Emopoiesi Clonale: impatto sulla prognosi e sulla valutazione della

MRD Matteo G Della Porta

Cancer Center IRCCS Humanitas Research Hospital

& Humanitas University Milano

matteo.della_porta@hunimed.eu

DICHIARAZIONE

Relatore: Ma#eoGDellaPorta Come da nuova regolamentazione della Commissione Nazionale per la Formazione Continua del Ministero della Salute, è richiesta la trasparenza

delle fonti di finanziamento e dei rapporti con soggetti portatori di interessi commerciali in campo sanitario.

•  Posizione di dipendente in aziende con interessi commerciali in campo sanitario (NIENTE DA DICHIARARE / NOME AZIENDA) •  Consulenza ad aziende con interessi commerciali in campo sanitario (NIENTE DA DICHIARARE / NOME AZIENDA)

•  Fondi per la ricerca da aziende con interessi commerciali in campo sanitario (NIENTE DA DICHIARARE / NOME AZIENDA)

•  Partecipazione ad Advisory Board (NIENTE DA DICHIARARE / NOME AZIENDA)

•  Titolarietà di brevetti in compartecipazione ad aziende con interessi commerciali in campo sanitario (NIENTE DA DICHIARARE /

NOME AZIENDA) •  Partecipazioni azionarie in aziende con interessi commerciali in campo sanitario (NIENTE DA DICHIARARE / NOME AZIENDA)

•  Altro

PROGETTO FORMATIVO SIE DALL’EMOPOIESI CLONALE ALLE LEUCEMIE “THERAPY-RELATED"

Bologna, Starhotels Excelsior, 09 aprile 2019

Acquired mutations in TET2 in myeloid neoplasms

N Engl J Med 2009;360:2289-301; Nature Genetics 2009;41:838-842; Nature 2010;468:839-43

Recurrent somatic TET2 mutations in normal elderly individuals with clonal hematopoiesis

Nat Genet. 2012 Sep 23. [Epub ahead of print]

Blood. 2009;114:3538-3545

Age-Related Clonal Hematopoiesis

Jaiswal S et al. N Engl J Med 2014;371:2488-98.

Age-Related Clonal Hematopoiesis and Mortality (all causes)

Jaiswal S et al. N Engl J Med 2014;371:2488-98.

Age-Related Clonal Hematopoiesis and risk of Hematologic Cancer

Jaiswal S et al. N Engl J Med 2014;371:2488-98.

Clinical relevance of clonal hematopoiesis in the oldest-old

population: analysis of the "Health and Anemia" study.

M. Rossi, M. Meggendorfer, M. Zampini, M. Tettamanti, E. Riva, E.

Saba, N. Manes, C. Milanesi, M. Ubezio, L. Morabito, E. Travaglino, C. Peano, G. Solda, R. Asselta, S. Duga, K. Malik, C. Selmi, E. Civilini, S.

Mandelli, N. Bolli, GS. Vassiliou, W. Kern, A. Santoro, U. Lucca, T. Haferlach, and MG. Della Porta

Submitted

Study Population The Health and Anemia Study (2003-2017)

•  Prospective population-based observational study of all elderly (>65y) residents in the municipality of Biella, Italy (n=10,082)

•  Prevalence day: –  Hematological parameters together with clinical history –  Screening for anemia (serum folic acid, vitamin B12, iron, ferritin and

transferrin, transferrin saturation, reticulocytes, creatinine) •  Follow-up :

–  Data on hospitalization and mortality –  Information on the development of hematological and solid cancers

(provided by local tumor registry up to 2017 www.registri-tumori.it/cms/RTBiella).

–  344,565 laboratory tests available

Tettamanti M et al. Haematologica 2010;95:1849

Mild grade anemia: Hb 10.0-11.9 g/dL in women

Hb 10.0-12.9 g/dL in men

Prevalence of mild anemia in the elderly: the Health and Anemia population-based study

Haematologica 2009;94:22-28

Association of mild anemia with hospitalization and mortality in the elderly:

the Health and Anemia population-based study

Haematologica 2009;94:22-28

•  1059 subjects •  median age 84.2y (range 80-105) •  peripheral blood DNA •  targeted sequencing of 47 genes •  33% subjects with ARCH

PrevalenceandCharacteris0csofSoma0cMuta0ons

Most Frequently Mutated Genes %

DNMT3A 36.4 TET2 24.3 ASXL1 6.5

Splicing (SF3B1, SRSF2, U2AF1) 8

TP53 pathway (TP53, PPM1D) 7

JAK2 2

Number of patients

Num

ber o

f mut

atio

ns

Association of Somatic mutations with Overall Survival

p<.001 p<.001

In a Cox proportional-hazards analysis adjusted for age and sex, carrying a mutation was associated with increased all-cause mortality (HR 1.24 p=.006)

No ARCH ARCH

No mutations 1 mutation ≥2 mutations

•  The absence of mutations in the 47 genes studied had a negative predictive value for MDS of 0.97

•  Spliceosome genes (SF3B1, SRSF2, U2AF1) had the highest predictive value for MDS irrespective of co-occurring mutations, with positive predictive value of 0.76

•  The positive predictive value of mutations in TET2, or DNMT3A were 0,17 and 0.08, whereas that of the same mutations combined with other genetic lesions was higher (0.42 and 0.31, respectively)

•  VAF ≥ 10 had a positive predictive value of 29% •  Overall, mutations in spliceosome genes and co-mutation

patterns involving TET2 and DNMT3A accounted for 74% of MDS.

