TP53 Mutation and Survival in Chronic Lymphocytic Leukemia

Purpose The precise prognostic impact of TP53 mutation and its incorporation into treatment algorithms in chronic lymphocytic leukemia (CLL) is unclear. We set out to define the impact of TP53 mutations in CLL. Patients and Methods We assessed TP53 mutations by denaturing high-performance liquid chromatography (exons 2 to 11) in a randomized prospective trial (n = 375) with a follow-up of 52.8 months (German CLL Study Group CLL4 trial; fludarabine [F] v F + cyclophosphamide [FC]). Results We found TP53 mutations in 8.5% of patients (28 of 328 patients). None of the patients with TP53 mutation showed a complete response. In patients with TP53 mutation, compared with patients without TP53 mutation, median progression-free survival (PFS; 23.3 v 62.2 months, respectively) and overall survival (OS; 29.2 v 84.6 months, respectively) were significantly decreased (both P < .001). TP53 mutations in the absence of 17p deletions were found in 4.5% of patients. PFS and OS for patients with 17p deletion and patients with TP53 mutation in the absence of 17p deletion were similar. Multivariate analysis identified TP53 mutation as the strongest prognostic marker regarding PFS (hazard ratio [HR] = 3.8; P < .001) and OS (HR = 7.2; P < .001). Other independent predictors of OS were IGHV mutation status (HR = 1.9), 11q deletion (HR = 1.9), 17p deletion (HR = 2.3), and FC treatment arm (HR = 0.6). Conclusion CLL with TP53 mutation carries a poor prognosis regardless of the presence of 17p deletion when treated with F-based chemotherapy. Thus, TP53 mutation analysis should be incorporated into the evaluation of patients with CLL before treatment initiation. Patients with TP53 mutation should be considered for alternative treatment approaches.

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Clinical Impact of Clonal and Subclonal TP53, SF3B1, BIRC3, and ATM Mutations in Chronic Lymphocytic Leukemia

Blood ◽

10.1182/blood.v126.23.4138.4138 ◽

2015 ◽

Vol 126 (23) ◽

pp. 4138-4138

Author(s):

Ferran Nadeu ◽

Julio Delgado ◽

Cristina Royo ◽

Tycho Bauman ◽

Tatjana Stankovic ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Allele Frequency ◽

Lymphocytic Leukemia ◽

Molecular Characteristics ◽

Prognostic Impact ◽

Driver Genes ◽

Germline Variants ◽

Tp53 Mutations ◽

Mutational Status ◽

The Impact

Abstract Genomic studies have provided a complete profile of somatic mutations in chronic lymphocytic leukemia (CLL). These comprehensive approaches have revealed a relatively large number of mutated genes, the adverse prognostic value of some of which has been demonstrated in a number of reports. Recent studies have shown the clinical relevance of TP53 mutations at very low allele frequency. The presence and prognostic impact of minor mutated clones of other CLL driver genes and their clonal dynamics in the evolution of the disease is not well known. The goal of this study was to explore the presence of clonal and subclonal mutations of TP53, SF3B1, BIRC3, and ATM using an ultra-deep next-generation sequencing (NGS) strategy, to define the evolution of these subclones in different time-points of the disease, and to determine their influence in the outcome of the patients. Samples from 363 untreated CLL cases were included in this study. Copy number alterations were investigated by high density SNP-arrays or by quantitative PCR in 341 and 16 cases, respectively. Targeted ultra-deep NGS of TP53 (exons 4-10), ATM (exons 2-63), BIRC3 (exons 2-9), and SF3B1 (exons 14-16 and 18), including splicing sites, was performed using the Access-Array system (Fluidigm) and sequenced in a MiSeq equipment (Illumina). This methodology combined with a robust bioinformatic analysis based on well-known available tools allowed the identification of mutations down to 0.3% of variant allele frequency (VAF). Results obtained were fully verified by orthogonal techniques. Twelve per cent of VAF was used as threshold for the classification of clonal or subclonal mutations since 12% was the cut-off for detection of mutations by Sanger sequencing. Deletions of 11q comprising ATM or BIRC3 were found in 7% of the cases and were associated with mutations of the other ATM allele in 19/26 (73%) cases and BIRC3 in 3/23 (13%). Deletions of 17p were found in 19 (5%) cases and co-existed with TP53 mutations in 15 (79%) of them. Regarding the mutational status of the studied genes, TP53 mutations were present in 11.6% of patients (7.2% clonal, 4.4% subclonal), ATM mutations in 10% (7% clonal, 1% subclonal, 2% germline mutations considered pathogenic), SF3B1 mutations in 12% (7% clonal, 5% subclonal), and BIRC3 mutations in 4% (2% clonal, 2% subclonal). These subclonal mutations had similar molecular characteristics to their respective high-allele frequency mutations supporting a comparable pathogenic effect. In this regard, clonal and subclonal SF3B1 mutations were associated with shorter time to first treatment (TTT) independently of IGHV mutations. Clonal and subclonal TP53 mutations predicted for shorter overall survival (OS) together with the IGHV mutational status, although the impact of isolated TP53 mutations (i.e. without 17p deletion) on OS was not so evident, as has been the case in other studies. In addition, the outcome of patients with clonal and subclonal BIRC3 mutations showed a similar significant shorter OS. Regarding ATM, the effect of isolated subclonal ATM mutations could not be evaluated because of their low number, but ATM mutations as a whole had a significant impact on TTT even in the absence of 11q deletions. This study also reinforces the need to study the germline of the patients to fully characterize the ATM mutations observed in the tumors. Of note, germline variants previously described as pathogenic were associated with 11q deletions, confirming the hypothesis already suggested that these germline variants may influence disease progression through loss of the otherallele. Clonal dynamics was examined in longitudinal samples of 45 CLL patients. We confirmed the expansion of most TP53 mutated clones after therapy. However, both TP53 and SF3B1 mutations expanded also before any therapy in some patients, indicating that progressive dynamics of these clones is not only dependent on therapy selection. On the contrary, small ATM mutated clones seemed to be more stable. Although the number of cases is limited, we observed that clonal evolution in longitudinal samples had an unfavorable impact on OS. In conclusion, this study shows the presence of a high number of subclonal mutations of different driver genes in CLL and provides insights on the impact of these mutations on the outcome of the patients. These findings suggest that the characterization of the subclonal architecture may be relevant for a better management of CLL patients. Disclosures No relevant conflicts of interest to declare.

