Despite the relevant therapeutic progresses made in these last 2 decades, the prognosis of acute myeloid leukemia (AML) remains poor. Phorbol esters are used at very low concentrations as differentiating agents in the therapy of myeloid leukemias. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), in turn, is a death ligand that spares normal cells and is therefore currently under clinical trials for cancer therapy. Emerging evidence, however, suggests that TRAIL is also involved in nonapoptotic functions, like cell differentiation. PKC⑀ is differentially modulated along normal hematopoiesis, and its levels modulate the response of hematopoietic precursors to TRAIL. Here, we investigated the effects of the combination of phorbol esters (phorbol ester 4--phorbol-12,13-dibutyrate [PDBu]) and TRAIL in the survival/differentiation of AML cells. We demonstrate here that PDBu sensitizes primary AML cells to both the apoptogenic and the differentiative effects of TRAIL via PKC⑀ down-modulation, without affecting TRAIL receptor surface expression. We believe that the use of TRAIL in combination with phorbol esters (or possibly more specific PKC⑀ down-modulators) might represent a significative improvement of our therapeutic arsenal against AML. (Blood. 2009;113:3080-3087)
IntroductionAlthough these last 2 decades have seen relevant progresses in the therapy of acute myelogenous leukemia (AML) in terms of cytogenetic prognostic factors, bone marrow transplantation, and targeted therapies, 1 the 5-year survival rate is still 20% to 30% 2 for adult primary AML, and is even worse for AML arising from myeloproliferative disorders or myelodysplastic syndromes (MDSs). 3 Moreover, conventional antitumor treatments make a selective pressure for p53-inactivated tumor cells, and the development of drug resistance remains a serious problem. In this context, a special effort is currently dedicated to targeted therapies whose cornerstones-at least in terms of clinical success-have been all-trans retinoic acid (ATRA) for promyelocytic leukemia 4,5 and imatinib for chronic myelogenous leukemia, 6 while several other compounds-including apoptosis inducers and antiapoptotic inhibitors-are in the pipeline in the future perspective of combinations of multiple targeted therapies for the treatment of AML.Recombinant, soluble tumor necrosis factor-related apoptosisinducing ligand (TRAIL) is currently being developed as a promising natural immune molecule for patients with cancer because it selectively induces apoptosis in transformed or stressed cells but not in most normal cells. 7 Although primary AML cells are generally resistant to TRAIL-induced apoptosis in patients with cancer, phase 1 and 2 clinical trials using agonistic mAbs that engage the human TRAIL receptors 1 (TRAIL-R1) and 2 (TRAIL-R2) have also provided encouraging results. 7 Although hepatotoxicity was observed as side effect using agonistic antibodies against TRAIL-R2, 8 the emerging idea is that TRAIL will likely be used as one component of more complex antit...