1
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Mian SA, Philippe C, Maniati E, Protopapa P, Bergot T, Piganeau M, Nemkov T, Bella DD, Morales V, Finch AJ, D’Alessandro A, Bianchi K, Wang J, Gallipoli P, Kordasti S, Kubasch AS, Cross M, Platzbecker U, Wiseman DH, Bonnet D, Bernard DG, Gribben JG, Rouault-Pierre K. Vitamin B5 and succinyl-CoA improve ineffective erythropoiesis in SF3B1-mutated myelodysplasia. Sci Transl Med 2023; 15:eabn5135. [PMID: 36857430 PMCID: PMC7614516 DOI: 10.1126/scitranslmed.abn5135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 02/08/2023] [Indexed: 03/03/2023]
Abstract
Patients with myelodysplastic syndrome and ring sideroblasts (MDS-RS) present with symptomatic anemia due to ineffective erythropoiesis that impedes their quality of life and increases morbidity. More than 80% of patients with MDS-RS harbor splicing factor 3B subunit 1 (SF3B1) mutations, the founder aberration driving MDS-RS disease. Here, we report how mis-splicing of coenzyme A synthase (COASY), induced by mutations in SF3B1, affects heme biosynthesis and erythropoiesis. Our data revealed that COASY was up-regulated during normal erythroid differentiation, and its silencing prevented the formation of erythroid colonies, impeded erythroid differentiation, and precluded heme accumulation. In patients with MDS-RS, loss of protein due to COASY mis-splicing led to depletion of both CoA and succinyl-CoA. Supplementation with COASY substrate (vitamin B5) rescued CoA and succinyl-CoA concentrations in SF3B1mut cells and mended erythropoiesis differentiation defects in MDS-RS primary patient cells. Our findings reveal a key role of the COASY pathway in erythroid maturation and identify upstream and downstream metabolites of COASY as a potential treatment for anemia in patients with MDS-RS.
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Affiliation(s)
- Syed A Mian
- The Francis Crick Institute, London NW1 1AT, United Kingdom
| | - Céline Philippe
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Eleni Maniati
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Pantelitsa Protopapa
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Tiffany Bergot
- University of Brest, Inserm, EFS, UMR1078, GGB, 29238 Brest, France
| | | | - Travis Nemkov
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Doriana Di Bella
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Valle Morales
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Andrew J Finch
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Angelo D’Alessandro
- Department of Biochemistry and Molecular Genetics, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Katiuscia Bianchi
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Jun Wang
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Paolo Gallipoli
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Shahram Kordasti
- System Cancer Immunology, Comprehensive Cancer Centre, King's College London, London WC2R 2LS, United Kingdom
| | - Anne Sophie Kubasch
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, 04103 Leipzig, Germany
| | - Michael Cross
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, 04103 Leipzig, Germany
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy and Hemostaseology, Leipzig University Hospital, 04103 Leipzig, Germany
| | - Daniel H Wiseman
- Division of Cancer Sciences, The University of Manchester, Manchester M20 4GJ, UK
| | | | - Delphine G Bernard
- University of Brest, Inserm, EFS, UMR1078, GGB, 29238 Brest, France
- Centre de Ressources Biologiques du CHRU de Brest, 29238 Brest, France
| | - John G Gribben
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
| | - Kevin Rouault-Pierre
- Barts Cancer Institute, Queen Mary University of London, London EC1M 6BQ, United Kingdom
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2
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Anjos-Afonso F, Buettner F, Mian SA, Rhys H, Perez-Lloret J, Garcia-Albornoz M, Rastogi N, Ariza-McNaughton L, Bonnet D. Single cell analyses identify a highly regenerative and homogenous human CD34+ hematopoietic stem cell population. Nat Commun 2022; 13:2048. [PMID: 35440586 PMCID: PMC9018830 DOI: 10.1038/s41467-022-29675-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 03/18/2022] [Indexed: 01/02/2023] Open
Abstract
The heterogeneous nature of human CD34+ hematopoietic stem cells (HSCs) has hampered our understanding of the cellular and molecular trajectories that HSCs navigate during lineage commitment. Using various platforms including single cell RNA-sequencing and extensive xenotransplantation, we have uncovered an uncharacterized human CD34+ HSC population. These CD34+EPCR+(CD38/CD45RA)- (simply as EPCR+) HSCs have a high repopulating and self-renewal abilities, reaching a stem cell frequency of ~1 in 3 cells, the highest described to date. Their unique transcriptomic wiring in which many gene modules associated with differentiated cell lineages confers their multilineage lineage output both in vivo and in vitro. At the single cell level, EPCR+ HSCs are the most transcriptomically and functionally homogenous human HSC population defined to date and can also be easily identified in post-natal tissues. Therefore, this EPCR+ population not only offers a high human HSC resolution but also a well-structured human hematopoietic hierarchical organization at the most primitive level.
