Use of all-trans-retinoic acid (ATRA) in combinatorial differentiation therapy of acute promyelocytic leukemia (APL) results in exceptional cure rates. However, potent cell differentiation effects of ATRA are so far largely restricted to this disease and long-term survival rates in non-APL acute myelogeneous leukemia (AML) remain unacceptably poor, requiring development of novel therapeutic strategies. We demonstrate here that my-
IntroductionRetinoids regulate growth and differentiation of normal and malignant cells. 1 In the hematopoietic system, all-trans retinoic acid (ATRA) has been shown to inhibit growth, induce differentiation of myelomonocytic progenitor cells, and to enhance selfrenewal of more immature multipotent stem cells. 2,3 In acute promyelocytic leukemia (APL) ATRA is a potent inducer of APL cell differentiation, and its use in anti-APL therapy markedly improved survival and prognosis of patients with this disease. 4 This ability of APL cells to respond to ATRA with terminal differentiation is likely due to the presence of RAR␣ gene translocation and expression of the RAR␣ chimeric proteins, which do not respond to physiologic levels of ATRA. Pharmacological doses of ATRA trigger the dissociation of nuclear receptor co-repressors from such "dominant-negative" RAR␣-fusion proteins. [5][6][7][8][9] These findings underscore the importance of ATRA signaling in myeloid cell differentiation. 3 Nevertheless, the use of ATRA as a single agent has not been successful in other types of acute myelogeneous leukemia (AML), where long-term survival rates remain low at 25% (http:// seer.cancer.gov/cgi-bin/csr/1975_2001/search.pl#results). Although ATRA by itself has not been effective in non-APL AML cell differentiation, potential use of ATRA in combination with other factors such as histone deacetylase inhibitors, 10 granulocyte colonystimulating factor (G-CSF), 11,12 and granulocyte-macrophage colony-stimulating factor (GM-CSF) 13 has been evaluated in some studies. Recently, we have demonstrated that ATRA and G/GM-CSF cooperate to promote myelomonocytic differentiation in murine pluripotent myeloid progenitor cells. This differentiation induction was associated with increased expression of ATRAinducible RAR␣2 isoform. 14 Although these findings indicated a cross-talk between ATRA and myelomonocytic growth factors (GFs), the downstream signaling cascades that could be involved in the potential activation of RAR␣ expression by G/GM-CSF remain unknown. In order to further investigate the relationship between myelomonocytic GFs and ATRA, particularly in the context of human leukemic cell differentiation, we have used AML as a model. We demonstrate that through MAP kinase pathways G-and GM-CSF are able to potentiate transcriptional activities of liganded RAR␣1 and ␣2 isoforms and enhance ATRA-induced gene expression and myeloid differentiation of human leukemic cells. Convergence of these 2 major signaling pathways in myeloid differentiation reinforce the view that combinatorial use of retinoids with myelomon...