Hem 00066
Hem 00066
Hem 00066
1
Wellcome Trust Sanger Institute, Wellcome Genome Campus, Hinxton, United Kingdom; 2Department of
Haematology, Cambridge Institute for Medical Research and Wellcome Trust/MRC Stem Cell Institute,
University of Cambridge, United Kingdom; and 3Department of Haematology, Addenbrooke’s Hospital,
Cambridge, United Kingdom
Substantial progress has been made in our understanding of the pathogenetic basis of myeloproliferative neoplasms.
The discovery of mutations in JAK2 over a decade ago heralded a new age for patient care as a consequence of improved
This article was selected by the Blood and Hematology 2017 American Society of Hematology Education Program editors for concurrent submission to Blood and
Hematology 2017. It is reprinted with permission from Blood 2017, Volume 130.
Conflict-of-interest disclosure: The authors declare no competing financial interests.
Off-label drug use: None disclosed.
MPL
EPOR G-CSFR Mutant
CALR Mutant
MPL MPL
JAK2 JAK2 JAK2 JAK2
JAK2 JAK2
JAK2
JAK2
Mutant JAK2
JAK2
Figure 1. Mutations in JAK2, CALR, and MPL drive excessive myeloproliferation via constitutively active signaling downstream of JAK2. JAK2 associates
with the cytoplasmic portion of a variety of receptors, such as those for erythropoietin (EPOR), thrombopoietin (MPL), and granulocyte/macrophage
colony-stimulating factor (G-CSFR). JAK2 is also activated in response to additional cytokines (eg, growth hormone and IL-5) (not shown). (A) Mutant
JAK2, shown in red, is constitutively active and leads to variable levels of erythroid, megakaryocytic, and, to a lesser degree, granulocytic proliferation and
differentiation. It is unclear whether mutant JAK2 dimerizes with mutant or wild-type JAK2 with respect to the individual receptors. (B) Mutations in CALR
and MPL result in aberrant activation of signaling downstream of the MPL receptor. Mutant CALR complexes with MPL in the ER. Both mutations in
CALR and MPL result in receptor dimerization and activation of JAK2. MAPK/ERK, mitogen-activated protein kinases/extracellular signal-regulated
kinases; PI3/AKT, phosphoinositide 3-kinase/serine/threonine kinase Akt; STAT, signal transducer and activator of transcription.
backgrounds are more permissive for an MPN to emerge. Two recent additional mutations reveal common molecular perturbations, as il-
studies provide evidence for the existence of such an interaction. (1) lustrated in the examples below.
The association between ET and HBS1L-MYB SNP rs9376092 is un-
derstood to be through reduction in MYB expression, which is a recog- Methylation of cytosines at CpG sites is a mechanism through which
nized driver of thrombocytosis.42 (2) Germline duplication of ATG2B information establishing stem cell and differentiation states is retained by
and GSKIP has been shown to enhance sensitivity of megakaryocyte cells following cell division. DNMT3A is a de novo methyltransferase,
progenitors to TPO, particularly in the presence of JAK2V617F, resulting in and TET2, a member of the TET family of proteins, hydroxymethylates
highly penetrant MPNs within certain families.38 Several additional methylcytosines, which may be viewed simplistically as a process of
predisposition loci for MPNs have been recently identified across genes demethylation. Mutations in both genes are prevalent across MPNs,
involved in cell senescence (TERT), JAK-STAT signaling (SH2B3), understood to be loss of function (or dominant-negative effects for
myeloid differentiation (GFI1B), DNA damage and repair (ATM, DNMT3AR882H),45 and result in a hematopoietic stem cell (HSC)
CHEK2), and epigenetic regulation (TET2); this suggests that the germline advantage in murine models.46-49 The similarities in loss-of-function
genetic background of an individual may influence diverse biological consequences despite seemingly opposing functions have recently been
cellular functions to accentuate the molecular and cellular consequences reconciled by work demonstrating that DNMT3A cooperates with
of nascent MPN clones after their acquisition of phenotypic driver TET2 to (1) promote the activity of enhancers important in ensuring
mutations.43 stem cell fitness through the maintenance of high levels of DNA hy-
droxymethylation at enhancer centers50 and (2) repress key lineage-specific
Additional somatic mutations in MPNs transcription factors that promote differentiation in hematopoiesis.51
Approximately one third of patients with MPN have additional mu- Mutations in IDH1/2 also affect DNA methylation via the generation
tations in known drivers of myeloid malignancies. These mutations alter of 2-hydroxyglutarate that competitively inhibits a-KG–dependent DNA
DNA methylation (DNMT3A, TET2, IDH1/2), chromatin modifications hydroxylases, such as TET2 and Jumonji family histone demethylases.52,53
(ASXL1, EZH2, IDH1/2), messenger RNA splicing (U2AF1, SF3B1, Mutant IDH1 has also been linked to increased DNA damage via
SRSF2, ZRSR2), and DNA repair (TP53).10 The presence of certain downregulation of the DNA damage sensor ATM.54 Knock-in mice
mutations, such as in ASXL1, SRSF2, IDH1/2, and EZH2, in patients for IDH1R132H suffer expansion of hematopoietic stem/progenitor cells
with MF is associated with an increased risk of leukemic transformation (HSPCs), extramedullary hematopoiesis, and anemia,55 in keeping with
and/or reduced survival.44 Investigation of the biological effects of these this mutation being found in advanced phases of MPN.
Erythrocytosis Thrombocytosis
Perturbation of polycomb repressor complex 2 (PRC2) is another response to the second mutation. Thus, the transcriptional response to
pathogenic mechanism prevalent in MF. EZH2, the enzymatically active TET2 is altered by the presence of a prior JAK2V617F mutation.35 (2) The
subunit of PRC2, compacts chromatin and represses gene transcription first mutation may alter HSC differentiation and give rise to altered target
via histone H3 trimethylation at lysine 27 (H3K27). In myeloid malig- cell populations in which the second mutation can arise. (3) The first
nancies, EZH2 loss-of-function mutations lead to derepression of several mutation may alter the number and function of mature progeny and thus
target genes, such as the Hox gene family, which enhances HSC self- affect the bone marrow microenvironment. Further studies are required
renewal, and Lin28b/ Hmga2, which promotes fibrosis and reduces to address which mechanisms are most important in driving the phe-
erythropoiesis in a JAK2V617F context.56-58 Loss of EZH2 can also be notypic differences in patients with different temporal patterns of
a consequence of other genetic perturbations, such as loss of heterozy- mutation acquisition, and whether phenotype in chronic phase, or
gosity at chromosome 7q, as well as mutations in spliceosome com- disease progression, is influenced by the order of acquisition of other
ponents U2AF1 and SRSF2.59,60 Mutations in ASXL1 are present in up to pairs of common mutations.
a quarter of patients with MF and also lead to reduced PRC2 recruitment,
although other additional pathogenic effects have been reported.61-63 Disease initiation and clonal outgrowth in MPNs
The conventional view of hematopoiesis envisions a self-renewing pool
Order of mutation acquisition of long-term repopulating HSCs producing terminally differentiated
Akin to other cancers, MPNs are clonally heterogeneous, reflecting cells via a series of intermediates. However, recent data from mice
the ongoing interplay between somatic mutation, cellular adaptation to suggest that steady-state hematopoiesis does not routinely rely on HSCs
the changing microenvironment, and selection of tumor subclones. The but predominantly reflects the successive recruitment of thousands of
sequence of acquisition of somatic mutations can be inferred from the transiently active progenitors.65,66 Furthermore, there is now com-
genotypes of detectable subclones. For instance, if some tumor cells pelling evidence for heterogeneity in the differentiation potential of
have JAK2V617F, and others from the same patient bear JAK2V617F with individual cells within the HSC compartment in mice.67-69
an additional somatic mutation, then this indicates that JAK2V617F came
first. Genotyping individual hematopoietic colonies has shown that Direct evidence for a clonal stem-cell origin of MPNs came 40 years ago
the order of acquisition of JAK2V617F, relative to mutations in TET2 or when Adamson and colleagues demonstrated that females with PV who
DNMT3A, influences subclonal composition within HSPCs and mature were heterozygous for 2 glucose-6-phosphate dehydrogenase alleles
cell compartments, disease presentation, and clinical outcome.35,64 In expressed only 1 allele in their blood cells.70 Both JAK2V617F and CALR-
JAK2-first patients, the HSPC compartment is dominated by double- mutated cells are readily detectable in immunophenotypically defined
mutant cells, and such patients present at a younger age, often with PV.35 HSPCs and across all myeloid lineages, confirming that these mutations
Conversely, in TET2-first patients, the HSPC compartment is dominated arise in cells close to the apex of the hematopoietic hierarchy.10,71 It is
by single-mutant cells, and such patients present at an older age, usually tempting to speculate that after the acquisition of a driver mutation,
with ET. Studies of mutation order have also revealed that DNMT3A platelet-biased HSCs might be particularly prone to giving rise to an
mutations, often thought to be early events, frequently occur after an MPN, but direct evidence for this is lacking. In some studies but not
initial JAK2 mutation. This situation is difficult to detect in the absence others, JAK has been found in the lymphoid compartments of patients
of clonal assays because only small numbers of JAK2 single-mutant with MPN, raising the possibility that HSCs with differing degrees of
colonies may be present, probably reflecting their outcompetition by lymphoid potential are targets of somatic mutation in different
double-mutant clones. At least 3 mechanisms, not mutually exclusive, patients.72-76 However, alternative explanations include the presence of
may underlie these observations: (1) The first mutation may alter a cell’s other somatic mutations or the long-lived nature of mature lymphocytes,
progression through modulation of inflammatory cascades, in- Clinical implications and future directions
cluding elevated IL-8 expression.95,96 Overall, it remains unclear The JAK inhibitor ruxolitinib has been a valuable addition to the
exactly how a single phenotypic driver mutation initiates a clonal therapeutic armamentarium for MPNs, in particular for patients with
expansion that will evolve into an overt MPN, but current evidence MF who have splenomegaly and/or disease-related symptoms.97,98
suggests that the constitutional genetic background, aging process, and However, allogeneic stem cell transplantation still remains the only
tumor microenvironment are key factors, with each exerting cell- potentially curative treatment of MPNs, an approach limited by age-
intrinsic and environmental effects (Figure 3). related comorbidities and high treatment-related mortality. Demonstrable