Dysplasie in AML en (cyto)genetische afwijkingen: Chromosoom 3q26 afwijkingen en EVI1
patient 0390606 BM H11-172 8-2-2011
patient 0390606 dag 24 kuur I H11-428 4-4-2011
patient 0390606 dag 24 kuur I H11-428 4-4-2011
Het betreft een patiente uit 1958. bij presentatie Hb 6.8 WBC 5.6 thrombo 412. Diagnose WHO 2008: AML met t(3;3)(q21;q26)rpn1-evi1 behandeld in de HOVON 42: na 1e kuur geen response na 2e kuur morfologisch en immunologisch in remissie daarna allo transplantatie en na 3 weken recidief en overleden. Cytogenetica: t(3;3) en -7.
Acute myeloid leukemia: Molecular biology Normal AML
Bone marrow: Morphology Normal Leukemia
Normal bloodcell formation Stemcell Bone marrow Blood
One cell transforms: The beginning of leukemia. Bonemarrow Immature cell Blood
Leukemia cells in bone marrow and blood Bone marrow Blood
AML behaves differently in different patients patient A in 1 month patient B cured patient C Cured, but one year later
Why do AML patients respond differently to therapy?
Why do AML patients respond differently to therapy? AML is not one disease AML is a disease of the genes Different AMLs have different recurrent genetic abnormalities
Identification of genetic defects in AML: Improved diagnostics and prognostics More specific treatment protocols
Identification of genetic defects in AML: Improved diagnostics and prognostics More specific treatment protocols
Normal: 2 x 23 chromosomes Kern Cel DNA
AML is a clonal disease with frequent chromosomal abnormalities. Translocation t(8;21): an example
percentage living Acute myeloid leukemia Prognosis based on chromosomal abnormalities 100 inv(16) t(15;17) t(8;21) favorable 50 0 0-7/7q-, t(3;3)/inv3, t(6;9), t(9;22), complex, a.o. 1 2 3 4 5 years intermediate unfavorable
Chromosome analysis treatment Favorable t(8;21) Chemotherapy Intermediate poor Inv (3) Chemotherapy + Transplantation
Chromosome analysis treatment Good t(8;21) Chemotherapy Intermediate poor Inv (3)? Chemotherapy + Transplantation
Chromosome 3q26 aberrations in AML 3q26 aberrations: ~2% AML Inv 3 t(3;3)
Cum Survival Chromosome 3q26 aberrations in AML 3q26 aberrations: ~2% AML 1.2 1.0 AML with 3q26 aberrations.8 AML intermediate risk Inv 3.6.4 t(3;3).2 0.0 0 20 40 60 80 100 120 140 160 Event free survival, [m]
Chromosome 3q26 aberrations in AML 3q26 aberrations: ~2% AML 3 3 3 3 Inv 3 t(3;3)
EVI1 is the gene that is located at the breakpoint region at Chromosome 3q26 3q26 aberrations: ~2% AML 3 3 Inv 3 Evi1 t(3;3)
Identification of genetic defects and analysis gene expression in AML: INTERMEZZO I
Two cells from the same individual and thus with the same DNA
23 chromosomes: ~20.000 genes. Gene: turned on Gene: turned off DNA Normal myeloid cell Skin cell Liver cell
22 paar chromosomen XX of XY 22.000 genen/cel
Een chromosoom
DNA
DNA
DNA
Genen coderen voor eiwitten 22.000 genen/cel
Een Gen start stop DNA RNA polymerase ATG TGA AAAA RNA ribosomen M-AZ-AZ-AZ-AZ-AZ-AZ EIWIT
EVI1 is the gene that is located at the breakpoint region at Chromosome 3q26 3q26 aberrations: ~2% AML 3 3 Inv 3 Evi1 t(3;3)
The EVI1 gene is located on Chromosome 3 is switched off in normal bone marrow cells. Normal marrow EVI1 off Chromosome 3
The EVI1 gene located on Chromosome 3 is switched on in AML with a chromosome 3q26 break. Normal marrow Leukemia EVI1 off Chromosome 3 EVI1 on Chromosome 3: break
treatment Favorable t(8;21) Chemotherapy Intermediate? EVI1? Poor Inv (3) Chemotherapy = EVI1 + Transplantation
The EVI1 gene is turned on in ~10 % subset of AML patients without a chromosome 3 break. Normal marrow Leukemia Leukemie EVI1 off Chromosome 3 EVI1 on Chromosome 3: break EVI1 on Chromosom3
Treatment Favorable Intermediate EVI1 expression without 3q26 break(`~10%)? Poor +
Combined AML cohorts revealed prognostic impact of high EVI1 levels Overall Survival (%) Event-free Survival (%) Relapse-free Survival (%) 100 100 100 75 75 75 50 EVI1 - n=1234 50 50 EVI1 - n=952 EVI1 - n=1234 25 0 EVI1 + n=148 P <.001 25 0 EVI1 + n=148 P <.0001 25 0 EVI1 + n=79 P <.001 0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 18 0 2 4 6 8 10 12 14 16 Time (years) Time (years) Time (years) Achievement of CR OS EFS DFS HR, 0.54; 95%CI, (0.36-0.80), P=0.002 HR, 1.17; 95%CI, (0.93-1.46), P=0.18 HR,1.46; 95%CI, (1.19-1.87), P=0.0003 HR, 1.32 ; 95%CI, (0.99-1.76),P=0.05 *Cox regression model stratified for cohorts and other prognostic AML markers, age, WBC, platelets, cytogenetic risk, type of AML and NPM1wt/FLTITDneg.
Overall Survival (%) Relapse-free Survival (%) EVI1 + AML cases benefit of allogeneic transplant in first CR A B 100 100 75 75 50 Allo-TPL in 1 st CR n=28 50 Allo-TPL in 1 st CR n=28 25 No Allo-TPL in 1 st CR n=51 25 No Allo-TPL in 1 st CR n=51 P =.05 0 P =.001 0 0 1 2 3 4 5 6 7 8 9 10 11 12 0 1 2 3 4 5 6 7 8 9 10 11 12 Time (years) Time (years)
Favorable Intermediate EVI1 expression without 3q26 break (10%) + Poor +
De search for other genetic abnormalities continues. Favorable Intermediate Other mutation? Poor +
Gene expression profiling in AML
23 chromosomes: ~20.000 genes. Gene: turned on Gene: turned off DNA Leukemia A Leukemia B Leukemia C
Gene expression profiling of AML: Expression analysis of 13.000 genes The Genetic (bar)code
Gen expressie profiel analyse bij AML: Expressie analyse van 13.000 genen The Genetic (bar)code
AMLs zijn morphologisch vergelijkbaar: Een studie bij 285 patienten. AML 1 AML 2 AML 3 AML 4 AML 5..... AML 283 AML 284 AML 285
Gen expressie profielen bij AML: Opslaan van de genetische codes bij 285 AML patiënten AML 1 AML 2 AML 3 AML 4 AML 5..... AML 283 AML 284 AML 285
Gene expression profiling
Omniviz Pearson's correlatie coefficient analyse B A
Omniviz Pearson's correlatie coefficient analyse A B C A A A D E F A A A
Analyse en vergelijking van de gen expressie profilen bij 6 AML patiënten 1 2 3 4 5 6 285 AML patients (random order) 1 2 3 4 5 6 285 AML patients
50 AML patienten Analyse en vergelijking van de gen expressie profilen bij 50AML patiënten 50 AML patienten 285 AML patients (random order) 285 AML patients
285 AML patienten Analyse en vergelijking van de gen expressie profielen 285 AML patienten 285 AML patients (random order) 285 AML patients
Clustering van AML patiënten met zelfde gen expressie profiel 285 AML patienten 285 AML patients 285 AML patients 285 AML patienten
285 AML patienten kunnen worden onderverdeeld in 16 subgroepen of clusters 285 AML patienten
285 AML patienten kunnen worden onderverdeeld in 16 subgroepen of clusters
285 AML patienten kunnen worden onderverdeeld in 16 subgroepen of clusters
Patienten met dezelfde bekende translocaties zitten in een zelfde cluster: Zelfde gen expressie profiel Inv(16) t(15;17) t(8;21)
Wat betekent dit voor de andere clusters? Inv(16)????? t(15;17) t(8;21)
Chromosome 3q26 defects in AML cases from cluster 10: EVI1 defects EVI1 +/EVI1 -
Cumulative percentage AML cases from cluster 10 respond poor to treatment Event free survival 100 75 50 t(8;21), inv 16, t(15;17) 25 Cluster 10 0 Months 0 60
Gene profiling of AML Identification of genetically defined AML Subgroups within genetically defined AML Novel subclasses of AML Novel insight into the biology of AML
Acknowledgements Erasmus MC Sanne Lugthart Marije Havermans Bob Löwenberg Claudia Erpelinck Eric Bindels Chantal Goudswaard Berna Beverloo Kirsten van Lom Antoinette van Hoven-Beijen Roel Verhaak Peter Valk University of Ulm Stefan Gröschel Richard F. Schlenk Karina Eiwen Hartmut Döhner Konstanze Döhner