In Acute Promyelocytic Leukemia (APL) Low BAALC Gene Expression Identifies a Group of Patients with Favorable Outcome in Overall Survival and Relapse Free Survival,

Acute promyelocytic leukemia (APL) is characterized by the translocation t(15;17) which results in the PML-RARα fusion protein. ATRA based treatment regimens lead to long term survival in approximately 75% of cases. However, relapse occurs in about 15% of APL patients. Moreover, it is not yet known which underlying pathomechanisms drive relapse of the disease. In addition, to avoid over- or undertreatment of patients, respectively, risk stratification of patients according to biological or molecular criteria would most probably improve current treatment modalities. As opposed to other leukemias, in APL no molecular markers have been established for risk stratification as yet. The gene brain and acute leukemia, cytoplasmic (BAALC) has been shown to be of prognostic relevance in other leukemias such as T acute lymphoblastic leukemia (T-ALL) and acute myeloid leukemia (AML). Therefore, the aim of our study was to evaluate whether BAALC expression could be of prognostic value in APL.

Materials and Methods: Bone marrow mononuclear cells were retrospectively evaluated in 86 APL patients after informed consent. 50 patients were female and 36 patients were male. Median age was 47 years (range: 19–82 years). All patients were diagnosed and treated in the German AML Cooperative Group (AMLCG) study. The treatment consisted of simultaneous ATRA and double induction (TAD/HAM) chemotherapy including high-dose ara-C, one cycle of consolidation chemotherapy (TAD) and 3 years monthly maintenance chemotherapy. BM cells were analyzed by multiplex reverse transcriptase quantitative real-time PCR (qRT-PCR) in triplicates on a LightCycler 480 (Roche, Mannheim, Germany). Glucose-6-phosphate-isomerase (GPI) served as a housekeeping gene for normalization. For quantification of relative expression values a modified delta-delta CT calculation model according to Pfaffl was used (Pfaffl MW, Nucleic Acids Res; 2001) after determination of PCR efficiencies. BAALC expression groups were defined as follows: BAALC expression lower than the 25th percentile (BAALC^low) and higher than the 25th percentile (BAALC ^high). Time to complete remission, relapse free survival (RFS) and overall survival (OS) were calculated using the Kaplan-Meier method and a log-rank test was used to compare differences between the groups (p < 0.05). For statistical analysis the Statistical Analysis Software version 9.2 was used.

In univariate analysis low BAALC expression was significantly associated with a superior OS. Patients in the BAALC^low group showed an OS at 10 years of 82% as compared to 60% in the BAALC^high group (p=0.025). Moreover, RFS in the BAALC^low group was significantly higher at 10 years as compared to the BAALC^high group (86% vs. 59%; p=0.0087). Time to complete remission was not correlated to BAALC expression levels.

Low BAALC expression identifies a group of APL patients with a highly superior outcome indicated by a better OS and RFS in these patients. However, these findings need to be validated in an independent prospective study and it should be investigated whether this marker is independent of the applied treatment regimen and other known relevant markers. However, since the translocation t(15;17) by itself is not able to induce leukemia BAALC might be an interesting target for further investigation.

No relevant conflicts of interest to declare.