FLT3-ITD impedes retinoic acid, but not arsenic, responses in murine acute promyelocytic leukemias

Cécile Esnault, Ramy Rahmé, Kim L. Rice, Caroline Berthier, Coline Gaillard, Samuel Quentin, Anne-Lise Maubert, Scott Kogan and Hugues de Thé

Key points

  • FLT3 Activation confers ATRA resistance in mouse models of APL.

  • Arsenic trioxide circumvents ATRA resistance in this setting.


Acute promyelocytic leukemia (APL) is often associated with activating FLT3 signaling mutations. These are highly related to hyperleukocytosis, a major adverse risk factor with chemotherapy-based regimens. APL is a model for oncogene-targeted therapies: all-trans retinoic acid (ATRA) and arsenic both target and degrade its PML/RARA driver. Combined ATRA/arsenic regimen now cures virtually all standard risk APL patients. Although FLT3-ITD was an adverse risk factor for historical ATRA/chemotherapy regimens, the molecular bases for this effect remain unknown. Using mouse APL models, we unexpectedly demonstrate that FLT3-ITD severely blunts ATRA response. Remarkably, while the transcriptional output of initial ATRA response is unaffected, ATRA-induced PML/RARA degradation is blunted, as is PML nuclear body reformation and activation of P53 signaling. Critically, combination of ATRA and arsenic fully rescues therapeutic response in FLT3-ITD APLs, restoring PML/RARA degradation, PML nuclear body reformation, P53 activation and APL eradication. Moreover, arsenic targeting of normal PML also contributes to APL response in vivo. These unexpected results explain the less favorable outcome of FLT3-ITD APLs with ATRA-based regimens and stress the key role of PML nuclear bodies in APL eradication by the ATRA/arsenic combination.

  • Submitted July 27, 2018.
  • Accepted January 16, 2019.