[Show abstract][Hide abstract] ABSTRACT: Background De novo acute myeloid leukemia (AML) with concurrent DNMT3A, FLT3 and NPM1 mutations (AML DNMT3A/FLT3/NPM1 ) has been suggested to represent a unique AML subset on the basis of integrative genomic analysis, but the clinical features of such patients have not been characterized systematically. Methods
We assessed the features of patients (n¿=¿178) harboring mutations in DNMT3A, FLT3 and/or NPM1, including an index group of AML DNMT3A/FLT3/NPM1 patients.ResultsPatients with AML DNMT3A/FLT3/NPM1 (n¿=¿35) were significantly younger (median, 56.0 vs. 62.0 years; p¿=¿0.025), mostly women (65.7% vs. 46.9%; p¿=¿0.045), and presented with a higher percentage of bone marrow blasts (p¿<¿0.001) and normal cytogenetics (p¿=¿0.024) in comparison to other groups in this study. Among patients <60 years old, those with AML DNMT3A/FLT3/NPM1 had a shorter event-free survival (EFS) (p¿=¿0.047). DNMT3A mutations and not FLT3 or NPM1 mutations were independently associated with overall survival (OS) (p¿=¿0.026). Within mutation subgroups, patients with AML DNMT3A/NPM1 had a significantly shorter OS compared to those with AML FLT3-ITD/NPM1 (p¿=¿0.047) suggesting that the adverse impact of DNMT3A mutations is more pronounced than that of FLT3-ITD among patients with NPM1 mutation.ConclusionsDNMT3A has a significant effect on the clinical features and outcomes of de novo AML patients with concurrent DNMT3A, FLT3 and NPM1 mutations.
[Show abstract][Hide abstract] ABSTRACT: Acute myeloid leukemias with MLL rearrangements are frequently associated with myelomonocytic and monoblastic/monocytic morphology, with an increased risk of leukocytosis and leukostasis-related complications. Yet, little is known regarding the clinical presentation of adult AML patients with MLL translocations based on the specific translocation partner.
[Show abstract][Hide abstract] ABSTRACT: Here it was determined that Chronic Lymphocytic Leukemia (CLL) cells express the alpha-subunit but not the beta-subunit of the granulocyte-macrophage colony-stimulating factor receptor (GMCSFR/CSF3R). GM-CSFRalpha was detected on the surface, in the cytosol, and the nucleus of CLL cells via confocal microscopy, cell fractionation, and GM-CSFRalpha antibody epitope mapping. Because STAT3 is frequently activated in CLL and the GM-CSFRalpha promoter harbors putative STAT3 consensus binding sites, MM1 cells were transfected with truncated forms of the GMCSFRalpha promoter, then stimulated with IL-6 to activate STAT3 to identify STAT3 binding sites. Chromatin immunoprecipitation (ChIP) and an electoromobility shift assay (EMSA) confirmed STAT3 occupancy to those promoter regions in both IL-6 stimulated MM1 and CLL cells. Transfection of MM1 cells with STAT3 siRNA or CLL cells with STAT3 shRNA significantly downregulated GM-CSFRalpha mRNA and protein levels. RNA transcripts, involved in regulating cell survival pathways, and the proteins KAP1 (TRIM28) and ISG15 co-immunoprecipitated with GMCSFRalpha. GM-CSFRalpha-bound KAP1 enhanced the transcriptional activity of STAT3, whereas ISG15 inhibited the NF-kappaB pathway. Nevertheless, overexpression of GM-CSFRalpha protected MM1 cells from dexamethasone-induced apoptosis, and GM-CSFRalpha knockdown induced apoptosis in CLL cells, suggesting that GM-CSFRalpha provides a ligand-independent survival advantage. Implications: Constitutively activate STAT3 induces the expression of GM-CSFRalpha and protects CLL cells from apoptosis, suggesting that inhibition of STAT3 or GM-CSFRalpha may benefit patients with CLL.
