Heterogeneity Of Acute Myeloid Leukemia Research Articles

Mutation Patterns Predict Drug Sensitivity in Acute Myeloid Leukemia.

The inherent genetic heterogeneity of acute myeloid leukemia (AML) has challenged the development of precise and effective therapies. The objective of this study was to elucidate the genomic basis of drug resistance or sensitivity, identify signatures for drug response prediction, and provide resources to the research community. We performed targeted sequencing, high-throughput drug screening, and single-cell genomic profiling on leukemia cell samples derived from patients with AML. Statistical approaches and machine learning models were applied to identify signatures for drug response prediction. We also integrated large public datasets to understand the co-occurring mutation patterns and further investigated the mutation profiles in the single cells. The features revealed in the co-occurring or mutual exclusivity pattern were further subjected to machine learning models. We detected genetic signatures associated with sensitivity or resistance to specific agents, and identified five co-occurring mutation groups. The application of single-cell genomic sequencing unveiled the co-occurrence of variants at the individual cell level, highlighting the presence of distinct subclones within patients with AML. Using the mutation pattern for drug response prediction demonstrates high accuracy in predicting sensitivity to some drug classes, such as MEK inhibitors for RAS-mutated leukemia. Our study highlights the importance of considering the gene mutation patterns for the prediction of drug response in AML. It provides a framework for categorizing patients with AML by mutations that enable drug sensitivity prediction.

Approach to Acute Myeloid Leukemia with Increased Eosinophils and Basophils

There is remarkable morphologic and genetic heterogeneity in acute myeloid leukemia (AML). In a small percentage of cases of AML, increased eosinophils and/or basophils are present in the bone marrow and sometimes in the peripheral blood. This is often a puzzling diagnostic situation but also an important finding that requires special investigation. Unique chromosomal rearrangements have been correlated with an increased number of eosinophils and basophils in AML. The identification of the underlying genetic lesion that promotes eosinophilia and basophilia can dramatically change both the prognosis and the treatment of the patient. Thus, clinicians must be vigilant in searching for the cause of eosinophilia and basophilia in patients with AML, since the different causes may lead to different treatments and survival outcomes. In this article, we examine the significance of increased eosinophils and/or basophils in the context of AML, provide guidance that simplifies the differential diagnosis, and give prognostic and therapeutic information about specific subtypes of AML associated with eosinophilia and/or basophilia. Evidence supporting personalized (molecularly targeted) therapy for these patients is also presented.

Metabolomic profile of acute myeloid leukaemia parallels of prognosis and response to therapy

The heterogeneity of acute myeloid leukemia (AML), a complex hematological malignancy, is caused by mutations in myeloid cells affecting their differentiation and proliferation. Thus, various cytogenetic alterations in AML cells may be characterized by a unique metabolome and require different treatment approaches. In this study, we performed untargeted metabolomics to assess metabolomics differences between AML patients and healthy controls, AML patients with different treatment outcomes, AML patients in different risk groups based on the 2017 European LeukemiaNet (ELN) recommendations for the diagnosis and management of AML, AML patients with and without FLT3-ITD mutation, and a comparison between patients with FLT3-ITD, CBF-AML (Core binding factor acute myelogenous leukemia), and MLL AML (mixed-lineage leukemia gene) in comparison to control subjects. Analyses were performed in serum samples using liquid chromatography coupled with mass spectrometry (LC–MS). The obtained metabolomics profiles exhibited many alterations in glycerophospholipid and sphingolipid metabolism and allowed us to propose biomarkers based on each of the above assessments as an aid for diagnosis and eventual classification, allowing physicians to choose the best-suited treatment approach. These results highlight the application of LC–MS-based metabolomics of serum samples as an aid in diagnostics and a potential minimally invasive prognostic tool for identifying various cytogenetic and treatment outcomes of AML.

The future paradigm of HMA + VEN or targeted inhibitor approaches: sequencing or triplet combinations in AML therapy.

The routine use of next-generation sequencing methods has underscored the genetic and clonal heterogeneity of acute myeloid leukemia (AML), subsequently ushering in an era of precision medicine-based targeted therapies exemplified by the small-molecule inhibitors of FLT3, IDH1/IDH2, and BCL2. This advent of targeted drugs in AML has broadened the spectrum of antileukemic therapies, and the approval of venetoclax in combination with a hypomethylating agent has been a welcome addition to our AML patients unable to tolerate intensive chemotherapy. Mounting evidence demonstrates that molecularly targeted agents combined with epigenetic therapies exhibit synergistic augmented leukemic cell kill compared to single-agent therapy. With such great power comes greater responsibility in determining the appropriate frontline AML treatment regimen in a molecularly defined subset and identifying safe and effective combination therapies with different mechanisms of action to outmaneuver primary and secondary resistance mechanisms in AML.

A nomogram based on clinical features and molecular abnormalities for predicting the prognosis of patients with acute myeloid leukemia.

The high clinical and molecular heterogeneity of acute myeloid leukemia (AML) has led to an unsatisfactory clinical prognosis, thus we sought to incorporate both clinical features and molecular abnormalities to construct a new prognostic model. A database search of the Gene Expression Omnibus (GEO) revealed 238 cases of adult AML. The independent risk factors were assessed using both univariate and multivariate Cox regression, as well as least absolute shrinkage and selection operator (LASSO) regression. The predictive accuracy, discriminatory power and clinical applicability of the nomogram were determined by the consistency index (C-index), calibration curves and decision curve analysis (DCA). In addition, a single-centre cohort of 135 cases was used for external validation. Multivariate Cox regression analysis showed that the independent influences on overall survival (OS) were age, type of disease, DNMT3A, IDH2 and TP53 mutations. The area under the curve (AUC) values for the training set were 0.755, 0.745 and 0.757 at 1, 2 and 3 years respectively; the AUC for the validation set were 0.648, 0.648 and 0.654 at 1, 2 and 3 years; and the AUC for the northwest China set were 0.692, 0.724 and 0.689 at 1, 2 and 3 years. The calibration and DCA indicated good consistency and clinical utility of the nomogram. Finally, younger (age <60 years) and elderly (age ≥60 years) patients were each divided into two risk groups with significantly different survival rates. A nomogram consisting of five risk factors was developed for forecasting the prognosis of AML with guaranteed reliability.

Label-Free Identification of Biochemical Footprints of Key Mutations in Acute Myeloid Leukemia Using Raman Spectroscopy

Introduction: With increasing understanding of the complexity and heterogeneity of acute myeloid leukemia (AML), the diagnostic process becomes more complicated and time-consuming. Therefore, there is a need to supplement AML diagnostics with a quick method to identify key, druggable genetic lesions that serve as a target for small molecule drugs. To address this need, we used Raman spectroscopy (RS)-based imaging methods. RS uses non-elastic scattering of laser light on cell biomolecules. When coupled to computational image segmentation and analysis, composition of the analyzed fragment of the cytoplasm can be characterized. In this way, by mapping the focal surface of the cell, we obtain a multidimensional image containing information about the distribution of its biochemical components. In our study, we utilized RS microscopy to investigate how single mutations affect the Raman spectral images of leukemic cells. The primary objective was to determine whether this technique could be utilized to identify mutations in key genes related to leukemia development. Methods: Genetic models of AML were generated by introducing wild-type and mutated forms of three frequently mutated and/or druggable genes (FLT3, IDH1/2, and MLL) into myeloid cell lines (THP1, HEL, HL60). The presence of the desired phenotype was confirmed using flow cytometry, immunoblotting, high-throughput kinase activity assay (Pamgene), and confocal microscopy. For RS experiments, the cells were fixed, and subjected to Raman imaging measurements using the WITec Alpha 300 microscope. Reference or control samples consisted of cells with wild-type genes (WT). The recorded hyperspectral data was subjected to multidimensional chemometric analysis, including k-means cluster analysis (KMCA), principal component analysis (PCA) and partial least squares discriminant analysis (PLS-DA). To validate the findings from the cell models, primary AML cells from 30 patients diagnosed with FLT-3 ITD, MLL or IDH1/2 mutations were examined with RS. Peripheral blood mononuclear cells (PBMC) isolated from healthy donors blood served as reference. Results: The spectral differences between cells with wild-type FLT3 and FLT3/ITD were subtle, yet significant. The results revealed distinct variances in lipid (1440, 1240, 1660, and 2850 cm -1) and hemoprotein content (740-760 cm -1). Additionally, we successfully distinguished cells harboring IDH1/2 and MLL mutations from those with the wild-type genes. In these cases Raman bands corresponding to protein and nucleic acids composition were changed in comparison to control cells. Raman features in PCA loadings were also related to proteins and nucleic acids. Using the PLS-DA method and simple AI model, we built successful algorithm for distinguishing transgenic models carrying mutation from wild-type cells. PCA analysis also enabled us to distinguish AML primary cells from PBMC. Analysis weather primary cells carrying the selected mutations can be distinguished from non-mutated AML cells is concordant with our findings on models, however, it requires further analysis in larger group of patients to increase statistical power of these observations. Conclusions: Collectively, these findings suggest that Raman spectroscopy coupled with appropriate chemometric analysis may serve as rapid, label-free tool for identification of key druggable mutations in AML. Acknowledgements: The studies were performed as a part of the “ Label-free and rapid optical imaging, detection and sorting of leukemia cells” project carried out within the Team-Net programme of the Foundation for Polish Science co-financed by the European Union under the European Regional Development Fund.