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Select High-Risk Genetic Features Predict Earlier Progression Following Chemoimmunotherapy With Fludarabine and Rituximab in Chronic Lymphocytic Leukemia: Justification for Risk-Adapted Therapy

Journal of Clinical Oncology ◽

10.1200/jco.2005.03.1021 ◽

2006 ◽

Vol 24 (3) ◽

pp. 437-443 ◽

Cited By ~ 184

Author(s):

John C. Byrd ◽

John G. Gribben ◽

Bercedis L. Peterson ◽

Michael R. Grever ◽

Gerard Lozanski ◽

...

Keyword(s):

Treatment Outcome ◽

Prognostic Factors ◽

High Risk ◽

Chronic Lymphocytic Leukemia ◽

Progression Free Survival ◽

Complete Response ◽

Lymphocytic Leukemia ◽

Interphase Cytogenetics ◽

Mutational Status ◽

The Impact

Purpose Several new prognostic factors predicting rapid disease progression in chronic lymphocytic leukemia (CLL) have been identified, including unmutated Ig VH mutational status, del(11)(q23), del(17)(p13.1), and p53 mutations. To date, the impact of these same prognostic factors have not been examined relative to treatment outcome with chemoimmunotherapy. Methods We examined the impact of these new prognostic factors on predicting treatment outcome in symptomatic, untreated CLL patients who received chemoimmunotherapy with fludarabine and rituximab as part of a completed, randomized phase II study, Cancer and Leukemia Group B (CALGB) 9712. Results Eighty-eight patients treated as part of CALGB 9712 had detailed prognostic factor assessment performed. Using Ig VH mutational status to classify risk, there was no association between complete response rate with either unmutated Ig VH mutational status or high-risk interphase cytogenetics. However, the median progression-free survival (PFS; P = .048) and overall survival (OS; P = .01) were shorter among the Ig VH unmutated patients as compared with the Ig VH mutated patients. Using the hierarchical classification of Döhner, PFS (P = .005) and OS (P = .004) were significantly longer as the classification moved from high risk [del (11)(q22.3) or del (17)(p13.1)] to low risk. Conclusion These data demonstrate that high-risk CLL patients characterized by Ig VH unmutated (≥ 98%) or high-risk interphase cytogenetics, including either del(17p) or del(11q), appear to have a shorter PFS and OS with chemoimmunotherapy. Larger prospective studies will be required to determine the independent influence of Ig VH mutational status and interphase cytogenetics on treatment outcome.

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Clinical Impact Of Small TP53 Mutated Subclones In Chronic Lymphocytic Leukemia

Blood ◽

10.1182/blood.v122.21.116.116 ◽

2013 ◽

Vol 122 (21) ◽

pp. 116-116

Author(s):

Davide Rossi ◽

Hossein Khiabanian ◽

Carmela Ciardullo ◽

Valeria Spina ◽

Alessio Bruscaggin ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Sanger Sequencing ◽

