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Sorafenib promotes graft-versus-leukemia activity in mice and humans through IL-15 production in FLT3-ITD-mutant leukemia cells

An Erratum to this article was published on 01 April 2018

This article has been updated


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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Figure 1: Sorafenib synergizes with allogeneic T cells and improves survival in mouse models of FLT3-ITD-driven AML through increasing IL-15 production.
Figure 2: Sorafenib-induced IL-15 production derives from leukemia cells in vivo and synergizes with T cells in humanized mouse models.
Figure 3: Sorafenib promotes cytotoxicity and longevity of donor CD8+ T cells via IL-15.
Figure 4: Sorafenib induces phosphorylation of IRF7 via reducing levels of its inhibitor ATF4.
Figure 5: Treatment with sorafenib induces IL-15 in human primary FLT3-ITD+ leukemia cells.
Figure 6: Treatment with sorafenib increases the frequency of T cells that are actively glycolytic in patients with FLT3-ITD+ AML who relapse after allo-HCT.

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  • 06 March 2018

    In the version of this article initially published, Omid Shah’s name was misspelled as Omid Sha. The error has been corrected in the PDF and HTML versions of this article.


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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.

Author information




N.R.M. performed the majority of the experiments, helped develop the overall concept behind the study, and helped write the manuscript. F.B. helped with the experiments and with development of the overall concept behind the study. L.B. performed ATF4 overexpression experiments. D.O'S. helped with Seahorse analysis. S. Thomas and S. Tugues helped with mouse experiments. M.W., T.A.M., K.H., P.A., A.L.I., G.I., K.S., W.M., S. Duqusne and A.W. helped with experiments and data interpretation. A.S.-G. performed immunohistological analysis. L.O. and K.-L.Y. helped with experiments. D.P., M.F., R. Claus, M. Lübbert, C.R., H. Bertz, R.W., J.H., A. Schmidts, M.S., D. Bettinger, R.T., E.U., Y.T., G.L.V., R.A., P.H., D. Wolf, M.D., C.J., K.W., C. Leiber, S. Gerull, J.H., C. Lengerke, T.P., T.S., G.K., W.R., S. Doostkam, S.M., and S.K.M. provided patient data. S. Taromi, S.S., and B.B. helped with mouse experiments. S.H. and T.B. helped with western blot and knockdown experiments. Z.H. and J. Dengjel performed mass spectrometry and data analysis. S.K. and B.K. performed mass spectrometry of sorafenib binding partners and kinome analysis. B.H., C. Schmid, U.H., C. Scheid, A. Spyridonidis, F.S., R.O., L.P.M., F.S.-d.-F., and J.K. provided patient data and helped with the analysis. M.P. performed analysis of the biopsy specimen. A.B., A. Nagler, D. Bunjes, A.M., W.H., and G.S. provided patient data and helped develop the overall concept behind the study. J.E.E. and D.F. analyzed the level of FLT3 inhibition upon sorafenib exposure. E.-M.W., J.-Y.C., F.K., D. Beelen, R. Chakraverty, S.R., S. Gill, N.K., F.A., L.V., J.S., and F.C. provided and analyzed patient data. E.R. and C.B. performed TRC sequencing and analyzed related data. A.M.M., T.K., T.T., B.K., D.K., D. Weisdorf, W.v.d.V., D.D., W.B., I.H., A.H., G.A., M. Börries, H. Busch, J.M., P.R., M. Labopin, J.H.A., A.S.H., G.R.H., G.A.K., M. Bar, A. Sarma, D.M., G.M., B.O., K.R., O.S., R.S.N., and A. Neubauer provided and analyzed patient data. E.U. and M.A.C. provided reagents and contributed to the development of the concept behind the study and the manuscript. B.R.B., N.v.B., and G.H. provided reagents, helped with the experiments, and analyzed data. E.P. helped to plan and analyze the T cell metabolism experiments. J. Duyster and J.F. helped develop the concept behind the study, analyze the data, and write the manuscript. R.Z. developed the overall concept behind the study, supervised the experiments, analyzed the data, and wrote the manuscript.

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Correspondence to Robert Zeiser.

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Supplementary Figures 1–21 & Supplementary Tables 2–12 (PDF 8654 kb)

Life Sciences Reporting Summary (PDF 274 kb)

Supplementary Table 1

Patients raw data (XLSX 69 kb)

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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).

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