Figure 1: Hierarchical Model of Normal Hematopoiesis and Human Acute Myeloid Leukemia

(A) Self-renewing HSC reside at the top of the hierarchy, giving rise to multipotent progenitors that in turn give rise to lineage-committed progenitors that eventually produce terminally differentiated blood cells. (B) AML is organized as a hierarchy initiated by self-renewing leukemia stem cells that give rise to leukemic progenitors, which in turn give rise to the leukemia blasts.

Acute myeloid leukemia (AML) is an aggressive malignancy of immature myeloid cells in the bone marrow affecting almost 20,000 adults annually in the US, most of them over the age of 65. Current standard of care includes treatment with high dose chemotherapy, novel agents including venetoclax and azacitidine, and often includes allogeneic hematopoietic cell transplantation. Even with these aggressive treatments, five-year overall survival is between 25-30%, and much lower for those over age 65. Normal blood development is organized as a cellular hierarchy initiated and maintained by self-renewing hematopoietic stem cells (HSCs). Similarly, AML is also organized as a cellular hierarchy, with a subset of aberrant leukemia stem cells (LSCs) driving the disease (Figure 1). Recent studies have demonstrated that AML LSCs are not always rare or restricted to immunophenotypically defined populations. The clinical significance of the AML LSC model is supported by the demonstration that LSC gene expression signatures are prognostic in multiple cohorts of patients. Clinically, this model implies that LSCs must be eradicated in order to achieve cures. Currently, patients treated with standard chemotherapy exhibit clinical responses, including complete remissions in most cases. However, the majority of patients relapse, presumably due to incomplete elimination of LSCs. Thus, novel therapies must be developed that target and eliminate LSCs in order to cure AML.


  1. Thomas D. and Majeti R. Biology and relevance of human acute myeloid leukemia stem cells. Blood, 129:1577-1585 (2017)
  2. Gentles AJ, Plevritis SK, Majeti R*, and Alizadeh AA*. Association of a leukemic stem cell gene expression signature with clinical outcomes in acute myeloid leukemia. JAMA, 304: 2706-15 (2010)

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