scholarly journals IDH2 mutations in patients with normal karyotype AML predict favorable responses to daunorubicin, cytarabine and cladribine regimen

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Marta Libura ◽  
Emilia Bialopiotrowicz ◽  
Sebastian Giebel ◽  
Agnieszka Wierzbowska ◽  
Gail J. Roboz ◽  
...  
Keyword(s):  
Myeloid Leukemia ◽  
Prognostic Significance ◽  
Normal Karyotype ◽  
Wild Type ◽  
Dna Hypermethylation ◽  
Isocitrate Dehydrogenase 1 ◽  
Mutation Status ◽  
Group 4 ◽  
Induction Regimen ◽  
Favorable Prognostic Factor

AbstractMutations in isocitrate dehydrogenase 1 and 2 (IDH1/2) genes occur in about 20% patients with acute myeloid leukemia (AML), leading to DNA hypermethylation and epigenetic deregulation. We assessed the prognostic significance of IDH1/2 mutations (IDH1/2+) in 398 AML patients with normal karyotype (NK-AML), treated with daunorubicine + cytarabine (DA), DA + cladribine (DAC), or DA + fludarabine. IDH2 mutation was an independent favorable prognostic factor for 4-year overall survival (OS) in total NK-AML population (p = 0.03, censoring at allotransplant). We next evaluated the effect of addition of cladribine to induction regimen on the patients’ outcome according to IDH1/2 mutation status. In DAC group, 4-year OS was increased in IDH2+ patients, compared to IDH-wild type group (54% vs 33%; p = 0.0087, censoring at allotransplant), while no difference was observed for DA-treated subjects. In multivariate analysis, DAC independently improved the survival of IDH2+ patients (HR = 0.6 [0.37–0.93]; p = 0.024; censored at transplant), indicating that this group specifically benefits from cladribine-containing therapy. In AML cells with R140Q or R172K IDH2 mutations, cladribine restrained mutations-related DNA hypermethylation. Altogether, DAC regimen produces better outcomes in IDH2+ NK-AML patients than DA, and this likely results from the hypomethylating activity of cladribine. Our observations warrant further investigations of induction protocols combining cladribine with IDH1/2 inhibitors in IDH2-mutant.

The effects of lestaurtinib (CEP701) and PKC412 on primary AML blasts: the induction of cytotoxicity varies with dependence on FLT3 signaling in both FLT3-mutated and wild-type cases

Blood ◽  
2006 ◽  
Vol 108 (10) ◽  
pp. 3494-3503 ◽  
Author(s):  
Steven Knapper ◽  
Kenneth I. Mills ◽  
Amanda F. Gilkes ◽  
Steve J. Austin ◽  
Val Walsh ◽  
...  
Keyword(s):  
Myeloid Leukemia ◽  
Wild Type ◽  
Mutation Status ◽  
Activating Mutations ◽  
Drug Concentrations ◽  
Flt3 Inhibitors ◽  
Show Evidence ◽  
Flt3 Expression ◽  
Molecular Therapeutic ◽  
Cytotoxic Responses

Abstract The receptor tyrosine kinase FLT3 is a promising molecular therapeutic target in acute myeloid leukemia (AML). Activating mutations of FLT3 are present in approximately one-third of patients, while many nonmutants show evidence of FLT3 activation, which appears to play a significant role in leukemogenesis. We studied the effects of lestaurtinib (CEP701) and PKC412, 2 small molecule inhibitors of FLT3, on 65 diagnostic AML blast samples. Both agents induced concentration-dependent cytotoxicity in most cases, although responses to PKC412 required higher drug concentrations. Cytotoxic responses were highly heterogeneous and were only weakly associated with FLT3 mutation status and FLT3 expression. Importantly, lestaurtinib induced cytotoxicity in a synergistic fashion with cytarabine, particularly in FLT3 mutant samples. Both lestaurtinib and PKC412 caused inhibition of FLT3 phosphorylation in all samples. Translation of FLT3 inhibition into cytotoxicity was influenced by the degree of residual FLT3 phosphorylation remaining and correlated with deactivation of STAT5 and MAP kinase. FLT3 mutant and wild-type cases both varied considerably in their dependence on FLT3 signaling for survival. These findings support the continued clinical assessment of FLT3 inhibitors in combination with cytotoxic chemotherapy: Entry to future clinical trials should include FLT3 wild-type patients and should remain unrestricted by FLT3 expression level.

