Additional Sex Combs-like 1 Research Articles

Gain-of-Function of ASXL1 Truncating Protein in the Pathogenesis of Myeloid Malignancies

Introduction: Additional Sex Combs-Like 1 (ASXL1) is mutated at a high frequency in all forms of myeloid malignancies associated with poor prognosis. We and others have reported that loss of ASXL1 impairs hematopoietic stem/progenitor cell functions (HSC/HPCs) and leads to myeloid dysplastic syndrome (MDS) in mice. It remains controversial whether truncating mutations in ASXL1 result in gain- or loss-of-function, or whether they confer dominant-negative activity in vivo . Answering this question is critical for determining how to target these mutations therapeutically.Methods: We generated a transgenic mouse model using HS321/45-vav vector that expresses the Asxl1 Y588X cDNA under the control of the Vav1 promoter. The transgene contains the entire coding region of mouse Asxl1 (full-length) with a stop codon mutation at the Y588 site (Asxl1 Y588X), leading to a production of truncating protein ASXL1aa1-587 in the hematopoietic system only. Utilizing the transgenic model, we performed a serial hematopoietic analyses, including peripheral blood (PB) counts, histological characterization on blood smear, tissue sections of femur and spleen, and flow cytometric analysis. Bone marrow(BM) transplantation was performed to identify the effects of truncating ASXL1aa1-587 on HSC/HPCs functions. RNA-seq and ATAC-seq analyses were performed to survey the differentially expressed genes in HSC/HPCs of WT and Asxl1 Y588X Tg mice. Liquid chromatography-tandem mass spectrometry (LC-MS) and co-immunoprecipitation (IP) experiments were performed to identify the specific protein binding partner of ASXL1aa1-587. An epigenetic drug screening was used to identify specific targets to block the gain-of-function protein, ASXL1aa1-587, in the pathogenesis of myeloid malignancies in vivo.Results: The Asxl1Y588X Tg mice had an enlarged hematopoietic stem cell (HSC) pool, shortened survival, and predisposition to a spectrum of myeloid malignancies, thereby recapitulating the characteristics of myeloid malignancy patientswith ASXL1 mutations. Competitive transplantation of WT and Asxl1Y588XTg BM cells revealed that expression of A SXL 1 aa587 was associated with a higher percentage of CD45.2+ cells in the PB of the recipients, indicating that A SXL11-587aa expression increases HSC self-renewal capacity in vitro and in vivo. ATAC- and RNA-Seq analyses revealed that the ASXL11-587aa truncating protein expression results in more open chromatin in cKit+ cells compared to wildtype cells, accompanied by dysregulated expression of genes critical for HSC self-renewal and differentiation. LC-MS) and co-IP experiments showed that ASXL11-587aa acquired an interaction with BRD4. An epigenetic drug screening demonstrated a hyper-sensitivity of Asxl1Y588X Tg bone marrow cells to BET bromodomain inhibitors.Conclusion: This study demonstrates that ASXL11-587aa plays a gain-of-function role in promoting myeloid malignancies and that BET bromodomain inhibitors significantly reduced the colony forming capacity of ASXL1Y588XTgHSPCs. Our model provides a powerful platform to test therapeutic approaches of targeting the ASXL1 truncation mutations in myeloid malignancies. DisclosuresNo relevant conflicts of interest to declare.

Clinical and histopathological features of myeloid neoplasms with concurrent Janus kinase 2 (JAK2) V617F and KIT proto-oncogene, receptor tyrosine kinase (KIT) D816V mutations.

We report on 45 patients with myeloid neoplasms and concurrent Janus kinase 2 (JAK2) V617F and KIT proto-oncogene, receptor tyrosine kinase (KIT) D816V (JAK2pos. /KITpos. ) mutations, which are individually identified in >60% of patients with classical myeloproliferative neoplasms (MPN) and >90% of patients with systemic mastocytosis (SM) respectively. In SM, the concurrent presence of a clonal non-mast cell neoplasm [SM with associated haematological neoplasm (SM-AHN)] usually constitutes a distinct subtype associated with poor survival. All 45 patients presented with a heterogeneous combination of clinical/morphological features typical of the individual disorders (e.g. leuco-/erythro-/thrombocytosis and elevated lactate dehydrogenase for MPN; elevated serum tryptase and alkaline phosphatase for SM). Overlapping features identified in 70% of patients included splenomegaly, cytopenia(s), bone marrow fibrosis and additional somatic mutations. Molecular dissection revealed discordant development of variant allele frequency for both mutations and absence of concurrently positive single-cell derived colonies, indicating disease evolution in two independent clones rather than monoclonal disease in >60% of patients examined. Overall survival of JAK2pos. /KITpos. patients without additional somatic high-risk mutations [HRM, e.g. in serine and arginine-rich splicing factor 2 (SRSF2), additional sex combs like-1 (ASXL1) or Runt-related transcription factor 1 (RUNX1)] at 5years was 77%, indicating that the mutual impact of JAK2 V617F and KIT D816V on prognosis is fundamentally different from the adverse impact of additional HRM in the individual disorders.

Gender-related differences in the outcomes and genomic landscape of patients with myelodysplastic syndrome/myeloproliferative neoplasm overlap syndromes.

Myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) overlap syndromes show a male predominance and men with MDS/MPN have worse outcomes, but it is unknown if the mutational burden differs between genders. We reviewed 167 patients with MDS/MPN and found that men had worse overall survival [hazard ratio (HR) 2·09, 95% confidence interval (CI) 1·16-3·75; P=0·013] independent of subtype, Revised International Prognostic Scoring System score and age at diagnosis. We analysed the genomic data of a subset of 100 patients. Men had 0·88 more somatic mutations on average (95% CI 0·20-1·56, P=0·011) independent of subtype, sample source and blast percentage. More somatic mutations was associated with a higher incidence of transformation to acute myeloid leukaemia (subdistribution HR 1·30, 95% CI 1·01-1·70; P=0·046). Men had 0·70 more mutations in high-risk genes [additional sex combs like-1 (ASXL1), enhancer of zeste homolog 2 (EZH2), Runt-related transcription factor 1 (RUNX1), SET binding protein 1 (SETBP1), NRAS proto-oncogene, GTPase (NRAS), stromal antigen 2 (STAG2)] on average (95% CI 0·11-1·29, P=0·021), and 13-times higher odds of harbouring an EZH2 mutation (95% CI 1·64-102·94, P=0·015). The presence of an EZH2 mutation was associated with worse survival among men (HR 2·98, 95% CI 1·1-8·0; P=0·031). Our present findings suggest that the worse outcomes in men with MDS/MPN are associated with a higher number of somatic mutations, especially in high-risk genes. These results warrant validation in larger cohorts and investigation of the underlying mechanisms.

The Impact of Epigenetic Modifications in Myeloid Malignancies.

