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Acute myeloid leukemia

The genetics and clinical characteristics of children morphologically diagnosed as acute promyelocytic leukemia

Leukemia volume 33, pages 1387–1399 (2019)Cite this article

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Abstract

Acute promyelocytic leukemia (APL) is characterized by t(15;17)(q22;q21), resulting in a PML-RARA fusion that is the master driver of APL. A few cases that cannot be identified with PML-RARA by using conventional methods (karyotype analysis, FISH, and RT-PCR) involve abnormal promyelocytes that are fully in accordance with APL in morphology, cytochemistry, and immunophenotype. To explore the mechanisms involved in pathogenesis and recurrence of morphologically diagnosed APL, we performed comprehensive variant analysis by next-generation sequencing in 111 pediatric patients morphologically diagnosed as APL. Structural variant (SV) analysis in 120 DNA samples from both diagnosis and relapse stage identified 95 samples with RARA rearrangement (including 94 with PML-RARA and one with NPM-RARA) and two samples with KMT2A rearrangement. In the eligible 13 RNA samples without any RARA rearrangement at diagnosis, one case each with CPSF6-RARG, NPM1-CCDC28A, and TBC1D15-RAB21 and two cases with a TBL1XR1-RARB fusion were discovered. These uncovered fusion genes strongly suggested their contributions to leukemogenesis as driver alternations and APL phenotype may arise by abnormalities of other members of the nuclear receptor superfamily involved in retinoid signaling (RARB or RARG) or even by mechanisms distinct from the formation of aberrant retinoid receptors. Single-nucleotide variant (SNV) analysis in 77 children (80 samples) with RARA rearrangement showed recurrent alternations of primary APL in FLT3, WT1, USP9X, NRAS, and ARID1A, with a strong potential for involvement in pathogenesis, and WT1 as the only recurrently mutated gene in relapsed APL. WT1, NPM1, NRAS, FLT3, and NSD1 were identified as recurrently mutated in 17 primary samples without RARA rearrangement and WT1, NPM1, TP53, and RARA as recurrently mutated in 9 relapsed samples. The survival of APL with RARA rearrangement is much better than without RARA rearrangement. Thus, patients morphologically diagnosed as APL that cannot be identified as having a RARA rearrangement are more reasonably classified as a subclass of AML other than APL, and individualized treatment should be considered according to the genetic abnormalities.

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Data availability

The authors declare that all the data supporting the findings of this study are available within the paper and its Supplementary Information files.

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Acknowledgements

This study was supported by grants from National Natural Science Foundation of China (No. 81670136) and the National Key Research and Development Program of China (No. 2016YFC0902803).

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  1. These authors contributed equally: Jie Zhao, Jian-Wei Liang

Authors and Affiliations

  1. Key Laboratory of Pediatric Hematology and Oncology Ministry of Health, Department of Hematology and Oncology, Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Jie Zhao, Jian-Wei Liang, Hui-Liang Xue, Shu-Hong Shen, Jing Chen, Yan-Jing Tang, Li-Sha Yu, Huan-Huan Liang, Long-Jun Gu, Jing-Yan Tang & Ben-Shang Li

  2. Pediatric Translational Medicine Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China

    Ben-Shang Li

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Contributions

Ben-Shang Li and Jing-Yan Tang designed the research. Jie Zhao performed the experiments. Ben-Shang Li, Jian-Wei Liang, and Jie Zhao performed bioinformatics analyses of the sequencing data. Jie Zhao wrote the manuscript and analyzed the data. Jie Zhao, Hui-Liang Xue, Shu-Hong Shen, Jing Chen, Yan-Jing Tang, Li-Sha Yu, Huan-Huan Liang, and Long-Jun Gu collected the clinical information and samples.

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Correspondence to Jing-Yan Tang or Ben-Shang Li.

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Zhao, J., Liang, JW., Xue, HL. et al. The genetics and clinical characteristics of children morphologically diagnosed as acute promyelocytic leukemia. Leukemia 33, 1387–1399 (2019). https://doi.org/10.1038/s41375-018-0338-z

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