Fusion oncogenes are prevalent in several pediatric cancers, yet little is known about the specifi c associations between age and phenotype. We observed that fusion oncogenes, such as ETO2-GLIS2 , are associated with acute megakaryoblastic or other myeloid leukemia subtypes in an age-dependent manner. Analysis of a novel inducible transgenic mouse model showed that ETO2-GLIS2 expression in fetal hematopoietic stem cells induced rapid megakaryoblastic leukemia whereas expression in adult bone marrow hematopoietic stem cells resulted in a shift toward myeloid transformation with a strikingly delayed in vivo leukemogenic potential. Chromatin accessibility and singlecell transcriptome analyses indicate ontogeny-dependent intrinsic and ETO2-GLIS2 -induced differences in the activities of key transcription factors, including ERG, SPI1, GATA1, and CEBPA. Importantly, switching off the fusion oncogene restored terminal differentiation of the leukemic blasts. Together, these data show that aggressiveness and phenotypes in pediatric acute myeloid leukemia result from an ontogeny-related differential susceptibility to transformation by fusion oncogenes. SIGNIFICANCE:This work demonstrates that the clinical phenotype of pediatric acute myeloid leukemia is determined by ontogeny-dependent susceptibility for transformation by oncogenic fusion genes. The phenotype is maintained by potentially reversible alteration of key transcription factors, indicating that targeting of the fusions may overcome the differentiation blockage and revert the leukemic state.

Acute erythroleukemia (AML-M6 or AEL) is a rare but aggressive hematologic malignancy. Previous studies showed that AEL leukemic cells often carry complex karyotypes and mutations in known AML-associated oncogenes. To better define the underlying molecular mechanisms driving the erythroid phenotype, we studied a series of 33 AEL samples representing three genetic AEL subgroups including TP53-mutated, epigenetic regulator-mutated (e.g. DNMT3A, TET2 or IDH2), and undefined cases with low mutational burden. We established an erythroid vs. myeloid transcriptomics-based space in which, independently of the molecular subgroup, the majority of the AEL samples exhibited a unique mapping different from both non-M6 AML and myelodysplastic syndrome samples. Notably, more than 25% of AEL patients, including in the genetically-undefined subgroup, showed aberrant expression of key transcriptional regulators, including SKI, ERG, and ETO2. Ectopic expression of these factors in murine erythroid progenitors blocked in vitro erythroid differentiation and led to immortalization associated with decreased chromatin accessibility at GATA1 binding sites and functional interference with GATA1 activity. In vivo models showed development of lethal erythroid, mixed erythroid/myeloid or other malignancies depending on the cell population in which AEL-associated alterations were expressed. Collectively, our data indicates that AEL is a molecularly heterogeneous disease with an erythroid identity that results in part from the aberrant activity of key erythroid transcription factors in hematopoietic stem or progenitor cells.

Rhabdomyosarcoma is the most common soft tissue sarcoma in childhood and histologically resembles developing skeletal muscle. Alveolar rhabdomyosarcoma (ARMS) is an aggressive subtype with higher rate of metastasis and poorer prognosis. The majority of ARMS tumors (80%) harbor a PAX3-FOXO1 or less commonly a PAX7-FOXO1 fusion gene. The presence of either the PAX3-FOXO1 or PAX7-FOXO1 fusion gene foretells a poorer prognosis resulting in clinical re-classification as either fusion-positive (FP-RMS) or fusion-negative RMS (FN-RMS). The PAX3/7-FOXO1 fusion genes result in the production of a rogue transcription factors that drive FP-RMS pathogenesis and block myogenic differentiation. Despite knowing the molecular driver of FP-RMS, targeted therapies have yet to make an impact for patients, highlighting the need for a greater understanding of the molecular consequences of PAX3-FOXO1 and its target genes including microRNAs. Here we show FP-RMS patient derived xenografts and cell lines display a distinct microRNA expression patterns. We utilized both loss- and gain-of function approaches in human cell lines with knockdown of PAX3-FOXO1 in FP-RMS cell lines and expression of PAX3-FOXO1 in human myoblasts and identified microRNAs both positively and negatively regulated by the PAX3-FOXO1 fusion protein. We demonstrate PAX3-FOXO1 represses miR-221/222 that functions as a tumor suppressing microRNA through the negative regulation of CCND2, CDK6, and ERBB3. In contrast, miR-486-5p is transcriptionally activated by PAX3-FOXO1 and promotes FP-RMS proliferation, invasion, and clonogenic growth. Inhibition of miR-486-5p in FP-RMS xenografts decreased tumor growth illustrating a proof of principle for future therapeutic intervention. Therefore, PAX3-FOXO1 regulates key microRNAs that may represent novel therapeutic vulnerabilities in FP-RMS.

Relapses and treatment-related events contributed equally to poor prognosis in children with ABLclass fusion positive B-cell acute lymphoblastic leukemia treated according to AIEOP-BFM protocols. Haematologica 2020;105(7): 1887-1894. 10. Schwab C, Ryan SL, Chilton L, et al. EBF1-PDGFRB fusion in pediatric B-cell precursor acute lymphoblastic leukemia (BCP-ALL): genetic profile and clinical implications. Blood. 2016;127(18):2214-2218. 11. Conter V, Bartram CR, Valsecchi MG, et al. Molecular response to treatment redefines all prognostic factors in children and adolescents with B-cell precursor acute lymphoblastic leukemia: results in 3184 patients of the AIEOP-BFM ALL 2000 study. Blood. 2010;115 (16):3206-3214. 12. Arico M, Valsecchi MG, Camitta B, et al. Outcome of treatment in children with Philadelphia chromosome-positive acute lymphoblastic leukemia. N Engl J Med. 2000;342(14):998-1006. 13. Schultz KR, Carroll A, Heerema NA, et al. Long-term follow-up of imatinib in pediatric Philadelphia chromosome-positive acute lymphoblastic leukemia: Children's Oncology Group study AALL0031.

Malignancies of the erythroid lineage are rare but aggressive diseases. Notably, the first insights into their biology emerged over half a century ago from avian and murine tumor viruses-induced erythroleukemia models providing the rationale for several transgenic mouse models that unraveled the transforming potential of signaling effectors and transcription factors in the erythroid lineage. More recently, genetic roadmaps have fueled efforts to establish models that are based on the epigenomic lesions observed in patients with erythroid malignancies. These models, together with often unexpected erythroid phenotypes in genetically modified mice, provided further insights into the molecular mechanisms of disease initiation and maintenance. Here, we review how the increasing knowledge of human erythroleukemia genetics combined with those from various mouse models indicate that the pathogenesis of the disease is based on the interplay between signaling mutations, impaired TP53 function, and altered chromatin organization. These alterations lead to aberrant activity of erythroid transcriptional master regulators like GATA1, indicating that erythroleukemia will most likely require combinatorial targeting for efficient therapeutic interventions.

No abstract

The NFIA-ETO2 fusion is the product of a t(1;16)(p31;q24) chromosomal translocation so far exclusively found in pediatric patients with pure erythroid leukemia (PEL). To address the role for the pathogenesis of the disease, we expressed the NFIA-ETO2 fusion in murine erythroblasts. We observed that NFIA-ETO2 significantly increased proliferation and impaired erythroid differentiation of murine erythroleuemia (MEL) cells and of primary fetal liver-derived erythroblasts. However, NFIA-ETO2-expressing erythroblasts acquired neither aberrant in vitro clonogenic activity nor disease-inducing potential upon transplantation into irradiated syngenic mice. In contrast, in the presence of one of the most prevalent erythroleukemia-associated mutations, TP53R248Q, expression of NFIA-ETO2 resulted in aberrant clonogenic activity, and induced a fully penetrant transplantable PEL-like disease in mice. Molecular studies support that NFIA-ETO2 interferes with erythroid differentiation by preferentially binding and repressing erythroid genes that contain NFI binding sites and/or are decorated by ETO2, resulting in a activity shift from GATA- to ETS-motif-containing target genes. In contrast, TP53R248Q does not affect erythroid differentiation but provides self-renewal and survival potential, mostly via downregulation of known TP53 targets. Collectively, our work indicates that NFIA-ETO2 initiates PEL by suppressing gene expression programs of terminal erythroid differentiation and cooperates with TP53 mutation to induce erythroleukemia.

