Advertisement

Emergence of clonal hematopoiesis in the majority of patients with acquired aplastic anemia

  • Daria V. Babushok
    Correspondence
    Corresponding author.
    Affiliations
    Division of Hematology-Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA

    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Nieves Perdigones
    Affiliations
    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Juan C. Perin
    Affiliations
    Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Timothy S. Olson
    Affiliations
    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Wenda Ye
    Affiliations
    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Jacquelyn J. Roth
    Affiliations
    Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA

    Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Curt Lind
    Affiliations
    Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA

    Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Carine Cattier
    Affiliations
    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Yimei Li
    Affiliations
    Department of Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Helge Hartung
    Affiliations
    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Michele E. Paessler
    Affiliations
    Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Dale M. Frank
    Affiliations
    Department of Pathology and Laboratory Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Hongbo M. Xie
    Affiliations
    Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Shanna Cross
    Affiliations
    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Joshua D. Cockroft
    Affiliations
    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Gregory M. Podsakoff
    Affiliations
    Center for Cellular and Molecular Therapeutics, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Dimitrios Monos
    Affiliations
    Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA

    Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Jaclyn A. Biegel
    Affiliations
    Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA

    Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Philip J. Mason
    Affiliations
    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
  • Monica Bessler
    Affiliations
    Division of Hematology-Oncology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA

    Comprehensive Bone Marrow Failure Center, Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
    Search for articles by this author
      Acquired aplastic anemia (aAA) is a nonmalignant disease caused by autoimmune destruction of early hematopoietic cells. Clonal hematopoiesis is a late complication, seen in 20–25% of older patients. We hypothesized that clonal hematopoiesis in aAA is a more general phenomenon, which can arise early in disease, even in younger patients. To evaluate clonal hematopoiesis in aAA, we used comparative whole exome sequencing of paired bone marrow and skin samples in 22 patients. We found somatic mutations in 16 patients (72.7%) with a median disease duration of 1 year; of these, 12 (66.7%) were patients with pediatric-onset aAA. Fifty-eight mutations in 51 unique genes were found primarily in pathways of immunity and transcriptional regulation. Most frequently mutated was PIGA, with seven mutations. Only two mutations were in genes recurrently mutated in myelodysplastic syndrome. Two patients had oligoclonal loss of the HLA alleles, linking immune escape to clone emergence. Two patients had activating mutations in key signaling pathways (STAT5B (p.N642H) and CAMK2G (p.T306M)). Our results suggest that clonal hematopoiesis in aAA is common, with two mechanisms emerging—immune escape and increased proliferation. Our findings expand conceptual understanding of this nonneoplastic blood disorder. Future prospective studies of clonal hematopoiesis in aAA will be critical for understanding outcomes and for designing personalized treatment strategies.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Cancer Genetics
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Young N.S.
        • Maciejewski J.
        The pathophysiology of acquired aplastic anemia.
        N Engl J Med. 1997; 336: 1365-1372
        • Socie G.
        • Henry-Amar M.
        • Bacigalupo A.
        • et al.
        Malignant tumors occurring after treatment of aplastic anemia. European bone marrow Transplantation-severe aplastic anaemia working Party.
        N Engl J Med. 1993; 329: 1152115-1152117
        • Young N.S.
        • Maciejewski J.P.
        • Sloand E.
        • et al.
        The relationship of aplastic anemia and PNH.
        Int J Hematol. 2002; 76: 168-172
        • Dunn D.E.
        • Tanawattanacharoen P.
        • Boccuni P.
        • et al.
        Paroxysmal nocturnal hemoglobinuria cells in patients with bone marrow failure syndromes.
        Ann Intern Med. 1999; 131: 401-408
        • Katagiri T.
        • Sato-Otsubo A.
        • Kashiwase K.
        • et al.
        Frequent loss of HLA alleles associated with copy number-neutral 6pLOH in acquired aplastic anemia.
        Blood. 2011; 118: 6601-6609
        • Babushok D.V.
        • Xie H.M.
        • Roth J.J.
        • et al.
        Single nucleotide polymorphism array analysis of bone marrow failure patients reveals characteristic patterns of genetic changes.
        Br J Haematol. 2014; 164: 73-82
        • Afable 2nd, M.G.
        • Wlodarski M.
        • Makishima H.
        • et al.
        SNP array-based karyotyping: differences and similarities between aplastic anemia and hypocellular myelodysplastic syndromes.
