IDH1 and IDH2 Mutations in Therapy-Related Myelodysplastic Syndrome and Acute Myeloid Leukemia Are Associated with a Normal Karyotype and with Der(1;7)(Q10;P10)

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Letters to the Editor 957 IDH1 and IDH2 mutations in therapy-related myelodysplastic syndrome and acute myeloid leukemia are associated with a normal karyotype and with der(1;7)(q10;p10)

Leukemia (2013) 27, 957–959; doi:10.1038/leu.2012.347 sequence variations identified by HRM were confirmed by Sanger sequencing. Mechanisms associated with epigenetic regulation have recently Mutations in exon 4 of IDH1 or IDH2 were detected in 12 of 140 been shown to be implicated in the pathogenesis of acute patients with t-MDS/t-AML (9%). Detailed clinical, genetic and myeloid leukemia (AML) and myelodysplastic syndrome (MDS). cytogenetic characteristics for each of the 12 cases with IDH1/2 For instance, mutations of the isocitrate dehydrogenase gene mutations are shown in Table 1. In our study, 9 of 12 patients (IDH) have a role in AML and other types of cancer through altered displayed mutations of IDH2, as opposed to only 3 of 12 patients cellular respiration.1 IDH1 at chromosome band 2q33.3 and IDH2 with mutations of IDH1. This is in agreement with other studies, in at 15q26.1 encode metabolic enzymes active in the tricarboxylic which IDH2 mutations have been found to be more prevalent in cycle catalyzing the oxidative decarboxylation of isocitrate into AML.2,3 Half of the patients with mutated IDH harbored the IDH2 a-ketoglutarate. Gain-of-function mutations of IDH1 and IDH2 R140Q mutation, the most common type in de novo AML.2,3 All leads to the production and accumulation of 2-hydroxyglutarate, IDH mutations detected in the present study were heterozygous, which in turn causes disturbed gene expression profiles through indicating a dominant effect in leukemogenesis.1 None of the dysregulated epigenetic function.1 patients had concurrent mutations in IDH1 and IDH2. Recurrent mutations of IDH1 and IDH2 have been reported in IDH1/2 mutations were observed with a frequency of 7% 5–15% of patients with de novo AML.2–5 Mutated IDH strongly in t-MDS and 12% in t-AML (Table 1). These frequencies are similar associates with a normal karyotype2,6 in AML and with trisomy 8 in to the 5–15% reported in studies of de novo AML2,3 and 5% in de AML and MDS in a few studies.3,7 IDH1 and IDH2 mutations are novo MDS.4 Only one study has so far investigated IDH mutations common in patients with mutations of the nucleophosmin gene in overt t-AML; Pichler et al.5 reported on IDH mutations in 5% of (NPM1),2,6 the runt-related transcription factor 1 gene (RUNX1)8 73 patients with t-AML. The discrepancy in frequency of IDH and the mixed-lineage leukemia gene (MLL-PTD).6 mutations between the present study and the study by Pichler To evaluate the frequency of IDH1/2 mutations in therapy- may be explained by a different selection of patients and thus a related MDS (t-MDS) and AML (t-AML) and their possible different distribution of cytogenetic abnormalities in the two association to type of previous therapy, to leukemic transforma- cohorts. tion from t-MDS to t-AML and to other genetic abnormalities, 140 Table 2 outlines important characteristics of the 12 IDH mutated previously published patients with t-MDS and t-AML9 were cases in comparison with the 128 cases with non-mutated IDH. analyzed. Mononuclear cells isolated from the bone marrow or No significant association could be established between the blood at diagnosis of 89 patients with t-MDS and of 51 patients occurrence of IDH mutations and previous genotoxic therapy with with overt t-AML were included in the study. All patients were alkylating agents, topoisomerase II inhibitors or radiotherapy previously karyotyped and investigated for mutations of FLT3 (ITD, (Table 2). However, IDH mutations were significantly associated TKD), KIT, JAK2, KRAS, NRAS, BRAF, PTN11, RUNX1, MLL (PTD), CEBPA, with transformation from MDS to AML as five out of six patients with NPM1 and TP53.9 Screening for IDH mutations was performed by t-MDS and IDH mutations progressed to AML (Table 2, P ¼ 0.018). means of amplification of the fourth exon of IDH1 and IDH2, This observation is consistent with other studies on IDH mutations followed by high-resolution melting (HRM) analysis. Possible showing an association with leukemic transformation of MDS.10

