Immunotherapy with immune checkpoint inhibitors (ICIs) for solid tumors had significantly improved overall survival. This type of therapy is still not available for acute myeloid leukemia (AML). One major issue is the lack of knowledge for the expression patterns of immune checkpoints (IC) in AML. In this study, we first explored the prognostic value of ICs for AML patients by analyzing RNA-seq and mutation data from 176 AML patients from the Cancer Genome Atlas (TCGA) database. We further validated the results of the database analysis by analyzing bone marrow (BM) samples from 62 patients with de novo AML. Both TCGA data and validation results indicated that high expression of PD-1, PD-L1, and PD-L2 was associated with poor overall survival (OS) in AML patients. In addition, increased co-expression of PD-1/CTLA-4 or PD-L2/CTLA-4 correlated with poor OS in AML patients (3-year OS: TGCA data 30% vs 0% and 20% vs 0%, validation group 57% vs 31% and 57% vs 33%, respectively) (P < 0.05). Moreover, co-expression of PD-1/PD-L1, PD-1/PD-L1/PD-L2, and PD-1/LAG-3 was found to correlate with poor OS in AML patients with FLT3mut, RUNX1mut, and TET2mut, respectively. In conclusion, high expression of ICs in the BM leukemia cells of AML patients correlated with poor outcome. The co-expression patterns of PD-1/CTLA-4, PD-L2/CTLA-4, PD-1/PD-L1, PD-1/PD-L1/PD-L2, and PD-1/LAG-3 might be potential immune biomarkers for designing novel AML therapy.
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Abkürzungen
AML
Acute myeloid leukemia
BM
Bone marrow
CTLA-4
Cytotoxic T-lymphocyte associated protein 4
FLT3
Fms-related receptor tyrosine kinase 3
IC
Immune checkpoint
ICI
Immune checkpoint inhibitor
LAG-3
Lymphocyte activation gene-3
mut
Mutation
PD-1
Programmed cell death 1
PD-L1
Programmed cell death 1 ligand 1
PD-L2
Programmed cell death 1 ligand 2
RUNX1
RUNX family transcription factor 1
TCGA
The Cancer Genome Atlas
TET2
Tetmethylcytosine dioxygenase 2
wt
Wildtype
To the Editor,
Immune checkpoint (IC) blockade by inhibitors of the programmed cell death 1 (PD-1) and PD-1 ligand 1 (PD-L1) has significantly improved clinical outcome for a variety of solid tumors [1, 2], while little is known about the role of ICs in leukemia [3]. Previous reports have shown that higher numbers of PD-1 + T cells are related to poor outcome for patients with acute myeloid leukemia (AML) [3]. Clinical trials using PD-1 inhibitors are ongoing to treat patients with a high risk for AML relapse [4]. However, the response rate varies widely, ranging from 22 to 72% [4], which may be due to heterogeneity in the IC expression level as well as distinct dominant IC expression patterns in different AML cases [5]. Therefore, it is worth studying the expression patterns of ICs in AML. In this study, we first explored the prognostic value of ICs in AML patients through analyzing RNA-seq and mutation data from the Cancer Genome Atlas (TCGA) database [6] and further validated the results by quantitative real-time PCR analysis of AML bone marrow (BM) samples from our clinical center.
