Wild-type RUNX1 Research Articles

Clinical characteristics and prognosis of acute myeloid leukemia patients with Runt-related transcription factor 1 mutation: A single-center retrospective analysis.

This study aimed to investigate the clinical characteristics and prognosis of Runt-related transcription factor 1 (RUNX1) mutant acute myeloid leukemia (AML) patients by comparing the features of AML patients with or without RUNX1 mutation. We retrospectively analyzed 180 AML patients including 36 AML patients with mutant RUNX1(AML-RUNX1mut ) and 144 AML patients with wild-type RUNX1(AML-RUNX1wt ) were selected using the case-pair method(1:4). Compared to AML-RUNX1wt , AML-RUNX1mut showed higher frequency of ASXL1 (p<0.001), SRSF2 (p<0.001), BCORL1 (p<0.001), RAS (p=0.010) mutations, and absent NPM1 mutations (p=0.022). The 3-year overall survival (OS) and disease-free survival (DFS) of AML-RUNX1mut and AML-RUNX1wt were 73.1% versus 68.0% (p=0.64) and 80.7% versus 71.6% (p=0.37), respectively. AML-RUNX1mut receiving allogeneic hematopoietic cell transplantation (allo-HSCT) showed better survival than those who did not receive allo-HSCT (3-year OS, 84.3% vs. 52.7%; p=0.006). Multivariate analysis showed that EZH2 mutation (p=0.003), white blood cell (WBC) ≥30×109 /L (p=0.036) and age ≥60years (p=0.038) were significant independent risk factors for inferior OS of AML-RUNX1mut ; WBC ≥30×109 /L (p=0.013) and DNMT3A mutation (p=0.045) were significant independent risk factors for shorter DFS of AML-RUNX1mut . In conclusion, AML-RUNX1mut showed unique clinical characteristics, but the survival between AML-RUNX1mut and AML-RUNX1wt were comparable. EZH2 co-mutation, DNMT3A co-mutation, old age and high WBC count were associated with inferior survival of AML-RUNX1mut . Allo-HSCT can significantly improve the prognosis of AML-RUNX1mut .

RUNX1 Mutation Does Not Significantly Impact the Outcome of Newly Diagnosedadult AML: A Retrospective Study of Chinese AML Patients

Background RUNX1 is one of the recurrent mutated genes in newly diagnosed acute myeloid leukemia (AML) with a frequency of 6%~15%. Although historically recognized as a provisional distinct entity, the AML subtype with RUNX1 mutations (AML- RUNX1mut) was eliminated from the 2022 WHO classification system. With the update of AML diagnosis and treatment protocol, different outcomes of AML- RUNX1muthave been reported. However, an in-depth study about the prognostic value of RUNX1 mutations, epecifically the classification change related to AML- RUNX1mut in a large well-annotated cohort is lacking. Methods The clinical data of 1065 AML (excluding acute promyelocytic leukemia and RUNX1 germline mutations) patients according to WHO 2016 and treated from January 2017 to December 2021 at Jiangsu Institute of Hematology were retrospectively collected and analyzed after informed consent. All AML diagnosis samples were analyzed by targeted Next Generation Sequencing (NGS) panel covering 172 frequently mutated genes in hematological malignancies. Demographic and clinical data, disease characteristics at diagnosis, first-line treatment and clinical outcome data were available for all patients. The survival time of allogeneic hematopoietic stem cell transplantation patients was censored at the time of stem cell transfusion. Cytogenetic and molecular characteristics were used to classify patients into ELN2017 and ELN2022 risk groups (excluding the effect of RUNX1 mutation). Results RUNX1 mutations were detected in 112 (10.5%) patients, namely, 66 (58.9%) male and 46 (41.1%) female. A total of 132 RUNX1 alterations were detected with a medianvariant allelic frequency of 40% (3%~93%). RUNX1 mutations were associated with older age (48.5 vs. 46.0 years old, P=0.087) and antecedent myeloid disorders (6.3% vs. 1.0%, P&amp;lt;0.001). One or more comutations were detected in 106 (94.7%) AML- RUNX1mut patients. The most frequent co-gene abnormalities were FLT3-ITD and DNMT3A mutations which represented the 23.2% and 18.7%. Mutations of CEBPA bZIP, NPM1 and translocations of t(8;21), t(16;16)/inv(16) were uncommon in AML- RUNX1mut with a frequency of 6.3%, 1.8%, 2.7%, 0%, respectively (Table 1). Compared with AML with wild-type RUNX1 (AML- RUNX1wt), AML- RUNX1mut patients had a lower complete remission rate (19.6% vs. 29.7%, P=0.034), lower overall response rate (ORR) (73.5% vs. 84.3%, P=0.006) and higher no response rate (26.5% vs. 15.5%, P=0.021) in the first induction chemotherapy. When comparing groups based on the ELN2017 risk stratification criteria, no significant difference in ORR was observed between RUNX1mut and RUNX1wt patients in the favorable (91.2% vs. 94.0%, P=0.572), intermediate (75.0% vs. 78.4%, P=0.570) and adverse (63.3% vs. 71.4%, P=0.370 ) subgroups (Table 2). The median duration of follow-up of the entire cohort was 8.7 months ( RUNX1wt: 8.4 months; RUNX1mut: 10.0 months). Comparing the two groups, patients with RUNX1 mutations had a lower 5-year overall survival (OS) rate (35.4% vs. 42.3%; HR=1.563; 95% CI: 1.091~2.237, P=0.026), but no significant difference was observed in the 5-year event-free survival (EFS) rate (40.8% vs. 35.4%; HR=1.084; 95% CI: 0.750~1.570, P=0.098) (Table 2). However, when patients were stratified according to the ELN2017 guidelines (excluding the effect of RUNX1 mutation), outcomes did not differ between patients withor without RUNX1 mutation in the favorable (OS: P=0.629, EFS: P=0.137), intermediate (OS: P=0.629, EFS: P=0.114) and adverse (OS: P=0.544; EFS: P=0.714) subgroups. Similar results were obtained according to the ELN2022 guidelines. In multivariate analysis, RUNX1 was not an independent prognostic factor for OS (HR=1.353, 95% CI: 0.922~1.985, P=0.122) and EFS (HR=1.422, 95% CI: 0.975~2.075, P=0.068), while significantly worse OS and EFS were observed in patients with mutated FLT3-ITD, TP53, and DNMT3A ( P-values were all less than 0.05). Conclusion RUNX1 mutations were rarely isolated genetic abnormities that conferred inferior outcomes. However, on the basis of ELN prognosis risk stratification, RUNX1mutation had no impact on the clinical outcomes of AML patients in stratified subgroups. RUNX1 was not an independent prognostic factor for survival. Overall, our findings agree with the updated WHO classification system for AML that AML- RUNX1mut should not be recognized as a distinct AML entity.

Functional Classification of Germline RUNX1 Variants Identified in Patients Suspected of Familial Platelet Disorder with Associated Myeloid Malignancies

RUNX1 is a master regulator of hematopoiesis. A highly conserved runt-homology domain (RHD) located near the N-terminus is responsible for DNA binding and interaction with its heterodimeric partner CBFβ, whereas the C-terminus contains the transactivation domain (TAD). Somatic variants and chromosomal abnormalities affecting RUNX1 are commonly observed in hematological malignancies, such as myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML). Heterozygous germline RUNX1 variants are responsible for familial platelet disorder with associated myeloid malignancies (FPDMM), an autosomal dominant disorder with incomplete penetrance and a broad spectrum of clinical phenotypes, including thrombocytopenia, functional platelet defects, and an increased risk (35-45%) of developing MDS and AML. In 2019, our group launched a longitudinal natural history study of patients with germline RUNX1 variants to increase our understanding of FPDMM, which will hopefully lead to better clinical management and potentially new therapies. The majority of RUNX1 variants are private with limited segregation data available, making variant interpretation challenging. A significant number of cases have variants of unknown significance (VUS) in RUNX1. Therefore, it is important to determine if these VUS are pathogenic (or benign) in order to improve the diagnosis and clinical management for these individuals. To functionally characterize each variant, we used well-established in vitro functional assays to assess the damaging effect of each RUNX1 VUS, including transactivation reporter assays, electrophoretic mobility shift assays, co-immunoprecipitation, immunofluorescence, and western blot with cell fractionation. All assays include RUNX1 wildtype and known benign and pathogenic controls, as well as co-expression with its binding partner CBFβ. The VUS Ser94Arg located in RHD of RUNX1 has showed impaired CSF1R transactivation (&amp;lt; 20% of wildtype), reduced subcellular co-localization of RUNX1 with CBFβ, and reduced heterodimerization with CBFβ. These results together with population frequency data, in silico prediction, phenotype and segregation data support the reclassification of this variant into the likely pathogenic category. On the other hand, the VUS Asp123His shows no damaging effect in vitro, and could be reclassified to likely benign. Using these assays, we have confirmed or reclassified several RUNX1 variants using the criteria set by the ACGM Myeloid Malignancy VCEP (Luo et al, Blood Adv. 2019; 3:2962). Together, these results highlight the importance of using in vitro functional assays for RUNX1 variant classification. Moreover, we sought to determine the potential of using platelet transcriptomics for RUNX1 variant classification and to gain a deeper understanding of FPDMM pathogenesis. Clariom™ D microarrays identified 218 differentially expressed genes (DEG; absolute fold change ≥ 2; q-value &amp;lt; 0.05) between FPDMM patients and healthy controls, with 90 genes (41%) being upregulated and 128 genes (59%) being downregulated in patients. Hierarchical clustering showed that the selected FPDMM patients with pathogenic and likely pathogenic RUNX1 variants clustered together and separately from healthy controls, with well-established pathogenic variants, such as Arg201Ter and Arg201Gln, at the opposite end of the dendrogram, and likely pathogenic variants such as Tyr403Cysfs153 closer to healthy controls. Our results show that FPDMM patients exhibit reduced expression of important genes related to thrombocytopenia and platelet dysfunction. Furthermore, several top upregulated genes identified in FPDMM patient's platelets are associated with poorer outcomes in AML patients, according to the TCGA dataset. Overall, our study shows the importance of performing functional assays to aid RUNX1 variant classification and to facilitate the study of FPDMM pathogenesis. We are currently analyzing the platelet proteome data of FPDMM patients by LC-MS/MS, which will be reported at the annual meeting.

RUNX1 Isoforms Regulate RUNX1 and Target-Genes Differentially in Platelets/Megakaryocytes: Association with Clinical Cardiovascular Events

RUNX1 is an essential transcription factor for hematopoiesis. Germline RUNX1 haplodeficiency is associated with thrombocytopenia, platelet dysfunction and predisposition to myeloid malignancies. Three major RUNX1 isoforms (A, B and C) are recognized and share a DNA binding RUNT domain; RUNX1A lacks the transactivation domain. Two distinct promoters regulate RUNX1 expression: distal P1 regulates RUNX1C; proximal P2 regulates RUNX1B and RUNX1A. Little is known regarding the differential effects of isoforms in RUNX1 autoregulation, target-gene regulation and association with clinical events. We performed studies in megakaryocytic HEL cells, HeLa cells (which do not express RUNX1) and in platelets of healthy subjects (n=74) and provide evidence for isoform-specific differential autoregulation and target-gene regulation by RUNX1. We show an association between expression of specific RUNX1-regulated genes in whole blood with cardiovascular events in patients. There are 5 RUNX1 consensus binding sites in P1 promoter and 1 in P2 promoter within ~1000 bp from ATG. Wild type RUNX1 P1 and P2 promoter regions were individually cloned into PGL4 luciferase promoter vector. ChIP studies using PMA-treated megakaryocytic HEL cells showed RUNX1 binding to chromatin regions encompassing the RUNX1 binding sites in both promoters. Mutations of 2 RUNX1 binding sites in intron region of P1 promoter reduced promoter activity; mutations of first 2 RUNX1 binding sites at the exon region of P1 promoter increased activity. Mutation of single RUNX1 binding site in P2 promoter increased promoter activity. Thus, RUNX1 binds to P1 and P2 promoters to regulate activities. To examine the RUNX1 autoregulation by individual isoforms, we co-transfected each isoform with P1 or P2 promoter vector in HeLa cells, which do not express endogenous RUNX1. In response to RUNX1B over-expression, both P1 and P2 promoters showed a dose-dependent decrease in promoter activity. RUNX1C over-expression increased P1 and P2 promoter activities. Thus, RUNX1B and RUNX1C regulate P1 and P2 promoters differentially. In HEL cells, which have endogenous RUNX1, RUNX1B overexpression decreased RUNX1C and RUNX1A mRNA/protein expression by ~50%. RUNX1C overexpression increased RUNX1B and RUNX1A mRNA/protein expression. Thus, RUNX1B decreases RUNX1C and RUNX1A expression; RUNX1C increases RUNX1B and RUNX1A. We studied the regulation by RUNX1 isoforms of target genes PCTP (phosphatidylcholine transfer protein), MYL9 (myosin light chain), PDE5A (phosphodiesterase 5A) and F13A (factor XIIIA) . In HeLa cells. RUNX1B overexpression increased PCTP, MYL9 and PDE5A (protein and mRNA); RUNX1C overexpression reduced PCTP and MYL9. In HEL cells RUNX1B increased PCTP, MYL9, PDE5A and F13A expression; RUNX1C reduced PCTP and MYL9 expression. To obtain evidence in vivo, we studied the relationships between RUNX1 isoforms and their relationships to RUNX1-target genes by RNAseq in leukocyte-poor platelets (74 healthy donors; ages 30-75 yrs). RUNX1B correlated negatively with RUNX1C (R= -0.413 and p=1.5e-06) and RUNX1A (R= -0.493 and p=0.00e+oo); RUNX1C correlated positively with RUNX1A (R=0.45, p&amp;lt;0.0001). RUNX1B correlated positively with PCTP, F131A, PDE5A and RAB1B, and negatively with MYL9 (Figure 1); no significant relationships were observed with RUNX1C or RUNX1A. To understand the relationships to cardiovascular events (MI or death), we explored whole blood gene expression using microarrays in 587 patients (2 cohorts, 190 and 397 patients) presenting to cardiac catherization for chest pain and followed for 3.8 years. In our previous studies RUNX1B transcripts were higher and RUNX1C lower in those with MI or death. We now found that higher expressions of F13A1(Figure 2) and RAB31, which have been shown by us to be RUNX1-targets, were associated with cardiovascular events. Conclusions: RUNX1 isoforms autoregulate RUNX1 expression differentially and regulate target genes in a differential manner, a pattern consistent with in vivo platelet gene expression. The relative expression of RUNX1B and RUNX1C isoforms and of their target genes associate with clinical cardiovascular events. RUNX1-isoform specific effects need to be considered in clinical scenarios where RUNX1 is involved and in its pharmacologic modulation.

RUNX1 Mutated AML and MDS: Similarities, Differences and Molecular Factors Leading to Disease Progression

Background: Mutations in the myeloid transcription factor RUNX1 are frequently detected in AML and MDS. Differences have been described regarding additional cytogenetic and molecular genetic abnormalities, however the molecular factors responsible for progression of RUNX1 mutated MDS to AML are yet not fully elucidated. Aim: Analysis of genetic (1) similarities and (2) differences of RUNX1 mutated AML and MDS cases, (3) identification of factors potentially causing disease progression from RUNX1 mutated MDS to AML. Methods: Whole-genome sequencing (WGS) was performed for 773 AML and 747 MDS patients (median coverage 100x). 151bp paired-end reads were generated on NovaSeq 6000 and HiSeqX machines (Illumina, San Diego, CA). As no sample specific normal tissue was available, a so-called Tumor/Unmatched normal (TUN) workflow was used to reduce technical artefacts and germline calls. All reported p-values are two-sided and were considered significant at p<0.05. Results: Mutations in RUNX1 (RUNX1mut) were detected at comparable frequencies in AML and MDS (AML: 97/773 cases, 13%; MDS: 71/747, 10%). In MDS, an association of the RUNX1mut frequency with higher blast counts was observed (0-5% blasts: 15/419 with RUNX1mut, 4%; ≥5,<10%: 16/175, 9%; ≥10,<20%: 40/153, 26%). However, blast count did not influence overall survival (OS) in RUNX1mut subgroups (0-5% blasts: 18 months (m); ≥5,<10%: 25 m; ≥10,<20%: 18 m; AML: 21 m). The variant allele frequency (VAF) of RUNX1mut differed significantly dependent on the blast count (median VAF in cases <5% blasts: 0.22; ≥5%: 0.42; p<0.001). Regarding cytogenetic abnormalities, RUNX1mut MDS showed a higher frequency of normal karyotype (NK) compared to AML (66% vs. 38%, p<0.001) but similar frequencies of trisomies (18% vs. 22%) and complex karyotype (3% vs. 5%), although differences regarding the trisomy type were detected (MDS: only trisomy 8; AML: trisomies 8, 11 and 13). In 10% of AML cases with RUNX1mut a rearrangement involving MECOM was detected (5% GATA::MECOM, 5% other MECOM rearrangements), which was absent in MDS with RUNX1mut. Similarly, KMT2A-PTD and FLT3-ITD alterations were detected in AML but not in MDS with RUNX1mut (KMT2A-PTD: 7% in AML vs. 0% in MDS, p=0.021; FLT3-ITD: 13% vs. 0%, p=0.001). By contrast, TP53mut were found at comparably low frequencies (MDS: 4/71, 6%; AML: 3/97, 3%). For both AML and MDS, a strong association of RUNX1mut with mutations in spliceosome genes (SF3B1, SRSF2, U2AF1, ZRSR2) was detected (AML: 58/97 = 60% in RUNX1mut vs. 139/676 = 21% in RUNX1wild type (wt); p<0.001; MDS: 52/71 = 73% vs. 346/676 = 51%, p<0.001). However, while SRSF2mut in MDS were associated with increasing blast counts similar to RUNX1mut (0-5% blasts: 25/419 with SRSF2mut, 6%; ≥5,<10%: 130/175, 17%; ≥10,<20%: 50/153, 32%), SF3B1mut were negatively correlated to blast counts and thus to RUNX1mut (0-5% blasts: 179/419, 43%; ≥5,<10%: 28/175, 16%; ≥10,<20%: 11/153, 7%). In the total AML cohort, in 24/773 of cases a CN-LOH involving RUNX1 was detected, 21 of these also showed a RUNX1mut (22% (21/97) of RUNX1mut cases). By contrast, in the total MDS cohort in only 2/747 cases a CN-LOH covering RUNX1 was found, none of them harboring a RUNX1mut. The VAF of cases with RUNX1mut + CN-LOH (RUNX1mutLOH) was >0.5 for all cases and was significantly higher than the VAF of RUNX1mut cases without CN-LOH (0.89 (range 0.54-0.97) vs. 0.42 (range 0.05-0.85), p<0.001). Moreover, cases with RUNX1mutLOH were found to be significantly associated with FLT3-ITD (RUNX1mutLOH, 6/21 = 29%; RUNX1mut without CN-LOH, 7/76 = 9%; p=0.032). Conclusions: (1) RUNX1mut occur at similar frequencies in AML and MDS and genetically show an MDS signature, reflected e.g. by association with mutations in spliceosome genes. OS is similar in all subgroups independent of blast counts. (2) In MDS, RUNX1mut are associated with higher blast counts, thus potentially functioning as driver towards progression to AML. (3) Additional cytogenetic/molecular genetic alterations that might function as progression factors from RUNX1mut MDS to AML include: (i) karyotype, especially MECOM rearrangements, trisomy 11 and trisomy 13 (ii) KMT2A-PTD, (iv) FLT3-ITD, (v) and CN-LOH covering RUNX1 (Figure). (4) By contrast, TP53mut do not seem to play a role in progression of RUNX1 mutated MDS to AML. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

In-silico probing of AML related RUNX1 cancer-associated missense mutations: Predicted relationships to DNA binding and drug interactions.

The molecular consequences of cancer associated mutations in Acute myeloid leukemia (AML) linked factors are not very well understood. Here, we interrogated the COSMIC database for missense mutations associated with the RUNX1 protein, that is frequently mis-regulated in AML, where we sought to identify recurrently mutated positions at the DNA-interacting interface. Indeed, six of the mutated residues, out of a total 417 residues examined within the DNA binding domain, evidenced reduced DNA association in in silico predictions. Further, given the prominence of RUNX1’s compromised function in AML, we asked the question if the mutations themselves might alter RUNX1’s interaction (off-target) with known FDA-approved drug molecules, including three currently used in treating AML. We identified several AML-associated mutations in RUNX1 that were calculated to enhance RUNX1’s interaction with specific drugs. Specifically, we retrieved data from the COSMIC database for cancer-associated mutations of RUNX1 by using R package “data.table” and “ggplot2” modules. In the presence of DNA and/or drug, we used docking scores and energetics of the complexes as tools to evaluate predicted interaction strengths with RUNX1. For example, we performed predictions of drug binding pockets involving Enasidenib, Giltertinib, and Midostaurin (AML associated), as well as ten different published cancer associated drug compounds. Docking of wild type RUNX1 with these 13 different cancer-associated drugs indicates that wild-type RUNX1 has a lower efficiency of binding while RUNX1 mutants R142K, D171N, R174Q, P176H, and R177Q suggested higher affinity of drug association. Literature evidence support our prediction and suggests the mutation R174Q affects RUNX1 DNA binding and could lead to compromised function. We conclude that specific RUNX1 mutations that lessen DNA binding facilitate the binding of a number of tested drug molecules. Further, we propose that molecular modeling and docking studies for RUNX1 in the presence of DNA and/or drugs enables evaluation of the potential impact of RUNX1 cancer associated mutations in AML.

The Role of Runx2 in Microtubule Acetylation in Bone Metastatic Breast Cancer Cells.

Simple SummaryBreast cancer is the most commonly diagnosed cancer type, making up a quarter of all cases among women. While modern-day research has shown tremendous progress in the development of treatment options, complications related to bone metastasis remain an obstacle that demands further attention. Cancer cells that migrate into the bone microenvironment show significant alterations in their metabolism and gene expression profiles. In this study, we set out to better understand the changes induced by Runx2 in bone-derived breast cancer cells. We identified key changes in the stability of the microtubule cytoskeleton of bone-derived cells expressing Runx2. These changes have implications on a variety of processes related to metabolism, cellular stress response, and response to common chemotherapies. These studies help to shed light on the changes that take place as a tumor begins to metastasize and to better predict which therapies will benefit patients with bone metastasis.Bone metastasis of breast cancer results in severe bone loss, fractures, and death. Crosstalk between breast cancer cells and bone resident cells promotes osteoclast activity and the release of growth factors from the bone matrix resulting in aggressive tumor growth and bone loss. We and others have shown that Runt-related transcription factor-2 (Runx2) promotes metastatic tumor growth-associated bone loss. Breast cancer cells also induce autophagy to survive metabolic stress at the metastatic site. Recently, we reported a Runx2-dependent increase in autophagy. In this study, to examine the underlying mechanisms of metastasis and tumor resistance to stress, we used a bone metastatic isogenic variant of breast cancer MDA-MB-231 cells isolated from a xenograft tumor mouse model of metastasis. Our results with immunofluorescence and biochemical approaches revealed that Runx2 promotes microtubule (MT) stability to facilitate autophagy. Stable MTs are critical for autophagosome trafficking and display increased acetylation at Lysine 40 of α-tubulin. Runx2 silencing decreases acetylated α-tubulin levels. The expression levels of HDAC6 and αTAT1, which serve to regulate the acetylation of α-tubulin, were not altered with Runx2 silencing. We found that HDAC6 interaction with α-tubulin is inhibited by Runt-related factor-2 (Runx2). We show that the expression of wild-type Runx2 can restore the acetylated polymer of MTs in Runx2 knockdown cells, while the C-terminal deletion mutant fails to rescue the polymer of MTs. Importantly, cellular stress, such as glucose starvation also increases the acetylation of α-tubulin. We found that the loss of Runx2 increases the sensitivity of breast cancer cells to MT-targeting agents. Overall, our results indicate a novel regulatory mechanism of microtubule acetylation and suggest that Runx2 and acetylated microtubules may serve as therapeutic targets for bone metastatic tumors.

Identification and characterization of TGF-β1-responsive Runx2 acetylation sites for matrix Metalloproteinase-13 expression in osteoblastic cells

In skeletal tissues, transforming growth factor-beta 1 (TGF-β1) serves a number of activities. For example, in osteoblastic cells, TGF-β1 stimulates the expression of matrix metalloproteinase-13 (MMP-13, a bone remodeling gene), which requires the bone transcription factor Runx2. Although TGF-β1 is known to stimulate Runx2 acetylation, the sites involved in MMP-13 gene activation remain unknown. Mass spectrometry analysis revealed that Runx2 was acetylated at one site (K134) and three sites (K24, K134, and K169) following control and TGF-β1-treatment, respectively, in osteoblastic cells. In addition, we mutated the lysine residues in the Runx2 construct into arginine and transfected the construct into mouse mesenchymal stem cells (C3H10T1/2). Wild-type Runx2 expression and acetylation were significantly increased by TGF-β1-treatment, whereas this effect was decreased in the presence of the Runx2 double mutant construct (K24 + K169) in C3H10T1/2 cells. TGF-β1 enhanced MMP-13 promoter activity in cells transfected with the wild-type Runx2 construct, but this effect was considerably reduced in cells transfected with the Runx2 double mutant construct (K24 + K169), according to a luciferase reporter test. Hence, the stability of Runx2 may be mediated by TGF-β1-induced acetylation at K24 and K169 and is required for MMP-13 expression in osteoblastic cells. These findings add to our knowledge of TGF-β1, Runx2, and MMP-13's physiological roles in bone metabolism.

Myeloid neoplasms and clonal hematopoiesis from the RUNX1 perspective.

RUNX1 is a critical transcription factor for the emergence of definitive hematopoiesis and the precise regulation of adult hematopoiesis. Dysregulation of its regulatory network causes aberrant hematopoiesis. Recurrent genetic alterations in RUNX1, including chromosomal translocations and mutations, have been identified in both inherited and sporadic diseases. Recent genomic studies have revealed a vast mutational landscape surrounding genetic alterations in RUNX1. Accumulating pieces of evidence also indicate the leukemogenic role of wild-type RUNX1 in certain situations. Based on these efforts, part of the molecular mechanisms of disease development as a consequence of dysregulated RUNX1-regulatory networks have become increasingly evident. This review highlights the recent advances in the field of RUNX1 research and discusses the critical roles of RUNX1 in hematopoiesis and the pathobiological function of its alterations in the context of disease, particularly myeloid neoplasms, and clonal hematopoiesis.

Identification a novel de novo RUNX2 frameshift mutation associated with cleidocranial dysplasia

BackgroundCleidocranial dysplasia (CCD) is a rare genetic disorder affecting bone and cartilage development. Clinical features of CCD comprise short stature, delayed ossification of craniofacial structures with numerous Wormian bones, underdeveloped or aplastic clavicles and multiple dental anomalies. Several studies have revealed that CCD development is strongly linked with different mutations in runt-related transcription factor 2 (RUNX2) gene.ObjectiveIdentification and functional characterization of RUNX2 mutation associated with CCD.MethodsWe performed genetic testing of a patient with CCD using whole exome sequencing and found a novel RUNX2 frameshift mutation: c.1550delT in a sporadic case. We also compared the functional activity of the mutant and wild-type RUNX2 through immunofluorescence microscopy and osteocalcin promoter luciferase assay.ResultsWe found a novel RUNX2 frameshift mutation, c.1550delT (p.Trp518Glyfs*60). Both mutant RUNX2 and wild-type RUNX2 protein were similarly confined in the nuclei. The novel mutation caused abrogative transactivation activity of RUNX2 on osteocalcin promoter.ConclusionsWe explored a novel RUNX2 deletion/frameshift mutation in a sporadic CCD patient. This finding suggests that the VWRPY domain may play a key role in RUNX2 transactivation ability.

Homoharringtonine and Mebendazole Are Preferentially Lethal Against Models of Myeloid Malignancy Associated with Germline Mutant RUNX1

RUNX1 is a master-transcriptional regulator involved in normal and malignant hematopoiesis. Majority of mono-allelic germline mutations in RUNX1 are missense, large deletions or truncation mutations, behaving mostly as loss of function (LOF) mutations. They are ~40%-penetrant and cause Familial Platelet Disorder (RUNX1-FPD) that has a propensity to evolve into myeloid malignancy (FPD-MM), i.e., MDS or AML. FPD-MM harbors co-mutations, most commonly on the second allele of RUNX1, and on BCOR, PHF6, K-RAS, WT1 or TET2, which confer relative resistance to standard therapy for MDS or AML. Although curative in some patients with FPD-MM, allogeneic transplantation from matched, un-related donors carries risk of graft versus host disease and frequent AML relapse. This creates a strong rationale and an unmet need to develop novel targeted therapies for FPD-MM. We previously reported on utilizing the RNA-Seq signature of RUNX1 knockdown, which exerted more lethality in AML cells with mutant (mt) RUNX1 compared to AML harboring two copies of wild-type RUNX1, for conducting LINCS1000-CMap analysis. This identified several expression mimickers (EMs), including the protein synthesis inhibitor homoharringtonine (HHT or omacetaxine) and anthelmintic fenbendazole (analog of mebendazole). Present studies demonstrate that treatment with HHT or mebendazole (MB) dose-dependently induced significantly greater loss of viability in four patient-derived (PD) bone marrow aspirate (BMA) samples of FPD-MM (3 AML and 1 MDS) compared to RUNX1-FPD (3 samples) or in normal CD34+ progenitor cells. In a patient with RUNX1-FPD (expressing mtRUNX1 K194N), who developed FPD-MM, following co-mutations were documented by NGS: BCOR A1437fs, PHF6 L324fs, SF3B1 D781G and SRSF2 P95R/L. From BMA of this patient, we successfully established the first ever, continuously cultured cell line (GMR-AML1) expressing the same germline mtRUNX1. GMR-AML1 cells were cytogenetically diploid and lacked MYC or MLL1 rearrangement, or any copy number gains or losses on array CGH. However whole exome sequencing (WES) identified additional mutations in TP53 (P72R), AIM2 (K340fs), NELFB (L523F), CEP152 (Y370X), SUGP2 (H23L), RRM2B (R71fs), TADA3 (T27R), SPDYE6 (G292C) and PRDM9 (S814R) with % VAF ranging between 33 to 55%. GMR-AML1 cells exhibited high surface expression of CD117 (c-KIT), CD123 (IL3R), CD86 and CD33, but without expression of CD34, CD14, CD11b, MPO or CD135 (FLT3). Compared to the AML OCI-AML5 cells with somatic mtRUNX1, GMR-AML1 cells demonstrated markedly reduced protein expression of RUNX1, RUNX2, PU.1, c-Myb, GFI1, GFI1B, FLT3, MEIS1 and CEBPα (p42), but much higher protein expression of RUNX3 and NOTCH (p120). CRISPR-Cas9 knockout of RUNX3 in GMR-AML1 cells restored RUNX1 expression, while significantly increasing % of differentiated cells. Although dose-dependently sensitive to daunorubicin, etoposide, cytarabine and panobinostat (class I and II HDAC inhibitor), GMR-AML1 cells were relatively insensitive to venetoclax, A1155463 (Bcl-xL inhibitor), AZD-5991 (MCL1 inhibitor), azacytidine or decitabine. Notably, treatment with HHT or MB dose-dependently induced loss of viability of GMR-AML1 cells (LD50: 40 and 330 nM, respectively). Additionally, co-treatment with HHT and venetoclax synergistically induced apoptosis in GMR-AML1 cells, as determined by the SynergyFinder algorithm. This synergy in GMR-AML1 cells was associated with abrogation of venetoclax-induced increase in MCL1 and Bcl-xL levels, as well as greater decline in levels of RUNX3, PU.1, c-Myb, c-Myc, MPL and CDK4/6. Tail vein infusion and engraftment of luciferase-transduced GMR-AML1 (10 6 cells) caused marked splenomegaly and 100% mortality of NSG mice by day-18, post-infusion. We will present at the ASH meeting findings of ongoing in vivo studies determining effects of treatment with HHT and/or venetoclax, versus vehicle control, on AML burden and overall survival of NSG mice engrafted with GMR-AML1 cells. Overall, preclinical findings presented here highlight the molecular and genetic features associated with progression of RUNX1-FPD to FPD-MM, especially in the newly established GMR-AML1 cell line. They also demonstrate that HHT or MB are preferentially more lethal against FPD-MM versus RUNX1-FPD cells and exert synergistic lethality with venetoclax against GMR-AML1 cells. DisclosuresDiNardo: GlaxoSmithKline: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria; AbbVie: Consultancy, Research Funding; Agios/Servier: Consultancy, Honoraria, Research Funding; Notable Labs: Current holder of stock options in a privately-held company, Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Honoraria, Research Funding; Takeda: Honoraria; ImmuneOnc: Honoraria, Research Funding; Forma: Honoraria, Research Funding; Foghorn: Honoraria, Research Funding; Celgene, a Bristol Myers Squibb company: Honoraria, Research Funding. Takahashi: GSK: Consultancy; Celgene/BMS: Consultancy; Symbio Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; Novartis: Consultancy. Khoury: Stemline Therapeutics: Research Funding; Angle: Research Funding; Kiromic: Research Funding.

Effective therapy for AML with RUNX1 mutation by cotreatment with inhibitors of protein translation and BCL2

AbstractThe majority of RUNX1 mutations in acute myeloid leukemia (AML) are missense or deletion-truncation and behave as loss-of-function mutations. Following standard therapy, AML patients expressing mtRUNX1 exhibit inferior clinical outcome than those without mutant RUNX1. Studies presented here demonstrate that as compared with AML cells lacking mtRUNX1, their isogenic counterparts harboring mtRUNX1 display impaired ribosomal biogenesis and differentiation, as well as exhibit reduced levels of wild-type RUNX1, PU.1, and c-Myc. Compared with AML cells with only wild-type RUNX1, AML cells expressing mtRUNX1 were also more sensitive to the protein translation inhibitor homoharringtonine (omacetaxine) and BCL2 inhibitor venetoclax. Homoharringtonine treatment repressed enhancers and their BRD4 occupancy and was associated with reduced levels of c-Myc, c-Myb, MCL1, and Bcl-xL. Consistent with this, cotreatment with omacetaxine and venetoclax or BET inhibitor induced synergistic in vitro lethality in AML expressing mtRUNX1. Compared with each agent alone, cotreatment with omacetaxine and venetoclax or BET inhibitor also displayed improved in vivo anti-AML efficacy, associated with improved survival of immune-depleted mice engrafted with AML cells harboring mtRUNX1. These findings highlight superior efficacy of omacetaxine-based combination therapies for AML harboring mtRUNX1.

RUNX1 Upregulates CENPE to Promote Leukemic Cell Proliferation.

RUNX1 is a Runt family transcription factor that plays a critical role in normal hematopoiesis, including the differentiation and proliferation of hematopoietic cells. RUNX1 mutations, including chromosomal translocations, cause abnormal cell differentiation, but the mutation alone is not sufficient to cause leukemia. In MLL-fusion-induced leukemia, dysregulated wild-type RUNX1 can promote leukemia survival. Nevertheless, the underlying mechanisms of dysregulated wild-type RUNX1 in leukemia development have not been fully elucidated. This study overexpressed and knocked down RUNX1 expression in THP-1 human leukemia cells and CD34+ hematopoietic stem/progenitor cells to investigate the biological functions affected by dysregulated RUNX1. Our data indicated RUNX1 facilitated proliferation to promote leukemia cell growth. Furthermore, we demonstrated that RUNX1 knockdown in leukemia cells drastically diminished colony-forming ability. Finally, the RUNX1-knocked down cell depletion phenotype could be rescued by overexpression of CENPE, a cell proliferation gene and a RUNX1 direct target gene. Our results indicate a possible mechanism involving the RUNX1-CENPE axis on promoting leukemic cell growth.

RUNX1 mutation and elevated FLT3 gene expression cooperates to induce inferior prognosis in cytogenetically normal acute myeloid leukemia patients

BackgroundAcute myeloid leukemia (AML) is a bone marrow malignancy having multiple molecular pathways driving its progress. In recent years, the main causes of AML considered all over the world are genetic variations in cancerous cells. The RUNX1 and FLT3 genes are necessary for the normal hematopoiesis and differentiation process of hematopoietic stem cells into mature blood cells, therefore they are the most common targets for point mutations resulting in AML.MethodsWe screened 32 CN-AML patients for FLT3-ITD (by Allele-specific PCR) and RUNX1 mutations (by Sanger sequencing). The FLT3 mRNA expression was assessed in all AML patients and its subgroups.ResultsEight patients (25%) carried RUNX1 mutation (K83E) while three patients (9.37%) were found to have internal tandem duplications in FLT3 gene. The RUNX1 mutation data were correlated with clinical parameters and FLT3 gene expression profile. The RUNX1 mutations were observed to be significantly prevalent in older males. Moreover, RUNX1 and FLT3-mutated patients had lower complete remission rate, event-free survival rate, and lower overall survival rate than patients with wild-type RUNX1 and FLT3 gene. The RUNX1 and FLT3 mutant patients with up-regulated FLT3 gene expression showed even worse prognosis. Bradford Assay showed that protein concentration was down-regulated in RUNX1 and FLT3 mutants in comparison to RUNX1 and FLT3 wild-type groups.ConclusionThis study constitutes the first report from Pakistan reporting significant molecular mutation analysis of RUNX1 and FLT3 genes including FLT3 expression evaluation with follow-up. This provides an insight that aforementioned mutations are markers of poor prognosis but the study with a large AML cohort will be useful to further investigate their role in disease biology of AML.

Clinical and genomic characterization of patients diagnosed with the provisional entity acute myeloid leukemia with BCR-ABL1, a Swedish population-based study.

Acute myeloid leukemia (AML) with t(9;22)(q34;q11), also known as AML with BCR-ABL1, is a rare, provisional entity in the WHO 2016 classification and is considered a high-risk disease according to the European LeukemiaNet 2017 risk stratification. We here present a retrospective, population-based study of this disease entity from the Swedish Acute Leukemia Registry. By strict clinical inclusion criteria we aimed to identify genetic markers further distinguishing AML with t(9;22) as a separate entity. Twenty-five patients were identified and next-generation sequencing using a 54-gene panel was performed in 21 cases. Interestingly, no mutations were found in NPM1, FLT3, or DNMT3A, three frequently mutated genes in AML. Instead, RUNX1 was the most commonly mutated gene, with aberrations present in 38% of the cases compared to around 10% in de novo AML. Additional mutations were identified in genes involved in RNA splicing (SRSF2, SF3B1) and chromatin regulation (ASXL1, STAG2, BCOR, BCORL1). Less frequently, mutations were found in IDH2, NRAS, TET2, and TP53. The mutational landscape exhibited a similar pattern as recently described in patients with chronic myeloid leukemia (CML) in myeloid blast crisis (BC). Despite the concomitant presence of BCR-ABL1 and RUNX1 mutations in our cohort, both features of high-risk AML, the RUNX1-mutated cases showed a superior overall survival compared to RUNX1 wildtype cases. Our results suggest that the molecular characteristics of AML with t(9;22)/BCR-ABL1 and CML in myeloid BC are similar and do not support a distinction of the two disease entities based on their underlying molecular alterations.

Cell Cycle Regulates Phosphorylation of RUNX1 to Modulate Megakaryocyte-Erythroid Progenitor Fate Specification

Human Megakaryocytic-Erythroid Progenitors (MEP) produce megakaryocytic progenitors (MkP) and erythroid progenitors (ErP). Though some of the players have been identified, the molecular mechanisms underlying the MEP fate decision have not yet been determined. Using a functional single cell CFU-Mk/E assay, and single-cell RNA sequencing (scRNAseq), we have revealed that MEP cell cycling regulates MEP fate decisions with decreased cycling promoting Mk fate commitment and increased cycling promoting E fate commitment (Lu et al, Cell Reports, 2018). Our data point to RUNX1 (aka AML1), already known to be important for both Mk and E maturation, as playing a key role in MEP fate determination. RUNX1 target genes vary significantly between Common Myeloid Progenitors (CMP), MEP, MkP, and ErP. For example, the RUNX1 targets MPL, FLI1, and THBS1 are higher in MkP than in MEP and lowest in CMP and ErP. Analysis of scRNAseq data indicates that 11.8% and 9.3% of differentially (adj.p &amp;lt; 0.05, fold change &amp;gt; 2) expressed genes are predicted RUNX1 targets when comparing MEP to MkP and MEP to ErP, respectively (p=2.9e-8 and 5.6e-16). However, RUNX1 mRNA levels do not change significantly between CMP, MEP, MkP and ErP. We therefore assessed whether total RUNX1 protein levels and post-translational modifications change with Mk and E lineage commitment. Intracellular staining normalized to levels in CMP revealed that total RUNX1 protein is elevated 1.34-fold from CMP to MEP, is highest (1.65-fold) in MkP, and is intermediate in ErP (1.5-fold) consistent with RUNX1 perhaps promoting Mk over E fate. RUNX1 can be phosphorylated by cyclin dependent serine/threonine kinases (CDKs) as well as Src tyrosine kinases. Significant differences in RUNX1 phosphoprotein levels were revealed by intracellular FACS assays for differential phosphorylation of RUNX1. Phosphoserine modified RUNX1 (Ser21, Ser276, and Ser 397) levels, which likely reflect active RUNX1, are highest in MkP (1.28-fold over MEP), and diminished in ErP (-1.32-fold over MEP). To determine whether RUNX1 and phosphor-RUNX1 variants affect MEP commitment, we overexpressed wildtype (WT) RUNX1 or RUNX1-S4D (phospho-mimetic on S249, S277, T273, S276 residues). WT RUNX1 overexpression affected fate specification of primary MEP (p&amp;lt;0.05) with an increase in the Mk-only colony percentage from 24% to 43% at the expense of E-only colonies (from 26% to 16%) with little change in bipotent CFU-Mk/E. RUNX1-S4D more dramatically (p&amp;lt;0.04) increased Mk-only colonies (from 25% to 75%) and decreased E-only (from 25% to &amp;lt; 4%) and Mk/E (from 50% to 21%) colonies. Surprisingly, overexpression of RUNX1-S4D in FACSorted primary human ErP caused them to develop more (p&amp;lt;0.01) Mk/E-colonies (from 12% to 60%) with a dramatic decrease in E-only colonies (from 85% to 28%) suggesting that the E commitment of ErP is reversed (or reprogrammed) by activated RUNX1. In contrast, RUNX1 variants mimicking tyrosine phosphorylation (RUNX1-Y6D) promote E fate specification. Tyrosine phosphorylation on RUNX1 is mediated by Src family kinases (Huang te al, Genes Dev., 2012). We found that Src kinase inhibition results in increasing Mk lineage bias (from 20% to 71%) suggest differential phosphorylation of RUNX1 plays a pivotal role in MEP fate specification. Epigenetic modifications induced by phospho-serine vs phospho-tyrosine mimetics are currently under evaluation. Combining our data on cell cycle control of MEP with RUNX1 reveals that RUNX1 inhibition prevents the Mk bias induced by slowing the cell cycle. For example, the RUNX1 inhibitor Ro5-3335 causes MEP to have an Er bias from 27% to 61% while the mTOR inhibitor Rapamycin (slows MEP cell cycle) induces a Mk bias from 19% to 52%. The combination of Ro5-3335 plus Rapa results in increased Er from 27% to 45% suggest that RUNX1 influences MEP fate specification downstream of the cell cycle machinery. In summary, the phosphorylation status of RUNX1 in primary human hematopoietic progenitors regulates MEP fate commitment. Detailed mechanisms linking the cell cycle machinery to RUNX1 protein levels and function toward Mk vs E specification are being explored. Disclosures No relevant conflicts of interest to declare.

Effects of miR-18a on proliferation and apoptosis of gastric cancer cells by regulating RUNX1.

The aim of this study was to explore the effects of micro ribonucleic acid (miR)-18a on the proliferation and apoptosis of gastric cancer (GC) cells, and to elucidate the possible underlying mechanism. In this study, the expression of miR-18a in GC tissues and para-cancer tissues was verified by in situ hybridization (ISH) of GC tissue microarray (TMA). Meanwhile, the effect of miR-18a expression on the prognosis of GC patients was evaluated. GC AGS cell line was selected and transfected with miR-18a mimic and mimic control (NC) to up-regulate miR-18a expression in vitro. Thereafter, changes in cell proliferation, apoptosis and migration after transfection were detected by biological functional assays. Luciferase reporter gene assay was carried out to verify the target gene Runt-related transcription factor 1 (RUNX1) modulated by miR-18a. Finally, the Spearman's grade correlation coefficient was calculated to explore the correlation between the expressions of miR-18a and RUNX1. ISH results of TMA showed that overexpression of miR-18a in GC tissues was significantly associated with low survival rate of patients (p<0.001). High expression of miR-18a remarkably enhanced the proliferation, migration and invasion of GC cells (p<0.05). Besides, it has been predicted in biology that RUNX1 is one of the target genes of miR-18a. Luciferase reporter gene assay showed that Luciferase activity in cells transfected with wild-type (WT) RUNX1 3' untranslated region (3'UTR) was significantly reduced (p<0.05). Moreover, the protein expression of RUNX1 decreased remarkably in GC cells with over-expression of miR-18a (p<0.05). All these findings indicated that the expression of miR-18a was negatively correlated with RUNX1 in GC cells (p<0.001, r=0.86). MiR-18a exerts a high predictive value for the prognosis of GC patients by directly targeting the transcription factor RUNX1. All our findings may provide therapeutic candidates for GC identification.

Cooperating, congenital neutropenia\u2013associated Csf3r and Runx1 mutations activate pro-inflammatory signaling and inhibit myeloid differentiation of mouse HSPCs

Patients with the pre-leukemia bone marrow failure syndrome called severe congenital neutropenia (CN) have an approximately 15% risk of developing acute myeloid leukemia (AML; called here CN/AML). Most CN/AML patients co-acquire CSF3R and RUNX1 mutations, which play cooperative roles in the development of AML. To establish an in vitro model of leukemogenesis, we utilized bone marrow lin− cells from transgenic C57BL/6-d715 Csf3r mice expressing a CN patient–mimicking truncated CSF3R mutation. We transduced these cells with vectors encoding RUNX1 wild type (WT) or RUNX1 mutant proteins carrying the R139G or R174L mutations. Cells transduced with these RUNX1 mutants showed diminished in vitro myeloid differentiation and elevated replating capacity, compared with those expressing WT RUNX1. mRNA expression analysis showed that cells transduced with the RUNX1 mutants exhibited hyperactivation of inflammatory signaling and innate immunity pathways, including IL-6, TLR, NF-kappaB, IFN, and TREM1 signaling. These data suggest that the expression of mutated RUNX1 in a CSF3R-mutated background may activate the pro-inflammatory cell state and inhibit myeloid differentiation.

Comparison of mutational profiles and clinical outcomes in patients with acute myeloid leukemia with mutated RUNX1 versus acute myeloid leukemia with myelodysplasia-related changes with mutated RUNX1

Studies comparing the prognostic role of RUNX1 mutations (RUNX1mut) in acute myeloid leukemia (AML) and acute myeloid leukemia-with myelodysplasia-related changes (AML-MRC) are limited. Our study examines the genetic profile of 118 RUNX1mut AML patients including 57 AML with RUNX1mut and 61 AML-MRC with RUNX1mut and 100 AML, NOS patients with wild type RUNX1 (RUNX1wt). Results revealed that AML-MRC patients with RUNX1mut had shorter median overall survival (OS) (11 ± 3.3 months) when compared to AML with RUNX1mut (19 ± 7.1 months) and AML, NOS with RUNX1wt (not reached) (p = .001). The most common concurrent mutations observed in AML-MRC with RUNX1mut patients were DNMT3A, SRSF2, ASXL1, and IDH2 while in AML with RUNX1mut patients were ASXL1, SRSF2, TET2, IDH2, and DNMT3A. ASXL1 and TET2 mutations appeared to adversely affect OS in AML-MRC, but not in AML with RUNX1mut. Concurrent RUNX1/DNMT3A mutations, in contrast had negative impact on OS in AML with RUNX1mut, but not in AML-MRC with RUNX1mut.

New Function of RUNX2 in Regulating Osteoclast Differentiation via the AKT/NFATc1/CTSK Axis.

Cleidocranial dysplasia is an autosomal dominant skeletal disorder resulting from RUNX2 mutations. The influence of RUNX2 mutations on osteoclastogenesis and bone resorption have not been reported. To investigate the role of RUNX2 in osteoclast, RUNX2 expression in macrophages (RAW 264.7 cells) was detected. Stable RAW 264.7 cell lines expressing wild-type RUNX2 or mutated RUNX2 (c.514delT, p.172fs) were established, and their functions in osteoclasts were investigated. Wild-type RUNX2 promoted osteoclast differentiation, formation of F-actin ring, and bone resorption, while mutant RUNX2 attenuated the positive differentiation effect. Wild-type RUNX2 increased the expression and activity of mTORC2. Subsequently, mTORC2 specifically promoted phosphorylation of AKT at the serine 473 residue. Activated AKT improved the nuclear translocation of NFATc1 and increased the expression of downstream genes, including CTSK. Inhibition of AKT phosphorylation abrogated the osteoclast formation of wild-type macrophages, whereas constitutively activated AKT rescued the osteoclast formation of mutant macrophages. The present study suggested that RUNX2 promotes osteoclastogenesis and bone resorption through the AKT/NFATc1/CTSK axis. Mutant RUNX2 lost the function of regulating osteoclast differentiation and bone remodeling, resulting in the defective formation of the tooth eruption pathway and impaction of permanent teeth in cleidocranial dysplasia. This study, for the first time, verifies the effect of RUNX2 on osteoclast differentiation and bone resorption and provides new insight for the explanation of cleidocranial dysplasia.