The Impact of Mutation of Myelodysplasia-Related Genes in De Novo Acute Myeloid Leukemia Carrying NPM1 Mutation †
by
, , , , , , , ,
Yi Wang
1,2,
Andres E. Quesada
2,
Zhuang Zuo
2,
L. Jeffrey Medeiros
2,
C. Cameron Yin
2
,
Shaoying Li
2,
Jie Xu
2,
Gautam Borthakur
3,
Yisheng Li
4,
Chao Yang
4,
Yasmin Abaza
5,
Juehua Gao
6,
Xinyan Lu
6,
M. James You
2,
Yizhuo Zhang
1,7,8,* and
Pei Lin
2,* 1
Department of Hematology, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Key Laboratory of Cancer Prevention and Therapy, Tianjin’s Clinical Research Center for Cancer, Tianjin 300060, China
2
Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
3
Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
4
Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
5
Division of Hematology and Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
6
Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
7
State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
8
Department of Pediatric Oncology, Sun Yat-sen University Cancer Center, Guangzhou 510060, China
*
Authors to whom correspondence should be addressed.
†
The work was performed while at MD Anderson Cancer Center.
Cancers 2023, 15(1), 198; https://doi.org/10.3390/cancers15010198
Submission received: 4 October 2022
/
Revised: 21 December 2022
/
Accepted: 26 December 2022
/
Published: 29 December 2022
(This article belongs to the Collection Acute Myeloid Leukemia (AML))
Abstract
:Simple Summary
NPM1-mutated acute myeloid leukemia (AML) is one of the most common subtypes of AML in patients with a normal karyotype. In the recently introduced International Consensus Classification, detection of gene mutations typically associated with myelodysplastic syndrome (MDS) is considered an adverse biomarker in AML patients. However, the impact of these gene mutations occurring in the setting of AML with NPM1 mutation and without FLT3-ITD mutation, a favorable subtype, is unclear. Furthermore, correlation between minimal measurable disease (MMD) with survival in the context of these co-mutations also remains unclear. This study aims to address these issues. We found that patients with or without MDS-related gene mutations treated intensively had a similar MMD rate; however, the former group had a higher relapse rate and shorter progression-free survival (PFS).
Abstract
Background: The impact of gene mutations typically associated with myelodysplastic syndrome (MDS) in acute myeloid leukemia (AML) with NPM1 mutation is unclear. Methods: Using a cohort of 107 patients with NPM1-mutated AML treated with risk-adapted therapy, we compared survival outcomes of patients without MDS-related gene mutations (group A) with those carrying concurrent FLT3-ITD (group B) or with MDS-related gene mutations (group C). Minimal measurable disease (MMD) status assessed by multiparameter flow cytometry (MFC), polymerase chain reaction (PCR), and/or next-generation sequencing (NGS) were reviewed. Results: Among the 69 patients treated intensively, group C showed significantly inferior progression-free survival (PFS, p < 0.0001) but not overall survival (OS, p = 0.055) compared to group A. Though groups A and C had a similar MMD rate, group C patients had a higher relapse rate (p = 0.016). Relapse correlated with MMD status at the end of cycle 2 induction (p = 0.023). Survival of group C patients was similar to that of group B. Conclusion: MDS-related gene mutations are associated with an inferior survival in NPM1-mutated AML.
1. Introduction
Acute myeloid leukemia (AML) with NPM1 mutation and a normal karyotype comprises 30% of AML and is one of the most common subtypes [1,2,3]. This group is clinically heterogeneous with variable responses to therapy and outcomes likely attributable, at least in part, to coexisting mutations of other genes. While cases with concurrent FLT3-ITDhigh (allelic ratio (AR) > 0.5) were previously designated as “intermediate-risk” based on the European LeukemiaNet (ELN) risk stratification [4,5], the newly updated ELN classification now categorizes all cases with NPM1-mutated AML with FLT3-ITD co-mutation as intermediate-risk group regardless of AR [6].
Historically, patients who developed AML preceded by a history of myelodysplastic syndrome (MDS) or with cytogenetic aberrations associated with MDS (-7/7q-, complex, etc.) were designated as AML with myelodysplasia-related changes (AML-MRC) rather than AML with NPM1 mutation even if the mutation was detected [7]. The recently introduced International Consensus Classifications (ICC) and ELN risk stratification proposed to include cases with gene mutations typically associated with MDS as the third pathway to the category of AML-MRC, designated as AML with myelodysplasia-related gene mutations [6,8]. A pathological variant of any of ASXL1, BCOR, EZH2, RUNX1, SF3B1, SRSF2, STAG2, U2AF1, or ZRSR2 genes denotes MDS-related gene mutations. Studies have shown their prevalence in secondary AML [9]. However, both ICC and ELN acknowledged that the impact of these mutations in NPM1-mutated AML is less clear. Additionally, AML with TP53 mutation and WT1 mutation has been shown to be aggressive [3], and yet, its role in NPM1-mutated AML is also unclear. To address this issue, we designed and performed the current study comparing survival of three subgroups of NPM1 mutated AML: group A, without MDS-related gene mutations; group B, with FLT3-ITD mutation regardless of AR; and group C, with MDS-related gene mutations. For this study, TP53-mutated cases were included in group C, as it is also commonly seen in secondary AML [3,9,10,11]. Cases with co-mutation of WT1 but without FLT3-ITD were excluded from group C and designated as group D.
Pretreatment variables such as age, performance status, white blood cell (WBC) count, and molecular genetic data currently represent the best-established, albeit imperfect, predictors of response to therapy [12]. Increasingly, post-treatment factors such as MMD have been evaluated as a surrogate of treatment efficacy [13]. MMD can be assessed by multi-color flow cytometry (MFC) or molecular genetic methods such as reverse transcriptase polymerase chain reaction (RT-PCR) methods or next-generation sequencing (NGS) [14]. The relationship between mutation profile, MMD status, and outcome are not fully described in AML with mutations of NPM1- and MDS-related genes.
