The therapeutic potential of targeting PI3K/AKT/PTEN signalling in B-cell malignancies remains attractive. Whilst PI3K-α/δ inhibitors demonstrate clinical benefit in certain B-cell lymphomas, PI3K signalling inhibitors have been inadequate in relapsed/refractory diffuse large B-cell lymphoma (DLBCL) in part, due to treatment related toxicities. Clinically, AKT inhibitors exhibit a differentiated tolerability profile offering an alternative approach for treating patients with B-cell malignancies. To explore how AKT inhibition complements other potential therapeutics in the treatment of DLBCL patients, an in vitro combination screen was conducted across a panel of DLCBL cell lines. The AKT inhibitor, capivasertib, in combination with the BCL-2 inhibitor, venetoclax, produced notable therapeutic benefit in preclinical models of DLBCL. Capivasertib and venetoclax rapidly induced caspase and PARP cleavage in GCB-DLBCL PTEN wildtype cell lines and those harbouring PTEN mutations or reduced PTEN protein, driving prolonged tumour growth inhibition in DLBCL cell line and patient derived xenograft lymphoma models. The addition of the rituximab further deepened the durability of capivasertib and venetoclax responses in a RCHOP refractory DLBCL in vivo models. These findings provide preclinical evidence for the rational treatment combination of AKT and BCL-2 inhibitors using capivasertib and venetoclax respectively alongside anti-CD20 antibody supplementation for treatment of patients with DLBCL.

Bioscience Early Oncology AstraZeneca Boston USA

Bioscience Early Oncology AstraZeneca Cambridge UK

Department of Medicine A Haematology Oncology and Pneumology University Hospital Münster Münster Germany

Institute of Pathological Physiology 1st Faculty of Medicine Charles University Prague Prague Czech Republic

Zobrazit více v PubMed

Swerdlow SH, Campo E, Pileri SA, Harris NL, Stein H, Siebert R, et al. The 2016 revision of the World Health Organization classification of lymphoid neoplasms. Blood. 2016;127:2375–90. PubMed PMC

Wright GW, Huang DW, Phelan JD, Coulibaly ZA, Roulland S, Young RM, et al. A Probabilistic Classification Tool for Genetic Subtypes of Diffuse Large B Cell Lymphoma with Therapeutic Implications. Cancer Cell. 2020;37:551–68.e14. PubMed PMC

Roschewski M, Phelan JD, Wilson WH. Molecular Classification and Treatment of Diffuse Large B-Cell Lymphoma and Primary Mediastinal B-Cell Lymphoma. Cancer J. 2020;26:195–205. PubMed PMC

Tilly H, Morschhauser F, Sehn LH, Friedberg JW, Trneny M, Sharman JP, et al. Polatuzumab Vedotin in Previously Untreated Diffuse Large B-Cell Lymphoma. N. Engl J Med. 2022;386:351–63. PubMed PMC

Wang J, Xu-Monette ZY, Jabbar KJ, Shen Q, Manyam GC, Tzankov A, et al. AKT Hyperactivation and the Potential of AKT-Targeted Therapy in Diffuse Large B-Cell Lymphoma. Am J Pathol. 2017;187:1700–16. PubMed PMC

Pfeifer M, Lenz G. PI3K/AKT addiction in subsets of diffuse large B-cell lymphoma. Cell Cycle. 2013;12:3347–8. PubMed PMC

Erdmann T, Klener P, Lynch JT, Grau M, Vočková P, Molinsky J, et al. Sensitivity to PI3K and AKT inhibitors is mediated by divergent molecular mechanisms in subtypes of DLBCL. Blood. 2017;130:310–22. PubMed

Pongas GN, Annunziata CM, Staudt LM. PI3Kδ inhibition causes feedback activation of PI3Kα in the ABC subtype of diffuse large B-cell lymphoma. Oncotarget. 2017;8:81794–802. PubMed PMC

Chen L, Monti S, Juszczynski P, Ouyang J, Chapuy B, Neuberg D, et al. SYK inhibition modulates distinct PI3K/AKT- dependent survival pathways and cholesterol biosynthesis in diffuse large B cell lymphomas. Cancer Cell. 2013;23:826–38. PubMed PMC

Dreyling M, Morschhauser F, Bouabdallah K, Bron D, Cunningham D, Assouline SE, et al. Phase II study of copanlisib, a PI3K inhibitor, in relapsed or refractory, indolent or aggressive lymphoma. Ann Oncol. 2017;28:2169–78. PubMed PMC

Lenz G, Hawkes E, Verhoef G, Haioun C, Thye Lim S, Seog Heo D, et al. Single-agent activity of phosphatidylinositol 3-kinase inhibition with copanlisib in patients with molecularly defined relapsed or refractory diffuse large B-cell lymphoma. Leukemia. 2020;34:2184–97. PubMed PMC

Turner NC, Oliveira M, Howell SJ, Dalenc F, Cortes J, Gomez Moreno HL, et al. Capivasertib in Hormone Receptor-Positive Advanced Breast Cancer. N. Engl J Med. 2023;388:2058–70. PubMed PMC

Ezell SA, Wang S, Bihani T, Lai Z, Grosskurth SE, Tepsuporn S, et al. Differential regulation of mTOR signaling determines sensitivity to AKT inhibition in diffuse large B cell lymphoma. Oncotarget. 2016;7:9163–74. PubMed PMC

Xu W, Berning P, Lenz G. Targeting B-cell receptor and PI3K signaling in diffuse large B-cell lymphoma. Blood. 2021;138:1110–9. PubMed

Cory S, Roberts AW, Colman PM, Adams JM. Targeting BCL-2-like Proteins to Kill Cancer Cells. Trends Cancer. 2016;2:443–60. PubMed

DiNardo CD, Jonas BA, Pullarkat V, Thirman MJ, Garcia JS, Wei AH, et al. Azacitidine and Venetoclax in Previously Untreated Acute Myeloid Leukemia. N. Engl J Med. 2020;383:617–29. PubMed

Stilgenbauer S, Eichhorst B, Schetelig J, Coutre S, Seymour JF, Munir T, et al. Venetoclax in relapsed or refractory chronic lymphocytic leukaemia with 17p deletion: a multicentre, open-label, phase 2 study. Lancet Oncol. 2016;17:768–78. PubMed

Scholze H, Stephenson RE, Reynolds R, Shah S, Puri R, Butler SD, et al. Combined EZH2 and Bcl-2 inhibitors as precision therapy for genetically defined DLBCL subtypes. Blood Adv. 2020;4:5226–31. PubMed PMC

Morschhauser F, Feugier P, Flinn IW, Gasiorowski R, Greil R, Illes A, et al. A phase 2 study of venetoclax plus R-CHOP as first-line treatment for patients with diffuse large B-cell lymphoma. Blood. 2021;137:600–9. PubMed PMC

Choudhary GS, Al-Harbi S, Mazumder S, Hill BT, Smith MR, Bodo J, et al. MCL-1 and BCL-xL-dependent resistance to the BCL-2 inhibitor ABT-199 can be overcome by preventing PI3K/AKT/mTOR activation in lymphoid malignancies. Cell Death Dis. 2015;6:e1593. PubMed PMC

Ackler S, Xiao Y, Mitten MJ, Foster K, Oleksijew A, Refici M, et al. ABT-263 and rapamycin act cooperatively to kill lymphoma cells in vitro and in vivo. Mol Cancer Ther. 2008;7:3265–74. PubMed

Coloff JL, Macintyre AN, Nichols AG, Liu T, Gallo CA, Plas DR, et al. Akt-dependent glucose metabolism promotes Mcl-1 synthesis to maintain cell survival and resistance to Bcl-2 inhibition. Cancer Res. 2011;71:5204–13. PubMed PMC

Lee JS, Tang SS, Ortiz V, Vo TT, Fruman DA. MCL-1-independent mechanisms of synergy between dual PI3K/mTOR and BCL-2 inhibition in diffuse large B cell lymphoma. Oncotarget. 2015;6:35202–17. PubMed PMC

Davies AJ. Precision Medicine in DLBCL: Are We There Yet? J Clin Oncol. 2021;39:1314–6. PubMed

