We have previously reported that intracellular tumor necrosis factor (enTNF) is responsible for resistance, in established cell lines to doxorubicin (DOX), exogenous TNF, and heat stress by inducing manganous superoxide dismutase (MnSOD), thereby scavenging reactive oxygen free radicals. Leukemic cells from 19 patients (6 acute lymphoblastic leukemia, 13 acute myeloid leukemia) were examined for their sensitivity to DOX and TNF in relation to their enTNF expression and MnSOD activity. Sensitivity to DOX and the expression of enTNF or MnSOD activity were inversely correlated. In a case with acquired resistance to chemotherapy which included DOX, enTNF expression and MnSOD activity were increased. Furthermore, in 14 cases treated with a regimen including an anthracycline, 4 cases that failed to respond to chemotherapy showed relatively high amounts of enTNF expression. KG-1 (human acute myelogenous leukemia) cells transfected with a nonsecretory-type TNF expression vector (pTNF delta pro) showed resistance to DOX. A significant increase in MnSOD levels was also noted in the transfectants. TNF antisense cDNA was transfected into isolated leukemic cells from five patients. Sensitivity of the antisense transfectants to DOX was increased, approximately 1.4- to 2.5-fold. These results suggest that enTNF acts as a resistance factor against DOX in leukemia, and that enTNF may be useful as a predictor of DOX sensitivity in leukemia.