TET2 and TP53 Mutations Cooperatively Modulate the Response to Inflammation to Promote Leukemic Transformation

TET2 is a commonly mutated gene in hematologic malignancies, including as an initiating event in clonal hematopoiesis (CH). Its mutation alters hematopoietic self-renewal, differentiation, and systemic inflammation responses. TP53 mutations co-occur with TET2 mutations and are also observed in patients with high-risk clonal hematopoiesis and hematologic malignancies. Using a murine model, we found that HSPCs with both mutations initially promoted a myeloproliferative phenotype. Over time these double mutant HSPCs acquire additional genomic alternations, leading to disease progression to acute leukemias including B-ALL. We observed enhanced inflammatory signatures at transformation and identified NLRP1 as a target of TP53 activation. Decreased response to an inflammatory cell death pathway in the setting of TP53 mutation allows cells to tolerate inflammatory stress. This pathway also modifies response to chemotherapies that induce protein translational stalling. Our results identify a hematopoietic stem cell stress response pathway with implications on adaptation to inflammation and chemotherapy tolerance. Significance TET2 and TP53 mutations co-operate leading to advanced hematologic malignancy. TET2 mutations promote an inflammatory environment and TP53 mutation supports tolerance to this inflammatory stress.