Identification and evaluation of novel prognostic genetic markers for childhood acute lymphoblastic leukemia

Abstract: Childhood acute lymphoblastic leukemia (ALL) is the most common form of childhood cancer today. Due to advances in risk stratification and treatment, survival rates have increased drastically the last decades. Currently, children with acute leukemia in the Nordic countries are diagnosed and treated according to the NOPHO-2008 treatment protocol. In this protocol, a number of cytogenetic markers are used for risk stratification and guidance of treatment intensity. However, genetic markers associated with high risk are infrequent and relapses occur across all genetic subtypes, including those associated with a favorable outcome. Importantly, over 25% of childhood ALL cases harbor none of the currently used genetic risk markers in their bone marrow cells at diagnosis. The aim of this thesis was to generate a greater understanding of the genetic landscape in ALL, as well as to identify novel genetic markers of prognostic relevance, with special focus on the group of patients lacking risk-stratifying markers. In paper I, we investigated the frequency and prognostic impact of IKZF1 deletions in patients diagnosed with B-cell precursor (BCP) ALL in the Stockholm region; IKZF1 deletions were present in 15% of cases and significantly associated with inferior outcome. These results led to paper II, where the cohort was extended to include BCP ALL cases with available IKZF1 data from other centers in Sweden. This study verified that IKZF1 deletion was an independent risk factor for decreased survival, and could confirm that the frequency and prognostic effect was most pronounced in patients without risk-stratifying markers. A high frequency of IKZF1 deletions could also be detected in paper III, where we investigated the genetic copy number landscape of BCP ALL across the different cytogenetic subtypes. This study showed that a majority of cases without risk-stratifying markers harbor deletions with potential prognostic significance, suggesting that a large proportion of this group could be assigned to distinct genetic subtypes. Intrachromosomal amplification of chromosome 21 (iAMP21) is an intermediate/high-risk subtype for which the biological cause of the high relapse risk is unknown. In paper IV, we used an integrated molecular approach to investigate the iAMP21 subtype, and identified significant overexpression of tree potential candidate genes, i.e. DYRK1A, SON and CHAF1B, with leukemia-relevant functions that could represent future targets for therapy. Together, these studies have identified a number of potential novel prognostic genetic markers that may contribute to the clinical risk-evaluation of children diagnosed with BCP ALL, and to our understanding of the biology behind relapse and poor outcome in this disease.