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In the current study we examined the ability of 4-methylumbelliferone (4-MU), which can inhibit hyaluronic acid synthesis, to sensitize K562 chronic myelogenous leukemia (CML) cells to doxorubicin therapy. Exposure of K562 cells to doxorubicin led to increased hyaluronic acid synthase (HAS) gene expression and increased levels of cell surface hyaluronic acid. Furthermore, exposure of K562 cells to exogenous HA caused resistance to doxorubicin-induced cell death. The combination of low dose 4-MU and doxorubicin led to increased apoptosis when compared to higher doses of any agent alone. Additionally, treatment with 4-MU led to a significant reduction in doxorubicin-induced increase in HA cell surface expression. Mechanistically, 4-MU treatment led to an increase in p38 activation and PARP cleavage. The role of p38 in 4-MU/doxorubicin-treated K562 cells was confirmed when p38 inhibitors led to protection from 4-MU/doxorubicin-induced apoptosis. Together, results from this study suggest that treatment with 4-MU increases the sensitivity of CML to chemotherapeutics by decreasing their HA-mediated resistance to apoptosis.

An estimated 20-30% of CML patients will become resistant to tyrosine kinase inhibitors (TKIs) including imatinib. Recent reports suggest that CML resistance to TKI's is driven by interactions with protective microenvironment niches that influence their survival and self-renewal capacity. Hyaluronic acid (HA) has emerged as a key contributor in this phenomenon of CML resistance to TKI’s. HA influences cell viability through molecular weight dependent interactions with cell-surface receptors CD44 and RHAMM. Low molecular weight (LMW) HA, is typically found in association with many cancers including CML and promotes apoptotic resistance, proliferation, and migration of cancer cells. High molecular weight (HMW) HA is primarily produced by fibroblasts and its catabolism to LMW HA is mediated by hyaluronidase (HYAL) activity. HYAL activity may provide a potential therapeutic target in combination with current TKI treatments. Using a co-culture model, we investigated the role of HA produced by bone marrow stromal fibroblasts on CML viability when subject to imatinib (IM) treatment. Furthermore, we investigated the possibility of targeting hyaluronidase as an adjuvant in combination with IM for the treatment of CML. Co-culture with stromal fibroblasts protected CML cells from proliferation inhibition by IM. HA production and its catabolic products including LMW HA were elevated in the supernatant of co-cultures exposed to IM. The expression of genes encoding for HA metabolic proteins including hyaluronic acid synthases and HYALs, were significantly increased in co-cultures subject to IM stress. Additionally, HA treatment of CML mono-culture protected against chemotherapy-induced apoptosis. Treatment of CML co-culture with HYAL inhibitor, glycrrhizic acid (GA), inhibited HYAL activity, greatly reduced proliferation and increased apoptosis of CML cells alone and in combination with IM. This investigation provides additional evidence of the importance of stromal cell support in CML pathology and that resistance to TKI therapy may be mediated in part through upregulation of total HA production and its catabolism. Furthermore, we establish the potent therapeutic effects of GA on CML cells alone and in combination with current IM treatment strategies as a prospective method of circumventing TKI-resistant CML. For the first time we demonstrate GA's effectiveness as a HYAL inhibitor in culture. HYALs are an attractive target not only in CML resistance but in many cancers due to the reported role of its product, LMW HA, in inflammation, proliferation, and apoptotic resistance. Citation Format: Bryan Hostetler, Olga Uchakina, Robert McKallip. Targeting hyaluronidase reduces stromal cell protection of chronic myeloid leukemia to imatinib therapy. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3848.

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The development of tyrosine kinase inhibitors (TKIs) such as imatinib has greatly improved the prognosis and survival of patients diagnosed with chronic myeloid leukemia (CML). However, many CML patients relapse due to the presence of minimal residual disease and the development of TKI resistance. It is unknown exactly what causes the relapse, but based on research from our laboratory we hypothesize that hyaluronic acid (HA) produced by fibroblasts in the microenvironment of the bone marrow provide for a protective environment preventing the tumor cells from therapy-induced cell death or senescence. The purpose of this study is to determine the influence that HA and its binding to its receptor (CD44) has on CML survival and resistance development. Initially, we examined the effect that stromal cell derived and/or exogenously added HA has on CML resistance to imatinib. Cell survival, apoptosis, HA production, and signaling events elicited by the interactions of HA with CD44 was examined using methods such as ELISA, western blotting, and MTT analysis. Furthermore, we examined the potential therapeutic use of compounds known to alter HA production and/or signaling for the treatment of CML. Our study demonstrates increased cell survival when the tumor cells are co-cultured with fibroblasts or have exogenous HA added to them after imatinib treatment. Additionally, we show that knocking out hyaluronic acid synthases reduces this protective effect. This data supports our hypothesis and we believe it could help lead to improved therapeutic treatment for CML. Note: This abstract was not presented at the meeting. Citation Format: Kylie Humphries, Olga Uchakina, Bryan Hostetler, Robert McKallip. The influence of CD44/HA signaling on CML survival and resistance to tyrosine kinase inhibitor treatment [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 119.