BCSCs. Furthermore, nutrient deprivation associated metabolic stress seen during tumor progression is reportedly associated with the cancer stem cell phenotype. We hypothesized that metabolic stress could induce spontaneous generation of GD2+ BCSCs during tumor progression. To test our hypothesis, we cultured breast cancer cell lines MDA-MB-231 and SUM159 at low seeding density and measured percentage and absolute number of GD2+ cells daily. Flow cytometry analysis revealed that the percentage of GD2+ cells increased from 4.5 ± 2.5 on day 2 to 15 ± 3.8% on day 5 in MDA MB-231 cells and from 8.5 ± 2.8% on day2 to 28 ± 6.2% on day 5 in SUM159 cells (both designated as triple-negative breast cancer, TNBC). To investigate this phenomenon in-vivo, we injected GFP+ MDA-MB-231 cells in NSG mice mammary fat pads and examined GD2 expression in the implanted tumors weekly. Interestingly, we noticed that the percentage of GD2+ also increased from 12 ± 1.5% on week 1 to 30 ± 2.5% on week 6. Next, SUM159 cells were cultured in either nutrient rich (NR, i.e., 10% serum) or nutrient deprived (ND, 1% serum) for 4 days. We found that the percentage of GD2+ cells in NR medium at the end of 4 day culture was ~20% of the total cell population, whereas in ND medium was almost 50%. We then tested the effects of nutrient rich environment on GD2 expression by refreshing the media daily. Interestingly, cells that received fresh media had lower number of GD2+ cells (15 ± 1.5%) compared to cells cultured in the same medium for 4 days (33 ± 2.5%). Our data suggests that nutrient deprivation induces a stem cell phenotype in TNBC cells.

Next, we performed global metabolic profiling (i.e., for a total of 300 biochemical metabolites) using a mass spectroscopy-based approach. We profiled SUM159 cells cultured with NR vs. ND medium (set-1); GD2+ vs GD2- SUM159 cells (set -2); GD2+ vs GD2- MDA-MB-231 cell (set-3). Metabolites associated with amino acid metabolism, in particular glutathione metabolism, including glutamyl-alanine, 5-oxy-proline, proline, glutamine, and glutathione itself were found to be most highly up-regulated in GD2+ compared to GD2- cells and also in cells cultured in serum starved compared to serum rich conditions. Further analysis of these metabolites and their association with GD2+ cell signature raveled that gamma-glutamyl transferase (GGT5), was one of the most highly up-regulated (>150-fold) gene across all the groups. GGT is expressed on cell surface and transfers glutamyl group to amino acids, which then get transported across the membrane. In cancer, cells expressing GGT has been shown to be resistant to chemotherapeutic agents including cisplatin. Targeting glutathione metabolism could be future therapeutic strategy to inhibit BCSC growth in TNBC.

Citation Format: Battula VL, Piyaranthna B, Nguyen K, Sun JC, Jin F, Coarfa C, Nagireddy P, Andreeff M. Metabolic stress induces GD2 expression and cancer stem cell phenotype in triple negative breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P6-02-01.

Abstract P1-06-03: Epithelial to mesenchymal transition (EMT) regulates the spontaneous generation of GD2+ breast cancer stem-like cells through NFκB activation

Breast cancer recurrence may be a consequence of persistent breast cancer stem-like cells (BCSCs) that survive chemo- or hormonal therapy. Therefore, targeting BCSCs could complement standard chemotherapy. We discovered that the ganglioside GD2 is expressed on and defines BCSCs (Battula et al., JCI, 2012), as consequence of activation of the enzyme GD3 synthase (GD3S). Inhibition of GD3S expression inhibited breast cancer metastasis to lung. We also observed that GD2- breast cancer cells spontaneously generate GD2+ cells in vitro. As induction of EMT generates a stem cell–like phenotype, we hypothesized that EMT regulates the generation of GD2+ breast cancer cells. To test this hypothesis, MDA-MB-231and SUM159 cells were cultured in vitro and the percentage of GD2+ cells was measured over time. Interestingly, the percentage and absolute number of GD2+ cells increased in a time-dependent manner, suggesting the spontaneous generation of GD2+ cells. Concomitantly, mesenchymal-related markers including vimentin, N-cadherin, and twist increased 3 to 6 - fold. To further investigate whether this process is operational in vivo, GFP+ MDA-MB-231 cells were transplanted into mammary fat pads of NOD/SCID mice. Each week, a group of mice was sacrificed, tumors were extracted and the number of GFP+GD2+ cells was determined by flow cytometry. In line with our in vitro results, we observed significant increases in GD2+ BCSCs with increasing tumor volume from 15.1%±4.6% to 37%±8.7% over a 6 week period, suggesting that breast cancer cells spontaneously undergo EMT during tumor progression and generate GD2+ BCSCs.

