{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,30]],"date-time":"2026-06-30T09:47:25Z","timestamp":1782812845836,"version":"3.54.5"},"reference-count":42,"publisher":"MDPI AG","issue":"3","license":[{"start":{"date-parts":[[2023,2,3]],"date-time":"2023-02-03T00:00:00Z","timestamp":1675382400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"FiLMC-Pfizer-2017"},{"name":"Universit\u00e9 C\u00f4te d\u2019Azur"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Cancers"],"abstract":"<jats:p>Background &amp; aims: In CML, Leukemic Stem Cells (LSCs) that are insensitive to Tyrosine Kinase Inhibitors are responsible for leukemia maintenance and relapses upon TKI treatment arrest. We previously showed that downregulation of the BMI1 polycomb protein that is crucial for stem\/progenitor cells self-renewal induced a CCNG2\/dependent proliferation arrest leading to elimination of Chronic Myeloid Leukemia (CML) cells. Unfortunately, as of today, pharmacological inhibition of BMI1 has not made its way to the clinic. Methods: We used the Connectivity Map bioinformatic database to identify pharmacological molecules that could mimick BMI1 silencing, to induce CML cell death. We selected the bis-biguanide Alexidin (ALX) that produced a transcriptomic profile positively correlating with the one obtained after BMI silencing in K562 CML cells. We then evaluated the efficiency of ALX in combination with TKI on CML cells. Results: Here we report that cell growth and clonogenic activity of K562 and LAMA-84 CML cell lines were strongly inhibited by ALX. ALX didn\u2019t modify BCR::ABL1 phosphorylation and didn\u2019t affect BMI1 expression but was able to increase CCNG2 expression leading to autophagic processes that preceed cell death. Besides, ALX could enhance the apoptotic response induced by any Tyrosine Kinase Inhibitors (TKI) of the three generations. We also noted a strong synergism between ALX and TKIs to increase expression of caspase-9 and caspase-3 and induce PARP cleavage, Bad expression and significantly decreased Bcl-xL family member expression. We also observed that the blockage of the mitochondrial respiratory chain by ALX can be associated with inhibition of glycolysis by 2-DG to achieve an enhanced inhibition of K562 proliferation and clonogenicity. ALX specifically affected the differentiation of BCR::ABL1-transduced healthy CD34+ cells but not of mock-infected healthy CD34+ control cells. Importantly, ALX strongly synergized with TKIs to inhibit clonogenicity of primary CML CD34+ cells from diagnosed patients. Long Term Culture of Initiating Cell (LTC-IC) and dilution of the fluorescent marker CFSE allowed us to observe that ALX and Imatinib (IM) partially reduced the number of LSCs by themselves but that the ALX\/IM combination drastically reduced this cell compartment. Using an in vivo model of NSG mice intravenously injected with K562-Luciferase transduced CML cells, we showed that ALX combined with IM improved mice survival. Conclusions: Collectively, our results validate the use of ALX bis-biguanide to potentiate the action of conventional TKI treatment as a potential new therapeutic solution to eradicate CML LSCs<\/jats:p>","DOI":"10.3390\/cancers15030995","type":"journal-article","created":{"date-parts":[[2023,2,6]],"date-time":"2023-02-06T05:29:05Z","timestamp":1675661345000},"page":"995","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Repurposing the Bis-Biguanide Alexidine in Combination with Tyrosine Kinase Inhibitors to Eliminate Leukemic Stem\/Progenitor Cells in Chronic Myeloid Leukemia"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6654-9472","authenticated-orcid":false,"given":"Fabien","family":"Muselli","sequence":"first","affiliation":[{"name":"Institut National de la Sant\u00e9 et de la Recherche M\u00e9dicale (Inserm) U1065, Centre M\u00e9diterran\u00e9en de M\u00e9decine Mol\u00e9culaire, Universit\u00e9 C\u00f4te d\u2019Azur, Team 4, CEDEX 03, 06204 