p97 Inhibition Synergistically Enhances Hypomethylating Therapy through Targeting of PLK1 in Acute Myeloid Leukemia.

UNLABELLED: Acute myeloid leukemia (AML) remains defined by therapeutic resistance, adverse genetic heterogeneity, and poor long-term survival, underscoring the need for mechanistically informed regimens that exploit core stress-adaptation liabilities. Polo-like kinase 1 (PLK1) is a central regulator of replication recovery and mitotic progression, yet direct PLK1 inhibitors have been limited by tolerability and incomplete target suppression. Here, we define a clinically actionable strategy that functionally targets PLK1 by combining inhibition of the AAA+ ATPase p97/valosin-containing protein with the hypomethylating agent decitabine (DAC). Using AML cell lines, primary patient specimens, and an orthotopic in vivo model, we show that the clinically relevant p97 inhibitor CB-5339 induces proteotoxic and replication stress, activates the unfolded protein response, and triggers apoptosis. Formal synergy analyses demonstrate that CB-5339 and DAC cooperate across molecular subtypes, including FLT3-ITD+, KMT2A-rearranged, and TP53-mutant AML, to reduce cell viability at pharmacologically relevant concentrations. Transcriptomic, biochemical, and genetic studies identify synergistic suppression of PLK1 as a central consequence of combination treatment, converting stress-dependent PLK1 reliance into a therapeutic vulnerability. Consistent with this mechanism, PLK1 knockdown phenocopies the antileukemic effects of the combination and enhances sensitivity to both agents. In vivo, CB-5339/DAC is well tolerated, significantly prolongs survival, reduces leukemic burden, and suppresses PLK1 in bone marrow blasts. Together, these data establish p97 inhibition as a rational means to exploit replication and proteotoxic stress in AML and provide strong rationale for clinical evaluation of CB-5339 plus DAC in high-risk disease.

SIGNIFICANCE: This study defines a clinically actionable strategy to overcome therapeutic resistance in AML by functionally suppressing PLK1 through combined p97 inhibition and hypomethylating therapy. By exploiting convergent proteotoxic and replication stress, the regimen produces robust, well-tolerated antileukemic activity across high-risk genetic subtypes, supporting near-term clinical evaluation.