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Introduction: Relapse of pediatric acute myeloid leukemia (AML) remains a leading cause of childhood cancer mortality, and leukemias with activation of the Fms-like tyrosine kinase 3 (FLT3) are particularly susceptible to relapsed disease. Risk-directed therapy to prevent relapse is based both on genetic changes known to drive drug resistance, and measurable residual disease (MRD) at the end of induction therapy (EOI). In adult AML, resistance to type II FLT3-inhibitors, like sorafenib, is primarily driven by on-target FLT3 kinase domain (KD) mutations. However, the resistance mechanisms for pediatric leukemias, which are treated on combination therapies, have not been fully elucidated. MRD is considered the among the most predictive markers of future relapsed disease. It has been assumed that the major clone at the time of MRD assessment will predict the majority clone at relapse. However, this assumption has not been proven. The definition of the most specific genetic and MRD markers of relapse are essential to prognosticate and personalize therapy to prevent relapsed disease. Methods: We performed single cell sequencing (SCS) with a high-throughput DNA sequencing platform, Mission Bio Tapestri, on bone marrow or peripheral blood samples from 24 samples from 8 pediatric patients treated on COG AAML1031 with serial samples from diagnosis, EOI, and relapse. Results: We analyzed a total of 94,833 cells from 8 pediatric patients (median cells per patient 12,428) all treated on AAML1031. SCS revealed a sensitive and specific description of clonal evolution on the combination of sorafenib with cytotoxic chemotherapy. The FLT3 internal tandem duplication (ITD) was controlled by the therapy in only half of the patients. In five of the patients, the FLT3-ITD was present in multiple clones. The FLT3-ITD co-mutated with additional mutations (NRAS, SH2B3, WT1, TET2, or NPM1) in half of the patients. However, the presence of a co-mutation did not necessarily correlate with whether or not the ITD-containing clone persisted at the time of relapse. Of the leukemias whose relapse was not driven by FLT3, the most likely mutational driver of resistance was NRAS. Notably, however, despite the fact that FLT3 KD mutations make up the bulk of mutational resistance to type II FLT3i such as sorafenib in adult patients, there were no on-target FLT3 mutations found in any of these pediatric patients. Further, SCS allows for an unprecedented depth of analysis of the genetic complexity of pediatric AML. Phylogenic analysis revealed that the same mutations may arise independently in different cells (NPM1 W288fs, NRAS G60E). Additionally, the same gene may be mutated twice within the same cell (WT1, TET2). These data, consistent with our prior work, suggest that some leukemias may have a predilection to mutations within specific loci. Finally, although there is a standing assumption that the dominant MRD population will proliferate into relapsed disease, in 3/8 patients, the dominant MRD clone did not predict the dominant relapse clone. Conclusions: SCS allows for direct measurement of clonal hierarchy and evolution, phylogeny, co-mutational status, and zygosity, which can only be inferred through traditional bulk NGS. The mutational mechanisms of resistance seen in adult leukemias treated with sorafenib monotherapy are not necessarily relevant to the pediatric population; rather than on-target FLT3 mutations, off target mutations including NRAS are found. This corroborates prior findings that off-target RAS pathway mutations may drive resistance to FLT3i. Non-RAS off-target mutations found in this cohort do not necessarily predict sorafenib resistance, so may be passenger mutations. The lack of consistent resistance mutations suggests that other mechanisms of resistance such as epigenetic modifications may also drive resistance to combination chemotherapy with FLT3i in pediatric leukemia. Further, SCS exposes more genetic complexity in pediatric AML than has previously been appreciated: the same mutation may independently arise in more than one cell or the same cell may have multiple mutations within the same gene. Finally, the sensitivity of SCS reveals that the major clone at the time of MRD assessment is not necessarily the major clone at relapse. This suggests a benefit of more frequent MRD monitoring to track clonal evolution in real time. Disclosures Smith: Daiichi Sankyo: Consultancy; Revolutions Medicine: Research Funding; AbbVie: Research Funding; Amgen: Honoraria; FUJIFILM: Research Funding; Astellas Pharma: Consultancy, Research Funding.

Mutations in receptor tyrosine kinases (RTK) FLT3 and KIT occur frequently in Acute Myeloid Leukemia (AML) and are associated with high risk of relapse. FLT3 tyrosine kinase inhibitors (TKI) are clinically approved in AML, but resistance is common and involves emerging clones reliant on oncogenic signaling, particularly in the RAS/MAPK pathway. Patients who relapse on FLT3 TKIs have inauspicious prognoses and no specific therapeutic options, highlighting the unmet need for effective strategies to target oncogenic signaling and improve outcomes in relapsed/refractory (R/R) AML. The protein tyrosine phosphatase SHP2 (PTPN11) is a central node in RAS/MAPK activation downstream of various RTKs, including FLT3, acting as a scaffold for adaptor proteins that promote RAS-GTP loading. Novel allosteric inhibitors are being clinically investigated in cancers with signaling activating mutations. Here, we demonstrate that the allosteric SHP2 inhibitor RMC-4550 modulates expression of pro and anti-apoptotics in FLT3 and KIT mutant AML providing rationale for combinatorial targeting of SHP2 and BCL2 as a synergistic approach. We subsequently report the preclinical efficacy of RMC-4550 and the FDA-approved, BCL2 selective inhibitor, Venetoclax combination in both in vitro and in vivo AML models. We evaluated cell viability of multiple AML cell lines treated with RMC-4550. FLT3-ITD (Molm14, MV4-11) and KIT mutant (Kasumi1, SKNO1) lines were sensitive to SHP2 inhibition. RMC-4550 maintained its efficacy in FLT3-ITD Molm14 cells with secondary mutations in FLT3 tyrosine kinase domain (TKD) and in NRAS G12C. RMC-4550 biochemically represses pERK (Figure 1A) and transcriptionally downregulates mRNA expression of DUSP6 and anti-apoptotic BCL2 and MCL1. We functionally evaluated the mitochondrial outer membrane permeabilization (MOMP) in response to SHP2 inhibition using a dynamic iBH3 profiling assay. RMC-4550 increased the overall priming and the dependency on BCL2 in both Molm14 and MV4-11 cell lines (Figure 1A). To investigate the global transcriptomic changes induced by allosteric SHP2 inhibition, we performed total mRNA sequencing on Molm14, MV4-11 and SKNO1 cell lines. GSEA analysis revealed that RMC-4550 significantly upregulated expression of genes repressed by RAS activation, downregulated MYC targets, but also dysregulated genes mediating apoptosis. The most consistently upregulated pro-apoptotic gene was BMF (fold change: 4.39, FDR We next treated Molm14, MV4-11, Kasumi and SKNO1 lines with incremental doses of RMC-4550 and Venetoclax in an 8x8 combination matrix to assess the synergy of the two compounds using cell viability and apoptosis readouts. The assay showed highly synergistic activity in both FLT3-ITD and KIT lines. Remarkably, we noted a potent synergy in Molm14 cells with concurrent mutation in NRAS G12C (Figure 1C). In a Molm14 cell line xenograft model, we demonstrated that the combination of RMC-4550 (30 mg/kg) and Venetoclax (100 mg/kg) administered orally 5 times a week for 28 days significantly decreased leukemia burden and improved survival (p In a FLT3-ITD AML patient-derived xenograft (PDX) model, the combination of RMC-4550 and Venetoclax markedly decreased %hCD45 in both cardiac blood and spleen of NSGS mice compared to vehicle-treated control (Figure 1E). Supporting a potential therapeutic index for the combination, RMC-4550 and Venetoclax strongly inhibited colony formation in FLT3 AML primary samples compared to samples from healthy volunteers. Collectively, our data suggest that SHP2 inhibition increases the apoptotic dependency on BCL2 through up-regulation of the pro-apoptotic BMF, a mechanistic rationale to synergistically inhibit both targets. We provide preclinical evidence that co-targeting SHP2 and BCL2 is a potential effective therapeutic strategy in RTK-driven AML. Figure 1 Figure 1. Disclosures Stahlhut: Revolutions Medicine: Current Employment, Current equity holder in publicly-traded company. Smith: Daiichi Sankyo: Consultancy; Amgen: Honoraria; AbbVie: Research Funding; Revolutions Medicine: Research Funding; FUJIFILM: Research Funding; Astellas Pharma: Consultancy, Research Funding.

Genetic and immunophenotypic diversity is a hallmark of hematopoietic malignancies, and clonal evolution has been implicated as a driver of tumor initiation, progression, treatment response, and relapse. Consequently, a deeper understanding of the complex relationship between mutational profiles and disease phenotypes is critical to better understand the underlying disease processes. Probing the question of genotype-immunophenotype interplay at scale has historically proven difficult due to technical limitations permitting capture of only a single datatype from an individual cell. In acute myeloid leukemia (AML), flow cytometry for detection of measurable residual disease (MRD) has become standard of care for monitoring of treatment response and risk for relapse. At the same time, DNA-based molecular profiling of AML provides prognostic information and can guide therapeutic decisions at the time of diagnosis and disease progression. However, it remains a challenge to effectively integrate these assessments into a comprehensive model of disease state that can be used for clinical decision-making. Here we present DNA and Antibody sequencing (DAb-seq), a novel technology for simultaneously performing high-throughput, single-cell measurements of both DNA genotype and protein markers from >5,000 single cells. To our knowledge, DAb-seq is the first technology to directly integrate readouts of DNA genotype and cellular phenotype at the single-cell level. The experimental workflow leverages the single-cell microfluidic technology on the Mission Bio Tapestri platform, a system optimized to conduct multiplex single-cell targeted genomic DNA amplification. In our modified protocol, cells are stained with a pool of monoclonal antibodies conjugated with barcoded oligonucleotides, enabling a sequencing-based readout of single-cell protein signatures. The sequencing data is analyzed with a bioinformatic pipeline that separates antibody signal from targeted genotyping data on a cell-by-cell basis. We apply DAb-seq to the analysis of multiple AML patient samples, using a panel of 50 DNA targets comprising recurrently mutated genes in AML and 23 antibodies commonly used in flow cytometry-based MRD detection. In a single test case of pediatric AML, we identify cells harboring known pathogenic KRAS and FLT3 mutations at diagnosis and relapse. Among these genetically defined cell subsets, we observe differential protein expression of CD56, CD11b, and CD15. Specifically, we find a significant positive correlation between KRAS mutational status and combined expression of CD56 and CD11b. Similarly, FLT3 mutant cells, the dominant clone at relapse, are found to express elevated levels of CD15. We further apply DAb-seq technology to the profiling of mixed phenotype leukemia and monitoring the phenotypic dynamics of genetic clones in response to CD33 targeted therapy. Our data suggest cell populations defined by single variants in reality comprise multiple immunophenotypic subpopulations, underscoring the complex interplay between genotype and protein expression. While the precise mechanism underlying this immunophenotypic diversity remains to be elucidated, our work demonstrates the utility of DAb-seq in uncovering broader patterns of genotypic and phenotypic evolution in large AML patient cohorts. Ultimately, such studies could support further stratification of disease subtypes and increase the precision with which therapies are applied. Figure Disclosures Ruff: Mission Bio Inc.: Employment. Ooi:Mission Bio: Employment, Equity Ownership. Smith:Astellas Pharma: Research Funding; Abbvie: Research Funding; fujiFilm: Research Funding; Revolution Medicines: Research Funding. Abate:Mission Bio, Inc.: Equity Ownership.

Introduction: Clonal selection occurring under the selective pressure of Fms-like tyrosine kinase 3 (FLT3) tyrosine kinase inhibitor (TKI) therapy is not fully understood. To date, the most common mutations found at the time of resistance to potent and selective type II FLT3 TKIs, like quizartinib, are on-target kinase domain (KD) mutations. Activating RAS pathway mutations are a common mechanism of resistance to type I FLT3 TKIs (McMahon et al., 2019 and Zhang et al., 2019). Changes in the acute myeloid leukemia (AML) genetic landscape at relapse on single agent or combination type II FLT3 TKI therapy have not been well-characterized at the single cell (SC) level. Methods: We performed SC sequencing with a novel high-throughput SC DNA sequencing platform, Mission Bio Tapestri, on bone marrow or peripheral blood samples from 11 patients with FLT3-mutant relapsed/refractory (R/R) AML treated with quizartinib. We analyzed 13 samples from 7 patients treated with quizartinib monotherapy and 12 samples from 4 patients treated with a combination of quizartinib and omacetaxine. Results: We analyzed a mean of 6,636 cells/sample (range 2,437-13,538). Each leukemia was made up of an average of 5 clonal sub-populations (range 2-7). 5/10 patients with serial samples demonstrated increased polyclonality at relapse, with a mean of 4 clones pretreatment (range 2-6) and 5 at relapse (range 2-7). All patients had an internal tandem duplication in FLT3 (FLT3-ITD) in at least 1 clone. Using SC sequencing, we visualized distinct clones with both hetero -and homo-zygous FLT3-ITD mutations. At the time of relapse after quizartinib, 7 patients (6 on monotherapy and 1 with combination therapy) developed at least one additional FLT3 KD mutation. These on-target mutations were found either as co-mutations within the FLT3-ITD clone or in a native FLT3 clone without an ITD. 4 of these 7 patients had polyclonal KD mutations (mean 2 distinct KD mutations; range 1-3), most commonly at the D835 locus. In 6/7 patients, each KD mutation was found in separate cellular subclones. However, 1 patient had multiple KD mutations within the same subclone (at the D835 and S838 loci). In 6/7 patients who relapsed with a KD mutation, the KD mutation was the dominant clone at relapse. No clones with on-target KD mutations were present prior to therapy. However, all relapse clones containing off-target mutations, found in 3/11 patients, were present in small subclones prior to clinical relapse. As an example, 1 patient who relapsed with 2 NRAS mutations had 2 distinct pre-existing clonal NRAS mutant populations, without FLT3-ITD co-mutations, detectable at Conclusions: Single cell (SC) sequencing allows for direct measurement of clonality, co-mutational status, zygosity, and clonal evolution, which can only be inferred through traditional bulk NGS. This detail reveals that individual mutations may be present in a number of different combinations and confirms that polyclonality is common even within a single leukemia. From time of diagnosis, knowledge of which mutations co-exist in the same clone can suggest potential mechanisms of resistance and help direct treatment. On therapy, SC sequencing can conclusively demonstrate clonal selection. SC sequencing allows for detection of clones not detectable by bulk NGS. The fact that all 4 patients sequenced at the time of morphologic remission had measurable residual disease (MRD) by SC sequencing suggests the benefit of SC sequencing as a strategy for MRD detection. At the time of relapse, identifying the dominant as well as smaller clonal subsets can help direct appropriate combination targeted therapy. Despite the fact that highly selective type II agents, like quizartinib, have historically been thought to select for on-target resistance, SC sequencing highlights more diverse mechanisms of resistance including off-target mutations. Our data supports the need for effective combination therapy to delay or suppress outgrowth of resistant clones. Disclosures Jacob: Mission Bio Inc.: Employment. Durruthy-Durruthy:Mission Bio Inc.: Employment. Levis:FUJIFILM: Consultancy, Research Funding; Daiichi Sankyo Inc: Consultancy, Honoraria; Agios: Consultancy, Honoraria; Menarini: Consultancy, Honoraria; Novartis: Consultancy, Research Funding; Astellas: Consultancy, Research Funding; Amgen: Consultancy, Honoraria. Perl:Novartis: Honoraria, Other: Advisory board, Non-financial support included travel costs for advisory board meetings as well as a medical writing company that assisted with manuscript preparation/submission and slide deck assembly for academic meeting presentations of the data., Research Funding; Astellas: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings as well as a medical writing company that assisted with manuscript preparation/submission and slide deck assembly for academic meeting presentations of trial data., Research Funding; Daiichi Sankyo: Consultancy, Honoraria, Other, Research Funding; Actinium Pharmaceuticals: Consultancy, Honoraria, Other: Clinical Advisory Board member, Research Funding; Takeda: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; BioMed Valley Discoveries: Research Funding; NewLink Genetics: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; Arog: Consultancy, Other: Non-financial support included travel costs for advisory board meetings.; FujiFilm: Research Funding; Bayer: Research Funding; Agios: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Non-financial support included travel costs for advisory board meetings.; AbbVie: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.; Jazz: Consultancy, Honoraria, Other: Non-financial support included travel costs for advisory board meetings.. Smith:Astellas Pharma: Research Funding; Abbvie: Research Funding; Revolution Medicines: Research Funding; fujiFilm: Research Funding.

Inherited factor XI deficiency is an injury-related bleeding disorder that is rare in most populations except for Jews, in whom 2 mutations, a stop mutation in exon 5 (type II) and a missense mutation in exon 9 (type III), predominate. Recently, a cluster of 39 factor XI–deficient patients was described in the Basque population of Southwestern France. In this study, we determined the molecular basis of factor XI deficiency in 16 patients belonging to 12 unrelated families of French Basque origin. In 8 families, a nucleotide 209T>C transition in exon 3 was detected that predicts a Cys38Arg substitution. Four additional novel mutations in the factor XI gene, Cys237Tyr, Tyr493His, codon 285delG, and IVS6 + 3A>G, were identified in 4 families. Expression studies showed that Cys38Arg and Cys237Tyr factor XI were produced in transfected baby hamster kidney cells, but their secretion was impaired. Cells transfected with Tyr493His contained reduced amounts of factor XI and displayed decreased secretion. A survey of 206 French Basque controls for Cys38Arg revealed that the prevalence of the mutant allele was 0.005. Haplotype analysis based on the study of 10 intragenic polymorphisms was consistent with a common ancestry (a founder effect) for the Cys38Arg mutation.