Myeloid malignancy is a broad term encapsulating myeloproliferative neoplasms (MPN), myelodysplastic syndrome (MDS) and acute myeloid leukaemia (AML). Initial studies into genomic profiles of these diseases have shown 2000 somatic mutations prevalent across the spectrum of myeloid blood disorders. Epigenetic mutations are emerging as critical components of disease progression, with mutations in genes controlling chromatin regulation and methylation/acetylation status. Genes such as DNA methyltransferase 3A (DNMT3A), ten eleven translocation methylcytosine dioxygenase 2 (TET2), additional sex combs-like 1 (ASXL1), enhancer of zeste homolog 2 (EZH2) and isocitrate dehydrogenase 1/2 (IDH1/2) show functional impact in disease pathogenesis. In this review we discuss how current knowledge relating to disease progression, mutational profile and therapeutic potential is progressing and increasing understanding of myeloid malignancies.

Abstract 17182: Coronary Endothelial Dysfunction in Humans is Associated With Elevated Expression of Clonal Hematopoiesis of Indeterminate Potential

Introduction: Recent evidence has demonstrated that Clonal Hematopoiesis of Indeterminate Potential (CHIP) increases the risk of cardiovascular events. However, the exact role played by CHIP in early stages of coronary atherosclerosis, characterized by coronary endothelial dysfunction remains to be elucidated. Hypothesis: The current study was designed to test the hypothesis that the presence of CHIP in peripheral blood cells is associated with coronary endothelial dysfunction and increased levels of inflammatory markers. Methods: Next generation sequencing was used to detect mutations among patients who had coronary endothelial dysfunction and control group (normal coronary endothelial function). Endothelial dysfunction was defined by ≥ 20% decrease in coronary artery diameter or ≤50% increase in blood flow in response to acetylcholine injection compared to baseline. Plasma cytokine levels of Interleukin (IL)-6 and IL-8 were also assessed. Results: Clonal hematopoiesis relevant gene mutations were found in 1 out of 64 patients with normal endothelial function (1.5%) and 11 out of 119 cases in the endothelial dysfunction group (9.2%) (P = 0.04) with ASXL1 (Additional sex combs-like 1) being the most frequent gene (4.2%) mutated. Cytokine analysis demonstrated that mutations in ASXL1, DNMT3A (DNA methyltransferase 3A) and TET2 (Ten-eleven-translocation-2) in the endothelial dysfunction group were associated with increased levels of IL-6 and IL-8 (P = 0.001, P = 0.003; respectively). Conclusions: The current study supports a potential role for CHIP in mechanisms of coronary artery disease starting at early stage of atherosclerosis. Furthermore, enhanced expression levels of IL-6 and IL-8 seem to be related to mutations in DNMT3A, ASXL1 and TET2 genes, more than other gene mutations relevant CHIP.

Gene Body Methylation and Transcriptional Activity in ASXL1-Mutant Chronic Myelomonocytic Leukemia

Introduction: Truncating mutations in Additional Sex Combs-Like 1 (ASXL1) are associated with a high-risk disease phenotype in myeloid malignancies. In chronic myelomonocytic leukemia (CMML), truncating ASXL1 mutations are known to increase transcriptional activity of leukemic driver genes and have been associated with gene body hypermethylation. We interrogated the transcriptome and methylome of patients with ASXL1-mutant (MT) and -wildtype (WT) CMML using a multi-omics approach to test the hypothesis that gene expression is mediated through gene body methylation. Methods: Bone marrow mononuclear cells from patients with ASXL1 WT (n=8) and MT (n=8) CMML were subjected to targeted NGS of DNA, whole transcriptome shotgun sequencing (RNA-seq), and immunoprecipitation of DNA methyl residues (DIP-seq). After quality control all samples were sequenced on an Illumina HiSeq 4000 before further processing and data analysis. Differential gene expression analysis was performed to identify genes up-regulated in MT CMML. The samples in the two groups were treated as biological replicates and subjected to a consensus peak calling strategy requiring an overlap of at least 30% between samples and an adjusted p-value < 5x10-5 for a methylation peak to be considered statistically significant. For validation purposes methylation analysis was performed on 3 ASXL1 MT and 3 WT CMML patients using Illumina Infinium MethylationEPIC microarrays and differentially methylated regions were identified using a bump hunting strategy. Gene body methylation was defined as methylation in gene bodies (outside the promoter region, i.e. transcription start site ±2kb). Gene body methylation was compared between WT and MT CMML for the up-regulated genes and correlated with expression of all genes in MT CMML. Results: Sixteen WHO-defined CMML patients were included, median age 69 years (48-77), 63% male, 50% had truncating ASXL1 frame shift mutations. Abnormal karyotypes were observed in the same number of patients and the burden of co-mutations was similar between the two groups (median number per group 3 vs. 3, p=0.508). This included several modulators of DNA methylation including TET2, DNMT3A, and IDH2 (median number per group 1 vs. 1, p=0.699). There was a predominant up-regulation of gene expression in MT CMML: 707 genes up- and 124 down-regulated (FDR<0.050) without evidence of differential methylation in promoter regions of the differentially expressed genes. There was no difference in the number of genes with consensus methylation peaks in the gene body or the extent of gene body methylation (area under the consensus peaks) between MT and WT CMML for the differentially expressed genes (Figure 1a). We further validated these results using methylation microarrays (Figure 1b). Among the MT CMML patients, there was a curvilinear relationship between gene body methylation and gene expression across all genes with intermediate gene body methylation being associated with the highest gene expression (Figure 1c). As an alternative unbiased approach, we identified 1595 differentially methylated regions (DMR, regions with FDR<0.05) in the validation data set. We mapped all hypermethylated regions to gene bodies requiring that there was no concurrent hypermethylation of the promoter region of the same gene. With this approach we identified one of the 707 up-regulated genes (0.14%) with evidence of isolated gene body hypermethylation (HBZ, log2-fold change in gene expression 4.25, FDR=0.0008, DMR area=1.61, DMR FDR=0.018). Representative examples of up-regulated mitotic kinases without evidence of differential gene body methylation are shown in Figure 1d (pie charts represent the mean β-values of microarray probes, p-values represent the comparisons of mean β-values between MT and WT CMML per gene). Conclusions: Gene body methylation was positively associated with gene expression in MT CMML. However, the lack of differential gene body methylation between WT and MT CMML for the up-regulated genes make it an unlikely explanation for the observed increase in transcriptional activity among patients with MT CMML. Figure 1 Disclosures Ordog: Millipore Sigma: Patents & Royalties.