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Affiliation(s)
- Fernando Anjos-Afonso
- Haematopoietic Signalling Group, European Cancer Stem Cell Institute, School of Biosciences, Cardiff University, Cardiff, UK.
| | - Florian Buettner
- German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium, Heidelberg, Germany
- Frankfurt University, Frankfurt, Germany
| | - Syed A Mian
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, UK
| | - Hefin Rhys
- Flow Cytometry Facility, The Francis Crick Institute, London, UK
| | | | | | - Namrata Rastogi
- Haematopoietic Signalling Group, European Cancer Stem Cell Institute, School of Biosciences, Cardiff University, Cardiff, UK
| | | | - Dominique Bonnet
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, UK.
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3
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Mian SA, Bonnet D. Nature or Nurture? Role of the Bone Marrow Microenvironment in the Genesis and Maintenance of Myelodysplastic Syndromes. Cancers (Basel) 2021; 13:4116. [PMID: 34439269 PMCID: PMC8394536 DOI: 10.3390/cancers13164116] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 12/18/2022] Open
Abstract
Myelodysplastic syndrome (MDS) are clonal haematopoietic stem cell (HSC) disorders driven by a complex combination(s) of changes within the genome that result in heterogeneity in both clinical phenotype and disease outcomes. MDS is among the most common of the haematological cancers and its incidence markedly increases with age. Currently available treatments have limited success, with <5% of patients undergoing allogeneic HSC transplantation, a procedure that offers the only possible cure. Critical contributions of the bone marrow microenvironment to the MDS have recently been investigated. Although the better understanding of the underlying biology, particularly genetics of haematopoietic stem cells, has led to better disease and risk classification; however, the role that the bone marrow microenvironment plays in the development of MDS remains largely unclear. This review provides a comprehensive overview of the latest developments in understanding the aetiology of MDS, particularly focussing on understanding how HSCs and the surrounding immune/non-immune bone marrow niche interacts together.
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Affiliation(s)
| | - Dominique Bonnet
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London NW1 1AT, UK;
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4
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Mian SA, Abarrategi A, Kong KL, Rouault-Pierre K, Wood H, Oedekoven CA, Smith AE, Batsivari A, Ariza-McNaughton L, Johnson P, Snoeks T, Mufti GJ, Bonnet D. Ectopic humanized mesenchymal niche in mice enables robust engraftment of myelodysplastic stem cells. Blood Cancer Discov 2021; 2:135-145. [PMID: 33778768 PMCID: PMC7610449 DOI: 10.1158/2643-3230.bcd-20-0161] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 11/12/2020] [Accepted: 12/18/2020] [Indexed: 12/13/2022] Open
Abstract
Myelodysplastic syndrome (MDS) are clonal stem cell diseases characterized mainly by ineffective hematopoiesis. Here, we present an approach that enables robust long-term engraftment of primary MDS stem cells (MDS-SCs) in mice by implantation of human mesenchymal cell-seeded scaffolds. Critically for modelling MDS, where patient sample material is limiting, mononuclear bone marrow cells containing as few as 104 CD34+ cells can be engrafted and expanded by this approach with the maintenance of the genetic make-up seen in the patients. Non-invasive high-resolution ultrasound imaging shows that these scaffolds are fully perfused. Our data shows that human microenvironment but not mouse is essential to MDS-SCs homing and engraftment. Notably, the alternative niche provided by healthy donor MSCs enhanced engraftment of MDS-SCs. This study characterizes a new tool to model MDS human disease with the level of engraftment previously unattainable in mice, and offers insights into human-specific determinants of MDS-SC microenvironment.
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Affiliation(s)
- Syed A Mian
- Department of Haematology, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, United Kingdom
| | - Ander Abarrategi
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, United Kingdom
| | - Kar Lok Kong
- Department of Haematology, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Kevin Rouault-Pierre
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, United Kingdom
| | - Henry Wood
- Department of Haematology, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
- King's College Hospital London, London, United Kingdom
| | - Caroline A Oedekoven
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, United Kingdom
| | - Alexander E Smith
- Department of Haematology, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
- King's College Hospital London, London, United Kingdom
| | - Antoniana Batsivari
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, United Kingdom
| | | | - Peter Johnson
- Imaging Research Facility, The Francis Crick Institute, London, United Kingdom
| | - Thomas Snoeks
- Imaging Research Facility, The Francis Crick Institute, London, United Kingdom
| | - Ghulam J Mufti
- Department of Haematology, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom.
- King's College Hospital London, London, United Kingdom
| | - Dominique Bonnet
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, United Kingdom.
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5
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Mian SA, Anjos-Afonso F, Bonnet D. Advances in Human Immune System Mouse Models for Studying Human Hematopoiesis and Cancer Immunotherapy. Front Immunol 2021; 11:619236. [PMID: 33603749 PMCID: PMC7884350 DOI: 10.3389/fimmu.2020.619236] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 12/18/2020] [Indexed: 12/20/2022] Open
Abstract
Immunotherapy has established itself as a promising tool for cancer treatment. There are many challenges that remain including lack of targets and some patients across various cancers who have not shown robust clinical response. One of the major problems that have hindered the progress in the field is the dearth of appropriate mouse models that can reliably recapitulate the complexity of human immune-microenvironment as well as the malignancy itself. Immunodeficient mice reconstituted with human immune cells offer a unique opportunity to comprehensively evaluate immunotherapeutic strategies. These immunosuppressed and genetically modified mice, with some overexpressing human growth factors, have improved human hematopoietic engraftment as well as created more functional immune cell development in primary and secondary lymphoid tissues in these mice. In addition, several new approaches to modify or to add human niche elements to further humanize these immunodeficient mice have allowed a more precise characterization of human hematopoiesis. These important refinements have opened the possibility to evaluate not only human immune responses to different tumor cells but also to investigate how malignant cells interact with their niche and most importantly to test immunotherapies in a more preclinically relevant setting, which can ultimately lead to better success of these drugs in clinical trials.
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Affiliation(s)
- Syed A Mian
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, United Kingdom.,Department of Haematology, School of Cancer and Pharmaceutical Sciences, King's College London, London, United Kingdom
| | - Fernando Anjos-Afonso
- Haematopoietic Signalling Group, European Cancer Stem Cell Institute, School of Biosciences, Cardiff University, Cardiff, United Kingdom
| | - Dominique Bonnet
- Haematopoietic Stem Cell Lab, The Francis Crick Institute, London, United Kingdom
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6
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Crisà E, Kulasekararaj AG, Adema V, Such E, Schanz J, Haase D, Shirneshan K, Best S, Mian SA, Kizilors A, Cervera J, Lea N, Ferrero D, Germing U, Hildebrandt B, Martínez ABV, Santini V, Sanz GF, Solé F, Mufti GJ. Impact of somatic mutations in myelodysplastic patients with isolated partial or total loss of chromosome 7. Leukemia 2020; 34:2441-2450. [PMID: 32066866 DOI: 10.1038/s41375-020-0728-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 12/19/2019] [Accepted: 01/28/2020] [Indexed: 11/09/2022]
Abstract
Monosomy 7 [-7] and/or partial loss of chromosome 7 [del(7q)] are associated with poor and intermediate prognosis, respectively, in myelodysplastic syndromes (MDS), but somatic mutations may also play a key complementary role. We analyzed the impact on the outcomes of deep targeted mutational screening in 280 MDS patients with -7/del(7q) as isolated cytogenetic abnormality (86 with del(7q) and 194 with -7). Patients with del(7q) or -7 had similar demographic and disease-related characteristics. Somatic mutations were detected in 79% (93/117) of patients (82% in -7 and 73% in del(7q) group). Median number of mutations per patient was 2 (range 0-8). There was no difference in mutation frequency between the two groups. Patients harbouring ≥2 mutations had a worse outcome than patients with <2 or no mutations (leukaemic transformation at 24 months, 38% and 20%, respectively, p = 0.044). Untreated patients with del(7q) had better overall survival (OS) compared with -7 (median OS, 34 vs 17 months, p = 0.034). In multivariable analysis, blast count, TP53 mutations and number of mutations were independent predictors of OS, whereas the cytogenetic subgroups did not retain prognostic relevance. This study highlights the importance of mutational analysis in terms of prognosis in MDS patients with isolated -7 or del(7q).
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Affiliation(s)
- Elena Crisà
- Department of Haematological Medicine, King's College Hospital, NHS Foundation Trust, London, UK. .,Division of Hematology, Department of Translational Medicine, University of Eastern Piedmont, Novara, Italy. .,Fondazione Italiana Sindromi Mielodisplastiche (FISiM), Bologna, Italy.
