Transformation of Chronic Lymphocytic Leukemia Towards Richter´s Syndrome Is Induced By AKT Activation
Authors: Nickel Nadine , Al-Maarri Mona , Pal Martin , Roth Andreas , Knittel Gero , Herling Carmen D. , Reinart Nina , Schäfer Stephan , Hartmann Elena M , Rosenwald Andreas , Klapper Wolfram , Büttner Reinhard , Herling Marco , Bruening Jens , Reinhardt Christian , Hallek Michael , Wunderlich Thomas , Pallasch Christian 
Published: October 2019

Abstract
Richter's syndrome (RS) is an aggressive transformation of Chronic Lymphocytic Leukemia (CLL) to Diffuse Large B Cell Lymphoma (DLBCL) refractory to current therapies with dismal prognosis. Richter Syndrome arises from CLL cells independent of common DLBCL mutations. Frequently, mutations in p53, CDKN2 or cMyc genes are involved, but a significant proportion displays no specifically acquired driver mutation.
We could observe activation of AKT in 6 out 48 Richter syndrome biopsies by positive staining for active phosphorylated AKT while in CLL lymph nodes, DLBCL and Burkitt´s Lymphoma no phospho-AKT by IHC could be observed.
However in primary patient CLL cases we could detect varying levels of pAKT by Western blot, elevated levels were identified predominantly in patients harboring high-risk mutations such p53, ATM, NOTCH1 and XPO1. Furthermore, B-cell receptor mediated stimulation of the PI3K/AKT axis provided protection towards genotoxic stress induced apoptosis via post-translation stabilization of MCL1. This provides subsequently a synergistic induction of apoptosis by combining idelalisib and bendamustin.
Thus we analyzed the functional impact of AKT signaling using a conditional constitutive allele for AKT (AKT-C) specifically activated using CD19-Cre and Cγ1-Cre fro post-GC-activation. AKT activation alone could not induce a malignant phenotype, however we could demonstrate that Eµ-Tcl-1 mice with AKT-C develop Richter Syndrome. Both in EµTCL1:CD19-CreAKT-C (TCA) and EµTCL1:Cγ1- CreAKT-C (TCγ1A) mice developed a high-grade lymphoma phenotype leading to decreased survival. Transformed cells displayed blastoid characteristics with significantly increased cellular size and the histomorphological features of DLBCL. Large transformed cells show high percentage of KI67-positive staining (>90%) and frequent mitotic figures.
Here, AKT-mediated GSK-3b inhibition and subsequent cMyc and Mcl-1 stabilization might transform CLL to RS cells and combinatory treatments with DNA-damaging and PI3K-inhibiting compounds revealed promising therapeutic results. Collectively, we have identified AKT signaling as an oncogenic signaling pathway in progression of CLL towards Richter´s syndrome and generated the first murine Richter Syndrome model (TCA and TCγ1A) providing novel mechanistic insights into the molecular understanding of Richter's transformation that is amenable to model therapeutic strategies and to address the efficacy of synergistic treatment combinations.

Disclosures
Klapper: Roche, Novartis, Amgen, Takeda: Research Funding. Hallek:Amgen: Consultancy, Honoraria, Other: travel support, Research Funding, Speakers Bureau; Mundipharma: Consultancy, Honoraria, Other: travel support, Research Funding, Speakers Bureau; AbbVie: Consultancy, Honoraria, Other: travel support, Research Funding, Speakers Bureau; F. Hoffmann-LaRoche: Consultancy, Honoraria, Other: travel support, Research Funding, Speakers Bureau; Celgene: Consultancy, Honoraria, Other: travel support, Research Funding, Speakers Bureau; Janssen-Cilag: Consultancy, Honoraria, Other: travel support, Research Funding, Speakers Bureau; Gilead: Consultancy, Honoraria, Other: travel support, Research Funding, Speakers Bureau.