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Targeting Hallmarks of Acute Myelocytic Leukemia (AML): Differentiation Induction in Non-Acute Promyelocytic Leukemia (Non-APL) AML

A special issue of International Journal of Molecular Sciences (ISSN 1422-0067). This special issue belongs to the section "Molecular Oncology".

Deadline for manuscript submissions: 31 July 2026 | Viewed by 4139

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Department of Internal Medicine III, Haematology & Oncology, University Hospital of Regensburg, Regensburg, Germany
Interests: cancer biology; anakoinosis; oncology; hematological malignancies
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Special Issue Information

Dear Colleagues,

Clinical trials have revealed that the potential for inducing differentiation is present in non-acute promyelocytic leukemia (non-APL) acute myeloid leukemia (AML), even in cases with complex, abnormal phenotypes. Promoting differentiation as a therapeutic option is valuable, as AML often arises in elderly patients who have a reduced chance of being cured by systemic therapy, which often compromises quality of life. The successful introduction of targeted therapies in AML subgroups is promising.

In practice, many questions remain regarding the most effective method of inducing apoptosis in AML via differentiation, given the significant heterogeneity of acquired chromosomal aberrations in this type of acute leukemia.

The differentiation trajectories induced by ATRA are the most well-studied and reveal a gene regulatory circuit that could be widely applied to induce differentiation in AML. However, ATRA monotherapy leads to insufficient clinical results in non-APL AML. Nevertheless, targeting hallmarks of AML opens up the possibility of diversifying therapeutic trajectories by the feasibility of their targeted reprogramming.

To extend the possibilities of phenotypic unlocking AML, potential non-oncogene-addicted (NOA) targets must be considered as circuits that are tightly regulated by acquired oncogenic events via the AML transcriptional landscape. Therefore, reprogramming the oncogene-triggered transcription via epigenetic modifiers and targeted therapies that aim to target specific NOAs facilitate the reversion of oncogene-driven AML phenotypes. An even more comprehensive approach is the combined targeting of receptor-triggered transcription factors with respective agonists/antagonists for reprogramming NOA networks in AML hallmarks and/or stress responses. Such approaches have been shown to induce complete remission in relapsed/refractory AML at a low rate of toxicity, even in an outpatient setting, and could form the basis for subsequent curative immunotherapy.

We are pleased to invite you to contribute to a Special Issue that welcomes original clinical and pre-clinical research, review articles and case reports on the induction of differentiation in non-APL AML, as well as more comprehensive studies on the phenotypic unlocking of AML hallmarks.

Prof. Dr. Albrecht Reichle
Guest Editor

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Keywords

  • differentiation induction in non-APL AML
  • phenotypic unlocking of AML hallmarks
  • targeting non-oncogene addictions in AML
  • small molecules with differentiation-inducing capacity
  • epigenetic modelling in AML (azacitidine, decitabine)
  • receptor-triggered transcription factors in AML
  • combined targeting of receptor-triggered transcription factors in AML
  • metronomic application of AML therapy
  • reduction in treatment toxicity by phenotypic unlocking of AML hallmarks
  • combination therapies for phenotypic unlocking of AML hallmarks
  • acquired genetic/molecular-genetic aberrations and adaptation of differentiation promoting therapy in AML

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Published Papers (2 papers)