[Show abstract][Hide abstract] ABSTRACT: Atypical chronic myeloid leukemia (aCML) is a rare subtype of myelodysplastic/myeloproliferative neoplasm (MDS/MPN) largely defined morphologically. It's, unclear, however, whether aCML associated features are distinctive enough to allow its separation from unclassifiable MDS/MPN (MDS/MPN-U). To study these two rare entities, 134 patient archives were collected from 7 large medical centers, of which, 65 (49%) cases were further classified as aCML and the remaining 69 (51%) MDS/MPN-U. Distinctively, aCML was associated with many adverse features and an inferior overall survival (12.4 vs.21.8 months, p=0.004) and AML free survival (11.2 vs.18.9 months, p=0.003). The aCML defining features as of leukocytosis and circulating myeloid precursors, but not dysgranulopoiesis, were independent negative predictors. Other factors, such as LDH, circulating myeloblasts, platelets, and cytogenetics could further stratify MDS/MPN-U but not aCML patient risks. aCML appeared to have more mutated RAS [7/20(35%) vs.4/29(14%)] and less JAK2p.V617F [3/42(7%) vs.10/52(19%)]; but not statistically significant. Somatic CSF3R T618I(0/54) and CALR (0/30) mutations were not detected either in aCML or MDS/MPN-U. In conclusion, within the MDS/MPN, the WHO 2008 criteria for aCML identify a subgroup of patients with features clearly distinct from MDS/MPN-U. The MDS/MPN-U category is heterogeneous, and patient risk can be further stratified by a number of clinicopathological parameters.
[Show abstract][Hide abstract] ABSTRACT: Purpose Epstein-Barr virus (EBV)-positive diffuse large B-cell lymphoma (DLBCL) of the elderly is a variant of DLBCL with worse outcome that occurs most often in East Asian countries and is uncommon in the Western hemisphere. We studied the largest cohort of EBV+ DLBCL, independent of age, treated with R-CHOP in developed Western countries. Experimental design A large cohort (n=732) of patients with DLBCL treated with R-CHOP chemotherapy are included from the multicenter Consortium. This study group has been studied for expression of different biomarkers by immunohistochemistry, genetic abnormalities by fluorescent in situ hybridization and mutation analysis, genomic information by gene expression profiling (GEP) and gene set enrichment analysis (GSEA). Results Twenty-eight patients (4.0%) were positive for EBV with a median age of 60.5 years. No clinical characteristics distinguished patients with EBV+ DLBCL from patients with EBV-negative DLBCL. Genetic aberrations were rarely seen. NF-κB p50, phosphorylated STAT-3 and CD30 were more commonly expressed in EBV+ DLBCLs (P<.05). Significant differences in survival were not observed in patients with EBV-positive DLBCL versus EBV-negative DLBCL. CD30 co-expression appeared to confer inferior outcome although statistical significance was not achieved. GEP showed a unique expression signature in EBV-positive DLBCL. GSEA revealed enhanced activity of the NF-κB and JAK/STAT pathways. Conclusions The clinical characteristics of patients with EBV+ versus EBV-negative DLBCL are similar and EBV infection does not predict a worse outcome. EBV+ DLBCL, however, has a unique genetic signature. CD30 expression is more common in EBV+ DLBCL and, when present, is associated with an adverse outcome.
Clinical Cancer Research 02/2014; · 7.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Comorbidities significantly affect the prognosis and outcomes of patients with hematological malignancies. We have previously reported the impact of comorbidities on the IPSS score. The aim of this study was to determine whether comorbidities continued to have a significant impact when patients were reclassified according to the Revised-International Prognostic Scoring System (IPSS-R). Methods: The medical records of 600 consecutive MDS patients who presented to MD Anderson Cancer Center between January 2002 and June 2004 were reviewed. The Adult Comorbidity Evaluation-27 (ACE-27) was used to assess the severity of comorbid conditions. Results: Four hundred and two (67%) patients were male. Median age at presentation was 66.6 years (17 - 94). Mean duration of follow-up was 54 months (1 - 100). Five hundred and two (84%) patients died, and 54 (9%) patients underwent SCT. Overall median survival was 16.8 months (1 - 100). Median survival by IPSS-R was 47, 34, 21, 16, and 6 months for patients in very low, low, intermediate, high and very high-risk groups, respectively (P<0.001). The ACE-27 comorbidity score significantly impacted the median survival of patients in the intermediate (P<0.001), high (P=0.045), and very high (P=0.004) IPSS-R groups; but did not significantly impact the median survival in the low (P=0.11) and very low (P=0.49) IPSS-R groups. The ACE-27 comorbidity score significantly impacted the median survival of patients ≤ 65 years (P<0.001) but did not significantly impact those > 65 years (P=0.18). Conclusion: Assessment of comorbidity may enhance the prognostic ability of the IPSS-R.
American Journal of Hematology 01/2014; · 4.00 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Myelodysplastic syndromes (MDS) are characterized by impaired proliferation and differentiation of hematopoietic stem cells. The participation of toll-like receptor (TLR)-mediated signaling in MDS is well documented. Increased TLR signaling leads to the constitutive activation of NF-κB, which mediates inflammation, cell proliferation and apoptosis. In addition, the TLR pathway induces the expression of miRNAs which participate in the fine-tuning of the inflammatory response. miRNAs also regulate other biological processes, including hematopoiesis. miR-125a and miR-125b are known modulators of hematopoiesis and are abnormally expressed in several hematologic malignancies. However, little is known about their role in MDS. NF-κB-activating ability has been described for both miRNAs. We studied the role of miR-125a/miR-125b in MDS and their relationship with TLR signaling and hematopoietic differentiation. Our results indicate that miR-125a is significantly overexpressed in MDS patients and correlates negatively with patient survival. Expression of miR-99b, which is clustered with miR-125a, is also directly correlated with prognosis of MDS. Both miR-125a and miR-99b activated NF-κB in vitro; however, we observed a negative correlation between miR-99b expression and the levels of TLR2, TLR7 and two downstream genes, suggesting that NF-κB activation by the miRNA cluster occurs in the absence of TLR signaling. We also show that TLR7 is negatively correlated with patient survival in MDS. In addition, our data suggest that miR-125a may act as an NF-κB inhibitor upon TLR stimulation. These results indicate that miR-125a is involved in the fine-tuning of NF-κB activity and that its effects may depend on the status of the TLR pathway. Furthermore, we observed that miR-125a inhibits erythroid differentiation in leukemia and MDS cell lines. Therefore, this miRNA could serve as a prognostic marker and a potential therapeutic target in MDS.
PLoS ONE 01/2014; 9(4):e93404. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Blockade of immune checkpoints is emerging as new form of anticancer therapy. We studied the expression of PD-L1, PD-L2, PD-1 and CTLA4 mRNA expression in CD34+ cells from MDS, CMML and AML patients (N=124). Aberrant up-regulation (2 fold) was observed in 34, 14, 15 and 8% of the patients respectively. Increased expression of these 4 genes was also observed in PBMNC (N=61). The relative expression of PD-L1 from PBMNC was significantly higher in MDS (P=0.018) and CMML (P=0.0128) compared to AML. By immunohistochemical (IHC) analysis, PD-L1 protein expression was observed in MDS CD34+ cells, whereas stroma/non-blast cellular compartment was positive for PD-1. In a cohort of patients treated with epigenetic therapy, PD-L1, PD-L2, PD-1 and CTLA4 expression was upregulated. Patients resistant to therapy had relative higher increments in gene expression compared to patients that achieved response. Treatment of leukemia cells with decitabine resulted in a dose dependent up-regulation of above genes. Exposure to decitabine resulted in partial demethylation of PD-1 in leukemia cell lines and human samples. This study suggests PD-1 signaling may be involved in MDS pathogenesis and resistance mechanisms to HMAs. Blockade of this pathway can be a potential therapy in MDS and AML.Leukemia accepted article preview online, 25 November 2013. doi:10.1038/leu.2013.355.
Leukemia: official journal of the Leukemia Society of America, Leukemia Research Fund, U.K 11/2013; · 10.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Primary myelofibrosis (PMF) is myeloproliferative neoplasm whose diagnosis is based on a combination of clinical and pathology criteria. We evaluated 560 consecutive patients who were diagnosed with PMF upon a referral to our center and evaluated the frequency of and reasons for diagnostic discordance. Discordance in the diagnosis was found in 70 (12.5%) patients. Discordant cases had a significantly lower grade of bone marrow fibrosis (grade 0-1), more likely to be JAK2V617F-mutation negative, and have no peripheral blood blasts, possibly explaining the difficulty in making a proper diagnosis and underscoring the need for a complete evaluation at a tertiary center.