In the current study, we evaluated 107 consecutive patients of de novo AML with NPM1 mutation. MMD status assessed by various combinations of MFC, PCR, and NGS was correlated with mutation profiles as well as survival.
2. Materials and Methods
2.1. Patients
We searched databases in MD Anderson Cancer Center and Northwestern University Feinberg School of Medicine from 1 January 2012 through 31 December 2018 for patients diagnosed with de novo AML associated with mutated NPM1. AML with other recurrent genetic aberrations or secondary/transformed AML was excluded [15]. All patients had a normal karyotype except for 5 patients who had abnormalities commonly associated with NPM1 mutation. These abnormalities have not been shown to affect prognosis [5,7,16,17], including one patient with –Y, one with del(9q), one with +8, one with -16q, and one patient with +8, +8, and dup(13) [18,19]. Clinical and laboratory data were obtained by review of the medical records in accordance with the institutional internal review-board-approved protocols.
2.2. Treatment and Follow-Up
Patients were treated based on clinical assessment and institutional protocols. Patients who were treated intensively received either Fludarabine + Ara-C + G-CSF + Idarubicin (FLAG-IDA), Cladribine combined with Idarubicin and Ara-C (CLIA) with or without venetoclax, or standard “3 + 7”. Alternatively, non-intensive regimens included hypomethylating agents (HMA) with or without venetoclax or Cladribine or low-dose Ara-C alternating with decitabine. FLT3 or IDH inhibitors were added in the appropriate context. All patients with FLT3-ITD mutation were treated with FLT3 inhibitor. A subset of intensively treated patients received allogeneic hematopoietic stem cell transplantation (HSCT).
2.3. Multiparameter Flow Cytometric (MFC) Immunophenotyping
Initial and post-treatment bone marrow aspirate samples were processed using standard methods and analyzed using FACS Canto II 8-color instruments (BD Biosciences, San Diego, CA, USA). Details of the assay have been previously described [20,21]. The detection sensitivity is generally 0.1–1% in an adequate sample.
2.4. Polymerase Chain Reaction (PCR) and Next-Generation Sequencing (NGS)
FLT3-ITD and tyrosine kinase domain (TKD) mutations and NPM1 mutations were identified using PCR-based methods followed by capillary electrophoresis on Genetic Analyzer (Applied Biosystems, Foster City, CA, USA), as described previously [22,23]. The sensitivity level of these PCR assays is 1% and can detect most common (A, B, and D) types of NPM1 mutations. High-throughput sequencing was performed using a MiSeq sequencer (Illumina Inc., San Diego, CA, USA), and data were analyzed using MiSeq Reporter Software. A 28-gene NGS-panel assessed full exons for mutations in the following genes: ABL, EGFR, GATA2, IKZF2, MDM2, NOTCH1, RUNX1, ASXL1, EZH2, HRAS, JAK2, MLL, NPM1, TET2, BRAF, FLT3, IDH1, KIT, MPL, NRAS, TP53, DNMT3A, GATA1, IDH2, KRAS, MYD88, PTPN11, and WT1. In a subset of cases, an 81-gene panel was also performed (Table S1). Adequate coverage was defined as ≥ 250 reads for each exon. The analytical sensitivity of the platform is variable for different genes but is generally 2.5% for most genes; the sensitivity of the NPM1 p.W288 locus with manual review of IGV reads is 0.01–0.1% [21].
2.5. Mutational Profile and Assignment of Molecular Risk Groups
NGS analysis was performed on the initial diagnostic and post-treatment samples. Results of FLT3-ITD and NPM1 analyzed by PCR were used in conjunction with NGS to stratify patients into four risk groups using published models as guidelines (Table S2) [2,11,24]. Specifically, group A consisted of patients without mutations of ASXL1, BCOR, EZH2, RUNX1, SF3B1, SRSF2, STAG2, U2AF1, ZRSR2, MLL, TP53, WT1, or FLT3-ITD [25]; group B: concurrent FLT3-ITD regardless of AR level; and group C: concurrent mutations of any of the MDS-related genes listed above. Cases with WT1 mutation but without FLT3-ITD were designated as group D [26,27,28]. Due to the limited size of group D (N = 4), no further survival comparison was performed.
2.6. Statistical Analysis
Survival distributions were estimated by the Kaplan–Meier method (Log-rank test) using Graph-Pad software (Prism, San Diego, CA, USA); unpaired t-test, Fisher’s exact test, and chi-square test were performed to assess the clinical characteristics and treatment response of each molecular risk group. Cox proportional hazards models were estimated with regards to various parameters by R software version 4.0.3 (Vienna, Austria).
Complete remission (CR) and CR with incomplete blood count recovery (CRi) are defined according to the standard criteria [29,30]. For the purpose of this study, we classified those that failed to achieve CR by the end of first cycle of induction (EOC1) (day 28–35) as delayed CR. The best response achieved was noted for each patient. MMD status was determined once the patients met the criteria for morphologically free of leukemia state (MLFS) (<5% blasts by morphology) or CR/CRi, which was usually assessed at EOC1 and EOC2. DNMT3A, IDH1/2, ASXL1, TET2, or SRSF2 were considered as underlying clonal hematopoiesis of undetermined significance (CHIP). Survival was determined from the date of diagnosis to date of death from any cause or last follow-up.
Statistical analyses were performed by two biostatisticians independently.
3. Results
The mutation profiles of all 107 cases are summarized in Table S2 and illustrated in Figure 1. Sixty-nine patients were treated with intensive chemotherapy, whereas thirty-eight patients were treated with less-intensive regimens. The demographic and hematologic features of the two groups are summarized in Table 1. The median follow-up for the entire cohort was 30.1 months (range, 2.1–84.8 months).
