ALKBH1 drives tumorigenesis and drug resistance via tRNA decoding reprogramming and codon-biased translation.

Cancer cells utilize codon-biased translation to fuel tumorigenesis and drug resistance, but underlying mechanisms remain poorly understood. Here, we show ALKBH1 is overexpressed in acute myeloid leukemia (AML) and essential for leukemia stem/initiating cell (LSC/LIC) self-renewal and AML development/maintenance, whereas dispensable for normal hematopoiesis. ALKBH1 enhances mitochondrial assembly/function and oxidative phosphorylation (OXPHOS), crucial for AML survival/proliferation and resistance to venetoclax, a potent BCL2 inhibitor and widely-used first-line targeted therapy for AML in clinic. Mechanistically, ALKBH1 catalyzes 5-formylcytosine (f5C) at tRNA wobble positions, reprograming decoding and facilitating codon-biased translation, a mechanism we term "Epitranslatomic Midas touch", which in turn drives leukemogenesis and drug resistance by promoting synthesis of key oncogenic proteins like WDR43. Targeting ALKBH1, particularly together with venetoclax, exhibited potent anti-leukemia efficacy in preclinical models with favorable safety profiles. Collectively, our findings elucidate ALKBH1's pivotal role in codon-biased translation and tumorigenesis, and propose a novel therapeutic strategy for cancer treatment.