Polycomb contraction differentially regulates terminal human hematopoietic differentiation programs.

BACKGROUND: Lifelong production of the many types of mature blood cells from less differentiated progenitors is a hierarchically ordered process that spans multiple cell divisions. The nature and timing of the molecular events required to integrate the environmental signals, transcription factor activity, epigenetic modifications, and changes in gene expression involved are thus complex and still poorly understood. To address this gap, we generated comprehensive reference epigenomes of 8 phenotypically defined subsets of normal human cord blood. RESULTS: We describe a striking contraction of H3K27me3 density in differentiated myelo-erythroid cells that resembles a punctate pattern previously ascribed to pluripotent embryonic stem cells. Phenotypically distinct progenitor cell types display a nearly identical repressive H3K27me3 signature characterized by large organized chromatin K27-modification domains that are retained by mature lymphoid cells but lost in terminally differentiated monocytes and erythroblasts. We demonstrate that inhibition of polycomb group members predicted to control large organized chromatin K27-modification domains influences lymphoid and myeloid fate decisions of primary neonatal hematopoietic progenitors in vitro. We further show that a majority of active enhancers appear in early progenitors, a subset of which are DNA hypermethylated and become hypomethylated and induced during terminal differentiation. CONCLUSION: Primitive human hematopoietic cells display a unique repressive H3K27me3 signature that is retained by mature lymphoid cells but is lost in monocytes and erythroblasts. Intervention data implicate that control of this chromatin state change is a requisite part of the process whereby normal human hematopoietic progenitor cells make lymphoid and myeloid fate decisions.

Selective expression of CD45 isoforms on functional subpopulations of CD34+ hemopoietic cells from human bone marrow.

We have found that the small population of cells in human marrow that are characterized by their expression of CD34 can be readily subdivided into two apparently nonoverlapping subpopulations of approximate equal size, one expressing CD45RO and one CD45R. Functional studies of these subpopulations revealed that all of the primitive erythroid colony-forming cells (BFU-E) are CD34+ CD45RO+. Similarly, more primitive cells that give rise to both erythroid and granulopoietic colony-forming cells after being maintained for 5 wk on confluent irradiated long-term marrow culture feeder layers, also show this phenotype. In contrast, most granulopoietic colony-forming cells are CD34+ CD45RO- cells. The differential expression of CD45 isoforms on distinct functional subpopulations of hemopoietic cells is consistent with the concept that these molecules play an important role in the differentiation or activation of primitive, normally quiescent, hemopoietic cells. The presence of CD45RO and the lack of CD45R on human cells capable of initiating hemopoiesis in the long-term marrow culture system correspond to the reported lack of CD45R on transplantable hemopoietic stem cells in rodents and may be a useful addition to strategies for human stem cell purification, or for purging CD45R+ leukemic cells.

Differential cytokine effects on primitive (CD34+CD38-) human hematopoietic cells: novel responses to Flt3-ligand and thrombopoietin.

A high proportion of the CD34+CD38- cells in normal human marrow are defined as long-term culture-initiating cells (LTC-IC) because they can proliferate and differentiate when co-cultured with cytokine-producing stromal feeder layers. In contrast, very few CD34+CD38- cells will divide in cytokine-containing methylcellulose and thus are not classifiable as direct colony-forming cells (CFC), although most can proliferate in serum-free liquid cultures containing certain soluble cytokines. Analysis of the effects of 16 cytokines on CD34+CD38- cells in the latter type of culture showed that Flt3-ligand (FL), Steel factor (SF), and interleukin (IL)-3 were both necessary and sufficient to obtain an approximately 30-fold amplification of the input LTC-IC population within 10 d. As single factors, only FL and thrombopoietin (TPO) stimulated a net increase in LTC-IC within 10 d. Interestingly, a significantly increased proportion of the CFC produced from the TPO-amplified LTC-IC were erythroid. Increases in the number of directly detectable CFC of > 500-fold were also obtainable within 10 d in serum-free cultures of CD34+CD38- cells. However, this required the presence of IL-6 and/or granulocyte/colony-stimulating factor and/or nerve growth factor beta in addition to FL, SF, and IL-3. Also, for this response, the most potent single-acting factor tested was IL-3, not FL. Identification of cytokine combinations that differentially stimulate primitive human hematopoietic cell self-renewal and lineage determination should facilitate analysis of the intracellular pathways that regulate these decisions as well as the development of improved ex vivo expansion and gene transfer protocols.

Correction of sickle cell disease in transgenic mouse models by gene therapy.

Sickle cell disease (SCD) is caused by a single point mutation in the human betaA globin gene that results in the formation of an abnormal hemoglobin [HbS (alpha2betaS2)]. We designed a betaA globin gene variant that prevents HbS polymerization and introduced it into a lentiviral vector we optimized for transfer to hematopoietic stem cells and gene expression in the adult red blood cell lineage. Long-term expression (up to 10 months) was achieved, without preselection, in all transplanted mice with erythroid-specific accumulation of the antisickling protein in up to 52% of total hemoglobin and 99% of circulating red blood cells. In two mouse SCD models, Berkeley and SAD, inhibition of red blood cell dehydration and sickling was achieved with correction of hematological parameters, splenomegaly, and prevention of the characteristic urine concentration defect.

An approach to the management of chronic myeloid leukemia in British Columbia.

Chronic myeloid leukemia (cml) is a myeloproliferative disorder whose therapy has changed dramatically since the late 1990s. With the introduction of the tyrosine kinase inhibitor (tki) imatinib mesylate, the treatment outcomes for patients with cml have improved markedly, and hematopoietic stem-cell transplantation is no longer routinely offered as first-line therapy for most patients in chronic phase.However, resistance to tki therapy is increasingly being recognized, and alternative therapy is needed for this group of patients. In addition, the development of models predicting response to tki therapy is desired, so that appropriate treatment strategies can be used for individual patients. The present report serves to outline the approach to the treatment of cml in British Columbia and to highlight areas of ongoing research.

Unregulated proliferation of primitive neoplastic progenitor cells in long-term polycythemia vera marrow cultures.

Marrow cells from seven untreated patients with polycythemia vera (PV) were used to initiate standard single inoculum long-term marrow cultures. The numbers, erythropoietin independence, and cycling behavior of all detectable classes of erythroid, granulopoietic, and multilineage progenitors were then evaluated and the results obtained compared with preculture values. Time course studies showed that the long-term marrow culture system supports the continuous proliferation of primitive neoplastic progenitor cells from PV patients for many weeks. However, these progenitors fail to respond to signals from the adherent layer that return their counterparts in normal long-term marrow cultures to a quiescent state 5-7 d after each medium change. This abnormal cycling behavior of PV cells in the long-term culture system appears to mimic that operative in vivo, where primitive hemopoietic progenitors are also in a continuous state of turnover, in contrast to similar primitive progenitor compartments in normal individuals, which are quiescent. The long-term marrow culture system thus offers new possibilities for the further analysis of abnormal cellular and molecular mechanisms underlying clonal expansion at the stem cell level in PV.

Differential effects of microenvironmentally presented interleukin 3 versus soluble growth factor on primitive human hematopoietic cells.

The effect of IL-3 on hematopoiesis in long-term culture (LTC) was studied by cocultivating normal human marrow cells with human marrow fibroblast feeders engineered to constitutively produce IL-3 and by adding soluble IL-3 to LTC according to a variety of dose-time schedules. Feeders stably producing 7 ng/ml IL-3, or LTC to which 10 ng/ml IL-3 was added daily for 5 wk, but not once or twice weekly for the same time period, increased the output of mature nonadherent cells and progenitors from LTC as compared to control cultures. At the time of the weekly half-medium change, when primitive clonogenic progenitors in the adherent layer of standard LTC are quiescent, such cells were actively cycling in cultures containing a continuous source of an adequate dose of IL-3. In LTC, where the proportion of IL-3-producing cells in the feeder layer was diluted to 10% and no IL-3 was detectable in culture medium, primitive adherent layer progenitors were, nevertheless, maintained as a population of continuously proliferating cells. Thus, the presence of IL-3 in LTC can enhance the proliferation and differentiation of very early human hematopoietic cells, but the concentration, duration of exposure, and method of IL-3 presentation are important determinants of the ultimate effects observed.

Transplantable hematopoietic stem cells in human fetal liver have a CD34(+) side population (SP)phenotype.

