CD123 Immunostaining in Systemic Mastocytosis: Differential Expression in Disease Subgroups and Potential Prognostic Value
Authors: Pardanani Animesh , Reichard Kaaren , Zblewski Darci , Abdelrahman Ramy , Wassie Emnet , Morice William G. , Brooks Christopher L. , Hanson Curtis A. , Tefferi Ayalew , Chen Dong 
Published: October 2019

Abstract
Background: CD123 is the α-subunit of the high-affinity receptor for interleukin-3; its expression in normal bone marrow (BM) is highly restricted, however CD123 is highly expressed in certain hematolymphoid malignancies. In a pilot study of 11 systemic mastocytosis (SM) patients (Lasho et al., Leukemia, 2015), we made the following novel observations (i) CD123 was aberrantly expressed on neoplastic mast cells (MC); and (ii) there was focal proliferation of plasmacytoid dendritic cells (PDC) around MC aggregates, suggesting a tumor promoting role for PDC.
Objectives: To study MC CD123 expression by IHC in a larger cohort of SM patients to ascertain: (i) whether there is a significant difference in CD123 expression between SM subtypes; (ii) whether focal PDC proliferation around MC aggregates is correlated with CD123 expression; and (iii) whether CD123 expression has prognostic value for overall survival (OS).
Methods: The current study was approved by the Mayo Clinic institutional review board. SM was classified as per standard criteria. Archived BM slides were stained for tryptase and CD123 as previously described (Lasho et al., Leukemia, 2015). Slides were reviewed independently by 2 hematopathologists who were blinded with regards to SM subgroups and scored on the following pre-defined parameters: (i) CD123 expression yes/no; (ii) CD123 expression strong/weak; (iii) focal PDC proliferation yes/no; and (iv) BM MC%.
Results: We studied 58 SM patients and 3 controls. Of the former, 23 had indolent SM (ISM), 10 aggressive SM (ASM), 23 SM with associated hematological disease (SM-AHD), and 2 had mast cell leukemia (MCL). Of the SM-AHD patients, 10 (43%) had CMML, 5 (22%) myeloproliferative neoplasm-unclassified (MPN-u), 3 (13%) PV, 2 (9%) acute myeloid leukemia, and 1 each had lymphoma, myeloma and myelodysplastic syndrome. The median follow up from diagnosis was 32 months (range 0.1 to 162). Over this period, 3 patients (5%) had leukemic transformation and 30 patients (52%) died.
Concordance rates between hematopathologists for CD123 positive/negative, CD123 strong/weak, focal PDC proliferation yes/no and MC% were 97%, 94%, 98% and 100%, respectively. MC CD123 expression was absent in control cases but demonstrable in 37 (64%) SM patients; expression rates were 100%, 61%, 57%, and 0% in ASM, ISM, SM-AHD and MCL, respectively (p=0.02). Similar to MCL, both cases with SM-AML showed absent MC CD123 expression. Strong MC CD123 expression (comparable to background interstitial PDC) was observed in 23 patients (62%), including 85% with SM-AHD, 60% with ASM, and 43% with ISM (p=0.08). Focal PDC proliferation around MC aggregates, regardless of CD123 expression status, was noted in 44 patients (76%), including 90% with ASM, 87% with ISM, 65% with SM-AHD and 0% with MCL (p=0.02). Focal PDC proliferation was significantly higher in CD123-positive versus -negative patients (87% versus 50%, p=0.005).
OS was predicted by SM subtype; the median OS for ISM, ASM, SM-AHD and MCL patients was not reached, 30 months, 25 months and 3 months, respectively (p=0.005). CD123 expression status did not have prognostic value for OS overall, however, in SM-AHD patients, CD123 expression was associated with significantly inferior survival (p=0.04), independent of the associated disease (ie, CMML vs AML vs MPN vs other). Survival outcome of SM-CMML patients expressing MC CD123 (n=3, median OS=11 months) was significantly inferior as compared to patients who did not (n=7, median OS=44 months), independent of age and absolute monocyte count (p=0.01). CD123 staining intensity had borderline significance for OS in the overall cohort (p=0.08). When restricted to non-indolent SM cases, strong CD123 expression was associated with significantly worse overall survival (15 versus 88 months, p=0.04).
Conclusions: In this cohort, aberrant MC CD123 expression was observed in the majority of SM patients with highest prevalence in ASM patients and uniformly absent expression in leukemic phase SM (MCL or SM-AML). Focal PDC proliferation around MC aggregates was significantly higher in CD123-positive cases, indicating a potential functional interaction. CD123 expression identified SM-AHD patients with inferior OS, especially those with SM-CMML. Strong CD123 staining intensity may be associated with inferior OS in non-indolent SM patients. CD123 expression on MC and PDC constitutes a novel therapeutic target in non-leukemic SM.

Disclosures
Pardanani: Stemline: Research Funding. Brooks:Stemline Therapeutics, Inc.: Employment, Equity Ownership, Patents & Royalties.