ORY-1001

Targeting LSD1 for acute myeloid leukemia (AML) treatment
Shujing Zhang a, Menghan Liu a, Yongfang Yao a, b,*, Bin Yu a, b,*, Hongmin Liu a, b,*
a School of Pharmaceutical Sciences, Key Laboratory of Advanced Drug Preparation Technologies, Ministry of Education, Zhengzhou University, Zhengzhou 450001, PR China
b State Key Laboratory of Esophageal Cancer Prevention & Treatment, School of Pharmaceutical Sciences, Zhengzhou University, Zhengzhou, Henan Province 450052, PR China

A R T I C L E I N F O

Keywords:
Histone demethylase AML treatment LSD1 inhibitors
Tranylcypromine derivatives Combination therapy
A B S T R A C T

Targeted therapy for acute myeloid leukemia (AML) is an effective strategy, but currently there are very limited therapeutic targets for AML treatment. Histone lysine specific demethylase 1 (LSD1) is highly expressed in many cancers, impedes the differentiation of cancer cells, promotes the proliferation, metastasis and invasion of cancer cells, and is associated with poor prognosis. Targeting LSD1 has been recognized as a promising strategy for AML treatment in recent years. Based on these features, in the review, we discussed the main epigenetic drugs tar- geting LSD1 for AML therapy. Thus, this review focuses on the progress of LSD1 inhibitors in AML treatment, particularly those such as tranylcypromine (TCP), ORY-1001, GSK2879552, and IMG-7289 in clinical trials. These inhibitors provide novel scaffolds for designing new LSD1 inhibitors. Besides, combined therapies of LSD1 inhibitors with other drugs for AML treatment are also highlighted.

⦁ Introduction

Leukemia is a malignant tumor of the hematopoietic system that seriously harms human health, especially in pediatric malignancies [1, 2]. Acute myeloid leukemia (AML) is the most common type of acute leukemia in adults [3,4]. AML is an aggressive malignant disorder of hematopoietic cells, characterized by limited differentiation and un-
controlled proliferation of myeloid progenitor cells [5–8]. The classifi-
cation and prognosis of leukemia are very complex. At present, the treatment of leukaemia mainly includes: chemotherapy, targeted ther-
apy, differentiation therapy, immunotherapy, hematopoietic stem cell transplantation (HSCT) and other methods (Fig. 1) [9–12]. Firstly, traditional chemotherapy as follows: the standard therapy is still in- duction therapy with Anthracycline and Cytarabine, “3 + 7”, followed
by chemotherapy or HSCT [13–15]. New cytotoxic chemotherapy drugs
include CPX-351 and Vosaroxin. CPX-351 is a liposome contains cyto- sine arabinoside and daunorubicin at a ratio of 5:1, showing higher ef- ficacy in animal models than using the same traditional drug. Phase II
clinical trial for the treatment of AML is ongoing (NCT02286726) [16–18]. Vosaroxin is a novel, non-anthracycline quin-olone derivative. A Phase II study of vosaroxin and decitabine is currently being evaluated
in elderly patients with newly diagnosed AML or high-risk
myelodysplastic syndrome (MDS) (NCT01893320) [19–21]. However, many patients with chemotherapy drugs have a poor prognosis and eventually develop recurrent refractory tumors, with a 5-year survival
rate of only 20 % [22]. In addition, for the immunotherapy, T cells expressing chimeric antigen receptors (CAR) have created an impressive efficacy in patients with lymphocytic leukemia [23], and further studies have confirmed that Folate Receptor beta (FR-beta) is a wonderful target used to treat AML with CAR T-cell, but clinical studies into the efficacy of anti-AML treatment are lacking [24]. Moreover, given that the HSCT requires high individual specificity and low universality, the clinical
application of HSCT in AML therapy is limited [24–26].
Furthermore, AML also can be effectively treated by induced dif- ferentiation. In 1988, Wang et al., successfully applied ATRA used to treat acute promyelocytic leukemia (APL), which initiated the clinical application of differentiation inducers in the treatment of leukemia. Subsequently, researchers found that ATRA combined with arsenic
trioxide (ATO) was very effective in treating APL [27–29]. However,
when ATRA was used on AML cells without the APL subtype, the results were not satisfactory. And the irreversible drug resistance induced by ATRA and arsenic trioxide can lead to clinical complete remission fail- ure. Additionally, 125(OH)2D3 or vitamin D analogues (VDAs) also can effectively induce differentiation of AML cells both in vivo and in vitro,

