Phenotypic and Prognostic Correlates of Spliceosome Mutations (SRSF2, SF3B1, U2AF35) in Chronic Myelomonocytic Leukemia with ≥ 1% Ring Sideroblasts.

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 2803-2803
Author(s):  
Mrinal M. Patnaik ◽  
Terra L Lasho ◽  
Curtis A Hanson ◽  
Janice M Hodnefield ◽  
Ryan A Knudson ◽  
...  
Keyword(s):  
Conflicts Of Interest ◽  
Myeloproliferative Neoplasms ◽  
Univariate Analysis ◽  
Significant Risk ◽  
Chronic Myelomonocytic Leukemia ◽  
Prognostic Impact ◽  
Hematopoietic Stem ◽  
Mutational Hotspots ◽  
Ring Sideroblasts ◽  
Myelomonocytic Leukemia

Abstract Abstract 2803 Background: Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features between myelodysplastic syndromes (MDS) and myeloproliferative neoplasms. Ring sideroblasts (RS) represent abnormal mitochondrial iron accumulation in MDS; with ≥15% RS necessary for the conventional diagnosis of MDS-RS. Somatic spliceosome mutations are recurrent in MDS, with SF3B1 mutations being the most frequent in MDS-RS (∼75%) and SRSF2 in CMML (∼28%). The distribution of these mutations in the presence of both RS and monocytosis is unknown and their prognostic relevance, in the particular setting, undetermined. Methods: Using the Mayo Clinic database for myeloid malignancies (1997–2007), we identified patients who met the 2008 WHO criteria for CMML, and who also displayed at least 1% RS in their bone marrow (BM). All patients underwent BM examination and cytogenetic evaluation at diagnosis and the pathology slides, including iron stains, were centrally re-reviewed to accurately quantify BM RS. DNA was interrogated in the three most frequent spliceosome genes with somatic mutations; SF3B1, SRSF2 and U2AF35. Results: Sixty four patients met the above stipulated criteria for CMML with ≥1% RS; 46 (72%) were males and median age was 71 years (range, 17–90 years). Fifty three (83%) had CMML-1 and the remainder CMML-2. The percentage of patients with ≥15% RS was 41%: 30% had 15–49% RS and 11% had >50% RS. Thirty patients (47%) displayed SRSF2 mutations (mutational frequencies were 58% in the presence of <15% RS, 42% with 15–49% RS and 0% with >50% RS), 9 (14%) SF3B1 mutations (3% with <15% RS, 26% with 15–49% RS and 43% with >50% RS), and 5 (8%) U2AF35 mutations (8% with <15% RS, 11% with 15–49% RS and 0% with >50% RS). Mutational hotspots were P95 for SRSF2 (93%), K700 for SF3B1 (67%) and Q157 for U2AF35 (60%). The three spliceosome mutations were mutually exclusive. At a median follow-up of 26 months, 49 (77%) deaths and 11 (17%) leukemic transformations were documented. In univariate analysis, significant risk factors for survival included increased levels of white blood cell (WBC), absolute neutrophil (ANC), absolute monocyte (AMC), absolute lymphocyte (ALC) counts, the Spanish cytogenetics risk stratification system (Haematologica 2011;96:375), and the presence of circulating blasts. Neither the presence of spliceosome mutations (SF3B1/SRSF2/U2AF35) nor the percentage of RS (considered both as a continuous and a categorical variable), had an impact on either overall or leukemia-free survival. Conclusions: Among spliceosome mutations in CMML, those involving SRSF2 are by far the most frequent, even in the presence of ring sideroblasts. However, in patients with >50% RS, only SF3B1 mutations were seen whereas in those with 15–49% RS, SRSF2 mutations were more common. These observations suggest that SF3B1 mutations play a dominant but not exclusive role in the pathogenesis of RS. Regardless, the current study did not suggest prognostic impact from either the presence of the spliceosome mutations studied or the percentage of RS. Disclosures: No relevant conflicts of interest to declare.

Concomitant Analysis of EZH2 and ASXL1 Mutations In Myelofibrosis, Chronic Myelomonocytic Leukemia and Blast-Phase Myeloproliferative Neoplasms

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 3070-3070 ◽  
Author(s):  
Omar Abdel-Wahab ◽  
Animesh Pardanani ◽  
Jay Patel ◽  
Terra Lasho ◽  
Adriana Heguy ◽  
...  
Keyword(s):  
Mutation Analysis ◽  
Conflicts Of Interest ◽  
Myeloproliferative Neoplasms ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Normal Karyotype ◽  
Chronic Myelomonocytic Leukemia ◽  
Blast Phase ◽  
Idh Mutations ◽  
Myelomonocytic Leukemia

Abstract Abstract 3070 Background: EZH2 and ASXL1 mutations were recently described in a spectrum of myeloid malignancies; mutational analysis of small patient cohorts has suggested the highest mutational frequency in myelofibrosis (MF) and chronic myelomonocytic leukemia (CMML). The current study seeks to determine i) EZH2 and ASXL1 mutational frequencies in WHO-defined subcategories of MF, CMML and blast-phase myeloproliferative neoplasm (MPN), ii) if these mutations are mutually exclusive of TET2, IDH, JAK2 and MPL mutations and iii) clinical correlates of ASXL1 and EZH2 mutations in primary MF (PMF) and CMML. Methods: The study population included 94 patients: 46 PMF, 22 post-polycythemia vera/essential thrombocythemia MF (post-PV/ET MF), 11 blast-phase MPN and 15 CMML (10 CMML-1 and 5 CMML-2). High throughput DNA resequencing was used to screen archived bone marrow for EZH2, ASXL1, TET2, IDH, JAK2 and MPL mutations. Results: ASXL1 mutations were identified in all disease categories, including PMF (13%), post-PV/ET MF (23%), blast phase MPN (18%), and CMML (20%). We identified somatic mutations in TET2 in 15%, 14%, 18%, and 13% of PMF, post-PV/ET MF, blast phase MPN, and CMML, respectively. By contrast, mutations in EZH2 and IDH1/2 were less frequent. EZH2 mutations were seen in 3 out of 46 PMF patients (7%) and were not observed in patients with post-PV/ET MF or blast phase MPN. Mutations in IDH1/2 were restricted to blast-phase MPN (36%) and PMF (7%). No mutations in EZH2 or IDH1/2 were seen in CMML. Although we identified frequent TET2 and ASXL1 mutations, we only identified one patient with concurrent mutations in both genes. Three ASXL1 mutation-positive patients also had mutations in EZH2 or IDH and one patient had concurrent ASXL1, TET2 and IDH mutations. In addition, 7 ASXL1, 7 TET2, and 1 IDH mutated patients were JAK2V617F-positive. MPL mutations were also documented in all three mutation categories. All EZH2- and ASXL1-mutated PMF patients displayed normal karyotype and none underwent leukemic transformation during follow-up. Furthermore, mutated versus unmutated patients, in both instances, were not significantly different in age and sex distribution or clinical characteristics. The 3 EZH2-mutated PMF patients died after 29, 48 and 67 months from the time of mutation analysis. In univariate analysis, the presence of mutant ASXL1 in PMF was associated with worse survival (p=0.06) but the borderline significance was lost during multivariable analysis that included risk stratification according to DIPSS (Passamonti et al. Blood 2010; 115: 1703–1708). The 3 ASXL1 mutated CMML cases were alive after 40, 34 and 12 months from time of mutation analysis and none of them had progressed to acute leukemia; karyotype was normal in two of the patients and showed isolated trisomy 8 in one. Conclusions: ASXL1 mutations are as frequent as TET2 mutations in MF and CMML. In contrast, EZH2 mutations are infrequent and cluster with PMF. ASXL1 and EZH2 mutations are not mutually exclusive events, seem to be associated with normal karyotype and do not appear to be leukemogenic or prognostically detrimental in PMF or CMML. Disclosures: No relevant conflicts of interest to declare.

Prognostic Interaction Between ASXL1 and TET2 Mutations in Chronic Myelomonocytic Leukemia

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 2864-2864
Author(s):  
Mrinal M Patnaik ◽  
Terra L. Lasho ◽  
Pooja Vijayvargiya ◽  
Christy Finke ◽  
Curtis A. Hanson ◽  
...  
Keyword(s):  
Survival Data ◽  
Prognostic Model ◽  
Conflicts Of Interest ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Chronic Myelomonocytic Leukemia ◽  
Signal Pathways ◽  
Prognostic Impact ◽  
Significant Difference ◽  
Myelomonocytic Leukemia

