Defining the Transcriptional Control of Pediatric AML Highlights RARA as a Super-Enhancer Regulated Druggable Dependency
Somatic mutations are rare in pediatric AML (pAML), indicating alternate strategies are needed to identify targetable dependencies. We performed the first enhancer mapping of 3 pAML in 22 patient samples. Generally, pAML samples were distinct from adult AML 4 samples, and MLL (KMT2A)-rearranged samples were also distinct from non-KMT2A-5 rearranged samples. Focusing specifically on super-enhancers (SEs), we identified SEs 6 associated with many known leukemia regulators. The retinoic acid receptor alpha 7 (RARA) gene was differentially regulated in our cohort, and a RARA associated SE was 8 detected in 64% our cohort across all cyto/molecular subtypes tested. RARA SE-positive 9 pAML cell lines and samples demonstrated high RARA mRNA levels. These samples 10 were specifically sensitive to the synthetic RARA agonist tamibarotene in vitro, with 11 slowed proliferation, apoptosis induction, differentiation, and upregulated retinoid target 12 gene expression, compared to RARA SE-negative samples. Tamibarotene prolonged 13 survival and suppressed the leukemia burden of a RARA SE-positive pAML patient-14 derived xenograft (PDX) mouse model compared to a RARA SE-negative PDX. Our work 15 demonstrates that examining chromatin regulation can identify new, druggable 16 dependencies in pAML and provides rationale for a pediatric tamibarotene trial in children 17 with RARA-high AML.