We report on markedly different frequencies of genetic lesions within subsets of chronic lymphocytic leukemia patients carrying mutated or unmutated stereotyped B-cell receptor immunoglobulins in the largest cohort (n=565) studied for this purpose. By combining data on recurrent gene mutations (BIRC3, MYD88, NOTCH1, SF3B1 and TP53) and cytogenetic aberrations, we reveal a subset-biased acquisition of gene mutations. More specifically, the frequency of NOTCH1 mutations was found to be enriched in subsets expressing unmutated immunoglobulin genes, i.e. #1, #6, #8 and #59 (22-34%), often in association with trisomy 12, and was significantly different (P<0.001) to the frequency observed in subset #2 (4%, aggressive disease, variable somatic hypermutation status) and subset #4 (1%, indolent disease, mutated immunoglobulin genes). Interestingly, subsets harboring a high frequency of NOTCH1 mutations were found to carry few (if any) SF3B1 mutations. This starkly contrasts with subsets #2 and #3 where, despite their immunogenetic differences, SF3B1 mutations occurred in 45% and 46% of cases, respectively. In addition, mutations within TP53, whilst enriched in subset #1 (16%), were rare in subsets #2 and #8 (both 2%), despite all being clinically aggressive. All subsets were negative for MYD88 mutations, whereas BIRC3 mutations were infrequent. Collectively, this striking bias and skewed distribution of mutations and cytogenetic aberrations within specific chronic lymphocytic leukemia subsets implies that the mechanisms underlying clinical aggressiveness are not uniform, but rather support the existence of distinct genetic pathways of clonal evolution governed by a particular stereotyped B-cell receptor selecting a certain molecular lesion(s).

1st Department of Propaedeutic Medicine University of Athens Greece

Cancer Sciences Faculty of Medicine University of Southampton UK

Central European Institute of Technology Masaryk University and University Hospital Brno Czech Republic

Department of Haematology Royal Bournemouth Hospital Bournemouth UK

Department of Hematology Rigshospitalet Copenhagen Denmark

Department of Immunology Erasmus MC University Medical Center Rotterdam The Netherlands

Department of Immunology Genetics and Pathology Science for Life Laboratory Uppsala University Uppsala Sweden

Department of Immunology Genetics and Pathology Science for Life Laboratory Uppsala University Uppsala Sweden Institute of Applied Biosciences CERTH Thessaloniki Greece Hematology Department and HCT Unit G Papanicolaou Hospital Thessaloniki Greece

Division of Haematology Department of Translational Medicine Amedeo Avogadro University of Eastern Piedmont Novara Italy

Hematology Department and University Pierre et Marie Curie Hopital Pitie Salpetriere Paris France

Hematology Department Nikea General Hospital Piraeus Greece

Hematopathology Unit and Department of Hematology Hospital Clinic University of Barcelona Institut d'Investigacions Biomèdiques August Pi iSunyer Barcelona Spain

Institute of Applied Biosciences CERTH Thessaloniki Greece

The Feinstein Institute for Medical Research North Shore Long Island Jewish Health System Manhasset New York NY USA

Università Vita Salute San Raffaele Milan Italy Division of Experimental Oncology and Department of Onco Hematology IRCCS San Raffaele Scientific Institute Milan Italy

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