Targeting The Bcl-2 Family in B Cell Lymphoma

REVIEW
published: 08 January 2019

doi: 10.3389/fonc.2018.00636
Targeting the Bcl-2 Family in B Cell

Lymphoma
Clare M. Adams 1 , Sean Clark-Garvey 2 , Pierluigi Porcu 3 and Christine M. Eischen 1*
1
Department of Cancer Biology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, United States,
2
Internal Medicine Residency Program, Department of Internal Medicine, Sidney Kimmel Medical College, Thomas Jefferson
University, Philadelphia, PA, United States, 3 Division of Hematologic Malignancies and Hematopoietic Stem Cell
Transplantation, Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia,
PA, United States
Although lymphoma is a very heterogeneous group of biologically complex malignancies,

tumor cells across all B cell lymphoma subtypes share a set of underlying traits that
promote the development and sustain malignant B cells. One of these traits, the ability
to evade apoptosis, is essential for lymphoma development. Alterations in the Bcl-2
family of proteins, the key regulators of apoptosis, is a hallmark of B cell lymphoma.
Significant efforts have been made over the last 30 years to advance knowledge of
the biology, molecular mechanisms, and therapeutic potential of targeting Bcl-2 family
members. In this review, we will highlight the complexities of the Bcl-2 family, including
our recent discovery of overexpression of the anti-apoptotic Bcl-2 family member Bcl-w
Edited by:
in lymphomas, and describe recent advances in the field that include the development of
Silvia Bea,
Institut d’Investigacions Biomèdiques inhibitors of anti-apoptotic Bcl-2 family members for the treatment of B cell lymphomas
August Pi i Sunyer (IDIBAPS), Spain and their performance in clinical trials.
Reviewed by:
Keywords: BCL-2, BCL-W, B cell lymphoma, apoptosis, venetoclax, navitoclax, BH-3 mimetic, CLL
Benjamin Bonavida,
University of California, Los Angeles,
United States
Alberto Fabbri, INTRODUCTION
Azienda Ospedaliera Universitaria
Senese, Italy Acquiring resistance to apoptosis, a highly-regulated, evolutionarily conserved process, is a
*Correspondence: characteristic shared among all types of cancer, including B cell lymphomas (1). For a cell to
Christine M. Eischen divide and grow uncontrollably, as malignant cells do, it must not only hijack the normal cellular
christine.eischen@jefferson.edu growth pathways, but it must also avoid cellular death signals. During lymphomagenesis, B cells
encounter a broad range of stress stimuli, including oncogene activation, DNA damage, and oxygen
Specialty section: and cytokine deprivation, all of which can elicit an apoptotic cell death response. Apoptosis is
This article was submitted to regulated by complex interactions between pro-apoptotic and anti-apoptotic members of the B
Hematologic Malignancies, cell lymphoma-2 (Bcl-2) protein family (2). Thus, a delicate balance between members of the Bcl-
a section of the journal
2 family dictate whether the B cell will live or die under stress conditions. As such, alterations
Frontiers in Oncology
that deregulate the apoptotic process lead to increased survival and facilitate lymphomagenesis (3).
Received: 10 September 2018 Moreover, these alterations can render lymphoma cells refractory to therapies that are designed to
Accepted: 05 December 2018
induce death (4). Specifically, overexpression of the anti-apoptotic Bcl-2 family members and/or
Published: 08 January 2019
reduced expression of specific pro-apoptotic members are a common feature shared among B
Citation:
cell lymphomas (4, 5). Much of what we know today about the Bcl-2 family and its role in
Adams CM, Clark-Garvey S, Porcu P
and Eischen CM (2019) Targeting the
B cells and B cell lymphoma comes from decades of research utilizing genetically engineered
Bcl-2 Family in B Cell Lymphoma. mice and a mouse model of Myc oncogene-induced B cell lymphoma [Eµ-myc transgenic mice,
Front. Oncol. 8:636. (6)]. However, recent discoveries and low complete response rates in clinical trials with targeted
doi: 10.3389/fonc.2018.00636 therapy against BCL-2 in lymphoma reveal significant gaps in knowledge remain (7–9). This review
Frontiers in Oncology | www.frontiersin.org 1 January 2019 | Volume 8 | Article 636

Adams et al. Targeting the Bcl-2 Family in B-Cell Lymphoma
comprehensively examines each member of the Bcl-2 protein

family, defining their contribution to B cell lymphomagenesis
through mouse models and the alterations that occur in them in
human B cell lymphomas, including our recent discovery of Bcl-
w overexpression. In addition, this review also describes current
therapeutic efforts to target specific anti-apoptotic Bcl-2 family
members in lymphoma patients alone or in combinations to
improve survival.
BCL-2 PROTEIN FAMILY AND APOPTOSIS

B cells continuously monitor their environment and make
decisions as to whether they should live or die. The Bcl-2
protein family are the central gatekeepers of the intrinsic or
mitochondrial apoptotic response. The family is comprised of
structurally-related proteins with opposing functions that either
promote or inhibit apoptosis by interacting with one another
(10). The Bcl-2 family is typically classified into three groups,
including pro-apoptotic initiators, pro-apoptotic effectors, and
anti-apoptotic proteins (Figure 1A). The apoptotic-promoting
effects from the pro-apoptotic initiators and effectors are
countered by their direct interaction with the anti-apoptotic
family members. It is this delicate and dynamic balance between
the pro- and anti-apoptotic Bcl-2 family members that governs
whether a B cell undergoes apoptosis or survives. We discuss the
consequences of alterations for each of the Bcl-2 family members
in lymphoma in mouse models and make comparisons to what is
observed in human lymphomas (see Table 1).
Pro-apoptotic Bcl-2 Family Members

Members of the Bcl-2 protein family share sequence homology
within conserved regions known as Bcl-2 homology (BH)
domains, which dictate structure and function (67, 68). All
anti-apoptotic family members and a subset of pro-apoptotic
members are multi-domain proteins, sharing sequence homology
within three to four BH domains. A subset of pro-apoptotic Bcl-
2 family members known as BH-3 only proteins only contain the
BH-3 domain, which is known as the minimal death domain that
is required for binding the multi-domain Bcl-2 family members
(69).
BH-3 Only Proteins: Initiators of Apoptosis FIGURE 1 | Bcl-2 family members regulate apoptosis. (A) Various cellular
The BH-3 only group of pro-apoptotic Bcl-2 proteins consists of stressors induce apoptosis through the intrinsic, mitochondrial pathway, which
Bim (BCL2L11), Puma/BBC3, Bad (Bcl-2/Bcl-x-associated death is regulated by the Bcl-2 family of proteins. These stress signals activate
promoter), Bid (BH-3 interacting-domain death agonist), Bik pro-apoptotic BH-3 only initiators (red), which inhibit the anti-apoptotic
(Bcl-2-interacting killer), Noxa/PMAIP1, Bmf (Bcl-2-modifying proteins (green). This, in turn, allows the pro-apoptotic effectors (blue) to be
activated. Activation of the effector proteins results in their oligomerization and
factor), and Hrk (Harakiri) [Figure 1A, (70)] and are essential for subsequent mitochondrial outer membrane permeabilization (MOMP),
initiating the apoptotic cascade. While the BH-3 only proteins enabling the release of apoptotic factors that initiate the caspase cascade and
can initiate apoptotic signaling by binding directly to the anti- final stages of cellular destruction. (B) Pro-apoptotic BH-3 only proteins bind
apoptotic Bcl-2 proteins, thereby freeing up Bax and Bak to to anti-apoptotic Bcl-2 family members with different affinities. BIM, PUMA,
and BID bind strongly to all anti-apoptotic Bcl-2 proteins, whereas BAD binds
undergo homo-dimerization, some have been reported to bind
preferentially to BCL-2, BCL-X, and BCL-W, and NOXA binds preferentially to
directly to and activate Bax and Bak (71). Years of studies using MCL-1 and A1/BFL-1.
mouse models have revealed certain BH-3 only proteins are
preferentially solicited in response to different apoptotic stimuli
(72–76). Myc, and serve as a blockade against the development of B
BH-3 only proteins serve as the first responders to cellular cell lymphoma. For example, loss of Bim or Puma accelerated
insults, including from dysregulation of oncogenes, such as Myc-driven B cell lymphoma development in a mouse model

TABLE 1 | Alterations in Bcl-2 family members in mouse models and human lymphoma.
Family Mouse models Human patients

member
PRO-APOPTOTIC
BIM Loss accelerates Myc-driven BCL (11) Deleted in 20% MCL (12);
SNPs present in FL, DLBCL, CLL (13);
Low mRNA expression in 40% BL (14)
PUMA Loss accelerates Myc-driven BCL (15, 16) Low mRNA expression in 40% BL (15)
NOXA Loss does not accelerate Myc-driven BCL, but does increase B cell Unknown
numbers (16)
BAD Loss accelerates Myc-driven BCL (17); No known link with DLBCL
25% with deletion develop DLBCL at old age (18)
BID Loss causes CMML (19) Unknown
BIK Loss does not accelerate Myc-driven BCL (20) and has no effect on Somatic missense mutations in FL, MZL, and DLBCL (22)
hematopoietic cells (21)
BMF Loss accelerates Myc-driven BCL and increases B cell numbers (17) Reduced protein levels in BL (17)
BAK Null mice are phenotypically normal (23); Unknown
Unknown effects on Myc-driven BCL
BAX Null mice have mild lymphoid hyperplasia (24); Unknown
Loss accelerates Myc-driven BCL (25)
BOK Loss does not accelerate Myc-driven BCL (26) Unknown
ANTI-APOPTOTIC
BCL-2 Null mice have a premature death (27); Translocated in 90% FL (29) and 20% DLBCL (30);
Overexpression increases B cells and accelerates Myc-driven BCL (28) Somatic mutations in FL associated with transformation and reduced
survival (31); Increased mRNA levels linked to reduced survival (31);
Increased mRNA in a subset of MZL (32) and protein in MCL (33)
BCL-X Null mice are embryonic lethal (34, 35); Overexpressed in subset of BL (9), FL (9, 39), DLBCL (9, 39), and
Loss delays Myc-driven BCL (36); MCL (9, 40);
Overexpression increases mature lymphocytes (37); overexpression with Low protein expression in MZL (33); Increased mRNA in MZL (9);
Myc causes lymphoproliferation and plasma cell malignancy (38) High mRNA and protein expression in MM (41–44)
MCL-1 Null mice are embryonic lethal (45–47); Amplification or chromosomal gains in 20–25% ABC DLBCL (53);
Loss delays Myc-driven BCL (48, 49); Overexpression increases B cells Increased mRNA in CLL (54, 55) and MM (56) and correlated with disease
(50, 51) and accelerates Myc-driven BCL (52) progression in MM (57); Low protien levels in MCL (33)
A1/BFL-1 Null mice are embryonic lethal (58, 59); No change (9) or elevated mRNA in DLBCL (61); Elevated mRNA in CLL
Overexpression does not accelerate Myc-driven BCL (60) (62, 63); Low mRNA levels in BL (9)
BCL-W Null male mice are sterile (64, 65); Loss delays Myc-driven BCL (8); Overexpressed in BL, DLBCL, FL, MZL, and MCL (8, 9)
Overexpression accelerates Myc-driven leukemogenesis (66)
BCL, B cell lymphoma; MCL, mantle cell lymphoma; SNP, single nucleotide polymorphism; FL, follicular lymphoma; DLBCL, diffuse large B cell lymphoma; CLL, chronic lymphocytic
leukemia; BL, Burkitt lymphoma; CMML, chronic myelomonocytic leukemia; MZL, marginal zone lymphoma; MM, multiple myeloma; ABC, activated B cell subtype of DLBCL.
engineered to overexpress Myc in B cells (Eµ-myc transgenic) the findings in mice, BAD loss has not been linked to DLBCL
(11, 15, 16). Loss of BIM may also contribute to human in humans. Deletion of Bid did not result in B cell lymphoma
lymphomas, as ∼20% of mantle cell lymphomas (MCL) have development in mice. Instead, chronic myelomonocytic leukemia
deleted both alleles of BIM (12). In addition, single nucleotide emerged in Bid-null mice after a long latency period, indicating
polymorphisms in the BIM gene have been associated with Bid function is critical for the myeloid lineage (19). It is unknown
risk of developing follicular lymphoma (FL), diffuse large B if alterations in BID contribute to human lymphoma. In mice,
cell lymphoma (DLBCL), and chronic lymphocytic leukemia loss of Bik alone had no effect on hematopoietic cells and
(CLL) (13). Furthermore, ∼40% of human Burkitt lymphomas did not accelerate Myc-induced B cell lymphoma development,
express very low levels of BIM or PUMA mRNA, which may suggesting that it has no role in B cells (20, 21). However,
be the result of epigenetic silencing (14, 15). In contrast to Bim somatic missense mutations have been observed in BIK in
and Puma, loss of Noxa had no effect on Myc-induced B cell B cell lymphomas in humans, including FL, marginal zone
lymphomagenesis in mice, but did increase the number of B (MZL), and DLBCL (22), suggesting that its loss may contribute
lineage cells (16). It is unknown whether NOXA loss contributes to these lymphomas. Loss of Bmf in mice increased B cell
to human B cell lymphoma. A quarter of mice with deletion of numbers and cooperated with Myc overexpression to accelerate
Bad develop DLBCL at old age, suggesting that it may have a lymphomagenesis; preferentially developing an IgM+ B cell
tumor suppressive function in mature B cells (18). Deletion of lymphoma (17). Reduced levels of BMF were observed in Burkitt
Bad also accelerated Myc-induced B cell lymphoma (17). Despite lymphoma patient samples and cell lines (17). Together, the data

indicate that each pro-apoptotic BH-3 only family member may [Figure 1B, (10, 84, 85)]. We will discuss each of the anti-
facilitate tumor suppression in specific hematopoietic cells, but apoptotic Bcl-2 family members, focusing particular attention
not all may have a role in B cells. on Bcl-w to highlight its newly-exposed contributions to B cell
survival and lymphomagenesis.
Bax, Bak, and Bok: Effectors of Apoptosis
Activation of Bax and Bak, and possibly the lesser-studied Bok, BCL-2
involves homo-dimerization followed by oligomerization BCL-2 is translocated t(14;18)(q32;q21) to the immunoglobulin
within the outer mitochondrial membrane (71). This heavy chains, resulting in its constitutive expression in 90%
conformational change induces mitochondrial outer membrane of FL (29, 86–90). Bcl-2 knockout mice showed that Bcl-2 is
permeabilization (MOMP) by creating a pore and triggering required for normal B cells to survive (27), providing evidence
the release of apoptosis-inducing proteins, such as cytochrome for why B cell lymphomas would select for its overexpression.
c and second mitochondria-derived activator of caspase Somatic mutations in BCL-2 in FL are often associated with
(Smac)/direct IAP-binding protein with low pI (DIABLO) transformation of this indolent disease to more aggressive diffuse
from the mitochondria [Figure 1A, (77)]. Following this large B cell lymphoma (DLBCL) and decreased patient survival
release, the caspase cascade is activated, ultimately resulting (31). Some of these mutations increased the affinity of BCL-2 to
in the proteolysis of intra-cellular proteins and cellular pro-apoptotic BH-3 only proteins and have also been detected in
destruction. lymphoid cell lines (91, 92).
The combined function of Bax and Bak is critical for Approximately 20% of de novo DLBCL also harbor BCL-
development and mediating apoptosis. Mice lacking both 2 translocations (30). Increased BCL-2 expression has been
Bak and Bax have severe developmental defects and have linked to reduced survival of patients with DLBCL (93, 94).
hematopoietic cells that are resistant to diverse stimuli that The first large-scale gene expression profiling studies classified
activate the intrinsic apoptotic pathway (23, 78). Mice lacking DLBCL into two major molecular subgroups, germinal center
either Bak or Bax are phenotypically normal (23) or have B cell (GCB) and activated B cell (ABC) subtypes (95). GCB
mild lymphoid hyperplasia, respectively (24). Using the Eµ-myc DLBCL that have increased levels of BCL-2 is most often
mouse model of Myc-driven B cell lymphomagenesis, loss of due to a t(14;18) translocation (96), whereas in ABC DLBCL,
Bax accelerated lymphoma development (25), but the effects of amplification of the BCL-2 gene is more often observed (93,
inactivation of Bak in Myc-induced B cell lymphoma have not 97). Using gene expression profiling, Iqbal and colleagues
been reported. Loss of Bok did not alter Myc-induced B cell reported a significant correlation between elevated BCL-2 mRNA
lymphoma development (26). In humans, mutations in BAX expression and poor overall survival within the ABC subtype
that caused a frameshift were detected in cell lines derived from (93). We also observed elevated levels of BCL-2 in both
hematologic malignancies that did not include lymphoma and subtypes of DLBCL, but BCL-2 was more highly expressed in
were associated with resistance to cell death and microsatellite the ABC subtype than the GCB subtype (9). More recently,
instability (79–81). Alterations of BAX, BAK, or BOK have not new classifications of DLBCL subtypes have been reported by
been reported in human lymphoma; thus, loss/inactivation of two groups (98, 99). Shipp and colleagues described a new
BAX, BAK, or BOK either does not occur or is a rare event in classification of DLBCL subtypes based on genetic signatures
human B cell lymphoma. of low-frequency alterations, recurrent mutations, somatic copy
number alterations, and structural variants. One of their two
Anti-apoptotic Bcl-2 Family Members distinct subtypes of GCB-DLBCL (cluster 3) has structural
Acquired resistance to apoptosis is regarded as one of the variants of BCL-2 and correlate to poor risk (98). Their ABC-
hallmarks of cancer (1). Accordingly, evidence continues to DLBCL subtype (cluster 5) had amplification of BCL-2 (98), as
reveal that elevated expression of anti-apoptotic Bcl-2 family previously described (93). Staudt and colleagues also reported
members (Bcl-2, Bcl-x, Bcl-w, Mcl-1, A1/Bfl-1) is one of the new classifications of DLBCL that include four new genetic
major contributing factors to B cell lymphomagenesis (2). subtypes, one of which is EZB, which has EZH2 mutations and
Distinct biological roles for the individual anti-apoptotic Bcl-2 BCL-2 translocations (99).
family members have been unveiled by genetically-engineered DLBCL lymphomas that contain both rearrangements in
mouse models (3). Additionally, it has been hypothesized BCL-2 and translocation of MYC are classified as “double
that levels of expression of individual anti-apoptotic Bcl-2 hit lymphomas” (DHL) and represent ∼10% of DLBCL cases
family proteins may be an indication of how dependent a (100, 101). DLBCLs that co-express high levels of MYC and
cell is on the protein to maintain its survival (82). The BCL-2 proteins due to mechanisms other than chromosomal
mechanism by which the anti-apoptotic Bcl-2 family proteins translocations are referred to as “dual expresser lymphomas”
inhibit apoptosis is predominately governed by their capacity (DEL) and represent ∼30% of DLBCL (102, 103). Both DHL
to bind and sequester the pro-apoptotic BH-3-only proteins or and DEL tend to be clinically more aggressive and have a higher
Bax and Bak, ultimately preventing mitochondrial membrane frequency of treatment failure than those that are non-DHL or
permeabilization [Figure 1A, (83)]. The ability of the anti- non-DEL (102, 103). Because of this, these subtypes of DLBCL
apoptotic Bcl-2 proteins to bind pro-apoptotic Bcl-2 proteins have become a new biomarker-defined subset, which illustrates
does vary and depends, at least in part, on the apoptotic stimuli the importance of knowing the status of MYC and BCL-2 to
and which BH-3 only proteins are expressed and/or activated help guide treatment and monitoring of patients. These results