Tp53 Mutation ◽

Lymphocytic Leukemia ◽

Genetic Defects ◽

Prognostic Impact ◽

Newly Diagnosed ◽

Genetic Event ◽

Tp53 Mutations

Abstract Introduction TP53 mutations are strong predictors of poor survival and refractoriness in chronic lymphocytic leukemia (CLL) and have direct implications for disease management. Clinical information on TP53 mutations are currently limited to lesions that are represented in the majority of CLL cells. Next generation sequencing (NGS) allows sensitive detection of mutations harbored by a small fraction of the tumor cell population. Here we aim at assessing the frequency, evolution during disease course, and prognostic impact of small TP53 mutated subclones in newly diagnosed CLL. Methods The study was based on a consecutive series of 309 newly diagnosed and previously untreated CLL (median age: 71 years; Binet A/B/C: 79/12/9%; unmutated IGHV genes: 35%; clonal TP53/NOTCH1/SF3B1/BIRC3 lesions: 11/11/7/5%; median follow-up: 8.1 years). TP53 mutations (exons 4-8) were screened on peripheral blood (PB) samples (tumor representation 70-98%) by amplicon-based deep-NGS (GSJ, 454 Life Sciences) (average depth: 2660). A bioinformatic algorithm was developed to call TP53 variants out of background noise. By dilution experiments, deep-NGS allowed to detect mutant allele fractions of 0.3%. TP53 variants were considered subclonal if missed by Sanger sequencing, which was performed in parallel. Subclonal TP53 variants were confirmed by duplicate deep-NGS and independently validated by allele specific PCR (AS-PCR). TP53 variant allele frequency (VAF) was corrected for tumor representation. Results Deep-NGS identified 50 subclonal TP53 mutations (VAF 0.3%-11%) in 28/309 (9%) CLL (Fig 1A). All subclonal mutations were non-silent, were missed by Sanger sequencing, and were validated by AS-PCR. The molecular spectrum of subclonal TP53 mutations (i.e. missense/truncating ratio, transition/transversion ratio, distribution across hot spot codons; p>.05; Fig. 1B-D), as well as the residual transactivational activity of mutants toward the p21 promoter (p=.872) were highly consistent with that of fully clonal TP53 mutations reported in CLL (Zenz T, Leukemia 2010). Subclonal TP53 mutations were the sole TP53 genetic event in 15/309 (4.8%) CLL, while in 13/309 (4.2%) cases subclonal TP53 mutations co-existed in the same leukemic population along with a clonal TP53 mutation or with 17p deletion. In cases (n=12) harboring more than one TP53 mutation, the variants mapped on distinct sequencing reads from the same amplicon suggesting that they belonged to different CLL subclones. By combining subclonal TP53 mutations, clonal TP53 mutations and 17p deletion, 50/309 (16%) CLL harbored at least one TP53 defect at diagnosis. Subclonal TP53 mutations were significantly enriched among cases presenting with advanced stage (Binet C: 26%; p=.005) and clonal TP53 abnormalities (37%; p<001). Cases harboring solely subclonal TP53 mutation showed a median overall survival (3.4 years) significantly shorter than TP53 wild type cases (10.8 years; p=.028), and similar to that of cases with clonal TP53 genetic defects (3.1 years; p=.375) (Fig. 1E). By multivariate analysis, cases harboring subclonal TP53 mutations had a significantly increased hazard of death (HR: 2.0; p=.023) after adjusting for age, disease stage, IGHV mutation status, clonal TP53 genetic defects, and lesions of NOTCH1, SF3B1 and BIRC3. Subclonal TP53 mutations showed a similar allele fraction in paired PB and lymph-node CLL cells in 3/5 assessable cases, suggesting a systemic spread of mutated subclones across disease compartments. Among cases harboring solely subclonal TP53 mutations, longitudinal deep-NGS of sequential samples documented the outgrowth of the TP53 variant to a fully clonal level in 57% (4/7) of cases. In all these cases, clonal selection was strongly associated with treatment exposure and development of a chemorefractory phenotype. Conversely, in cases managed by watch-and-wait only, the load of TP53 mutations did not increase during follow-up. Conclusions Small TP53 mutated subclones detected by deep-NGS occur in a significant fraction of newly diagnosed CLL, have the same unfavorable prognostic impact as clonal TP53 defects, and anticipate the development of a chemorefractory phenotype among CLL requiring treatment. Search of minor subclones by deep-NGS should be considered for a comprehensive assessment of TP53 disruption in CLL. D.R. and H.K equally contributed; R.F., R.R. and G.G equally contributed. Disclosures: No relevant conflicts of interest to declare.

