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CHRONIC MYELOPROLIFERATIVE NEOPLASMS

Phenotypic characterization of leukemia-initiating stem cells in chronic myelomonocytic leukemia

Leukemia volume 35, pages 3176–3187 (2021)Cite this article

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Abstract

Chronic myelomonocytic leukemia (CMML) is a stem cell-derived neoplasm characterized by dysplasia, uncontrolled expansion of monocytes, and substantial risk to transform to secondary acute myeloid leukemia (sAML). So far, little is known about CMML-initiating cells. We found that leukemic stem cells (LSC) in CMML reside in a CD34+/CD38− fraction of the malignant clone. Whereas CD34+/CD38− cells engrafted NSGS mice with overt CMML, no CMML was produced by CD34+/CD38+ progenitors or the bulk of CD34− monocytes. CMML LSC invariably expressed CD33, CD117, CD123 and CD133. In a subset of patients, CMML LSC also displayed CD52, IL-1RAP and/or CLL-1. CMML LSC did not express CD25 or CD26. However, in sAML following CMML, the LSC also expressed CD25 and high levels of CD114, CD123 and IL-1RAP. No correlations between LSC phenotypes, CMML-variant, mutation-profiles, or clinical course were identified. Pre-incubation of CMML LSC with gemtuzumab-ozogamicin or venetoclax resulted in decreased growth and impaired engraftment in NSGS mice. Together, CMML LSC are CD34+/CD38− cells that express a distinct profile of surface markers and target-antigens. During progression to sAML, LSC acquire or upregulate certain cytokine receptors, including CD25, CD114 and CD123. Characterization of CMML LSC should facilitate their enrichment and the development of LSC-eradicating therapies.

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Fig. 1: CD34+ cells from CMML or sAML donors engraft in NSGS mice.
Fig. 2: Differential engraftment of CD38+ cells in CMML and sAML.
Fig. 3: Expression of selected markers on the surface of CMML- and sAML-LSC.
Fig. 4: Upregulation of cell surface markers on LSC during progression to sAML.
Fig. 5: Effect of GO and venetoclax on CMML LSC proliferation and engraftment.

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References

  1. Storniolo AM, Moloney WC, Rosenthal DS, Cox C, Bennett JM. Chronic myelomonocytic leukemia. Leukemia. 1990;4:766–70.

    CAS  PubMed  Google Scholar 

  2. Bennett JM, Catovsky D, Daniel MT, Flandrin G, Galton DA, Gralnick HR, et al. Proposals for the classification of the myelodysplastic syndromes. Br J Haematol. 1982;51:189–99.

    Article  CAS  PubMed  Google Scholar 

  3. Bennett JM, Catovsky D, Daniel MT, Flandrin G, Galton DA, Gralnick H, et al. The chronic myeloid leukaemias: guidelines for distinguishing chronic granulocytic, atypical chronic myeloid, and chronic myelomonocytic leukaemia. Proposals by the French–American–British cooperative leukaemia group. Br J Haematol. 1994;87:746–54.

    Article  CAS  PubMed  Google Scholar 

  4. Patnaik MM, Parikh SA, Hanson CA, Tefferi A. Chronic myelomonocytic leukaemia: a concise clinical and pathophysiological review. Br J Haematol. 2014;165:273–86.

    Article  PubMed  Google Scholar 

  5. McCullough KB, Patnaik MM. Chronic myelomonocytic leukemia: a genetic and clinical Update. Curr Hematol Malig Rep. 2015;10:292–302.

    Article  PubMed  Google Scholar 

  6. Arber DA, Orazi A, Hasserjian R, Thiele J, Borowitz MJ, Beau MML, et al. The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood. 2016;127:2391–405.

    Article  CAS  PubMed  Google Scholar 

  7. Orazi A, Bennett JM, Germing U, Brunning RD, Bain BJ, Cazzola M et al. Chronic myelomonocytic leukaemia. In: WHO classification of tumours of haematopoietic and lymphoid tissues. IARC Press, 2017, pp 82–86.

  8. Kohlmann A, Grossmann V, Klein H-U, Schindela S, Weiss T, Kazak B, et al. Next-generation sequencing technology reveals a characteristic pattern of molecular mutations in 72.8% of chronic myelomonocytic leukemia by detecting frequent alterations in TET2, CBL, RAS, and RUNX1. J Clin Oncol. 2010;28:3858–65.

    Article  CAS  PubMed  Google Scholar 

  9. Itzykson R, Duchmann M, Lucas N, Solary E. CMML: clinical and molecular aspects. Int J Hematol. 2017;105:711–9.

    Article  PubMed  Google Scholar 

  10. Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2020 update on diagnosis, risk stratification and management. Am J Hematol. 2020;95:97–115.

    Article  CAS  PubMed  Google Scholar 

  11. Pich A, Riera L, Sismondi F, Godio L, Davico Bonino L, Marmont F, et al. JAK2V617F activating mutation is associated with the myeloproliferative type of chronic myelomonocytic leukaemia. J Clin Pathol. 2009;62:798–801.

    Article  CAS  PubMed  Google Scholar 

  12. Gur HD, Loghavi S, Garcia-Manero G, Routbort M, Kanagal-Shamanna R, Quesada A, et al. Chronic myelomonocytic leukemia with fibrosis is a distinct disease subset with myeloproliferative features and frequent JAK2 p.V617F mutations. Am J Surg Pathol. 2018;42:799–806.

    Article  PubMed  Google Scholar 

  13. Sperr WR, Horny H-P, Valent P. Spectrum of associated clonal hematologic non-mast cell lineage disorders occurring in patients with systemic mastocytosis. Int Arch Allergy Immunol. 2002;127:140–2.

    Article  CAS  PubMed  Google Scholar 

  14. Sotlar K, Fridrich C, Mall A, Jaussi R, Bültmann B, Valent P, et al. Detection of c-kit point mutation Asp-816 –> Val in microdissected pooled single mast cells and leukemic cells in a patient with systemic mastocytosis and concomitant chronic myelomonocytic leukemia. Leuk Res. 2002;26:979–84.

    Article  CAS  PubMed  Google Scholar 

  15. Valent P, Orazi A, Savona MR, Patnaik MM, Onida F, van de Loosdrecht AA, et al. Proposed diagnostic criteria for classical chronic myelomonocytic leukemia (CMML), CMML variants and pre-CMML conditions. Haematologica. 2019;104:1935–49.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  16. Patnaik MM, Vallapureddy R, Lasho TL, Hoversten KP, Finke CM, Ketterling RP, et al. A comparison of clinical and molecular characteristics of patients with systemic mastocytosis with chronic myelomonocytic leukemia to CMML alone. Leukemia. 2018;32:1850–6.

    Article  PubMed  Google Scholar 

  17. Itzykson R, Kosmider O, Renneville A, Gelsi-Boyer V, Meggendorfer M, Morabito M, et al. Prognostic score including gene mutations in chronic myelomonocytic leukemia. J Clin Oncol. 2013;31:2428–36.

    Article  CAS  PubMed  Google Scholar 

  18. Elena C, Gallì A, Such E, Meggendorfer M, Germing U, Rizzo E, et al. Integrating clinical features and genetic lesions in the risk assessment of patients with chronic myelomonocytic leukemia. Blood. 2016;128:1408–17.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Palomo L, Garcia O, Arnan M, Xicoy B, Fuster F, Cabezón M, et al. Targeted deep sequencing improves outcome stratification in chronic myelomonocytic leukemia with low risk cytogenetic features. Oncotarget. 2016;7:57021–35.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Itzykson R, Fenaux P, Bowen D, Cross NCP, Cortes J, De Witte T, et al. Diagnosis and treatment of chronic myelomonocytic leukemias in adults: recommendations from the European hematology association and the European leukemiaNet. Hemasphere. 2018;2:e150.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Kröger N, Zabelina T, Guardiola P, Runde V, Sierra J, Van Biezen A, et al. Allogeneic stem cell transplantation of adult chronic myelomonocytic leukaemia. A report on behalf of the chronic leukaemia working party of the european group for blood and marrow transplantation (EBMT). Br J Haematol. 2002;118:67–73.

    Article  PubMed  Google Scholar 

  22. de Witte T, Bowen D, Robin M, Malcovati L, Niederwieser D, Yakoub-Agha I, et al. Allogeneic hematopoietic stem cell transplantation for MDS and CMML: recommendations from an international expert panel. Blood. 2017;129:1753–62.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  23. Dick JE, Lapidot T, Pflumio F. Transplantation of normal and leukemic human bone marrow into immune-deficient mice: development of animal models for human hematopoiesis. Immunol Rev. 1991;124:25–43.

    Article  CAS  PubMed  Google Scholar 

  24. Lapidot T, Sirard C, Vormoor J, Murdoch B, Hoang T, Caceres-Cortes J, et al. A cell initiating human acute myeloid leukaemia after transplantation into SCID mice. Nature. 1994;367:645–8.

    Article  CAS  PubMed  Google Scholar 

  25. Bonnet D, Dick JE. Human acute myeloid leukemia is organized as a hierarchy that originates from a primitive hematopoietic cell. Nat Med. 1997;3:730–7.

    Article  CAS  PubMed  Google Scholar 

  26. Eisterer W, Jiang X, Christ O, Glimm H, Lee KH, Pang E, et al. Different subsets of primary chronic myeloid leukemia stem cells engraft immunodeficient mice and produce a model of the human disease. Leukemia. 2005;19:435–41.

    Article  CAS  PubMed  Google Scholar 

  27. Kavalerchik E, Goff D, Jamieson CHM. Chronic myeloid leukemia stem cells. J Clin Oncol. 2008;26:2911–5.

    Article  PubMed  Google Scholar 

  28. Krause DS, Van Etten RA. Right on target: eradicating leukemic stem cells. Trends Mol Med. 2007;13:470–81.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  29. Misaghian N, Ligresti G, Steelman LS, Bertrand FE, Bäsecke J, Libra M, et al. Targeting the leukemic stem cell: the Holy Grail of leukemia therapy. Leukemia. 2009;23:25–42.

    Article  CAS  PubMed  Google Scholar 

  30. Copland M. Chronic myelogenous leukemia stem cells: what’s new? Curr Hematol Malig Rep. 2009;4:66–73.

    Article  PubMed  Google Scholar 

  31. Valent P. Targeting of leukemia-initiating cells to develop curative drug therapies: straightforward but nontrivial concept. Curr Cancer Drug Targets. 2011;11:56–71.

    Article  CAS  PubMed  Google Scholar 

  32. Taussig DC, Miraki-Moud F, Anjos-Afonso F, Pearce DJ, Allen K, Ridler C, et al. Anti-CD38 antibody-mediated clearance of human repopulating cells masks the heterogeneity of leukemia-initiating cells. Blood. 2008;112:568–75.

    Article  CAS  PubMed  Google Scholar 

  33. Jamieson CHM, Ailles LE, Dylla SJ, Muijtjens M, Jones C, Zehnder JL, et al. Granulocyte-macrophage progenitors as candidate leukemic stem cells in blast-crisis CML. N Engl J Med. 2004;351:657–67.

    Article  CAS  PubMed  Google Scholar 

  34. Järås M, Johnels P, Hansen N, Agerstam H, Tsapogas P, Rissler M, et al. Isolation and killing of candidate chronic myeloid leukemia stem cells by antibody targeting of IL-1 receptor accessory protein. Proc Natl Acad Sci USA. 2010;107:16280–5.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Herrmann H, Sadovnik I, Cerny-Reiterer S, Rülicke T, Stefanzl G, Willmann M, et al. Dipeptidylpeptidase IV (CD26) defines leukemic stem cells (LSC) in chronic myeloid leukemia. Blood. 2014;123:3951–62.

    Article  CAS  PubMed  Google Scholar 

  36. Saito Y, Kitamura H, Hijikata A, Tomizawa-Murasawa M, Tanaka S, Takagi S, et al. Identification of therapeutic targets for quiescent, chemotherapy-resistant human leukemia stem cells. Sci Transl Med. 2010;2:17ra9–17ra9.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  37. Hosen N, Park CY, Tatsumi N, Oji Y, Sugiyama H, Gramatzki M, et al. CD96 is a leukemic stem cell-specific marker in human acute myeloid leukemia. Proc Natl Acad Sci USA. 2007;104:11008–13.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. van Rhenen A, van Dongen GAMS, Kelder A, Rombouts EJ, Feller N, Moshaver B, et al. The novel AML stem cell associated antigen CLL-1 aids in discrimination between normal and leukemic stem cells. Blood. 2007;110:2659–66.

    Article  PubMed  CAS  Google Scholar 

  39. Majeti R, Chao MP, Alizadeh AA, Pang WW, Jaiswal S, Gibbs KD, et al. CD47 is an adverse prognostic factor and therapeutic antibody target on human acute myeloid leukemia stem cells. Cell. 2009;138:286–99.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  40. Zhang Y, He L, Selimoglu-Buet D, Jego C, Morabito M, Willekens C, et al. Engraftment of chronic myelomonocytic leukemia cells in immunocompromised mice supports disease dependency on cytokines. Blood Adv. 2017;1:972–9.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Yoshimi A, Balasis ME, Vedder A, Feldman K, Ma Y, Zhang H, et al. Robust patient-derived xenografts of MDS/MPN overlap syndromes capture the unique characteristics of CMML and JMML. Blood. 2017;130:397–407.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Ramshaw HS, Bardy PG, Lee MA, Lopez AF. Chronic myelomonocytic leukemia requires granulocyte-macrophage colony-stimulating factor for growth in vitro and in vivo. Exp Hematol. 2002;30:1124–31.

    Article  CAS  PubMed  Google Scholar 

  43. Rongvaux A, Willinger T, Martinek J, Strowig T, Gearty SV, Teichmann LL, et al. Development and function of human innate immune cells in a humanized mouse model. Nat Biotechnol. 2014;32:364–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  44. Valent P, Schmidt G, Besemer J, Mayer P, Zenke G, Liehl E, et al. Interleukin-3 is a differentiation factor for human basophils. Blood. 1989;73:1763–9.

    Article  CAS  PubMed  Google Scholar 

  45. Saito H, Hatake K, Dvorak AM, Leiferman KM, Donnenberg AD, Arai N, et al. Selective differentiation and proliferation of hematopoietic cells induced by recombinant human interleukins. PNAS. 1988;85:2288–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  46. Sadovnik I, Hoelbl-Kovacic A, Herrmann H, Eisenwort G, Cerny-Reiterer S, Warsch W, et al. Identification of CD25 as STAT5-dependent growth regulator of leukemic stem cells in Ph+ CML. Clin Cancer Res. 2016;22:2051–61.

    Article  CAS  PubMed  Google Scholar 

  47. Hadzijusufovic E, Keller A, Berger D, Greiner G, Wingelhofer B, Witzeneder N, et al. STAT5 is expressed in CD34+/CD38– stem cells and serves as a potential molecular target in Ph-negative myeloproliferative neoplasms. Cancers. 2020;12:1021.

    Article  CAS  PubMed Central  Google Scholar 

  48. Wingelhofer B, Neubauer HA, Valent P, Han X, Constantinescu SN, Gunning PT, et al. Implications of STAT3 and STAT5 signaling on gene regulation and chromatin remodeling in hematopoietic cancer. Leukemia. 2018;32:1713–26.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Wingelhofer B, Maurer B, Heyes EC, Cumaraswamy AA, Berger-Becvar A, de Araujo ED, et al. Pharmacologic inhibition of STAT5 in acute myeloid leukemia. Leukemia. 2018;32:1135–46.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  50. Müller‐Thomas C, Heider M, Piontek G, Schlensog M, Bassermann F, Kirchner T, et al. Prognostic value of indoleamine 2,3 dioxygenase in patients with higher‐risk myelodysplastic syndromes treated with azacytidine. Br J Haematol. 2020;190:361–70.

    Article  PubMed  CAS  Google Scholar 

  51. Mangaonkar AA, Reichard KK, Binder M, Coltro G, Lasho TL, Carr RM, et al. Bone marrow dendritic cell aggregates associate with systemic immune dysregulation in chronic myelomonocytic leukemia. Blood Adv. 2020;4:5425–30.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  52. Lou Y, Shao L, Mao L, Lu Y, Ma Y, Fan C, et al. Efficacy and predictive factors of venetoclax combined with azacitidine as salvage therapy in advanced acute myeloid leukemia patients: a multicenter retrospective study. Leuk Res. 2020;91:106317.

    Article  CAS  PubMed  Google Scholar 

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Acknowledgements

We like to thank Christiana Winding, Tina Bernthaler, and Siegfried Kosik for skillful technical assistance. This study was supported by the Austrian Science Fund (FWF), grants F4704-B20, P30625-B28, and a Research Grant of the Medical University of Vienna, Austria. Cell sorting experiments were performed with support from the Core Facility Flow Cytometry, Medical University of Vienna.

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  1. These authors contributed equally: Gregor Eisenwort, Irina Sadovnik.

Authors and Affiliations

  1. Department of Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Vienna, Austria

    Gregor Eisenwort, Irina Sadovnik, Alexandra Keller, Daniel Ivanov, Barbara Peter, Daniela Berger, Gabriele Stefanzl, Karin Bauer, Karoline V. Gleixner, Wolfgang R. Sperr & Peter Valent

  2. Ludwig Boltzmann Institute for Hematology and Oncology, Medical University of Vienna, Vienna, Austria

    Gregor Eisenwort, Irina Sadovnik, Barbara Peter, Daniela Berger, Gabriele Stefanzl, Karin Bauer, Katharina Slavnitsch, Georg Greiner, Karoline V. Gleixner, Wolfgang R. Sperr, Michael Willmann, Thomas Rülicke & Peter Valent

  3. Institute of Laboratory Animal Science, University of Veterinary Medicine Vienna, Vienna, Austria

    Katharina Slavnitsch & Thomas Rülicke

  4. Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria

    Georg Greiner

  5. Ihr Labor, Medical Diagnostic Laboratories, Vienna, Austria

    Georg Greiner

  6. Department for Companion Animals and Horses, Clinic for Internal Medicine, University of Veterinary Medicine Vienna, Vienna, Austria

    Michael Willmann

  7. Department of Internal Medicine, Division of Hematology, Medical University of Graz, Graz, Austria

    Heinz Sill

  8. Elisabethinen Hospital Linz, Linz, Austria

    Peter Bettelheim

  9. Medical School, Sigmund Freud University, Vienna, Austria

    Klaus Geissler

  10. Division of Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA

    Michael Deininger

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  1. Gregor Eisenwort
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Contributions

GE, IS, and PV designed the study, analyzed the data and wrote the manuscript. GE, BP, IS, AK, DI, KB, DB, and GS performed key laboratory experiments. PB, HS, KG, KVG, WRS, and MD provided patients’ samples and clinical information. GG performed and analyzed molecular studies. MW, KS and TR performed animal experiments. All authors wrote parts of the manuscript, corrected the draft version of the manuscript and approved the final version of the document.

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Correspondence to Peter Valent.

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Conflict of interest

PV received honoraria from Pfizer. HS received honoraria from Pfizer and AbbVie. MD received honoraria from Pfizer and Incyte. The other authors declare no conflict of interest.

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Eisenwort, G., Sadovnik, I., Keller, A. et al. Phenotypic characterization of leukemia-initiating stem cells in chronic myelomonocytic leukemia. Leukemia 35, 3176–3187 (2021). https://doi.org/10.1038/s41375-021-01227-z

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