Nice, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lucas","family":"Mourgues","sequence":"additional","affiliation":[{"name":"Institut National de la Sant\u00e9 et de la Recherche M\u00e9dicale (Inserm) U1065, Centre M\u00e9diterran\u00e9en de M\u00e9decine Mol\u00e9culaire, Universit\u00e9 C\u00f4te d\u2019Azur, Team 4, CEDEX 03, 06204 Nice, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9995-6699","authenticated-orcid":false,"given":"Nathalie","family":"Rochet","sequence":"additional","affiliation":[{"name":"Institut de Biologie Valrose, Universit\u00e9 C\u00f4te d\u2019Azur, CNRS UMR 7277, Inserm U1091, CEDEX 02, 06107 Nice, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Marielle","family":"Nebout","sequence":"additional","affiliation":[{"name":"Institut National de la Sant\u00e9 et de la Recherche M\u00e9dicale (Inserm) U1065, Centre M\u00e9diterran\u00e9en de M\u00e9decine Mol\u00e9culaire, Universit\u00e9 C\u00f4te d\u2019Azur, Team 4, CEDEX 03, 06204 Nice, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Agn\u00e8s","family":"Guerci","sequence":"additional","affiliation":[{"name":"Hematology Department, University Hospital, 54000 Nancy, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9224-5491","authenticated-orcid":false,"given":"Els","family":"Verhoeyen","sequence":"additional","affiliation":[{"name":"Institut National de la Sant\u00e9 et de la Recherche M\u00e9dicale (Inserm) U1065, Centre M\u00e9diterran\u00e9en de M\u00e9decine Mol\u00e9culaire, Universit\u00e9 C\u00f4te d\u2019Azur, Team 4, CEDEX 03, 06204 Nice, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6538-1655","authenticated-orcid":false,"given":"Adrien","family":"Krug","sequence":"additional","affiliation":[{"name":"Institut National de la Sant\u00e9 et de la Recherche M\u00e9dicale (Inserm) U1065, Centre M\u00e9diterran\u00e9en de M\u00e9decine Mol\u00e9culaire, Universit\u00e9 C\u00f4te d\u2019Azur, Team 4, CEDEX 03, 06204 Nice, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laurence","family":"Legros","sequence":"additional","affiliation":[{"name":"Department of Hematology, Paul Brousse Hospital, 94000 Cr\u00e9teil, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6113-916X","authenticated-orcid":false,"given":"Jean-Fran\u00e7ois","family":"Peyron","sequence":"additional","affiliation":[{"name":"Institut National de la Sant\u00e9 et de la Recherche M\u00e9dicale (Inserm) U1065, Centre M\u00e9diterran\u00e9en de M\u00e9decine Mol\u00e9culaire, Universit\u00e9 C\u00f4te d\u2019Azur, Team 4, CEDEX 03, 06204 Nice, France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4136-3556","authenticated-orcid":false,"given":"Didier","family":"Mary","sequence":"additional","affiliation":[{"name":"Institut National de la Sant\u00e9 et de la Recherche M\u00e9dicale (Inserm) U1065, Centre M\u00e9diterran\u00e9en de M\u00e9decine Mol\u00e9culaire, Universit\u00e9 C\u00f4te d\u2019Azur, Team 4, CEDEX 03, 06204 Nice, France"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,2,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"561","DOI":"10.1038\/nm0596-561","article-title":"Effects of a selective inhibitor of the Abl tyrosine kinase on the growth of Bcr-Abl positive cells","volume":"2","author":"Druker","year":"1996","journal-title":"Nat. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"841","DOI":"10.1016\/S1470-2045(11)70201-7","article-title":"Nilotinib versus imatinib for the treatment of patients with newly diagnosed chronic phase, Philadelphia chromosome-positive, chronic myeloid leukaemia: 24-month minimum follow-up of the phase 3 randomised ENESTnd trial","volume":"12","author":"Kantarjian","year":"2011","journal-title":"Lancet Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1352","DOI":"10.1038\/sj.leu.2403416","article-title":"Efficacy of dual-specific Bcr-Abl and Src-family kinase inhibitors in cells sensitive and resistant to imatinib mesylate","volume":"18","author":"Tipping","year":"2004","journal-title":"Leukemia"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1586\/ehm.09.42","article-title":"Bosutinib: A dual SRC\/ABL kinase inhibitor for the treatment of chronic myeloid leukemia","volume":"2","author":"Keller","year":"2009","journal-title":"Expert Rev. Hematol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"635","DOI":"10.2147\/OTT.S189391","article-title":"Ponatinib: A novel multi-tyrosine kinase inhibitor against human malignancies","volume":"12","author":"Tan","year":"2019","journal-title":"Onco Targets Ther."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"396","DOI":"10.1172\/JCI35721","article-title":"Human chronic myeloid leukemia stem cells are insensitive to imatinib despite inhibition of BCR-ABL activity","volume":"121","author":"Corbin","year":"2011","journal-title":"J. Clin. Investig."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1501","DOI":"10.1182\/blood-2010-12-326843","article-title":"Chronic myeloid leukemia stem cells are not dependent on Bcr-Abl kinase activity for their survival","volume":"119","author":"Hamilton","year":"2012","journal-title":"Blood"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"319","DOI":"10.1182\/blood.V99.1.319","article-title":"Primitive, quiescent, Philadelphia-positive stem cells from patients with chronic myeloid leukemia are insensitive to STI571 in vitro","volume":"99","author":"Graham","year":"2002","journal-title":"Blood"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"4532","DOI":"10.1182\/blood-2005-07-2947","article-title":"Dasatinib (BMS-354825) targets an earlier progenitor population than imatinib in primary CML but does not eliminate the quiescent fraction","volume":"107","author":"Copland","year":"2006","journal-title":"Blood"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"4016","DOI":"10.1182\/blood-2006-11-057521","article-title":"Nilotinib exerts equipotent antiproliferative effects to imatinib and does not induce apoptosis in CD34+ CML cells","volume":"109","author":"Allan","year":"2007","journal-title":"Blood"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"2329","DOI":"10.1182\/blood-2007-05-092056","article-title":"Effective and selective inhibition of chronic myeloid leukemia primitive hematopoietic progenitors by the dual Src\/Abl kinase inhibitor SKI-606","volume":"111","author":"Konig","year":"2008","journal-title":"Blood"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1824","DOI":"10.1182\/blood-2012-02-412890","article-title":"Microenvironmental protection of CML stem and progenitor cells from tyrosine kinase inhibitors through N-cadherin and Wnt-\u03b2-catenin signaling","volume":"121","author":"Zhang","year":"2013","journal-title":"Blood"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"238","DOI":"10.1016\/j.ccr.2008.08.003","article-title":"Expansion of Bcr-Abl-positive leukemic stem cells is dependent on Hedgehog pathway activation","volume":"14","author":"Dierks","year":"2008","journal-title":"Cancer Cell"},{"key":"ref_14","doi-asserted-by":"crossref","unstructured":"Muselli, F., Mourgues, L., Morcos, R., Rochet, N., Nebout, M., Guerci-Bresler, A., Faller, D.V., William, R.M., Mhaidly, R., and Verhoeyen, E. (2021). Combination of PKC\u03b4 Inhibition with Conventional TKI Treatment to Target CML Models. Cancers, 13.","DOI":"10.3390\/cancers13071693"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"655","DOI":"10.1182\/blood-2016-10-745588","article-title":"Targeting chronic myeloid leukemia stem cells with the hypoxia-inducible factor inhibitor acriflavine","volume":"130","author":"Cheloni","year":"2017","journal-title":"Blood"},{"key":"ref_16","doi-asserted-by":"crossref","unstructured":"Kawada, H., Kaneko, M., Sawanobori, M., Uno, T., Matsuzawa, H., Nakamura, Y., Matsushita, H., and Ando, K. (2013). High concentrations of L-ascorbic acid specifically inhibit the growth of human leukemic cells via downregulation of HIF-1\u03b1 transcription. PLoS ONE, 8.","DOI":"10.1371\/journal.pone.0062717"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1234","DOI":"10.1038\/nm.4399","article-title":"Targeting mitochondrial oxidative phosphorylation eradicates therapy-resistant chronic myeloid leukemia stem cells","volume":"23","author":"Kuntz","year":"2017","journal-title":"Nat. Med."