Abstract Background : Gene mutations are common (~90%) in patients with chronic myelomonocytic leukemia (CMML) and involve epigenetic regulators (TET2 ~ 60%, ASXL1 ~40%), spliceosome components (SRSF2 ~40%) and signal pathways (RAS ~30%). Of these, thus far, only ASXL1 mutations have been shown to adversely impact overall survival (OS). In the current study, we used a 27-gene panel assay to identify additional prognostically-relevant mutations in CMML and to also determine if number of mutations carries prognostic relevance. Methods : 175 patients with WHO-defined CMML were included in the study. All patients had bone marrow (BM) biopsies and cytogenetics performed at diagnosis. Targeted capture assays were carried out on BM DNA specimens obtained at diagnosis for the following genes; TET2, DNMT3A, IDH1, IDH2, ASXL1, EZH2, SUZ12, SRSF2, SF3B1, ZRSR2, U2AF1, PTPN11, Tp53, SH2B3, RUNX1, CBL, NRAS, JAK2, CSF3R, FLT3, KIT, CALR, MPL, NPM1, CEBPA, IKZF, and SETBP1. Paired-end indexed libraries were prepared from individual patient DNA using the NEBNext Ultra Library prep protocol on the Agilent Bravo liquid handler. Capture libraries were assembled according to Nimblegen standard library protocol. Base-calling was performed using Illumina's RTA version 1.17.21.3. Genesifter software was utilized to analyze targeted sequence data. Specific variants were deemed as mutations if they were associated with a hematological malignancy (as identified by COSMIC database), or if they were not associated with a dbSNP Results: Among the 175 study patients, 66% were males and median age was 70 years. 146 (83%) patients were subclassified as CMML-1. At a median follow-up of 23 months, 146 (83%) deaths and 25 (14%) leukemic transformations were documented. Median survivals were 24 months for CMML-1 and 16 months for CMML-2 (p=0.38). Mutational frequencies were; TET2 46%, ASXL1 45%, SRSF2 45%, SETBP1 19%, CBL 14%, RUNX1 14%, NRAS 12%, U2AF1 8%, SF3B1 6%, ZRSR2 6%, Tp53 5%, DNMT3A 5%, IDH2 5%, PTPN11 5%, SH2B3 5%, JAK2 4%, NPM1 3%, CSF3R 2%, IDH1 2%, EZH2 1%, SUZ12 1%, KIT 1%, FLT3 1%, CALR 1%. 172 patients (98%) had at least one mutation, 21 (12%) had 2, 24 (14%) had 3, 20 (11%) had 4, 9 (5%) had 5, while one (1%) patient had 6 concurrent mutations. Risk stratification was based on Mayo prognostic model: 25% high, 32% intermediate and 43 % low risk. In univariate analysis, presence of ASXL1 mutations (p=0.01), absence of TET2 mutations (p=0.005) and presence of DNMT3A mutations (p=0.02) were associated with inferior survival; in multivariable analysis, ASXL1 (p=0.01) and TET2 (p=0.03) mutations remained significant. In order to determine prognostic interaction between these two mutations, patients were stratified into four mutational categories: ASXL1wt/TET2wt (n =56), ASXL1mut/TET2wt (n =31), ASXL1mut/TET2mut (n =50) and ASXL1wt/TET2mut (n =38). Survival data in these four groups showed significant difference in favor of ASXL1wt/TET2mut (median survival 38 months; p=0.016), compared to those with ASXL1wt/TET2wt (19 months), ASXL1mut/TET2wt (31 months)and ASXL1mut/TET2mut (16 months); there was no significant difference in survival among the latter three groups (p=0.3) (Figure). The number of mutations per patient did not affect outcome (p=0.3). In multivariable analysis, presence of ASXL1 mutations (P=0.01) and absence of TET2 mutations (p=0.003) remained significant when risk factors used in the Mayo prognostic model (HB <10 gm/dl, AMC >10 x 10(9)/L, platelets <100 x 10(9)/L, circulating IMC) were added to the model; the same was true for ASXL1wt/TET2mut (p=0.036). In a separate multivariable analysis that included the Mayo prognostic model as a single variable along with presence of ASXL1 and absence of TET2 mutations; or absence of ASXL1wt/TET2mut mutational status, the respective hazard ratios were 1.4 (95% CI 1.07-2.1; p=0.012), 1.5 (95% CI 1.07-2.1; p=0.03) and 1.8 (95% CI 1.2-2.7; p=0.001). Leukemia-free survival was worse in ZRSR2 -mutated cases (p=0.03). Conclusions: Almost 100% of patients with CMML express one or more myeloid neoplasm-relevant mutations. The current study suggests a favorable prognostic impact from TET2 mutations, unless accompanied by ASXL1 mutations. Disclosures No relevant conflicts of interest to declare.

DNTM3A Mutations and Prognosis in Chronic Myelomonocytic Leukemia

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 1988-1988
Author(s):  
Mrinal M Patnaik ◽  
Terra L. Lasho ◽  
Christy Finke ◽  
Matthew T Howard ◽  
Curtis A. Hanson ◽  
...  
Keyword(s):  
Conflicts Of Interest ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Gene Mutations ◽  
Chronic Myelomonocytic Leukemia ◽  
World Health ◽  
Prognostic Impact ◽  
Wild Type ◽  
The Impact ◽  
Myelomonocytic Leukemia

