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Supplementary Figure 1. Pro-inflammatory cytokines are elevated in MF mice and reversed with JAK inhibitor treatment. Supplementary Figure 2. Principal component analysis of MF cells. Supplementary Figure 3. Single cell analysis of immunophenotypically-defined subpopulations from MF and control mice. Supplementary Figure 4. Elevated IL8 expression in MF patients. Supplementary Figure 5. Complete removal of Il6 from the mouse system shows only minor effects on MPLW515L disease. Supplementary Figure 6. Peripheral blood and cytometric flow analysis of MPLW515L transplanted mice with and without Stat3 deletion. Supplementary Figure 7. Constitutive activation of STAT3 in the BM of MPLW515L mice and primary MF patients. Supplementary Figure 8. Schematic illustration of bone marrow transplantation experiments using Stat3-deficient mice or littermate control mice as donors. Supplementary Figure 9. Excision of Stat3 post engraftment prolongs survival and reduces leukocytosis. Supplementary Figure 10. Mutant-restricted deletion of Stat3 does not affect disease severity in vivo. Supplementary Figure 11. Single cell analysis of populations from MF and control mice. Supplementary Figure 12. Mutant and non-mutant hematopoietic cells feature a higher percentage of cytokine secreting cells. Supplementary Figure 13. Single cell analysis of populations from Jak2V617F MF and control mice. Supplementary Figure 14. Mutant and non-mutant hematopoietic cells feature a higher percentage of cytokine secreting cells. Supplementary Figure 15. JAK1/2 inhibition reduces cytokine expression from CD45.1-positive wild-type cells and CD45.2-positive mutant cell population. Supplementary Table 1. Primary myelofibrosis patient characteristics. Supplementary Table 2. Genetic alterations of patient PMF#11.

INTRODUCTION: Tumors employ many strategies to attenuate immune responses. High levels of extracellular adenosine generated in the tumor microenvironment engage A2a and A2b adenosine receptors on immune cells, resulting in immunosuppression. Expression of A2aR and A2bR can vary by cell type, with T cells predominantly expressing A2aR while myeloid cells express both A2aR and A2bR. We have previously shown that etrumadenant, a dual A2aR/A2bR antagonist, blocks the immunosuppressive effects of adenosine in immune cells and enhances anti-tumor immune responses in mouse syngeneic tumors. Using dual and selective adenosine receptor antagonists, we assessed the contribution of these receptors to adenosine-mediated phenotypes in immune and cancer cells. METHODS: Human CD8+ T cells were isolated from healthy human blood and activated using CD3/CD28/CD2 stimulation and cytokines were analyzed by cytokine bead array at 72 hours. Primary human dendritic cells (DC) were isolated from healthy blood and matured with LPS/IFN-γ for 24 hours. Cancer cell lines were purchased from ATCC. The adenosine analogue NECA was used to stimulate A2aR/A2bR-mediated signaling. RESULTS: Activated human CD8+ T cells stimulated in the presence of NECA showed suppression of activation markers (CD69) and cytokine production (IFN-γ, IL-2 and granzyme B). As expected, we observed similar rescue of this phenotype with both etrumadenant and an A2aR-specific antagonist owing to the sole expression of A2aR on T cells. In contrast, primary DC have comparable expression of A2aR and A2bR, suggesting that dual blockade may provide greater resistance to adenosine-mediated suppression than A2aR antagonism. Indeed, etrumadenant was able to attenuate the adenosine-mediated upregulation of IL-10 and enhance IL-12p70 production, whereas a comparable A2aR-specific antagonist showed no significant rescue versus NECA-stimulated controls. These observations may be extended to suppressive myeloid populations as well as tumor-resident macrophages and myeloid-derived suppressor cells isolated from mouse syngeneic tumors, which have very high expression of both A2aR and A2bR. RNA-sequencing identified a cassette of genes regulated by adenosine-signaling in these cells, which were largely reversed by etrumadenant. Finally, cultured human cancer cell lines have high expression of A2bR, which has been implicated in driving their tumorigenesis. Etrumadenant reversed adenosine-stimulated gene expression changes in non-small cell lung cancer cell lines, restoring enriched pathways driven by adenosine signaling. CONCLUSIONS: Taken together, these results show an important role for A2aR/A2bR in adenosine-mediated immunosuppression and provide a mechanistic rationale for stimulation of anti-tumor immune responses with the dual adenosine receptor antagonist etrumadenant. Citation Format: Sachie Marubayashi, Bindi Patel, Livia Yamashiro, Dana Piovesan, Sean Cho, Jenna Jeffrey, Manmohan Leleti, Jay Powers, Matt Walters, Daniel DiRenzo. Dual A2aR/A2bR antagonism with etrumadenant (AB928) eliminates the suppressive effects of adenosine on immune and cancer cells in the tumor microenvironment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 256.

Background Checkpoint inhibitors (CPIs) such as anti-PD(L)-1 and anti-CTLA-4 antibodies have resulted in unprecedented rates of antitumor responses and extension of survival of patients with a variety of cancers. But some patients fail to respond or initially respond but later relapse as they develop resistance to immune therapy. One of the tumor-extrinsic mechanisms for resistance to immune therapy is the accumulation of regulatory T cells (Treg) in tumors. In preclinical and clinical studies, it has been suggested that tumor trafficking of Treg is mediated by CC chemokine receptor 4 (CCR4). Over 90% of human Treg express CCR4 and migrate toward CCL17 and CCL22, two major CCR4 ligands that are either high at baseline or upregulated in tumors on CPI treatment. Hence, CCR4 antagonism has the potential to be an effective antitumor treatment by reducing the accumulation of Treg into the tumor microenvironment (TME). Methods We developed in vitro and in vivo models to assess Treg migration and antitumor efficacy using a potent and selective CCR4 antagonist, CCR4-351. We used two separate tumor models, Pan02 and CT26 mouse tumors, that have high and low CCR4 ligand expression, respectively. Tumor growth inhibition as well as the frequency of tumor-infiltrating Treg and effector T cells was assessed following the treatment with CCR4 antagonist alone or in combination with CPI. Results Using a selective and highly potent, novel small molecule inhibitor of CCR4, we demonstrate that migration of CCR4+ Treg into the tumor drives tumor progression and resistance to CPI treatment. In tumor models with high baseline levels of CCR4 ligands, blockade of CCR4 reduced the number of Treg and enhanced antitumor immune activity. Notably, in tumor models with low baseline level of CCR4 ligands, treatment with immune CPIs resulted in significant increases of CCR4 ligands and Treg numbers. Inhibition of CCR4 reduced Treg frequency and potentiated the antitumor effects of CPIs. Conclusion Taken together, we demonstrate that CCR4-dependent Treg recruitment into the tumor is an important tumor-extrinsic mechanism for immune resistance. Blockade of CCR4 led to reduced frequency of Treg and resulted in increased antitumor activity, supporting the clinical development of CCR4 inhibitors in combination with CPI for the treatment of cancer. Statement of significance CPI upregulates CCL17 and CCL22 expression in tumors and increases Treg migration into the TME. Pharmacological antagonism of the CCR4 receptor effectively inhibits Treg recruitment and results in enhanced antitumor efficacy either as single agent in CCR4 ligandhigh tumors or in combination with CPIs in CCR4 ligandlow tumors.

BackgroundCheckpoint inhibitors (CPIs) such as anti-PD(L)-1 and anti-CTLA-4 antibodies have resulted in unprecedented rates of antitumor responses and extension of survival of patients with a variety of cancers. But some patients fail to respond or initially respond but later relapse as they develop resistance to immune therapy. One of the tumor-extrinsic mechanisms for resistance to immune therapy is the accumulation of regulatory T cells (Treg) in tumors. In preclinical and clinical studies, it has been suggested that tumor trafficking of Treg is mediated by CC chemokine receptor 4 (CCR4). Over 90% of human Treg express CCR4 and migrate toward CCL17 and CCL22, two major CCR4 ligands that are either high at baseline or upregulated in tumors on CPI treatment. Hence, CCR4 antagonism has the potential to be an effective antitumor treatment by reducing the accumulation of Treg into the tumor microenvironment (TME).MethodsWe developed in vitro and in vivo models to assess Treg migration and antitumor efficacy using a potent and selective CCR4 antagonist, CCR4-351. We used two separate tumor models, Pan02 and CT26 mouse tumors, that have high and low CCR4 ligand expression, respectively. Tumor growth inhibition as well as the frequency of tumor-infiltrating Treg and effector T cells was assessed following the treatment with CCR4 antagonist alone or in combination with CPI.ResultsUsing a selective and highly potent, novel small molecule inhibitor of CCR4, we demonstrate that migration of CCR4+ Treg into the tumor drives tumor progression and resistance to CPI treatment. In tumor models with high baseline levels of CCR4 ligands, blockade of CCR4 reduced the number of Treg and enhanced antitumor immune activity. Notably, in tumor models with low baseline level of CCR4 ligands, treatment with immune CPIs resulted in significant increases of CCR4 ligands and Treg numbers. Inhibition of CCR4 reduced Treg frequency and potentiated the antitumor effects of CPIs.ConclusionTaken together, we demonstrate that CCR4-dependent Treg recruitment into the tumor is an important tumor-extrinsic mechanism for immune resistance. Blockade of CCR4 led to reduced frequency of Treg and resulted in increased antitumor activity, supporting the clinical development of CCR4 inhibitors in combination with CPI for the treatment of cancer.Statement of significanceCPI upregulates CCL17 and CCL22 expression in tumors and increases Treg migration into the TME. Pharmacological antagonism of the CCR4 receptor effectively inhibits Treg recruitment and results in enhanced antitumor efficacy either as single agent in CCR4 ligandhigh tumors or in combination with CPIs in CCR4 ligandlow tumors.

The identification of JAK2/MPL mutations in patients with myeloproliferative neoplasms (MPN) has led to the clinical development of JAK kinase inhibitors, including ruxolitinib. Ruxolitinib reduces splenomegaly and systemic symptoms in myelofibrosis and improves overall survival; however, the mechanism by which JAK inhibitors achieve efficacy has not been delineated. Patients with MPN present with increased levels of circulating proinflammatory cytokines, which are mitigated by JAK inhibitor therapy. We sought to elucidate mechanisms by which JAK inhibitors attenuate cytokine-mediated pathophysiology. Single-cell profiling demonstrated that hematopoietic cells from myelofibrosis models and patient samples aberrantly secrete inflammatory cytokines. Pan-hematopoietic Stat3 deletion reduced disease severity and attenuated cytokine secretion, with similar efficacy as observed with ruxolitinib therapy. In contrast, Stat3 deletion restricted to MPN cells did not reduce disease severity or cytokine production. Consistent with these observations, we found that malignant and nonmalignant cells aberrantly secrete cytokines and JAK inhibition reduces cytokine production from both populations. Significance: Our results demonstrate that JAK–STAT3-mediated cytokine production from malignant and nonmalignant cells contributes to MPN pathogenesis and that JAK inhibition in both populations is required for therapeutic efficacy. These findings provide novel insight into the mechanisms by which JAK kinase inhibition achieves therapeutic efficacy in MPNs. Cancer Discov; 5(3); 316–31. ©2015 AACR. See related commentary by Belver and Ferrando, p. 234 This article is highlighted in the In This Issue feature, p. 213

The tumor microenvironment (TME) is characterized by deficiencies in oxygen and key nutrients, such as glucose and amino acids, resulting in an overall immune-suppressive environment. Key suppressive cell types in the TME include tumor, stromal and myeloid-derived suppressor cells (MDSC) which create a nutrient-poor environment that supports tumor growth and limits immune surveillance. General control nonderepressible 2 (GCN2), a stress response kinase, plays a key role in sensing and modulating the cellular response to amino acid deprivation. GCN2 activation in T cells triggers the integrated stress response pathway and promotes T cell anergy and apoptosis. We have developed small molecule GCN2 inhibitors (GCN2i) that are highly potent and selective in vitro. Culturing primary mouse or human immune cells under low nutrient conditions activates the GCN2 pathway limiting T cell proliferation and function. Treatment of these nutrient-deprived T cells with GCN2i resulted in rescue of CD8+ T cell proliferation and effector functions. In addition, GCN2 inhibition in MDSC alone fully reversed CD33+MDSC-induced T cell suppression and effector functions. Our GCN2 inhibitors are orally bioavailable with drug like in vivo ADME properties. Our GCN2i is currently being evaluated in vivo, in murine syngeneic tumor models. Our results demonstrate that inhibition of GCN2 is an attractive approach for relieving T cell suppression and promoting effector function, demonstrating GCN2 as a promising therapeutic target for the treatment of cancer. Note: This abstract was not presented at the meeting. Citation Format: Buvana Ravishankar, Lavanya Adusumilli, Deepa Pookot Pookot, Emily Huang, Raashi Sreenivasan, Lisa Marshall, Deepika Kaveri, Oezcan Talay, Silpa Suthram, Svetlana Miakicheva, Abood Okal, Mikhail Zibinsky, Jeffrey Jackson, Grant Shibuya, Paul Leger, Parcharee Tivitmahaisoon, Scott Jacobson, Steve Wong, Angela Wadsworth, Jerick Sanchez, Martin Brovarney, David Chian, Sachie Marubayashi, Aparna Jorapur, Delia Bradford, Christophe Colas, Gene Cutler, Jacob Schwartz, David Wustrow, Paul Kassner, Dirk Brockstedt. Targeting the stress response kinase GCN2 to restore immunity in the tumor microenvironment [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 1104.