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TP53 Disruption and Telomere Instability In Chronic Lymphocytic Leukemia

Blood ◽

10.1182/blood.v122.21.4135.4135 ◽

2013 ◽

Vol 122 (21) ◽

pp. 4135-4135

Author(s):

Mélanie Pagès ◽

Lauren Veronese ◽

Patricia Combes ◽

Romain Guièze ◽

Gwendoline Soler ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Chromosomal Instability ◽

Tp53 Mutation ◽

Tp53 Gene ◽

Lymphocytic Leukemia ◽

Prognostic Impact ◽

Wild Type ◽

Expression Levels ◽

The Impact ◽

Tp53 Status

Abstract Background Disruptions of the TP53 tumor suppressor pathway by TP53 gene mutations and/or by17p deletions resulting in loss of the TP53 locus are clearly associated with poor survival and chromosomal instability in chronic lymphocytic leukemia (CLL). Chromosomal instability is promoted by telomere dysfunction, and the TP53 pathway is involved in the monitoring of telomere integrity. Aim The purpose of the present study was to describe the changes in main telomeric parameters, which can affect telomere integrity, associated with TP53 mutations and 17p deletions and to evaluate their potential prognostic value. Patients and Methods We performed a comparison between a group of TP53 disrupted CLL patients (n= 24) and a group of TP53 wild-type CLL patients (n= 61). Median age was 70 [39-89] years, M/F ratio was 2.4/1. At the time of sampling, 35 patients were in Binet stage A, 19 patients in stage B and 31 patients in stage C. A total of 50 patients were subsequently treated by immunochemotherapy (FCR n= 30, other n= 8), alemtuzumab (n= 8) or alkylating agent-based regimens (n= 4). TP53 gene mutation screening was performed using Sanger sequencing of the entire coding region (exons 2–11). Cytogenetic analysis (karyotype and FISH) were performed to evaluate the chromosomal instability and detect the marks of telomeric fragility. Quantitative PCR approaches were used to measure the relative telomere length and to evaluate expression levels of shelterin genes (TRF1, TRF2, POT1, RAP1, TPP1, and TIN2) and telomerase (hTERT). Results The patients showing a TP53 mutation without a 17p deletion and the patients carrying a 17p deletion with or without TP53 mutation appear to display the same level of telomeric instability. These cases are characterized by significant telomeric erosion (P<10-7), hTERT over expression (P<10-4) and decreased TRF1 (P<0.04) and TPP1 (P<0.016) expression levels. The impact of TP53 status on telomeric shortening is independent on Binet stages and classical markers of CLL progression (IgVH status, CD38 expression, lymphocyte doubling time). Moreover, TP53 disruption is strongly associated with telomere deletions, end-to-end fusions and chromosomal aberrations. Multivariate analysis on time to progression (TTP) including TP53 status and telomere characteristics revealed that two shelterin genes TTP1 (HR 7.1; 95% CI 2.0, 25.0; P= 0.0026) and RAP1 (HR 3.7; 95% CI 1.4, 9.6; P= 0.0088) have a significant prognostic impact which was independent on that of TP53 status (HR 6.9; 95% CI 2.3, 20.5; P= 0.0053). Low TPP1 and high RAP1 expression identify subsets of TP53 wild type patients with significantly shorter TTP as illustrated in Figure 1 and 2. Conclusion These results suggest that TP53 disruption may play a major role in telomeric and chromosomal instability in CLL. Shelterin gene expression may help to identify a subset of TP53 wild-type patients with adverse prognosis. Disclosures: No relevant conflicts of interest to declare.

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Utilization of Targeted Exome Sequencing to Determine Implications of TP53 Mutation Status in Relation to 17p Deletion in Chronic Lymphocytic Leukemia (CLL)

Blood ◽

10.1182/blood.v124.21.3287.3287 ◽

2014 ◽

Vol 124 (21) ◽

pp. 3287-3287

Author(s):

