KMT2A/AFDN Jean-Loup Huret Genetics, Dept Medical Information, University of Poitiers, CHU Poitiers Hospital, F-86021 Poitiers, France

Atlas of Genetics and Cytogenetics in Oncology and Haematology OPEN ACCESS JOURNAL AT INIST-CNRS

Leukaemia Section Review t(6;11)(q27;q23) KMT2A/AFDN Jean-Loup Huret Genetics, Dept Medical Information, University of Poitiers, CHU Poitiers Hospital, F-86021 Poitiers, France

Published in Atlas Database: July 2017 Online updated version : http://AtlasGeneticsOncology.org/Anomalies/t0611ID1015.html Printable original version : http://documents.irevues.inist.fr/bitstream/handle/2042/68924/07-2017-t0611ID1015.pdf DOI: 10.4267/2042/68924 This article is an update of : Huret, JL. t(6;11)(q27;q23). Atlas Genet Cytogenet Oncol Haematol. 1997;1(2):87-88.

B lymphoblastic leukemia; T-cell lymphoblastic Abstract leukemia. Review on the t(6;11)(q27;q23) involving KMT2A (better known as MLL), and AFDN (Afadin), also Identity known as AF6 or MLLT4. It occurs in acute myeloid Other names leukemia, at times treatment-related leukemia, B t(6;11)(q27;q23) MLL/MLLT4 lymphoblastic leukemia, and T-cell lymphoblastic t(6;11)(q27;q23) MLL/AF6 leukemia. It carries a poor prognosis. Note KEYWORDS Herein below, the well-known term "MLL" will be Chromosome 6; chromosome 11; t(6;11)(q27;q23); used, instead of the poorly known term "KMT2A" KMT2A; MLL; AFDN; Afadin; AF6; MLLT4; A total of 135 different MLL rearrangements have acute myeloid leukemia; treatment-related leukemia; been identified so far (Meyer et al., 2017).

t(6;11)(q27;q23) G- banding - Courtesy Diane H. Norback, Eric B. Johnson, Sara Morrison-Delap Cytogenetics at theWaisman Center (left and middle), and Jean-Luc Lai (right).

The t(4;11)(q21;q23) MLL / AFF1, one of the most Clinics and pathology common 11q23 abnormalities, occurs in 2% of Note children and adults with ALL (Raimondi 2004). The incidence of 11q23 abnormalities in infants with acute lymphoblastic leukemia (ALL) ranges from The incidence of 11q23 abnormalities in children 60% to 80%., and from 4.5% to 5.7% among with acute myeloid leukemia (AML) ranges from children who are older than 1 year and have ALL. 15% to 25%. In children younger than 2 years, the

Atlas Genet Cytogenet Oncol Haematol. 2018; 22(7) 308 t(6;11)(q27;q23) KMT2A/AFDN

