KMT2A-Rearranged Infant Acute Lymphoblastic Leukemia Cells Undergo ER-Stress-Induced Apoptosis Following Exposure to Proteasome Inhibitors

Infants diagnosed with KMT2A-rearranged (KMT2Ar) acute lymphoblastic leukemia (ALL) have a poor prognosis with an event free survival of 23-44%. To identify new treatment approaches we previously performed in vitro and in vivo assays to evaluate the activity of FDA approved compounds in 15 primary KMT2Ar infant leukemia samples. Three classes of agents were found to be active in these assays: proteasome inhibitors, anthracyclines, and histone deacetylase inhibitors (HDACi). KMT2Ar infant leukemia samples were exquisitely sensitive to the proteasome inhibitor bortezomib, requiring 10-100 fold less drug to achieve 50% toxicity when compared to non-KMT2Ar childhood ALL. Bortezomib is FDA approved for multiple myeloma and laboratory studies using this model system have previously demonstrated responses to be mediated through several mechanisms including NFKB inhibition, stabilization of cell cycle regulatory proteins, and perhaps most importantly the induction of an unfolded protein response (UPR) and endoplasmic reticulum (ER)-stress-induced apoptosis.

To evaluate global protein dynamics in KMT2Ar ALL cells treated with bortezomib, we performed tandem mass tag (TMT) quantitative mass spectrometry on synchronized SEM cells exposed to either 50nM of bortezomib or DMSO at 0 hours (hr), 6hr, 12hr, 16hr, and 20hr. Applying pairwise comparison for 9232 unique proteins measured over the time course compared to untreated controls, we identified 1593 proteins with a log2 fold change >1.5 in bortezomib treated cells compared to 101 proteins in the DMSO control (FDR<0.01). Several proteins associated with ER-stress-induced apoptosis including ATF4, DDIT4, ATF3, TSC22D3 (GILZ), and PMAIP1 (NOXA) were upregulated more than 3-fold between 6 and 20hr, suggesting this pathway may play a role in bortezomib induced apoptosis of KMT2Ar cells (p<0.05 and log2 fold change of +/- 0.58). To validate this finding and further understand the role of the UPR and ER-stress-induced apoptosis, we evaluated seven key mediators of this pathway by western blot following bortezomib exposure on synchronized SEM cells over a 12 hour time course including ATF4, ATF6, CHOP, PERK, GADD34, CReP, and eIF2α as well as phosphorylated PERK (p-PERK) and eIF2α (p-eIF2α). This demonstrated a critical time point at 6hr where an increase in ATF4 (3.5 fold), CHOP (1.6 fold), and CReP (2.9 fold) protein levels was accompanied by a decrease in p-PERK (0.7 fold), and p-eIF2α (0.8 fold) whereas GADD34 levels remained constant. Although full-sized ATF6 (ATF6a) protein showed a considerable increase (1.9 fold), the levels of cleaved ATF6 (ATF6f) were only slightly increased (1.2 fold) consistent with ATF4-mediated upregulation of CHOP leading to increased protein synthesis along with ATP depletion, oxidative stress, and cell death.

While GADD34 has been shown to be the main phosphatase that functions in a negative feedback loop to resolve cell stress, recent data suggests that stabilization of CReP mRNA by ER stress is able to reverse eIF2α phosphorylation at later stages of UPR leading to re-expression of key UPR proteins. Further, p-eIF2α-attenuated protein synthesis, and not ATF4 mRNA translation has been shown to promote cell survival. Our data support a model whereby the UPR and ER-stress in KMT2Ar ALL cells is induced upon exposure to bortezomib leading to increased levels of ATF4 and CHOP. Attenuation of p-eIF2α by CReP further contributes to cell death through the recovery of protein synthesis in a setting of limited protein folding capacity. These results support the use of proteasome inhibitors in KMT2Ar leukemia which is currently being formally evaluated in a Phase II clinical trial for newly diagnosed patients with infant ALL (NCT02553460).