To identify possible targets to inhibit EMT in breast cancer cells, proteomic analysis using Kinexus® antibody arrays revealed activation of NFκB and focal adhesion kinase (FAK) signaling in GD2+ breast cancer cells. The activation of NFκB (phospho p65) in GD2+ cells was validated by CyTOF mass cytometry using metal tagged antibodies. These data suggest that inhibition of NFκB signaling may inhibit GD2+ BCSC growth. Indeed, the IKK inhibitor BMS345541 reduced GD2+ cells by >95% and inhibited GD3S expression (determined by qRT-PCR) in a dose- and time-dependent fashion. In contrast, treatment with doxorubicin increased the percentage of GD2+ cells, from 13.5±2.5% to 21±2.6% in MDA-MB-231 cells, suggesting that GD2+ cells are resistant to doxorubicin. In addition, treatment with BMS345541 inhibited the ability of breast cancer cells to form mammospheres by >90% in vitro. In-vivo tumorigenesis assay demonstrated that BMS345541 induced a significant decrease (p <0.01) in tumor volume, and increased survival of tumor bearing mice: median survival was 78 days for BMS345541-treated mice vs. 58 days for controls (p<0.002).

Conclusion: GD2+ BCSCs are spontaneously produced during tumor progression by EMT and NFκB and FAK mediated signaling might regulate this process. Inhibition of NFκB and FAK signaling pathways may inhibit the spread of BCSCs and reduce breast cancer metastases.

Citation Format: Battula VL, Sun J, Nguyen K, Hortobagyi G, Andreeff M. Epithelial to mesenchymal transition (EMT) regulates the spontaneous generation of GD2+ breast cancer stem-like cells through NFκB activation. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-06-03.

GD2 and GD3 synthase: novel drug targets for cancer therapy

Our recent study suggests that targeting GD3 synthase (also known as ST8SIA1)—the rate-limiting enzyme in biosynthesis of the breast cancer stem cell marker GD2—abrogates metastasis and depletes the cancer stem cell populations within a tumor, thus providing an effective therapeutic strategy against metastatic breast cancers.

GD3 synthase regulates epithelial-mesenchymal transition and metastasis in breast cancer

The epithelial-mesenchymal transition (EMT) bestows cancer cells with increased stem cell properties and metastatic potential. To date, multiple extracellular stimuli and transcription factors have been shown to regulate EMT. Many of them are not druggable and therefore it is necessary to identify targets, which can be inhibited using small molecules to prevent metastasis. Recently, we identified the ganglioside GD2 as a novel breast cancer stem cell marker. Moreover, we found that GD3 synthase (GD3S)--an enzyme involved in GD2 biosynthesis--is critical for GD2 production and could serve as a potential druggable target for inhibiting tumor initiation and metastasis. Indeed, there is a small molecule known as triptolide that has been shown to inhibit GD3S function. Accordingly, in this manuscript, we demonstrate that the inhibition of GD3S using small hairpin RNA or triptolide compromises the initiation and maintenance of EMT instigated by various signaling pathways, including Snail, Twist and transforming growth factor-β1 as well as the mesenchymal characteristics of claudin-low breast cancer cell lines (SUM159 and MDA-MB-231). Moreover, GD3S is necessary for wound healing, migration, invasion and stem cell properties in vitro. Most importantly, inhibition of GD3S in vivo prevents metastasis in experimental as well as in spontaneous syngeneic wild-type mouse models. We also demonstrate that the transcription factor FOXC2, a central downstream effector of several EMT pathways, directly regulates GD3S expression by binding to its promoter. In clinical specimens, the expression of GD3S correlates with poor prognosis in triple-negative human breast tumors. Moreover, GD3S expression correlates with activation of the c-Met signaling pathway leading to increased stem cell properties and metastatic competence. Collectively, these findings suggest that the GD3S-c-Met axis could serve as an effective target for the treatment of metastatic breast cancers.

FOXC2 expression links epithelial-mesenchymal transition and stem cell properties in breast cancer

Resistance to chemotherapy and metastases are the major causes of breast cancer-related mortality. Moreover, cancer stem cells (CSC) play critical roles in cancer progression and treatment resistance. Previously, it was found that CSC-like cells can be generated by aberrant activation of epithelial-mesenchymal transition (EMT), thereby making anti-EMT strategies a novel therapeutic option for treatment of aggressive breast cancers. Here, we report that the transcription factor FOXC2 induced in response to multiple EMT signaling pathways as well as elevated in stem cell-enriched factions is a critical determinant of mesenchymal and stem cell properties, in cells induced to undergo EMT- and CSC-enriched breast cancer cell lines. More specifically, attenuation of FOXC2 expression using lentiviral short hairpin RNA led to inhibition of the mesenchymal phenotype and associated invasive and stem cell properties, which included reduced mammosphere-forming ability and tumor initiation. Whereas, overexpression of FOXC2 was sufficient to induce CSC properties and spontaneous metastasis in transformed human mammary epithelial cells. Furthermore, a FOXC2-induced gene expression signature was enriched in the claudin-low/basal B breast tumor subtype that contains EMT and CSC features. Having identified PDGFR-β to be regulated by FOXC2, we show that the U.S. Food and Drug Administration-approved PDGFR inhibitor, sunitinib, targets FOXC2-expressing tumor cells leading to reduced CSC and metastatic properties. Thus, FOXC2 or its associated gene expression program may provide an effective target for anti-EMT-based therapies for the treatment of claudin-low/basal B breast tumors or other EMT-/CSC-enriched tumors.