* Corresponding authors at: School of Pharmaceutical Sciences, Key Laboratory of Advanced Drug Preparation Technologies, Ministry of Education, Zhengzhou University, Zhengzhou 450001, PR China.
E-mail addresses: [email protected] (Y. Yao), [email protected] (B. Yu), [email protected] (H. Liu).

https://doi.org/10.1016/j.phrs.2020.105335

Received 24 September 2020; Received in revised form 6 November 2020; Accepted 24 November 2020
Available online 4 December 2020
1043-6618/© 2020 Elsevier Ltd. All rights reserved.

Please cite this article as: Shujing Zhang, Pharmacological Research, https://doi.org/10.1016/j.phrs.2020.105335

Fig. 1. The therapeutic methods of treatment of leukemia. the treatment of leukemia mainly includes: chemotherapy, targeted therapy, differentiation therapy, immunotherapy and hematopoietic stem cell transplantation (HSCT).

which is the reason for early clinical trials in patients with AML and MDS [30–32]. While, clinical trials are restricted by the dose-limiting hy- percalcemia, and the risk of development of resistance to 125(OH)2D3
[33,34]. Therefore, according to the above reasons, it is necessary to explore safer and more effective AML therapeutic strategies.
Epigenetic drugs have also played an irreplaceable role in the treatment of AML in recent years. Epigenetic modifications associated with AML include DNA methylation, histone methylation, and histone
deacetylation (Fig. 2) [35–39]. DNA methyltransferase inhibitors, aza-
citidine and decitabine, approved by FDA for use in adult MDS, have also been confirmed to extend survival in elderly AML patients [40,41]. The latest clinical study evaluated a new regimen of low-intensity chlor- propidine combined with low-dose cytosine alternating with decitabine, providing a new strategy for elderly patients with AML [42]. In addition, Histone methyltransferase inhibitor, 3-deazaneplanocin A (DZNep), has been shown in vitro and in animal studies to be applicable to AML [43, 44]. Moreover, Histone deacetylase (HDAC) inhibitor panobinostat combined with vorinostat were used for treatment of AML or high-risk patients with MDS, and currently in phase II/III clinical studies [45, 46]. The other two HDAC inhibitors, entinostat and pracinostat, are still
in the early stages of development [47–49]. Furthermore, LSD1 is also an irreplaceable target in AML. In this review, we aim to summarize the research progress of LSD1 inhibitors in the treatment of AML, focusing
on some novel LSD1 inhibitor scaffolds and new strategies for combining LSD1 inhibitors with other drugs for the AML therapy, which may pro- vide fresh approaches for AML.
⦁ Current status of LSD1 inhibitor in AML therapy

In 1987, Holiday proposed that epigenetics is the study of heritable gene expression changes without DNA sequence changes. While genetic changes are irreversible, epigenetic modifications are reversible. Therefore, epigenetic modification plays an irreplaceable role used to
treat diseases and is a great target for drug therapy [50–52]. Histone
methylation modification is one of the epigenetic regulatory mecha- nisms. The histone lysine specific demethylase 1 (abbreviated as LSD1, also known as KDM1A, AOF2, BHC110 or KIAA0601), the first histone demethylase discovered by professor Shi Yang in 2004, is a member of the flavin adenine dinucleotide (FAD)-dependent amine oxidase family of demethylases [53]. Inhibition of LSD1 can target both the scaffold and the enzymatic function of this protein. In terms of enzyme activity, LSD1 has a dual function of transcriptional inhibition and activation in response to differences in sites 4 and 9 of histone H3. Generally, LSD1 demethylates H3K4me2/1 and inhibits gene transcription by binding to CoREST or nucleosome remodeling and deacetylase repressive complex. However, when LSD1 activity specifically targets H3K9, it promotes
transcriptional activation by binding to the androgen receptor (AR) or estrogen receptor (ER) (Fig. 3A and B) [35,54–56]. In particular, LSD1-NuRD complex, as an inactivated enhancer of pluripotency pro-
gram during differentiation, is crucial to embryonic stem cell (ESC) gene expression program. Studies have shown that LSD1 is the key to the inactivation of enhancers during the differentiation of mouse ESCs [57]. Additionally, Mohammad et al. reported that the LSD1 inhibitor GSK2879552 increased LSD1 signal enrichment of the SCLC specific typical and super enhancers [58].
LSD1 can also play a gene regulatory role as a protein scaffold. lncRNA Hotair scaffolds HBXIP and the Hotair of LSD1 acted as scaf- folding to form c-MYC /HBXIP/Hotair/LSD1 complex, leading to c-MYC target gene transcription in human MCF-7 breast cancer cells (Fig. 3C) [59]. In addition, differentiation of myeloid leukemia cells resulting from LSD1 inhibitor also depended on LSD1 scaffold function. Such as, Maiques Diaz et al. demonstrated that drug-induced differentiation of myeloid leukemia cells was mainly due to the physical separation of LSD1/RCOR1 complex from GFI1, leading to the activation of the dependent myeloid transcription factor genes, rather than histone

