LAUSR

Tyrosine kinase inhibitors (TKI) are very effective in treating chronic myelogenous leukemia (CML), but primitive, quiescent leukemia stem cells persist as a barrier to cure. We performed a comprehensive evaluation of metabolic adaptation to TKI treatment and its role in CML hematopoietic stem and progenitor cell persistence. Using a CML mouse model, we found that glycolysis, glutaminolysis, TCA cycle and oxidative phosphorylation (OXPHOS) were initially inhibited by TKI treatment in CML committed progenitors but were restored with continued treatment, reflecting both selection and metabolic reprogramming of specific subpopulations. TKI treatment selectively enriched primitive CML stem cells with reduced metabolic gene expression. Persistent CML stem cells also showed metabolic adaptation to TKI treatment through altered substrate utilization and maintenance of mitochondrial respiration. Evaluation of transcription factors underlying these changes identified increased HIF-1 protein levels and activity in TKI-treated stem cells. Treatment with a HIF-1 inhibitor depleted murine and human CML stem cells in combination with TKI treatment. HIF-1 inhibition increased mitochondrial activity and ROS levels, and reduced quiescence, increased cycling, and reduced self-renewal and regenerating potential of dormant CML stem cells. We therefore identify HIF-1-mediated inhibition of OXPHOS and ROS and maintenance of CML stem cell dormancy and repopulating potential as a key mechanism of CML stem cell adaptation to TKI treatment. Our results identify a key metabolic dependency in CML stem cells persisting after TKI treatment that can be targeted to enhance their elimination.