Phase Separation Mediates RUNX1- Mutation Leukemic Transformation

B ackground : The high degree of genetic heterogeneity in acute myeloid leukemia (AML) leads to refractory or relapse in some patients, so it is important to deepen the mechanistic studies and find specific drug targets.As a classical regulatory molecule associated with AML, the absence or down-regulation of RUNX1 can lead to the development of AML. Liquid-liquid phase separation is closely related to the occurrence and development of the disease, and it is not clear whether RUNX1 can participate in the pathogenesis of AML through phase separation. This study is the first to explore the involvement of RUNX1 in the pathogenesis of AML from the perspective of phase separation. Methods: The fluorescent expression of RUNX1 was detected by immunofluorescence. The extracellular phase separation of RUNX1 and the mutants were studied by prokaryotic expression of the target protein RUNX1. The intracellular phase separation of RUNX1 was studied by cellular transfection and live-cell imaging. The cellular differentiation ability after phase separation of AML cell lines was investigated by using Rachel Giemsa staining and flow cytometry. The specific mechanism of RUNX1 phase separation regulation of downstream target molecules was examined by Co-IP coupled with mass spectrometry and Western Blot. The effect of RUNX1 phase separation on the pathogenesis of AML was studied by using the AML mouse model. Results: In this study, we firstly confirmed that RUNX1 showed obvious spot aggregation during hematopoietic differentiation. We then confirmed that RUNX1 can perform liquid-liquid phase separation both in vitro and intracellularly. Furthermore, based on the structural domain of RUNX1 and the RUNX1 mutation sites in AML patients, it was confirmed that the IDR region of RUNX1 drove occurrence of phase separation, while the RHD region had an inhibitory effect on phase separation, and the RUNX1 point mutants associated with poor prognosis of AML had abnormal phase separation.The occurrence of phase separation of RUNX1 could regulate the differentiation function of AML cells, and the differentiation of AML cells in the phase separation-deficient type was inhibited. Transcriptome sequencing results showed that RUNX1 phase separation promoted the enrichment of signaling pathways such as cell differentiation, and it was also found that RUNX1 phase separation promoted downstream target molecules to participate in the regulation of AML cell function. In addition, we demonstrated that aberrant RUNX1 phase separation was involved in the pathogenesis of AML in the mouse model of AML. Conclusion: This study reveals for the first time that RUNX1 liquid-liquid phase separation is involved in the process of AML occurrence and development, and refines the functional regulation mechanism of RUNX1, providing new ideas for AML targeted therapy.

Higher expression of programmed cell death 4 (PDCD4) in acute myeloid leukemia is associated with better prognosis after chemotherapy.

Acute myeloid leukemia (AML) is a common heterogeneous malignancy. Novel molecular markers aid diagnosis, patient sub-categorization, and optimal clinical decisions. Here, we explored the prognostic implications associated with the expression of the programmed cell death (PDCD) family of molecules in AML patients. Based on the findings from the TCGA and OHSU cohorts, we observed that the mRNA abundance of PDCD4 is significantly higher compared to other molecules within the PDCD family. Furthermore, high expression of PDCD4 was associated with predicted long-term patient survival in diagnosed AML patients. In the chemotherapy group, patients with high PDCD4 expression showed a tendency toward longer overall survival (OS) (P = 0.0266) and event-free survival (EFS) (P = 0.0008). High PDCD4 levels served as a favorable independent predictor for both OS and EFS in AML patients. However, subgroup analyses in the hematopoietic stem cell transplantation (HSCT) group revealed no significant difference in OS or EFS between individuals with high and low PDCD4 expression. Furthermore, in the low PDCD4 expression group, AML patients who underwent HSCT experienced improved survival outcomes (P = 0.0015), helping to mitigate the unfavorable prognosis associated with PDCD4 downregulation. Conversely, in the high PDCD4 expression group, HSCT offered a notable short-term survival advantage, while patients with high PDCD4 expression responded favorably to long-term survival through chemotherapy. Biological function enrichment showed that the expression of PDCD4 was correlated with complement and coagulation cascades, cell receptor signaling pathways, and cholesterol metabolism. The findings from this study will aid in better categorizing heterogeneous AML patients and guiding more appropriate clinical decision-making.

Real-Time Characterization of Clonal Fate Decisions in Complex Leukemia Samples by Fluorescent Genetic Barcoding.

Clonal heterogeneity in acute myeloid leukemia (AML) forms the basis for treatment failure and relapse. Attempts to decipher clonal evolution and clonal competition primarily depend on deep sequencing approaches. However, this prevents the experimental confirmation of the identified disease-relevant traits on the same cell material. Here, we describe the development and application of a complex fluorescent genetic barcoding (cFGB) lentiviral vector system for the labeling and subsequent multiplex tracking of up to 48 viable AML clones by flow cytometry. This approach allowed the visualization of longitudinal changes in the in vitro growth behavior of multiplexed color-coded AML clones for up to 137 days. Functional studies of flow cytometry-enriched clones documented their stably inherited increase in competitiveness, despite the absence of growth-promoting mutations in exome sequencing data. Transplantation of aliquots of a color-coded AML cell mix into mice revealed the initial engraftment of similar clones and their subsequent differential distribution in the animals over time. Targeted RNA-sequencing of paired pre-malignant and de novo expanded clones linked gene sets associated with Myc-targets, embryonic stem cells, and RAS signaling to the foundation of clonal expansion. These results demonstrate the potency of cFGB-mediated clonal tracking for the deconvolution of verifiable driver-mechanisms underlying clonal selection in leukemia.

GSK3 inhibitor enhances gemtuzumab ozogamicin-induced apoptosis in primary human leukemia cells by overcoming multiple mechanisms of resistance.

In acute myeloid leukemia (AML), the heterogeneity of genetic and epigenetic characteristics makes treatment difficult. The prognosis for AML is therefore poor, and there is an urgent need for new treatments for this condition. Gemtuzumab ozogamicin (GO), the first antibody-drug conjugate (ADC), targets the CD33 antigen expressed in over 90% of AML cases. GO therefore has the potential to counter the heterogeneity of AML patients. However, a major clinical problem is that drug resistance to GO diminishes its effect over time. Here, we report that the inhibition of glycogen synthase kinase 3 (GSK3) alone overcomes several forms of GO resistance at concentrations without antileukemic effects. The GSK3 inhibitors tested significantly enhanced the cytotoxic effect of GO in AML cell lines. We elucidated four mechanisms of enhancement: (1) increased expression of CD33, the target antigen of GO; (2) activation of a lysosomal function essential for hydrolysis of the GO linker; (3) reduced expression of MDR1 that eliminates calicheamicin, the payload of GO; and (4) reduced expression of the anti-apoptotic factor Bcl-2. A similar combination effect was observed against patient-derived primary AML cells. Combining GO with GSK3 inhibitors may be efficacious in treating heterogeneous AML.

Abnormal DNA Damage Response Suggests Novel Fingerprint of Relapse in Acute Monocytic Leukemia Post Transplantation

Background The heterogeneity of acute myeloid leukemia plays an important role in the development of drug resistance. Minimal residual disease is the major cause of relapse for the patients who already received chemotherapy and stem cell transplantation. Some rare subgroups of leukemia cells harboring relapse-inducing genes were selected after chemotherapy. To unravel intra-tumoral heterogeneity and selective drug-resistance, single-cell RNA sequencing (scRNA-seq) was already performed on many solid tumors and blood cancer to achieve the high-resolution transcriptomic profiling on individual cells from a larger heterogeneous population. However, the mechanism underlying the reason of leukemia heterogeneity is still not validated. Methods Since single-cell suspension was obtained from bone marrow of acute myeloid leukemia samples, we used the 10x Genomics Chromium platform to capture transcriptomes of single cells on barcoded mRNA capture beads for massively parallel scRNA-seq. Data processing followed by Cell Ranger software pipeline to demultiplex cellular barcodes, and map reads to the genome and transcriptome hg38 using the STAR aligner. Unique molecular identifier (UMI) count matrix and quality control was performed using Seurat. The t-SNE map was calculated using Rtsne package. The related genes were overexpressed or knockdown in Thp1 cell line to investigate their roles in DNA damage response. Results We analyzed transcriptome data from above 50K single leukemia bone marrow cells across 3 patients during newly diagnosed, complete remission and relapse stages. These 3 patients belong to M4 or M5, according to French-American-British classification. The genotyping of them exhibited positive WT1-ABL, and negative for c-Kit, NPM1, FLT3-ITD and FL3-TKD. To define the landscape of cellular heterogeneity and its association with outcome in an unbiased manner, we performed unsupervised machine learning algorithm on near 50K single cells from leukemia bone marrow and identify one robust 14-cluster solution (from 0 to 13, Figure 1A) and the hallmark genes within each clusters (Figure 1B). The pattern exhibits distinct distribution on different stages (Figures 1C), indicating intra-tumoral heterogeneity during leukemia progression. The cluster 0 mainly contains newly diagnosed cells. Within cluster 0, several hallmark genes (Figure 2A), such as LILRB2(Leukocyte immunoglobulin like receptor 2) and TNFAIP2(TNF alpha induced protein 2) were already reported to be associated with AML. Interestingly, the subpopulation of PTAFR (Platelet-activating factor receptor) highly expressing cells were identified in newly diagnosed group, though whether PTAFR can induce acute myeloid leukemia is still elusive. Cells expressing these genes rarely occur at relapse region (Figure 1C), implying that these genes may be not related to relapse. However, cells expressing genes, such as RPS4Y1(Ribosomal protein S4, Y isoform 1), CDKN2A, KLF1 or GATA1 were mainly distributed in relapse group, and rare cells can be found in newly diagnosed group, implying that these genes may have potential role in chemotherapy resistance, and subclones expressing these genes expanded during leukemia progression. The high expression of KLF1 as erythropoietic transcription factor and GATA1 was associated with AML. Higher levels of GATA1 expression had poor outcomes. Next, we found these genes were associated with abnormal DNA damage response, which contributes to leukemia heterogeneity. These genes can regulate the pathway of DNA damage repair as the switch between NHEJ (Non-Homologous End Joining) and HR (Homologous recombination). Conclusion The application of scRNA-seq in cancer has been relatively limited in patients who achieve remission and appear relapse after therapy. We analyze heterogeneity of acute myeloid leukemia during progression and identify novel relapse subgroups in these heterogeneous populations. Our results show a greater degree of heterogeneity in AML tumor samples during leukemia progression, compared to traditional bulk RNA-seq, and highlights the potential of single-cell RNA-seq to identify novel subgroups in AML related to relapse, demonstrating the value of single-cell analysis for AML. Furthermore, we illustrate the roles of relapse-related genes in regulating DNA damage response, which facilitate better understanding of leukemia heterogeneity.

Discrete single-cell microRNA analysis for phenotyping the heterogeneity of acute myeloid leukemia

Acute myeloid leukemia (AML) is a highly heterogenous cancer in hematopoiesis, and its subtype specification is greatly important in the clinical practice for AML diagnosis and prognosis. Increasing evidence has shown the association between microRNA (miRNA) phenotype and AML therapeutic outcomes, emphasizing the need for novel techniques for convenient, sensitive, and efficient miRNA profiling in clinical practices. Here, we describe a nanoneedle-based discrete single-cell microRNA profiling technique for multiplexed phenotyping of AML heterogeneity without the requirement of sequencing or polymerase chain reaction (PCR). In virtue of a biochip-based and non-destructive nature of the assay, the expression of nine miRNAs in large number of living AML cells can be simultaneously analyzed with discrete single-cell level information, thus providing a proof-of-concept demonstration of an AML subtype classifier based on the multidimensional miRNA data. We showed successful analysis of subtype-specific cellular composition with over 90% accuracy and identified drug-responsive leukemia subpopulations among a mixed suspension of cells modeling different AML subtypes. The adoption of machine learning algorithms for processing the large-scale nanoneedle-based miRNA data shows the potential for powerful prediction capability in clinical applications to assist therapeutic decisions. We believe that this platform provides an efficient and cost-effective solution to move forward the translational prognostic usage of miRNAs in AML treatment and can be readily and advantageously applied in analyzing rare patient-derived clinical samples.

Functional Drug Screening of Small Molecule Inhibitors of Epigenetic Modifiers in Refractory AML Patients.

Simple SummaryAcute myeloid leukemia is a cancer originating in the bone marrow and peripheral blood. Genetic mutations observed with the disease are difficult to target therapeutically and patients often have different treatment responses to the standard of care. By finding epigenetic compounds that work in a variety of patients, we could discover better therapies to treat the disease apart from the current standard of care. Here we present an unbiased drug screen of a variety of epigenetic compounds, with some showing effective responses in all or most patient samples. The use of inhibitors of epigenetic modifiers in the treatment of acute myeloid leukemia (AML) has become increasingly appealing due to the highly epigenetic nature of the disease. We evaluated a library of 164 epigenetic compounds in a cohort of 9 heterogeneous AML patients using an ex vivo drug screen. AML blasts were isolated from bone marrow biopsies according to established protocols and treatment response to the epigenetic library was evaluated. We find that 11 histone deacetylase (HDAC) inhibitors, which act upon mechanisms of cell cycle arrest and apoptotic pathways through inhibition of zinc-dependent classes of HDACs, showed efficacy in all patient-derived samples. Other compounds, including bromodomain and extraterminal domain (BET) protein inhibitors, showed efficacy in most samples. Specifically, HDAC inhibitors are already clinically available and can be repurposed for use in AML. Results in this cohort of AML patient-derived samples reveal several epigenetic compounds with high anti-blast activity in all samples, despite the molecular diversity of the disease. These results further enforce the notion that AML is a predominantly epigenetic disease and that similar epigenetic mechanisms may underlie disease development and progression in all patients, despite differences in genetic mutations.

Dissecting the Genetic and Non-Genetic Heterogeneity of Acute Myeloid Leukemia Using Next-Generation Sequencing and In Vivo Models.

Simple SummaryAcute myeloid leukemia (AML) is an extremely aggressive form of blood cancer with high rates of treatment failure. AML arises from the stepwise acquisition of genetic aberrations and is a highly heterogeneous disorder. Recent research has shown that individual AML samples often contain several clones that are defined by a distinct combination of genetic lesions, epigenetic patterns and cell surface marker expression profiles. A better understanding of the clonal dynamics of AML is required to develop novel treatment strategies against this disease. In this review, we discuss the recent developments that have further deepened our understanding of clonal evolution and heterogeneity in AML.Acute myeloid leukemia (AML) is an extremely aggressive and heterogeneous disorder that results from the transformation of hematopoietic stem cells. Although our understanding of the molecular pathology of AML has greatly improved in the last few decades, the overall and relapse free survival rates among AML patients remain quite poor. This is largely due to evolution of the disease and selection of the fittest, treatment-resistant leukemic clones. There is increasing evidence that most AMLs possess a highly complex clonal architecture and individual leukemias are comprised of genetically, phenotypically and epigenetically distinct clones, which are continually evolving. Advances in sequencing technologies as well as studies using murine AML models have provided further insights into the heterogeneity of leukemias. We will review recent advances in the field of genetic and non-genetic heterogeneity in AML.

Current strategies for the treatment of acute myeloid leukemia

Introduction. Acute myeloid leukemia is a rare malignancy with an average age of 70 years at diagnosis. Until recently, five-year survival of younger patients with this disease, despite being treated with allogenic hematopoietic stem cell transplantation, was &lt; 30%, while in patients older than 60 years it was &lt; 10%. Treatment overview. Due to the heterogeneity of acute myeloid leukemia no new drugs for treating this disease have been introduced for decades. The introduction of new drugs began from 2017: midostaurin, gilteritinib, CPX351, enasidenib, ivosidenib, venetoclax, glasdegib, while gemtuzumab ozogamicin has been reintroduced. Modern treatment strategies require an individual approach, based on prognostic parameters such as cytogenetical and molecular profile of acute myeloid leukemia at diagnosis and the assessment of minimal residual disease evaluated after two cycles of chemotherapy. Moreover, determining the eligibility of patients for ??intensive?? treatment, based on functional status, comorbidities and geriatric assessment of older patients, is necessary. Regarding the treatment of acute promyelocytic leukemia, the combination of arsenic trioxide and all-trans retinoic acid is universally accepted as the standard of care for non-high risk patients (WBC &lt; 10x109/L), while standard chemotherapy combined with all-trans retinoic acid is still used for high-risk patients (WBC &gt;10x109/L). Conclusion. Novel therapeutic modalities, along with allo-HSCT have changed the outcome of AML patients. However, treating patients unfit for intensive chemotherapy, as well as patients with relapse/refractory disease, is still challenging.

