Venetoclax with azacitidine disrupts energy metabolism and targets leukemia stem cells in patients with acute myeloid leukemia

• Published in: Nature medicine Vol. 24; no. 12; pp. 1859 - 1866
• Main Authors: Pollyea, Daniel A., Stevens, Brett M., Jones, Courtney L., Winters, Amanda, Pei, Shanshan, Minhajuddin, Mohammad, D’Alessandro, Angelo, Culp-Hill, Rachel, Riemondy, Kent A., Gillen, Austin E., Hesselberth, Jay R., Abbott, Diana, Schatz, Derek, Gutman, Jonathan A., Purev, Enkhtsetseg, Smith, Clayton, Jordan, Craig T.
• Format: Journal Article
• Language: English
• Published: New York Nature Publishing Group US 01-12-2018; Nature Publishing Group
• Subjects: 692/308/2779/109; 692/699/67; 692/699/67/1990; 692/699/67/1990/283; 692/699/67/1990/283/1897; Acute leukemia; Acute myelocytic leukemia; Acute myeloid leukemia; Adults; Aged; Aged, 80 and over; Analysis; Antineoplastic agents; Apoptosis - drug effects; Azacitidine; Azacitidine - administration & dosage; Bcl-2 protein; Biomedical and Life Sciences; Biomedicine; Bridged Bicyclo Compounds, Heterocyclic - administration & dosage; Cancer Research; Cancer treatment; Chemotherapy; Disruption; Dosage and administration; Drug therapy; Elderly patients; Electron transport; Electron transport chain; Electron Transport Complex II - drug effects; Energy metabolism; Energy Metabolism - drug effects; Female; Humans; Infectious Diseases; Ketoglutaric acid; Ketoglutaric Acids - metabolism; Leukemia; Leukemia, Myeloid, Acute - drug therapy; Leukemia, Myeloid, Acute - genetics; Leukemia, Myeloid, Acute - pathology; Lymphocytes B; Lymphoma; Lymphomas; Male; Medical schools; Metabolic Diseases; Metabolism; Molecular Medicine; Myeloid leukemia; Neoplastic Stem Cells - drug effects; Neoplastic Stem Cells - pathology; Neurosciences; Non-Hodgkin's lymphomas; Oxidative phosphorylation; Oxidative Phosphorylation - drug effects; Patients; Phosphorylation; Proto-Oncogene Proteins c-bcl-2 - antagonists & inhibitors; Proto-Oncogene Proteins c-bcl-2 - genetics; Stem cells; Succinate dehydrogenase; Succinate Dehydrogenase - genetics; Sulfonamides - administration & dosage; Tricarboxylic acid cycle; Tricarboxylic Acids - metabolism; Tumors; Venetoclax
• ISSN: 1078-8956; 1546-170X
• DOI: 10.1038/s41591-018-0233-1

Acute myeloid leukemia (AML) is the most common acute leukemia in adults. Leukemia stem cells (LSCs) drive the initiation and perpetuation of AML, are quantifiably associated with worse clinical outcomes, and often persist after conventional chemotherapy resulting in relapse
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. In this report, we show that treatment of older patients with AML with the B cell lymphoma 2 (BCL-2) inhibitor venetoclax in combination with azacitidine results in deep and durable remissions and is superior to conventional treatments. We hypothesized that these promising clinical results were due to targeting LSCs. Analysis of LSCs from patients undergoing treatment with venetoclax + azacitidine showed disruption of the tricarboxylic acid (TCA) cycle manifested by decreased α-ketoglutarate and increased succinate levels, suggesting inhibition of electron transport chain complex II. In vitro modeling confirmed inhibition of complex II via reduced glutathionylation of succinate dehydrogenase. These metabolic perturbations suppress oxidative phosphorylation (OXPHOS), which efficiently and selectively targets LSCs. Our findings show for the first time that a therapeutic intervention can eradicate LSCs in patients with AML by disrupting the metabolic machinery driving energy metabolism, resulting in promising clinical activity in a patient population with historically poor outcomes.
Targeting of mitochondrial metabolism in combination with BCL-2 inhibition eradicates leukemia stem cells and induces long-lasting responses in patients with acute myeloid leukemia.