also provide impetus to investigate the expression of other anti- lowly expressed in multiple myeloma (MM), levels of BCL-X are
apoptotic BCL-2 family members in lymphomas, as others may much higher and may therefore be a critical survival factor for
also alter prognosis. MM (41–44). To date, no chromosomal translocation involving
Besides BCL-2 translocation and amplification, additional BCL-X has been reported in human tumor samples, but somatic
mechanisms are reported to contribute to its increased copy number amplifications have been detected in hematopoietic
expression, including BCL-2 gene rearrangement (104), malignancies, including non-Hodgkin lymphomas (120). High
promoter hypomethylation (105), promoter hypermutation levels of BCL-X have also been attributed to the loss or silencing
(106), and phosphorylation (107). A small subset of mantle cell of the let-7 family of miRNA that targets BCL-X (109, 121, 122).
lymphoma (MCL) have increased expression of BCL-2 (33). Therefore, BCL-X likely contributes to B cell lymphomas.
Additionally, BCL-2 can also become overexpressed in the
indolent MZL (32). For patient samples of both MCL and MZL, MCL-1
BCL-2 overexpression is reportedly caused by non-genomic Upregulation of the anti-apoptotic Bcl-2 family member Mcl-
changes to BCL-2 (33, 108). BCL-2 expression can also be 1 likely also contributes to lymphomagenesis. Mcl-1 was first
regulated by non-coding RNA. In B cells, BCL-2 expression is identified in an immortalized myeloid leukemia-derived cell
negatively regulated by the miR-15a/miR-16-1 cluster (109, 110). line, and consequently named myeloid cell leukemia 1 (123).
This region is deleted or inactivated by mutations in ∼70% Consistent with Bcl-2 and Bcl-x overexpression models, Mcl-1
of CLL (110); however, no other B cell malignancy has been overexpression in transgenic mice renders hematopoietic cells
associated with loss of the region (111, 112). largely resistant to varying apoptotic stimuli and causes the
Although the belief in the importance of BCL-2 in human accumulation of mature B and T lymphocytes (50, 51). In
B cell lymphomas is firmly embedded, two different transgenic addition, half of the Mcl-1 transgenic mice develop B cell
mice generated ∼30 years ago revealed that Bcl-2 is not a driver lymphomas within two years (52). Mcl-1 knockout mice are
of B cell lymphoma, but increased levels in B cells did lead to their embryonic lethal, but conditional knockout of Mcl-1 in mice
accumulation (113, 114). Bcl-2 overexpression did cooperate shows a requirement for Mcl-1 in hematopoietic stem cell and
with Myc overexpression to accelerate B cell lymphomagenesis neutrophil survival (45–47). Furthermore, loss of Mcl-1 inhibited
(28). The requirements of BCL-2 in the continued survival of Myc-induced B cell lymphomagenesis in mice (48, 49).
human B cell lymphomas is just now being explored with some A somatically acquired increase in MCL-1 copy number
surprising results, as described below. has been documented in a variety of non-hematopoietic
malignancies, but only in a limited number of non-Hodgkin
BCL-X lymphomas (120). Gene amplification or chromosomal gains of
Shortly following the cloning of the BCL-2 gene, the gene coding MCL-1 occur in 20–25% of the activated B cell (ABC) subtype
for BCL-X (BCL2L1 for Bcl-2 like 1) was discovered due to its of DLBCL (53). Although individual lymphomas may select for
high level of sequence similarity to BCL-2 (115, 116). Similar overexpression of MCL-1, we determined MCL-1 expression was
to Bcl-2 transgenic mice, mice engineered to overexpress Bcl-x not elevated in a cohort of Burkitt lymphomas compared to
renders lymphoid cells resistant to numerous apoptotic stimuli normal human B cells, and that it was also not significantly
and causes an abnormal accumulation of mature lymphocytes, different in patient samples of DLBCL, FL, MZL, and MCL
but not overt lymphoma development (37). However, mice compared to normal B cells (9). However, increased levels of
double-transgenic for Bcl-x and Myc in B cells developed MCL-1 mRNA are suggested to be essential for sustained growth,
lymphoproliferative disease and plasma cell malignancies (38). survival, and resistance to chemotherapeutics in multiple types
Knocking out Bcl-x revealed that it is not required for lymphocyte of lymphoma as well as CLL (54, 55). Unlike BCL-2 and BCL-X,
development, but is critical for erythropoiesis and platelets which are overexpressed in a subset of MCL, MCL-1 expression
(34, 35, 117, 118). Loss of Bcl-x did delay Myc-induced B cell is typically low in this lymphoma (33). Increased levels of MCL-
lymphoma development, suggesting that under conditions of 1 have been observed in multiple myeloma (56) and shown to
oncogenic stress, B cells may rely on Bcl-x for survival (36). correlate with disease progression (57).
Burkitt lymphomas can select to overexpress BCL-X (9). The expression of Mcl-1 is tightly regulated at both the
Elevated BCL-X expression has been detected in other B cell transcriptional and post-transcriptional level. In contrast to Bcl-
non-Hodgkin lymphomas, including FL and DLBCL, as well 2 and Bcl-x, Mcl-1 is a short-lived protein with a half-life of
as T cell non-Hodgkin lymphomas (39). Moreover, it has been ∼30 min compared to the >6 h half-lives observed for Bcl-2
demonstrated that in DLBCL, elevated expression of BCL-X and Bcl-x (124–126). Mcl-1 levels are also regulated by miRNA.
mRNA is associated with a chemoresistant, short-lived group of Loss of miR-29 and decreased levels of miR-125b and miR-133b,
patients (119). Like BCL-2, selection for BCL-X overexpression miRNA that bind and negatively regulate MCL-1 expression
occurs in a subset of MCL (40). Moderate levels of BCL-X protein (127–130), have been reported in many lymphomas, including
were reported in several cases of CLL, FL, and MCL, but it Burkitt, anaplastic large cell, and DLBCL, which may also
was lowly expressed in MZL (33). In a large-scale analysis of contribute to increased MCL-1 expression (131–133). Elevated
gene expression profiling data, we reported that BCL-X mRNA expression of MCL-1 can also be the result of aberrant post-
was significantly elevated compared to normal human B cells translational mechanisms. For instance, increased expression of
in multiple types of non-Hodgkin B cell lymphoma, including the deubiquitinase USP9X, which is responsible for removing
Burkitt, DLBCL, FL, MCL, and MZL (9). Unlike BCL-2, which is polyubiquitin chains that target MCL-1 protein for degradation,

correlates with increased MCL-1 protein in FL, DLBCL, and apoptosis (8). We also evaluated the importance of BCL-W in
multiple myeloma (134). In addition, increased protein stability human lymphomas known to be driven by or reliant on MYC
of MCL-1 can also lead to protein overexpression as a result of expression, specifically Burkitt and DLBCL. The vast majority
genetic inactivation of FBW7, a ubiquitin ligase (135, 136). of Burkitt lymphoma patient samples examined overexpressed
BCL-W at both the mRNA and protein levels (8). When BCL-W-
A1/BFL-1 specific shRNA was introduced into human Burkitt lymphoma
Protein-based structural analyses indicate, A1 (BCL2A1), the cell lines, they rapidly underwent apoptosis, indicating BCL-
mouse homolog of human BFL-1, is most highly related to W is essential for their continued survival. Additionally, we
the anti-apoptotic Mcl-1 (137). Because A1/Bfl-1-null mice are determined BCL-W was frequently overexpressed in DLBCL.
embryonic lethal, recently, an A1/Bfl-1-conditional knockout We detected BCL-W mRNA and protein were as often and as
mouse was generated that was viable, fertile, and only showed highly expressed as BCL-2 in DLBCL, where BCL-2 has long
minor defects in the hematopoietic system (58, 59). A1/Bfl-1 served as the hallmark of a prognostically unfavorable subset
transgenic mice demonstrated that overexpression of A1/Bfl-1 (94). Notably, we also observed that increased BCL-W mRNA
did not cooperate with Myc to drive B cell lymphomagenesis expression correlated with poor patient survival when levels of
(60). However, overexpression of A1/BFL-1 in lymphoma cell BCL-2 mRNA were lower in DLBCL (8).
lines provided protection from apoptosis induced by a number More recently, we expanded our analyses to explore the
of stimuli, including ligation of the B cell receptor (138), additional contributions of BCL-W in other non-Hodgkin B
cytokine deprivation (139), and treatment with staurosporine cell lymphomas. We performed an unprecedented analysis of
or etoposide (139, 140). In contrast, knocking down A1/BFL- all anti-apoptotic BCL-2 family members across different B cell
1 resulted in increased sensitivity of B cell lymphoma cells to lymphomas, including Burkitt, DLBCL, FL, MZL, and MCL (9).
cell death caused by CD20 cross-linking and DNA-damaging In all five types of B cell lymphomas, BCL-W was overexpressed
drugs (141). compared to normal B cell controls. Increased levels of BCL-
Increased levels of A1/BFL-1 mRNA have been reported W mRNA and protein mirrored those of BCL-2 in FL, which
in DLBCL and CLL (61–63). However, our analysis of public was unexpected, as FL is historically recognized to be driven
gene expression data showed that compared to normal B cells, by a BCL-2 translocation (9, 86–90). Of note, and consistent
A1/BFL-1 was not overexpressed in DLBCL, FL, MZL, and MCL with previous reports, as the grade of FL increased, levels of
(9). We also observed reduced A1/BFL-1 expression in Burkitt BCL-2 decreased (9, 145), whereas BCL-W expression remained
lymphoma patient samples compared to normal human B cells elevated in both low and high grade FL (9). Taken together,
(9). A1/BFL-1 protein can be post-translationally regulated by BCL-W appears to have a critically important, and previously
ubiquitin-mediated proteasomal degradation (139, 140). While unrecognized, anti-apoptotic role in B cell lymphoma.
regulatory mechanisms, including ubiquitination/proteasomal Multiple avenues to regulate levels of Bcl-w have been
degradation (139, 140) and direct transcriptional activation by proposed. Overexpression of BCL-W can result from increased
NF-κB (nuclear factor-kappaB) (142) have been reported, the activity at the BCL-W promoter (146). A number of studies
contributions of these mechanisms to increased levels of A1/BFL- using different tumor types have documented that elevated
1 in B cell lymphomas have not been evaluated. Based on the expression of BCL-W may be attributed to the downregulation
available data, the contribution of A1/BFL-1 to B cell lymphomas of miRNA that target BCL-W mRNA (128, 147, 148). We
does not appear to be significant. recently demonstrated that tumor suppressive miRNA target
BCL-W, BCL-2, and BCL-X as a novel, miRNA-mediated
BCL-W mechanism of apoptosis induced by the oncogenic transcription
The gene encoding BCL-W (BCL2L2 for Bcl-2 like 2) was factor Myc (8, 109, 121). Specifically, in normal cells, Myc
initially discovered via a PCR-based strategy while searching transcriptionally activates the miR-15 family and let-7a, which
for additional BCL-2 related genes (143). Mice lacking Bcl- bind and negatively regulate the expression of BCL-W, BCL-
w were determined to be essentially normal, except for a 2, and BCL-X, causing cells to undergo apoptosis (Figure 2).
profound block in male spermatogenesis (64, 65). Several However, cancer cells, including lymphoma, inactivate this
observations have pointed to a potential role for Bcl-w in mechanism. By means that have not been fully elucidated,
tumorigenesis. For example, in a mouse model of Myc-driven but do involve histone deacetylase (HDAC) enzymes, Myc
myeloid leukemogenesis, Bcl-w overexpression cooperated with switches from a transcriptional activator to a transcriptional
Myc to accelerate leukemia development (66). In addition, repressor of the miR-15 family and let-7a in lymphoma. This,
high levels of BCL-W were present in cell lines derived from in turn, allows the expression of anti-apoptotic BCL-W, BCL-
human lymphomas, leukemias, and multiple solid organ cancers 2, and BCL-X to increase, thereby facilitating tumorigenesis
(66). Similar to its anti-apoptotic relatives, overexpression of (Figure 2). We established a link between regulation of BCL-
Bcl-w in mouse B and T lymphocytes imparted resistance to W expression and Myc. Identifying this novel mechanism of
cytotoxic agents (143, 144). Recently, we discovered Bcl-w has miRNA-mediated apoptosis also answered a question that has
a critical, previously unexplored function in B cell survival remained largely unexplored. Previously, it was shown that
and lymphomagenesis (8, 9). We demonstrated with mouse Myc suppressed the expression of Bcl-2 and Bcl-x through
models that loss of Bcl-w profoundly delayed Myc-induced B cell an unknown, indirect mechanism (149, 150). These recent
lymphoma development and sensitized B cells to Myc-induced studies provide direct evidence of a mechanism whereby Myc

FIGURE 2 | MicroRNA mediate a novel mechanism of Myc-induced apoptosis that is inactivated in malignant cells, but re-activated by HDAC inhibition. In normal B
cells (top), MYC transcriptionally upregulates the miR-15 family and let-7a to target and reduce BCL-2, BCL-W, and BCL-X levels, thereby promoting apoptosis.
However, in lymphoma cells (bottom), MYC, in complex with histone deacetylases (HDAC), transcriptionally repress the same miRNA, causing increased levels of
anti-apoptotic proteins and reduced apoptosis. This mechanism can be re-activated in lymphoma cells by inhibiting HDACs (purple arrow).
transcriptionally modulates miRNA expression leading to altered

expression of Bcl-w as well as Bcl-2 and Bcl-x (8, 109, 121).
Therefore, increased expression of anti-apoptotic Bcl-2 family
members, through a variety of mechanisms, are essential survival
factors to B cell lymphoma.
TARGETING ANTI-APOPTOTIC BCL-2

FAMILY MEMBERS IN LYMPHOMA
Biological Rationale, Drug Development,
and Early Clinical Studies for Targeting
BCL-2
Due to the persuasive in vitro and in vivo evidence that anti-
apoptotic BCL-2 family members confer a survival advantage to
neoplastic cells, and contribute to chemotherapeutic resistance
in different types of hematologic malignancies, including B
cell lymphomas, several strategies have been developed to
target them. Since BCL-2 was considered the most important FIGURE 3 | Targeting anti-apoptotic BCL-2 family members for therapy.
Therapeutic strategies directed at targeting single or multiple anti-apoptotic
anti-apoptotic BCL-2 family member in B cell lymphoma, it BCL-2 family members include the use of antisense oligonucleotides and small
was targeted first. Initial attempts to pharmacologically target molecule inhibitors or mimetics. Like the pro-apoptotic BH-3 only proteins,
BCL-2 consisted of decreasing the intracellular levels of BCL-2 these small molecules display varying affinities for anti-apoptotic BCL-2 family
with the delivery of RNA antisense molecules (Figure 3). members as indicated.
Several of these antisense molecules had encouraging preclinical
efficacy and entered clinical trials, including Oblimersen
(G3139/Genasense) (151, 152), PNT2258 (NCT02226965) The limited efficacy of Oblimersen in AML (158) and other
(153, 154), and SPC2996 (NCT00285103) (155). Of the three hematologic malignancies was attributed, in part, to inefficient
anti-BCL-2 antisense oligonucleotides, the best characterized intracellular delivery and led to the search for small molecules
was Oblimersen sodium (G3139, Genasense; Genta Inc.). that could target the anti-apoptotic proteins themselves. Each of
Oblimersen was the first drug to demonstrate proof-of-principle the anti-apoptotic proteins has a hydrophobic groove where they
specific down-regulation of BCL-2 protein in human tumors interact with the BH-3 domains of other BCL-2 family members.
(156, 157) and provided initial preclinical and clinical evidence With the advances made by structural biology and improved
of synergy with cytotoxic drugs, biological agents, and steroids in knowledge of the protein-protein interactions within the Bcl-2
a variety of human cancers, including non-Hodgkin lymphoma, family, small molecule inhibitors, known as BH-3 mimetics were
multiple myeloma and acute myeloid leukemia (AML) developed. BH-3 mimetics, based on their functional mimicry of
(156–159). the BH-3 only pro-apoptotic proteins, can bind with high affinity

to the same hydrophobic pocket of one or more anti-apoptotic dose (50 mg) and developing a weekly intra-patient dose ramp-
Bcl-2 family members. The high affinity and specificity of the up scheme, in addition to careful prophylaxis and management
BH-3 mimetics displaces already-bound or prevents binding of of TLS. Despite the implementation of this strategy, additional
newly synthesized pro-apoptotic BH-3 only proteins from their episodes of severe TLS were observed, leading to the death
anti-apoptotic partners, leaving the cells in a “primed” state for of one patient at the highest dose level (1,200 mg) in a large
apoptosis. This has proven particularly important in combination (N = 56) cohort of patients with CLL (175). After the starting
treatments, where the addition of BH-3 mimetics sensitizes cells dose of venetoclax was further decreased to 20 mg and with even
to a variety of anti-cancer compounds and aids in circumventing more stringent TLS prophylaxis and monitoring, 60 additional
intrinsic or acquired resistance (160). CLL patients were treated in an expansion cohort, with ramp-
The first synthetic BH-3 mimetic was ABT-737, a small- up dosing up to 400 mg daily. No additional events of severe
molecule that binds with high affinity to BCL-2, BCL-X, and TLS were observed in this group. The most common Grade
BCL-W, but not MCL-1 or A1/BFL-1 (Figure 3), and was shown 3–4 non-TLS toxicity was Grade 3–4 neutropenia (∼40% of
to efficiently induce apoptosis at sub-micromolar concentrations patients) (175), which is believed to be an on-target effect of BCL-
in a variety of non-Hodgkin lymphoma cell lines (161, 162) and 2 inhibition in neutrophil progenitor cells (180). Other common
in primary CLL cells (163, 164). An orally bioavailable derivative toxicities included Grade 1–2 gastrointestinal symptoms, such as
of ABT-737, ABT-263 (navitoclax), was later developed. ABT- nausea and diarrhea (∼50% or patients). From the standpoint
263 (navitoclax) proved to be efficacious in B cell lymphoma of anti-tumor responses, venetoclax showed highly encouraging
xenograft models as a single agent or in combination with a efficacy in R/R CLL, with an overall response rate (ORR) of
variety of cytotoxic drugs, including rituximab (165). Of note, 79%, and a complete response rate (CRR) of 20%, in 116
ectopic overexpression of BCL-2 in B cell lymphoma cell lines patients. Most notably, responses were observed in high-risk
protects from ABT-263 (navitoclax)-induced death in vitro (8, CLL patients, including those with del(17p). These important
166). We demonstrated that, similar to BCL-2 overexpression, early observations in high-risk CLL led to a landmark phase II
BCL-W overexpression in Burkitt lymphoma cell lines conferred study where 107 patients with del(17p) CLL were treated with
resistance to ABT-737 and ABT-263 (8). Also, ectopic Bcl- venetoclax with the proven ramp-up dosing to 400 mg daily,
w overexpression in primary murine precursor and mature with an ORR of 79% and a CRR of 8%. Based on the data from
B and T cells induced resistance to ABT-737 (144). In early these phase I and II studies, venetoclax received accelerated FDA
phase clinical trials, navitoclax showed antitumor activity in approval on April 11, 2016 for the treatment of patients with
indolent B cell malignancies (CLL and FL) (167–169). However, del(17p) CLL who have relapsed after, or are refractory to, ≥1
the drug was found to induce rapid and severe, dose-limiting, prior line of therapy. Based primarily on data from 389 R/R CLL
thrombocytopenia and further studies were stopped. Navitoclax- patients enrolled in the MURANO clinical trial (NCT02005471),
induced thrombocytopenia is believed to be due to an on-target on June 8, 2018 the FDA expanded the approval of venetoclax,
effect on BCL-X, which is a key factor for platelet survival in combination with rituximab, to include patients with CLL
(165, 170, 171). The hematologic toxicity of navitoclax led to who progressed after at least one prior therapy, regardless of the
a significant effort to develop a BH-3 mimetic that selectively presence of del(17p) (181).
targeted BCL-2. This effort was successful and produced ABT-199
(venetoclax), an orally bioavailable BCL-2-specific BH-3 mimetic
[Figure 3, (172)]. Venetoclax (ABT-199) showed promising
efficacy in vitro and in xenografts in vivo for a variety of Clinical Trials With Single Agent Venetoclax
hematologic malignancies (e.g., leukemia, CLL, DLBCL) without in B Cell Lymphomas
inducing severe thrombocytopenia (172–174). In parallel with the clinical development of venetoclax in
Based on these encouraging preclinical data, further clinical CLL, the drug’s profile was also evaluated in patients with
development of venetoclax was launched in 2011 (Table 2), with a broad variety of B cell lymphomas, including DLBCL,
a primary focus on relapsed/refractory (R/R) CLL and NHL FL, MCL, lymphoplasmacytic lymphoma/Waldenström
(M12-175). There were high expectations of clinical benefit with macroglobulinemia (LPL/WM), and MZL [Table 2, (7)].
venetoclax in low grade lymphomas, which historically have The observed toxicity and the efficacy were significantly different
served as the canonical disease model for BCL-2 overexpression. compared to those in CLL. TLS did not occur and severe
The first subjects treated on the M12-175 venetoclax study, at neutropenia was only observed in 11% of patients. The ORR
daily doses of 100 or 200 mg, were R/R CLL patients with high for the entire cohort was 44%, with the best responses seen
nodal and blood tumor burden. These patients experienced very in MCL (75% ORR; 21% CRR). Remarkably, despite the well-
rapid (<12 h) and dramatic reductions in lymphocyte count and characterized overexpression of BCL-2 in FL, ORR in FL was
lymph node size, but they also developed severe, life-threatening, only 38%. A slightly higher ORR of 44% was noted in patients
tumor lysis syndrome (TLS). In all cases, the TLS was effectively with FL treated at ≥1,200 mg compared with 27% in those
managed, and the patients were able to resume therapy on study. treated at ≤900 mg, suggesting that higher doses could lead to
These early data demonstrated the rapid pro-apoptotic effect and better efficacy in the nodal disease, which is the primary disease
therapeutic potential of venetoclax in R/R CLL, but required the site in FL. Results in DLBCL were even more disappointing, with
development of a mitigating strategy to prevent life-threatening ORR of 18% and no clear association between BCL-2 protein
TLS. The strategy included selecting a lower venetoclax starting expression levels and response.

TABLE 2 | Venetoclax as monotherapy in CLL and B cell lymphoma.
Disease Phase Enrollment Outcomes (%) Common grade 3–4 AEs (%)
R/R CLL (175) I 116 ORR: 79; CR: 20 Neutropenia: 41

Anemia: 12
Thrombocytopenia: 12
CLL (w/ del[17p]) (176) II 158 (153 were R/R & 5 TN) ORR: 77; CR: 20 Neutropenia: 40
Anemia: 18
R/R CLL (w/prior II
BCRi):
Prior Ibrutinib (177) 91 ORR: 65; CR: 9 Neutropenia: 51
Anemia: 29
Prior Idelalisib (178) 36 ORR: 67; CR: 8 Neutropenia: 50
Anemia: 17
Hypokalemia: 11
>1 Prior BCRi (179) 28 ORR: 39; CR: 4 Neutropenia: 43
Anemia: 39
Hypokalemia: 21
Hypophosphatemia: 21
R/R NHL (7): I
Overall 106 ORR: 44; CR: 13 Anemia: 15
MCL 28 ORR: 75; CR: 21 Neutropenia: 11
FL 29 ORR: 38; CR: 14
DLBCL 34 ORR: 18; CR: 12
DLBCL-RT 7 ORR: 43; CR: 0
WM/MZL 4/3 —
AE, adverse event; R/R, relapsed/refractory; TN, treatment naïve; ORR, overall response rate; CR, complete response; BCRi, B cell receptor pathway inhibitor; CLL, chronic lymphocytic
leukemia; NHL, non-Hodgkin lymphoma; MCL, mantle cell lymphoma; FL, follicular lymphoma; DLBCL, diffuse large B cell lymphoma; RT, Richter transformation; WM, Waldenstrom
macroglobulinemia; MZL, marginal zone lymphoma.
Combination Treatments With Venetoclax preliminary report indicated that, as expected, CR rates were
in Clinical Trials With CLL and B Cell high, but follow-up was too short to assess progression-free
survival (PFS). The toxicity profile was acceptable, but venetoclax
Lymphoma
dosing had to be reduced to administration only on days 1
In light of the low single agent activity of venetoclax in B cell
to 10 (rather than continuous dosing) to mitigate the rate of
lymphomas, combination regimens are now being evaluated,
Grade 3–4 neutropenia. A phase II study of venetoclax and
mostly in the context of the general strategy of adding venetoclax
dose-adjusted R-EPOCH in patients with Richter transformation
to well-recognized chemo-immunotherapy combination with
to DLBCL has begun (NCT03054896), in addition to a
established efficacy (bendamustine and rituximab; CHOP and
study using a similar regimen for patients with de novo
rituximab; CHOP and obinutuzumab; EPOCH and rituximab),
aggressive B cell lymphomas, including double-hit DLBCL
or highly promising new drugs (ibrutinib) (Tables 3, 4). A
(NCT03036904). A phase I study is also ongoing to examine
phase II trial comparing a venetoclax/rituximab doublet to the
the combination of venetoclax and the SYK tyrosine kinase
three-drug combination of venetoclax/bendamustine/rituximab
inhibitor TAK-659 for patients with R/R DLBCL and FL
is ongoing in patients with R/R FL (NCT02187861), with
(NCT03357627).
preliminary evidence of superior efficacy with the three drug
combination vs. the doublet (ORR 64 vs. 33%) (194). A
combination of venetoclax with obinutuzumab in previously
untreated FL is also currently underway (NCT02877550). As Inhibiting Other Anti-apoptotic BCL-2
in CLL, the combination of ibrutinib and venetoclax is being Family Members
evaluated in a phase II study in relapsed/refractory MCL The accompanying toxicities that come with targeting multiple
(NCT02471391). The early experience in this trial suggests good BCL-2 family members have fueled the development of new
tolerability and promising efficacy of the combination (196). inhibitors to selectively target specific anti-apoptotic BCL-2
There are also ongoing studies exploring whether venetoclax may family members. Furthermore, individual lymphomas may be
act as a chemosensitizing agent, such as a study of venetoclax differentially reliant on one or more of the anti-apoptotic BCL-
administered in combination with R-CHOP or obinutuzumab- 2 family members, which can be exploited therapeutically. In
CHOP in previously untreated DLBCL (NCT02055820). A addition to the BCL-2 specific inhibitors developed, BCL-X

TABLE 3 | Venetoclax in combination with anti-neoplastic agents in CLL and B cell lymphoma.
Intervention/Disease Phase Enrollment Outcomes (%) Common grade 3–4 AEs (%)
R + V in R/R CLL (182) Ib 49 ORR: 86; CR: 51 Neutropenia: 53

Anemia: 14
Febrile Neutropenia: 12
Leukopenia: 12
Pyrexia: 12
R + V vs. R + B in R/R CLL (183) III R + V: 194 24-mo PFS est: 84.9; Neutropenia: 57.7
ORR: 93.3; CR: 26.8 Anemia: 10.8
Thrombocytopenia: 5.7
Febrile Neutropenia: 3.6
R + B: 195 24-mo PFS est: 36.3; Neutropenia: 38.8
ORR: 67.7; CR: 8.2 Anemia: 13.8
I + V in R/R CLL (184) II 38 ORR: 100; CR: 47 Neutropenia: 19/25 pts 76
Infection: 5/25 pts 20
I + V in R/R and TN high risk CLL II R/R: 29 ORR: 100; CR: 64 Atrial Fibrillation: 11
(185) (14 evaluable pts)
TN: 32 ORR: 100; CR 56
(16 evaluable pts)
G + V in TN CLL in pts with III 12 (from run-in phase) ORR: 100; CR: 58 Neutropenia: 58.3
coexisting medical conditions (186) Febrile Neutropenia: 25
Infection: 16.7
Laboratory TLS: 16.7
Syncope: 16.7
V + BR vs. V + BG in TN or R/R CLL Ib 55
(187)
V + BR in R/R 30 ORR: 96; CR: 26 Neutropenia: 63
(27 evaluable pts) Thrombocytopenia: 27
Infection: 27
Anemia: 20
Diarrhea: 10
V + BR in TN 17 ORR: 100; CR: 43 Neutropenia: 71
Anemia: 29
V + BG in TN 8 ORR: 100; CR: 43 Thrombocytopenia: 63
(7 evaluable pts) Neutropenia: 25
Fatigue: 13
Infusion reaction: 13
V + G in TN CLL (188)* Ib 32 ORR: 100; CR: 56.3 Neutropenia: 40.6
V + G in R/R CLL (189)* Ib 26 ORR: 100; CR: 23.5 Neutropenia: 47
(17 evaluable pts) Infection: 19
Laboratory TLS: 13
G + I + V in R/R CLL (190) Ib 12 ORR: 92; CR: 42 Neutropenia: 33
(6 evaluable pts) Lymphopenia: 17
Hypertension: 25
Fatigue: 17
G + I + V in TN CLL (191) II 25 ORR: 100; CR: 50 Neutropenia: 44
(23 evaluable pts) Leukopenia: 36
Lymphopenia: 32
Hypertension: 20
B (debulking) -> G + V in TN and R/R II 35 TN ORR: 100; CR: 50 Neutropenia: 44
CLL (192) (34 evaluable pts) Thrombocytopenia: 12
Infection: 14
(Continued)

TABLE 3 | Continued
Intervention/Disease Phase Enrollment Outcomes (%) Common grade 3–4 AEs (%)
31 R/R ORR: 90; CR: 28

(29 evaluable pts)
V + R-CHOP vs. V + G-CHOP in TN I 56 Neutropenia: 46
(91%) and R/R NHL (193): (FL 24; DLBCL 17; Febrile Neutropenia: 29
MZL 5; Composite 5; Thrombocytopenia: 21
Other 5)
V + R-CHOP 21 ORR: 85.7; CR: 67
(21 evaluable pts)
V + G-CHOP 21 ORR: 81; CR: 62
(21 evaluable pts)
V + BR vs. BR vs. V + R in RR FL II
(194):
V + BR 51 ORR: 68; CR: 50 Neutropenia: 59
BR 51 ORR: 64; CR: 41 Neutropenia: 24
V+R 53 ORR: 33; CR: 14 Neutropenia: 27
I + V in R/R or TN MCL (195) 24 ORR: 71; CR: 63 Neutropenia: 25
(23 were R/R) (At week 16)
AE, adverse event; R/R, relapsed/refractory; TN, treatment naïve; ORR, overall response rate; CR, complete response (includes complete remission with incomplete hematologic
recovery); PFS, progression free survival; BCRi, B cell receptor pathway inhibitor; CLL, chronic lymphocytic leukemia; MCL, mantle cell lymphoma; FL, follicular lymphoma; DLBCL,
diffuse large B cell lymphoma; RT, Richter transformation; MZL, marginal zone lymphoma; NHL, non-Hodgkin lymphoma; TLS, tumor lysis syndrome; pts, patients.
Treatment Abbreviations: V, Venetoclax; R, Rituximab; B, Bendamustine; I, Ibrutinib; G, Obinutuzumab.
* Data were obtained from same trial, but 2017 ASH abstract only contained updated data on TN patients. Abstract from 2015 contained data on R/R (14) and TN (6) patients.
and MCL-1 inhibitors have also been generated (5). There are [known as “stapled” peptides (201)] and alpha- or beta-
currently no known inhibitors specific for BCL-W or A1/BFL-1. peptide foldamers (202) were designed to target MCL-1. Several
compounds with affinity for MCL-1 were identified by screening
BCL-X Inhibitors libraries of natural compounds and small molecules. However,
While compounds selective for BCL-2 over BCL-X have shown many of these have reported off-target or minimal effects
anti-tumor effects in vivo with limited platelet toxicities (175, (203, 204). Although obatoclax (GX15-070) targets other anti-
180), not all cancers express BCL-2 or require BCL-2 for their apoptotic BCL-2 family members, it was one of the first
continued survival (5, 197). The first reported BCL-X selective BH-3 mimetics reported to inhibit MCL-1 [Figure 3, (205)].
inhibitor with sub-nanomolar affinity and selectivity was WEHI- Obatoclax has completed phase I/II clinical trials for a number
539, which antagonized the anti-apoptotic activity of BCL-X of malignancies, including CLL, but with modest efficacy and
(198). However, WEHI-539 has been limited to in vitro studies neutropenia as a common toxicity (206). At this time, no further
as a tool compound due to its unfavorable chemical properties clinical trials with obatoclax are ongoing. Similar to obatoclax,
for use in vivo (198). Other efforts using high-throughput TW-37, a gossypol derivative, has shown some toxicity, but
screening with nuclear magnetic resonance and structure-based has demonstrated potency as a single agent in the treatment of
medicinal chemistry led to the development of the BCL-X DLBCL cell lines and synergized with other chemotherapies in
selective inhibitors A-1155463 and its orally bioavailable analog xenograft models [Figure 3, (207)]. Phase I clinical trials for AT-
A-1331852 [Figure 3, (199, 200)]. Cell lines from a variety of 101, a more refined variant of the gossypol family of pan-BCL-
malignancies, including AML showed sensitivity to the BCL-X 2 family inhibitors, show that it is well-tolerated with treatable
inhibitors. In vivo studies in mice indicated inhibition of BCL-X neutropenia (208). Two clinical trials of AT-101 as a single agent
with A-1331852 as a single agent reduced the volume of a T- in R/R B cell lymphomas (NCT00275431) and in combination
cell leukemia, whereas venetoclax did not (180). In addition, the with rituximab in CLL (NCT00286780) have been completed, but
mice tolerated the BCL-X inhibitor. These data suggest that some final results have not been published.
cancers appear to be dependent on BCL-X and not on BCL-2 and A-1210477 was the first selective MCL-1 inhibitor to
that targeting one over the other may be beneficial. demonstrate picomolar binding to MCL-1 while maintaining
selectivity for MCL-1 over other anti-apoptotic family members
MCL-1 Inhibitors [Figure 3, (209)]. A-1210477 forms complexes with MCL-
Multiple approaches have been explored to selectively target 1, thereby disrupting endogenous MCL-1:BIM complexes.
MCL-1. Initially, stabilized alpha-helices of BH-3 only proteins As a single agent, this compound induced apoptosis in

TABLE 4 | Ongoing venetoclax combination studies in B cell lymphomas and CLL.
Phase N Population Trial number
B CELL LYMPHOMAS
Ven + Ibrutinib I 28 MCL R/R NCT02419560
Ven + Ibrutinib II 24 MCL first line NCT02471391
Ven + Ibrutinib + Obinu I/II 48 MCL R/R NCT02558816
Ven + Benda + Ritux (BR) vs. BR II 164 FL R/R NCT02187861
Ven + Obinu I 25 FL first line NCT02877550
Ven + CHOP + Ritux or Obinu I/II 248 1L DLBCL NCT02055820
Ritux-DA-EPOCH II 20 Richter’s NCT03054896
CLL
Ven + Rituximab Ib 49 R/R NCT01682616
Ven + Benda + Ritux or Obinu Ib 100 First line + R/R NCT01671904
Ven + Obinutuzumab Ib 81 First line + R/R NCT01685892
Ven + Benda followed by Obinu II 66 First line + R/R NCT02401503
Ven + Rituximab III 391 R/R NCT02005471
Ven + Obinu III 445 First line NCT02242942
Ven + Ibrutinib II 78 First line + R/R NCT02756897
Ven + Ibrutinib, Obinu II 40 First line del(17p) NCT02758665
Ven + Ibrutinib, Obinu I/II 68 First line + R/R NCT02427451
N, number enrolled; Ven, Venetoclax; Benda (or B), Bendamustine; Ritux (or R), Rituximab; Obinu, Obinutuzumab; MCL, mantle cell lymphoma; FL, follicular lymphoma; DLBCL, diffuse
large B cell lymphoma; R/R, relapsed/refractory; CLL, chronic lymphocytic leukemia.
MCL-1-dependent multiple myeloma cell lines (210). However, ALL or R/R lymphoblastic lymphoma (NCT03181126). A phase
A-1210477 does not demonstrate the necessary pharmacokinetics I study evaluating the safety of navitoclax administered in
for in vivo use. AMG176 was the first putative MCL-1 inhibitor combination with rituximab is active for patients with CD20-
to undergo clinical evaluation (NCT02675452) (211), but no positive lymphoproliferative disorders and CLL (NCT00788684).
data in humans has been reported. In addition, phase I trials In addition, obatoclax mesylate (GX15-070MS), which inhibits
are actively recruiting or soon to recruit patients for testing BCL-2, BCL-X, BCL-W, and MCL-1 (Figure 3) has been
the MCL-1 specific inhibitors S64315 (MIK665) in patients with evaluated as a single agent followed by a combination with
R/R DLBCL and multiple myeloma, AML, and myelodysplastic rituximab for treatment naive patients with FL (NCT00427856).
syndrome (NCT02992483, NCT02979366, and NCT03672695) Obatoclax has also been combined with bortezomib for the
and AZD5991 in patients with R/R hematologic malignancies, treatment of R/R MCL (NCT00407303). A phase I/II trial was
CLL, T-cell lymphoma, and multiple myeloma (NCT03218683). initiated to study the side effects and the dose of obatoclax when
A question that remains largely unanswered is whether normal given together with rituximab and bendamustine in treating
cells will tolerate MCL-1 inhibition at the level necessary for patients with R/R non-Hodgkin lymphoma including MZL,
therapeutic benefit. Potential on-target toxicities may include FL, and MCL; however, the study was withdrawn due to lack
cardiac (212, 213), hepatic (214, 215), and hematological (45– of patient accrual (NCT01238146). A phase I dose escalation
47), which are based on those observed in Mcl-1 knockout mouse study of the MCL-1 selective inhibitor S64315 in combination
models (45–47, 212–215). with venetoclax (estimated start date: December 3, 2018) will
be testing the safety and tolerability in patients with AML
Combination Treatments With Other (NCT03672695). The continued efforts to develop novel anti-
Anti-apoptotic BCL-2 Family Inhibitors apoptotic BCL-2 family protein inhibitors will continue to pave
At present, there are a limited number of clinical trials the way for new clinical trials combining current inhibitors
dedicated to evaluating the effects of anti-apoptotic BCL-2 with both conventional and other novel agents in various
family inhibitors aside from venetoclax either alone or in lymphomas.
combination with other therapies. Navitoclax, which inhibits
BCL-2, BCL-X, and BCL-W, was being tested in combination Resistance Mechanisms for BCL-2 Family
with bendamustine and rituximab in patients with relapsed Protein Inhibitors
DLBCL as part of the NAVIGATE study, but recruitment was Given that venetoclax selectively inhibits BCL-2, this compound
terminated due to non-safety-related reasons (NCT01423539). A should be effective in cancer cells that express BCL-2; however,
study of navitoclax together with venetoclax and chemotherapy this does not always occur. For example, FL expresses high
(including peg-asparaginase, vincristine, dexamethasone, and levels of BCL-2 due to its t(14;18) translocation; yet, the clinical
tyrosine kinase inhibitor) is ongoing for patients with R/R response rate to venetoclax is quite low in FL patients (7).

This suggests BCL-2 expression alone is insufficient to predict include combinations with BTK inhibitors (229), dual delta-
BCL-2 dependence. In a recent study, a subset of lymphoma and gamma-PI3 kinase inhibitors (230), SYK inhibitors (231),
cell lines expressing BCL-2 protein were resistant to venetoclax, and BET inhibitors (232). While all these studies are of
resulting from acquired mutations in BCL-2 and the pro- very high interest, and many of the preclinical concepts are
apoptotic protein BAX or a phosphorylation event on BCL- being evaluated in clinical trials, there is a need to better
2 that prevented venetoclax from binding, thereby blocking understand the specific mechanistic functions of the BCL-2
apoptosis (216–218). Similarly, upon comparing venetoclax- family members in each of these pro-apoptotic combinations,
resistant FL cells with their parental cell lines, the resistant where they are redundant and where they may lead to synthetic
FL cells had significantly higher levels of ERK1/2 and BIM lethality.
phosphorylation at serine 69, targeting BIM for proteasomal With clinical trials on-going and many more being developed
degradation; thus, reducing the pro-apoptotic nature of the using anti-apoptotic BCL-2 family inhibitors for treatment of
cells (219, 220). Another study showed increased phospho- B cell lymphoma, as well as other hematologic malignancies
ATK levels in a venetoclax-resistant B cell lymphoma line, and solid-organ cancers, there remains a significant lack of
suggesting activation of the PI3K pathway (221). Whole- knowledge of these proteins and their requirements in non-
exome sequencing and methylation profiling of serial CLL Hodgkin lymphomas. Aside from FL and DLBCL, alterations
samples from eight patients before venetoclax treatment in specific anti-apoptotic BCL-2 family members have not been
and at the time of venetoclax resistance did not show well-characterized or associated with other B cell lymphomas,
genetic alterations in BCL-2 (222). However, most patients which is likely due to the lack of a comprehensive analysis
acquired mutations in cancer-related genes, including BRAF, prior to the one we recently published (9). Therefore, it
NOTCH1, RB1, and TP53, and had homozygous deletion of is likely necessary to measure and monitor the levels of
CDKN2A/B. BCL-2 family members when enrolling patients onto clinical
Resistance of FL and DLBCL to single agent venetoclax may trials testing selective anti-apoptotic inhibitors. Inhibiting one
be attributed, in part, to elevated levels of other anti-apoptotic anti-apoptotic BCL-2 family member that is not expressed
family members. For example, we recently reported that BCL- in that lymphoma should have no effect on the lymphoma
W was elevated in both FL and DLBCL at a similar frequency and be unnecessary treatment for that patient. Additionally,
as BCL-2 (9). Moreover, our recent large-scale evaluation of all targeting one anti-apoptotic BCL-2 family member may lead to
anti-apoptotic BCL-2 family members in multiple non-Hodgkin the dependency on another, ultimately leading to therapeutic
lymphomas revealed that many selected for the overexpression of resistance.
more than one anti-apoptotic family member, simultaneously (9).
These data provide a potential explanation into why just targeting
BCL-2 with venetoclax did not result in high complete response Non-apoptotic Effects of BCL-2 Family
rates for FL or DLBCL (7). Moreover, levels of BCL-X and MCL-1 Inhibition
were upregulated in venetoclax-resistant DLBCL cell lines (221). There have been reports suggesting that inhibition of anti-
Furthermore, in lymphoma cell lines that have become resistant apoptotic BCL-2 family members may activate cell signaling
to navitoclax, increased levels of anti-apoptotic A1/BFL-1 and pathways, in addition to apoptosis, to further promote survival
MCL-1 are observed (223). and resistance to cell death. For example, a recent proteomic
With the increasing focus on MCL-1 as an important regulator analysis following treatment of DLBCL and MCL cell lines
of apoptosis in leukemia and lymphoma (224) and potential with venetoclax showed venetoclax treatment (both short- and
mediator of venetoclax resistance, a number of efforts are in long-term) altered the levels of proteins involved in apoptosis,
progress to better define the role of MCL-1 in venetoclax but also the expression levels and phosphorylation status of
resistance and to develop strategies to downregulate MCL- proteins involved in the DNA damage response (i.e., γH2AX,
1 levels as a possible way to overcome it. While MCL-1 CHK2, ATM), growth/survival signaling pathways (i.e., PTEN,
specific inhibitors are in early phase of development (225, Src, MAPK, AKT), and cellular metabolism (i.e., HK2, PDK1,
226), several studies have already shown that downregulation PKM2, GCLM) were also affected (233). However, further
of MCL-1 mRNA and/or protein levels in BH-3 mimetic- studies are necessary to determine whether these effects are
resistant cells increases the sensitivity to navitoclax and directly attributable to venetoclax-mediated BCL-2 inhibition
venetoclax (54, 227). For example, the pan CDK inhibitor and the resulting apoptosis or effects that are independent of
dinaciclib restored sensitivity to navitoclax- and venetoclax- BCL-2. The BCL-2 family of proteins has also been reported to
mediated apoptosis in resistant lymphoma cells via inhibition function in maintaining calcium homeostasis (234). The early
of MCL-1 phosphorylation by CDK2/Cyclin E, which in turn BH-3-only protein mimetic HA14-1 was shown to dysregulate
led to the destabilization of MCL-1 protein and release of intracellular calcium signaling in platelets, reportedly due
BIM from MCL-1 (228). The combination of dinaciclib and to off-target effects, but neither navitoclax nor venetoclax
venetoclax resulted in robust synergistic cell death in DLBCL disrupted intracellular calcium transport mechanisms (235, 236).
cell lines and in primary CLL patient samples. Additional Furthermore, investigations have shown that BCL-2 family
ongoing strategies to enhance the therapeutic efficacy of proteins may be involved in autophagy (237). Specifically,
venetoclax in B cell neoplasms (increasing response rate, depth studies have reported that navitoclax and the BH-3-mimetic
of response, overcoming primary and secondary resistance), HA14-1 can block the interaction between BCL-2/BCL-X and

Beclin1, a protein important for the localization of autophagic opened the door to studying its possible role in treatment
proteins, leading to the activation of Beclin1-dependent resistance. To fully exploit the potential of selective inhibitors
autophagy (237–240). BCL-2 family BH-3-only mimetics of anti-apoptotic BCL-2 proteins for the treatment of B cell
can also regulate cell autophagy through activation of the lymphoma, we must know which inhibitors should be given
unfolded protein response signaling pathway PERK-eIF2α- to which patients. To guide the use of specific inhibitors in
ATF4, which upregulates expression of the autophagy gene individual patients, or molecularly defined patient subsets, we
Atg12 (241–243). must know which anti-apoptotic BCL-2 protein(s) are the most
relevant target(s). For example, while one malignancy may
CONCLUSION have requirements for BCL-2, another might require BCL-
X and/or BCL-W, highlighting the importance of using the
Defects in apoptosis are universal to all B cell lymphomas right biomarkers to evaluate each lymphoma. In the era of
and defects in apoptotic signaling is frequently associated with personalized medicine, these recent advances attest to the power
resistance to chemotherapy (2, 4, 244). In this review, we have of discoveries in basic science being directly translated into the
highlighted the Bcl-2 family network of proteins in lymphoma, clinic to improve targeted treatment strategies for individual
including the recent discovery of BCL-W overexpression in lymphomas.
B cell lymphomas, and described current clinical strategies
to inhibit anti-apoptotic Bcl-2 family proteins that aim to AUTHOR CONTRIBUTIONS
develop more effective therapies for B cell lymphoma. Despite
decades of significant progress in identifying the molecular CA, SC-G, PP, and CE contributed to the literature review, and
underpinnings of apoptotic cell death and their contributions to the writing and editing of the material presented in this
to the pathogenesis, survival, and resistance to treatment of manuscript.
individual B cell lymphomas, recent efforts have revealed that
several critical factors have been significantly underestimated. FUNDING
The identification of BCL-W as a previously unrecognized
key contributor to B cell lymphoma has substantially aided This work was supported by the NCI Cancer Center support
in increasing our understanding of the BCL-2 family and grant P30CA056036 and the Sidney Kimmel Cancer Center.
the alterations in their expression that contribute to B cell
lymphoma survival and therapy resistance. This new knowledge ACKNOWLEDGMENTS
has opened the door to the development of additional selective
cancer therapeutics and combination therapies that may redefine We thank members of the Eischen laboratory for their thoughtful
the treatment of B cell lymphoma. Revealing the involvement discussions and technical efforts that have contributed to any of
of BCL-W in many types of B cell lymphoma has also our studies highlighted in this review.
REFERENCES 9. Adams CM, Mitra R, Gong JZ, Eischen CM. Non-Hodgkin and Hodgkin
lymphomas select for overexpression of BCLW. Clin Cancer Res. (2017)
1. Hanahan D, Weinberg RA. Hallmarks of cancer: the next generation. Cell 23:7119–29. doi: 10.1158/1078-0432.CCR-17-1144
(2011) 144:646–74. doi: 10.1016/j.cell.2011.02.013 10. Kale J, Osterlund EJ, Andrews DW. BCL-2 family proteins: changing
2. Adams JM, Cory S. The BCL-2 arbiters of apoptosis and their growing role as partners in the dance towards death. Cell Death Differ. (2018) 25:65–80.
cancer targets. Cell Death Differ. (2018) 25:27–36. doi: 10.1038/cdd.2017.161 doi: 10.1038/cdd.2017.186
3. Delbridge AR, Grabow S, Strasser A, Vaux DL. Thirty years of BCL-2: 11. Egle A, Harris AW, Bouillet P, Cory S. Bim is a suppressor of Myc-
translating cell death discoveries into novel cancer therapies. Nat Rev Cancer induced mouse B cell leukemia. Proc Natl Acad Sci USA. (2004) 101:6164–9.
(2016) 16:99–109. doi: 10.1038/nrc.2015.17 doi: 10.1073/pnas.0401471101
4. Vogler M, Walter HS, Dyer MJS. Targeting anti-apoptotic BCL2 family 12. Tagawa H, Karnan S, Suzuki R, Matsuo K, Zhang X, Ota A, et al.
proteins in haematological malignancies–from pathogenesis to treatment. Br Genome-wide array-based CGH for mantle cell lymphoma: identification
J Haematol. (2017) 178:364–79. doi: 10.1111/bjh.14684 of homozygous deletions of the proapoptotic gene BIM. Oncogene (2005)
5. Ashkenazi A, Fairbrother WJ, Leverson JD, Souers AJ. From basic apoptosis 24:1348–58. doi: 10.1038/sj.onc.1208300
discoveries to advanced selective BCL-2 family inhibitors. Nat Rev Drug 13. Kelly JL, Novak AJ, Fredericksen ZS, Liebow M, Ansell SM, Dogan A,
Discov. (2017) 16:273–84. doi: 10.1038/nrd.2016.253 et al. Germline variation in apoptosis pathway genes and risk of non-
6. Adams JM, Harris AW, Pinkert CA, Corcoran LM, Alexander WS, Cory S, Hodgkin’s lymphoma. Cancer Epidemiol Biomarkers Prev. (2010) 19:2847–
et al. The c-myc oncogene driven by immunoglobulin enhancers induces 58. doi: 10.1158/1055-9965.EPI-10-0581
lymphoid malignancy in transgenic mice. Nature (1985) 318:533–8. 14. Richter-Larrea JA, Robles EF, Fresquet V, Beltran E, Rullan AJ, Agirre
7. Davids MS, Roberts AW, Seymour JF, Pagel JM, Kahl BS, Wierda WG, X, et al. Reversion of epigenetically mediated BIM silencing overcomes
et al. Phase I first-in-human study of venetoclax in patients with relapsed chemoresistance in Burkitt lymphoma. Blood (2010) 116:2531–42.
or refractory non-Hodgkin lymphoma. J Clin Oncol. (2017) 35:826–33. doi: 10.1182/blood-2010-02-268003
doi: 10.1200/JCO.2016.70.4320 15. Garrison SP, Jeffers JR, Yang C, Nilsson JA, Hall MA, Rehg JE,
8. Adams CM, Kim AS, Mitra R, Choi JK, Gong JZ, Eischen CM. BCL-W has et al. Selection against PUMA gene expression in Myc-driven B-cell
a fundamental role in B cell survival and lymphomagenesis. J Clin Invest. lymphomagenesis. Mol Cell Biol. (2008) 28:5391–402. doi: 10.1128/MCB.
(2017) 127:635–50. doi: 10.1172/JCI89486 00907-07

16. Michalak EM, Jansen ES, Happo L, Cragg MS, Tai L, Smyth GK, 36. Kelly PN, Grabow S, Delbridge AR, Strasser A, Adams JM. Endogenous
et al. Puma and to a lesser extent Noxa are suppressors of Myc- Bcl-xL is essential for Myc-driven lymphomagenesis in mice. Blood (2011)
induced lymphomagenesis. Cell Death Differ. (2009) 16:684–96. 118:6380–6. doi: 10.1182/blood-2011-07-367672
doi: 10.1038/cdd.2008.195 37. Fang W, Weintraub BC, Dunlap B, Garside P, Pape KA, Jenkins MK, et al.
17. Frenzel A, Labi V, Chmelewskij W, Ploner C, Geley S, Fiegl H, et al. Self-reactive B lymphocytes overexpressing Bcl-xL escape negative selection
Suppression of B-cell lymphomagenesis by the BH3-only proteins Bmf and and are tolerized by clonal anergy and receptor editing. Immunity (1998)
Bad. Blood (2010) 115:995–1005. doi: 10.1182/blood-2009-03-212670 9:35–45.
18. Ranger AM, Zha J, Harada H, Datta SR, Danial NN, Gilmore AP, et al. Bad- 38. Linden M, Kirchhof N, Carlson C, Van Ness B. Targeted overexpression
deficient mice develop diffuse large B cell lymphoma. Proc Natl Acad Sci USA. of Bcl-XL in B-lymphoid cells results in lymphoproliferative
(2003) 100:9324–9. doi: 10.1073/pnas.1533446100 disease and plasma cell malignancies. Blood (2004) 103:2779–86.
19. Zinkel SS, Ong CC, Ferguson DO, Iwasaki H, Akashi K, Bronson RT, doi: 10.1182/blood-2003-10-3399
et al. Proapoptotic BID is required for myeloid homeostasis and tumor 39. Xerri L, Parc P, Brousset P, Schlaifer D, Hassoun J, Reed JC, et al. Predominant
suppression. Genes Dev. (2003) 17:229–39. doi: 10.1101/gad.1045603 expression of the long isoform of Bcl-x (Bcl-xL) in human lymphomas. Br J
20. Happo L, Phipson B, Smyth GK, Strasser A, Scott CL. Neither loss of Bik Haematol. (1996) 92:900–6.
alone, nor combined loss of Bik and Noxa, accelerate murine lymphoma 40. Rummel MJ, de Vos S, Hoelzer D, Koeffler HP, Hofmann WK. Altered
development or render lymphoma cells resistant to DNA damaging drugs. apoptosis pathways in mantle cell lymphoma. Leuk Lymphoma (2004)
Cell Death Dis. (2012) 3:e306. doi: 10.1038/cddis.2012.42 45:49–54. doi: 10.1080/1042819031000151112
21. Coultas L, Bouillet P, Stanley EG, Brodnicki TC, Adams JM, Strasser 41. Krajewski S, Krajewska M, Shabaik A, Wang HG, Irie S, Fong L, et al.
A. Proapoptotic BH3-only Bcl-2 family member Bik/Blk/Nbk is Immunohistochemical analysis of in vivo patterns of Bcl-X expression.
expressed in hemopoietic and endothelial cells but is redundant Cancer Res. (1994) 54:5501–7.
for their programmed death. Mol Cell Biol. (2004) 24:1570–81. 42. Puthier D, Derenne S, Barille S, Moreau P, Harousseau JL, Bataille R, et al.
doi: 10.1128/MCB.24.4.1570-1581.2004 Mcl-1 and Bcl-xL are co-regulated by IL-6 in human myeloma cells. Br J
22. Arena V, Martini M, Luongo M, Capelli A, Larocca LM. Mutations of the BIK Haematol. (1999) 107:392–5.
gene in human peripheral B-cell lymphomas. Genes Chromosomes Cancer 43. Tu Y, Renner S, Xu F, Fleishman A, Taylor J, Weisz J, et al. BCL-X expression
(2003) 38:91–6. doi: 10.1002/gcc.10245 in multiple myeloma: possible indicator of chemoresistance. Cancer Res.
23. Lindsten T, Ross AJ, King A, Zong WX, Rathmell JC, Shiels HA, et al. The (1998) 58:256–62.
combined functions of proapoptotic Bcl-2 family members bak and bax 44. Gauthier ER, Piche L, Lemieux G, Lemieux R. Role of bcl-X(L) in the control
are essential for normal development of multiple tissues. Mol Cell (2000) of apoptosis in murine myeloma cells. Cancer Res. (1996) 56:1451–6.
6:1389–99. doi: 10.1016/S1097-2765(00)00136-2 45. Opferman JT, Letai A, Beard C, Sorcinelli MD, Ong CC, Korsmeyer
24. Knudson CM, Tung KS, Tourtellotte WG, Brown GA, Korsmeyer SJ. Bax- SJ. Development and maintenance of B and T lymphocytes requires
deficient mice with lymphoid hyperplasia and male germ cell death. Science antiapoptotic MCL-1. Nature (2003) 426:671–6. doi: 10.1038/
(1995) 270:96–9. nature02067
25. Eischen CM, Roussel MF, Korsmeyer SJ, Cleveland JL. Bax loss impairs 46. Opferman JT, Iwasaki H, Ong CC, Suh H, Mizuno S, Akashi K, et al. Obligate
Myc-induced apoptosis and circumvents the selection of p53 mutations role of anti-apoptotic MCL-1 in the survival of hematopoietic stem cells.
during Myc-mediated lymphomagenesis. Mol Cell Biol. (2001) 21:7653–62. Science (2005) 307:1101–4. doi: 10.1126/science.1106114
doi: 10.1128/MCB.21.22.7653-7662.2001 47. Dzhagalov I, St John A, He YW. The antiapoptotic protein Mcl-1 is essential
26. Ke F, Voss A, Kerr JB, O’Reilly LA, Tai L, Echeverry N, et al. BCL-2 for the survival of neutrophils but not macrophages. Blood (2007) 109:1620–
family member BOK is widely expressed but its loss has only minimal 6. doi: 10.1182/blood-2006-03-013771
impact in mice. Cell Death Differ. (2012) 19:915–25. doi: 10.1038/cdd. 48. Grabow S, Delbridge AR, Aubrey BJ, Vandenberg CJ, Strasser A.
2011.210 Loss of a single Mcl-1 allele inhibits MYC-driven lymphomagenesis
27. Veis DJ, Sorenson CM, Shutter JR, Korsmeyer SJ. Bcl-2-deficient mice by sensitizing pro-B cells to apoptosis. Cell Rep. (2016) 14:2337–47.
demonstrate fulminant lymphoid apoptosis, polycystic kidneys, and doi: 10.1016/j.celrep.2016.02.039
hypopigmented hair. Cell (1993) 75:229–40. 49. Kelly GL, Grabow S, Glaser SP, Fitzsimmons L, Aubrey BJ, Okamoto T, et
28. Strasser A, Harris AW, Bath ML, Cory S. Novel primitive lymphoid tumours al. Targeting of MCL-1 kills MYC-driven mouse and human lymphomas
induced in transgenic mice by cooperation between myc and bcl-2. Nature even when they bear mutations in p53. Genes Dev. (2014) 28:58–70.
(1990) 348:331–3. doi: 10.1038/348331a0 doi: 10.1101/gad.232009.113
29. Kahl BS, Yang DT. Follicular lymphoma: evolving therapeutic strategies. 50. Campbell KJ, Bath ML, Turner ML, Vandenberg CJ, Bouillet P, Metcalf D,
Blood (2016) 127:2055–63. doi: 10.1182/blood-2015-11-624288 et al. Elevated Mcl-1 perturbs lymphopoiesis, promotes transformation of
30. Schuetz JM, Johnson NA, Morin RD, Scott DW, Tan K, Ben-Nierah S, hematopoietic stem/progenitor cells, and enhances drug resistance. Blood
et al. BCL2 mutations in diffuse large B-cell lymphoma. Leukemia (2012) (2010) 116:3197–207. doi: 10.1182/blood-2010-04-281071
26:1383–90. doi: 10.1038/leu.2011.378 51. Zhou P, Qian L, Bieszczad CK, Noelle R, Binder M, Levy NB, et al. Mcl-1 in
31. Correia C, Schneider PA, Dai H, Dogan A, Maurer MJ, Church AK, et transgenic mice promotes survival in a spectrum of hematopoietic cell types
al. BCL2 mutations are associated with increased risk of transformation and immortalization in the myeloid lineage. Blood (1998) 92:3226–39.
and shortened survival in follicular lymphoma. Blood (2015) 125:658–67. 52. Zhou P, Levy NB, Xie H, Qian L, Lee CY, Gascoyne RD, et al.
doi: 10.1182/blood-2014-04-571786 MCL1 transgenic mice exhibit a high incidence of B-cell lymphoma
32. Meda BA, Frost M, Newell J, Bohling SD, Huebner-Chan DR, Perkins SL, manifested as a spectrum of histologic subtypes. Blood (2001) 97:3902–9.
et al. BCL-2 is consistently expressed in hyperplastic marginal zones of the doi: 10.1182/blood.V97.12.3902
spleen, abdominal lymph nodes, and ileal lymphoid tissue. Am J Surg Pathol. 53. Wenzel SS, Grau M, Mavis C, Hailfinger S, Wolf A, Madle H, et al. MCL1 is
(2003) 27:888–94. doi: 10.1097/00000478-200307000-00003 deregulated in subgroups of diffuse large B-cell lymphoma. Leukemia (2013)
33. Agarwal B, Naresh KN. Bcl-2 family of proteins in indolent B-cell non- 27:1381–90. doi: 10.1038/leu.2012.367
Hodgkin’s lymphoma: study of 116 cases. Am J Hematol. (2002) 70:278–82. 54. Phillips DC, Xiao Y, Lam LT, Litvinovich E, Roberts-Rapp L, Souers AJ, et
doi: 10.1002/ajh.10139 al. Loss in MCL-1 function sensitizes non-Hodgkin’s lymphoma cell lines to
34. Motoyama N, Wang F, Roth KA, Sawa H, Nakayama K, Nakayama K, the BCL-2-selective inhibitor venetoclax (ABT-199). Blood Cancer J. (2015)
et al. Massive cell death of immature hematopoietic cells and neurons in 5:e368. doi: 10.1038/bcj.2015.88
Bcl-x-deficient mice. Science (1995) 267:1506–10. 55. Al-Harbi S, Hill BT, Mazumder S, Singh K, Devecchio J, Choudhary G, et
35. Motoyama N, Kimura T, Takahashi T, Watanabe T, Nakano T. bcl-x prevents al. An antiapoptotic BCL-2 family expression index predicts the response
apoptotic cell death of both primitive and definitive erythrocytes at the end of chronic lymphocytic leukemia to ABT-737. Blood (2011) 118:3579–90.
of maturation. J Exp Med. (1999) 189:1691–8. doi: 10.1182/blood-2011-03-340364

56. Zhang B, Gojo I, Fenton RG. Myeloid cell factor-1 is a critical 76. Michalak EM, Villunger A, Adams JM, Strasser A. In several cell types
survival factor for multiple myeloma. Blood (2002) 99:1885–93. tumour suppressor p53 induces apoptosis largely via Puma but Noxa
doi: 10.1182/blood.V99.6.1885 can contribute. Cell Death Differ. (2008) 15:1019–29. doi: 10.1038/cdd.
57. Quinn BA, Dash R, Azab B, Sarkar S, Das SK, Kumar S, et al. Targeting Mcl- 2008.16
1 for the therapy of cancer. Expert Opin Investig Drugs (2011) 20:1397–411. 77. Chipuk JE, Green DR. How do BCL-2 proteins induce mitochondrial
doi: 10.1517/13543784.2011.609167 outer membrane permeabilization? Trends Cell Biol. (2008) 18:157–64.
58. Tuzlak S, Schenk RL, Vasanthakumar A, Preston SP, Haschka MD, doi: 10.1016/j.tcb.2008.01.007
Zotos D, et al. The BCL-2 pro-survival protein A1 is dispensable for T 78. Zong WX, Lindsten T, Ross AJ, MacGregor GR, Thompson CB. BH3-
cell homeostasis on viral infection. Cell Death Differ. (2017) 24:523–33. only proteins that bind pro-survival Bcl-2 family members fail to induce
doi: 10.1038/cdd.2016.155 apoptosis in the absence of Bax and Bak. Genes Dev. (2001) 15:1481–6.
59. Schenk RL, Tuzlak S, Carrington EM, Zhan Y, Heinzel S, Teh CE, doi: 10.1101/gad.897601
et al. Characterisation of mice lacking all functional isoforms of 79. Meijerink JP, Smetsers TF, Sloetjes AW, Linders EH, Mensink EJ. Bax
the pro-survival BCL-2 family member A1 reveals minor defects in mutations in cell lines derived from hematological malignancies. Leukemia
the haematopoietic compartment. Cell Death Differ. (2017) 24:534–45. (1995) 9:1828–32.
doi: 10.1038/cdd.2016.156 80. Meijerink JP, Mensink EJ, Wang K, Sedlak TW, Sloetjes AW, de Witte T, et
60. Mensink M, Anstee NS, Robati M, Schenk RL, Herold MJ, Cory S, al. Hematopoietic malignancies demonstrate loss-of-function mutations of
et al. Anti-apoptotic A1 is not essential for lymphoma development in BAX. Blood (1998) 91:2991–7.
Emicro-Myc mice but helps sustain transplanted Emicro-Myc tumour 81. Brimmell M, Mendiola R, Mangion J, Packham G. BAX frameshift mutations
cells. Cell Death Differ. (2018) 25:795–806. doi: 10.1038/s41418-017- in cell lines derived from human haemopoietic malignancies are associated
0045-8 with resistance to apoptosis and microsatellite instability. Oncogene (1998)
61. Park IC, Lee SH, Whang DY, Hong WS, Choi SS, Shin HS, et al. Expression 16:1803–12. doi: 10.1038/sj.onc.1201704
of a novel Bcl-2 related gene, Bfl-1, in various human cancers and cancer cell 82. Rooswinkel RW, van de Kooij B, de Vries E, Paauwe M, Braster R,
lines. Anticancer Res. (1997) 17:4619–22. Verheij M, et al. Antiapoptotic potency of Bcl-2 proteins primarily relies
62. Morales AA, Olsson A, Celsing F, Osterborg A, Jondal M, Osorio LM. on their stability, not binding selectivity. Blood (2014) 123:2806–15.
High expression of bfl-1 contributes to the apoptosis resistant phenotype doi: 10.1182/blood-2013-08-519470
in B-cell chronic lymphocytic leukemia. Int J Cancer (2005) 113:730–7. 83. Czabotar PE, Lessene G, Strasser A, Adams JM. Control of apoptosis by the
doi: 10.1002/ijc.20614 BCL-2 protein family: implications for physiology and therapy. Nat Rev Mol
63. Olsson A, Norberg M, Okvist A, Derkow K, Choudhury A, Tobin G, Cell Biol. (2014) 15:49–63. doi: 10.1038/nrm3722
et al. Upregulation of bfl-1 is a potential mechanism of chemoresistance 84. Certo M, Del Gaizo Moore V, Nishino M, Wei G, Korsmeyer S, Armstrong
in B-cell chronic lymphocytic leukaemia. Br J Cancer (2007) 97:769–77. SA, et al. Mitochondria primed by death signals determine cellular addiction
doi: 10.1038/sj.bjc.6603951 to antiapoptotic BCL-2 family members. Cancer Cell (2006) 9:351–65.
64. Print CG, Loveland KL, Gibson L, Meehan T, Stylianou A, Wreford N, et doi: 10.1016/j.ccr.2006.03.027
al. Apoptosis regulator bcl-w is essential for spermatogenesis but appears 85. Willis SN, Chen L, Dewson G, Wei A, Naik E, Fletcher JI, et al.
otherwise redundant. Proc Natl Acad Sci USA. (1998) 95:12424–31. Proapoptotic Bak is sequestered by Mcl-1 and Bcl-xL, but not Bcl-2,
65. Ross AJ, Waymire KG, Moss JE, Parlow AF, Skinner MK, Russell LD, et al. until displaced by BH3-only proteins. Genes Dev. (2005) 19:1294–305.
Testicular degeneration in Bclw-deficient mice. Nat Genet. (1998) 18:251–6. doi: 10.1101/gad.1304105
doi: 10.1038/ng0398-251 86. Fukuhara S, Rowley JD. Chromosome 14 translocations in non-Burkitt
66. Beverly LJ, Varmus HE. MYC-induced myeloid leukemogenesis is lymphomas. Int J Cancer (1978) 22:14–21.
accelerated by all six members of the antiapoptotic BCL family. Oncogene 87. Tsujimoto Y, Finger LR, Yunis J, Nowell PC, Croce CM. Cloning of the
(2009) 28:1274–9. doi: 10.1038/onc.2008.466 chromosome breakpoint of neoplastic B cells with the t(14;18) chromosome
67. Moldoveanu T, Follis AV, Kriwacki RW, Green DR. Many players translocation. Science (1984) 226:1097–9.
in BCL-2 family affairs. Trends Biochem Sci. (2014) 39:101–11. 88. Cleary ML, Sklar J. Nucleotide sequence of a t(14;18) chromosomal
doi: 10.1016/j.tibs.2013.12.006 breakpoint in follicular lymphoma and demonstration of a breakpoint-
68. Petros AM, Olejniczak ET, Fesik SW. Structural biology of the cluster region near a transcriptionally active locus on chromosome 18. Proc
Bcl-2 family of proteins. Biochim Biophys Acta (2004) 1644:83–94. Natl Acad Sci USA (1985) 82:7439–43.
doi: 10.1016/j.bbamcr.2003.08.012 89. Cleary ML, Meeker TC, Levy S, Lee E, Trela M, Sklar J, et al. Clustering of
69. Gross A, McDonnell JM, Korsmeyer SJ. BCL-2 family members and the extensive somatic mutations in the variable region of an immunoglobulin
mitochondria in apoptosis. Genes Dev. (1999) 13:1899–911. heavy chain gene from a human B cell lymphoma. Cell (1986) 44:97–106.
70. Huang DC, Strasser A. BH3-Only proteins-essential initiators of apoptotic 90. Bakhshi A, Jensen JP, Goldman P, Wright JJ, McBride OW, Epstein AL, et
cell death. Cell (2000) 103:839–42. doi: 10.1016/S0092-8674(00)00187-2 al. Cloning the chromosomal breakpoint of t(14;18) human lymphomas:
71. Youle RJ, Strasser A. The BCL-2 protein family: opposing activities clustering around JH on chromosome 14 and near a transcriptional unit on
that mediate cell death. Nat Rev Mol Cell Biol. (2008) 9:47–59. 18. Cell (1985) 41:899–906.
doi: 10.1038/nrm2308 91. Dai H, Meng XW, Lee SH, Schneider PA, Kaufmann SH. Context-dependent
72. Villunger A, Michalak EM, Coultas L, Mullauer F, Bock G, Ausserlechner Bcl-2/Bak interactions regulate lymphoid cell apoptosis. J Biol Chem. (2009)
MJ, et al. p53- and drug-induced apoptotic responses mediated 284:18311–22. doi: 10.1074/jbc.M109.004770
by BH3-only proteins puma and noxa. Science (2003) 302:1036–8. 92. Smith AJ, Dai H, Correia C, Takahashi R, Lee SH, Schmitz I, et al. Noxa/Bcl-2
doi: 10.1126/science.1090072 protein interactions contribute to bortezomib resistance in human lymphoid
73. Jeffers JR, Parganas E, Lee Y, Yang C, Wang J, Brennan J, et al. Puma cells. J Biol Chem. (2011) 286:17682–92. doi: 10.1074/jbc.M110.189092
is an essential mediator of p53-dependent and -independent apoptotic 93. Iqbal J, Neppalli VT, Wright G, Dave BJ, Horsman DE, Rosenwald A,
pathways. Cancer Cell (2003) 4:321–8. doi: 10.1016/S1535-6108(03) et al. BCL2 expression is a prognostic marker for the activated B-cell-
00244-7 like type of diffuse large B-cell lymphoma. J Clin Oncol. (2006) 24:961–8.
74. Bouillet P, Metcalf D, Huang DC, Tarlinton DM, Kay TW, Kontgen doi: 10.1200/JCO.2005.03.4264
F, et al. Proapoptotic Bcl-2 relative Bim required for certain apoptotic 94. Tsuyama N, Sakata S, Baba S, Mishima Y, Nishimura N, Ueda K, et al.
responses, leukocyte homeostasis, and to preclude autoimmunity. Science BCL2 expression in DLBCL: reappraisal of immunohistochemistry with new
(1999) 286:1735–8. criteria for therapeutic biomarker evaluation. Blood (2017) 130:489–500.
75. Puthalakath H, O’Reilly LA, Gunn P, Lee L, Kelly PN, Huntington ND, et al. doi: 10.1182/blood-2016-12-759621
ER stress triggers apoptosis by activating BH3-only protein Bim. Cell (2007) 95. Sandoval-Sus JD, Chavez J, Dalia S. A new therapeutic era in GCB
129:1337–49. doi: 10.1016/j.cell.2007.04.027 and ABC diffuse large B-cell lymphoma molecular subtypes: a cell

