Quantitative Assessment of Indoleamine 2,3-Dioxygenase (IDO) Expression at Diagnosis Predicts Clinical Outcome in Patients with Acute Myeloid Leukemia Undergoing Allogeneic Stem Cell Transplantation
Authors: Parisi Sarah , Ragaini Simone , Ocadlikova Darina , Lecciso Mariangela , Marconi Giovanni , Paolini Stefania , Papayannidis Cristina , Abbenante Maria Chiara , Sartor Chiara , Martinelli Giovanni , Ottaviani Emanuela , Bonifazi Francesca , Cavo Michele , Curti Antonio 
Published: October 2019

Abstract
Introduction
Indoleamine 2,3-dioxygenase (IDO) is an intracellular heme-containing enzyme that catalyzes the initial rate-limiting step in tryptophan degradation along the kynurenine pathway. IDO is physiologically expressed by a wide variety of human cells in response to several stimuli and it is known to have a crucial role in the induction of immune tolerance during pregnancy, infections, transplantation, autoimmunity and tumors. IDO-mediated tryptophan degradation results in inhibition of T-cell proliferation, increase of T-cell apoptosis and T-reg induction. Several studies demonstrated that IDO production can induce the increase of Regulatory T-cells (Tregs) directly through the conversion of CD25- into CD25+ T cells, even in acute myeloid leukemia (AML) patients. IDO expression can be considered a novel mechanism of leukemia escape from immune control and its inhibition may represent an antileukemia therapeutic strategy. Aim of our work is to analyze IDO mRNA expression in a cohort of AML patients and to investigate the presence of any significant correlation between IDO expression and standard prognostic factors or clinical outcome.
Methods
We analyzed a cohort of 68 adult patients aged 18 years or older, who were diagnosed with de novo or secondary AML. IDO mRNA expression was evaluated by Real-Time (RT)-PCR in blood bone marrow and peripheral blood samples at diagnosis. Patients were then retrospectively stratified according to standard risk factors at diagnosis and to IDO mRNA expression levels.
Results
Median age of analyzed patients was 57 years (range 21-76). Fifty-nine out of 68 patients (87%) had de novo AML, whereas 9 out of 68 patients (13%) had secondary AML. A comprehensive risk assessment was available for 61 patients. Among these 61 patients who were evaluable for risk stratification, 13 patients (21%) resulted to have a favorable risk AML, 30 (49%) had an intermediate risk AML and 17 patients (30%) were stratified as high-risk AML. Sixty out of 68 patients received intensive, standard, induction chemotherapy regimens. The remaining 8 patients were not candidate to receive intensive chemotherapy mainly because of comorbidities. Twenty-three out of 68 patients (34%) were considered eligible for allogeneic stem cells transplantation (alloSCT) as consolidation therapy, after obtaining complete remission with standard chemotherapy. IDO expression in peripheral blood (PB) samples was between 0.07 and 4272.26 (median 5.60). Conversely, IDO expression in bone marrow (BM) samples was between 0.17 and 243.16 (median 1.21). Our data did not establish any significant correlation between IDO expression and leukemia risk factors at diagnosis, in particular cytogenetics, de novo or secondary AML, leukocytosis. Among the 60 patients who received induction chemotherapy, 35 achieved morphological complete remission (CR), 24 did not respond and 1 patient was not evaluable for response. Response to induction chemotherapy was not influenced by IDO mRNA expression levels. Interestingly, among patients undergoing alloSCT, high levels of IDO mRNA expression in PB samples negatively correlated with patients' overall survival. In particular, high IDO expression of more than 10 was associated with worse overall survival after alloSCT even when adjusted by patients' age and disease status at transplant (log rank P=0.02) (Fig.1). With the limitations of the low number of patients, these results from the group of transplanted patients were not likely due to differences in the incidence and severity of graft-versus-host-disease, whereas high IDO mRNA expression level was predictive of increased incidence of relapse.
Conclusions
This work suggests that IDO mRNA expression levels can be considered as predictive of AML outcome, independently from other risk factors at diagnosis. In our set, higher level of IDO mRNA expression at diagnosis was correlated with worse clinical outcome in patients undergoing alloSCT. Larger studies are warranted in order to establish the real predictive role of IDO mRNA expression in influencing AML outcome.

Disclosures
Cavo: Adaptive Biotechnologies: Honoraria, Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Bristol-Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees; GlaxoSmithKline: Honoraria, Membership on an entity's Board of Directors or advisory committees; AbbVie: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau.