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RUNX1 Mutations in Acute Myeloid Leukemia Are Associated with Distinct Clinico-Pathologic and Genetic Features

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RUNX1 Mutations in Acute Myeloid Leukemia Are Associated with Distinct Clinico-Pathologic and Genetic Features Leukemia (2016) 30, 2160–2168 © 2016 Macmillan Publishers Limited, part of Springer Nature. All rights reserved 0887-6924/16 www.nature.com/leu ORIGINAL ARTICLE RUNX1 mutations in acute myeloid leukemia are associated with distinct clinico-pathologic and genetic features VI Gaidzik1,13, V Teleanu1,13,EPapaemmanuil2,DWeber1,PPaschka1,JHahn1, T Wallrabenstein1, B Kolbinger1,CHKöhne3,HAHorst4, P Brossart5,GHeld6, A Kündgen7, M Ringhoffer8, K Götze9,MRummel10, M Gerstung2, P Campbell2,JMKraus11, HA Kestler11,FThol12, MHeuser12, B Schlegelberger12,AGanser12, L Bullinger1,RFSchlenk1, K Döhner1 and H Döhner1 for the German-Austrian Acute Myeloid Leukemia Study Group (AMLSG)14 We evaluated the frequency, genetic architecture, clinico-pathologic features and prognostic impact of RUNX1 mutations in 2439 adult patients with newly-diagnosed acute myeloid leukemia (AML). RUNX1 mutations were found in 245 of 2439 (10%) patients; were almost mutually exclusive of AML with recurrent genetic abnormalities; and they co-occurred with a complex pattern of gene mutations, frequently involving mutations in epigenetic modifiers (ASXL1, IDH2, KMT2A, EZH2), components of the spliceosome complex (SRSF2, SF3B1) and STAG2, PHF6, BCOR. RUNX1 mutations were associated with older age (16–59 years: 8.5%; ⩾ 60 years: 15.1%), male gender, more immature morphology and secondary AML evolving from myelodysplastic syndrome. In univariable analyses, RUNX1 mutations were associated with inferior event-free (EFS, Po0.0001), relapse-free (RFS, P = 0.0007) and overall survival (OS, Po0.0001) in all patients, remaining significant when age was considered. In multivariable analysis, RUNX1 mutations predicted for inferior EFS (P = 0.01). The effect of co-mutation varied by partner gene, where patients with the secondary genotypes RUNX1mut/ASXL1mut (OS, P = 0.004), RUNX1mut/SRSF2mut (OS, P = 0.007) and RUNX1mut/PHF6mut (OS, P = 0.03) did significantly worse, whereas patients with the genotype RUNX1mut/IDH2mut (OS, P = 0.04) had a better outcome. In conclusion, RUNX1-mutated AML is associated with a complex mutation cluster and is correlated with distinct clinico-pathologic features and inferior prognosis. Leukemia (2016) 30, 2160–2168; doi:10.1038/leu.2016.126 INTRODUCTION ‘AML with mutated CEBPA’.3 These have also been endorsed by Over the last few decades, the discovery of recurrent structural the European LeukemiaNet (ELN) recommendations, which in balanced and unbalanced chromosome abnormalities have largely addition to CEBPA and NPM1 mutations propose that FLT3 internal contributed to the clinical management of patients with acute tandem duplications (ITDs) are also included in a standardized myeloid leukemia (AML).1 These chromosomal abnormalities are reporting system of genetic markers.2 Although other gene among the most important prognostic markers and in part define mutations have been shown to provide prognostic information, – specific clinico-pathologic entities of the disease.1–4 In more recent none of these markers have to date entered clinical practice.1,6 8 years, the development of novel genomics technologies, including Beyond the prognostic and predictive value of a molecular next-generation sequencing,5 has greatly contributed to deciphering biomarker, one important question is whether there are specific the molecular genetic changes associated with the development of gene mutations other than NPM1 or CEBPA that define a disease AML. With the advent of these technologies, it has become evident entity that is correlated with distinct morphologic, immunopheno- that AML is characterized by remarkable genetic heterogeneity, with typic and clinical features. The planned update of WHO classification individual patients presenting with a distinct and almost unique considers AML with RUNX1 mutation as a new provisional entity. combination of structural genomic changes and somatically acquired RUNX1 is a transcriptional factor widely expressed in hema- gene mutations. topoietic cells and indispensable for the establishment of Although great progress has been made in unraveling the AML definitive hematopoiesis. In mouse models, lack of the Runx1 genome, to date only few molecular markers have been shown gene impairs definitive hematopoiesis and causes embryonic to have clinical relevance.5–7 In the WHO 2008 classification, for death. In adult hematopoiesis, disruption of the RUNX1 gene by the first time two provisional entities defined by the presence intragenic mutations leads to a preleukemic state that predis- – of gene mutations were added: ‘AML with mutated NPM1’ and poses to AML.9 12 1Klinik für Innere Medizin III, Universitätsklinikum Ulm, Ulm, Germany; 2Cancer Genome Project, Wellcome Trust Sanger Institute, Cambridge, UK; 3Klinik für Hämatologie und Onkologie, Klinikum Oldenburg, Oldenburg, Germany; 4Klinik für Innere Medizin II, Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel, Germany; 5Medizinische Klinik und Poliklinik III, Universitätsklinikum Bonn, Bonn, Germany; 6Klinik für Innere Medizin I, Universitätskliniken des Saarlandes, Homburg, Germany; 7Klinik für Hämatologie, Onkologie und Klinische Onkologie, Universitätsklinikum Düsseldorf, Düsseldorf, Germany; 8Medizinische Klinik III, Städtisches Klinikum Karlsruhe gGmbH, Karlsruhe, Germany; 9III. Medizinische Klinik, Klinikum Rechts der Isar, Technische Universität München, München, Germany; 10Medizinische Klinik IV, Universitätsklinikum Gießen, Gießen, Germany; 11Medical Systems Biology, Universität Ulm, Ulm, Germany and 12Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Medizinische Hochschule Hannover, Hannover, Germany. Correspondence: Professor H Döhner, Department of Internal Medicine III, University Hospital of Ulm, Albert-Einstein-Allee 23, Ulm 89081, Germany. E-mail: [email protected] 13These authors contributed equally to this work. 14A complete list of the members of the German-Austrian Acute Myeloid Leukemia Study Group (AMLSG) appears in the 'Supplementary information'. Received 10 January 2016; revised 13 April 2016; accepted 21 April 2016; accepted article preview online 3 May 2016; advance online publication, 10 June 2016 RUNX1 mutations in AML VI Gaidzik et al 2161 In human acute leukemia, RUNX1 is involved in recurrent (n =1381) and SF3B1 (n = 1381); secondary genotypes were evaluated for chromosomal translocations, such as t(8;21)(q22;q22); RUNX1- their impact on response to therapy as well as survival. RUNX1T1 and t(3;21)(q26.2;q22); MECOM(EVI1)-RUNX1 in AML, or In 16 cases, we analyzed paired BM samples from diagnosis and relapse. t(12;21)(p13;q22); TEL-RUNX1 in B-lineage acute lymphoblastic In another 10 cases, germline material (DNA obtained from buccal swabs leukemia. In addition to these balanced rearrangements, recurrent or from PB in complete remission (CR)) was studied for the presence of fi RUNX1 germline mutations. intragenic mutations have been identi ed in AML, myelodysplastic Furthermore, PB samples from 29 healthy volunteers were analyzed for the syndrome (MDS), chronic myelomonocytic leukemia and T-cell 13–28 presence of RUNX1 polymorphisms. All RUNX1 sequence variations were acute lymphoblastic leukemia. aligned to different SNP databases (http://www.ncbi.nlm.nih.gov/sites/snp; From a clinical point of view, there are interesting aspects to http://genome.ucsc.edu/cgi-bin/hgGateway; http://www.ensembl.org) to detect myeloid neoplasms with RUNX1 mutations. First, RUNX1 mutations known polymorphisms. have been frequently found in radiation-exposed patients with MDS/AML; furthermore, RUNX1 mutations have been linked to Statistical analyses therapy-related MDS and within this group a significant associa- 29–31 Statistical analyses for clinical outcome were performed according to tion was found with monosomy 7 or 7q deletions. Second, previous reports.42 The median follow-up for survival was calculated MDS/AML developing in patients with inherited disorders, such as according to the method of Korn.46 The definition of CR, event-free survival Fanconi anemia or congenital neutropenia, have been shown to (EFS), relapse-free survival (RFS) and overall survival (OS), as well as genetic frequently carry RUNX1 mutations.32,33 Finally, there are rare categorization into favorable-, intermediate-I/II and adverse-risk groups germline RUNX1 mutations that are associated with the autosomal followed the recommended criteria.2 Pairwise comparisons between dominant familial platelet disorder predisposing the affected patient characteristics (covariates) were performed by using the Mann– individuals to AML.34–37 Whitney test for continuous variables and by using Fisher’s exact test for – We and others previously reported on the frequency and clinical categorical variables. The Kaplan Meier method was used to estimate the 47 fi significance of RUNX1 mutations in adult AML patients.19–22,23,25 In distribution of EFS, RFS and OS. Estimation of con dence intervals (CIs) for the survival curves was based on Greenwood’s formula for the the present study of 2439 clinically and genetically annotated adult standard error estimation. A logistic regression model was used to analyze patients with AML, we show that RUNX1 mutations are associated associations between baseline characteristics and the achievement of CR. with characteristic clinico-pathologic features and inferior prognosis. Cox models were used to identify prognostic variables.48,49 Cox models for Furthermore, we show that in the context of RUNX1-mutated AML the entire cohort were stratified
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