From www.bloodjournal.org by guest on January 14, 2017. For personal use only.

Therefore, there is a pressing need to

identify the most effective inhibitors that
simultaneously inhibit both upstream and
downstream components of these pathways
and also suppress activation of escape
mechanisms that induce therapeutic resistance.
In their article, Tasian et al developed
a preclinical strategy to tackle this daunting
issue by using pediatric PDX models of Ph-like
ALL treated with various PI3K, mTOR, and
dual-PI3K/mTOR inhibitors that directly
targeted PI3Ka (BYL719), PI3Kd (idelalisib),
TORC1/TORC2 (AZD2014), and PI3K/
mTOR (gedatolisib). They hypothesized that
ablating the signaling cascades emanating from
these molecules would inhibit the proliferative
potential of these cells. Indeed, treatment with
each of these inhibitors substantially reduced
leukemic burden in transplanted mice.
Importantly, the most robust activity was noted
in the gedatolisib-treated cohort. Furthermore,
pharmacodynamic analyses revealed that
gedatolisib treatment provided the most
signicant inhibition of mTORC1 (pS6 and
p4EBP1) and mTORC2 (pAKTSer473)
targets. Next, the authors hypothesized that
combined PI3K/mTOR pathway inhibition,
along with JAK inhibition or ABL inhibition
in genetically dened Ph-like ALL models
(CLRF2 and ABL/PDGFR alterations,
respectively), would have superior efcacy
compared with monotherapy. These
multipronged treatment strategies signicantly
prolonged survival and resulted in neareradication of Ph-like ALL in CRLF2/JAK2mutant models compared with monotherapy
with gedatolisib or ruxolitinib (a JAK
inhibitor). Likewise, the combination of
gedatolisib plus dasatinib (an ABL inhibitor) in
Ph-like ALL ABL1-mutant models effectively
eliminated leukemic proliferation and extended
survival when compared with either inhibitor
alone. Taken as a whole, the investigation
revealed the superior efcacy of gedatolisib
compared with isoform-specic PI3Ks and
mTOR inhibitors, and most strikingly, it
demonstrated the combinatorial impact
of including JAK2 or ABL inhibitors in
genetically dened contexts.
Going forward, these studies offer 2 seminal
points. First and most obvious is that clinical
trials that combine multiple kinase inhibitors
are warranted for patients with Ph-like ALL.
Second, these studies highlight the fact that the
painstaking approach to developing preclinical
models based on specic genetic alterations for

which there are relevant targeted therapies

offers a robust platform for testing novel
genetically tailored therapeutic concepts.
This is a salient point, because clinicians are
often presented with a critical dilemma when
biological paradigms are incompletely
understood: How does one simultaneously
target a multifaceted pathway when it is not
overtly clear whether a specic agent(s) will
apply the necessary therapeutic pressure?
This is often the case in Ph-like ALL,
because there are many redundant and
complementary signaling events activating
the same targets. Thus, the most logical
(yet difcult) choices are to select agent(s)
that can directly ablate an entire pathway
(such as dual-PI3K/mTOR inhibitors in
combination with JAK or ABL inhibitors).
Given the multitude of novel agents
currently being tested in clinical trials, only
time will tell if the combinations presented
here will be as efcacious in human patients,
but these empirical studies based on rational
combinatorial approaches dened by clinical
and genomic contexts provide an excellent
starting point for offering patients a chance
for long-term disease eradication.
Conict-of-interest disclosure: The author
declares no competing nancial interests. n

REFERENCES
1. Tasian SK, Teachey DT, Li Y, et al. Potent efcacy of
combined PI3K/mTOR and JAK or ABL inhibition in
murine xenograft models of Ph-like acute lymphoblastic
leukemia. Blood. 2017;129(2):177-187
2. Hunger SP, Lu X, Devidas M, et al. Improved survival
for children and adolescents with acute lymphoblastic
leukemia between 1990 and 2005: a report from the
childrens oncology group. J Clin Oncol. 2012;30(14):
1663-1669.
3. Jabbour E, OBrien S, Konopleva M, Kantarjian H.
New insights into the pathophysiology and therapy of adult
acute lymphoblastic leukemia. Cancer. 2015;121(15):
2517-2528.
4. Den Boer ML, van Slegtenhorst M, De Menezes RX,
et al. A subtype of childhood acute lymphoblastic
leukaemia with poor treatment outcome: a genome-wide
classication study. Lancet Oncol. 2009;10(2):125-134.
5. Roberts KG, Li Y, Payne-Turner D, et al. Targetable
kinase-activating lesions in Ph-like acute lymphoblastic
leukemia. N Engl J Med. 2014;371(11):1005-1015.
6. Yoda A, Yoda Y, Chiaretti S, et al. Functional
screening identies CRLF2 in precursor B-cell acute
lymphoblastic leukemia. Proc Natl Acad Sci USA. 2010;
107(1):252-257.
7. Zoncu R, Efeyan A, Sabatini DM. mTOR: from
growth signal integration to cancer, diabetes and ageing.
Nat Rev Mol Cell Biol. 2011;12(1):21-35.
8. Carracedo A, Ma L, Teruya-Feldstein J, et al.
Inhibition of mTORC1 leads to MAPK pathway activation
through a PI3K-dependent feedback loop in human
cancer. J Clin Invest. 2008;118(9):3065-3074.
DOI 10.1182/blood-2016-11-749168
2017 by The American Society of Hematology

