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ASXL1 but Not TET2 Mutations Adversely Impact Overall Survival of Patients Suffering Systemic Mastocytosis with Associated Clonal Hematologic Non-Mast-Cell Diseases

  • Gandhi Damaj ,

    damaj.gandhi@chu-amiens.fr

    Affiliations Service d'Hématologie, Centre Hospitalier Universitaire, Hôpital Sud; Amiens, France, Centre de Référence des Mastocytoses, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France, CNRS UMR 8147 and Institut Imagine, AP-HP, Hôpital Necker-Enfants Malades, Paris, France

  • Magalie Joris,

    Affiliation Service d'Hématologie, Centre Hospitalier Universitaire, Hôpital Sud; Amiens, France

  • Olivia Chandesris,

    Affiliations Centre de Référence des Mastocytoses, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France, Service d'Hématologie Adulte, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France

  • Katia Hanssens,

    Affiliation Inserm, U1068, CRCM, (Signaling, Hematopoiesis and Mechanism of Oncogenesis); Institut Paoli-Calmettes,Marseille; Aix-Marseille Univ; CNRS, UMR7258, Marseille, France

  • Erinn Soucie,

    Affiliation Inserm, U1068, CRCM, (Signaling, Hematopoiesis and Mechanism of Oncogenesis); Institut Paoli-Calmettes,Marseille; Aix-Marseille Univ; CNRS, UMR7258, Marseille, France

  • Danielle Canioni,

    Affiliation Service d'Anatomo-pathologie, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France

  • Brigitte Kolb,

    Affiliation Service d'Hématologie, Centre Hospitalier Universitaire, Reims, France

  • Isabelle Durieu,

    Affiliation Service de médecine interne, Groupe Hospitalier Sud. Hospices Civils, Lyon, France

  • Emanuel Gyan,

    Affiliation Service d'Hématologie et thérapie cellulaire, CIC INSERMU202, Centre Hospitalier Universitaire, Tours, France

  • Cristina Livideanu,

    Affiliation Département de Dermatologie, Centre Hospitalier Universitaire, Toulouse, France

  • Stephane Chèze,

    Affiliation Service d'Hématologie, Centre Hospitalier Universitaire, Caen, France

  • Momar Diouf,

    Affiliation Département de bio-statistiques et de Recherche clinique, Centre Hospitalier Universitaire, Amiens, France

  • Reda Garidi,

    Affiliation Service d'Hématologie, Centre Hospitalier, St Quentin, France

  • Sophie Georgin-Lavialle,

    Affiliation Service de Médecine Interne, Hôpital Tenon, Assistance Publique-Hôpitaux, Université Pierre et Marie Curie, Paris, France

  • Vahid Asnafi,

    Affiliation Laboratoire d'hématologie Biologique et UMR CNRS 8147, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et Assistance Publique-Hôpitaux de Paris (AP-HP) Necker-Enfants Malades, Paris, France

  • Ludovic Lhermitte,

    Affiliation Laboratoire d'hématologie Biologique et UMR CNRS 8147, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et Assistance Publique-Hôpitaux de Paris (AP-HP) Necker-Enfants Malades, Paris, France

  • Christian Lavigne,

    Affiliation Service d'Hématologie, Centre Hospitalier Universitaire, Angers, France

  • David Launay,

    Affiliation Service de Médecine Interne, CHRU, Lille, France

  • Michel Arock,

    Affiliations CNRS UMR 8113, Laboratoire de Biologie et Pharmacologie Appliquée, Ecole Normale Supérieure, Cachan, France, Laboratoire Central d'Hématologie, Groupe Hospitalier Pitié-Salpetrière, Paris, France

  • Olivier Lortholary,

    Affiliation Service de Médecine Interne et de Maladie Infectieuses, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France

  • Patrice Dubreuil ,

    Contributed equally to this work with: Patrice Dubreuil, Olivier Hermine

    Affiliation Inserm, U1068, CRCM, (Signaling, Hematopoiesis and Mechanism of Oncogenesis); Institut Paoli-Calmettes,Marseille; Aix-Marseille Univ; CNRS, UMR7258, Marseille, France

  •  [ ... ],
  • Olivier Hermine

    Contributed equally to this work with: Patrice Dubreuil, Olivier Hermine

    Affiliations Centre de Référence des Mastocytoses, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France, CNRS UMR 8147 and Institut Imagine, AP-HP, Hôpital Necker-Enfants Malades, Paris, France, Service d'Hématologie Adulte, Université Paris Descartes, Paris Sorbonne Cité, Faculté de Médecine et AP-HP Necker-Enfants Malades, Paris, France