Predictive value of mutation status and hematopoietic clone size in the diagnosis of

myeloid neoplasms (MDS)

Non-mutational factors predicting the risk of MDS

•  The combination of mutations and non-mutational factors (RDW and MCV, after excluding iron/vitamin depletion and thalassemia) improves the capability to capture individual risk of MDS with respect to molecular data alone (P=.01)

Normal MCV High MCV

p=.01

Normal RDW High RDW

p=.001

mutationsalonePPV

mutation+highRDW/MCVPPV

Splicingfactors 0,76 0,92DNMT3A/TET2+others 0,33 0,49

Clonalevolu0on

99pairsofserialsamples-  23clonalevolu,ons7withsignificantVAFincrease,16withappearanceofanewclone

012TET2VAF%

Subject1145

2SF3B1VAF%

Subject269

MDSdiagnosis

MDSdiagnosis

YEARS YEARS

RDWHbg/dl

RDWHbg/dl

TP53 mutation can pre-exists in t-AML

Wong TN, Nature 2015

Josephine D. Kahn et al. Blood 2018;132:1095-1105

©2018 by American Society of Hematology

Truncating mutations in the terminal exon of protein phosphatase Mg2+/Mn2+ 1D (PPM1D) have been identified in clonal hematopoiesis and myeloid neoplasms, with a striking enrichment in patients previously

exposed to chemotherapy.

Unexplained Anemia (Cytopenia)

Normal Hb value Mild anemia

p=.001

Moderate-severe anemia Age(y) Prevalenceof

anemia(%)

80-84 18,985-89 26,690+ 41,8

Types of anemia in the study population

Prevalence of anemia in the study population

Causeofanemia

%

VitaminB12/folate/irondeficiency 26,3Anemiaofchronicdisease 17,2Renalinsufficiency 15,1Unexplainedanemia 28,7

Unexplained Anemia and risk of MDS

Prevalenceofmuta0ons(p=ns)

Genes Unexplainedanemiawithmuta0ons(n=59)

Age-mathcedMDS(n=206)

RNASplicing

45%

52%

TET2/DNMT3A/ASXL1

42%

49%

RUNX1

7%

11%

•  Among patients with unexplained anemia, carrying one or more mutations was associated with reduced probability of survival (p=.002)

•  Carrying a somatic mutation had a positive predictive value (0.80) for persistent, progressive, multilineage cytopenia (consistent with MDS phenotype)

•  We compared survival and mutational characteristics of 59 subjects with unexplained anemia and mutations with those of 206 age-matched MDS :

Unexplained anemia/ ARCH

p=.087

Age-matched MDS

•  Prospec0vepopula0on-basedobserva0onalstudyamongallresidents80yearsorolderineightneighboringmunicipali0esintheprovinceofVarese,Italy

•  Studypopula0on=2,139

•  890peripheralbloodsamplesavailable

•  Prevalenceday:–  Hematologicalparameters

–  Clinicalhistory–  Laboratorytests

•  Follow-up:–  Dataonhospitaliza0onandmortality

–  Informa0ononthedevelopmentofhematologicalandsolidcancers

(providedbylocaltumorregistry)

LuccaUBMCNeurol.2011;11:54.

Valida0onoftheResults:The“Monzino80plus”study

Salute&Anemiavs

Monzino

DNMT3A36%

TET225%

ASXL16%

PPM1D5%

SF3B14%

ATM2%

JAK22%

SRSF22%

MPL2%

TP532%

NF12%

U2AF11%

BCOR1%

IDH21%

RAD211%

ZRSR21%

CALR1%

CUX11%

Others6%

TET230%

DNMT3A29%

ASXL17%

BCOR3%

SF3B13%

TP533%

PPM1D3%

SRSF22%

CBL2%

RAD212%

STAG22%

ASXL22%

JAK21%

EZH21%

CUX11%

SETBP11%GATA11%

PIGA1%

GATA21%

BCORL11%

RUNX11%

ETNK10%FLT30%

IDH20%

MPL0%

PTPN110%

NF10%

CALR0%

CEBPA0%

MostFrequentlyMutatedGenes %

DNMT3A 36.4

TET2 24.3

ASXL1 6.5

Splicing(SF3B1,SRSF2,U2AF1) 8

TP53pathway(TP53,PPM1D) 7

JAK2 2

MostFrequentlyMutatedGenes %

DNMT3A 29

TET2 30

ASXL1 7

Splicing(SF3B1,SRSF2,U2AF1) 6

TP53pathway(TP53,PPM1D) 6

JAK2 1

190/730=26%ptswithCH340/1043=33%ptswithCH

2roundofsequencingwithmatchedcontrols

1roundofsequencingwithnomatchedcontrols

ARCH •  Clonal hematopoiesis is associated with reduced survival in an

oldest-old population •  Specific mutational profiles define different risks of developing MDS

and inflammatory/vascular diseases. •  Carrying a somatic mutation with a variant allele frequency (VAF) ≥.

10, carrying ≥2 mutations, spliceosome gene mutations and co-mutation patterns involving TET2, DNMT3A has a positive predictive value for MDS

•  Non mutational factors, such as early changes in red blood cell indices, may improve the capability to identify patients at increased risk of developing myeloid cancers.

•  In patients with unexplained anemia, carrying a somatic mutation has a positive predictive value for persistent, progressive, multilineage cytopenia (findings consistent with a MDS phenotype) and shorter survival. On this basis, 8% of all cytopenias might be undiagnosed MDS.

Restoration of TET2 Function Blocks Aberrant Self-Renewal and Leukemia Progression

•  Tet2 restoration reverses aberrant self-renewal of Tet2-deficient cells

•  Tet2 restoration promotes DNA demethylation, differentiation, and cell death

•  Vitamin C treatment mimics Tet2 restoration to block leukemia progression

Cell. 2017 Sep 7;170(6):1079-1095.e20

Weiden0fiedmuta0onsinmacrophagesisolatedfromsynovialfluidof7/16pa0entswithrheumatoidarthri0s

TET2andriskofcoronaryheartdisease ARCHandriskofrheumatoid/psoriaHcarthriHs

TET2mutTET2wt

HR3.12,p<.001 ARCHNoARCH

HR1.34,p=.01

ClonalHematopoiesisandVascular/InflammatoryDiseases

Weiden0fiedmuta0onsinmacrophagesisolatedfrombloodandatherosclero0cplaquesof9/25pa0entswithcaro0dstenosis

Therapy-Related Clonal Hematopoiesis in Patients with Non-hematologic Cancers Is Common and

Associated with Adverse Clinical Outcomes

•  Deep sequencing shows clonal hematopoiesis (CH) is common in solid tumor patients

•  CH is associated with increasing age, tobacco use, and prior radiation therapy

•  CH is associated with an increased risk of hematologic cancers

•  The presence of CH adversely impacts survival from non-hematologic cancers

Cell Stem Cell.2017;21(3):374-382

Clonal Hematopoiesis Associated With Adverse Outcomes After ASCT for

Lymphoma

Gibrosn T, J Clin Oncol 35:1598-1605. 2017

Molecular Minimal Residual Disease in AML

N Engl J Med 2018; 378:1189-1199

Mutation patterns observed in MDS treated with allo-HSCT

RUNX1 23% SRSF2 17% ASXL1 17% SF3B1 16% KRAS/NRAS 16% DNMT3A 15% TP53 13% TET2 10%

Matteo G. Della Porta et al. JCO doi:10.1200/JCO.2016.67.3616

Relationship between type of oncogenic mutations and overall survival of MDS receiving allo-HSCT

Multivariableanalysis

MDSpatients ProbabilityofrelapseOverallSurvival

Variable HR P HR P

ASXL1 1.89 .003 1.72 .008

RUNX1 1.67 .02 1.59 .035

TP53 1.90 .019 1.82 .022

Matteo G. Della Porta et al. JCO doi:10.1200/JCO.2016.67.3616

Mutation Pattern at Disease Relapse After HSCT in Patients With MDS and MDS/AML

Matteo G. Della Porta et al. JCO doi:10.1200/JCO.2016.67.3616

Mutation Clearance after Transplantation for Myelodysplastic Syndrome

N Engl J Med 2018;379:1028-41.

Summary •  Specific mutational profiles define different risks of developing

MDS and inflammatory/vascular diseases.

•  Restoration of TET2 Function Blocks Aberrant Self-Renewal and Leukemia Progression (cancer prevention)

•  Therapy-Related Clonal Hematopoiesis in Patients with Non-hematologic Cancers Is Common and Associated with Adverse Clinical Outcomes.

•  Clonal Hematopoiesis Associated With Adverse Outcomes After Autologous Transplantation for Lymphoma

•  In patients with Myeloid Neoplasms, Molecular Monitoring of MRD is Able to Identify Patients at Early Risk of Disease Relapse

MariannaRossiMaJeoZampiniNiclaManesElenaSabaLucioMorabitoMartaUbezioChiaraMilanesiEricaTravaglinoCleliaPeanoStefanoDugaArmandoSantoro

UgoLuccaEmmaRivaMauroTeJamanHSaraMandelli

NiccolòBolli

GeorgeVassiliou

RoccoPiazza

ManjaMeggendorferWolfgangKernTorstenHaferlach

ValeriaSanHniAllFISMcenters

Acknowledgments

An integrated European platform to conduct translational studies in Myelodysplastic Syndromes based on the

EuroBloodNet infrastructure

CVto:maqeo.della_porta@hunimed.eu

2MEDICIRICERCATORI(3anni)