Type 2 helper T cells (Th2)cells have been shown to express CCR4 receptor, and play a critical role in driving the pathogenesis of asthma and atopic dermatitis. FLX193 is a best-in-class, highly-potent and selective small molecule CCR4 antagonist under investigation for the treatment of allergic disorders. FLX193 blocked migration of CCR4+ Th2 cells (human and mouse) towards CCL17 and CCL22 in an in vitro chemotaxis assay. FLX193 is well-tolerated in animals at efficacious doses. In an Ovalbumin (OVA)-induced asthma model, FLX193 significantly reduced lymphocyte and eosinophil counts in the Bronchoalveolar lavage (BAL) fluid and showed a reduction of the effector Th2-relevant cytokines IL-5 and IL-13. FLX193 treatment also reduced the levels of CCL17 and CCL22 in the BAL fluid, indicating an overall reduction of inflammation. In addition, we used an atopic dermatitis mouse model to demonstrate that treatment with FLX193 decreased CCR4+ T-cell mediated inflammation. Hence, FLX193 shows promise in the treatment of atopic dermatitis.

Chronic exposure to JAK2 inhibitors leads to reactivation of downstream signalling through the formation of heterodimers between JAK2 and other JAK kinases in myeloproliferative neoplasms, which can be overcome with Hsp90 inhibitors. Mutations in JAK kinases, in particular JAK2, are frequent in some malignancies and JAK inhibitors have been trialled for example in patients with myeloproliferative neoplasms (MPNs). Here, Ross Levine and colleagues demonstrate that MPN cells can persist under conditions of chronic JAK2 inhibition, because JAK2 forms a heterodimer with other JAK kinases, leading to persistent JAK2 activation. This mode of drug 'persistence' seems to occur in patients treated with JAK2 inhibitor. Therapeutic approaches that induce JAK2 degradation may therefore be more effective than treatment with JAK2 inhibitors alone. The identification of somatic activating mutations in JAK2 (refs 1–4) and in the thrombopoietin receptor gene (MPL)5 in most patients with myeloproliferative neoplasm (MPN) led to the clinical development of JAK2 kinase inhibitors6,7. JAK2 inhibitor therapy improves MPN-associated splenomegaly and systemic symptoms but does not significantly decrease or eliminate the MPN clone in most patients with MPN. We therefore sought to characterize mechanisms by which MPN cells persist despite chronic inhibition of JAK2. Here we show that JAK2 inhibitor persistence is associated with reactivation of JAK–STAT signalling and with heterodimerization between activated JAK2 and JAK1 or TYK2, consistent with activation of JAK2 in trans by other JAK kinases. Further, this phenomenon is reversible: JAK2 inhibitor withdrawal is associated with resensitization to JAK2 kinase inhibitors and with reversible changes in JAK2 expression. We saw increased JAK2 heterodimerization and sustained JAK2 activation in cell lines, in murine models and in patients treated with JAK2 inhibitors. RNA interference and pharmacological studies show that JAK2-inhibitor-persistent cells remain dependent on JAK2 protein expression. Consequently, therapies that result in JAK2 degradation retain efficacy in persistent cells and may provide additional benefit to patients with JAK2-dependent malignancies treated with JAK2 inhibitors.

We have performed experiments to test whether Epstein Barr Virus (EBV)-infected tumors are enhanced for regulatory T cell (Treg) infiltration and whether selective and potent CCR4 antagonists would be a particularly effective therapeutic in this class of indications. Treg cells, which contribute to an immune-suppressive tumor microenvironment (TME), are attracted to tumors via the recognition of CCL17 and CCL22 ligands by the CCR4 receptor. These chemokines have been shown to be expressed in cells infected by the Epstein Barr Virus (EBV) via the viral LMP1 gene. Tumor types which are frequently associated with EBV-infection include gastric adenocarcinoma (~10% positive), classical Hodgkin's Lymphoma (~50%), and nasopharyngeal carcinoma (~100%). Analyzing RNA expression in EBV-associated tumors, we found strong expression of CCL17, CCL22, and FOXP3, a marker of Treg, when compared to EBV-negative tumors. In fact, NPC tumors show extremely high FOXP3 levels. To further test this link, we obtained EBV-associated tumor samples and performed RNA in situ hybridization (ISH) to measure co-expression of these genes. Strong co-localization, was indeed found, further supporting a link between EBV and Treg recruitment. To directly test whether EBV-positive tumors recruit Treg into tumors via CCL22/17 upregulation, we developed models in which mice were inoculated subcutaneously with EBV-positive cancer cell lines. These EBV-positive cancer cells were assessed for chemokine production in vitro and in vivo by ELISA. We assessed tumor-infiltrating lymphocytes (TILs) in established tumors, including Treg, CD4+ and CD8+ T cells as well as T cell activation markers. Treating these tumor-bearing mice with selective and potent CCR4 small-molecule antagonists alone or in combination with checkpoint-targeting antibodies allowed us to demonstrate meaningful antitumor responses in EBV-positive tumors. Together, these data suggest that EBV-positive tumors, such as gastric adenocarcinomas, Hodgkin's lymphomas, and nasopharyngeal carcinomas, are a class of indications of particular interest and potentially increased responsiveness to small-molecule CCR4 antagonists. These results are helping to inform the ongoing FLX475 trials currently in the clinic. Citation Format: Oezcan Talay, Aparna Jorapur, Scott Jacobson, Sachie Marubayashi, Lisa Marshall, Silpa Suthram, Omar Robles, John Ketcham, Maureen K. Reilly, Ashkaan Younai, Berenger Biannic, Dennis Hu, Minna Bui, Jacob Schwarz, Paul Kassner, Gene Cutler. EBV associated tumors have increased regulatory T cell recruitment and are therefore a potential indication for treatment with potent and selective small molecule CCR4 antagonists [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4752.

