Leukemia

The 5th Edition of the World Health Organization Classification of Haematolymphoid Neoplasms (WHO5th) and the 2022 International Consensus Classification (ICC) both recognize myelodysplasia-related acute myeloid leukemia (AML-MR) as a diagnostic entity increasingly defined by integrated genomic data. Although largely concordant, the two classifications differ in various ways that should be resolved to achieve future harmonization. To address the areas of uncertainty, we retrospectively analyzed 615 newly diagnosed AML cases from adult patients treated at two large cancer centers. We demonstrate that AML-MR, whether defined by gene mutations (MR-GM) or cytogenetic abnormalities (MR-CGA), constitutes a prognostically distinct group with inferior outcome compared to most AML subtypes, second only to TP53-mutated or EVI1-rearranged AML. Isolated RUNX1 mutations were not associated with antecedent myeloid neoplasia. Neither the number of mutated MR genes nor their variant allele frequency independently impacted outcomes. Trisomy 8 and del(20q) did not confer inferior outcomes and may warrant exclusion from MR-CGA. Complex karyotype without TP53 mutations did not worsen outcomes within AML-MR and may be considered equivalent to other MR-CGA. The adverse prognosis of AML-MR appeared to be at least partly driven by ASXL1 and/or EZH2 mutations. These findings provide evidence toward a unified schema across the WHO5th and ICC.

In developed countries, the rate of childhood B-cell acute lymphoblastic leukemia (B-ALL), the most common pediatric cancer with a peak incidence at 2-5 years of age, has been rising for several decades. Epidemiological studies suggest that reduced exposure to common infections in early life increases the risk of B-ALL. However, no specific infection capable of protecting against such cancer has been identified. One of the most prevalent infectious agents in humans is Epstein-Barr virus (EBV), a B-cell tropic tumor virus that infects ~95% of the global population by adult age. Paradoxically, recent studies reveal that EBV, through its signaling protein LMP1, elicits potent cytotoxic CD4+ and CD8+ T cell responses against a wide range of tumor-associated antigens (TAAs), which can recognize and attack EBV-unrelated cancer cells via shared TAAs. In developed countries, primary EBV infection is often delayed from early childhood into adolescence or young adulthood. Taken together, we hypothesized that EBV (LMP1)-induced TAA-specific T cells may help protect against some childhood B-ALL by targeting shared TAAs. If so, lack of EBV infection in early life may contribute to the rise of childhood B-ALL seen in developed countries. In this work, EBV serology assessment in pediatric B-ALL patients revealed strong exclusion of the commonest high hyperdiploid (HHD) subtype of B-ALL in children having recent primary EBV infection. Our mouse model studies demonstrated that LMP1-induced T cell immunity can eradicate some B-ALL-like leukemias via shared TAAs during the effector phase. These findings support the notion that EBV-induced anti-tumor immunity may help protect against some childhood B-ALL.

RNA editing is a widespread post-transcriptional regulatory mechanism, but its role in acute myeloid leukemia (AML) remains incompletely understood. We analyzed RNA editing in 59 paired diagnosis-relapse AML samples and eight age-matched healthy controls using a stringent discovery pipeline and beta-binomial regression framework accounting for overdispersion and repeated measurements. A total of 166,323 high-confidence RNA editing sites mapping to 5,917 genes were identified. Of tested sites, 1.2%-3.6% varied significantly by disease stage or ELN-2022 risk group. Disease stage-specific editing signatures distinguished healthy controls, diagnosis, and relapse samples, with relapse-associated signals validated in an independent AML cohort. ELN-2022 risk-specific editing signatures showed substantial overlap between intermediate- and adverse-risk groups. Cross-cohort analyses identified four bone marrow (BM) editing sites in TMEM165, COQ4, TIMM17A, and PLXDC2 reproducibly associated with relapse and one peripheral blood (PB) editing site in ABHD18 elevated in higher-risk ELN-2022 groups. Most editing sites were shared between BM and PB; only 2.1%-2.3% exhibited tissue-specific differences. Higher global editing levels were correlated with leukemic state, white blood cell count, and selected clinical features. These findings identify reproducible RNA editing signatures linked to AML disease stage and risk and support the use of RNA editing biomarkers for PB disease assessment.

Leukemic stem cells (LSCs) play a central role in disease progression, therapeutic resistance, and relapse in acute myeloid leukemia (AML). However, the identification and characterization of LSCs remain challenging because of their low abundance and their close phenotypic resemblance to normal hematopoietic stem and progenitor cells. Although patient-derived xenograft (PDX) models have provided important insights into AML biology and LSC heterogeneity, the relative engraftment potential of distinct CEBPA mutation subtypes and the immunophenotypic identity of LSCs in CEBPA N-terminal mutant AML (CEBPA-N-AML) remain poorly defined. To address these questions, we compared the engraftment characteristics of primary human CEBPA-mutated AML samples representing the major mutational subtypes using the highly permissive NSGS xenograft model. Primary CEBPA-N-AML samples exhibited markedly greater engraftment efficiency and leukemogenic potential than other CEBPA-mutated AML subtypes. Furthermore, we identified a CD366CD73CD123CD117CD371CD247 cell population that is highly enriched for functional LSCs in CEBPA-N-AML, demonstrating enhanced clonogenic activity, leukemia-initiating capacity, and long-term self-renewal. Collectively, our findings demonstrate that the leukemogenic potential of CEBPA-mutated AML is strongly influenced by mutation subtype, with CEBPA-N-AML exhibiting superior leukemia-propagating capacity in vivo. We further define a novel immunophenotypic LSC signature specific to CEBPA-N-AML, providing new insights into LSC heterogeneity in CEBPA-mutated AML and establishing a foundation for the development of LSC-directed therapeutic strategies.

Large genomically annotated acute myeloid leukaemia (AML) datasets exist, but population-based contemporary cohorts remain scarce. Here we report clinicopathological, genomic, and outcome data from Danish AML patients. 2,512 AML patients were identified between 2015-2022, of whom 33.8% had available NGS data (NGS+). In patients [≤]70 years, baseline characteristics and outcomes were comparable between NGS+ and NGS- groups. In patients >70 years, more NGS+ patients received intensive treatment, but survival was similar among intensively treated patients. The distribution of mutations varied significantly by age and sex, with older age and male sex exhibiting higher frequencies of adverse-risk gene mutations. In intensively treated NGS+ patients, ELN2017 stratified 5-year OS: 58.4% (favorable), 43.4% (intermediate), and 28.2% (adverse), with hazard ratios (HRs) of 0.63 (favorable) and 1.45 (adverse) relative to intermediate. ELN2022 yielded corresponding OS rates of 56.9%, 51.8%, and 29.7%, with HRs of 0.78 and 1.86. The two models had comparable predictive performance for OS in a time-dependent model. In conclusion, outcomes of intensively treated AML patients were comparable irrespective of NGS status, underscoring the representativeness of the REFORM-AML database for the Danish AML population. Age and male sex correlated with adverse-risk mutations, and both ELN2017 and ELN2022 robustly predicted survival.

Hyperleukocytosis (white blood cell [WBC] count >100 000/uL) at diagnosis is an important prognostic risk factor in pediatric acute lymphoblastic leukemia (ALL), though its significance with contemporary therapy is unclear. We analyzed 1 826 pediatric ALL patients from a multi-institution cohort to determine whether hyperleukocytosis independently predicts outcomes using multivariable Cox proportional hazard modeling. Hyperleukocytosis occurred in 211 patients (12%), with 121 having B-ALL, and showed no prognostic significance in T-ALL patients. In B-ALL, 5-year event-free survival (EFS) was 65% versus 89% for non-hyperleukocytosis patients, and overall survival (OS) was 78% versus 93%. After adjustment for age, cytogenetic risk, central nervous system disease status, and treatment site, hyperleukocytosis remained an independent predictor of end-of-induction minimal residual disease (MRD) positivity (odds ratio 2.53 [95% confidence interval [CI]: 1.71-3.94; p<0.001]), inferior EFS (hazard ratio [HR] 2.44; 95% CI: 1.77-3.38; p<0.001) and inferior OS (HR 2.00; 95% CI: 1.29-3.12; p=0.002). A continuous dose-response relationship was observed between WBC count and these outcomes. Survival associations persisted across all cytogenetic risk categories and MRD strata. Despite risk-adapted therapy with treatment intensification for high-risk features, hyperleukocytosis identifies an aggressive B-ALL phenotype with persistently inferior outcomes, suggesting these patients may benefit from novel therapeutic approaches.

Although B-cell acute lymphoblastic leukemia (B-ALL) is highly responsive to antigen-directed immunotherapies, treatment resistance remains a major barrier to achieving durable responses in patients. We recently developed a novel VpreB1 (CD179a)-directed antibody-drug conjugate with calicheamicin (VpreB1-ADC) that exploits the restricted expression of VpreB1 within the surrogate light chain in early B cells, including B-ALL. In the present work, we investigated mechanisms of resistance to the VpreB1-ADC. Mechanisms of resistance were evaluated using a TCF3::HLF B-ALL model, assessing target engagement parameters including VpreB1 surface expression and antibody internalization. The role of the multidrug resistance transporter ABCB1 (P-glycoprotein) was evaluated via pharmacologic inhibition, using tariquidar and zosuquidar, and enforced overexpression across multiple B-ALL cell lines. Sensitivity to alternative non-ABCB1 substrate payloads exatecan and PNU-159682 was also assessed. Resistant TCF3::HLF cells retained VpreB1 expression and efficient antibody internalization. Instead, resistance was driven by elevated ABCB1 expression and activity. ABCB1 inhibition with tariquidar or zosuquidar restored VpreB1-ADC sensitivity. Conversely, enforced ABCB1 overexpression conferred ADC resistance, which was reversed by ABCB1 inhibition. Cells with high ABCB1 activity remained fully sensitive to alternative payloads, including exatecan and PNU-159682, which are not ABCB1 substrates. ABCB1-mediated drug efflux drives intrinsic resistance to calicheamicin-conjugated ADCs in B-ALL. Combining ADCs with ABCB1 inhibitors or selecting payloads non-susceptible to ABCB1 efflux offer viable strategies to overcome resistance and optimize future ADC therapies.

While therapy resistance in acute myeloid leukemia (AML) is often attributed to leukemic stem cells (LSCs), their functional properties are not fully captured by their well-established genetic landscape and cell lineage transcriptional programs. Here, we explore AML cell states and their associations to drug response and systemic immune context. We performed integrated single-cell transcriptomics and immunophenotyping on diagnostic AML samples (n=6) to define transcriptional cell state gene signatures. These were projected onto bulk RNA-seq data from 448 AML patients to assess associations with drug sensitivity, plasma proteomics, clinical features, and established prognostic scores. Longitudinal single-cell data from external cohorts and cell-cell communication analyses were used to examine treatment dynamics and microenvironmental signaling. We defined nine AML cell states, including progenitor-like, stromal-like, antigen-presenting, and monocytic programs. Stemness features were distributed across multiple states, with lymphoid-primed and stress-adapted progenitors showing the strongest alignment with established stemness scores. Distinct drug sensitivities emerged, including cell cycle checkpoint inhibitor sensitivity in stress-adapted progenitors and kinase inhibitor sensitivity in cycling progenitors, alongside shared resistance to BH3 mimetics in monocytic states. Stress-adapted progenitors were associated with adverse clinical features and expanded following venetoclax-based therapy. Monocytic states acted as immunosuppressive hubs via TIGIT signaling, while stromal-associated states received niche-derived survival signals. Overall, we define a framework that associates AML cell states with stemness, drug response, and microenvironmental interactions. These findings highlight distributed stemness, state-specific vulnerabilities, and niche-driven resistance mechanisms, informing more precise therapeutic strategies in AML.

Background CD19-directed CAR-T cell therapy can induce durable remissions in chronic lymphocytic leukemia (CLL), but response rates are lower than in other B-cell malignancies, in part because CLL is characterized by T-cell dysfunction, defective immune synapse formation, and impaired target-cell co-stimulation. Lenalidomide is an immunomodulatory drug with the potential to act on both sides of the CAR-T/CLL interface by improving T-cell fitness and modifying malignant B-cell susceptibility to immune engagement. Methods We are conducting an open-label, non-randomized phase I/II clinical trial VTB-CLL002 (ClinicalTrials.gov identifier: NCT06762431) evaluating the safety and efficacy of CD19 CAR-T cell therapy combined with concomitant lenalidomide in patients with relapsed or refractory CLL and small lymphocytic lymphoma followed by lenalidomide maintenance. The primary endpoint was safety. The secondary endpoint included overall response rate (ORR), complete response (CR), progression-free survival (PFS) and overall survival (OS). Results Twelve patients were treated. The median age was 60 years and the median number of prior lines of therapy was 2. All patients were BTK inhibitor-naive, and all had measurable disease at the time of infusion. CAR-T manufacturing was successful in all patients. All treated patients achieved complete remission, with a median time to response of 1 month. CAR T-cells expansion was observed in all patients, with a median peak expansion of 137 cells/L and a median time to peak expansion of 14 days. CAR T-cells remained detectable at the last follow-up in all patients, with persistence documented up to 24 months. At dose levels 2-3, eight of nine patients had ongoing MRD-negative responses at the time of analysis. Toxicity was clinically meaningful. Cytokine release syndrome (CRS) occurred in all patients, with severe CRS observed in 2 of 12 patients. ICANS occurred in 5 of 12 patients, including severe ICANS in 4 of 12 patients. One patient developed late grade 4 ICANS temporally associated with lenalidomide reintroduction and secondary CAR-T expansion. Early and late immune effector cell-associated hematotoxicity were common. In mechanistic studies, lenalidomide enhanced CAR-T proliferation and cytotoxicity, shifted CAR-T cells toward effector-associated phenotypes, reduced selected exhaustion markers during repeated antigen challenge, and increased IL-2 and IFN-{gamma} secretion. Lenalidomide also increased CAR-T/CLL conjugate formation and upregulated CD54/ICAM-1 on CLL target cells without broad induction of CD80, CD86, or CD40, consistent with improved adhesive target-cell engagement rather than classical co-stimulation. Transcriptomic profiling supported enhanced Th1/cytotoxic and T-cell activation-associated programs with lower T reg -associated genes in lenalidomide-treated CAR-T cells. Conclusions Lenalidomide-augmented CD19 CAR-T therapy demonstrated strong early clinical activity in relapsed/refractory CLL, characterized by deep responses, durable CAR-T persistence, and substantial incidence of immune effector-associated toxicities. These findings support further evaluation of lenalidomide as a rational CAR-T partner in CLL and suggest that its activity may involve both improved CAR-T fitness and enhanced target-cell engagement. Future studies should optimize lenalidomide timing and dosing to preserve response depth while reducing delayed immune-effector toxicity.

