Prognostic impact of DNMT3A mutation in acute myeloid leukemia with mutated NPM1

Prognostic impact; Mutation; Acute myeloid leukemiaImpacte pronòstic; Mutació; Leucèmia mieloide agudaImpacto pronóstico; Mutación; Leucemia mieloide agudaThe negative prognostic impact of internal tandem duplication of FLT3 (FLT3-ITD) in patients with acute myeloid leukemia with mutated NPM1 (AML-NPM1) is restricted to those with a higher FLT3-ITD allelic ratio (FLT3high; ≥0.5) and considered negligible in those with a wild-type (FLT3WT)/low ITD ratio (FLT3low). Because the comutation of DNMT3A (DNMT3Amut) has been suggested to negatively influence prognosis in AML-NPM1, we analyzed the impact of DNMT3Amut in FLT3-ITD subsets (absent, low, and high ratios). A total of 164 patients diagnosed with AML-NPM1 included in 2 consecutive CETLAM protocols and with DNMT3A and FLT3 status available were studied. Overall, DNMT3Amut status did not have a prognostic impact, with comparable overall survival (P = .2). Prognostic stratification established by FLT3-ITD (FLT3WT = FLT3low > FLT3high) was independent of DNMT3Amut status. Measurable residual disease (MRD) based on NPM1 quantitative polymerase chain reaction was available for 94 patients. DNMT3Amut was associated with a higher number of mutated NPM1 transcripts after induction (P = .012) and first consolidation (C1; P < .001). All DNMT3Amut patients were MRD+ after C1 (P < .001) and exhibited significant MRD persistence after C2 and C3 (MRD+ vs MRD−; P = .027 and P = .001, respectively). Finally, DNMT3Amut patients exhibited a trend toward greater risk of molecular relapse (P = .054). In conclusion, DNMT3Amut did not modify the overall prognosis exerted by FLT3-ITD in AML-NPM1 despite delayed MRD clearance, possibly because of MRD-driven preemptive intervention.This work was supported in part by the Biomedical Research Institute (IIB Sant-Pau) and the José Carreras Leukemia Research Institute as well as grants from the Catalan Government (PERIS SLT002/16/0043 and AGAUR 2017 SGR 139) and the Instituto de Salud Carlos III, Ministerio de Economía y Competitividad, Spain (PI17/01246, PI20/01621 and CM20/00061)

The expression level of BAALC-associated microRNA miR-3151 is an independent prognostic factor in younger patients with cytogenetic intermediate-risk acute myeloid leukemia

Acute myeloid leukemia (AML) is a heterogeneous disease whose prognosis is mainly related to the biological risk conferred by cytogenetics and molecular profiling. In elderly patients (>= 60 years) with normal karyotype AML miR-3151 have been identified as a prognostic factor. However, miR-3151 prognostic value has not been examined in younger AML patients. In the present work, we have studied miR-3151 alone and in combination with BAALC, its host gene, in a cohort of 181 younger intermediate-risk AML (IR-AML) patients. Patients with higher expression of miR-3151 had shorter overall survival (P = 0.0025), shorter leukemia-free survival (P = 0.026) and higher cumulative incidence of relapse (P = 0.082). Moreover, in the multivariate analysis miR-3151 emerged as independent prognostic marker in both the overall series and within the unfavorable molecular prognostic category. Interestingly, the combined determination of both miR-3151 and BAALC improved this prognostic stratification, with patients with low levels of both parameters showing a better outcome compared with those patients harboring increased levels of one or both markers (P = 0.003). In addition, we studied the microRNA expression profile associated with miR-3151 identifying a six-microRNA signature. In conclusion, the analysis of miR-3151 and BAALC expression may well contribute to an improved prognostic stratification of younger patients with IR-AML

The lincRNA HOTAIRM1, located in the HOXA genomic region, is expressed in acute myeloid leukemia, impacts prognosis in patients in the intermediate-risk cytogenetic category, and is associated with a distinctive microRNA signature