Abstract Background : DNMT3A mutations result in epigenetic dysregulation and impart a negative prognostic impact in acute myeloid leukemia and myelodysplastic syndromes. In chronic myelomonocytic leukemia (CMML), DNMT3A mutations are seen in 2-5% of patients. In a large Groupe Français des Myélodysplasies (GFM) study (n=312), DNMT3A mutations were seen in 2% and were not included in further survival analyses (Itzykson JCO 2013). In a prior Mayo Clinic study (n=175), DNMT3A mutations were seen in 5% (n=9) and on univariate, but not multivariate analysis (Patnaik Blood C J 2016), were associated with shortened over-all survival (OS). We carried out this study on a larger CMML cohort (n=261), with more (n=15) informative cases to assess the impact of DNMT3A mutations. Methods : 261 patients with World Health Organization (WHO)-defined CMML were included in the study. All patients had bone marrow (BM) biopsies and cytogenetics performed at diagnosis. Targeted capture assays were carried out on BM DNA specimens obtained at diagnosis for the following genes; TET2, DNMT3A, IDH1, IDH2, ASXL1, EZH2, SUZ12, SRSF2, SF3B1, ZRSR2, U2AF1, PTPN11, Tp53, SH2B3, RUNX1, CBL, NRAS, KRAS, JAK2, CSF3R, FLT3, KIT, CALR, MPL, NPM1, CEBPA, IKZF, and SETBP1. The 2016 WHO diagnostic criteria were used. Results: Among the 261 study patients, 65% were males and median age was 70 years (range, 28-91). 154 (59%), 64 (25%) and 43 (16%) patients were classified as CMML-0, 1 and 2, respectively. At a median follow-up of 23 months, 174 (67%) deaths and 37 (14%) leukemic transformations (LT) were documented. Mutational frequencies ≥4% were encountered in; TET2 45%, ASXL1 45%, SRSF2 40%, NRAS 14%, SETBP1 13%, CBL 10%, JAK2 7%, RUNX1 6%, DNMT3A 6%, U2AF1 6%, SF3B1 5%, ZRSR2 4%, Tp53 4%, and IDH2 4%. i) DNTM3A mutated CMML: phenotypic and molecular correlates DNMT3A mutations were seen in 15 (6%) patients; 64% male with a median age of 64 years. DNMT3A amino acid substitutions included; R882H 50%, R882C 29%, R910P 7%, R598* 7% and R320* 7%. The median variant allele frequency burden was 45%. Concurrent gene mutations were detected in; TET2 43%, ASXL1 21%, SF3B1 21%, U2AF1 14%, RUNX1 14%, SETBP1 14%, NRAS 14%, SRSF2 7%, JAK2 7% and Tp53 7%. There was no difference between DNMT3A mutated and wild-type patients in terms of age and gender distribution, hemoglobin level, leukocyte, monocyte (AMC), and platelet counts, peripheral blood (PB) or BM blast content. Concurrent gene mutations were equally distributed with the exception for a higher prevalence of SF3B1 (p=0.003) and a lower prevalence of SRSF2 (p=0.004) mutations in DNMT3A mutated CMML. Four (29%) patients underwent leukemic transformation. ii) Impact on OS and leukemia-free survival (LFS): Median survival for the entire cohort (n=261) was 24 months. In univariate analysis, survival was shorter in DNMT3A mutated (median 8 months) versus wild-type (median 27 months) patients (p=0.0007; HR 2.9, 95% CI 1.5-5.7; Figure 1A). Other variables of significance, in univariate analysis, included lower hemoglobin (p=0.002), higher leukocyte count (p=0.0009), higher AMC (p=0.0012), PB blast % (p=0.001), circulating immature myeloid cells (IMC, p=0.01), BM blast % (p=0.045), abnormal karyotype (p=0.02), and ASXL1 (p=0.01) mutations. Survival was also adversely affected by the presence of either (n=133) or both (n=3) ASXL1/DNMT3A mutations (0=0.007, Figure 1B). In multivariable analysis (MVA) excluding ASXL1 and DNMT3A mutations, hemoglobin (p=0.03), IMC (p=0.013) and AMC (p=0.02) retained significance. When ASXL1 mutations were added to the MVA, ASXL1 (p=0.01) mutations, AMC (p=0.012) and IMC (p=0.03) retained significance. Similarly, when only DNMT3A mutations were added to the MVA, DNMT3A (p=0.003) mutations, IMC (p=0.01) and AMC (p=0.02) retained significance. When both DNMT3A and ASXL1 mutations were added to the MVA, only DNMT3A (p<0.0001) and ASXL1 (p=0.004) mutations remained significant. DNMT3A mutations predicted shortened OS, independent of the ASXL1 inclusive GFM model (p<0.0001) and Mayo Molecular Model (p=0.002). DNMT3A mutations (p=0.0018), along with low hemoglobin levels (p=0.003) independently predicted for a shorter LFS. Conclusions: DNMT3A mutations are seen in ~5% of patients with CMML and impart a negative prognostic impact on both OS and LFS. This finding warrants inclusion of DNMT3A mutations in molecularly integrated CMML prognostic models. Disclosures No relevant conflicts of interest to declare.

Myelodysplastic/Myeloproliferative Neoplasms

Hematology ◽  
2011 ◽  
Vol 2011 (1) ◽  
pp. 264-272 ◽  
Author(s):  
Mario Cazzola ◽  
Luca Malcovati ◽  
Rosangela Invernizzi
Keyword(s):  
Clinical Laboratory ◽  
Myeloproliferative Neoplasms ◽  
Chronic Myelomonocytic Leukemia ◽  
World Health ◽  
Refractory Anemia ◽  
Molecular Diagnostic ◽  
Juvenile Myelomonocytic Leukemia ◽  
Lymphoid Tissues ◽  
Ring Sideroblasts ◽  
Myelomonocytic Leukemia

Abstract According to the World Health Organization (WHO) classification of tumors of hematopoietic and lymphoid tissues, myelodysplastic/myeloproliferative neoplasms are clonal myeloid neoplasms that have some clinical, laboratory, or morphologic findings that support a diagnosis of myelodysplastic syndrome, and other findings that are more consistent with myeloproliferative neoplasms. These disorders include chronic myelomonocytic leukemia, atypical chronic myeloid leukemia (BCR-ABL1 negative), juvenile myelomonocytic leukemia, and myelodysplastic/myeloproliferative neoplasms, unclassifiable. The best characterized of these latter unclassifiable conditions is the provisional entity defined as refractory anemia with ring sideroblasts associated with marked thrombocytosis. This article focuses on myelodysplastic/myeloproliferative neoplasms of adulthood, with particular emphasis on chronic myelomonocytic leukemia and refractory anemia with ring sideroblasts associated with marked thrombocytosis. Recent studies have partly clarified the molecular basis of these disorders, laying the groundwork for the development of molecular diagnostic and prognostic tools. It is hoped that these advances will soon translate into improved therapeutic approaches.

