Loss of KDM6A-mediated genomic instability and metabolic reprogramming differentially regulates responses to immune checkpoint therapy and chemotherapy in bladder cancer.

Mutations in genes encoding critical epigenetic regulators are frequently noted in bladder cancer, however, the impact of these mutations on therapeutic efficacy is unclear. One of the most common driver mutations in bladder cancer occurs in the KDM6A gene, which encodes a histone demethylase that promotes gene transcription. Retrospective analyses of patients with bladder cancer demonstrated that KDM6A mutations correlate with improved overall survival (OS) with immune checkpoint therapy (ICT), while they are associated with lower OS in patients undergoing cisplatin-based chemotherapy. Mechanistic studies utilizing CRISPR-Cas9 mediated deletion of Kdm6a showed reduced expression of DNA mismatch repair (MMR) and DNA double-stranded base repair (DSBR) genes in tumor cells with improved response to anti-PD-1 therapy and attenuated sensitivity to cisplatin-based chemotherapy in preclinical models of bladder cancer. Additionally, the loss of Kdm6a-mediated reduction in glycolysis and intratumoral lactate accumulation impaired histone 3 lysine 9 lactylation (H3K9la) and histone 3 lysine 18 lactylation (H3K18la) in Tregs with concurrent decrease in the expression of key genes including Foxp3, Tgfb and Pdcd1 and their immune-suppressive function. Further, reduced expansion of PD-1hi Tregs improved the ratio of cytotoxic T cells to Tregs and response to anti-PD-1 therapy in Kdm6a deficient tumor-bearing mice. Collectively, this study provided key insights into the role of KDM6A-mediated epigenetic regulation of DNA repair and metabolic reprogramming which potentially govern response to chemotherapy and ICT thus highlighting the utility of KDM6A mutation status for patient stratification and development of personalized treatment algorithms.