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Evaluation of CD96 Expression in Adult Acute Myeloid Leukemia Patients at Diagnosis and after Induction Therapy

Eman A. ELMoqammar1*, Mustafa N.M 2, Hany A Labib 3, Ahmed A Alnagar4, and Mohamed Eissa5

1M.B.B.CH, Faculty of Medicine – Zagazig University.

2Professor of Clinical Pathology Faculty of Medicine, Zagazig University, Egypt.

3Professor of Clinical Pathology Faculty of Medicine, Zagazig University, Egypt.

4Assistant Professor of Medical Oncology, Faculty of Medicine, Zagazig University, Egypt.

5 Department of Clinical Pathology, faculty of Medicine, Zagazig University.

Correspondingauthor:Eman A. EL Moqammar Email:[email protected]

Abstract

Background:Acute Myeloid Leukemia (AML) is a clonal hematopoietic disorder that may be derived from either an HSC or a lineage-specific progenitor cell. AML is characterized both by a predominance of immature forms (with variable, but incomplete, maturation) and loss of normal hematopoiesis. Single or multiple hematopoietic lineages may comprise the leukemic clone.Increased expression of Cluster of Differentiation 96 (CD96) was shown in several subsequent studies to correlate with poor prognosis and enhanced resistance to chemotherapy.

Aim of the study: This work aimed to assess whether the expression of CD96 could be considered as a useful biomarker for the assessment of response to induction therapy in patients with AML.

Patients and methods:The study was carried out at as a cohort study at the Clinical Pathology Department on 38 adult AML patients who were admitted to the Medical Oncology Department, in the Faculty of Medicine, Zagazig University Hospitals through the duration between 10\2018 to 10\2019. All patients were undergone full history, clinical examination, laboratory investigations included complete blood count, bone marrow aspiration and examination, liver and kidney functions, and LDH. Virology report including (HCVAb, HBsAg, and HIVAb). PT, aPTT. ESR and measuring of CD96 expression.

Results:CD96 was expressed in 16/38 patients (42.1%).We found a significant positive correlation between CD96 expression and BM blast cells percentage.Only thirty-one % of patients with CD96+ve expression respond to the induction therapy, while 77.3% of patients without CD96 expression showed a response to induction. There was a statistically significant increase in the CD96+ve expression patients in the non-responder group compared to the responders.The median time of disease-free survival was longer in –ve CD96 patients compared to +ve CD96 patients (7 months and 3 months respectively).

Conclusion:CD96 is frequently expressed in AML patients. CD96+ve expression is significantly associated with some poor prognostic markers like, increased BM blasts percentage, leukocytosis, and elevated LDH.Expression of CD96 is associated with less response to induction therapy and lower median time of disease-free survival.

Keywords:Acute Myeloid Leukemia (AML), Cluster of Differentiation 96 (CD96).

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1. Introduction:

Acute myeloid leukemia (AML) is a clonal malignant disease of hematopoietic tissues that is defined by the accumulation of leukemic blast cells in the marrow resulting in hematopoietic failure. In Egypt, leukemia is the most common presented hematological malignancy (75%), nearly half of leukemic cases were acute myeloid leukemia which develops as the consequence of a series of genetic changes in a hematopoietic precursor cell (1).

Laboratory data suggest that AML originates from a rare population of cells termed leukemic stem cells (LSCs), which are capable of self-renewal, proliferation, and differentiation into malignant blasts (2).

Various surface markers have been assigned to LSCs such as CD96, so there is universal agreement that LSCs exist within the CD34+ compartment of hematopoietic cells and the majority of LSCs are CD38-ve (3).It is assumed that in leukemia the disease-causing incident(s) occur among stem cells generating a leukemic stem cell (LSC) that shares self-renewal potency with the stem cells. (3).

CD96, also known as TACTILE (T-cell activated increased late expression), is a Type I membrane protein that belongs to the immunoglobulin superfamily. It is expressed by T and NK cells but not the majority of B cells, monocytes, and granulocytes in human peripheral blood (4).

CD96 has been identified as a LSC-specific marker in human AML (5).CD96 plays a role in the adhesive interactions of activated NK and T cells during the immune response. CD96 binds to the poliovirus receptor (CD155). CD96-mediated uptake of CD155 may adversely affect NK cells and thus reduce their effectiveness in anti-tumor response (4).

