Erythroid/megakaryocytic differentiation confers BCL-XL dependency and venetoclax resistance in acute myeloid leukemia

Heikki Kuusanmäki, Olli Dufva, Markus Vähä-Koskela, Aino Maija Leppä, Jani Huuhtanen, Ida Vänttinen, Petra Nygren, Jay Klievink, Jonas Bouhlal, Petri Pölönen, Qi Zhang, Shady Adnan-Awad, Cristina Mancebo-Pérez, Joseph Saad, Juho Miettinen, Komal K. Javarappa, Sofia Aakko, Tanja Ruokoranta, Samuli Eldfors, Merja HeinäniemiKim Theilgaard-Mönch, Ulla Wartiovaara-Kautto, Mikko Keränen, Kimmo Porkka, Marina Konopleva, Krister Wennerberg, Mika Kontro, Caroline A. Heckman, Satu Mustjoki*

*Corresponding author for this work

Research output: Contribution to journalArticleScientificpeer-review

11 Citations (Scopus)
60 Downloads (Pure)


Myeloid neoplasms with erythroid or megakaryocytic differentiation include pure erythroid leukemia, myelodysplastic syndrome with erythroid features, and acute megakaryoblastic leukemia (FAB M7) and are characterized by poor prognosis and limited treatment options. Here, we investigate the drug sensitivity landscape of these rare malignancies. We show that acute myeloid leukemia (AML) cells with erythroid or megakaryocytic differentiation depend on the antiapoptotic protein B-cell lymphoma (BCL)-XL, rather than BCL-2, using combined ex vivo drug sensitivity testing, genetic perturbation, and transcriptomic profiling. High-throughput screening of >500 compounds identified the BCL-XL–selective inhibitor A-1331852 and navitoclax as highly effective against erythroid/megakaryoblastic leukemia cell lines. In contrast, these AML subtypes were resistant to the BCL-2 inhibitor venetoclax, which is used clinically in the treatment of AML. Consistently, genome-scale CRISPR-Cas9 and RNAi screening data demonstrated the striking essentiality of BCL-XL-encoding BCL2L1 but not BCL2 or MCL1, for the survival of erythroid/megakaryoblastic leukemia cell lines. Single-cell and bulk transcriptomics of patient samples with erythroid and megakaryoblastic leukemias identified high BCL2L1 expression compared with other subtypes of AML and other hematological malignancies, where BCL2 and MCL1 were more prominent. BCL-XL inhibition effectively killed blasts in samples from patients with AML with erythroid or megakaryocytic differentiation ex vivo and reduced tumor burden in a mouse erythroleukemia xenograft model. Combining the BCL-XL inhibitor with the JAK inhibitor ruxolitinib showed synergistic and durable responses in cell lines. Our results suggest targeting BCL-XL as a potential therapy option in erythroid/megakaryoblastic leukemias and highlight an AML subgroup with potentially reduced sensitivity to venetoclax-based treatments.

Original languageEnglish
Pages (from-to)1610-1625
Number of pages16
Issue number13
Early online date2023
Publication statusPublished - 30 Mar 2023
MoE publication typeA1 Journal article-refereed


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