Abstract Despite the dramatic efficacies of imatinib and second-generation BCR-ABL kinase inhibitors (dasatinib and nilotinib) in chronic myelogenous leukemia (CML), these drugs fail to provide durable therapeutic benefit in patients with Philadelphia-chromosome positive (Ph+) BCR-ABL-induced acute lymphoblastic leukemias (ALLs). In contrast to chronic-phase CML, deletion of the CDKN2A (INK4A-ARF) tumor suppressor locus occurs in 65% of Ph+ ALL cases. Accordingly, introduction of cultured Arf−/− p185BCR-ABL-expressing (p185+) pre-B cells, but not their Arf+/+ counterparts, into healthy syngeneic recipient mice induces fulminant B cell leukemia; virtually every p185+, Arf−/− cell is a leukemia-initiating cell (LIC). We have now monitored disease progression and dasatinib-responsiveness in vivo by following the fate of p185+ Arf−/− luciferase-expressing LICs. In animals bearing high leukemic burdens (simulating the human clinical condition at diagnosis), two weeks of dasatinib therapy induced dramatic reductions in luminescent signals, but all animals harbored persistent, measurable deposits of drug-refractory cells. The vast majority of BCR-ABL alleles from these residual cells were free of kinase domain (KD) mutations, but rare leukemic clones harboring the T315I KD mutation, known to confer near-complete drug resistance to imatinib, dasatinib and nilotinib, were detectable in a subset of recipients. Following several weeks of continued dasatinib therapy, all mice developed clinical relapse preceded by dramatic increases in luminescent signals, both in the hematopoietic compartment and central nervous system. Many of these drug-resistant leukemic cells now harbored the T315I KD mutation. Animals that had been maintained in remission with 4 weeks of continuous dasatinib therapy quickly relapsed upon therapy discontinuation, almost always without evidence of KD mutations. In this clinically-relevant Ph+ ALL model, several factors including Arf loss-of-function, disease burden, intensity of therapy, and length of drug exposure interact to determine therapeutic outcome and to trigger confluent mechanisms of drug resistance. Critically, while continuous dasatinib therapy efficiently selects for and maintains cells harboring drug-resistant KD mutations that mediate eventual clinical relapse, most drug-refractory leukemic cells survive in hematopoietic tissues in the absence of KD mutations during maintenance therapy, implying that mutation-independent factors sustain LIC survival. We propose that Arf inactivation in Ph+ ALL (but not in CML) enhances the biological ‘fitness’ of leukemic cells and diminishes the efficiency with which targeted therapy can successfully eradicate drug-refractory disease. This facilitates the subsequent emergence of cell-intrinsic drug resistance, most frequently manifested as BCR-ABL KD mutations. Citation Information: Mol Cancer Ther 2009;8(12 Suppl):A253.
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