Fig. 2. Inhibitors targeting epigenetic modifiers in acute myeloid leukemia. Inhibitors targeting epigenetic modifiers include: DNA methyltransferase inhibitors, azacitidine and decitabine; histone methyltransferase inhibitor, 3-deazaneplanocin A (DZNep); histone deacetylase (HDAC) inhibitors, panobinostat, entinostat and pracinostat; Histone lysine specific demethylase 1 (LSD1) inhibitors, Tranylcypromine, ORY-1001, IMG-7289 and GSK2879552.

Fig. 3. Lysine specific demethylase 1 (LSD1) dual functions as transcriptional repressor and activator. LSD1 that demethylates both ’Lys-4′ (H3K4me) and ’Lys-9′ (H3K9me) of histone H3,
thereby acting as a coactivator or a corepressor, depending on the context. A. Acts as a corepressor by mediating demethyla- tion of H3K4me, a specific tag for epigenetic transcriptional activation. B. Acts as a coactivator by mediating demethylation of H3K9me. C. LSD1 can also play a gene regulatory role as a protein scaffold. lncRNA Hotair scaffolds HBXIP and the Hotair of LSD1 acted as scaffolding to form c-MYC /HBXIP/Hotair/ LSD1 complex, leading to c-MYC target gene transcription in human MCF-7 breast cancer cells.

demethylation (Fig. 4A and B) [60].
Based on the biological characteristics of LSD1, an increasing num-
ber of studies indicate that LSD1 plays a vital role in cancer and is a wonderful target used to treat AML [59–62]. Numerous small molecule inhibitors of LSD1 are being developed for cancer treatment. Among
them, a number of irreversible LSD1 inhibitors have entered clinical trials for the treatment of AML with broad prospects.

⦁ The role of LSD1 in the progress of AML

LSD1 and corepressor CoREST regulate hematopoietic differentia- tion by mediating GFI1 and GFI1b. GFI1 and GFI1b regulate the pro- liferation, differentiation and survival of blood cells and are irreplaceable transcription factors in the hematopoietic process. Mouse model studies have confirmed that GFI1 is involved in the development and function of hematopoietic stem cells (HSCs), B and T cells, dendritic cells, granulocytes and macrophages, while GFI1b is necessary for the development of megakaryocytic and erythroid [63,64]. GFI1 controls the proliferation and differentiation of myeloid progenitor cells and plays a crucial role in the promotion of myeloid progenitor cells. LSD1 restricts the proliferation of hematopoietic progenitor and is a necessary
condition for terminal differentiation. For instance, by constructing an in vivo knockdown model, it was reported that LSD1 knockdown (LSD1-KD) caused granulomonocytic, erythroid and megakaryocytic progenitors to proliferate. However, it significantly inhibited the for- mation of terminal granulopoiesis, erythropoiesis and platelet. This suggests some serious side effects of LSD1 inhibitors such as thromo- botopenia. Notably, studies indicated that peripheral granulocytopenia, mononucleosis, anemia and thrombocytopenia are reversible after LSD1-KD termination [65,66].
Not only in the hematopoietic process, but also in AML, LSD1 in- hibitors work by blocking the interaction between LSD1 and the chro- matin transcription factor GFI1b [67]. The inhibition of LSD1 prevents GFI1-mediated inhibition of PU.1 target genes to induce AML differen- tiation. Inhibition of LSD1 plays an anti-leukemia role by reactivating
PU.1 and C/EBP alpha-dependent enhancers in AML [68–71]. In addi-
tion, in the constructed AML xenotransplantation model, pharmaco- logical inhibition of LSD1 led to the complete elimination of tumor growth in the AML xenograft model containing runx1-runx1t1 trans- locations [71]. At present, some irreversible inhibitors developed based on tranylcypromine (TCP) have entered clinical trials of AML therapy, and numerous new TCP derivatives are considered to be effective LSDI