ASXL1-Mutant Chronic Myelomonocytic Leukemia Is Associated with Increased Intratumoral Heterogeneity and Single-Cell Chromatin Co-Accessibility

Introduction: Additional Sex Combs-Like 1 (ASXL1) is a chromatin modifier frequently affected by truncating mutations in myeloid malignancies. In chronic myelomonocytic leukemia (CMML), truncating ASXL1 mutations are associated with the overexpression of leukemogenic driver genes, however the molecular mechanisms underlying this transcriptional activation remain controversial. We performed single-cell chromatin accessibility studies of ASXL1-mutant (MT) and -wildtype (WT) CMML to identify cis-regulatory elements (CREs) such as distal enhancer elements that may explain the observed transcriptional activity in MT CMML. Methods: Bone marrow mononuclear cells from a patient with WT and a patient with MT CMML were subjected to single-cell DNA transposase accessibility studies (scATAC-seq). The cryopreserved cells were thawed and resuspended and approximately 100000 viable mononuclear cells per sample were subjected to transposase assays before proceeding to single-cell partitioning into gel beads in emulsion, barcoding, library construction, and sequencing following an established 10X Genomics workflow. The target cell recovery was approximately 2000 cells per sample. Genomic libraries were sequenced on an Illumina HiSeq 4000 before demultiplexing, alignment to the reference genome, and post-alignment quality control. The 10X Genomics Cell Ranger ATAC software was used for demultiplexing, alignment of the reads to the GRCh38 reference genome, filtering and quality control, counting of barcodes and unique molecular identifiers, identification of transposase cut sites, detection of accessible chromatin peaks, count matrix generation for peaks and transcription factors, clustering, and differential accessibility analysis. The two-sample Kolmogorov-Smirnov test for equality of distribution functions was used to compare the distributions of single-cell entropies. Single-cell cis-co-accessibility scores were estimated using Cicero. Results: To mitigate potential effects on the analysis introduced by unequal cell recovery due to experimental conditions, we randomly sampled 1500 single cells from each genotype. Visualizing the first two principal components of the chromatin accessibility data revealed the differences in chromatin conformation between genotypes and also the increased heterogeneity within the MT sample (Figure 1a). To quantify this increase in intratumoral heterogeneity of chromatin accessibility in MT CMML, we calculated the single-cell entropies for both genotypes. There was an increase in the dispersion of single-cell entropy values (mean 0.793±0.026 versus 0.811±0.012, p=6.19x10-151) in MT compared to WT disease (Figure 1b). To leverage the power of the single-cell chromatin accessibility data, we estimated cis-co-accessibility scores (two-way chromatin interactions). There were 631 genes involved in two-way chromatin interactions that were either specific to MT CMML or were shared between MT and WT CMML and showed an increase in co-accessibility in MT CMML. Co-accessibility was higher in MT compared to WT CMML, regardless whether the chromatin interaction was MT-specific or shared between the genotypes (Figure 1c). Gene ontology analysis revealed increased chromatin accessibility in genes involved in the regulation of cell cycle, nuclear division, chromosome organization, cell cycle phase transition, DNA conformation change, and DNA replication (FDR<1.00x10-5). The construction of cis-co-accessibility networks demonstrated a remodeling of the chromatin landscape with MT-specific chromatin interactions involving key mitotic kinases such as MAP2K3 (Figure 1d). Conclusions: MT CMML is characterized by an increase in intratumoral heterogeneity and increased chromatin accessibility. The increased chromatin co-accessibility involved key mitotic kinases and may serve as a plausible explanation for the increased transcriptional activity observed in MT CMML. Figure 1 Disclosures Ordog: Millipore Sigma: Patents & Royalties.

EZH2 in Myeloid Malignancies.

Our understanding of the significance of epigenetic dysregulation in the pathogenesis of myeloid malignancies has greatly advanced in the past decade. Enhancer of Zeste Homolog 2 (EZH2) is the catalytic core component of the Polycomb Repressive Complex 2 (PRC2), which is responsible for gene silencing through trimethylation of H3K27. EZH2 dysregulation is highly tumorigenic and has been observed in various cancers, with EZH2 acting as an oncogene or a tumor-suppressor depending on cellular context. While loss-of-function mutations of EZH2 frequently affect patients with myelodysplastic/myeloproliferative neoplasms, myelodysplastic syndrome and myelofibrosis, cases of chronic myeloid leukemia (CML) seem to be largely characterized by EZH2 overexpression. A variety of other factors frequently aberrant in myeloid leukemia can affect PRC2 function and disease pathogenesis, including Additional Sex Combs Like 1 (ASXL1) and splicing gene mutations. As the genetic background of myeloid malignancies is largely heterogeneous, it is not surprising that EZH2 mutations act in conjunction with other aberrations. Since EZH2 mutations are considered to be early events in disease pathogenesis, they are of therapeutic interest to researchers, though targeting of EZH2 loss-of-function does present unique challenges. Preliminary research indicates that combined tyrosine kinase inhibitor (TKI) and EZH2 inhibitor therapy may provide a strategy to eliminate the residual disease burden in CML to allow patients to remain in treatment-free remission.

The molecular analysis of four coexistent mutations in additional sex combs like 1 (ASXL1) gene in a patient with acute myeloid leukemia

Mutations in the additional sex combs like 1 (ASXL1) gene are frequently involved in clonal hematopoiesis and are connected with an increased risk of hematologic cancer. These aberrations are frequently detected in a number of different hematological neoplasms including acute myeloid leukemia (AML). Patients harboring ASXL1 mutations tend to have a poor prognosis and poor response to therapy. Here, we report the coexistence of four different mutations in ASXL1 gene in a patient with AML. Such accumulation of mutations, in this gene, has not been described yet. Our findings suggest that accumulations of mutations in ASXL1 gene may play an important role in the development and/or progression of AML.

Genomic Features and Clinical Characteristics of Adolescents and Young Adults With Cholangiocarcinoma.

Background: Adolescents and young adults (AYAs) diagnosed with cancer between ages 15 and 45 years may exhibit unique biologic and genomic characteristics as well as clinical features, resulting in differences in clinical characters and drug resistance. However, compared to other solid cancers, relatively few studies have been conducted in this age group in cholangiocarcinoma (CCA). This study is performed to investigate the clinical and molecular features of AYAs with CCA.Methods: Three cohorts, including the external dataset (TCGA and MSKCC) and the perihilar CCA databank of Chinese tertiary hospitals, were contained in this study. Pathway and process enrichment analysis had been carried out with the following ontology sources: KEGG Pathway, GO Biological Processes, Reactome Gene Sets, Canonical Pathways, and CORUM. Metascape and GEPIA datasets were used for bioinformatic analysis. P < 0.05 was considered statistically significant. All statistical analyses were performed with GraphPad Prism (version 7.0; GraphPad Software, La Jolla, California) and R studio (version 3.6.1; R studio, Boston, Massachusetts).Results: Compared to older adults, AYAs with CCA presented with worse overall survival, although the difference was not significant. Specific to patients with stage IV CCAs who underwent chemotherapy, AYAs were associated with significantly poorer overall survival (OS) (p = 0.03, hazards ratio (HR) 3.01, 95% confidence interval (CI) 1.14-4.91). From the anatomical perspective, more extrahepatic CCA was detected in the AYA group. Microsatellite instability (MSI) occurred in 3% of older patients in the present study. Nevertheless, none of the AYAs had MSI status. In this study, AYAs gained an enhanced frequency of additional sex combs like 1 (ASXL1) (p = 0.02) and KMT2C (p = 0.02) mutation than their older counterparts. Besides ASXL1 and KMT2C, the genes enriched in AYAs with CCA were analyzed by pathway and process enrichment analysis. And those genes were found to be associated with poorer differentiation, deubiquitination, and WNT signal pathway. Moreover, AYAs were relevant to poor differentiation and advanced tumor stage.Conclusion: This study offered a preliminary landscape of the clinical and molecular features of early-onset biliary cancers. Further studies including more samples are essential to investigate whether ASXL1 and KMT2C could be considered as potentially targetable genomic signatures for young patients.

