PNNL

Abstract

This study reports a stepwise evolution of gilteritinib resistance in acute myeloid leukemia (AML) relapse, and identifies therapeutic vulnerabilities that could be exploited. Our in vitro model demonstrates that extrinsic microenvironmental factors within the bone marrow nurture the growth of residual cells that underlie early gilteritinib resistance. These early resistant cells exhibit a dependency upon Aurora B (AURKB) and undergo dynamic metabolic adaptations that fostered their transition to late resistance. In line with clinical observations of gilteritinib resistance, late resistant cells displayed an expansion of NRAS mutant subclones and a unique metabolic profile that originated during early resistance. Pharmacological inhibition of AURKB resensitized early resistant cells to gilteritinib. Early resistant cells from AML patients were found to display exquisite sensitivitye to AURKB inhibition. Together, our findings support that eradication of early resistant AML cells may increase the efficacy and durability of gilteritinib.