Davies BR, Greenwood H, Dudley P, Crafter C, Yu DH, Zhang J, et al. Preclinical pharmacology of AZD5363, an inhibitor of AKT: pharmacodynamics, antitumor activity, and correlation of monotherapy activity with genetic background. Mol Cancer Ther. 2012;11:873–87. PubMed

Souers AJ, Leverson JD, Boghaert ER, Ackler SL, Catron ND, Chen J, et al. ABT-199, a potent and selective BCL-2 inhibitor, achieves antitumor activity while sparing platelets. Nat Med. 2013;19:202–8. PubMed

Maloney DG, Grillo-Lopez AJ, White CA, Bodkin D, Schilder RJ, Neidhart JA, et al. IDEC-C2B8 (Rituximab) anti-CD20 monoclonal antibody therapy in patients with relapsed low-grade non-Hodgkin’s lymphoma. Blood. 1997;90:2188–95. PubMed

Crafter C, Vincent JP, Tang E, Dudley P, James NH, Klinowska T, et al. Combining AZD8931, a novel EGFR/HER2/HER3 signalling inhibitor, with AZD5363 limits AKT inhibitor induced feedback and enhances antitumour efficacy in HER2-amplified breast cancer models. Int J Oncol. 2015;47:446–54. PubMed PMC

Xu W, Berning P, Erdmann T, Grau M, Bettazova N, Zapukhlyak M, et al. mTOR inhibition amplifies the anti-lymphoma effect of PI3Kbeta/delta blockage in diffuse large B-cell lymphoma. Leukemia. 2023;37:178–89. PubMed PMC

Kilkenny C, Browne WJ, Cuthill IC, Emerson M, Altman DG. Improving bioscience research reporting: The ARRIVE guidelines for reporting animal research. J Pharm Pharmacother. 2010;1:94–99. PubMed PMC

Brunet A, Bonni A, Zigmond MJ, Lin MZ, Juo P, Hu LS, et al. Akt promotes cell survival by phosphorylating and inhibiting a forkhead transcription factor. Cell. 1999;96:857–68. PubMed

Cross DAE, Alessi DR, Cohen P, Andjelkovich M, Hemmings BA. Inhibition of glycogen synthase kinase-3 by insulin mediated by protein kinase B. Nature. 1995;378:785–9. PubMed

Kovacina KS, Park GY, Bae SS, Guzzetta AW, Schaefer E, Birnbaum MJ, et al. Identification of a proline-rich Akt substrate as a 14-3-3 binding partner. J Biol Chem. 2003;278:10189–94. PubMed

Rena G, Guo S, Cichy SC, Unterman TG, Cohen P. Phosphorylation of the transcription factor forkhead family member FKHR by protein kinase B. J Biol Chem. 1999;274:17179–83. PubMed

Alessi DR, Andjelkovic M, Caudwell B, Cron P, Morrice N, Cohen P, et al. Mechanism of activation of protein kinase B by insulin and IGF-1. EMBO J. 1996;15:6541–51. PubMed PMC

Alessi DR, James SR, Downes CP, Holmes AB, Gaffney PRJ, Reese CB, et al. Characterization of a 3-phosphoinositide-dependent protein kinase which phosphorylates and activates protein kinase Bα. Curr Biol. 1997;7:261–9. PubMed

Hresko RC, Mueckler M. mTOR.RICTOR is the Ser473 kinase for Akt/protein kinase B in 3T3-L1 adipocytes. J Biol Chem. 2005;280:40406–16. PubMed

Jacinto E, Facchinetti V, Liu D, Soto N, Wei S, Jung SY, et al. SIN1/MIP1 maintains rictor-mTOR complex integrity and regulates Akt phosphorylation and substrate specificity. Cell. 2006;127:125–37. PubMed

Sarbassov DD, Guertin DA, Ali SM, Sabatini DM. Phosphorylation and regulation of Akt/PKB by the rictor-mTOR complex. Science. 2005;307:1098–101. PubMed

Scheid MP, Marignani PA, Woodgett JR. Multiple phosphoinositide 3-kinase-dependent steps in activation of protein kinase B. Mol Cell Biol. 2002;22:6247–60. PubMed PMC

