HOX genes have emerged as critical effectors of leukemogenesis, but the mechanisms that regulate their expression in leukemia are not well understood. Recent data suggest that the caudal homeobox transcription factors CDX1, CDX2, and CDX4, developmental regulators of HOX gene expression, may contribute to HOX gene dysregulation in leukemia. We report here that CDX4 is expressed normally in early hematopoietic progenitors and is expressed aberrantly in Ϸ25% of acute myeloid leukemia (AML) patient samples. Cdx4 regulates Hox gene expression in the adult murine hematopoietic system and dysregulates Hox genes that are implicated in leukemogenesis. (2), and several lines of evidence highlight the importance of CDX family members as upstream regulators of HOX gene expression. These include a key role for CDX2 in regulation of HOX gene expression in the epithelium of the gastrointestinal tract (3), and similar homeotic transformations in Cdx1-, Cdx2-, and Cdx4-deficient mice and zebrafish to those observed in Hox-deficient animals (4, 5).CDX family members are also important in hematopoietic development. Loss of function of Cdx4 in zebrafish results in a bloodless phenotype, associated with homeotic transformation, and marked abnormalities in Hox gene expression pattern during development (5, 6). These phenotypes can be rescued, in part, by expression of Hox family members, further supporting a role for Cdx4 as an upstream positive regulator of Hox gene expression. Additional data support the role of CDX4 in hematopoietic development and suggest an epistatic relationship between CDX4 and MLL. For example, overexpression of Cdx4 in ES cells increases hematopoietic colony formation from embryoid bodies, upregulates a Hox gene expression program, and rescues Mll-deficient hematopoiesis in vitro (5,7,8). CDX genes also have been implicated in acute myeloid leukemia (AML). For example, an acquired t(12;13) in AML results in overexpression of CDX2 as a consequence of juxtaposition of CDX2 to the ETV6 promoter (9), and overexpression of Cdx2 results in AML in a murine bone marrow (BM) transplantation model (10).Hox genes are expressed in hematopoietic precursors, with preferential expression in self-renewing hematopoietic stem cells (HSC) and are down-regulated during differentiation (11). Their importance in normal blood formation and maintenance has been demonstrated in gene-targeting studies in which abnormalities of multiple hematopoietic lineages have been observed in mice deficient in individual Hox genes (12). Moreover, overexpression of specific Hox genes, such as HOXB4 or HOXA9, is associated with expansion of the HSC compartment in vitro and in vivo and results in enhanced competitive repopulating activity in murine transplantation experiments (13,14).Substantial evidence also has linked aberrant expression of HOX genes to the pathogenesis of acute leukemia. For example, fusions of the HOXA9 or HOXD13 genes with NUP98, a gene that encodes a component of the nuclear pore complex, have been described in AML, and expr...