| | - Austin G Kulasekararaj
- Department of Haematological Medicine, King's College Hospital, NHS Foundation Trust, London, UK
| | - Vera Adema
- Institut de Recerca Contra la Leucèmia Josep Carreras, ICO-Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain.,Department of Translational Hematology and Oncology Research, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Esperanza Such
- Department of Hematology, Hospital Universitario La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, Madrid, Spain
| | - Julie Schanz
- Department of Hematology and Medical Oncology, University Medical Center of Göttingen, Göttingen, Germany
| | - Detlef Haase
- Department of Hematology and Medical Oncology, University Medical Center of Göttingen, Göttingen, Germany
| | - Katayoon Shirneshan
- Department of Hematology and Medical Oncology, University Medical Center of Göttingen, Göttingen, Germany
| | - Steven Best
- Laboratory for Molecular Haemato-Oncology, King's College Hospital, NHS Foundation Trust, London, UK
| | - Syed A Mian
- Department of Haematological Medicine, King's College Hospital, NHS Foundation Trust, London, UK.,Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, UK
| | - Aytug Kizilors
- Laboratory for Molecular Haemato-Oncology, King's College Hospital, NHS Foundation Trust, London, UK
| | - José Cervera
- Genetics Unit, Hospital Universitario La Fe, Valencia, Spain
| | - Nicholas Lea
- Laboratory for Molecular Haemato-Oncology, King's College Hospital, NHS Foundation Trust, London, UK
| | - Dario Ferrero
- Fondazione Italiana Sindromi Mielodisplastiche (FISiM), Bologna, Italy.,Division of Hematology, University of Torino, AOU Città della Salute e della Scienza, Torino, Italy
| | - Ulrich Germing
- Department of Hematology, Oncology, and Clinical Immunology, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Barbara Hildebrandt
- Institute of Human Genetics, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | | | - Valeria Santini
- Fondazione Italiana Sindromi Mielodisplastiche (FISiM), Bologna, Italy.,MDS UNIT, AOU Careggi, University of Florence, Firenze, Italy
| | - Guillermo F Sanz
- Department of Hematology, Hospital Universitario La Fe, Valencia, Spain.,Centro de Investigación Biomédica en Red de Cáncer (CIBERONC), Instituto de Salud Carlos III, Madrid, Spain.,Department of Medicine, University of Valencia, Valencia, Spain
| | - Francesc Solé
- Institut de Recerca Contra la Leucèmia Josep Carreras, ICO-Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ghulam J Mufti
- Department of Haematological Medicine, King's College Hospital, NHS Foundation Trust, London, UK
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Abarrategi A, Mian SA, Passaro D, Rouault-Pierre K, Grey W, Bonnet D. Modeling the human bone marrow niche in mice: From host bone marrow engraftment to bioengineering approaches. J Exp Med 2018; 215:729-743. [PMID: 29453226 PMCID: PMC5839768 DOI: 10.1084/jem.20172139] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Revised: 01/19/2018] [Accepted: 01/30/2018] [Indexed: 12/11/2022] Open
Abstract
Xenotransplantation of patient-derived samples in mouse models has been instrumental in depicting the role of hematopoietic stem and progenitor cells in the establishment as well as progression of hematological malignancies. The foundations for this field of research have been based on the development of immunodeficient mouse models, which provide normal and malignant human hematopoietic cells with a supportive microenvironment. Immunosuppressed and genetically modified mice expressing human growth factors were key milestones in patient-derived xenograft (PDX) models, highlighting the importance of developing humanized microenvironments. The latest major improvement has been the use of human bone marrow (BM) niche-forming cells to generate human-mouse chimeric BM tissues in PDXs, which can shed light on the interactions between human stroma and hematopoietic cells. Here, we summarize the methods used for human hematopoietic cell xenotransplantation and their milestones and review the latest approaches in generating humanized BM tissues in mice to study human normal and malignant hematopoiesis.
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Affiliation(s)
- Ander Abarrategi
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, England, UK
| | - Syed A Mian
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, England, UK
- Department of Haematological Medicine, King's College London School of Medicine, London, England, UK
| | - Diana Passaro
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, England, UK
| | - Kevin Rouault-Pierre
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, England, UK
- Department of Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, England, UK
| | - William Grey
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, England, UK
| | - Dominique Bonnet
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, England, UK
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8
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Rouault-Pierre K, Mian SA, Goulard M, Abarrategi A, Di Tulio A, Smith AE, Mohamedali A, Best S, Nloga AM, Kulasekararaj AG, Ades L, Chomienne C, Fenaux P, Dosquet C, Mufti GJ, Bonnet D. Preclinical modeling of myelodysplastic syndromes. Leukemia 2017; 31:2702-2708. [PMID: 28663577 PMCID: PMC5729336 DOI: 10.1038/leu.2017.172] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 04/25/2017] [Accepted: 05/23/2017] [Indexed: 12/12/2022]
Abstract
Myelodysplastic syndromes (MDS) represent a heterogeneous group of hematological clonal disorders. Here, we have tested the bone marrow (BM) cells from 38 MDS patients covering all risk groups in two immunodeficient mouse models: NSG and NSG-S. Our data show comparable level of engraftment in both models. The level of engraftment was patient specific with no correlation to any specific MDS risk group. Furthermore, the co-injection of mesenchymal stromal cells (MSCs) did not improve the level of engraftment. Finally, we have developed an in vitro two-dimensional co-culture system as an alternative tool to in vivo. Using our in vitro system, we have been able to co-culture CD34+ cells from MDS patient BM on auto- and/or allogeneic MSCs over 4 weeks with a fold expansion of up to 600 times. More importantly, these expanded cells conserved their MDS clonal architecture as well as genomic integrity.
