Normal Acute Myeloid Leukemia Research Articles

Functions of N6-methyladenosine (m6A) RNA modifications in acute myeloid leukemia.

N6-methyladenosine (m6A) is the most common modification of eukaryotic RNA. m6A participates in RNA splicing, nuclear export, translation, and degradation through regulation by methyltransferases, methylation readers, and demethylases, affecting mRNA stability and translation efficiency. Through the dynamic and reversible regulatory network composed of " Writers-Erasers-Readers", m6A modification plays a unique role in the process of hematopoiesis. Acute myeloid leukemia (AML) is a heterogeneous disease characterized by malignant proliferation of hematopoietic stem cells/progenitor cells. Many studies have shown that m6A-related proteins are abnormally expressed in AML and play an important role in the occurrence and development of AML, acting as carcinogenic or anticancer factors. Here, we describe the mechanisms of action of reversing m6A modification in hematopoiesis and AML occurrence and progression to provide a basis for further research on the role of m6A methylation and its regulatory factors in normal hematopoiesis and AML, to ultimately estimate its potential clinical value.

B7-H3 in acute myeloid leukemia: From prognostic biomarker to immunotherapeutic target.

B7-H3 (CD276), an immune checkpoint protein of the B7 family, exhibits significant upregulation in solid tumors and hematologic malignancies, exerting a crucial role in their pathophysiology. The distinct differential expression of B7-H3 between tumors and normal tissues and its multifaceted involvement in tumor pathogenesis position it as a promising therapeutic target for tumors. In the context of acute myeloid leukemia (AML), B7-H3 is prominently overexpressed and closely associated with unfavorable prognoses, yet it has remained understudied. Despite various ongoing clinical trials demonstrating the potential efficacy of immunotherapies targeting B7-H3, the precise underlying mechanisms responsible for B7-H3-mediated proliferation and immune evasion in AML remain enigmatic. In view of this, we comprehensively outline the current research progress concerning B7-H3 in AML, encompassing in-depth discussions on its structural attributes, receptor interactions, expression profiles, and biological significance in normal tissues and AML. Moreover, we delve into the protumor effects of B7-H3 in AML, examine the intricate mechanisms that underlie its function, and discuss the emerging application of B7-H3-targeted therapy in AML treatment. By juxtaposing B7-H3 with other molecules within the B7 family, this review emphasizes the distinctive advantages of B7-H3, not only as a valuable prognostic biomarker but also as a highly promising immunotherapeutic target in AML.

A novel t(X;21)(p11.4;q22.12) translocation adds to the role of BCOR and RUNX1 in myelodysplastic syndromes and acute myeloid leukemias.

In myeloid neoplasms, both fusion genes and gene mutations are well-established events identifying clinicopathological entities. In this study, we present a thus far undescribed t(X;21)(p11.4;q22.12) in five cases with myelodysplastic syndrome (MDS) or acute myeloid leukemia (AML). The translocation was isolated or accompanied by additional changes. It did not generate any fusion gene or gene deregulation by aberrant juxtaposition with regulatory sequences. Molecular analysis by targeted next-generation sequencing showed that the translocation was accompanied by at least one somatic mutation in TET2, EZH2, RUNX1, ASXL1, SRSF2, ZRSR2, DNMT3A, and NRAS genes. Co-occurrence of deletion of RUNX1 in 21q22 and of BCOR in Xp11 was associated with t(X;21). BCOR haploinsufficiency corresponded to a significant hypo-expression in t(X;21) cases, compared to normal controls and to normal karyotype AML. By contrast, RUNX1 expression was not altered, suggesting a compensatory effect by the remaining allele. Whole transcriptome analysis showed that overexpression of HOXA9 differentiated t(X;21) from both controls and t(8;21)-positive AML. In conclusion, we characterized a new recurrent reciprocal t(X;21)(p11.4;q22.12) chromosome translocation in MDS and AML, generating simultaneous BCOR and RUNX1 deletions rather than a fusion gene at the genomic level.

[Gene Profile and Clinical Significance of Concomitant Mutations in CN-AML Patients with CEBPA Mutation].

To analyze the occurrence of concomitant gene mutations in cytogenetically normal acute myeloid leukemia (CN-AML) patients with CEBPA mutation and its impact on the clinical characteristics and prognosis of the patients. 151 newly diagnosed patients with CN-AML in the Second Hospital of Shanxi Medical University from June 2013 to June 2020 were analyzed retrospectively. 34 common genetic mutations associated with hematologic malignancies were detected by next-generation sequencing technology. The occurrence of concomitant gene mutations in patients with CEBPA positive and negative groups was compared, and the correlation between concomitant mutations in different functional groups and the clinical characteristics and prognosis of CN-AML patients with CEBPA mutation was analyzed. In 151 patients with CN-AML, 55 (36.42%) were positive for CEBPA mutation (including 36 cases of CEBPAdm and 19 cases of CEBPAsm), of which 41 (74.55%) had co-mutations with other genes. The main mutated genes were GATA2 (25.45%, 14/55), TET2 (21.82%, 12/55), FLT3 (20.00%, 11/55), NRAS (12.73%, 7/55) and WT1 (9.09%, 9/55), etc. Some cases had two or more concomitant gene mutations. Grouping the mutant genes according to their functions showed that CEBPA+ group had lower mutation rates of histone methylation (P =0.002) and chromatin modification genes (P =0.002, P =0.033), and higher mutation rates of transcription factors (P =0.037) than CEBPA- group. In 55 patients with CEBPA+ CN-AML, the platelet count at diagnosis in signaling pathway gene mutation-positive group was lower than that in the mutation-negative group (P =0.005), the proportion of bone marrow blasts in transcription factor mutation-positive group was higher than that in the mutation-negative group (P =0.003), and the onset age in DNA methylation gene mutation-positive group and chromatin modifier mutation-positive group was older than that in the mutation-negative group, respectively (P =0.002, P =0.008). DFS of CEBPA+ CN-AML patients in signaling pathway gene mutation group was shorter than that in signaling pathway gene mutation-negative group (median DFS: 12 months vs not reached) (P =0.034). Compared with DNA methylation gene mutation-negative group, CEBPA+ CN-AML patients with DNA methylation gene mutation had lower CR rate (P =0.025) significantly shorter OS and DFS (median OS: 20 months vs not reached, P =0.006; median DFS: 15 months vs not reached, P =0.049). OS in patients with histone methylation gene mutation was significantly shorter than that in the histone methylation gene mutation-negative group (median OS: 12 months vs 40 months) (P =0.008). Multivariate analysis of prognostic factors showed that the proportion of bone marrow blasts (P =0.046), concomitant DNA methylation gene mutation (P =0.006) and histone methylation gene mutation (P =0.036) were independent risk factors affecting the prognosis. CN-AML patients with CEBPA mutation have specific concomitant gene profile, and the concomitant mutations of different functional genes have a certain impact on the clinical characteristics and prognosis of the patients.

Internal m 6 A and m 7 G RNA modifications in hematopoietic system and acute myeloid leukemia.

Epitranscriptomics focuses on RNA modifications-mediated post-transcriptional regulation of gene expression. The current decade has witnessed tremendous progress in understanding the landscapes and biological functions of RNA modifications as prompted by potent analytical approaches. The hematopoietic system provides a lifelong supply of blood cells, and gene expression is tightly modulated during the differentiation of hematopoietic stem cells (HSCs). Dysregulation of gene expression during hematopoiesis may lead to severe disorders, including acute myeloid leukemia (AML). Emerging evidence has indicated the involvement of mRNA modification system in normal hematopoiesis and AML pathogenesis, which led to the accelerating development of small-molecule inhibitors targeting N6-methyladenosine (m 6 A) modification machinery for treatment. Here, we summarize the latest findings and address the state-of-the-art knowledge on the role of m 6 A and N7-methylguanine (m 7 G) in both physiological and pathological conditions in the hematopoietic system. Furthermore, we discuss the therapeutic potential and limitations of cancer treatment targeting m 6 A.

Targeting PRAME for acute myeloid leukemia therapy.

Despite significant progress in targeted therapy for acute myeloid leukemia (AML), clinical outcomes are disappointing for elderly patients, patients with less fit disease characteristics, and patients with adverse disease risk characteristics. Over the past 10 years, adaptive T-cell immunotherapy has been recognized as a strategy for treating various malignant tumors. However, it has faced significant challenges in AML, primarily because myeloid blasts do not contain unique surface antigens. The preferentially expressed antigen in melanoma (PRAME), a cancer-testis antigen, is abnormally expressed in AML and does not exist in normal hematopoietic cells. Accumulating evidence has demonstrated that PRAME is a useful target for treating AML. This paper reviews the structure and function of PRAME, its effects on normal cells and AML blasts, its implications in prognosis and follow-up, and its use in antigen-specific immunotherapy for AML.

Differential prognostic values of the three AKT isoforms in acute myeloid leukemia

The PI3K-AKT-mTOR pathway lies at the confluence of signaling pathways in which various components are subjected to activating genetic alterations in acute myeloid leukemia (AML), thus contributing to oncogenesis. Three AKT isoforms exist in humans. However, whether one isoform predominates in AML remains unknown. This study reveals that AKT3 behaves very distinctly than AKT1 or AKT2 in both normal myeloid differentiation and AML. During normal differentiation, AKT3 is preferentially expressed in hematopoietic stem cells whilst AKT1 becomes preferentially expressed as cells differentiate into granulocytes or monocytes. AKT2 expression remains unchanged. In AML, AKT3 expression varies widely among patient samples and is counterintuitively high in mature/monocytic leukemia. Furthermore, a low level of AKT3 expression is strongly correlated to genetic alterations associated with a better outcome (NPM1 mutations and RUNX1-RUNX1T1 translocation), while a high level is correlated to alterations associated to a bad outcome (RUNX1 mutations; and SRSF2, U2AF1, SF3B1, ASXL1 and BCOR mutations occurring frequently in MDS and MPN). Consistently, a high AKT3 expression level appears as a very strong predictor of poor survival. Curiously, although modestly varying among AML samples, a high AKT1 expression shows in contrast as a strong predictor of a better patient outcome. These data suggest that AKT3 and AKT1 expressions have strong, yet opposite, prognostic values.

Abstract 3604: NKX101, an allogeneic off-the-shelf NKG2D CAR-NK cell therapy, has potent in vitro cytotoxicity against patient-derived AML leukemic stem cells and non-leukemic stem cell blasts

Abstract Introduction: Acute myeloid leukemia (AML) is a malignancy of immature myeloid cells characterized by rapid proliferation of abnormal myeloblasts. Treatment options for patients with AML are limited, especially for relapsed/refractory (r/r) disease. Leukemic cells with stem cell features, known as leukemic stem cells (LSCs), have been implicated as the origin of relapse in minimal residual disease positive (MRD+) AML (Khaldoyanidi et al. 2022, Kamel et al. 2022). NKX101 is an allogeneic, off-the-shelf, healthy donor-derived chimeric antigen receptor (CAR) NK cell therapy candidate engineered to express an NKG2D CAR and membrane bound IL-15. In a clinical trial, NKX101 has shown promise for the treatment of r/r AML, including generating complete responses (CR) with MRD negativity (MRD−). In this study, we utilize a flow cytometry-based approach to (i) evaluate the cell surface expression of NKG2D-Ls on normal cells vs. primary AML blasts, (ii) assess the expression pattern of NKG2D-Ls on AML blast subsets, and (iii) determine NKX101 cytotoxic killing of LSC and non-LSC AML blasts. Methods: NKX101 cells were generated from peripheral blood leukopaks from healthy donors. Cryopreserved bone marrow mononuclear cells (BMMCs) were obtained from AML patients (n=20) and healthy donors (n=10) in accordance with approved IRB protocols. AML somatic mutation status was determined using an Illumina TruSight® Myeloid Sequencing Panel. NKX101 cytotoxicity against patient-derived AML blasts was assessed using a flow cytometry-based assay that measured specific cytotoxicity and AML blast/LSC markers. NKG2D-L expression was determined using flow cytometry with antibodies specific to individual NKG2D-Ls. Results: Utilizing patient-derived primary samples, we demonstrate that NKG2D-Ls are expressed on AML blast cells and expressed at higher levels on AML blast cells compared to healthy normal hematopoietic cells (p = 0.002). Furthermore, we show that NKG2D-Ls are expressed at similar levels on LSCs compared to non-LSC AML blast populations. Target cell specific flow cytometry-based cytotoxicity assays revealed that NKX101 potently kills patient-derived AML blasts in a dose-dependent manner. Moreover, NKX101 had similar cytotoxic potency against both LSC and non-LSC AML blasts. Conclusions: In summary, we show that NKG2D-Ls are expressed on the surface of both LSC and non-LSC AML blasts and at levels above those observed in normal hematopoietic cells. Additionally, the ability of NKX101 to potently kill AML LSC blasts suggests that NKG2D-L targeting may be a viable mechanism for eliminating LSCs in the blood and bone marrow of patients with r/r AML. Taken together, these data support NKG2D-Ls as promising therapeutic targets for AML and support further investigation of NKX101 CAR-NK therapy for the treatment of r/r AML. Citation Format: Kyle Hansen, Cynthia Cho, Nishi Kothari, David Shook, James Trager. NKX101, an allogeneic off-the-shelf NKG2D CAR-NK cell therapy, has potent in vitro cytotoxicity against patient-derived AML leukemic stem cells and non-leukemic stem cell blasts [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3604.

GATA2 mutant variant allele frequency may reflect prognosis in Chinese adult patients with de novo cytogenetically normal acute myeloid leukemia.

In this study, we analyzed GATA2 mutations (GATA2mut) and co-mutations in 166 Chinese patients with cytogenetically normal acute myeloid leukemia. This was done through targeted next-generation sequencing of 34 genes associated with myeloid leukemia. GATA2mut was identified in 17 (10%) patients being significantly correlated with co-mutations in CCAAT/enhancer-binding protein alpha (CEBPA) double mutation (P = 0.001). We observed that the N-terminal zinc finger domain (ZF1) was linked to CEBPA mutations, while the C-terminal zinc finger domain (ZF2) was associated with Wilms' tumor 1 (WT1) mutations. It was also noted that patients with GATA2mut had lower platelet counts at diagnosis (P = 0.032). In the entire cohort, GATA2mut had no significant prognostic impact on overall survival (OS) (P = 0.762) and relapse-free survival (RFS) (P = 0.369) compared to patients with GATA2wt. The OS (P = 0.737) and RFS (P = 0.894) of the ZF1 mutation were similar to those of the ZF2 mutation. Most patients with GATA2 mutations were classified in the ELN2022 favorable- and intermediate-risk groups. GATA2mut patients in the favorable-risk group were divided into GATA2High and GATA2Low groups using a median cutoff variant allele frequency (VAF) of 40.13%. GATA2High patients were associated with worse OS (P = 0.031) and RFS (P = 0.021) than GATA2Low patients. In the intermediate-riskgroup, the high median VAF ofGATA2 (≥38.51%) had no significant effect in OS and RFS compared with the low median VAF (<38.51%). This study offers new insights on the prognosis of GATA2mut in the favorable-risk group, where VAF can be used as a guide.

Tri-ing to decipher trisomy AML.

Lam etal. compared trisomy acute myeloid leukaemia (AML) patients (inclusive of single trisomy, double trisomy or tetrasomy cases) with cytogenetically normal AML to uncover distinguishing molecular and prognostic features of trisomy AML. The study contributes to our understanding of trisomy AML, but the heterogeneity of trisomy subtypes remains a barrier to its study. Commentary on: Lam etal. Distinct karyotypic and mutational landscape in trisomy AML. Br J Haematol 2024;204:939-944.

Stem-Cell Enriched Cellular Hierarchy of TP53 Mutant Acute Myeloid Leukemia Is Vulnerable to Targeted Protein Degradation of c-MYC

Deregulation of MYC genes occurs in up to 70% of all human cancers and is associated with hallmarks of cancer including mitochondrial and ribosomal biogenesis, cell cycle progression, and metabolic abnormalities. TP53 regulates MYC while MYC suppresses TP53, suggesting counteracting negative feedback loops. Therefore, MYC or its function can be activated when TP53 is not functional. TP53 mutations occur in 30% of relapsed/refractory acute myeloid leukemias (AMLs) patients' survival is dismal, and there are no effective therapies for these patients. Compared to TP53 wild-type (TP53wt), TP53 mutant (TP53mut) AMLs have lower percentages and numbers of leukemia blasts with increased immature CD34+ cells and resistance to chemo- or molecularly targeted therapies. However, the exact cellular hierarchy of TP53mut AML has not been elucidated. We observed significantly increased MYC mRNA levels in (TP53mut), as compared to TP53wt AML, and also increased levels in TP53mut versus TP53wt AML leukemia stem cell (LSC) fractions. This finding was confirmed in a dataset from the Munich Leukemia Laboratory (N = 732). We found significantly upregulated MYC pathways in TP53mut compared to TP53wt AML LSC. We confirmed the increased MYC mRNA levels at the protein level in TP53mut AML by single-cell mass cytometry (CyTOF). To dissect the cellular hierarchy in TP53mut AML, we performed single-cell RNA sequencing of 32 BM samples from healthy donors (N = 3), newly diagnosed, high-risk TP53wt (N = 7) and TP53mut (N = 22) AML patients, with 6,685, 10,687 and 10,687 cells from normal, TP53wt and TP53mut AML bone marrow (BM) cells, respectively. We found highly enriched HSC-like cells and reduced progenitor- and GMP-like cells in TP53mut AML compared to normal BM (NBM) and TP53wt AML samples. We overlayed MYC expression levels on the mapping of cellular components and found higher MYC levels in HSC-like cells in TP53mut AML compared to HSC and HSC-like cells in NBM and TP53wt AML samples, suggesting enrichment of immature HSC-like cells and increased activity of MYC in TP53mut AML LSCs ( Fig. A). To target c-MYC and MYC signaling, we utilized GT19715, the first-in-class cereblon modulator (CELMoD) for c-MYC protein (Nishida, ASH 2022). CyTOF confirmed the presence of much increased c-MYC protein levels in primary CD34+ AML than in CD34+ NBM hematopoietic stem cells (HSCs). Notably, CD34+ AML cells showed much greater sensitivity to GT19715 compared to CD34+ NBM cells. Data suggest on-target activity of GT19715 against c-MYC in LSCs with a therapeutic window between LSCs vs. NBM HSCs. Intriguingly, c-MYC protein levels are higher in CD34+CD38+ than in CD34+CD38- AML cells, suggesting that c-MYC drives the proliferation of AML progenitor cells differentiating from quiescent LSCs. Consequently, CD34+CD38+ AML progenitor cells exhibited greater sensitivity to GT19715 compared to CD34+CD38- LSCs. Using paired, TP53 null HL-60 GT19715-sensitive and -resistant cells generated through chronic exposure to GT19715, we interrogated the impact of GT19715 on metabolic changes. GT19715 induced pronounced reductions in basal and maximal oxygen consumption rates (OCRs) in GT19715-sensitive HL-60 cells. GT19715 reduced both basal, glutamine- and glucose-dependent extracellular acidification rates (ECARs) in GT19715-sensitive cells while no inhibition in OCRs or ECARs was observed in GT19715-resistant cells. GT19715 severely inhibited ECARs even after adding glucose to GT19715-sensitive cells, suggesting irreversible inhibition of glycolysis as one of the mechanisms of action of GT19715. GT19715 profoundly reduced AML blasts in TP53mut AML samples (N = 3) ( Fig. B), and in a very aggressive patient-derived xenograft (PDX) TP53mut AML model established from a patient with TP53 p.Y220C and p.P151A mutations along with MECOM rearrangement and K/NRAS mutations. In humanized Crbn I391V mice, where the Crbn-mediated protein degradation is operational, GT19715 only reduced WBC counts along with minimal body weight loss. GT19715 but did not reduce total mouse BM CD45+ cells, suggesting favorable toxicity profiles of GT19715. In conclusion, TP53mut AML comprised highly enriched LSC populations compared to TP53wt AML and targeting of c-MYC protein is highly effective in TP53mut AML in vitro and in vivo with a therapeutic window between AML LSC and normal hematopoietic cells.

Selected Genomic Structural Variants Refine ELN-Based Prognostic Stratification of Patients with Acute Myeloid Leukemia and Normal Karyotype

Background. Normal karyotype Acute Myeloid Leukemia (nk-AML) accounts for 40% of all AML. Conventionally, nk-AML patients (pts) have been associated with the ELN favorable and intermediate risk category, characterized by extreme prognostic heterogeneity, representing an unmet therapeutic need especially as regards effective positioning of allogeneic transplantation (ASCT) as consolidation treatment. Aim. To improve risk stratification of nk-AML, on top of 2017 ELN criteria, by identification of structural variants (SV) with prognostic significance through the analysis of whole genome sequencing by long reads Nanopore platform. Patients and Methods. A total of 247 nk-AML pts receiving intensive therapy was included. The learning cohort included 95 pts from the prospective NILG 02/06 trial ( Bassan R Blood Adv 2019; 3:1103) comparing standard vs high-dose chemotherapy and 67 pts from the prospective GIMEMA AML1310 trial of risk-adapted, MRD-directed therapy ( Venditti A, Blood 2019;134:935). The validation cohort comprised 85 pts from Florence database. Whole genome long-read nanopore sequencing was performed on GridION platform to a median depth of 5x. After alignment to hgr38 genome, only those SV that had been concurrently identified by 4 independent callers were retained for analysis. Results. In the whole series (WS),197 pts (79.7%) obtained CR, 91 (46.2%) relapsed; 50 pts (20.2%) were primary refractory, 83 (33.6%) underwent ASCT. According to ELN criteria, 56.7%, 29.2% and 14.1% of the pts were in the favorable, intermediate and adverse risk category. Median survival (OS) was 16.9mo (9-24.7) in adverse risk category, 24.1mo (4.5-43.7) intermediate, and not reached in favorable risk category (P= 0.00007). However, adverse and intermediate category did not differ significantly (P=0.63), as expected considering the selection of nk-AML. Extensive filtering against 100 healthy donors and publicly available datasets of genomic variants to remove SV with &amp;gt;0.01% allele frequency resulted in 2,038 SV; after removal of private SV (ie, present in ≤2 pt), 122 SV were finally retained. Univariate regression analysis resulted in 10 SV associated with OS, of which 7 were validated with independent technology (Sanger and high-resolution melting, HRM). Multivariate analysis including all ELN-risk score variables showed that 5 of the 7 SV were independently associated with OS (hence, referred as high-risk variants, HRV). Three HRV affected the locus of coding genes on Chr4 q32.3 (inversion spanning 6,103bp), Chr5 p12 (333bp insertion) and Chr9 q34.3 (57bp deletion); Chr3 q26.1 (64bp insertion) in a Long Intergenic Non-Protein Coding RNA gene; Chr2 p13.2 (64bp deletion), in intergenic region. Presence of HRV impacted on OS with HR of 4.1 (95%CI,2.4-7; P=1.5e-7) in the learning cohort and HR 3.4 (95%CI, 1.5-7.6; P=0.003) in the validation cohort. Censoring at ASCT had no impact in either cohort. In total, 29 pts (11.7%) were HRV+, and their OS was 12.6mo (95%CI, 5.4-19.9) vs not reached (95%CI, 33.5-40.9; P=8.4183e-11) in HRV- pts (HR 3.9, 95%CI, 2.5-6; P=1.6261e-9) (Figure 1). DFS and EFS was 7mo (95%CI: 3.6-10.5) and 14.6mo (95%CI,2.1-27) in HRV+ pts vs not reached (95%CI, 31.7-40) and 30mo (95%CI: 29.9-30.1) (P&amp;lt;0.01 for both). Also, the rate of relapse was higher among HRV+, 58.6% vs 34.4% (P=0.01), with a trend to lower rate of CR attainment (72.4% vs 82.6%). There was no remarkable difference between HRV+ and HRV- pts as regarded frequency and type of ELN molecular variables. We finally evaluated whether integration of HRV within ELN risk score might improve the predictive performance of the latter. The resulting model enlisted 4 tiers, favorable (median OS not reached), intermediate (27.4mo, 95%CI: 3.6-51.1, HR:2.4; 95%CI,1.5-3.8), adverse (21.5mo, 95%CI: 5.4-37.6, HR:2.5; 95%CI,1.4-4.3) and HRV+ (12.6mo, 95%CI: 5.4-19.9, HR:5.9; 95%CI,3.6-9.8) categories (P=1.3395e-12) (Figure 2). Of note, the HRV+ category included 79.3% of pts otherwise categorized as ELN favorable or intermediate. Conclusions. We have identified, by long-read whole genome sequencing, a set of 5 structural variants that marks a subgroup of nk-AML pts with outmost dismal prognosis and may be integrated in ELN-risk score to help therapeutic decisions. Since HRV can be conveniently interrogated by routine approaches such as Sanger sequencing and HRM, further studies on larger cohorts might support these findings.

Identification and Validation of Ferroptosis-Related Genes As Novel Prognosis Prediction Panel for Acute Myeloid Leukemia

Acute myeloid leukemia (AML) is a main type of adult acute leukemia, especially in elderly population. The development of AML ascribed to various factors including chromosomal abnormalities, isolated gene mutations, etc. and the 5-year survival rate is around 30%. Currently, the most popular and precise assessment of AML is based on cytogenetic differences, and the patients with higher risk molecular mutations had inferior prognosis. However, with the development and application of new drugs, including bcl-2 inhibitors, many AML with high risks (such as FLT3, P53 mutated) also achieve better remission and longer survival. Up to date, many novel prognosis models are in process, with the better understanding of the initiation and development of leukemia. Ferroptosis, a widespread and ancient form of cell death driven by iron-dependent phospholipid peroxidation. Its involvement in AML has been reported, as leukemic cells frequently exhibit enhanced iron uptake and reduced iron efflux, resulting in elevated intracellular iron levels. Targeting iron homeostasis and inducing ferroptosis may provide novel insights into AML therapy. Herein, we integrated multi-gene information to identify a novel prediction model for ferroptosis-related genes (FRGs), and validated the accuracy of the model using clinical samples from our center (Figure A). In this study, we downloaded RNA-seq data and clinicopathological features of 151 AML patients from The Cancer Genome Atlas (TCGA) database (https://www.cancer.gov/ccg/research/genome-sequencing/tcga) and 70 corresponding health samples from the Genotype-Tissue Expression (GTEx) database (https://gtexportal.org/). Retrieve the ferroptosis-related genes (FRGs) set from the FerrDb database (http://www.zhounan.org/ferrdb/current/). The difference analysis, LASSO regression and Cox regression were used to determine the FRGs signature to construct prognostic models (Figure B). We finally identified 10 FRGs signature (ACSF2, SOCS1, CDO1, MYB, LPIN1, DNAJB6, PSAT1, GPX4, MT1G, FH) to establish a risk scoring model, and AML patients were divided into high-risk and low-risk group according to the median risk score. The risk score for each sample was determined using the following formula: . Kaplan-meier analysis showed that the overall survival of patients in the high-risk group was significantly worse( P&amp;lt;0.001) (Figure C). Cox regression analysis, ROC and DCA results found that these features have good predictive ability for prognosis of AML (Figure D-F). We also grouped the TCGA AML patients into poor/adverse and favorable/intermediate group based on NCCN guideline (risk stratification based on genomic mutation background), and found that the survival differences based on classical risk model were not that obvious ( P=0.062) (Figure G) when compared to our model ( P&amp;lt;0.001 in Figure C). Which suggested that our model may have its superior in distinguishing real high risk AML patients. In order to validate the accuracy of our model, we also conducted a retrospective study on 30 AML patients and 13 healthy controls (bone marrow stem cell donor) from September 2019 to September 2022. Bone marrow mononuclear cells (BMNC) from our biobank were obtained, and the ten FRGs panel was applied. Results indicated that there was a significantly difference between normal control and AMLs in FRGs expression (Figure H), and the survival data of high-risk AML patients with higher FRGs level was significantly inferior than that in low-risk group as expected ( P&amp;lt;0.05) (Figure I). To search for possible therapeutic drugs for high-risk patients, we downloaded AMLs data from the GDSC database (https://www.cancerrxgene.org/) and calculated the IC50 of commonly used chemotherapeutic drugs. We found that bcl-2 inhibitor (Obatoclax Mesylate) and TKI (Gefitinib) may have less sensitivity in our high-risk group ( P&amp;lt;0.05), while some unconventional drugs (paclitaxe, dactinomycin, camptothecin, irinotecan and vinorelbine) may benefit in patients with higher FRGs expression (Figure J). In summary, we identified and validated 10 FRGs signature to well predict the prognosis and drug sensitivity of AML. Based on our findings, appropriate combination of new drugs at the time of treatment may achieve unexpected therapeutic outcomes, but still need to go through further verification.

Preferential Efficacy of Remission Maintenance with HDC/IL-2 in Age Groups of Patients with Chemoresponsive or Normal Karyotype AML

Background Relapse in complete remission (CR) remains a leading cause of morbidity and mortality in acute myeloid leukemia (AML). Previous phase 3 trial data show that combinatorial immunotherapy with histamine dihydrochloride and low-dose interleukin-2 (HDC/IL-2) reduces relapse incidence in the post-consolidation phase, in particular among younger adult AML patients (&amp;lt;60 years old) in CR1 (Brune et al., Blood 108:88). Recent post-hoc analyses identified subgroups of responding patients including (1) those achieving CR1 after the first induction course of chemotherapy (referred to as chemoresponsive AML) and (2) those carrying leukemic cells of normal karyotype (NK-AML), i.e. devoid of structural or numerical chromosomal aberrations. Here we report analyses of treatment efficacy in a phase 3 trial within age groups of patients with chemoresponsive AML or NK-AML. Methods Three hundred and twenty AML patients (18-84 years old, median 57) who were ineligible for allogeneic stem cell transplantation were randomly assigned to receive HDC/IL-2 or no treatment (control) for remission maintenance in a phase 3 trial. Patients were recruited in Europe, Israel, Oceania, and USA. Treatment was initiated in CR after the completion of consolidation chemotherapy and comprised 10 consecutive 3-week cycles of HDC/IL-2 for 18 months (mo) with 3- or 6-week rest periods. In each cycle, patients received HDC at 0.5 mg and human recombinant low-dose IL-2 (aldesleukin; 16,400 IU/kg) s.c. twice daily (n=160) or no treatment (control; n=160). After 18 months of treatment, all patients were monitored for &amp;gt;18 additional mo (median follow-up 48 mo). Results Among study subjects in CR1 203/261 (78%) of evaluable patients attained CR after the first induction cycle (chemoresponsive AML) and 128/220 (58%) had NK-AML. Within both subgroups, analysis of efficacy by age at diagnosis implied preferred benefit of HDC/IL-2 vs. control in patients 40-59 years old (Figure 1) with independent efficacy in patients 40-49 and 50-59 years old (Table 1). The treatment arm was not significantly superior over the control arm for LFS or OS in the youngest patients (18-39 years old) or in patients &amp;gt;60 years old (P&amp;gt;0.2, logrank test, for all comparisons (LFS and OS)) within subgroups of chemosensitive AML or NK-AML. Conclusions We speculate that the observed benefit of HDC/IL-2 in patients responding swiftly to initial chemotherapy may be explained by more efficient immune-mediated elimination of leukemic cells at a lower burden of leukemia. The preferential efficacy of HDC/IL-2 in NK-AML points towards efficacy in subgroups of leukemic mutations that are less common in the youngest group of patients. The reason for the lack of significant efficacy in patients &amp;gt;60 years old, despite achievement of CR1 after the initial chemotherapy and despite having NK-AML, remains unknown but may be explained by fading anti-leukemic immunity in old patients. Overall, these findings may be considered for the selection of patients suitable for immunotherapy with HDC/IL-2 in an emerging landscape of strategies for relapse prevention in AML.

Spatial Technologies Reveal the Immune Landscape of Pediatric Acute Myeloid Leukemia

Pediatric acute myeloid leukemia (AML) is a cancer with a particularly low mutational burden in comparison to other pediatric and adult cancers and therefore, thought to be a poor candidate for T cell-engaging immunotherapies (Gröbner et al., 2018; Pfister et al., 2022). However, little is known about the composition and function of T cells in the bone marrow (BM) of pediatric AML patients. Insight into the frequency and function of BM T cells in children with AML is relevant for naturally occurring AML immune defenses, as well as for T cell-engaging immunotherapies (Koedijk et al., 2021). Here, we performed a multidimensional characterization of the tumor immune microenvironment in children with newly diagnosed AML. We obtained 82 formalin-fixed and paraffin-embedded (FFPE) diagnostic bone biopsies from a representative cohort of pediatric patients with treatment-naïve de novo AML (N=72) and from age- and sex-matched pediatric patients with treatment-naïve early-stage rhabdomyosarcoma without malignant BM infiltration (non-leukemic controls, N=10). We employed immunohistochemistry (IHC) alongside immune-related gene expression profiling (NanoString PanCancer IO 360 TM Panel) and spatial transcriptomics (NanoString GeoMx TM Whole Transcriptome Atlas). Moreover, we acquired an additional dataset of pre-treatment immune-related gene expression profiling obtained from the BM of 30 flotetuzumab-treated (CD3 x CD123 bispecific antibody) refractory/relapsed (R/R) adult AML patients (NCT02152956; Vadakekolathu et al., 2020) for TIDE-based immune deconvolution (Jiang et al., 2018). Using IHC, we identified (a trend towards) a decreased abundance of the overall number of T cells ( P=0.09) and CD8 + T cells ( P=0.011; Panel A) in the BM of pediatric AML patients in comparison to non-leukemic controls, respectively. Notably, the extent of overall T cell and CD8 + T cell infiltration could differ up to 180-fold between individual AML patients. In general, this difference in T cell infiltration was not associated with the abundance of leukemic blasts or patient's cytogenetic alterations. Nevertheless, children with complex karyotype AML had higher numbers of BM T cells compared to children with normal karyotype AML ( P=0.03).Using differential gene expression analysis, we identified genes related to T cell-attracting chemokines, cytotoxicity, and immune checkpoints to be significantly upregulated in T cell-infiltrated- compared to T cell-depleted samples. Moreover, the ratio of anti- to pro-inflammatory macrophages (M2/M1-ratio) was significantly lower in T cell-infiltrated- compared to T cell-depleted pediatric AML samples ( P&amp;lt;0.001). Interestingly, this M2/M1-ratio was also significantly lower in R/R adults that responded to flotetuzumab immunotherapy in comparison to non-responders ( P&amp;lt;0.001). In fact, this M2/M1-ratio outperformed several other known predictors of response to flotetuzumab immunotherapy (AUROC: 0.852 (95% CI: 0.71-0.99), P=0.001; Jiang et al., 2018; Ayers et al., 2017). In addition, IHC revealed that 9 immune-infiltrated samples, including 6 KMT2A-rearranged AML samples, harbored large networks of T- and B cells (representative image of B cell-networks shown in panel B). Using spatial transcriptomics, we dissected the composition of these lymphoid aggregates and revealed localized anti-tumor immunity in the BM of AML. In comparison to tumor areas, these aggregates showed a higher abundance of activated cytotoxic T cells ( P&amp;lt;0.001), memory B cells ( P&amp;lt;0.001), and plasma cells ( P&amp;lt;0.001), suggesting the presence of tertiary lymphoid structure-like (TLS-like) aggregates in the BM of AML. In conclusion, we identified a subset of pediatric AML patients with relatively high T cell infiltration and a relatively low abundance of anti-inflammatory macrophages in the BM at diagnosis. Furthermore, we found that the BM M2/M1-ratio may be informative of response to T-cell engaging immunotherapies in adult AML, which needs to be validated in pediatric AML. Lastly, for the first time, we identified TLS-like aggregates in the BM of AML patients, which have been associated with immunotherapy response in many cancers (Schumacher &amp; Thommen, 2022). Additional studies to further characterize the function and relevance of these lymphoid aggregates are ongoing.

The Impact of DNMT3A Mutation on Survival of AML Patients Receiving Allogeneic Hematopoietic Cell Transplantation in First Remission Depends on the Karyotype and Co-Occurring Mutations: On Behalf of the EBMT Acute Leukemia Working Party

DNMT3A gene mutations are more frequent in cytogenetically normal acute myeloid leukemia (AML) and frequently associated with NPM1 mutation and internal tandem duplication (ITD) of the FLT3 gene. However, DNMT3A mutation is not included as a distinct prognostic group in the recent European Leukemia Net (ELN) 2022 genetic risk classification of AML. In the context of allogeneic hematopoietic cell transplantation (allo-HCT), the prognostic value of DNMT3A is still not well studied. We evaluated, through the European Society for Blood and Marrow Transplantation (EBMT) registry, the impact of DNMT3A mutation, according to the karyotype, and NPM1 and FLT3-ITD mutation status, on post-transplant outcomes in AML patients receiving allo-HCT in first complete remission (CR1). We identified a total of 1374 adult AML patients (51% female, median age 57 years; range 18-78 years) with ELN-2022 intermediate- or poor-risk cytogenetics and available DNMT3A, FLT3ITD and NPM1 mutation status, who underwent their first allo-HCT in CR1 between 2013 and 2021. Of these, 631 (46%) patients had DNMT3A mutation. Patients with mutant DNMT3A were more likely to be female (57% versus 46%, p&amp;lt;0.001), to have normal cytogenetics (75% versus 54%, p&amp;lt;0.001), FLT3-ITD co-mutation (50% vs 23%, p&amp;lt;0.001), NPM1 co-mutation (60% vs 21%, p&amp;lt;0.001), and to receive a myeloablative conditioning and in vivo T cell depletion. After a median follow-up of 2.3 years, the 2-year leukemia free survival (LFS) and overall survival (OS) were 62% and 69%, respectively. The subsequent analysis was split according to baseline karyotype (normal or abnormal). Among 870 patients with normal cytogenetics, 472 (54%) patients had DNMT3A mutation. The 2-year relapse incidence (RI), LFS and OS were 24%, 63% and 70% respectively, in patients with DNMT3A mutation compared to 18%, 69% and 74% in patients with wild type DNMT3A. Among these patients with normal karyotype, multivariable analyses (MVA) were done within the 4 groups of FLT3-ITD and NPM1 mutations. Within the group of 324 patients with both FLT3-ITD and NPM1 positives, 244 were triple-positive (75%), LFS and OS were not significantly different with and without DNMT3A mutation (2y LFS: 62% vs 63%, HR: 0.98, p=0.95; 2y OS: 70% vs 73%, HR: 1.17, p=0.58). Conversely, among 146 patients with NPM1 mutation without FLT3-ITD, LFS was significantly lower for 91 patients with DNMT3A mutation (2y LFS: 68% vs 87%, HR: 2.70, p=0.02) but OS was not significantly different (2y OS: 79% vs 87%, HR: 2, p=0.13). On the other hand, among 318 with wild type NPM1 and without FLT3-ITD, LFS and OS were not significantly different for 108 patients with DNMT3A mutation compared to 210 patients with wild type DNMT3A (2y LFS: 62% vs 67%, HR: 1, p=0.98; 2y OS: 65% vs 71%, HR: 1.02, p=0.94). Conversely, among 82 patients with FLT3-ITD and wild type NPM1, 2-year LFS and OS were 53% and 58% respectively, for 29 patients with DNMT3A mutation compared to 71% and 76% respectively, for 53 patients with wild type DNMT3A. The number of patients didn't allow to perform MVA in this group. Finally, among 504 patients with abnormal cytogenetics, 159 (31%) patients had DNMT3A mutation. On MVA, DNMT3A mutation did not significantly affect LFS or OS. Poor-risk cytogenetics was associated with worse LFS, OS and increased RI. Older age negatively affected LFS and OS. In conclusion, in AML patients allografted in CR1, the impact of DNMT3A mutation depends on the karyotype and co-occurring mutations. Our data suggest that DNMT3A mutation negatively affects post-transplant survival selectively in patients with normal karyotype and either NPM1 mutation without FLT3-ITD, or patients with normal karyotype, FLT3-ITD and wild type NPM1. DNMT3A mutation shows no impact on post-transplant outcomes in other settings.

The Ancestry-Related Landscape of Long Non-Coding RNAs (LncRNAs) in Acute Myeloid Leukemia (AML) and Its Impact on Patient (Pt) Survival

Background In addition to molecular genetic and cytogenetic findings, gene expression profiles provide independent prognostic information in AML. Aberrant expression of non-coding RNAs, including lncRNAs, further inform pt prognosis. However, non-coding expression profiles and their clinical relevance in AML almost exclusively stem from studies of pts of European ancestry (hereafter referred to as White). Given the inferior survival of African-American (hereafter referred to as Black) AML pts, we hypothesized that aberrant, possibly ancestry-associated lncRNA expression may contribute to survival disparities. Hence, we set out to (1) characterize the lncRNA landscape of African-American ancestry, (2) delineate associations of lncRNAs with clinical and molecular characteristics and (3) assess the prognostic significance of ancestry-associated lncRNAs in AML. Methods We used diagnostic samples from 681 adult AML pts (&amp;lt;60y) treated similarly on Alliance frontline protocols (White, n=616; Black, n=65) for RNAseq, mutational profiling and centrally reviewed karyotyping. A negative binomial model was fit to identify lncRNAs differentially expressed between Black and White pts. To determine prognostic relevance of identified lncRNAs, 10-fold cross-validation repeated 1000 times was performed on LASSO penalized Cox proportional hazards model to overall survival (OS). LncRNAs appearing in at least 900 of the 1000 models were retained and coefficient estimates were averaged then applied to form the “lncRNA score.” Ancestry-associated SNPs in regulatory regions of select lncRNAs were identified using the ENCODE registry for cCREs, SNP2TFBS and population allele frequency data from NCBI ALFA. Results Comparing Black and White AML pts, 135 lncRNAs were upregulated and 55 lncRNAs were downregulated. The differentially expressed lncRNAs were equally distributed throughout the genome and no lncRNA was ancestry-exclusive in its expression, indicating high conservation. lncRNAs with the highest differential expression include several lncRNAs previously implicated in cancer/leukemia, but also thus far unstudied lncRNAs. Using the 190 aberrantly expressed lncRNAs identified from comparison of Black and White pts, we derived a prognostic score (lncRNA score) consisting of 13 lncRNAs. LncRNA High strongly associated with inferior OS in all pts ( Fig. 1). In all pts combined, presence of lncRNA High positively associated with several adverse-risk features, and negatively associated with core-binding factor AML and CEBPA bZIP mutations. Notably, select genetic features differed in their lncRNA score associations based on ancestry, including a relative paucity of cytogenetically normal AML (29% vs 57%), NPM1 (13% vs 40%) and CEBPA bZIP (8% vs 17.5%) mutations in Black pts compared to White pts in the lncRNA Low group. lncRNA score was an independent prognosticator of worse OS in both Black and White pts that refined the prognostication of the European LeukemiaNet 2022 Favorable (P=.004) and Intermediate (P&amp;lt;.001) genetic risk groups. It also provided further prognostic information to the LSC17 score in both low (P&amp;lt;.001) and high (P&amp;lt;.001) LSC17 groups. Examination of the genomic context of regulatory regions within the 13 lncRNAs revealed multiple ancestry-associated SNPs that putatively altered transcription factor / chromatin regulator binding sites in cis-regulatory regions, including rs58515841 (MAF White vs Black, 24% vs 9%, CTCF binding site within ENSG00000284052) and rs1400262 (MAF, 62% vs 10%, REST binding site upstream of NCK1-DT). Conclusions We show an ancestry-related landscape of lncRNAs in AML, including an ancestry-associated expression profile of lncRNAs and evidence of ancestry-associated SNPs as expression modulators. A prognosis-associated lncRNA score based on differentially expressed lncRNAs in Black versus White AML pts carries prognostic significance irrespective of ancestry and refines both mutation/cytogenetically-based (ELN 2022) and gene-expression-based (LSC17) prognostic algorithms. Our findings highlight the importance of ancestry-diverse populations in the establishment of prognostic scoring systems to provide ancestry-connected survival prediction. Support: U10CA180821, U10CA180882, U24CA196171; https://acknowledgments.alliancefound.org. Clinicaltrials.gov Ids: NCT00048958, NCT00899223, NCT00900224

Single-cell RNA sequencing distinctly characterizes the wide heterogeneity in pediatric mixed phenotype acute leukemia

BackgroundMixed phenotype acute leukemia (MPAL), a rare subgroup of leukemia characterized by blast cells with myeloid and lymphoid lineage features, is difficult to diagnose and treat. A better characterization of MPAL is essential to understand the subtype heterogeneity and how it compares with acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). Therefore, we performed single-cell RNA sequencing (scRNAseq) on pediatric MPAL bone marrow (BM) samples to develop a granular map of the MPAL blasts and microenvironment landscape.MethodsWe analyzed over 40,000 cells from nine pediatric MPAL BM samples to generate a single-cell transcriptomic landscape of B/myeloid (B/My) and T/myeloid (T/My) MPAL. Cells were clustered using unsupervised single-cell methods, and malignant blast and immune clusters were annotated. Differential expression analysis was performed to identify B/My and T/My MPAL blast-specific signatures by comparing transcriptome profiles of MPAL with normal BM, AML, and ALL. Gene set enrichment analysis (GSEA) was performed, and significantly enriched pathways were compared in MPAL subtypes.ResultsB/My and T/My MPAL blasts displayed distinct blast signatures. Transcriptomic analysis revealed that B/My MPAL profile overlaps with B-ALL and AML samples. Similarly, T/My MPAL exhibited overlap with T-ALL and AML samples. Genes overexpressed in both MPAL subtypes’ blast cells compared to AML, ALL, and healthy BM included MAP2K2 and CD81. Subtype-specific genes included HBEGF for B/My and PTEN for T/My. These marker sets segregated bulk RNA-seq AML, ALL, and MPAL samples based on expression profiles. Analysis comparing T/My MPAL to ETP, near-ETP, and non-ETP T-ALL, showed that T/My MPAL had greater overlap with ETP-ALL cases. Comparisons among MPAL subtypes between adult and pediatric samples showed analogous transcriptomic landscapes of corresponding subtypes. Transcriptomic differences were observed in the MPAL samples based on response to induction chemotherapy, including selective upregulation of the IL-16 pathway in relapsed samples.ConclusionsWe have for the first time described the single-cell transcriptomic landscape of pediatric MPAL and demonstrated that B/My and T/My MPAL have distinct scRNAseq profiles from each other, AML, and ALL. Differences in transcriptomic profiles were seen based on response to therapy, but larger studies will be needed to validate these findings.

A new prognostic risk model for acute myeloid leukemia patients based on telomere-related genes

Telomere maintenance is critical to ensure unlimited cancer cell proliferation, but the role of telomere-related genes in acute myeloid leukemia (AML) has not yet been thoroughly discussed. This study aims to develop a new prognostic risk model based on telomere-related genes and analyze potential mechanisms and targets. Cox regression analyses were used to build the prognostic risk model. Kaplan-Meier (KM) survival analysis and receiver operating characteristic (ROC) curve were used to assess the model performance. At the same time, we analyzed the relationship between the risk score and chemotherapy and immunotherapy and preliminarily explored possible mechanisms of immune resistance. The real-time polymerase chain reaction (PCR) was used to detect the prognosis gene expression levels. Finally, a prognostic signature of six telomere-related genes (TGPS6) including ALDH2, CDK18, DNMT3B, FRAT2, LGALSL, and RBL2 was constructed. The TGPS6 score was confirmed as an independent prognostic factor (HR 2.74, CI [2.13–3.53], p < 0.001) in AML and the five-year area under the ROC curve (AUC) value of the score in the training and validation set reached 0.74, 0.81 respectively. In addition, the TGPS6 perfected the European LeukemiaNet (ELN) 2017 prognosis risk stratification and performed well in both AML and cytogenetically normal AML (CN-AML) cohorts. The TGPS6 score also provided a reference for chemotherapy and immunotherapy in patients with AML.

Dynamic alterations of the transcriptome-wide m6A methylome in cytogenetically normal acute myeloid leukaemia during initial diagnosis and relapse

Accumulating studies have indicated that N6-methyladenosine (m6A) plays an important role in acute myeloid leukaemia (AML). However, little is known about the m6A methylome at a transcriptome-wide scale in AML patients. We obtained three pairs of bone marrow (BM) samples from cytogenetically normal AML patients at the timepoints of diagnosis (AML) and relapse (R_AML) and three BM samples from healthy donors used as normal controls (NCs). Methylated RNA immunoprecipitation next-generation sequencing (MeRIP-Seq) was conducted to identify differences in the m6A methylomes between AML and NC and between R_AML and AML. We identified a total of 11,076 and 11,962 differential m6A peaks in AML and R_AML group, respectively. These dysregulated m6A peaks were detected on all chromosomes, especially chr1, chr19 and chr17, and were mainly enriched in 3′ untranslated regions, stop codon and coding sequence regions. Moreover, GO and KEGG analyses indicated that m6A -modified genes were significantly enriched in cancer-related biological functions and pathways. Additionally, we identified a link between the m6A methylome and RNA transcriptome via combined analyses of MeRIP-seq and RNA-seq data. In addition, 5 genes, HSPG2, HOMER3, TSPO2, CXCL12 and FUT1 regulated by m6A modification potentially, were shown to be related to the prognosis of AML patients. Additionally, we detected the mRNA expression of major m6A regulators and potential target mRNA on the leukemogenesis and found that the expression of IGF2BP2, HSPG2 and HOMER3 were upregulated in AML at the time of diagnosis. Moreover, their expression became downregulated after remission and then elevated again at relapse. Our study provides the first data on the differential m6A methylome in AML patients during initial diagnosis and relapse. This study demonstrates a novel relationship between m6A modification and AML relapse and paves the way for further studies aimed at elucidating the epigenic mechanisms involved in the relapse of AML.