Table 1. Characteristics of 12 patients with t-MDS/t-AML and mutations in IDH1/2

Case Age/sex t-AML/t-MDS Primary disease Previous therapy Latency period Karyotype Other mutations IDH mutation (months)

19 74/F MDS - AML Multiple myeloma IgA Alkeran þ Pred 45 45,XX, À 7/48,XX, þ 1,der(1;7)(q10;p10) — IDH1 R132G þ 11, þ 13/46,XX 29 63/F AML Carcinoma uteri I B RT 24 46,XX NPM1 FLT3-ITD IDH1 R132G 36 63/F AML Morbus Hodgkin LPIIIB BOPP, CLB, CVPP 120 48,XX, þ 2, þ 8/47,XX,der(6)t(1;6)(q?25;p21), NRAS IDH2 R172K þ 8 44 72/M MDS Multiple myeloma (IgA Alkeran þ Pred 33 46,XY, þ 1,der(1;7)(q10;p10)/46,XY — IDH2 R140Q kappa) 55 62/F MDS -AML Cancer uterine cervix RT 72 46,XX RUNX1 IDH2 R140L 72 72/F MDS -AML Breast cancer RT CCNU- MELPH- MTX, 84 46,XX, þ 1,der(1;7)(q10;p10)/ RUNX1 IDH2 R140Q 4-epi-dox 50,XX,idem, þ 8, þ 9, þ 14 þ 21 81 78/M AML NHL Chl, Ctx þ VCR þ Pred 32 46,XY,der(17)t(11;17)(q13;p13),i(13)(q10)/ — IDH2 R172K 47,idem, þ der(13)t(11;13) (q13;p11) 104 43/F MDS -AML Thymoma CtxþCCNUþVCRþPred 94 47,XX, þ 1,der(1;7)(q10;p10), þ 8 RUNX1 IDH1 R132C 109 44/F AML Sarcoidosis Mtx, Aza 126 46,XX — IDH2 R140Q 119 52/F AML NHL RT Ctx þ Dox þ VCR þ 52 46,XX NPM1 IDH2 R140Q Pred 133 25/M AML ALL VCR, MTX, Asp,6-MP 167 46,XX — IDH2 R140Q 180 60/M MDS -AML Rheumatoid arthritis Mtx 55 46,XX MLL-PTD IDH2 R140Q Abbreviations: 4-epi-dox, 4-epi-doxorubicin; 6-MP, 6 mercaptopurine; AML, acute myeloid leukemia; ALL, acute lymphoblastic leukemia; Asp, l-asparaginase; Aza, azathioprine; BOPP, carmustine þ vincristine þ procarbazine þ prednisone; CCNU, lomustine; CLB, chlorambucil; CTX, cyclophosphamide; CVPP, lomustine þ vinblastine þ procarbazine þ prednisone; Dox, doxorubicin; F, female; IDH, isocitrate dehydrogenase gene; IgA, immunoglobulin A; M, male; MDS, myelodysplastic syndrome; MELPH, melphalan; Mtx, methotrexate; MLL-PTD, mixed-lineage leukemia gene; NHL, non-hodgkin lymphoma; NPM1, nucleophosmin gene; Pred, Prednisone; RT, radiotherapy; RUNX1, runt-related transcription factor 1 gene; t-AML, therapy-related AML; t-MDS, therapy-related MDS; VCR, vincristine.

