As we head into March, we'd like to take this opportunity to highlight Multiple Myeloma Awareness Month.

Multiple myeloma is a cancer that begins in plasma cells, a type of white blood cell. These cells are part of your immune system, which helps protect the body from germs and other harmful substances. In multiple myeloma, the overgrowth of plasma cells in the bone marrow can crowd out normal blood-forming cells, leading to low blood counts. Myeloma cells also interfere with cells that help keep bones strong. In multiple myeloma, the myeloma cells crowd out the normal plasma cells, so that antibodies to fight the infection can’t be made. Myeloma cells make an antibody that can harm the kidneys, leading to kidney damage and even kidney failure. In time, myeloma cells collect in the bone marrow and in the solid parts of bones. This cancer can weaken the immune system, cause kidney damage, and weaken bones, which may lead to fractures.

Multiple myeloma is a relatively uncommon cancer. In the United States, the lifetime risk of getting multiple myeloma is 1 in 132. Average survival rates have improved considerably thanks to new treatment options. Although the combination of immunomodulatory imide drugs lenalidomide and pomalidomide with other drugs like proteasome inhibitors, antibodies, corticosteroids, and high-dose chemotherapy can induce remissions in most patients, almost all patients eventually relapse due to acquired resistance of the multiple myeloma cells to one or several of the drugs. When cancer growth eventually resumes despite treatment, the patient’s prognosis is poor.

Using the latest improvements for a method known as proteomics, an interdisciplinary team of researchers in Berlin was able to decode a previously unknown mechanism that can cause this type of relapse. The team applied quantitative proteomic analyses in paired, longitudinal primary multiple myeloma samples and identified CDK6 upregulation as a non-genetic resistance mechanism for IMiDs in multiple myeloma that can be overcome by pharmacologic intervention. Comparing cancer cells collected before and after relapse, the researchers found that a range of proteins was present at either higher or lower concentrations post-relapse. Using statistical and bioinformatics analyses, the researchers were able to trace the majority of these effects back to a single protein: cyclin-dependent kinase 6, or CDK6, an enzyme that controls the cell’s entry into the cell division phase of the cell cycle.

As a first step, the researchers used cell cultures to demonstrate that CDK6 plays a key role in the development of treatment resistance in multiple myeloma. They found that CDK6 protein is upregulated in in vitro generated, lenalidomide-resistant multiple myeloma cells, and overexpression of CDK6 impairs IMiD sensitivity. Given that CDK6 upregulation was found in lenalidomide-resistant patients and induced expression reduced lenalidomide-sensitivity, they next tested the effects of the CDK6 inhibitor palbociclib in multiple myeloma cell lines. As a result, palbociclib markedly enhanced the anti-multiple myeloma effects of IMiDs when both drugs were combined with high synergy scores. This effect was observed across all cell lines expressing CDK6 at various levels. These data show that palbociclib treatment increases the sensitivity to lenalidomide and pomalidomide in multiple myeloma cells. In contrast, combined treatment of palbociclib and melphalan, bortezomib, or dexamethasone was mostly additive.

The researchers were then able to confirm this effect in an animal model, where the combination of pomalidomide with a CDK6 inhibitor significantly improved the odds of survival. In lab mice, pomalidomide and palbociclib as monotherapy significantly delayed tumor growth, while combination therapy reduced tumor volumes below detection limits after 2 weeks. The potent suppression of tumor growth in the combination group translated to a significant improvement in survival as compared to mice that received pomalidomide or palbociclib alone.

To investigate the effects of CDK6 inhibition and the basis for the synergy with IMiDs in multiple myeloma, the researchers performed quantitative proteomic and phosphoproteomic analyses in MM.1S cells treated with pomalidomide, palbociclib, and CDK6-specific PROTACs alone or in combination. They observed a striking pattern where proteins upregulated in patient samples at relapse were downregulated by CDK6 inhibition or degradation in MM.1S cells and vice versa. Among the CDK6 regulated proteins included in the signature were the two top upregulated proteins in relapse, TRIP13 and RRM1. Other proteins upregulated in relapse and targeted by CDK6 inhibition are comprised of cell cycle-related genes (CDK2, MCM3/5, NCAPH, NCAPD2, PDCD2L, USP16), DNA damage regulators (PAXIP1, RAD18, and MLH1) and transcriptional/ epigenetic regulators (DNMT1, BTF3, EDRF1, KEAP1, MORF4L1). The down regulated proteins in cluster c are dominated by 27 mitochondrial genes including key factors for leucine catabolic metabolism (AUH), TCA cycle (IDH3B), the electron transport chain (NDUFA10, COX5B), ATP synthase (ATP5D, ATP5J), and fatty acid metabolism (ACAD9, ECHS1, HADHB, MLYCD, MCEE).

To identify CDK6 substrates in multiple myeloma, the researchers performed phosphoproteomics analyses in MM.1S cells treated with palbociclib or the CDK6-specific PROTAC BSJ-03-123. We identified 29,811 phosphopeptides across all samples of which 122 phosphopeptides on 96 proteins were significantly downregulated after 3 h of palbociclib or BSJ-03-123 treatment (0.1 FDR). In addition, phosphorylation status of 558 proteins (1022 phosphopeptides) not regulated on global protein level was specifically downregulated after 24 h palbociclib treatment, with an overlap of 45 proteins to the 3 h timepoint. This is very interesting since these phosphosites were downregulated at an early time point and in a sustained manner.