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Affiliation(s)
- K Rouault-Pierre
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, UK
| | - S A Mian
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, UK
- King’s College London School of Medicine, Department of Haematological Medicine, London, UK
| | - M Goulard
- INSERM, UMRS1131–University Paris Diderot, Saint Louis Hospital, Paris, France
| | - A Abarrategi
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, UK
| | - A Di Tulio
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, UK
| | - A E Smith
- King’s College London School of Medicine, Department of Haematological Medicine, London, UK
- King’s College Hospital, Department of Haematology, London, UK
| | - A Mohamedali
- King’s College London School of Medicine, Department of Haematological Medicine, London, UK
| | - S Best
- King’s College London School of Medicine, Department of Haematological Medicine, London, UK
| | - A-M Nloga
- Senior Haematology Department, Saint Louis Hospital, APHP, Paris, France
| | | | - L Ades
- Senior Haematology Department, Saint Louis Hospital, APHP, Paris, France
| | - C Chomienne
- INSERM, UMRS1131–University Paris Diderot, Saint Louis Hospital, Paris, France
- Cell Biology Department, Saint Louis Hospital, APHP, Paris, France
| | - P Fenaux
- INSERM, UMRS1131–University Paris Diderot, Saint Louis Hospital, Paris, France
- Senior Haematology Department, Saint Louis Hospital, APHP, Paris, France
| | - C Dosquet
- INSERM, UMRS1131–University Paris Diderot, Saint Louis Hospital, Paris, France
- Cell Biology Department, Saint Louis Hospital, APHP, Paris, France
| | - G J Mufti
- King’s College London School of Medicine, Department of Haematological Medicine, London, UK
- King’s College Hospital, Department of Haematology, London, UK
| | - D Bonnet
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, UK
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9
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Abarrategi A, Foster K, Hamilton A, Mian SA, Passaro D, Gribben J, Mufti G, Bonnet D. Versatile humanized niche model enables study of normal and malignant human hematopoiesis. J Clin Invest 2017; 127:543-548. [PMID: 28067666 PMCID: PMC5272182 DOI: 10.1172/jci89364] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 11/17/2016] [Indexed: 12/12/2022] Open
Abstract
The BM niche comprises a tightly controlled microenvironment formed by specific tissue and cells that regulates the behavior of hematopoietic stem cells (HSCs). Here, we have provided a 3D model that is tunable in different BM niche components and useful, both in vitro and in vivo, for studying the maintenance of normal and malignant hematopoiesis. Using scaffolds, we tested the capacity of different stromal cell types to support human HSCs. Scaffolds coated with human mesenchymal stromal cells (hMSCs) proved to be superior in terms of HSC engraftment and long-term maintenance when implanted in vivo. Moreover, we found that hMSC-coated scaffolds can be modulated to form humanized bone tissue, which was also able to support human HSC engraftment. Importantly, hMSC-coated humanized scaffolds were able to support the growth of leukemia patient cells in vivo, including the growth of samples that would not engraft the BM of immunodeficient mice. These results demonstrate that an s.c. implantation approach in a 3D carrier scaffold seeded with stromal cells is an effective in vivo niche model for studying human hematopoiesis. The various niche components of this model can be changed depending on the context to improve the engraftment of nonengrafting acute myeloid leukemia (AML) samples.
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Affiliation(s)
- Ander Abarrategi
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, United Kingdom
| | - Katie Foster
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, United Kingdom
| | - Ashley Hamilton
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, United Kingdom
| | - Syed A. Mian
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, United Kingdom
- King’s College London School of Medicine, Department of Haematological Medicine, London, United Kingdom
| | - Diana Passaro
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, United Kingdom
| | - John Gribben
- Department of Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Ghulam Mufti
- King’s College London School of Medicine, Department of Haematological Medicine, London, United Kingdom
| | - Dominique Bonnet
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, London, United Kingdom
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Rouault-Pierre K, Smith AE, Mian SA, Pizzitola I, Kulasekararaj AG, Mufti GJ, Bonnet D. Myelodysplastic syndrome can propagate from the multipotent progenitor compartment. Haematologica 2016; 102:e7-e10. [PMID: 27758823 DOI: 10.3324/haematol.2016.152520] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Kevin Rouault-Pierre
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, Department of Haematological Medicine, London, UK
| | - Alexander E Smith
- Kings College Hospital, Department of Haematology, Department of Haematological Medicine, London, UK.,King's College London School of Medicine, Department of Haematological Medicine, London, UK
| | - Syed A Mian
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, Department of Haematological Medicine, London, UK.,King's College London School of Medicine, Department of Haematological Medicine, London, UK
| | - Irene Pizzitola
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, Department of Haematological Medicine, London, UK
| | - Austin G Kulasekararaj
- Kings College Hospital, Department of Haematology, Department of Haematological Medicine, London, UK.,King's College London School of Medicine, Department of Haematological Medicine, London, UK
| | - Ghulam J Mufti
- Kings College Hospital, Department of Haematology, Department of Haematological Medicine, London, UK .,King's College London School of Medicine, Department of Haematological Medicine, London, UK
| | - Dominique Bonnet
- Haematopoietic Stem Cell Laboratory, The Francis Crick Institute, Department of Haematological Medicine, London, UK
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11
