Identification of a small subpopulation of candidate leukemia-initiating cells in the side population of patients with acute myeloid leukemia

In acute myeloid leukemia (AML), apart from the CD34⁺CD38 ^- compartment, the side population (SP) compartment contains leukemic stem cells (LSCs). We have previously shown that CD34⁺CD38 ^- LSCs can be identified using stem cell-associated cell surface markers, including C-type lectin-like molecule-1 (CLL-1), and lineage markers, such as CD7, CD19, and CD56. A similar study was performed for AML SP to further characterize the SP cells with the aim of narrowing down the putatively very low stem cell fraction. Fluorescence-activated cell sorting (FACS) analysis of 48 bone marrow and peripheral blood samples at diagnosis showed SP cells in 41 of 48 cases that were partly or completely positive for the markers, including CD123. SP cells in normal bone marrow (NBM) were completely negative for markers, except CD123. Further analysis revealed that the SP fraction contains different subpopulations: (a) three small lymphoid subpopulations (with T-, B-, or natural killer-cell markers); (b) a differentiated myeloid population with high forward scatter (FSC^high) and high sideward scatter (SSC ^high), high CD38 expression, and usually with aberrant marker expression; (c) a more primitive FSC^low/SSC^low, CD38 ^low, marker-negative myeloid fraction; and (d) a more primitive FSC^low/SSC^low, CD38^low, marker-positive myeloid fraction. NBM contained the first three populations, although the aberrant markers were absent in the second population. Suspension culture assay showed that FSC^low/SSC^low SP cells were highly enriched for primitive cells. Fluorescence in situ hybridization (FISH) analyses showed that cytogenetically abnormal colonies originated from sorted marker positive cells, whereas the cytogenetically normal colonies originated from sorted marker-negative cells. In conclusion, AML SP cells could be discriminated from normal SP cells at diagnosis on the basis of expression of CLL-1 and lineage markers. This reveals the presence of a low-frequency (median, 0.0016%) SP subfraction as a likely candidate to be enriched for leukemia stem cells.