1 4265 144 MICRO-RNA-125A MEDIATES THE EFFECTS OF HYPOMETHYLATING AGENTS IN CHRONIC MYELOMONOCYTIC LEUKEMIA. BACKGROUND: CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML) IS AN AGGRESSIVE HEMATOPOIETIC MALIGNANCY THAT ARISES FROM HEMATOPOIETIC STEM AND PROGENITOR CELLS (HSPCS). PATIENTS WITH CMML ARE FREQUENTLY TREATED WITH EPIGENETIC THERAPEUTIC APPROACHES, IN PARTICULAR THE HYPOMETHYLATING AGENTS (HMAS), AZACITIDINE (AZA) AND DECITABINE (DEC). ALTHOUGH HMAS ARE BELIEVED TO MEDIATE THEIR EFFICACY VIA RE-EXPRESSION OF HYPERMETHYLATED TUMOR SUPPRESSORS, KNOWLEDGE ABOUT RELEVANT HMA TARGETS IS SCARCE. AS SILENCING OF TUMOR-SUPPRESSIVE MICRO-RNAS (MIRS) BY PROMOTER HYPERMETHYLATION IS A CRUCIAL STEP IN MALIGNANT TRANSFORMATION, WE ASKED FOR A ROLE OF MIRS IN HMA EFFICACY IN CMML. RESULTS: INITIALLY, WE PERFORMED GENOME-WIDE MIR-EXPRESSION PROFILING IN A KRAS(G12D)-INDUCED CMML MOUSE MODEL. SELECTED CANDIDATES WITH PROMINENTLY DECREASED EXPRESSION WERE VALIDATED BY QPCR IN CMML MICE AND HUMAN CMML PATIENTS. THESE EXPERIMENTS REVEALED THE CONSISTENT DECREASE IN MIR-125A, A MIR WITH PREVIOUSLY DESCRIBED TUMOR-SUPPRESSIVE FUNCTION IN MYELOID NEOPLASIAS. FURTHERMORE, WE SHOW THAT MIR-125A DOWNREGULATION IS CAUSED BY HYPERMETHYLATION OF ITS UPSTREAM REGION AND CAN BE REVERSED BY HMA TREATMENT. BY EMPLOYING BOTH LENTIVIRAL AND CRISPR/CAS9-BASED MIR-125A MODIFICATION, WE DEMONSTRATE THAT HMA-INDUCED MIR-125A UPREGULATION INDEED CONTRIBUTES TO MEDIATING THE ANTI-LEUKEMIC EFFECTS OF THESE DRUGS. THESE DATA WERE VALIDATED IN A CLINICAL CONTEXT, AS MIR-125A EXPRESSION INCREASED AFTER HMA TREATMENT IN CMML PATIENTS, A PHENOMENON THAT WAS PARTICULARLY PRONOUNCED IN CASES SHOWING CLINICAL RESPONSE TO THESE DRUGS. CONCLUSIONS: TAKEN TOGETHER, WE REPORT DECREASED EXPRESSION OF MIR-125A IN CMML AND DELINEATE ITS RELEVANCE AS MEDIATOR OF HMA EFFICACY WITHIN THIS NEOPLASIA. 2021 2 2582 29 EPIGENETICS OF MYELODYSPLASTIC SYNDROMES. MYELODYSPLASTIC SYNDROMES (MDS) ARE CLONAL DISEASES OF THE ELDERLY CHARACTERIZED BY CHRONIC CYTOPENIAS, DYSPLASIA AND A VARIABLE RISK OF PROGRESSION TO ACUTE MYELOID LEUKEMIA (AML). ABERRANT METHYLATION OF TUMOR-SUPPRESSOR GENE PROMOTERS HAS BEEN ESTABLISHED FOR MANY YEARS AND RECENTLY TRACKED TO THE MOST IMMATURE CELLS OF MDS, SUGGESTING THAT THESE ALTERATIONS ARE DRIVERS OF MDS PATHOGENESIS. IN RECENT YEARS, RECURRENT SOMATIC MUTATIONS IN GENES ENCODING PROTEINS INVOLVED IN DNA METHYLATION AND DEMETHYLATION AND IN COVALENT HISTONE MODIFICATIONS HAVE BEEN REPORTED IN MYELOID MALIGNANCIES, INCLUDING MDS. WHOLE-GENOME EPIGENETIC PROFILES OF MDS ARE ALSO EMERGING. IN PARALLEL WITH THESE ADVANCES IN THE MOLECULAR PATHOGENESIS OF MDS, CLINICAL TRIALS HAVE ESTABLISHED HYPOMETHYLATING AGENTS (HMAS) AS THE MAINSTAY OF THERAPY IN THE ADVANCED FORMS OF THE DISEASE. IN THIS REVIEW, WE SUMMARIZE THE CURRENT UNDERSTANDING OF THE MOLECULAR MACHINERY INVOLVED IN EPIGENETIC REGULATION, DISCUSS HOW EPIGENETIC ALTERATIONS ARISE IN MDS AND CONTRIBUTE TO ITS PATHOGENESIS AND THEN DISCUSS THE MODE OF ACTION OF HMAS IN MDS. 2014 3 6780 40 [BLASTIC PLASMACYTOID DENDRITIC CELL NEOPLASM ACCOMPANIED BY CHRONIC MYELOMONOCYTIC LEUKEMIA SUCCESSFULLY TREATED WITH AZACITIDINE]. BLASTIC PLASMACYTOID DENDRITIC CELL NEOPLASM (BPDCN) IS A RARE DISEASE THAT DEVELOPS WITH A SKIN LESION AND IS OFTEN ACCOMPANIED BY LEUKEMIC TRANSFORMATION. THE NORMAL COUNTERPARTS OF BPDCN TUMOR CELLS ARE PROGENITORS OF PLASMACYTOID DENDRITIC CELLS, WHEREAS THE ORIGINS ARE THOUGHT TO BE HEMATOPOIETIC STEM CELLS. APPROXIMATELY 10%-20% OF BPDCN PATIENTS DEVELOP OTHER HEMATOLOGIC MALIGNANCIES, INCLUDING CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML). MUTATIONS IN EPIGENETIC REGULATORS ARE FREQUENTLY OBSERVED IN BOTH BPDCN AND CMML TUMORS. AZACITIDINE, A DRUG THAT TARGETS EPIGENETIC DYSREGULATION, IS KNOWN TO BE AN EFFECTIVE TREATMENT FOR CMML. HOWEVER, IT HAS BEEN USED IN FEW BPDCN PATIENTS. HERE, WE REPORT A BPDCN PATIENT WITH SKIN LESIONS, BONE MARROW INFILTRATION, AND LYMPHADENOPATHY. CMML ALSO DEVELOPED DURING THE COURSE OF BPDCN. AZACITIDINE HAD POSITIVE EFFECTS ON CMML; HOWEVER, BPDCN AGGRESSIVELY RELAPSED DURING TREATMENT. TWO TET2 MUTATIONS WERE FOUND IN BOTH BPDCN AND CMML TUMORS; ONE OF WHICH WAS COMMONLY IDENTIFIED IN BOTH TUMORS. 2018 4 205 28 ACTIVATION OF HLA-G EXPRESSION BY 5-AZA-2 - DEOXYCYTIDINE IN MALIGNANT HEMATOPOETIC CELLS ISOLATED FROM LEUKEMIA PATIENTS. HUMAN LEUKOCYTE ANTIGEN - G (HLA-G) IS A NON-CLASSICAL HLA CLASS I ANTIGEN WITH RESTRICTED DISTRIBUTION IN NORMAL TISSUES. ECTOPIC HLA-G EXPRESSION OBSERVED AT SOME PATHOLOGICAL CIRCUMSTANCES AS MALIGNANT TRANSFORMATION MIGHT BE TRIGGERED BY EPIGENETIC MODIFICATIONS SUCH AS DNA DEMETHYLATION. RECENTLY IT WAS DEMONSTRATED THAT DNA METHYLTRANSFERASE INHIBITOR 5-AZA-2 - DEOXYCYTIDINE (ADC) INDUCES/ENHANCES HLA-G TRANSCRIPTION IN MANY LEUKEMIA CELL LINES OF DIFFERENT ORIGIN. HERE WE INVESTIGATED THE EFFECT OF ADC ON HLA-G EXPRESSION IN MALIGNANT HEMATOPOETIC CELLS ISOLATED FROM PATIENTS WITH ACUTE MYELOID LEUKEMIA (AML) AND CHRONIC LYMPHOCYTIC LEUKEMIA (B-CLL). WE DETECTED HLA-G EXPRESSION IN UNTREATED CELLS FROM SOME PATIENTS. NEVERTHELESS TREATMENT WITH 5-AZA-2 - DEOXYCYTIDINE ENHANCED HLA-G TRANSCRIPTION AND CONCOMITANTLY HLA-G PROTEIN SYNTHESIS IN SOME LEUKEMIA CELLS. 2009 5 3878 39 KDM6B OVEREXPRESSION ACTIVATES INNATE IMMUNE SIGNALING AND IMPAIRS HEMATOPOIESIS IN MICE. KDM6B IS AN EPIGENETIC REGULATOR THAT MEDIATES TRANSCRIPTIONAL ACTIVATION DURING DIFFERENTIATION, INCLUDING IN BONE MARROW (BM) HEMATOPOIETIC STEM AND PROGENITOR CELLS (HSPCS). OVEREXPRESSION OF KDM6B HAS BEEN REPORTED IN BM HSPCS OF PATIENTS WITH MYELODYSPLASTIC SYNDROMES (MDS) AND CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML). WHETHER THE OVEREXPRESSION OF KDM6B CONTRIBUTES TO THE PATHOGENESIS OF THESE DISEASES REMAINS TO BE ELUCIDATED. TO STUDY THIS, WE GENERATED A VAV-KDM6B MOUSE MODEL, WHICH OVEREXPRESSES KDM6B IN THE HEMATOPOIETIC COMPARTMENT. KDM6B OVEREXPRESSION ALONE LED TO MILD HEMATOPOIETIC PHENOTYPE, AND CHRONIC INNATE IMMUNE STIMULATION OF VAV-KDM6B MICE WITH THE TOLL-LIKE RECEPTOR (TLR) LIGAND LIPOPOLYSACCHARIDE (LPS) RESULTED IN SIGNIFICANT HEMATOPOIETIC DEFECTS. THESE DEFECTS RECAPITULATED FEATURES OF MDS AND CMML, INCLUDING LEUKOPENIA, DYSPLASIA, AND COMPROMISED REPOPULATING FUNCTION OF BM HSPCS. TRANSCRIPTOME STUDIES INDICATED THAT KDM6B OVEREXPRESSION ALONE COULD LEAD TO ACTIVATION OF DISEASE-RELEVANT GENES SUCH AS S100A9 IN BM HSPCS, AND WHEN COMBINED WITH INNATE IMMUNE STIMULATION, KDM6B OVEREXPRESSION RESULTED IN MORE PROFOUND OVEREXPRESSION OF INNATE IMMUNE AND DISEASE-RELEVANT GENES, INDICATING THAT KDM6B WAS INVOLVED IN THE ACTIVATION OF INNATE IMMUNE SIGNALING IN BM HSPCS. FINALLY, PHARMACOLOGIC INHIBITION OF KDM6B WITH THE SMALL MOLECULE INHIBITOR GSK-J4 AMELIORATED THE INEFFECTIVE HEMATOPOIESIS OBSERVED IN VAV-KDM6B MICE. THIS EFFECT WAS ALSO OBSERVED WHEN GSK-J4 WAS APPLIED TO THE PRIMARY BM HSPCS OF PATIENTS WITH MDS BY IMPROVING THEIR REPOPULATING FUNCTION. THESE RESULTS INDICATE THAT OVEREXPRESSION OF KDM6B MEDIATES ACTIVATION OF INNATE IMMUNE SIGNALS AND HAS A ROLE IN MDS AND CMML PATHOGENESIS, AND THAT KDM6B TARGETING HAS THERAPEUTIC POTENTIAL IN THESE MYELOID DISORDERS. 