Upload
others
View
7
Download
0
Embed Size (px)
Citation preview
PML and RARA mutations in relapsed
Acute Promyelocytic Leukemia
Licia Iaccarino
Department of Biomedicine and Prevention
University of Tor Vergata, Rome
Rome, September 25, 2017
7th INTERNATIONAL SYMPOSIUM ON
ACUTE PROMYELOCYTIC LEUKEMIA
Zhu H.H., et al, NEJM 2014
PML and RARA mutations associated to therapy-resistance in APL
• ATRA resistance is associated to mutations in the ligand-binding domain of the
RARA moiety of PML/RARA
• PML mutations within the B2 domain of PML/RARA confer ATO resistance
• Mutations in PML and RARA genes have been described in up to 47% of
relapsed APL patients Goto E., et al, Blood 2011; Zhu H.H., et al, NEJM 2014; Chendamarai E., et al, Plos One 2015; Lou Y., et al, Ann Hematol 2015; Iaccarino L., et al, BJH 2016
RA
RA
RXR
Corepressors
RARE
Granulocytic differentiation Promoter clearance
PML
PML
PML NBs reformation
ATO
ATO
ATO P53 activation
Loss of
self-renewal
Jeanne M, et al., Cancer Cell 2010
ATO
PML ATO
RARA
PML PML/RARA
degradation
*
* mutations
PML mutations in APL
RARA mutations in APL
RA
RA
RXR
RARE
Granulocytic differentiation
ATRA
ATRA
PML
ATRA
RARA
PML
PML/RARA degradation
PML
PML
PML NBs reformation
P53 activation
Loss of self-renewal
Ablain J., et al, Nat Med 2014
*
** mutations
Coactivators
• Mutations in the normal PML allele have been proposed as additional
mechanism associated with ATO resistance
PML and RARA mutations associated to therapy-resistance in APL
ATO
PML
PML
PML NBs reformation
ATO
ATO
ATO
P53 activation
Loss of self-renewal
* *
PML degradation
• Two refractory APL cases with PML A216V mutation reported
Jeanne M., et al, Cancer Cell 2010 * mutations
Lehmann-Che et al, NEJM 2014; Iaccarino et al, BJH 2016
Iaccarino L., et al, BJH 2016
ATRA/CHT
11 months 9 months 2°relapse
* *
APL Diagnosis
12 months
Death
* **
3 months
1° relapse
ATRA/ATO CHT
* **
PML A216V
RARA R272Q
RARA T285I
PML/RARA
Mutation
PML unrearranged
*
ATRA
ATO
Chemotherapy
PML and RARA mutations associated to therapy-resistance in APL
Lehmann-Che et al, NEJM 2014; Iaccarino et al, BJH 2016
• Mutations in the normal PML allele have been proposed as additional
mechanism associated with ATO resistance
• Two refractory APL cases with PML A216V mutation reported
! Design a sensitive NGS assay for detection of PML and RARA
mutations predictive of treatment resistance in APL patients
! Investigate the time of onset of the mutations
Aims of the study
firstPCR
nestedPCR
bcr3 bcr2 bcr1
PML RARA
firstPCR
nestedPCR
1 2 3 4 5 6 7 8 9
bcr3 bcr1-2 PML
1 2 3 4 5 6 2 3 4 5 6 7 8
B2 domain ligand binding domain
• 23 APL patients relapsing after ATRA-CHT (n=14) and/or ATRA-ATO (n=9)
PML/RARA mutational analysis by NGS
Coverage (mean): PML: 33886X per base
RARA: 26051X per base
• 6/23 patients (26%) had at least one mutation in PML and RARA genes
• No mutations detectable at initial diagnosis in 3 of 6 available samples
single mutation wild-type multiple mutations ATRA-CHT ATRA-ATO
Results: mutational profile of PML and RARA at relapse
#1 #2 #3 #4 #5 #6 #7 #8 #9 #10 #11 #12 #13 #14 #15 #16 #17 #18 #19 #20 #21 #22 #23
ATRA-CHTATRA-ATOPMLRARA
B2 LBD
PML RARA
A216V (2)
A216T (1)
L224I (1)
T291A (1) T285I
(1)
C235F (1)
F286del (1)
R272Q (1)
I222_D223insE (1)
W225C (1)
S287L (1)
3% ≤ VAF ≤ 100%
B2
PML
A216V (2)
A216T (1) E224G
(1)
L220P (1)
L290V (1)
Results: location of mutations in PML and RARA
14 mutations in 6 pts
4 mutations in 2 pts
B2 LBD
PML RARA
A216V 5%
A216T 4%
T291A 21% T285I
60%
C235F 4%
R272Q 12%
I222_D223insE 6%
B2
PML
A216V 79%
A216T 6% E224G
3%
therapy-related APL with multiple relapses after ATRA-CHT and ATRA-ATO
UPN 17
B2 LBD
PML RARA
L224I 12%
B2
PML
A216V 12%
de novo APL relapsed after ATRA-ATO as first-line therapy
UPN 23
• High prevalence of PML and RARA mutations in relapsed APL
• A sensitive method for PML and RARA mutational analysis is required
to early detect resistant clones
• Screening of PML and RARA mutations may help to identify ATRA and/
or ATO-resistant APL patients candidates to alternative treatment
strategies
Conclusions
Tiziana Ottone Mariadomenica Divona Laura Cicconi Serena Lavorgna Valentina Alfonso Claudia Ciardi Syed Khizer Hasan Adriano Venditti Sergio Amadori William Arcese Maria Teresa Voso Francesco Lo-Coco
Roberto Cairoli, Niguarda Hospital, Milan Monica Bocchia, University of Siena
Acknowledgements
Annette Fasan
Constance Regina Bär
Torsten Haferlach