Fig. 4. LSD1 inhibition causes separation of LSD1/CoREST from GFI1 at SPI1-bound enhancers, and finally resulted in local increase of histone acetylation and consequent increased transcription of nearby genes.

inhibitors. While, the development of effective reversible inhibitors faces enormous challenges now. At the same time, LSD1 inhibitor combined with some other drugs to further enhance the efficacy and overcome the resistance of acute myeloid leukemia cells to LSD1 inhi- bition is also under investigation.
⦁ LSD1 inhibitors in clinical trials of AML therapy

Tranylcypromine, a clinical treatment for depression (named TCP and PCPA), is a monoamine oxidase inhibitor (MAO), also known as an
irreversible LSD1 inhibitor [72–74]. Three clinical trials of Tranylcy-
promine used to treat AML and MDS are undergoing (https://www.cl inicaltrials.gov/ct2/home). for instance, on October 10th, 2014, a
⦁ The research progression of Novel LSD1 inhibitors in the treatment of AML
⦁ Irreversible LSD1 inhibitors

⦁ Novel cyclopropylamine derivatives. In addition to these irre- versible inhibitors developed based on tranylcypromine (TCP) which have entered clinical trials, some new TCP derivatives are also under active development (Table 2). TCP derivatives induce differentiation of AML by preventing GFI1-mediated inhibition of PU.1 target genes [68].

Table 2
Novel irreversible LSD1 inhibitors used in the treatment of AML.

Phase I/II study of the pharmacodynamics and efficacy of ATRA and TCP in patients with relapsed or refractory AML and AML without intensive
Compound Names
Structure In vitro or vivo
Effects
Ref

treatment was performed (CT identifier: NCT02261779). On October 23th, 2014, safety and tolerance of ATRA and TCP in combination was evaluated. in a phase I study. In addition, on March 24th, 2016, a Phase I/II study which investigated the effects of TCP-sensitized non-M3 AML cells on ATRA was implemented to determinate the maximum tolerated
dose (MTD) of TCP in combination with ATRA or with AraC (Cytar-
5a Improved the
survival rate after oral administration in promyeloid leukemia mouse
[77]

abine), and to evaluate the efficacy of TCP at the Recommended Phase II Dose (RP2D) in combination with ATRA or with AraC (CT identifier: NCT02717884).
Tranylcypromine (TCP) is the dominant stent for the design of irre- versible LSD1 inhibitors. Currently, LSD1 inhibitors which design based on TCP include ORY-1001 (Oryzon Genomics Barcelona, Spain),
Compounds 3
models Inhibited proliferation in
MV4—11 AML and
APL NB4 cells
[78]

GSK2879552 (GlaxoSmithKline) and IMG-7289 (Imago Biosciences), Clinical trials of LSD1 inhibitors used alone or in combination with ATRA for AML and MDS are being evaluated (https://www.clinicaltrial
7v Inhibited colony
formation of leukemia cells in
[79]

s.gov/ct2/home) (Table 1). Such as, Oryzon Genomics reported ORY- 1001 (also abbreviated as iadademstat, RG6016 or RO7051790), is an extremely efficient and selective covalent LSD1 inhibitor. Maes and colleagues determined in the mice PDX (patient-derived xenograft)
7ad
culture
Inhibited colony formation of leukemia cells in culture
[79]