IIbb3 integrin is a heterodimeric receptor facilitating platelet aggregation. Both genes are on chromosome 17q21.32. Intergenic distance between them has been reported to be 125 to 260 kilobasepairs (kb) by pulsed-field gel electrophoresis (PFGE) genomic analysis, suggesting that they may be regulated coordinately during megakaryopoiesis. In contrast, other studies suggest these genes are greater than 2.0 megabasepairs (mb) apart. Because of the potential biological implications of having these two megakaryocytic-specific genes contiguous, we attempted to resolve this discrepancy. Taking advantage of large kindreds with mutations in either IIb or β3, we have developed a genetic linkage map between the thyroid receptor hormone-1 gene (THRA1) and β3 as follows: cen-THRA1-BRCA1-D17S579/IIb-β3-qter, with a distance of 1.3 centiMorgans (cM) between IIb and β3 and the two genes being oriented in the same direction. PFGE genomic and YAC clone analysis showed that the β3 gene is distal and ≥365 kb upstream of IIb. Additional restriction mapping shows IIb is linked to the erythrocyte band 3 (EPB3) gene, and β3 to the homeobox HOX2b gene. Analysis of IIb+-BAC and P1 clones confirm that the EPB3 gene is ∼110 kb downstream of the IIb gene. Sequencing the region surrounding the human IIb locus showed the Granulin gene ∼18 kb downstream to IIb, and the KIAA0553 gene ∼5.7 kb upstream. This organization is conserved in the murine sequence. These studies show that IIb and β3 are not closely linked, with IIb flanked by nonmegakaryocytic genes, and imply that they are unlikely to share common regulatory domains during megakaryopoiesis.

IIbb3 integrin is a heterodimeric receptor facilitating platelet aggregation. Both genes are on chromosome 17q21.32. Intergenic distance between them has been reported to be 125 to 260 kilobasepairs (kb) by pulsed-field gel electrophoresis (PFGE) genomic analysis, suggesting that they may be regulated coordinately during megakaryopoiesis. In contrast, other studies suggest these genes are greater than 2.0 megabasepairs (mb) apart. Because of the potential biological implications of having these two megakaryocytic-specific genes contiguous, we attempted to resolve this discrepancy. Taking advantage of large kindreds with mutations in either IIb or β3, we have developed a genetic linkage map between the thyroid receptor hormone-1 gene (THRA1) and β3 as follows: cen-THRA1-BRCA1-D17S579/IIb-β3-qter, with a distance of 1.3 centiMorgans (cM) between IIb and β3 and the two genes being oriented in the same direction. PFGE genomic and YAC clone analysis showed that the β3 gene is distal and ≥365 kb upstream of IIb. Additional restriction mapping shows IIb is linked to the erythrocyte band 3 (EPB3) gene, and β3 to the homeobox HOX2b gene. Analysis of IIb+-BAC and P1 clones confirm that the EPB3 gene is ∼110 kb downstream of the IIb gene. Sequencing the region surrounding the human IIb locus showed the Granulin gene ∼18 kb downstream to IIb, and the KIAA0553 gene ∼5.7 kb upstream. This organization is conserved in the murine sequence. These studies show that IIb and β3 are not closely linked, with IIb flanked by nonmegakaryocytic genes, and imply that they are unlikely to share common regulatory domains during megakaryopoiesis.

The polymorphism G20210A in the 3′ untranslated region of the prothrombin gene is associated with an increased level of factor II activity and confers a twofold to fivefold increase in the risk for venous thromboembolism. Among Caucasian populations, the prevalence of factor II G20210A heterozygotes is 1% to 6%, whereas in non-Caucasian populations it is very rare or absent. The aim of the present study was to discern whether factor II G20210A originated from a single or recurrent mutational events. Allele frequencies of four dimorphisms spanning 16 of 21 kb of the factor II gene were determined in 133 unrelated Caucasian subjects of Jewish, Austrian, and French origins who bore factor II G20210A (10 homozygotes and 123 heterozygotes) and 110 Caucasian controls. Remarkable differences in the allele frequencies for each dimorphism were observed between the study groups (P = .0007 or less), indicating strong linkage disequilibrium and suggesting a founder effect. Indeed, a founder haplotype was present in 68% of 20210A mutant alleles and only in 34% of 20210G normal alleles (P < .0001). These data strongly support a single origin for factor II G20210A that probably occurred after the divergence of Africans from non-Africans and of Caucasoid from Mongoloid subpopulations.© 1998 by The American Society of Hematology.

Previous studies showed that factor XI (FXI) deficiency commonly observed in Ashkenazi Jews is caused by two similarly frequent mutations, type II (Glu117stop) and type III (Phe283Leu) with allele frequencies of 0.0217 and 0.0254, respectively. In Iraqi Jews, who represent the ancient gene pool of Jews, only the type II mutation was observed with an allele frequency of 0.0167. In this study we sought founder effects for each mutation by examination of four FXI gene polymorphisms enabling haplotype analysis in affected Jewish patients of Ashkenazi, Iraqi, and other origins and in Arab patients. Initial population surveys of 387 Middle Eastern Jews (excluding Iraqi Jews), 560 North African/Sephardic Jews, and 382 Arabs revealed allele frequencies for the type II mutation of 0.0026, 0.0027, and 0.0065, respectively. In contrast, the type III mutation was not detected in any of these populations. All 60 independent chromosomes bearing the type III mutation were solely observed in Ashkenazi Jewish patients and were characterized by a relatively rare haplotype. All 103 independent chromosomes bearing the type II mutation in patients of Ashkenazi, Iraqi, Yemenite, Syrian, and Moroccan Jewish origin and of Arab origin were characterized by another distinct haplotype that was rare among normal Ashkenazi Jewish, Iraqi Jewish, and Arab chromosomes. These findings constitute the first example of a mutation common to Ashkenazi Jews, non-Ashkenazi Jews, and Arabs and are consistent with the origin of type II mutation in a founder before the divergence of the major segments of Jews. Our findings also indicate that the type III mutation arose more recently in an Ashkenazi Jewish individual.

