Resistant Acute Myeloid Leukemia Cell Research Articles

Discernable machine learning methods for Raman micro‐spectroscopic stratification of mitoxantrone‐induced drug‐resistant cells in acute myeloid leukemia

AbstractDrug resistance plays a vital role in both cancer treatment and prognosis. Especially, early insights into such drug‐induced resistance in acute myeloid leukemia (AML) can help to improve treatment plans, reduce costs, and bring overall positive outcomes for patients. Raman spectroscopy provides precise biomolecular information and can provide all these necessities effectively. In this study, we employed machine learning (ML) discrimination of Raman micro‐spectroscopic data of myelocytic leukemia cell line HL‐60 from its drug‐resistant counterpart HL‐60/MX2. Principal component analysis (PCA), linear discriminant analysis (LDA), and logistic regression (LR) methods were evaluated for their ability to identify and discriminate drug resistance in AML cells. Our study demonstrates the power of ML to classify drug‐induced resistance in AML cells utilizing subtle variations in biomolecular information contained in molecular spectroscopic data by obtaining 94.11% and 97.05% classification accuracies by LDA and LR models, respectively. We also showed that the ML methods are discernable. Our findings depict the importance of automation and its optimal usage in cancer study and diagnosis. The results of our study are expected to take ML‐assisted Raman spectroscopy one step closer to making it a generalized tool in medical diagnosis in the future.

Double-negative T cells utilize a TNFα–JAK1–ICAM-1 cytotoxic axis against acute myeloid leukemia

AbstractAllogeneic double-negative T cells (DNTs) are a rare T-cell subset that effectively target acute myeloid leukemia (AML) without inducing graft-versus-host disease in an allogeneic setting. A phase 1 clinical trial demonstrated the feasibility, safety, and potential efficacy of allogeneic DNT therapy among patients with relapsed AML. However, the molecular mechanisms of DNT-mediated cytotoxicity against AML remain elusive. Thus, we used a flow cytometry–based high throughput screening to compare the surface molecule expression profile on DNTs during their interaction with DNT-susceptible or -resistant AML cells and identified a tumor necrosis factor α (TNFα)-dependent cytotoxic pathway in DNT-AML interaction. TNFα secreted by DNTs, upon encountering susceptible AML targets, sensitized AML cells to DNT-mediated killing, including those otherwise resistant to DNTs. Mechanistically, TNFα upregulated ICAM-1 on AML cells through a noncanonical JAK1-dependent pathway. DNTs then engaged with AML cells more effectively through an ICAM-1 receptor, lymphocyte function–associated antigen 1, leading to enhanced killing. These results reveal a TNFα–JAK1–ICAM-1 axis in DNT-mediated cytotoxicity against AML to improve therapeutic efficacy.

Glucose Metabolism as a Potential Therapeutic Target in Cytarabine-Resistant Acute Myeloid Leukemia.

Altered glycolytic metabolism has been associated with chemoresistance in acute myeloid leukemia (AML). However, there are still aspects that need clarification, as well as how to explore these metabolic alterations in therapy. In the present study, we aimed to elucidate the role of glucose metabolism in the acquired resistance of AML cells to cytarabine (Ara-C) and to explore it as a therapeutic target. Resistance was induced by stepwise exposure of AML cells to increasing concentrations of Ara-C. Ara-C-resistant cells were characterized for their growth capacity, genetic alterations, metabolic profile, and sensitivity to different metabolic inhibitors. Ara-C-resistant AML cell lines, KG-1 Ara-R, and MOLM13 Ara-R presented different metabolic profiles. KG-1 Ara-R cells exhibited a more pronounced glycolytic phenotype than parental cells, with a weaker acute response to 3-bromopyruvate (3-BP) but higher sensitivity after 48 h. KG-1 Ara-R cells also display increased respiration rates and are more sensitive to phenformin than parental cells. On the other hand, MOLM13 Ara-R cells display a glucose metabolism profile similar to parental cells, as well as sensitivity to glycolytic inhibitors. These results indicate that acquired resistance to Ara-C in AML may involve metabolic adaptations, which can be explored therapeutically in the AML patient setting who developed resistance to therapy.

Exosome-shuttled FTO from BM-MSCs contributes to cancer malignancy and chemoresistance in acute myeloid leukemia by inducing m6A-demethylation: A nano-based investigation

Although bone marrow mesenchymal stem cells (BM-MSCs)-derived exosomes have been reported to be closely associated with acute myeloid leukemia (AML) progression and chemo-resistance, but its detailed functions and molecular mechanisms have not been fully delineated. Besides, serum RNA m6A demethylase fat mass and obesity-associated protein (FTO)-containing exosomes are deemed as important indicators for cancer progression, and this study aimed to investigate the role of BM-MSCs-derived FTO-exosomes in regulating the malignant phenotypes of AML cells. Here, we verified that BM-MSCs-derived exosomes delivered FTO to promote cancer aggressiveness, stem cell properties and Cytosine arabinoside (Ara-C)-chemoresistance in AML cells, and the underlying mechanisms were also uncovered. Our data suggested that BM-MSCs-derived FTO-exo demethylated m6A modifications in the m6A-modified LncRNA GLCC1 to facilitate its combination with the RNA-binding protein Hu antigen R (HuR), which further increased the stability and expression levels of LncRNA GLCC1. In addition, LncRNA GLCC1 was verified as an oncogene to facilitate cell proliferation and enhanced Ara-C-chemoresistance in AML cells. Further experiments confirmed that demethylated LncRNA GLCC1 served as scaffold to facilitate the formation of the IGF2 mRNA binding protein 1 (IGF2BP1)-c-Myc complex, which led to the activation of the downstream tumor-promoting c-Myc-associated signal pathways. Moreover, our rescuing experiments validated that the promoting effects of BM-MSCs-derived FTO-exo on cancer aggressiveness and drug resistance in AML cells were abrogated by silencing LncRNA GLCC1 and c-Myc. Thus, the present firstly investigated the functions and underlying mechanisms by which BM-MSCs-derived FTO-exo enhanced cancer aggressiveness and chemo-resistance in AML by modulating the LncRNA GLCC1-IGF2BP1-c-Myc signal pathway, and our work provided novel biomarkers for the diagnosis, treatment and therapy of AML in clinic.

Minimal Residual Disease in Acute Myeloid Leukemia Following Induction Chemotherapy Can be Effectively Eradicated By Targeting Mitochondrial Metabolism

Acute myeloid leukemia (AML) stem cells (AMLSCs) AMLSCs and residual cytarabine (AraC)-resistant AML cells (constituting minimal residual disease, MRD) thought to be responsible for chemoresistance and treatment failure, were shown to be highly dependent on mitochondrial function for survival and thus are vulnerable to pharmacological blockade of the oxidative phosphorylation (OXPHOS) (Farge et al. Cancer Discov, 2017). Efficacy of OXPHOS inhibitor IACS-010759 (OXPHOS-i) was previously reported, demonstrating potent inhibition of mitochondrial complex I, OXPHOS suppression and growth inhibition of AML cells (Molina, et al. Nat Med, 2018). Here we evaluated OXPHOS dependency of AML MRD cells and determined impact of OXPHOS blockade on residual AML cells surviving standard chemotherapy (Doxorubicin/AraC, DA). Our results demonstrated that AML cell lines treated with AraC or DA induced accumulation of reactive oxygen species, mitochondrial superoxides, increased mitochondrial mass and mitochondrial membrane potential. AraC- and DA therapies in vitro were significantly enhanced by OXPHOS-i. OXPHOS dependency shown as a significantly increased basal and maximal oxygen consumption rate after AraC and DA treatment, was fully inhibited by OXPHOS-i, leading to complete mitochondrial collapse. OXPHOS inhibition in combination with DA translated into reduction of viable cell numbers, induction of apoptosis and differentiation in AraC-sensitive and AraC-resistant cell lines models. In vitro efficacy was also observed in engineered p53-mutated MOLM13 model, indicating that combination of OXPHOS-i and DA might successfully overcome p53 mutation-driven chemoresistance. These effects were further validated in a subset of AraC-resistant primary patient samples. Mechanistically, induction of ROS caused by OXPHOS-i addition upon DA contributed to differentiation and cell death, and was partially reversed by ROS scavengers. Next, the efficacy of IACS-010759 together with DA chemotherapy was evaluated in several chemotherapy-sensitive and -resistant animal models in vivo. DA/IACS-010759 combination significantly reduced leukemia burden and extended survival in OCI-AML3/Luc/GFP model and in FLT3-ITD + AML PDX model. In the latter, IACS-010759 led to the reduction of leukemia burden and delayed leukemia recurrence when administered post completion of DA. At the single-cell level, CyTOF analysis demonstrated that this combination reduced frequency of CD34 +CD38 lowCD123 +AML LSCs and facilitated differentiation of immature subpopulations (Fig.1A). Furthermore, addition of OXPHOS-i to DA extended survival of mice inoculated with chemoresistant PDX AML models. Finally, OXPHOS-i administered during consolidation phase significantly extended mice survival compared to standard of care arm, supporting clinical utility of OXPHOS inhibitors in AML (Fig.1B). In conclusion, our findings indicate that chemotherapy fosters mitochondrial respiration in AML, which could be abrogated by OXPHOS inhibitor at the LSCs and MRD level , in vitro and in vivo. While IACS-010759 (Yap et al. Nat Med 2023) showed toxicities impeding its clinical utility, our data advocate for combining mitochondrial targeting strategies with chemotherapy as a part of induction and consolidation treatment for improved control of MRD, eradication of AMLSC and extended response duration. Thus, further studies to identify compounds with improved safety profile are warranted.

Single-Cell Genomics and Proteomics Reveals Venetoclax-Resistant Monocytic Differentiation of TP53 LOH Clones in TP53 Mutant AML

Introduction: Acute myeloid leukemia (AML) is a heterogeneous disease characterized by accumulation of abnormal hematopoietic stem and progenitor cells. TP53 mutations, present in 8 - 30 % of AML, are associated with high risk of relapse and poor prognosis. The mechanisms underlying their persistence are not well understood. Here, we attempt to describe the clonal architecture and immunophenotypes of TP53 mutant ( TP53-mut) clones during therapy. Leveraging advancements in single-cell sequencing and machine learning models, this study integrated single-cell mass cytometry (CyTOF) and single-cell DNA + protein sequencing (seq) profiling of ten paired pre- and post-treatment samples from five TP53-mut AML patients. Methods: Patients 1 and 3 received treatment with CD47AB (Magrolimab), 5'-Azacitidine (Aza), and Venetoclax (Ven); Patient 2 received IMGN632 (CD123-targeting ADC), Aza and Ven. Patient 4 received p97 Inhibitor CB-5339; Patient 5 received CD47 inhibitor (ALX148), Aza, Ven. Consequently, Ven/Aza served as the therapeutic backbone for most patients. For single cell DNA+protein analysis, we sequenced a total of 44,550 cells from these 10 samples. Samples with at least 70% viability were stained with the Total-Seq™-D Human Heme Oncology Cocktail, containing 45 oligo-conjugated antibodies for surface markers relevant to AML. For mutation analysis, we utilized a validated AML custom panel (Morita et al. 2020) covering recurrent mutations in 37 genes. For CyTOF, we multiplexed samples and stained with 50 antibodies characterizing lineage, apoptosis, and signaling pathways. We successfully constructed a machine learning model for integrating both data types using our gradient boosting algorithm established pipelines and were able to predict DNA mutation status in CyTOF data with over 95% accuracy. Results: Analysis of the clonal architecture revealed the presence of TP53 mutations not only in AML blasts but also in lymphocyte subpopulations in all TP53-mut clones from the patients in this study. For example, in patient 1, as a representative case, TP53 mutations were observed in 16.5% of CD4+ T cells, 35.9% of CD8+ T cells, and 19.2% of NK cells. Clonal evolution analysis showed sensitivity of TP53-mut clones with TP53 Loss of heterozygosity ( TP53 mut + LOH) to Ven/Aza and monocytic differentiation in resistant cells, potentially a manifestation of their stem-like nature. Patient 1 displayed three distinct subclones: clone 1 harbored an ETV6 mutation (p.V322S), clone 2, derived from clone 1, acquired additional IDH1 (p.R132L) and TP53 (p.R241G) mutations, clone 3, originating from clone 2 and comprising the highest proportion, exhibited loss of the other TP53 allele (LOH), and decreased from 96.2% to 55.2% post-treatment (Figure 1A). Meanwhile, clone 1 and clone 2 increased from 1.9% to 27.3% and 1.9% to 17.4% respectively. Dissecting the phenotypic changes, clone 3 showed significant pre- and post-treatment shifts in cellular composition. Pre-treatment, it consisted predominantly of 89.7% CD34+ blasts and only 0.2% CD16+ monocytic cells. Post-treatment, CD34+ blasts decreased to 9.3%, while CD16+ monocytic cells increased to 67.8%. CyTOF analysis corroborated our findings (Figure 1B) with trajectory analysis revealing that AML cells had a stemness profile (CD34+CD38- and C-kit+) located at the beginning of the trajectory. Conversely, post-treatment AML cells displayed a loss of stemness and expressed myeloid differentiation markers, including CD33, CD11b, CD14, and CD68. We concluded that Ven-based treatments induce monocytic differentiation in resistant AML cells. CyTOF analysis of the proteomic profiles of resistant cells revealed an increase in Ki67, BCL-XL, and 4EBP1 and a decrease in CD34 and C-KIT, suggesting a potential resistance mechanism involving the upregulation of anti-apoptotic molecules and mTOR pathway. Notably, CD36, a fatty acid transporter, exhibited increased expression in monocytic cells, suggesting an altered metabolism in the survival monocytic cells. Conclusion: This study establishes a genotype-phenotype connection through single-cell proteogenomic profiling of TP53-mutated AML, describing the clonal evolution and immunophenotypic dynamics during treatment while proposing a potential mechanism of resistance.

Targeting Abnormally Increased Expression of ULK1 Sensitizes Acute Myeloid Leukemia Resistant Cells to Venetoclax

Background Venetoclax (VEN) is a potent B-cell lymphoma-2 (BCL-2) inhibitor used for treatment of acute myeloid leukemia (AML). However, some patients display marked resistance to VEN, limiting its efficacy. BCL-2 is overexpressed in AML cells, and acts as both an inhibitor of apoptosis and autophagy, indicating an interaction between these two pathways in AML which may provide insight into the origins of resistance, though specific molecular and biological changes remain unknown. Objective To investigate the interplay of apoptosis and autophagy in mediating VEN resistance via genomic and gene expression analysis of VEN-treated AML patient cells, as well as identify and characterize key autophagic and biological changes in VEN resistant AML cells. Methods Gene expression analysis was performed on 176 specimens with both RNA-seq and VEN drug sensitivity screen data from the BEAT AML patient dataset using DESeq2 to identify differentially expressed genes. These genes were cross matched with 199 autophagy-associated genes, then further refined via selecting druggable targets or known key regulators of autophagy to identify specific genes of interest. Genes of interest were further investigated in cell lines via qRT-PCR and Western blotting. Resistant cell lines were generated from MV4-11 and MOLM13 cell lines via culturing in increasing concentrations of VEN for 14 weeks. Autophagic flux reporter lines were generated via viral transduction with an RFP-GFP-LC3 tandem reporter. Molecular and biological changes were then investigated in VEN-resistant cells. Results Gene expression analysis of the BEAT-AML dataset revealed 2,788 genes to be significantly elevated with a corrected p value <0.01 in VEN-resistant patients. When compared to a list of 199 autophagy-associated genes, 56 were identified from those 2,788 elevated genes. From this, 11 genes were short listed for further investigation due to their roles as druggable targets or known key autophagic regulators. RT-PCR in several cell lines revealed from this shortlist that ULK1 exhibited highly elevated expression in resistant lines, which was confirmed via western blotting of both phosphorylation and total ULK1 protein levels (ULK1: > 2-fold, p < 0.01; pULK1: > 2-fold, p < 0.01) VEN resistance was confirmed in our newly generated resistant lines via cell viability and apoptosis assays, with resistant lines showing a marked lack of response to VEN compared to parental lines (40-fold , p < 0.001). Inhibition of ULK1 via SBI-0206965 and a more potent inhibitor, SBP-7455, re-sensitized resistant cell lines to VEN, with increased cell killing seen in co-treatment of ULK1 inhibitor and VEN resulting in decreased viability compared to treatment of VEN alone (> 2-fold decrease, p < 0.01). Notably, there was no significant decrease in viability with ULK1 inhibitor treatment alone without VEN. Apoptosis assays further confirmed this, with increased levels of apoptotic and necrotic cells under co-treatment conditions. Analysis of autophagy-related processes specifically further revealed dysregulation in this process in resistant cells. Imaging displayed increased autophagic puncta in resistant lines under starvation conditions (2-fold, p < 0.0001), indicating increased autophagic activity, corresponding with increased ULK1 and pULK1 expression. This increased activity was further confirmed via western blotting, with resistant cells showing increased expression of autophagy-associated genes and cleavage. Conclusion We have discovered that ULK1, a necessary inducer of autophagy, displays increased expression and activity in VEN-resistant AML cells, and that these cells experience dysregulated autophagic processes. Inhibition of ULK1 via SBI and SBP inhibitors sensitizes VEN-resistant cells to VEN, indicating a potential strategy to combat VEN resistance in AML. Keywords AML stem cells, drug resistance, Venetoclax, Autophagy, ULK1, BCL-2

Metabolism-Related Features Identify the Combination Metformin Plus NAMPT Inhibitors As a Selective Treatment Strategy in Acute Myeloid Leukemia

Acute myeloid leukemia (AML) is a heterogeneous disease, which remains difficult to treat due to its heterogeneous nature. Recently, metabolic adaptation has been recognized as a trademark of leukemogenesis. Notably, altered function of mitochondria (mt) in leukemic stem cells (LSCs) has been linked to chemoresistance in some patients, causing relapse of disease. Thus, targeting the rewired energy metabolism of leukemic cells has gained a lot of attention in recent years. Here, using a large cohort of adult de novo AML samples (n=502 patients, all intensively treated with 3+7 scheme), we identified a subset of patients with increased mitochondrial DNA content (mtDNAcn, n=163) compared to age- and sex-matched healthy controls (n=308). mtDNAcn was significantly higher in patients harboring FLT3-ITD (31%) and IDH1 mutations (50%). Patients with high mtDNAcn were associated with worse clinical outcomes regardless of European Leukemia Net (ELN) risk stratification, sex, and age. In contrast, high mtDNAcn was not a predictive survival marker in a cohort of adult AML patients treated with venetoclax (VEN) + hypomethylating agents (HMA), indicating that these metabolic features are specifically linked to the resistance to intensive chemotherapy. Using label-free quantitative proteome analysis (11272 proteins) combined with metabolomic screening (173 metabolites) on sorted CD34 +/CD117 + AML blasts (n=26), we found that AMLs with high mtDNAcn were enriched for signatures like “GMP-like” and “mt complex I activity”, being metabolically enriched for long-chain fatty acids, suggesting that these cells rely more on oxidative phosphorylation (OXPHOS) metabolism. Functionally, AML blasts with high mtDNAcn displayed increased levels of BCL2, mt mass, and mt membrane potential, which was associated with increased oxygen consumption rate (OCR) measured by extracellular flux analysis. Considering the impact of mtDNAcn on AML survival in patients treated with intensive chemotherapy, which was not observed in the context of VEN+HMA, and considering the increased reliance of LSC on mtOXPHOS, we studied the impact of mtDNAcn on chemotherapy response. Ex vivo analysis of primary AML samples with high mtDNAcn indicated increased resistance to AraC-induced apoptosis, which was reverted upon knock-down of the DNA polymerase gamma gene (POLG) encoding the catalytic subunit of the mtDNA polymerase. Due to the link between mtDNAcn and mt complex I activity, we investigated if the treatment with metformin, known to inhibit complex I, would sensitize AML patients with high mtDNAcn to the standard of care AML drugs, such as Cytarabine (AraC), FLT3-inhibitors and VEN. Treatment with low dose of metformin (1 mM) effectively reduced the mtDNAcn in AML cells (n=40), resulting in decreased OCR, while glycolysis was increased, suggesting metabolic rewiring. Furthermore, the combination of metformin with AraC, VEN and FLT3-inhibitors synergistically increased drug-induced apoptosis in AML cells with high mtDNAcn and helped to overcome VEN resistance in AML cells. In vivo, combination of metformin with VEN prolonged the survival of mice transplanted with K562 cells (VEN resistant), resulting in decreased leukocyte counts and blood chimerism. Since treatment with metformin resulted in metabolic rewiring, with increased glycolysis and NAD + consumption, we wondered if the combination of metformin with glycolytic (2-DG/DAP) and NAMPT (KPT-9274) inhibitors would impede the metabolic rewiring, enhancing cytotoxicity. Among the different treatment combinations, we find that the combination of metformin and KPT-9274 gave the best therapeutic window by significantly increasing drug-induced apoptosis, with more pronounced effects in patients with high mtDNAcn, while sparing healthy CD34 + cells. Concomitantly, OXPHOS and glycolysis were diminished upon KPT-9274+metformin, suggesting that the combination was able to bypass the metabolic rewiring of the AML cells. In conclusion, we uncover a subgroup of patients with high mtDNAcn linked to increased mtOXPHOS that is resistant to chemotherapy-induced apoptosis and is characterized by poor clinical outcomes, which can be overcome by the inhibition of the mt complex I. Moreover, the quantification of mtDNAcn can be easily incorporated into clinical practice as a simple and cost-effective metabolic readout of AML patients to identify metabolic vulnerabilities.

CD74 + Leukemia-Associated Macrophages Supporess T Cell Immune Surveillance and Promote Leukemic Cell Growth in Acute Myeloid Leukemia

The bone marrow microenvironment plays a pivotal role in the recurrence of acute myeloid leukemia (AML). However, the exact mechanisms are not fully understood. Single-cell technologies have emerged as powerful tools for unraveling the immune microenvironment in leukemia. In this study, utilizing scRNA-seq on a cohort of 13 paired AML patients, we have unveiled a distinctive subcluster of tumor-associated macrophages (TAMs) linked to relapse leukemia. To explore the heterogeneity of the bone marrow microenvironment during the progression of AML, we conducted a scRNA-seq analysis on bone marrow cells obtained from 13 paired AML patients at the time of diagnosis (DX) and relapse (RE) (Figure 1A). Employing UMAP for dimensionality reduction, we detected multiple subclusters and observed a notable rise in the Macrophage CD74 cluster in all paired RE patients, suggesting a pivotal role of CD74+ TAMs in AML relapse (Figure 1B-C). Furthermore, CD274, FOS, TGFβ1, and CD163, recognized as markers of M2 macrophages, were significantly enriched in the CD74+ TAMs population (Figure 1D). Intriguingly, a higher proportion of CD74+ TAMs correlated with unfavorable outcomes in TCGA database (Figure 1E). Meanwhile, we found that the ligand macrophage migration inhibitory factor (MIF) of CD74 was associated with poor prognosis of AML (Figure 1F). To investigate the association of CD74+ TAMs with AML cells, Gene Set Variation Analysis (GSVA) was employed and revealed restrained pathways related to T cell function (Figure 2A). Through in vitro experiments on patient samples, we found that CD74+TAM can inhibit the proliferation of T cells and the secretion of IFN-γ. Further monoclonal antibody block experiments unveiled that this inhibitory effect might be attributed to the heightened expression of PD-L1, TGFβ1, and IL-10 by the macrophages (Figure 2B-C). In conclusion, we have substantiated the inhibitory role of CD74+ TAMs on T cells, which hampers their ability to engage in effective tumor killing. To elucidate the interplay between CD74+ TAMs and AML cells, we examined the gene expression profile of cytokines, noting a significant increase in the expression level of IL-6 within the CD74+ TAMs subclusters of the RE group (Figure 3A). Furthermore, upon co-culture with CD74+ TAMs, THP-1 cells exhibited notable activation of IL-6 related pathways (Figure 3B). The injection of CD74+ TAMs resulted in heightened AML initiation and poorer survival in patient-derived xenograft (PDX) model, which was reversed by blocking the IL-6-IL-6R axis (Figure 3C-D). These findings collectively confirm that IL-6 secreted by CD74+ TAMs fosters the malignancy and drug resistance of AML cells. Subsequently, MLL-AF9-induced AML mouse model was employed to explore the spatial interplay between CD74+ TAMs, AML cells and T cells. Immunofluorescence (IF) analysis of mouse bone marrow tissue revealed that after chemotherapy, the proximity between AML cells and CD74+ TAMs decreased (Figure 4A-B). Conversely, the presence of T cells surrounding CD74+ TAMs increased (Figure 4C-D). These findings indicate that CD74+ TAMs can inhibit T cell function and directly influence AML cells within the tumor microenvironment. In summary, our study revealed a notable rise in the proportion of TAMs expressing CD74 in relapsed AML patients. These CD74+ TAMs were found to facilitate leukemia progression while concurrently inhibiting T cell immune surveillance in the context of AML. Thus, our findings indicate that CD74+ TAMs represent a distinct type of macrophages associated with AML relapse.

Artesunate reverses cytarabine resistance in acute myeloid leukemia by blocking the JAK/STAT3 signaling

ABSTRACTObjectivesAlthough cytarabine (AraC) has greatly contributed to improving the prognosis of patients with acute myeloid leukemia (AML), many patients developed drug resistance and eventually succumbed to AML. Thus, resistance to AraC is a major obstacle to improve the efficacy of chemotherapy in AML. Hence, this study aimed to demonstrate that artesunate (ART) can reliably induce cell death in vitro and block AraC resistance.MethodsAML cell lines resistant to AraC were first constructed by repeated dosing for 5 months. Further, we analyzed whether ART intervention affected the sensitivity of AraC-resistant cells to AraC by cell function experiments, mainly including CCK-8 to assess cell viability, flow cytometry to examine apoptosis, and Western blotting to measure the Janus kinase (JAK)/signal transducers and activators of transcription 3 (STAT3) pathway protein expression. Furthermore, whether JAK/STAT3 pathway knockdown has a blocking effect on the efficacy of ART was also assessed.ResultsCo-treatment of ART and AraC increased the sensitivity of AML cells to AraC. Also, it effectively reversed the resistance of AML cells to AraC that is shown by the significantly reduced proliferation and increased apoptosis rates. ART intervention suppressed the activation of the JAK/STAT3 signaling pathway in AraC-resistant AML cells, suggesting that the function of ART in reversing AraC resistance is indeed dependent on the JAK/STAT3 signaling pathway.ConclusionsIn summary, ART enhanced the sensitivity of AML/AraC-resistant cells to AraC by modulating the JAK/STAT3 pathway.

Galectin-9 has non-apoptotic cytotoxic activity toward acute myeloid leukemia independent of cytarabine resistance

Acute myeloid leukemia (AML) is a malignancy still associated with poor survival rates, among others, due to frequent occurrence of therapy-resistant relapse after standard-of-care treatment with cytarabine (AraC). AraC triggers apoptotic cell death, a type of cell death to which AML cells often become resistant. Therefore, therapeutic options that trigger an alternate type of cell death are of particular interest. We previously identified that the glycan-binding protein Galectin-9 (Gal-9) has tumor-selective and non-apoptotic cytotoxicity towards various types of cancer, which depended on autophagy inhibition. Thus, Gal-9 could be of therapeutic interest for (AraC-resistant) AML. In the current study, treatment with Gal-9 was cytotoxic for AML cells, including for CD34+ patient-derived AML stem cells, but not for healthy cord blood-derived CD34+ stem cells. This Gal-9-mediated cytotoxicity did not rely on apoptosis but was negatively associated with autophagic flux. Importantly, both AraC-sensitive and -resistant AML cell lines, as well as AML patient samples, were sensitive to single-agent treatment with Gal-9. Additionally, Gal-9 potentiated the cytotoxic effect of DNA demethylase inhibitor Azacytidine (Aza), a drug that is clinically used for patients that are not eligible for intensive AraC treatment. Thus, Gal-9 is a potential therapeutic agent for the treatment of AML, including AraC-resistant AML, by inducing caspase-independent cell death.

The role of m6A demethylase FTO in chemotherapy resistance mediating acute myeloid leukemia relapse

Acute myeloid leukemia (AML) is the most common hematopoietic malignancies, and chemotherapy resistance is one of the main causes of relapse. Because of lower survival rate for patients with relapse, it is pivotal to identify etiological factors responsible for chemo-resistance. In this work, direct MeRIP-seq analysis of sequential samples at stage of complete remission (CR) and relapse identifies that dysregulated N6-methyladenosine (m6A) methylation is involved in this progression, and hypomethylated RNAs are related to cell differentiation. m6A demethylase FTO is overexpressed in relapse samples, which enhances the drug resistance of AML cells in vivo and in vitro. In addition, FTO knockdown cells exhibit stronger capacity of differentiation towards granules and myeloid lineages after cytosine arabinoside (Ara-C) treatment. Mechanistically, FOXO3 is identified as a downstream target of FTO, the hypomethylation of FOXO3 mRNA affects its RNA degradation and further reduces its own expression, which ultimately result in attenuated cell differentiation. Collectively, these results demonstrate that FTO-m6A-FOXO3 is the main regulatory axis to affect the chemotherapy resistance of AML cells and FTO is a potential therapeutic target of chemotherapy resistance in AML.

Abstract B019: ASO-mediated NRAS knockdown overcomes gilteritinib late resistance in FLT3-AML

Abstract The internal tandem duplication of the FLT3 receptor (FLT3-ITD) leads to constitutive receptor activation and is one of the most common mutations (~30%) in acute myeloid leukemia (AML), resulting in poor prognosis. Multiple FLT3 inhibitors (FLT3i) have been developed, including the potent FDA-approved FLT3i, gilteritinib. However, AML patients only respond to gilteritinib for approximately 6 months due to the emergence of drug resistance. Through an approach that integrated genomic, metabolomic, proteomic, and phosphoproteomic analyses with complementary genetic and pharmacologic screens, we demonstrated that gilteritinib resistance occurs in a stepwise manner with two distinct phases of early and late resistance (Joshi et al., Cancer Cell, 2021). While gilteritinib efficiently eliminates leukemia cells in the blood, residual cells survive within the bone marrow, where they are protected by extrinsic microenvironmental factors fostering early resistance. These lingering cells eventually develop intrinsic mutations in NRAS that allow them to resist gilteritinib treatment, leading to late resistance. Acquisition of mutations in the RAS pathway, particularly NRAS, are a common mode of late resistance (~11%) for many patients that relapse on FLT3i. Developing therapeutics to block NRAS activity remains a challenge with the lack of direct small-molecule inhibitors. Indirect approaches to inhibit mutant NRAS/MAPK pathway signaling have also not met much clinical success. Hence, therapeutic nucleic acid-based approaches, including antisense oligonucleotides (ASOs), may offer an alternative approach to target NRAS-driven cancers. We evaluated the effectiveness of a novel ASO targeting NRAS mRNA to restore gilteritinib sensitivity in resistant cultures in vitro and in primary AML patient samples ex vivo. We first assessed the potency of the NRAS ASO in both gilteritinib-sensitive and late resistant MOLM-14 AML cell lines (N=9) that expressed wild-type or mutant NRAS (G12S or G12D) via free uptake of ASO. NRAS expression was evaluated by qPCR after 48 hours. ASO treatment down-regulated mutant NRAS mRNA expression in a dose-dependent manner with an IC50 of < 1 µM and decreased NRAS protein levels. No changes in NRAS mRNA or protein levels were observed with non-targeting ASO control. Decreased NRAS mRNA expression restored sensitivity to gilteritinib in late-resistant cultures, leading to decreased cell viability and increased apoptosis. A similar trend was observed in primary AML cells from patients (N=2) that relapsed on gilteritinib, where reduction of approximately 50% of mutant NRAS mRNA robustly sensitized patient cells to gilteritinib. In contrast, the combination of gilteritinib and the MEK inhibitor trametinib was not as effective in either cell cultures or patient samples. Our results suggest that ASO-mediated knockdown of NRAS may circumvent the development of resistance and improve the durability of FLT3i. Citation Format: Sunil K. Joshi, Janét Pittsenbarger, Xiaolin Luo, Hadi Maazi, Alexey Revenko, Brian J. Druker, Elie Traer. ASO-mediated NRAS knockdown overcomes gilteritinib late resistance in FLT3-AML [abstract]. In: Proceedings of the AACR Special Conference: Targeting RAS; 2023 Mar 5-8; Philadelphia, PA. Philadelphia (PA): AACR; Mol Cancer Res 2023;21(5_Suppl):Abstract nr B019.

Abstract A35: Overcoming Venetoclax Resistance in Acute Myeloid Leukemia (AML) via the Novel Imipridone ONC213

Abstract Older adults make up most of the AML patient population and have an especially dismal prognosis due to limited therapeutic options. The Bcl-2 inhibitor, venetoclax (VEN), was approved for use in combination with low-dose cytarabine or a hypomethylating agent [azacitidine (AZA) or decitabine] in AML patients who are ≥75 years old or ineligible for intensive chemotherapy (IC). Due to superior survival data and tolerability, the combination of VEN and AZA has become a new standard of care for older patients and those unfit for IC. Though this was a promising therapeutic option for these patients, resistance to this therapy results in a 1-year overall survival rate of only 30-40% and the median overall survival following treatment failure is less than three months, highlighting the urgent need of new therapies to address this. Previous studies have found VEN resistance can be overcome by targeting mitochondria and Mcl-1. Our studies on ONC213, a novel imipridone, have found that it has potent antileukemic activity against both AML cell lines and primary patient samples. It reduces Mcl-1 and targets mitochondria of AML cells – and was thus a promising agent to overcome VEN resistance. When used in combination, ONC213 and VEN are highly synergistic in both AML cell lines and primary patient samples, including those intrinsically resistant to VEN. The combination also targets AML progenitor cells determined by colony formation assays and shows in vivo efficacy in a cell line derived xenograft mouse model (median survival of 57 days vs 37 days in control mice, p=0.002). To determine if ONC213 could overcome acquired resistance to VEN and AZA, we developed VEN and AZA double resistant ML-2 and MV4-11 AML cells (designated ML-2/VEN+AZA-R and MV4-11/VEN+AZA-R) by stepwise increasing concentrations of VEN and AZA at 1:3 fixed ratio over an extended period. ML-2/VEN+AZA-R and MV4-11/VEN+AZA-R AML cells demonstrate 437- and 1156-fold, respectively, increase in VEN+AZA (1:3 ratio) IC50 compared to parental cells (5,285.3 nM vs 12.1 nM and 6,704.3 nM vs 5.8 nM, respectively). ONC213 can resensitize resistant cells to VEN and the combination of ONC213 and VEN is highly synergistic in both ML-2/VEN+AZA-R and MV4-11/VEN+AZA-R cells as evident by a combination index (CI) value of < 0.05. ONC213 alone and in combination with VEN suppress oxidative phosphorylation (OXPHOS) and Mcl-1 in AML cells, including those with inherent resistance to VEN or with acquired resistance to VEN+AZA. Overexpression of Mcl-1 can partially rescue cells from combination therapy. These results suggest that ONC213 suppresses OXPHOS and Mcl-1 to overcome VEN resistance. Here we demonstrate that VEN resistance can be addressed through dual targeting of mitochondria and Mcl-1 using the novel imipridone, ONC213. ONC213 resensitizes VEN + AZA resistant cells to VEN and offers a new approach to combat VEN+AZA resistance in AML. Citation Format: Jenn L. Carter, Yongwei Su, Holly Edwards, Lisa Polin, Joshua E. Allen, Varun V. Prabhu, Jay Yang, Maik Huettermann, Yubin Ge. Overcoming Venetoclax Resistance in Acute Myeloid Leukemia (AML) via the Novel Imipridone ONC213 [abstract]. In: Proceedings of the AACR Special Conference: Acute Myeloid Leukemia and Myelodysplastic Syndrome; 2023 Jan 23-25; Austin, TX. Philadelphia (PA): AACR; Blood Cancer Discov 2023;4(3_Suppl):Abstract nr A35.

Redox metabolism maintains the leukemogenic capacity and drug resistance of AML cells

Rewiring of redox metabolism has a profound impact on tumor development, but how the cellular heterogeneity of redox balance affects leukemogenesis remains unknown. To precisely characterize the dynamic change in redox metabolism invivo, we developed a bright genetically encoded biosensor for H2O2 (named HyPerion) and tracked the redox state of leukemic cells insitu in a transgenic sensor mouse. A H2O2-low (HyPerion-low) subset of acute myeloid leukemia (AML) cells was enriched with leukemia-initiating cells, which were endowed with high colony-forming ability, potent drug resistance, endosteal rather than vascular localization, and short survival. Significantly high expression of malic enzymes, including ME1/3, accounted for nicotinamide adenine dinucleotide phosphate (NADPH) production and the subsequent low abundance of H2O2. Deletion of malic enzymes decreased the population size of leukemia-initiating cells and impaired their leukemogenic capacity and drug resistance. In summary, by establishing an invivo redox monitoring tool at single-cell resolution, this work reveals a critical role of redox metabolism in leukemogenesis and a potential therapeutic target.

Heme oxygenase-1 inhibits the cytotoxicity of natural killer cells to acute myeloid leukemia by downregulating human leukocyte antigen-C

Background aimsRecently, immune escape has been considered as a factor leading to relapse of acute myeloid leukemia (AML). In our previous study, heme oxygenase 1 (HO-1) proved to play an essential role in the proliferation and drug resistance of AML cells. In addition, recent studies by our group have shown that HO-1 is involved in immune escape in AML. Nevertheless, the specific mechanism by which HO-1 mediates immune escape in AML remains unclear. MethodsIn this study, we found that patients with AML and an overexpression of HO-1 had a high rate of recurrence. In vitro, overexpression of HO-1 attenuated the toxicity of natural killer (NK) cells to AML cells. Further study indicated that HO-1 overexpression inhibited human leukocyte antigen-C and reduced the cytotoxicity of NK cells to AML cells, leading to AML relapse. Mechanistically, HO-1 inhibited human leukocyte antigen-C expression by activating the JNK/C-Jun signaling pathway. ResultsIn AML, HO-1 inhibits cytotoxicity of NK cells by inhibiting the expression of HLA-C, thus causing immune escape of AML cells. ConclusionsNK cell-mediated innate immunity is important for the fight against tumors, especially when acquired immunity is depleted and dysfunctional, and the HO-1/HLA-C axis can induce functional changes in NK cells in AML. Anti-HO-1 treatment can promote the antitumor effect of NK cells and may play an important role in the treatment of AML.

Dihydropyrimidinase-like 2 can serve as a novel therapeutic target and prognostic biomarker in acute myeloid leukemia.

Identifying therapeutic targets and prognostic biomarkers significantly contributes to individualized treatment of acute myeloid leukemia (AML). Dihydropyrimidinase-like 2 (DPYSL2) expression was decreased in homoharringtonine (HHT)-resistant AML cells, which were established by our group. DPYSL2 plays an important role in axon growth and has oncogene effect in glioblastoma. However, little research has been conducted to investigate the function of DPYSL2 in AML pathogenesis. Auto-docking was used to reveal the targeting relationship between HHT and DPYSL2. Overall survival (OS), event-free survival (EFS), and relapse-free survival (RFS) were used to evaluate the prognostic impact of DPYSL2 for AML. ShRNA was used to knockdown the expression of SPATS2L. Apoptosis was assessed by flow cytometry. In vivo growth and survival were assessed using a xenotransplantation mice model. RNA sequencing was performed to elucidate the molecular mechanisms underlying the role of SPATS2L in AML and were confirmed by Western blot. We found DPYSL2 was the target of HHT. Next, we found AML cell lines and patients had higher DPYSL2 expression levels than the normal samples. Further multivariate analysis demonstrated that high DPYSL2 expression was an independent poor prognostic factor for OS, EFS, and RFS in AML. Inhibition of DPYSL2 expression suppressed cell growth, induced apoptosis in AML cell lines, and prolonged the survival of AML xenograft NCG mice. Through RNA-seq analysis from TCGA and our data, the JAK2/STAT3/STAT5-PI3K P85/AKT/GSK3b axis was thought to be the critical pathway in regulating DPYSL2 in AML development. We first time confirmed that DPYSL2 was a target of HHT and played an oncogene role in AML by regulating JAK/STAT signaling pathway. Therefore, DPYSL2 could serve as a novel prognostic marker and therapeutic target for AML treatment.

Overexpression of Nrf2 Promotes OGG1 Expression By Activating AKT Signaling Pathway to Mediate Cytarabine Resistance in Acute Myeloid Leukemia Cells

Background：Nuclear factor E2 related factor 2 (Nrf2) exerts a vital function in drug resistance of many tumors. Base excision repair (BER) pathway gene 8-hydroxyguanine DNA glycosidase (OGG1) is a key component of tumor drug resistance. Nevertheless, the potential molecular mechanism of its mediating drug resistance in acute myeloid leukemia (AML) remains unclear. Methods: Firstly, isolation of mononuclear cells from normal healthy donors and AML patients. Drug-resistant AML cell lines were cultured by increasing drug concentration, and AML cell lines with up-regulation and down-regulation of Nrf2 were constructed by lentivirus transfection. The possible mechanism of drug resistance of leukemic cells mediated by overexpression of Nrf2 was investigated by CCK-8 method, immunofluorescence, immunocytochemistry, immunohistochemistry, flow cytometry, Chromatin immunoprecipitation, Western blot, xenograft mouse model and so on. Results: In clinical samples, we found that the expression of Nrf2 and OGG1 were higher in patients with relapse AML. At the cellular level, we confirmed that up-regulation of Nrf2 increased the expression of OGG1, decreased the sensitivity of leukemic cells to cytarabine, and activated the AKT signaling pathway. However, after down-regulation of Nrf2, the expression of OGG1 decreased, the sensitivity of leukemic cells to cytarabine increased and the expression of phosphorylated AKT decreased. MK-2206, an inhibitor of AKT pathway, can inhibit the activation of AKT signaling pathway, decrease the expression of OGG1 and increase the expression of apoptotic protein. In the case of overexpression of Nrf2, the use of OGG1 inhibitors can increase the sensitivity of AML cells to cytarabine. In vivo, we found that the expression of OGG1 decreased after down-regulation of Nrf2, which had a certain protective effect on xenografted tumor mice. Conclusion: overexpression of Nrf2 may promote the expression of OGG1 and mediate drug resistance in AML cells by activating AKT signal pathway. In order to prevent the progression of AML cells, blocking AKT signal pathway with MK-2206 or targeting OGG1 inhibitors may be a potential therapeutic strategy for AML resistance.

C/EBPα-p30 Confers AML Cell Susceptibility to the Terminal Unfolded Protein Response and Resistance to Venetoclax By Activating DDIT3 Transcription

Introduction: CCAAT-enhancer-binding protein α (C/EBPα) is one of the most essential lineage-specific transcription factors involved in myeloid differentiation and includes two isoforms of protein: full-length C/EBPα-p42 and truncated C/EBPα-p30. Acute myeloid leukemia (AML) with CEBPA biallelic (CEBPAbi) mutation or single mutation in the bZIP region is associated with a favorable prognosis, but the mechanisms are still unclear. The unfolded protein response (UPR) is a conserved adaptive signal transduction pathway triggered by endoplasmic reticulum (ER) stress. UPR first strives to restore protein homeostasis and maintain cell survival through a pro-survival arm called adaptive UPR. However, in the setting of irremediable ER stress, the UPR transforms into pro-apoptotic terminal UPR signaling that promotes cell apoptosis. DNA damage-inducible transcript 3 (DDIT3) is a key transcription factor responsible for terminal UPR under severe ER stress. Here, we hypothesize that C/EBPα two isoforms regulate DDIT3 transcription, resulting in easier elimination of AML cells with CEBPA mutations and dysregulation by terminal UPR. Methods: Human AML cell lines and mouse 32Dcl3 were transduced with recombinant lentiviruses to knockdown CEBPA expression or over-express of C/EBPα two isoforms. RT-qPCR was used to detected the mRNA levels and western immunoblotting was used to determine the protein levels. The cell apoptosis rates were determined as the percentage of Annexin V-positive cells by flow cytometry. We performed CFU assays to confirm the declined granulocytic differentiation of 32Dcl3 cells with Cebpa knockdown. To identify potential C/EBPα-binding DNA sequences in the genome, we performed ChIP-seq. Luciferase reporter analysis was used to confirm the transcriptional regulation ability of C/EBPα two isoforms and independent ChIP-qPCR of candidate sequences were performed to further verify the transcription factor binding sites of C/EBPα. Finally, we generated a xenograft model with NCG mice to determine the potential application value of our findings. Results: Firstly, we found a negative correlation between CEBPA expression and DDIT3 levels in AML cell lines and primary de novo AML patients. After knockdown of CEBPA in THP-1 cells, which has high endogenous C/EBPα expression, DDIT3 expression was upregulated, and an increased apoptotic rate of AML cells was induced by ER stress. Cebpa knockdown also induced easier elimination of mouse myeloid progenitor cells 32Dcl3 due to upregulation of Ddit3, so as to avoid leukemogenesis since their differentiation was blocked. After the overexpression of C/EBPα-p42 and C/EBPα-p30 in NB4 cells, which have relatively low levels of endogenous C/EBPα isoforms, we found that C/EBPα-p30 activated DDIT3 expression to increase the sensitivity of AML cells to tunicamycin. However, C/EBPα-p42 had the opposite effect to C/EBPα-p30. Through luciferase reporter analysis, we confirmed that C/EBPα-p30 and C/EBPα-p42 directly regulate the transcription of DDIT3 in a contrasting manner, indicating that the two isoforms maintain protein homeostasis corporately. ChIP-seq and ChIP-qPCR revealed that C/EBPα-p30 has a special binding site in DDIT3 gene promoter with stronger affinity than C/EBPα-p42 (hg38, Chr12:57520654-57521026). Given that the BCL2 family proteins are major targets of DDIT3, we further observed that a low p42/p30 ratio was related to reduced BCL2 levels-a major target of DDIT3, increased MCL1 levels, and resistance of AML cells to venetocalx. Finally, in vitro and in vivo we found that tunicamycin and sorafenib could synergistically reverse venetoclax resistance in AML cells by activating the terminal UPR and inhibiting MCL1. Conclusions: Collectively, our results identified a critical regulation of C/EBPα two isoforms on the transcription of DDIT3 in AML cells as well as normal myeloid progenitor cells and confirmed the importance of this regulation in leukemia surveillance and elimination of AML cells. Moreover, we demonstrated that patients with AML having a low C/EBPα p42/p30 ratio and CEBPAbi mutation may not benefit from monotherapy with BCL2 inhibitors. This can be resolved by a combination of ER stress inducers or MCL1 inhibitors, including tunicamycin and sorafenib, which may represent a novel therapeutic strategy for AML patients with CEBPA mutations and dysregulation. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Targeting the Mevalonate Pathway in the Mitochondria-Dependent Chemotherapy Resistance of TP53 Mutant Acute Myeloid Leukemia

Acute myeloid leukemia (AML) bearing mutations in the TP53 tumor suppressor gene is the most fatal of AMLs with a two-year overall survival between 0-15%. Patients with TP53 mutant (MT) AML typically respond to initial therapy but quickly relapse and die of disease due to chemotherapy resistance. We have undertaken to understand the mechanisms of chemotherapy resistance in TP53 MT AML. Initially, we purified AML blasts to 99% purity using flow sorting and performed RNA sequencing on TP53 MT and wildtype samples. Gene set enrichment analysis demonstrated that TP53 MT AML patient samples were enriched in the cholesterol synthesis or mevalonate pathway. This was validated using the BEAT AML dataset. Interestingly, p53 loss and/or mutation in breast, liver, colon and pancreatic cancer models leads to a dependency on an upregulated mevalonate pathway. Despite these data, the role of the mevalonate pathway in TP53 MT AML is unknown. We have subsequently explored the role of the mevalonate pathway in TP53 MT AML chemotherapy resistance. Experiments were performed in CRISPR-engineered TP53 mutated human AML cells with isogenic controls. Treatment with DNA damaging agents and analysis for cell survival confirmed that loss of wildtype p53 function enhanced cell survival. Recent results have demonstrated that chemotherapy resistance in AML cells is associated with an increase in oxidative phosphorylation (OXPHOS), which is dynamically induced by DNA damage. We confirmed that TP53 MT AML cells increase OXPHOS after DNA damage (Figure 1). Treatment of cells with rosuvastatin, a potent inhibitor of the mevalonate pathway, blocked this increase in OXPHOS and induced chemosensitivity. Lipidomic analysis demonstrates that the increase in OXPHOS correlates with an increase in coenzyme Q10 (CoQ10), a byproduct of the mevalonate pathway. Importantly, co-treatment of cells with a soluble form of mevalonate or a downstream byproduct, geranylgeranyl pyrophosphate (GGPP), recovered OXPHOS and subsequent chemoresistance. This indicates rosuvastatin's activity is specific to the mevalonate pathway, independent of cholesterol, and dependent on the GGPP branch of the pathway. Analysis is ongoing to determine the role of GGPP in regulating the mitochondrial response to DNA damage in TP53 MT cells, including if GGPP is required for CoQ10 synthesis as this remains a controversy in the literature. Overall, this data supports a model where TP53 MT AML cells dynamically upregulate the mevalonate pathway to regulate OXPHOS and avoid DNA damage-induced cell death (Figure 2). To determine if this model is physiologically relevant, we studied a patient derived xenograft (PDX) model of TP53 MT AML cells. Engrafted mice were treated with standard AML chemotherapeutic agent, cytarabine (AraC), for five days alone or in combination with high dose rosuvastatin. Interestingly, mice sacrificed three days after completing AraC administration continue to demonstrate an enhanced OXPHOS response. This response is blunted by co-treatment with rosuvastatin. As expected, TP53 MT AML cells respond modestly to AraC alone and this response was increased with the combination therapy. Overall, these results demonstrate that TP53 MT AML requires the mevalonate pathway for chemotherapy resistance and targeting of the mevalonate pathway in combination with chemotherapy may improve clinical responses. Through detailed biochemical analysis of this mechanism, we will elucidate novel therapeutic approaches to TP53 MT AML. Figure Legend: (1) Oxygen consumption rate measured by seahorse technology in indicated cell lines and conditions. Statistics performed with unpaired T-test in GraphPad with stars indicating significance as per figure. (2) Proposed schema of mevalonate pathway dependencies in TP53 mutant (MT) AML. Bold arrows indicate increased byproduct dependency in TP53 MT AML cells treated with DNA damaging chemotherapy. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal