Contribution of lysine deacetylases to the therapy of malignant pleural mesothelioma

Malignant pleural mesothelioma (MPM) is a rare cancer arising from mesothelial cells from the pleura. The first line chemotherapy of the epithelioid subtype of MPM is based on a combined regimen of cisplatin and an antifolate (pemetrexed). Recently, immunotherapy with two checkpoint inhibitors (PD-1, nivolumab and CTLA-4, ipilimumab) showed promising results for the sarcomatoid subtype. Despite this major breakthrough, the median overall survival of patients only reached 18.1 months, compared to 14 months in standard chemotherapy. With an objective response rate of 40%, only a subset of patients benefits from immunotherapy. Therefore, options for second line treatment are still mandatory.

We previously proposed a therapy based on the combination of a topoisomerase inhibitor (doxorubicin) and a lysine deacetylase inhibitor (valproate, VPA) (Scherpereel et al, European Respiratory Journal 37:129-135). We identified one of the key determinants that modulates the chemoresistance (Staumont et al, Cancers 12:1484).

In this study, we aimed to further investigate the mechanisms involved by analyzing the effect of VPA on the tumor microenvironment and more particularly on the interactions between monocytes and tumor cells.

We showed that VPA affects the viability of doxorubicin-treated mesothelioma cells and promotes their apoptosis. The use of caspase and calpeptin inhibitors demonstrated that apoptosis occurs through a caspase-dependent mechanism involving both intrinsic and extrinsic pathway. Western blot analysis revealed that the combination of VPA and doxorubicin increases the expression of clived-Bid, Bax and cytochrome c while decreasing the expression of Bcl-2 and Bcl-XL. Transcriptomic analysis unveiled that epithelioid mesothelioma cells express more p21, Fas, Bbc3 and TP53INP1 upon treatment compared to the sarcomatoid subtype. To investigate the role of the microenvironment, we designed two models to study the influence of tumor-associated monocytes. Mesothelioma cells were co-cultured with THP-1 monocytes differentiated in presence of PMA. Flow cytometry, confocal microscopy and live imaging demonstrated that THP-1-derived monocytes are able to interact and kill tumor cells. Furthermore, VPA promotes the interaction between monocytes and tumor cells and fosters the cytotoxic activity of monocytes. In contrast to PMA, VPA does not affect the motility of THP-1 monocytes. These observations were validated and extended to primary monocytes isolated from peripheral blood. Increased cytotoxicity of primary monocytes is correlated with a reduced frequency of CD16+ cells. In this model, VPA augments the average speed of primary monocytes. Finally, RNA sequencing highlighted the key mechanisms involved in monocyte antitumor activity.

In conclusion, we demonstrate that VPA directly affects the survival of tumor cells and indirectly modulates the cytotoxic activity of monocytes in the microenvironment.