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"98","DOI":"10.1002\/emmm.201000062","article-title":"Stat5 is indispensable for the maintenance of bcr\/abl-positive leukaemia","volume":"2","author":"Hoelbl","year":"2010","journal-title":"EMBO Mol. Med."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"380","DOI":"10.1038\/nature15248","article-title":"Erosion of the chronic myeloid leukaemia stem cell pool by PPAR\u03b3 agonists","volume":"525","author":"Prost","year":"2015","journal-title":"Nature"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1993","DOI":"10.1038\/leu.2015.112","article-title":"The BMI1 polycomb protein represses cyclin G2-induced autophagy to support proliferation in chronic myeloid leukemia cells","volume":"29","author":"Mourgues","year":"2015","journal-title":"Leukemia"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1060","DOI":"10.1158\/1940-6207.CAPR-10-0175","article-title":"Metformin and other biguanides in oncology: Advancing the research agenda","volume":"3","author":"Pollak","year":"2010","journal-title":"Cancer Prev. Res."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"2234","DOI":"10.1158\/1535-7163.MCT-06-0134","article-title":"Potential use of alexidine dihydrochloride as an apoptosis-promoting anticancer agent","volume":"5","author":"Yip","year":"2006","journal-title":"Mol. Cancer Ther."},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Graber, M.A. (2013). A New Introduction to American Constitutionalism, Oxford University Press.","DOI":"10.1093\/acprof:oso\/9780199943883.001.0001"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"1956","DOI":"10.2174\/1871520620666200508085439","article-title":"Repurposing of Alexidine Dihydrochloride as an Apoptosis Initiator and Cell Cycle Inhibitor in Human Pancreatic Cancer","volume":"20","author":"Kasikci","year":"2020","journal-title":"Anticancer Agents Med. Chem."},{"key":"ref_25","doi-asserted-by":"crossref","unstructured":"Dell\u2019Anno, I., Melani, A., Martin, S.A., Barbarino, M., Silvestri, R., Cipollini, M., Giordano, A., Mutti, L., Nicolini, A., and Luzzi, L. (2022). A Drug Screening Revealed Novel Potential Agents against Malignant Pleural Mesothelioma. Cancers, 14.","DOI":"10.3390\/cancers14102527"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1092","DOI":"10.4161\/auto.5.8.9889","article-title":"Autophagy is an important event for megakaryocytic differentiation of the chronic myelogenous leukemia K562 cell line","volume":"5","author":"Colosetti","year":"2009","journal-title":"Autophagy"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"2088","DOI":"10.1182\/bloodadvances.2017007773","article-title":"Measles virus envelope pseudotyped lentiviral vectors transduce quiescent human HSCs at an efficiency without precedent","volume":"1","author":"Amirache","year":"2017","journal-title":"Blood Adv."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"188","DOI":"10.1016\/j.canlet.2014.01.006","article-title":"Metformin: A metabolic disruptor and anti-diabetic drug to target human leukemia","volume":"346","author":"Rosilio","year":"2014","journal-title":"Cancer Lett."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"6399","DOI":"10.1182\/blood-2011-01-332783","article-title":"Antileukemic effects of AMPK activators on BCR-ABL-expressing cells","volume":"118","author":"Vakana","year":"2011","journal-title":"Blood"},{"key":"ref_30","first-page":"1004","article-title":"Identification of putative drugs for gastric adenocarcinoma utilizing differentially expressed genes and connectivity map","volume":"19","author":"Chen","year":"2019","journal-title":"Mol. Med. Rep."