Acute myeloid leukemia (AML) is the most common acute leukemia in adults. Leukemia stem cells (LSCs) drive the initiation and perpetuation of AML, are quantifiably associated with worse clinical outcomes, and often persist after conventional chemotherapy resulting in relapse1,2,3,4,5. In this report, we show that treatment of older patients with AML with the B cell lymphoma 2 (BCL-2) inhibitor venetoclax in combination with azacitidine results in deep and durable remissions and is superior to conventional treatments. We hypothesized that these promising clinical results were due to targeting LSCs. Analysis of LSCs from patients undergoing treatment with venetoclax + azacitidine showed disruption of the tricarboxylic acid (TCA) cycle manifested by decreased α-ketoglutarate and increased succinate levels, suggesting inhibition of electron transport chain complex II. In vitro modeling confirmed inhibition of complex II via reduced glutathionylation of succinate dehydrogenase. These metabolic perturbations suppress oxidative phosphorylation (OXPHOS), which efficiently and selectively targets LSCs. Our findings show for the first time that a therapeutic intervention can eradicate LSCs in patients with AML by disrupting the metabolic machinery driving energy metabolism, resulting in promising clinical activity in a patient population with historically poor outcomes.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Data availability

Patient-related clinical data not included in the paper were generated as part of a multicenter clinical trial (NCT02203773). A detailed description of the dose escalation portion of the study has been published (Dinardo et al.)1. The dose expansion portion of the study is now complete and the manuscript describing these data is currently in preparation. All DNA and RNA raw and analyzed sequencing data can be found at the GEO database and are available via accession number GSE116481 (single-cell RNA-seq) and accession number GSE116567 (bulk RNA-seq).

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.


  1. 1.

    Bonnet, D. & Dick, J. E. Human acute myeloid leukemia is organized as a hierarchy that originates from a primitive hematopoietic cell. Nat. Med. 3, 730–737 (1997).

  2. 2.

    van Rhenen, A. et al. High stem cell frequency in acute myeloid leukemia at diagnosis predicts high minimal residual disease and poor survival. Clin. Cancer Res. 11, 6520–6527 (2005).

  3. 3.

    Shlush, L. I. et al. Identification of pre-leukaemic haematopoietic stem cells in acute leukaemia. Nature 506, 328–333 (2014).

  4. 4.

    Lapidot, T. et al. A cell initiating human acute myeloid leukaemia after transplantation into SCID mice. Nature 367, 645–648 (1994).

  5. 5.

    Jordan, C. T., Guzman, M. L. & Noble, M. Cancer stem cells. N. Engl. J. Med. 355, 1253–1261 (2006).

  6. 6.

    Chao, D. T. & Korsmeyer, S. J. BCL-2 family: regulators of cell death. Annu. Rev. Immunol. 16, 395–419 (1998).

  7. 7.

    Lagadinou, E. D. BCL-2 inhibition targets oxidative phosphorylation and selectively eradicates quiescent human leukemia stem cells. Cell Stem Cell 12, 329–341 (2013).

  8. 8.

    Konopleva, M. et al. Mechanisms of antileukemic activity of the novel Bcl-2 homology domain-3 mimetic GX15-070 (obatoclax). Cancer Res. 68, 3413–3420 (2008).

  9. 9.

    Konopleva, M. et al. Mechanisms of apoptosis sensitivity and resistance to the BH3 mimetic ABT-737 in acute myeloid leukemia. Cancer Cell 10, 375–388 (2006).

  10. 10.

    Chan, S. M. et al. Isocitrate dehydrogenase 1 and 2 mutations induce BCL-2 dependence in acute myeloid leukemia. Nat. Med. 21, 178–184 (2015).

  11. 11.

    Souers, A. J. et al. ABT-199, a potent and selective BCL-2 inhibitor, achieves antitumor activity while sparing platelets. Nat. Med. 19, 202–208 (2013).

  12. 12.

    Pan, R. et al. Selective BCL-2 inhibition by ABT-199 causes on-target cell death in acute myeloid leukemia. Cancer Discov. 4, 362–375 (2014).

  13. 13.

    Konopleva, M. et al. Efficacy and biological correlates of response in a phase II study of venetoclax monotherapy in patients with acute myelogenous leukemia. Cancer Discov. 6, 1106–1117 (2016).

  14. 14.

    DiNardo, C. D. et al. Safety and preliminary efficacy of venetoclax with decitabine or azacitidine in elderly patients with previously untreated acute myeloid leukaemia: a non-randomised, open-label, phase 1b study. Lancet. Oncol. 19, 216–228 (2018).

  15. 15.

    Ng, S. W. et al. A 17-gene stemness score for rapid determination of risk in acute leukaemia. Nature 540, 433–437 (2016).

