Pharmacological Targeting of Osteoblast-Induced MDS and AML

The bone marrow hematopoietic stem cell niche has emerged as a regulator and instigator of hematological myeloid malignancies. Activation of b-catenin signaling in osteoblasts, by deletion of exon3 or by inactivating mutations in APC, induces myelodysplasia (MDS), rapidly progressing to acute myeloid leukemia (AML) in mice. Activated b-catenin signaling is present in osteoblasts of one third of MDS and AML patients and it is the most active pathway in stromal cells of MDS patients suggesting that it may sustain dysplastic hematopoiesis and progression to MDS and AML in humans. Therefore, targeting this pathway may provide a new therapeutic approach for this subgroup of MDS/AML patients. To examine this hypothesis we searched for an FDA-approved compound with the ability to inhibit b-catenin signaling and identified all-trans-retinoic acid (ATRA) as a potential candidate. We show here that treatment of osteoblastic cells with ATRA inhibits the induction of b-catenin target genes by Wnt3a and abrogates nuclear localization of b-catenin, as shown by immunohistochemistry and western blot analysis. These effects are at least in part independent of its phosphorylation by GSK3b on exon3 and are mediated by the retinoic acid receptor a (RARa) since silencing RARa, but not RARb or RARg, in osteoblasts abolishes the inhibitory effect of ATRA on Wnt3a-induced b-catenin signaling. Similarly, treatment of leukemic mice expressing constitutively active b-catenin in their osteoblasts with ATRA, inhibited b-catenin signaling as measured by expression of its target genes Axin2 and Lef1 in bone. At the same time, ATRA improved anemia and thrombocytopenia, decreased the percentage of blasts in bone marrow and blood and prolonged overall survival in these leukemic mice as compared to vehicle-treated mice. The response to ATRA treatment of two MDS patients with active b-catenin in their osteoblasts, and not responding to other treatments, was monitored. The hematologic phenotype of the patients improved and disease status stabilized so that patients remain transfusion independent and disease-related symptom-free with a good quality of life thereafter. The improvement in disease status coincided with absence of b-catenin in the nucleus as flow cytometry analysis showed a high percentage of patient osteoblasts expressing activated b-catenin in pre-therapy samples but not in on-therapy samples. These results suggest that ATRA may find a new use in the treatment of the specific portion of MDS/AML patients with activated b-catenin in their osteoblasts.