Prognostic significance of, and gene and microRNA expression signatures associated with, CEBPA mutations in cytogenetically normal acute myeloid leukemia with high-risk molecular features: a Cancer and Leukemia Group B Study.

PURPOSE To evaluate the prognostic significance of CEBPA mutations in the context of established molecular markers in cytogenetically normal (CN) acute myeloid leukemia (AML) and gain biologic insights into leukemogenesis of the CN-AML molecular high-risk subset (FLT3 internal tandem duplication [ITD] positive and/or NPM1 wild type) that has a significantly higher incidence of CEBPA mutations than the molecular low-risk subset (FLT3-ITD negative and NPM1 mutated). PATIENTS AND METHODS One hundred seventy-five adults age less than 60 years with untreated primary CN-AML were screened before treatment for CEBPA, FLT3, MLL, WT1, and NPM1 mutations and BAALC and ERG expression levels. Gene and microRNA (miRNA) expression profiles were obtained for the CN-AML molecular high-risk patients. RESULTS CEBPA mutations predicted better event-free (P = .007), disease-free (P = .014), and overall survival (P < .001) independently of other molecular and clinical prognosticators. Among patients with CEBPA mutations, 91% were in the CN-AML molecular high-risk group. Within this group, CEBPA mutations predicted better event-free (P < .001), disease-free (P = .004), and overall survival (P = .009) independently of other molecular and clinical characteristics and were associated with unique gene and miRNA expression profiles. The major features of these profiles were upregulation of genes (eg, GATA1, ZFPM1, EPOR, and GFI1B) and miRNAs (ie, the miR-181 family) involved in erythroid differentiation and downregulation of homeobox genes. CONCLUSION Pretreatment testing for CEBPA mutations identifies CN-AML patients with different outcomes, particularly in the molecular high-risk group, thus improving molecular risk-based classification of this large cytogenetic subset of AML. The gene and miRNA expression profiling provided insights into leukemogenesis of the CN-AML molecular high-risk group, indicating that CEBPA mutations are associated with partial erythroid differentiation.

[1]  C. Bloomfield,et al.  Prognostic factors and outcome of core binding factor acute myeloid leukemia patients with t(8;21) differ from those of patients with inv(16): a Cancer and Leukemia Group B study. , 2005, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[2]  Y. Okuno,et al.  PU.1 is a major downstream target of AML1 (RUNX1) in adult mouse hematopoiesis , 2008, Nature Genetics.

[3]  S. Fröhling,et al.  CEBPA mutations in younger adults with acute myeloid leukemia and normal cytogenetics: prognostic relevance and analysis of cooperating mutations. , 2004, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[4]  M. Caligiuri,et al.  Wilms' tumor 1 gene mutations independently predict poor outcome in adults with cytogenetically normal acute myeloid leukemia: a cancer and leukemia group B study. , 2008, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[5]  D. Bartel,et al.  MicroRNAs Modulate Hematopoietic Lineage Differentiation , 2004, Science.

[6]  Kimihiro Hino,et al.  Regulatory Interaction of HNF1α to microRNA194 Gene During Intestinal Epithelial Cell Differentiation , 2007 .

[7]  R. Humphries,et al.  Hox genes in hematopoiesis and leukemogenesis , 2007, Oncogene.

[8]  J. Kutok,et al.  Absence of the transcription factor CCAAT enhancer binding protein alpha results in loss of myeloid identity in bcr/abl-induced malignancy. , 2006, Proceedings of the National Academy of Sciences of the United States of America.

[9]  Kyu-Tae Kim,et al.  Internal tandem duplications of the FLT3 gene are present in leukemia stem cells. , 2004, Blood.

[10]  C. Bloomfield,et al.  A Randomized Comparison of Induction Therapy for Untreated Acute Myeloid Leukemia (AML) in Patients < 60 Years Using P-Glycoprotein (Pgp) Modulation with Valspodar (PSC833): Preliminary Results of Cancer and Leukemia Group B Study 19808. , 2005 .

[11]  J. Klein,et al.  Survival Analysis: Techniques for Censored and Truncated Data , 1997 .