Increased expression of CD96 was shown in several subsequent studies to correlate with poor prognosis and enhanced resistance to chemotherapy (6).AML-LSC can be distinguished from normal HSC by the presence of CD96 expression. This finding suggests that CD96 may prove to be an excellent target for antibody therapy against LSC because hematopoietic progenitors are regenerated rapidly from HSC (5).

We aimed at this study to assess the role of CD96 as a new biomarker for the prognosis of AML and to estimate the validity of CD96 for prediction of response to induction therapy in AML patients.

2. Patients and Methods:

2.1.The current study was conducted ascohort study. A total number of 38 acute myeloid leukemia patients were included in the study. The study was carried out at Clinical Pathology Department on patients who were admitted to Medical Oncology Department, Faculty of Medicine, Zagazig University Hospitals through the duration between October 2018 to October 2019.

2.2.A consent form approved by the committee of human rights in research in Zagazig University was obtained from each participant before the study initiation.

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2.3.Patients who were included in this study20 males and 18 females with a male to female ratio of 1.1:1 aged from 18 to 60 years.Newly diagnosed AML patients who were admitted to the medical oncology department with adequate liver, kidney, and cardiac functionswere included in this study.

2.4.All patients who were on other treatment modalities of inflammatory conditions, AML subtype M3, patients with other malignancies, patients who already started therapy and patients who refused to give consentwere excluded from the study.

2.5.The patients who met the inclusion criteria and were suitable candidates for the study have been subjected to:

Full History Taking: age, sex, residency, etc.

b- Clinical Examination.

c- Routine Laboratory Investigations including:

Complete blood count (CBC) using automated cell counter with examination of Leishman stained peripheral blood (PB) smears for differential leucocytic count and blast cell percentage.

Bone marrow aspiration and examination to detect the percentage of BM blast cells.

Liver functions, kidney functions, and LDH.

Virology report including (HCVAb, HBsAg, and HIVAb).

PT, aPTT.

ESR.

d- Specific Investigations including: measuring of CD96 expression using flow cytometry at the time of diagnosis and after 28 days from induction therapy.

Treatment:-

All patients had received induction chemotherapy "3+7" as following:-cytarabine 100 mg/m2/day continuous intravenous infusion from day 1 to day 7, and doxorubicin 25 mg/m2/day from day 1 to day 3.

For all patients with AML, BM aspirate samples were repeated at about day 28 from the start of chemotherapy to assess the CR. Patients achieved CR will receive 3 cycles of HIDAC (High dose Ara- C) as consolidation ,while non responders will receive salvage protocols (7).

2.6. Methods:

i- RoutineLaboratory Investigationsincluding:-

CBC using automated cell counter "Sysmex XN-2000" supplied by SysmexCorporation (Japan), with examination of Leishman stained PB smears for differential leucocytic count.

Cytochemical stain: peroxidase stain.

Bone marrow aspiration and examination of Leishman stained smears.

Liver, kidney functions, and LDH: using automated analyzer "Cobas 8000-c702'' supplied by Roche Diagnostics (Germany).

Virology report including (HCVAb, HBsAg and HIVAb) : using automated analyzer "Cobas 8000-e601'' supplied by Roche Diagnostics (Germany).

PT, aPTT: using "Sysmex CS-2100i" supplied by SysmexCorporation (Japan).

ESR: using vision-B, yhlo biotech.

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ii- Specific Investigations including: measuring of CD96 expression using flow cytometry at the time of diagnosis and after 28 days from induction therapy.

Immunophenotyping:-

Using (FACscan, Becton Dickinson, San Jose California, USA), flow cytometric analysis was performed using Cell Quest Software (BD Bioscience). The following monoclonals panel used in AML labeled with fluorescein isothiocyanate (FITC), phycoerythrin (PE) and peridinin- chlorophyll-protein (PerCP):

CD45, CD34, TDT, MPO, HLA-DR, CD13, CD33, CD14, CD64, CD5, CD20, CD22, CD10, CD19, CD3, CD7, MPO, and CD96.

Measuring of CD96 by flow cytometry:- a- Equipmenets for immunophenotyping:

1. Flow cytometer (FACScan, Becton Dickison, San Jose, California, USA).

2. Fixed automatic pipette 100ml.

3. Adjustable 5-50ml automatic pipette.

4. Centrifuge.

5. Vortex.

6. Reagents which includes :

a. Flow cytometric lysing solution.

b. Isotype control (IgG1a & IgG2b) labeled with FITC, PE and PerCP.

c. Monoclonal Ab CD96 PE.

b- Preparation of sample:

1. One hundred µl of K- Ethylene Diamine Tetra Acetate (K-EDTA) anticoagulated blood were transferred to two tubes.

2. The first was the isotypic control to exclude auto-fluorescence region.

3. Ten µl of CD96 MoAb was added in the second tube, then sample vortexed for 2 minutes.

4. The 2 tubes were incubated for 10 minutes and protected from light. At the end of incubation, 500µl of flow cytometric lysing solution (1:9) was added to each tube and incubated for 10 minutes.