2018 6 1184 29 COOPERATIVE EPIGENETIC REMODELING BY TET2 LOSS AND NRAS MUTATION DRIVES MYELOID TRANSFORMATION AND MEK INHIBITOR SENSITIVITY. MUTATIONS IN EPIGENETIC MODIFIERS AND SIGNALING FACTORS OFTEN CO-OCCUR IN MYELOID MALIGNANCIES, INCLUDING TET2 AND NRAS MUTATIONS. CONCURRENT TET2 LOSS AND NRAS(G12D) EXPRESSION IN HEMATOPOIETIC CELLS INDUCED MYELOID TRANSFORMATION, WITH A FULLY PENETRANT, LETHAL CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML), WHICH WAS SERIALLY TRANSPLANTABLE. TET2 LOSS AND NRAS MUTATION COOPERATIVELY LED TO DECREASE IN NEGATIVE REGULATORS OF MITOGEN-ACTIVATED PROTEIN KINASE (MAPK) ACTIVATION, INCLUDING SPRY2, THEREBY CAUSING SYNERGISTIC ACTIVATION OF MAPK SIGNALING BY EPIGENETIC SILENCING. TET2/NRAS DOUBLE-MUTANT LEUKEMIA SHOWED PREFERENTIAL SENSITIVITY TO MAPK KINASE (MEK) INHIBITION IN BOTH MOUSE MODEL AND PATIENT SAMPLES. THESE DATA PROVIDE INSIGHTS INTO HOW EPIGENETIC AND SIGNALING MUTATIONS COOPERATE IN MYELOID TRANSFORMATION AND PROVIDE A RATIONALE FOR MECHANISM-BASED THERAPY IN CMML PATIENTS WITH THESE HIGH-RISK GENETIC LESIONS. 2018 7 2277 34 EPIGENETIC REGULATION BY ASXL1 IN MYELOID MALIGNANCIES. MYELOID MALIGNANCIES ARE CLONAL HEMATOPOIETIC DISORDERS THAT ARE COMPRISED OF A SPECTRUM OF GENETICALLY HETEROGENEOUS DISORDERS, INCLUDING MYELODYSPLASTIC SYNDROMES (MDS), MYELOPROLIFERATIVE NEOPLASMS (MPN), CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML), AND ACUTE MYELOID LEUKEMIA (AML). MYELOID MALIGNANCIES ARE CHARACTERIZED BY EXCESSIVE PROLIFERATION, ABNORMAL SELF-RENEWAL, AND/OR DIFFERENTIATION DEFECTS OF HEMATOPOIETIC STEM CELLS (HSCS) AND MYELOID PROGENITOR CELLS HEMATOPOIETIC STEM/PROGENITOR CELLS (HSPCS). MYELOID MALIGNANCIES CAN BE CAUSED BY GENETIC AND EPIGENETIC ALTERATIONS THAT PROVOKE KEY CELLULAR FUNCTIONS, SUCH AS SELF-RENEWAL, PROLIFERATION, BIASED LINEAGE COMMITMENT, AND DIFFERENTIATION. ADVANCES IN NEXT-GENERATION SEQUENCING LED TO THE IDENTIFICATION OF MULTIPLE MUTATIONS IN MYELOID NEOPLASMS, AND MANY NEW GENE MUTATIONS WERE IDENTIFIED AS KEY FACTORS IN DRIVING THE PATHOGENESIS OF MYELOID MALIGNANCIES. THE POLYCOMB PROTEIN ASXL1 WAS IDENTIFIED TO BE FREQUENTLY MUTATED IN ALL FORMS OF MYELOID MALIGNANCIES, WITH MUTATIONAL FREQUENCIES OF 20%, 43%, 10%, AND 20% IN MDS, CMML, MPN, AND AML, RESPECTIVELY. SIGNIFICANTLY, ASXL1 MUTATIONS ARE ASSOCIATED WITH A POOR PROGNOSIS IN ALL FORMS OF MYELOID MALIGNANCIES. THE FACT THAT ASXL1 MUTATIONS ARE ASSOCIATED WITH POOR PROGNOSIS IN PATIENTS WITH CMML, MDS, AND AML, POINTS TO THE POSSIBILITY THAT ASXL1 MUTATION IS A KEY FACTOR IN THE DEVELOPMENT OF MYELOID MALIGNANCIES. THIS REVIEW SUMMARIZES THE RECENT ADVANCES IN UNDERSTANDING MYELOID MALIGNANCIES WITH A SPECIFIC FOCUS ON ASXL1 MUTATIONS. 2023 8 2760 37 EXPRESSION OF PD-L1, PD-L2, PD-1 AND CTLA4 IN MYELODYSPLASTIC SYNDROMES IS ENHANCED BY TREATMENT WITH HYPOMETHYLATING AGENTS. BLOCKADE OF IMMUNE CHECKPOINTS IS EMERGING AS A NEW FORM OF ANTICANCER THERAPY. WE STUDIED THE EXPRESSION OF PROGRAMMED DEATH LIGAND 1 (PD-L1), PD-L2, PROGRAMMED DEATH 1 (PD-1) AND CYTOTOXIC T LYMPHOCYTE-ASSOCIATED ANTIGEN 4 (CTLA4) MRNA IN CD34+ CELLS FROM MYELODYSPLASTIC SYNDROME (MDS), CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML) AND ACUTE MYELOID LEUKEMIA (AML) PATIENTS (N=124). ABERRANT UPREGULATION (?2-FOLD) WAS OBSERVED IN 34, 14, 15 AND 8% OF THE PATIENTS. INCREASED EXPRESSION OF THESE FOUR GENES WAS ALSO OBSERVED IN PERIPHERAL BLOOD MONONUCLEAR CELLS (PBMNCS) (N=61). THE RELATIVE EXPRESSION OF PD-L1 FROM PBMNC WAS SIGNIFICANTLY HIGHER IN MDS (P=0.018) AND CMML (P=0.0128) COMPARED WITH AML. BY IMMUNOHISTOCHEMICAL ANALYSIS, PD-L1 PROTEIN EXPRESSION WAS OBSERVED IN MDS CD34+ CELLS, WHEREAS STROMA/NON-BLAST CELLULAR COMPARTMENT WAS POSITIVE FOR PD-1. IN A COHORT OF PATIENTS TREATED WITH EPIGENETIC THERAPY, PD-L1, PD-L2, PD-1 AND CTLA4 EXPRESSION WAS UPREGULATED. PATIENTS RESISTANT TO THERAPY