Stephens L, Anderson K, Stokoe D, Erdjument-Bromage H, Painter GF, Holmes AB, et al. Protein kinase B kinases that mediate phosphatidylinositol 3,4,5- trisphosphate-dependent activation of protein kinase B. Science. 1998;279:710–4. PubMed

Herrant M, Jacquel A, Marchetti S, Belhacene N, Colosetti P, Luciano F, et al. Cleavage of Mcl-1 by caspases impaired its ability to counteract Bim-induced apoptosis. Oncogene. 2004;23:7863–73. PubMed

Weng C, Li Y, Xu D, Shi Y, Tang H. Specific cleavage of Mcl-1 by caspase-3 in tumor necrosis factor-related apoptosis-inducing ligand (TRAIL)-induced apoptosis in Jurkat leukemia T cells. J Biol Chem. 2005;280:10491–10500. PubMed

Chipuk JE, Bouchier-Hayes L, Green DR. Mitochondrial outer membrane permeabilization during apoptosis: the innocent bystander scenario. Cell Death Differ. 2006;13:1396–402. PubMed

Chipuk JE, Green DR. How do BCL-2 proteins induce mitochondrial outer membrane permeabilization? Trends Cell Biol. 2008;18:157–64. PubMed PMC

Kale J, Osterlund EJ, Andrews DW. BCL-2 family proteins: changing partners in the dance towards death. Cell Death Differ. 2018;25:65–80. PubMed PMC

Tait SW, Green DR. Mitochondria and cell death: outer membrane permeabilization and beyond. Nat Rev Mol Cell Biol. 2010;11:621–32. PubMed

Cost GJ, Freyvert Y, Vafiadis A, Santiago Y, Miller JC, Rebar E, et al. BAK and BAX deletion using zinc-finger nucleases yields apoptosis-resistant CHO cells. Biotechnol Bioeng. 2010;105:330–40. PubMed

Lindsten T, Ross AJ, King A, Zong W-X, Rathmell JC, Shiels HA, et al. The Combined Functions of Proapoptotic Bcl-2 Family Members Bak and Bax Are Essential for Normal Development of Multiple Tissues. Mol Cell. 2000;6:1389–99. PubMed PMC

Wei MC, Zong WX, Cheng EHY, Lindsten T, Panoutsakopoulou V, Ross AJ, et al. Proapoptotic BAX and BAK: A requisite gateway to mitochondrial dysfunction and death. Science. 2001;292:727–30. PubMed PMC

Jaksa R, Karolova J, Svaton M, Kazantsev D, Grajciarova M, Pokorna E, et al. Complex genetic and histopathological study of 15 patient-derived xenografts of aggressive lymphomas. Lab Invest. 2022;102:957–65. PubMed PMC

Klanova M, Andera L, Brazina J, Svadlenka J, Benesova S, Soukup J, et al. Targeting of BCL2 Family Proteins with ABT-199 and Homoharringtonine Reveals BCL2- and MCL1-Dependent Subgroups of Diffuse Large B-Cell Lymphoma. Clin Cancer Res. 2016;22:1138–49. PubMed

Hopcroft L, Wigmore EM, Williamson SC, Ros S, Eberlein C, Moss JI, et al. Combining the AKT inhibitor capivasertib and SERD fulvestrant is effective in palbociclib-resistant ER+ breast cancer preclinical models. NPJ Breast Cancer. 2023;9:64. PubMed PMC

Eberlein C, Williamson SC, Hopcroft L, Ros S, Moss JI, Kerr J, et al. Capivasertib combines with docetaxel to enhance anti-tumour activity through inhibition of AKT-mediated survival mechanisms in prostate cancer. Br J Cancer. 2024;130:1377–87. PubMed PMC

Lynch JT, McEwen R, Crafter C, McDermott U, Garnett MJ, Barry ST, et al. Identification of differential PI3K pathway target dependencies in T-cell acute lymphoblastic leukemia through a large cancer cell panel screen. Oncotarget. 2016;7:22128–39. PubMed PMC

