PML and RARA mutations in relapsed Acute Promyelocytic Leukemia

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1 7 th INTERNATIONAL SYMPOSIUM ON ACUTE PROMYELOCYTIC LEUKEMIA and mutations in relapsed Acute Promyelocytic Leukemia Licia Iaccarino Department of Biomedicine and Prevention University of Tor Vergata, Rome Rome, September 25, 2017

2 and mutations associated to therapy-resistance in APL mutations within the B2 domain of / confer resistance ATRA resistance is associated to mutations in the ligand-binding domain of the moiety of / Mutations in and genes have been described in up to 47% of relapsed APL patients Goto E., et al, Blood 2011; Zhu H.H., et al, NEJM 2014; Chendamarai E., et al, Plos One 2015; Lou Y., et al, Ann Hematol 2015; Iaccarino L., et al, BJH 2016 Zhu H.H., et al, NEJM 2014

3 mutations in APL * / degradation Corepressors RXR RARE P53 activation Loss of selfrenewal Promoter clearance * mutations Granulocytic differentiation NBs reformation Jeanne M, et al., Cancer Cell 2010

4 mutations in APL Coactivators ATRA * RARE RXR ATRA Granulocytic differentiation P53 activation Loss of self-renewal * Ablain J., et al, Nat Med 2014 ATRA / degradation NBs reformation * mutations

5 and mutations associated to therapy-resistance in APL Mutations in the normal allele have been proposed as additional mechanism associated with resistance Two refractory APL cases with A216V mutation reported Lehmann-Che et al, NEJM 2014; Iaccarino et al, BJH 2016 * * P53 activation Loss of self-renewal NBs reformation degradation Jeanne M., et al, Cancer Cell 2010 * mutations

6 and mutations associated to therapy-resistance in APL Mutations in the normal allele have been proposed as additional mechanism associated with resistance Two refractory APL cases with A216V mutation reported Lehmann-Che et al, NEJM 2014; Iaccarino et al, BJH 2016 ATRA/CHT ATRA/ CHT R272Q T285I * ** * ** * * 3 months 9 months 11 months 12 months APL Diagnosis 1 relapse 2 relapse A216V Death ATRA / Chemotherapy unrearranged * Mutation Iaccarino L., et al, BJH 2016

7 Aims of the study! Design a sensitive NGS assay for detection of and mutations predictive of treatment resistance in APL patients! Investigate the time of onset of the mutations

8 / mutational analysis by NGS 23 APL patients relapsing after ATRA-CHT (n=14) and/or ATRA- (n=9) bcr3 bcr2 bcr first PCR bcr3 bcr1-2 nested PCR first PCR nested PCR Coverage (mean): : 33886X per base : 26051X per base B2 domain ligand binding domain

9 Results: mutational profile of and at relapse ATRA-CHT ATRA- #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16 #17 #18 #19 #20 #21 #22 #23 ATRA-CHT ATRA- single mutation multiple mutations wild-type 6/23 patients (26%) had at least one mutation in and genes No mutations detectable at initial diagnosis in 3 of 6 available samples

10 Results: location of mutations in and A216T A216V (2) L220P I222_D223insE W225C L224I C235F 14 mutations in 6 pts B2 LBD A216T A216V (2) E224G R272Q T285I F286del S287L T291A L290V B2 4 mutations in 2 pts 3% VAF 100%

11 UPN 17 therapy-related APL with multiple relapses after ATRA-CHT and ATRA- A216T 4% A216V 5% I222_D223insE 6% C235F 4% B2 LBD A216T 6% A216V 79% E224G 3% R272Q 12% T285I 60% T291A 21% B2

12 UPN 23 L224I 12% de novo APL relapsed after ATRA- as first-line therapy B2 LBD A216V 12% B2

13 Conclusions High prevalence of and mutations in relapsed APL A sensitive method for and mutational analysis is required to early detect resistant clones Screening of and mutations may help to identify ATRA and/ or -resistant APL patients candidates to alternative treatment strategies

14 Acknowledgements Tiziana Ottone Mariadomenica Divona Laura Cicconi Serena Lavorgna Valentina Alfonso Claudia Ciardi Syed Khizer Hasan Adriano Venditti Sergio Amadori William Arcese Roberto Cairoli, Niguarda Hospital, Milan Monica Bocchia, University of Siena Annette Fasan Constance Regina Bär Torsten Haferlach Maria Teresa Voso Francesco Lo-Coco