Open Access

High WT1 expression is an early predictor for relapse in patients with acute promyelocytic leukemia in first remission with negative PML-RARa after anthracycline-based chemotherapy: a single-center cohort study

  • Jae-Ho Yoon1,
  • Hee-Je Kim1Email author,
  • Dae-Hun Kwak1,
  • Sung-Soo Park1,
  • Young-Woo Jeon1,
  • Sung-Eun Lee1,
  • Byung-Sik Cho1,
  • Ki-Seong Eom1,
  • Yoo-Jin Kim1,
  • Seok Lee1,
  • Chang-Ki Min1,
  • Seok-Goo Cho1,
  • Dong-Wook Kim1,
  • Jong Wook Lee1 and
  • Woo-Sung Min1
Journal of Hematology & Oncology201710:30

https://doi.org/10.1186/s13045-017-0404-4

Received: 17 November 2016

Accepted: 18 January 2017

Published: 23 January 2017

Abstract

Wilms’ tumor gene 1 (WT1) expression is a well-known predictor for relapse in acute myeloid leukemia. We monitored WT1 decrement along the treatment course to identify its significant role as a marker for residual disease in acute promyelocytic leukemia (APL) and tried to suggest its significance for relapse prediction. In this single center retrospective study, we serially measured PML-RARa and WT1 expression from 117 APL patients at diagnosis, at post-induction and post-consolidation chemotherapies, and at every 3 months after starting maintenance therapy. All 117 patients were in molecular remission after treatment of at least 2 consolidation chemotherapies. We used WT1 ProfileQuant™ kit (Ipsogen) for WT1 monitoring. High WT1 expression (>120 copies/104 ABL1) after consolidation and at early period (3 months) after maintenance therapy significantly predicted subsequent relapse. All paired PML-RARa RQ-PCR were not detected except for one sample with early relapse. Patients with high WT1 expression at 3 months after maintenance therapy (n = 40) showed a significantly higher relapse rate (30.5 vs. 6.9%, P < 0.001) and inferior disease free survival (62.8 vs. 91.4%, P < 0.001). Multivariate analysis revealed that high peak leukocyte counts at diagnosis (HR = 6.4, P < 0.001) and high WT1 expression at 3 months after maintenance therapy (HR = 7.1, P < 0.001) were significant factors for prediction of relapse. Our data showed high post-remission WT1 expression was a reliable marker for prediction of subsequent molecular relapse in APL. In this high-risk group, early intervention with ATRA ± ATO, anti-CD33 antibody therapy, and WT1-specific therapy may be used for relapse prevention.

Trial registration

Clinical Research Information Service (CRIS), KCT0002079

Keywords

Acute promyelocytic leukemia WT1 FLT3 mutation Minimal residual disease

Findings

In acute promyelocytic leukemia (APL), PML-RARa transcript is used as a marker for minimal residual disease (MRD), but the marker is not useful for pre-emptive management since its positivity directly indicates relapse. High Wilms’ tumor gene 1 (WT1) expression was related with subsequent relapse in acute myeloid leukemia, and Hecht et al. recently reported that high initial WT1 expression was associated with more relapse in APL [13].

We confirmed APL by chromosome analysis and PML-RARα reverse transcriptase polymerase chain reaction (RT-PCR) method. All were treated with idarubicin (12 mg/m2, days 1, 3, 5, and 7) and all-trans retinoic acid (ATRA; 45 mg/m2/day) [4, 5]. After achievement of hematological complete remission (CR), all received three courses of consolidation—first, idarubicin (7 mg/m2, days 1–4); second, mitoxantrone (10 mg/m2, days 1–4); and third, idarubicin (12 mg/m2, day 1–2)—followed by 2-year maintenance using 6-mercaptopurine (50 mg/m2/day) plus ATRA [57]. The molecular studies were performed at diagnosis and 1 month after chemotherapy, and every 3 months after maintenance. Quantification of PML-RARα and WT1 were performed using the real-time quantitative (RQ)-PCR methods (Real-Q PML-RARα quantification kit, Biosewoom, Korea, and WT1 ProfileQuant™ kit, Ipsogen, France) presenting a similar sensitivity of 4.5 log.