Ateefa Chaudhury ◽

Julio C Chavez ◽

Javier Pinilla-Ibarz

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Exome Sequencing ◽

Poor Prognosis ◽

Tp53 Mutation ◽

Lymphocytic Leukemia ◽

Cancer Center ◽

Tp53 Mutations ◽

Targeted Exome Sequencing ◽

The Impact

Abstract Background: Advances in molecular genetics have changed the risk stratification and treatment of patients with Chronic Lymphocytic Leukemia (CLL). Previous studies have shown the worst patient outcomes associated with 17p deletion from diminished overall and progression free survival, in addition to lack of response to conventional Fludarabine based chemotherapy regimens. More recently, analyses of the role of TP53 mutation utilizing next generation sequencing (NGS) in CLL patients has shown that it may also be associated with poor prognosis and similar outcomes to those patients with 17p deletion. This study seeks to characterize the role of TP53 mutation and 17p deletion with overall survival (OS) of CLL patients treated at H. Lee Moffitt Cancer Center who underwent Targeted Exome Sequencing (TES). Methods: We utilized the Total Cancer Care/H. Lee Moffitt Cancer Center (MCC) database containing 844 CLL patients of diverse ethnic backgrounds and long survival follow up to determine the rates and outcomes of 17p deletion within our population. A subset of 93 patients treated between 2004 and 2010 at MCC were randomly chosen for TES. Bone marrow and/or peripheral blood samples were subjected to genomic capture and massive parallel sequencing of 1,321 cancer-related genes. Sequences were aligned to the hs37d5 human reference. Insertion/deletion realignment, quality score recalibration, and variant identification were performed with the Genome Analysis ToolKit (GATK). Sequence variants for TP53 and 17p deletion were annotated with ANNOVAR. Alignments using BWA and Stampy were manually inspected with Samtools View. The primary objective was to determine OS stratified into four groups: 1) TP53 positive/17p deletion positive (tp53+/17pdel+), 2) TP53 negative/17p deletion positive (tp53-/17pdel+), 3) TP53 positive/17p deletion negative (tp53+/17pdel-), and lastly 4) TP53 negative/17p deletion negative (tp53-/17pdel-). Results: Analysis of patients with genetic data available in our larger population of CLL patients at MCC (n=844), revealed the median OS of patients with 17pdel+ (n=46) was 6 years vs. 13 years for 17pdel- patients (Figure 1, p<0.001). These results were comparable to our CLL patients that underwent TES. Among patients who underwent TES (n=93), the median age was 58 (34-87) years and the male/female ratio was 63/30. Sixteen patients had Rai Stage III/IV disease (17.3%). ZAP70 and CD38 were positive in 41 (44.1%) and 11 patients (11.8%), respectively. Recurrent CLL mutations by FISH showed 13qdel in 54 (58.1%), 11qdel in 19 (20.4%), trisomy 12 in 18 (19.4%), and 17pdel in 12 (12.9%) cases. By TES, TP53 mutation was the most frequent mutation and detected in 18/93 (19.4%) of patients. The median OS for 17pdel+ vs. 17pdel- in this population were 9.6 and 14 years, respectively (p=0.023). When patients were divided by subgroups the frequencies were as follows: tp53+/17p+ in 10 (10.8%), tp53-/17p+ in 2 (2.2%), tp53+/17p- in 8 (8.6%), and tp53-/17p- in 73 (78.5%). The median OS for patients with tp53+/17pdel+, tp53+/17pdel-, and tp53-/17pdel- were 2, 9, and 13 years, respectively (Figure 2, p=0.028). Due to the small number in the tp53-/17pdel+ subgroup, the median OS could not be determined. Conclusion: The impact of TP53 mutations detected by NGS in CLL patients is still under investigation. TP53 mutation and 17p deletion are associated with a very poor prognosis. The impact of TP53 mutation in the absence of 17p deletion is not well understood. Within our study, our findings clearly show the 84.6% reduction in OS (11 years) of tp53+/17p+ patients when compared to tp53-/17pdel- patients. TP53 mutation in the absence of 17p deletion did reduce OS by 4 years (30.8%) when compared to patients who lack the 17p deletion or TP53 mutation. TP53 mutation does appear to impact and shorten OS most strikingly in the presence of 17p deletion, suggesting that 17p deletion may play a greater role in prognosis than TP53 alone. Larger number of patients will be needed in order to confirm these findings and to determine the impact of 17p deletion in patients lacking TP53 mutations. Further analyses of CLL patients utilizing NGS technologies and functional analyses to determine if these mutations fully inactivate TP53 will need to be performed to help further elucidate the role of TP53 mutation in patients with high-risk CLL. Figure 1 Figure 1. Figure 2 Figure 2. Disclosures No relevant conflicts of interest to declare.

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Subcutaneous Alemtuzumab in Fludarabine-Refractory Chronic Lymphocytic Leukemia: Clinical Results and Prognostic Marker Analyses From the CLL2H Study of the German Chronic Lymphocytic Leukemia Study Group

Journal of Clinical Oncology ◽

10.1200/jco.2008.21.1128 ◽

2009 ◽

Vol 27 (24) ◽

pp. 3994-4001 ◽

Cited By ~ 198

Author(s):

Stephan Stilgenbauer ◽

Thorsten Zenz ◽

Dirk Winkler ◽

Andreas Bühler ◽

Richard F. Schlenk ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Performance Status ◽