[12]  Daniel G. Tenen,et al.  Disruption of differentiation in human cancer: AML shows the way , 2003, Nature Reviews Cancer.

[13]  M. Caligiuri,et al.  FLT3 D835/I836 mutations are associated with poor disease-free survival and a distinct gene-expression signature among younger adults with de novo cytogenetically normal acute myeloid leukemia lacking FLT3 internal tandem duplications. , 2008, Blood.

[14]  J. Cayuela,et al.  Favorable prognostic significance of CEBPA mutations in patients with de novo acute myeloid leukemia: a study from the Acute Leukemia French Association (ALFA). , 2002, Blood.

[15]  Stefan Fröhling,et al.  Mutant nucleophosmin (NPM1) predicts favorable prognosis in younger adults with acute myeloid leukemia and normal cytogenetics: interaction with other gene mutations. , 2005, Blood.

[16]  Pu Zhang,et al.  Dominant-negative mutations of CEBPA, encoding CCAAT/enhancer binding protein-α (C/EBPα), in acute myeloid leukemia , 2001, Nature Genetics.

[17]  C. Nerlov.  C/EBPα mutations in acute myeloid leukaemias , 2004, Nature Reviews Cancer.

[18]  P. Ney.  Gene expression during terminal erythroid differentiation , 2006, Current opinion in hematology.

[19]  A. Viale,et al.  Induction of C/EBPalpha activity alters gene expression and differentiation of human CD34+ cells. , 2003, Blood.

[20]  M. Caligiuri,et al.  BAALC expression predicts clinical outcome of de novo acute myeloid leukemia patients with normal cytogenetics: a Cancer and Leukemia Group B Study. , 2003, Blood.

[21]  Bob Löwenberg,et al.  Biallelic mutations in the CEBPA gene and low CEBPA expression levels as prognostic markers in intermediate-risk AML. , 2003, The hematology journal : the official journal of the European Haematology Association.

[22]  C. Bloomfield,et al.  BAALC expression and FLT3 internal tandem duplication mutations in acute myeloid leukemia patients with normal cytogenetics: prognostic implications. , 2006, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[23]  C. Bloomfield,et al.  High BAALC expression associates with other molecular prognostic markers, poor outcome, and a distinct gene-expression signature in cytogenetically normal patients younger than 60 years with acute myeloid leukemia: a Cancer and Leukemia Group B (CALGB) study. , 2008, Blood.

[24]  M. Caligiuri,et al.  Overexpression of the ETS-related gene, ERG, predicts a worse outcome in acute myeloid leukemia with normal karyotype: a Cancer and Leukemia Group B study. , 2005, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[25]  C. Bloomfield,et al.  Pretreatment cytogenetic abnormalities are predictive of induction success, cumulative incidence of relapse, and overall survival in adult patients with de novo acute myeloid leukemia: results from Cancer and Leukemia Group B (CALGB 8461). , 2002, Blood.

[26]  Muller Fabbri,et al.  A MicroRNA signature associated with prognosis and progression in chronic lymphocytic leukemia. , 2005, The New England journal of medicine.

[27]  K. Akashi,et al.  GATA-1 converts lymphoid and myelomonocytic progenitors into the megakaryocyte/erythrocyte lineages. , 2003, Immunity.

[28]  Paola Fazi,et al.  Cytoplasmic nucleophosmin in acute myelogenous leukemia with a normal karyotype. , 2005, The New England journal of medicine.

[29]  M. Fey,et al.  Risk Assessment in Patients with Acute Myeloid Leukemia and a Normal Karyotype , 2005, Clinical Cancer Research.

[30]  J. Cayuela,et al.  Prevalence, clinical profile, and prognosis of NPM mutations in AML with normal karyotype. , 2005, Blood.

[31]  T. Naoe,et al.  Activating mutation of D835 within the activation loop of FLT3 in human hematologic malignancies. , 2001, Blood.

[32]  T. A. Lister,et al.  Mutation of the Wilms’ Tumor 1 Gene Is a Poor Prognostic Factor Associated with Chemoresistance in Normal Karyotype Acute Myeloid Leukemia. , 2007 .

