Two Distinct Mechanisms Contribute to Granulomonocytic Hyperplasia in Chronic Myelomonocytic Leukemias (CMML)

The granulomonocytic (GM) hyperplasia of CMML has been attributed to GM-CSF hypersensitivity triggered by mutations in the CBL/RAS pathway according to the prevailing model in juvenile myelomonocytic leukemias (Kotecha Cancer Cell 2008). Recurrent mutations affecting epigenetic (eg TET2 and ASXL1) and splicing (eg SRSF2) machineries, or cytokine signaling (N/KRAS, CBL, JAK2) are present in most CMML cases, but none is specific of CMML. In 224 CMML patients (pts), we found TET2 (58%), SRSF2 (47%) and ASXL1 (38%) to be the most frequently mutated genes; only 66 (35%) cases had mutations in cytokine signaling genes (CBL, N/KRAS, JAK2, FLT3, KIT) (abstract submitted). We analyzed the differentiation of CD34⁺populations from genetically annotated CMML pts to address the mechanisms of GM hyperplasia in CMML.

CD34⁺ populations (hematopoietic stem cells [HSC]; multipotent [MPP]; common myeloid [CMP] and granulomonocytic progenitors [GMP] defined by the CD34/CD38/CD90/CD123/CD45RA panel; Majeti Cell Stem Cell 2007) from 28 genetically annotated CMML and TET2 mutated MPN (n=8) or MDS (n=5) cases were cloned and genotyped for each mutation identified in mature CD14⁺ cells, and differentiated in vitro.

Early clonal dominance, with at least one mutation in > 75% of HSC/MPP clones, was found in all cases. In 18/19 pts with ≥2 mutations, a linear succession of mutations was found, with signaling mutations often following TET2 or ASXL1 mutations. Contrasting with the dominance of first events in HSC/MPP, second events reached clonal dominance in GMP, suggesting that they provide a selective advantage during the early steps of myeloid differentiation.

We next analyzed the clonogenicity of peripheral blood (PB) CD34⁺ cells in the presence of GM-CSF (10 ng/mL) in 20 CMML cases and 4 controls. GM-CSF hypersensitivity (clonogenicity > mean+2SD of controls) was found in 7 (35%) cases. A mutation in a signaling gene was found in 6/7 pts (1 homozygous JAK2, 1 homozygous CBL, 4 heterozygous N/KRAS mutations), compared to 3/13 in pts without GM-CSF hypersensitivity (2 JAK2, 1 CBL, all heterozygous; P=.02) Median WBC was 29.2 and 11.4 G/L in pts with and without GM-CSF hypersensitivity, respectively (P=.08). The proportion of GMP in bone marrow (BM) CD34⁺cells was not significantly different in 33 CMML pts compared to 15 age-matched controls. Clonogenicity of GMP was similar in CMML and controls, except for a trend toward increased clonogenicity in pts with mutations in signaling genes.

In contrast, the proportion of MPP and CMP was higher in CMML than in controls (P<.01 and P <.05, resp.). In erythromyeloid conditions (SCF, IL-3, G-CSF & EPO), both CMP and to a lesser extent MPP had an increased ability to form GM colonies at the expense of erythroid colonies (P <.001 and P<.01, resp.). Compared to healthy CMP, CMML CMP had and increased ability to mature into GMP in short-term culture, and increased PU.1 mRNA expression (P<.05), without significant changes in the levels of GATA1, CEBPA and CEBPB. Finally, in 16 pts, the proportion of GM colonies differentiating from CMP at the expense of erythroid colonies was inversely correlated to patient hemoglobin level (P=.002). Thus, premature GM differentiation of CMP, and to a lesser extent MPP, appears as the dominant mechanism of GM hyperplasia in CMML, whereas GM-CSF hypersensitivity and GMP expansion contribute only in the minority of patients with mutations in signaling genes.

We next explored a possible link between early clonal dominance of TET2 mutations and premature GM differentiation. In TET2 mutated MPN (n=8) or MDS (n=5), the PB monocyte count was significantly correlated to the size of the TET2-mutated clone in the CD34⁺/CD38⁻ (P=.006) rather than in the CD34⁺/CD38⁺ population (P=.08). Finally, functional invalidation by shRNA of TET2 in CD34⁺/CD38⁻ followed by culture in the presence of SCF, IL-3, G-CSF & EPO caused a GM expansion that was not observed in CD34⁺/CD38⁺ cells. Similar analyses are underway for ASXL1.

Our results suggest that early clonal dominance of mutations affecting the epigenetic machinery leading to premature GM differentiation of multipotent progenitors, rather than GM-CSF hypersensitivity, is the main mechanism of GM hyperplasia in CMML. This suggests a model whereby a single mutation can lead to different phenotypes, depending on the stage of differentiation at which the mutation has gained clonal dominance.

No relevant conflicts of interest to declare.