The immunosuppressive bone marrow microenvironment is an important contributor to the limited success of immunotherapy in acute myeloid leukemia (AML), but the cellular interactions underlying AML immune evasion are incompletely understood. We therefore generated a single-cell spatial transcriptomic and proteomic atlas using 148 bone biopsies from 113 individuals comprising pediatric and adult AML at diagnosis and non-leukemic controls. We observed an expansion of regulatory T cells (Tregs) in AML, with stronger colocalization between Tregs and macrophages compared to non-leukemic bone marrow. Distinct cellular neighborhoods were enriched for myeloid progenitor-like cells together with macrophages and T cells, which correlated with higher macrophage and T cell immune checkpoint expression. Moreover, these neighborhoods were associated with specific AML subtypes, especially KMT2A-rearranged and RUNX1::RUNX1T1 AML. These spatial patterns were validated by identification of malignant cells via in situ fusion detection in RUNX1::RUNX1T1 cases. Functional experiments revealed that macrophages and AML cells not only actively recruit Tregs, but also promote naive T cell differentiation into Tregs. Spatially informed ligand-receptor analysis predicted the involvement of the Galectin-9 - CD44/TIM-3 axis in this immunosuppressive crosstalk, which was supported by in vitro inhibition of CD44 and/or TIM-3 preventing macrophage- and AML-induced Treg differentiation. Collectively, this comprehensive spatial map of the AML bone marrow identified tripartite crosstalk between AML, macrophages, and T cells mediated by the Galectin-9 - CD44/TIM-3 axis as a key component of the immunosuppressive microenvironment. Targeting Galectin-9 - CD44/TIM-3 interactions may be a promising strategy to overcome immune evasion and enhance immunotherapeutic success in AML. HighlightsO_LISpatial transcriptomic and proteomic atlas of pediatric and adult acute myeloid leukemia (AML) bone marrow C_LIO_LIIncreased colocalization of macrophages and regulatory T cells (Tregs) in AML C_LIO_LIMacrophages and AML cells induce differentiation of naive T cells to Tregs in vitro, which can be prevented by inhibition of CD44 or TIM-3 C_LI O_FIG O_LINKSMALLFIG WIDTH=200 HEIGHT=166 SRC="FIGDIR/small/743431v1_ufig1.gif" ALT="Figure 1"> View larger version (47K): org.highwire.dtl.DTLVardef@5887f4org.highwire.dtl.DTLVardef@45d17corg.highwire.dtl.DTLVardef@1bc3264org.highwire.dtl.DTLVardef@9059aa_HPS_FORMAT_FIGEXP M_FIG C_FIG

Preclinical evaluation of chimeric antigen receptor (CAR)-T therapies for acute myeloid leukemia (AML) is limited by the lack of models that faithfully recapitulate the human bone marrow (BM) niche. Here, we implemented a humanized ossicle-based AML model that enables simultaneous engraftment of leukemic blasts and longitudinal assessment of responses to CAR-based immunotherapies. Intravenous or intra-ossicle injection of AML blasts produced robust, reproducible disease mimicking features of human AML within its microenvironment. To monitor tumor burden and immune effector cells in real-time, we developed a dual bioluminescence system using distinct luciferases in AML and CAR-T cells. This approach allowed non-invasive longitudinal tracking of CAR-T cell localization, expansion, persistence, and leukemic clearance within the ossicle. Overall, our model provides a powerful platform to study CAR-T cell behavior within a human BM niche and, for the first time, allows simultaneous longitudinal visualization of leukemic burden and CAR-T cell dynamics in a physiologically relevant ossicle-based AML model. TeaserHumanized ossicles combined with dual BLI enable tracking of AML progression and CAR-T cell dynamics in a human stromal niche.