  16. 16.

    Eppert, K. et al. Stem cell gene expression programs influence clinical outcome in human leukemia. Nat. Med. 17, 1086–1093 (2011).

  17. 17.

    Pei, S. et al. MPK/FIS1-Mediated mitophagy is required for self-renewal of human AML stem cells. Cell Stem Cell 23, 86–100 (2018).

  18. 18.

    Sarry, J. E. et al. Human acute myelogenous leukemia stem cells are rare and heterogeneous when assayed in NOD/SCID/IL2Rgammac-deficient mice. J. Clin. Invest. 121, 384–395 (2011).

  19. 19.

    Ho, T. C. et al. Evolution of acute myelogenous leukemia stem cell properties after treatment and progression. Blood 128, 1671–1678 (2016).

  20. 20.

    Chen, Y. R., Chen, C. L., Pfeiffer, D. R. & Zweier, J. L. Mitochondrial complex II in the post-ischemic heart: oxidative injury and the role of protein S-glutathionylation. J. Biol. Chem. 282, 32640–32654 (2007).

  21. 21.

    Yadav, B., Wennerberg, K., Aittokallio, T. & Tang, J. Searching for drug synergy in complex dose–response landscapes using an interaction potency model. Comput. Struct. Biotechnol. J. 13, 504–513 (2015).

  22. 22.

    Ianevski, A., He, L., Aittokallio, T. & Tang, J. SynergyFinder: a web application for analyzing drug combination dose–response matrix data. Bioinformatics 33, 2413–2415 (2017).

  23. 23.

    Dombret, H. et al. International phase 3 study of azacitidine vs conventional care regimens in older patients with newly diagnosed AML with > 30% blasts. Blood 126, 291–299 (2015).

  24. 24.

    Ivey, A. et al. Assessment of minimal residual disease in standard-risk AML. N. Engl. J. Med. 374, 422–433 (2016).

  25. 25.

    Pollyea, D. A., Gutman, J. A., Gore, L., Smith, C. A. & Jordan, C. T. Targeting acute myeloid leukemia stem cells: a review and principles for the development of clinical trials. Haematologica 99, 1277–1284 (2014).

  26. 26.

    Pollyea, D. A. & Jordan, C. T. Therapeutic targeting of acute myeloid leukemia stem cells. Blood 129, 1627–1635 (2017).

  27. 27.

    Warburg, O. On the origin of cancer cells. Science 123, 309–314 (1956).

  28. 28.

    Viale, A. et al. Oncogene ablation-resistant pancreatic cancer cells depend on mitochondrial function. Nature 514, 628–632 (2014).

  29. 29.

    Lee, K. M. et al. MYC and MCL1 cooperatively promote chemotherapy-resistant breast cancer stem cells via regulation of mitochondrial oxidative phosphorylation. Cell Metab. 26, 633–647.e7 (2017).

  30. 30.

    Sriskanthadevan, S. et al. AML cells have low spare reserve capacity in their respiratory chain that renders them susceptible to oxidative metabolic stress. Blood 125, 2120–2130 (2015).

  31. 31.

    Cole, A. et al. Inhibition of the mitochondrial protease ClpP as a therapeutic strategy for human acute myeloid leukemia. Cancer Cell 27, 864–876 (2015).

  32. 32.

    Skrtic, M. et al. Inhibition of mitochondrial translation as a therapeutic strategy for human acute myeloid leukemia. Cancer Cell 20, 674–688 (2011).

  33. 33.

    Kurtz, S. E. et al. Molecularly targeted drug combinations demonstrate selective effectiveness for myeloid- and lymphoid-derived hematologic malignancies. Proc. Natl Acad. Sci. USA 114, E7554–E7563 (2017).

  34. 34.

    Bogenberger, J. M. et al. Ex vivo activity of BCL-2 family inhibitors ABT-199 and ABT-737 combined with 5-azacytidine in myeloid malignancies. Leukemia Lymphoma 56, 226–229 (2015).

  35. 35.

    Bogenberger, J. M. et al. BCL-2 family proteins as 5-azacytidine-sensitizing targets and determinants of response in myeloid malignancies. Leukemia 28, 1657–1665 (2014).

  36. 36.

    Slovak, M. L. et al. Karyotypic analysis predicts outcome of preremission and postremission therapy in adult acute myeloid leukemia: a Southwest Oncology Group/Eastern Cooperative Oncology Group Study. Blood 96, 4075–4083 (2000).

  37. 37.

    Cheson, B. D. et al. Revised recommendations of the International Working Group for Diagnosis, Standardization of Response Criteria, Treatment Outcomes, and Reporting Standards for Therapeutic Trials in Acute Myeloid Leukemia. J. Clin. Oncol. 21, 4642–4649 (2003).

  38. 38.

    Pei, S. et al. Rational design of a parthenolide-based drug regimen that selectively eradicates acute myelogenous leukemia stem cells. J. Biol. Chem. 291, 21984–22000 (2016).

  39. 39.

    Amir, E.-A. D. et al. viSNE enables visualization of high dimensional single-cell data and reveals phenotypic heterogeneity of leukemia. Nat. Biotechnol. 31, 545–552 (2013).

  40. 40.

    Nemkov, T., D’Alessandro, A. & Hansen, K. C. Three-minute method for amino acid analysis by UHPLC and high-resolution quadrupole orbitrap mass spectrometry. Amino Acids 47, 2345–2357 (2015).

Download references


In memory of Richard Berger, a warrior in all aspects of life, who bravely confronted every obstacle and brought courage and inspiration to us, his family and all who were privileged enough to know him. Grant support: D.A.P is supported by the University of Colorado Department of Medicine Outstanding Early Career Scholar Program. B.M.S. and C.T.J are supported by a pilot grant provided by the University of Colorado RNA Bioscience Initiative. C.L.J. was supported by the American Cancer Society (25A5072) and the Colorado Clinical and Translational Sciences Institute (AEF CCTSI YR9 CO 2301425). A.D. is supported by the Webb-Waring Early Career award 2017 sponsored by the Boettcher Foundation. C.T.J. is generously supported by the Nancy Carroll Allen Chair in Hematology Research and NIH (grant R01CA200707). We thank J. DeGregori and E. Pietras for their comments on our manuscript.

Author information

Author notes

  1. These authors contributed equally: Daniel A. Pollyea, Brett M. Stevens, Courtney L. Jones.


  1. Division of Hematology, University of Colorado School of Medicine, Aurora, CO, USA

    • Daniel A. Pollyea
    • , Brett M. Stevens
    • , Courtney L. Jones
    • , Shanshan Pei
    • , Mohammad Minhajuddin
    • , Derek Schatz
    • , Jonathan A. Gutman
    • , Enkhtsetseg Purev
    • , Clayton Smith
    •  & Craig T. Jordan
  2. Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA

    • Amanda Winters
  3. Department of Biochemistry and Molecular Genetics, University of Colorado School of Medicine, Aurora, CO, USA

    • Angelo D’Alessandro
    • , Rachel Culp-Hill
    •  & Jay R. Hesselberth
  4. RNA Bioscience Initiative, University of Colorado School of Medicine, Aurora, CO, USA

    • Kent A. Riemondy
    • , Austin E. Gillen
    •  & Jay R. Hesselberth
  5. Department of Biostatistics and Informatics, University of Colorado School of Medicine, Aurora, CO, USA

    • Diana Abbott


  1. Search for Daniel A. Pollyea in:

  2. Search for Brett M. Stevens in:

  3. Search for Courtney L. Jones in:

  4. Search for Amanda Winters in:

  5. Search for Shanshan Pei in:

  6. Search for Mohammad Minhajuddin in:

  7. Search for Angelo D’Alessandro in:

  8. Search for Rachel Culp-Hill in:

  9. Search for Kent A. Riemondy in:

  10. Search for Austin E. Gillen in:

  11. Search for Jay R. Hesselberth in:

  12. Search for Diana Abbott in:

  13. Search for Derek Schatz in:

  14. Search for Jonathan A. Gutman in:

  15. Search for Enkhtsetseg Purev in:

  16. Search for Clayton Smith in:

  17. Search for Craig T. Jordan in:


D.A.P., B.M.S., C.L.J., A.W., M.M., and R.C.-H. designed and performed the research; collected, analyzed, and interpreted the data; performed the statistical analysis; and wrote the manuscript. S.P., A.D., K.A.R., A.E.G., J.R.H., D.A., and D.S. analyzed and interpreted data, performed statistical analysis, and wrote the manuscript. J.A.G., E.P., and C.S. designed the research and wrote the manuscript. C.T.J. designed and directed the research, analyzed and interpreted data, and wrote the manuscript.

Competing interests

The authors declare no competing interests.

Corresponding author

Correspondence to Craig T. Jordan.

Supplementary information

  1. Supplementary Text and Figures

    Supplementary Figures 1–9, Supplementary Tables 1, 3, and 6–8 and Supplementary Methods

  2. Reporting Summary

  3. Supplementary Table 2

    Institutional control patient characteristics

  4. Supplementary Table 4

    True-seq library coverage

  5. Supplementary Table 5

    Patient peripheral blood temporal response

About this article

Publication history