Clinical Impact of GATA2 Mutations in Acute Myeloid Leukemia Patients Harboring CEBPA Mutations: A Study of the AML Study Group (AMLSG)
Authors: Theis Frauke , Corbacioglu Andrea , Gaidzik Verena I. , Paschka Peter , Späth Daniela , Rehrl Michaela , Bullinger Lars , Schlegelberger Brigitte , Göhring Gudrun , Köhne Claus-Henning , Germing Ulrich , Brossart Peter , Horst Heinz-August , Haase Detlef , Götze Katharina S. , Ringhoffer Mark , Fiedler Walter , Nachbaur David , Kindler Thomas , Held Gerhard , Lübbert Michael , Wattad Mohammed , Salih Helmut R. , Krauter Jürgen , Heuser Michael , Ganser Arnold , Döhner Hartmut , Schlenk Richard F. , Döhner Konstanze 
Published: October 2019

Abstract

Background
Based on their association with certain biological and clinical features as well as their prognostic significance, mutations in the CCAAT/enhancer-binding protein-alpha (CEBPA) gene have been included as a provisional entity into the 2008 World Health Organization (WHO) classification of myeloid neoplasms. CEBPA mutations (CEBPAmut) are mainly found in acute myeloid leukemia (AML) with normal cytogenetics, and approximately 60% of the mutated patients (pts) carry biallelic mutations. Several studies showed that in particular pts with double mutant CEBPA (CEBPAdm) have a favorable outcome compared to all others. Recently, mutations in the transcription factor GATA2 were identified as genetic lesions potentially cooperating with CEBPAdm. Both, CEBPA and GATA2 are involved in the control of proliferation and differentiation of myeloid progenitors, and mutations in both genes are discussed as pre-disposing events in myeloid leukemia. Based on functional studies there is an important interplay between the two genes, e.g. through the formation of direct protein complexes. Finally, preliminary data suggest that the genotype CEBPAdm/GATA2 mutated (GATA2mut) is associated with a favorable outcome in AML pts.

Aims
To evaluate the frequency and the clinical impact of GATA2mut within a large cohort of CEBPAmut AML pts and to further analyze the CEBPAmut/GATA2mutgenotype within the context of other genetic alterations.

Methods
In total 202 AML pts (age 18 to 78 years) with CEBPA single mutations (n=89) or CEBPAdm (n=113) were analyzed for the presence of GATA2mut. All pts were enrolled on one of 6 AMLSG treatment trials applying intensive therapy [AMLHD93 n=15; AMLHD98A (NCT00146120) n=53; AMLHD98B n=13; AMLSG 07-04 (NCT00151242) n=74; AMLSG 06-04 (NCT00151255) n=25 and AMLSG 12-09 (NCT01180322) n=22]. GATA2 mutation screening was performed using a DNA-based PCR-assay covering exons 2 to 6 followed by Sanger sequencing.

Results
GATA2 mut were restricted to the cytogenetic intermediate-risk group; in total we detected 42 GATA2mut in 40 of the 202 pts (20.7%); 36 pts had CEBPAdm (36/113, 31.8%), 4 were CEBPA single mutated (4/89, 4.4%). All mutations were heterozygous, with 2 pts having two mutations (in exon 4 and 5, respectively). 31 (73.8%) of the 42 mutations were located in zinc-finger 1 (ZF1, exon 4) and 11 (26.1%) in ZF2 (exon 5). GATA2 sequence alterations included 39 missense and 3 frameshift mutations. The median follow-up of the 202 pts was 64.2 months (95%-CI: 60.1 – 75.1). First, we evaluated the clinical impact of GATA2mut in the whole cohort. Here, we found no differences in overall (OS), event-free (EFS), and relapse-free (RFS) survival as well as for the cumulative incidence of relapse (CIR) between GATA2mut and GATA2 wildtype pts. Next, the effects of GATA2mut in CEBPAdm pts (n=113) were analyzed without seeing any differences for the clinical endpoints OS, EFS, RFS and CIR. The same was also true when we investigated the impact of GATA2mut with respect to their location in the ZF domains; there were no differences between pts with ZF1 (n=29) and ZF2 (n=9) mutations, respectively. Finally, we evaluated the possible relevance of GATA2mut in the subgroup of CEBPAdm pts <60 years with intermediate-risk cytogenetics (n=94); but again GATA2mut did not impact the endpoints OS, EFS, RFS and CIR. In contrast to recently published data, we also detected GATA2mut in a small number of pts with CEBPA single mutations (n=4); however the low pt number did not allow a meaningful analysis. In addition, in our study GATA2mut occurred in rare cases with NPM1mut, FLT3-ITD or FLT3-TKD mutations.

Conclusions
In our study on a large cohort of CEBPA mutated AML pts we could confirm the high coincidence of GATA2 mutations, in particular in the subgroup of pts with CEBPA double mutations. However, GATA2 mutations had no impact on clinical outcome neither in the whole cohort nor in distinct pt subgroups.

Disclosures:
Schlegelberger: Celgene: Consultancy. Germing:Celgene: Honoraria, Research Funding. Kindler:Novartis: Membership on an entity’s Board of Directors or advisory committees. Schlenk:Novartis: Research Funding; Amgen: Research Funding; Chugai: Research Funding; Pfizer: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Ambit: Honoraria.