Combinatorial antigen targeting strategies for acute leukemia: application in myeloid malignancy

Background aimsEfforts to safely and effectively treat acute myeloid leukemia (AML) by targeting a single leukemia-associated antigen with chimeric antigen receptor (CAR) T cells have met with limited success, due in part to heterogeneous expression of myeloid antigens. The authors hypothesized that T cells expressing CARs directed toward two different AML-associated antigens would eradicate tumors and prevent relapse. MethodsFor co-transduction with the authors’ previously optimized CLL-1 CAR currently in clinical study (NCT04219163), the authors generated two CARs targeting either CD123 or CD33. The authors then tested the anti-tumor activity of T cells expressing each of the three CARs either alone or after co-transduction. The authors analyzed CAR T-cell phenotype, expansion and transduction efficacy and assessed function by in vitro and in vivo activity against AML cell lines expressing high (MOLM-13: CD123 high, CD33 high, CLL-1 intermediate), intermediate (HL-60: CD123 low, CD33 intermediate, CLL-1 intermediate/high) or low (KG-1a: CD123 low, CD33 low, CLL-1 low) levels of the target antigens. ResultsThe in vitro benefit of dual expression was most evident when the target cell line expressed low antigen levels (KG-1a). Mechanistically, dual expression was associated with higher pCD3z levels in T cells compared with single CAR T cells on exposure to KG-1a (P < 0.0001). In vivo, combinatorial targeting with CD123 or CD33 and CLL-1 CAR T cells improved tumor control and animal survival for all lines (KG-1a, MOLM-13 and HL-60); no antigen escape was detected in residual tumors. ConclusionsOverall, these findings demonstrate that combinatorial targeting of CD33 or CD123 and CLL-1 with CAR T cells can control growth of heterogeneous AML tumors.

Assessment of Minimal/Measurable Residual Disease Testing in Acute Myeloid Leukaemia By Molecular Methods in an Interlaboratory Study

BackgroundMinimal/measurable residual disease (MRD) testing is increasingly utilised and accepted as standard of care to manage a range of different haematological malignancies. It's use as a surrogate outcome in clinical trials of new therapies is being explored, where it has the potential to accelerate drug assessment and approval. The phenotypic and genetic heterogeneity of acute myeloid leukaemia (AML) has limited the use of MRD in this context; however, the European LeukaemiaNet (ELN) MRD working group have recently published consensus guidelines to standardise both flow cytometric and molecular genetic MRD testing. To assess the accuracy of testing and concordance between laboratories, crucial to patient safety, external quality assessment (EQA)/proficiency testing (PT) is required.AimsTo determine the performance of molecular methods for measuring of MRD using the t(8;21)(q22:q22) RUNX1-RUNX1T1, inv(16)(p13q22) CBFB-MYH11, t(15;17)(q24.1;q21.2) PML-RARA and NPM1 Type A markers in an international interlaboratory study.MethodsA total of 12 batches of lyophilised EQA material were manufactured. These consisted of three batches of samples for each marker all containing 9x10^6 cells: an MRD ‘high’ sample; an MRD ‘low’ sample; and an MRD ‘negative’ sample. The t(8;21)(q22:q22) RUNX1-RUNX1T1 positive samples were manufactured using the KASUMI-1 cell line, the inv(16)(p13q22) CBFB-MYH11 positive samples using the ME-1 cell line; t(15;17)(q24.1;q21.2 PML-RARA positive samples using the NB4 cell line and the NPM1 Type A (NM_002520.6:c.860_863dup) positive samples using the OCI-AML3 cell line. MRD positive samples were diluted with HL60 cells to achieve the desired MRD level. MRD negative samples were manufactured using the HL60 cell line. The samples were shipped at ambient temperature to the 29 laboratories in 12 countries. Participants were asked to test the blinded samples with their in-house assay and report % normalised ratio of the relevant marker alongside additional methodological and technical data.ResultsFor t(8;21) RUNX1-RUNX1T1, all participants who returned results (n=23) classified the MRD ‘high’ and MRD ‘low’ samples as positive and the MRD ‘negative’ sample as negative. The robust mean log reduction between the MRD ‘high’ and MRD low sample was 2.7 (range 2.5-2.9). For inv(16) CBFB-MYH11, all participants who returned results (n=22) classified the MRD ‘high’ sample as positive, 21/22 (95.5%) classified the MRD ‘low’ sample as positive and 21/22 (95.5%) classified the MRD negative sample as negative. The robust mean log reduction between the MRD ‘high’ and MRD ‘low’ sample was 3.16 (range 2.8-4.2). For t(15;17) PML-RARA, all participants who returned results (n=22) classified the MRD ‘high’ sample as positive, 21/22 (95.5%) classified the MRD ‘low’ sample as positive and 21/22 (95.5%) classified the MRD negative sample as negative. The robust mean log reduction between the MRD ‘high’ and MRD ‘low’ sample was 2.1 (range 1.4-2.4). For NPM1, all participants who returned results (n=23) classified the MRD ‘high’ as positive, 21/23 (91.3%) classified the MRD ‘low’ sample as positive and, 17/23 (73.4%) classified the MRD negative sample as negative. The robust mean log reduction between the MRD ‘high’ and MRD ‘low’ sample was 3.8 (range 3.2-4.2).Summary/ConclusionThe majority of participants in this study were able to detect and accurately quantify MRD when assessing the t(8;21)(q22:q22) RUNX1-RUNX1T1, inv(16)(p13q22) CBFB-MYH11, t(15;17)(q24.1;q21.2) PML-RARA and NPM1 markers, at levels that would be expected within a clinical trial or standard of care setting. A high proportion of participants reported false positive results in the NPM1 marker negative sample. This would have significant consequences clinically, with NPM1 marker false-positivity potentially committing patients to unneeded additional chemotherapy and/or transplant with the attendant risk of morbidity and mortality which highlights the need for ongoing EQA in this area. UK NEQAS LI will work with laboratories advocating they undertake a root cause analysis process to identify the source(s) of error contributing to false positive NPM1 marker results and support their subsequent corrective actions; sharing any educational findings with all participants. [Display omitted] DisclosuresScott: Novartis: Research Funding; Biorad: Research Funding. Dillon: Abbvie: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: Research Support, Educational Events; Amgen: Other: Research support (paid to institution); Astellas: Consultancy, Other: Educational Events , Speakers Bureau; Menarini: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Other: Session chair (paid to institution), Speakers Bureau; Pfizer: Consultancy, Membership on an entity's Board of Directors or advisory committees, Other: educational events; Jazz: Other: Education events; Shattuck Labs: Membership on an entity's Board of Directors or advisory committees. Whitby: Roche: Membership on an entity's Board of Directors or advisory committees; Alexion: Honoraria, Other: Teaching.

Patient Heterogeneity in Acute Myeloid Leukemia: Leukemic Cell Communication by Release of Soluble Mediators and Its Effects on Mesenchymal Stem Cells.

Acute myeloid leukemia (AML) is an aggressive bone marrow malignancy, and non-leukemic stromal cells (including mesenchymal stem cells, MSCs) are involved in leukemogenesis and show AML-supporting effects. We investigated how constitutive extracellular mediator release by primary human AML cells alters proteomic profiles of normal bone marrow MSCs. An average of 6814 proteins (range 6493−6918 proteins) were quantified for 41 MSC cultures supplemented with AML-cell conditioned medium, whereas an average of 6715 proteins (range 6703−6722) were quantified for untreated control MSCs. The AML effect on global MSC proteomic profiles varied between patients. Hierarchical clustering analysis identified 10 patients (5/10 secondary AML) showing more extensive AML-effects on the MSC proteome, whereas the other 31 patients clustered together with the untreated control MSCs and showed less extensive AML-induced effects. These two patient subsets differed especially with regard to MSC levels of extracellular matrix and mitochondrial/metabolic regulatory proteins. Less than 10% of MSC proteins were significantly altered by the exposure to AML-conditioned media; 301 proteins could only be quantified after exposure to conditioned medium and 201 additional proteins were significantly altered compared with the levels in control samples (153 increased, 48 decreased). The AML-modulated MSC proteins formed several interacting networks mainly reflecting intracellular organellar structure/trafficking but also extracellular matrix/cytokine signaling, and a single small network reflecting altered DNA replication. Our results suggest that targeting of intracellular trafficking and/or intercellular communication is a possible therapeutic strategy in AML.

An Integer Weighted Genomic Mutation Score (GMS) Using Next Generation Sequencing Is Predictive of Prognosis in Intermediate Risk AML Patients

Introduction: The genomic heterogeneity in Acute Myeloid Leukemia (AML) has been shown to affect the overall prognosis and should be taken into account to decide the best course of treatment. Study of AML genomic landscape by The Cancer Genome Atlas (TCGA) research network by Ley, et.al, analyzed the genomes of 200 patients (pts) with de-novo AML and showed at least one potential driver mutation in nearly all AML samples and further classified these mutation in 9 functional categories: Myeloid transcription factor and fusion genes, Tumor suppressor genes, gene encoding Nucleophosmin, Activated signaling genes, DNA methylation related genes, Chromatin modifying genes, Cohesion complex genes and Spliceosome complex genes . The availability of Next Generation Sequencing (NGS) has allowed easy characterization of patient samples. However, this has now became increasingly important to prioritize the influence of different mutations clones so as to give actionable and prognostic information. We developed an Integer Weighted Genomic Mutation Score (GMS) to address this in the context of the TCGA data and applied this to a retrospective cohort of pts with AML. The goal was to meaningfully stratify the Intermediate risk AML patients per current ELN criteria based identified by NGS technique into low and high risk group and correlate this with clinical outcome.Study Method: We screened 1200 AML patients at our institution from 2010 to 2016 and identified 111 patients from our hospital database who had information on both cytogenetics and gene mutation detected by NGS. We queried for the diagnosis of AML and demographics, Cy, NGS and OS. We divided the patients into 3 groups according to their cytogenetic risks- Favorable (FCy), Intermediate (ICy),Poor (PCy). Mutations in 54 genes associated with myeloid disorders were tested in NGS by using the TruSight Myeloid Sequencing Panel (Illumina) (Table1). We also performed flow cytometric evaluation on a BD FACSCantos™ II 3-laser (405, 488, 630 nm excitation sources), 8-color flow cytometer (BD Biosciences, San Jose, CA, USA) and data analyzed using BD FACSDiva software. We then utilized the TCGA data by Leyet.al and developed a system of Integer Weights forthe Genomic Mutation Score (GMS) obtained by targeted NGS at Houston Methodist Hospital mentioned below. GMS was designed by assigning a score for each genomic mutation between the range of negative 2 (-2) for good risk to positive 2 (+2) for each of 9 TCGA mutation categories .The total IWGMS for each patient was calculated by the sum of mutation scores in each 9 categories. A score of 3 or greater than 3 was defined as high risk. We then performed a retrospective analysis of 111 AML patients to correlate the GMS with 2 year mortality and survival outcome. Statistical Analysis was done using multivariate logistic regression method.Results: Pts were grouped into 51 intermediate risk and 60 poor risk cytogenetics. Median age of the pts was 66 years and 57.6% were male. Immunophenotyping of CD34 and CD38, and CD117 did not emerge as significant predictors of survival when adjusting for covariates. 32% of patients underwent allogeneic stem cell transplant as consolidation therapy. Median overall survival for the entire study population was 24 months with a median follow up time was 20.01 months (95% CI; 15.77 - 25.17). Univariate analysis using cox proportional hazard method showed age and cytogenetics risk as a statistically significant predictor of overall survival as shown in Fig: 1. Overall survival in all AML patients and Intermediate risk patients showed a trend toward better OS with lower GMS but no such trend was seen in poor risk AML patients as shown in Fig: 2-4.Conclusion: We have developed an GMS system to further stratify Intermediate Risk AML patients into high and low risk groups. Age and cytogenetics risk per ELN criteria were independent prognostic factor for overall survival in our study cohort as expected. Patients with lower GMS in our study cohort had a trend towards better OS but patients with high GMS had a trend towards worse OS in intermediate risk AML patients. Larger size prospective study is required to validate this scoring system; it has a great potential to identify high risk patients among Intermediate risk group and plan different consolidation therapies to further improve their outcomes.Further treatment related analysis will be presented at ASH,Atlanta 2017. [Display omitted] DisclosuresIyer:Takeda: Research Funding; Genentech: Research Funding.