HAD RELATIVE HIGHER INCREMENTS IN GENE EXPRESSION COMPARED WITH PATIENTS WHO ACHIEVED RESPONSE. TREATMENT OF LEUKEMIA CELLS WITH DECITABINE RESULTED IN A DOSE-DEPENDENT UPREGULATION OF ABOVE GENES. EXPOSURE TO DECITABINE RESULTED IN PARTIAL DEMETHYLATION OF PD-1 IN LEUKEMIA CELL LINES AND HUMAN SAMPLES. THIS STUDY SUGGESTS THAT PD-1 SIGNALING MAY BE INVOLVED IN MDS PATHOGENESIS AND RESISTANCE MECHANISMS TO HYPOMETHYLATING AGENTS. BLOCKADE OF THIS PATHWAY CAN BE A POTENTIAL THERAPY IN MDS AND AML. 2014 9 6512 42 TRANSCRIPTION INTERMEDIARY FACTOR 1GAMMA IS A TUMOR SUPPRESSOR IN MOUSE AND HUMAN CHRONIC MYELOMONOCYTIC LEUKEMIA. TRANSCRIPTION INTERMEDIARY FACTOR 1GAMMA (TIF1GAMMA) WAS SUGGESTED TO PLAY A ROLE IN ERYTHROPOIESIS. HOWEVER, HOW TIF1GAMMA REGULATES THE DEVELOPMENT OF DIFFERENT BLOOD CELL LINEAGES AND WHETHER TIF1GAMMA IS INVOLVED IN HUMAN HEMATOLOGICAL MALIGNANCIES REMAIN TO BE DETERMINED. HERE WE HAVE SHOWN THAT TIF1GAMMA WAS A TUMOR SUPPRESSOR IN MOUSE AND HUMAN CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML). LOSS OF TIF1G IN MOUSE HSCS FAVORED THE EXPANSION OF THE GRANULO-MONOCYTIC PROGENITOR COMPARTMENT. FURTHERMORE, TIF1G DELETION INDUCED THE AGE-DEPENDENT APPEARANCE OF A CELL-AUTONOMOUS MYELOPROLIFERATIVE DISORDER IN MICE THAT RECAPITULATED ESSENTIAL CHARACTERISTICS OF HUMAN CMML. TIF1GAMMA WAS ALMOST UNDETECTABLE IN LEUKEMIC CELLS OF 35% OF CMML PATIENTS. THIS DOWNREGULATION WAS RELATED TO THE HYPERMETHYLATION OF CPG SEQUENCES AND SPECIFIC HISTONE MODIFICATIONS IN THE GENE PROMOTER. A DEMETHYLATING AGENT RESTORED THE NORMAL EPIGENETIC STATUS OF THE TIF1G PROMOTER IN HUMAN CELLS, WHICH CORRELATED WITH A REESTABLISHMENT OF TIF1GAMMA EXPRESSION. TOGETHER, THESE RESULTS DEMONSTRATE THAT TIF1G IS AN EPIGENETICALLY REGULATED TUMOR SUPPRESSOR GENE IN HEMATOPOIETIC CELLS AND SUGGEST THAT CHANGES IN TIF1GAMMA EXPRESSION MAY BE A BIOMARKER OF RESPONSE TO DEMETHYLATING AGENTS IN CMML. 2011 10 4557 22 MUTATIONS IN ASXL1 ARE ASSOCIATED WITH POOR PROGNOSIS ACROSS THE SPECTRUM OF MALIGNANT MYELOID DISEASES. THE ASXL1 GENE IS ONE OF THE MOST FREQUENTLY MUTATED GENES IN MALIGNANT MYELOID DISEASES. THE ASXL1 PROTEIN BELONGS TO PROTEIN COMPLEXES INVOLVED IN THE EPIGENETIC REGULATION OF GENE EXPRESSION. ASXL1 MUTATIONS ARE FOUND IN MYELOPROLIFERATIVE NEOPLASMS (MPN), MYELODYSPLASTIC SYNDROMES (MDS), CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML) AND ACUTE MYELOID LEUKEMIA (AML). THEY ARE GENERALLY ASSOCIATED WITH SIGNS OF AGGRESSIVENESS AND POOR CLINICAL OUTCOME. BECAUSE OF THIS, A SYSTEMATIC DETERMINATION OF ASXL1 MUTATIONAL STATUS IN MYELOID MALIGNANCIES SHOULD HELP IN PROGNOSIS ASSESSMENT. 2012 11 4876 32 OVEREXPRESSION OF ARGINASE 1 IS LINKED TO DNMT3A AND TET2 MUTATIONS IN LOWER-GRADE MYELODYSPLASTIC SYNDROMES AND CHRONIC MYELOMONOCYTIC LEUKEMIA. IMMUNE DYSREGULATION IS A COMMON FEATURE OF MYELODYSPLASTIC SYNDROMES (MDS) AND CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML), PARTICULARLY IN EARLY STAGES. HOWEVER, THE GENETIC BASIS REMAINS POORLY UNDERSTOOD. WE RECENTLY REPORTED THAT MACROPHAGES FROM MICE DEFICIENT IN TET METHYLCYTOSINE DIOXYGENASE 2 (TET2), A MODEL OF MDS/CMML, ARE HYPERINFLAMMATORY AND HAVE INCREASED EXPRESSION OF ARGINASE 1 (ARG1). IN MACROPHAGES AND MYELOID DERIVED SUPPRESSOR CELLS (MDSCS) EXPRESSION OF ARG1 CONTRIBUTES TO T-CELL SUPPRESSION AND IMMUNE EVASION BY L-ARGININE DEPLETION, IN THE SETTING OF CHRONIC INFLAMMATION AND CANCER. SINCE HUMAN MDS AND CMML ARE DRIVEN BY TET2 MUTATIONS AND ASSOCIATED WITH CHRONIC INFLAMMATION, WE HYPOTHESIZED THAT ARGINASE ENZYMATIC ACTIVITY AND ARG1 EXPRESSION WOULD BE INCREASED IN HUMAN MDS/CMML BONE MARROW. ELEVATED ARGINASE ACTIVITY WAS OBSERVED IN BONE MARROW MONONUCLEAR CELLS OF MDS AND CMML PATIENTS WITH LOWER-GRADE FEATURES. IMMUNOHISTOCHEMICAL STUDIES CONFIRMED THAT MYELOMONOCYTIC CELLS OVEREXPRESS ARG1. ADDITIONALLY, MUTATIONS IN THE EPIGENETIC REGULATORS TET2 AND DNMT3A CORRESPONDED TO HIGH ARG1 EXPRESSION AND ACTIVITY. THESE FINDINGS SUGGEST ARG1 IS A BIOMARKER OF IMMUNE DYSREGULATION IN EARLY MDS AND CMML. RECENT MURINE FINDINGS HAVE IMPLICATED TET2 AND DNMT3A IN REGULATION OF INNATE IMMUNITY. OUR STUDY SUGGESTS SIMILAR CHANGES MAY BE DRIVEN BY HUMAN TET2 AND DNMT3A MUTATIONS. 