model of T cell acute leukemia, ORY-1001 showed strong synergistic effects with standard therapeutic drugs or other selective epigenetic inhibitors to reduce the growth of AML xenograft models and extend survival [75,76]. Additionally, a phase I study of pharmacokinetics and safety of ORY1001 is currently undergoing used to treat patients with relapsed or refractory AML (EudraCT 2013 002447-29). Moreover, another irreversible LSD1 inhibitor, GSK2879552, developed by Glax- oSmithKline, is also used to treat AML, but a Phase I Dose Escalation Study of GSK2879552 in patients With Acute Myeloid Leukemia has been terminated because the risk benefit of relapsed refractory AML does not support the study (CT identifier: NCT02177812). Furthermore, a phase I study of IMG-7289 (Imago Biosciences), with or without ATRA, used to treat patients with AML or MDS have been completed (CT identifier: NCT02842827). Although these LSD1 inhibitors have shown favourable results in clinical trials, but given the urgent clinical need for
11b Inhibited the
cloning potential of promyelocytes in mice
11 g Inhibited the
cloning potential of promyelocytes in mice
11 h Inhibited the
cloning potential of promyelocytes in mice
9e Inhibited the
proliferation of THP-1 cells
[82]

[82]

[82]

[83]

new drugs to treat AML, so, it is very necessary to explore novel LSD1
inhibitors.

Table 1
LSD1 inhibitors in clinical trials.
LSD1 inhibitors Phase Trial number Disease(s) Study Status

ORY-1001 I/II EudraCT
Relapsed or
A phase I study of pharmacokinetics and safety of ORY1001 Unknown

GSK2879552,ATRA I
2013—002447-29 refractory AML
A Phase I Dose Escalation Study of GSK2879552 in Subjects With
Terminated

NCT02177812 AML

Acute Myeloid Leukemia (AML)

IMG – 7289, all-trans retinoic acid I NCT02842827 AML and MDS IMG-7289, With and Without ATRA, in Patients With Advanced
Myeloid Malignancies
Completed

Tranylcypromine (TCP),Tretinoin I/II NCT02261779 Relapsed or
refractory AML Tranylcypromine (TCP),Tretinoin I NCT02273102 AML,MDS and
Leukemia
Phase I/II Trial of ATRA and TCP in Patients With Relapsed or Refractory AML and no Intensive Treatment is Possible (TCP-AML) Phase 1 Study of TCP-ATRA for Adult Patients With AML and MDS (TCP-ATRA)
Unknown

Active, not recruiting

Tranylcypromine (TCP), all-trans retinoic acid, cytarabine
I/II NCT02717884 AML and MDS A phase I/II study of sensitization of Non-M3 AML blasts to ATRA
by TCP treatment
Recruiting

Trifiro et al. reported new TCP derivatives substituted on the cyclo- propyl moiety (5a) can significantly improve the survival rate after oral

Table 3
Novel reversible LSD1 inhibitors used in the treatment of AML.

administration in promyeloid leukemia mouse models [77]. In addition,
Fioravanti et al. prepared three series of TCP analogs, in which com-
Compound Names
Structure In vitro or vivo
Effects
Ref


pound 3 could significantly inhibit the proliferation of MV4 11 AML. Simultaneously, compounds 3 induced the expression of target genes GFI1b, ITGAM and KCTD12. [78]. Besides, another novel class of LSD1 inhibitors, N-substituted derivative 7v and 7ad of TCP, clinical candi- dates used to treat AML, are selective to monoamine oxidase (MAO-A and MAO-B) and effectively inhibits colony formation of leukemia cells
15 u Inhibited
proliferation in OCL-AML3, K562, THP-1 and U937
[84]

[79]. Furthermore, N-alkylated trans-2-phenylcyclopropylamine-based LSD1 Inhibitors, S2116 and S2157, exhibited enhanced LSD1 inhibi- tory activity and showed better selectivity over MAO [80].

However, most studies on the structure-activity relationship (SAR) of these TCP derivatives are racemes. Ji et al. provided SAR data for a series of TCP-based LSD1 inhibitors, including racemes and enantiomers that increase CD86 expression in human MV4 11 AML cells [81]. Addi- tionally, Valente et al. reported that compounds 11b, 11 g, and 11 h
Compound 17

Compound 32
Inhibited proliferation in a few leukemia cells
Inhibited colony formation of leukemia cells in culture
[85]

