Chemotherapies may increase mutagenesis of healthy cells and change the selective pressures in tissues, thus influencing their evolution. However, their contributions to the mutation burden and clonal expansions of healthy somatic tissues are not clear. Here, exploiting the mutational footprint of some chemotherapies, we explore their influence on the evolution of hematopoietic cells. Cells of Acute Myeloid Leukemia (AML) secondary to treatment with platinum-based drugs show the mutational footprint of these drugs, indicating that non-malignant blood cells receive chemotherapy mutations. No trace of the 5-fluorouracil (5FU) mutational signature is found in AMLs secondary to exposure to 5FU, suggesting that cells establishing the leukemia could be quiescent during treatment. Using the platinum-based mutational signature as a barcode, we determine that the clonal expansion originating the secondary AMLs begins after the start of the cytotoxic treatment. Its absence in clonal hematopoiesis cases is consistent with the start of the clonal expansion predating the exposure to platinum-based drugs.

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Despite emerging molecular information on chronic myelomonocytic leukemia (CMML), patient outcome remains unsatisfactory and little is known about the transformation to acute myeloid leukemia (AML). In a single-center cohort of 219 CMML patients, we explored the potential correlation between clinical features, gene mutations, and treatment regimens with overall survival (OS) and clonal evolution into AML. The most commonly detected mutations were TET2, SRSF2, ASXL1, and RUNX1. Median OS was 34 months and varied according to age, cytogenetic risk, FAB, CPSS and CPSS-Mol categories, and number of gene mutations. Hypomethylating agents were administered to 37 patients, 18 of whom responded. Allogeneic stem cell transplantation (alloSCT) was performed in 22 patients. Two-year OS after alloSCT was 60.6%. Six patients received targeted therapy with IDH or FLT3 inhibitors, three of whom attained a long-lasting response. AML transformation occurred in 53 patients and the analysis of paired samples showed changes in gene mutation status. Our real-world data emphasize that the outcome of CMML patients is still unsatisfactory and alloSCT remains the only potentially curative treatment. However, targeted therapies show promise in patients with specific gene mutations. Complete molecular characterization can help to improve risk stratification, understand transformation, and personalize therapy.

Chemotherapies may influence the evolution of somatic tissues through the introduction of genetic variation in cells and by changing the selective pressures they face. However, the contributions of chemotherapeutic agents to the mutation burden of healthy cells and to clonal expansions in somatic tissues are not clear. Here, we exploit the mutational footprint of some chemotherapies to explore their influence on the evolution of hematopoietic cells. Cells of Acute Myeloid Leukemia (AML) secondary to treatment with platinum-based drugs showed a clear mutational footprint of these drugs, indicating that healthy blood cells received chemotherapy mutations. In contrast, no trace of 5-fluorouracil (5-FU) mutational signature was found in AML secondary to exposure to 5-FU, suggesting that cells establishing the AML were quiescent during treatment. We used the platinum-based mutational signature as a barcode to precisely time clonal expansions with respect to the moment of exposure to the drug. The enrichment for clonal mutations among treatment-related mutations in all platinum treated AMLs shows that these secondary neoplasms begin their clonal expansion after the start of the cytotoxic treatment. In contrast, the absence of detectable platinum-related mutations in healthy blood samples with clonal hematopoiesis is consistent with a clonal expansion that predates the exposure to the cytotoxic agent, which favours particular pre-existing clones.