Glucocorticoids reprogram human AML leukemic stem cells to promote elimination through differentiation and apoptosis

Abstract

Acute myeloid leukemia (AML) is sustained by leukemic stem cells (LSCs) that can evade standard therapies and drive relapse. Targeting LSC-specific vulnerabilities is therefore essential for durable remission. Here we demonstrate that glucocorticoids (GCs) induce potent depletion of AML LSCs by promoting terminal differentiation and apoptosis. This effect is observable within 24 hours and is conserved across multiple LSC-enriched models and primary patient samples. Mechanistically, we establish that GC targeting of LSCs is mediated through the glucocorticoid receptor (NR3C1), with higher receptor binding affinity correlating with greater anti-LSC activity. We performed structure activity relationship (SAR) modeling of 24 corticosteroids and identified key features, including bulky D-ring substituents, associated with enhanced anti-LSC efficacy. Bulk and single-cell transcriptomic data revealed that GC treatment of LSCs suppresses NF-{kappa}B inflammatory signaling and disrupts stemness and quiescence programs while inducing transcriptional signatures associated with transient proliferation, metabolic stress, and terminal differentiation. Notably, GC sensitivity was associated with the expression of pre-existing inflammatory or extracellular matrix (ECM) signatures. Finally, we found that FLT3 ligand (FLT3L) is required for GC-induced proliferation of CD34- blasts but not for LSC depletion, suggesting that FLT3L levels may serve as a biomarker for blast expansion in patients receiving GC therapy. These findings support the clinical development of GC-based therapies in AML and provide mechanistic insights into how GCs target inflammatory and metabolic programs required for LSC survival.