USP7 is a deubiquitinase (DUB) that has attracted much attention recently due to its multiple roles in promoting cancer progression. By removal of ubiquitin from protein substrates, USP7 stabilizes oncogenes such as MDM2 and Myc, destabilizes and inactivates the key tumor suppressors p53 and PTEN, and imparts resistance to DNA-damaging chemotherapy by enhancing DNA repair responses. USP7 plays an important role in suppression of immune responses in the tumor microenvironment by stabilizing the transcription factor FOXP3 and thereby enhancing the suppressive function of regulatory T cells. Thus, inhibition of USP7 is an appealing therapeutic strategy because it has the potential to impact important oncology targets such as transcription factors that have been widely viewed as undruggable. We employed structure-based and other medicinal chemistry techniques to enable the design of potent and selective USP7 inhibitors. Using a high-throughput assay of DUB activity employing rhodamine-labeled ubiquitin, we optimized several series of reversible USP7 inhibitors to sub-100 pM potency and selectivity of >10,000-fold over all other DUBs. Cellular activity was demonstrated using a luciferase reporter gene assay of p53 activation, revealing compounds with EC50 values ranging down to 20 nM. To assess the role of USP7 inhibition in enhancement of immune responses, we determined relief of suppression of effector T cells in vitro. Effector T cells (CD8+) were co-cultured with regulatory T cells (CD4+ FOXP3+) and antigen-presenting cells for 4 days, after which CD8+ cell proliferation was determined by flow cytometry. Treatment with USP7 inhibitors during co-culture resulted in relief of regulatory T cell suppression of CD8+ cell proliferation. In vivo enhancement of immune responses was assessed in rodent models of inflammation and tumor growth. Direct effects on tumor cell growth and viability were explored by profiling cytotoxicity of USP7 inhibitors as single agents and in combination with chemotherapeutic agents in a broad range of cancer cell lines. In preparation for future clinical development, compounds were modified to obtain desirable in vitro and in vivo ADME and toxicity profiles. Following extensive pre-clinical optimization, we have in hand orally bioavailable compounds with high permeability, low clearance, and minimal off-target activity. Citation Format: Betty Abraham, Lavanya Adusumilli, Berenger Biannic, Delia Bradford, Martin Brovarney, David Chian, Gene Cutler, Xinping Han, Dennis Hu, Scott Jacobson, Sherra Johnson, Paul Kassner, Deepika Kaveri, John Ketcham, Andrea Kim, Paul Leger, Lisa Marshall, Sachie Marubayashi, Jack Maung, Jenny McKinnell, Cesar Meleza, Yamini Ohol, Akinori Okano, Leanne Peiser, Deepa Pookot, Payal Rana, Jacob Schwarz, Nick Shah, Grant Shibuya, Michael Sun, Silpa Suthram, Oezcan Talay, Angela Wadsworth, David Wustrow, Kyle Young, Andrew Napper. Discovery and optimization of potent and selective inhibitors of USP7 to enhance anti-tumor immunity and target tumor growth [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 2915.

The discovery of JAK2 and MPL mutations in patients with myeloproliferative neoplasms (MPNs) provided important insight into the genetic basis of these disorders and led to the development of JAK2 kinase inhibitors for MPN therapy. Although recent studies have shown that JAK2 kinase inhibitors demonstrate efficacy in a JAK2V617F murine bone marrow transplantation model, the effects of JAK2 inhibitors on MPLW515L-mediated myeloproliferation have not been investigated. In this report, we describe the in vitro and in vivo effects of INCB16562, a small-molecule JAK2 inhibitor. INCB16562 inhibited proliferation and signaling in cell lines transformed by JAK2 and MPL mutations. Compared with vehicle treatment, INCB16562 treatment improved survival, normalized white blood cell counts and platelet counts, and markedly reduced extramedullary hematopoeisis and bone marrow fibrosis. We observed inhibition of STAT3 and STAT5 phosphorylation in vivo consistent with potent inhibition of JAK-STAT signaling. These data suggest JAK2 inhibitor therapy may be of value in the treatment of JAK2V617F-negative MPNs. However, we did not observe a decrease in the size of the malignant clone in the bone marrow of treated mice at the end of therapy, which suggests that JAK2 inhibitor therapy, by itself, was not curative in this MPN model.

Polycythemia vera, essential thrombocythemia and primary myelofibrosis are myeloproliferative neoplasms (MPN) characterized by multilineage clonal hematopoiesis1–5. Given that the identical somatic activating mutation in the JAK2 tyrosine kinase gene (JAK2V617F) is observed in most individuals with polycythemia vera, essential thrombocythemia and primary myelofibrosis6–10, there likely are additional genetic events that contribute to the pathogenesis of these phenotypically distinct disorders. Moreover, family members of individuals with MPN are at higher risk for the development of MPN, consistent with the existence of MPN predisposition loci11. We hypothesized that germline variation contributes to MPN predisposition and phenotypic pleiotropy. Genome-wide analysis identified an allele in the JAK2 locus (rs10974944) that predisposes to the development of JAK2V617F-positive MPN, as well as three previously unknown MPN modifier loci. We found that JAK2V617F is preferentially acquired in cis with the predisposition allele. These data suggest that germline variation is an important contributor to MPN phenotype and predisposition.

The development of the dual Janus kinase 1/2 (JAK1/2) inhibitor ruxolitinib for the treatment of myeloproliferative neoplasms (MPNs) has led to studies of ruxolitinib in other clinical contexts, including JAK-mutated acute lymphoblastic leukemia (ALL). However, the limited ability of JAK inhibition to induce molecular or clinicopathological responses in MPNs suggests a need for development of better therapies for JAK kinase-dependent malignancies. Here, we demonstrate that heat shock protein 90 (HSP90) inhibition using a purine-scaffold HSP90 inhibitor in early clinical development is an effective therapeutic approach in JAK-dependent ALL and can overcome persistence to JAK-inhibitor therapy in ALL cells.

JAK inhibitor treatment is limited by the variable development of anemia and thrombocytopenia thought to be due to on target JAK2 inhibition. We evaluated the impact of Jak2 deletion in platelets and megakaryocytes on blood counts stem/progenitor cells and Jak Stat signaling. Pf4 Cre mediated Jak2 deletion in platelets and megakaryocytes did not compromise platelet formation but caused thrombocytosis and resulted in expansion of megakaryocyte progenitors and Lin( )Sca1(+)Kit(+) cells. Serum thrombopoietin was maintained at normal levels in Pf4 Cre positive Jak2(f/f) mice consistent with reduced internalization/turnover by Jak2 deficient platelets. These data demonstrate that Jak2 in terminal megakaryopoiesis is not required for platelet production and that Jak2 loss in platelets and megakaryocytes results in non autonomous expansion of stem/progenitors and of megakaryocytes and platelets via dysregulated thrombopoietin turnover. This suggests that the thrombocytopenia frequently seen with JAK inhibitor treatment is not due to JAK2 inhibition in platelets and megakaryocytes but rather due to JAK2 inhibition in stem/progenitor cells.