peak incidence of 11q23/MLL gene rearrangements 16 patients (0.6%) were identified with t(6;11). there is 50%-60%. was 3 M1, 7 M4, 5 M5 (Blum et al., 2004). Clinics The incidence of 11q23 abnormalities in adults with AML is approximately 5% (Coenen et al., 2012). Central nervous system involvement was found in 15% of 35 cases of childhood 11q23/MLL- The incidence of 11q23 abnormalities among adult rearranged acute myeloid leukemia (Balgobind et al., ALL cases is about 10% (Pui et al., 2004). 2009) Disease Epidemiology Translocation t(6;11) represent about 5% of acute In the large study of 2,345 acute leukemia patients leukemia with 11q23/MLL rearrangement and is with 11q23-MLL-rearrangement, there was 876 more frequent in AML than in ALL. Different infants, 671 "pediatric" cases (infants excluded), and studies are available, each involving specific groups 798 adults. Of the the 95 cases with t(6;11) in this of patients, and they cannot be pooled in one meta- study, median age was 19 years, with 3 infant, 44 analysis: pediatric, and 48 adult cases; this abnormality is rare in infants (0,3%) and more frequent in children and In a large study on 2,345 acute leukemia patients adults: 6,6 and 6% respectively. Sex ratio was with 11q23/MLL rearrangement, there were 1,420 45M/50F. Mean age of T-cell ALL cases with patients diagnosed with ALL (61%), 872 diagnosed t(6;11) was 17 years, with 14 pediatric and 9 adult with AML (37%) and 7 with MDS; 38 were mixed cases. Sex ratio was 11M/12F (Meyer et al., 2017). lineage leukemia (1.6%), 4 lymphomas, and 4 other. In another study of t(6;11)(q27;q23) acute leukemia, Of these 2,345 patients with MLL rearrangements, median age was 30-35 years (range 0.5-72, with 2 there was 95 cases of t(6;11). They represented 4% infant cases and 6 other children under 16). Sex ratio of the cases. Of these 95 cases, there were 26 ALL, was 17M/13F (57%) (Martineau et al., 1998). 68 AML, and 1 "other"; two of them were 2 treatment related leukemia. Translocation t(6;11) In a study of 35 childhood AMLs, median age 12 was found in 7.8% of AML with MLL years (8% were infant cases, 34% were aged 2-9 yrs, rearrangements and 1.8% of ALL with MLL and 57% were older children). M/F was 19/16 (54%) rearrangements. There were 59 cases of T-cell ALL (Balgobind et al., 2009). in this series of 2,345 acute leukemia patients. T- ALL was mainly composed of AFDN (AF6, On 8 adult AML cases : age were 22-58 years, and MLLT4) and MLLT1 (ENL) gene fusions: there sex ratio was 3M/5F (Lavallee et al 2015). Median were 23 AFDN (AF6, MLLT4) cases and 22 MLLT1 age of adults with de novo AML was 45 years (range (ENL) cases (Meyer et al., 2017). 22-65) in another study and sex ratio was 7M/8F (Blum et al., 2004). In a series of 550 cases with an 11q23 Prognosis rearrangement, 30 cases (5.5%) were shown to have Complete remission (CR) was obtained in 23 of 26 a t(6;11)(q27;q23) There were 27 AMLs (26 de novo AML cases, but median survival was only 12 months and 1 secondary, 3 M1, 2 M2, 8 M4, 1 M4/5, 13 M5) (Martineau et al., 1998). The 35 patients with a and 3 infant/childhood ALL, 1 being a T-ALL t(6;11)(q27;q23) had the worst outcome compared to (Martineau et al., 1998). other childhood 11q23/MLL-rearranged acute

myeloid leukemia groups: 5-year event free survival In a study of 756 childhood AML with 11q23 (EFS) was 11% (± 5%) and 5-year overall survival rearrangement, 35 (5%) showed a t(6;11). The (OS) was 22% (Balgobind et al., 2009). CR was disease was an AML-M1 in 15%, AML-M2 in 6%, achieved in 69% of adults with de novo AML (11 of AML-M4 in 35%, AML-M5 in 41% (Balgobind et 16 patients), but CR duration was short (median 9 al., 2009). months). The estimated probability of 2-year

survival was 13%. Both long-term survivors In a study of 415 adult AML cases (389 de novo and received allogeneic stem cell transplantation. The 26 treatment-related AML), 54 were rearranged for estimated probability of 2-year survival of patients MLL (31 MLL-fusions and 23 MLL partial tandem reported in the literature was 15% (Blum et al., duplications (PTD)), 8 of which (26% of 11q23 2004). However, as there are many progresses in rearrangements, 1,9% of adult AML cases) were therapy, one cannot rely on survival studies made 10 t(6;11) cases. There was 2 AML-M1, 1 AML-M2, 2 or 20 years ago. AML-M4, 3 AML-M5 (Lavallee et al 2015). 11q23 rearrangements were identified in 118 adult AML cases (85 de novo and 33 t-AML). A t(6;11) (n=17) Cytogenetics was found in 14% of 11q23 rearrangements (Grossmann). Out of 2667 adults with de novo AML,