Compared with the intensively treated group, the not-intensively treated group was older (median age 72, range 23–87 years) (p < 0.0001) and MMD was more frequently detected in 26/34 (76.47%) patients (p < 0.0001) (Table 1). At last follow-up, 31 (81.58%) patients had died, and the median OS was 18.1 months (range, 2.8–79.4 months). In contrast, the median age of the intensively treated group of patients was 53 years (range, 17–69 years). This group was then the main focus of MMD study and survival comparison among the three subgroups are detailed in Table 2.
3.1. Correlation between MMD and Relapse and Survival
We identified MMD in 22 (22/66, 33.33%) and 13 (13/66, 19.70%) patients at EOC1 and EOC2, respectively, seen across all the three subgroups (A, B, C) at a similar rate (Table 2). However, group B and C patients had a higher relapse rate (p = 0.0009) (Table 2). Among the 27 patients who eventually had relapsed AML, 12 (12/25, 48%) patients had detectable MMD at EOC1, and 9 (9/25, 36.00%) had MMD at EOC2. Only MMD at EOC2 correlated with relapse (p = 0.023) (Figure 2).
Kaplan–Meier survival analysis showed a significant survival difference among group A, B, and C (Table 2). The median OS and PFS of the patients in group A were not yet reached. The median OS and PFS of the patients in group B are 56.90 and 62.10 months, respectively. The median OS and PFS of the patients in group C are 50.80 and 14.60 months, respectively (Table 2). Consistent with previous studies, the subgroup with FLT3-ITD showed significantly higher relapse rate and worse survival than patients of group A (Table S3). Most notably, group C showed worse PFS (Figure 3a, p < 0.0001) but not OS (Figure 3b, p = 0.055) than group A (Table 3). Comparison of patients in group B and C found no significant differences in relapse rate (p = 0.46), PFS (Figure 3c, p = 0.28), or OS (Figure 3d, p = 0.89) (Table S4). In addition, among the 69 patients treated intensively, no PFS or OS differences were noted among patients who were treated with HSCT (N = 43) vs. those without (N = 26) (p = 0.95 and p = 0.32, respectively). Survival curves were censored for patients who received HSCT from the date of transplantation (Table 2).
At relapse, all patients retained NPM1 mutation, and eight patients acquired additional mutations not seen at initial diagnosis, including FLT3-ITD in five, FLT3-TKD in two, and WT1 in two. Additionally, six patients who initially had a normal karyotype developed an abnormal karyotype, and 5/6 died within 12 months (Table S5). Multivariate Cox proportional hazard analysis showed that both FLT3-ITD- and MDS-related gene mutations were independent prognostic markers (Table 4).
3.2. Comparison of MFC to Molecular Testing
A total of 151, 459, and 559 post-therapy samples were analyzed by NGS, MFC, and PCR, respectively. Discordant results between MFC and molecular testing were observed in 30 samples, and the discordance was predominantly due to a negative or indeterminate MFC result compared with a positive molecular result; in particular, NPM1 or FLT3-ITD were most commonly detected by PCR or rarely by NGS.
4. Discussion
The ELN risk stratification for NPM1-mutated AML based solely on FLT3-ITD is now presumed to represent an oversimplified model for risk assessment [5,7,13,28,31]. In recent years, NGS studies have refined risk stratification among patients with intermediate-risk AML [3,28,32]. Most recently, the ICC has introduced a new pathway to arrive at the diagnosis of AML-MRC based on mutation of genes typically associated with MDS, designated as AML with MDS-related gene mutations. The new category involves pathological variants of ASXL1, BCOR, EZH2, RUNX1, SF3B1, SRSF2, STAG2, U2AF1, and ZRSR2. AML with TP53 mutation is also a new category in the ICC given its adverse effect on many subtypes of AML and its common occurrence in secondary AML. An AML with NPM1 mutation and without FLT3-ITD is considered a favorable subtype; however, the impact of MDS-related gene mutations on the specific subtype is unclear or controversial [32]. In addition, the new classification recognizes all FLT3-ITD, regardless of AR, as an adverse risk factor.
To further explore the issue, we stratified patients with NPM1-mutated AML as unfavorable risk, along with FLT3-ITD, based on presence of these MDS-associated gene mutations and TP53 mutations using NGS profiling. WT1-mutated AML has been shown to adversely impact survival and is proposed as a distinct molecular subgroup of AML [3,11,26,27,28]. Thus, we designated WT1-mutated cases as group D, separate from the other subgroups.
Patients in the group C treated with intensive regimens showed a similar rate of treatment response compared to group A. The MMD rate was also similar at ECO1 and ECO2. However, group C patients suffered a higher rate of relapse as well as shorter PFS compared to group A. The PFS and OS of the group C patients were comparable to those of group B. These findings support incorporating these secondary (MDS)-related mutation profiles into the risk stratification.
Detectable MMD at EOC2 but not EOC1 correlated with relapse. This finding supports the notion that delayed blast clearance is an adverse risk factor [33] and the consensus recommendation that MMD testing is most informative at EOC2 [14]. For patients who had relapse, all had molecular evidence of disease. Because our PCR and NGS assays for NPM1 have a sensitivity level of 0.01–1%, it was significant whenever abnormal variants were detected. However, samples obtained at EOC1 often and sometimes EOC2 are hypocellular, potentially limiting MFC assay sensitivity. Thus, not unexpectedly, we observed discordant results between MFC and molecular methods.
DNMT3A, ASXL1, TET2, IDH1/2, and SRSF2 are now recognized as CHIP-like mutations that can persist during CR [34,35]. In contrast to CHIP, clonal hematopoiesis of oncogenic potential (CHOP)-type mutations that persist after therapy are more ominous [36,37]. The high frequency of relapse in group C patients suggests that the MDS-related gene mutations, like CHIP, may predispose the patients to secondary/relapsed AML. In fact, concurrent DNMT3A mutation was shown to have no adverse impact on survival but more likely correlated with MMD positivity and potentially increased the risk for relapse or secondary AML [2]. Despite a similar rate of MMD compared to group A patients, group C patients had a higher relapse rate, suggesting that the MDS-related gene mutations are implicated in the inferior survival.
