Drug resistance is a fundamental clinical concern in pediatric
acute lymphoblastic leukemia (pALL), and
methotrexate (MTX) is an essential
chemotherapy drug administered for the treatment. In the current study, the effect of
iron in response to
methotrexate and its underlying mechanisms were investigated in pALL cells. CCRF-CEM and Nalm6 cell lines were selected as T and B-ALL subtypes. Cells were pretreated with
ferric ammonium citrate, exposed to the IC50 concentration of MTX and cell viability was assessed using MTT, colony formation, and flow cytometry assays.
Iron-loaded cells were strongly resistant to MTX cytotoxicity. The inhibitory effect of N-acetyl
cysteine to reverse the acquired MTX resistance was greater than that of the
iron chelator,
deferasirox, highlighting the importance of
iron-mediated ROS in MTX resistance. Subsequently, the upregulation of BCL2, SOD2, NRF2, and
MRP1 was confirmed using quantitative RT-PCR. Moreover, a positive correlation was demonstrated between the
MRP1 expression levels and bone marrow
iron storage in pALL patients. Further supporting our findings were the
hematoxylin and
eosin-stained histological sections showing that
iron-treated nude mice xenografts demonstrated significantly more liver damage than those unexposed to
iron. Overall,
iron is introduced as a player with a novel role contributing to
methotrexate resistance in pALL. Our findings suggest that the patients' bone marrow
iron stores are necessary to be assessed during the
chemotherapy, and transfusions should be carefully administrated.