Introduction: Complex (≥3) abnormalities (cA) are associated with an inferior outcome in myelodysplastic syndromes (MDS). About 50% of MDS with cA show mutations in TP53 that might contribute to the formation of the cA and worsen prognosis (Haase et al., Leukemia, 2019). In former single nucleotid polymorphism (SNP) analysis we found chromosome 17q being affected in several patients with cA with a higher incidence as by chance. In just this region is a gene called PPM1D located which already has been observed as one of the most frequently mutated genes in pts./individuals with clonal hematopoiesis with indetermined significance (CHIP). PPM1D is encoding for a protein named Wip1. This protein acts as an inhibitor of p53. About 5% of MDS with 5q deletions show mutations in PPM1D (Panagiota et al., ASH 2017). Mutations in PPM1D are even more common among pts with therapy-related MDS (15%, Lindsley et al., 2017). The aim of our study was to determine the frequency of PPM1D mutations in MDS with cA and to shed light upon their possible contribution to the formation of cA.
Methods and patients: We included 100 patients characterized by conventional cytogenetics in our analysis (67x MDS; 30x secondary acute myeloid leukemia, AML; 3x chronic myelomonocytic leukemia, CMML). 20 pts had a therapy-related MDS. All the included pts had cA with a median number of aberrations of 8 (range: 3-50). The median age at first diagnosis of MDS with cA was 72 (range 29-95). A deletion of 5q was found in 71 patients (71%). The TP53 status was known for all pts by fluorescence in situ hybridization (FISH) and/or molecular karyotyping (TP53 deletion status) and sequencing (TP53 mutation status). 68 of 100 pts had an alteration on TP53 (68%, 4 deletions, 34 mutations, 30 biallelic changes). All pts were subjected to next generation sequencing of PPM1D. Amplicons for exons 1 to 6 were generated by multiplex polymerase chain reaction (PCR). The pooled amplicons were processed using the Nextera XT2 sample preparation kit (Illumina, San Diego, Ca, USA) followed by sequencing on a MiniSeq platform (Illumina, San Diego, Ca, USA). We used our local bioinformatics pipeline to identify single-nucleotide variants (SNVs) and indels.
Results: In ten pts (10%) we found single-nucleotide variants of PPM1D. The median number of aberrations was 8 (range: 5-15). Six of those PPM1D variants have already been described as very rare SNPs. Three of them were located in the 3'UTR (untranslated region), the other three seem to be silent mutations. The other four are not listed in common databases. Three of those four are potential missense mutations, one is a potential nonsense mutation. Two variants are located at the same -previously undescribed- position (c.230A>C, p.D77A). Two of those four patients showed an additional TP53 mutation, one of them biallelic. A deletion of 5q was identified in two of them. One pt had therapy related MDS. At a clone size of the complex karyotype of 94% and 90%, the VAF of three of the recurrent mutation was just 7% and 8%, indicating that the PPM1D mutation arised in a subclone in these pts. In one pt the VAF was 33,6%. The VAF of 30-38% in the other cases implies PPM1D being an ancestral or co-dominant mutation.
Conclusion: We were able to show that PPM1D is mutated in MDS with cA in a relevant fraction of pts. In our cohort, 10% of MDS pts with cA are affected. 4% may have a deleterious mutation of PPM1D. Although PPM1D mutations were described to preferentially occur in therapy related diseases (Lindsley et al., 2017), in our cohort three of four patients with potential PPM1D mutation had no known prior chemo-/radiation therapy. Mutations in PPM1D might contribute to the formation or toleration of cA alternatively to TP53 mutations as two of four patients with PPM1D mutations did not show TP53 mutations and the PPM1D mutations could be the ancestral or co-dominant mutation in two of four cases. Our data imply that also mutations in PPM1D may be important for prognosis and therapy decisions in MDS patients with cA. We will continue observing our patients in order to enlarge the database and to find out which impact mutations in PPM1D may have on overall survival and whether they can affect the prognosis of patients with cA.
Germing:Jazz Pharmaceuticals: Honoraria; Novartis: Honoraria, Research Funding; Celgene: Honoraria, Research Funding; Amgen: Honoraria. Hertenstein:RS Media: Research Funding. Platzbecker:Novartis: Consultancy, Honoraria, Research Funding; Abbvie: Consultancy, Honoraria; Celgene: Consultancy, Honoraria, Research Funding.
Asterisk with author names denotes non-ASH members.