Bojarczuk K, Wienand K, Ryan JA, Chen L, Villalobos-Ortiz M, Mandato E, et al. Targeted inhibition of PI3Kalpha/delta is synergistic with BCL-2 blockade in genetically defined subtypes of DLBCL. Blood. 2019;133:70–80. PubMed PMC

Lynch JT, Polanska UM, Delpuech O, Hancox U, Trinidad AG, Michopoulos F, et al. Inhibiting PI3Kbeta with AZD8186 Regulates Key Metabolic Pathways in PTEN-Null Tumors. Clin Cancer Res. 2017;23:7584–95. PubMed

Lynch JT, Polanska UM, Hancox U, Delpuech O, Maynard J, Trigwell C, et al. Combined Inhibition of PI3Kbeta and mTOR Inhibits Growth of PTEN-null Tumors. Mol Cancer Ther. 2018;17:2309–19. PubMed

Fontana F, Giannitti G, Marchesi S, Limonta P. The PI3K/Akt Pathway and Glucose Metabolism: A Dangerous Liaison in Cancer. Int J Biol Sci. 2024;20:3113–25. PubMed PMC

Dunn S, Eberlein C, Yu J, Gris-Oliver A, Ong SH, Yelland U, et al. AKT-mTORC1 reactivation is the dominant resistance driver for PI3Kbeta/AKT inhibitors in PTEN-null breast cancer and can be overcome by combining with Mcl-1 inhibitors. Oncogene. 2022;41:5046–60. PubMed PMC

Paulus A, Akhtar S, Yousaf H, Manna A, Paulus SM, Bashir Y, et al. Waldenstrom macroglobulinemia cells devoid of BTK(C481S) or CXCR4(WHIM-like) mutations acquire resistance to ibrutinib through upregulation of Bcl-2 and AKT resulting in vulnerability towards venetoclax or MK2206 treatment. Blood Cancer J. 2017;7:e565. PubMed PMC

Pham LV, Huang S, Zhang H, Zhang J, Bell T, Zhou S, et al. Strategic Therapeutic Targeting to Overcome Venetoclax Resistance in Aggressive B-cell Lymphomas. Clin Cancer Res. 2018;24:3967–80. PubMed

Scott Lee J, Tang SS, Ortiz V, Vo TT, Fruman DA. MCL-1-independent mechanisms of synergy between dual PI3K/ mTOR and BCL-2 inhibition in diffuse large B cell lymphoma. Oncotarget. 2015;6:35202–17. PubMed PMC

Spender LC, Inman GJ. Phosphoinositide 3-kinase/AKT/mTORC1/2 signaling determines sensitivity of Burkitt’s lymphoma cells to BH3 mimetics. Mol Cancer Res. 2012;10:347–59. PubMed PMC

Phillips DC, Xiao Y, Lam LT, Litvinovich E, Roberts-Rapp L, Souers AJ, et al. Loss in MCL-1 function sensitizes non-Hodgkin’s lymphoma cell lines to the BCL-2-selective inhibitor venetoclax (ABT-199). Blood Cancer J. 2015;5:e368. PubMed PMC

Tron AE, Belmonte MA, Adam A, Aquila BM, Boise LH, Chiarparin E, et al. Discovery of Mcl-1-specific inhibitor AZD5991 and preclinical activity in multiple myeloma and acute myeloid leukemia. Nat Commun. 2018;9:5341. PubMed PMC

Rahmani M, Nkwocha J, Hawkins E, Pei X, Parker RE, Kmieciak M, et al. Cotargeting BCL-2 and PI3K Induces BAX-Dependent Mitochondrial Apoptosis in AML Cells. Cancer Res. 2018;78:3075–86. PubMed PMC

Kale J, Kutuk O, Brito GC, Andrews TS, Leber B, Letai A, et al. Phosphorylation switches Bax from promoting to inhibiting apoptosis thereby increasing drug resistance. EMBO Rep. 2018;19:e45235. PubMed PMC

Sun L, Huang Y, Liu Y, Zhao Y, He X, Zhang L, et al. Ipatasertib, a novel Akt inhibitor, induces transcription factor FoxO3a and NF-κB directly regulates PUMA-dependent apoptosis. Cell death Dis. 2018;9:911. PubMed PMC