myelomonocytic leukemia at infancy

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1 Journal of Human Genetics / Original article JHG--R Adults with germline BL mutation complicated with juvenile myelomonocytic leukemia at infancy Michiko Muraoka, hiho Okuma, Kiichiro Kanamitsu, Hisashi Ishida, Yui Kanazawa, Kana Washio, Masafumi Seki, Motohiro Kato, Junko Takita, Yusuke Sato, Seishi Ogawa, Hirokazu Tsukahara, Megumi Oda,, Akira Shimada * 0 Department of Pediatrics, Department of Pediatric Hematology/Oncology, Okayama University Hospital, Okayama, Japan Department of Pediatrics, Graduate School of Medicine, the University of Tokyo, Tokyo, Japan Department of Tumor Biology, Faculty of Medicine, Kyoto University, Kyoto, Japan Division of Leukemia and Lymphoma, hildren s ancer enter, National enter for hild Health and Development, Tokyo, Japan * orrespondence to: Akira Shimada, M.D., PhD. Assistant Professor, Okayama University Hospital, Department of Pediatrics, Department of Pediatric

2 Hematology/Oncology, Okayama University Hospital, Okayama, --, Shikatacho, Kitaku, Okayama, 00-, Japan, Phone: +---, FAX: Main Text:, words Abstract: words Key words: BL, JMML, Germline, Noonan syndrome Running Title: Germline BL mutation complicated with JMML at the infancy Number of Table 0 and number of Figure Supported in part by a Grant-in-Aid for ancer Research and a grant for linical ancer 0 Research and Research on hildren and Families from the Ministry of Health, Labor and Welfare of Japan, All author don t have a conflict of interest to declare.

3 Abstract Juvenile myelomonocytic leukemia (JMML) appears to be a life threatening disease and showed poor prognosis even after hematopoietic stem cell transplantation (HST) because of high relapse rate. On the other hand, recent molecular analysis revealed the heterogeneity of JMML. Here we report that JMML patients survived more than 0 years without HST and both patients had uniparental disomy (UPD) of q where BL is located without the phenomenon found in Noonan syndrome nor Noonan syndrome- like disorder. We think that some JMML patients with BL mutation might 0 show the good prognosis in later life after remission of JMML.

4 Introduction Juvenile myelomonocytic leukemia (JMML) was estimated to show the poor prognosis. Hematopoietic stem cell transplantation (HST) was strongly recommended for JMML patients, however, about 0% of patients showed relapse even after HST. Recent study revealed that the prognosis might be different from the genetic alterations, NRAS, KRAS, PTPN, NF and BL. Perez et al identified a heterozygous germline mutation in the BL gene (YH) in unrelated JMML patients with a Noonan syndrome-like 0 disorder. The mutation occurred de novo in patients and was inherited from an unaffected father in patient. Leukemic cells of all patients showed somatic loss of heterozygosity (LOH) at chromosome q, including the BL gene. These findings indicate that heterozygous mutation in the BL gene is associated with predisposition for the development of JMML. We found two JMML patients survived with good health longer than 0 years without HST (0 years old female and years old male). Molecular analysis revealed that these patients had the germline BL mutation with different frequency in each organ. Uniparental disomy (UPD) of chromosome

5 q was also found in the recent peripheral blood, both. Furthermore, there are no typical features of Noonan syndrome nor Noonan syndrome like disorders in either patients. We will discuss about JMML with the BL mutation. Patients Diagnostic criterion of JMML was depended on WHO 00 classification. ase : A six-month-old girl was admitted to our hospital because of abdominal swelling. She did not have the characteristics of Noonan syndrome (Supplemental Figure A). She was diagnosed as having JMML. We repeated 0 chemotherapy using low-dose cytarabine (Ara-) (0mg/m for 0 days) and -mercaptoprine (-MP) (0mg/m for days) for times (about 0. years). Leukocytosis and hepatosplenomegaly diminished within one year after starting chemotherapy. She is now 0 years old and healthy without short stature, hearing loss, optic atrophy, congenital heart defects, malformations of certain blood and lymph vessels, hypertension or cardiomyopathy. Her intelligence quotient (IQ) was borderline (IQ test was 0 to ). On her recent laboratory test, anti-nuclear antigen has been positive, however, she has no symptom of collagen disease.

