Effect of In Vivo Azacitidine on GvHD and Gvl: Mechanistic Studies
Authors: Choi Jaebok , Ritchey Julie , Su Jessica , Prior Julie , Ziga Edward , Piwnica-Worms David , DiPersio John F. 
Published: October 2019

Abstract
Abstract 2537

Introduction:
Regulatory T cells (Tregs) have been shown to mitigate graft-versus-host disease (GvHD) while preserving the beneficial graft-versus-leukemia (GvL) effect in animal models of allogeneic bone marrow transplantation (BMT). However, three major obstacles prevent their use in human clinical trials: the low numbers of Tregs, loss of suppressor activity following in vitro expansion, and the lack of Treg-specific markers to purify expanded Tregs. The locus of the Foxp3 gene, the master regulator of Tregs, is unmethylated and expressed only in Tregs. We have recently reported that the hypomethylating agent azacitidine (AzaC) induces FOXP3 expression in non-Tregs, converting them into Tregs in vitro and in vivo when administered after allogeneic BMT completely mitigating GvHD without abrogating GvL (Choi, et al Blood 2010). Three possible mechanisms for these effects include: 1) AzaC induces FOXP3+ Tregs, which in turn mitigate GvHD without abrogating GvL by regulating alloreactive donor T cells, 2) AzaC directly suppresses the proliferation of alloreactive donor T cells reducing GvHD, 3) AzaC alters donor T cell trafficking to GvHD target organs to prevent GvHD without altering interaction of donor T cells with recipient leukemia or trafficking of leukemic cells.

Methods:
Balb/c (CD45.2+, H-2Kd) were lethally irradiated one day prior to injection of T cell-depleted BM cells isolated from B6 (CD45.1+, H-2Kb) and luciferase-expressing A20 leukemia cells derived from Balb/c. Allogeneic donor T cells isolated from B6 (CD45.2+, H-2Kb) were given 11 days after BMT. AzaC (2 mg/kg) was administrated subcutaneously every other day (4 doses total) starting 4 days after T cell injection. In vivo bioluminescence imaging (BLI) was performed to assess leukemia cell localization. For T cell proliferation/trafficking analyses, Balb/c were lethally irradiated one day prior to injection of T cell-depleted BM cells isolated from B6 (CD45.1+). Allogeneic donor T cells isolated from B6 (CD45.2+) were transduced with Click Beetle Red luciferase and were given 11 days after BMT, followed by AzaC treatment as described above. BLI was performed to track the donor T cells.

Results:
While neither T cell or leukemia cell trafficking was affected by the AzaC treatment, proliferation of donor T cells was significantly reduced compared to mice treated with PBS. The observed reduced T cell proliferation is not likely due to the direct effect of AzaC on T cells since the AzaC treatment preserved GvL activity comparable with the PBS control group. In addition, T cells isolated from both AzaC and PBS groups were equally reactive against third party antigen presenting cells, based on mixed lymphocyte reactions and cytotoxic T lymphocyte killing assays. These data along with our previous report demonstrating that the AzaC treatment increases Tregs in vivo strongly suggest that the therapeutic effect of AzaC on GvHD and GvL are mediated by the AzaC-induced Tregs which preferentially target alloreactive T cells while preferentially sparing anti-tumor T cells. Currently, secondary transplantation of Treg-depleted/replete T cells isolated from AzaC/PBS-treated recipient mice is underway to further confirm that donor T cells in the AzaC-treated mice are fully functional and that alloresponses of donor T cells are regulated by AzaC-induced Tregs.

Conclusions:
In vivo administration of AzaC after donor T cell infusion mitigates GvHD while preserving GvL via peripheral conversion of alloreactive donor T cells to FOXP3+ Tregs that preferentially inhibit alloreactive T cells while sparing anti-tumor T cells. These data provides the foundation for future clinical trials using epigenetic therapy aimed at mitigating GvHD without abrogating GvL and overcoming HLA barriers.

Disclosures:
No relevant conflicts of interest to declare.