Subcutaneous Administration ◽

Cost Savings ◽

Progression Free Survival ◽

Complete Response ◽

Clinical Results ◽

Lymphocytic Leukemia ◽

Prognostic Impact ◽

Skin Reactions

Purpose The phase II CLL2H trial evaluated safety and efficacy of subcutaneous alemtuzumab in patients with fludarabine-refractory chronic lymphocytic leukemia (CLL). Clinical and biologic markers were evaluated for their impacts on outcome. Patients and Methods One hundred nine patients were enrolled, and 103 received at least one dose of alemtuzumab. After dose escalation, alemtuzumab was administered subcutaneously at 30 mg three times weekly for up to 12 weeks. Response was assessed every 4 weeks during treatment and quarterly thereafter. Results The overall response rate was 34% (complete response, 4%; partial response, 30%). The median progression-free survival was 7.7 months, and the median overall survival (OS) was 19.1 months. Grades 3 to 4 neutropenia, thrombocytopenia, and anemia occurred in 56%, 57%, and 49% of patients, respectively. Grades 3 to 4 noncytomegalovirus and cytomegalovirus infections occurred in 29% and 8% of patients, respectively. Injection-site skin reactions were generally mild. Efficacy did not vary significantly in subgroups defined by genetic parameters (in particular, in 17p deletion, 11q deletion, mutated TP53, and unmutated VH), but efficacy was inferior in patients with increased β2-microglobulin (β2-MG) and thymidine kinase (TK). In multivariate analysis of clinical and biologic variables, age, performance status, β2-MG, and TK were independent prognostic factors for OS. Conclusion Subcutaneous alemtuzumab appears as effective and safe as intravenous alemtuzumab in fludarabine-refractory CLL. Subcutaneous administration should be the preferred delivery route because of its efficacy, convenience, improved adverse effect profile, and cost savings. In contrast to chemotherapy-based therapy, alemtuzumab treatment overcomes the adverse prognostic impact of VH mutation status, TP53 mutation, and genomic aberrations.

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Monoallelic TP53 inactivation is associated with poor prognosis in chronic lymphocytic leukemia: results from a detailed genetic characterization with long-term follow-up

Blood ◽

10.1182/blood-2008-04-154070 ◽

2008 ◽

Vol 112 (8) ◽

pp. 3322-3329 ◽

Cited By ~ 272

Author(s):

Thorsten Zenz ◽

Alexander Kröber ◽

Katrin Scherer ◽

Sonja Häbe ◽

Andreas Bühler ◽

...

Keyword(s):

Tp53 Mutation ◽

Direct Sequencing ◽

Clonal Evolution ◽

Lymphocytic Leukemia ◽

Prognostic Impact ◽

Clone Size ◽

Tp53 Mutations ◽

Long Term Follow Up ◽

Serial Samples

AbstractThe exact prognostic role of TP53 mutations (without 17p deletion) and any impact of the deletion without TP53 mutation in CLL are unclear. We studied 126 well-characterized CLL patients by direct sequencing and DHPLC to detect TP53 mutations (exons 2-11). Most patients with 17p deletions also had TP53 mutations (81%). Mutations in the absence of 17p deletions were found in 4.5%. We found a shorter survival for patients with TP53 mutation (n = 18; P = .002), which was more pronounced when analyzed from the time point of mutation detection (6.8 vs 69 months, P < .001). The survival was equally poor for patients with deletion 17p plus TP53 mutation (7.6 months, n = 13), TP53 mutation only (5.5 months, n = 5), and 17p deletion only (5.4 months, n = 3). The prognostic impact of TP53 mutation (HR 3.71) was shown to be independent of stage, VH status, and 11q and 17p deletion in multivariate analysis. Serial samples showed evidence of clonal evolution and increasing clone size during chemotherapy, suggesting that there may be patients where this treatment is potentially harmful. TP53 mutations are associated with poor sur-vival once they occur in CLL. The de-monstration of clonal evolution under selective pressure supports the biologic significance of TP53 mutations in CLL.

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Prognostic Impact of NOTCH1 Hotspot Mutation in TP53-Mutated Patients with Chronic Lymphocytic Leukemia

Blood ◽

10.1182/blood.v124.21.3283.3283 ◽

2014 ◽

Vol 124 (21) ◽

pp. 3283-3283

Author(s):

Barbara Kantorova ◽

Jitka Malcikova ◽

Veronika Navrkalova ◽

Jana Smardova ◽

Kamila Brazdilova ◽

...

Keyword(s):

