Leukemia Stem/Progenitor Cells From AML Patients Treated With The Multi-Kinase Inhibitor TG02 Demonstrate Increased Proliferation and Are Sensitized To Chemotherapeutic Agents

TG02 is a multi-kinase inhibitor that targets cyclin-dependent kinases (CDKs), ERK5, JAK2, and Flt3. In vitro studies of TG02 have shown robust induction of apoptosis in both acute myeloid leukemia (AML) cell lines and primary cells (Goh et al, 2011). Leukemia stem cells (LSCs) comprise a largely quiescent, highly chemotherapy-resistant cell population and are believed to initiate and maintain AML, as well as contribute to its poor prognosis. Thus, we sought to investigate the impact of TG02 on LSCs collected from patients with relapsed/refractory AML enrolled in a phase I dose escalation trial. Patients ≥ 18 years with advanced hematological malignancies or newly diagnosed AML pts ≥ 65 years unfit for intensive therapy were enrolled onto daily (A) and intermittent (B, 5 days on 2 days off X 2 weeks) schedules in 28-day cycles. Pts had acceptable organ function and ECOG PS 0-2. Dose levels were 10 - 70 mg on arm A and 30 - 150 mg on arm B.

We evaluated immunophenotypically defined leukemia stem and progenitor cells (LSPCs) by flow cytometry, cell cycle status and colony forming assays. A total of 16 patients were evaluated with treatment doses ranging from 10-150 mg of TG02.

Clinically, treatment with TG02 did not have an effect in AML tumor burden, and most patients at our center only received one cycle of treatment (Roboz et al ASCO 2012 Annual Meeting Abstract #6557, J Clin. Oncol. 30, 2012). However, we found that 8 patient samples showed increased LSPCs in both the bone marrow and peripheral blood. Interestingly, we observed an increase in LSPC cell proliferation, as determined by Ki-67 positive staining. AML colony forming assays also showed increased colony formation (n=5) after one cycle of treatment, which suggests an increase in the frequency of LSPCs. The increase in colony formation in peripheral blood samples suggests mobilization of LSPCs from the marrow into the circulation. Thus, we hypothesized that exposure to TG02 in vivo may result in sensitization to other chemotherapeutic agents, such as Ara-C.

We evaluated the effects of Ara-C and other chemotherapeutics, such as vincristine, in primary AML cells obtained from patients before and after treatment with TG02. We found that in vivo exposure to TG02 resulted in significantly increased sensitivity to Ara-C in vitro in 3 out of 4 samples tested

Together, our data suggest that TG02 induces an effect in LSCs resulting in increased proliferation and, thus, sensitization to other chemotherapeutic drugs, such as Ara-C. Importantly, although no patients at our center receiving single agent TG02 met the criteria for an objective response, by performing correlative studies in association with the clinical trial, we found the TG02 has a marked effect in AML LSCs that could potentially be exploited by combining it with other agents.