Venetoclax Synergizes with Radiotherapy for Treatment of B cell Lymphomas

Constitutive B cell receptor signaling leads to overexpression of the anti-apoptotic BCL-2 protein and is implicated in the pathogenesis of many types of B cell Non-Hodgkin Lymphoma (B-NHL). The BCL-2 small molecule inhibitor venetoclax shows promising clinical response rates in several lymphomas, but is not curative as monotherapy. Radiotherapy (RT) is a rational candidate for combining with BCL-2 inhibition, as DNA damage caused by RT increases the activity of pro-apoptotic BCL-2 pathway proteins, and lymphomas are exquisitely sensitive to radiation. We tested B-NHL responses to venetoclax combined with either external beam RT or radioimmunotherapy (RIT), which joins the selectivity of antibody targeting with the effectiveness of irradiation. We first tested cytotoxicity of cesium-137 irradiation plus venetoclax in 14 B-NHL cell lines representing five lymphoma sub-types. Combination treatment synergistically increased cell death in ten of 14 lines. Lack of synergy was predicted by resistance to single-agent venetoclax and high BCL-XL expression. We then assessed the efficacy of external beam RT plus venetoclax in murine xenograft models of mantle cell (MCL), germinal-center diffuse large B-cell (GCB-DLBCL), and activated B-cell (ABC-DLBCL) lymphomas. In each model, external beam RT plus venetoclax synergistically increased mouse survival time, curing up to 10%. We finally combined venetoclax treatment of MCL and ABC-DLBCL xenografts with a pretargeted RIT (PRIT) system directed against the CD20 antigen. Optimal dosing of PRIT plus venetoclax cured 100% of mice with no detectable toxicity. Venetoclax combined with RT may be a promising treatment for a wide range of lymphomas.

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