Despite rapid progress in genomic profiling in acute lymphoblastic leukemia (ALL), identification of actionable targets and prediction of response to drugs remains challenging. To identify specific vulnerabilities in ALL, we performed a drug screen using primary human ALL samples cultured in a model of the bone marrow microenvironment combined with high content image analysis. Among the 2487 FDA-approved compounds tested, anthelmintic agents of the class of macrocyclic lactones exhibited potent anti-leukemia activity, similar to the already known anti-leukemia agents currently used in induction chemotherapy. Ex vivo validation in 55 primary ALL samples of both precursor B cell and T-ALL including refractory relapse cases confirmed strong anti-leukemia activity with IC50 values in the low micromolar range. Anthelmintic agents increased intracellular chloride levels in primary leukemia cells, inducing mitochondrial outer membrane depolarization and cell death. Supporting the notion that simultaneously targeting cell death machineries at different angles may enhance the cell death response, combination of anthelmintic agents with the BCL-2 antagonist navitoclax or with the chemotherapeutic agent dexamethasone showed synergistic activity in primary ALL. These data reveal anti-leukemia activity of anthelmintic agents and support exploiting drug repurposing strategies to identify so far unrecognized anti-cancer agents with potential to eradicate even refractory leukemia.

Department of Oncology and Children's Research Center Children's Hospital Zurich Lengghalde 5 Balgrist Campus AG 8008 Zurich Switzerland

Department of Pediatric Haemato Oncology IRCCS Ospedale Pediatrico Bambino Gesù Sapienza University of Rome Rome Italy

Department of Pediatric Hematology and Oncology 2nd Faculty of Medicine Charles University and University Hospital Motol Prague Czech Republic

Department of Pediatric Oncology Hematology Charité Universitätsmedizin Berlin Campus Virchow Klinikum Berlin Germany

Department of Pediatrics University Hospital Schleswig Holstein Kiel Germany

German Cancer Consortium Berlin Germany

Pediatric Hematology and Oncology Hannover Medical School Hannover Germany

Zobrazit více v PubMed

Pui CH, et al. Childhood acute lymphoblastic leukemia: progress through collaboration. J. Clin. Oncol. 2015;33:2938–2948. PubMed PMC

Schrappe M, et al. Key treatment questions in childhood acute lymphoblastic leukemia: results in 5 consecutive trials performed by the ALL-BFM study group from 1981 to 2000. Klin. Padiatr. 2013;225(Suppl 1):S62–S72. PubMed

Bhojwani D, Pui CH. Relapsed childhood acute lymphoblastic leukaemia. Lancet Oncol. 2013;14:e205–e217. PubMed

Chen KH, et al. Preclinical targeting of aggressive T-cell malignancies using anti-CD5 chimeric antigen receptor. Leukemia. 2017;31:2151–2160. PubMed PMC

Pan J, et al. High efficacy and safety of low-dose CD19-directed CAR-T cell therapy in 51 refractory or relapsed B acute lymphoblastic leukemia patients. Leukemia. 2017;31:2587–2593. PubMed

von Stackelberg A, et al. Phase I/Phase II study of blinatumomab in pediatric patients with relapsed/refractory acute lymphoblastic leukemia. J. Clin. Oncol. 2016;34:4381–4389. PubMed

Fischer U, et al. Genomics and drug profiling of fatal TCF3-HLF-positive acute lymphoblastic leukemia identifies recurrent mutation patterns and therapeutic options. Nat. Genet. 2015;47:1020–1029. PubMed PMC

Peirs S, et al. ABT-199 mediated inhibition of BCL-2 as a novel therapeutic strategy in T-cell acute lymphoblastic leukemia. Blood. 2014;124:3738–3747. PubMed

Jerchel IS, et al. RAS pathway mutations as a predictive biomarker for treatment adaptation in pediatric B-cell precursor acute lymphoblastic leukemia. Leukemia. 2018;32:931–940. PubMed PMC

Liu Q, et al. Characterization of Torin2, an ATP-competitive inhibitor of mTOR, ATM, and ATR. Cancer Res. 2013;73:2574–2586. PubMed PMC

McComb S, et al. Activation of concurrent apoptosis and necroptosis by SMAC mimetics for the treatment of refractory and relapsed ALL. Sci. Transl. Med. 2016;8:339ra70. PubMed