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ASXL1 but Not TET2 Mutations Adversely Impact Overall Survival of Patients Suffering Systemic Mastocytosis with Associated Clonal Hematologic Non-Mast-Cell Diseases

  • Gandhi Damaj, 
  • Magalie Joris, 
  • Olivia Chandesris, 
  • Katia Hanssens, 
  • Erinn Soucie, 
  • Danielle Canioni, 
  • Brigitte Kolb, 
  • Isabelle Durieu, 
  • Emanuel Gyan, 
  • Cristina Livideanu
PLOS
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Abstract

Systemic mastocytosis with associated hematologic clonal non-mast cell disease (SM-AHNMD) is a rare and heterogeneous subtype of SM and few studies on this specific entity have been reported. Sixty two patients with Systemic mastocytosis with associated hematologic clonal non-mast cell disease (SM-AHNMD) were presented. Myeloid AHNMD was the most frequent (82%) cases. This subset of patients were older, had more cutaneous lesions, splenomegaly, liver enlargement, ascites; lower bone mineral density and hemoglobin levels and higher tryptase level than lymphoid AHNMD. Defects in KIT, TET2, ASXL1 and CBL were positive in 87%, 27%, 14%, and 11% of cases respectively. The overall survival of patients with SM-AHNMD was 85.2 months. Within the myeloid group, SM-MPN fared better than SM-MDS or SM-AML (p = 0.044,). In univariate analysis, the presence of C-findings, the AHNMD subtypes (SM-MDS/CMML/AML versus SM-MPN/hypereosinophilia) (p = 0.044), Neutropenia (p = 0.015), high monocyte level (p = 0.015) and the presence of ASXL1 mutation had detrimental effects on OS (p = 0.007). In multivariate analysis and penalized Cox model, only the presence of ASXL1 mutation remained an independent prognostic factor that negatively affected OS (p = 0.035). SM-AHNMD is heterogeneous with variable prognosis according to the type of the AHNMD. ASXL1 is mutated in a subset of myeloid AHNMD and adversely impact on OS.

Introduction

Mastocytosis is a heterogeneous group of disorders characterized by abnormal growth and accumulation of mast cells (MCs) in one or more organ systems. Indolent forms of mastocytosis are the most frequent followed by systemic mastocytosis (SM) with associated clonal hematologic non-MC lineage disease (SM-AHNMD) which constitutes a sub-category of aggressive SM [1][3].

Although most of these patients display KIT mutations, little is known about the clinical and prognostic relevance of other gene defects in SM-AHNMD. Only studies with a small number of SM cases, including few cases of SM-AHNMD, have been reported in 23 and 8 patients respectively [4], [5]. The overall prognosis for this disease is poor as compared to indolent SM patients. Furthermore, the subtype of the AHNMD has a prognostic value [6]. For example, patients with associated AML or MDS have a worse prognosis compared to patients with SM-MPN [6]. Nevertheless, some SM-AHNMD patients have a chronic course that seems to embrace the course of the associated hematologic disease.

The prognostic value of gene mutations has not been evaluated in large studies. In one study, reporting on 42 patients with SM, TET2 mutations were not found to alter the prognosis of the disease [4], whereas two other studies showed that the presence of TET2 mutations conferred a poor prognosis to patients with aggressive SM [5], [7].

In the present study, we report on 62 patients with SM-AHNMD with the following aims: 1/ To describe the clinical and laboratory characteristics of myeloid and lymphoid AHNMD patients; 2/ To evaluate the occurrence of genetic mutations such as KIT D816V and JAK2 V617F as well as TET-2, ASXL1, and CBL; 3/ To evaluate a possible impact of these genetic mutations on the clinical and laboratory characteristics of SM-AHNMD patients as well as on their prognosis.

Patients and Methods

This retrospective study was approved by the Institutional Review Board of Necker Enfants-Malades Hospital, and was carried out according to the Helsinki Declaration. Written Informed consent was obtained from adult patients or parents or next of kin for teenage patients at the first or second hematology clinic appointment. Patients aged 16 years or more, diagnosed with SM-AHNMD according to the WHO criteria [1] for mastocytosis and other hematologic neoplasms were eligible. Mutations analyses were centrally performed for all patients (KH, ES, PD). Mutations analyses were done on bone marrow samples and/or skin biopsy as previously described using a highly sensitive technique for KIT D816V [8], JAK-2 [9] and TET-2 [10]. ASLX1 mutations status was detected in blood and/or marrow as already described [11].