[86]

consumingly inhibited the cloning potential of promyelocytes in mice, and both inhibited LSD1 by inducing the expression of GFI1b and ITGAM genes [82].
⦁ Non-cyclopropylamine derivatives. The first irreversible LSD1 inhibitor that is not derived from a monoamine oxidase inhibitor 9e effectively inhibited THP-1 cell proliferation [83].
⦁ Reversible LSD1 inhibitors
Although numerous TCP derivatives have been proved to be effective irreversible inhibitors of LSD1, there are still big challenges in devel- oping effective reversible LSD1 inhibitors (Table 3). Li and colleagues indicated that the triazole-fused pyrimidine derivatives compound 15 u had a reversible inhibitory effect on LSD1 and competed with H3K4me2, and the selectivity of 15 u to LSD1 was higher than MAO-A/B, which provides a new scaffold for LSD1 inhibitors. The IC50 of 15 u in four
leukemia cell lines were 1.79, 1.30, 0.45, and 1.22 μM, respectively
[84]. Besides, Wu et al. showed that compound 17 has high selectivity
21 g Increased the
expression of the cell marker CD86 in human THP-1 cells
12a Induced
differentiation on the NB4 cell line of acute promyelocytic leukemia
8c up-regulated the
expression of the substitute cell marker CD86 in THP-1
2d increased the
global level of monomethylated and dimethylated of H3K4 proteins
[87]

[88]

[89]

[90]

to the related MAO-A and B (> 160x). It is a competitive inhibitor of
dimethylated H3K4 substrates and has a intense proliferation inhibition effect on a few leukemia cells with an EC50 value of 280nM [85]. Mold et al. developed acyclic scaffold-hops from gsk-690, further optimization of scaffold (4-cyanophenyl) glyceramide was used to obtain (4-cyano- phenyl) glycine derivative compound 32, which is a novel LSD1 in-
compound 11p
up-regulated the expression of CD86 in human THP-1 cells
[91]

hibitor [86]. In addition, they found 4-(pyrrolidin-3-yl) benzonitrile derivatives, compound 21 g, which significantly increased the expres- sion of CD86 in human THP-1 cells [87].
In addition, reversible LSD1 inhibitors have many other structural compounds. The 5-arylidene barbiturate derivative 12a has a strong differentiation inducing effect on the NB4 cell line of AML and signifi-
Complex 2 Inhibited
proliferation in OCL-AML3, K562, THP-1 and U937
[92]

cantly up-regulates the methylation level of H3K4 [88]. The stilbene
derivative compound 8c can up-regulate the expression of the substitute

cell marker CD86 in THP-1, and has a good inhibitory effect on THP-1 and MOLM-13 cells, with IC50 values of 5.76 and 8.34 μM, severally [89]. The polyamine analogue LSD1 inhibitor 2d induced cytotoxicity in
AML cells and increases the global level of monomethylated and dime- thylated of H3K4 proteins [90]. 5-hydroxypyrazole derivative com- pound 11p up-regulated the expression of CD86 in human THP-1 cells [91]. Complex 2, the first vanadium-based LSD1 inhibitor, with an IC50
value of 19.0 μM, has a good selectivity to MAO [92].
Some natural products also have selective inhibition on LSD1. Nat- ural protoberberine alkaloids epiberberine has obvious inhibitory effect on LSD1. Epiberberine also can significantly induce the expression of CD86, CD11b and CD14 in THP-1 and HL-60 cells and prolong the survival of the mice engrafted with THP-1 cells [93]. It is suggested that natural protoberberine alkaloids epiberberine can be used to further develop LSD1 inhibitors.
⦁ The current status of LSD1 inhibitors combined with other drugs in the treatment of AML
⦁ LSD1 inhibitors in combination with ATRA for AML therapy

⦁ ATRA. Generally, romyelocytic leukemia (PML)-retinoic acid receptor alpha (RARalpha) translocation always occurs in APL patients. Traditional drugs such as ATRA and arsenic trioxide (ATO) are adopted for the treatment of APL [94,95]. Kayser, S et al. showed that patients with ATRA or CTX/ATRA with ATO in t-APL presented a higher overall survival rate than those with CTX/ATRA [96]. However, ATRA and ATO induced irreversible resistance which could explain the clinical failure of complete remission. In addition, ATRA was clinically used for the
treatment of APL. In contrast, ATRA-based treatment was not effective in non-APL AML patients [97–99]. Therefore, the combination of ATRA

with other drugs used to treat non-APL was a promising therapeutic strategy.
⦁ +
⦁ LSD1 inhibitors combined with ATRA. LSD1 inhibitors com- bined with ATRA are expected to significantly alleviate non-APL AML patients. As a combination treatment, TCP and its derivative IMG-7289 were using with ATRA to evaluate the clinical outcome against leuke- mia. Significant effects on cytotoxic and differentiation marker were observed when ATRA and GSK2879552 was applied combinedly [100]. Schenk, T et al. substantiated that inhibition of LSD1 could reactivate the ATRA differentiation pathway in AML. And animal experiments confirmed that ATRA TCP drug combination has strong anti-leukemia effect, which is superior to either drug alone [101]. In addition, studies have revealed that acetyltransferase GCN5 promotes ATRA resistance in non-APL. This resistance was observed due to aberrant acetylation of histone 3 lysine 9 (H3K9Ac) residues by GCN5 which regulate the ex- pressions of stem cell and leukemia-associated genes. It is suggested that the high efficacy of GCN5 and LSD1 inhibitors combined with epigenetic therapy may make it possible for ATRA to be used in the differentiation therapy of non-APL AML [102].
⦁ LSD1 inhibitors in combination with HDAC inhibitors for AML therapy
⦁ HDAC inhibitors. Histone deacetylase (HDAC) media- tingchromosome modification is also involved in regulating gene tran- scription. In general, the acetylation of histones is conducive to the dissociation of DNA from histone octamer, which led to the conforma- tion of DNA in an “open” state and the activation of gene transcription. HDAC can promote the deacetylation of histones, make histones binding
to DNA closely and gene transcription inhibition [103–105]. The inhi-
bition of HDAC can induce apoptosis and prevent the expression of tumor-related proteins [106]. The pathogenic protein, AML1/ETO, re- cruits histone deacetylases (HDACs) that cause t [8,21] acute myeloid leukemia (AML). Panobinostat, one HDACi, was found to produce a strong anti-leukemia effect in mice bearing t [8,21] AML [107]. Abnormal translocation of the mixed-lineage leukemia (MLL) genes is one of the factors inducing AML and that MLL- rearranged AML is sus- ceptible to resistance to conventional chemotherapy. The synergistic inhibition of HDAC and MLL-rearranged AML cells, providing a fresh therapeutic strategy for MLL -rearranged leukemia patients with poor prognosis [108,109].
⦁ LSD1 inhibitor combined with HDAC inhibitors. Histone deace- tylase inhibitors combined with chemotherapy drugs such as doxoru- bicin or all-trans retinoic acid can improve the treatment of refractory
and high-risk AML patients [110–113]. Furthermore, Histone deacety-
lase inhibitors (HDACi) are used in combination with other epigenetic drugs for the treatment of AML [114–116].
LSD1 inhibitors in combination with other epigenetic drugs can significantly enhance the efficacy (Table 3). The LSD1 antagonist SP2509 attenuated LSD1 binding to corepressor CoREST and increased levels of P21, P27, and CCAAT/enhancer binding protein in AML cells. SP2509 in combination with histone deacetylase inhibitor panobinostat could significantly enhance the survival of the mice engrafted with human AML cells, and displayed synergistic lethal effects on primary AML cells [117] (Table 4).

