Genetics of acute myeloid leukemia in the elderly: mutation spectrum and clinical impact in intensively treated patients aged 75 years or older

A cute myeloid leukemia is a disease of the elderly (median age at diagnosis, 65-70 years). The prognosis of older acute myeloid leukemia patients is generally poor. While genetic markers have become important tools for risk stratification and treatment selection in young and middle-aged patients, their applicability in very old patients is less clear. We sought to validate existing genetic risk classification systems and identify additional factors associated with outcomes in intensively treated patients aged ≥75 years. In 151 patients who received induction chemotherapy in the AMLCG-1999 trial, we investigated recurrently mutated genes using a targeted sequencing assay covering 64 genes. The median number of mutated genes per patient was four. The most commonly mutated genes were TET2 (42%), DNMT3A (35%), NPM1 (32%), SRSF2 (25%) and ASXL1 (21%). The complete remission rate was 44% and the 3-year survival was 21% for the entire cohort. While adverse-risk cytogenetics (MRC classification) were associated with shorter overall survival (P=0.001), NPM1 and FLT3-ITD mutations (present in 18%) did not have a significant impact on overall survival. Notably, none of the 13 IDH1-mutated patients (9%) reached complete remission. Consequently, the overall survival of this subgroup was significantly shorter than that of IDH1-wildtype patients (P<0.001). In summary, even among very old, intensively treated, acute myeloid leukemia patients, adverse-risk cytogenetics predict inferior survival. The spectrum and relevance of driver gene mutations in elderly patients differs from that in younger patients. Our data implicate IDH1 mutations as a novel marker for chemorefractory disease and inferior prognosis. (AMLCG-1999 trial: clinicaltrials.gov identifier, NCT00266136).

Activating FLT3 mutants show distinct gain-of-function phenotypes in vitro and a characteristic signaling pathway profile associated with prognosis in acute myeloid leukemia

About 30% of patients with acute myeloid leukemia (AML) harbour mutations of the receptor tyrosine kinase FLT3, mostly internal tandem duplications (ITD) and point mutations of the second tyrosine kinase domain (TKD). It was the aim of this study to comprehensively analyze clinical and functional properties of various FLT3 mutants.

In 672 normal karyotype AML patients FLT3-ITD, but not FLT3-TKD mutations were associated with a worse relapse free and overall survival in multivariate analysis. In paired diagnosis-relapse samples FLT3-ITD showed higher stability (70%) compared to FLT3-TKD (30%). In vitro, FLT3-ITD induced a strong activating phenotype in Ba/F3 cells. In contrast, FLT3-TKD mutations and other point mutations – including two novel mutations – showed a weaker but clear gain-of-function phenotype with gradual increase in proliferation and protection from apoptosis. The pro-proliferative capacity of the investigated FLT3 mutants was associated with cell surface expression and tyrosine 591 phosphorylation of the FLT3 receptor. Western blot experiments revealed STAT5 activation only in FLT3-ITD positive cell lines, in contrast to FLT3-non-ITD mutants, which displayed an enhanced signal of AKT and MAPK activation. Gene expression analysis revealed distinct difference between FLT3-ITD and FLT3-TKD for STAT5 target gene expression as well as deregulation of SOCS2, ENPP2, PRUNE2 and ART3.

FLT3-ITD and FLT3 point mutations show a gain-of-function phenotype with distinct signalling properties in vitro. Although poor prognosis in AML is only associated with FLT3-ITD, all activating FLT3 mutations can contribute to leukemogenesis and are thus potential targets for therapeutic interventions.

Casitas B-lineage lymphoma mutants activate AKT to induce transformation in cooperation with class III receptor tyrosine kinases

