Identification of Targeted Therapies for Rare Adult Mature T-Cell Leukemia Using Functional Ex Vivo Screening of Primary Patient Samples

Introduction: T-cell prolymphocytic leukemia (T-PLL) is an aggressive lymphoproliferative disorder and accounts for ~2% of cases of mature lymphocytic leukemia in adults. The sparsity of patients with this disease poses a challenge to effectively develop targeted treatments. Recent studies suggest chromosome 14 abnormalities are most common in T-PLL (75% of patients), resulting in overexpression of the proto-oncogene TCL1 and activation of protein kinase B (Stengel, Anna, et al. 2016). Presently alemtuzumab is the only effective, available therapeutic option, with almost all patients relapsing within months after completion of therapy. With the aim of identifying new therapeutics for T-PLL, we assessed the sensitivity of primary patient samples to various targeted agents using an ex vivo functional screening platform.

Methods: We have previously screened over 1000 primary specimens from patients with various hematologic malignancies against a panel of 143 single-agent small-molecular inhibitors, including kinase inhibitors, bromodomain inhibitors, BHM mimetics, proteasome inhibitors, IDH1/2 inhibitors, and several other drug classes. Primary patient specimens were cultured in the presence of each drug in a 7-point dose series. Sensitivity was assessed by a tetrazolium-based viability assay on day 3. An IC₅₀ value was then calculated for each inhibitor and compared with the median of the IC₅₀ values for the full patient sample cohort screened to date. Inhibitors for which the IC₅₀ value was < 20% of the cohort median were considered effective. T-PLL primary patient samples were assessed for sensitivities using this historical drug sensitivity data and we ranked all drugs by their IC₅₀.

Results: Our database identified 5 adults (3 male, 2 female) with T-PLL who had analyzable data obtained within 1 month of diagnosis (Table 1). Median age was 65 years (range, 49-88 years). At diagnosis, the median white blood cell count was 56.2 K/cu mm (16-243.65 K/cu mm) and all patients had detectable 14q11 abnormalities and TCR gene rearrangements. All patients were treated with standard first-line therapy with IV alemtuzumab (30 mg 3x/week) for an average of 11.6 weeks (8.59 -14.75 weeks). Their median progression free survival (PFS) was 9.3 months (5.4-20 months) and duration of response was 5.6 months (2.9 -16.8 months). Three patients received second-line therapy after alemtuzumab failure with a PFS of 6.9 months (1.1- 9.8 months). Three patients went on to an allogeneic stem cell transplants with PFS of 6.7 months (4.5-7.7 months). The median overall survival was 19.1 months (2.07-11.6 months).

Our ex vivo assay showed that 9 (6.2%) of 143 small-molecular inhibitors were considered effective (20% of median IC₅₀) in the majority of subjects. This included 6 FDA approved tyrosine kinase inhibitors (axitinib, dasatinib, sunitinib, sorafenib, pazopanib, and ponatinib), midostaurin, an NF-kB activation inhibitor, and CSF1R inhibitors. Sensitivity of T-PLL patients to these drugs is shown in the log plot (Figure 1). Patient 4 had no strong targets identified. Dasatinib showed the most efficacy in 4 of the 5 patients, with an average IC₅₀ of 0.003 ± 0.0007 µm, followed by CSFIRJ inhibitor with an average IC₅₀ of 0.02 ± 0.015 µm.

Conclusions: Our functional ex vivo screen of primary patient samples allowed us to evaluate the effectiveness of several FDA approved and investigational therapeutic agents targeting multiple oncogenic pathways in T-PLL, a rare disease with limited existing therapies. Our approach indicates that several existing inhibitors may be effective in this aggressive leukemia and can be tested in prospective clinical trials.

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