The discovery of JAK2/MPL mutations in patients with myeloproliferative neoplasms (MPN) led to clinical development of Janus kinase (JAK) inhibitors for treatment of MPN. These inhibitors improve constitutional symptoms and splenomegaly but do not significantly reduce mutant allele burden in patients. We recently showed that chronic exposure to JAK inhibitors results in inhibitor persistence via JAK2 transactivation and persistent JAK-signal transducer and activator of transcription signaling. We performed genetic and pharmacologic studies to determine whether improved JAK2 inhibition would show increased efficacy in MPN models and primary samples. Jak2 deletion in vivo led to profound reduction in disease burden not seen with JAK inhibitors, and deletion of Jak2 following chronic ruxolitinib therapy markedly reduced mutant allele burden. This demonstrates that JAK2 remains an essential target in MPN cells that survive in the setting of chronic JAK inhibition. Combination therapy with the heat shock protein 90 (HSP90) inhibitor PU-H71 and ruxolitinib reduced total and phospho-JAK2 and achieved more potent inhibition of downstream signaling than ruxolitinib monotherapy. Combination treatment improved blood counts, spleen weights, and reduced bone marrow fibrosis compared with ruxolitinib alone. These data suggest alternate approaches that increase JAK2 targeting, including combination JAK/HSP90 inhibitor therapy, are warranted in the clinical setting.

Acquired secondary resistance mutations in FLT3 have been shown to limit the therapeutic benefit of FLT3 inhibitors in FLT3-ITD mutated AML. Multiple strategies have been pursued to address such resistance, including the development of kinase inhibitors that use alternate binding modes or by simultaneously targeting additional pathways. This latter approach may be focused on suppression of parallel oncogenic pathways to treat the acquired resistance, or on strategies to reduce or delay the acquisition of resistance. Here, we describe a rationally conceived next generation FLT3 inhibitor, FLX925, that was prospectively designed to address or avoid common resistance mechanisms with a unique binding mode and potent activity against CDK4/CDK6. We contextualize our findings by comparing FLX925 to other FLT3 inhibitors (quizartinib and gilteritinib) currently in late-stage clinical development and demonstrate that FLX925 has a superior resistance profile. FLX925 is a potent and selective type-1 inhibitor of FLT3 that retains its cellular potency against clinically relevant secondary resistance mutations in FLT3. This was evaluated in multiple experimental systems including isogenic Ba/F3 cells engineered to express FLT3-ITD with, or without, various known secondary FLT3 mutations. In addition, these data were extended to the human setting using both the MOLM13 and MOLM14 FLT3-ITD mutated AML cell lines and subclones of these lines harboring well-characterized resistance mutations described elsewhere. Data have been published previously demonstrating a superior resistance profile for FLX925 when compared to quizartinib and sorafenib. When compared to gilteritinib, FLX925 had a favorable profile of relative potencies against a range of FLT3-ITD resistance mutations. In addition to the isogenic murine and human models of FLT3 inhibitor resistance, with engineered known genetic alterations, we explored the activity of FLX925 and other FLT3 inhibitors in a model of in vitro acquired resistance. Using MOLM13 cells and standard protocols for the generation of drug resistance, we demonstrate that the magnitude of resistance to quizartinib and gilteritinib greatly exceeds that observed with FLX925 during the same timeframe. Pools of resistant cells from each compound treatment are being analyzed by next-generation sequencing in an effort to better understand the mechanism of resistance associated with each compound. We hypothesize that the CDK4/6 inhibitory activity, which is unique to FLX925, contributes to its superior resistance profile. Whether this is solely linked to an impact on the cell cycle or more recent findings of CDK6-driven transcription of FLT3 and PIM1 is an active area of investigation. Nonetheless, the CDK4/6 activity of FLX925 potentially broadens the utility of this compound to FLT3 wild-type AML. Here, we show FLX925, in contrast to other FLT3 inhibitors, potently suppresses the proliferation of a panel of AML cell lines. These data have been extended to FLT3 wild-type AML patient samples in which FLX925, but not gilteritnib, induced a desirable pharmacodynamic effects. The totality of the preclinical data suggest FLX925 may be a best-in-class inhibitor for the treatment of AML with, or without, FLT3-ITD mutations. FLX925 is currently being investigated in a Ph1/b dose-escalation study in subject with relapsed or refractory AML (NCT02335814). Disclosures Marubayashi: FLX Bio: Employment, Equity Ownership. Park:FLX Bio: Employment, Equity Ownership. Noubade:FLX Bio: Employment, Equity Ownership. Phan:FLX Bio: Employment. Cutler:FLX Bio: Employment, Equity Ownership; Amgen, Inc: Equity Ownership. Kassner:FLX Bio: Employment, Equity Ownership. Fridman:FLX Bio: Employment, Equity Ownership.

Hsp90 inhibition in B cell acute lymphoblastic leukemia overcomes resistance to JAK2 inhibitors., Enzymatic inhibitors of Janus kinase 2 (JAK2) are in clinical development for the treatment of myeloproliferative neoplasms (MPNs), B cell acute lymphoblastic leukemia (B-ALL) with rearrangements of the cytokine receptor subunit cytokine receptor–like factor 2 (CRLF2), and other tumors with constitutive JAK2 signaling. In this study, we identify G935R, Y931C, and E864K mutations within the JAK2 kinase domain that confer resistance across a panel of JAK inhibitors, whether present in cis with JAK2 V617F (observed in MPNs) or JAK2 R683G (observed in B-ALL). G935R, Y931C, and E864K do not reduce the sensitivity of JAK2-dependent cells to inhibitors of heat shock protein 90 (HSP90), which promote the degradation of both wild-type and mutant JAK2. HSP90 inhibitors were 100–1,000-fold more potent against CRLF2-rearranged B-ALL cells, which correlated with JAK2 degradation and more extensive blockade of JAK2/STAT5, MAP kinase, and AKT signaling. In addition, the HSP90 inhibitor AUY922 prolonged survival of mice xenografted with primary human CRLF2-rearranged B-ALL further than an enzymatic JAK2 inhibitor. Thus, HSP90 is a promising therapeutic target in JAK2-driven cancers, including those with genetic resistance to JAK enzymatic inhibitors.

