Background: Extramedullary manifestations (EM) are rare in acute myeloid leukemia (AML) and their impact on clinical outcomes is controversially discussed. - Methods: We retrospectively analyzed a large multi-center cohort of 1583 newly diagnosed AML patients, of whom 225 (14.21%) had EM. - Results: AML patients with EM presented with significantly higher counts of white blood cells (p < 0.0001), peripheral blood blasts (p < 0.0001), bone marrow blasts (p = 0.019), and LDH (p < 0.0001). Regarding molecular genetics, EM AML was associated with mutations of NPM1 (OR: 1.66, p < 0.001), FLT3-ITD (OR: 1.72, p < 0.001) and PTPN11 (OR: 2.46, p < 0.001). With regard to clinical outcomes, EM AML patients were less likely to achieve complete remissions (OR: 0.62, p = 0.004), and had a higher early death rate (OR: 2.23, p = 0.003). Multivariable analysis revealed EM as an independent risk factor for reduced overall survival (hazard ratio [HR]: 1.43, p < 0.001), however, for patients who received allogeneic hematopoietic cell transplantation (HCT) survival did not differ. For patients bearing EM AML, multivariable analysis unveiled mutated TP53 and IKZF1 as independent risk factors for reduced event-free (HR: 4.45, p < 0.001, and HR: 2.05, p = 0.044, respectively) and overall survival (HR: 2.48, p = 0.026, and HR: 2.63, p = 0.008, respectively). - Conclusion: Our analysis represents one of the largest cohorts of EM AML and establishes key molecular markers linked to EM, providing new evidence that EM is associated with adverse risk in AML and may warrant allogeneic HCT in eligible patients with EM.

The development and design of immune-based strategies have become an increasingly important topic during the last few years in acute myeloid leukemia (AML), based on successful immunotherapies in solid cancer. The spectrum ranges from antibody drug conjugates, immune checkpoint inhibitors blocking programmed cell death protein 1 (PD1), cytotoxic T lymphocyte antigen 4 (CTLA4) or T cell immunoglobulin and mucin domain containing-3 (TIM3), to T-cell based monoclonal and bispecific T-cell engager antibodies, chimeric antigen receptor-T-cell (CAR-T) approaches and leukemia vaccines. Currently, there are many substances in development and multiple phase I/II studies are ongoing. These trials will help us to deepen our understanding of the pathogenesis of AML and facilitate the best immunotherapeutic strategy in AML. We discuss here the mode of action of immune-based therapies and provide an overview of the available data.

Patients with acute promyelocytic leukemia (APL) often present with potentially lifethreatening hemorrhagic diathesis. The underlying pathomechanisms of APLassociated coagulopathy are complex. However, two pathways considered to be APLspecific had been identified: 1) annexin A2 (ANXA2)-associated hyperfibrinolysis and 2) podoplanin (PDPN)-mediated platelet activation and aggregation. In contrast, since disseminated intravascular coagulation (DIC) is far less frequent in patients with non- APL acute myeloid leukemia (AML), the pathophysiology of AML-associated hemorrhagic disorders is not well understood. Furthermore, the potential threat of coagulopathy in non- APL AML patients may be underestimated. Herein, we report a patient with non-APL AML presenting with severe coagulopathy with hyperfibrinolysis. Since his clinical course resembled a prototypical APL-associated hemorrhagic disorder, we hypothesized pathophysiological similarities. Performing multiparametric flow cytometry (MFC) and immunofluorescence imaging (IF) studies, we found the patient’s bone-marrow mononuclear cells (BM-MNC) to express ANXA2 - a biomarker previously thought to be APL-specific. In addition, whole-exome sequencing (WES) on sorted BM-MNC (leukemiaassociated immunophenotype (LAIP)1: ANXAlo, LAIP2: ANXAhi) demonstrated high intratumor heterogeneity. Since ANXA2 regulation is not well understood, further research to determine the coagulopathy-initiating events in AML and APL is indicated. Moreover, ANXA2 and PDPN MFC assessment as a tool to determine the risk of life-threatening DIC in AML and APL patients should be evaluated.

