Chronic myeloid leukemia (CML) is effectively treated with imatinib (imatinib mesylate, IM), a small molecule inhibitor of the BCR-ABL tyrosine kinase that is expressed in the entire hematopoietic compartment including stem cells (HSC) and progenitors. However, it is still unclear whether IM-therapy is able to eradicate BCR-ABL-positive HSC and progenitors. By transforming murine E2A-deficient pluripotent hematopoietic cells (Ikawa, et al., Immunity 04) with p210BCR-ABL, we determined that as few as 50 granulocyte macrophage progenitors (GMP)-like cells were sufficient to induce a transplantable CML-like disease in congenic mice, and that the leukemogenic GMP displayed higher levels of β-catenin activity than either the non-transformed GMP or the transformed nonGMP (most of which were myeloid differentiated cells), both in culture and in transplanted mouse bone marrow (Proc Natl Acad Sci USA 08, in press). The initiation of transformation required BCR-ABL kinase activity; however, whereas transformed nonGMP were sensitive to IM-treatment, expansion and survival of the leukemogenic progenitors in ex vivo-culture or in mice were not completely inhibited by IM-treatment. The drug resistance did not correlate with higher levels of BCR-ABL, mutations at ABL-kinase domain, induction of quiescence, stromal support or drug efflux. Additionally, the differential responses between the transformed progenitors and differentiated cells to IM-treatment were not affected by the restoration of E2A-function. These results imply that leukemic progenitors possess innate resistance to IM and that eradication of these cells with other drugs is required to cure CML. We are also investigating BCR-ABL-positive residual disease in HSC and progenitors of chronic phase CML patients on IM-therapy.

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