of origin-driven review. Curr Cancer Drug Targets (2016) 16:305–22. 115. Gonzalez-Garcia M, Perez-Ballestero R, Ding L, Duan L, Boise LH,
doi: 10.2174/1568009615666151030102539 Thompson CB, et al. bcl-XL is the major bcl-x mRNA form expressed during
96. Iqbal J, Sanger WG, Horsman DE, Rosenwald A, Pickering DL, Dave B, et al. murine development and its product localizes to mitochondria. Development
BCL2 translocation defines a unique tumor subset within the germinal center (1994) 120:3033–42.
B-cell-like diffuse large B-cell lymphoma. Am J Pathol. (2004) 165:159–66. 116. Boise LH, Gonzalez-Garcia M, Postema CE, Ding L, Lindsten T, Turka LA,
doi: 10.1016/S0002-9440(10)63284-1 et al. bcl-x, a bcl-2-related gene that functions as a dominant regulator of
97. Monni O, Joensuu H, Franssila K, Klefstrom J, Alitalo K, Knuutila S. BCL2 apoptotic cell death. Cell (1993) 74:597–608.
overexpression associated with chromosomal amplification in diffuse large 117. Gregoli PA, Bondurant MC. The roles of Bcl-X(L) and apopain in the control
B-cell lymphoma. Blood (1997) 90:1168–74. of erythropoiesis by erythropoietin. Blood (1997) 90:630–40.
98. Chapuy B, Stewart C, Dunford AJ, Kim J, Kamburov A, Redd RA, et al. 118. Wagner KU, Claudio E, Rucker EB III, Riedlinger G, Broussard C,
Molecular subtypes of diffuse large B cell lymphoma are associated with Schwartzberg PL, et al. Conditional deletion of the Bcl-x gene from erythroid
distinct pathogenic mechanisms and outcomes. Nat Med. (2018) 24:679–90. cells results in hemolytic anemia and profound splenomegaly. Development
doi: 10.1038/s41591-018-0016-8 (2000) 127:4949–58. doi: 10.1016/S0925-4773(01)00549-4
99. Schmitz R, Wright GW, Huang DW, Johnson CA, Phelan JD, Wang JQ, et al. 119. Bairey O, Zimra Y, Shaklai M, Okon E, Rabizadeh E. Bcl-2, Bcl-X, Bax, and
Genetics and pathogenesis of diffuse large B-cell lymphoma. N Engl J Med. Bak expression in short- and long-lived patients with diffuse large B-cell
(2018) 378:1396–407. doi: 10.1056/NEJMoa1801445 lymphomas. Clin Cancer Res. (1999) 5:2860–6.
100. Dunleavy K. Double-hit lymphomas: current paradigms and novel treatment 120. Beroukhim R, Mermel CH, Porter D, Wei G, Raychaudhuri S,
approaches. Hematology Am Soc Hematol Educ Program (2014) 2014:107–12. Donovan J, et al. The landscape of somatic copy-number alteration
doi: 10.1182/asheducation-2014.1.107 across human cancers. Nature (2010) 463:899–905. doi: 10.1038/nature
101. Lindsley RC, LaCasce AS. Biology of double-hit B-cell lymphomas. Curr 08822
Opin Hematol. (2012) 19:299–304. doi: 10.1097/MOH.0b013e328353bbbd 121. Adams CM, Eischen CM. Histone deacetylase inhibition reveals a
102. Johnson NA, Slack GW, Savage KJ, Connors JM, Ben-Neriah S, Rogic S, et al. tumor-suppressive function of MYC-regulated miRNA in breast and
Concurrent expression of MYC and BCL2 in diffuse large B-cell lymphoma lung carcinoma. Cell Death Differ. (2016) 23:1312–21. doi: 10.1038/cdd.
treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, 2016.9
and prednisone. J Clin Oncol. (2012) 30:3452–9. doi: 10.1200/JCO.2011. 122. Shimizu S, Takehara T, Hikita H, Kodama T, Miyagi T, Hosui A, et al. The let-
41.0985 7 family of microRNAs inhibits Bcl-xL expression and potentiates sorafenib-
103. Green TM, Young KH, Visco C, Xu-Monette ZY, Orazi A, Go RS, induced apoptosis in human hepatocellular carcinoma. J Hepatol. (2010)
et al. Immunohistochemical double-hit score is a strong predictor 52:698–704. doi: 10.1016/j.jhep.2009.12.024
of outcome in patients with diffuse large B-cell lymphoma treated 123. Kozopas KM, Yang T, Buchan HL, Zhou P, Craig RW. MCL1, a gene
with rituximab plus cyclophosphamide, doxorubicin, vincristine, and expressed in programmed myeloid cell differentiation, has sequence
prednisone. J Clin Oncol. (2012) 30:3460–7. doi: 10.1200/JCO.2011.4 similarity to BCL2. Proc Natl Acad Sci USA. (1993) 90:3516–20.
1.4342 124. Morel C, Carlson SM, White FM, Davis RJ. Mcl-1 integrates the opposing
104. Rao PH, Houldsworth J, Dyomina K, Parsa NZ, Cigudosa JC, Louie DC, et actions of signaling pathways that mediate survival and apoptosis. Mol Cell
al. Chromosomal and gene amplification in diffuse large B-cell lymphoma. Biol. (2009) 29:3845–52. doi: 10.1128/MCB.00279-09
Blood (1998) 92:234–40. 125. Stewart DP, Koss B, Bathina M, Perciavalle RM, Bisanz K, Opferman JT.
105. Hanada M, Delia D, Aiello A, Stadtmauer E, Reed JC. bcl-2 gene Ubiquitin-independent degradation of antiapoptotic MCL-1. Mol Cell Biol.
hypomethylation and high-level expression in B-cell chronic lymphocytic (2010) 30:3099–110. doi: 10.1128/MCB.01266-09
leukemia. Blood (1993) 82:1820–8. 126. Mojsa B, Lassot I, Desagher S. Mcl-1 ubiquitination: unique regulation of an
106. Saito M, Novak U, Piovan E, Basso K, Sumazin P, Schneider C, et essential survival protein. Cells (2014) 3:418–37. doi: 10.3390/cells3020418
al. BCL6 suppression of BCL2 via Miz1 and its disruption in diffuse 127. Crawford M, Batte K, Yu L, Wu X, Nuovo GJ, Marsh CB, et al.
large B cell lymphoma. Proc Natl Acad Sci USA. (2009) 106:11294–9. MicroRNA 133B targets pro-survival molecules MCL-1 and BCL2L2
doi: 10.1073/pnas.0903854106 in lung cancer. Biochem Biophys Res Commun. (2009) 388:483–9.
107. Breitschopf K, Haendeler J, Malchow P, Zeiher AM, Dimmeler S. doi: 10.1016/j.bbrc.2009.07.143
Posttranslational modification of Bcl-2 facilitates its proteasome-dependent 128. Gong J, Zhang JP, Li B, Zeng C, You K, Chen MX, et al. MicroRNA-125b
degradation: molecular characterization of the involved signaling pathway. promotes apoptosis by regulating the expression of Mcl-1, Bcl-w and IL-6R.
Mol Cell Biol. (2000) 20:1886–96. doi: 10.1128/MCB.20.5.1886-1896.2000 Oncogene (2013) 32:3071–9. doi: 10.1038/onc.2012.318
108. Davids MS. Targeting BCL-2 in B-cell lymphomas. Blood (2017) 130:1081–8. 129. Mott JL, Kobayashi S, Bronk SF, Gores GJ. mir-29 regulates Mcl-
doi: 10.1182/blood-2017-04-737338 1 protein expression and apoptosis. Oncogene (2007) 26:6133–40.
109. Adams CM, Hiebert SW, Eischen CM. Myc induces miRNA-mediated doi: 10.1038/sj.onc.1210436
apoptosis in response to HDAC inhibition in hematologic malignancies. 130. Steele R, Mott JL, Ray RB. MBP-1 upregulates miR-29b that represses Mcl-
Cancer Res. (2016) 76:736–48. doi: 10.1158/0008-5472.CAN-15-1751 1, collagens, and matrix-metalloproteinase-2 in prostate cancer cells. Genes
110. Cimmino A, Calin GA, Fabbri M, Iorio MV, Ferracin M, Shimizu M, et al. Cancer (2010) 1:381–7. doi: 10.1177/1947601910371978
miR-15 and miR-16 induce apoptosis by targeting BCL2. Proc Natl Acad Sci 131. Desjobert C, Renalier MH, Bergalet J, Dejean E, Joseph N, Kruczynski A, et al.
USA. (2005) 102:13944–9. doi: 10.1073/pnas.0506654102 MiR-29a down-regulation in ALK-positive anaplastic large cell lymphomas
111. Di Lisio L, Sanchez-Beato M, Gomez-Lopez G, Rodriguez ME, Montes- contributes to apoptosis blockade through MCL-1 overexpression. Blood
Moreno S, Mollejo M, et al. MicroRNA signatures in B-cell lymphomas. (2011) 117:6627–37. doi: 10.1182/blood-2010-09-301994
Blood Cancer J. (2012) 2:e57. doi: 10.1038/bcj.2012.1 132. Mazzoccoli L, Robaina MC, Apa AG, Bonamino M, Pinto LW, Queiroga E,
112. Di Lisio L, Martinez N, Montes-Moreno S, Piris-Villaespesa M, et al. MiR-29 silencing modulates the expression of target genes related to
Sanchez-Beato M, Piris MA. The role of miRNAs in the pathogenesis proliferation, apoptosis and methylation in Burkitt lymphoma cells. J Cancer
and diagnosis of B-cell lymphomas. Blood (2012) 120:1782–90. Res Clin Oncol. (2018) 144:483–97. doi: 10.1007/s00432-017-2575-3
doi: 10.1182/blood-2012-05-402784 133. Malumbres R, Sarosiek KA, Cubedo E, Ruiz JW, Jiang X, Gascoyne
113. McDonnell TJ, Deane N, Platt FM, Nunez G, Jaeger U, McKearn JP, et al. bcl- RD, et al. Differentiation stage-specific expression of microRNAs in B
2-immunoglobulin transgenic mice demonstrate extended B cell survival and lymphocytes and diffuse large B-cell lymphomas. Blood (2009) 113:3754–64.
follicular lymphoproliferation. Cell (1989) 57:79–88. doi: 10.1182/blood-2008-10-184077
114. Strasser A, Whittingham S, Vaux DL, Bath ML, Adams JM, Cory S, et al. 134. Schwickart M, Huang X, Lill JR, Liu J, Ferrando R, French DM, et al.
Enforced BCL2 expression in B-lymphoid cells prolongs antibody responses Deubiquitinase USP9X stabilizes MCL1 and promotes tumour cell survival.
and elicits autoimmune disease. Proc Natl Acad Sci USA. (1991) 88:8661–5. Nature (2010) 463:103–7. doi: 10.1038/nature08646