Accepted article preview online 29 November 2012; advance online publication, 21 December 2012

& 2013 Macmillan Publishers Limited Leukemia (2013) 954 – 995 Letters to the Editor 958 study (case 36) who had an unbalanced translocation, Table 2. Characteristics of IDH mutated versus non-mutated of der(6)t(1;6)(q?25;p21), resulting in partial gain of a large part of 1q, t-MDS/t-AML but normal chromosomes 7 (Table 1). Consistent with our findings, a different clinical outcome has been reported between MDS patients Characteristics IDH IDH P-value 13 mutated, wild-type, with der(1;7)(q10;p10) and patients with À 7/7q À although other 12,14 n ¼ 12 n ¼ 128 studies have been unable to confirm this difference. Other gene mutations have been shown as common in IDH1/2 Age, years (median) 63 59 0.582a mutated cases of de novo AML.2,6,8 In our cohort, 7 of 12 patients Female/male 8/4 65/63 0.372 with IDH mutations displayed mutations of RUNX1 (n ¼ 3), NPM1 (n ¼ 2), FLT3, NRAS and MLL-PTD (one case each; Table 1). Previous therapy However, no statistically significant correlation could be estab- Alkylating agents 7 108 0.040 Alkylating only 5 31 0.187 lished between these mutations and mutations of IDH1/2, possibly Topo-II inhibitors 2 59 0.068 due to the small number of cases (Table 2). The lack of association RT±CT 4 62 0.376 between IDH mutations and either class I mutations (accelerating Radiotherapy only 2 15 0.641 proliferation) or II mutations (impairing differentiation), supports current suggestions that IDH belongs to a novel class of mutations Presentation involved in epigenetic regulation.6 t-MDS/t-AML 6/6 83/45 0.354 Based on cytogenetic characteristics, we have previously t-MDS-t-AML 5/6 26/83 0.018 9,15 a discussed different genetic pathways in t-MDS/t-AML. Latency period (months) 64 48 0.118 Patients with IDH mutations seem to cluster in two pathways. Cytogenetics The first, pathway I is defined by À 7/7q À but normal chromo- der(1;7) 4 7 0.008 somes 5 and are often associated with RUNX1 mutations and with Other 7 1/11 54/74 0.028 methylation of CDKN2B (p15). The second, pathway VII comprises abnormalities (7q À / À 7) patients with a normal karyotype frequently presenting mutations þ 1q abnormalities 5 9 0.002 of NPM1, FLT3 and RAS. A combination of trisomy 1q, mutation of Normal 6 18 0.006 IDH, and perhaps mutation of RUNX1 could represent a new Trisomy 8 3 8 0.054 specific pathway in t-MDS/t-AML. 5q À / À 5 0 34 0.039 In conclusion, mutations of IDH1/2 are of the same type and Balanced translocations 0 22 0.213 occur at the same frequency in therapy-related and de novo MDS Gene mutations and AML. They are unrelated to type of previous therapy, but are NPM1 2 8 0.206 significantly associated with leukemic transformation. Further- RUNX1 3 19 0.402 more, they are associated with a normal karyotype and with FLT3 1 10 1.00 der(1;7)(q10;p10), but are inversely correlated to other chromo- TP53 0 34 0.039 some 7 abnormalities. This suggests a specific biological effect in RAS 1 13 1.00 leukemogenesis different from that of other chromosome 7 MLL-PTD 1 1 0.165 defects perhaps linked to trisomy 1q. Class II mutations 5 41 0.530 Class I mutations 1 12 1.00 Class I þ II mutations 1 10 1.00 CONFLICT OF INTEREST Abbreviations: AML, acute myeloid leukemia; CT, computed tomography; The authors declare no conflict of interest. IDH, isocitrate dehydrogenase gene; MDS, myelodysplastic syndrome; MLL-PTD, mixed-lineage leukemia gene; NPM1, nucleophosmin gene; RT, radiotherapy; RUNX1, runt-related transcription factor 1 gene; t-AML, MK Westman, J Pedersen-Bjergaard, therapy-related AML; t-MDS, therapy-related MDS. aCalculated using the MT Andersen and MK Andersen Wilcoxon’s two-sample test. Section of Hematology/Oncology, Department of Clinical Genetics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark IDH mutations were significantly associated with a normal E-mail: [email protected] karyotype (P ¼ 0.006, Table 2), similar to observations from de novo disease.2,6 IDH mutations have also been shown to be correlated to isolated trisomy 8 in de novo MDS and AML.3,7 Although three patients with IDH mutations in our study had REFERENCES trisomy 8 as part of a complex karyotype, the association did not 1 Prensner JR, Chinnaiyan AM. Metabolism unhinged: IDH mutations in cancer. reach statistical significance (Table 2). Interestingly, a novel Nat Med 2011; 17: 291–293. significant association was observed between IDH mutations 2 Paschka P, Schlenk RF, Gaidzik VI, Habdank M, Kronke J, Bullinger L et al. IDH1 and and der(1;7)(q10;p10) (P ¼ 0.008, Table 2), whereas IDH mutations IDH2 mutations are frequent genetic alterations in acute myeloid leukemia and confer adverse prognosis in cytogenetically normal acute myeloid leukemia with were inversely correlated with other chromosome 7 abnormalities NPM1 mutation without FLT3 internal tandem duplication. J Clin Oncol 2010; 28: (P ¼ 0.0028, Table 2). This correlation was not observed by Pichler 3636–3643. et al., who did not have any patients with der(1;7)(q10;10) in their 3 Caramazza D, Lasho TL, Finke CM, Gangat N, Dingli D, Knudson RA et al. IDH study of t-AML. mutations and trisomy 8 in myelodysplastic syndromes and acute myeloid The unbalanced translocation der(1;7)(q10;p10) resulting in leukemia. Leukemia 2010; 24: 2120–2122. trisomy 1q and loss of 7q is a characteristic recurrent cytogenetic 4 Kosmider O, Gelsi-Boyer V, Slama L, Dreyfus F, Beyne-Rauzy O, Quesnel B et al. abnormality in MDS and AML particularly frequent in therapy- Mutations of IDH1 and IDH2 genes in early and accelerated phases of myelo- related disease following treatment with alkylating agents.11,12 dysplastic syndromes and MDS/myeloproliferative neoplasms. Leukemia 2010; 24: The association between IDH mutations and der(1;7) may indicate 1094–1096. 5 Pichler MM, Bodner C, Fischer C, Deutsch AJ, Hiden K, Beham-Schmid C et al. that der(1;7)(q10;p10) belongs to a specific subgroup, biologically Evaluation of mutations in the isocitrate dehydrogenase genes in therapy-related distinct from other chromosome 7 abnormalities, and suggests and secondary acute myeloid leukaemia identifies a patient with clonal evolution that trisomy 1q may be of importance in leukemogenesis. This is to IDH2 R172K homozygosity due to uniparental disomy. Br J Haematol 2011; 152: further supported by another patient with IDH mutation in our 669–672.

