Interleukin 4 Induces Macrophage-Mediated Phagocytosis of Leukemia Cells
Authors: Peña-Martínez Pablo , Eriksson Mia , Ramakrishnan Ramprasad , Chapellier Marion , Högberg Carl , Jansson Caroline , Gisselsson Nord David , Järås Marcus 
Published: October 2019

Abstract
Acute myeloid leukemia (AML) is an aggressive disease associated with poor prognosis, hence, new therapeutic strategies are needed. The AML cells reside in the bone marrow niche and depend on external signals such as cytokines for their growth and survival. In contrast to providing a supporting role, cytokines can act as negative regulators of AML cells. We previously identified that interleukin 4 (IL-4) induces apoptosis of AML cells in a Stat6-dependent manner and demonstrated strong anti-leukemic activity of IL-4 in a murine AML model driven by MLL-AF9 (Peña-Martínez et al., Leukemia 2017). Ectopic expression of IL-4 in AML cells resulted in prolonged survival in C57BL/6 mice, with mice almost devoid of leukemia cells in bone marrow and spleen upon the time of sacrifice. However, the IL-4-induced apoptosis of AML cells did not fully explain the strong antileukemic activity of IL-4 in vivo.
To investigate whether the anti-leukemic effect of ectopic IL-4 expression in vivo was microenvironment dependent, we used IL-2 receptor gamma(-/-) immunodeficient mice, which lack a functional IL-4 receptor type I complex, as recipients for transplantation of murine MLL-AF9 AML cells. Notably, there was no antileukemic activity of IL-4 in these mice, suggesting that the in vivo anti-leukemic effect of IL-4 was predominantly microenvironment-dependent. To identify the cell population that was responsible for the antileukemic effect of IL-4 stimulation, we performed flow cytometry analysis of bone marrow and spleen cells in mice exposed to high IL-4 levels. We found that the anti-leukemic activity of IL-4 was associated with a significant expansion of F4/80+ macrophages in both the bone marrow and spleen, which was confirmed by immunohistochemistry.
To determine whether macrophages were responsible for the anti-leukemic effect of IL-4, we depleted macrophages with clodronate liposomes in mice receiving IL-4-secreting AML cells. Depletion of macrophages partially rescued the anti-leukemic effect of IL-4, indicating that macrophages stimulated with IL-4 were responsible for the antileukemic activity. Consistent with these findings, in macrophage differentiation assays with either murine or human monocytes, IL-4 enhanced the phagocytosis of leukemia cells.
To characterize the IL-4-induced macrophages, we performed RNA sequencing of F4/80+ macrophages from animals exposed to high IL-4 levels. Gene expression analysis revealed IL-4-induced M2 polarization of the macrophages, as key markers of M2 activation such as Arg1, Retnla and Chil3 were upregulated. Moreover, consistent with the in vitro findings, gene set enrichment analysis revealed an enrichment of phagocytosis signatures in the macrophages stimulated with IL-4.
Strikingly, we found that exposure of AML cells to IL-4 resulted in strong upregulation of CD47, a 'don't eat me signal', which protects cells from macrophage-mediated phagocytosis. By CRISPR/Cas9-mediated disruption of Stat6 in IL-4 treated AML cells, we found that the CD47 upregulation was Stat6 dependent, recognizing a previously unknown link between IL-4 signalling and CD47 upregulation. Consistent with this finding, combined antibody blockade of CD47 on leukemia cells and IL-4 stimulation of macrophages resulted in enhanced phagocytosis of AML cells.
Taken together, this study shows that IL-4 has anti-leukemic activity by activating macrophages, findings that might translate into new immunotherapeutic opportunities in AML and possibly other malignancies.

Disclosures
No relevant conflicts of interest to declare.