AML with Translocation T(8;16) Shows Unique Cytomorphological, Cytogenetic, Molecular, and Prognostic Features and Therefore Qualifies as An Own Entity According to WHO Criteria.
Authors: Kohlmann Alexander , Dugas Martin , Klein Hans-Ulrich , Ruckert Christian , Kern Wolfgang , Schnittger Susanne , Löffler Helmut , Haferlach Claudia , Haferlach Torsten 
Published: April 2020

Abstract
Balanced chromosomal rearrangements define distinct biological subsets in acute myeloid leukemia (AML). It is recognized that recurrent balanced aberrations, such as t(15;17), t(8;21), inv(16), and 11q23/MLL translocations, show a close correlation to cytomorphology and also harbor specific gene expression signatures. We here present a cohort of 13 AML cases with t(8;16)(p11;p13). This translocation is rare with only 13 cases (6 males, 7 females) diagnosed from our overall cohort of 6124 cases of AML over recent years, and is more frequently found in therapy-related AML than in de novo AML (7/438 t-AML, and 6/5686 de novo, p=0.00001). Prognosis was poor with median overall survival of 4.7 months. Five patients deceased within the first month after diagnosis. AML with t(8;16) is characterized by striking cytomorphologic features: In all 13 cases the positivity for myeloperoxidase (MPO) on bone marrow smears was &gt;30% (median: 85%) and intriguingly, in parallel also &gt;40% (median: 88%) of blast cells stained strongly positive for non-specific esterase (NSE) in the same cell, suggesting that AML with t(8;16) arise from a very early stem cell with both myeloid and monoblastic differentiation potential. Therefore, AML with t(8;16) cases can not be classified according to standard FAB categories. Morphologically we also detected erythrophagocytosis in 7/13 cases, a specific feature in AML with t(8;16) that was previously described. With respect to cytogenetics, 6/13 patients had t(8;16)(p11;p13) as sole abnormality. 7/13 patients demonstrated additional non-recurrent abnormalities, 4 cases with single additional aberrations, and 3 cases with two or more additional aberrations. Molecular analyses detected the MYST3- CREBBP fusion transcript in all cases tested (12/12). We then compared gene expression patterns in 7 cases of AML with t(8;16) to: (i) AML FAB subtypes M1 and M4/5 with strong MPO or NSE with normal karyotype and to (ii) distinct AML subtypes with balanced chromosomal aberrations according to WHO classification. In a first series using Affymetrix HG-U133A+B microarrays 4 cases of AML with t(8;16) were compared to FAB M1 (n=46), M4 (n=41), M5a (n=9), and M5b (n=16). Hierarchical clustering and principal component analyses revealed that AML with t(8;16) were intercalating rather with FAB subtypes M4 and M5b and did not cluster near to FAB M1, although strong positivity for MPO was seen in all t(8;16) cases. Thus, monocytic characteristics influence the gene expression pattern stronger than myeloid features. When further compared to AML WHO subtypes t(15;17) (n=43), t(8;21) (n=43), inv(16) (n=49), and 11q23/MLL (n=50), AML with t(8;16) samples were repeatedly grouped in the vicinity of the 11q23/MLL cases. This can be explained by a similar expression of genes such as EAF2, HOXA9, HOXA10, PRKCD, or HNMT. Yet, in a subsequent pairwise comparison AML with t(8;16) could also be clearly discriminated from 11q23/MLL with differentially expressed genes including CAPRIN1, RAN, SMARCD2, LRRC41, or H2BFS, higher expressed in AML with t(8;16) and SOCS2, PRAME, RUNX3, or TPT1, lower expressed in AML with t(8;16), respectively. Moreover, the respective FAB-type or WHO-type signatures were validated on a separate cohort of patients (n=3 AML with t(8;16); n=107 other AML subtypes as above), all prospectively analyzed with the successor HG-U133 Plus 2.0 microarray. Again, in direct comparison to FAB-type or WHO-type cases, dominant and unique gene expression patterns were seen for AML with t(8;16), confirming the molecular distinctiveness of this rare AML entity. Using a classification algorithm we were able to correctly predict all AML with t(8;16) cases by their gene expression pattern. This accuracy was observed not only for both FAB-type and WHO-type signatures, but also correctly classified the cases across the different patient cohorts and microarray designs. In conclusion, AML with t(8;16) is a specific subtype of AML with very poor prognosis that often presents as treatment-related AML and with particular characteristics not only in morphology and clinical profile, but also on a molecular level. Due to these unique features, it qualifies as a specific recurrent entity according to WHO criteria.