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Review

15 pages, 262 KB  
Review
Differentiation Syndrome in Acute Myeloid Leukemia: Molecular Mechanisms, Clinical Spectrum, and Emerging Therapeutic Paradigms
by Razan Mansour, Abeer Yaseen and Zaid Abdel Rahman
Int. J. Mol. Sci. 2026, 27(4), 1775; https://doi.org/10.3390/ijms27041775 - 12 Feb 2026
Cited by 1 | Viewed by 2712
Abstract
Acute myeloid leukemia (AML) is characterized by differentiation arrest, driving blast proliferation, and abnormal blood formation. While differentiation therapy revolutionized acute promyelocytic leukemia (APL) with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), its extension into non-APL AML has been limited until recent [...] Read more.
Acute myeloid leukemia (AML) is characterized by differentiation arrest, driving blast proliferation, and abnormal blood formation. While differentiation therapy revolutionized acute promyelocytic leukemia (APL) with all-trans retinoic acid (ATRA) and arsenic trioxide (ATO), its extension into non-APL AML has been limited until recent targeted agents. This narrative review synthesizes preclinical and clinical evidence into differentiation-inducing therapy, with a focus on IDH1/2, FLT3 and menin inhibitors. Following SANRA guidelines, we searched PubMed (2010–September 2025) for clinical trials and key preclinical studies, with particular attention to the molecular mechanism of differentiation induction, clinical efficacy, and the management of differentiation syndrome (DS). IDH1/2 inhibitors (ivosidenib, enasidenib, olutasidenib) yield overall response rates (ORRs) of 30–94% in AML with DS in 10–19%. Menin inhibitors (revumenib, ziftomenib, enzomenib, bleximenib) achieve ORRs of 33–88% in KMT2A-rearranged or NPM1-mutated AML, with DS in 10–25% and QT prolongation as key toxicities. FLT3 inhibitors (gilteritinib, quizartinib) improve survival in FLT3-mutated AML with DS in 1–5%. Resistance mutations limit durability and combinations enhance efficacy. Differentiation therapy represents a paradigm shift towards non-cytotoxic AML management. Improved recognition of DS and rational combination approaches will be essential to maximize the therapeutic benefit. Future research should address mechanisms of resistance and biomarkers to achieve cures beyond APL. Full article
27 pages, 954 KB  
Review
Genome Agnostic Reprogramming of Acute Myelocytic Leukemia Hallmarks by Targeting Non-Oncogene Addictions with Azacitidine Plus Pioglitazone and All-Trans Retinoic Acid
by Dennis Christoph Harrer, Florian Lüke, Tobias Pukrop, Albrecht Reichle and Daniel Heudobler
Int. J. Mol. Sci. 2026, 27(2), 1067; https://doi.org/10.3390/ijms27021067 - 21 Jan 2026
Cited by 1 | Viewed by 1018
Abstract
The search for new therapeutic principles is essential for treating relapsed/refractory (r/r) acute myeloid leukemia (AML). Novel principles include genome-agnostic differentiation induction, controlling AML-triggering inflammation, potentiating the immune response and ‘normalizing’ AML metabolism. This review summarizes data from a phase I study (10 [...] Read more.
The search for new therapeutic principles is essential for treating relapsed/refractory (r/r) acute myeloid leukemia (AML). Novel principles include genome-agnostic differentiation induction, controlling AML-triggering inflammation, potentiating the immune response and ‘normalizing’ AML metabolism. This review summarizes data from a phase I study (10 patients, pts) and three case reports reporting 7 pts on the treatment of r/r AML by reprogramming AML hallmarks using APA, low-dose azacitidine, pioglitazone (PPARα/γ agonist) and all-trans retinoic acid. APA reprograms the r/r AML phenotype in patients with clinically and molecularly/genetically unfavorable risk profiles (17 pts, 16 refractory, one relapsed) in a genome-agnostic manner, restoring the plasticity of AML hallmarks, thereby improving immune surveillance, attenuating inflammation-triggered promotion of AML and distant microbial inflammation (healing of fungal pneumonia during induction of complete remission (CR) with APA), while normalizing leukemia metabolism (restoring phagocytosis and ROS production in leukemic neutrophils). APA induces CR in 10 pts (59%), with only modest hematotoxicity following CR induction. This allows treatment to be carried out in an outpatient setting, including for elderly and comorbid patients. Triple transcriptional modulation, facilitated by epigenetic modelling with azacitidine, targets reprogramming of non-oncogene addiction networks in AML, re-establishing functionally active, closely interrelated myeloid hallmarks and AML cell death genome-agnostically. Full article
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