135. Inuzuka H, Shaik S, Onoyama I, Gao D, Tseng A, Maser RS, et al. SCF(FBW7) 155. Durig J, Duhrsen U, Klein-Hitpass L, Worm J, Hansen JB, Orum H, et al. The
regulates cellular apoptosis by targeting MCL1 for ubiquitylation and novel antisense Bcl-2 inhibitor SPC2996 causes rapid leukemic cell clearance
destruction. Nature (2011) 471:104–9. doi: 10.1038/nature09732 and immune activation in chronic lymphocytic leukemia. Leukemia (2011)
136. Wertz IE, Kusam S, Lam C, Okamoto T, Sandoval W, Anderson DJ, et 25:638–47. doi: 10.1038/leu.2010.322
al. Sensitivity to antitubulin chemotherapeutics is regulated by MCL1 and 156. van de Donk NW, Kamphuis MM, van Dijk M, Borst HP, Bloem AC,
FBW7. Nature (2011) 471:110–4. doi: 10.1038/nature09779 Lokhorst HM. Chemosensitization of myeloma plasma cells by an antisense-
137. Lin EY, Orlofsky A, Berger MS, Prystowsky MB. Characterization of A1, a mediated downregulation of Bcl-2 protein. Leukemia (2003) 17:211–9.
novel hemopoietic-specific early-response gene with sequence similarity to doi: 10.1038/sj.leu.2402768
bcl-2. J Immunol. (1993) 151:1979–88. 157. van de donk N, Kamphuis M, van Dijk M. Evaluation of Bcl-2
138. Kuss AW, Knodel M, Berberich-Siebelt F, Lindemann D, Schimpl A, antisense oligonucleotide drugs in multiple myeloma. Blood (2000) 96:757a.
Berberich I. A1 expression is stimulated by CD40 in B cells and rescues doi: 10.1182/blood.V96.757a
WEHI 231 cells from anti-IgM-induced cell death. Eur J Immunol. 158. Marcucci G, Stock W, Dai G, Klisovic RB, Liu S, Klisovic MI, et
(1999) 29:3077–88. doi: 10.1002/(SICI)1521-4141(199910)29:10<3077::AID- al. Phase I study of oblimersen sodium, an antisense to Bcl-2, in
IMMU3077>3.0.CO;2-R untreated older patients with acute myeloid leukemia: pharmacokinetics,
139. Kucharczak JF, Simmons MJ, Duckett CS, Gelinas C. Constitutive pharmacodynamics, and clinical activity. J Clin Oncol. (2005) 23:3404–11.
proteasome-mediated turnover of Bfl-1/A1 and its processing in response doi: 10.1200/JCO.2005.09.118
to TNF receptor activation in FL5.12 pro-B cells convert it into a prodeath 159. Pro B, Leber B, Smith M, Fayad L, Romaguera J, Hagemeister F, et
factor. Cell Death Differ. (2005) 12:1225–39. doi: 10.1038/sj.cdd.4401684 al. Phase II multicenter study of oblimersen sodium, a Bcl-2 antisense
140. Herold MJ, Zeitz J, Pelzer C, Kraus C, Peters A, Wohlleben G, et al. The oligonucleotide, in combination with rituximab in patients with recurrent
stability and anti-apoptotic function of A1 are controlled by its C terminus. J B-cell non-Hodgkin lymphoma. Br J Haematol. (2008) 143:355–60.
Biol Chem. (2006) 281:13663–71. doi: 10.1074/jbc.M600266200 doi: 10.1111/j.1365-2141.2008.07353.x
141. Brien G, Trescol-Biemont MC, Bonnefoy-Berard N. Downregulation of Bfl-1 160. Grant S. Rational combination strategies to enhance venetoclax activity and
protein expression sensitizes malignant B cells to apoptosis. Oncogene (2007) overcome resistance in hematologic malignancies. Leuk Lymphoma (2018)
26:5828–32. doi: 10.1038/sj.onc.1210363 59:1292–9. doi: 10.1080/10428194.2017.1366999
142. Zong WX, Edelstein LC, Chen C, Bash J, Gelinas C. The prosurvival Bcl-2 161. Anderson MA, Huang D, Roberts A. Targeting BCL2 for the
homolog Bfl-1/A1 is a direct transcriptional target of NF-kappaB that blocks treatment of lymphoid malignancies. Semin Hematol. (2014) 51:219–27.
TNFalpha-induced apoptosis. Genes Dev. (1999) 13:382–7. doi: 10.1053/j.seminhematol.2014.05.008
143. Gibson L, Holmgreen SP, Huang DC, Bernard O, Copeland NG, Jenkins 162. Paoluzzi L, Gonen M, Bhagat G, Furman RR, Gardner JR, Scotto L, et al.
NA, et al. bcl-w, a novel member of the bcl-2 family, promotes cell survival. The BH3-only mimetic ABT-737 synergizes the antineoplastic activity of
Oncogene (1996) 13:665–75. proteasome inhibitors in lymphoid malignancies. Blood (2008) 112:2906–16.
144. Merino D, Khaw SL, Glaser SP, Anderson DJ, Belmont LD, Wong C, et al. Bcl- doi: 10.1182/blood-2007-12-130781
2, Bcl-x(L), and Bcl-w are not equivalent targets of ABT-737 and navitoclax 163. Vogler M, Dinsdale D, Sun XM, Young KW, Butterworth M, Nicotera P, et
(ABT-263) in lymphoid and leukemic cells. Blood (2012) 119:5807–16. al. A novel paradigm for rapid ABT-737-induced apoptosis involving outer
doi: 10.1182/blood-2011-12-400929 mitochondrial membrane rupture in primary leukemia and lymphoma cells.
145. Ott G, Rosenwald A. Molecular pathogenesis of follicular lymphoma. Cell Death Differ. (2008) 15:820–30. doi: 10.1038/cdd.2008.25
Haematologica (2008) 93:1773–6. doi: 10.3324/haematol.2008.001495 164. Del Gaizo Moore V, Brown JR, Certo M, Love TM, Novina CD, Letai A.
146. Lapham A, Adams JE, Paterson A, Lee M, Brimmell M, Packham G. The Chronic lymphocytic leukemia requires BCL2 to sequester prodeath BIM,
Bcl-w promoter is activated by beta-catenin/TCF4 in human colorectal explaining sensitivity to BCL2 antagonist ABT-737. J Clin Invest. (2007)
carcinoma cells. Gene (2009) 432:112–7. doi: 10.1016/j.gene.2008.12.002 117:112–21. doi: 10.1172/JCI28281
147. Xu Y, Zhao F, Wang Z, Song Y, Luo Y, Zhang X, et al. MicroRNA-335 acts 165. Tse C, Shoemaker AR, Adickes J, Anderson MG, Chen J, Jin S, et al. ABT-263:
as a metastasis suppressor in gastric cancer by targeting Bcl-w and specificity a potent and orally bioavailable Bcl-2 family inhibitor. Cancer Res. (2008)
protein 1. Oncogene (2012) 31:1398–407. doi: 10.1038/onc.2011.340 68:3421–8. doi: 10.1158/0008-5472.CAN-07-5836
148. Cao J, Cai J, Huang D, Han Q, Yang Q, Li T, et al. miR-335 represents an 166. Inoue-Yamauchi A, Jeng PS, Kim K, Chen HC, Han S, Ganesan YT, et al.
invasion suppressor gene in ovarian cancer by targeting Bcl-w. Oncol Rep. Targeting the differential addiction to anti-apoptotic BCL-2 family for cancer
(2013) 30:701–6. doi: 10.3892/or.2013.2482 therapy. Nat Commun. (2017) 8:16078. doi: 10.1038/ncomms16078
149. Eischen CM, Packham G, Nip J, Fee BE, Hiebert SW, Zambetti GP, et al. Bcl-2 167. Wilson WH, O’Connor OA, Czuczman MS, LaCasce AS, Gerecitano JF,
is an apoptotic target suppressed by both c-Myc and E2F-1. Oncogene (2001) Leonard JP, et al. Navitoclax, a targeted high-affinity inhibitor of BCL-
20:6983–93. doi: 10.1038/sj.onc.1204892 2, in lymphoid malignancies: a phase 1 dose-escalation study of safety,
150. Eischen CM, Woo D, Roussel MF, Cleveland JL. Apoptosis pharmacokinetics, pharmacodynamics, and antitumour activity. Lancet
triggered by Myc-induced suppression of Bcl-X(L) or Bcl-2 is Oncol. (2010) 11:1149–59. doi: 10.1016/S1470-2045(10)70261-8
bypassed during lymphomagenesis. Mol Cell Biol. (2001) 21:5063–70. 168. Gandhi L, Camidge DR, Ribeiro de Oliveira M, Bonomi P, Gandara D, Khaira
doi: 10.1128/MCB.21.15.5063-5070.2001 D, et al. Phase I study of Navitoclax (ABT-263), a novel Bcl-2 family inhibitor,
151. Advani PP, Paulus A, Masood A, Sher T, Chanan-Khan A. Pharmacokinetic in patients with small-cell lung cancer and other solid tumors. J Clin Oncol.
evaluation of oblimersen sodium for the treatment of chronic (2011) 29:909–16. doi: 10.1200/JCO.2010.31.6208
lymphocytic leukemia. Expert Opin Drug Metab Toxicol. (2011) 7:765–74. 169. Roberts AW, Seymour JF, Brown JR, Wierda WG, Kipps TJ, Khaw
doi: 10.1517/17425255.2011.579105 SL, et al. Substantial susceptibility of chronic lymphocytic leukemia to
152. Galatin PS, Advani RH, Fisher GA, Francisco B, Julian T, Losa R, BCL2 inhibition: results of a phase I study of navitoclax in patients
et al. Phase I trial of oblimersen (Genasense(R)) and gemcitabine in with relapsed or refractory disease. J Clin Oncol. (2012) 30:488–96.
refractory and advanced malignancies. Invest New Drugs (2011) 29:971–7. doi: 10.1200/JCO.2011.34.7898
doi: 10.1007/s10637-010-9416-4 170. Mason KD, Carpinelli MR, Fletcher JI, Collinge JE, Hilton AA, Ellis S, et
153. Ebrahim AS, Kandouz M, Liddane A, Sabbagh H, Hou Y, Li C, et al. Programmed anuclear cell death delimits platelet life span. Cell (2007)
al. PNT2258, a novel deoxyribonucleic acid inhibitor, induces cell cycle 128:1173–86. doi: 10.1016/j.cell.2007.01.037
arrest and apoptosis via a distinct mechanism of action: a new class 171. Park CM, Bruncko M, Adickes J, Bauch J, Ding H, Kunzer A, et
of drug for non-Hodgkin’s lymphoma. Oncotarget (2016) 7:42374–84. al. Discovery of an orally bioavailable small molecule inhibitor of
doi: 10.18632/oncotarget.9872 prosurvival B-cell lymphoma 2 proteins. J Med Chem. (2008) 51:6902–15.
154. Ebrahim AS, Sabbagh H, Liddane A, Raufi A, Kandouz M, Al-Katib A. doi: 10.1021/jm800669s
Hematologic malignancies: newer strategies to counter the BCL-2 protein. J 172. Souers AJ, Leverson JD, Boghaert ER, Ackler SL, Catron ND, Chen J, et
Cancer Res Clin Oncol. (2016) 142:2013–22. doi: 10.1007/s00432-016-2144-1 al. ABT-199, a potent and selective BCL-2 inhibitor, achieves antitumor

activity while sparing platelets. Nat Med. (2013) 19:202–8. doi: 10.1038/ 189. Flinn IW, Brunvand M, Choi MY, Dyer MJ, Gribben JG, Hillmen P, et al.
nm.3048 Safety and efficacy of a combination of venetoclax (GDC-0199/ABT-199) and
173. Itchaki G, Brown JR. The potential of venetoclax (ABT-199) in obinutuzumab in patients with relapsed/refractory or previously untreated
chronic lymphocytic leukemia. Ther Adv Hematol. (2016) 7:270–87. chronic lymphocytic leukemia–results from a phase 1b study (GP28331).
doi: 10.1177/2040620716655350 Blood (2015) 126:494. doi: 10.1182/blood.v126.23.494
174. Vogler M, Dinsdale D, Dyer MJ, Cohen GM. ABT-199 selectively inhibits 190. Rogers KA, Huang Y, Ruppert AS, Awan FT, Heerema NA, Hoffman C, et
BCL2 but not BCL2L1 and efficiently induces apoptosis of chronic al. Phase 1b study of obinutuzumab, ibrutinib, and venetoclax in relapsed
lymphocytic leukaemic cells but not platelets. Br J Haematol. (2013) 163:139– and refractory chronic lymphocytic leukemia. Blood (2018) 132:1568–72.
42. doi: 10.1111/bjh.12457 doi: 10.1182/blood-2018-05-853564
175. Roberts AW, Davids MS, Pagel JM, Kahl BS, Puvvada SD, Gerecitano JF, 191. Rogers KA, Huang Y, Stark A, Awan FT, Maddocks KJ, Woyach J, et al.
et al. Targeting BCL2 with venetoclax in relapsed chronic lymphocytic Initial results of the phase 2 treatment naive cohort in a phase 1b/2 study of
leukemia. N Engl J Med. (2016) 374:311–22. doi: 10.1056/NEJMoa15 obinutuzumab, ibrutinib, and venetoclax in chronic lymphocytic leukemia.
13257 Blood (2017) 130:431. doi: 10.1182/blood.v130.suppl1.431
176. Stilgenbauer S, Eichhorst B, Schetelig J, Hillmen P, Seymour JF, Coutre 192. Cramer P, von Tresckow J, Bahlo J, Robrecht S, Langerbeins P, Al-Sawaf
S, et al. Venetoclax for patients with chronic lymphocytic leukemia O, et al. Bendamustine followed by obinutuzumab and venetoclax in
with 17p deletion: results from the full population of a phase II chronic lymphocytic leukaemia (CLL2-BAG): primary endpoint analysis of
pivotal trial. J Clin Oncol. (2018) 36:1973–80. doi: 10.1200/JCO.2017.7 a multicentre, open-label, phase 2 trial. Lancet Oncol. (2018) 19:1215–28.
6.6840 doi: 10.1016/S1470-2045(18)30414-5
177. Jones JA, Mato AR, Wierda WG, Davids MS, Choi M, Cheson BD, et al. 193. Zelenetz AD, Salles GA, Mason KD, Casulo C, Le Gouill S, Sehn LH,
Venetoclax for chronic lymphocytic leukaemia progressing after ibrutinib: et al. Results of a phase Ib study of venetoclax plus R- or G-CHOP
an interim analysis of a multicentre, open-label, phase 2 trial. Lancet Oncol. in patients with B-Cell non-Hodgkin lymphoma. Blood (2016) 128:3032.
(2018) 19:65–75. doi: 10.1016/S1470-2045(17)30909-9 doi: 10.1200/JCO.2016.34.15_suppl.7566
178. Coutre S, Choi M, Furman RR, Eradat H, Heffner L, Jones JA, et 194. Zinzani PL, Topp MS, Yuen SLS, Rusconi C, Fleury I, Pro B, et
al. Venetoclax for patients with chronic lymphocytic leukemia who al. Phase 2 study of venetoclax plus rituximab or randomized ven
progressed during or after idelalisib therapy. Blood (2018) 131:1704–11. plus bendamustine + rituximab (BR) versus BR in patients with
doi: 10.1182/blood-2017-06-788133 relapsed/refractory follicular lymphoma: interim data. Blood (2016) 128:617.
179. Wierda W, Davids MS, Furman RR, Cheson BD, Barr PM, Eradat H, et al. doi: 10.1182/blood.v128.22.617
Venetoclax (VEN) is active in chronic lymphocytic leukemia (CLL) relapsed 195. Tam CS, Anderson MA, Pott C, Agarwal R, Handunnetti S, Hicks
or refractory to more than one B-cell receptor pathway inhibitor (BCRi). RJ, et al. Ibrutinib plus venetoclax for the treatment of mantle-cell
Blood (2017) 130:3025. doi: 10.1182/blood.v130.suppl1.3025 lymphoma. N Engl J Med. (2018) 378:1211–23. doi: 10.1056/NEJMoa
180. Leverson JD, Phillips DC, Mitten MJ, Boghaert ER, Diaz D, Tahir SK, 1715519
et al. Exploiting selective BCL-2 family inhibitors to dissect cell survival 196. Tam C, Roberts A, Anderson MA, Dawson SJ, Hicks R, Pott C, et al. The
dependencies and define improved strategies for cancer therapy. Sci Transl combination of ibrutinib and venetoclax (ABT-199) to achieve complete
Med. (2015) 7:279ra40. doi: 10.1126/scitranslmed.aaa4642 remissions in patients with relapsed/refractory mantle cell lymphoma:
181. Seymour JF, Kipps TJ, Eichhorst B, Hillmen P, D’Rozario J, Assouline S, preliminary results of the phase II AIM study. J Clin Oncol. (2016) 34:7548.
et al. Venetoclax-rituximab in relapsed or refractory chronic lymphocytic doi: 10.1200/JCO.2016.34.15_suppl.7548
leukemia. N Engl J Med. (2018) 378:1107–20. doi: 10.1056/NEJMoa1713976 197. Montero J, Letai A. Why do BCL-2 inhibitors work and where
182. Seymour JF, Ma S, Brander DM, Choi MY, Barrientos J, Davids MS, should we use them in the clinic? Cell Death Differ. (2018) 25:56–64.
et al. Venetoclax plus rituximab in relapsed or refractory chronic doi: 10.1038/cdd.2017.183
lymphocytic leukaemia: a phase 1b study. Lancet Oncol. (2017) 18:230–40. 198. Lessene G, Czabotar PE, Sleebs BE, Zobel K, Lowes KN, Adams JM, et al.
doi: 10.1016/S1470-2045(17)30012-8 Structure-guided design of a selective BCL-X(L) inhibitor. Nat Chem Biol.
183. Seymour JF, Kipps TJ, Eichhorst B, Hillmen P, D’Rozario JM, Assouline S, et (2013) 9:390–7. doi: 10.1038/nchembio.1246
al. Venetoclax plus rituximab is superior to bendamustine plus rituximab in 199. Koehler MF, Bergeron P, Choo EF, Lau K, Ndubaku C, Dudley D, et al.
patients with relapsed/refractory chronic lymphocytic leukemia–results from Structure-guided rescaffolding of selective antagonists of BCL-XL. ACS Med
pre-planned interim analysis of the randomized phase 3 murano study. Blood Chem Lett. (2014) 5:662–7. doi: 10.1021/ml500030p
(2017) 130:LBA-2. doi: 10.1182/blood.v130.suppl1.LBA-2 200. Tao ZF, Hasvold L, Wang L, Wang X, Petros AM, Park CH, et al. Discovery of
184. Hillmen P, Munir T, Rawstron A, Brock K, Vicente SM, Yates F, et al. Initial a potent and selective BCL-XL inhibitor with in vivo activity. ACS Med Chem
results of ibrutinib plus venetoclax in relapsed, refractory CLL (Bloodwise Lett. (2014) 5:1088–93. doi: 10.1021/ml5001867
TAP CLARITY Study): high rates of overall response, complete remission 201. Muppidi A, Doi K, Edwardraja S, Drake EJ, Gulick AM, Wang HG,
and mrd eradication after 6 months of combination therapy. Blood (2017) et al. Rational design of proteolytically stable, cell-permeable peptide-
130:428. doi: 10.1182/blood.v130.suppl1.428 based selective Mcl-1 inhibitors. J Am Chem Soc. (2012) 134:14734–7.
185. Jain N, Thompson PA, Ferrajoli A, Burger JA, Borthakur G, Takahashi K, et doi: 10.1021/ja306864v
al. Combined venetoclax and ibrutinib for patients with previously untreated 202. Smith BJ, Lee EF, Checco JW, Evangelista M, Gellman SH, Fairlie WD.
high-risk CLL, and relapsed/refractory CLL: a phase II trial. Blood (2017) Structure-guided rational design of alpha/beta-peptide foldamers with
130:429. doi: 10.1182/blood.v130.suppl1.429 high affinity for BCL-2 family prosurvival proteins. Chembiochem (2013)
186. Fischer K, Al-Sawaf O, Fink AM, Dixon M, Bahlo J, Warburton S, et 14:1564–72. doi: 10.1002/cbic.201300351
al. Venetoclax and obinutuzumab in chronic lymphocytic leukemia. Blood 203. Varadarajan S, Vogler M, Butterworth M, Dinsdale D, Walensky LD, Cohen
(2017) 129:2702–5. doi: 10.1182/blood-2017-01-761973 GM. Evaluation and critical assessment of putative MCL-1 inhibitors. Cell
187. Stilgenbauer S, Morschhauser F, Wendtner CM, Cartron G, Hallek Death Differ. (2013) 20:1475–84. doi: 10.1038/cdd.2013.79
M, Eichhorst B, et al. Phase Ib study (GO28440) of venetoclax with 204. Belmar J, Fesik SW. Small molecule Mcl-1 inhibitors for
bendamustine/rituximab or bendamustine/obinutuzumab in patients with the treatment of cancer. Pharmacol Ther. (2015) 145:76–84.
relapsed/refractory or previously untreated chronic lymphocytic leukemia. doi: 10.1016/j.pharmthera.2014.08.003
Blood (2016) 128:4393. doi: 10.1182/blood.V128.22.4393 205. Nguyen M, Marcellus RC, Roulston A, Watson M, Serfass L, Murthy
188. Flinn IW, Gribben JG, Dyer MJ, Wierda W, Maris MB, Furman RR, et al. Madiraju SR, et al. Small molecule obatoclax (GX15-070) antagonizes MCL-
Safety, efficacy and MRD negativity of a combination of venetoclax and 1 and overcomes MCL-1-mediated resistance to apoptosis. Proc Natl Acad
obinutuzumab in patients with previously untreated chronic lymphocytic Sci USA. (2007) 104:19512–7. doi: 10.1073/pnas.0709443104
leukemia–results from a phase 1b study (GP28331). Blood (2017) 130:430. 206. O’Brien SM, Claxton DF, Crump M, Faderl S, Kipps T, Keating MJ, et al.
doi: 10.1182/blood.v130.suppl1.430 Phase I study of obatoclax mesylate (GX15-070), a small molecule pan-Bcl-2