5. Tubes were washed twice by 2 ml of phosphate buffered saline (PBS) and centrifuged for 5 minutes then supernatant was discarded.

6. Five hundred µl of PBS were added to the pellet, and cell preparation was analyzed.

c- Flow cytometric analysis for immunophenotyping:

After warming up the argon laser (488hz) for 30 minutes, the full alignment procedures were performed using standard immune check alignment fluorosphere for adjust formed at side scatter, photomultiplier tube (PMT) 2,3,4 for orange, red and green adjustment respectively. The proper protocol for color flow cytometry was labeled and used for interpretation of the result.

Thirteen thousands cells were passed in front of the laser for each case from which the lymphocytes were selectively gated for immunophenotypic analysis. Gated cells were based on the SSC/FSC within the plastic region.

d- Interpretation:

Diagnosis of AML was based on the presence of blast cells ≥20% in BM film according to WHO proposal, together with MPO positive staining and presence of immunophenotyping results consistent with AML. From this population of cells, the expression of CD96 immunophenotype are defined when at least 20% of the blast cells expressed this marker (8).

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2.7. Follow-up:

After 1 month; patients were re-evaluated for the assessment of initial response to induction therapy by CBC and bone marrow aspirate examination.

Complete remission (CR): he¬moglobin> 90 g/L, white blood cells normal or reduce, without immature cells, platelets >100×109/L; blast cells in the bone marrow < 5%, normal RBC and megakaryocyte system (6).

Partial remission (PR): BM blast cells< 20% (6).

No remission (NR): BM blast cells > 20% (6).

Resistance disease, related to failure of therapy to eliminate the disease. Patients who had CR followed up about 1 year to assess the outcome and disease-free survival (DFS).

2.8. Statistical analysis:

Data were tested for normal distribution using the Shapiro Wilk test. Qualitative data were represented as frequencies and relative percentages. Chi square test (χ2) and Fisher exact was used to calculate difference between qualitative variables as indicated. Quantitative data were expressed as mean ± SD (Standard deviation) for parametric and median and range for non-parametric data.

Independent T test and Mann Whitney test were used to calculate difference between quantitative variables in two groups for parametric and non-parametric variables respectively. Paired t-test was used to compare between two dependent groups of normally distributed variables while Wilcoxon signed ranks test was used for non-normally distributed variables. Spearman’s correlation coefficient was used for correlating non-parametric variables.

The (+) sign was considered as indication for direct correlation i.e. increase frequency of independent lead to increase frequency of dependent and (-) sign as indication for inverse correlation i.e. increase frequency of independent leads to decrease frequency of dependent, also we consider values near to 1 as strong correlation and values near 0 as weak correlation.

Kaplan-Meier method used to estimate event free survival and log rank test compared survival curves (P value was considered significant at ≤ 0.05 levels).

All statistical comparisons were two tailed with significance Level of P-value ≤ 0.05 indicates significant, P < 0.001 indicates highly significant difference while, P > 0.05 indicates Non- significant difference..

3. Results:

There were no significant differences in age and sex between CD96 –ve and CD96 +ve patients (Table 1). There was a statistically significant increase in TLC, LDH, and BM blast cells% in CD96 +ve expression group compared to CD96 -ve expression group (p<0.05) (Table 2).

We found a significant positive correlation between CD96 expression with TLC, LDH, BM blast cells%, and uric acid, and a significant negative correlation between CD96 expression and platelet count(Table 3).

There was a significant positive correlation between CD96 mean expression and CD34, CD13, CD33, CD14, CD64, and TdT(Table 4). After the induction therapy, we found 22 out of 38 patients (57.9%) respond to induction, while 16 out of 38 (42.1%) did not show any response to the induction therapy as illustrated in Fig. 1.There was a statistically significant increasein CD96+ve expression patients in the non-responder group compared to the responder groupFig. 2.