Overall Survival ◽

Chronic Lymphocytic Leukemia ◽

Tp53 Mutation ◽

Direct Sequencing ◽

Lymphocytic Leukemia ◽

The Other ◽

Wild Type ◽

Tp53 Mutations ◽

Time To First Treatment ◽

Hotspot Mutation

Abstract Introduction A presence of activating mutations in NOTCH1 gene has been recently associated with reduced survival and chemo-immunotherapy resistance in chronic lymphocytic leukemia (CLL). However, a prognostic significance of the NOTCH1 mutations with respect to TP53mutation status has not been fully explained yet. Methods An examined cohort included 409 patients with CLL enriched for high risk cases; in 121 patients consecutive samples were investigated. To determine the TP53 mutation status, a functional analysis of separated alleles in yeast (FASAY, exons 4-10) combined with direct sequencing was performed; the ambiguous cases were retested using an ultra-deep next generation sequencing (MiSeq platform; Illumina). The presence of NOTCH1 hotspot mutation (c.7544_7545delCT) was analyzed using direct sequencing complemented by allele-specific PCR in the selected samples. In several patients harboring concurrent NOTCH1 and TP53 mutations, single separated cancer cells were examined using multiplex PCR followed by direct sequencing. A correlation between mutation presence and patient overall survival, time to first treatment and other molecular and cytogenetic prognostic markers was assessed using Log-rank (Mantel-cox) test and Fisher's exact test, respectively. Results The NOTCH1 and TP53 mutations were detected in 16% (65/409) and 27% (110/409) of the examined patients, respectively; a coexistence of these mutations in the same blood samples was observed in 11% (19/175) of the mutated patients. The detected increased mutation frequency attributes to more unfavorable profile of the analyzed cohort; in the TP53-mutated patients missense substitutions predominated (75% of TP53 mutations). As expected, a significantly reduced overall survival in comparison to the wild-type cases (147 months) was observed in the NOTCH1-mutated (115 months; P = 0.0018), TP53-mutated (79 months; P < 0.0001) and NOTCH1-TP53-mutated patients (101 months; P = 0.0282). Since both NOTCH1 and TP53 mutations were strongly associated with an unmutated IGHV gene status (P < 0.0001 and P = 0.0007), we reanalyzed the IGHV-unmutated patients only and interestingly, the impact of simultaneous NOTCH1 and TP53 mutation presence on patient survival was missed in this case (P = 0.1478). On the other hand, in the NOTCH1 and/or TP53-mutated patients significantly reduced time to first treatment was identified as compared to the wild-type cases (41 months vs. 25 months in NOTCH1-mutated, P = 0.0075; 17 months in TP53-mutated, P < 0.0001; and 18 months in NOTCH1-TP53-mutated patients, P = 0.0003). The similar results were observed also in the subgroup of the IGHV-unmutated patients, with the exception of patients carrying sole NOTCH1 mutation (P = 0.2969). Moreover, in the NOTCH1-TP53-mutated patients an increased frequency of del(17p)(13.1) was found in comparison to the TP53-mutated patients only (72% vs. 56%); this cytogenetic defect was not detected in the patients with sole NOTCH1 mutation. Our results might indicate, that NOTCH1 mutation could preferentially co-selected with particular, less prognostic negative type of TP53 defects. Notably, in our cohort the NOTCH1 mutation predominated in the patients harboring truncating TP53 mutations localized in a C-terminal part of the TP53 gene behind the DNA-binding domain (P = 0.0128). Moreover, in one of the NOTCH1-TP53-mutated patients the analysis of separated cancer cells revealed a simultaneous presence of NOTCH1 mutation and TP53 in-frame deletion in the same CLL cell. In contrast, in the other examined NOTCH1-TP53-mutated patient the concurrent NOTCH1 mutation and TP53 missense substitution (with presumed negative impact on patient prognosis) were found in different CLL cells. Conclusions The parallel presence of NOTCH1 hotspot mutation might be detected in a significant proportion of TP53-mutated patients and it seems to be associated with less prognostic unfavorable TP53 mutations. Nevertheless, these preliminary data should be further confirmed in a large cohort of patients. This study was supported by projects VaVPI MSMT CR CZ.1.05/1.1.00/02.0068 of CEITEC, IGA MZ CR NT13493-4/2012, NT13519-4/2012 and CZ.1.07/2.3.00/30.0009. Disclosures Brychtova: Roche: Travel grants Other. Doubek:Roche: Travel grants Other.

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Mutational Status of the TP53 Gene As a Predictor of Response and Survival in Patients With Chronic Lymphocytic Leukemia: Results From the LRF CLL4 Trial

Journal of Clinical Oncology ◽

10.1200/jco.2010.32.0838 ◽

2011 ◽

Vol 29 (16) ◽

pp. 2223-2229 ◽

Cited By ~ 170

Author(s):

David Gonzalez ◽

Pilar Martinez ◽

Rachel Wade ◽

Sarah Hockley ◽

David Oscier ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Survival Data ◽

Prognostic Value ◽

Gene Mutations ◽

Progression Free Survival ◽

Tp53 Gene ◽

Lymphocytic Leukemia ◽

Tp53 Mutations ◽

Mutational Status ◽

Gene Tp53

Purpose TP53 mutations have been described in chronic lymphocytic leukemia (CLL) and have been associated with poor prognosis in retrospective studies. We aimed to address the frequency and prognostic value of TP53 abnormalities in patients with CLL in the context of a prospective randomized trial. Patients and Methods We analyzed 529 CLL samples from the LRF CLL4 (Leukaemia Research Foundation Chronic Lymphocytic Leukemia 4) trial (chlorambucil v fludarabine with or without cyclophosphamide) at the time of random assignment for mutations in the TP53 gene. TP53 mutation status was correlated with response and survival data. Results Mutations of TP53 were found in 40 patients (7.6%), including 25 (76%) of 33 with 17p deletion and 13 (3%) of 487 without that deletion. There was no significant correlation between TP53 mutations and age, stage, IGHV gene mutations, CD38 and ZAP-70 expression, or any other chromosomal abnormality other than 17p deletion, in which concordance was high (96%). TP53 mutations were significantly associated with poorer overall response rates (27% v 83%; P < .001) and shorter progression-free survival (PFS) and overall survival (OS; 5-year PFS: 5% v 17%; 5-year OS: 20% v 59%; P < .001 for both). Multivariate analysis that included baseline clinical variables, treatment, and known adverse genetic factors confirmed that TP53 mutations have added prognostic value. Conclusion TP53 mutations are associated with impaired response and shorter survival in patients with CLL. Analysis of TP53 mutations should be performed in patients with CLL who have progressive disease before starting first-line treatment, and those with mutations should be selected for novel experimental therapies.