We initially identified 142 APL patients from 2009 to 2014 but finally focused on 117 patients (median age 44 years old (range 19–70 years)) who underwent at least 2 cycles of consolidation after hematological CR. All patients were in complete molecular response (CMR) at the time of enrollment (Additional file 1: Figure S1, Table 1). Relapse was identified in 16 (13.7%) patients with a median duration of 22.8 months (range, 4.3–64.0). After median follow-up of 46.0 months (range, 14.7–86.3), 4-year cumulative incidence of relapse (CIR), non-relapse mortality (NRM), disease-free survival (DFS), and overall survival (OS) rates were 16.2, 1.2, 82.6, and 92.5%, respectively. We identified that high-risk Sanz-criteria, peak leukocyte count >40.0 × 109/L, and FLT3 mutation were predictive for relapse.
Table 1

Baseline characteristics of enrolled patients

Total n = 117

Number or median value

Age, median (range)

44 (19–70)

Gender, male

70 (59.8%)

Laboratory findings at diagnosis

 Leukocyte count (×109/L)

2.68 (0.4–112.0)

  Leukocytes count at peak (×109/L)

16.6 (0.4–112.0)

 Hemoglobin (g/dL)

8.9 (4.0–15.0)

 Platelet (×109/L)

33.0 (5.0–163.0)

 Lactate dehydrogenase (LDH, U/L)

692 (250–4070)

 Prothrombin time (PT, %)

63.0 (35.0–101.0%)

 Partial thromboplastin time (aPTT, s)

28.0 (20–45)

 Fibrinogen (mg/dL)

134.0 (31.0–500.0)

 Antithrombin III (%)

94.0 (49.0–150.0)

 D-dimer (mg/L)

17.0 (1.0–36.0)

Sanz criteria

 High

64 (54.7%)

 Intermediate

19 (16.2%)

 Low

34 (29.1%)

Karyotype

 Normal karyotype

5 (4.3%)

 t(15;17) alone

79 (67.5%)

 t(15;17) with 1 additional karyotype

20 (17.1%)

 t(15;17) with ≥2 additional karyotype

13 (11.1%)

PML-RARa subtype

 BCR1

85 (72.6%)

 BCR3

32 (27.4%)

FLT3 mutation

 No FLT3 mutation

86 (73.5%)

FLT3-ITD

25 (21.4%)

FLT3-TKD

6 (5.1%)

WT1 (copies/104 ABL), median (range)

 At diagnosis (n = 117)

18330 (20.0–236160.0)

 Post-induction (n = 117)

63.9 (4.9–2360.0)

 Post 1st consolidation (n = 117)

66.2 (1.1–2320.0)

 Post 2nd consolidation (n = 117)

80.1 (1.3–2110.0)

 Post 3rd consolidation (n = 117)

71.9 (10.8–808.0)

aPost-maintenance 3 months (n = 117)

70.0 (6.0–5520.0)

aPost-maintenance 1 year (n = 87)

57.5 (10.0–1630.0)

aPost-maintenance 2 year (n = 62)

54.4 (10.0–500.0)

 At relapse (n = 16)

239.5 (77.1–34910.0)

Leukapheresis at initial treatment

20 (17.1%)

Differentiation syndrome

21 (17.9%)

Hematological complete response

 After induction

115 (98.3%)

 After 2nd induction

2 (1.7%)

Complete molecular response (CMR)

 After induction

68 (58.1%)

 After 2nd induction

2 (1.7%)

 After 1st consolidation

42 (35.9%)

 After 2nd consolidation

5 (4.3%)

Abbreviation: BCR breakpoint cluster region, FLT3 Fms-related tyrosine kinase 3, ITD internal tandem duplication, TKD tyrosine kinase domain, ABL Abelson murine leukemia viral oncogene, WT1, Wilms tumor 1, ATRA all-trans retinoic acid, AML acute myeloid leukemia

aPost-maintenance indicates the time from starting maintenance therapy

We compared the level of WT1 between relapsed and non-relapsed group during the course of treatment (Additional file 1: Figure S2) and identified that median WT1 was significantly different at post 2nd consolidation (171.5 vs. 76.3, P = 0.049), at post 3rd consolidation (156.0 vs. 67.6, P = 0.013) and at 3 months post-maintenance (162.0 vs. 59.1, P = 0.002). We found that WT1 post-maintenance 3 months was the most significant parameter for relapse prediction at the cutoff of ≥120.0 copies/104 ABL.