[33]  M. Caligiuri,et al.  Dose escalation studies of cytarabine, daunorubicin, and etoposide with and without multidrug resistance modulation with PSC-833 in untreated adults with acute myeloid leukemia younger than 60 years: final induction results of Cancer and Leukemia Group B Study 9621. , 2004, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[34]  Tariq Enver,et al.  Transcription factor‐mediated lineage switching reveals plasticity in primary committed progenitor cells , 2002, The EMBO journal.

[35]  W. Hiddemann,et al.  Nucleophosmin gene mutations are predictors of favorable prognosis in acute myelogenous leukemia with a normal karyotype. , 2005, Blood.

[36]  C. Bloomfield,et al.  Clinical relevance of mutations and gene-expression changes in adult acute myeloid leukemia with normal cytogenetics: are we ready for a prognostically prioritized molecular classification? , 2007, Blood.

[37]  Carl W. Miller,et al.  Mutations in the gene encoding the transcription factor CCAAT/enhancer binding protein alpha in myelodysplastic syndromes and acute myeloid leukemias. , 2002, Blood.

[38]  F. Carneiro,et al.  Genetic changes of CEBPA in cancer: mutations or polymorphisms? , 2007, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[39]  M. Caligiuri,et al.  Absence of the wild-type allele predicts poor prognosis in adult de novo acute myeloid leukemia with normal cytogenetics and the internal tandem duplication of FLT3: a cancer and leukemia group B study. , 2001, Cancer research.

[40]  G. Ehninger,et al.  Analysis of Flt3-activating Mutations in 979 Patients with Acute Myelogenous Leukemia: Association with Fab Subtypes and Identification of Subgroups with Poor Prognosis , 2022 .

[41]  M. Caligiuri,et al.  MicroRNA expression in cytogenetically normal acute myeloid leukemia. , 2008, The New England journal of medicine.

[42]  Axel Benner,et al.  Prognostic significance of activating FLT3 mutations in younger adults (16 to 60 years) with acute myeloid leukemia and normal cytogenetics: a study of the AML Study Group Ulm. , 2002, Blood.

[43]  D. Tenen,et al.  Negative cross-talk between hematopoietic regulators: GATA proteins repress PU.1. , 1999, Proceedings of the National Academy of Sciences of the United States of America.

[44]  Gerhard Ehninger,et al.  Prevalence and prognostic impact of NPM1 mutations in 1485 adult patients with acute myeloid leukemia (AML). , 2006, Blood.

[45]  Bas J. Wouters,et al.  A recurrent in-frame insertion in a CEBPA transactivation domain is a polymorphism rather than a mutation that does not affect gene expression profiling-based clustering of AML. , 2007, Blood.

[46]  P. Amouyel,et al.  Recurrent in-frame insertion in C/EBPα TAD2 region is a polymorphism without prognostic value in AML , 2008, Leukemia.

[47]  C. Bloomfield,et al.  High expression levels of the ETS-related gene, ERG, predict adverse outcome and improve molecular risk-based classification of cytogenetically normal acute myeloid leukemia: a Cancer and Leukemia Group B Study. , 2007, Journal of clinical oncology : official journal of the American Society of Clinical Oncology.

[48]  Meng Ling Choong,et al.  MicroRNA expression profiling during human cord blood-derived CD34 cell erythropoiesis. , 2007, Experimental hematology.

[49]  Guido Marcucci,et al.  Independent confirmation of a prognostic gene-expression signature in adult acute myeloid leukemia with a normal karyotype: a Cancer and Leukemia Group B study. , 2006, Blood.

[50]  M. Caligiuri,et al.  Long-term disease-free survivors with cytogenetically normal acute myeloid leukemia and MLL partial tandem duplication: a Cancer and Leukemia Group B study. , 2007, Blood.

[51]  Jih-Luh Tang,et al.  Characterization of CEBPA Mutations in Acute Myeloid Leukemia: Most Patients with CEBPA Mutations Have Biallelic Mutations and Show a Distinct Immunophenotype of the Leukemic Cells , 2005, Clinical Cancer Research.