        Blood. 2011; 117: 6876-6884
        • Kulasekararaj A.G.
        • Jiang J.
        • Smith A.E.
        • et al.
        Somatic mutations identify a sub-group of aplastic anemia patients that progress to myelodysplastic syndrome.
        Blood. 2014; 124: 2698-2704
        • Lane A.A.
        • Odejide O.
        • Kopp N.
        • et al.
        Low frequency clonal mutations recoverable by deep sequencing in patients with aplastic anemia.
        Leukemia. 2013; 27: 968-971
        • Heuser M.
        • Schlarmann C.
        • Dobbernack V.
        • et al.
        Genetic characterization of acquired aplastic anemia by targeted sequencing.
        Haematologica. 2014; 99: e165-e167
        • Dumitriu B.
        • Feng X.
        • Townsley D.M.
        • et al.
        Telomere attrition and candidate gene mutations preceding monosomy 7 in aplastic anemia.
        Blood. 2015; 125: 706-709
      1. Incidence of aplastic anemia: the relevance of diagnostic criteria. By the International Agranulocytosis and Aplastic Anemia Study.
        Blood. 1987; 70: 1718-1721
        • Swerdlow S.H.
        • Campo E.
        • Harris N.L.
        • et al.
        WHO classification of tumours of haematopoietic and lymphoid tissues.
        IARC Press, Lyon, France2008
      2. American academy of pediatrics Council on child and adolescent health: age limits of pediatrics.
        Pediatrics. 1988; 81: 736
        • Koboldt D.C.
        • Zhang Q.
        • Larson D.E.
        • et al.
        VarScan 2: somatic mutation and copy number alteration discovery in cancer by exome sequencing.
        Genome Res. 2012; 22: 568-576
        • Thorvaldsdottir H.
        • Robinson J.T.
        • Mesirov J.P.
        Integrative Genomics Viewer (IGV): high-performance genomics data visualization and exploration.
        Brief Bioinformatics. 2013; 14: 178-192
        • Mardis E.R.
        • Ding L.
        • Dooling D.J.
        • et al.
        Recurring mutations found by sequencing an acute myeloid leukemia genome.
        N Engl J Med. 2009; 361: 1058-1066
        • Lind C.
        • Ferriola D.
        • Mackiewicz K.
        • et al.
        Next-generation sequencing: the solution for high-resolution, unambiguous human leukocyte antigen typing.
        Hum Immunol. 2010; 71: 1033-1042
        • Du H.Y.
        • Idol R.
        • Robledo S.
        • et al.
        Telomerase reverse transcriptase haploinsufficiency and telomere length in individuals with 5p- syndrome.
        Aging Cell. 2007; 6: 689-697
        • Luo V.
        • Lessin S.R.
        • Wilson R.B.
        • et al.
        Detection of clonal T-cell receptor gamma gene rearrangements using fluorescent-based PCR and automated high-resolution capillary electrophoresis.
        Mol Diagn. 2001; 6: 169-179
        • Wang J.
        • Duncan D.
        • Shi Z.
        • et al.
        Web-based GEne SeT AnaLysis toolkit (WebGestalt): update 2013.
        Nucleic Acids Res. 2013; 41: W77-W83
        • Benjamini Y.
        • Hochberg Y.
        Controlling the false discovery rate: a practical and powerful approach to multiple testing.
        J R Stat Soc. 1995; 57: 289-300
        • Shen W.
        • Clemente M.J.
        • Hosono N.
        • et al.
        Deep sequencing reveals stepwise mutation acquisition in paroxysmal nocturnal hemoglobinuria.
        J Clin Invest. 2014; 124: 4529-4538
        • Rajala H.L.
        • Eldfors S.
        • Kuusanmaki H.
        • et al.
        Discovery of somatic STAT5b mutations in large granular lymphocytic leukemia.
        Blood. 2013; 121: 4541-4550
        • Patton B.L.
        • Miller S.G.
        • Kennedy M.B.
        Activation of type II calcium/calmodulin-dependent protein kinase by Ca2+/calmodulin is inhibited by autophosphorylation of threonine within the calmodulin-binding domain.
        J Biol Chem. 1990; 265: 11204-11212
        • Hanson P.I.
        • Schulman H.
        Inhibitory autophosphorylation of multifunctional Ca2+/calmodulin-dependent protein kinase analyzed by site-directed mutagenesis.
        J Biol Chem. 1992; 267: 17216-17224
        • Heuser M.
        • Schlarmann C.
        • Dobbernack D.
        • et al.
        Genetic characterization of aplastic anemia patients by targeted sequencing American society of hematology.
        Blood, New Orleans, LA2013: 2470
        • Mikhailova N.
        • Sessarego M.
        • Fugazza G.
        • et al.
        Cytogenetic abnormalities in patients with severe aplastic anemia.
        Haematologica. 1996; 81: 418-422
        • Rioux J.D.
        • Goyette P.
        • Vyse T.J.
        • et al.
        Mapping of multiple susceptibility variants within the MHC region for 7 immune-mediated diseases.
        Proc Natl Acad Sci U S A. 2009; 106: 18680-18685
        • Osumi T.
        • Miharu M.
        • Saji H.
        • et al.
        Nonsense mutation in HLA-B*40:02 in a case with acquired aplastic anaemia: a possible origin of clonal escape from autoimmune insult.
        Br J Haematol. 2013; 162: 706-707
        • Bessler M.
        • Mason P.
        • Hillmen P.
        • et al.
        Somatic mutations and cellular selection in paroxysmal nocturnal haemoglobinuria.
        Lancet. 1994; 343: 951-953
      3. Betensky M, Babushok DV, Roth JJ, et al. Clonal evolution and clinical significance of copy number neutral loss of heterozygosity of chromosome arm 6p in acquired aplastic anemia. American Society of Hematology Annual Meeting. San Francisco, CA; December 6–9, Blood 124, 2014, 4387.

        • Si J.
        • Collins S.J.
        Activated Ca2+/calmodulin-dependent protein kinase IIgamma is a critical regulator of myeloid leukemia cell proliferation.
        Cancer Res. 2008; 68: 3733-3742
        • Si J.
        • Mueller L.
        • Collins S.J.
        CaMKII regulates retinoic acid receptor transcriptional activity and the differentiation of myeloid leukemia cells.
        J Clin Invest. 2007; 117: 1412-1421
        • Kubokawa M.
        • Nakamura K.
        • Komagiri Y.
        Interaction between calcineurin and Ca/calmodulin kinase-II in modulating cellular functions.
        Enzyme Res. 2011; 2011: 587359
        • Welch J.S.
        • Ley T.J.
        • Link D.C.
        • et al.
        The origin and evolution of mutations in acute myeloid leukemia.
        Cell. 2012; 150: 264-278
        • Busque L.
        • Patel J.P.
        • Figueroa M.E.
        • et al.
        Recurrent somatic TET2 mutations in normal elderly individuals with clonal hematopoiesis.
        Nat Genet. 2012; 44: 1179-1181
        • Busque L.
        • Mio R.
        • Mattioli J.
        • et al.
        Nonrandom X-inactivation patterns in normal females: lyonization ratios vary with age.
        Blood. 1996; 88: 59-65
        • Mossner M.
        • Nolte F.
        • Hutter G.
        • et al.
        Skewed X-inactivation patterns in ageing healthy and myelodysplastic haematopoiesis determined by a pyrosequencing based transcriptional clonality assay.
        J Med Genet. 2013; 50: 108-117
        • Holstege H.
        • Pfeiffer W.
        • Sie D.
        • et al.
        Somatic mutations found in the healthy blood compartment of a 115-yr-old woman demonstrate oligoclonal hematopoiesis.
        Genome Res. 2014; 24: 733-742
        • Xie M.
        • Lu C.
        • Wang J.
        • et al.
        Age-related mutations associated with clonal hematopoietic expansion and malignancies.
        Nat Med. 2014; 20: 1472-1478
        • Genovese G.
        • Kahler A.K.
        • Handsaker R.E.
        • et al.
        Clonal hematopoiesis and blood-cancer risk inferred from blood DNA sequence.
        N Engl J Med. 2014; 371: 2477-2487
        • Jaiswal S.
        • Fontanillas P.
        • Flannick J.
        • et al.
        Age-related clonal hematopoiesis associated with adverse outcomes.
        N Engl J Med. 2014; 371: 2488-2498