2018 12 3877 37 KDM6A PROMOTES IMATINIB RESISTANCE THROUGH YY1-MEDIATED TRANSCRIPTIONAL UPREGULATION OF TRKA INDEPENDENTLY OF ITS DEMETHYLASE ACTIVITY IN CHRONIC MYELOGENOUS LEUKEMIA. RATIONALE: DESPITE LANDMARK THERAPY OF CHRONIC MYELOGENOUS LEUKEMIA (CML) WITH TYROSINE KINASE INHIBITORS (TKIS), DRUG RESISTANCE REMAINS PROBLEMATIC. CANCER PATHOGENESIS INVOLVES EPIGENETIC DYSREGULATION AND IN PARTICULAR, HISTONE LYSINE DEMETHYLASES (KDMS) HAVE BEEN IMPLICATED IN TKI RESISTANCE. WE SOUGHT TO IDENTIFY KDMS WITH ALTERED EXPRESSION IN CML AND DEFINE THEIR CONTRIBUTION TO IMATINIB RESISTANCE. METHODS: BIOINFORMATICS SCREENING COMPARED KDM EXPRESSION IN CML VERSUS NORMAL BONE MARROW WITH SHRNA KNOCKDOWN AND FLOW CYTOMETRY USED TO MEASURE EFFECTS ON IMATINIB-INDUCED APOPTOSIS IN K562 CELLS. TRANSCRIPTOMIC ANALYSES WERE PERFORMED AGAINST KDM6A CRISPR KNOCKOUT/SHRNA KNOCKDOWN K562 CELLS ALONG WITH GENE RESCUE EXPERIMENTS USING WILDTYPE AND MUTANT DEMETHYLASE-DEAD KDM6A CONSTRUCTS. CO-IMMUNOPRECIPITATION, LUCIFERASE REPORTER AND CHIP WERE EMPLOYED TO ELUCIDATE MECHANISMS OF KDM6A-DEPENDENT RESISTANCE. RESULTS: AMONGST FIVE KDMS UPREGULATED IN CML, ONLY KDM6A DEPLETION SENSITIZED CML CELLS TO IMATINIB-INDUCED APOPTOSIS. RE-INTRODUCTION OF DEMETHYLASE-DEAD KDM6A AS WELL AS WILD-TYPE KDM6A RESTORED IMATINIB RESISTANCE. RNA-SEQ IDENTIFIED NTRK1 GENE DOWNREGULATION AFTER DEPLETION OF KDM6A. MOREOVER, NTRK1 EXPRESSION POSITIVELY CORRELATED WITH KDM6A IN A SUBSET OF CLINICAL CML SAMPLES AND KDM6A KNOCKDOWN IN FRESH CML ISOLATES DECREASED NTRK1 ENCODED PROTEIN (TRKA) EXPRESSION. MECHANISTICALLY, KDM6A WAS RECRUITED TO THE NTRK1 PROMOTER BY THE TRANSCRIPTION FACTOR YY1 WITH SUBSEQUENT TRKA UPREGULATION ACTIVATING DOWN-STREAM SURVIVAL PATHWAYS TO INVOKE IMATINIB RESISTANCE. CONCLUSION: CONTRARY TO ITS REPORTED ROLE AS A TUMOR SUPPRESSOR AND INDEPENDENT OF ITS DEMETHYLASE FUNCTION, KDM6A PROMOTES IMATINIB-RESISTANCE IN CML CELLS. THE IDENTIFICATION OF THE KDM6A/YY1/TRKA AXIS AS A NOVEL IMATINIB-RESISTANCE MECHANISM REPRESENTS AN UNEXPLORED AVENUE TO OVERCOME TKI RESISTANCE IN CML. 2021 13 5911 27 TARGETED NEXT-GENERATION SEQUENCING IN MYELODYSPLASTIC SYNDROME AND CHRONIC MYELOMONOCYTIC LEUKEMIA AIDS DIAGNOSIS IN CHALLENGING CASES AND IDENTIFIES FREQUENT SPLICEOSOME MUTATIONS IN TRANSFORMED ACUTE MYELOID LEUKEMIA. OBJECTIVES: OPTIMAL INTEGRATION OF NEXT-GENERATION SEQUENCING (NGS) INTO CLINICAL PRACTICE IN HEMATOLOGIC MALIGNANCIES REMAINS UNCLEAR. WE EVALUATE THE UTILITY OF NGS IN MYELOID MALIGNANCIES. METHODS: A 42-GENE PANEL WAS USED TO SEQUENCE 109 CASES OF MYELODYSPLASTIC SYNDROME (MDS, N = 38), CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML, N = 14), MYELOPROLIFERATIVE NEOPLASM (MPN, N = 24), AND MDS AND/OR MPN TRANSFORMED TO ACUTE MYELOID LEUKEMIA (AML, N = 33). RESULTS: AT LEAST ONE PATHOGENIC MUTATION WAS IDENTIFIED IN 74% OF CASES OF MDS, 100% OF CMMLS, AND 96% OF MPNS. IN CONTRAST, ONLY 47% OF CASES OF MDS (18/38) AND 7% (1/14) OF CMMLS EXHIBITED ABNORMAL CYTOGENETICS. IN DIAGNOSTICALLY DIFFICULT CASES OF MDS OR CMML WITH NORMAL CYTOGENETICS, NGS IDENTIFIED A PATHOGENIC MUTATION AND WAS CRITICAL IN ESTABLISHING THE CORRECT DIAGNOSIS. SPLICEOSOMAL GENES AND EPIGENETIC MODIFIERS WERE FREQUENTLY MUTATED. SPLICEOSOME MUTATIONS WERE ALSO FREQUENTLY DETECTED IN AML ARISING FROM MDS, CMML, OR MPN (39%) COMPARED WITH THE REPORTED RATE IN DE NOVO AML (7%-14%). CONCLUSIONS: IN DIFFICULT CASES OF MDS OR MPN, NGS FACILITATES DIAGNOSIS BY DETECTION OF GENE MUTATIONS TO CONFIRM CLONALITY, AND AMLS EVOLVING FROM MDS OR MPN CARRY FREQUENT MUTATIONS IN SPLICEOSOMAL GENES. 2016 14 2971 29 GENETIC AND EPIGENETIC SILENCING OF MICRORNA-203 ENHANCES ABL1 AND BCR-ABL1 ONCOGENE EXPRESSION. THE MAMMALIAN GENOME CONTAINS SEVERAL HUNDRED MICRORNAS THAT REGULATE GENE EXPRESSION THROUGH MODULATION OF TARGET MRNAS. HERE, WE REPORT A FRAGILE CHROMOSOMAL REGION LOST IN SPECIFIC HEMATOPOIETIC MALIGNANCIES. THIS 7 MB REGION ENCODES ABOUT 12% OF ALL GENOMIC MICRORNAS, INCLUDING MIR-203. THIS MICRORNA IS ADDITIONALLY HYPERMETHYLATED IN SEVERAL HEMATOPOIETIC TUMORS, INCLUDING CHRONIC MYELOGENOUS LEUKEMIAS AND SOME ACUTE LYMPHOBLASTIC LEUKEMIAS. A PUTATIVE MIR-203 TARGET, ABL1, IS SPECIFICALLY ACTIVATED IN THESE HEMATOPOIETIC MALIGNANCIES IN SOME CASES AS A BCR-ABL1 FUSION PROTEIN (PHILADELPHIA CHROMOSOME). RE-EXPRESSION OF MIR-203 REDUCES ABL1 AND BCR-ABL1 FUSION PROTEIN LEVELS AND INHIBITS TUMOR CELL PROLIFERATION IN AN ABL1-DEPENDENT MANNER. THUS, MIR-203 FUNCTIONS AS A TUMOR SUPPRESSOR, AND RE-EXPRESSION OF THIS MICRORNA MIGHT HAVE THERAPEUTIC BENEFITS IN SPECIFIC HEMATOPOIETIC MALIGNANCIES. 2008 15 6574 30 TREATMENT OF CHRONIC MYELOMONOCYTIC LEUKEMIA WITH 5-AZACYTIDINE: CASE REPORTS. EPIGENETIC THERAPY WITH HYPOMETHYLATING AGENT (5-AZACYTIDINE; AZA) IS COMMON IN THE MANAGEMENT OF SPECIFIC SUBTYPES OF MYELODYSPLASTIC SYNDROME (MDS), BUT THERE ARE ONLY FEW STUDIES IN CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML) PATIENTS. IN THIS PAPER OUR EXPERIENCE WITH 3 CMML PATIENTS TREATED WITH AZA IS DESCRIBED. IN ONE PATIENT TRANSFUSION INDEPENDENCY WAS OBSERVED AFTER 4 TREATMENT CYCLES; IN ONE CASE A PARTIAL RESPONSE WAS RECORDED, BUT A PROGRESSION TO ACUTE MYELOID LEUKEMIA (AML) AFTER 13 AZA CYCLES HAS APPEARED. IN ONE PATIENT, AZA IN REDUCED DOSAGE WAS ADMINISTERED AS A BRIDGING TREATMENT BEFORE ALLOGENEIC STEM CELL TRANSPLANTATION (ASCT), BUT IN THE CONTROL BONE MARROW ASPIRATE (BEFORE ASCT) A PROGRESSION TO AML WAS RECORDED. FUTURE STUDIES ARE MANDATORY FOR EVALUATION OF NEW MOLECULAR AND CLINICAL FEATURES WHICH COULD PREDICT THE EFFICIENCY OF HYPOMETHYLATING AGENTS IN CMML THERAPY WITH RESPECT TO OVERALL SURVIVAL, EVENT-FREE SURVIVAL, QUALITY-ADJUSTED LIFE YEAR, AND PHARMACOECONOMY. 2012 16 6793 34 [DOWN-REGULATION OF TRANSCRIPTION FACTOR PU.1 VIA ABNORMAL EPIGENETIC MODIFICATION IN CHRONIC MYELOID LEUKEMIA]. OBJECTIVE: TO INVESTIGATE THE UNDERLYING MECHANISM AND CLINICAL SIGNIFICANCE OF PU.1 DOWN-EXPRESSION IN CHRONIC MYELOID LEUKEMIA (CML) PATIENTS. METHODS: DIFFERENT METHYLATION STATUS OF PU.1 PROMOTER REGION CONTAINING 20 CPG ISLANDS IN NORMAL INDIVIDUALS, CML CHRONIC PHASE AND BLAST CRISIS PATIENTS, COMPLETE CYTOGENETIC REMISSION PATIENTS AFTER IMATINIB TREATMENT, AND BLAST CRISIS BONE MARROW K562 CML CELLS WAS DETECTED BY BISULFITE SEQUENCING. SEMI-QUANTITATIVE PCR WAS USED TO DETECT THE PU.1 MRNA EXPRESSION IN NORMAL CONTROLS, CML CHRONIC PHASE AND BLAST CRISIS PATIENTS, AND BLAST CRISIS BONE MARROW K562 CML CELLS. INDIRECT IMMUNE FLUORESCENCE AND WESTERN BLOT WERE USED TO ANALYZE THE EXPRTESSION OF PU.1 PROTEIN IN NORMAL INDIVIDUALS, CML CHRONIC PHASE AND BLAST CRISIS PATIENTS, AND BLAST CRISIS BONE MARROW K562 CML CELLS. RESULTS: ABERRANT METHYLATION IN THE PROMOTER REGION OF TRANSCRIPTION FACTOR PU.1 WAS FOUND IN BOTH CML CHRONIC PHASE AND BLAST CRISIS PHASE BONE MARROW CELLS, AS WELL AS IN CML BLAST K562 CELLS. DOWN-EXPRESSION OF PU.1 MRNA AND PROTEIN LEVELS WAS FOUND IN ABOVE CELLS. NO METHYLATION IN THE PROMOTER REGION OF PU.1 WAS OBSERVED IN NORMAL INDIVIDUALS, AND THE PU.1 MRNA AND PROTEIN EXPRESSIONS WERE NOT REDUCED AT ALL. FURTHERMORE, HIGH METHYLATION STATUS OF BONE MARROW CELLS WAS EVEN OBSERVED IN THE CML PATIENTS WHO ACQUIRED COMPLETE CYTOGENETIC REMISSION. CONCLUSIONS: THE RESULTS OF OUR STUDY INDICATE THAT THE EPIGENETIC MODIFICATION OF PU.1 IN CML PATIENTS AND K562 CELL LINE MIGHT BE RESPONSIBLE FOR THE DOWN-EXPRESSION OF PU.1. THE DATA SUGGEST THAT ABERRANT METHYLATION OF PU.1 PLAYS A ROLE IN CML PATHOGENESIS, THEREFORE, IT MIGHT SERVE AS A USEFUL BIOMARKER AND POTENTIAL TARGET IN THERAPY FOR CHRONIC MYELOID LEUKEMIA. 2012 17 1070 29 CLONAL ARCHITECTURE OF CHRONIC MYELOMONOCYTIC LEUKEMIAS. GENOMIC STUDIES IN CHRONIC MYELOID MALIGNANCIES, INCLUDING MYELOPROLIFERATIVE NEOPLASMS (MPN), MYELODYSPLASTIC SYNDROMES (MDS), AND MPN/MDS, HAVE IDENTIFIED COMMON MUTATIONS IN GENES ENCODING SIGNALING, EPIGENETIC, TRANSCRIPTION, AND SPLICING FACTORS. IN THE PRESENT STUDY, WE INTERROGATED THE CLONAL ARCHITECTURE BY MUTATION-SPECIFIC DISCRIMINATION ANALYSIS OF SINGLE-CELL-DERIVED COLONIES IN 28 PATIENTS WITH CHRONIC MYELOMONOCYTIC LEUKEMIAS (CMML), THE MOST FREQUENT MPN/MDS. THIS ANALYSIS REVEALS A LINEAR ACQUISITION OF THE STUDIED MUTATIONS WITH LIMITED BRANCHING THROUGH LOSS OF HETEROZYGOSITY. SERIAL ANALYSIS OF UNTREATED AND TREATED SAMPLES DEMONSTRATES A DYNAMIC ARCHITECTURE ON WHICH MOST CURRENT THERAPEUTIC APPROACHES HAVE LIMITED EFFECTS. THE MAIN DISEASE CHARACTERISTICS ARE EARLY CLONAL DOMINANCE, ARISING AT THE CD34(+)/CD38(-) STAGE OF HEMATOPOIESIS, AND GRANULOMONOCYTIC DIFFERENTIATION SKEWING OF MULTIPOTENT AND COMMON MYELOID PROGENITORS. COMPARISON OF CLONAL EXPANSIONS OF TET2 MUTATIONS IN MDS, MPN, AND CMML, TOGETHER WITH FUNCTIONAL INVALIDATION OF TET2 IN SORTED PROGENITORS, SUGGESTS A CAUSATIVE LINK BETWEEN EARLY CLONAL DOMINANCE AND SKEWED GRANULOMONOCYTIC DIFFERENTIATION. ALTOGETHER, EARLY CLONAL DOMINANCE MAY DISTINGUISH CMML FROM OTHER CHRONIC MYELOID NEOPLASMS WITH SIMILAR GENE MUTATIONS. 2013 18 6529 32 TRANSCRIPTIONAL DOWN-REGULATION OF THE WNT ANTAGONIST SFRP1 IN HAEMATOPOIETIC CELLS OF PATIENTS WITH DIFFERENT RISK TYPES OF MDS. SECRETED FRIZZLED RELATED PROTEIN 1 (SFRP1) IS AN EXTRACELLULAR ANTAGONIST OF THE WNT SIGNALLING PATHWAY THAT PLAYS AN IMPORTANT ROLE IN THE PATHOGENESIS OF SOLID TUMOURS AND HAEMATOPOIETIC MALIGNANCIES. SFRP1 HAS BEEN OBSERVED TO BE TRANSCRIPTIONALLY DOWN-REGULATED DUE TO HYPERMETHYLATION IN ACUTE AND CHRONIC LEUKAEMIA, BUT SO FAR NOT IN MYELODYSPLASTIC SYNDROME (MDS). MOREOVER, IT HAS BEEN SHOWN THAT THE EPIGENETIC INACTIVATION OF SFRP1 CORRELATES WITH AN OVEREXPRESSION OF THE WNT RECEPTOR FRIZZLED 3 (FZD3) IN ACUTE LEUKAEMIA. USING REAL-TIME QUANTITATIVE REVERSE TRANSCRIPTION POLYMERASE CHAIN REACTION (RT-PCR) WE EXAMINED MRNA EXPRESSION OF SFRP1 AND FZD3 IN BONE MARROW CELLS DERIVED FROM 121 PATIENTS WITH DIFFERENT RISK TYPES OF MDS, ACUTE MYELOID LEUKAEMIA (AML) AND ACUTE LYMPHOBLASTIC LEUKAEMIA (ALL). WE EMPLOYED PYROSEQUENCING TO QUANTIFY PROMOTER DNA METHYLATION IN MDS AND ACUTE LEUKAEMIA. WE DETECTED SIGNIFICANT LOWER MRNA TRANSCRIPTION OF SFRP1 IN MDS COMPARED TO HEALTHY INDIVIDUALS. HOWEVER, DNA SEQUENCE MUTATIONS OR FREQUENT ELEVATED DNA METHYLATION LEVELS OF THE SFRP1 PROMOTER COULD NOT BE OBSERVED IN MDS BUT IN AML AND ALL AS PREVIOUSLY REPORTED. THE EXPRESSION LEVELS OF FZD3 WERE UP-REGULATED IN BOTH ACUTE LEUKAEMIA AND MDS. OUR DATA SHOW A SIGNIFICANT TRANSCRIPTIONAL DOWN-REGULATION OF SFRP1 AS A COMMON EVENT IN AML, ALL AND - AS DEMONSTRATED FOR THE FIRST TIME - IN MDS. AN INACTIVATION OF SFRP1 AND THE TRANSCRIPTIONAL UP-REGULATION OF FZD3 SEEM TO BE ASSOCIATED WITH AN ACTIVATION OF THE WNT SIGNALLING PATHWAY IN THESE HAEMATOPOIETIC DISEASES. 2010 19 535 37 ASXL1 MUTATION CORRECTION BY CRISPR/CAS9 RESTORES GENE FUNCTION IN LEUKEMIA CELLS AND INCREASES SURVIVAL IN MOUSE XENOGRAFTS. RECURRENT SOMATIC MUTATIONS OF THE EPIGENETIC MODIFIER AND TUMOR SUPPRESSOR ASXL1 ARE COMMON IN MYELOID MALIGNANCIES, INCLUDING CHRONIC MYELOID LEUKEMIA (CML), AND ARE ASSOCIATED WITH POOR CLINICAL OUTCOME. CRISPR/CAS9 HAS RECENTLY EMERGED AS A POWERFUL AND VERSATILE GENOME EDITING TOOL FOR GENOME ENGINEERING IN VARIOUS SPECIES. WE HAVE USED THE CRISPR/CAS9 SYSTEM TO CORRECT THE ASXL1 HOMOZYGOUS NONSENSE MUTATION PRESENT IN THE CML CELL LINE KBM5, WHICH LACKS ASXL1 PROTEIN EXPRESSION. CRISPR/CAS9-MEDIATED ASXL1 HOMOZYGOUS CORRECTION RESULTED IN PROTEIN RE-EXPRESSION WITH RESTORED NORMAL FUNCTION, INCLUDING DOWN-REGULATION OF POLYCOMB REPRESSIVE COMPLEX 2 TARGET GENES. SIGNIFICANTLY REDUCED CELL GROWTH AND INCREASED MYELOID DIFFERENTIATION WERE OBSERVED IN ASXL1 MUTATION-CORRECTED CELLS, PROVIDING NEW INSIGHTS INTO THE ROLE OF ASXL1 IN HUMAN MYELOID CELL DIFFERENTIATION. MICE XENOGRAFTED WITH MUTATION-CORRECTED KBM5 CELLS SHOWED SIGNIFICANTLY LONGER SURVIVAL THAN UNCORRECTED XENOGRAFTS. THESE RESULTS SHOW THAT THE SOLE CORRECTION OF A DRIVER MUTATION IN LEUKEMIA CELLS INCREASES SURVIVAL IN VIVO IN MICE. THIS STUDY PROVIDES PROOF-OF-CONCEPT FOR DRIVER GENE MUTATION CORRECTION VIA CRISPR/CAS9 TECHNOLOGY IN HUMAN LEUKEMIA CELLS AND PRESENTS A STRATEGY TO ILLUMINATE THE IMPACT OF ONCOGENIC MUTATIONS ON CELLULAR FUNCTION AND SURVIVAL. 2015 20 4485 29 MOLECULAR SIMILARITY BETWEEN MYELODYSPLASTIC FORM OF CHRONIC MYELOMONOCYTIC LEUKEMIA AND REFRACTORY ANEMIA WITH RING SIDEROBLASTS. CHRONIC MYELOMONOCYTIC LEUKEMIA IS SIMILAR TO BUT A SEPARATE ENTITY FROM BOTH MYELOPROLIFERATIVE NEOPLASMS AND MYELODYSPLASTIC SYNDROMES, AND SHOWS EITHER MYELOPROLIFERATIVE OR MYELODYSPLASTIC FEATURES. WE ASK WHETHER THIS DISTINCTION MAY HAVE A MOLECULAR BASIS. WE ESTABLISHED THE GENE EXPRESSION PROFILES OF 39 SAMPLES OF CHRONIC MYELOMONOCYTIC LEUKEMIA (INCLUDING 12 CD34-POSITIVE) AND 32 CD34-POSITIVE SAMPLES OF MYELODYSPLASTIC SYNDROMES BY USING AFFYMETRIX MICROARRAYS, AND STUDIED THE STATUS OF 18 GENES BY SANGER SEQUENCING AND ARRAY-COMPARATIVE GENOMIC HYBRIDIZATION IN 53 SAMPLES. ANALYSIS OF 12 MRNAS FROM CHRONIC MYELOMONOCYTIC LEUKEMIA ESTABLISHED A GENE EXPRESSION SIGNATURE OF 122 PROBE SETS DIFFERENTIALLY EXPRESSED BETWEEN PROLIFERATIVE AND DYSPLASTIC CASES OF CHRONIC MYELOMONOCYTIC LEUKEMIA. AS COMPARED TO PROLIFERATIVE CASES, DYSPLASTIC CASES OVER-EXPRESSED GENES INVOLVED IN RED BLOOD CELL BIOLOGY. WHEN APPLIED TO 32 MYELODYSPLASTIC SYNDROMES, THIS GENE EXPRESSION SIGNATURE WAS ABLE TO DISCRIMINATE REFRACTORY ANEMIAS WITH RING SIDEROBLASTS FROM REFRACTORY ANEMIAS WITH EXCESS OF BLASTS. BY COMPARING MRNAS FROM THESE TWO FORMS OF MYELODYSPLASTIC SYNDROMES WE DERIVED A SECOND GENE EXPRESSION SIGNATURE. THIS SIGNATURE SEPARATED THE MYELODYSPLASTIC AND MYELOPROLIFERATIVE FORMS OF CHRONIC MYELOMONOCYTIC LEUKEMIAS. THESE RESULTS WERE VALIDATED USING TWO INDEPENDENT GENE EXPRESSION DATA SETS. WE FOUND THAT MYELODYSPLASTIC CHRONIC MYELOMONOCYTIC LEUKEMIAS ARE CHARACTERIZED BY MUTATIONS IN TRANSCRIPTION/EPIGENETIC REGULATORS (ASXL1, RUNX1, TET2) AND SPLICING GENES (SRSF2) AND THE ABSENCE OF MUTATIONS IN SIGNALING GENES. MYELODYSPLASTIC CHRONIC MYELOMONOCYTIC LEUKEMIAS AND REFRACTORY ANEMIAS WITH RING SIDEROBLASTS SHARE A COMMON EXPRESSION PROGRAM SUGGESTING THEY ARE PART OF A CONTINUUM, WHICH IS NOT TOTALLY EXPLAINED BY THEIR SIMILAR BUT NOT, HOWEVER, IDENTICAL MUTATION SPECTRUM. 2013