Therapy resistance in acute myeloid leukemia (AML) is linked to metabolic plasticity and mitochondrial fitness of leukemic stem and progenitor cells. Clever-1 is a scavenger receptor with established immunoregulatory functions, but its leukemia cell-intrinsic roles remain unclear. Here we identify Clever-1 as a regulator of mitochondrial integrity and lipid-dependent oxidative metabolism in AML. Using the anti-Clever-1 antibody bexmarilimab, we show that Clever-1 inhibition induces early mitochondrial transcriptional reprogramming, followed by suppression of oxidative phosphorylation (OXPHOS) in AML cell lines. Immunoelectron microscopy demonstrates mitochondrial localization of Clever-1, while proteomic analyses reveal altered association with mitochondrial-linked proteins, including ATAD3. Functionally, Clever-1 inhibition reduces mitochondrial delivery of lipoprotein-derived lipids, resulting in selective changes in mitochondrial lipid composition. These changes are accompanied by impaired respiratory complex IV assembly, disrupted cristae architecture, accumulation of dysfunctional mitochondria, and reduced spare respiratory capacity. AML models with high baseline OXPHOS activity are particularly sensitive to Clever-1 inhibition, with mitochondrial dysfunction exacerbated under lipid-restricted or metabolically stressful conditions. Together, these findings define Clever-1 as a regulator of mitochondrial bioenergetic resilience and a targetable metabolic vulnerability in AML.

CD19-4-1BBL is a bispecific antibody fusion protein that targets CD19 and costimulates 4-1BB on T cells and other immune cells. Its antitumor activity has been reported in B-cell non-Hodgkin lymphoma with emphasis on its T-cell mediated cytotoxic activity. Its effect on other 4-1BB expressing immune cells is unexplored. Here, we investigated the molecular mechanisms and the antileukemic effect of CD19-4-1BBL in chronic lymphocytic leukemia (CLL), a B-cell malignancy profoundly marked by the immunosuppressive activity of myeloid-derived suppressor cells, tumor-associated macrophages and CD4+ regulatory T cells. We demonstrated that CD19-4-1BBL simultaneously mitigates the immunosuppressive phenotype and transcriptome machinery of these cells and promotes antitumor CD8+ T-cell immunity. Finally, in a preclinical, patient-derived xenograft model of CLL, we observed a favourable survival impact, especially in mice transplanted with immune cells from patients with high-risk/progressive leukemia. Our findings provide evidence that the CD19-4-1BBL treatment is a multifaceted, immune-based strategy that should be clinically explored in patients with chronic lymphocytic leukemia. KEY POINTSO_LICD19-4-1BBL sharpens the myeloid cell transcriptome and stimulates diverse memory CD8+ T cell clonotypic responses. C_LIO_LICD19-4-1BBL costimulation can be therapeutically exploited in high-risk chronic lymphocytic leukemia. C_LI

Concurrent mutations in DNMT3A, NPM1, and FLT3 define a high-risk subtype of acute myeloid leukemia (AML) associated with increased relapse risk and inferior survival following standard chemotherapy. However, the mechanisms by which DNMT3A mutations promote treatment resistance in NPM1c-FLT3ITD AML remain unclear. Using genetically engineered murine models of Npm1c-Flt3ITD AML with or without Dnmt3aR878H (homologous to human DNMT3AR882H), we demonstrate that Dnmt3aR878H promotes chemotherapy resistance through epigenetic regulation of leukemia stem cell (LSC) quiescence. Integrated transcriptomic and epigenetic profiling revealed coordinated remodeling of DNA methylation and chromatin accessibility in LSC-enriched populations, characterized by preferential hypomethylation and increased accessibility at loci associated with stemness and quiescence programs. These data were confirmed in human DNMT3AR882H-NPM1c-FLT3ITD AML datasets with enrichment of quiescence-associated and stem cell enriched transcriptional programs. Conversely, Dnmt3a-mutant LSCs retained sensitivity to the cell-cycle independent regimen venetoclax plus azacitidine, but residual LSCs exhibited transcriptional plasticity and reversion to a de-differentiated state. We have identified LSC heterogeneity spanning primitive hematopoietic stem cell (HSC)-and progenitor-like states and our data demonstrate preferential maintenance of a quiescent HSC-like LSC subpopulation in Dnmt3aR878H-mutant AML following chemotherapy treatment. Pharmacologic induction of cell-cycle entry using pegylated interferon (pegIFN) disrupted the quiescent LSC state and restored chemotherapy sensitivity, identifying quiescence as a reversible and therapeutically actionable mechanism of resistance. These findings identify DNMT3A-mediated epigenetic regulation of LSC quiescence as a conserved mechanism of standard chemotherapy resistance and position therapeutic reactivation of quiescent LSCs as a promising strategy to overcome chemotherapy resistance and improve outcomes in high-risk DNMT3A-mutant AML.

BackgroundDrug-tolerant persister (DTP) cell states have been implicated in relapse across multiple cancers, including acute myeloid leukaemia (AML) [1,2]. Methods that score such states from transcriptomic data, generalise to held-out samples, expose calibrated probability outputs, and link predictions to candidate biology are useful for prioritising follow-up experimental work. Existing transcriptomic methods for scoring drug-tolerant or persister-like states largely rely on fixed gene signatures or general-purpose cell-type classifiers adapted post hoc (scPred, scANVI, scClassify); deep-learning approaches developed specifically for AML drug-tolerant persister scoring with calibrated probability outputs, prespecified thresholds, and transparent external validation against ex-vivo drug-response data are, to our knowledge, lacking. Our approach addresses this gap by combining a Transformer teacher with a knowledge-distilled 1,000-gene student, prespecified threshold {tau} = 0.31, and direct evaluation against BeatAML drug-AUC. Our in silico approach aims to fill this gap of non-existent analytical methods to identify and mark the DTP cells. MethodsWe trained a Transformer classifier on a pooled scRNA-seq corpus of nine samples (six from GSE123902-lung adenocarcinoma metastasis, normal, and primary tumour [4]-plus three primary AML samples; 32,342 cells, 13,369 common genes), with stratified 5-fold cross-validation at the cell level, a 20% held-out test split, and a prespecified probability threshold selected on out-of-fold predictions. A 1,000-gene student model was trained by knowledge distillation [5]. For every input cell, the student outputs a probability between 0 and 1 (hereafter "the score") representing predicted membership in the positive training class. The trained model was applied without re-tuning to five external or independent application cohorts: 39 primary AML donors[in-house]; GSE74246[6]; BeatAML (n = 452 with linked ex-vivo drug-AUC; n = 405 with overall-survival metadata)[7]; TCGA-LAML (n = 149)[8]; and an in-house n = 10 scRNA-seq cohort with linked survival. Survival and drug-response data were not used during training, threshold selection, or tuning. The score was anchored mechanistically against CRISPR/DepMap essentiality[9], pathway enrichment, and a normal-tissue-filtered surface-protein candidate list (HPA[11], GTEx[12]). To assess concordance between transcriptomic prioritisation and protein-level evidence, each ranked candidate was additionally annotated with two HPA-derived flags: HPA_surface_protein (Yes/No, derived from HPA Protein class and Subcellular location fields, identifying genes annotated as plasma-membrane, GPCR, ion-channel, transporter, receptor, or CD-marker) and HPA_antibody_reliability (Enhanced, Supported, Approved, Uncertain, or Not available, per HPA antibody validation tier). Annotations were merged on HGNC symbol; 248 of 250 candidates (99.2%) matched. Two candidates using the older CORF nomenclature did not auto-match HPAs lowercase convention and were resolved manually. HPAs per-gene RNA-protein numeric correlation is published only on per-gene web pages and not in the bulk download; we therefore used the detection-level and antibody-reliability tiers as the operational concordance filter. ResultsCross-validation area under the receiver operating characteristic curve (AUROC) was 0.936 +/- 0.014 (held-out test 0.941, Matthews correlation coefficient (MCC) 0.696, F1-score 0.895). The 1,000-gene student showed Spearman {rho} {approx} 0.96 with the teacher and >85% class agreement at the prespecified threshold. The principal external result was in BeatAML: the score correlated with ex-vivo drug-response AUC across seven AML-relevant drugs, with consistent per-drug Spearman correlations (r = 0.41-0.53, all p < 0.05). The aggregate correlation across 3,164 patient-drug pairs from 452 patients was r = +0.482 and is reported as a summary, recognising that pairs from the same patient are not fully independent. The score did not stratify overall survival in TCGA-LAML or in the in-house n = 10 cohort, in part because predicted high-score fractions saturated. At the prespecified threshold the score did not separate cell types in GSE74246, indicating that absolute calibration is cohort-dependent. Compared against logistic regression, random forest, the LSC17 stemness signature, and a mean-expression baseline on the same gene panel, the Transformer was the most stable model under aliquot-grouped cross-validation and the only one to transfer with strong, positive correlation to BeatAML drug-AUC. The mechanistic candidate-target pipeline produced a 250-candidate ranked surface-protein list (full breakdown in Results); FLT3 and CD33 were recovered from the unbiased ranking as positive controls. ConclusionWe present a Transformer-derived transcriptomic score that addresses the lack of validated computational methods for identifying drug-tolerant persister-like states in AML. The score shows external rank-order association with ex-vivo drug response, providing a research-use tool for prioritising candidate persister-associated transcriptional programs for follow-up. Together, these results support the score as a research-use transcriptomic ranking tool for AML drug-response-associated states. The strongest external support comes from the consistent association with BeatAML ex-vivo drug-response AUC. The fixed probability threshold did not transfer reliably across all cohorts, so threshold-based classification should require cohort-specific recalibration. The score is not validated for clinical decision-making and is not proposed as a survival predictor. The candidate-target list is a starting point for functional follow-up.

Molecular testing in hematology requires different assays for disease subgroup identification, risk stratification and selection of appropriate treatment regimens. Yet, molecular tests are not necessarily standardized between diagnostic laboratories, resulting in varying turnaround times and potentially divergent results. To resolve this issue and enable single-assay molecular testing, we have developed a hierarchical classification framework that combines epigenetic and genetic data from whole genome nanopore sequencing (WGNS) with machine learning to determine disease entities, epigenetic subgroups (epitypes) and genetic aberrations in hematopoietic neoplasms. We curated DNA methylation data from 5,420 samples and trained a classifier allowing entity-level diagnostics featuring 21 conditions, including healthy controls, acute and chronic myeloid and lymphoid neoplasms. This classifier was subsequently combined with entity-specific epitype classifiers predicting 44 therapeutically or prognostically relevant states, followed by integration of genetic data. Benchmarking of the combined (epi-)genetic testing strategy using WGNS confirmed high accuracy in the detection of diagnostic groups and risk stratification, and identified diagnosis-defining molecular alterations that were not reported by standard-of-care work-up.

Acute lymphoblastic leukemia (ALL) remains a major therapeutic challenge due to non-specific cytotoxicity of conventional chemotherapeutics, leading to bone marrow suppression and immune dysfunction. Therapeutic strategies capable of simultaneously controlling leukemic blast and restoring hematopoietic activity, including immune composition remain limited. Here, we report seminal in vivo evaluation of a first-in-class intravenously deliverable organomercury- curcumin derivative, -Mercurin, in N-nitroso-N-ethylurea (ENU)-induced autochthonous ALL rat model with intact immune physiology. Previously, -Mercurin demonstrated selective leukemic cytotoxicity via reactive oxygen species (ROS)-mediated mitochondrial dysfunction and intrinsic apoptosis, in vitro and ex vivo. The preferential blast elimination and multimodal therapeutic profile is achieved by bonding mercury to the -carbon of curcumin, preserving its organic framework and biological properties, while conferring physiological stability along with aqueous solubility as sodium salt for intravenous delivery. Consequently, in present study -Mercurin significantly reduced circulating leukemic blasts and improved median survival compared to cytarabine. Longitudinal hematological analyses revealed progressive restoration of erythroid, myeloid and megakaryocytic compartments, along with sustained control of leucocytosis. Immunophenotypic profiling demonstrated coordinated immune restoration across peripheral blood, bone marrow, thymus, spleen, and lymph nodes. Histopathology indicated reduced leukemic infiltration with preserved tissue architecture. Biodistribution confirmed predominant renal clearance and no detectable accumulation in brain with substantially higher mercury retention in leukemia-bearing animals comparing to healthy treated controls. Mass-balance estimation indicated renal content is only [~]1.1% of total administered mercury. Collectively, -Mercurin demonstrated multimodal therapeutic activity by preferentially reducing leukemic burden, while restoring hematopoietic and immune function, highlighting its potential as a promising therapeutic candidate against ALL.

AML is an aggressive blood cancer associated with poor clinical outcomes. Chemotherapy remains the standard of treatment, but unfortunately relapse is very common, highlighting the need for alternative therapies. T cell dysfunction and exhaustion are prominent in AML and may represent a barrier to effective immunotherapy yet remains poorly studied in AML. DNA methylation is a major driver of T cell exhaustion and inhibition of de novo methylation can block exhaustion and restore T cell function in chronic viral infections and other cancers but is understudied in AML. Here, we investigated the impact of azacytidine (Aza), an FDA-approved hypomethylating agent, on T cell exhaustion in AML. Using a spontaneous AML mouse model and samples from patients with AML, we found that Aza treatment modulates T cell function. In vivo Aza-treatment of AML-bearing mice decreased tumor burden and reshaped CD8+ T cell states, with increases in frequencies of memory subsets and decreases in regulatory T cells (Tregs). Functionally, Aza treatment overcame the impaired proliferation displayed by both CD4 and CD8+ T cells in our model. DNA methylation sequencing of T cells after Aza treatment revealed hypomethylation and increased expression of stem-like precursor gene TCF7 and E2F2, a regulator of cell cycle progression and proliferation. Similar changes in phenotypes were observed in cultures of AML patient samples treated with Aza. Collectively, we show that Aza remodels epigenetic and functional states in AML and has the potential to reverse T cell exhaustion, with enhanced memory and proliferation capacity. Our work generates a mechanistic framework that provides rationale of combining hypomethylating agents with T cell-based immunotherapies in this lethal disease. Data Sharing StatementRRBS data is available in GEO under the accession number GSE328721. For original data please contact Dr. Evan F. Lind. Key PointsAzacytidine mediated epigenetic modulation can alleviate T cell exhaustion in AML Translational RelevanceImmune therapy has shown limited efficacy in AML, despite increasing evidence of T cell dysfunction in this malignancy. Azacytidine (Aza) is an FDA approved drug for AML, but patients develop therapy resistance and relapse. Studies have mainly focused on Azas tumor intrinsic effects. In this study, we investigated the impact of Aza on immune function, especially T cell exhaustion in AML, since exhaustion is a major mechanism of disease resistance. We demonstrated that Aza can modulate T cell phenotype and restore T cell proliferation. Mechanistically, Aza induces epigenetic reprogramming in T cells and increases the expression of a stem-like precursor marker, TCF7. By shifting the focus on T cell biology, our study provides a rationale for combining Aza with other immunotherapies that can enhance durable immune responses in this malignancy.

Uncontrolled proliferation of myeloid progenitor cells in acute myeloid leukemia (AML) is counteracted in most patients by toxic and often ineffective systemic treatments. Poly (ADP-ribose) polymerase inhibitors (PARPi) show subtype-restricted activity - potent in RUNX1-RUNX1T1 and PML-RAR[a] fusions, limited in KMT2A-rearranged (KMT2A-r) disease - but the lack of molecular understanding has hampered their clinical implementation. We combined single-cell and single-molecule assays on DNA replication intermediates and DNA damage signalling with therapy response readouts to investigate the role of fork plasticity factors in response to PARPi and AML standard-of-care (cytarabine, araC). In PARPi-sensitive AML models, PARP inhibition deregulates RECQ1-mediated fork restart, initially triggering fork acceleration and later fork breakage within the same S phase. Conversely, PARPi resistant KMT2A-r AML lines are protected by PrimPol-dependent DNA synthesis and its inactivation promptly induces fork breakage and PARPi sensitivity. Strikingly, PrimPol overexpression in PARPi-sensitive AML models prevents fork collapse and PARPi/araC therapy response, both in vitro and in vivo, identifying PrimPol as novel predictive biomarker and therapeutic target in AML. Our data uncover novel tissue-specific mechanisms of action for PARPi and pinpoint replication fork plasticity as key molecular determinant of AML therapy response. HighlightsO_LIFork plasticity is a key molecular determinant of treatment response in leukemia. C_LIO_LIPARP inhibition triggers fork breakage via deregulated restart of reversed forks. C_LIO_LIBypassing fork reversal, PrimPol limits therapy-induced DNA damage and cytotoxicity in AML. C_LIO_LIPrimPol drives resistance to cytarabine and PARP inhibition in vitro and in vivo. C_LI

The extent to which rare and common genetic variants jointly contribute to the risk of acute myeloid leukemia (AML) still remains relatively unexplored in large-scale biobank whole-genome sequencing cohorts. Here, we leverage the latest sequencing and phenotypic data from the All of Us Research Program to identify variants, genes, and gene-sets associated with AML. We performed set-based association tests for rare protein-coding variants (Ncases=265 and Ncontrols=169,706) and single-variant association tests for common variants (Ncases=265 and Ncontrols=169,705) utilizing the large European-like ancestry sample. For the rare-variant set-based tests conducted using SAIGE-GENE+, four genes were statistically significant: DNMT3A, TET2, SRSF2, and IDH2 (Bonferroni-corrected Cauchy p-value < 0.05). We also constructed multiple rare-variant burden risk scores using different gene-sets to identify those with a substantial rare-variant burden for AML. Gene-sets derived from Genomic Data Commons whole-genome sequencing data, comprising two distinct groups-genes observed to harbor somatic mutations in AML and genes observed to harbor somatic mutations across all cancer types-showed a statistically significant rare-variant burden (Bonferroni-corrected p-value < 0.05). Ultimately, these findings demonstrate that leveraging whole-genome sequencing in large-scale biobanks enables the identification of rare protein-coding variants, genes, and gene sets associated with AML.