There was a statistically significant increase in the mean expression of CD96 inthe non-responder groupcompared to the responders to induction therapy (p=0.005)(Table 5).There was a

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statistically significant increase in the mean expression of CD96 and BM blast cells % in the non- responder group compared to the responders to induction therapy (p<0.001) (Table 6).We found that the median time of disease-free survival was longer in CD96 – ve patients (7 months) compared to CD96+ve patients (3 months), but not reach a significant level (Table 7&Fig. 3).

Table (1): Demographic characteristics of the studied patients.

Variables CD96 -ve

(n=22)

CD96 +ve

(n=16) t / χ2 P

Age (years)

Mean± SD 40.32 ± 13.66 38.61 ± 14.22

t

0.581 0.316

Sex, n (%)

Male 12 (54.5) 8 (50) χ2

0.142 0.730

Female 10 (45.5) 8 (50)

t: t-test, x2: chi square, SD: standard deviation, P: probability level (p-value)

Table (2): Laboratory parameters among the studied patients according to CD96 expression.

Variables CD96 -ve (n=22)

CD96 +ve (n=16)

Test P

Hemoglobin (g/dl) Mean± SD Median (Range)

7.96 ± 1.54 8 (4.2 - 11.1)

7.69 ± 1.68

8.1 (4.3 - 10.1) 0.525# 0.603 TLC (×103 /μL)

Mean± SD Median (Range)

26.23 ± 15.63 21.5 (3 - 57)

37.01 ±15.81

38.5 (12 -62) 108$ 0.045*

Platelets count (×103/μL) Mean± SD Median

(Range)

59.09 ± 28.95 60.5 (12 - 107)

33.81 ± 22.63

40.5 (9 - 85) 120$ 0.07 ALT (U/L)

Mean± SD Median (Range)

56.91 ±49.85 32 (12 -167)

68.94 ±50.15

40 (19 -160) 145.5$ 0.366 LDH (U/L)

Mean± SD Median (Range)

291.59 ± 103.69 255 (112 - 540)

410.63 ± 157.85

313 (100 - 623) 122.5$ 0.04*

ESR (mm/hr) Mean± SD

Median (Range) 51.64 ± 23.41 45 (24 - 96)

50.56 ±21.42

52.5 (22 -90) 0.145# 0.886 Uric acid(mg/dl) Mean±

SD

Median (Range)

8.28 ± 3.38 8.4 (2.8 - 14.2)

9.57 ± 2.76

10.2 (4.7 - 14.2) 1.254# 0.218 BM blast cells (%)

Mean± SD Median (Range)

45 ± 12.25 44.5 (25 - 74)

61.38 ±19.49

61.5 (29 -95) 3.179# 0.003*

#t-test, $Mann Whitney, SD: standard deviation, TLC: total leucocytic count, ALT: Alanine aminotransferase, LDH: lactate dehydrogenase, ESR: erythrocyte sedimentation rate, BM: bone marrow,

* significant. P: probability level (p- value).

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Table (3): Correlation between CD96 expression and the laboratory parameters.

Correlation CD96 Hemoglobin

R 0.003

P 0.893

TLC

R 0.470**

P 0.003

Platelets count

R -0.427**

P 0.007

ALT

R 0.176

P 0.292

LDH

R 0.631**

P 0.000

BM blast cells%

R 0.683**

P 0.000

ESR

R 0.059

P 0.724

Uric acid

R 0.339*

P 0.037

TLC: total leucocytic count, ALT: Alanine aminotransferase, LDH: lactate dehydrogenase, ESR:

erythrocyte sedimentation rate, BM: bone marrow, P: probability level (p- value), R: spearman correlation coefficient *: significant, **: highly significant.

Table (4): Correlations between CD96 expression and other CDs.

Correlation CD96

CD34 R 0.917

P 0.000

CD13 R 0.613

P 0.002

CD33 R 0.716

P 0.001

CD14 R 0.589

P 0.004

MPO R 0.139

P 0.414

HLA-DR R 0.305

P 0.101

CD7 R 0.312

P 0.08

CD64 R 0.512

P 0.004

CD19 R -0.197

P 0.297

TdT R 0.653

P 0.002

P: probability level (p- value), R: spearman correlation coefficient

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57.90%

42.10%

Outcome

Response Not Response

Fig.1 Outcome after the induction therapy

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

Respond No respond

77.30%

22.70%

31.20%

68.80%

CD96 -ve CD96 +ve

Fig. 2 Outcome among the studied patients regarding CD96 expression.

Table (5): CD96 mean expression values, at diagnosis, according to response to the induction therapy.

Variables Respond (n=22)

Not (n=16)

MW P

CD96 Mean± SD

Median (Range)

18.58 ± 16.39 13 (5 – 59.1)

49.28 ± 34.24 49.25 (4 – 97.95)

81 0.005*

SD: standard deviation, MW: Mann Whitney, *: significant. P: probability level (p- value) Table (6): BM blast cells% and CD96 mean values after the induction therapy.

Variables Respond (n=22)

Not (n=16)

MW P

BM blast cells (%) Mean± SD

Median (Range)

3.01 ± 1.94 2.15 (1 – 4)

35.43 ± 17.72 41.5 (14 – 55)

11 0.000**

CD96 Mean± SD

Median (Range)

8.24 ± 0.42 4 (2 – 16.6)

33.63 ± 4.25 35.25 (28 – 73.5)

59.5 0.000**

SD: standard deviation, MW: Mann Whitney, **: Highly significant, P: probability level (p- value)

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Table (7): Disease-free survival (DFS) among the studied patients according to CD96 expression.

Variables

-ve +ve

Median S.E. 95% Confidence P

Interval Median S.E. 95% Confidence Interval

DFS 7 2.5 2.1 - 11.9 3 1 1.04 - 4.96 0.069

SE: standard error, P: probability level (p- value), DFS: disease-free survival

Fig.3 Disease-free survival (DFS) among the studied patients according to CD96 expression.

4. Discussion:

Acute myeloid leukemia (AML) is a clonal, malignant disease of hematopoietic tissues that is defined by the accumulation of leukemic blast cells, mainly in the marrow resulting in hematopoietic failure(9).

In Egypt, leukemia is the most common presented hematological malignancy (75%), nearly half of leukemic cases were acute myeloid leukemia which develops as the consequence of a series of genetic changes in a hematopoietic precursor cell (1).

Laboratory data suggest that AML originates from a rare population of cells, termed leukemic stem cells (LSCs), which are capable of self-renewal, proliferation, and differentiation into malignant blasts. Various surface markers have been assigned to LSCs such as CD96 and CD123, though there is universal agreement that LSCs exist within the CD34+ compartment of hemopoietic cells and the majority of LSCs are CD38−ve (2).

CD96; also known as TACTILE (T-cell activation increased late expression) is a Type I membrane protein that belongs to immunoglobulin superfamily. CD96 was previously introduced as a novel cell surface marker on NK cells and an antigen for T-cell. CD96 is not expressed in the majority of normal HSC population; however, it is intensely expressed in CD34+ CD38− AML cells. Furthermore, CD96+ LSCs have a high ability for engraftment in mice. Therefore, it may be probable to use this molecule for LSC-targeted antibody therapy (5).

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This agrees with (,10)who performed a retrospective study on 86 patients diagnosed with acute leukemia at Department of Hematology, Tianjin First Central Hospital, Tianjin, China, from August 2008 to May 2012 to evaluate the expression of the LSC markers CD96 and CD123 in de novo acute leukemia (AL) patients, and to explore the relationship between those markers and response to induction therapy and prognostic factors in AML. They found that the median age for CD96 positive patients was less than that of CD96 negative patients, but the statistical difference was not significant (p=0.435).

(11) investigated the expression pattern of CD 90, 96,117, and 123 in bone marrow or peripheral blood from adult patients with AML and their use as markers for diagnosis and prognosis also found that the mean ages ranged between 18-65 years with a mean ± SD (37.9 ± 12.6) in patients expressing CD96.

In our study, the mean age of patients and the peak incidence were markedly lower than that observed in the developed countries where the incidence of AML increased with age, and the majority of cases were above 55 years of age (12).

This might be attributed to the small sample size or other factors related to the biology of leukemia.

This study showed that there was a statistically significant increase in the mean values of WBCs count in CD96+ve AML patients. Moreover, a significant positive correlation was found between WBCs count and the mean of CD96 expression.

(8)found that the total WBCs count in CD96+ve AML patients was high compared to CD96–ve patients. In another study, ( 10)observed the same results. Also, (13) found that the WBCs count of AML patients with CD96 expression was significantly higher than CD96–ve expression (P<0.05). Our results go hand in hand with these studies.

In contrast to these results, (14)found that there was no statistical significance association between CD96 expression level and WBCs count.

In our study there was a statistically significant reduction in mean values of platelet count in CD96+ve group compared to CD96–ve group and there was a significant negative correlation with the mean of CD96 expression.

