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Inhibition of NRF2 signaling overcomes acquired resistance to arsenic trioxide in FLT3-mutated Acute Myeloid Leukemia

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Abstract

De novo acute myeloid leukemia (AML) patients with FMS-like tyrosine kinase 3 internal tandem duplications (FLT3-ITD) have worse treatment outcomes. Arsenic trioxide (ATO) used in the treatment of acute promyelocytic leukemia (APL) has been reported to be effective in degrading the FLT3 protein in AML cell lines and sensitizing non-APL AML patient samples in-vitro. We have previously reported that primary cells from FLT3-ITD mutated AML patients were sensitive to ATO in-vitro compared to other non-M3 AML and molecular/pharmacological inhibition of NF-E2 related factor 2 (NRF2), a master regulator of antioxidant response improved the chemosensitivity to ATO and daunorubicin even in non FLT3-ITD mutated cell lines and primary samples. We examined the effects of molecular/pharmacological suppression of NRF2 on acquired ATO resistance in the FLT3-ITD mutant AML cell line (MV4-11-ATO-R). ATO-R cells showed increased NRF2 expression, nuclear localization, and upregulation of bonafide NRF2 targets. Molecular inhibition of NRF2 in this resistant cell line improved ATO sensitivity in vitro. Digoxin treatment lowered p-AKT expression, abrogating nuclear NRF2 localization and sensitizing cells to ATO. However, digoxin and ATO did not sensitize non-ITD AML cell line THP1 with high NRF2 expression. Digoxin decreased leukemic burden and prolonged survival in MV4-11 ATO-R xenograft mice. We establish that altering NRF2 expression may reverse acquired ATO resistance in FLT3-ITD AML.

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Funding

This study is supported by grants from the Department of Science and Technology, India: EMR/2017/003880 and CRG/2021/004281 to Dr. Poonkuzhali Balasubramanian.

RVS and PB are supported by Wellcome DBT India Alliance (IA/S/17/1/503118, IA/CPHS/18/1/503930, and IA/S/21/2/505932), respectively. DZP, SI, and BMR are supported by ICMR (Indian Council of Medical Research) SRF. SD and NKB are funded by the University Grants Commission and RTV by CSIR. We thank the staff of the animal facility, flow cytometry, and imaging facility of the Centre for Stem Cell Research, a unit of in Stem Bengaluru, CMC Campus, Vellore for their help.

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Authors and Affiliations

  1. Department of Hematology, Christian Medical College Vellore-Ranipet Campus, Tamil Nadu, Vellore, 632517, India

    Daniel Zechariah Paul Jebanesan, Raveen Stephen Stallon Illangeswaran, Bharathi M. Rajamani, Rakhi Thalayattu Vidhyadharan, Saswati Das, Nayanthara K. Bijukumar, Balaji Balakrishnan, Vikram Mathews, Shaji R. Velayudhan & Poonkuzhali Balasubramanian

  2. Manipal Academy of Higher Education, Manipal, India

    Daniel Zechariah Paul Jebanesan

  3. Department of Integrative Biology, School of BioSciences and Technology, Vellore Institute of Technology, Vellore, India

    Balaji Balakrishnan

  4. Adjunct Scientist, Centre for Stem Cell Research, A Unit of InStem Bengaluru, CMC Campus, Vellore, India

    Shaji R. Velayudhan

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  1. Daniel Zechariah Paul Jebanesan
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Contributions

DZ, RSSI and BR designed the research, performed experiments, analyzed results, and wrote the manuscript.

RTV, SD and NB performed experiments and analyzed the results.

VM and SRV contributed to the analysis and review of the manuscript.

PB designed the research, performed experiments, analyzed results, wrote the manuscript, and procured funding.

All authors contributed to the article and approved the submitted version and revision.

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Correspondence to Poonkuzhali Balasubramanian.

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Jebanesan, D.Z.P., Illangeswaran, R.S.S., Rajamani, B.M. et al. Inhibition of NRF2 signaling overcomes acquired resistance to arsenic trioxide in FLT3-mutated Acute Myeloid Leukemia. Ann Hematol (2024). https://doi.org/10.1007/s00277-024-05742-8

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