Long non-coding RNAs (lncRNAs) are deregulated in several tumors, although their role in acute myeloid leukemia (AML) is mostly unknown.We have examined the expression of the lncRNA HOX antisense intergenic RNA myeloid 1 (HOTAIRM1) in 241 AML patients. We have correlated HOTAIRM1 expression with a miRNA expression profile. We have also analyzed the prognostic value of HOTAIRM1 expression in 215 intermediate-risk AML (IR-AML) patients.The lowest expression level was observed in acute promyelocytic leukemia (P < 0.001) and the highest in t(6;9) AML (P = 0.005). In 215 IR-AML patients, high HOTAIRM1 expression was independently associated with shorter overall survival (OR:2.04;P = 0.001), shorter leukemia-free survival (OR:2.56; P < 0.001) and a higher cumulative incidence of relapse (OR:1.67; P = 0.046). Moreover, HOTAIRM1 maintained its independent prognostic value within the favorable molecular subgroup (OR: 3.43; P = 0.009). Interestingly, HOTAIRM1 was overexpressed in NPM1-mutated AML (P < 0.001) and within this group retained its prognostic value (OR: 2.21; P = 0.01). Moreover, HOTAIRM1 expression was associated with a specific 33-microRNA signature that included miR-196b (P < 0.001). miR-196b is located in the HOX genomic region and has previously been reported to have an independent prognostic value in AML. miR-196b and HOTAIRM1 in combination as a prognostic factor can classify patients as high-, intermediate-, or low-risk (5-year OS: 24% vs 42% vs 70%; P = 0.004).Determination of HOTAIRM1 level at diagnosis provided relevant prognostic information in IR-AML and allowed refinement of risk stratification based on common molecular markers. The prognostic information provided by HOTAIRM1 was strengthened when combined with miR-196b expression. Furthermore, HOTAIRM1 correlated with a 33-miRNA signature

Impacto de las alteraciones moleculares en el pronóstico de la Leucemia Mieloide Aguda (LMA) "de novo"

[spa] La Leucemia Mieloide Aguda (LMA) es una enfermedad hematológica heterogénea, que se caracteriza por la acumulación de células inmaduras en médula ósea. Los pacientes diagnosticados de LMA tienen una supervivencia del 40%, aproximadamente. Existen factores que predicen el pronóstico de los pacientes, como la edad, la leucocitosis, las comorbilidades, la enfermedad residual mínima y la citogenética. Además y gracias a la aparición de las nuevas técnicas moleculares se han descrito un elevado número de marcadores genéticos. Algunos de ellos ya se utilizan en la práctica clínica, pero para la mayor parte se necesitan mas evidencias sobre su efecto pronóstico para poder incluirlos en el diagnóstico habitual. El objetivo de nuestro estudio fue analizar el impacto pronóstico de algunas de las alteraciones moleculares en pacientes con LMA " de novo". Estudiamos el efecto de las mutaciones en IDH1 e IDH2 en pacientes con cariotipo normal. En el mismo estudio, también se analizó la frecuencia y el valor pronóstico de las mutaciones en TET2. Posteriormente, estudiamos los pacientes diagnosticados de LMA con los reordenamientos RUNX1-RUNX1T1 y CBFB-MYH11 (LMA CBF). Se analizaron los factores clínico-biologicos para establecer un "score" pronóstico. También se analizó el valor de la sobre-expresión de dos marcadores moleculares, MN1 y BAALC, y de la determinación del número de copias de tránscrito tras la quimioterapia de inducción. Finalmente, y utilizando toda la serie de pacientes se estudió la utilidad clínica y pronóstica de la determianción de los niveles de expresión del gen WT1 al diagnóstico, tras la quimioterapia de inducció y de intensificación. También se estudió el valor pronóstico y la frecuencia de las mutaciones en WT1. La frecuencia de mutaciones de IDH1 e IDH2 en nuestra serie de pacientes fue del 22,5%. Observamos que aportaban información adicional en los pacientes con cariotipo normal, sobretodo en pacientes que presentavan los genes NPM1 o CEBPA mutados sin la presencia de la FLT3-ITD. En estos grupos, las mutaciones en IDH1 e IDH2 se asociaron a peor pronóstico. Las mutaciones en TET2 fueron muy poco frecuentes en nuestra serie (6,3%) y por ello no se pudo identificar su impacto pronóstico. En el grupo de pacientes con LMA reordenamientos de RUNX1-RUNX1T1 y CBFB-MYH11 la edad y el recuento leucocitario fueron parámetros que permitieron generar un "score" pronóstico. Así, los enfermos menores de 50 años y sin leucocitosis tuvieron una supervivencia mayor que los de edad avanzada y más de 20x10e9/l leucocitos. En el análisis de la sobre-expresión tanto de MN1 como de BAALC, observamos que los pacientes que presentavan el reordenamiento CBFB-MYH11 tenian una expresión de MN1 mas elevada que los pacientes RUNX1-RUNX1T1. Asimismo, la sobre-expresión de BAALC y MN1 al diagnóstico nos identifican un grupo de pacientes con peor pronóstico y un elevado número de copias de tránscrito tras la inducción también fue un factor de pronóstico adverso. En el ánalisis del gen WT1, el 10% de los pacientes presentaron el gen mutado, sin efecto pronóstico. La determinación de los niveles de expresión de WT1 al diagnóstico, tras la quimioterapia de inducción y la de consolidación tuvieron impacto pronóstico adverso. Por lo tanto, podemos concluir que las mutaciones en IDH1 e IDH2 identifican un grupo de pacientes con peor pronóstico. Las mutaciones en TET2 y WT1 son muy poco frecuentes en nuestra serie y no aportaron información predictiva de la evolución. El "score" generado en pacientes con LMA CBF, permite diferenciar grupos de pacientes con distinto pronóstico. La sobre-expresión de MN1 y BAALC nos ayudaria también a estratificar el riesgo en la LMA CBF, considerada clásicamente como de relativo buen pronóstico, así como también la determinación de número de tránscritos tras el tratamiento La determinación de la expresión de WT1 es una buena técnica para el análisis de la enfermedad residual mínima. Además, la determinación tras la quimioterapia de intensificación fue un factor pronóstico independient