Evidence-based software engineering (EBSE) solutions for drug discovery that are effective, affordable, and accessible all-in-one are lacking. This thesis chronicles the progression and accomplishments of the AiDA (Artificially-intelligent Desktop Assistant) functional artificial intelligence (AI) project for the purposes of drug discovery in the challenging acute myeloid leukemia context (AML). AiDA is a highly automated combined natural language processing (NLP) and spreadsheet feature extraction solution that harbours potential to disrupt the state of current research investigation methods using big data and aggregated literature. The completed work includes a text-to-function (T2F) NLP method for automated text interpretation, a ranked-list algorithm for multi-dataset analysis, and a custom multi-purpose neural network engine presented to the user using an open-source graphics engine. Validation of the deep learning engine using MNIST and CIFAR machine learning benchmark datasets showed performance comparable to state-of-the-art libraries using similar architectures. An n-dimensional word embedding method for the handling of unstructured natural language data was devised to feed convolutional neural network (CNN) models that over 25 random permutations correctly predicted functional responses to up to 86.64% of over 300 validation transcripts. The same CNN NLP infrastructure was then used to automate biomedical context recognition in >20000 literature abstracts with up to 95.7% test accuracy over several permutations. The AiDA platform was used to compile a bidirectional ranked list of potential gene targets for pharmaceuticals by extracting features from leukemia microarray data, followed by mining of the PubMed biomedical citation database to extract recyclable pharmaceutical candidates. Downstream analysis of the candidate therapeutic targets revealed enrichments in AML- and leukemic stem cell (LSC)-related pathways. The applicability of the AiDA algorithms in whole and part to the larger biomedical research field is explored. / Thesis / Master of Science (MSc) / Lead generation is an integral requirement of any research organization in all fields and is typically a time-consuming and therefore expensive task. This is due to the requirement of human intuition to be applied iteratively over a large body of evidence. In this thesis, a new technology called the Artificially-intelligent Desktop Assistant (AiDA) is explored in order to provide a large number of leads from accumulated biomedical information. AiDA was created using a combination of classical statistics, deep learning methods, and modern graphical interface engineering. It aims to simplify the interface between the researcher and an assortment of bioinformatics tasks by organically interpreting written text messages and responding with the appropriate task. AiDA was able to identify several potential targets for new pharmaceuticals in acute myeloid leukemia (AML), a cancer of the blood, by reading whole-genome data. It then discovered appropriate therapeutics by automatically scanning through the accumulated body of biomedical research papers. Analysis of the discovered drug targets shows that together, they are involved in key biological processes that are known by the scientific community to be involved in leukemia and other cancers.

Background The role of allogeneic hematopoietic cell transplantation (alloHCT) in acute myeloid leukemia (AML) with mutated IDH1/2 has not been defined. Therefore, we analyzed a large cohort of 3234 AML patients in first complete remission (CR1) undergoing alloHCT or conventional chemo-consolidation and investigated outcome in respect to IDH1/2 mutational subgroups (IDH1 R132C, R132H and IDH2 R140Q, R172K). Methods Genomic DNA was extracted from bone marrow or peripheral blood samples at diagnosis and analyzed for IDH mutations with denaturing high-performance liquid chromatography, Sanger sequencing and targeted myeloid panel next-generation sequencing, respectively. Statistical as-treated analyses were performed using R and standard statistical methods (Kruskal–Wallis test for continuous variables, Chi-square test for categorical variables, Cox regression for univariate and multivariable models), incorporating alloHCT as a time-dependent covariate. Results Among 3234 patients achieving CR1, 7.8% harbored IDH1 mutations (36% R132C and 47% R132H) and 10.9% carried IDH2 mutations (77% R140Q and 19% R172K). 852 patients underwent alloHCT in CR1. Within the alloHCT group, 6.2% had an IDH1 mutation (43.4% R132C and 41.4% R132H) and 10% were characterized by an IDH2 mutation (71.8% R140Q and 24.7% R172K). Variants IDH1 R132C and IDH2 R172K showed a significant benefit from alloHCT for OS (p = .017 and p = .049) and RFS (HR = 0.42, p = .048 and p = .009) compared with chemotherapy only. AlloHCT in IDH2 R140Q mutated AML resulted in longer RFS (HR = 0.4, p = .002). Conclusion In this large as-treated analysis, we showed that alloHCT is able to overcome the negative prognostic impact of certain IDH mutational subclasses in first-line consolidation treatment and could pending prognostic validation, provide prognostic value for AML risk stratification and therapeutic decision making.

Measurable residual disease (MRD) detected by multiparametric flow cytometry (MFC) is associated with unfavorable outcome in patients with AML. A simple, broadly applicable eight-color panel was implemented and analyzed utilizing a hierarchical gating strategy with fixed gates to develop a clear-cut LAIP-based DfN approach. In total, 32 subpopulations with aberrant phenotypes with/without expression of markers of immaturity were monitored in 246 AML patients after completion of induction chemotherapy. Reference values were established utilizing 90 leukemia-free controls. Overall, 73% of patients achieved a response by cytomorphology. In responders, the overall survival was shorter for MRDpos patients (HR 3.8, p = 0.006). Overall survival of MRDneg non-responders was comparable to MRDneg responders. The inter-rater-reliability for MRD detection was high with a Krippendorffs α of 0.860. The mean time requirement for MRD analyses at follow-up was very short with 04:31 minutes. The proposed one-tube MFC approach for detection of MRD allows a high level of standardization leading to a promising inter-observer-reliability with a fast turnover. MRD defined by this strategy provides relevant prognostic information and establishes aberrancies outside of cell populations with markers of immaturity as an independent risk feature. Our results imply that this strategy may provide the base for multicentric immunophenotypic MRD assessment.

No description available.

Les leucémies myéloïdes aigües résultent d’un dérèglement du processus de l’hématopoïèse et regroupent des maladies hétérogènes qui présentent des profils cliniques et génétiques variés. La compréhension des processus cellulaires responsables de l’initiation et du maintien de ces cancers permettrait de développer des outils thérapeutiques efficaces et ciblés. Au cours des dernières années, une quantité croissante d’anomalies génétiques reliées au développement de leucémies ont été corrélées à une expression anormale des gènes HOX et de leurs cofacteurs MEIS et PBX. Des modèles expérimentaux murins ont confirmé le rôle direct joué par ces protéines dans le développement de leucémies. En effet, la protéine MEIS1 collabore avec HOXA9 dans la leucémogenèse et requiert pour ce faire trois domaines distincts. Deux de ces domaines sont conservés chez PREP1, un membre de la même classe d’homéoprotéine que MEIS1. En utilisant une approche de gain-de-fonction, j’ai confirmé l’importance du rôle joué par le domaine C-terminal de MEIS1 dans l’accélération des leucémies induites par HOXA9. J’ai également montré que l’activité de ce domaine était corrélée avec une signature transcriptionnelle associée à la prolifération cellulaire. J’ai ensuite réalisé un criblage à haut débit afin d’identifier des antagonistes de l’interaction MEIS-PBX, également essentielle à l’accélération des leucémies HOX. À cette fin, j’ai développé un essai de transfert d’énergie de résonance de bioluminescence (BRET) permettant de détecter la dimérisation MEIS-PBX dans les cellules vivantes. Plus de 115 000 composés chimiques ont été testés et suite à une confirmation par un essai orthogonal, une vingtaine de molécules ont été identifiées comme inhibiteurs potentiels. Ces composés pourront être rapidement testés sur la prolifération de cellules leucémiques primaires dans un contexte d’étude préclinique. Finalement, deux approches protéomiques complémentaires ont permis d’identifier des partenaires potentiels de MEIS1 et PREP1. La catégorisation fonctionnelle de ces candidats suggère un nouveau rôle pour ces homéoprotéines dans l’épissage de l’ARN et dans la reconnaissance de l’ADN méthylé. / Acute myeloid leukemias are the result of a perturbed hematopoietic process and regroup heterogeneous diseases with distinct clinical and genetic profiles. Identifying and understanding the faulty cellular processes would allow the development of targeted and efficient therapeutic tools. Over the last 15 years, a growing number of disease-linked genetic anomalies have been correlated with abnormal expression levels of HOX genes and their cofactors MEIS and PBX. Mouse model experimentations revealed a direct role for these proteins in leukemogenesis. Indeed, the protein MEIS1 collaborates with HOXA9 in the acceleration of leukemia development. This specific function requires the presence of three different domains, two of which are highly conserved in PREP1, another member of the MEIS class of homeoproteins. Using a gain-of-function approach, I confirmed the importance of the C-terminal domain of MEIS1 in the acceleration of HOXA9-induced leukemias. I also correlated the activity of this domain with a transcriptional signature related to cell proliferation. Furthermore, I performed a high-throughput screen to identify antagonists of the MEIS-PBX interaction, also required for acceleration of HOX-induced leukemogenesis. In this regard I developed an assay that exploits bioluminescence resonance energy transfer (BRET) to monitor the MEIS-PBX dimerization in living cells. More than 115 000 compounds were tested and upon confirmation of their activity using an orthogonal assay, 20 small molecules were identified as potential inhibitors. These compounds will be rapidly tested on proliferation of primary leukemic cells in a preclinical setting. Finally two complementary proteomic approaches allowed the identification of new potential partners of MEIS1 and PREP1. The functional clustering of these candidates suggests a new role for homeoproteins in mRNA splicing and methylated DNA recognition.

Le protéasome (CP) contrôle la majorité des fonctions cellulaires par la dégradation des protéines intracellulaires. En plus d’exprimer le CP, les vertébrés expriment également l’immunoprotéasome (IP), caractérisé par des préférences de dégradation distinctes. Le rôle le mieux caractérisé pour l’IP est la génération d’antigènes adaptés pour la liaison au complexe majeur d’histocomptabilité de classe I (CMH-I). Cependant, les nombreux phénotypes observés au niveau de cellules déficientes en IP ou avec une mutation révèlent que l’IP influence des fonctions immunitaires indépendamment de la génération d’antigènes et peut atténuer le stress présent au niveau de cellules non-immunitaires. L’objectif de cette thèse était de caractériser les rôles de l’IP qui ne sont pas reliés à la génération d’antigènes associés au CMH-I. L’analyse du transcriptome de cellules dendritiques IP-déficientes en cours de maturation révèle que l’IP affecte l’expression de plus de 8 000 transcrits. L’IP affecte l’expression génique principalement au niveau transcriptionnel en contrôlant l’abondance de régulateurs de transcriptions tels que NF-κB et les membres des familles IRF et STAT. Les cellules dendritiques IP-déficientes sont également moins efficaces pour activer des lymphocytes T CD8+, même chargées artificiellement avec des quantités optimales d’antigènes associés au CMH-I. En outre, nos études montrent que l’IP est fortement exprimé au niveau de cellules de patients atteints de leucémie myéloïde aigue. L’expression de l’IP est intrinsèque aux leucémies, puisque qu’elle n’est pas corrélée à la présence de lymphocytes sécréteurs d’IFN-γ. De plus, l’expression d’IP est particulièrement élevée au niveau de leucémies monocytaires et/ou possédant un réarrangement MLL. Notamment, des analyses de corrélation montrent que l’IP est connecté à des gènes impliqués dans le métabolisme, l’activité mitochondriale et la réponse au stress. En effet l’inhibition de la sous-unité PSMB8 de l’IP mène à l’accumulation de protéines ubiquitinées et la mort de cellules leucémiques monocytaires. Globalement, nos travaux montrent que le rôle de l’IP n’est pas limité à la génération d’antigènes, mais qu’il peut contrôler l’expression génique et la survie des leucémies. / By regulating protein degradation, constitutive proteasomes (CP) control practically all cellular functions. In addition to CP, vertebrates express immunoproteasomes (IP), which display distinct substrate preferences. The first non-redundant role ascribed to IP is its enhanced ability to generate MHC I-associated antigens. However, deletion or inhibition of IP subunits can affect several immune cell functions independently of MHC-I antigen generation. Moreover, recent work has shown that IP can be expressed in non-immune cells to deal with cell stress. Thus, we wished to investigate the roles of IP that are not related to antigen generation and that are not redundant with the CP. Based on profiling of WT and IP-deficient maturing mouse dendritic cells (DCs), we report that IP regulate the expression of more than 8,000 transcripts. The broad impact of IP on gene expression is cell-autonomous, mediated mainly at the transcriptional level, and involves major signaling pathways including IRFs, NF-kB and STATs. Moreover, even when engineered to present optimal amounts of antigenic peptides, IP-deficient DCs are inefficient for in vivo T-cell priming. In addition, consistent with the fact that cancer cells endure proteotoxic stress, we report that acute myeloid leukemia (AML) cells from patients express high levels of IP genes. Expression of IP genes in AML is a cell-autonomous and IFN-independent feature that correlates with the methylation status of IP genes, and is particularly high in AML with a monocytic phenotype and/or MLL rearrangement. Notably, IP inhibition leads to accumulation of polyubiquitinated proteins and cell death in IPhigh but not IPlow AML cells. Co-clustering analysis reveals that genes correlated with IP subunits in monocytic AMLs are primarily implicated in cell metabolism and proliferation, mitochondrial activity and stress responses. Overall, our studies show that the role of IP is not limited to antigen processing and reveals major non-redundant roles for IP in transcription regulation and resistance to cell stress in AML.

Klasické schéma vývoje hematopoetických buněk předpokládá časné oddělení lymfoidního a myeloidního prekurzoru. V poslední době jsou navrhovány složitější modely, které předpokládají větší flexibilitu hematopoezy a navrhují existenci progenitorů s lymfoidním i myeloidním potenciálem. Akutní hybridní leukémie jsou malignity, které podle různých kritérií nelze jednoznačně zařadit k lymfoidní nebo k myeloidní linii a jejichž chování spíše dává za pravdu novým modelům hematopoezy. Předkládaná práce se zabývala především výzkumem dětských leukémií s přesmykem z lymfoidní do myeloidní linie během indukční léčby. Jedná se o rozsáhlý projekt, v jehož rámci si diplomová práce si kladla za úkol určit liniové zařazení leukemických blastů pomocí detekce přestaveb genů pro imunoglobuliny a T-buněčné receptory (TCR). Potvrdili jsme, že myeloidní buňky derivované v průběhu léčby pochází u všech pacientů z původního lymfoidního klonu. Dále jsme u těchto případů zkoumali expresi vytipovaných genů ve srovnání s běžnými druhy leukémií. Třetí částí práce byl výzkum prognostického významu přítomnosti přestaveb TCR (a tedy příslušnosti k lymfoidní linii) u leukémií z T-lymfoidní řady.