Leukemia (2013) 954 – 995 & 2013 Macmillan Publishers Limited Letters to the Editor 959 6 Schnittger S, Haferlach C, Ulke M, Alpermann T, Kern W, Haferlach T. IDH1 ficantly related to previous treatment with alkylating agents and suggests a mutations are detected in 6.6% of 1414 AML patients and are associated with specific susceptibility to chromosome breakage at the centromere. Leukemia intermediate risk karyotype and unfavorable prognosis in adults younger than 60 2000; 14: 105–111. years and unmutated NPM1 status. Blood 2010; 116: 5486–5496. 12 Hsiao HH, Sashida G, Ito Y, Kodama A, Fukutake K, Ohyashiki JH et al. 7 Chou WC, Hou HA, Chen CY, Tang JL, Yao M, Tsay W et al. Distinct clinical and Additional cytogenetic changes and previous genotoxic exposure predict biologic characteristics in adult acute myeloid leukemia bearing the isocitrate unfavorable prognosis in myelodysplastic syndromes and acute myeloid dehydrogenase 1 mutation. Blood 2010; 115: 2749–2754. leukemia with der(1;7)(q10;p10). Cancer Genet Cytogenet 2006; 165: 8 Gaidzik VI, Bullinger L, Schlenk RF, Zimmermann AS, Rock J, Paschka P et al. 161–166. RUNX1 mutations in acute myeloid leukemia: results from a comprehensive 13 Sanada M, Uike N, Ohyashiki K, Ozawa K, Lili W, Hangaishi A et al. Unbalanced genetic and clinical analysis from the AML study group. JClinOncol2011; 29: translocation der(1;7)(q10;p10) defines a unique clinicopathological subgroup of 1364–1372. myeloid neoplasms. Leukemia 2007; 21: 992–997. 9 Pedersen-Bjergaard J, Andersen MK, Andersen MT, Christiansen DH. Genetics of 14 Slovak ML, O’Donnell M, Smith DD, Gaal K. Does MDS with der(1;7)(q10;p10) therapy-related myelodysplasia and acute myeloid leukemia. Leukemia 2008; 22: constitute a distinct risk group? A retrospective single institutional analysis of 240–248. clinical/pathologic features compared to -7/del(7q) MDS. Cancer Genet Cytogenet 10 Thol F, Weissinger EM, Krauter J, Wagner K, Damm F, Wichmann M et al. IDH1 2009; 193: 78–85. mutations in patients with myelodysplastic syndromes are associated with an 15 Pedersen-Bjergaard J, Christiansen1111 DH, Desta F, Andersen MK. Alternative unfavorable prognosis. Haematologica 2010; 95: 1668–1674. genetic pathways and cooperating genetic abnormalities in the pathogenesis of 11 Andersen MK, Pedersen-Bjergaard J. Increased frequency of dicentric chromo- therapy-related myelodysplasia and acute myeloid leukemia. Leukemia 2006; 20: somes in therapy-related MDS and AML compared to de novo disease is signi- 1943–1949.

A lack of positive effect of enhanced vegetative nervous system tonus on mobilization of hematopoietic stem and progenitor cells in patients suffering from acute psychotic syndromes

Leukemia (2013) 27, 959–961; doi:10.1038/leu.2012.349

It has been demonstrated in mice that enhanced tonus of 5 Control vegetative nervous system regulates mobilization of hematopoie- 4.5 tic stem and progenitor cells (HSPCs) into peripheral blood (PB). It 4 Psychotic l PB is well known that HSPCs circulate under steady-state conditions μ 3.5 patients at detectable levels in PB, with their numbers increasing in 3 1–3 response to stress, inflammation, and tissue and organ injury. 2.5 Circulation of these cells under normal steady-state conditions is 2 regulated by a circadian rhythm, with the peak of these circulating 1.5 cells occurring in the early morning hours and the nadir at 1 1–4 night. As observed in mice exposed to daylight changes, this Circulating cells/ 0.5 oscillation in HSPC levels is affected as postulated by changes in 0 4,5 tonus of the vegetative nervous system. CD34+ CD133+ CD34+ CD34+ CD133+ HSPCs can be also mobilized into PB in an enforced manner by CD133+ CD45+ CD45+ administration of granulocyte-colony stimulating factor (G-CSF), LIN- LIN- and it has also been shown in mice that release of these cells into 4,5 300 PB depends critically on the vegetative nervous system. Control Moreover, UDP-galactose:ceramide galactosyltransferase-deficient mice, which exhibit aberrant nerve conduction and do not 250 Psychotic patients release norepinephrine (NE) into the bone marrow (BM) micro- 200 environment, do not mobilize HSPCs in response to G-CSF.4 To explain how NE signaling influences HSPC mobilization, it 150 has been postulated that it modulates expression of stromal derived factor-1 (SDF-1) in the BM microenvironment, and 100 such a mechanism would be consistent with the finding that Number of colonies 50 administration of b2-adrenergic agonists enhances mobilization of HSPCs in both control and NE-deficient mice.4 In a recent study, it 0 has also been proposed that G-CSF increases sympathetic tonus BFU-E CFU-GM directly via G-CSF receptors that are expressed on peripheral Figure 1. The number of HSPCs circulating in PB in patients with sympathetic neurons, which would reduce NE reuptake and acute psychosis and matched controls. (a) The number of CD34 þ , 5 increase NE availability in the BM microenvironment. CD133 þ , CD34 þ CD45 þ Lin À and CD133 þ CD45 þ Lin À cells circu- However, as recently reported modification of sympathetic lating in PB. (b): The number of circulating CFU-GM and BFU-E output does not affect G-CSF-induced mobilization in humans, as clonogenic progenitors.

Accepted article preview online 4 December 2012; advance online publication, 21 December 2012

& 2013 Macmillan Publishers Limited Leukemia (2013) 954 – 995