6 ase : A nine-month-old boy was admitted to our hospital because of hepatosplenomegaly and leukocytosis. He did not have the characteristics of Noonan syndrome (Supplemental Figure B). He was diagnosed as having JMML. We continued chemotherapy using Ara- and -MP for about years. Hepatosplenomegaly and leukocytosis diminished within years after starting chemotherapy. He is now years old and healthy without short stature, intellectual disability, hearing loss, optic atrophy, congenital heart defects, malformations of certain blood and lymph vessels, hypertension or cardiomyopathy. 0 Materials and Methods We analyzed several genes affecting the JMML leukemogenesis as follows, NRAS, KRAS, PTPN, BL, SETBP and JAK.,,,,0 Written informed consent including picture presentation was obtained from each patient and institutional review board of Okayama University Hospital approved this project. Total DNA was extracted from stored BM mononuclear cells (BM- MNs) sample, stored or recent peripheral blood MNs (PB-MNs) sample, buccal smear cells, nail or hair using QIAamp DNA Mini or Investigator kit

7 (QIAGEN, Hilden, Germany), according to the manufacturer s instructions. Polymerase chain reaction (PR) was performed using primer pair as described previously.,,,, PR product was directly sequenced using ABI 0 or 0 sequencer (Applied Biosystems, Tokyo). We used pyrosequencing to quantify the fraction of mutated alleles in DNA samples from the different somatic tissues. DNA extracted from samples was analyzed using the PyroMarkQ Gold Reagents according to the manufacturer s recommendation (QIAGEN, Hilden, Germany). Data analysis was performed using the allelic quantitation software of the PyroMark Q 0 system. Genome-wide analysis for genetic lesions of mutated BL was performed by single nucleotide polymorphism (SNP) array analysis. DNA extracted from samples was analyzed using the Genehip Human Mapping 0K NspI array (Affymetrix, Santa lara, alifornia). The data thus obtained were processed using NAG/AsNAR software. Results The same BL Tyr(Y)His(H) mutation was found in the recent PB-MNs in both patients without other gene mutations. Furthermore, the same BL

8 mutation was found in the diagnostic BM-MNs of case. Unfortunately we could not check the diagnostic sample of case because his sample was not available. We identified the same BL YH mutation in DNA derived from buccal smear cells, nails of hands and hairs in two patients (Figure ). The mutated frequency by pyrosequencing was different in each sample (Figure ). In DNA from buccal smear cells of the both patients parents, no mutation was detected (Figure ). We found that both cases are de novo mutation. SNP array data suggested that BL mutations were related to the LOH of chromosome q which included the BL gene, both (Figure ). 0

9 Discussion JMML was estimated to be a life-threatening disease and HST was strongly recommended as soon as possible, however, high relapse rate was still observed and resulted in the poor prognosis. Recent study revealed JMML prognosis might be quite different from the genetic alterations.,,,,0 Our two cases survived for more than 0 years without HST and had the same sporadic germline BL mutation with qupd. Recently germline BL mutation syndrome was presented.,,, Interestingly, BL mutation in our two patients was found with different frequency in the different organ even 0 after JMML remission. BL mutations are generally associated with LOH of the q chromosomal region resulting in apparent homozygosity for a BL mutation in JMML, but our cases still showed the LOH of the q in healthy PB samples, especially case. Previous reports suggested that germline heterozygous missense BL mutations were detected in sporadic and familial cases (total of cases)., None of the individuals with a BL mutation had any hematological or solid tissue malignancy; however, the authors proposed the hypothesis that carriers of a germline BL mutation could be at increased risk for both, analogous to the predisposition to

10 malignancies seen in NF, another disorder involving the RAS-MAPK pathway., These studies suggest that germline heterozygous BL mutation carriers are susceptible to malignancy if reduction to homozygosity in somatic tissues occurs due to acquired UPD. For example, Kato et al reported duplication of KRAS due to acquired UPD caused JMML aggressive transformation. However, now our two cases have no malignancy except for JMML at infancy, although they had the germline BL mutation with qupd. We think the relationship between BL mutation and qupd in both cases (Supplemental figure ). There seems to be four types which were 0 shown in supplemental figure, they would exist as mixed status in each patients, however, type A would be dominant in case, and Type B would be dominant in case. Further large study about BL mutation with qupd in adult cases will be needed in future. Niemeyer et al suggested that germline BL mutations have developmental, tumorigenic and functional consequences that resemble disorders that are caused by hyperactive Ras/Raf/MEK/ERK signaling and include NF-, Noonan syndrome, ostello syndrome, cardiofaciocutaneous syndrome and Legius syndrome. Therefore, these germline mutated syndrome might 0

