Effect of the BET Inhibitor, Cpi-0610, Alone and in Combination with Lenalidomide in Multiple Myeloma
Authors: Siu Ka Tat , Eda Homare , Santo Loredana , Ramachandran Janani , Koulnis Miroslav , Mertz Jennifer , Sims Robert J. , Cooper Michael , Raje Noopur S. 
Published: October 2019

Abstract
The bromodomain and extraterminal (BET) proteins recognize acetylated lysine residues on histone tails and recruit transcriptional machinery to promote gene expression. The BET proteins are attractive drug targets because they regulate the expression of MYC, BCL2 and NF- κB target genes. We investigated the therapeutic potential of CPI-0610, an inhibitor of BET proteins, currently in Phase I testing in multiple myeloma (MM). Our preliminary data show that human MM cell lines are sensitive to BET inhibition, with IC50 values of 800-1000 nM being observed in MM.1S, MM.1R, RPMI-8226, LR5, H929 and U266 cell lines in 72h culture. We further show that CPI-0610 inhibits MM cell growth in the presence of cytokines and when co-cultured with bone marrow stromal cells. CPI-0610 induces apoptosis and G1 cell cycle arrest associated with MYC downregulation. However, protein levels of BCL2, NF- κ B and MCL1 remain unchanged in MM cells upon BET inhibition.
The zinc finger transcriptional factor Ikaros (IKZF1) is highly expressed in MM (GEO dataset GSE36133). It is actively transcribed in the MM.1S cell line with an active transcription start site occupied by BRD4 and MED1 (Loven J et al. Cell 2013). Interestingly, we found that CPI-0610 suppresses Ikaros and IRF4 expression at the levels of both transcription and protein in MM cells. With the use of doxycycline-inducible shRNAs targeting IKZF1, IRF4 and MYC, we identified a positive feedback mechanism that is critical for MM cell survival. Individual knockdown of IRF4, IKZF1 or MYC all lead to induction of apoptosis in MM cells. Suppression of IRF4 decreases both Ikaros and MYC protein expression, suggesting that IRF4 is upstream of both Ikaros and MYC. Downregulation of MYC protein expression is observed following IKZF1 knockdown, suggesting that MYC is downstream of Ikaros. Finally, we observed a decrease in IRF4 protein level upon MYC downregulation, implicating a feedback mechanism from MYC to IRF4. Together, these data illustrate a molecular sequence of events going from IRF4 to IKZF1 to MYC and then back to IRF4, forming a positive feedback loop in MM cells.
Based on the observation that shRNA-mediated knockdown of MYC and IKZF1 are toxic to MM, we combined CPI-0610 with lenalidomide, an immunomodulatory drug which stabilizes cereblon and facilitates Ikaros degradation in MM cells (Kronke J et al., and Lu G et al., Science 2014). We observed a synergistic cytotoxic effect in the cell lines tested (MM.1S and RPMI-8226). The enhanced cytotoxic effect of the combined treatment in MM cell lines is due in part to suppression of MYC, IKZF1 and IRF4. Ongoing studies will focus on understanding the molecular mechanism underlying this synergistic combination and validating its efficacy in vivo in order to provide a rationale for clinical protocols of BET inhibitors in MM.

Disclosures
Mertz: Constellation Pharmaceuticals: Employment, Equity Ownership. Sims:Constellation Pharmaceuticals: Employment, Equity Ownership. Cooper:Constellation Pharmaceuticals: Employment, Equity Ownership. Raje:Celgene Corporation: Consultancy; Eli Lilly: Research Funding; Takeda: Consultancy; Amgen: Consultancy; Onyx: Consultancy; AstraZeneca: Research Funding; Novartis: Consultancy; BMS: Consultancy; Acetylon: Research Funding; Millenium: Consultancy.