Targeting leukemia-initiating cells in acute lymphoblastic leukemia (ALL).

The concept that different leukemias are developmentally distinct and, like in normal hematopoiesis, generated by restricted populations of cells named leukemia-initiating cells (LIC), is becoming more established. These cancer stem-like cells have been assumed to have unique properties, including the capability of self-renewing and giving rise to "differentiated" or non-LIC that make up the whole tumor. Cell populations enriched with LIC-activity have been characterized in different hematopoietic malignancies, including human acute lymphoblastic leukemia (ALL). Related studies have also demonstrated that LIC are functionally distinct from bulk cells and modulated by distinct molecular signaling pathways and epigenetic mechanisms. Here we review several biological and clinical aspects related to LIC in ALL, including: 1) immunophenotypic characterization of LIC-enriched subsets in human and mouse models of ALL; 2) emerging therapeutics against regulatory signaling pathways involved in LIC progression and maintenance in T- and B-cell leukemias; 3) novel epigenetic and age-related mechanisms of LIC propagation, and 4) ongoing efforts in immunotherapy to eradicate LIC-enriched cell subsets in relapsed and refractory ALL cases. Current conventional treatments do not efficiently eliminate LIC. Therefore, innovative therapeutics that exclusively target LIC hold great promise for developing an effective cure for ALL.