Abstract A43: Targeting ERK1/2 overcomes resistance to venetoclax by altering Drp1-dependent mitochondrial fission and metabolism in AML
Authors: Sharma Priyanka , Ostermann Lauren , Piya Sujan , Baran Natalia , Tyagi Anudishi , Zal Anna , Hindley Christopher , Dao Kim-Hien , Sims Martin , Zal Tomasz , Ruvolo Vivian , Andreeff Michael , Borthakur Gautam 
Published: May 2023

Abstract
Background: RAS/RAF/ERK pathway activation is associated with primary or secondary resistance to venetoclax in AML. Oncogenic RAS activates mitochondrial fission through ERK1/2 mediated phosphorylation of the mitochondrial fission GTPase Drp1. Although the deletion of Drp1 inhibits KRAS driven pancreatic cancer, the role of RAS-driven mitochondrial dynamics in AML is unclear. Inhibiting ERK1/2 may, therefore, shed light on AML cells' dependence on RAS driven mitochondrial dynamics and metabolism.
Objectives: We assessed the anti-leukemia efficacy of concomitant Bcl2 and ERK1/2 inhibition in preclinical models of venetoclax resistance and further investigated the role of ERK1/2/Drp1-dependent mitochondrial fission in mediating resistance to venetoclax through altered metabolism.
Results: ERK1/2 inhibition using Compound 27 (Heightman et al., 2018), sensitized intrinsically resistant and NRAS-mutant OCI-AML3 cells to venetoclax with combination index (CI) of 0.008. Synergy was also confirmed in OCI-AML2 cells with acquired resistance to venetoclax (75% apoptosis versus 22% by venetoclax, CI=0.6). Bulk and CD34+CD38- leukemia initiating cells (LICs) were also eliminated in primary AML samples by the combination (CI:0.03-0.23). Colony formation assay and CyTOF using NRAS-mutant PDX showed impaired clonogenic potential (p=0.0002) and decreased expression of cMyc and CD44 in LICs in response to ERK1/2 inhibition and combination treatment, suggesting impact on stemness. ERK1/2 inhibition using ASTX029 (Heightman et al., 2021) alone and in combination with venetoclax reduced leukemia burden in-vivo and extended survival (p&lt;0.05). Mitochondrial ROS mitigation, Drp1-mediated mitochondrial fission and glycolysis are critical to maintain stemness in AML. ERK1/2 inhibition decreased pDrp1-Ser616 levels along with an increase in mitochondrial length (p&lt;0.001) and mitochondrial ROS (p&lt;0.01), suggesting impaired mitochondrial fission. In OCI-AML3 cells, combination treatment caused downregulation of Drp1 mRNA and decreased phosphorylation of Drp1 at Ser616. Overexpression of a phospho-mimetic i.e. Drp1-Ser616Glu-Ser637Ala in OCI-AML3 cells decreased apoptosis and reversed synergy between ERK1/2 and Bcl-2 inhibition as compared to wild type and phospho-null (Ser616Ala) Drp1 (p&lt;0.001). Of note, overexpression of Drp1-phospho-mimetic led to decreased mitochondrial length, suggesting enhanced fission with a distinct metabolic phenotype including reduced basal respiration, significantly decreased maximal oxygen consumption rate, ATP production and ROS production. Moreover, combination treatment failed to significantly induce ROS production in cells expressing phospho-mimetic Drp1 as opposed to those expressing phospho-null or wildtype Drp1.
Conclusion: Inhibition of ERK1/2/Drp1dependent mitochondrial fission and metabolic alterations may be a potential mechanism of synergistic tumor cell killing for the combination treatment. In summary, these data support combining ERK1/2 and Bcl-2 inhibitors in the treatment of AML and warrant further clinical investigation.
Citation Format: Priyanka Sharma, Lauren Ostermann, Sujan Piya, Natalia Baran, Anudishi Tyagi, Anna Zal, Christopher Hindley, Kim-Hien Dao, Martin Sims, Tomasz Zal, Vivian Ruvolo, Michael Andreeff, Gautam Borthakur. Targeting ERK1/2 overcomes resistance to venetoclax by altering Drp1-dependent mitochondrial fission and metabolism in AML [abstract]. In: Proceedings of the AACR Special Conference: Acute Myeloid Leukemia and Myelodysplastic Syndrome; 2023 Jan 23-25; Austin, TX. Philadelphia (PA): AACR; Blood Cancer Discov 2023;4(3_Suppl):Abstract nr A43.