Comprehensive Methylation Analysis in Pediatric Patients with Acute Myeloid Leukemia —the JCCG Study, JPLSG AML-05-

IntroductionThe genetic heterogeneity of acute myeloid leukemia (AML) makes it difficult to predict an appropriate prognosis of patients with AML. Currently, several gene mutations associated with the pathogenesis of AML have been identified owing to recent advances in massively parallel sequencing technologies. However, despite incorporating these molecular markers, the prognosis of many patients remains uncertain. Aberrant DNA methylation has frequently been observed in myeloid cells of patients with AML. Reportedly, DNA methylation patterns are associated with molecular features. Furthermore, a previous report has demonstrated that the methylation levels of polycomb target genes are associated with the outcome, implying that the definition of DNA methylation patterns of AML is expected to reveal clinical and molecular features and survival in patients with AML. However, there are few reports of DNA methylation in pediatric patients with AML. Thus, we analyzed genome-wide DNA methylation in pediatric patients with AML to reveal its association with clinical features, genetic alterations, and prognostic impact. Besides, our previous study revealed that the high expression of MECOM (also known as EVI1 ) or PRDM16 (also known as MEL1 ) was associated with inferior outcomes in patients with AML. We also investigated the correlation between DNA methylation and gene expression in pediatric patients with AML.MethodsBetween 2006 and 2010, 443 pediatric patients with de novo AML (0-17 years) participated in the Japanese AML-05 trial conducted by the Japanese Pediatric Leukemia/Lymphoma Study Group. Of these, 369 samples were available, and 64 patients were enrolled in this study. The cytogenetic features of 64 patients were as follows: normal karyotype, 33; RUNX1-RUNX1T1 , 8; KMT2A rearrangement, 10; complex karyotype, 6; and other cytogenetics, 7. This cohort included 15 patients with FLT3 -internal tandem duplication (ITD), 8 with CEBPA biallelic mutations, 10 with high MECOM expression, and 30 with high PRDM16 expression. We performed comprehensive DNA methylation analysis using Infinium MethylationEPIC BeadChip (Illumina, Inc., San Diego, CA, USA) in 64 pediatric patients with AML to reveal the correlations among DNA methylation patterns, clinical features, genetic alterations, and prognostic impact in pediatric AML.Results and DiscussionUnsupervised hierarchical clustering based on methylation values of the 567 CpG sites, which showed most variable methylation values between 64 individuals, generated four clusters (clusters 1-4). The number of patients in clusters 1, 2, 3, and 4 was 23, 12, 13, and 16, respectively. Interestingly, these four clusters harbored their molecular features. Cluster 1 included patients with RUNX1/RUNX1T1 , normal karyotype with low PRDM16 expression, or KMT2A rearrangement with low MECOM expression. Cluster 2 included patients with FLT3 -ITD and/or normal karyotype with high PRDM16 expression. Cluster 3 included patients with normal karyotype with CEBPA biallelic mutations and cluster 4 patients with FLT3 -ITD, normal karyotype with high PRDM 16 expression, or KMT2A rearrangement with high MECOM expression. Differences in frequencies of common molecular aberrations among clusters were assessed with the Fisher-Freeman-Halton test. There was an unequal distribution of FLT3 -ITD and high PRDM16 expression (P = 0.003 for both), with concordantly high frequencies in clusters 2 and 4 and low in clusters 1 and 3. Clusters 2 and 4 tended to be correlated with older age, higher white blood cell counts at diagnosis, high relapse rate, and high mortality. These results suggest that DNA methylation can stratify the risk in pediatric AML. Conversely, no independent methylation marker was present to predict the adverse outcome, thereby indicating that an assortment of several methylation sites may be a useful marker for risk stratification.ConclusionWe investigated DNA methylation patterns in pediatric patients with AML and found four distinct clusters. Furthermore, our findings indicated that quantitative determination of DNA methylation percentage at specific CpG sites may be useful for risk stratification in pediatric AML. Considering the need of further analyses to reveal the significance of DNA methylation, we are analyzing the results currently and would like to discuss these data at the annual meeting. DisclosuresNo relevant conflicts of interest to declare.