Treatment of hematologic malignancies is evolving from a uniform approach to targeted therapies directed at the underlying molecular abnormalities of disease. The mixed lineage leukemia (MLL) protooncogene is a recurrent site of genetic rearrangements in acute leukemias; and since its discovery in 1992, many advances have been made in understanding its role in leukemogenesis. A variety of MLL translocation partners have been described, and detailed structure/function studies have identified functional domains that are required for transformation. Proteins associated with the MLL core complex or its fusion partners have been isolated and characterized for their critical roles in leukemia pathogenesis. Downstream mediators of MLL transcriptional regulation and multiple collaborating signaling pathways have been described and characterized. These advances in our understanding of MLL-related leukemogenesis provide a foundation for ongoing and future efforts to develop novel therapeutic strategies that will hopefully result in better treatment outcomes. (Blood. 2009;113: 6061-6068)
IntroductionThe mixed lineage leukemia (MLL) gene is frequently rearranged in acute myeloid and lymphoblastic leukemias in adults and children 1,2 and identifies a patient population with a particularly poor prognosis. 3 Leukemogenic MLL rearrangements occur in a variety of forms, including reciprocal chromosomal translocations and partial tandem duplications of internal coding regions. 4 The MLL gene encodes a histone methyltransferase (HMT) implicated in epigenetic regulation of transcription that is critical for normal embryonic development and hematopoiesis. 5 Among the most widely studied target genes of MLL transcriptional regulation are HOX genes, which themselves are implicated in the malignant transformation of hematopoietic progenitors. 6,7 In leukemias, chromosomal translocations fuse the aminoterminal part of MLL in-frame to one of more than 50 partner proteins. 8 The most common translocations in acute lymphoblastic leukemia (ALL) are t(4;11) and t(11;19), resulting in expression of MLL-AF4 and MLL-ENL, respectively, whereas acute myeloid leukemia (AML) is frequently associated with t(9;11) and t(6;11) giving rise to MLL-AF9 and MLL-AF6, respectively. All MLL fusion proteins retain the amino-terminal portion containing AT hooks and the CxxC domain of MLL, thus preserving DNAbinding activity. In contrast, a region with transactivating potential, the plant homeodomain (PHD) fingers, and the suppressor of variegation-enhancer of zeste-trithorax (SET) domain, which mediates histone H3 lysine 4 (H3K4) methylation, are lost. Although loss of the carboxy-terminal regions of MLL in chimeric oncoproteins would be predicted to result in abrogation of transactivation and HMT functions, transforming MLL fusion proteins function as transcriptional regulators and induce aberrant expression of downstream MLL targets, including HOX genes. 9,10 The precise mechanism for this aberrant transcriptional activity is not known but involves formation...