IntroductionOur understanding of the molecular pathogenesis of myeloid malignancies, most notably acute myeloid leukemia (AML) and chronic myeloid leukemia (CML), has largely resulted from the identification and characterization of recurrent chromosomal translocations. 1 However, in many patients with myeloproliferative neoplasms (MPNs) and chronic myelomonocytic leukemia (CMML), recurrent clonal cytogenetic abnormalities are not observed. More recently, DNA resequencing studies of candidate genes, 2 gene families, 3,4 and the cancer genome 5 in MPN, CMML, and AML have identified somatic mutations in FLT3, 6 JAK2, [7][8][9][10][11][12][13]14,15 and the RAS family of oncogenes. 16 These discoveries demonstrate activation of signal transduction pathways is a common pathogenic event in myeloid malignancies and have led to the development of molecularly targeted therapies. However, with the exception of CML, these therapies have yet to substantively improve outcomes for patients with myeloid malignancies. 17,18 This may reflect insufficient target inhibition, or, alternatively, this may indicate incomplete dependence on these activated pathways resulting from the presence of additional somatic mutations with prognostic, therapeutic, and biologic relevance.The role of TET (Ten-Eleven Translocation) family gene members in hematopoietic transformation was thought to be restricted to the involvement of TET1 as a translocation partner MLL-translocated AML, until the recent identification of inactivating mutations in TET2 in MPN and MDS patients. 19 We therefore sought to evaluate a large set of MPN, CMML, and AML samples for somatic TET2 alterations. We sequenced all coding exons of TET2 in 408 paired tumor/normal samples and then assessed the frequency of somatic TET2 mutations in 606 patients with MPN, CMML, and AML. We also investigated whether deletion or epigenetic inactivation of TET2 are observed in MPN and evaluated MPN patients for somatic mutations in TET1 and TET3. Methods Copy number analysis of TET1, TET2, and TET3A total of 207 MPN tumor samples were analyzed using Affymetrix 250K StyI Arrays. 20 The JAK2V617F-mutant AML cell lines HEL and SET2 were analyzed using Affymetrix 6.0 SNP Arrays. Methylation-specific polymerase chain reactionMethylation of 2 CpG islands in the promoter region of TET2 was assessed in 37 MPN patients and 4 JAK2V617F-positive leukemia cell lines (SET2, MBO2, HEL, UKE1). Methylation-specific polymerase chain reaction was performed as previously described (primers are listed in supplemental Table 1). 21 StatisticsStatistical analyses were performed using MedCalc (MedCalc). Results and discussionSequence analysis of all coding exons of TET2 in 408 paired tumor/normal samples identified 8 frameshift, 12 nonsense, and 37 nonsynonymous alterations not present in dbSNP. Analysis of germ line DNA distinguished between 31 somatic missense mutations and 6 unannotated SNPs (Table 1; supplemental Figure 1); all unannotated SNPs were observed in matched normal tissue in at least 2 samples. Al...

Children with Down syndrome (DS) show a spectrum of clinical anomalies, including cognitive impairment, cardiac malformations, and craniofacial dysmorphy. Moreover, hematologists have also noted that these children commonly show macrocytosis, abnormal platelet counts, and an increased incidence of transient myeloproliferative disease (TMD), acute megakaryocytic leukemia (AMKL), and acute lymphoid leukemia (ALL). In this review, we summarize the clinical manifestations and characteristics of these leukemias, provide an update on therapeutic strategies and patient outcomes, and discuss the most recent advances in DSleukemia research. With the increased knowledge of the way in which trisomy 21 affects hematopoiesis and the specific genetic mutations that are found in DSassociated leukemias, we are well on our way toward designing improved strategies for treating both myeloid and lymphoid malignancies in this high-risk population. (Blood. 2009;113:2619-2628) IntroductionDown syndrome (DS), or constitutional trisomy 21, is the most common human aneuploidy, with an incidence of 1 in 700 births. Nearly 80 different clinical phenotypes have been identified in people with DS, including cognitive impairment, craniofacial dysmorphy, gastrointestinal tract abnormalities, congenital heart defects, endocrine abnormalities, neuropathology leading to dementia, and immunologic defects. With respect to the hematopoietic system, children with DS frequently show macrocytosis, abnormalities in platelet counts, and an increased prevalence of leukemia. 1,2 The incidence of acute lymphoblastic leukemia (ALL; the most common leukemia in childhood) in children with DS is approximately 20-fold higher than in the general population, while the incidence of acute megakaryoblastic leukemia (AMKL) is 500-fold higher. 2 Furthermore, it has been estimated that between 4% and 10% of infants with DS are born with transient myeloproliferative disease (TMD), a clonal disease that is characterized by immature megakaryoblasts in the fetal liver and peripheral blood. 3,4 Although TMD spontaneously disappears in most cases, it is regarded as a preleukemic syndrome; approximately 20% of children diagnosed with TMD develop DS-AMKL within 4 years. The natural history of leukemia in children with DS suggests that trisomy 21 directly and functionally contributes to the malignant transformation of hematopoietic cells. It is important to note, however, that DS is not a classic genomic instability syndrome, as the overall risk of developing cancer, in particular solid tumors, is lower in these people. 5 In line with these data, experiments with a mouse model of DS showed that trisomy for orthologs of about half of the genes on chromosome 21 led to a significant reduction in the number of adenomatous polyposis coli (multiple intestinal neoplasia [APC(min)]-mediated intestinal tumors. 6 To better understand the impact of trisomy 21 on hematopoiesis, studies have been undertaken with human fetal liver cells as well as animal and cell-line models to determine the c...

