Clonality & Aplastic anemia / PNH

Transcription

1 Clonality & Aplastic anemia / PNH What is in a word W Shakespear : Hamlet Prof G SOCIE, MD, PhD Head Division of Hematology / Immunology / Oncology French reference Center Aplastic Anemia & PNH Hospital Saint Louis, Paris, FRANCE gerard.socie@aphp.fr

2 BLood, VOL. 30, No. 2 ( AUGUST ), 1967

3 BLood, VOL. 79, No. 6 ( Marsh ), 1992

4 AA/PNH PNH LGL (clonal or polyclonal) FA DC RBDS VSAA SAA NSAA Low Risk MDS High Risk AML Hypocellular MDS 5q- MDS/MPD Hypo AML Maciejewski et al. Blood 2002; 19(9):

5 Mast cells Plasma cells Increased erythroblasts Dyserythropoiesis Frequent in SAA Frequent in PNH Frequent in both Risk of over-diagnosing MDS Tichelli et al. Blood 1992; 80 (2):

6 Studies Period N Age (median) Resp Relapse Clonal Evolution Survival Germany % 19% 8% NIH % 35% 11% EGMBT % 12% 11% Japan % 22% 6% Germany/Australia % 12% 6% Japan % 42% 8% NIH % 37% 9% NIH % 26% 10% 58% à 11 ans 55% à 7 ans 87% à 5 ans 88% à 3 ans 87% à 4 ans 88% à 4 ans 80% à 4 ans 93% à 3 ans Young et al. Blood 2006

7 IST: 18% 3% Socié G., et al. 1993; (329)

8 Clonal evolution (morphology): ~ 15% Am. J. Hematol. 89: , 2014.

9 G-CSF / MDS-AML? Kojima; Blood 2002

10 G-CSF / MDS-AML? G Socié et al. Blood 2007; 107:2794 Risk factors HR p MDS Age > 45yr AML Age > 45yr G-CSF MDS/AML Age > 45yr G-CSF

11 Association of Telomere Length of Peripheral Blood Leukocytes With Hematopoietic Relapse, Malignant Transformation, and Survival in Severe Aplastic Anemia. Scheinberg, Phillip; Cooper, James; Sloand, Elaine; Wu, Colin; Calado, Rodrigo; MD, PhD; Young, Neal JAMA. 304(12): , September 22/29, 2010.

12 Skewed X-chromosome inactivation i.e., skewing from the expected 1:1 ratio for random Lionization Small series from >70% (van Kamp et al.) to 10%. Interpretation of NRXI extreme skewing (>3:1) in normal females Acquired during normal aging Abnormal cytogenetic in AA 4% 11% of AA cases difficulty in obtaining sufficient numbers of metaphases Predominant lesions; +8, 7, & del(5q)

13 Maciejewski, Blood 2001 No risk factors del7/7q, +8, 11q-, +21, +6, complex karyotypes most common

14 Could AA be considered a pre-pre-leukemic disorder? Eur.J. Haematol. 1996; 60 (Suppl.): HSC (or Common Myeloid Progenitor?) HSC abnormal; Quantitatively and/or qualitatively Clonal hematopoiesis; PNH +++; SAA + or?? CD8 Intrinsic block Telomere loss; aging of residual HSC RBC MK Chromosomal abnormality; -7, +8 MDS/Leukemia PMN N-Ras mutation

15 SNP array based karyotyping: differences and similarities between aplastic anemia and hypo cellular MDS Jaroslaw P. Maciejewski AA (N = 93) and hypo cellular MDS (N = 24) SNP-A identify cryptic clonal genomic aberrations In 19% of AA Blood. 2011;117(25):

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17 Austin G Kulasekararaj et al NSAA (n=65) SAA (n=51) VSAA (n=23) Aplastic Anaemia (n=150) Evolved to MDS with somatic mutations (N=11) No evolution to MDS but have mutations (N=18) Detected pre evolution -7 associated with DNMT3A/ASXL1 <10% clones in 10 Longer F/U needed Others (n=11) Evolution to MDS but no mutations (N=6) Mutated in other genes Undetectable low level clones Somatic mutations identify a sub-group of aplastic anemia patients that progress to myelodysplastic syndrome

18 Longitudinal Austin G Kulasekararaj et al SOMATIC MUTATIONS AT PRESENTATION ARE PREDICTIVE OF SUBSEQUENT RISK OF PROGRESSION Mutations detected by WES Targeted deep NGS Detection of somatic mutations ATG Whole Exome Sequencing Initial unbiased search AA presentation MDS Detection of mutations at presentation 8/18 (30 events) Somatic mutations 18/18

19 Austin G Kulasekararaj et al IST YARS YARS GNL3 ABCA10 SHROOM3 IST ERBB4 ERBB4 CSMD1 ATP2C2 LRRC31 MYRIP Diagnosis Karyotype AA saml 46,XY Complex (months) Diagnosis AA saml Karyotype n/a Complex (months) SETBP1 SETBP1 CBL ASXL1 SETBP1 CBL SETBP1 RUNX1 CBL SETBP1 RUNX1 PTPN11 TET2 CBL IST IST Diagnosis AA CMML Karyotype 46,XY Monosomy 7 (months) Diagnosis Karyotype AA AA saml 46,XX -7 by SNP-A 45,XX,-7[20] (months)

