NLRP3 Inflammasome-Derived ASC Specks Are a Diagnostic Biomarker for Myelodysplastic Syndromes (MDS)
Authors: Basiorka Ashley A , Ma Zhenjun , Mcgraw Kathy L , Sallman David , Irvine Brittany A , Al Ali Najla H , Padron Eric , Pinilla-Ibarz Javier , Komrokji Rami S. , Sokol Lubomir , Wei Sheng , List Alan F 
Published: October 2019

Abstract
Background: We reported that ineffective hematopoiesis in MDS results from caspase-1-dependent, pyroptotic cell death. Pyroptosis, which culminates in cytolysis, is initiated by the NOD-like receptor NLRP3, a redox-sensitive, cytosolic sensor of danger signals. Upon activation, NLRP3 recruits the ASC (apoptosis-associated speck-like protein containing a CARD (caspase activation and recruitment domain)) adapter protein that polymerizes to create large cytoplasmic filaments. Exposure of the ASCCARDdomain on the filament surface fosters docking of pro-caspase-1 that initiates processing of pro-IL1β and -IL18. Large cytoplasmic aggregates formed by filament clusters are known as ASC specks. Upon cytolysis, ASC specks are released into the extracellular space where they retain catalytic activity and propagate inflammation. Given the magnitude of pyroptosis in the bone marrow (BM) and maturing cells, we hypothesized that detection of ASC specks in peripheral blood (PB) plasma may serve as a biologically-rational MDS biomarker.
Methods: We optimized a flow cytometry assay for detection of extracellular ASC specks averaging 1µm in size. Following protein quantitation, 300µg was aliquoted from each donor and stained with rabbit-anti-ASC 1o-Ab at a 1:1500 dilution for 60' at 37°C. 1:1500 dilution 2o-Ab was added and incubated for 30' at 37°C. Sample acquisitions were made on a BD FACSCalibur flow cytometer. PB plasma samples were obtained from normal donors (ND, n=40) and patients with MDS (n=220), de novo AML (n=16), 2o AML (n=26), CMML (n=20), CLL (n=50), CML (n=52), ALL (n=7), ET (n=20), PV (n=20), myeloma (n=20) and patients with Type-2 diabetes (T2D, n=25) on IRB-approved protocols, providing >90% power to detect significant differences between diseases. The diagnostic biomarker is defined as % of PB plasma ASC specks adjusted for glucose. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were used to evaluate classification accuracy of the biomarker at varied cutoff points.
Results: The % PB-ASC specks was significantly increased in lower-risk (LR) MDS vs. ND (n=196, 27.7±1.5 vs. 7.2±0.7, respectively; p=2.8x10-32). No significant difference was observed between ND and higher-risk (HR) MDS (12.4±3.0), however, % of PB-ASC specks was significantly increased in LR (n=196) vs. HR (n=16) MDS (p= 2.0x10-5). Because hyperglycemia stimulates NLRP3 inflammasome assembly and activation, we measured plasma glucose by colorimetric assay to adjust for this potentially confounding variable. % PB-ASC specks were normalized to plasma glucose concentration and corrected for volume. Glucose-adjusted speck % in LR-MDS remained significantly higher vs. ND (1.2±0.2 and 0.02±3.0x10-3, respectively; p=3.7x10-6). Notably, the corrected % PB specks was not significantly greater in HR-MDS (0.6±0.5) vs. ND or between LR-MDS vs. HR-MDS, although the HR-MDS sample size is small. Importantly, LR-MDS samples (1.2±0.2) displayed significantly greater corrected % ASC specks compared to de novo AML (0.3±0.2, p=2.3x10-3), 2o-AML (0.16±0.05, p=5.5x10-5), CMML (0.03±0.01; p=4.4x10-6), CLL (0.03±4.4x10-3, p=4.4x10-6), CML (0.04±0.01; p=5.2x10-6), ALL (0.2±0.09, p=9.9x10-5), ET (0.17±0.07, p=8.7x10-5), PV (0.12±0.06, p=3.8x10-5), myeloma (0.14±0.04, p=3.8x10-5) and PB from non-cancer patients with T2D (p=4.8x10-6), suggesting specificity for MDS (see Figure). A cut off of 0.053 was selected to minimize total misclassification error (false positive + false negative). With this cutoff, the biomarker achieves 99% sensitivity and 81% specificity in classifying MDS from ND. The corresponding PPV and NPV are both 95%. In a preliminary cohort of lenalidomide-treated LR-MDS patients, PB-ASC specks decreased a mean of 48% (range, 3-69%) at week 16, suggesting that specks may serve as a biomarker index of ineffective hematopoiesis.
Conclusion: ASC specks are readily quantified by flow cytometry and profoundly increased in PB plasma of MDS patients compared to ND and other hematologic malignancies. ASC specks are a sensitive and specific diagnostic biomarker for MDS that may also serve as an index of disease activity and emerging treatment response.

Disclosures
Pinilla-Ibarz: Novartis: Consultancy; Janssen: Consultancy, Honoraria; Abbvie: Consultancy, Speakers Bureau; Pharmacyclics: Consultancy, Speakers Bureau; Novartis: Consultancy; Gilead: Consultancy, Speakers Bureau; Gilead: Consultancy, Speakers Bureau. Komrokji:Novartis: Consultancy, Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding.