Modelling of TKI Resistance In CML Cell Lines: Kinase Domain Mutations Usually Arise In the Setting of BCR-ABL Overexpression.
Authors: Tang Carine , Schafranek Lisa , Watkins Dale , Parker Wendy T , Prime Jodi , White Deborah L , Hughes Timothy 
Published: October 2019

Abstract
Abstract 3383
There are three currently identified secondary resistance mechanisms observed in chronic myeloid leukemia (CML) patients receiving tyrosine kinase inhibitors (TKIs). These include overexpression of drug-efflux proteins (ABCB1 and ABCG2), increased BCR-ABL expression, and mutations in the kinase domain (KD) of BCR-ABL. We investigated the interplay between these three modes of resistance in vitro, as well as looking for other mechanisms. Three CML blast crisis cell lines (K562, its ABCB1-overexpressing variant, K562 Dox, and KU812) were cultured in gradually increasing concentrations of imatinib (IM) to 2μ M, or dasatinib (DAS) to 200nM. Two IM-resistant K562 lines were established, both with increased IC50s for IM (from 13.7μ M in naïve cells, to ~50μ M), as well as increased IC50s for DAS and nilotinib (NIL). No cell-surface expression of ABCB1 or ABCG2 was observed, nor were KD mutations present. However, BCR-ABL expression was seen to steadily increase in both lines from 178% in naïve cells, to ~380% and 1200% in the resistant lines, suggesting this was the major mode of resistance. However, when a DAS-resistant K562 culture was generated the T315I mutation emerged. Studies of the intermediate stages of resistance revealed that BCR-ABL overexpression occurred in a step-wise fashion, peaking at 1915% in the 3.5nM intermediate, but then dropping significantly to ~1000% in the 5nM intermediate (P=0.0003). BCR-ABL expression then stabilised at this level, and the T315I mutation was subsequently detected. Thus, it appears that BCR-ABL overexpression was the first mechanism of resistance detectable, but was followed by the emergence of a KD mutation which had a clear selective advantage. This sequential selection was observed a further four times: in a DAS-resistant K562 Dox culture, and in three IM-resistant KU812 cultures. BCR-ABL expression in the DAS-resistant K562 Dox culture increased from 186% in naïve cells to 540% in the final culture. Studies of intermediate cultures revealed that BCR-ABL expression peaked at 850% in the 55nM intermediate, but then dropped significantly to ~500% in the 75nM intermediate (P=0.004). This drop in BCR-ABL expression coincided with the appearance of the V299L mutation. Interestingly, the K562 Dox DAS-resistant line also displayed resistance to NIL and IM, likely conferred by BCR-ABL overexpression as the 55nM intermediate (with the highest BCR-ABL expression levels) had the highest IC50s for NIL and IM, while the 75nM intermediate (with the V299L mutation) had increased IC50DAS but lower NIL and IM IC50s. Thus, BCR-ABL overexpression was the primary event, followed by the KD mutation. Likewise in three IM-resistant KU812 cultures, BCR-ABL expression levels rose from 443% in naïve cells, to peak levels of 6210%, 10,448% and 990% respectively, followed by drops in expression which coincided with the appearance of compound KD mutations, and the F359C mutation respectively (Table). In contrast, three IM-resistant K562 Dox cells were not found to have any KD mutations, nor BCR-ABL overexpression. Instead, the primary cause of resistance in these lines appears to be a further increase in ABCB1 expression. All three lines had increased IC50s for IM (from 12μ M in naïve cells, to ~27μ M), NIL (from 400nM to ~1000nM) and DAS (from 100nM to >625nM). The addition of PSC833 (an ABCB1 inhibitor) decreased the IM, NIL, and DAS IC50s for all three resistant lines to the level of the naïve control (~3μ M, ~250nM and ~10nM respectively), indicating that ABCB1 expression, facilitating active efflux of the drugs, is the primary mechanism of resistance in these lines. We have demonstrated that KD emergence is a stochastic event, as the same mutation did not always occur twice, however BCR-ABL and ABCB1 overexpression were more likely to arise recurrently in predisposed lines. Notably, different TKIs elicited different resistant mechanisms, but all were BCR-ABL dependent. Furthermore, all resistant lines showed cross-resistance to the three TKIs tested (IM, DAS and NIL), suggesting that currently available TKIs share the same susceptibilities to drug resistance.
Table 1. Summary of resistance mechanisms detected in three cell lines exposed to IM or DAS. ✓ = yes; × = no. Culture condition K562 K562 Dox KU812 IM IM DAS IM IM IM DAS IM IM IM Resistance to 3 TKIs ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ KD Mutation x x T315I x x x V299L E450QE459KE470K E459KE462KE466E F359C Increased BCR-ABL ✓ ✓ ✓ x x x ✓ ✓ ✓ ✓ Increased ABCB1 x x x ✓ ✓ ✓ x x x x

Disclosures:
White: Novartis Pharmaceuticals: Honoraria, Research Funding; Bristol-Myers Squibb: Honoraria, Research Funding. Hughes:Novartis Pharmaceuticals: Honoraria, Research Funding, Speakers Bureau; Bristol-Myers Squibb: Honoraria, Research Funding, Speakers Bureau.