5. Conclusions
The mutation profiles of NPM1-mutated AML have implications in patient survival in the current era of risk-adapted therapy. In addition to FLT3-ITD, concurrent MDS-related gene mutations are associated with an inferior outcome, supporting their recognition in NPM1-mutated AML. The mechanisms of this phenomenon remain to be explored, but they are most likely related to persistence of underlying preleukemic clone and unremitted risk for genetic alterations in affected patients despite achieving CR.
Supplementary Materials
The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/cancers15010198/s1, Table S1: Eighty-one gene NGS panel; Table S2: Mutational Profile and Risk Group Assignment; Table S3: Comparison between subgroups of patients without MDS-related gene mutations (Group A) versus with FLT3-ITD (Group B) treated with intensive chemotherapy. Table S4: Comparison between subgroups of patients with FLT3-ITD (Group B) versus with MDS-related gene mutations (Group C) treated with intensive chemotherapy; Table S5: Abnormal karyotype identified at or after relapse.
Author Contributions
Y.W., P.L., M.J.Y., L.J.M. and G.B. wrote the manuscript; Y.W., P.L., S.L., A.E.Q., Z.Z., C.C.Y., J.X., Y.A., J.G. and X.L. collected the data; Y.W., P.L., S.L., A.E.Q., Z.Z., L.J.M., C.C.Y., J.X., Y.L. and C.Y. analyzed the data; P.L. designed the study; A.E.Q., L.J.M. and Y.Z. revised and edited the manuscript. All authors have read and agreed to the published version of the manuscript.
Funding
M.J.Y. was partially supported by the University Cancer Foundation via the Institutional Research Grant program at the University of Texas MD Anderson Cancer Center.
Institutional Review Board Statement
This study was approved by the Institutional Review Board at MD Anderson Cancer Center. The protocol number: LAB04-0180.
Informed Consent Statement
Patient consent was waived due to this being a retrospective data review study.
Data Availability Statement
Not applicable.
Conflicts of Interest
The authors declare no conflict of interest.
References
- Kelemen, K. The Role of Nucleophosmin 1 (NPM1) Mutation in the Diagnosis and Management of Myeloid Neoplasms. Life 2022, 12, 109. [Google Scholar] [CrossRef]
- Oñate, G.; Bataller, A.; Garrido, A.; Hoyos, M.; Arnan, M.; Vives, S.; Coll, R.; Tormo, M.; Sampol, A.; Escoda, L.; et al. Prognostic impact of DNMT3A mutation in acute myeloid leukemia with mutated NPM1. Blood Adv. 2022, 6, 882–890. [Google Scholar] [CrossRef]
- Tazi, Y.; Arango-Ossa, J.E.; Zhou, Y.; Bernard, E.; Thomas, I.; Gilkes, A.; Freeman, S.; Pradat, Y.; Johnson, S.J.; Hills, R.; et al. Unified classification and risk-stratification in Acute Myeloid Leukemia. Nat. Commun. 2022, 13, 4622. [Google Scholar] [CrossRef]
- Döhner, H.; Estey, E.; Grimwade, D.; Amadori, S.; Appelbaum, F.R.; Büchner, T.; Dombret, H.; Ebert, B.L.; Fenaux, P.; Larson, R.A.; et al. Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. Blood 2017, 129, 424–447. [Google Scholar] [CrossRef] [Green Version]
- Falini, B.; Sciabolacci, S.; Falini, L.; Brunetti, L.; Martelli, M.P. Diagnostic and therapeutic pitfalls in NPM1-mutated AML: Notes from the field. Leukemia 2021, 35, 3113–3126. [Google Scholar] [CrossRef]
- Döhner, H.; Wei, A.H.; Appelbaum, F.R.; Craddock, C.; DiNardo, C.D.; Dombret, H.; Ebert, B.L.; Fenaux, P.; Godley, L.A.; Hasserjian, R.P.; et al. Diagnosis and Management of AML in Adults: 2022 ELN Recommendations from an International Expert Panel. Blood 2022, 140, 1345–1377. [Google Scholar] [CrossRef]
- Falini, B.; Brunetti, L.; Martelli, M.P. How I diagnose and treat NPM1-mutated AML. Blood 2021, 137, 589–599. [Google Scholar] [CrossRef]
- Arber, D.A.; Orazi, A.; Hasserjian, R.P.; Borowitz, M.J.; Calvo, K.R.; Kvasnicka, H.M.; Wang, S.A.; Bagg, A.; Barbui, T.; Branford, S.; et al. International Consensus Classification of Myeloid Neoplasms and Acute Leukemia: Integrating Morphological, Clinical, and Genomic Data. Blood 2022, 140, 1200–1228. [Google Scholar]
- Lindsley, R.C.; Mar, B.G.; Mazzola, E.; Grauman, P.V.; Shareef, S.; Allen, S.L.; Pigneux, A.; Wetzler, M.; Stuart, R.K.; Erba, H.P.; et al. Acute myeloid leukemia ontogeny is defined by distinct somatic mutations. Blood 2015, 125, 1367–1376. [Google Scholar] [CrossRef] [Green Version]
- Tashakori, M.; Kadia, T.; Loghavi, S.; Daver, N.; Kanagal-Shamanna, R.; Pierce, S.; Sui, D.; Wei, P.; Khodakarami, F.; Tang, Z.; et al. TP53 copy number and protein expression inform mutation status across risk categories in acute myeloid leukemia. Blood 2022, 140, 58–72. [Google Scholar] [CrossRef]
- Grossmann, V.; Schnittger, S.; Kohlmann, A.; Eder, C.; Roller, A.; Dicker, F.; Schmid, C.; Wendtner, C.M.; Staib, P.; Serve, H.; et al. A novel hierarchical prognostic model of AML solely based on molecular mutations. Blood 2012, 120, 2963–2972. [Google Scholar] [CrossRef] [PubMed]
