Abstract 20: Oncolytic virotherapy enhances Smac mimetic treatment of acute myeloid leukemia
Authors: Hopper Joanne L. , Müller Louise ME , Jennings Victoria A. , Scott Gina B. , McConnell Stewart , Kelly Richard , Errington-Mais Fiona 
Published: August 2018

Abstract
This study demonstrates that the combination of Smac mimetic and oncolytic virotherapy (OVT) induces cell death in acute myeloid leukemia (AML) cell lines and primary patient samples; this is the first time the efficacy of this combination approach has been investigated in a human cancer model and for the treatment of AML.
Methods: The Smac mimetic LCL161 and several oncolytic viruses (OVs) were tested for in vitro cytotoxicity against a panel of diverse AML cell lines. Bystander killing of LCL161-treated AML cells was explored using conditioned media from OV-treated PBMCs. Multiplex immunoassays were used to detect potential mediators of bystander cytotoxicity produced following OV treatment. Several upregulated cytokines were tested for their ability to enhance LCL161 toxicity in AML cell lines by MTS assay. The activation of healthy donor peripheral blood mononuclear cells (PBMC) was investigated by flow cytometry and immune cell-mediated death of AML cells was measured using chromium release assays. In vitro direct and bystander toxicity was further verified using fresh blood samples from AML patients.
Results: A rhabdovirus, MG1, showed the greatest cytotoxicity across a panel of AML cell lines compared to several other OVs. In resistant cell lines the addition of LCL161 treatment led to increased cell death, indicating the potential merits of a combination strategy. Primary AML samples exposed to both LCL161 and MG1 showed greater levels of cell death than either treatment alone, confirming combinational efficacy. Treating healthy donor PBMCs with virus induced the activation of innate immune effector cells, as indicated by an increase in CD69 on NK cells as well as stimulating CD14+ monocytes to produce membrane-bound TNFα-related apoptosis-inducing ligand (TRAIL). Immune cell-mediated death was increased following activation by MG1, and LCL161 sensitized AML cell lines to death by the membrane mimicking KillerTRAIL. Conditioned media from MG1-treated healthy and patient-derived PBMCs displayed an inflammatory milieu that was toxic to AML cell lines. Further analysis identified several cytokines relevant to AML therapy, including the anti-viral interferon alpha (IFNα), soluble TRAIL, and tumor necrosis factor alpha (TNFα); LCL161 was able to increase the sensitivity of AML cells to MG1-conditioned media and recombinant versions of IFNα and TNFα.
Discussion: OVT has shown positive clinical efficacy in many solid tumors; however, it is underexplored in the context of hematologic malignancies. Many cases of spontaneous remission following viral infection, the correlation of cytomegalovirus reactivation and positive prognosis following hematologic stem cell transplant, along with the identification of OVs which target leukemic cells without harming healthy hematologic stem cells, suggest that AML patients may be suitable for OVT. Indeed, data from our lab suggest that PBMCs from AML patients are able to recognize and respond to OV, to induce antitumor cytotoxicity. MG1 is cytotoxic to AML cells and acts as an immunogenic agent to induce the release of soluble inflammatory mediators by PBMCs that lead to the death of bystander cells without the need for direct infection. Recent studies into the use of Smac mimetics in hematologic malignancies have demonstrated the synergistic action of combining treatment with inflammatory cytokines, suggesting that combination with an immunogenic agent may be beneficial. Indeed, LCL161 is able to sensitize both AML cell lines and patient-derived AML blasts to MG1 treatment. The release of inflammatory mediators following MG1 treatment also stimulates the activation of innate immune effector cells to induce AML cell death, indicating the ability to initiate a cell-mediated innate immune attack on AML cells using this regime. In conclusion, these data suggest that MG1 should be considered in combination with the Smac mimetic, LCL161, for the treatment of AML.
Citation Format: Joanne L. Hopper, Louise ME Müller, Victoria A. Jennings, Gina B. Scott, Stewart McConnell, Richard Kelly, Fiona Errington-Mais. Oncolytic virotherapy enhances Smac mimetic treatment of acute myeloid leukemia [abstract]. In: Proceedings of the Second AACR Conference on Hematologic Malignancies: Translating Discoveries to Novel Therapies; May 6-9, 2017; Boston, MA. Philadelphia (PA): AACR; Clin Cancer Res 2017;23(24_Suppl):Abstract nr 20.