In addition to overexpression and the occurrence of activating mutations, receptors can be aberrantly activated by impaired downregulation. In this study, we show that an oncogenic mutant of the ubiquitin ligase casitas B-lineage lymphoma (CBL; CBLΔexon8), which is found in acute myeloid leukemia patients, predominantly cooperates with receptor tyrosine kinase (RTK) class III receptors (PDGFRA, PDGFRB, KIT, and FLT3), but not with non-class III RTKs or cytokine receptors, to induce IL-3-independent growth of Ba/F3 cells. In cells coexpressing RTK class III/CBLΔexon8, receptor internalization was delayed, and cells were protected from apoptosis after cytokine withdrawal. Ligand-stimulated Ba/F3 cells and acute myeloid leukemia cell lines coexpressing the CBL deletion mutant and FLT3 showed enhanced AKT phosphorylation. Combined pharmacologic inhibition of the PI3K/AKT pathway and FLT3 had an additive effect on cell proliferation. The transforming potential of the CBL mutant was completely abolished by the mutation of the CBL PTB domain and was decreased by the mutation of tyrosines 589 and 591 in the juxtamembrane domain of FLT3. A constitutively active AKT1 mutant (E17K) recapitulated the phenotype induced by the CBL deletion mutant in Ba/F3 cells. This study reveals FLT3-CBL interaction sites and the AKT pathway as critical mediators of transformation by oncogenic CBL mutants.

Assessment of the acute toxicity of eutrophic sediments after the addition of calcium nitrate (Ibirité reservoir, Minas Gerais-SE Brazil): initial laboratory experiments

This study evaluated the acute toxicity of sediment in a eutrophic reservoir after remediation with a calcium nitrate solution to retain phosphorus. The study involved microcosms of surface sediments and water from the sediment-water interface in the Ibirité reservoir. This reservoir, located in the vicinity of metropolitan Belo Horizonte (Minas Gerais, SE Brazil), is a water body that receives treated effluents from an oil refinery (REGAP-Petrobras), as well as high loads of untreated urban effluents from the city of Ibirité and surrounding areas and industrial effluents from a major industrial park. Incubation times of the treatment experiments were: t = 0, t = 5, t = 10, t = 25, t = 50, t = 85 and t = 135 days. One control microcosm and three treated microcosms were analysed in each time interval. Acute toxicity of water samples was assessed with Ceriodaphnia silvestrii Daday, 1902 and that of bulk sediment samples with Chironomus xanthus Rempel, 1939. Toxicity tests were carried out concomitantly with chemical analyses of dissolved inorganic nitrogen species (ammonia, nitrate and nitrite), sulfate and metals in the water samples of the microcosms. Acid volatile sulfides (AVS), simultaneously extracted metal (SEM) and potentially bioavailable metal were analyzed in bulk sediment samples. Neither of the tested organisms showed toxicity in the control microcosm samples. The water column of the treated microcosm showed toxicity to C. silvestrii, starting at t = 10 days, while the sediment pore water toxicity started at t = 0 day. However, toxicity was found to decline from t = 85 days to t = 135 days. Sediments showed toxicity to C. xanthus during the entire experiment, except at the longest incubation time (t = 135 days). The overall results indicate that nitrate, which reached concentrations exceeding 1,200 mg N-NO3- L-1 in the sediment pore water of the treated microcosms, was most probably responsible for the toxicity of the samples. Although the calcium nitrate technology proved effective in retaining phosphorus, promoting sediment oxidation via denitrification, from the ecotoxicological standpoint and under the experimental conditions of this study, the application of nitrate for remediation of the sediments in the Ibirité reservoir did not prove effective up to a period of 135 days of incubation. However, we presume that after longer periods of incubation, treated sediments may recover their ability to sustain a benthic community. More advanced experiments are planned involving longer incubation times, thus extending the denitrification process, which may lead to a higher phosphorus retention capacity and to more complete abatement of sediment toxicity.

[Iliac crest biopsy findings in malignant non-Hodgkin lymphoma]

Issuing from the clinico-prognostic importance of the classification after Kiel of the malignant non-Hodgkin-lymphomas the results of the attempt of a reclassification of positive bioptic findings of the iliac crest judged according to the former German nomenclature are described and discussed after the Kiel classification. In the total material of 725 biopsies 76 positive findings of the marrow were stated in malignant non-Hodgkin-lymphomas, which at 67.1% consist of such with a lower and at 32.9% of such with a high degree of malignity, in which case a strong decrease of the formerly diagnosed CLL is to be seen after reclassification, whereas the immunocytomas render the by far largest proportion. The former malignant reticuloses disappear per definitionem after reclassification and, as it was expected, are broadly distributed. In 112 biopsies which were performed on account of the suspicion of an affection of the marrow in malignant non-Hodgkin-lymphomas the 76 positive findings correspond to a frequency of 67.9%, which, however, must critically be judged, since the case in question are very selected numbers of patients.