Brumatti G, et al. The caspase-8 inhibitor emricasan combines with the SMAC mimetic birinapant to induce necroptosis and treat acute myeloid leukemia. Sci. Transl. Med. 2016;8:339ra69. PubMed

Pantziarka P. Scientific advice—is drug repurposing missing a trick? Nat. Rev. Clin. Oncol. 2017;14:455–456. PubMed

Pushpakom S, et al. Drug repurposing: progress, challenges and recommendations. Nat. Rev. Drug Discov. 2019;18:41–58. PubMed

Frismantas V, et al. Ex vivo drug response profiling detects recurrent sensitivity patterns in drug-resistant acute lymphoblastic leukemia. Blood. 2017;129:e26–e37. PubMed PMC

Conter V, et al. Molecular response to treatment redefines all prognostic factors in children and adolescents with B-cell precursor acute lymphoblastic leukemia: results in 3184 patients of the AIEOP-BFM ALL 2000 study. Blood. 2010;115:3206–3214. PubMed

Schmitz M, et al. Xenografts of highly resistant leukemia recapitulate the clonal composition of the leukemogenic compartment. Blood. 2011;118:1854–1864. PubMed

Malo N, et al. Statistical practice in high-throughput screening data analysis. Nat. Biotechnol. 2006;24:167–175. PubMed

Boutros M, Bras LP, Huber W. Analysis of cell-based RNAi screens. Genome Biol. 2006;7:R66. PubMed PMC

Prummer M. Hypothesis testing in high-throughput screening for drug discovery. J. Biomol. Screen. 2012;17:519–529. PubMed

Ianevski A, et al. SynergyFinder: a web application for analyzing drug combination dose-response matrix data. Bioinformatics. 2017;33:2413–2415. PubMed PMC

Yadav B, et al. Searching for drug synergy in complex dose-response landscapes using an interaction potency model. Comput. Struct. Biotechnol. J. 2015;13:504–513. PubMed PMC

McComb S, et al. Efficient apoptosis requires feedback amplification of upstream apoptotic signals by effector caspase-3 or -7. Sci. Adv. 2019;5:eaau9433. PubMed PMC

Huang Y, et al. The leukemogenic TCF3-HLF complex rewires enhancers driving cellular identity and self-renewal conferring EP300 vulnerability. Cancer Cell. 2019;36:630–644 e9. PubMed

Fava LL, et al. The PIDDosome activates p53 in response to supernumerary centrosomes. Genes Dev. 2017;31:34–45. PubMed PMC

Melotti A, et al. The river blindness drug Ivermectin and related macrocyclic lactones inhibit WNT-TCF pathway responses in human cancer. EMBO Mol. Med. 2014;6:1263–1278. PubMed PMC

Wang K, et al. Ivermectin induces PAK1-mediated cytostatic autophagy in breast cancer. Autophagy. 2016;12:2498–2499. PubMed PMC

Dou Q, et al. Ivermectin induces cytostatic sutophagy by nlocking the PAK1/Akt axis in breast vancer. Cancer Res. 2016;76:4457–4469. PubMed

Fritz LC, Wang CC, Gorio A. Avermectin B1a irreversibly blocks postsynaptic potentials at the lobster neuromuscular junction by reducing muscle membrane resistance. Proc. Natl Acad. Sci. USA. 1979;76:2062–2066. PubMed PMC

Cully DF, et al. Cloning of an avermectin-sensitive glutamate-gated chloride channel from Caenorhabditis elegans. Nature. 1994;371:707–711. PubMed

Prichard R, Menez C, Lespine A. Moxidectin and the avermectins: consanguinity but not identity. Int. J. Parasitol. Drugs Drug Resist. 2012;2:134–153. PubMed PMC

Krusek J, Zemkova H. Effect of ivermectin on gamma-aminobutyric acid-induced chloride currents in mouse hippocampal embryonic neurones. Eur. J. Pharmacol. 1994;259:121–128. PubMed

Shan Q, Haddrill JL, Lynch JW. Ivermectin, an unconventional agonist of the glycine receptor chloride channel. J. Biol. Chem. 2001;276:12556–12564. PubMed

Krause RM, et al. Ivermectin: a positive allosteric effector of the alpha7 neuronal nicotinic acetylcholine receptor. Mol. Pharmacol. 1998;53:283–294. PubMed