20 next-generation sequencing and array-based karyotyping using 668 blood samples obtained from 439 patients Clonal hematopoiesis; in 47% mutations in DNMT3A and ASXL1 ; worse outcomes. However, clonal dynamics were highly variable and might not necessarily have predicted the response to therapy and long-term survival among individual patients N Engl J Med 373(1):35-47; 2015

21 N Engl J Med 373(1):35-47; 2015

22 N Engl J Med 373(1):35-47; 2015

23 N Engl J Med 2015;373:

24 Step 1 Somatic Mutation of PIG-A Step 2 Immunologic Attack Selective Damage Step 3 Growth Advantage GPI-Deficient Cell Selected Cells Expanded Cells Normal Hematopoietic Stem Cells GPI-Anchor Deficiency Immunologic Selection Expansion Expansion may be due to another somatic mutation The need for both selection and expansion may explain the rarity of PNH

25 Maciejewski, Blood 2001 Clonal expansion Immune escape -Mutations present at presentation -Trigger immune surveillance -Subsequent clonal evolution VS. Immune selection pressure PNH clone(n=65) large (>50%): 15 moderate (10-50%): 14 subclinical (<10%): 36 PIGA sequencing (n=23) -True late clonal event Clone >10% (n=17) Clone <10% (n=6) Single PIGA mutation (n=7) Double PIGA mutation(n=6) PIGA with other somatic mutation(n=4) No PIG-A mutations Kulasekararaj et al. Blood 2014

26 Maciejewski, JCI 2014 Normal cells PNH patient PNH cells Variable Whole cohort (N=58) WES (n=12) Sorting Age Median,y CD59 negative fraction (PNH +) CD59 rich fraction (PNH -) PNH clone size Median,% Range,% 5.0~ ~99.6 Targeted deep NGS (N=58) Whole exome sequencing (N=12) Single cell colony culture PNH bone marrow CFU-GM CFU-E Colony sequencing

27 Allelic frequency(%) 58% 76% 80% 82% Clonal architecture Single cell colony sequencing WT PIGA N=3 PIGA c11orf34 RBP3 MUC7 N=2 Deep sequencing of PNH sorted cells c11orf34 PIGA N=2 c11orf34 PIGA(Q18X) c11orf34(f15l) Maciejewski, JCI 2014 c11orf34 RBP3 PIGA N=1 N= PNH+ PNH+ RBP3(G560S) PNH+ PNH+ MUC7(R358X) MUC7 c11orf34 PIGA MUC7 c11orf34 RBP3 PIGA N=1 MUC7 c11orf34 N=6 MUC7 RBP3 PIGA N=2 N=1

28 Additional mutation events Following PIG-A mutation as secondary events CCR9, ALDH1B1, CPD, CELSR2, KDM3B, ZRSR2, MUC7, RBP3, c11orf34, PEX14, FBN1, BCOR, U2AF1, MECOM, KDM6A Preceding PIG-A mutation NTNG1, MAGEC1, TMC1, WDR96, NRXN3, STAC3, SLC20A1, MAN1A2, SYNE2, PEX14, DHX29 100% Clonogenic mutation both in PIGA mutant and wild-type cells followed by PIG-A mutation TET2, JAK2, SUZ12 PIG-A mutation detection 80% Maciejewski, JCI % 40% 1 PIGA mutation 2 PIGA mutations 20% 0% PIG-A mutation microdeletion no detection

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30 S. OGAWA; Blood 2016, in press

31 S. OGAWA; Blood 2016, in press

32 An aging population

33 Xie, NatMed,2014, , Genovese, NEJM, 2014, Jaiswal, NEJM, 2014, Welch, Cell 2012 Busque, Nat Gen, 2012

34 clone size Siddhartha Jaiswal et al, Dec 2014; Ebert lab - Study of 17,182 individuals unselected for hematologic phenotypes persons had detectable mutation.

35 Age related (bystanders/passengers, present at/prior to diagnosis of AA); necessary to maintain hemopoiesis? Clonal flux True driver mutation(s) Cellular composition (myeloid vs lymphoid) and accurate determination of VAF/MAB (small clones) Mutational architecture, hierarchy and chronology

36 Toward the CHIP s concept? Clonal hematopoiesis of indeterminate potential and its distinction from myelodysplastic syndromes by David P. Steensma, Rafael Bejar, Siddhartha Jaiswal, R. Coleman Lindsley, Mikkael A. Sekeres, Robert P. Hasserjian, and Benjamin L. Ebert Blood Volume 126(1):9-16; July 2, 2015

37 Toward the CHIP s concept?

38 Toward the CHIP s concept?

39 Toward the CHIP s concept?

40 S. OGAWA; Blood 2016, in press

41 Annual Review of Immunology 2016

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43 Merci pour votre attention! CR Cytopénies auto-immunes Adulte Observatoire Blackfan-Diamond Cohorte DEFI Registre Neutropénies chroniques Enfant Registre proloférations LGL et neutropénies Adulte - contact@marih.fr