Abstract SY13-01: Genetic and non-genetic mechanisms contribute to long term clonal growth dynamics and therapy resistance
Authors: Dick John E. 
Published: May 2015

Abstract
The cellular and molecular basis for intra-tumoral heterogeneity is poorly understood. Tumor cells can be genetically diverse due to mutations and clonal evolution resulting in intra-tumoral functional heterogeneity. Often proposed as mutually exclusive, cancer stem cell (CSC) models postulate that tumors are cellular hierarchies sustained by CSC heterogeneity due to epigenetic differences (i.e. long term tumor propagation only derives from CSC). The presentation will focus on three lines of evidence showing these models are highly integrated. Gene signatures specific to either AML LSC or normal HSC are highly similar and define a common stemness program. Compared to non-stem cell transcriptional programs, only stem cell signatures were significant independent predictors of patient survival in 4 large clinical databases of &gt;1000 samples. Thus, determinants of stemness influence clinical outcome of AML across a spectrum of mutations indicating that many genetic abnormalities coalesce around stem cell properties. These studies provide strong support that the CSC model is clinically relevant and not an artifact of the xenografts model. Secondly, we have carried out a series of combined genetic and functional studies of the LSC from either B-ALL or AML that point to commonalities between clonal evolution and CSC models of cancer. LSC from diagnostic patient samples were genetically diverse and reconstruction of their genetic ancestry showed that multiple LSC subclones were related through a complex branching evolutionary process and specific genetic events influence L-IC frequency. Also study of paired diagnostic (Dx) and relapse (Rx) samples are revealing that individual subclones possess distinct functional growth properties and that rare Dx subclones are chemotherapy resistant and become enriched at Rx. Thus the clonal evolution models are highly relevant in cancer but need to be extended to adopt the concept that CSC are subject to clonal evolutionary forces. Finally, the combined genetic and functional analysis of AML is revealing fundamental insights into the cell of origin, nature and biological consequences of initiating lesions and order of subsequent mutations; concepts that demonstrate how highly integrated the CSC and genetic evolution models must be. Highly purified hematopoietic stem cells (HSC), progenitor and mature cell fractions from the blood of AML patients were found to contain recurrent DNMT3a mutations (DNMT3amut) at high allele frequency, but without coincident NPM1 mutations (NPM1c) present in AML blasts. DNMT3amut-bearing HSC exhibited multilineage repopulation advantage over non-mutated HSC in xenografts, establishing their identity as pre-leukemic-HSC (preL-HSC). preL-HSC were found in remission samples indicating that they survive chemotherapy. Thus DNMT3amut arises early in AML evolution, likely in HSC, leading to a clonally expanded pool of preL-HSC from which AML evolves. Our findings provide a paradigm for the detection and treatment of pre-leukemic clones before the acquisition of additional genetic lesions engenders greater therapeutic resistance. Collectively, these three lines of evidence show that the CSC and evolution models can be unified. Moreover, these studies point to the need to develop therapies that effective target, all the genetic subclones present in a tumor, the ancestral cell types from which recurrences can arise and ultimately all leukemia and pre-leukemic cells possessing stemness properties, to ensure further evolution and recurrence are prevented.
Citation Format: John E. Dick. Genetic and non-genetic mechanisms contribute to long term clonal growth dynamics and therapy resistance. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr SY13-01. doi:10.1158/1538-7445.AM2014-SY13-01