Atlas Genet Cytogenet Oncol Haematol. 2018; 22(7) 309

t(6;11)(q27;q23) KMT2A/AFDN

Cytogenetics morphological AFDN was previously called MLLT4 (myeloid/lymphoid or mixed-lineage leukemia; In a series of 30 cases with t(6;11)(q27;q23), (27 translocated to, 4) or AF6 (ALL1 fused gene from AMLs and 3 ALLs). The t(6;11) was the sole chromosome 6) abnormality in 24 cases (at least in a subclone), +der(6)t(6;11), +8, +19 and +21 were found in 10% Protein (3 times) each. All three patients with AML-M1 had The protein, called afadin, is a scaffolding protein additional abnormalities. (Martineau et al., 1998). In with a role in cell-cell junctional complexes a series of adults with de novo AML, the t(6;11) was (adherens junctions and in tight junctions). The the sole abnormality in 12/15 cases; der(6)t(6;11) transmembrane proteins cadherins and nectins and +8 were found in one case each (Blum et al., interact with other proteins through their 2004) cytoplasmic domain to form adherens junctions. CTNNA1, CTNNA2 or CTNNA3 (α-catenins) Cytogenetics molecular /CTNNB1 (β-catenin) links cadherins to the actin The t(6;11) translocation can escape recognition: cytoskeleton and afadin links nectins to the actin chromosome 6 involvement may be overlooked and cytoskeleton (Boettner et al., 2000; Tachibana et al., the abnormality may be missinterpreted as a 2000; Bégay-Müller et al., 2002). Afadin plays an del(11q), with conventional banding techniques; essential role in regulating apical-basal polarity and FISH techniques necessary. adherens junction integrity (Rakotomamonjy et al., 2017). Genes involved and Loss of expression or lower expression of afadin is proteins found in pancreatic cancer, and is correlated with Note poor prognosis in colon cancer and breast cancer, Frequent KRAS and NRAS mutations were found induces cell migration and cell invasion of (30% and 18% respectively) in AML adult cases and myometrium in endometrial cancer, where it is there was MECOM overexpression in 100% associated with high histological grades (Fournier et (Grossmann et al., 2013).There was high expression al., 2011; Sun et al., 2014; Xu et al., 2015; levels of NKX2-3 and MECOM in AML adult cases. Yamamoto et al., 2015a). (Lavallee et al 2015). Methylation of lysine79 of histone H3 (H3K79) is a prerequisite for Result of the chromosomal maintenance of RNA transcription. MLL/AFF1 anomaly (AF4), MLL/ MLLT3 (AF9), MLL/MLLT1 (ENL), MLL/MLLT10 (AF10) and MLL/AFDN (AF6, Hybrid gene MLLT4), result in an increased and extended H3K79 Description methylation (Meyer et al., 2017). The breakpoint in AFDN (AF6, MLLT4) was KMT2A determined from two AML, one T-ALL, and one cell Location line. It was found between exons 1 and 2, 11q23.3 corresponding to the junction of amino acid 35 and Note 36 (Tanabe et al., 1996); i.e. Better known as MLL MSAGGRDEERRKLADIIHHWNANRLDLFEIS DNA/RNA QPTE/DLEFHGVMRFYFQDKAAGNFATKCIRV 37 exons, spanning about 120 kb; 13-15 mRNA SSTATTQD Protein 3969 amino acids, 431 kDa; Transcriptional In 8 of 8 AML adult cases, MLL exon/intron 8 was regulatory factor. MLL is known to be associated fused to AFDN (AF6, MLLT4) exon/intron 1 with more than 30 proteins, including the core (Lavallee et al 2015). components of the SWI/SNF chromatin remodeling complex and the transcription complex TFIID. MLL In the large study of 95 cases of acute leukemia with binds promotors of HOX genes through acetylation t(6;11); the breakpoint in MLL was more often in and methylation of histones. MLL is a major intron 9 (65% on cases) than it was in other fusions regulator of hematopoesis and embryonic (e.g. AFF1 (AF4): 33%, MLLT3 (AF9): 38%, development, through regulation of HOX genes MLLT1 (ENL): 23%, where intron 11 is equally or expression regulation (HOXA9 in particular). more frequent). The breakpoint was in: intron 9: 62 AFDN cases, exon 10: 4 cases, intron 10: 15 cases, exon 11: 4 cases, intron 11: 3 cases, exon 12: 2 cases. Only in Location MLL/AFDN cases were observed very unusual MLL 6q27 breakpoints (n=4), within intron 21 and 23. The Note authors pointed out that "This is quite important