Cells with a verapamil-sensitive ability to efflux Hoechst 33342 (termed side population [SP] cells) have been identified in adult marrow from several species including humans and in several tissues from adult mice. In mice, the SP phenotype appears to be a common feature of stem cells, but human SP cells have been less well characterized. We show here, for the first time to our knowledge, that SP cells are present in the second-trimester human fetal liver. They include all of the transplantable human hematopoietic stem cell activity detectable in NOD/SCID mice and also certain other, more differentiated hematopoietic cell types. Notably, the stem cell activity was confined to the CD34(+)CD38(-) SP(+) population, and isolation of these cells gave an approximately tenfold enrichment of transplantable stem cells. This subset was not, however, coenriched in hematopoietic progenitors detectable by either short- or long-term in vitro assays, indicating most of these to be distinct from transplantable stem cells. These findings suggest that the SP phenotype is an important and distinguishing property of human hematopoietic stem cells and that early in ontogeny they express CD34.

Transient suppression of clonal hemopoiesis associated with pregnancy in a patient with a myeloproliferative disorder.

We have used restriction fragment length polymorphism analysis to study the clonal involvement of the blood cells in a woman with myeloproliferative disease, whose initially high platelet count (940,000/microliter) spontaneously decreased during a normal pregnancy but then returned rapidly to the same high level after delivery of her child. Analysis of her erythroid progenitors showed the presence of erythropoietin-independent progenitors before, during, and after her pregnancy, consistent with a diagnosis of myeloproliferative disease, and persistence of the abnormal clone throughout the period of study. Analysis of DNA from her blood granulocytes showed these to be polyclonal at mid-pregnancy, when her platelet count had decreased to normal values, in comparison to the monoclonal pattern exhibited by her blood granulocytes 3 mo postpartum, when her platelet count was again elevated. These results demonstrate a partial conversion to normal, polyclonal hemopoiesis during her pregnancy and suggest a previously unanticipated differential sensitivity of normal and neoplastic hemopoietic cells to physiological changes associated with this state.

Retroviral gene transfer to primitive normal and leukemic hematopoietic cells using clinically applicable procedures.

Clinical uses of gene transfer to bone marrow transplants require the establishment of a reproducible method for infecting large numbers of very primitive hematopoietic cells at high efficiency using cell-free retrovirus-containing media. In this study we report the results of experiments with preparations of a high-titer (2-5 x 10(7)/ml) helper-free recombinant neo(r) retrovirus that indicate this goal can now be achieved based on measurements of gene transfer efficiencies to cells referred to as long-term culture initiating cells (LTC-IC) because they give rise to clonogenic cells after greater than or equal to 5 wk in long-term culture (LTC). Intermittent, repeated exposure of normal human marrow mononuclear cells to virus-containing supernatant over a 3-d period of cell maintenance on an IL-3/granulocyte colony-stimulating factor (G-CSF) producing stromal layer resulted in gene transfer efficiencies to LTC-IC of 41%; a level previously obtainable only using co-cultivation infection techniques. Marrow cells enriched greater than or equal to 500-fold for LTC-IC (1-2% pure) by flow cytometry showed gene transfer efficiencies of 27% when infected in a similar fashion over a shorter period (24 h), but in the presence of added soluble IL-3 and G-CSF without stromal feeders, and this increased to 61% when Steel factor was also present during the infection period. By using a less highly enriched population of LTC-IC obtained by a bulk immunoselection technique applicable to large-scale clinical marrow harvests, gene transfer efficiencies to LTC-IC of 40% were achieved and this was increased to 60% by short-term preselection in G418. Southern analysis of DNA from the nonadherent cells produced by these LTC over a 6-wk period provided evidence of clonal evolution of LTC-IC in vitro. Leukemic chronic myelogenous leukemia LTC-IC were also infected at high efficiency using the same supernatant infection strategy with growth factor supplementation. These data demonstrate the feasibility of using cell-free virus preparations for infecting clinical marrow samples suitable for transplantation, as well as for further analysis of human marrow stem cell dynamics in vitro.

Previously undetected human hematopoietic cell populations with short-term repopulating activity selectively engraft NOD/SCID-beta2 microglobulin-null mice.