Overall survival (OS) was defined as the time between diagnosis of AHNMD and the date of death or last follow-up. Survival distributions were estimated using the Kaplan-Meier method. Univariate and multivariate Cox proportional hazards model were used to assess prognostic factors of OS and to compute hazard ratios (HRs) and their 95% confidence interval (95% CI). Variables tested in the univariate model were those listed in table 1. Variables eligible for the multivariate Cox model were those having a p-value<0.15 in univariate Cox model because most of the variables significant at 10% other than ASXL1 were highly correlated with each other; thus limiting multicollinearity in the multivariate model. Proportional hazard assumption was tested using Schoenfeld residuals test. P values were two sided and values <0.05 were considered significant. Due to the low proportion of event in our study, a complementary analysis using a penalized ridge Cox model [12] was applied with a shrinkage parameter equal to 3. The SAS software version 9.2® (SAS Institute, Cary, NC) was used for all analysis.

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Table 1. Demographic, clinical and biological characteristics of patients with myeloid and lymphoid SM-AHNMD patients at inclusion.

https://doi.org/10.1371/journal.pone.0085362.t001

Results and Discussion

Sixty-two SM-AHNMD patients were analyzed. Myeloid AHNMD were the most frequent type of AHNMD encountered (82% of the patients) (table S1). MDS was the leading myeloid disease (29%) of patients, followed by CMML (16%) and MPN (16%) including essential thrombocytopenia (n = 4), primary myelofibrosis (n = 2) and polycythemia (n = 1). MDS/MPNs were present in 8% along with PDGFRα negative hypereosinophilia (8%). AML was associated with true SM in only 5% of cases. Lymphoid AHNMD were rare and constituted only 17% of cases. They were represented mainly by non-Hodgkin's lymphoma (6 patients; 8%) and monoclonal gammapathy of undetermined significance (MGUS) (4 patients; 5%).

Patients' characteristics are detailed in Table 1. Briefly, patients with myeloid AHNMD were older (p = 0.032), had less cutaneous lesions (p = 0.038), splenomegaly (p = 0.003), ascites (p = 0.046) and less bone mineral density (p = 0.045). They had significantly lower hemoglobin level (p = 0.029), higher monocyte counts (p = 0.028), and tryptase (p = 0.046) and LDH (p = 0.020) levels than lymphoid AHNMD. AHNMD was diagnosed concomitantly with SM in 39(67%) patients. For the other patients, the median time from the diagnosis of SM to the diagnosis of the AHNMD was 110 (3–370) months. Of note, in one patient, the diagnosis of polycythemia vera was diagnosed 18 months before the diagnosis of SM was made.

KIT mutations were the most frequent alteration, found in 87% of the patients. TET2 mutation was positive in 12 (27%) cases, only in the myeloid AHNMD group (SM-MDS = 5, SM-CMM = 6; SM-AML = 1). TET2 positive patients tended to be older (p = 0.08), with more hepatomegaly (p = 0.03), splenomegaly (p = 0.003), ascites p = 0.04), low bone mineral density (p = 0.02). The same patients had lower hemoglobin level (p = 0.01), and had lower platelet counts (p = 0.009) than those negative for TET2 mutation (table 1). The presence of TET2 mutation correlated with the presence of KIT D816V mutations (p = 0.03) but not with that of ASXL1 mutations (p = 0.45).

Six (14%) patients (SM-MDS = 3, SM-CMML = 1, SM-AML = 1, SM-PMF = 1) were found positive for ASXL1 mutations. Patients with lymphoid AHNMD all tested negative for ASLX1. Again, ASXL1 positive patients were not different from ASXL1 negative patients regarding the main clinical and biological characteristics. CBL mutations were found positive in 3 (11%) patients (ET = 1, CMML = 1, MDS/MPN = 1) and JAK2 Val617Phe mutation in 3 (6%) patients (MDS = 1; ET = 1; PMF = 1).

For the whole group of patients, the median OS time was 85.2 months (58.8–111.7) (Figure S1A). The OS was not statistically different between the lymphoid AHNMD and the myeloid AHNMD groups (median OS: 85.2 vs 60months respectively; p = 0.928). However, within the myeloid group, SM-MPN fared better than SM-MDS or SM-AML (median OS: not reached vs 79.6 months respectively; p = 0.044,) (data not shown). While median survival time for SM-MPN/SM-hypereosinophilia was not reached, it was of 91.8 (13.2–170.4) months for SM-MDS, of 79.6 (0.1–159.5) months for SM-CMML, of 39.9 (8.5–71.4) months for SM-AML and of 60 (58.8–111.7) months for SM-lymphoproliferative diseases (Figure S1B).

In univariate analysis, the presence of C-findings as defined by the WHO criteria (cytopenia, organomegaly with organ dysfunction, malabsorption, weight loss, hypoalbuminemia) [HR = 3.12; (1.11–8.77); p = 0.030], the AHNMD subtypes (SM-MDS/CMML/AML vs SM-MPN/hypereosinophilia) (median OS: 79.66 months vs not reached; p = 0.044), Neutropenia [HR = 1.10; (1.02–1.20); p = 0.015], high monocytes level [HR = 1.31; (1.02–1.20); p = 0.015] and the presence of ASXL1 mutations [HR = 4.91; (1.53–15.71); p = 0.007] had detrimental effects on overall survival.

In multivariate analysis, as well as, after using penalized Cox regression model [12], only the presence of ASXL1 mutation remained an independent prognostic factor that negatively affected OS [HR = 5.75; 95%CI (1.09–30.25); p = 0.035] (Figure 1).

This study is, to the best of our knowledge, the second largest study which reports [6], [13][15] on SM-AHNMD. KIT, TET2, ASXL1, JAK2, and CBL were found mutated in 87%, 27%, 14%, 14%, and 11% of the patients respectively.

In this series dedicated to SM-AHNMD subtypes myeloid AHNMD was the most frequent associated disease (82%) where MDS, CMML and MPN represented 29%, 16% and 16% of AHNMD respectively. The median age at the onset of the disease was higher in the myeloid AHNMD than in the lymphoid one, and higher than the median age of mastocytosis patients without AHNMD as already reported [16].

Patients with SM-myeloid AHNMD had more splenomegaly, ascites, low bone density, lower hemoglobin and higher tryptase levels than SM-lymphoid AHNMD patients. However, there was no difference in OS between the 2 groups and this might be explained by the heterogeneity of the subcategories of AHNMD and their prognosis within the myeloid and lymphoid groups.

KIT D816V, JAK2 and C-CBL mutations were found in 85%,13% and 11.5% of the patients as already reported [5], [6].

We found TET2 mutations in 27% of SM-AHNMD patients. This frequency is higher than the incidence encountered in patients with MPN [17] and lower than previously reported in SM-AHNMD in two series of 23 and 8 patients respectively [5], [18].

TET2 mutated patients tended to be older with more C-findings than patients with wild type TET2. However, these findings did not translate into poor prognosis in contrast to the negative prognostic value in cytogenetically normal AML [19], MPNs or mastocytosis patients [20].

Recently, ASXL1 mutations have been analyzed in only 8 SM patients and found mutated in 2(25%) patients [5]. In our cohort, we found an intermediate frequency of ASXL1 mutations (14%). They are of prognostic value and shown to adversely affect the OS of patients with SM-AHNMD independently from other clinically utilized prognosticators. ASXL1 mutations retained also its independent negative impact in the group of patients with SM-MDS/AML (Figure S1C).

As such, mutations in ASXL1 appear to be novel biomarkers of adverse overall survival in patients with SM-myeloid AHNMD as it has been reported with other myeloid malignancies such as MDS, CMML and subgroups of AML [21][23].

In conclusion

ASXL1 mutations in SM-AHNMD adversely impact on OS. More studies comparing individual subcategories of SM-AHNMD to their hematological non MCs counterpart without SM are needed.

Supporting Information

Figure S1.

Overall survival (OS) of the whole group (S1A); OS according to the subtype of the AHNMD (S1B); OS of SM-MDS according to ASXL1 mutations (S1C).

https://doi.org/10.1371/journal.pone.0085362.s002

(PDF)

Acknowledgments

We would like to thank Isabelle Hirsch and Cedric Baude for technical help and data management

Author Contributions

Conceived and designed the experiments: GD OH. Analyzed the data: GD MD. Wrote the paper: GD. Approved the manuscript: GD MJ OC KH ES DC BK ID EG CL SC MD RG SGL VA LL CL DL MA OL PD OH. Enrollment of patients: GD MJ OC KH ES DC BK ID EG CL SC MD RG SGL VA LL CL DL MA OL PD OH.

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