Acute erythroid leukemia (AEL) is characterized by uncontrolled accumulation of transformed erythroblasts. Previous analysis of murine and human AEL revealed aberrant regulation of the master regulator GATA1, which controls terminal erythroid differentiation in multi-protein complexes acting as activators or repressors of gene expression. Although most malignant erythroblasts constitutively express abundant GATA1 protein, terminal erythroid differentiation is impaired. Notably, overexpression of GATA1 significantly induced partial or complete terminal erythroid differentiation of the human AEL cell line K562 or immortalised HUDEP2 human erythroblasts, respectively. These observations led us to hypothesize that blocked terminal erythroid differentiation in AEL might be the consequence of titratable dose-dependent aberrant GATA1 protein interactions. We comparatively analysed nuclear extracts from three human AEL cell lines (F36P, K562, KMOE2) and primary cells from an AEL patient. In addition, we analysed HUDEP2 and primary human erythroblasts (hEBST) from healthy donors that retain the potential for complete in vitro terminal erythroid differentiation. We quantified protein expression using a tandem mass tag (TMT) based approach (n=3/cell type) and we compared putative GATA1 interactions by immunoprecipitation (IP) followed by liquid chromatography mass spectrometry (MS) (n=3/cell type). Quantitative proteomics identified 6774 commonly expressed proteins in AEL and "normal" erythroblasts with a high reproducibility (mean coefficients of variation <10%) for all six different cell types. Unsupervised hierarchical clustering displayed a clear separation of the AEL cells from the "normal erythroblasts" (hEBST, HUDEP2). 386 proteins were higher expressed in the AEL group (logFC>=2; q<0.05), whereas 623 were more abundant in normal erythroblasts (logFC>=2; q<0.05). IP-MS analysis of nuclear lysates from the AEL cell lines, the AEL primary sample, HUDEP2 and hEBST resulted in a matrix containing 1616 proteins from which 126 proteins seem to significantly differentially interact with GATA1. 54 proteins were more enriched in the AEL group, whereas 72 proteins were more enriched in "normal" erythroblasts (q<0.5). Principal component analysis (PCA) showed for all cell lines a similar clustering pattern, accounting for 24% and 32% of the variance. Pulled-down proteins in hEBST and HUDEP2 clustered together and were closer to F36P and KMOE, than LAM49 and K562. Notably, we found significant enrichment (validated by immunoblotting) of the SKI protooncogene in AEL cells (logFC=1.82; q=0.013), a finding which not only confirmed previous findings in murine AEL models (MEL cells, erythroblasts from Nsd1 -/- mice) but also speaks for the functionality of our approach. Similarly, the LRPPRC leucine-rich PPR-motif-containing protein overexpressed in several cancers, as well the lactate dehydrogenases A and B (LDHA, LDHB) were significantly enriched in malignant erythroblasts (logFC>2; q<0.05). Furthermore, the ZEB2 zinc finger E-box-binding homeobox 2 protein, was significantly enriched in AEL cells (logFC=2.02; q=0.005). In contrast, the hematopoietic master transcription factor Runt-related transcription factor 1 (RUNX1) (logFC=2.48; q=0.0018) as well as DNA binding protein Ikaros (IKZF1) (logFC=1.71; q=0.13) were significantly enriched (validated by immunoblotting) in HUDEP2 and hEBST. Moreover, the MCM6 DNA binding mini-chromosome maintenance complex component 6 critical for proper DNA replication was enriched in normal erythroblasts (logFC=1.99; q=0.0001). Interestingly, one of the most strongly enriched (and validated by immunoblotting) proteins in normal erythroblasts was the nuclear pore complex protein NUP155 (logFC=6.1; q=0.0000001). Integration of the quantitative proteomics and the IP-MS analysis identified 118 proteins differentially expressed and differentially pulled-down by GATA1-IP, of which 49 were enriched in malignant and 69 proteins in normal erythroblasts (q<0.5). This shows that we reproducibly identified proteins that are differentially associated with GATA1 which are also differentially expressed in AEL cells versus normal erythroblasts. A targeted CRISPR/Cas9 screen is under way to identify GATA1-interacting proteins responsible for impaired erythroid differentiation of AEL cells. Disclosures Valent: Novartis: Honoraria; Pfizer: Honoraria, Research Funding; Celgene/BMS: Honoraria, Research Funding; Incyte: Honoraria, Research Funding; OAP Orphan Pharmaceuticals: Honoraria.