[Show abstract][Hide abstract] ABSTRACT: Objectives: To assess CD105 (endoglin) expression in 119 acute myeloid leukemia (AML) and 13 control cases using immunohistochemistry. Methods: CD105 expression was assessed retrospectively by using immunohistochemistry in bone marrow specimens. Results: CD105 was strongly and diffusely positive in all 9 (100%) AMLs with t(15;17)(q24.1;q21.2), 2 (100%) AMLs with t(8;21)(q22;q22), 1 (100%) AML with t(6;9)(p23;q34), 7 (28%) of 25 AMLs with myelodysplasia-related changes, 1 (33%) of 3 therapy-related AMLs, 3 (16%) of 19 AMLs unclassifiable, 1 (14%) of 7 AMLs with inv(16)(p13.1q22), and 5 (11%) of 45 AMLs not otherwise specified. Uninvolved bone marrow in these cases showed no CD105 expression by erythroid precursors, megakaryocytes, or endothelial or stromal cells. Two of 13 control bone marrow specimens showed partial CD105 positivity in myeloid cells. In 21 strongly CD105+ AML cases tested for the IDH2 mutation, 9 (42%) were mutated (P = .004). Conclusions: These data suggest that CD105 could be a therapeutic target in a subset of patients with AML.
American Journal of Clinical Pathology 09/2013; 140(3):370-8. · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We sought to describe the clinical features and outcomes of therapy-related chronic myelomonocytic leukemia (t-CMML) and compare to those of de novo CMML. We identified 358 CMML patients, of whom 39 (11%) had t-CMML. Although the groups had similar demographic, hematological, and molecular alteration profiles, the proportion of patients with intermediate or high CMML-specific cytogenetics risk in the t-CMML was significantly higher than that in the de novo CMML (P = 0.011). The median latency to develop t-CMML was 6 years. The median overall and leukemia-free survival duration of the t-CMML were shorter than those of the de novo CMML; however, t-CMML itself was not prognostic after adjusting for the effects of other covariates including cytogenetics. These results suggest that compared to de novo CMML, t-CMML is associated with more high-risk cytogenetics that manifest as poor outcomes. We propose that t-CMML be recognized as one of the therapy-related myeloid neoplasms.
[Show abstract][Hide abstract] ABSTRACT: A 67 year old woman presented with a 3 month history of progressive fatigue, fever, night sweats, weight loss and poor performance status. Her initial investigations showed anemia and pancytopenia - hemoglobin - 11.2 g/dl WBC - 2.3 K/uL and platelets 63 K/uL. This article is protected by copyright. All rights reserved.
European Journal Of Haematology 06/2013; · 2.55 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recent studies have implicated the innate immunity system in the pathogenesis of myelodysplastic syndromes (MDS). Toll-like receptor (TLR) genes encode key innate immunity signal initiators. We recently identified multiple genes, known to be regulated by TLRs, to be overexpressed in MDS bone marrow (BM) CD34+ cells, and hypothesized that TLR signaling is abnormally activated in MDS. We analyzed a large cohort of MDS cases and identified that TLR1, 2 and 6 to be significantly overexpressed in MDS BM CD34+ cells. Deep-sequencing followed by Sanger-resequencing of TLR1, 2, 4 and 6 genes uncovered a recurrent genetic variant, TLR2-F217S, in 11% of 149 patients. Functionally, TLR2-F217S results in enhanced activation of downstream signaling including NF-kB activity after TLR2 agonist treatment. In cultured primary BM CD34+ cells of normal donors, TLR2 agonists induced histone demethylase JMJD3 and interleukin-8 gene expression. Inhibition of TLR2 in BM CD34+ cells from patients with lower-risk MDS using shRNA resulted in increased erythroid colony formation. Finally, RNA expression levels of TLR2 and 6 as well as presence of TLR2-F217S are associated with distinct prognosis and clinical characteristics. These findings indicate that TLR2-centered signaling is deregulated in MDS and that its targeting may have potential therapeutic benefit in MDS.Leukemia accepted article preview online, 14 June 2013; doi:10.1038/leu.2013.180.