Adult and fetal hematopoietic stem cells (HSCs) display a glycolytic phenotype, which is required for maintenance of stemness; however, whether mitochondrial respiration is required to maintain HSC function is not known. Here we report that loss of the mitochondrial complex III subunit Rieske iron sulfur protein (RISP) in fetal mouse HSCs allows them to proliferate but impairs their differentiation, resulting in anemia and prenatal death. RISP null fetal HSCs displayed impaired respiration resulting in a decreased NAD+/NADH ratio. RISP null fetal HSCs and progenitors exhibited an increase in both DNA and histone methylation associated with increases in 2-hydroxyglutarate (2-HG), a metabolite known to inhibit DNA and histone demethylases. RISP inactivation in adult HSCs also impaired respiration resulting in loss of quiescence concomitant with severe pancytopenia and lethality. Thus, respiration is dispensable for adult or fetal HSC proliferation, but essential for fetal HSC differentiation and maintenance of adult HSC quiescence.

Individuals with Down syndrome (DS; also known as trisomy 21) have a markedly increased risk of leukemia in childhood but a decreased risk of solid tumors in adulthood. Acquired mutations in the transcription factor-encoding GATA1 gene are observed in nearly all individuals with DS who are born with transient myeloproliferative disorder (TMD), a clonal preleukemia, and/or who develop acute megakaryoblastic leukemia (AMKL). Individuals who do not have DS but bear germline GATA1 mutations analogous to those detected in individuals with TMD and DS-AMKL are not predisposed to leukemia. To better understand the functional contribution of trisomy 21 to leukemogenesis, we used mouse and human cell models of DS to reproduce the multistep pathogenesis of DS-AMKL and to identify chromosome 21 genes that promote megakaryoblastic leukemia in children with DS. Our results revealed that trisomy for only 33 orthologs of human chromosome 21 (Hsa21) genes was sufficient to cooperate with GATA1 mutations to initiate megakaryoblastic leukemia in vivo. Furthermore, through a functional screening of the trisomic genes, we demonstrated that DYRK1A, which encodes dual-specificity tyrosine-(Y)-phosphorylation-regulated kinase 1A, was a potent megakaryoblastic tumor-promoting gene that contributed to leukemogenesis through dysregulation of nuclear factor of activated T cells (NFAT) activation. Given that calcineurin/NFAT pathway inhibition has been implicated in the decreased tumor incidence in adults with DS, our results show that the same pathway can be both proleukemic in children and antitumorigenic in adults. IntroductionTrisomy 21 is the most common cytogenetic abnormality observed at birth (about 1 out of 700 individuals) and one of the most recurrent aneuploidies seen in leukemia. As an acquired clonal chromosomal change, its incidence varies between 4.1% and 14.8% in hematological disorders and malignant lymphomas (1). Supporting the link between trisomy 21 and abnormal hematopoiesis, epidemiological studies have shown that individuals with Down syndrome (DS) have an increased frequency of leukemia but a lower incidence of solid tumors (2). Whereas recent studies implicated a subset of trisomic genes, including Erg, Ets2, Adamts1, and Dscr1, in tumor growth inhibition, in part through an altered angiogenesis (3-6), the role of trisomy 21, the initiating event in DS leukemogenesis, and the functional implication of specific genes at dosage imbalances that predispose to and/or participate in leukemogenesis remain unclear.Children with DS are at an elevated risk of both acute megakaryoblastic leukemia (AMKL) and acute lymphoblastic leukemia (ALL) (7). Moreover, epidemiological studies showed that approximately 4%-5% of children with DS are born with transient myeloproliferative disorder (TMD), a clonal preleukemia characterized by an accumulation of immature megakaryoblasts in the fetal liver and peripheral blood (8,9). Although TMD spontaneously disappears in most cases, TMD clones reemerge as AMKL in 20% of cases within 4 to 5 y...

Oncogenic activation of tyrosine kinase signaling pathway is recurrent in human leukemia. To gain insight into the oncogenic process leading to acute megakaryoblastic leukemia (AMKL), we performed sequence analyses of a subset of oncogenes known to be activated in human myeloid and myeloproliferative disorders. In a series of human AMKL samples from both Down syndrome and non-Down syndrome patients, mutations were identified within KIT, FLT3, JAK2, JAK3, and MPL genes, with a higher frequency in DS than in non-DS patients. The novel mutations were analyzed using