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Kordasti S, Costantini B, Seidl T, Perez Abellan P, Martinez Llordella M, McLornan D, Diggins KE, Kulasekararaj A, Benfatto C, Feng X, Smith A, Mian SA, Melchiotti R, de Rinaldis E, Ellis R, Petrov N, Povoleri GAM, Chung SS, Thomas NSB, Farzaneh F, Irish JM, Heck S, Young NS, Marsh JCW, Mufti GJ. Deep phenotyping of Tregs identifies an immune signature for idiopathic aplastic anemia and predicts response to treatment. Blood 2016; 128:1193-205. [PMID: 27281795 PMCID: PMC5009512 DOI: 10.1182/blood-2016-03-703702] [Citation(s) in RCA: 89] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 06/01/2016] [Indexed: 11/20/2022] Open
Abstract
Idiopathic aplastic anemia (AA) is an immune-mediated and serious form of bone marrow failure. Akin to other autoimmune diseases, we have previously shown that in AA regulatory T cells (Tregs) are reduced in number and function. The aim of this study was to further characterize Treg subpopulations in AA and investigate the potential correlation between specific Treg subsets and response to immunosuppressive therapy (IST) as well as their in vitro expandability for potential clinical use. Using mass cytometry and an unbiased multidimensional analytical approach, we identified 2 specific human Treg subpopulations (Treg A and Treg B) with distinct phenotypes, gene expression, expandability, and function. Treg B predominates in IST responder patients, has a memory/activated phenotype (with higher expression of CD95, CCR4, and CD45RO within FOXP3(hi), CD127(lo) Tregs), expresses the interleukin-2 (IL-2)/STAT5 pathway and cell-cycle commitment genes. Furthermore, in vitro-expanded Tregs become functional and take on the characteristics of Treg B. Collectively, this study identifies human Treg subpopulations that can be used as predictive biomarkers for response to IST in AA and potentially other autoimmune diseases. We also show that Tregs from AA patients are IL-2-sensitive and expandable in vitro, suggesting novel therapeutic approaches such as low-dose IL-2 therapy and/or expanded autologous Tregs and meriting further exploration.
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Affiliation(s)
- Shahram Kordasti
- Department of Haematological Medicine, King's College London, London, United Kingdom; Haematological Medicine, King's College Hospital, London, United Kingdom
| | - Benedetta Costantini
- Department of Haematological Medicine, King's College London, London, United Kingdom; Haematological Medicine, King's College Hospital, London, United Kingdom
| | - Thomas Seidl
- Department of Haematological Medicine, King's College London, London, United Kingdom
| | | | - Marc Martinez Llordella
- Division of Transplantation Immunology & Mucosal Biology, King's College London, London, United Kingdom
| | - Donal McLornan
- Haematological Medicine, King's College Hospital, London, United Kingdom
| | | | | | - Cinzia Benfatto
- Department of Haematological Medicine, King's College London, London, United Kingdom
| | - Xingmin Feng
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; and
| | - Alexander Smith
- Department of Haematological Medicine, King's College London, London, United Kingdom; Haematological Medicine, King's College Hospital, London, United Kingdom
| | - Syed A Mian
- Department of Haematological Medicine, King's College London, London, United Kingdom
| | - Rossella Melchiotti
- National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Emanuele de Rinaldis
- National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Richard Ellis
- National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Nedyalko Petrov
- National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Giovanni A M Povoleri
- Division of Transplantation Immunology & Mucosal Biology, King's College London, London, United Kingdom
| | - Sun Sook Chung
- Department of Haematological Medicine, King's College London, London, United Kingdom
| | - N Shaun B Thomas
- Department of Haematological Medicine, King's College London, London, United Kingdom
| | - Farzin Farzaneh
- Department of Haematological Medicine, King's College London, London, United Kingdom
| | - Jonathan M Irish
- Department of Cancer Biology, Vanderbilt University, Nashville, TN
| | - Susanne Heck
- National Institute for Health Research Biomedical Research Centre, King's College London, London, United Kingdom
| | - Neal S Young
- Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; and
| | - Judith C W Marsh
- Department of Haematological Medicine, King's College London, London, United Kingdom; Haematological Medicine, King's College Hospital, London, United Kingdom
| | - Ghulam J Mufti
- Department of Haematological Medicine, King's College London, London, United Kingdom; Haematological Medicine, King's College Hospital, London, United Kingdom
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Mian SA, Rouault-Pierre K, Smith AE, Seidl T, Pizzitola I, Kizilors A, Kulasekararaj AG, Bonnet D, Mufti GJ. SF3B1 mutant MDS-initiating cells may arise from the haematopoietic stem cell compartment. Nat Commun 2015; 6:10004. [PMID: 26643973 PMCID: PMC4686651 DOI: 10.1038/ncomms10004] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 10/23/2015] [Indexed: 12/14/2022] Open
Abstract
Despite the recent evidence of the existence of myelodysplastic syndrome (MDS) stem cells in 5q-MDS patients, it is unclear whether haematopoietic stem cells (HSCs) could also be the initiating cells in other MDS subgroups. Here we demonstrate that SF3B1 mutation(s) in our cohort of MDS patients with ring sideroblasts can arise from CD34(+)CD38(-)CD45RA(-)CD90(+)CD49f(+) HSCs and is an initiating event in disease pathogenesis. Xenotransplantation of SF3B1 mutant HSCs leads to persistent long-term engraftment restricted to myeloid lineage. Moreover, genetically diverse evolving subclones of mutant SF3B1 exist in mice, indicating a branching multi-clonal as well as ancestral evolutionary paradigm. Subclonal evolution in mice is also seen in the clinical evolution in patients. Sequential sample analysis shows clonal evolution and selection of the malignant driving clone leading to AML transformation. In conclusion, our data show SF3B1 mutations can propagate from HSCs to myeloid progeny, therefore providing a therapeutic target.