Several CDK4/6 inhibitors are approved by the FDA and EMA for advanced breast cancer and are being investigated in hematologic malignancies including acute lymphoblastic leukemia and acute myeloid leukemia. In multiple myeloma, a phase I/II clinical trial that combined palbociclib with bortezomib and dexamethasone showed that this regimen is feasible and has antitumor activity. The researchers said they will continue pursuing this new approach of using modern, comprehensive protein analyses to study cancer tissues – both in multiple myeloma and other cancers. They hope this will unveil further treatment targets and biomarkers for use in personalized cancer medicine.

Reference:

Ng YL, Ramberger E, Bohl SR, Dolnik A, Steinebach C, Conrad T, Müller S, Popp O, Kull M, Haji M, Gütschow M. Proteomic profiling reveals CDK6 upregulation as a targetable resistance mechanism for lenalidomide in multiple myeloma. Nature Communications. 2022 Feb 23;13(1):1-3.
Albagoush, S.A. and Azevedo, A.M., 2018. Cancer, Multiple Myeloma.

About CDK6

Cell division protein kinase 6 (CDK6) is an enzyme encoded by the CDK6 gene. It is a member of the CMGC family of serine/threonine protein kinases. This kinase is a catalytic subunit of the protein kinase complex that is important for cell cycle G1 phase progression and G1/S transition. The activity of this kinase first appears in the mid-G1 phase, which is controlled by the regulatory subunits including D-type cyclins and members of the INK4 family of CDK inhibitors. This kinase, as well as CDK4, has been shown to phosphorylate, and thus regulate the activity of, tumor suppressor protein Rb. Altered expression of this gene has been observed in multiple human cancers. A mutation in this gene resulting in reduced cell proliferation, and impaired cell motility and polarity, and has been identified in patients with primary microcephaly.

The direct targeting of CDK6 and CDK4 should be used with caution in the treatment of cancer because these enzymes are important for the cell cycle of normal cells as well. Furthermore, small molecules targeting these proteins might increase drug resistance events. However, these kinases have been shown to be useful as coadjuvants in breast cancer chemotherapy. Another indirect mechanism for the control of CDK6 expression is the use of a mutated D-cyclin that binds with high affinity to CDK6 but does not induce its kinase activity. This mechanism was studied in the development of mammary tumorigenesis in rat cells, however, the clinical effects have not yet been shown in human patients.

Other CDK6 inhibitors:
Ribociclib
Abemaciclib
P1446A-05
Trilaciclib
Purvalanol A
Olomoucine II
 

Other recent updates on multiple myeloma treatment
The Food and Drug Administration (FDA) has given the green light to cilta-cel, a cancer treatment for people with pretreated multiple myeloma. The drug will be sold under the brand name Carvytki. It’s manufactured by Janssen Pharmaceuticals, a company owned by Johnson & Johnson. It’s the second such therapy approved for multiple myeloma with the approval of Bristol Myers Squibb’s Abecma last year. Cilta-cel is part of the expanding world of chimeric antigen receptor T-cell immunotherapy, also known as CAR T therapy. CAR T employs a person’s own genetically modified T cells to find and kill cancer. The FDA approval was the result of clinical trial data presented at the American Society of Hematology annual meeting in Atlanta, Georgia, in December. That trial showed 83 percent of participants achieved a complete response at a median follow-up of 22 months. Clinicians also reported that 92 percent of evaluable patients achieved minimal residual disease negativity with progression-free survival and overall survival sustained in those participants for more than 6 months.

Naked monoclonal antibodies are novel agents that target a specific protein on the surface of multiple myeloma cells, enabling the patient's immune system to eliminate the targeted myeloma cells. Coming down the pipeline in this drug class is felzartamab (TJ202/MOR202; I-Mab), which is an investigational human monoclonal antibody directed against CD38 on the surface of multiple myeloma cells that uses innovative technology derived from MorphoSys’ HuCAL. Patient enrollment for the phase 3 registrational trial in China of felzartamab in combination with lenalidomide (Revlimid; Bristol Myers Squibb) for second-line treatment of MM has completed, and the biologics license application is expected to be submitted to the US FDA in the near future.

Elranatamab (PF-06863135; Pfizer Inc) is a BCMA CD3-targeted bispecific antibody being investigated in patients with relapsed/refractory multiple myeloma. The phase 2 MagnetisMM-3 study (NCT04649359) is evaluating the safety of elranatamab given subcutaneously in patients with multiple myeloma that is refractory to at least 1 drug therapy in each of the 3 major classes of medications approved for multiple myeloma treatment, and the expected primary completion date is June.

Currently, the ongoing phase 1/2 MyDRUG study (NCT03732703), which has an estimated primary completion date of February, is evaluating the following FDA-approved oncology medications targeting specific gene mutations, which could add future indications for multiple myeloma. These include cobimetinib, enasidenib, abemaciclib, erdafitinib, and venetoclax.

Reference:
Krishnan, Amrita Y., Krina K. Patel, Parameswaran Hari, Sundar Jagannath, Ruben Niesvizky, Rebecca Wang Silbermann, Deborah T. Berg, Qing Li, Kristina Allikmets, and Keith Stockerl-Goldstein. "A phase Ib study of TAK-079, an investigational anti-CD38 monoclonal antibody (mAb) in patients with relapsed/refractory multiple myeloma (RRMM): Preliminary results." (2020): 8539-8539.
Auclair, Daniel, Kenneth Carl Anderson, David Avigan, Giada Bianchi, Noa Biran, Maria Chaudhry, Hearn J. Cho et al. "The myeloma-developing regimens using genomics (MyDRUG) master protocol." (2019): TPS8057-TPS8057.