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"329","DOI":"10.1016\/j.stem.2012.12.013","article-title":"BCL-2 inhibition targets oxidative phosphorylation and selectively eradicates quiescent human leukemia stem cells","volume":"12","author":"Lagadinou","year":"2013","journal-title":"Cell Stem Cell"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"954","DOI":"10.1016\/j.ccell.2018.11.007","article-title":"Targeting PKCdelta as a Therapeutic Strategy against Heterogeneous Mechanisms of EGFR Inhibitor Resistance in EGFR-Mutant Lung Cancer","volume":"34","author":"Lee","year":"2018","journal-title":"Cancer Cell"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"4487","DOI":"10.1002\/anie.201208889","article-title":"Oral disinfectants inhibit protein-protein interactions mediated by the anti-apoptotic protein Bcl-xL and induce apoptosis in human oral tumor cells","volume":"52","author":"Hell","year":"2013","journal-title":"Angew. Chem. Int. Ed. Engl."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"1996","DOI":"10.1038\/leu.2013.151","article-title":"Bcl-xL anti-apoptotic network is dispensable for development and maintenance of CML but is required for disease progression where it represents a new therapeutic target","volume":"27","author":"Harb","year":"2013","journal-title":"Leukemia"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"782","DOI":"10.1158\/0008-5472.CAN-06-3964","article-title":"Mcl-1 down-regulation potentiates ABT-737 lethality by cooperatively inducing Bak activation and Bax translocation","volume":"67","author":"Chen","year":"2007","journal-title":"Cancer Res."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"1292","DOI":"10.1093\/carcin\/bgq062","article-title":"Bcl2 is not required for the development and maintenance of leukemia stem cells in mice","volume":"31","author":"Orfao","year":"2010","journal-title":"Carcinogenesis"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"584","DOI":"10.1124\/jpet.109.163329","article-title":"Pharmacological targeting of the mitochondrial phosphatase PTPMT1","volume":"333","author":"Joseph","year":"2010","journal-title":"J. Pharmacol. Exp. Ther."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1016\/j.stem.2012.11.022","article-title":"Metabolic regulation by the mitochondrial phosphatase PTPMT1 is required for hematopoietic stem cell differentiation","volume":"12","author":"Yu","year":"2013","journal-title":"Cell Stem Cell"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1562","DOI":"10.1182\/blood-2014-04-568949","article-title":"Maintenance of mouse hematopoietic stem cells ex vivo by reprogramming cellular metabolism","volume":"125","author":"Liu","year":"2015","journal-title":"Blood"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"690","DOI":"10.1016\/j.cmet.2011.04.007","article-title":"Mitochondrial phosphatase PTPMT1 is essential for cardiolipin biosynthesis","volume":"13","author":"Zhang","year":"2011","journal-title":"Cell Metab."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"694","DOI":"10.1016\/j.celrep.2015.01.010","article-title":"PTPMT1 Inhibition Lowers Glucose through Succinate Dehydrogenase Phosphorylation","volume":"10","author":"Nath","year":"2015","journal-title":"Cell Rep."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"560","DOI":"10.1002\/jbmr.2710","article-title":"Alexidine Dihydrochloride Attenuates Osteoclast Formation and Bone Resorption and Protects Against LPS-Induced Osteolysis","volume":"31","author":"Zhu","year":"2016","journal-title":"J. Bone Miner. Res."}],"container-title":["Cancers"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6694\/15\/3\/995\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:23:59Z","timestamp":1760120639000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6694\/15\/3\/995"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,2,3]]},"references-count":42,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2023,2]]}},"alternative-id":["cancers15030995"],"URL":"https:\/\/doi.org\/10.3390\/cancers15030995","relation":{},"ISSN":["2072-6694"],"issn-type":[{"value":"2072-6694","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,2,3]]}}}