Atlas Genet Cytogenet Oncol Haematol. 2018; 22(7) 310

t(6;11)(q27;q23) KMT2A/AFDN

because such a far away downstream breakpoint terminus, like chromatin reading, protein stability or includes the complete PHD1-3, the BD domain as PPIE (CYP33) binding. In the latter case, binding of well as the complete ePHD4 domain of MLL into the the BMI1 repressor complex will reverse the fusion protein with AFDN (AF6, MLLT4). These function of the MLL/AFDN fusion by repressing additional 581 amino acids could be an important gene transcription" (Meyer et al., 2017). hint for the importance of these MLL domains in T- Fusion protein ALL. The PHD1-3 and bromodomain exert important regulatory functions to the MLL N-

t(6;11)(q27;q23) MLL/AFDN

Oncogenesis childhood acute myeloid leukemia Atlas Genet Cytogenet Oncol Haematol. 2012;16(8):574-581. While AFDN localizes in the cytoplasm, MLL/AFDN localizes in the nucleus, leading to Deshpande AJ, Chen L, Fazio M, Sinha AU, Bernt KM, aberrant activation of RAS and of its downstream Banka D, Dias S, Chang J, Olhava EJ, Daigle SR, Richon VM, Pollock RM, Armstrong SA. Leukemic transformation targets (Deshpande et al., 2013; Manara et al. 2014). by the MLL-AF6 fusion oncogene requires the H3K79 methyltransferase Dot1l Blood 2013 Mar 28;121(13):2533- References 41 Fournier G, Cabaud O, Josselin E, Chaix A, Adélaïde J, Bégay-Müller V, Ansieau S, Leutz A. The LIM domain Isnardon D, Restouin A, Castellano R, Dubreuil P, protein Lmo2 binds to AF6, a translocation partner of the Chaffanet M, Birnbaum D, Lopez M. Loss of AF6/afadin, a MLL oncogene. FEBS Lett. 2002 Jun 19;521(1-3):36-8 marker of poor outcome in breast cancer, induces cell Balgobind BV, Raimondi SC, Harbott J, Zimmermann M, migration, invasiveness and tumor growth Oncogene 2011 Alonzo TA, Auvrignon A, Beverloo HB, Chang M, Creutzig Sep 8;30(36):3862-74 U, Dworzak MN, Forestier E, Gibson B, Hasle H, Harrison Grossmann V, Schnittger S, Poetzinger F, Kohlmann A, CJ, Heerema NA, Kaspers GJ, Leszl A, Litvinko N, Nigro LL, Stiel A, Eder C, Fasan A, Kern W, Haferlach T, Haferlach C. Morimoto A, Perot C, Pieters R, Reinhardt D, Rubnitz JE, High incidence of RAS signalling pathway mutations in MLL- Smith FO, Stary J, Stasevich I, Strehl S, Taga T, Tomizawa rearranged acute myeloid leukemia Leukemia 2013 D, Webb D, Zemanova Z, Zwaan CM, van den Heuvel- Sep;27(9):1933-6 Eibrink MM. Novel prognostic subgroups in childhood 11q23/MLL-rearranged acute myeloid leukemia: results of Lavallée VP, Baccelli I, Krosl J, Wilhelm B, Barabé F, an international retrospective study. Blood. 2009 Sep Gendron P, Boucher G, Lemieux S, Marinier A, Meloche S, 17;114(12):2489-96 Hébert J, Sauvageau G. The transcriptomic landscape and directed chemical interrogation of MLL-rearranged acute Blum W, Mrózek K, Ruppert AS, Carroll AJ, Rao KW, myeloid leukemias Nat Genet 2015 Sep;47(9):1030-7 Pettenati MJ, Anastasi J, Larson RA, Bloomfield CD. Adult de novo acute myeloid leukemia with t(6;11)(q27;q23): Manara E, Baron E, Tregnago C, Aveic S, Bisio V, Bresolin results from Cancer and Leukemia Group B Study 8461 and S, Masetti R, Locatelli F, Basso G, Pigazzi M. MLL-AF6 review of the literature. Cancer. 2004 Sep 15;101(6):1420- fusion oncogene sequesters AF6 into the nucleus to trigger 7 RAS activation in myeloid leukemia Blood 2014 Jul 10;124(2):263-72 Boettner B, Govek EE, Cross J, Van Aelst L. The junctional multidomain protein AF-6 is a binding partner of the Rap1A Martineau M, Berger R, Lillington DM, Moorman AV, GTPase and associates with the actin cytoskeletal regulator Secker-Walker LM. The t(6;11)(q27;q23) translocation in profilin. Proc Natl Acad Sci U S A. 2000 Aug 1;97(16):9064- acute leukemia: a laboratory and clinical study of 30 cases 9 EU Concerted Action 11q23 Workshop participants Leukemia Coenen EA, Harbott J, Zwaan CM, Raimondi SC, van den Heuvel-Eibrink MM. 11q23 rearrangements in de novo