Increasing use of purified or cultured human hematopoietic cells as transplants has revealed an urgent need for better methods to predict the speed and durability of their engraftment potential. We now show that NOD/SCID-beta2 microglobulin-null (NOD/SCID-beta2m-/-) mice are sequentially engrafted by two distinct and previously unrecognized populations of transplantable human short-term repopulating hematopoietic cells (STRCs), neither of which efficiently engraft NOD/SCID mice. One is predominantly CD34+CD38+ and is myeloid-restricted; the other is predominantly CD34+CD38- and has broader lymphomyeloid differentiation potential. In contrast, the long-term repopulating human cells that generate lymphoid and myeloid progeny in NOD/SCID mice engraft and self-renew in NOD/SCID-beta2m-/- mice equally efficiently. In short-term expansion cultures of adult bone marrow cells, myeloid-restricted STRCs were preferentially amplified (greater than tenfold) and, interestingly, both types of STRC were found to be selectively elevated in mobilized peripheral blood harvests. These results suggest an enhanced sensitivity of STRCs to natural killer cell-mediated rejection. They also provide new in vivo assays for different types of human STRC that may help to predict the engraftment potential of clinical transplants and facilitate future investigation of early stages of human hematopoietic stem cell differentiation.

Familial bone marrow monosomy 7. Evidence that the predisposing locus is not on the long arm of chromosome 7.

Loss of expression of a tumor-suppressing gene is an attractive model to explain the cytogenetic and epidemiologic features of cases of myelodysplasia and acute myelogenous leukemia (AML) associated with bone marrow monosomy 7 or partial deletion of the long arm (7q-). We used probes from within the breakpoint region on 7q-chromosomes (7q22-34) that detect restriction fragment length polymorphisms (RFLPs) to investigate three families in which two siblings developed myelodysplasia with monosomy 7. In the first family, probes from the proximal part of this region identified DNA derived from the same maternal chromosome in both leukemias. The RFLPs in these siblings diverged at the more distal J3.11 marker due to a mitotic recombination in one patient, a result that suggested a critical region on 7q proximal to probe J3.11. Detailed RFLP mapping of the implicated region was then performed in two additional unrelated pairs of affected siblings. In these families, DNA derived from different parental chromosome 7s was retained in the leukemic bone marrows of the siblings. We conclude that the familial predisposition to myelodysplasia is not located within a consistently deleted segment on the long arm of chromosome 7. These data provide evidence implicating multiple genetic events in the pathogenesis of myelodysplasia seen in association with bone marrow monosomy 7 or 7q-.

Lonafarnib reduces the resistance of primitive quiescent CML cells to imatinib mesylate in vitro.

Recent studies indicate that a rare population of primitive quiescent BCR-ABL(+) cells are innately insensitive to imatinib mesylate (IM) and persist after IM therapy of patients with chronic myeloid leukemia (CML). New approaches to the eradication of these cells are therefore likely to be crucial to the development of curative therapies for CML. We have now found that Ara-C, LY294002 (a PI-3 (phosphatidylinositol-3' kinase) kinase inhibitor), 17AAG (a heat-shock protein (HSP)-90 antagonist) and lonafarnib (a farnesyltransfease inhibitor) all enhance the toxicity of IM on K562 cells and on the total CD34(+) leukemic cell population from chronic phase CML patients. However, for quiescent CD34(+) leukemic cells, this was achieved only by concomitant exposure of the cells to lonafarnib. Ara-C or LY294002 alone blocked the proliferation of these cells but did not kill them, and Ara-C, LY294002 or 17AAG in combination with IM enhanced the cytostatic effect of IM but did not prevent the subsequent regrowth of the surviving leukemic cells. These studies demonstrate the importance of in vitro testing of novel agents on the subset of primary leukemic cells most likely to determine long-term treatment outcomes in vivo.

Different subsets of primary chronic myeloid leukemia stem cells engraft immunodeficient mice and produce a model of the human disease.

Xenograft models of chronic phase human chronic myeloid leukemia (CML) have been difficult to develop because of the persistence of normal hematopoietic stem cells in most chronic phase CML patients and the lack of methods to selectively isolate the rarer CML stem cells. To circumvent this problem, we first identified nine patients' samples in which the long-term culture-initiating cells were predominantly leukemic and then transplanted cells from these samples into sublethally irradiated NOD/SCID and NOD/SCID-beta2microglobulin-/- mice. This resulted in the consistent and durable (>5 months) repopulation of both host genotypes with similar numbers of BCR-ABL+/Ph+ cells. The regenerated leukemic cells included an initial, transient population derived from CD34+CD38+ cells as well as more sustained populations derived from CD34+CD38- progenitors, indicative of a hierarchy of transplantable leukemic cells. Analysis of the phenotypes produced revealed a reduced output of B-lineage cells, enhanced myelopoiesis with excessive production of erythroid and megakaropoietic cells and the generation of primitive (CD34+) leukemic cells displaying an autocrine IL-3 and G-CSF phenotype, all characteristics of primary CML cells. These findings demonstrate the validity of this xenograft model of chronic phase human CML, which should enable future investigation of disease pathogenesis and new approaches to therapy.