Induction of Truncating ASXL1 Mutations in Human CD34+ HSPCs Mimics Human ASXL1-Mutated Clonal Hematopoiesis and Progression to Myeloid Malignancies

Introduction: Mutations in additional sex combs like 1 (ASXL1) are recurrently found in myeloid malignancies including myelodysplastic syndromes (MDS) and acute myeloid leukemia (AML), but can also be found in pre-malignant states such as clonal hematopoiesis of indeterminate potential (CHIP). However, the mechanisms by which these mutations contribute to disease initiation and progression remain unresolved. Initial observations using murine models suggested a loss of function of the ASXL1 protein as relevant to disease. However more recently, several studies have suggested that recurrent mutations of ASXL1 result in a change-of function caused by a truncated ASXL1 protein. Most of these studies have been performed in a murine system and have used over-expression of truncated ASXL1. Methods: To interrogate the functional relevance of recurrent mutations in ASXL1 in human HSPCs, we generated a novel CRISPR/Cas9-mediated model that allows for the introduction of truncations or complete knockout of ASXL1 into CD34+ cord blood cells. Importantly, this is the first model which efficiently introduces these mutations into the native ASXL1 locus in human cord-blood and bone-marrow derived HSPCs while simultaneously introducing a fluorescent marker corresponding to the genotype, so individual cells can be tracked in vitro and in vivo. Results: Using this system, we demonstrate that truncated, but not deleted, ASXL1 shows a proliferative advantage, decreased ability to differentiate along the megakaryocyte and erythroid lineages, as well as increased serial replating in vitro. Interestingly, truncation of ASXL1 alone did not result in a myeloid differentiation block in vitro, in line with observations of mutant HSPCs in CHIP. In vivo, CD34+ cells harboring truncation of ASXL1 exhibited myeloid skewing and a proliferative advantage in competitive engraftment studies using a xenograft NSGS mouse model (both p&amp;lt;0.05). Human HSPCs expressing truncated ASXL1 showed polyclonal engraftment without development of overt myeloid disease or impaired lifespan in the majority of the host animals. However, similar to humans with ASXL1 CHIP, some of the engrafted animals (2/30) developed clonal expansion of ASXL1-truncated human HSPCs resulting in a myeloid-biased, proliferative disease-like state with infiltration of non-hematopoietic organs and severe cytopenia which ultimately led to shortened survival of affected mice. Functionally, ASXL1-truncated HSPCs displayed dysregulated gene expression with depletion of RUNX1, TAL1, and GATA1 target genes (Benjamini-Hochberg adjusted p&amp;lt;0.0001). In line with increased activity of the Polycomb repressive deubiquitinase complex, truncation of ASXL1, but not deletion, led to decreased H2AK119Ub in our system (MFI ratio 0.7 for truncated ASXL1 vs. control, p&amp;lt;0.05). Orthogonally, we were able to confirm these observations in several isogenic cell lines engineered to contain truncating ASXL1 mutations as well as correcting the mutation in ASXL1 found in K562 cells (Y591*) using CRISPR/Cas9. Finally, we aimed to determine whether the introduction of additional mutations commonly observed to co-occur with ASXL1 could alter the behavior of human HSPCs and their progression from healthy hematopoiesis to myeloid disease. Indeed, introduction of mutations in the native RUNX1 locus on the background of truncated ASXL1 showed aggressive expansion of immature myeloid progenitors in our xenograft model. This system allows us now to determine the relevant genomic target regions of truncated ASXL1 in human HSPCs, investigate the mechanism of action directly in the relevant biological system and identify therapeutic strategies targeting mutant ASXL1. Conclusion: In summary, our work demonstrates the utilization of a novel CRISPR/Cas9 model of human ASXL1-mutant HSPCs that closely resembles the phenotype seen in individuals with ASXL1 mutant CHIP and patients with myeloid malignancies carrying mutant ASXL1. Additionally, our model allows us to directly compare the deletion of ASXL1 with the truncation, adding to the evidence that truncated ASXL1 phenocopies pre-malignant and malignant hematopoiesis with recurrent ASXL1 mutations. Finally, we provide the first model for the spontaneous progression of pre-malignant human CHIP to myeloid malignancy, which should enable further studies of leukemogenesis and potentially disease prevention. Disclosures Majeti: FortySeven: Consultancy, Equity Ownership, Other: Board of Director; BioMarin: Consultancy.

Distal Enhancer Elements in ASXL1-Mutant Chronic Myelomonocytic Leukemia

Introduction: Additional Sex Combs-Like 1 (ASXL1) is a chromatin modifier frequently affected by truncating mutations in myeloid malignancies. These mutations are associated with poor survival outcomes and increased rates of acute leukemic transformation. In chronic myelomonocytic leukemia (CMML), ASXL1 mutations are thought to affect transcriptional activity mainly by modifying histone marks, however additional epigenomic mechanisms have not been fully explored. We interrogated the epigenome of patients with ASXL1-mutant (MT) and -wildtype (WT) CMML using a multiomics approach to define cis-regulatory elements (CREs) such as distal enhancers (DEs). Methods: Bone marrow mononuclear cells from patients with CMML were subjected to targeted NGS of DNA, whole transcriptome shotgun sequencing (RNA-seq), immunoprecipitation (IP) of DNA (hydroxy-)methyl residues (DIP-seq), IP of the histone modifications H3K4me1, H3K4me3, and H3K27me3 (ChIP-seq), and DNA transposase accessibility studies (ATAC-seq). After quality control all samples were sequenced on an Illumina HiSeq 4000 before further processing and data analysis. Global assessments of DNA (hydroxy-)methylation, DNA accessibility, and histone modifications between ASXL1 MT and WT CMML were performed. The samples in the two groups were treated as biological replicates and subjected to a consensus peak calling strategy requiring an overlap of at least 30% between samples and an adjusted p-value &lt; 5x10-5 for a signal peak to be considered statistically significant. Differential gene expression was estimated to define the up-regulated genes in ASXL1 MT CMML. Potential CREs were defined as sites with statistically significant signal peaks overlapping in at least two of the three epigenomic marks: H3K4me1, 5hmC, and ATAC. Potential DEs were defined as CREs in non-coding regions outside promoter regions (defined as transcription start site ±3kb) that were annotated in GeneHancer. Annotated DEs only present in ASXL1 MT but not WT CMML (specific DEs) were intersected with the list of up-regulated genes and the ReMap atlas. Results: Sixteen WHO-defined CMML patients were included, median age 69 years (48 - 77), 63% male; of which 8 patients (50%, all truncating frame shift mutations) were ASXL1 MT and 8 (50%) WT. The burden and spectrum of co-mutations was similar between ASXL1 WT and MT CMML (21 versus 23 per group; p = 0.684; heatmap). There was a predominant up-regulation of gene expression in ASXL1 MT CMML: 707 genes up- and 124 down-regulated (volcano plot, FDR &lt; 0.050 for all genes). There were 64336 potential CREs, the vast majority (97%) being present in both ASXL1 MT and WT CMML (left Venn diagram). These CREs were most commonly located in introns, promoter regions, and distal non-coding regions (bar graph and pie chart). There were 1303 CREs unique to ASXL1 MT CMML (specific DEs), 1161 (90%) of which were annotated in GeneHancer (left Euler diagram). Of these 1161 annotated specific DEs 859 (74%) were located outside promoter regions and 34 (4%) of them were known to be associated with genes up-regulated in ASXL1 MT CMML (Euler diagrams). These specific DEs were characterized by an increase in H3K4me1 occupancy and DNA accessibility (average signal tracks, purple bars indicating annotated DEs, thin bars below peaks indicating statistical significance). We previously observed epigenomic modification of promoter regions in 519 of the 707 up-regulated genes (73%) facilitating transcriptional activity in ASXL1 MT CMML. For 13 of the up-regulated genes (right Venn diagram, blue genes in volcano plot) the specific DEs were the sole identified mechanism, while for the other 21 genes there were additional mechanisms noted in the promoter region. The top five transcription factor candidates binding the 34 specific DEs included JMJD1C, MYC, KDM5B, RCOR1, and HDAC2 (-log10(E) &gt; 40 for all candidates). Conclusions: Using a multiomics approach based on H3K4me1, 5hmC, and ATAC data we identified potential CREs in ASXL1 MT CMML and characterized potential DEs using publicly available annotation data. Specific DEs were associated with up-regulated genes serving as a possible explanation for the observed transcriptional activity, shedding further light on the adverse prognostic impact associated with ASXL1 mutations. Figure 1 Disclosures Patnaik: Stem Line Pharmaceuticals.: Membership on an entity's Board of Directors or advisory committees.