Atlas Genet Cytogenet Oncol Haematol. 2018; 22(7) 311

t(6;11)(q27;q23) KMT2A/AFDN

Meyer C, Burmeister T, Gröger D, Tsaur G, Fechina L, 6/afadin aggravates malignant phenotypes of colon cancer Renneville A, Sutton R, Venn NC, Emerenciano M, Pombo- Biochim Biophys Acta 2014 Mar;1843(3):618-28 de-Oliveira MS, Barbieri Blunck C, Almeida Lopes B, Zuna J, Trka J, Ballerini P, Lapillonne H, De Braekeleer M, Tachibana K, Nakanishi H, Mandai K, Ozaki K, Ikeda W, Cazzaniga G, Corral Abascal L, van der Velden VHJ, Yamamoto Y, Nagafuchi A, Tsukita S, Takai Y. Two cell Delabesse E, Park TS, Oh SH, Silva MLM, Lund-Aho T, adhesion molecules, nectin and cadherin, interact through Juvonen V, Moore AS, Heidenreich O, Vormoor J, their cytoplasmic domain-associated proteins J Cell Biol Zerkalenkova E, Olshanskaya Y, Bueno C, Menendez P, 2000 Sep 4;150(5):1161-76 Teigler-Schlegel A, Zur Stadt U, Lentes J, Göhring G, Tanabe S, Zeleznik-Le NJ, Kobayashi H, Vignon C, Kustanovich A, Aleinikova O, Schäfer BW, Kubetzko S, Espinosa R 3rd, LeBeau MM, Thirman MJ, Rowley JD. Madsen HO, Gruhn B, Duarte X, Gameiro P, Lippert E, Analysis of the t(6;11)(q27;q23) in leukemia shows a Bidet A, Cayuela JM, Clappier E, Alonso CN, Zwaan CM, consistent breakpoint in AF6 in three patients and in the ML- van den Heuvel-Eibrink MM, Izraeli S, Trakhtenbrot L, 2 cell line Genes Chromosomes Cancer 1996 Archer P, Hancock J, Möricke A, Alten J, Schrappe M, Apr;15(4):206-16 Stanulla M, Strehl S, Attarbaschi A, Dworzak M, Haas OA, Panzer-Grümayer R, Sedék L, Szczepański T, Caye Xu Y, Chang R, Peng Z, Wang Y, Ji W, Guo J, Song L, Dai A, Suarez L, Cavé H, Marschalek R. The MLL recombinome C, Wei W, Wu Y, Wan X, Shao C, Zhan L. Loss of polarity of acute leukemias in 2017 Leukemia 2017 Jul 13 protein AF6 promotes pancreatic cancer metastasis by inducing Snail expression Nat Commun 2015 May Pui CH, Relling MV, Downing JR. Acute lymphoblastic 26;6:7184 leukemia N Engl J Med 2004 Apr 8;350(15):1535-48 Yamamoto T, Mori T, Sawada M, Matsushima H, Ito F, Raimondi, SC. 11q23 rearrangements in childhood acute Akiyama M, Kitawaki J. Loss of AF-6/afadin induces cell lymphoblastic leukemia Atlas Genet Cytogenet Oncol invasion, suppresses the formation of glandular structures Haematol. 2004;8(2):97-102. and might be a predictive marker of resistance to Rakotomamonjy J, Brunner M, Jüschke C, Zang K, Huang chemotherapy in endometrial cancer BMC Cancer 2015 EJ, Reichardt LF, Chenn A. Afadin controls cell polarization Apr 12;15:275 and mitotic spindle orientation in developing cortical radial glia Neural Dev 2017 May 8;12(1):7 This article should be referenced as such: Sun TT, Wang Y, Cheng H, Xiao HZ, Xiang JJ, Zhang JT, Huret JL. t(6;11)(q27;q23) KMT2A/AFDN. Atlas Yu SB, Martin TA, Ye L, Tsang LL, Jiang WG, Xiaohua J, Genet Cytogenet Oncol Haematol. 2018; Chan HC. Disrupted interaction between CFTR and AF- 22(7):308-312.

Atlas Genet Cytogenet Oncol Haematol. 2018; 22(7) 312