Autocrine production of pre-B-cell stimulating activity by a variety of transformed murine pre-B-cell lines.

Current evidence suggests that the proliferation and differentiation of normal pre-B-cells may be regulated by interactions with mesenchymally derived stromal cells. The nature of these cell-cell interactions has not yet been fully elucidated, but the involvement of pre-B-cell stimulating factors produced by various mesenchymal cell lines has recently been demonstrated in the murine system. In this model, transformed pre-B-cells differ from their normal counterparts in their acquisition of autonomous growth potential, as seen by an ability to be maintained in vitro in the absence of mesenchymal cell feeders. To test the hypothesis that autonomy might be associated with autocrine growth factor production, we tested the ability of a spontaneous pre-B-cell transformant (H9 cells) and two independently derived Abelson murine leukemia virus transformed pre-B-cell lines to produce pre-B-cell stimulating factors. All three lines released activities that stimulated the proliferation of themselves or H9 cells when cultured at low cell densities. One of the three transformed pre-B-cell lines could also substitute for mesenchymal feeders to stimulate normal pre-B-cells. Time course studies of an evolving Abelson murine leukemia virus transformant showed that the production of an autocrine pre-B-cell growth factor increased concomitantly with the acquisition of autonomous growth potential suggesting a relationship between these two phenotypic changes. Preliminary characterization of the growth factor responsiveness of H9 cells and the nature of the autostimulatory activity produced by this line suggested its nonidentity with any known hemopoietic growth factor. Activation of autocrine growth factor production appears to be a common event in the evolution of malignant pre-B-cells arising through different oncogenic mechanisms and may therefore be relevant to the pathogenesis of human acute lymphoid leukemia.

Advances in hematopoietic stem cell culture.

Recent advances in our understanding of the earliest stages of hematopoietic cell differentiation, and how these may be manipulated under defined conditions in vitro, have set the stage for the development of robust bioprocess technology applicable to hematopoietic cells. Sensitive and specific assays now exist for measuring the frequency of hematopoietic stem cells with long-term in vivo repopulating activity from human as well as murine sources. The production of natural or engineered ligands through recombinant DNA and/or combinatorial chemistry strategies is providing new reagents for enhancing the productivity of hematopoietic cell cultures. Multifactorial and dose-response analyses have yielded new insight into the different types and concentrations of factors required to optimize the rate and the extent of amplification of specific subpopulations of primitive hematopoietic cells. In addition, the rate of cytokine depletion from the medium has also been found to be dependent on the types of cell present. The discovery of these cell-type-specific parameters affecting cytokine concentrations and responses has introduced a new level of complexity into the design of optimized hematopoietic bioprocess systems.

Cell division tracking and expansion of hematopoietic long-term repopulating cells.

The combined use of rigorous assays for quantitating transplantable stem cell numbers and precise cell labeling and tracking procedures have provided definitive evidence that stem cell self-renewal divisions can occur in vitro in the absence of stromal feeder layers. These findings set the stage for defining conditions that may alter the ability of these cells to maintain their primitive status when mitogenically activated.

Altered patterns of CD44 epitope expression in human chronic and acute myeloid leukemia.

Abnormal expression of different isoforms of CD44 has been found to characterize many types of malignant cells although data for human acute and chronic myeloid leukemia is limited. In this study, we have identified significant, albeit variable, increases in these diseases of the frequency of both light density and CD34+ cells expressing two particular CD44 epitopes, neither of which is commonly found on normal human marrow cells. One of these epitopes is unique to exon v10-containing isoforms of CD44. The other is located in the common region of CD44 and was previously revealed on T cells only after their activation. Interestingly, another T cell activation-associated epitope was found to be expressed on a high proportion of normal marrow cells including the CD34+ subset and this remained the case for most of the primary leukemic samples evaluated. As expected, >90% of cells in all primary normal and leukemic samples expressed high levels of CD44, as shown by their reactivity with an antibody specific for the CD44 hyaluronan-binding site. To begin investigating how expression of the CD44 epitopes seen more commonly on leukemic than on normal CD34+ cells may be modulated, and to identify potentially associated effects on the hyaluronan-binding ability of the CD44 expressed, the effect of phorbol ester treatment on these properties of CD44 were examined. For these studies, a panel of five different human leukemic cell lines that were found to exhibit different patterns of CD44 expression and function in the absence of phorbol ester were used. Both the level and the hyaluronan-binding properties of CD44 could be stimulated in some, but not all, of these leukemic cell lines. Taken together, our findings indicate that CD44 expression is perturbed in a variety of leukemic populations suggesting a possible relationship to some of the pathogenetic features they share.