JAK2 kinase inhibitors were developed for the treatment of myeloproliferative neoplasms (MPNs), following the discovery of activating JAK2 mutations in the majority of patients with MPN. However, to date JAK2 inhibitor treatment has shown limited efficacy and apparent toxicities in clinical trials. We report here that an HSP90 inhibitor, PU-H71, demonstrated efficacy in cell line and mouse models of the MPN polycythemia vera (PV) and essential thrombocytosis (ET) by disrupting JAK2 protein stability. JAK2 physically associated with both HSP90 and PU-H71 and was degraded by PU-H71 treatment in vitro and in vivo, demonstrating that JAK2 is an HSP90 chaperone client. PU-H71 treatment caused potent, dose-dependent inhibition of cell growth and signaling in JAK2 mutant cell lines and in primary MPN patient samples. PU-H71 treatment of mice resulted in JAK2 degradation, inhibition of JAK-STAT signaling, normalization of peripheral blood counts, and improved survival in MPN models at doses that did not degrade JAK2 in normal tissues or cause substantial toxicity. Importantly, PU-H71 treatment also reduced the mutant allele burden in mice. These data establish what we believe to be a novel therapeutic rationale for HSP90 inhibition in the treatment of JAK2-dependent MPN.

Acquired secondary resistance mutations to clinically active kinase inhibitors remains a key obstacle between valid therapeutic hypotheses and meaningful patient benefit. In AML, evidence suggests that inhibition of FLT3 (particularly in FLT3-ITD mutated cancers) can be efficacious; however, relapse from complete remission is common and often rapid. As with other cancers driven by key oncogenic kinase mutations (e.g. BCR-ABL in CML), a primary mechanism of resistance is the acquisition of secondary resistance mutations in the oncogenic kinase themselves. Multiple strategies have been pursued to address such resistance, including the development of kinase inhibitors that either bind their respective targets differently or by targeting multiple important pathways simultaneously. Herein we describe a rationally conceived next generation FLT3 inhibitor, FLX925 (previously AMG 925), that was prospectively designed to address or avoid common resistance mechanism to earlier FLT3 inhibitors with its unique binding mode and potent activity against CDK4/CDK6. FLX925 is a potent and selective type 1 inhibitor of FLT3 that retains its cellular potency against clinically relevant secondary resistance mutations in FLT3 occurring with quizartinib or sorafenib treatment (FLX925 IC50: MOLM13ITD, 15 nM; MOLM13ITD/D835, 28 nM; MV4-11ITD, 16 nM; MV4-11ITD/D835, 19 nM; MV4-11ITD/N841, 16 nM; MV4-11ITD/F691, 73 nM). Indeed, while compounds currently in the clinic became more than 200-fold less potent against a number of mutants, FLX925 remained relatively equipotent (+/- 5-fold the parental cell line IC50) in these same resistant clones. This is in stark contrast to the striking cross-resistance observed with quizartinib in sorafenib resistant cells. Moreover, the few clones that grew out of a screen for resistance to FLX925 displayed a ‘persistence’ phenotype with modestly reduced sensitivity to FLX925 (∼5-fold IC50 shift) that was rapidly reversible. This persistence was associated with higher FLT3 protein levels and no detectable secondary mutations in FLT3. In addition to its suppression of FLT3 signaling, FLX925 potently inhibits CDK4/CDK6, central components of the cell cycle machinery. This unique profile may reduce the likelihood of emergent resistant clones and extends the therapeutic potential of FLX925 to other malignancies dependent on these pathways (e.g. MCL). Indeed, the addition of PD0332991 (a selective CDK4/6 inhibitor) to a relatively selective FLT3 inhibitor reduced the frequency of acquired resistance in a cell based screen, relative to a FLT3 inhibitor alone. These data suggest the unique profile of FLX925 makes it an ideal inhibitor for the treatment of cancers driven by FLT3 signaling, such as AML. A phase I clinical trial evaluating the safety, tolerability pharmacokinetics and pharmacodynamics effects of FLX925 in patients with AML is ongoing. Citation Format: Cong Li, Lingming Liang, Liqin Liu, Zhen Xia, Zhihong Li, Xianghong Wang, Lawrence McGee, Angus Sinclair, Sasha Kamb, Dineli Wickramasinghe, Sachie Marubayashi, Juan C. Jaen, Jordan S. Fridman, Kang Dai. FLX925 (AMG 925) is a rationally designed FLT3, CDK4/6 inhibitor that retains potency against clinically relevant secondary resistance mutations in FLT3. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 787. doi:10.1158/1538-7445.AM2015-787

Abstract 805 Following the discovery of JAK2V617F mutation in a majority of patients with Myeloproliferative Neoplasms (MPN), JAK kinase inhibitors have entered clinical trials. JAK kinase inhibitors, including the JAK1/JAK2 inhibitor INCB18424 (ruxolitinib™, Jakafi®) improve patient constitutional symptoms and reduce splenomegaly, but do not significantly reduce mutant allele burden in the majority of MPN patients. We recently showed that chronic exposure to JAK kinase inhibitors results in JAK inhibitor persistence in cell lines murine models, and patient samples. JAK inhibitor persistence is associated with heterodimerization between JAK2 and other JAK kinases; this results in JAK2-transactivation and persistent JAK-STAT signaling. ShRNA studies and pharmacologic studies with HSP90 inhibitors showed that JAK2 depletion retained efficacy in JAK inhibitor persistent cells, such that these cells remain dependent on JAK2 expression for proliferation and survival. These data suggest that pharmacologic approaches that reduce JAK2 protein expression in MPN cells may demonstrate efficacy and potentiate the effects of JAK kinase inhibition in vivo. However, combination studies with JAK inhibitors and HSP90 inhibitors in vivo have not been reported to date. In this study we tested the effects of the purine scaffold inhibitor, PU-H71, in combination with INCB18424 in a murine model of PMF. We investigated the effects of a series of different regimens in the MPLW515L murine bone marrow transplant model of PMF, including INCB18424 monotherapy, PU-H71 monotherapy, combined JAK/HSP90 inhibition at treatment onset, and INCB18424 therapy followed by the addition of PU-H71 therapy after initial response. Of note, all regimens, including combination therapy with PU-H71 and INCB18424 at maximal doses used in monotherapy trials, were well tolerated without additive hematologic or non-hematologic toxicity. Mice treated with combination therapy gained more weight compared to mice that received either monotherapy. We noted a significant reduction in WBC (89.9 K/ml vs. 8.5K/ml, p Disclosures: No relevant conflicts of interest to declare.