l l l MYELOID NEOPLASIA

Comment on Tarafdar et al, page 199

CML stem cells: evasion

for
better invasion
----------------------------------------------------------------------------------------------------Franck Emmanuel Nicolini

CENTRE HOSPITALIER LYON SUD; CENTRE LEON BERARD

In this issue of Blood, Tarafdar et al demonstrate the downregulation of major

histocompatibility complex (MHC)-II molecules (and their main regulator class
II transactivator [CIITA]) in chronic myeloid leukemia (CML) stem cells,
allowing them to evade the immune surveillance exerted by the innate immune
system that can be reverted or enhanced by JAK2 inhibitors and interferon g
(IFN-g).1

or more than 2 decades, the

immunogenicity of CML cells has been
demonstrated and therapeutically successfully
exploited in the allogeneic setting,2,3 leading
to indenite complete molecular remissions
in many CML patients, especially those in
chronic phase. In addition, the presence of host
immune effectors directed against CML

BLOOD, 12 JANUARY 2017 x VOLUME 129, NUMBER 2

aberrantly expressed proteins4 or BCR-ABL

peptides5 able to induce an effective lysis of
malignant cells has been also demonstrated and
exploited in the clinical arena in few patients
with real, but less success.6 These issues are
still currently under investigation.
In this original work, using a microarray
approach, Tarafdar et al carefully examined the

141

From www.bloodjournal.org by guest on January 14, 2017. For personal use only.

expression of MHC-II molecules in progenitor

cells of CML patients (CD341381, CD341
382, CD341382901), comparing them with
normal bone marrow counterparts. They
explored different hypotheses that may explain
why these cells evade the host immune
surveillance and persist despite life-long
tyrosine kinase inhibitor (TKI) treatment. The
expression of MHC-II genes and molecules
are specically reduced in CML stem cells,
as is the major regulator of these molecules,
CIITA. The addition in culture media of
IFN-g increased the expression of MHC-II
molecules, but to a lesser degree than it would
do for normal counterparts. The exposure of
CML stem cells to 3 different TKIs in vitro
for 2 to 7 days did not result in substantial
modication of the expression of MHC-II and
CIITA, suggesting that this phenomenon is
BCR-ABLindependent. The decreased
expression does not seem to be mediated via
epigenetic mechanisms. Because interleukin-4,
a natural antagonist of MHC-II and CIITA
expression, signals through the JAK/STAT
pathway (as do many other cytokines), the
authors demonstrate that the incubation of
CML stem cells with the JAK1/2-specic
inhibitor Ruxolitinib restored the expression
levels of CIITA and MHC-II as a result of the
inhibition of JAK-downstream mediators.
Finally, Tarafdar et al show that IFN-g and
ruxolitinib increase the proliferation of
responder CD41CD691 allogeneic T cells in
mixed lymphocyte reactions, which could be
abolished by the addition of antibodies against
MHC-II molecules.
The authors thus provide novel
information describing an additional BCRABLindependent mechanism that might
contribute to the resistance of CML stem cells
that persist despite TKI therapy by downregulating MHC-II molecules, which can be
reverted in vitro by ruxolitinib and IFN-g.
These data are in line with previous in vitro and
in vivo observations on the efcacy of type I
interferons (ie, IFN-a) in CML patients
with residual disease on TKI, which may work
by restoring MHC-I and MHC-II expression
in CML stem cells and allow their
recognition by the host immune effectors.7
This study also helps explain data from
previous or ongoing trials combining TKIs
with (pegylated forms of) IFN-a since
diagnosis, showing unexpectedly high
molecular response rates.8-10 Responses of
4 ongoing clinical trials in different clinical