During the last decade the frequency of therapy-related acute leukemia (t-leuk) and myelodysplastic syndrome (t-MDS) has been increasingly observed. Over the past 15 years, we treated 56 patients with t-leuk who had received prior chemotherapy (39%), radiotherapy (11%), or both (45%). The drugs received included alkylating agents and topoisomerase II inhibitors. The primary tumors included hematological malignancies (49%) and solid tumors such as breast or ovarian cancer. The median age at diagnosis of the primary tumor was relatively young (43 years +/- 18). Twelve patients had more than one primary tumor and 31 patients had a family history of malignancy. Karyotypic abnormalities were found in 91% of the patients. Prognosis was uniformly poor, with an overall median survival of 10 months. Twelve of the 18 patients examined (67%) had a multidrug resistance phenotype. P53 genes of the leukemic cells, as well as the original tumors, were analyzed in 21 patients using polymerase chain reaction (PCR) with single-stranded conformation polymorphism analysis followed by sequencing. P53 mutations were identified in 38% of these patients, a relatively high prevalence compared with other forms of MDS or de novo acute myeloid leukemia. Mutations were nongermline and restricted to the leukemic cells. We identified different p53 mutations in the various primary tumors of individual patients. The presence of a mutator phenotype was assessed by PCR analysis of microsatellites in eight loci (one trinucleotide repeat sequence, four dinucleotide, and three mononuclear repeat sequences). Microsatellite instability in two to seven loci were found in 15 of 16 (94%) of the patients. This instability is compatible with a mutator phenotype, which predisposes the patients to the development of malignancies including t-leuk.

Congenital dyserythropoietic anemia (CDA) type I is a rare macrocytic anemia of unknown etiology. In the present study, we redefined the clinical and laboratory picture of CDA type 1, some of its pathogenic aspects, and the association with thalassemia-like features in 20 patients, all of whom belong to one Bedouin tribal group and are probably descended from a common ancestor. In each case ultrastructural studies of bone marrow (BM) erythroblasts showed the classic morphological findings of CDA type 1. Serological tests for CDA type II were negative. The clinical picture was variable, but mostly benign. Some patients displayed elevated hemoglobin A2 levels or a high ratio of a-to non-a ONGENITAL dyserythropoietic anemias (CDAs) are a C rare group of red blood cell (RBC) disorders of unknown etiology characterized by ineffective erythropoiesis, pathognomonic cytopathology of the nucleated RBCs in the bone marrow (BM) and secondary hemochromatosis. In 1968, Heimpel and Wendtl classified these disorders into three types, which were later confirmed by electron microscopy and serological findings.' Type I is characterized by congenital macrocytic anemia, megaloblastoid erythroid hyperplasia, and the presence of nuclear chromatin bridges between erythroblasts. More than 60 sporadic cases of CDA type I have been reported in the literat~re.~" The typical morphological ultrastructural studies accompanied by negative acidified serum lysis and adult i/l agglutination test constitute the major diagnostic features. The more common type 11, also known as hereditary erythroblastic multinuclearity with a positive acidified serum test (HEMPAS): is characterized by normocytosis or macrocytosis with binucleated and multinucleated marrow erythroblasts and karyorrhexis. Type 111 is manifested by macrocytosis and erythroblastic multinuclearity with prominent gigantoblask3 More than 30 documented cases could not be clearly assigned to type I, 11, or III.3 Type IV was the classification used in four reports in which BM morphology resembling that in type I1 was accompanied by negative acid serum tests5 CDA in association with thalassemia has been described in 17 patients.'.' Members of more than a dozen other families had CDAs that were even more difficult to cla~sify.~ Anselstetter et a19 in 1977 were the first to report that band 3 glycoproteins from HEMPAS erythrocyte membranes migrate faster than those obtained from normal erythrocyte membranes. Reduced levels of N-glycans in HEMPAS erythrocyte membranes with low N-acetylglucosaminyltransferase I1 activity have been documented in some patients," and a defect in the a-mannosidase I1 gene was reported in one patient." Faulty glycosylation of transfemn, a glycoprotein produced in the liver, has also been described.I2 The molecular basis for the defects in other CDAs is not known. In the following study, we describe 20 patients with CDA type I who belong to seven Bedouin families living in the Negev (the southern part of Israel). The aim of the study was to redefine the clinical and laboratory characteristics of globin. However, neither family studies nor complete sequence analysis of the p-globin was compatible with pthalassemia. Increased erythropoiesis was manifested by a high number of BM erythroid burst-forming units. Serum erythropoietin was also elevated. BM flow cytometry studies demonstrated arrest of erythroid precursors in the S phase of the cell cycle. The ultrastructural morphological features of the erythroid precursors, showing peripheral chromatin condensation, suggest apoptosis. AddiCional studies are indicated to define the molecular basis of this disease. 0 1996 by The American Society of Hematology. CDA type I in this homogeneous population in an attempt to clarify the pathogenesis of the disorder and its association with thalassemia. MATERIALS AND METHODS Twenty patients (14 men, 6 women), aged 1 to 23 years (median, 10 years) from seven families were evaluated. Three patients were originally diagnosed and followed at our center, and the medical records of the 11 patients followed for anemia at the Soroka Medical Center in Beersheva were reviewed. Six additional patients were identified in the course of family studies. Each of the 20 patients underwent a complete physical examination. Bone age was determined in six patients. Control BM samples for culture studies and flow cytometry studies were obtained from healthy children who were donors for BM transplant. &thalassemia major BM samples were obtained at diagnosis. The following blood and BM examinations were performed for each patient.

Glanzmann's thrombasthenia is a bleeding disorder characterized by a decrease or absence of the functional platelet membrane glycoprotein (GP) complex, GPIIb/IIIa (alpha IIb beta 3). We describe a new deletion- insertion mutation in the GPIIb gene causing type I Glanzmann's thrombasthenia in two siblings of a consanguineous Iranian-Jewish family. The proband's platelets bound more antibodies against the vitronectin receptor-alpha V beta 3 than normal platelets, suggesting a normal GPIIIa (beta 3) gene and a defect in the GPIIb gene. Sequencing of amplified cDNA and genomic DNA fragments showed a 6-bp deletion and 31-bp insertion in exon 25 of the GPIIb gene. The predominant platelet GPIIb mRNA of the proband was a product of the splicing of exon 24 to a cryptic AG acceptor site in the insertion and encoded for deletion of amino acids Leu817-Asn826 and insertion of eight different amino acids. Cotransfection of COS-7 cells with expression vectors containing wild- type GPIIIa cDNA and the mutated GPIIb cDNA failed to produce detectable amounts of GPIIb/IIIa on the surface of the cells. Allele- specific restriction analysis of genomic DNA of family members showed homozygosity for the mutation in the affected siblings, heterozygosity in the parents, and homozygosity for the normal allele in an unaffected sibling. The observed mutation is in a region that is conserved from rodents to humans and has been suggested to be involved in the interaction between GPIIb and GPIIIa when these GPs are complexed in solution.

In recent years four mutations causing factor XI deficiency have been identified in Jews of Ashkenazi (European) origin. Two of them, type II (a nonsense mutation) and type III (a missense mutation), were found to prevail among 125 unrelated Ashkenazi Jews with severe factor XI deficiency. A finding of type II mutation in four unrelated Iraqi- Jewish families raised the possibility that this mutation is also common in Iraqi Jews, who represent the ancient gene pool of the Jews. A molecular-based analysis performed in 1,040 consecutively hospitalized patients disclosed the following results: Among 531 Ashkenazi-Jewish patients, the type II allele frequency was 0.0217 and among 509 Iraqi-Jewish patients, 0.0167 (P = .50). The type III allele frequency in the Ashkenazi-Jewish patients was 0.0254, whereas none of 502 Iraqi-Jewish patients examined had this mutation. These data suggest that the type II mutation was present in Jews already 2.5 millenia ago. The data also indicate that the estimated risk for severe factor XI deficiency in Ashkenazi Jews (due to either genotype) is 0.22% and in Iraqi Jews, 0.03%, and that the estimated risk of heterozygosity in Ashkenazi Jews is 9.0% and in Iraqi Jews, 3.3%. As patients with severe factor XI deficiency are prone to bleeding after injury and patients with partial deficiency may have similar bleeding complications when an additional hemostatic derangement is present, the observed high frequencies should be borne in mind when surgery is planned for individuals belonging to these populations.

Heparanase is an endoglycosidase that cleaves heparan sulfate (HS), the main polysaccharide of the basement membrane (BM). HS is responsible for BM integrity and barrier function. Hence, enzymatic degradation of HS in the vascular subendothelial BM is a prerequisite for extravasation of immune cells and plasma components during inflammation. Here, we demonstrate a highly coordinated local heparanase induction upon elicitation of delayed-type hypersensitivity (DTH) reaction in the mouse ear. By monitoring in vivo activation of luciferase gene driven by the heparanase promoter, we demonstrate activation of heparanase transcription at an early stage of DTH. We report that heparanase is produced locally by the endothelium at the site of DTH-associated inflammation. Key DTH mediators, tumor necrosis factor-α and interferon-γ, were found to induce heparanase in cultured endothelial cells. Endothelium emerges as an essential cellular source of heparanase enzymatic activity that, in turn, allows for remodeling of the vascular BM, increased vessel permeability, and extravasation of leukocytes and plasma proteins. In vivo administration of antiheparanase siRNA or an inhibitor of heparanase enzymatic activity effectively halted DTH inflammatory response. Collectively, our results highlight the decisive role of endothelial heparanase in DTH inflammation and its potential as a promising target for anti-inflammatory drug development.

The most frequent mutation causing Glanzmann thrombasthenia in Iraqi-Jews (IJ-1) is an 11-bp deletion in exon 13 of the glycoprotein (GP) IIIa gene. This deletion predicts a frameshift that results in the elimination of the C406-C655 disulfide bond and a premature termination codon shortly before the transmembrane domain. To determine the contribution of each of these alterations to the thrombasthenic phenotype, Chinese hamster ovary or baby hamster kidney cells were cotransfected with normal GPIIb complementary DNA (cDNA) and the following GPIIIa cDNAs: normal, cDNA bearing IJ-1 mutation, 2011T>A mutated cDNA predicting C655S (single-letter amino acid codes) substitution, and 2019A>T mutated cDNA predicting Stop657. Elimination of the C406-C655 disulfide bond by C655S substitution did not affect GPIIb/IIIa surface expression or binding of the transfected cells to immobilized fibrinogen, whereas elimination of the transmembrane and cytoplasmic domains in IJ-1 and Stop657 mutants prevented both surface expression and binding of the transfected cells to immobilized fibrinogen. Immunohistochemical staining and immunoprecipitation demonstrated that the elimination of amino acids 657-762 in IJ-1 and Stop657 prevented intracellular GPIIb/IIIa complex formation, and differential immunofluorescence staining of GPIIIa and cellular organelles suggested that the truncated uncomplexed GPIIIa protein was retained in the endoplasmic reticulum. Because the use of GPIIIa Stop693 and normal GPIIb cDNAs yielded GPIIb/IIIa complex formation, though with lower efficiency, it is suggested that amino acids 657-692 of GPIIIa are essential for the intracellular association of GPIIb and GPIIIa.

alphaIIbb3 integrin is a heterodimeric receptor facilitating platelet aggregation. Both genes are on chromosome 17q21.32. Intergenic distance between them has been reported to be 125 to 260 kilobasepairs (kb) by pulsed-field gel electrophoresis (PFGE) genomic analysis, suggesting that they may be regulated coordinately during megakaryopoiesis. In contrast, other studies suggest these genes are greater than 2.0 megabasepairs (mb) apart. Because of the potential biological implications of having these two megakaryocytic-specific genes contiguous, we attempted to resolve this discrepancy. Taking advantage of large kindreds with mutations in either alphaIIb or beta3, we have developed a genetic linkage map between the thyroid receptor hormone-1 gene (THRA1) and beta3 as follows: cen-THRA1-BRCA1-D17S579/alphaIIb-beta3-qte r, with a distance of 1.3 centiMorgans (cM) between alphaIIb and beta3 and the two genes being oriented in the same direction. PFGE genomic and YAC clone analysis showed that the beta3 gene is distal and/=365 kb upstream of alphaIIb. Additional restriction mapping shows alphaIIb is linked to the erythrocyte band 3 (EPB3) gene, and beta3 to the homeobox HOX2b gene. Analysis of alphaIIb(+)-BAC and P1 clones confirm that the EPB3 gene is approximately 110 kb downstream of the alphaIIb gene. Sequencing the region surrounding the human alphaIIb locus showed the Granulin gene approximately 18 kb downstream to alphaIIb, and the KIAA0553 gene approximately 5.7 kb upstream. This organization is conserved in the murine sequence. These studies show that alphaIIb and beta3 are not closely linked, with alphaIIb flanked by nonmegakaryocytic genes, and imply that they are unlikely to share common regulatory domains during megakaryopoiesis.

Glanzmann thrombasthenia (GT) is a rare bleeding disorder resulting from mutations in either glycoprotein (GP) IIb or GPIIIa genes. The disease is relatively frequent in highly inbred populations such as Iraqi Jews. The molecular basis of GT in 6 unrelated Iraqi-Jewish patients was previously identified as an 11-bp deletion in exon 12 of the GPIIIa gene. We now describe a second mutation found in 3 unrelated Iraqi-Jewish families that consists of an 11.2-kb deletion between an Alu repeat in intron 9 and exon 13 of the GPIIIa gene. The mutant DNA is transcribed into mRNA in which exons 10 through 13 are absent. Splicing of exon 9 directly to exon 14 leads to a shift in the reading frame resulting in a stop codon. The predicted protein is truncated in the middle of the third cysteine-rich domain before the transmembrane domain. Simple DNA-based methods were devised for identification of both mutations in Iraqi Jews for the purpose of carrier detection and prenatal diagnosis enabling prevention of GT. A survey of the general Iraqi-Jewish population for the first 11-bp deletion and the second 11.2-kb deletion disclosed that the allele frequency of the first mutation was 0.0043, whereas none of 700 individuals examined bore the second mutation (allele frequency0.0007). Among 40 GT patients of Iraqi-Jewish origin 31 were homozygous for the first mutation, 4 were compound heterozygotes for the first and second mutations, and 2 were homozygous for the second mutation. Haplotype analyses using 4 polymorphic markers in the GPIIIa gene showed that each mutation originated in a distinct founder.

In recent years four mutations causing factor XI deficiency have been identified in Jews of Ashkenazi (European) origin. Two of them, type II (a nonsense mutation) and type III (a missense mutation), were found to prevail among 125 unrelated Ashkenazi Jews with severe factor XI deficiency. A finding of type II mutation in four unrelated Iraqi-Jewish families raised the possibility that this mutation is also common in Iraqi Jews, who represent the ancient gene pool of the Jews. A molecular-based analysis performed in 1,040 consecutively hospitalized patients disclosed the following results: Among 531 Ashkenazi-Jewish patients, the type II allele frequency was 0.0217 and among 509 Iraqi-Jewish patients, 0.0167 (P = .50). The type III allele frequency in the Ashkenazi-Jewish patients was 0.0254, whereas none of 502 Iraqi-Jewish patients examined had this mutation. These data suggest that the type II mutation was present in Jews already 2.5 millenia ago. The data also indicate that the estimated risk for severe factor XI deficiency in Ashkenazi Jews (due to either genotype) is 0.22% and in Iraqi Jews, 0.03%, and that the estimated risk of heterozygosity in Ashkenazi Jews is 9.0% and in Iraqi Jews, 3.3%. As patients with severe factor XI deficiency are prone to bleeding after injury and patients with partial deficiency may have similar bleeding complications when an additional hemostatic derangement is present, the observed high frequencies should be borne in mind when surgery is planned for individuals belonging to these populations.

Abstract 4698 The diagnosis of Biphenotypic Acute Leukemia (BAL) is still a challenge in clinical hematology. In spite of the use of the score formulation of the European Group for the Immunological Classification of Leukemias (EGIL) there are still cases difficult to define. We assessed the contribution of ultrastructural morphology and cytochemistry to the diagnosis of BAL in pediatric leukemic patients. Twenty six patients diagnosed at Schneider Children's Medical Center of Israel between the years 1989 to 2004 have been classified as BAL in a retrospective analysis evaluated by various combinations of light-microscopy (LM) morphology, immunophenotype flow-cytometry, cytogenetics and electron-microscopy (EM) including myeloperoxidase (MPO) and platelet peroxidase (PPO) reaction. The identification of myeloid features by EM was based on the presence of 1) MPO positive granules and MPO reactivity in the nuclear membrane, profiles of endoplasmic reticulum (ER) and in the membranes of the Golgi system; 2) PPO reaction in the nuclear membrane and profiles of ER, and 3) the presence of primary basophilic granules in the cytoplasm of the blasts. The EGIL scoring system has been used with the addition of the ultrastructural findings for the definition of BAL. In 24 cases the morphologic appearance and cytochemistry by LM of the leukemic cells were that of undifferentiated blasts. By cytogenetic evaluation abnormal karyotypes were detected in 16 patients, normal in 4 and unknown in 6 patients. Out of 26 patients 15 had the combination of T-ALL with myeloid phenotype and 11 had the B-lineage with myeloid features. Unexpectedly the blasts of 9 of the 26 BAL patients had basophilic differentiation as indicated by the presence of typical primary basophilic granules with MPO reactivity in a scattered pattern as previously reported in basophylic leukemia. Interestingly 7 of these 9 cases had a T lymphoid component. By contrast among 15 patients who had FAB M0, 9 had the B lineage markers. The remaining 2 patients had M1 and M7 features with T lymphoid phenotype. The contribution of EM studies enabled to establish the diagnosis of BAL in 11 out of 26 patients, in other 6 patients it allowed for the refinement of the AML subgroup such as basophilic leukemia and in the remaining 9 patients EM confirmed the diagnosis of BAL as defined by flow cytometry. Conclusions Our study identified a subgroup of children with acute leukemia in whom BAL could be suggested only by the addition of ultrastructural studies. EM could further refine and confirm the diagnosis of BAL in all the other cases. Of interest is the high incidence of basophylic differentiation among BAL pediatric patients, and its association with T lymphoid phenotype. Disclosures: No relevant conflicts of interest to declare.