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Affiliation(s)
- Syed A. Mian
- Department of Haematological Medicine, King's College London School of Medicine, London SE5 9NU, UK
| | - Kevin Rouault-Pierre
- Human Normal and Malignant Haematopoiesis Stem Cells and Their Microenvironment Laboratory, The Francis Crick Institute, Lincoln's Inn Fields Laboratories, London WC2A 3LY, UK
| | - Alexander E. Smith
- Department of Haematological Medicine, King's College London School of Medicine, London SE5 9NU, UK
- Department of Haematology, King's College Hospital, London SE5 9RS, UK
| | - Thomas Seidl
- Department of Haematological Medicine, King's College London School of Medicine, London SE5 9NU, UK
| | - Irene Pizzitola
- Human Normal and Malignant Haematopoiesis Stem Cells and Their Microenvironment Laboratory, The Francis Crick Institute, Lincoln's Inn Fields Laboratories, London WC2A 3LY, UK
| | - Aytug Kizilors
- Department of Haematology, King's College Hospital, London SE5 9RS, UK
| | - Austin G. Kulasekararaj
- Department of Haematological Medicine, King's College London School of Medicine, London SE5 9NU, UK
- Department of Haematology, King's College Hospital, London SE5 9RS, UK
| | - Dominique Bonnet
- Human Normal and Malignant Haematopoiesis Stem Cells and Their Microenvironment Laboratory, The Francis Crick Institute, Lincoln's Inn Fields Laboratories, London WC2A 3LY, UK
| | - Ghulam J. Mufti
- Department of Haematological Medicine, King's College London School of Medicine, London SE5 9NU, UK
- Department of Haematology, King's College Hospital, London SE5 9RS, UK
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13
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Kulasekararaj AG, Smith AE, Mian SA, Mohamedali AM, Krishnamurthy P, Lea NC, Gäken J, Pennaneach C, Ireland R, Czepulkowski B, Pomplun S, Marsh JC, Mufti GJ. TP53 mutations in myelodysplastic syndrome are strongly correlated with aberrations of chromosome 5, and correlate with adverse prognosis. Br J Haematol 2013; 160:660-72. [PMID: 23297687 DOI: 10.1111/bjh.12203] [Citation(s) in RCA: 197] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 10/26/2012] [Indexed: 12/31/2022]
Abstract
This study aimed to determine the incidence/prognostic impact of TP53 mutation in 318 myelodysplastic syndrome (MDS) patients, and to correlate the changes to cytogenetics, single nucleotide polymorphism array karyotyping and clinical outcome. The median age was 65 years (17-89 years) and median follow-up was 45 months [95% confidence interval (CI) 27-62 months]. TP53 mutations occurred in 30 (9.4%) patients, exclusively in isolated del5q (19%) and complex karyotype (CK) with -5/5q-(72%), correlated with International Prognostic Scoring System intermediate-2/high, TP53 protein expression, higher blast count and leukaemic progression. Patients with mutant TP53 had a paucity of mutations in other genes implicated in myeloid malignancies. Median overall survival of patients with TP53 mutation was shorter than wild-type (9 versus 66 months, P < 0.001) and it retained significance in multivariable model (Hazard Ratio 3.8, 95%CI 2.3-6.3,P < 0.001). None of the sequentially analysed samples showed a disappearance of the mutant clone or emergence of new clones, suggesting an early occurrence of TP53 mutations. A reduction in mutant clone correlated with response to 5-azacitidine, however clones increased in non-responders and persisted at relapse. The adverse impact of TP53 persists after adjustment for cytogenetic risk and is of practical importance in evaluating prognosis. The relatively common occurrence of these mutations in two different prognostic spectrums of MDS, i.e. isolated 5q- and CK with -5/5q-, possibly implies two different mechanistic roles for TP53 protein.