- Walter, R.B.; Othus, M.; Burnett, A.K.; Löwenberg, B.; Kantarjian, H.M.; Ossenkoppele, G.J.; Hills, R.K.; Ravandi, F.; Pabst, T.; Evans, A.; et al. Resistance prediction in AML: Analysis of 4601 patients from MRC/NCRI, HOVON/SAKK, SWOG and MD Anderson Cancer Center. Leukemia 2015, 29, 312–320. [Google Scholar] [CrossRef] [PubMed]
- Estey, E.H. Acute myeloid leukemia: 2021 update on risk-stratification and management. Am. J. Hematol. 2020, 95, 1368–1398. [Google Scholar] [CrossRef]
- Forghieri, F.; Comoli, P.; Marasca, R.; Potenza, L.; Luppi, M. Minimal/Measurable Residual Disease Monitoring in NPM1-Mutated Acute Myeloid Leukemia: A Clinical Viewpoint and Perspectives. Int. J. Mol. Sci. 2018, 19, 3492. [Google Scholar] [CrossRef] [Green Version]
- Sabattini, E.; Bacci, F.; Sagramoso, C.; Pileri, S.A. WHO classification of tumours of haematopoietic and lymphoid tissues in 2008: An overview. Pathologica 2010, 102, 83–87. [Google Scholar]
- Haferlach, C.; Mecucci, C.; Schnittger, S.; Kohlmann, A.; Mancini, M.; Cuneo, A.; Testoni, N.; Rege-Cambrin, G.; Santucci, A.; Vignetti, M.; et al. AML with mutated NPM1 carrying a normal or aberrant karyotype show overlapping biologic, pathologic, immunophenotypic, and prognostic features. Blood 2009, 114, 3024–3032. [Google Scholar] [CrossRef] [Green Version]
- Walter, R.B.; Othus, M.; Paietta, E.M.; Racevskis, J.; Fernandez, H.F.; Lee, J.W.; Sun, Z.; Tallman, M.S.; Patel, J.; Gönen, M.; et al. Effect of genetic profiling on prediction of therapeutic resistance and survival in adult acute myeloid leukemia. Leukemia 2015, 29, 2104–2107. [Google Scholar] [CrossRef] [Green Version]
- Grimwade, D.; Walker, H.; Oliver, F.; Wheatley, K.; Harrison, C.; Harrison, G.; Rees, J.; Hann, I.; Stevens, R.; Burnett, A.; et al. The importance of diagnostic cytogenetics on outcome in AML: Analysis of 1612 patients entered into the MRC AML 10 trial. Blood 1998, 92, 2322–2333. [Google Scholar]
- Grimwade, D.; Hills, R.K.; Moorman, A.V.; Walker, H.; Chatters, S.; Goldstone, A.H.; Wheatley, K.; Harrison, C.J.; Burnett, A.K. Refinement of cytogenetic classification in acute myeloid leukemia: Determination of prognostic significance of rare recurring chromosomal abnormalities among 5876 younger adult patients treated in the United Kingdom Medical Research Council trials. Blood 2010, 116, 354–365. [Google Scholar] [CrossRef] [Green Version]
- Jaso, J.M.; Wang, S.A.; Jorgensen, J.L.; Lin, P. Multi-color flow cytometric immunophenotyping for detection of minimal residual disease in AML: Past, present and future. Bone Marrow Transplant. 2014, 49, 1129–1138. [Google Scholar] [CrossRef] [Green Version]
- Loghavi, S.; DiNardo, C.D.; Furudate, K.; Takahashi, K.; Tanaka, T.; Short, N.J.; Kadia, T.; Konopleva, M.; Kanagal-Shamanna, R.; Farnoud, N.R.; et al. Flow cytometric immunophenotypic alterations of persistent clonal haematopoiesis in remission bone marrows of patients with NPM1-mutated acute myeloid leukaemia. Br. J. Haematol 2021, 192, 1054–1063. [Google Scholar] [CrossRef]
- Warren, M.; Luthra, R.; Yin, C.C.; Ravandi, F.; Cortes, J.E.; Kantarjian, H.M.; Medeiros, L.J.; Zuo, Z. Clinical impact of change of FLT3 mutation status in acute myeloid leukemia patients. Mod. Pathol. 2012, 25, 1405–1412. [Google Scholar] [CrossRef] [Green Version]
- Barakat, F.H.; Luthra, R.; Yin, C.C.; Barkoh, B.A.; Hai, S.; Jamil, W.; Bhakta, Y.I.; Chen, S.; Medeiros, L.J.; Zuo, Z. Detection of nucleophosmin 1 mutations by quantitative real-time polymerase chain reaction versus capillary electrophoresis: A comparative study. Arch. Pathol. Lab. Med. 2011, 135, 994–1000. [Google Scholar] [CrossRef]
- Patel, J.P.; Gönen, M.; Figueroa, M.E.; Fernandez, H.; Sun, Z.; Racevskis, J.; Van Vlierberghe, P.; Dolgalev, I.; Thomas, S.; Aminova, O.; et al. Prognostic relevance of integrated genetic profiling in acute myeloid leukemia. N. Engl. J. Med. 2012, 366, 1079–1089. [Google Scholar] [CrossRef] [Green Version]
- Metzeler, K.H.; Maharry, K.; Kohlschmidt, J.; Volinia, S.; Mrózek, K.; Becker, H.; Nicolet, D.; Whitman, S.P.; Mendler, J.H.; Schwind, S.; et al. A stem cell-like gene expression signature associates with inferior outcomes and a distinct microRNA expression profile in adults with primary cytogenetically normal acute myeloid leukemia. Leukemia 2013, 27, 2023–2031. [Google Scholar] [CrossRef] [Green Version]
- Hollink, I.H.; van den Heuvel-Eibrink, M.M.; Zimmermann, M.; Balgobind, B.V.; Arentsen-Peters, S.T.; Alders, M.; Willasch, A.; Kaspers, G.J.; Trka, J.; Baruchel, A.; et al. Clinical relevance of Wilms tumor 1 gene mutations in childhood acute myeloid leukemia. Blood 2009, 113, 5951–5960. [Google Scholar] [CrossRef] [Green Version]
