Single cell multi-omics analysis of chronic myeloid leukemia links cellular heterogeneity to therapy response

Reviewer #1 (Public Review):

Summary:

This manuscript by Warfvinge et al. reports the results of CITE-seq to generate single-cell multi-omics maps from BM CD34+ and CD34+CD38- cells from nine CML patients at diagnosis. Patients were retrospectively stratified by molecular response after 12 months of TKI therapy using European Leukemia Net (ELN) recommendations. They demonstrate heterogeneity of stem and progenitor cell composition at diagnosis, and show that compared to optimal responders, patients with treatment failure after 12 months of therapy demonstrate increased frequency of molecularly defined primitive cells at diagnosis. These results were validated by deconvolution of an independent previously published dataset of bulk transcriptomes from 59 CML patients. They further applied a BCR-ABL-associated gene signature to classify primitive Lin-CD34+CD38- stem cells as BCR:ABL+ and BCR:ABL-. They identified variability in the ratio of leukemic to non-leukemic primitive cells between patients, showed differences in the expression of cell surface markers, and determined that a combination of CD26 and CD35 cell surface markers could be used to prospectively isolate the two populations. The relative proportion of CD26-CD35+ (BCR:ABL-) primitive stem cells was higher in optimal responders compared to treatment failures, both at diagnosis and following 3 months of TKI therapy.

Strengths:

The studies are carefully conducted and the results are very clearly presented. The data generated will be a valuable resource for further studies. The strengths of this study are the application of single-cell multi-omics using CITE-Seq to study individual variations in stem and progenitor clusters at diagnosis that are associated with good versus poor outcomes in response to TKI treatment. These results were confirmed by deconvolution of a historical bulk RNAseq data set. Moreover, they are also consistent with a recent report from Krishnan et al. and are a useful confirmation of those results. The major new contribution of this study is the use of gene expression profiles to distinguish BCR-ABL+ and BCR-ABL- populations within CML primitive stem cell clusters and then applying antibody-derived tag (ADT) data to define molecularly identified BCR:ABL+ and BCR-ABL- primitive cells by expression of surface markers. This approach allowed them to show an association between the ratio of BCR-ABL+ vs BCR-ABL- primitive cells and TKI response and study dynamic changes in these populations following short-term TKI treatment.

Weaknesses:

One of the limitations of the study is the small number of samples employed, which is insufficient to make associations with outcomes with confidence. Although the authors discuss the potential heterogeneity of primitive stem, they do not directly address the heterogeneity of hematopoietic potential or response to TKI treatment in the results presented. Another limitation is that the BCR-ABL + versus BCR-ABL- status of cells was not confirmed by direct sequencing for BCR-ABL. The BCR-ABL status of cells sorted based on CD26 and CD35 was evaluated in only two samples. We also note that the surface markers identified were previously reported by the same authors using different single-cell approaches, which limits the novelty of the findings. It will be important to determine whether the GEP and surface markers identified here are able to distinguish BCR-ABL+ and BCR-ABL- primitive stem cells later in the course of TKI treatment. Finally, although the authors do describe differential gene expression between CML and normal, BCR:ABL+ and BCR:ABL-, primitive stem cells they have not as yet taken the opportunity to use these findings to address questions regarding biological mechanisms related to CML LSC that impact on TKI response and outcomes.

Reviewer #2 (Public Review):

Summary:

The authors use single-cell "multi-comics" to study clonal heterogeneity in chronic myeloid leukemia (CML) and its impact on treatment response and resistance. Their main results suggest 1) Cell compartments and gene expression signatures both shared in CML cells (versus normal), yet 2) some heterogeneity of multiomic mapping correlated with ELN treatment response; 3) further definition of s unique combination of CD26 and CD35 surface markers associated with gene expression defined BCR::ABL1+ LSCs and BCR::ABL1- HSCs. The manuscript is well-written, and the method and figures are clear and informative. The results fit the expanding view of cancer and its therapy as a complex Darwinian exercise of clonal heterogeneity and the selective pressures of treatments.

Strengths:

Cutting-edge technology by one of the expert groups of single-cell 'comics.

Weaknesses:

Very small sample sizes, without a validation set.
The obvious main problem with the study is that an enormous amount of results and conjecture arise from a very small data set: only nine cases for the treatment response section (three in each of the ELN categories), only two normal marrows, and only two patient cases for the division kinetic studies. Thus, it is very difficult to know the "noise" in the system - the stability of clusters and gene expression and the normal variation one might expect, versus patterns that may be reproducibly study artifact, effects of gene expression from freezing-thawing, time on the bench, antibody labeling, etc. This is not so much a criticism as a statement of reality: these elegant experiments are difficult, time-consuming, and very expensive. Thus in the Discussion, it would be helpful for the authors to just frankly lay out these limitations for the reader to consider. Also in the Discussion, it would be interesting for the authors to consider what's next: what type of validation would be needed to make these studies translatable to the clinic? Is there a clever way to use these data to design a faster/cheaper assay?

Reviewer #3 (Public Review):

Summary:

In this study, Warfvinge and colleagues use CITE-seq to interrogate how CML stem cells change between diagnosis and after one year of TKI therapy. This provides important insight into why some CML patients are "optimal responders" to TKI therapy while others experience treatment failure. CITE-seq in CML patients revealed several important findings. First, substantial cellular heterogeneity was observed at diagnosis, suggesting that this is a hallmark of CML. Further, patients who experienced treatment failure demonstrated increased numbers of primitive cells at diagnosis compared to optimal responders. This finding was validated in a bulk gene expression dataset from 59 CML patients, in which it was shown that the proportion of primitive cells versus lineage-primed cells correlates to treatment outcome. Even more importantly, because CITE-seq quantifies cell surface protein in addition to gene expression data, the authors were able to identify that BCR/ABL+ and BCR/ABL- CML stem cells express distinct cell surface markers (CD26+/CD35- and CD26-/CD35+, respectively). In optimal responders, BCR/ABL- CD26-/CD35+ CML stem cells were predominant, while the opposite was true in patients with treatment failure. Together, these findings represent a critical step forward for the CML field and may allow more informed development of CML therapies, as well as the ability to predict patient outcomes prior to treatment.

Strengths:

This is an important, beautifully written, well-referenced study that represents a fundamental advance in the CML field. The data are clean and compelling, demonstrating convincingly that optimal responders and patients with treatment failure display significant differences in the proportion of primitive cells at diagnosis, and the ratio of BCR-ABL+ versus negative LSCs. The finding that BCR/ABL+ versus negative LSCs display distinct surface markers is also key and will allow for a more detailed interrogation of these cell populations at a molecular level.

Weaknesses:

CITE-seq was performed in only 9 CML patient samples and 2 healthy donors. Additional samples would greatly strengthen the very interesting and notable findings.