Clinical Phenotype of Myeloproliferative Neoplasms with Activating CBL-mutations Resembles Chronic Myelomonocytic Leukemia.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 3895-3895
Author(s):  
Juliana Popa ◽  
Susanne Schnittger ◽  
Philipp Erben ◽  
Tamara Weiss ◽  
Ayalew Tefferi ◽  
...  
Keyword(s):  
Myeloid Leukemia ◽  
Conflicts Of Interest ◽  
Clinical Phenotype ◽  
Myeloproliferative Neoplasms ◽  
Direct Sequencing ◽  
Jak2 V617f ◽  
Chronic Myelomonocytic Leukemia ◽  
A Genome ◽  
Length Mutations ◽  
Myelomonocytic Leukemia

Abstract Abstract 3895 Poster Board III-831 A genome-wide single nucleotide polymorphism (SNP) screen led to the identification of 11q aUPD in patients diagnosed with various subtypes of myeloproliferative neoplasms (MPN), e.g. chronic myelomonocytic leukemia (CMML), atypical chronic myeloid leukemia (aCML) and myelofibrosis (MF) (Grand et al., Blood 2009;113:6182). Further molecular analyses revealed acquired activating point and length mutations in CBL exons 8 and 9 in 10% of CMML, 8% of aCML and 6% of MF cases. Most variants were missense substitutions in the RING or linker domains that abrogated CBL ubiquitin ligase activity and conferred a proliferative advantage to 32D cells overexpressing FLT3. In this study, 160 patients with BCR-ABL and JAK2 V617F negative MPNs were screened for CBL mutations by PCR and direct sequencing. Eighteen known (Y371H, L380P [2x], C381R, C381Y [2x], C384Y, C396Y, H398P, H398Q, W408C, P417H, F418L, R420Q [5x]) and four new (F378L, G397V, I423N, V430M) missense mutations affecting fourteen residues were identified in 20 patients. Two patients harbored two different mutations. The clinical phenotype could be characterized more precisely in 17 patients. Median age was 68 years (range 59–85) with a slight female predominance (f, n=10; m, n=7). Striking hematological features were leukocytosis (14/17; 82%; median 29,000/μl, range 4,500-141,000) with continuously left-shifted granulopoiesis (blasts, promyelocytes, myelocytes, metamyelocytes) in 85% and elevated monocytes (median 2,500/μl, range 630-10,656) >1,000/μL in 88% (15/17) of patients. Eosinophilia (>1,500/μL) was rare (3/17, 18%). Anemia (normal values: f, Hb <12g/dL; m, Hb <14g/dL) was present in all 17 patients (f, median 10g/dL, range 8.7-11.8; m, median 11.2g/dL, range 8.6-12.9). Platelets did not exceed 300,000/μL in any patient while 11/17 (65%) patients presented with thrombocytopenia (median 125,000/μL, range 18,000-271,000). Splenomegaly was present in 11/17 patients (65%) and LDH was elevated (median 304U/L, range 189-729) in 9/17 patients (52%). Bone marrow histology and immunohistochemistry were available from 12 patients. Relevant features were hypercellularity, marked granulopoiesis and microlobulated megakaryocytes without clusters in 11/12 patients (92%), respectively. Increased fibres were seen in 8/12 (67%) patients of whom one showed severe fibrosis. Clinical follow-up was available from 17 patients. Thirteen patients (76%) have died because of progression to secondary acute myeloid leukemia/blast phase (n=7), cytopenia-related complications (n=2) or for unknown reasons (n=4) after a median of 23 months (range 3-60) following diagnosis. In conclusion, point mutations of CBL exons 8 and 9 are present in approximately 6-12% of BCR-ABL and JAK2 V617F negative MPNs. They are associated with a distinct clinical and hematological phenotype presenting with myeloproliferative features allowing diagnosis of a proliferative subtype of CMML rather than aCML or MF in the majority of cases. Patients with left-shifted leukocytosis, monocytosis, anemia and lack of thrombocytosis who are negative for BCR-ABL and point or length mutations of JAK2 should be routinely screened for CBL mutations. Disclosures: No relevant conflicts of interest to declare.

ASXL1 and SETBP1 Mutations and Their Prognostic Contribution In Chronic Myelomonocytic Leukemia: An International Study Of 431 Patients

Blood ◽  
2013 ◽  
Vol 122 (21) ◽  
pp. 1510-1510
Author(s):  
Mrinal M Patnaik ◽  
Raphael Itzykson ◽  
Terra L Lasho ◽  
Olivier Kosmider ◽  
Christy Finke ◽  
...  
Keyword(s):  
Platelet Count ◽  
Risk Stratification ◽  
Prognostic Model ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
International Study ◽  
Chronic Myelomonocytic Leukemia ◽  
Prognostic Impact ◽  
Missense Mutations ◽  
Myelomonocytic Leukemia