- Owen, C.; Fitzgibbon, J.; Paschka, P. The clinical relevance of Wilms Tumour 1 (WT1) gene mutations in acute leukaemia. Hematol. Oncol. 2010, 28, 13–19. [Google Scholar] [CrossRef]
- Eisfeld, A.K.; Kohlschmidt, J.; Mims, A.; Nicolet, D.; Walker, C.J.; Blachly, J.S.; Carroll, A.J.; Papaioannou, D.; Kolitz, J.E.; Powell, B.E.; et al. Additional gene mutations may refine the 2017 European LeukemiaNet classification in adult patients with de novo acute myeloid leukemia aged <60 years. Leukemia 2020, 34, 3215–3227. [Google Scholar]
- Shallis, R.M.; Pollyea, D.A.; Zeidan, A.M. The complete story of less than complete responses: The evolution and application of acute myeloid leukemia clinical responses. Blood Rev. 2021, 48, 100806. [Google Scholar] [CrossRef]
- Cheson, B.D.; Bennett, J.M.; Kopecky, K.J.; Büchner, T.; Willman, C.L.; Estey, E.H.; Schiffer, C.A.; Doehner, H.; Tallman, M.S.; Lister, T.A.; et al. Revised recommendations of the International Working Group for Diagnosis, Standardization of Response Criteria, Treatment Outcomes, and Reporting Standards for Therapeutic Trials in Acute Myeloid Leukemia. J. Clin. Oncol. 2003, 21, 4642–4649. [Google Scholar] [CrossRef]
- Carbonell, D.; Suárez-González, J.; Chicano, M.; Andrés-Zayas, C.; Díez-Díez, M.; Rodríguez-Macías, G.; Muñiz, P.; Kwon, M.; Anguita, J.; Díez-Martín, J.L.; et al. Genetic biomarkers identify a subgroup of high-risk patients within low-risk NPM1-mutated acute myeloid leukemia. Leuk. Lymphoma 2021, 62, 1178–1186. [Google Scholar] [CrossRef] [PubMed]
- Wright, M.F.; Pozdnyakova, O.; Hasserjian, R.P.; Aggarwal, N.; Shaver, A.C.; Weinberg, O.K.; Irlmeier, R.; Koyama, T.; Seegmiller, A.C.; Strickland, S.A.; et al. Secondary-type mutations do not impact prognosis in acute myelogenous leukemia AML with mutated NPM1. Am. J. Hematol. 2022, 97, E462–E465. [Google Scholar] [CrossRef]
- Freeman, S.D.; Hills, R.K.; Virgo, P.; Khan, N.; Couzens, S.; Dillon, R.; Gilkes, A.; Upton, L.; Nielsen, O.J.; Cavenagh, J.D.; et al. Measurable Residual Disease at Induction Redefines Partial Response in Acute Myeloid Leukemia and Stratifies Outcomes in Patients at Standard Risk Without NPM1 Mutations. J. Clin. Oncol. 2018, 36, 1486–1497. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Yang, L.; Rau, R.; Goodell, M.A. DNMT3A in haematological malignancies. Nat. Rev. Cancer 2015, 15, 152–165. [Google Scholar] [CrossRef] [PubMed]
- Krönke, J.; Bullinger, L.; Teleanu, V.; Tschürtz, F.; Gaidzik, V.I.; Kühn, M.W.; Rücker, F.G.; Holzmann, K.; Paschka, P.; Kapp-Schwörer, S.; et al. Clonal evolution in relapsed NPM1-mutated acute myeloid leukemia. Blood 2013, 122, 100–108. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Corces-Zimmerman, M.R.; Hong, W.J.; Weissman, I.L.; Medeiros, B.C.; Majeti, R. Preleukemic mutations in human acute myeloid leukemia affect epigenetic regulators and persist in remission. Proc. Natl. Acad. Sci. USA 2014, 111, 2548–2553. [Google Scholar] [CrossRef] [Green Version]
- Cappelli, L.V.; Meggendorfer, M.; Baer, C.; Nadarajah, N.; Hutter, S.; Jeromin, S.; Dicker, F.; Kern, W.; Haferlach, T.; Haferlach, C.; et al. Indeterminate and oncogenic potential: CHIP vs. CHOP mutations in AML with NPM1 alteration. Leukemia 2022, 36, 394–402. [Google Scholar] [CrossRef]
Figure 1.
Mutational landscape of 107 cases of NPM1 mutated AML. Mutations of genes acquired at relapse are highlighted in orange and those at diagnosis in blue. Each column represents a patient.
Figure 1.
Mutational landscape of 107 cases of NPM1 mutated AML. Mutations of genes acquired at relapse are highlighted in orange and those at diagnosis in blue. Each column represents a patient.
Figure 2.
Correlation of MMD status at EOC1 and EOC2 with relapse. MMD, minimal measurable disease; EOC1, end of cycle 1 induction; EOC2, end of cycle 2 induction.
Figure 2.
Correlation of MMD status at EOC1 and EOC2 with relapse. MMD, minimal measurable disease; EOC1, end of cycle 1 induction; EOC2, end of cycle 2 induction.
Figure 3.
Kaplan–Meier curves comparing groups A and C show significant difference in PFS (a) but not OS (b). Kaplan–Meier curves comparing groups B and C show no significant difference in PFS (c) or OS (d). Group A, without MDS-related gene mutations; Group B, with FLT3-ITD; Group C, with MDS-related gene mutations.
Figure 3.
Kaplan–Meier curves comparing groups A and C show significant difference in PFS (a) but not OS (b). Kaplan–Meier curves comparing groups B and C show no significant difference in PFS (c) or OS (d). Group A, without MDS-related gene mutations; Group B, with FLT3-ITD; Group C, with MDS-related gene mutations.
Table 1.