Growth factor regulation of the maintenance and differentiation of human long-term culture-initiating cells (LTC-IC).

Current evidence suggests that the most primitive of hematopoietic progenitors detectable in adult human marrow are cells that can give rise to clonogenic cells for > 5 weeks in vitro when co-cultured with certain stromal cells. Procedures developed to isolate these so-called long-term culture-initiating cells (LTC-IC) in highly purified form allow their separation from most other hematopoietic cells as well as from stromal cells and their precursors also present in the marrow. We have used such procedures in conjunction with the LTC system to identify specific growth factors that support human LTC-IC maintenance and differentiation and to make comparisons with effects on later events in hematopoiesis. In some studies, soluble growth factors were added exogenously to the study cultures. In others, marrow-derived fibroblasts were genetically engineered to allow increased levels of specific human growth factors to be endogenously produced. In both of these ways, the influence of granulocyte--macrophage colony-stimulating factor (GM-CSF), G-CSF, Interleukin-3 (IL-3), IL-6, and Steel factor were investigated. Increased provision of GM-CSF alone (or in combination with other factors) enhanced terminal cell differentiation (production of granulocytes and macrophages), although the same conditions had no influence on LTC-IC differentiation (production of clonogenic cells) or on LTC-IC maintenance. In contrast, G-CSF, IL-3 and IL-6 alone (and more so when combined) in the presence of feeders effectively enhanced LTC-IC differentiation and was less active on later stages of granulopoiesis. Provision of additional exogenous Steel factor also enhanced LTC-IC differentiation, although Steel factor alone, without feeders or other growth factors, did not support either the initial differentiation of LTC-IC into clonogenic cells or their subsequent differentiation into mature granulocytes and macrophages. No combination of exogenously added growth factors was found that enhanced LTC-IC maintenance over that achieved with primary marrow feeders. However, some murine fibroblasts (including those of SI/SI origin), as well as certain exogenous growth factors (including Steel factor), were able to substitute for feeders in this regard. These observations highlight the likelihood of redundancy in factors that can elicit similar biological responses at the earliest as well as later stages of hematopoietic cell development. Nevertheless, it appears that the responses of hematopoietic cells at different stages of differentiation to any particular factor may differ markedly and that the nature of any particular response is not yet predictable from a knowledge of effects on earlier or later cell types.

In vitro culture of bone marrow cells for autografting in CML.

Long-term maintenance of normal hematopoiesis in vitro is possible when very primitive progenitors are cocultivated with certain non-hematopoietic stromal cells that may co-exist in (or be derived from cells that co-exist in) hematopoietic tissues. Such long-term cultures (LTC) have been used to develop quantitative assays for the most primitive populations of hematopoietic cells currently detectable in adult marrow. In addition they provide a unique model for analysis of the complex molecular mechanisms that may regulate primitive hematopoietic cell population dynamics in vivo. Similar studies with LTC of cells from patients with chronic myeloid leukemia (CML) have made it possible to detect and characterize very primitive neoplastic cell populations in this disease. These latter studies have revealed differences in the properties of primitive CML cells that both reflect and explain their increased turnover and are thus presumably part of the mechanism that enables the neoplastic clone to expand in vivo. In addition, the most primitive neoplastic cells in CML patients are abnormally distributed between the marrow and blood and their ability to maintain their numbers in LTC has also been found to be defective. Assessment of the number and behaviour of primitive cells in LTC of CML marrow has been used to identify those patients most likely to benefit from intensive therapy supported by transplantation of cultured autologous marrow. Twenty-two such CML patients have now been treated with this experimental protocol. The results to date have clearly established the feasibility of this novel treatment strategy and, together with more recent laboratory findings, suggest future avenues for significantly improving the management of CML patients.