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A total of 176 de novo AML patients from the TCGA database and 62 AML BM samples were used for overall survival (OS) analysis and validation. Higher expression of PD-1, PD-L1, and PD-L2 correlated with poor OS in the TCGA database analysis (3-year OS 23% vs 38%, 19% vs 46%, and 15% vs 40%, respectively, P < 0.05). This result was confirmed in the validation group (3-year OS 40% vs 68%, 22% vs 64%, and 42% vs 68%, respectively, P < 0.05, Fig. 1a, b). We further analyzed the expression patterns of PD-1, PD-L1, and PD-L2 with other important ICs [7‐9]. Subsequently, with Pearson’s correlation analysis, we found that the expression of PD-1, PD-L1, or PD-L2 was positively associated with the expression of cytotoxic T-lymphocyte associated protein 4 (CTLA-4) (r = 0.259, P < 0.001; r = 0.435, P < 0.001; r = 0.269, P < 0.001, respectively) and lymphocyte activation gene-3 (LAG-3) (r = 0.275, P < 0.001; r = 0.276, P < 0.001; r = 0.160, P = 0.033, respectively) in the TCGA group (Fig. 1c). This concomitant expression pattern was again confirmed in the validation group (Fig. 1e), showing the possibility of concomitant expression of PD-1, PD-L1, or PD-L2 with CTLA-4 (r = 0.373, P = 0.003; r = 0.998, P < 0.001; r = 0.998, P < 0.001, respectively) and LAG3 (r = 0.372, P = 0.003; r = 0.994, P < 0.001; r = 0.994, P < 0.001, respectively). AML patients with high expression of CTLA-4 and LAG-3 were found to have poor OS (3-year OS 9% vs 36% and 13% vs 40% respectively) (Fig. 1d). This result was again confirmed in the validation group (Fig. 1f) (3-year OS: CTLA-4 34% vs 66%, LAG-3 33% vs 70%).
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Combination of IC inhibitors (ICIs) has the potential to improve responses [4, 10]. We analyzed expression patterns of ICs and found that pairwise combinations of PD-1, PD-L1, and PD-L2 and CTLA-4 and LAG-3 correlated with poor OS in AML patients (P < 0.05, Figure S1). Furthermore, among AML patients with high expressions of PD-1 or PD-L2, concomitant high expression of CTLA-4 correlated with poor OS in both the TCGA database (3-year OS: PD-1highCTLA-4low vs PD-1highCTLA-4high 30% vs 0%, 20% vs 0%) and validation group (3-year OS: PD-L2highCTLA-4low vs PD-L2highCTLA-4high 57% vs 31%, 57% vs 33%) (P < 0.05, Fig. 2a, b). AML with PD-L1highCTLA-4high correlated with poor OS in the TCGA dataset (3-year OS 24% vs 0%, P < 0.001); however, OS was not significantly different in the validation group (3-year OS 33% vs 20%, P = 0.353, Fig. 2a, b). In addition, high expression of LAG-3 with PD-1high, PD-L1high, or PD-L2high failed to correlate with OS in the TCGA and validation groups (Figures S2A - B).
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To obtain the effects of PD-1, PD-L1, and PD-L2 on the prognosis of AML patients with genetic mutations, we analyzed OS of the top ten AML patients with a recurrent mutation (Figures S3), including FLT3mut, RUNX1mut, or TET2mut [11‐13]. Interestingly, in comparison with AML patients without such mutations, high co-expressions of PD-1/PD-L1 (P = 0.029), PD-1/PD-L1/PD-L2 (P = 0.003), and PD-1/LAG-3 (P < 0.001) were found to be associated with poor OS in AML patients with FLT3mut, RUNX1mut, or TET2mut (1-year OS 0% vs 58% vs 49%, 0% vs 56% vs 100%, and 0% vs100% vs 63%, respectively) (Fig. 2c).
To the best of our knowledge, we for the first time described that high co-expressions of PD-1/CTLA-4 and PD-L2/CTLA-4 correlated with poor OS of AML patients. Moreover, high co-expressions of PD-1/PD-L1, PD-1/PD-L1/PD-L2, and PD-1/LAG-3 were associated with poor OS of AML patients with FLT3mut, RUNX1mut, or TET2mut, respectively (Fig. 2d). These co-expression patterns might be potential immune biomarkers for designing novel AML therapy.
This study was conducted according to the principals of the Declaration of Helsinki and was approved by the Ethics Committee of Guangzhou First People’s Hospital. All participants were provided with written informed consent.
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Not applicable
Competing interests
The authors declare that they have no competing interests.
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