Summary of clinicopathological features of the total study cohort.
| Intensively Treated | Not Intensively Treated | p-Value | |
|---|---|---|---|
| Number | 69 | 38 | N/A |
| Age (years) median and range | 53, (17–69) | 72, (23–87) | <0.0001 |
| Sex: | |||
| -Men -Women | 35 (50.72%) 34 (49.28%) | 18 (47.37%) 20 (52.63%) | 0.84 |
| BM blasts (%) median and range | 64, (1–95) | 59.5, (6–90) | 0.96 |
| WBC (k/µL) median and range | 12.25, (0.1–378.4) | 18.55, (0.9–140) | 0.70 |
| Response: | |||
| -CR/CRi | 56/68 (82.35%) | 33/37 (89.19%) | 0.06 |
| -MLFS | 10/68 (14.71%) | 1/37 (2.70%) | |
| -Refractory | 2/68 (2.94%) | 3/37 (8.11%) | |
| MMD (EOC1) | 22/66 (33.33%) | 26/34 (76.47%) | <0.0001 |
| Relapse | 27 (39.13%) | 20 (52.63%) | 0.22 |
| HSCT | 43 (62.32%) | 3 (7.89%) | <0.0001 |
| Mutation profiles: | |||
| -Group A | 25 (36.23%) | 21 (55.26%) | |
| -Group B | 30 (43.48%) | 15 (39.47%) | |
| -Group C | 10 (14.49%) | 2 (5.26%) | |
| TP53 | 2 | 0 | |
| RUNX1/ASXL1/SRSF2/EZH2 | 2/2/3/1 | 0/2/0/0 | |
| -Group D | 4 (5.80%) | 0 (0.00%) |
BM, bone marrow; WBC, white blood cell; CR, complete remission; CRi, CR with incomplete blood count recovery; MLFS, morphologic leukemia-free state; MMD, minimal measurable disease; EOC1, end of cycle 1 induction; HSCT, hematopoietic stem cell transplantation; Group A, without MDS-related gene mutations; Group B, with FLT3-ITD; Group C, with MDS-related gene mutations; Group D, with WT1 mutation. p-values in bold are of statistical significance.
Table 2.
Comparison between different risk groups of patients treated with intensive chemotherapy.
| Group A | Group B | Group C | p-Value | |
|---|---|---|---|---|
| Number | 25 | 30 | 10 | N/A |
| Age (years) median and range | 57, (17–69) | 51.5, (19–67) | 59, (33–68) | 0.58 |
| Age > 65 years | 4 (16.00%) | 5 (16.67%) | 3 (30%) | 0.59 |
| Sex: | ||||
| -Men -Women | 13 (52.00%) 12 (48.00%) | 14 (46.67%) 16 (53.33%) | 6 (60.00%) 4 (40.00%) | 0.76 |
| BM blasts (%) median and range | 51.5, (4–94) | 68, (1–95) | 67, (19–86) | 0.48 |
| WBC (k/µL) median and range | 11.2, (0.5–378.4) | 14.9, (1–160.4) | 17.95, (1–44.1) | 0.37 |
| PB blasts (%) median and range | 23.5, (0–97) | 35.5, (0–98) | 16, (0–83) | 0.43 |
| Hb (g/dL) median and range | 8.95, (5.1–12.4) | 9.35, (7.7–15.5) | 9.15, (8.5–14.4) | 0.17 |
| platelets (k/µL) median and range | 53, (11–385) | 57.5, (9–553) | 29.5, (7–87) | 0.18 |
| Response: | ||||
| -CR/CRi | 23/25 (92.00%) | 22/29 (75.86%) | 7/10 (70.00%) | 0.028 |
| -MLFS | 2/25 (8.00%) | 7/29 (24.14%) | 1/10 (10.00%) | |
| -Refractory | 0 (0.00%) | 0 (0.00%) | 2/10 (20.00%) | |
| MMD (EOC1) | 6/25 (24.00%) | 11/29 (37.93%) | 5/8 (62.50%) | 0.13 |
| MMD (EOC2) | 4/25 (16.00%) | 7/29 (24.14%) | 2/8 (25.00%) | 0.68 |
| Relapse | 3 (12.00%) | 15 (50.00%) | 7 (70.00%) | 0.0009 |
| Median OS (months) | NR | 56.90 | 50.80 | 0.045 |
| Median OS (months) (HSCT censored) | NR | NR | NR | 0.14 |
| Median PFS (months) | NR | 62.10 | 14.60 | 0.0006 |
| Median PFS (months) (HSCT censored) | NR | NR | 24.3 | 0.0014 |
All values taken at diagnosis; normal range, WBC, 4.0–11.0 k/µL; hemoglobin, 14–18 g/dL; platelets, 140–440 k/µL; Group A, without MDS-related gene mutations; Group B, with FLT3-ITD; Group C, with MDS-related gene mutations; BM, bone marrow; WBC, white blood cell; PB, peripheral blood; Hb, hemoglobin; CR, complete remission; CRi, CR with incomplete blood count recovery; MLFS, morphologic leukemia-free state; MMD, minimal measurable disease; EOC1, end of cycle 1 induction; EOC2, end of cycle 2 induction; OS, overall survival; HSCT, hematopoietic stem cell transplantation; PFS, progression-free survival; NR, median survival not reached. p-values in bold are of statistical significance.
Table 3.
Comparison between patients without (Group A) versus with (Group C) MDS-related gene mutations treated with intensive chemotherapy.
Table 3.