Abstract Background Chronic myelomonocytic leukemia (CMML) is a clonal stem cell disorder with overlapping features between myelodysplastic syndromes and myeloproliferative neoplasms. Numerous models exist for CMML prognostication, with more recent studies suggesting (JCO 201; 31:2428) or refuting (Leukemia 2013; 27:1504) the prognostic contribution of ASXL1 mutations. Furthermore, SETBP1 mutations were recently shown to be associated with shortened overall survival (OS) in CMML (Leukemia 2013; 10:1038). In the current international study, we examine these issues in a larger cohort of 431 patients. Methods 431 patients with WHO-defined CMML were included in the study. 235 (55%) were seen at the Mayo Clinic from 1997 through 2012. The remainders were from the French CMML registry (JCO 201; 31:2428). All patients underwent bone marrow (BM) examination and cytogenetic evaluation at diagnosis. DNA analysis for spliceosome component mutations (SRSF2, SF3B1 and U2AF1), ASXL1 and SETBP1 mutations were carried out on BM specimens obtained at diagnosis. In order to address the aforementioned discrepancy regarding the prognostic impact of ASXL1 mutations, relevant analyses in the Mayo cohort were first performed with and without inclusion of missense ASXL1 mutations. ASXL1 mutations from the French cohort did not include missense mutations. We evaluated the prognostic relevance of ASXL1 and SETBPI mutations, as well as several other clinical and laboratory parameters including those previously identified by the MDAPS (Blood 2002;99:840) the Spanish cytogenetic risk stratification (Haematologica 2011;96:375), and the Mayo prognostic model (Leukemia 2013;27;1504). Results Among the 431 study patients, 286 (66%) were males and median age was 73 years (range, 17-93 years). There were 368 (85%) patients with CMML-1 and the remainder had CMML-2. At a median follow-up of 23 months, 260 (60%) deaths and 70 (16%) leukemic transformations were documented. Median survivals were 38 months for CMML-1 and 24 months for CMML-2 (p=0.11). Mutational frequencies were 44% (173/390) for SRSF2, 6% (23/379) for SF3B1, 7% (27/387) for U2AF1, 38% (164/411) for ASXL1 (excluding missense mutations), and 5% (21/431) for SETBP1. Risk stratification was, based on i) Mayo prognostic model: 172 (40%) high, 151 (35%) intermediate and 94 (25 %) low risk, ii) MDAPS: 15 (3%) high, 73 (17%) intermediate-2, 125 (29%) intermediate-1 and 218 (50%) low risk and iii) Spanish cytogenetic stratification system: 316 (73%) low, 43 (10%) intermediate and 50 (12%) high risk. In the Mayo cohort, univariate analysis revealed that the exclusion of missense mutations changed the prognostic impact of ASXL1 mutations from non-significant (p=0.08) to significant (p=0.001). Accordingly, all subsequent analyses excluded missense ASXL1 mutations. In univariate analysis, lower hemoglobin (p<0.0001), lower platelet count (p=0.0027), higher absolute monocyte count (AMC) (p<0.0001), higher absolute lymphocyte count (ALC) (p=0.0002), circulating immature myeloid cells (IMC) (P<0.0001), cytogenetic risk stratification (p<0.0001) and ASXL1 mutations (p<0.0001) were significant for OS. In multivariable analysis, lower hemoglobin (p=0.0001; RR 2, 99% CI 1.6-2.6), lower platelet count (p=0.002; RR 1.5, 99% CI 1.2-1.9), higher AMC (p=0.0002; RR 2.2, 99% CI 1.6-3.1) and ASXL1mutations (p=0.0009; RR 1.9, 99% CI 1.5-2.4) retained their independent negative prognostic impact. Similarly, in univariate analysis, leukemia-free survival (LFS) was negatively affected by age (p=0.0015), lower hemoglobin (p=0.0002), lower platelet count (p=0.0002), higher AMC (p<0.0001), higher ALC (p=0.0001), circulating IMC (p<0.0001), BM blasts (p<0.0001), and cytogenetic risk stratification (p=.0002). ASXL1 (p=0.17) and SETBP1(p=0.87) mutations were not found to be significant. In multivariable analysis, lower platelet count (p=0.0005), higher AMC (P=0.0042), circulating IMC (P=0.008) and cytogenetic risk stratification (p=0.009) retained their independent negative prognostic impact. Conclusions In the current international study of a large cohort of patients with CMML, we confirm and clarify the independent prognostic relevance of ASXL1 mutations. The relatively high frequency of ASXL1 mutations in CMML warrants its inclusion in contemporary prognostic models. Disclosures: No relevant conflicts of interest to declare.

"Proliferative" Versus "Dysplastic" Chronic Myelomonocytic Leukemia: Molecular and Prognostic Correlates

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 1987-1987
Author(s):  
Mrinal M Patnaik ◽  
Terra L. Lasho ◽  
Christy Finke ◽  
Matthew T Howard ◽  
Curtis A. Hanson ◽  
...  
Keyword(s):  
Leukocyte Count ◽  
Univariate Analysis ◽  
Hemoglobin Level ◽  
Chronic Myelomonocytic Leukemia ◽  
World Health ◽  
Prognostic Impact ◽  
Apparent Difference ◽  
Myelomonocytic Leukemia ◽  
Proliferative Cmml