11 complicate JMML at infancy like transient abnormal myelopoiesis (TAM)/ transient myeloproliferative disorder (TMD) in Down syndrome. Furthermore, BL mutation syndrome was reported with or without JMML depended on the mutated site of BL gene., Interestingly, several reported cases and our two patients with the same mutation YH does not have any physiologic abnormalities such as hearing loss, optic atrophy, hypertension or cardiomyopathy. Future study will enable to predict the prognosis of BL- mutated JMML patients. Further study in long term survivor of JMML patients will be needed in future. 0 In conclusion, JMML seems to show the heterogeneity due to the genetic alterations. Some BL-mutated patients without typical phenomena like Noonan syndrome might show the good clinical course after JMML remission. Acknowledgement We thank for all the medical staff who participated for this patient care. Figure Ledgends Figure. Results of mutation analysis of BL by direct sequencing and

12 pyrosequencing in cases and. The same mutation of YH, T> was observed in both patients. The frequencies of mutated allele by pyrosequencing were different from the tissue type as follows, for ase, PB- MNs %, buccal smear cells %, nails %, hair 0%. For ase, PB- MNs %, buccal smear cells %, nails %, hair %. Their parents did not have this BL mutation in their buccal smear cells. Figure. Results of SNP array analysis in cases and. Figure A, and B; In case, uniparental disomy (UPD) of chromosome q was observed in the 0 first diagnostic bone marrow sample ( months old after birth) (Figure A) and in the recent peripheral blood (0 years old) (Figure B). Loss of heterogeneity (LOH) of chromosome q including the BL gene was observed and UPD was also observed in both samples. Figure ; Results of the recent peripheral blood of case ( years old). The difference is very small but UPD was found. Supplemental Figure. Patients pictures at present. A; ase, 0-year-old female. B; ase, -year-old male. Informed consent was obtained from each

13 patients. No typical findings are observed of Noonan syndrome. Supplemental Figure. Suspected relationship between BL mutation and qupd according to the frequency of BL mutation and SNP array analysis in both cases. Four types about BL mutation and qupd were considered, Type A; BL mutation with qupd, Type B; BL mutation without qupd, Type ; qupd alone, Type D; no BL mutation and no qupd. Star- shaped indicates BL mutation. We think they would exist as mixed status. Type A would be dominant in case, and Type B would be dominant in case. 0

14 0 0 0 References. Niemeyer M, Arico M, Basso G, Biondi A, antu Rajnoldi A, reutzig U, et al. hronic myelomonocytic leukemia in childhood: a retrospective analysis of 0 cases. European Working Group on Myelodysplastic Syndromes in hildhood (EWOG-MDS). Blood., - ().. Locatelli F, Nollke P, Zecca M, Korthof E, Lanino E, Peters, et al. Hematopoietic stem cell transplantation (HST) in children with juvenile myelomonocytic leukemia (JMML): results of the EWOG-MDS/EBMT trial. Blood. 0, 0- (00).. Loh ML. Recent advances in the pathogenesis and treatment of juvenile myelomonocytic leukaemia. Br J Haematol., - (0).. Perez B, Mechinaud F, Galambrun, Ben Romdhane N, Isidor B, Philip N, et al. Germline mutations of the BL gene define a new genetic syndrome with predisposition to juvenile myelomonocytic leukaemia. J Med Genet., - (00).. Baumann I, Bennett JM, Niemeyer M, Thiele J, Shannon K. Juvenile myelomonocytic leukemia. WHO lassification of Tumours of Haematopoietic and Lymphoid Tissues, Fourth Edition. (eds Swederlow, et al) - (IAR, Lyon, France, 00).. Sakaguchi H, Okuno Y, Muramatsu H, Yoshida K, Shiraishi Y, Takahashi M, et al. Exome sequencing identifies secondary mutations of SETBP and JAK in juvenile myelomonocytic leukemia. Nat Genet., - (0).. Yoshida N, Yagasaki H, Xu Y, Matsuda K, Yoshimi A, Takahashi Y, et al. orrelation of clinical features with the mutational status of GM-SF signaling pathway-related genes in juvenile myelomonocytic leukemia. Pediatr Res., -0 (00).. Flotho, Kratz P, Bergstrasser E, Hasle H, Stary J, Trebo M, et al. Genotypephenotype correlation in cases of juvenile myelomonocytic leukemia with clonal RAS mutations. Blood., - (00).. Park HD, Lee SH, Sung KW, Koo HH, Jung NG, ho B, et al. Gene mutations in the Ras pathway and the prognostic implication in Korean patients with juvenile myelomonocytic leukemia. Ann Hematol., - (0). 0. Takagi M, Piao J, Lin L, Kawaguchi H, Imai, Ogawa A, et al. Autoimmunity and persistent RAS-mutated clones long after the spontaneous regression of JMML. Leukemia., - (0).. Tartaglia M, Kalidas K, Shaw A, Song X, Musat DL, van der Burgt I, et al. PTPN mutations in Noonan syndrome: molecular spectrum, genotype-phenotype correlation, and phenotypic heterogeneity. Am J Hum Genet. 0, - (00).. Sanada M, Suzuki T, Shih LY, Otsu M, Kato M, Yamazaki S, et al. Gain-of-function of