family antagonist, in patients with advanced chronic lymphocytic leukemia. 224. Fernandez-Marrero Y, Spinner S, Kaufmann T, Jost PJ. Survival control of
Blood (2009) 113:299–305. doi: 10.1182/blood-2008-02-137943 malignant lymphocytes by anti-apoptotic MCL-1. Leukemia (2016) 30:2152–
207. Mohammad RM, Goustin AS, Aboukameel A, Chen B, Banerjee S, Wang 9. doi: 10.1038/leu.2016.213
G, et al. Preclinical studies of TW-37, a new nonpeptidic small-molecule 225. Brennan MS, Chang C, Tai L, Lessene G, Strasser A, Dewson G, et
inhibitor of Bcl-2, in diffuse large cell lymphoma xenograft model reveal al. Humanized Mcl-1 mice enable accurate pre-clinical evaluation of
drug action on both Bcl-2 and Mcl-1. Clin Cancer Res. (2007) 13:2226–35. MCL-1 inhibitors destined for clinical use. Blood (2018) 132:1573–83.
doi: 10.1158/1078-0432.CCR-06-1574 doi: 10.1182/blood-2018-06-859405
208. Schelman WR, Mohammed TA, Traynor AM, Kolesar JM, Marnocha RM, 226. Li Z, He S, Look AT. The MCL1-specific inhibitor S63845 acts synergistically
Eickhoff J, et al. A phase I study of AT-101 with cisplatin and etoposide with venetoclax/ABT-199 to induce apoptosis in T-cell acute lymphoblastic
in patients with advanced solid tumors with an expanded cohort in leukemia cells. Leukemia (2018). doi: 10.1038/s41375-018-0201-2. [Epub
extensive-stage small cell lung cancer. Invest New Drugs (2014) 32:295–302. ahead of print].
doi: 10.1007/s10637-013-9999-7 227. Luedtke DA, Niu X, Pan Y, Zhao J, Liu S, Edwards H, et al. Inhibition of Mcl-
209. Bruncko M, Wang L, Sheppard GS, Phillips DC, Tahir SK, Xue J, et al. 1 enhances cell death induced by the Bcl-2-selective inhibitor ABT-199 in
Structure-guided design of a series of MCL-1 inhibitors with high affinity acute myeloid leukemia cells. Signal Transduct Target Ther. (2017) 2:17012.
and selectivity. J Med Chem. (2015) 58:2180–94. doi: 10.1021/jm501258m doi: 10.1038/sigtrans.2017.12
210. Leverson JD, Zhang H, Chen J, Tahir SK, Phillips DC, Xue J, et al. Potent 228. Choudhary GS, Tat TT, Misra S, Hill BT, Smith MR, Almasan A, et al.
and selective small-molecule MCL-1 inhibitors demonstrate on-target cancer Cyclin E/Cdk2-dependent phosphorylation of Mcl-1 determines its stability
cell killing activity as single agents and in combination with ABT-263 and cellular sensitivity to BH3 mimetics. Oncotarget (2015) 6:16912–25.
(navitoclax). Cell Death Dis. (2015) 6:e1590. doi: 10.1038/cddis.2014.561 doi: 10.18632/oncotarget.4857
211. Caenepeel SR, Belmontes B, Sun J, Coxon A, Moody G, Hughes PE. 229. Aw A, Brown JR. The potential combination of BCL-2 inhibitors
Preclinical evaluation of AMG 176, a novel, potent and selective Mcl- and ibrutinib as frontline therapy in chronic lymphocytic leukemia.
1 inhibitor with robust anti-tumor activity in Mcl-1 dependent cancer Leuk Lymphoma (2017) 58:2287–97. doi: 10.1080/10428194.2017.13
models. Proc. Am. Assoc. Cancer Res. Annual Meeting 2017 (2017) 77:2027. 12387
doi: 10.1158/1538-7445.AM2017-2027 230. Patel VM, Balakrishnan K, Douglas M, Tibbitts T, Xu EY, Kutok
212. Thomas RL, Roberts DJ, Kubli DA, Lee Y, Quinsay MN, Owens JB, et al. JL, et al. Duvelisib treatment is associated with altered expression of
Loss of MCL-1 leads to impaired autophagy and rapid development of heart apoptotic regulators that helps in sensitization of chronic lymphocytic
failure. Genes Dev. (2013) 27:1365–77. doi: 10.1101/gad.215871.113 leukemia cells to venetoclax (ABT-199). Leukemia (2017) 31:1872–81.
213. Wang X, Bathina M, Lynch J, Koss B, Calabrese C, Frase S, et al. Deletion doi: 10.1038/leu.2016.382
of MCL-1 causes lethal cardiac failure and mitochondrial dysfunction. Genes 231. Bojarczuk K, Sasi BK, Gobessi S, Innocenti I, Pozzato G, Laurenti L, et
Dev. (2013) 27:1351–64. doi: 10.1101/gad.215855.113 al. BCR signaling inhibitors differ in their ability to overcome Mcl-1-
214. Hikita H, Takehara T, Shimizu S, Kodama T, Li W, Miyagi T, et al. Mcl-1 mediated resistance of CLL B cells to ABT-199. Blood (2016) 127:3192–201.
and Bcl-xL cooperatively maintain integrity of hepatocytes in developing and doi: 10.1182/blood-2015-10-675009
adult murine liver. Hepatology (2009) 50:1217–26. doi: 10.1002/hep.23126 232. Bui MH, Lin X, Albert DH, Li L, Lam LT, Faivre EJ, et al. Preclinical
215. Vick B, Weber A, Urbanik T, Maass T, Teufel A, Krammer PH, et al. characterization of BET family bromodomain inhibitor ABBV-075 suggests
Knockout of myeloid cell leukemia-1 induces liver damage and increases combination therapeutic strategies. Cancer Res. (2017) 77:2976–89.
apoptosis susceptibility of murine hepatocytes. Hepatology (2009) 49:627–36. doi: 10.1158/0008-5472.CAN-16-1793
doi: 10.1002/hep.22664 233. Pham LV, Huang S, Zhang H, Zhang J, Bell T, Zhou S, et al.
216. Fresquet V, Rieger M, Carolis C, Garcia-Barchino MJ, Martinez-Climent Strategic therapeutic targeting to overcome venetoclax resistance in
JA. Acquired mutations in BCL2 family proteins conferring resistance aggressive B-cell lymphomas. Clin Cancer Res. (2018) 24:3967–80.
to the BH3 mimetic ABT-199 in lymphoma. Blood (2014) 123:4111–9. doi: 10.1158/1078-0432.CCR-17-3004
doi: 10.1182/blood-2014-03-560284 234. Pinton P, Ferrari D, Rapizzi E, Di Virgilio F, Pozzan T, Rizzuto R. The
217. Song T, Chai G, Liu Y, Yu X, Wang Z, Zhang Z. Bcl-2 phosphorylation Ca2+ concentration of the endoplasmic reticulum is a key determinant
confers resistance on chronic lymphocytic leukaemia cells to the BH3 of ceramide-induced apoptosis: significance for the molecular mechanism
mimetics ABT-737, ABT-263 and ABT-199 by impeding direct binding. Br of Bcl-2 action. EMBO J. (2001) 20:2690–701. doi: 10.1093/emboj/20.
J Pharmacol. (2016) 173:471–83. doi: 10.1111/bph.13370 11.2690
218. Tahir SK, Smith ML, Hessler P, Rapp LR, Idler KB, Park CH, et al. Potential 235. Akl H, Vandecaetsbeek I, Monaco G, Kauskot A, Luyten T, Welkenhuyzen
mechanisms of resistance to venetoclax and strategies to circumvent it. BMC K, et al. HA14-1, but not the BH3 mimetic ABT-737, causes Ca2+
Cancer (2017) 17:399. doi: 10.1186/s12885-017-3383-5 dysregulation in platelets and human cell lines. Haematologica (2013)
219. Bodo J, Zhao X, Durkin L, Souers AJ, Phillips DC, Smith MR, et al. Acquired 98:e49–51. doi: 10.3324/haematol.2012.080598
resistance to venetoclax (ABT-199) in t(14;18) positive lymphoma cells. 236. Vervloessem T, Ivanova H, Luyten T, Parys JB, Bultynck G. The selective
Oncotarget (2016) 7:70000–10. doi: 10.18632/oncotarget.12132 Bcl-2 inhibitor venetoclax, a BH3 mimetic, does not dysregulate intracellular
220. Chiron D, Bellanger C, Papin A, Tessoulin B, Dousset C, Maiga Ca(2+) signaling. Biochim Biophys Acta Mol Cell Res. (2017) 1864:968–76.
S, et al. Rational targeted therapies to overcome microenvironment- doi: 10.1016/j.bbamcr.2016.11.024
dependent expansion of mantle cell lymphoma. Blood (2016) 128:2808–18. 237. Szegezdi E, Macdonald DC, Ni Chonghaile T, Gupta S, Samali A. Bcl-2
doi: 10.1182/blood-2016-06-720490 family on guard at the ER. Am J Physiol Cell Physiol. (2009) 296:C941–53.
221. Choudhary GS, Al-Harbi S, Mazumder S, Hill BT, Smith MR, Bodo J, doi: 10.1152/ajpcell.00612.2008
et al. MCL-1 and BCL-xL-dependent resistance to the BCL-2 inhibitor 238. Thomas LW, Lam C, Edwards SW. Mcl-1; the molecular
ABT-199 can be overcome by preventing PI3K/AKT/mTOR activation in regulation of protein function. FEBS Lett. (2010) 584:2981–9.
lymphoid malignancies. Cell Death Dis. (2015) 6:e1593. doi: 10.1038/cddis. doi: 10.1016/j.febslet.2010.05.061
2014.525 239. Germain M, Slack RS. MCL-1 regulates the balance between autophagy and
222. Herling CD, Abedpour N, Weiss J, Schmitt A, Jachimowicz RD, Merkel apoptosis. Autophagy (2011) 7:549–51. doi: 10.4161/auto.7.5.15098
O, et al. Clonal dynamics towards the development of venetoclax 240. Germain M, Nguyen AP, Le Grand JN, Arbour N, Vanderluit JL, Park DS, et
resistance in chronic lymphocytic leukemia. Nat Commun. (2018) 9:727. al. MCL-1 is a stress sensor that regulates autophagy in a developmentally
doi: 10.1038/s41467-018-03170-7 regulated manner. EMBO J. (2011) 30:395–407. doi: 10.1038/emboj.
223. Yecies D, Carlson NE, Deng J, Letai A. Acquired resistance 2010.327
to ABT-737 in lymphoma cells that up-regulate MCL-1 and 241. Verfaillie T, Salazar M, Velasco G, Agostinis P. Linking ER stress to
BFL-1. Blood (2010) 115:3304–13. doi: 10.1182/blood-2009-07-2 autophagy: potential implications for cancer therapy. Int J Cell Biol. (2010)
33304 2010:930509. doi: 10.1155/2010/930509

242. Malik SA, Orhon I, Morselli E, Criollo A, Shen S, Marino Conflict of Interest Statement: The authors declare that the research was
G, et al. BH3 mimetics activate multiple pro-autophagic conducted in the absence of any commercial or financial relationships that could
pathways. Oncogene (2011) 30:3918–29. doi: 10.1038/onc. be construed as a potential conflict of interest.
2011.104
243. Malik SA, Shen S, Marino G, BenYounes A, Maiuri MC, Kroemer G. Copyright © 2019 Adams, Clark-Garvey, Porcu and Eischen. This is an open-access
BH3 mimetics reveal the network properties of autophagy-regulatory article distributed under the terms of the Creative Commons Attribution License (CC
signaling cascades. Autophagy (2011) 7:914–6. doi: 10.4161/auto.7.8. BY). The use, distribution or reproduction in other forums is permitted, provided
15785 the original author(s) and the copyright owner(s) are credited and that the original
244. Maji S, Panda S, Samal SK, Shriwas O, Rath R, Pellecchia M, et al. Bcl-2 publication in this journal is cited, in accordance with accepted academic practice.
Antiapoptotic family proteins and chemoresistance in cancer. Adv Cancer No use, distribution or reproduction is permitted which does not comply with these
Res. (2018) 137:37–75. doi: 10.1016/bs.acr.2017.11.001 terms.

Targeting The Bcl-2 Family in B Cell Lymphoma

Uploaded by

Copyright:

Available Formats

Targeting The Bcl-2 Family in B Cell Lymphoma

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Targeting The Bcl-2 Family in B Cell Lymphoma

Uploaded by

Copyright:

Available Formats

REVIEW

published: 08 January 2019

Targeting the Bcl-2 Family in B Cell

Although lymphoma is a very heterogeneous group of biologically complex malignancies,

Frontiers in Oncology | www.frontiersin.org 1 January 2019 | Volume 8 | Article 636

comprehensively examines each member of the Bcl-2 protein

BCL-2 PROTEIN FAMILY AND APOPTOSIS

Pro-apoptotic Bcl-2 Family Members

Frontiers in Oncology | www.frontiersin.org 2 January 2019 | Volume 8 | Article 636

Family Mouse models Human patients

Frontiers in Oncology | www.frontiersin.org 3 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 4 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 5 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 6 January 2019 | Volume 8 | Article 636

transcriptionally modulates miRNA expression leading to altered

TARGETING ANTI-APOPTOTIC BCL-2

Frontiers in Oncology | www.frontiersin.org 7 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 8 January 2019 | Volume 8 | Article 636

TABLE 2 | Venetoclax as monotherapy in CLL and B cell lymphoma.

R/R CLL (175) I 116 ORR: 79; CR: 20 Neutropenia: 41

Frontiers in Oncology | www.frontiersin.org 9 January 2019 | Volume 8 | Article 636

R + V in R/R CLL (182) Ib 49 ORR: 86; CR: 51 Neutropenia: 53

Frontiers in Oncology | www.frontiersin.org 10 January 2019 | Volume 8 | Article 636

31 R/R ORR: 90; CR: 28

Frontiers in Oncology | www.frontiersin.org 11 January 2019 | Volume 8 | Article 636

TABLE 4 | Ongoing venetoclax combination studies in B cell lymphomas and CLL.

Phase N Population Trial number

Frontiers in Oncology | www.frontiersin.org 12 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 13 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 14 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 15 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 16 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 17 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 18 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 19 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 20 January 2019 | Volume 8 | Article 636

Frontiers in Oncology | www.frontiersin.org 21 January 2019 | Volume 8 | Article 636

You might also like