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Impact of Different Chemotherapy Regimen in Comorbid Patients with Advanced Chronic Lymphocytic Leukemia: Metaanalysis of Two Phase-III-Trials of the German CLL Study Group.

Blood ◽

10.1182/blood.v108.11.2840.2840 ◽

2006 ◽

Vol 108 (11) ◽

pp. 2840-2840 ◽

Cited By ~ 3

Author(s):

Paula Cramer ◽

Valentin Goede ◽

Petra Jenke ◽

Raymonde Busch ◽

Michael Hallek ◽

...

Keyword(s):

Chronic Lymphocytic Leukemia ◽

Chemotherapy Regimen ◽

Lymphocytic Leukemia ◽

Phase Iii ◽

Prognostic Impact ◽

Concomitant Disease ◽

Two Phase ◽

Phase Iii Trials ◽

The Impact ◽

Dose Reductions

Abstract Introduction: Since chronic lymphocytic leukemia (CLL) is a disease of elderly patients (pts) comorbidity is a frequent feature which has already been shown to be associated with survival-shortening in lymphoma patients. It has been hypothesized that intensity of chemotherapy may interfere with treatment outcome, but the precise mechanisms underlying the impact of comorbidity are still not understood. Consequently, comorbitity currently keeps away oncologists from administering intense combined (immuno−)chemotherapy to pts with CLL and concomitant diseases. Patients & methods: 554 pts treated in two different phase-III-trials of the GCLLSG were eligible for this analysis: 362 pts (65%) younger than 65 years were treated on the CLL4-protocol with Fludarabine (F) or Fludarabine-Cyclophosphamide (FC) and 192 pts (35%) aged 65 years and older on the CLL5-protocol with F or Chlorambucile (Clb). The mean age for all pts was 61 years; 68% of the pts were male. Results: Comorbidity was present in 53% of the pts, 25% had at least two comorbidities. The most common comorbidities were: hypertension (19%), lipometabolic disorders (16%), diabetes mellitus (10%) and coronary heart disease (7%). Progression free survival (PFS) and overall survival (OS) were significantly shorter in comorbid pts (median OS: 43,5 vs. 51,6 months, p=0,01; median PFS: 20,3 vs. 23,5 months, p=0,03). Survival was also impaired if pts had a higher number of comorbidities (PFS & OS: p=0,0001) or more severe concomitant diseases (PFS: p=0,007, OS: p=0,0000). Whereas this impact of comorbidity on OS was not significant in the FC- and Clb-arm, comorbid pts treated with F had a significantly shorter survival (median OS: 38,29 vs. 51,58 months, p=0,0452). Notably only the younger F-treated comorbid pts were affected by this disadvantage (CLL4: p=0,0221). Although myelotoxicity, infections and all grade III–IV adverse effects were not influenced by comorbidity, pts with concomitant disease had a higher rate of treatment terminations (38% vs. 25%, p=0,002). The higher percentage of dose reductions and treatment terminations for comorbid pts were only significant in the subgroup of F-treated pts (dose reduction: 31% vs. 19,1%, p=0,029; treatment termination in the younger CLL4-pts: 28,2% vs. 18,0%, p=0,023). Administration of more intense chemotherapy-regimen improved the survival of pts with concomitant disease (median OS: FC: not reached, F: 38,29 and Clb: 33,72 months, p=0,0248; median PFS: FC: not reached, F: 18,8 and Clb: 14,1 months, p=0,0000). A multivariate analysis on the prognostic impact of comorbidity and different chemotherapy regimen will be presented. Conclusions: Due to the here presented results the wide impact of comorbidity in CLL pts is apparent. It should be considered when it comes to treatment decisions eventhough this population was selected due to the strict criteria of the clinical trial. The mechanism of survival shortening in comorbid pts with CLL is not yet understood, but seems to be related with dose reductions and treatment terminations. Additional harm to these pts by an insufficient treatment and a poor control of the CLL ought to be avoided. As more intense chemotherapy-regimen, like FC are feasible for pts with comorbidity, more trials surveying these therapies in pts with more severe concomitant disease are needed.

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