The purpose of this study was to characterize mitoxantrone-induced cytotoxicity in KG1a and TF-1, two P-glycoprotein expressing AML cell lines which display early differentiation phenotypes, compared to more mature HL-60 and U937 cells. KG1a and TF-1 cells were found to be 30-40-fold more resistant to mitoxantrone than HL-60 and U937 cells. Uptake and efflux of mitoxantrone were similar for all cell lines. Moreover, a potent P-glycoprotein blocker (PSC833) had no impact on either accumulation or efflux. No differences were found in the appearance and removal of mitoxantrone-induced DNA-protein complexes. These results suggest that resistance of KG1a and TF-1 cells is not related to a decreased interaction between mitoxantrone and topoisomerase II. Further studies showed that the mechanisms of cell death were different for sensitive and resistant cell lines. Thus, mitoxantrone induced rapid apoptotic cell death in sensitive cells as indicated by characteristic morphological changes and both high molecular weight and internucleosomal DNA fragmentation. In contrast, mitoxantrone induced a G2-M block in resistant cells followed by a progressive loss of viability with necrotic features. Neither oligonucleosomal nor large DNA fragments were detected in these cells during a post-treatment period of up to 96 h. Finally, drug-induced activation of the AP-1 transcription factor was higher in resistant cell lines than in sensitive ones whereas activation of NF-kappaB was comparable. Therefore, our study provides evidence that certain AML cells display natural resistance to mitoxantrone which is independent of drug transport and drug-target interactions but appears to be associated with the inability of the drug to induce apoptosis in these cells.