Abstract Background : The 2016 revision to the World Health Organization (WHO) classification of myeloid neoplasms has recommended distinction between "proliferative" (WBC ≥ 13 x 10(9)/L) and "dysplastic" (WBC < 13 X 10(9)/L) subtypes of chronic myelomonocytic leukemia (CMML). In the current study of 261 molecularly-annotated cases, we sought to clarify the prognostic relevance of distinguishing proliferative from dysplastic CMML and also describe differences in the distribution of disease-associated mutations. Methods : 261 patients with WHO-defined CMML were included in the study. All patients had bone marrow (BM) biopsies and cytogenetics performed at diagnosis. Targeted capture assays were carried out on BM DNA specimens obtained at diagnosis for the following genes; TET2, DNMT3A, IDH1, IDH2, ASXL1, EZH2, SUZ12, SRSF2, SF3B1, ZRSR2, U2AF1, PTPN11, Tp53, SH2B3, RUNX1, CBL, NRAS, KRAS, JAK2, CSF3R, FLT3, KIT, CALR, MPL, NPM1, CEBPA, IKZF, and SETBP. The 2016 WHO criteria were used to sub-classify CMML into proliferative and dysplastic subtypes. Results :Among the 261 study patients, 65% were males and median age was 70 years. 154 (59%), 64 (25%) and 43 (16%) patients were classified as CMML-0, 1 and 2, respectively. At a median follow-up of 23 months, 174 (67%) deaths and 37 (14%) leukemic transformations were documented. Mutational frequencies were; TET2 45%, ASXL1 45%, SRSF2 40%, NRAS 14%, SETBP1 13%, CBL 10%, JAK2 7%, RUNX1 6%, U2AF1 6%, DNMT3A 6%, SF3B1 5%, ZRSR2 4%, Tp53 4%, IDH2 4%, KRAS 3%, PTPN11 2%, SH2B3 1%, CSF3R 1%, IDH1 1%, EZH2 1%, SUZ12 1%, KIT 1%, FLT3 1%, and CALR 1%. Risk stratification was based on the Mayo Molecular Model: 31% high, 30% intermediate-1, 28% intermediate-2 and 11 % low risk. i) Dysplastic versus proliferative CMML: phenotypic and molecular differences 139 (53%) patients had proliferative and 122 (47%) dysplastic subtypes. There was no difference between the CMML subtypes in terms of age and gender distribution, hemoglobin level, platelet count or BM blast content. Patients with proliferative CMML had higher absolute monocyte counts (AMC) (p<0.0001), circulating immature myeloid cells (IMC, p<0.001), circulating blasts (p<0.001) and serum LDH levels (p=0.01). The following gene mutations were more common in proliferative vs dysplastic CMML: ASXL1 (54% vs 37%, p=0.009), JAK2 (11% vs 3%, p=0.01) and CBL (11% vs 8%, p=0.047); SF3B1 mutations were more common in dysplastic CMML (8% vs 1%, p=0.02). There was no difference in the incidence of TET2, DNMT3A and SRSF2 mutations whereas there was a trend towards a higher prevalence of NRAS (p=0.06) and CSF3R (p=0.06) mutations in proliferative CMML. Cytogenetic abnormalities (p=0.03), including higher risk categories by the Spanish (p=0.03) and the Mayo-French (p=0.01) systems were more common in proliferative CMML. ii) Impact on overall and leukemia-free survival: Median survival for the entire cohort (n=261) was 24 months. In univariate analysis, survival was shorter in patients with proliferative (median 20 months) versus dysplastic (median 29 months) CMML (p=0.008; HR1.5, 95% CI 1.1-2.1; Figure 1A). Other variables of significance, in univariate analysis, included hemoglobin (p=0.001), leukocyte count (p=0.001), AMC (p=0.003), PB blast % (p=0.003), IMC (p=0.01), BM blast % (p=0.045), abnormal karyotype (p=0.02), ASXL1 (p=0.01) and DNMT3A (p=0.0003) mutations. In multivariable analysis, the difference in survival between proliferative and dysplastic subtypes remained significant with the addition of hemoglobin level (p=0.01), PB blast % (p=0.02), IMC (p=0.04), BM blast % (p=0.01) or DNMT3A mutations (p=0.01). This was, however, not the case with addition of leukocyte count (p=0.32), AMC (p=0.18) or ASXL1 mutational status (p=0.14); whereas the adverse impact on survival from the latter three parameters remained significant. The prognostic impact of ASXL1 mutations was most apparent in dysplastic CMML (Figure 1B). There was no difference in leukemic transformation rates (p=0.4). Conclusions: In the context of current prognostic models, sub-classification of CMML into proliferative and dysplastic subtypes might not provide additional prognostic value. The apparent difference in survival between the two subtypes of CMML is probably accounted for by the higher prevalence of leukocytosis/monocytosis and of ASXL1 mutations in proliferative CMML. Disclosures No relevant conflicts of interest to declare.

Prevalence and Prognostic Impact of Allelic Imbalances Associated with Leukemic Transformation of Philadelphia Chromosome-Negative Myeloproliferative Neoplasms.

Blood ◽  
2009 ◽  
Vol 114 (22) ◽  
pp. 1280-1280
Author(s):  
Nils Heinrich Thoennissen ◽  
Utz O. Krug ◽  
Dhong Hyun Lee ◽  
Norohiko Kawamata ◽  
Terra L Lasho ◽  
...  
Keyword(s):  
Conflicts Of Interest ◽  
Myeloproliferative Neoplasms ◽  
Philadelphia Chromosome ◽  
Snp Array ◽  
Chronic Phase ◽  
Prognostic Impact ◽  
Genomic Alterations ◽  
Leukemic Transformation ◽  
Blast Phase ◽  
Hematopoietic Stem

Abstract Abstract 1280 Poster Board I-302 Philadelphia-chromosome negative myeloproliferative neoplasms (MPNs) including polycythemia vera (PV), essential thrombocytosis (ET), and primary myelofibrosis (PMF) are defined as clonal hematopoietic stem cell disorders. These disorders show an inherent tendency for transformation into leukemia (MPN-blast phase) which is hypothesized to be accompanied by acquisition of additional genomic lesions. We, therefore, obtained a comprehensive profile of genomic alterations associated with leukemic transformation by using single-nucleotide polymorphism (SNP) array in 88 MPN patients, as well as 71 cases with MPN-blast phase, and correlated these findings with their clinical parameters. A relatively high number of genomic alterations was found in MPN after leukemic transformation with 4.6 ± 0.6 abnormalities per sample compared to only 1.4 ± 0.2 changes per patient in chronic phase (p<0.001). Compared to the cytogenetic data, SNP-chip analysis detected about 47% additional chromosomal changes in the MPN samples, and 31% more in the MPN-blast phase cases, whereas SNP-array allelokaryotyping practically captured all cytogenetic abnormalities in our study population. Several additionally altered regions were detected in patients with MPN-blast phase compared to chronic phase, including both deletion and copy-number neutral-loss of heterozygosity (CNN-LOH) on chromosome 12p (9%) and 21q (9%), involving ETV6 and RUNX1. Notably, deletion and CNN-LOH on 17p involving TP53 were diagnosed in 18% of MPN-blast phase samples, which was highly associated with preceding treatment with alkylating agents (p=0.016). Moreover, trisomy 8, as well as amplification of 8q24.21 involving the MYC gene, were detected in 13% of patients with MPN-blast phase who were almost exclusively negative for the JAK2V617F mutation. Genome-wide inspection of further critical regions with promising new candidate genes involved in the evolution to the MPN-leukemic phase included deletion and CNN-LOH on 7q22.1 (SH2B2) in 18%, duplication/amplification on 19p13.2 (PIN1, ICAM1, CDC37) in 13% and 21q22.2 (ERG) in 9% of MPN patients with blast crisis. In contrast, we detected a decreased frequency of JAK2V617F in MPN-blast phase samples (52%) compared to chronic phase (71%). Also, the percentage of patients with homozygous mutant JAK2 as a result of CNN-LOH was lower in the MPN-blast phase (43%) compared to the chronic phase (53%). Taken together, the data suggest that gain-of-function mutation of JAK2 is not a perquisite for leukemic transformation. Remarkably, CNN-LOH on either 7q or 9p was related to decreased survival after leukemic transformation (p=0.02 and p=0.012, respectively). Given the variety of allelic imbalances, our data suggest that MPN-blast phase appears to be a heterogeneous disease prone to have evolved multiple mechanisms to provide a proliferative advantage to the abnormal leukemic clone. Our analysis of MPN genomes in the chronic compared to the leukemic stage provided new prognostic insights, as well as novel causative genes which might be involved in the transformation to MPN-blast phase. Disclosures No relevant conflicts of interest to declare.

scholarly journals Tumor microenvironment and clonal monocytes from chronic myelomonocytic leukemia induce a procoagulant climate

2019 ◽  
Vol 3 (12) ◽  
pp. 1868-1880
Author(s):  
Johanna Zannoni ◽  
Natacha Mauz ◽  
Landry Seyve ◽  
Mathieu Meunier ◽  
Karin Pernet-Gallay ◽  
...  
Keyword(s):  
Tumor Microenvironment ◽  
Myeloproliferative Neoplasms ◽  
Tumor Development ◽  
Chronic Myelomonocytic Leukemia ◽  
Procoagulant Activity ◽  
Hematopoietic Stem ◽  
Thrombin Generation Assay ◽  
Healthy Donors ◽  
Myelomonocytic Leukemia

Abstract Chronic myelomonocytic leukemia (CMML) is a myeloid hematological malignancy with overlapping features of myelodysplastic syndromes (MDSs) and myeloproliferative neoplasms (MPNs). The knowledge of the role of the tumor microenvironment (TME), particularly mesenchymal stromal cells (MSCs), in MDS pathogenesis is increasing. Generally, cancer is associated with a procoagulant state participating in tumor development. Monocytes release procoagulant, tissue factor (TF)–bearing microparticles. We hypothesized that MSCs and clonal monocytes release procoagulant extracellular vesicles (EVs) within the CMML TME, inducing a procoagulant state that could modify hematopoietic stem cell (HSC) homeostasis. We isolated and cultured MSCs and monocytes from CMML patients and MSCs from healthy donors (HDs). Their medium EVs and small EVs (sEVs) were collected after iterative ultracentrifugations and characterized by nanoparticle tracking analysis. Their impact on hemostasis was studied with a thrombin generation assay and fibrinography. CMML or HD HSCs were exposed to sEVs from either CMML or HD MSCs. CMML MSC sEVs increased HD HSC procoagulant activity, suggesting a transfer of TF from the CMML TME to HD HSCs. The presence of TF on sEVs was shown by electron microscopy and western blot. Moreover, CMML monocyte EVs conferred a procoagulant activity to HD MSCs, which was reversed by an anti-TF antibody, suggesting the presence of TF on the EVs. Our findings revealed a procoagulant “climate” within the CMML environment related to TF-bearing sEVs secreted by CMML MSCs and monocytes.

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