Abstract 122 Although JAK2 inhibitor therapy improves MPN-associated splenomegaly and systemic symptoms, JAK2 inhibitor treatment does not significantly reduce or eliminate the MPN clone in most MPN patients. We therefore sought to characterize mechanisms by which MPN cells can persist despite chronic JAK2 inhibition. We performed saturation mutagenesis followed by next-generation sequencing in JAK2 mutant cells exposed to two different JAK2 inhibitors, INCB18424, a dual JAK1/JAK2 inhibitor, and JAK Inhibitor I, a pan-JAK inhibitor. Although we were able to identify candidate resistance alleles, these alleles were present in less than 50% of the total population. These data and the clinical experience with JAK2 inhibitors suggest that the failure of JAK2 inhibitors to reduce disease burden is not due to acquired drug resistance but rather due to persistent growth and signaling in the setting of chronic JAK2 kinase inhibition. We therefore generated JAK2/MPL mutant JAK2-inhibitor persistent (JAKper) cell lines (SET-2, UKE-1, Ba/F3-MPLW515L). JAKper cell lines are able to survive and proliferate in the presence of JAK2 inhibitors including JAK Inhibitor I, INCB18424 and TG101348 without acquiring second-site resistance alleles and are also insensitive to other JAK inhibitors. Signaling studies revealed JAK-STAT signaling was reactivated in persistent cells at concentrations of inhibitor that completely abrogated signaling in naïve cells, and JAK2 phosphorylation was reactivated in JAK inhibitor persistent cells consistent with reactivation of the JAK-STAT pathway in JAKper cells despite inhibitor exposure. We hypothesized that JAK2 may be activated in trans by other JAK kinases, and found an increased association between activated JAK2 and JAK1/TYK2 consistent with activation of JAK2 in trans by other JAK kinases in JAKper cells. We next assessed whether JAK inhibitor persistence was reversible. Withdrawal of JAK2 inhibitors from JAKper cells for 2 weeks led to resensitization such that JAKper resensitized cells were now sensitive to different JAK2 inhibitors regardless of previous exposure. Resensitization was associated with reversal of heterodimerization and loss of transactivation of JAK2 by JAK1 and TYK2. The reversible nature of JAK inhibitor persistence led us to hypothesize epigenetic alterations are responsible for JAK inhibitor insensitivity in JAKper cells; we observed increased expression of JAK2 at the mRNA and protein level in JAK2 inhibitor persistent cells compared to parental as well as resensitized cells. ChIP-PCR analysis of the JAK2 locus revealed a significant increase in H3K4-trimethylation and a reduction in H3K9 trimethylation in persistent cells compared to parental cells consistent with a change to a more active chromatin state at the JAK2 locus and increased JAK2 mRNA expression in persistent cells. We next assessed whether the same phenomenon of JAK2 inhibitor persistence was observed in vivo. In a MPLW515L-mutant murine bone marrow transplant model of primary myelofibrosis, we observed increased JAK2 expression, increased JAK2 phosphorylation and JAK-inhibitor induced association between JAK1 and JAK2 in hematopoietic cells from INCB18424 treated mice. We next extended our findings to samples from patients treated with INCB18424. We identified 5 patients who had a significant clinical response and 5 patients without a significant clinical response as assessed by spleen size and JAK2V617F allele burden responses and measured JAK2 granulocyte mRNA expression before and during INCB18424 treatment. We found that JAK2 mRNA levels significantly increased in INCB18424 nonresponders compared to responders (p=0.05) suggesting this phenomenon is observed in cell lines, mouse models and primary samples. Finally, we investigated whether JAKper cells remain JAK2 dependent. Studies with shRNA targeting JAK2 and pharmacologic studies using Hsp90 inhibitors that degrade JAK2 protein demonstrate that JAK2 inhibitor persistent cells remain dependent on JAK2 protein expression. Our data indicate that JAK2/MPL mutant cells persist in the presence of JAK2 kinase inhibitors through epigenetic alterations which reactivate signaling in persistent cells, and that therapies which lead to JAK2 degradation can be used to inhibit signaling and improve outcomes in patients with persistent disease despite chronic JAK2 inhibition. Disclosures: Verstovsek: Incyte Corporation: Research Funding.

Abstract 576 Enzymatic inhibitors of Janus kinase 2 (JAK2) are in clinical development for the treatment of B-cell acute lymphoblastic leukemia (B-ALL) with rearrangements of the cytokine receptor subunit CRLF2, myeloproliferative neoplasms, and other tumors with constitutive JAK2 signaling. In addition, JAK2 is a client of heat shock protein 90 (HSP90) and HSP90 inhibition results in JAK2 degradation. To explore the utility of blocking JAK2 in CRLF2-rearranged B-ALL, we exposed the MHH-CALL4 and MUTZ-5 cell lines, which both have CRLF2/IGH rearrangements and activating JAK2 mutations to a panel of JAK2 inhibitors (JAK inhibitor-1, INCB18424, tofacitinib, NVP-BSK805, NVP-BVB808, TG101348) and the HSP90 inhibitor NVP-AUY922. Both MUTZ-5 and MHH-CALL4 were highly sensitive to AUY922 (GI50, 25–26 nM), with 50- to >1,000-fold superior potency compared with the panel of JAK2 enzymatic inhibitors. AUY922 and the structurally divergent HSP90 inhibitors 17-AAG, PU-H71 and HSP990 were all potently active against a panel of Ba/F3 lines dependent on CRLF2 and JAK2 signaling (GI50, 1–11 nM). Treatment of MUTZ-5 and MHH-CALL4 cells with JAK inhibitor-1 reduced but did not eliminate phospho (P-) STAT5 and P-ERK1/2 in both lines but promoted increases in P-AKT in MUTZ-5 and P-JAK2 in MHH-CALL4. In contrast, AUY922 treatment more extensively reduced or eliminated phosphorylation of all the targets. The combination of AUY922+JAK inhibitor-1 had little or no additional effect on target phosphorylation compared with AUY922 alone and pairwise dose-response studies with isobologram analysis failed to identify synergistic effects. We performed transcriptional profiling on MUTZ-5 and MHH-CALL cells treated with either vehicle (DMSO), JAK inhibitor-1, AUY922 or JAK inhibitor-1+AUY922. Unsupervised hierarchical clustering distinguished samples treated with AUY922 (or combination) from those treated with JAK inhibitor-1 or vehicle. To formally assess whether AUY922 targets the same genes as JAK inhibitor-1, we defined a ‘JAK inhibitor signature' from the top/bottom 250 most differentially expressed genes following treatment with JAK inhibitor-1. Using gene set enrichment analysis (GSEA), the ‘JAK inhibitor signature' was highly enriched upon treatment with AUY922 (p=0.003). GSEA also demonstrated that STAT5A signatures were enriched upon treatment with JAK inhibitor-1, AUY922, or JAK inhibitor-1+AUY922. To identify additional targets of HSP90 inhibition beyond the inhibition of JAK2, we used the C3 database from the MsigDB compendium to perform a transcription factor binding site enrichment analysis on the most differentially expressed genes between JAK inhibitor-1 and AUY922. The top 5 hits were all heat-shock factors (HSF, FDR Disclosures: Romanet: Novartis Pharma AG: Employment. Murakami:Novartis Pharma AG: Employment. Sallan:Enzon Pharmaceuticals: Honoraria. Kung:Novartis Pharmaceuticals: Consultancy, Research Funding. Radimerski:Novartis Pharma AG: Employment. Weinstock:Novartis: Consultancy, Research Funding.