We calculated subsequent CIR and DFS rates in 116 patients after excluding 1 patient with early relapse. Patients with WT1 post-maintenance 3 months higher than 120.0 copies/104 ABL showed higher 4-year CIR (30.5 vs. 6.9%, P = 0.0002) and inferior 4-year DFS (62.8 vs. 91.4%, P < 0.0001) rates (Fig. 1a, b). Also in the high-risk subgroup, high WT1 post-maintenance 3 months showed higher 4-year CIR (43.3 vs. 11.1%, P < 0.0001) and inferior 4-year DFS (55.5 vs. 86.4%, P = 0.0015) rates (Fig. 1c, d). In FLT3 positive and negative subgroup, high WT1 post-maintenance 3 months showed higher 4-year CIR (51.4 vs. 0.0%, P < 0.0001 and 21.5 vs. 8.6%, P = 0.0434) and inferior 4-year DFS (46.7 vs. 100.0%, P = 0.0018 and 69.6 vs. 89.3%, P = 0.0154) rates (Fig. 1e, f).
Fig. 1

Treatment outcomes according to WT1 expression level (<120 vs. ≥120 copies/104 ABL) at 3 months post-maintenance (PM-WT1). a Four-year CIR rates. b Four-year DFS rates. c, d Four-year CIR and DFS rates according to WT1 expression level in the high-risk subgroup. e, f Four-year CIR and DFS rates according to the status of PM-WT1 and FLT3-ITD mutation

Multivariate analysis (Additional file 1: Table S1) revealed that 4-year CIR was significantly higher in patients with high peak leukocyte count (HR = 6.414; 95% CI, 2.1–19.3, P < 0.001) and high WT1 post-maintenance 3 month (HR = 7.533; 95% CI, 2.3–24.8, P < 0.001), and 4-year DFS was significantly inferior in patients with high peak leukocyte count (HR = 5.275; 95% CI, 1.9–14.7, P = 0.001) and high WT1 post-maintenance 3 month (HR = 8.241; 95% CI, 2.3–29.1, P = 0.001).

Unfortunately, our chemotherapy regimen was not differently specified for high-risk APL and the standard treatment of APL is now changed to a combination therapy using ATO. Therefore, current results may not be applicable in the treatment course using ATO and another validation is needed. Conclusively, high post-remission WT1 expression is a reliable marker for prediction of subsequent relapse in APL patients treated with conventional chemotherapy. For patients with high-risk of relapse, early intervention using WT1-specific therapy may prevent relapse and improve survival outcomes [8, 9].

Declarations

Acknowledgements

Not applicable.

Funding

This study was supported by the Research Fund of Seoul St. Mary’s Hospital, The Catholic University of Korea, and also supported by a grant from the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (2015R1D1A1A01059819).

Availability of data and materials

The data of the current study are available from the corresponding author on a reasonable request.

Authors’ contributions

J-HY performed the molecular research, collected and analyzed data, and wrote the manuscript. D-HK, S-SP, B-SC, Y-WJ, S-EL, K-SE, Y-JK, SL, C-KM, S-GC, D-WK, JWL, and W-SM provided patients and materials and reviewed the manuscript. H-JK designed and conducted the study, provided patients and materials, analyzed data, and wrote the manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

The consent for publication is not applicable for this study and is permitted by the Institutional Review Board and Ethics Committee guidelines of the Catholic Medical Center (KC15RISI0862).

Ethics approval and consent to participate

This research was conducted in accordance with the Institutional Review Board and Ethics Committee guidelines of the Catholic Medical Center (KC15RISI0862). Additionally, this research is also permitted and registered in Clinical Research Information Service (CRIS) which is connected to WHO ICTRP; Korea Centers for Disease Control and Prevention, Ministry of Health and Welfare (Republic of Korea); KCT0002079.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea

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Copyright

© The Author(s). 2017

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