Table 4
LSD1 inhibitor combined with other drugs in the treatment of AML.
⦁ LSD1 inhibitors in combination with EZH2 inhibitors for AML therapy
⦁ EZH2. Polycomb repressor complex 1 and 2 (PRC1 and PRC2) are transcriptional repressors. PRC2 demonstrates histone lysine meth-
yltransferase activity through its catalytic subunit consisting of EED, EZH2 and SUZ12. EZH2 is the core catalytic element [118–121]. Studies have shown that EZH2 is often overexpressed in ovarian cancer, sug-
gesting EZH2 may be an promising therapeutic target. Several small molecule inhibitors of EZH2 are in progress and are currently in clinical trials. High expression of EZH2 inhibits gene transcription, and inhibi-
tion of EZH2 induces differentiation of AML [122–124].
⦁ LSD1 inhibitor combined with EZH2 inhibitors. The inhibition on both EZH2 and LSD1 can exert synergistic effects against AML in vivo and in primary leukemia cells from AML patients. This synergistic mechanism was demonstrated by up-regulating H3K4me1/2, H3K9Ac and down-regulating H3K27me3, thereby reducing the anti-apoptotic protein Bcl-2. Although EZH2 and LSD1 have opposite histone methyl- ation functions, the combination of SP2509 and EPZ6438 resulted in the methylation changes of their respective sites (H3K4me1/2 and H3K27me3), the effects do not cancel each other. And the combination also led to significant accumulation of H3K9Ac, which altered the ex- pressions of Bcl-2, Bax, and Cyto-C. Notably, no cytotoxicity was detected in normal mononuclear cells isolated from healthy donors with either a single drug or a combination drug [125].
⦁ LSD1 inhibitors in combination with other drugs for AML therapy
Ishikawa, y et al. published a new irreversible LSD1 inhibitor, T- 3,775,440, which destroyed the interaction between LSD1 and GFI1b, and finally resulted in increased transcription of nearby genes. (Fig. 4). Further study found that in the subcutaneous tumor xenograft model and disseminated model of AML, the combination of LSD1 inhibitor T- 3,775,440 and the NEDD8-activating enzyme inhibitor pevonedistat could prolong the survival of mice, and synergistic anti-AML effect was achieved through transdifferentiation and DNA replication [126]. Notably, although LSD1 has been proven to play a crucial role in the pathogenesis of AML, preclinical studies show that AML cells often exhibit intrinsic resistance to LSD1 inhibitiors. Then, Abdel-aziz, a. k et al. found that inhibition of mTOR in vivo and in vitro can relieve resistance to LSD1 inhibitors in AML cell lines and primary cells are derived from the patient. Functional studies have shown that mTOR complex 1 (mTORC1) signaling is strongly triggered by LSD1 inhibition in drug-resistant leukemia. Insulin receptor substrate 1(IRS1)/ extra- cellular signaling of the key regulatory kinase ERK1/2 controls LSD1-induced mTORC1 activation [127]. It suggested that the combined therapy against LSD1 and mTOR might be a reasonable method for the treatment of AML.

⦁ Conclusion

AML relies on theclonal malignant proliferation of the hematopoietic myeloid system, mainly manifested as uncontrolled proliferation and the limited differentiation. Classification and prognosis are very complicated, that seriously endanger human health. At present, the therapy of leukemia includes chemotherapy, targeted therapy, differ- entiation therapy, monoclonal antibody therapy, stem cell trans- plantation and so on. However, different limitations have prevented

LSD1 Inhibitors Drugs In vitro or vivo Effects Ref
SP2509 HDAC inhibitor panobinostat Enhance the survival of the mice engrafted with human AML cells [113]
SP2509 EZH2 inhibitor (EPZ6438) Exert synergistic effects on against AML in vivo and in vitro [121]
T-3,775,440 NEDD8-activating enzyme inhibitor (pevonedistat) Prolong the survival of mice engrafted with human AML cells [122]

further development for AML treatment. Targeting LSD1 may be a promising strategy for AML treatment. Here, our review focuses on the progress of LSD1 inhibitors, and summarizes the LSD1 inhibitors alone or combined in clinical trials.
At present, some irreversible inhibitors developed based on tra- nylcypromine(TCP) have entered clinical trials. The discovery of novel scaffolds of LSD1 inhibitors such as phenylcyclopropylamine, poly- amine, glycine, indoles, pyrimidines and pyridines provides an ideal strategy for the development of LSD1 inhibitors. LSD1 inhibitors com- bined with other epigenetic drugs such as EZH2 and HDAC inhibitors can synergistically induce AML differentiation. To address the problem of resistance to LSD1 inhibitors in AML cells, combined LSD1 and mTOR inhibitors can overcome the resistance to LSD1 inhibitors in AML cell lines and primary patient-derived primary cells. These novel LSD1 in- hibitors and combination regimens provide new therapeutic strategies for the treatment of AML.
Funding

This work was supported by the National Natural Science Foundation of China (Nos. 81903623, 81773562, 81973177 and 81703326), Pro-
gram for Science & Technology Innovation Talents in Universities of Henan Province (No. 21HASTIT045), China Postdoctoral Science Foundation (Nos. 2019M652586, 2018M630840 and 2019T120641),
and the Postdoctoral Research Grant in Henan Province (Project No. 19030008).
Declaration of Competing Interest

The authors declare no conflict of interest, financial or otherwise.

Acknowledgment

None declared.

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