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Affiliation(s)
- Austin G Kulasekararaj
- Department of Haematological Medicine, King's College London, School of Medicine, London, UK
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14
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Mian SA, Smith AE, Kulasekararaj AG, Kizilors A, Mohamedali AM, Lea NC, Mitsopoulos K, Ford K, Nasser E, Seidl T, Mufti GJ. Spliceosome mutations exhibit specific associations with epigenetic modifiers and proto-oncogenes mutated in myelodysplastic syndrome. Haematologica 2013; 98:1058-66. [PMID: 23300180 DOI: 10.3324/haematol.2012.075325] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The recent identification of acquired mutations in key components of the spliceosome machinery strongly implicates abnormalities of mRNA splicing in the pathogenesis of myelodysplastic syndromes. However, questions remain as to how these aberrations functionally combine with the growing list of mutations in genes involved in epigenetic modification and cell signaling/transcription regulation identified in these diseases. In this study, amplicon sequencing was used to perform a mutation screen in 154 myelodysplastic syndrome patients using a 22-gene panel, including commonly mutated spliceosome components (SF3B1, SRSF2, U2AF1, ZRSR2), and a further 18 genes known to be mutated in myeloid cancers. Sequencing of the 22-gene panel revealed that 76% (n=117) of the patients had mutations in at least one of the genes, with 38% (n=59) having splicing gene mutations and 49% (n=75) patients harboring more than one gene mutation. Interestingly, single and specific epigenetic modifier mutations tended to coexist with SF3B1 and SRSF2 mutations (P<0.03). Furthermore, mutations in SF3B1 and SRSF2 were mutually exclusive to TP53 mutations both at diagnosis and at the time of disease transformation. Moreover, mutations in FLT3, NRAS, RUNX1, CCBL and C-KIT were more likely to co-occur with splicing factor mutations generally (P<0.02), and SRSF2 mutants in particular (P<0.003) and were significantly associated with disease transformation (P<0.02). SF3B1 and TP53 mutations had varying impacts on overall survival with hazard ratios of 0.2 (P<0.03, 95% CI, 0.1-0.8) and 2.1 (P<0.04, 95% CI, 1.1-4.4), respectively. Moreover, patients with splicing factor mutations alone had a better overall survival than those with epigenetic modifier mutations, or cell signaling/transcription regulator mutations with and without coexisting mutations of splicing factor genes, with worsening prognosis (P<0.001). These findings suggest that splicing factor mutations are maintained throughout disease evolution with emerging oncogenic mutations adversely affecting patients' outcome, implicating spliceosome mutations as founder mutations in myelodysplastic syndromes.
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Affiliation(s)
- Syed A Mian
- King's College London School of Medicine, Department of Haematological Medicine, London, UK
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Mohamedali AM, Smith AE, Gaken J, Lea NC, Mian SA, Westwood NB, Strupp C, Gattermann N, Germing U, Mufti GJ. Novel TET2 Mutations Associated With UPD4q24 in Myelodysplastic Syndrome. J Clin Oncol 2009; 27:4002-6. [DOI: 10.1200/jco.2009.22.6985] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Cryptic chromosomal aberrations, such as regions of uniparental disomy (UPD), have been shown to harbor homozygous mutations and are a common feature in myelodysplastic syndrome (MDS). We investigated the sequence integrity of 4q24 candidate tumor suppressor gene TET2 in MDS patients with UPD on chromosome 4. Patients and Methods The coding exons of TET2 were analyzed by 454 deep sequencing and Sanger sequencing in nine patients with UPD on 4q. Four patients had refractory cytopenia with multilineage dysplasia and ringed sideroblasts (RCMD-RS) and UPD4q24, and five patients (refractory anemia with excess blasts-II, n = 1; 5q– syndrome, n = 1; RCMD-RS, n = 1; refractory anemia, n = 1; refractory cytopenia with multilineage dysplasia, n = 1) had no UPD4q24. Results Mutations on TET2 were identified in all four patients with UPD4q24. These were localized to exons 3, 6, and 9 and resulted in two premature stop codons, one frameshift mutation, and one cysteine to glycine amino acid change. Mutant clone size varied between 30% and 85%. One patient with UPD outside of q24 (UPD4q28.3) displayed additional TET2 mutations, but these were at low clonal levels (13%, 4%, and 4% for a silent mutation, a 180-base pair deletion in exon 3, and a lysine to phenylalanine substitution in exon 11, respectively). The other patients who did not have UPD4q24 did not have verifiable TET2 mutations. Conclusion Our data identify novel TET2 mutations in a dominant clone in patients with UPD4q24. The presence of UPD4q24 and mutations in RCMD-RS patients may suggest specificity to this subtype. Our preliminary results need to be confirmed in a large cohort of all MDS subtypes.
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Affiliation(s)
- Azim M. Mohamedali
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Alexander E. Smith
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Joop Gaken
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Nicholas C. Lea
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Syed A. Mian
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Nigel B. Westwood
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Corinna Strupp
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Norbert Gattermann
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Ulrich Germing
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
| | - Ghulam J. Mufti
- From the Department of Haematological Medicine, King's College London School of Medicine, London, United Kingdom; and Klinik für Hämatologie, Onkologie und Klinische Immunologie, Heinrich-Heine-Universität, Düsseldorf, Germany
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