Comparison between patients without (Group A) versus with (Group C) MDS-related gene mutations treated with intensive chemotherapy.
| Group A | Group C | p-Value | |
|---|---|---|---|
| Number | 25 | 10 | N/A |
| Age (years) median and range | 57, (17–69) | 59, (33–68) | 0.90 |
| Age > 65 years | 4 (16.00%) | 3 (30%) | 0.38 |
| Sex: | |||
| -Men -Women | 13 (52.00%) 12 (48.00%) | 6 (60.00%) 4 (40.00%) | 0.72 |
| BM blasts (%) median and range | 51.5, (4–94) | 67, (19–86) | 0.87 |
| WBC (k/µL) median and range | 11.2, (0.5–378.4) | 17.95, (1–44.1) | 0.25 |
| PB blasts (%) median and range | 23.5, (0–97) | 16, (0–83) | 0.42 |
| Hb (g/dL) median and range | 8.95, (5.1–12.4) | 9.15, (8.5–14.4) | 0.09 |
| platelets (k/µL) median and range | 53, (11–385) | 29.5, (7–87) | 0.13 |
| Response: | |||
| -CR/CRi | 23/25 (92.00%) | 7/10 (70.00%) | 0.09 |
| -MLFS | 2/25 (8.00%) | 1/10 (10.00%) | |
| -Refractory | 0 (0.00%) | 2/10 (20.00%) | |
| MMD (EOC1) | 6/25 (24.00%) | 5/8 (62.50%) | 0.08 |
| MMD (EOC2) | 4/25 (16.00%) | 2/8 (25.00%) | 0.62 |
| Relapse | 3 (12.00%) | 7 (70.00%) | 0.0016 |
| Median OS (months) | NR | 50.80 | 0.055 |
| Median OS (months) (HSCT censored) | NR | NR | 0.051 |
| Median PFS (months) | NR | 14.60 | <0.0001 |
| Median PFS (months) (HSCT censored) | NR | 24.3 | <0.0001 |
All values taken at diagnosis; normal range, WBC, 4.0–11.0 k/µL; hemoglobin, 14–18 g/dL; platelets, 140–440 k/µL; Group A, without MDS-related gene mutations; Group C, with MDS-related gene mutations; BM, bone marrow; WBC, white blood cell; PB, peripheral blood; Hb, hemoglobin; CR, complete remission; CRi, CR with incomplete blood count recovery; MLFS, morphologic leukemia-free state; MMD, minimal measurable disease; EOC1, end of cycle 1 induction; EOC2, end of cycle 2 induction; OS, overall survival; HSCT, hematopoietic stem cell transplantation; PFS, progression-free survival; NR, median survival not reached. p-values in bold are of statistical significance.
Table 4.
Multivariate Cox proportional hazards model for overall survival (OS) and progression free survival (PFS) in patients treated with intensive chemotherapy.
Table 4.
Multivariate Cox proportional hazards model for overall survival (OS) and progression free survival (PFS) in patients treated with intensive chemotherapy.
| Variable | Hazard Ratio | 95% CI | p-Value |
|---|---|---|---|
| Overall Survival (OS) | |||
| -WBC count (>100 k/µL) | 3.73 | (1.14, 12.14) | 0.029 |
| -BM blast (%) | 0.98 | (0.97, 1.00) | 0.11 |
| -Age (>65 years) | 0.83 | (0.22, 3.20) | 0.79 |
| -MMD (EOC2) | 1.49 | (0.58, 3.84) | 0.41 |
| -Group (A as reference) | |||
| B | 2.77 | (1.05, 7.32) | 0.040 |
| C | 3.18 | (0.86, 11.80) | 0.08 |
| Progression-Free Survival (PFS) | |||
| -WBC count (>100 k/µL) | 0.93 | (0.23, 3.73) | 0.91 |
| -BM blast (%) | 1.01 | (0.99, 1.03) | 0.31 |
| -Age (>65 years) | 1.78 | (0.51, 6.25) | 0.37 |
| -MMD (EOC2) | 2.34 | (0.88, 6.23) | 0.09 |
| -Group (A as reference) | |||
| B | 5.16 | (1.42, 18.69) | 0.013 |
| C | 7.65 | (1.70, 34.48) | 0.0080 |
WBC stratified as below: <50, 50–100, >100 K; WBC, white blood cell; BM, bone marrow; MMD, minimal measurable disease; EOC2, end of cycle 2 induction; Group A, without MDS-related gene mutations; Group B, with FLT3-ITD; Group C, with MDS-related gene mutations. p-values in bold are of statistical significance.
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Wang, Y.; Quesada, A.E.; Zuo, Z.; Medeiros, L.J.; Yin, C.C.; Li, S.; Xu, J.; Borthakur, G.; Li, Y.; Yang, C.; et al. The Impact of Mutation of Myelodysplasia-Related Genes in De Novo Acute Myeloid Leukemia Carrying NPM1 Mutation. Cancers 2023, 15, 198. https://doi.org/10.3390/cancers15010198
AMA Style
Wang Y, Quesada AE, Zuo Z, Medeiros LJ, Yin CC, Li S, Xu J, Borthakur G, Li Y, Yang C, et al. The Impact of Mutation of Myelodysplasia-Related Genes in De Novo Acute Myeloid Leukemia Carrying NPM1 Mutation. Cancers. 2023; 15(1):198. https://doi.org/10.3390/cancers15010198
Chicago/Turabian StyleWang, Yi, Andres E. Quesada, Zhuang Zuo, L. Jeffrey Medeiros, C. Cameron Yin, Shaoying Li, Jie Xu, Gautam Borthakur, Yisheng Li, Chao Yang, and et al. 2023. "The Impact of Mutation of Myelodysplasia-Related Genes in De Novo Acute Myeloid Leukemia Carrying NPM1 Mutation" Cancers 15, no. 1: 198. https://doi.org/10.3390/cancers15010198
APA StyleWang, Y., Quesada, A. E., Zuo, Z., Medeiros, L. J., Yin, C. C., Li, S., Xu, J., Borthakur, G., Li, Y., Yang, C., Abaza, Y., Gao, J., Lu, X., You, M. J., Zhang, Y., & Lin, P. (2023). The Impact of Mutation of Myelodysplasia-Related Genes in De Novo Acute Myeloid Leukemia Carrying NPM1 Mutation. Cancers, 15(1), 198. https://doi.org/10.3390/cancers15010198
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