Prognostic impact of DNMT3A mutation in acute myeloid leukemia with mutated NPM1

The negative prognostic impact of internal tandem duplication of FLT3 (FLT3- ITD) in patients with acute myeloid leukemia with mutated NPM1 (AML- NPM1) is restricted to those with a higher FLT3 -ITD allelic ratio (FLT3 high ; ≥0.5) and considered negligible in those with a wild-type (FLT3 WT)/low ITD ratio (FLT3 low). Because the comutation of DNMT3A (DNMT3A mut) has been suggested to negatively influence prognosis in AML- NPM1, we analyzed the impact of DNMT3A mut in FLT3 -ITD subsets (absent, low, and high ratios). A total of 164 patients diagnosed with AML- NPM1 included in 2 consecutive CETLAM protocols and with DNMT3A and FLT3 status available were studied. Overall, DNMT3A mut status did not have a prognostic impact, with comparable overall survival (P =.2). Prognostic stratification established by FLT3 -ITD (FLT3 WT = FLT3 low > FLT3 high) was independent of DNMT3A mut status. Measurable residual disease (MRD) based on NPM1 quantitative polymerase chain reaction was available for 94 patients. DNMT3A mut was associated with a higher number of mutated NPM1 transcripts after induction (P =.012) and first consolidation (C1; P <.001). All DNMT3A mut patients were MRD + after C1 (P <.001) and exhibited significant MRD persistence after C2 and C3 (MRD + vs MRD − ; P =.027 and P =.001, respectively). Finally, DNMT3A mut patients exhibited a trend toward greater risk of molecular relapse (P =.054). In conclusion, DNMT3A mut did not modify the overall prognosis exerted by FLT3 -ITD in AML- NPM1 despite delayed MRD clearance, possibly because of MRD-driven preemptive intervention

Different methylation signatures at diagnosis in patients with high-risk myelodysplastic syndromes and secondary acute myeloid leukemia predict azacitidine response and longer survival

Background: Epigenetic therapy, using hypomethylating agents (HMA), is known to be effective in the treatment of high-risk myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) patients who are not suitable for intensive chemotherapy and/or allogeneic stem cell transplantation. However, response rates to HMA are low and there is an unmet need in finding prognostic and predictive biomarkers of treatment response and overall survival. We performed global methylation analysis of 75 patients with high-risk MDS and secondary AML who were included in CETLAM SMD-09 protocol, in which patients received HMA or intensive treatment according to age, comorbidities and cytogenetic. Results: Unsupervised analysis of global methylation pattern at diagnosis did not allow patients to be differentiated according to the cytological subtype, cytogenetic groups, treatment response or patient outcome. However, after a supervised analysis we found a methylation signature defined by 200 probes, which allowed differentiating between patients responding and non-responding to azacitidine (AZA) treatment and a different methylation pattern also defined by 200 probes that allowed to differentiate patients according to their survival. On studying follow-up samples, we confirmed that AZA decreases global DNA methylation, but in our cohort the degree of methylation decrease did not correlate with the type of response. The methylation signature detected at diagnosis was not useful in treated samples to distinguish patients who were going to relapse or progress. Conclusions: Our findings suggest that in a subset of specific CpGs, altered DNA methylation patterns at diagnosis may be useful as a biomarker for predicting AZA response and survival

Focal Adhesion Genes Refine the Intermediate-Risk Cytogenetic Classification of Acute Myeloid Leukemia

