Pre-B cell receptor expression in B-lineage acute lymphoblastic leukemia: A report from the Children’s Oncology Group.
Authors: Winter Stuart S. , McCaustland Amanda , Simeona No'eau , Carroll Andrew J. , Heerema Nyla A. , Wood Brent L. , Gheorghe Gabriela , Wilson Bridget S 
Published: June 2021

e19006 Background: The surface expression of mature B-cell markers have led to the development of immunotherapies against B-lineage lymphoblastic leukemia/lymphoma (B-ALL/B-LLy). Relapsing clones that have altered surface antigen expression are common means of treatment failure with immunotherapies. The elimination of the pan-B cell repertoire by current B-cell immunotherapies contributes to immune-compromise. A promising target is the pre-BCR surrogate light chain, comprised of the VpreB1 (CD179a) and Lamda5 (CD179b) subunits. Surrogate light chain is expressed on pro- and pre-B cells where it governs preBCR-mediated autonomous survival during B-cell maturation. Gene expression analyses have shown that CD179a is expressed in a sub-set of 10 to 15% of B-ALL cases. Because immunotherapies targeted to restricted stages of B-cell development may overcome the limitations of pan B-cell ablation, we tested the hypothesis that CD179a is more commonly expressed on B-lymphoblasts than previously thought. Methods: Utilizing an annotated set of 36 standard (AALL0331) and high-risk (AALL0232) B-ALL cases accrued to Children’s Oncology Group AALL03B1, we adapted the COG minimal residual disease (MRD) flow panel to include two additional PE- and FITC-conjugated mAbs against CD179a (Biolegend and i2Pharma). We assessed CD179a expression in 16 cases for which we had Day 28 end-induction samples, pre-selected to have ≥1% MRD, as determined by the COG Reference laboratories. Cases with ≥20% CD179a surface expression were determined to be positive for statistical comparisons. All analyses were performed on a 6-color Becton-Dickinson flow cytometer in a CLIA/CAP certified laboratory. Results: Thirty-four cases were arrested at the CD10-positive pre-B stage, and two cases at the CD10-negative pro-B stage. One or both mAbs showed that CD179a was present in ≥20% of the B-lymphoblast population, ranging from 20.2% to 90.6% for all 36 diagnostic samples. All cases expressed CD179a in the end-induction B-lymphoblast population. Compared to gene-expression based predictions, we found a significant difference between expected versus observed flow-based CD179a positivity (two-sided Fisher’s exact test, P< 0.001). We found that CD179a expression was observed in cases having E2A-PBX3, KMT2A, BCR-ABL1 and other re-arrangements that typify mixed phenotype acute leukemias (MPALs). Conclusions: Our results show that CD179a is commonly expressed in B-ALL, regardless of stage, NCI risk features, or molecular aberrations. Because the productively assembled preBCR mediates autonomous survival signaling in pro- and pre-B cells, it may also contribute to the mechanistic basis of MRD in B-ALL. Immunotherapies directed against the CD179a component of the preBCR may spare the immune-compromise that occurs with pan B-cell ablation, and prevent the emergence of therapy-resistant disease in B-ALL/B-LLy.