Leukemogenic Functions of Mutant ASXL1 Are Regulated By CDK-Mediated Phosphorylation

Additional sex combs-like 1 (ASXL1) is recurrently mutated in various myeloid neoplasms and its mutations confer poor prognosis. Most of the ASXL1 mutations in myeloid malignancies are frameshift or nonsense mutations, leading to expression of C-terminally truncated form of ASXL1 (ASXL1-MT). Recently, we have demonstrated that monoubiquitination of ASXL1-MT at lysine 351 plays an important role in enhancing the catalytic activity of BAP1, resulting in reduction of H2AK119ub and upregulation of posterior HOXA genes to promote myeloid leukemogenesis (Asada et al. Nat commun. 2018). However, roles of other post-translational modifications of ASXL1 including phosphorylation remain to be elucidated. In this study, we performed nano liquid chromatography tandem mass spectrometry (nano LC-MS/MS) and found that ASXL1 was phosphorylated at multiple serine (S) and threonine (T) residues including S503 residue, the major phosphorylated site of ASXL1. We generated an antibody that specifically recognizes phosphorylated S503 of ASXL1, and showed that CDK1/2 phosphorylated both wildtype ASXL1 and ASXL1-MT. However, phosphorylation status of ASXL1-MT at serine 503 did not affect its oncogenic activity. Thus, we considered the possibility that phosphorylations of other residues would compensate the effects of phosphorylation of ASXL1-MT at serine 503. Using public database and our data from mass spectrometry, we found additional five S/T residues containing a CDK phosphorylation motif (S/T-P). We then established a non-phosphomimetic mutant form of ASXL1-MT (ASXL1-MT-6A) whose six S/T residues were substituted to alanine. To compare the oncogenic functions between ASXL1-MT-6A and ASXL1-MT, we first assessed the impact of these mutants on differentiation of hematopoietic cells. Expression of ASXL1-MT-6A more strongly impaired differentiation of human CD34+ cord blood (CB) cells towards granulocytes and erythrocytes than that of ASXL1-MT. These effects of ASXL1-MT-6A on differentiation block were also observed in HL-60 cells. Next, we assessed the impact of phosphorylation of ASXL1-MT on its leukemogenic functions using RUNX1-ETO and N-Ras G12V-induced leukemia models, because RUNX1-ETO fusion or N-Ras mutations frequently coexist with ASXL1 mutations in patients with myeloid neoplasms. In agreement with our previous report, expression of ASXL1-MT enhanced proliferation of RUNX1-ETO expressing CB cells. ASXL1-MT-6A showed the stronger growth promoting effect than ASXL1-MT in RUNX1-ETO expressing CB cells in vitro by inhibiting apoptosis and progressing cell cycle. Moreover, ASXL1-MT-6A induced more rapid development of myeloid leukemia driven by N-Ras G12V than ASXL1-MT in vivo. ASXL1-MT-6A induced upregulation of Hoxa5, Hoxa7 and Hoxa9 more strongly than ASXL1-MT in myeloid progenitor cells. These data indicated that ASXL1-MT-6A is an active form of ASXL1-MT. Mechanistically, cycloheximide chasing assay revealed that ASXL1-MT-6A had increased protein stability than ASXL1-MT. Furthermore, cell cycle synchronization and immunoprecipitation assay demonstrated that degradation of ASXL1 protein began at early M phase by interacting with Cdc20, one of the coactivators of anaphase-promoting complex (APC/C), an E3 ubiquitin ligase complex involved in regulating cell cycle progression. Overexpression of Cdc20 promoted degradation of ASXL1, whereas depletion of Cdc20 using CRISPR-Cas9 system increased expression of ASXL1. These biochemical features were also observed for ASXL1-MT. Intriguingly, ASXL1-MT-6A showed resistance to degradation induced by APC/CCdc20. Therefore, CDK-mediated phosphorylation of ASXL1-MT triggers its degradation induced by APC/CCdc20. Collectively, we demonstrated that stability and leukemogenic functions of ASXL1-MT are regulated by CDK-mediated phosphorylation. Dynamics of protein degradation of ASXL1-MT triggered by phosphorylation and ubiquitination could be targets for therapeutic interventions of myeloid neoplasms harboring an ASXL1 mutation. Disclosures No relevant conflicts of interest to declare.

Epigenomic Determinants of Transcriptional Activity in ASXL1-Mutant Chronic Myelomonocytic Leukemia

Introduction: Truncating mutations in the Additional Sex Combs-Like 1 (ASXL1) gene are associated with a proliferative disease phenotype and poor survival outcomes across the spectrum of myeloid malignancies including chronic myelomonocytic leukemia (CMML). ASXL1 is thought to act as a chromatin modifier regulating transcriptional activity, however the exact mechanisms and resulting chromatin states remain controversial. We interrogated the epigenome of 16 patients with ASXL1-mutant and -wildtype CMML using a multiomics approach. Methods: Bone marrow mononuclear cells from patients with CMML (8 ASXL1-mutant, 8 -wildtype) were subjected to targeted NGS of DNA, whole transcriptome shotgun sequencing (RNA-seq), immunoprecipitation (IP) of DNA (hydroxy-)methyl residues (DIP-seq), IP of the histone modifications H3K4me1, H3K4me3, and H3K27me3 (ChIP-seq), and DNA transposase accessibility studies (ATAC-seq). After quality control all samples were sequenced on an Illumina HiSeq 4000 before further processing and data analysis. Global assessments of DNA (hydroxy-)methylation, DNA accessibility, and histone modifications between ASXL1-mutant and -wildtype CMML were performed. Differential gene expression was performed to define the up-regulated genes in ASXL1-mutant disease. The promoter regions of these up-regulated genes (defined as transcription start site ±3kb) were compared using the aforementioned multiomics approach. Epigenomic modification of the promoter region facilitating up-regulation of transcription was defined as the presence of a signal peak in ASXL1-mutant disease (in the absence of a signal peak in -wildtype disease) or 25% increase in a common signal peak (H3K4me1/3, 5hmC), the presence of a unique signal peak in ASXL1-mutant disease (ATAC), or the absence of a signal peak in ASXL1-mutant disease (in the presence of a signal peak in -wildtype disease), or 25% decrease in a common signal peak (H3K27me3, 5mC). Results: Sixteen patients with CMML, median age 69 years (48 - 77), 63% male, were included. Half of the patients had proliferative disease (pCMML) and half of them had truncating frameshift mutations in ASXL1 (heatmap). All ASXL1 variant allele frequencies were compatible with heterozygosity (31 - 48%). The burden of co-mutations was similar between ASXL1-wildtype and ASXL1-mutant disease (21 versus 23 per group; no difference in the median number of co-mutations, p = 0.684). The spectrum of co-mutations was typical for CMML, involving spliceosome components, epigenetic regulators, chromatin regulators, and cell signaling molecules (heatmap). There was a predominant up-regulation of gene expression in ASXL1-mutant patients: 707 genes up- and 124 down-regulated (volcano plot, FDR &lt; 0.05 for all genes). Functional annotation of the up-regulated genes showed cell division, mitotic nuclear division, sister chromatid cohesion, DNA replication, and G1/S transition to be the 5 most enriched processes (accounting for 29% of all up-regulated genes, FDR &lt; 1x10-10 for all terms). The up-regulated genes included several potential therapeutic targets and HOXA family members (including HOXA9). There were global increases in H3K4me1/3, 5mC, and 5hmC, decreases in H3K27me3, as well as a more relaxed chromatin conformation (bar graphs). Many of these epigenomic changes affected non-coding regions. When focusing on the promoter regions of the 707 up-regulated genes there was evidence of one or more of the interrogated epigenomic mechanisms facilitating transcription for 519 of the genes (73%). The most abundant mechanism was histone modification, followed by changes in DNA (hydroxy-)methylation, and increased chromatin accessibility, with considerable overlap (Venn diagram). For HOXA9, a known driver of leukemogenesis, the data supported a loss of H3K27me3 as the most prominent among the interrogated epigenomic regulatory mechanisms (average signal tracks). Conclusions: The transcriptome and chromatin conformation of ASXL1-mutant CMML are skewed towards proliferation and mirror the aggressive disease phenotype observed in practice. There is evidence of histone modification as well as changes in DNA methylation, and chromatin conformation facilitating transcriptional activity including known leukemogenic drivers. Additional regulatory mechanisms such as gene body methylation and enhancer elements require further exploration. Figure Disclosures Patnaik: Stem Line Pharmaceuticals.: Membership on an entity's Board of Directors or advisory committees.

Homeobox Transcription Factor Hhex Promotes Myeloid Leukemia in Cooperation with Mutant ASXL1

Additional sex combs-like 1 (ASXL1) mutations are frequently found in myeloid malignancies such as AML, MDS and MPNs. Our previous study on mutant Asxl1 expressing knock-in (Asxl1-MT KI) mice revealed that Asxl1-MT impaired normal hematopoiesis (Nagase R et al. J. Exp. Med. 2018). However, Asxl1-MT alone was insufficient to develop myeloid leukemia. Thus, additional factors are required for myeloid transformation in ASXL1-mutated cells. Retrovirus-mediated insertional mutagenesis approaches demonstrated susceptibility of Asxl1-MT KI cells to myeloid leukemia, and helped identifying Hematopoietically expressed homeobox (Hhex) gene as a common retrovirus integration site. Therefore, we here investigated the potential cooperation between ASXL1-MT and HHEX in myeloid leukemogenesis. We first assessed the effects of ASXL1-MT and HHEX on proliferation and differentiation of murine and human hematopoietic stem progenitor cells (HSPCs). Expression of HHEX enhanced proliferation and blocked differentiation of HSPCs expressing ASXL1-MT, while it showed only a modest effect in normal HSPCs. Some of the mice transplanted with cells expressing ASXL1-MT and HHEX developed myeloid leukemia. Expression of ASXL1-MT and HHEX dramatically promoted the growth of RUNX1-ETO-expressing Cord Blood (CB) cells in vitro by promoting cell cycle and inhibiting apoptosis. Moreover, ASXL1-MT and HHEX synergistically accelerated development of two distinct types of myeloid leukemia driven by RUNX1-ETO9a or FLT3-ITD in vivo. These data indicate that ASXL1-MT and HHEX cooperatively work in leukemic transformation of myeloid cells. Next, we evaluated the role of endogenous HHEX in ASXL1-MT-expressing leukemia cells. We here used two murine mutant ASXL1-expressing leukemia cells (cSAM cells: cells with combined expression of SETBP1 and ASXL1 mutations, cRAM cells: cells with combined expression of RUNX1 and ASXL1 mutations). Depletion of Hhex using CRISPR-Cas9 system profoundly attenuated the colony-forming ability and leukemogenicity of cSAM and cRAM cells. Similarly, depletion of HHEX attenuated the growth of human leukemia cell lines harboring an ASXL1 mutation including MEG-01 and Kasumi-1 by inducing apoptosis and differentiation. In contrast, the growth of ASXL1 wildtype cell lines such as THP-1 and U937 was unaffected by HHEX depletion. Thus, endogenous HHEX promotes survival of ASXL1-mutated leukemia cells. To elucidate the underlying molecular mechanisms, we performed RNA-seq using RUNX1-ETO expressing CB cells. Gene set enrichment analysis revealed that genes related to leukemia stem cells were more enriched in cells expressing both ASXL1-MT and HHEX than control cells. In combination with this RNA-seq data and ChIP-seq using 293T cells, we identified Myb and Etv5 as candidate genes upregulated by HHEX expression. We confirmed that ASXL1-MT and HHEX upregulated Myb and Etv5 in murine HSPCs by RT-qPCR and HHEX bound to promoter regions of MYB and ETV5 genes in HL-60 cells by ChIP-qPCR. Conversely, depletion of Hhex reduced expression of Myb and Etv5 in cSAM and cRAM cells. Luciferase reporter assay revealed that co-expression of ASXL1-MT and HHEX cooperatively enhanced promoter activity of MYB. In addition, preliminary expression analyses of primary cells showed that HHEX/ETV5 mRNA expression levels were significantly and MYB mRNA expression tended to be higher in primary AML samples including ASXL1 mutations compared to the ones of healthy controls (Beat AML). Finally, we assessed the role of MYB or ETV5 in leukemogenesis driven by ASXL1 mutations. Depletion of Myb or Etv5 reduced colony-forming activity in cSAM and cRAM cells by promoting apoptosis or differentiation, respectively. Furthermore, ectopic expression of MYB or ETV5 significantly reversed the reduced colony-forming activity of Hhex-depleted cSAM cells. Taken together, our study demonstrates that ASXL1-MT and HHEX are cooperative events promoting myeloid leukemogenesis through upregulation of MYB and ETV5. Disclosures Maciejewski: Novartis: Consultancy; Alexion: Consultancy.

Impact of Mutations in Epigenetic Modifiers in Acute Myeloid Leukemia: A Systematic Review and Meta-Analysis

Objectives: Mutations in epigenetic modifiers including IDH (Isocitrate dehydrogenase), DNMT3A (DNA Methyltransferase 3 Alpha), TET2 (Ten-Eleven Translocation 2), ASXL1 (Additional Sex Combs-Like 1), and EZH2 (Enhancer of Zeste Homolog 2) have been recently recognized in patients with Acute Myeloid Leukemia (AML). The DNMT3A and IDH were found to be associated with poor prognosis in most studies; however, there is no meta-analysis evaluating other mutations in the epigenetic modifiers. We performed a systematic review and meta-analysis to evaluate the prognostic significance of mutations in the epigenetic modifiers on the Overall Survival (OS) of patients with AML. Methods: We searched for studies evaluating epigenetic mutations in AML (up to August 2018) in PubMed. Two reviewers independently screened all citations and later abstracted data using a common data collection form. Risk of bias was assessed using Newcastle-Ottawa Scale (NOS) and Cohen kappa coefficient (k) was calculated to assess the agreement. Hazard ratio (HR) and 95% confidence interval (CI) of outcomes were extracted and random effects model was used to pool the results. Statistical heterogeneity was calculated using Cochran I2 and tested using chi-squared tests. Results: A total of 9543 citations were retrieved from the search strategy; of which 9415 were excluded after title screening and 37 articles were excluded after abstract screening. A review of full text excluded additional 49 articles for incomplete data and missing analysis on OS. Forty-two articles were identified for the systematic review and meta-analysis (IDH n=15, DNMT3A n=12, TET2 n=8, ASXL1 =7), all of which were fair to good quality studies based on the NOS. The analysis of IDH mutation included 15 articles covering 5100 patients with a median age of 55 years. The frequency of IDH mutations ranged from 7 to 33%. The pooled HR indicated that IDH mutation conferred significantly worse OS (HR = 1.54; 95% CI: 1.15-2.06) though with a substantial heterogeneity (I2 = 85%). Mutation analysis of DNMT3A was based on 12 articles including 5418 patients with a median age of 52 years. The proportion of patients with this mutation ranged from 14 to 34%. Results indicated a worse OS with a pooled HR of 1.35; 95% CI 1.16-1.56, and a substantial heterogeneity (I2=71%). For the ASXL1 mutation, our analysis included 4115 adult and pediatric patients from 7 studies. The pooled HR indicated that ASXL1 mutation conferred a significantly worse OS (HR = 1.88; 95% CI: 1.49‒2.36); however, with a moderate heterogeneity (I2 = 43%). The TET2 mutation analysis was based on eight studies with a total of 3286 patients. The pooled HR indicated that TET2 mutation conferred a significantly worse OS (HR = 1.39; 95% CI: 1.18‒1.63); with a low heterogeneity (I2 = 28%). Conclusions: Epigenetic mutations in IDH, DNMT3A, ASXL1 and TET2 adversely impact OS in patients with AML. These mutations in the epigenetic modifiers should be considered in the initial evaluation of patients with AML and in the decision on post induction management. Disclosures Al-Khabori: Shire (Takeda): Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; SOBI: Honoraria; AstraZeneca: Honoraria; NovoNardisk: Membership on an entity's Board of Directors or advisory committees; Roche: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Servier: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Loss of Asxl1 Cooperates with Oncogenic Nras to Drive CMML Progression

Chronic myelomonocytic leukemia (CMML) belongs to the group of "mixed myelodysplastic/myeloproliferative neoplasm". There is currently no effective chemotherapy to treat CMML. Approximately 30% of CMML cases evolve to acute myeloid leukemia (AML) soon after their initial diagnosis, contributing to the poor prognosis of CMML patients. Ras pathway genes are frequently mutated in CMML patients (NRAS:11%; CBL:10%; KRAS:8%). Our whole exome sequencing of CMML patient samples and targeted sequencing of CMML patient-derived myeloid colonies showed that oncogenic NRAS could serve as an initiating or progression mutation. Consistent with human genetics, all the oncogenic Nras mice we and others characterized (NrasG12D/+, NrasG12D/G12D, and NrasQ61R/+), develop myeloproliferative (MP)-CMML like phenotypes.However, oncogenic NRAS alone is insufficient to drive CMML progression or transformation to AML. Additional sex combs-like 1 (ASXL1) is a human homolog of fly Asx. Mutations in ASXL1are predominantly nonsense and frequently identified in all myeloid malignancies (e.g. 40% in CMML). ASXL1mutations predict inferior overall survival in univariable analysis in multiple large CMML cohort studies and are significantly associated with NRASmutations in CMML patients. Therefore, we hypothesize that loss of Asxl1 cooperates with oncogenic Nrasto drive CMML progression. To test our hypothesis, we used Vav-Cre to drive oncogenic Nras expression and/or Asxl1 deletion in hematopoietic system. We refer these mice as NrasG12D/+, Asxl1-/-and NrasG12D/+;Asxl1-/-(NA) mice. Consistent with the literature, Asxl1-/-mice are normal at 6-week old. NrasG12D/+ mice showed mild CMML-like phenotypes, including enlarged spleen, increased white blood cell and monocyte counts, and expanded LSKs (Lin-Sca-1+c-Kit+) and myeloid progenitors (MPs). Compared to NrasG12D/+ mice, NA mice showed more sever phenotypes that were associated with hyperactivated ERK signaling in MPs at both basal level and upon GM-CSF stimulation. Our new NrasG12D/+mice developed a fully penetrant MP-CMML with the median survival of ~430 days. Loss of Asxl1 significantly shortened the median survival of NrasG12D/+ mice to 220 days. Half of NA mice displayed CMML transformation to AML. The transformed AML was serially transplantable to recipients. To investigate the mechanism(s) underlying NA-driven CMML/AML, we performed RNA-Seq analysis in Lin- c-Kit+BM cells from age-matched control, Asxl1-/-, NrasG12D/+, and moribund NA mice with CMML or AML phenotypes. We found 844 differentially expressed genes (DEG) in AML cells compared to control cells (FDR&lt;0.05 and fold change&gt;2). Among these genes, 341 are common between NA and published Nf1+/-;Asxl1+/-AML cells, including AP-1 complex genes (Jun, Junb, Jund and Fosb) that are crucial for malignant propagation in several AML subtypes. The remaining 503 genes are unique in NA AML, including Flt3, one of the mostly mutated genes in AML. These data suggest that our NA AML model demonstrates some distinct mechanisms from Nf1+/-;Asxl1+/-model. In-depth analysis of RNA-seq data is still ongoing. We also examined multiple histone marks using Western blot in BM cells of 6-week old mice. Our data showed that levels of H3K4me3, H3K4me1, and H3K27me3 were downregulated in Asxl1-/-cells, whereas H3K27Ac level was comparable to that of control cells. In contrast, H3K27Ac level was upregulated in NrasG12D/+and NA cells, while levels of H3K4me3, H3K4me1, and H3K27me3 were indistinguishable from those of control cells. BRD4 is a member of the BET family of bromodomain-containing proteins that binds to acetylated histones to activate gene transcription. Thus, we hypothesized that Ras/MEK/ERK signaling and BRD/BET are potential targets to inhibit AML progression. To test this hypothesis, we treated the AML cells and BMT recipients using trametinib (a MEK inhibitor approved by FDA to treat melanoma) and GSK525762 (a pan BET inhibitor under clinical development). We demonstrated thatcombined treatment significantly inhibited the growth of leukemia cells in vitro and prolonged the survival of recipients in vivo. It was more effective than single agent alone. Overall, we established a novel CMML/AML mouse model, which represents a significant group of CMML patients with poor prognosis. Our study provides a strong rational to treat these patients with combined MEK and BET inhibition. Disclosures Patnaik: Stem Line Pharmaceuticals.: Membership on an entity's Board of Directors or advisory committees.