Abstract 2159 Background: Acute myeloid leukemia (AML) is a heterogeneous and intrinsically resistant disease group of malignant hematopoietic disorders that accounts for approximately 80% of all adult leukemias. Heat shock proteins (HSPs) are often overexpressed in AML are their expression is associated with poor-prognosis and resistance to chemotherapy. Among HSPs, HSP90 is the main chaperone required for the stabilization of multiple oncogenic kinases, which contribute to AML pathogenesis, providing a rationale for the use of HSP90 inhibitors in the treatment of AML. Hypothesis: To identify patients with AML who will benefit from HSP90 inhibitor therapy there is a need to discover molecules and pathways in AML cells that confer sensitivity and lead to significant apoptosis upon HSP90 inhibition. Study design and Results: To evaluate the spectrum of sensitivities of AML cells to HSP90 inhibitors, and to investigate a possible relationship between their genetic background and apoptotic sensitivity to HSP90 inhibition, we investigated the effects of HSP90 inhibitors in a set of genetically characterized human AML cells. Addition of several HSP90 inhibitors to each of these cell lines potently inhibited cell growth, with a potency reflective of their affinity for HSP90. Normal peripheral blood leukocytes were unaffected at similar concentrations. HSP90 inhibition was associated with destabilization and subsequent degradation of Akt and c-Raf in all tested cells, as well as of several cell-specific onco-proteins such as mutant Flt3 in MOLM-13, TEL-TRKC in M0-91, AML1-ETO and mutant cKit in Kasumi-1 and SKNO-1, and mutant Jak2 in HEL cells, respectively. Notably, the proclivity for these cells to undergo apoptosis upon HSP90 inhibition varied considerably. The most sensitive cell lines were MOLM-13, MV-4-11 and M0-91 cells, and for each these cell lines we observed near 100% killing of the initial cell population after 48–72 h of HSP90 inhibitor treatment. In contrast, only 20% death was seen in HEL and HL-60 cells under these conditions. We next made use of specific inhibitors of known oncogenic signaling pathways known to be dysregulated in AML to demonstrate that apoptotic sensitivity of AML cells to HSP90 inhibition correlated with PI3K-Akt and STAT5 activation, but not with activation of the Raf-MAPK pathway. Importantly, similar results were observed in cells lines, xenograft models and isogenic cell line systems. We also found that dual activation of these two pathways, especially in the context of Bcl-xL overexpression, lowers the apoptotic threshold of AML when HSP90 is inhibited. Conclusions: We found that activation of oncogenic signaling pathways and expression of leukemogenic anti-apoptotic molecules, most importantly p-Akt, predicts for AML sensitivity to HSP90 inhibitors. Importantly, 50– 70% of patients with AML display phosphorylation of both Thr308 and Ser4 Akt. This molecule contributes to proliferation, survival and drug resistance in AML, and is associated with adverse outcome. Taken together, our findings suggest that AML patients with activation of Akt and STAT5 signaling are most likely to benefit from HSP90 inhibitor therapy, and clinical trials should aim to enroll patients with specific activation of these important signaling pathways. Disclosures: No relevant conflicts of interest to declare.

Abstract 3898 Poster Board III-834 The discovery of mutations in the JAK-STAT signaling pathway in the majority of patients with myeloproliferative neoplasms (MPN) has led to the development of JAK2 kinase inhibitors for the treatment of these disorders. Although JAK2 inhibitors demonstrate efficacy in preclinical models and in early phase clinical trials, to date, JAK2 inhibitor treatment has not resulted in molecular responses or in improvements in blood counts. We therefore have investigated the effects of additional therapies that might provide benefit to patients with myeloproliferative disorders, including Hsp90 inhibition, which has been shown to abrogate oncogenic signaling pathways in other human malignancies. We analyzed the effect of PU-H71, a novel non-quinone based Hsp-90 inhibitor, in MPN cell lines, primary patient samples, and in animal models. PU-H71 treatment caused potent, dose-dependent inhibition of cell growth in isogenic cell lines expressing JAK2/MPL mutations, JAK2V617F-positive leukemia cell lines, and primary MPN patient samples, which was associated with induction of apoptotic cell death at clinically achievable concentrations. Further, we observed JAK2 degradation in cell lines and primary samples with PU-H71 treatment, and immunoprecipitation experiments documented association of JAK2 with HSP90 and with PU-H71, demonstrating that JAK2 is a client of the HSP90 chaperone complex. PU-H71 potently inhibited downstream signaling pathways, including STAT signaling, MAPK signaling, and AKT signaling in JAK2/MPL positive cell lines and primary samples. Most importantly, in vivo therapy with PU-H71 in mice expressing JAK2V617F or MPLW515L normalized peripheral blood counts, attenuated extramedullary hematopoiesis, and improved survival compared to vehicle treated mice. We observed reduction in total JAK2 expression in target organs from PUH-71 treated mice, and noted in vivo inhibition of signaling pathways in a manner analogous to in vitro studies. Taken together, these data indicate that Hsp90 inhibition, either alone or in combination with JAK2 inhibitors, may prove useful against human MPN. Disclosures: Levine: Novartis: Research Funding; TargeGen: Consultancy.