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Combination p53 activation and BCL-xL/BCL-2 inhibition as a therapeutic strategy in high-risk and relapsed acute lymphoblastic leukemia

Lookup NU author(s): Dr Hayden BellORCiD, Dr Helen Blair, Samantha Jepson Gosling, Dr Martin Galler, Dan AstleyORCiD, Professor Anthony MoormanORCiD, Professor Olaf Heidenreich, Professor Gareth Veal, Dr Frederik van DelftORCiD, Professor John LunecORCiD, Professor Julie Irving



This work is licensed under a Creative Commons Attribution 4.0 International License (CC BY 4.0).


© The Author(s) 2024.Due to the rarity of TP53 mutations in acute lymphoblastic leukemia (ALL), p53 re-activation by antagonism of the p53-MDM2 interaction represents a potential therapeutic strategy for the majority of ALL. Here, we demonstrate the potent antileukemic activity of the MDM2 antagonist idasanutlin in high-risk and relapsed ex vivo coculture models of TP53 wildtype ALL (n = 40). Insufficient clinical responses to monotherapy MDM2 inhibitors in other cancers prompted us to explore optimal drugs for combination therapy. Utilizing high-throughput combination screening of 1971 FDA-approved and clinically advanced compounds, we identified BCL-xL/BCL-2 inhibitor navitoclax as the most promising idasanutlin combination partner. The idasanutlin-navitoclax combination was synergistically lethal to prognostically-poor, primary-derived and primary patient blasts in ex vivo coculture, and reduced leukemia burden in two very high-risk ALL xenograft models at drug concentrations safely attained in patients; in fact, the navitoclax plasma concentrations were equivalent to those attained in contemporary “low-dose” navitoclax clinical trials. We demonstrate a preferential engagement of cell death over G1 cell cycle arrest, mechanistically implicating MCL-1-binding pro-apoptotic sensitizer NOXA. The proposed combination of two clinical-stage compounds independently under clinical evaluation for ALL is of high clinical relevance and warrants consideration for the treatment of patients with high-risk and relapsed ALL.

Publication metadata

Author(s): Bell HL, Blair HJ, Jepson Gosling SJ, Galler M, Astley D, Moorman AV, Heidenreich O, Veal GJ, van Delft FW, Lunec J, Irving JAE

Publication type: Article

Publication status: Published

Journal: Leukemia

Year: 2024

Pages: epub ahead of print

Online publication date: 10/04/2024

Acceptance date: 02/04/2024

Date deposited: 18/04/2024

ISSN (print): 0887-6924

ISSN (electronic): 1476-5551

Publisher: Springer Nature


DOI: 10.1038/s41375-024-02241-7


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