Leukemia: official journal of the Leukemia Society of America, Leukemia Research Fund, U.K 06/2013; · 10.16 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Mesenchymal stromal cells (MSCs) are a major component of the leukemia bone marrow (BM) microenvironment. Connective tissue growth factor (CTGF) is highly expressed in MSCs, but it's role in the BM stroma is unknown. Therefore, we knocked-down (KD) CTGF expression in human BM-derived MSCs by CTGF-shRNA. CTGF-KD-MSCs exhibited 5-fold lower proliferation compared to control MSCs and had significantly fewer cells in S phase (3.5% ± 0.4% vs 14.7% ± 0.8%). CTGF-KD-MSCs differentiated into adipocytes at a 6-fold higher rate than controls, both in vitro and in vivo. To study the effect of CTGF on engraftment of leukemia cells into BM, an in vivo model of humanized extramedullary BM (EXM-BM) was developed in NOD/SCID/IL-2rγ(null) mice. Transplanted Nalm-6 or Molm-13 human leukemia cells engrafted at a 3-fold higher rate in adipocyte-rich CTGF-KD-MSC-derived EXM-BM than in control EXM-BM. Leptin (adipocyte growth factor) was found to be highly expressed in CTGF-KD-EXM-BM and in BM samples of patients with acute myeloid and acute lymphoblastic leukemia while it was not expressed in normal controls. Given the established role of leptin receptor in leukemia cells, the data suggest an important role of CTGF in MSC differentiation into adipocytes and of leptin in homing and progression of leukemia.
[Show abstract][Hide abstract] ABSTRACT: Terminal deoxynucleotidyl transferase (TdT) can be downregulated in minimal residual disease of T-acute lymphoblastic leukemia/lymphoma (T-ALL/LBL) after chemotherapy. TdT-negative T-ALL/LBL cases are rare and have not been well characterized. We studied the clinicopathologic features of de novo T-ALL/LBL patients treated at our institution during 2003-2011, with an emphasis on immunophenotype and survival of TdT-negative versus TdT-positive cases. Absence of TdT expression was defined as <10% lymphoblasts positive. Seven (12%) TdT-negative cases were identified from a cohort of 59 de novo T-ALL/LBL. The TdT-negative and TdT-positive cases were similar with regard to gender, percentage of patients with a high leukocyte count (>100 × 10(9)/l), central nervous system involvement, and an abnormal karyotype. However, patients with TdT-negative T-ALL/LBL had a significantly higher rate of disease progression and shorter overall survival. Although not statistically significant, TdT-negative T-ALL/LBL cases were associated with an older median age and higher percentage of 'early T precursor' (ETP) immunophenotype than TdT-positive cases. Absence of TdT expression identifies a subset of high-risk T-ALL/LBL that overlaps with, but is not identical to, the ETP leukemia, providing additional prognostic value.Modern Pathology advance online publication, 24 May 2013; doi:10.1038/modpathol.2013.78.
[Show abstract][Hide abstract] ABSTRACT: The presence of moderate to severe bone marrow (BM) fibrosis has been shown to be an adverse feature in patients with primary myelodysplastic syndromes (MDS). However, the clinical importance of BM fibrosis is not clear in therapy-related MDS. We retrieved all therapy-related MDS (t-MDS) cases (n = 266) diagnosed at our hospital over a 10-year period (2003-2012). Reticulin and trichrome stains were performed in cases in which BM fibrosis was suspected on initial evaluation of hematoxylin and eosin-stained slide. BM fibrosis was graded according to European consensus guidelines, and a score of MF2/MF3 was defined as moderate/severe fibrosis. Moderate/severe BM fibrosis was found in 47 (17 %) patients. Compared to 219 patients with no/mild BM fibrosis, the patients with moderate/severe fibrosis presented with severer thrombocytopenia (p = 0.039) and higher numbers of circulating blasts (p = 0.051) but with similar degrees of anemia and neutropenia, transfusion requirements, and similar incidences of hepatosplenomegaly and constitutional symptoms. Histological examination revealed a comparable BM cellularity and BM blast percentage, but markedly increased megakaryocytes (p < 0.001) in the fibrotic group. Although the risk distribution of cytogenetic data was similar according to the New Comprehensive Cytogenetic Scoring criteria, -5 and -17 were more frequently observed in t-MDS with moderate/severe BM fibrosis (p = 0.031 and p = 0.043, respectively). With a median follow-up of 11.5 months, patients with moderate/severe BM fibrosis showed a similar risk of acute myeloid leukemia transformation and a comparable overall survival in univariate and multivariate analyses. Moderate/severe BM fibrosis in patients with t-MDS is associated with certain clinicopathological and genetic features. However, unlike the situation in patients with primary MDS, moderate/severe BM fibrosis does not add additional risk to patients with therapy-related MDS.
Annals of Hematology 05/2013; · 2.87 Impact Factor