Khakh BS, et al. Allosteric control of gating and kinetics at P2X(4) receptor channels. J. Neurosci. 1999;19:7289–7299. PubMed PMC

Ko SK, et al. Synthetic ion transporters can induce apoptosis by facilitating chloride anion transport into cells. Nat. Chem. 2014;6:885–892. PubMed

Galluzzi L, et al. Molecular mechanisms of cell death: recommendations of the Nomenclature Committee on Cell Death 2018. Cell Death Differ. 2018;25:486–541. PubMed PMC

Tse C, et al. ABT-263: a potent and orally bioavailable Bcl-2 family inhibitor. Cancer Res. 2008;68:3421–3428. PubMed

Pui CH, Evans WE. Treatment of acute lymphoblastic leukemia. N. Engl. J. Med. 2006;354:166–178. PubMed

Sharmeen S, et al. The antiparasitic agent ivermectin induces chloride-dependent membrane hyperpolarization and cell death in leukemia cells. Blood. 2010;116:3593–3603. PubMed

Song D, et al. Moxidectin inhibits glioma cell viability by inducing G0/G1 cell cycle arrest and apoptosis. Oncol. Rep. 2018;40:1348–1358. PubMed PMC

Kinrade SA, et al. Evaluation of the cardiac safety of long-acting endectocide moxidectin in a randomized concentration-QT study. Clin. Transl. Sci. 2018;11:582–589. PubMed PMC

Laing R, Gillan V, Devaney E. Ivermectin—old drug, new tricks? Trends Parasitol. 2017;33:463–472. PubMed PMC

Opoku NO, et al. Single dose moxidectin versus ivermectin for Onchocerca volvulus infection in Ghana, Liberia, and the Democratic Republic of the Congo: a randomised, controlled, double-blind phase 3 trial. Lancet. 2018;392:1207–1216. PubMed PMC

Paul AJ, Tranquilli WJ, Hutchens DE. Safety of moxidectin in avermectin-sensitive collies. Am. J. Vet. Res. 2000;61:482–483. PubMed

Cotreau MM, et al. The antiparasitic moxidectin: safety, tolerability, and pharmacokinetics in humans. J. Clin. Pharmacol. 2003;43:1108–1115. PubMed

Prichard RK, Geary TG. Perspectives on the utility of moxidectin for the control of parasitic nematodes in the face of developing anthelmintic resistance. Int. J. Parasitol. Drugs Drug Resist. 2019;10:69–83. PubMed PMC

Ghosh T, et al. Closing the brief case: crusted scabies in a leukemic patient following a stay in a long-term acute care facility. J. Clin. Microbiol. 2017;55:1599–1600. PubMed PMC

Yonekura K, et al. Crusted scabies in an adult T-cell leukemia/lymphoma patient successfully treated with oral ivermectin. J. Dermatol. 2006;33:139–141. PubMed

Molinari G, Soloneski S, Larramendy ML. New ventures in the genotoxic and cytotoxic effects of macrocyclic lactones, abamectin and ivermectin. Cytogenet. Genome Res. 2010;128:37–45. PubMed

Zhang X, et al. Inhibition of TMEM16A Ca(2+)-activated Cl(-) channels by avermectins is essential for their anticancer effects. Pharmacol. Res. 2020;156:104763. PubMed

Crottes D, Jan LY. The multifaceted role of TMEM16A in cancer. Cell Calcium. 2019;82:102050. PubMed PMC

Park SH, et al. Determinants of ion-transporter cancer cell death. Chem. 2019;5:2079–2098. PubMed PMC

Britschgi A, et al. Calcium-activated chloride channel ANO1 promotes breast cancer progression by activating EGFR and CAMK signaling. Proc. Natl Acad. Sci. USA. 2013;110:E1026–E1034. PubMed PMC

Song Y, et al. Inhibition of ANO1/TMEM16A induces apoptosis in human prostate carcinoma cells by activating TNF-alpha signaling. Cell Death Dis. 2018;9:703. PubMed PMC

Gururaja Rao S, Patel NJ, Singh H. Intracellular chloride channels: novel biomarkers in diseases. Front. Physiol. 2020;11:96. PubMed PMC

Jing D, et al. Opposing regulation of BIM and BCL2 controls glucocorticoid-induced apoptosis of pediatric acute lymphoblastic leukemia cells. Blood. 2015;125:273–283. PubMed