Abstract 4643: Mutant ASXL1 collaborates with HHEX to promote myeloid leukemogenesis

Abstract An epigenetic modulator Additional sex combs-like 1 (ASXL1) is recurrently mutated in myeloid neoplasms and its mutations are associated with poor prognosis. Recently, we generated mutant Asxl1 conditional knock-in (Asxl1-MT KI) mice mimicking human ASXL1 E635RfsX15 mutation, one of the most common mutations in myeloid neoplasms (Nagase et al. JEM 2018). Retrovirus-mediated insertional mutagenesis study exhibited susceptibility of Asxl1-MT KI bone marrow cells to myeloid leukemia, and we identified Hematopoietically expressed homeobox (Hhex) gene as one of the common retrovirus integration sites. In this study, we investigated the potential cooperation between the mutant ASXL1 and HHEX in myeloid leukemogenesis. We first performed colony-forming assay and found that forced expression of HHEX enhanced colony replating activity and blocked myeloid differentiation in bone marrow hematopoietic stem progenitor cells (HSPCs) derived from ASXL1-MT KI mice, while it showed only modest effect in normal HSPCs. The synergistic effect between the mutant ASXL1 and HHEX in blocking myeloid differentiation was also observed in human HL-60 cells. We next evaluated the role of endogenous Hhex in the mutant ASXL1-expressing cells. Depletion of endogenous Hhex using CRISPR-Cas9 system ameliorated mutant ASXL1-induced differentiation block in 32Dcl3 cells. Depletion of endogenous Hhex in murine mutant ASXL1-expressing leukemia cells [cSAM cells: cells with combined expression of SETBP1 and ASXL1 mutations (Inoue et al. Leukemia 2015), cRAM cells: cells with combined expression of RUNX1 and ASXL1 mutations (Nagase et al. JEM 2018)] also promoted differentiation and increased apoptosis. Furthermore, Hhex deletion profoundly attenuated the colonogenicity of cSAM and cRAM cells and leukemogenicity of cSAM cells. We then investigated target genes of the mutant ASXL1 and HHEX in myeloid neoplasms using public database and our previous RNA-Seq data. Among the potential target genes of the mutant ASXL1 and HHEX, we found that Myb, Etv5 and Oraov1 genes were upregulated by the mutant ASXL1 and HHEX in murine HSPCs. Conversely, Hhex depletion resulted in downregulation of these genes both in cSAM and cRAM leukemic cells. In addition, depletion of Myb, Etv5 or Oraov1 genes significantly abrogated the colonogenicity of cSAM cells. These data suggest that mutant ASXL1 and HHEX cooperatively induce myeloid leukemogenesis via dysregulating Myb, Etv5 and Oraov1. Citation Format: Shuhei Asada, Reina Takeda, Daichi Inoue, Susumu Goyama, Toshio Kitamura. Mutant ASXL1 collaborates with HHEX to promote myeloid leukemogenesis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 4643.

Pathological ASXL1 Mutations and Protein Variants Impair Neural Crest Development.

SummaryThe neural crest (NC) gives rise to a multitude of fetal tissues, and its misregulation is implicated in congenital malformations. Here, we investigated molecular mechanisms pertaining to NC-related symptoms in Bohring-Opitz syndrome (BOS), a developmental disorder linked to mutations in the Polycomb group factor Additional sex combs-like 1 (ASXL1). Genetically edited human pluripotent stem cell lines that were differentiated to NC progenitors and then xenotransplanted into chicken embryos demonstrated an impairment of NC delamination and emigration. Molecular analysis showed that ASXL1 mutations correlated with reduced activation of the transcription factor ZIC1 and the NC gene regulatory network. These findings were supported by differentiation experiments using BOS patient-derived induced pluripotent stem cell lines. Expression of truncated ASXL1 isoforms (amino acids 1–900) recapitulated the NC phenotypes in vitro and in ovo, raising the possibility that truncated ASXL1 variants contribute to BOS pathology. Collectively, we expand the understanding of truncated ASXL1 in BOS and in the human NC.

The role of ASXL1 in hematopoiesis and myeloid malignancies.

Recent high-throughput genome-wide sequencing studies have identified recurrent somatic mutations in myeloid neoplasms. An epigenetic regulator, Additional sex combs-like 1 (ASXL1), is one of the most frequently mutated genes in all subtypes of myeloid malignancies. ASXL1 mutations are also frequently detected in clonal hematopoiesis, which is associated with an increased risk of mortality. Therefore, it is important to understand how ASXL1 mutations contribute to clonal expansion and myeloid transformation in hematopoietic cells. Studies using ASXL1-depleted human hematopoietic cells and Asxl1 knockout mice have shown that deletion of wild-type ASXL1 protein leads to impaired hematopoiesis and accelerates myeloid malignancies via loss of interaction with polycomb repressive complex 2 proteins. On the other hand, ASXL1 mutations in myeloid neoplasms typically occur near the last exon and result in the expression of C-terminally truncated mutant ASXL1 protein. Biological studies and biochemical analyses of this variant have shed light on its dominant-negative and gain-of-function features in myeloid transformation via a variety of epigenetic changes. Based on these results, it would be possible to establish novel promising therapeutic strategies for myeloid malignancies harboring ASXL1 mutations by blocking interactions between ASXL1 and associating epigenetic regulators. Here, we summarize the clinical implications of ASXL1 mutations, the role of wild-type ASXL1 in normal hematopoiesis, and oncogenic functions of mutant ASXL1 in myeloid neoplasms.