Congenital dyserythropoietic anemia (CDA) type I is an inherited autosomal recessive macrocytic anemia associated with ineffective erythropoiesis and the development of secondary hemochromatosis. Distinct erythroid precursors with inter-nuclear chromatin bridges and spongy heterochromatin are pathognomonic for the disease. The mutated gene (CDAN1) encodes a ubiquitously expressed protein of unknown function, codanin-1. Based on the morphological features of CDA type I erythroblasts and the preliminary data on the Drosophila homolog, dlt, which was found to be required for cell survival and cell cycle progression, we investigated the location and the behavior of codanin-1 during the cell cycle. Using immunofluorescence and immune electron microscopy, we localized codanin-1 to the heterochromatin in interphase cells. During the cell cycle, high levels of codanin-1 were observed in S phase. At mitosis, codanin-1 underwent phosphorylation, which coincided with exclusion from condensed chromosomes. The proximal CDAN1 gene promoter region, never before characterized, was found to contain 5 putative E2F1 binding sites. E2F transcription factors are the main regulators of G1/S transition. Cotransfection of an E2F1 expression plasmid increased luciferase activity, confirming that E2F1 activates the transcription of CDAN1, and chromatin immunoprecipitation identified the codanin-1 promoter as a direct target of E2F1. Taken together, these data suggest that codanin-1 is a cell cycle-regulated protein active in S-phase. Based on the localization of codanin-1 to the heterochromatin and the spongy appearance of heterochromatin in CDA I, we suggest that codanin-1 may be involved in heterochromatin organization during DNA replication. This represents the first work towards understanding the function of the proteins involved in CDAs.

Background: An association between patients suffering from Parkinson Disease (PD) and type I Gaucher disease (GD) was previously described (N Engl J Med, 2004). The goals of the present study were to report the frequency of Parkinson disease among the clinically unaffected family members of Ashkenazi GD patients who are obligate or known glucocerebrosidase (GBA) mutations carriers, and evaluate the clinical course in Type I GD carriers with concomitant manifestations of Parkinson disease (PD). Methods: A cohort of forty three consecutive unrelated Ashkenazi Type I GD patients followed at the hematology department in the Rambam medical center in Haifa, Israel were evaluated for a family history of PD. Results: Among forty-three families of Ashkenazi GD patients twelve had one or more relatives with PD. All these subjects were known obligate or identified as (GBA) mutation carriers for one of the common mutations among the Ashkenazi Jewish population namely N370S, 1604 or 84GG. The age of PD onset among GD family members carriers of GBA mutation ranged from 40 to 67 years with a mean of 53 years. Conclusions: A high rate of relatives with PD was found among GD patient’s families. These results reinforce the association between GD carrier state and PD and suggest that glucocerebrosidase mutations might predispose to PD. PD in family members of Ashkenazi GD patients Age Genotype PD family history Age onset * GF - Grandfather 18 84GG/1604 mother & 2 GF* 50;55 20 84GG/1226 grandfather 50 59 1226/1226 2 uncles 55 31 1226/1226/no sister 46 18 1226/1226 grandmother 65 27 1226/1226 mother 52 18 1226/1226 father & aunt 70 32 1226/1226 2 aunts (identical twins) 55;67 40 1226/1226/no aunt 65 61 1226/1226 mother 40 8 1226/1226 grandfather 70 13 1226/1226 mother & aunt 60;64

Congenital dyserythropoietic anemia (CDA) type I is a rare autosomal recessive macrocytic moderate to severe anemia rarely associated with distal skeletal deformities. Erythroid bone marrow findings are pathognomonic with internuclear chromatin bridges, spongy heterochromatin, and invagination of the nuclear membrane. Our and others studied suggested erythroid S phase arrest. We recently identified the gene mutated in this disease, CDAN1 and named its ubiquitous encoded protein codanin-1. The function of this protein remains unknown. The aim of the present study was to determine the sub cellular localization of codanin-1. Human erythroid cultures as well as Hela, K562 and osteodarcoma cell line (U2OS) were grown. A polyclonal anti-codnain-1 antibody was generated by immunizaing rabbits with a synthetic 17 aa peptide. The anti-sera was affinity-purified against the immunizing peptide. Western blots, immunoflurescence stains and immunogold electromicroscopic studies were performed. Western blots of human erythroid cultures as well as HeLa, K562 and osteosarcoma cell lines identified one expected band of 130kD. Fluorescent and confocal microscopic studies of osteosarcoma and HeLa cells using anti-codanin-1 antibody showed that codanin-1 was an abundant nuclear protein. Immunogold electron microscopic studies with anti codanin-1 antibodies demonstrated that coodanin-1 is located within the heterochromatin. Future studies will focus on the role of codanin-1 within the heterochromatin.