(8) found that the mean platelet count was (58.96±48.97) ×109∕ l in CD96+ve expression group in adult AML patients and (60.94±35.77) ×109∕ l in AML patients with –ve CD96 expression, but without statistically significant difference (p-value = 0.914).

(11)alsofound a decreased level of platelet count as it ranged from (11 to 115) × 109 ̸ l with a mean of (63.5±19.5) ×109 ̸ l, nevertheless, no statistical difference was found between platelet count and CD96 expression.

As regards other routine laboratory data, we found an increase in LDH levels in AML patients, it was significantly higher in CD96+ve expression patients than CD96–ve expression patients, also there was a highly significant positive correlation between them.

This disagrees with ( 11)who found that there was no statistically significant difference between CD96 expression and LDH level.

This clash may be due to our small sample size or other factors related to inclusion and exclusion criteria.

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In the current study, BM blast cell of AML patients with CD96 expression was significantlly higher than CD96–ve expression patients.

This agrees with (8) who found that CD96 expression was significantlly associated with high BM blasts percentage (p-value=0.003). Also, (15) revealed that the expression level of CD96 was significantly correlated with the proportion of the BM blasts

We also found that the percentage of CD96 expression was significantlly positively correlated with CD34, CD13, CD33, CD14, CD64, and TdT.

(5)found that CD96 is highly expressed on the CD34 positive blasts, but at a lower frequency in CD34 negative blasts as they demonstrate that CD96 is frequently expressed in the CD34+CD38- LSC population in >60% of the human primary AML samples examined.

This agrees with(6) who found that CD33 presented the highest positive rate (80.8%), followed by CD96 (43.6%) among all AML patients. Also, (16)who aimed to analyze the expression of four cell surface antigens relevant to human hematopoiesis—CD90, CD96, CD117, and CD123—in bone marrow from pediatric AML patients, reportthat 35-40% of CD34+ CD38- cells were positive for CD96 antigen.

When we try to find if CD96 expression levels have any prognostic importance, the best method is to find its association with response to therapy, disease outcome, and survival.

After induction therapy, it was noted that 22 out of 38 (57.9%) of our patients had a response to induction therapy while 16 out of 38 (42.1%) did not show any response. Among cases with CD96 positive expression, (31.2%) achieved response to induction therapy, while among the cases with negative CD96 expression, (77.3%) achieved response to induction therapy. There was a statistically significant difference between the two groups regarding CD96 expression in response to induction therapy (p=0.005).

These findings serve to predict that CD96 is a marker for a bad prognosis.

Coping with our results,(6) reportedthat the response rate (CR + PR) was 42.3% in the CD96+ve expression group, which was significantly lower than that of the CD96–ve expression group (71.8%) (p<0.001).

Also(17)observed that a higher expression of CD96 promoted a poor response for chemotherapy, which may be closely associated with a primary resistance, the overall CR rate in a 55 cohort of AML patients was 69.1% (38/55) in low expression of CD96.

This also goes hand in hand with (8) who found that complete remission (CR) was achieved in 20/30 patients (66.67%) at the end of induction therapy in patients with negative CD96 expression.

(18)Supports the association between high levels of this surface marker and poor response to induction therapy.

There was a statistically significant increase in TLC, BM blast cells percent, LDH, and decrease in platelet count in non-responder group compared to the responders to induction treatment, while no significant difference regarding response to induction therapy and hemoglobin level, ALT, ESR and, uric acid.

(19)who aimed to identify the relationship between LDH and relapse in AL patients, found that serum LDH levels were elevated in the majority of AML patients at initial diagnosis and in relapsed patients. While regarding association between treatment response and TLC, Hb levels, and platelet count, there was no significant association in-between.

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In the present work, we found that the median time of disease-free survival was longer in –ve CD96 patients compared to +ve CD96 patients (7 months and 3 months respectively), but not reach a significant level.

This was in accordance with that reported by (6), who found that CD96 high expression group exhibited obviously shorter median survival time (30.6 months) than the low expression (35.7 months) (p=0.030).

5. Conclusion:

This study concluded that CD96 was frequently expressed in AML patients. CD96+ve expression was significantlly associated with some poor prognostic markers like, increased BM blasts percentage, leukocytosis, and elevated LDH.

Expression of CD96 was associated with less response to induction therapy and lower median time of disease-free survival, so the expression of CD96 is considered a poor prognostic factor in AML patients.

6. ConflictofInterest: Noconflictofinterest.

7. References

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