15 0 0 mutated -BL tumour suppressor in myeloid neoplasms. Nature. 0, 0-0 (00).. Fernandez-Mercado M, Yip BH, Pellagatti A, Davies, Larrayoz MJ, Kondo T, et al. Mutation patterns of genes in primary and secondary acute myeloid leukemia (AML) with normal cytogenetics. PLoS One., e (0).. Thol F, Suchanek KJ, Koenecke, Stadler M, Platzbecker U, Thiede, et al. SETBP mutation analysis in patients with MDS and AML. Leukemia., 0-0 (0).. Martinelli S, De Luca A, Stellacci E, Rossi, hecquolo S, Lepri F, et al. Heterozygous germline mutations in the BL tumor-suppressor gene cause a Noonan syndrome-like phenotype. Am J Hum Genet., 0- (00).. Niemeyer M, Kang MW, Shin DH, Furlan I, Erlacher M, Bunin NJ, et al. Germline BL mutations cause developmental abnormalities and predispose to juvenile myelomonocytic leukemia. Nat Genet., -00 (00).. Dunbar AJ, Gondek LP, O'Keefe L, Makishima H, Rataul MS, Szpurka H, et al. 0K single nucleotide polymorphism array karyotyping identifies acquired uniparental disomy and homozygous mutations, including novel missense substitutions of c-bl, in myeloid malignancies. ancer Res., 0-0 (00).. Kato M, Yasui N, Seki M, Kishimoto H, Sato-Otsubo A, Hasegawa D, et al. Aggressive transformation of juvenile myelomonocytic leukemia associated with duplication of oncogenic KRAS due to acquired uniparental disomy. J Pediatr., - (0).. Hall GW. ytogenetic and molecular genetic aspects of childhood myeloproliferative/myelodysplastic disorders. Acta Haematol. 0, - (00).

16 Figure. Direct sequencing and Pyrosequencing in ase and ase. ase (BL, Tyr(Y)His(H) T>) ase (BL, Tyr(Y)His(H) T>) BM onset T :% PB T :% PB T :% Buccal Smear T :% Buccal Smear T :% Nail T :% Nail T :% Hair T :0% Hair T :% Father's Buccal Smear (Wild-type) :% Father's Buccal Smear (Wild-type) :% Mother's Buccal Smear (Wild-type) :% Mother's Buccal Smear (Wild-type) :%

17 Figure. SNP array hr A B BL BL BL

18 Supplemental Figure. pictures at present A;ase. She is 0 years old. B;ase. He is years old.

19 Supplementary Figure A:BL mutation + UPD B:BL mutation :UPD D:Normal A B D case B A D case

News Release. Title Integrated molecular profiling of juvenile myelomonocytic leukemia

News Release. Title Integrated molecular profiling of juvenile myelomonocytic leukemia News Release Title Integrated molecular profiling of juvenile myelomonocytic leukemia Key Points We identified ALK/ROS1 tyrosine kinase fusions (DCTN1-ALK, RANBP2-ALK, and TBL1XR1-ROS1) in patients with