Molecular Subtypes in BCR::ABL1-Positive ALL Are Defined By Cellular Origins and Cooperating Genomic Events

Two developmental trajectories are acknowledged in BCR::ABL1-positive acute lymphoblastic leukemia (ALL) as distinct diagnostic entities by the ICC classification: ‘lymphoid-only’ with BCR::ABL1 restricted to the leukemic B precursor compartment vs. ‘multilineage’ with BCR::ABL1 involvement also in other hematopoietic lineages. Diagnostic standards for establishing this distinction are lacking and associated biological and clinical features are insufficiently characterized.

To establish developmental trajectories, biological phenotypes, and clinical impact we analyzed n=277 BCR::ABL1-positive ALL patients (age: 2-84 years, median: 46) including our GMALL reference data set (n=113) and two independent validation cohorts (MLL: n=61; St Jude's: n=103; Gu Z, et al. Nat Genet. 2019).

Unsupervised gene expression analysis (RNA-Seq: n=277) identified two major gene expression clusters with two further sub-clusters each (Figure A). This clustering was confirmed by a machine learning classifier trained on the GMALL data set which achieved similar grouping of samples in the external validation cohorts. BCR:: ABL1-FISH on FACS-sorted bone marrow/peripheral blood samples revealed the presence of BCR::ABL1 in leukemic as well as myeloid cells in n=18/18 samples from the 1 ^st major cluster (termed 'multilineage'). In the 2 ^nd major cluster ('lymphoid'), BCR::ABL1 was restricted to the lymphoid lineage in n=13/16 samples (p<0.001), with n=3/16 cases harboring BCR::ABL1-positive myeloid cells at lower frequencies compared to the multilineage cluster. In each cluster, two patients also harbored BCR::ABL1-positive mature B cells. T cells remained BCR::ABL1-negative. Diagnostic FACS data and analysis of proximity to normal human lymphoid gene expression confirmed more frequent myeloid co-expression and higher proximity to normal pro-B cells in the multilineage cluster, whereas lymphoid cases had increased lymphoid surface marker expression and a stronger proximity to normal pre-B I cells. Genomic profiling using WGS/SNParrays (n=160) revealed significant enrichment for genomic events in the four gene expression sub-clusters: focal deletions comprising exons 1 and 2 of HBS1-like translational GTPase ( HBS1L) or monosomy 7 were strongly enriched in the two multilineage sub-clusters ('delHBS1L'; n=20/27 vs. n=3/133 in remaining cohort or 'del7'; n=16/25 vs. n=10/135; p<0.001). Remarkably, a novel alternative HBS1L transcript with a putative TSS in intron 3 was highly expressed in both multilineage sub-clusters but not in BCR::ABL1 negative ALL cases or healthy B lymphoid progenitors, suggesting this transcript as novel cooperating event in multilineage BCR::ABL1-positive ALL. One lymphoid sub-cluster was enriched for homozygous deletions in IKZF1 ('IKZF1'; n=11/55 vs. n=4/105; p=0.008), whereas the other was enriched for homozygous CDKN2A/B deletions (n=21/53 vs. n=3/107; p<0.001) and PAX5 deletions (n=33/53 vs n=26/107; p<0.001; 'CDKN2A/PAX5'). Hyperdiploid karyotypes were exclusive to the lymphoid main cluster, mostly in CDKN2A/PAX5.

We analyzed the clinical implications of these newly established BCR::ABL1-positive ALL subtypes in our homogenously treated GMALL adult patient cohort (n=98, first diagnosis 2014-2021) including TKI treatment combined with age-adapted chemotherapy, MRD monitoring and allo-SCT in 1 ^st CR (n=84/98, 86%). Overall survival (OS) at 3 years was uniformly high in multilineage and lymphoid cases (70%±6% vs. 70%±8%; p=0.890; Figure B). However, analysis of the sub-clusters revealed an inferior 3-years OS for the IKZF1 ^-/- enriched cluster in contrast to excellent outcome in hyperdiploid cases and intermediate outcomes in the remaining sub-clusters (Figure B).

These data highlight that transcriptomic signatures in BCR::ABL1-positive ALL are driven by developmental disease origins (‘lymphoid’ vs. ‘multilineage‘) and specific patterns of corresponding genomic events. Novel molecular subtypes of BCR::ABL1-positive ALL have distinct outcomes in the context of current GMALL treatment protocols. Gene-expression based subtype definitions enable classification of BCR::ABL1-positive ALL according to ICC definitions based on RNA-Seq data alone. These definitions have been implemented in ALLCatchR - our freely available tool for ALL subtype allocation - to facilitate validation and application in clinical diagnostics.