In recent years, several attempts have been made to identify novel prognostic markers in patients with intermediate-risk acute myeloid leukemia (IR-AML), to implement risk-adapted strategies. The non-receptor tyrosine kinases are proteins involved in regulation of cell growth, adhesion, migration and apoptosis. They associate with metastatic dissemination in solid tumors and poor prognosis. However, their role in haematological malignancies has been scarcely studied. We hypothesized that PTK2/FAK, PTK2B/PYK2, LYN or SRC could be new prognostic markers in IR-AML. We assessed PTK2, PTK2B, LYN and SRC gene expression in a cohort of 324 patients, adults up to the age of 70, classified in the IR-AML cytogenetic group. Univariate and multivariate analyses showed that PTK2B, LYN and PTK2 gene expression are independent prognostic factors in IR-AML patients. PTK2B and LYN identify a patient subgroup with good prognosis within the cohort with non-favorable FLT3/NPM1 combined mutations. In contrast, PTK2 identifies a patient subgroup with poor prognosis within the worst prognosis cohort who display non-favorable FLT3/NPM1 combined mutations and underexpression of PTK2B or LYN. The combined use of these markers can refine the highly heterogeneous intermediate-risk subgroup of AML patients, and allow the development of risk-adapted post-remission chemotherapy protocols to improve their response to treatment

Different methylation signatures at diagnosis in patients with high-risk myelodysplastic syndromes and secondary acute myeloid leukemia predict azacitidine response and longer survival

Altres ajuts: This work was supported in part by a grant from [...] and a grant from Celgene Spain. Research in the Buschbeck and Zamora labs is further supported by the following grants: [...] the Deutsche José Carreras Leukämie Stiftung DJCLS 14R/2018 (to MB);[...] and Fundació La Marató de TV3 254/C/2019 (to MB). Research at the IJC is supported by the "La Caixa" Foundation, the Fundació Internacional Josep Carreras, Celgene Spain and[...].Epigenetic therapy, using hypomethylating agents (HMA), is known to be effective in the treatment of high-risk myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML) patients who are not suitable for intensive chemotherapy and/or allogeneic stem cell transplantation. However, response rates to HMA are low and there is an unmet need in finding prognostic and predictive biomarkers of treatment response and overall survival. We performed global methylation analysis of 75 patients with high-risk MDS and secondary AML who were included in CETLAM SMD-09 protocol, in which patients received HMA or intensive treatment according to age, comorbidities and cytogenetic. Unsupervised analysis of global methylation pattern at diagnosis did not allow patients to be differentiated according to the cytological subtype, cytogenetic groups, treatment response or patient outcome. However, after a supervised analysis we found a methylation signature defined by 200 probes, which allowed differentiating between patients responding and non-responding to azacitidine (AZA) treatment and a different methylation pattern also defined by 200 probes that allowed to differentiate patients according to their survival. On studying follow-up samples, we confirmed that AZA decreases global DNA methylation, but in our cohort the degree of methylation decrease did not correlate with the type of response. The methylation signature detected at diagnosis was not useful in treated samples to distinguish patients who were going to relapse or progress. Our findings suggest that in a subset of specific CpGs, altered DNA methylation patterns at diagnosis may be useful as a biomarker for predicting AZA response and survival

The expression level of BAALC-associated microRNA miR-3151 is an independent prognostic factor in younger patients with cytogenetic intermediate-risk acute myeloid leukemia

Acute myeloid leukemia (AML) is a heterogeneous disease whose prognosis is mainly related to the biological risk conferred by cytogenetics and molecular profiling. In elderly patients (>= 60 years) with normal karyotype AML miR-3151 have been identified as a prognostic factor. However, miR-3151 prognostic value has not been examined in younger AML patients. In the present work, we have studied miR-3151 alone and in combination with BAALC, its host gene, in a cohort of 181 younger intermediate-risk AML (IR-AML) patients. Patients with higher expression of miR-3151 had shorter overall survival (P = 0.0025), shorter leukemia-free survival (P = 0.026) and higher cumulative incidence of relapse (P = 0.082). Moreover, in the multivariate analysis miR-3151 emerged as independent prognostic marker in both the overall series and within the unfavorable molecular prognostic category. Interestingly, the combined determination of both miR-3151 and BAALC improved this prognostic stratification, with patients with low levels of both parameters showing a better outcome compared with those patients harboring increased levels of one or both markers (P = 0.003). In addition, we studied the microRNA expression profile associated with miR-3151 identifying a six-microRNA signature. In conclusion, the analysis of miR-3151 and BAALC expression may well contribute to an improved prognostic stratification of younger patients with IR-AML