Synergistic Cytotoxicity of Sorafenib with Busulfan and Nucleoside Analogs in Human FMS-like Tyrosine Kinase 3 Internal Tandem Duplications–Positive Acute.

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Synergistic Cytotoxicity of Sorafenib with Busulfan and Nucleoside Analogs in Human FMS-like Tyrosine Kinase 3 Internal Tandem Duplications–Positive Acute Myeloid Leukemia Cells  Guiyun Song, Benigno C. Valdez, Yang Li, Yan Liu, Richard E. Champlin, Borje S. Andersson  Biology of Blood and Marrow Transplantation  Volume 20, Issue 11, Pages 1687-1695 (November 2014) DOI: 10.1016/j.bbmt.2014.08.003 Copyright © 2014 American Society for Blood and Marrow Transplantation Terms and Conditions

Biology of Blood and Marrow Transplantation 2014 20, 1687-1695DOI: (10 Biology of Blood and Marrow Transplantation 2014 20, 1687-1695DOI: (10.1016/j.bbmt.2014.08.003) Copyright © 2014 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 1 Antiproliferative effects of Bu, Clo, Flu, and Sor in FLT3-ITD–positive (A,B) and FLT3-wild type (C,D) AML cell lines. Cells were exposed to drugs alone, or in combination, for 48 hours and analyzed by MTT and annexin V (Ann-V) assays. Results are expressed as the mean ± SD of 3 independent experiments. PCR analysis (E) shows the presence of mutated (FLT3-ITD) or wild type (WT-FLT3) FLT3 in the 4 cell lines. Bu or B, busulfan; Clo or C, clofarabine; Flu or F, fludarabine; Sor, sorafenib. Biology of Blood and Marrow Transplantation 2014 20, 1687-1695DOI: (10.1016/j.bbmt.2014.08.003) Copyright © 2014 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 2 Drug combinations activate the DNA damage response and induce apoptosis. MV-4-11 cells were exposed to Bu, Clo, Flu, and Sor alone, or in combination, for 48 hours and changes in the level and modification of proteins involved in DNA damage response pathway (A) and apoptosis (B) were analyzed by Western blot. Bu or B, busulfan; Clo or C, clofarabine; Flu or F, fludarabine; Sor, sorafenib. Biology of Blood and Marrow Transplantation 2014 20, 1687-1695DOI: (10.1016/j.bbmt.2014.08.003) Copyright © 2014 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 3 Drug exposures increase modifications of histones. MV-4-11 cells were exposed to Bu, Clo, Flu, and Sor alone, or in combination, for 48 hours and histone modifications were analyzed by Western blot. Bu or B, busulfan; Clo or C, clofarabine; Flu or F, fludarabine; Sor, sorafenib. Biology of Blood and Marrow Transplantation 2014 20, 1687-1695DOI: (10.1016/j.bbmt.2014.08.003) Copyright © 2014 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 4 Drug combinations inhibit tyrosine kinases and phosphorylation of their substrates. MV-4-11 cells were exposed to Bu, Clo, Flu, and Sor alone, or in combination, for 48 hours and the activation by phosphorylation of tyrosine kinases (A) and changes in the status of their downstream substrates (B) were analyzed by Western blot. Cyto, cytosolic fraction; Nuc, nuclear fraction; Bu or B, busulfan; Clo or C, clofarabine; Flu or F, fludarabine; Sor, sorafenib. Biology of Blood and Marrow Transplantation 2014 20, 1687-1695DOI: (10.1016/j.bbmt.2014.08.003) Copyright © 2014 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 5 Drug exposures decrease the mitochondrial membrane potential and induce release of death factors from isolated mitochondria. MV-4-11 cells (A) were exposed to 4.1 μM busulfan .01 μM, clofarabine, 2.5 μM fludarabine, ± 1 nM sorafenib (Sor) for 48 hours and analyzed for changes in mitochondrial membrane potential as described under Materials and Methods. Results are expressed as percentage of fluorescence changes relative to the control (mean ± SD of 3 independent experiments). §P < .05 relative to control. †P < .05 relative to BCF-treated group. Isolated mitochondria (B) from MV-4-11 cells were exposed to Sor alone or to BCF ± Sor for 30 minutes at the concentration indicated above. B, busulfan; C, clofarabine; F, fludarabine; Super, supernatant; Mito, mitochondria. Biology of Blood and Marrow Transplantation 2014 20, 1687-1695DOI: (10.1016/j.bbmt.2014.08.003) Copyright © 2014 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 6 Analysis of the BCL-2 family members involved in mitochondrial outer membrane permeabilization in MV-4-11 cells. Cells were exposed to 4.1 μM busulfan, .01 μM clofarabine, 2.5 μM fludarabine, ± 1 nM sorafenib (Sor) for 48 hours. Cell lysates for immunoprecipitation were analyzed by Western blot (A) and 450 μg was used to perform immunoprecipitation with antibody against MCL-1 (B) or PUMA (C). IgG was used as a negative control for the immunoprecipitation. The obtained immunoprecipitates were probed with antibodies against BIM and MCL-1 (B) or antibodies against BCL-2, MCL-1, and PUMA (C). The numbers at the bottom of each picture refer to the band density values. B, Busulfan; C, clofarabine; F, fludarabine. Biology of Blood and Marrow Transplantation 2014 20, 1687-1695DOI: (10.1016/j.bbmt.2014.08.003) Copyright © 2014 American Society for Blood and Marrow Transplantation Terms and Conditions

Figure 7 Analysis of mononuclear cells from the peripheral blood of 3 AML patients with FLT3-ITD mutations. FLT3-ITD mutations were confirmed by PCR with specific primers for FLT3-ITD (A). Mononuclear cells were exposed to the indicated concentrations of Sor, busulfan+clofarabine+fludarabine (BCF), or their combinations for 48 hours and analyzed for cell proliferation and apoptosis by the MTT and Annexin V assays, respectively (B). The levels of p-FLT3, p-P53, γ-H2AX, and PARP1 were determined by Western blot (C). Patient (Pt) number is indicated. BCF, busulfan+clofarabine+fludaribine; BCFS, BCF+Sor. 1X = 4.1 μM Bu, .01 μM Clo, 2.5 μM Flu, and 1 nM Sor. Biology of Blood and Marrow Transplantation 2014 20, 1687-1695DOI: (10.1016/j.bbmt.2014.08.003) Copyright © 2014 American Society for Blood and Marrow Transplantation Terms and Conditions