142

situations in CML, combining TKI and

ruxolitinib as discussed in Tarafdar et al, also
support these in vitro observations. That the
downregulation of MHC-II and CIITA
is intrinsic to CML stem cells or related
to some cytokine deregulations within the
CML niche, or both, requires further
exploration.
Conict-of-interest disclosure: The author
declares no competing nancial interests. n
REFERENCES
1. Tarafdar A, Hopcroft LEM, Gallipoli P, et al. CML
cells actively evade host immune surveillance through
cytokine-mediated downregulation of MHC-II expression.
Blood. 2017;129(2):199-208.
2. Slavin S, Nagler A, Naparstek E, et al.
Nonmyeloablative stem cell transplantation and cell
therapy as an alternative to conventional bone marrow
transplantation with lethal cytoreduction for the treatment
of malignant and nonmalignant hematologic diseases.
Blood. 1998;91(3):756-763.
3. Kolb HJ, Schattenberg A, Goldman JM, et al;
European Group for Blood and Marrow Transplantation
Working Party Chronic Leukemia. Graft-versus-leukemia
effect of donor lymphocyte transfusions in marrow grafted
patients. Blood. 1995;86(5):2041-2050.
4. Molldrem JJ, Lee PP, Wang C, et al. Evidence that
specic T lymphocytes may participate in the elimination
of chronic myelogenous leukemia. Nat Med. 2000;6(9):
1018-1023.

5. Bocchia M, Gentili S, Abruzzese E, et al. Effect of

a p210 multipeptide vaccine associated with imatinib or
interferon in patients with chronic myeloid leukaemia and
persistent residual disease: a multicentre observational trial.
Lancet. 2005;365(9460):657-662.
6. Bocchia M, Dena M, Aprile L, et al. Complete
molecular response in CML after p210 BCR-ABL1-derived
peptide vaccination. Nat Rev Clin Oncol. 2010;7(10):600-603.
7. Burchert A, Mu ller MC, Kostrewa P, et al. Sustained
molecular response with interferon alfa maintenance after
induction therapy with imatinib plus interferon alfa in
patients with chronic myeloid leukemia. J Clin Oncol. 2010;
28(8):1429-1435.
8. Preudhomme C, Guilhot J, Nicolini FE,
et al; SPIRIT Investigators; France Intergroupe
des Leucemies Myelodes Chroniques (Fi-LMC). Imatinib
plus peginterferon alfa-2a in chronic myeloid leukemia.
N Engl J Med. 2010;363(26):2511-2521.
9. Nicolini FE, Etienne G, Dubruille V, et al. Nilotinib
and peginterferon alfa-2a for newly diagnosed chronicphase chronic myeloid leukaemia (NiloPeg): a multicentre,
non-randomised, open-label phase 2 study. Lancet
Haematol. 2015;2(1):e37-e46.
10. Hjorth-Hansen H, Stentoft J, Richter J, et al. Safety
and efcacy of the combination of pegylated interferona2b and dasatinib in newly diagnosed chronic-phase
chronic myeloid leukemia patients. Leukemia. 2016;30(9):
1853-1860.

DOI 10.1182/blood-2016-11-750554
2017 by The American Society of Hematology

l l l THROMBOSIS AND HEMOSTASIS

Comment on Yoon et al, page 238

Driving
the hemophilia tolerance CAR
----------------------------------------------------------------------------------------------------Roland W. Herzog

UNIVERSITY OF FLORIDA

T-cell immunotherapy against cancer, using chimeric antigen receptors (CARs)

to specically target tumor antigens without major histocompatibility complex
(MHC) restriction, is widely viewed as one of the major scientic breakthroughs
of recent years.1 In this issue of Blood, Yoon et al demonstrate that this approach
can be adapted to redirect specicity of regulatory T cells (Tregs) to coagulation
factor VIII (FVIII), thereby suppressing antibody (inhibitor) development in
replacement therapy for hemophilia A.2

lthough treatment of the X-linked

bleeding disorder hemophilia is perhaps
the most extensively studied example of
antidrug antibody (ADA) formation against
therapeutic proteins, this is a recurring
problem in enzyme replacement therapies for
other genetic diseases and monoclonal antibody
therapies. Even though there are a number of
bypass agents available to restore hemostasis in
hemophilic patients with inhibitors, treatment
becomes substantially more complicated, with

an increased risk of morbidity and mortality.

In order to resume regular FVIII replacement
therapy, immune tolerance has to be established.
Immune tolerance induction (ITI) is currently
done through frequent high-dose FVIII
infusions. These regimens and use of bypassing
agents generate extraordinary costs. In addition,
ITI protocols can take months or even years
to complete and are not always successful.
The mammalian immune system has
evolved CD41 Tregs (characterized by

BLOOD, 12 JANUARY 2017 x VOLUME 129, NUMBER 2

From www.bloodjournal.org by guest on January 14, 2017. For personal use only.

2017 129: 141-142

doi:10.1182/blood-2016-11-750554

CML stem cells: evasion for better invasion

Franck Emmanuel Nicolini

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