FLT3-Kinase Inhibitors Quizartinib and Midostaurin Do Not Impair T-Cell Reactivity and Activation
Authors: Wolleschak Denise , Mack Thomas S. , Perner Florian , Schnoeder Tina M , Wagner Marie-Christine , Kliche Stefanie , Schraven Burkhart , Ranjan Satish , Isermann Berend H. , Lipka Daniel B. , Fischer Thomas , Heidel Florian H 
Published: October 2019

Abstract
Abstract 1045
In patients with FLT3-ITD mutated AML, FLT3-inhibitors have been used successfully as a ‘bridging therapy’ before allogeneic transplantation. Inhibitors of other kinases (such as imatinib for BCR-ABL positive CML) have previously been used successfully after allogeneic transplantation – even before discontinuation of immunosuppressive medication. However, it is known that some BCR-ABL inhibitors such as dasatinib exert strong inhibitory effects on primary T-cells through inhibition of Src-kinases relevant for T-cell receptor signaling. Even imatinib and nilotinib - although not affecting Src kinase activity – showed decreased T-cell activation and reactivity to some extent. Thus, the influence of FLT3-kinase inhibitors on T-cell function may be critical in the context of allogeneic bone marrow transplantation for FLT3-ITD-positive AML. Besides inhibition of FLT3-kinase, midostaurin (PKC412) exerts activity against PDGFR, VEGFR or c-KIT. In contrast, second generation inhibitors such as quizartinib (AC220) act in a far more FLT3-specific manner.
Therefore, we aimed to investigate the effects of both clinically relevant FLT3-inhibitors on T-cell receptor signaling in comparison to the well characterized and potent BCR-ABL inhibitor dasatinib. Investigating primary T-cells derived from healthy donors, we applied a dose range of 10–50 nM dasatinib, 5–50nM midostaurin and 10–50 nM quizartinib. These dose ranges have been previously described to be achievable as trough levels during inhibitor therapy in early clinical trials. Upon incubation with dasatinib (10nM and 50nM), we found overall reduction in global tyrosine phosphorylation as detected by Western-blotting using the 4G10 antibody. In contrast, treatment with midostaurin left the activation of T-cell receptor signaling pathways unaffected. Comparable to DMSO control, overall phosphorylation was induced almost immediately after stimulation. Western-blotting of LCK and Plcg1 showed similar time dependent activation compared to total phosphorylation. Likewise, quizartinib did not reduce overall tyrosine phosphorylation level and left activation of downstream kinases (ZAP70, MAPK, LCK, Plcg1) largely unaffected.
As activation of primary T-cells is a critical step in immune responses against viral and tumor antigens we aimed to investigate the influence of FLT3-kinase inhibitors quizartinib and midostaurin on activation of CD8+ T-cells. T-cells from healthy donors were stimulated using either PHA 0.5% or CD3/CD28 beads to ensure a more T-cell receptor specific stimulation. Using CD3/CD28 stimulation, CD69 expression was almost abrogated following dasatinib treatment. Applying clinically relevant doses of midostaurin or quizartinib to isolated T-cells did not influence CD69 expression. Expression levels upon PHA or CD3/CD28 stimulation were comparable to DMSO-control - even in the presence of 50nM midostaurin or quizartinib. Proliferation of T-cells upon CD3/CD28 stimulation was impaired by dasatinib treatment, while midostaurin and quizartinib left T-cell proliferation largely unaffected – as determined by CSFE staining. In order to investigate the T cell allo-reactivity, mixed lymphocyte culture was performed, where human pan-T-cells are co-cultured with allogeneic antigen presenting cells. T-cell proliferation – as measured by 3H-thymidine incorporation – was significantly impaired by dasatanib but neither midostaurin nor quizartinib treatment. Investigation of leukemia- and virus-antigen-specific T-cell responses are currently under way to gain deeper insight regarding this clinically relevant scenario.
Overall, we found FLT3-kinase inhibitors midostaurin and quizartinib to leave T-cell activation, proliferation and function unaffected in-vitro. This information may be useful for the design of up-coming clinical trials testing the safety and efficacy of FLT3-kinase inhibitors in combination with allogeneic stem-cell transplantation.

Disclosures:
Lipka: Novartis Inc.: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Heidel:Novartis Inc.: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding.