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Internal tandem duplication mutations in fms-like tyrosine kinase 3 (FLT3-ITD) are recurrent in acute myeloid leukemia (AML) and increase the risk of relapse. Clinical responses to FLT3 inhibitors (FLT3i) include myeloid differentiation of the FLT3-ITD clone in nearly half of patients through an unknown mechanism. We identified enhancer of zeste homolog 2 (EZH2), a component of polycomb repressive complex 2 (PRC2), as a mediator of this effect using a proteomic-based screen. FLT3i downregulated EZH2 protein expression and PRC2 activity on H3K27me3. FLT3-ITD and loss-of-function mutations in EZH2 are mutually exclusive in human AML. We demonstrated that FLT3i increase myeloid maturation with reduced stem/progenitor cell populations in murine Flt3-ITD AML. Combining EZH1/2 inhibitors with FLT3i increased terminal maturation of leukemic cells and reduced leukemic burden. Our data suggest that reduced EZH2 activity following FLT3 inhibition promotes myeloid differentiation of FLT3-ITD leukemic cells, providing a mechanistic explanation for the clinical observations. These results demonstrate that in addition to its known cell survival and proliferation signaling, FLT3-ITD has a second, previously undefined function to maintain a myeloid stem/progenitor cell state through modulation of PRC2 activity. Our findings support exploring EZH1/2 inhibitors as therapy for FLT3-ITD AML., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

Meningioma-1 (MN1) overexpression in AML is associated with poor prognosis, and forced expression of MN1 induces leukemia in mice. We sought to determine how MN1 causes AML. We found that overexpression of MN1 can be induced by translocations that result in hijacking of a downstream enhancer. Structure predictions revealed that the entire MN1 coding frame is disordered. We identified the myeloid progenitor-specific BAF complex as the key interaction partner of MN1. MN1 over-stabilizes BAF on enhancer chromatin, a function directly linked to the presence of a long polyQ-stretch within MN1. BAF over-stabilization at binding sites of transcription factors regulating a hematopoietic stem/progenitor program prevents the developmentally appropriate decommissioning of these enhancers and results in impaired myeloid differentiation and leukemia. Beyond AML, our data detail how the overexpression of a polyQ protein, in the absence of any coding sequence mutation, can be sufficient to cause malignant transformation., Competing Interests: Declaration of interests K.M.B. holds a patent on the use of DOT1L inhibitors for MN1 leukemia. K.M.B. has received research funding from Syndax and has previously consulted for Agios. I.H. received research funding from Bristol-Myers Squibb (BMS), Celgene, Merck Sharpe & Dohme (MSD), Astellas, Otsuka, Ono, Kyowa Kirin, Sanofi, Shionogi, Zenyaku, Daiichi Sankyo, Taiho, Takeda, Chugai, Eli Lilly, Nihon Shinyaku, Novartis, Pfizer, Fujimoto, Tanabe-Mitsubishi, Fukuyu Hospital, and Yamada Yohojo and received honoraria from or holds membership on an entity’s board of directors, speaker’s bureau, or its advisory committees for Celgene, Janssen, Takeda, Ono, BMS, Novartis, Daiichi Sankyo, Kyowa Kirin, Eisai, Nihon-Shinyaku, Pfizer, AbbVie, Otsuka, Shionogi, Mundi, CSL, and MSD. All other authors declare no competing interests., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Translocations of Meningioma-1 (MN1) occur in a subset of acute myeloid leukemias (AML) and result in high expression of MN1, either as a full-length protein, or as a fusion protein that includes most of the N-terminus of MN1. High levels of MN1 correlate with poor prognosis. When overexpressed in murine hematopoietic progenitors, MN1 causes an aggressive AML characterized by an aberrant myeloid precursor-like gene expression program that shares features of KMT2A-rearranged (KMT2A-r) leukemia, including high levels of Hoxa and Meis1 gene expression. Compounds that target a critical KMT2A-Menin interaction have proven effective in KMT2A-r leukemia. Here, we demonstrate that Menin (Men1) is also critical for the self-renewal of MN1-driven AML through the maintenance of a distinct gene expression program. Genetic inactivation of Men1 led to a decrease in the number of functional leukemia-initiating cells. Pharmacologic inhibition of the KMT2A-Menin interaction decreased colony-forming activity, induced differentiation programs in MN1-driven murine leukemia and decreased leukemic burden in a human AML xenograft carrying an MN1-ETV6 translocation. Collectively, these results nominate Menin inhibition as a promising therapeutic strategy in MN1-driven leukemia.

Understanding mechanisms of cooperation between oncogenes is critical for the development of novel therapies and rational combinations. Acute myeloid leukemia (AML) cells with KMT2A-fusions and KMT2A partial tandem duplications (KMT2APTD) are known to depend on the histone methyltransferase DOT1L, which methylates histone 3 lysine 79 (H3K79). About 30% of KMT2APTD AMLs carry mutations in IDH1/2 (mIDH1/2). Previous studies showed that 2-hydroxyglutarate produced by mIDH1/2 increases H3K79 methylation, and mIDH1/2 patient samples are sensitive to DOT1L inhibition. Together, these findings suggested that stabilization or increases in H3K79 methylation associated with IDH mutations support the proliferation of leukemias dependent on this mark. However, we found that mIDH1/2 and KMT2A alterations failed to cooperate in an experimental model. Instead, mIDH1/2 and 2-hydroxyglutarate exert toxic effects, specifically on KMT2A-rearranged AML cells (fusions/partial tandem duplications). Mechanistically, we uncover an epigenetic barrier to efficient cooperation; mIDH1/2 expression is associated with high global histone 3 lysine 79 dimethylation (H3K79me2) levels, whereas global H3K79me2 is obligate low in KMT2A-rearranged AML. Increasing H3K79me2 levels, specifically in KMT2A-rearrangement leukemias, resulted in transcriptional downregulation of KMT2A target genes and impaired leukemia cell growth. Our study details a complex genetic and epigenetic interaction of 2 classes of oncogenes, IDH1/2 mutations and KMT2A rearrangements, that is unexpected based on the high percentage of IDH mutations in KMT2APTD AML. KMT2A rearrangements are associated with a trend toward lower response rates to mIDH1/2 inhibitors. The substantial adaptation that has to occur for 2 initially counteracting mutations to be tolerated within the same leukemic cell may provide at least a partial explanation for this observation., (© 2020 by The American Society of Hematology.)

Inhibition of the H3K79 histone methyltransferase DOT1L has exhibited encouraging preclinical and early clinical activity in KMT2A (MLL)-rearranged leukemia, supporting the development of combinatorial therapies. Here, we investigated two novel combinations: dual inhibition of the histone methyltransferases DOT1L and EZH2, and the combination with a protein synthesis inhibitor. EZH2 is the catalytic subunit in the polycomb repressive complex 2 (PRC2), and inhibition of EZH2 has been reported to have preclinical activity in KMT2A-r leukemia. When combined with DOT1L inhibition, however, we observed both synergistic and antagonistic effects. Interestingly, antagonistic effects were not due to PRC2-mediated de-repression of HOXA9. HOXA cluster genes are key canonical targets of both KMT2A and the PRC2 complex. The independence of the HOXA cluster from PRC2 repression in KMT2A-r leukemia thus affords important insights into leukemia biology. Further studies revealed that EZH2 inhibition counteracted the effect of DOT1L inhibition on ribosomal gene expression. We thus identified a previously unrecognized role of DOT1L in regulating protein production. Decreased translation was one of the earliest effects measurable after DOT1L inhibition and specific to KMT2A-rearranged cell lines. H3K79me2 chromatin immunoprecipitation sequencing patterns over ribosomal genes were similar to those of the canonical KMT2A-fusion target genes in primary AML patient samples. The effects of DOT1L inhibition on ribosomal gene expression prompted us to evaluate the combination of EPZ5676 with a protein translation inhibitor. EPZ5676 was synergistic with the protein translation inhibitor homoharringtonine (omacetaxine), supporting further preclinical/clinical development of this combination. In summary, we discovered a novel epigenetic regulation of a metabolic process-protein synthesis-that plays a role in leukemogenesis and affords a combinatorial therapeutic opportunity., (Copyright © 2020 ISEH -- Society for Hematology and Stem Cells. Published by Elsevier Inc. All rights reserved.)

This study was aimed to investigate the expression levels of FLT3 gene in AML-M2 patients carrying AML1/ETO fusion gene, and analyze its relation with clinical and laboratorial features and prognosis. RQ-PCR method was used to detect the expression level of FLT3 in bone marrow of 21 AML-M2 patients with AML1/ETO(+). The correlation of the expression level of FLT3 with clinical features, other laboratorial examinations and disease prognosis were analyzed. The results showed that gene expression level of FLT3 (FLT3 gene/ reference gene) in patients at initial diagnosis were 1.65%-261.5%. The expression level of FLT3 over 35% was defined as high expression group (12 cases) , while the expression level below 35% was defined as low expression group (9 cases) . The proportion of patients with extramedullary infiltration in high expression group was higher than that in low expression group (25% vs 0%, P = 0.2286). The proportion of patients at initial diagnosis with white blood cell count > 10×10(9)/L in high expression group was higher than that in low expression group (66.67% vs 22.22%), but there was no statistical significance (P = 0.0805). No significant difference was observed at the age (P = 0.1369) and the rate of bone marrow blasts (P = 0.6923) between the above mentioned two groups. The differences in complete remission rate (66.67% vs 88.89%, P = 0.3383), the relapse rate (66.67% vs 22.22%,P = 0.0805) and the mortality rate (50% vs 22.22%, P = 0.3666) between the two group were not significant, but there was a clear trend that the low expression group has a higher CR rate and a lower relapse rate and mortality rate. It is concluded that FLT3 gene high expression in AML-M2 patients with AML1/ETO(+) have a higher rate of relapse and hence poor prognosis. Therefore, detection of FLT3 expression level in routine clinical practice is important for patient's risk stratification, prognostic evaluation and effective treatment selection.

Objective: To determine the expression level of GATA-2 gene in acute myeloid leukemia with maturation (AML-M2) patients carrying AML1/ETO fusion gene., Methods: Bone marrow samples were collected from 23 patients with de novo adult AML-M2 carrying AML1/ETO fusion gene. GATA-2 gene expression was detected by real-time quantitative polymerase chain reaction (RQ-PCR). We analyzed the correlation between GATA-2 gene expression and laboratorial features and clinical prognosis of patients., Results: GATA-2 expression levels (GATA-2 gene copies/reference gene copies) in the patients were found to be 2.17%-1 260.65%. A GATA-2 expression over or equal to 82% was defined as HIGH (10 cases), while an expression level below 82% was defined as LOW (13 cases). No significant differences were found in age, sex, white blood cell count or the rate of bone marrow blasts between HIGH and LOW expression groups (P > 0.05). Although the difference in complete remission rate between the two groups was not statistical significant (P = 0.067 8), the HIGH expression group had higher relapse rate (71.43% vs. 15.38%, P = 0.022 3) and higher mortality rate (70.00% vs. 7.69%, P < 0.05). The DFS and OS of the HIGH group are statistically significantly lower than that of the LOW group (P < 0.01). In the HIGH group, the patients choosing HSCT (2/10) are all alive without relapse, while among those choosing chemotherapy only (8/10), seven out of eight patients died., Conclusion: High expression level of GATA-2 in AML-M2 patients with AML1/ETO is associated with high risk of relapse and poor prognosis. Therefore, AML-M2 patients with AML1/ETO fusion gene and high expression of GATA-2 would possibly benefit from additional treatments except for chemotherapy.