Individuals with acute myeloid leukemia (AML) harboring an internal tandem duplication (ITD) in the gene encoding Fms-related tyrosine kinase 3 (FLT3) who relapse after allogeneic hematopoietic cell transplantation (allo-HCT) have a 1-year survival rate below 20%. We observed that sorafenib, a multitargeted tyrosine kinase inhibitor, increased IL-15 production by FLT3-ITD+ leukemia cells. This synergized with the allogeneic CD8+ T cell response, leading to long-term survival in six mouse models of FLT3-ITD+ AML. Sorafenib-related IL-15 production caused an increase in CD8+CD107a+IFN-γ+ T cells with features of longevity (high levels of Bcl-2 and reduced PD-1 levels), which eradicated leukemia in secondary recipients. Mechanistically, sorafenib reduced expression of the transcription factor ATF4, thereby blocking negative regulation of interferon regulatory factor 7 (IRF7) activation, which enhanced IL-15 transcription. Both IRF7 knockdown and ATF4 overexpression in leukemia cells antagonized sorafenib-induced IL-15 production in vitro. Human FLT3-ITD+ AML cells obtained from sorafenib responders following sorafenib therapy showed increased levels of IL-15, phosphorylated IRF7, and a transcriptionally active IRF7 chromatin state. The mitochondrial spare respiratory capacity and glycolytic capacity of CD8+ T cells increased upon sorafenib treatment in sorafenib responders but not in nonresponders. Our findings indicate that the synergism of T cells and sorafenib is mediated via reduced ATF4 expression, causing activation of the IRF7–IL-15 axis in leukemia cells and thereby leading to metabolic reprogramming of leukemia-reactive T cells in humans. Therefore, sorafenib treatment has the potential to contribute to an immune-mediated cure of FLT3-ITD-mutant AML relapse, an otherwise fatal complication after allo-HCT.
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We thank G. Prinz and H. Dierbach for their help with mouse experiments, K. Geiger and D. Herchenbach for cell sorting, and S. Decker (University of Freiburg) for providing NSG mice. We thank M.E.D. Flowers (University of Washington) for help with patient data. We thank D. Cittaro for the help with bioinformatic analysis. Il15−/− mice were provided by Y. Tanriver (University of Freiburg). Il15−/− mice were provided by B. Becher (University of Zurich).
This study was supported by the German Research Foundation (DFG) Heisenberg Professorship ZE 872/3-1 (R.Z.), DFG Sonderforschungsbereiche 1074 (SFB1074; F.K.), SFB1160 (R.Z.), SFB850 (T.B.), and TRR167 (R.Z.); European Research Council (ERC) Consolidator Grant no. 681012 GvHDCure (R.Z.); Deutsche Krebshilfe no. 111639 (G.H., R.Z.); Deutsche Jose Carreras Leukämie-Stiftung (DJCLS; G.H., R.Z.); Else Kröner-Fresenius Foundation (EKF) Stiftung no. 2015_A147 (P.A.), INTERREG V Rhin Supérieur (P.A., R.Z.); LOEWE–Gentherapie Frankfurt (CGT), Hessian Ministry of Higher Education, Research and the Arts, Germany no. III L 4- 518/17.004 (E.U.); Max-Eder-Nachwuchsgruppenprogramm, Deutsche Krebshilfe no. 109420 (F.K.); European Hematology Association fellowship 2010/04 (F.K.); and National Institutes of Health (NIH) grant no. R01 CA-72669 (B.R.B.). E.R. was supported by a fellowship from Associazione Italiana per la Ricerca sul Cancro (AIRC) that was cofunded by the European Union.
The authors declare no competing financial interests.
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Mathew, N., Baumgartner, F., Braun, L. et al. Sorafenib promotes graft-versus-leukemia activity in mice and humans through IL-15 production in FLT3-ITD-mutant leukemia cells. Nat Med 24, 282–291 (2018). https://doi.org/10.1038/nm.4484
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