PAK4 Inhibition Impacts Growth and Survival, and Increases Sensitivity to DNA-Damaging Agents in Waldestrostom Macroglobulinemia

p21-activated kinases (PAKs) are effectors for the small GTPases Cdc42 and Rac that control a wide range of cellular processes including cytoskeleton reorganization, cell proliferation, survival and motility. Based on our initial results showing significant biological and functional role of PAK4 in plasma cell malignancies, we investigated its role in Waldenström macroglobulinemia (WM). We first confirmed high level of PAK4 expression and activity in WM cells. Both genetic depletion via stable lentiviral knock down and pharmacological inhibition of PAK4 via allosteric modulator KPT-9274 decreased tumor cell growth and survival in a dose and time dependent manner in a panel of WM cell lines. The growth inhibitory effect was associated with induction of apoptotic cell death, caspases activation and PARP cleavage as well as modulation of pro-apoptotic proteins such as PUMA. In addition, related-PAK4 biological processes such as migration, invasion and adhesion to bone marrow stromal cells (BMSCs) were significantly impacted by the inhibitor. A significant effect of KPT9274 was also observed in primary tumor cells from both newly diagnosed and relapse WM patients, including primary cells from ibrutinib resistant patients.

To gain further insight into the consequences of PAK4 inhibition, we performed gene expression profile in WM cell lines treated with KPT-9274. Intriguingly we detected a significant impact on expression of Fanconi Anemia (FA)/BRCA pathway related genes, a DNA-damage response pathway essential for the repair of DNA interstrand crosslinks (ICLs) and regulation of cellular responses to replication stress. Since FA/BRCA deficient cells are defective in the formation of Rad51 foci, a crucial component of the homologous recombination (HR) repair machinery, we examined the effect of PAK4/NAMPT inhibition on Rad51 as well its impact on HR. We observed that, apart from inducing DNA damage, assessed by γH2AX expression, KPT-9274 specifically inhibited Rad51 and the double strand break repair by the homologous recombination pathway. Protein pull down analysis revealed the existence of a complex between nicotinamide phosphoribosyltransferase (NAMPT) and the conserved PAK binding domain; treatment with KPT-9274 disrupted this interaction and inhibited the enzymatic activity of NAMPT. NAD is necessary for PARP function especially with increasing DNA damage; and its depletion severely hamper DNA repair. Consistent with this, we observed that nicotinic acid supplementation rescued the effect of KPT-9274 on NAMPT inhibition as well as DNA damage and repair.

As FA/BRCA pathway has been shown to affects sensitivity to alkylating agents, we next combined KPT-9274 with either melphalan or bendamustine in MM and WM cells. The combination treatment resulted in a synergistic time- and dose-dependent inhibition of cell survival and growth in cell lines and primary patient tumor cells. We observed a synergistic induction of apoptosis and activation of caspase-3/7, -8 and -9 following treatment with combined versus single-agent therapy. Similarly, in PAK4 knock-down WM cells bendamustine significantly increased the rate of early and late apoptotic cells (60%) compared to scrambled knockdown cells (37%).

In summary, we report a significant anti-proliferative activity of dual PAK4-NAMPT inhibition in WM cells, with induction of apoptosis, DNA-damage response and FA/BRCA pathway disruption and a strong synergistic activity in combination with DNA damaging agents such as Bendamustine. Altogether, our data suggests dual PAK4-NAMPT inhibition represents a novel therapeutic strategies in WM.