The prognostic significance of IDH2 mutations in AML depends on the location of the mutation

Blood ◽  
2011 ◽  
Vol 118 (2) ◽  
pp. 409-412 ◽  
Author(s):  
Claire L. Green ◽  
Catherine M. Evans ◽  
Lu Zhao ◽  
Robert K. Hills ◽  
Alan K. Burnett ◽  
...  
Keyword(s):  
Myeloid Leukemia ◽  
Tandem Duplication ◽  
Medical Research Council ◽  
Prognostic Significance ◽  
Patient Characteristics ◽  
Significant Heterogeneity ◽  
Internal Tandem Duplication ◽  
Isocitrate Dehydrogenase 2 ◽  
Favorable Prognostic Factor ◽  
Flt3 Internal Tandem Duplication

Abstract We have investigated the prognostic significance of isocitrate dehydrogenase 2 (IDH2) mutations in 1473 younger adult acute myeloid leukemia patients treated in 2 United Kingdom Medical Research Council trials. An IDH2 mutation was present in 148 cases (10%), 80% at R140 and 20% at R172. Patient characteristics and outcome differed markedly between the 2 mutations. IDH2R140 significantly correlated with nucleophosmin mutations (NPM1MUT), whereas IDH2R172 cases generally lacked other molecular mutations. An IDH2R140 mutation was an independent favorable prognostic factor for relapse (P = .004) and overall survival (P = .008), and there was no significant heterogeneity with regard to NPM1 or FLT3 internal tandem duplication (FLT3/ITD) genotype. Relapse in FLT3/ITDWTNPM1MUTIDH2R140 patients was lower than in favorable-risk cytogenetics patients in the same cohort (20% and 38% at 5 years, respectively). The presence of an IDH2R172 mutation was associated with a significantly worse outcome than IDH2R140, and relapse in FLT3/ITDWTNPM1WTIDH2R172 patients was comparable with adverse-risk cytogenetics patients (76% and 72%, respectively).

scholarly journals The Relationship Between IDH1 Mutation Status and Metabolic Imaging in Nonenhancing Supratentorial Diffuse Gliomas: A 11C-MET PET Study

2019 ◽  
Vol 18 ◽  
pp. 153601211989408
Author(s):  
Nijiati Kudulaiti ◽  
Huiwei Zhang ◽  
Tianming Qiu ◽  
Junfeng Lu ◽  
Abudumijiti Aibaidula ◽  
...  
Keyword(s):  
Standardized Uptake Value ◽  
Idh1 Mutation ◽  
Metabolic Imaging ◽  
Wild Type ◽  
Isocitrate Dehydrogenase 1 ◽  
Mutation Status ◽  
Positron Emission ◽  
Diffuse Gliomas ◽  
The Relationship ◽  
Met Pet

Purpose: We evaluated the relationship between isocitrate dehydrogenase 1 (IDH1) mutation status and metabolic imaging in patients with nonenhancing supratentorial diffuse gliomas using 11C-methionine positron emission tomography (11C-MET PET). Materials and Methods: Between June 2012 and November 2017, we enrolled 86 (38 women and 48 men; mean age, 41.9 ± 13.1 years [range, 8-67 years]) patients with newly diagnosed supratentorial diffuse gliomas. All patients underwent preoperative 11C-MET PET. Tumor samples were obtained and immunohistochemically analyzed for IDH1 mutation status. Results: The mutant and wild-type IDH1 diffuse gliomas had significantly different mean maximum standardized uptake value values (2.73 [95% confidence interval, CI: 2.32-3.16] vs 3.85 [95% CI: 3.22-4.51], respectively; P = .004) and mean tumor-to-background ratio (1.90 [95% CI: 1.65-2.16] vs 2.59 [95% CI: 2.17-3.04], respectively; P = .007). Conclusions: 11C-methionine PET can noninvasively evaluate the IDH1 mutation status of patients with nonenhancing supratentorial diffuse gliomas.

Prognostic Implications of the IDH1 synonymous SNP rs11554137 In Pediatric and Adult AML: a Children's Oncology Group and Southwest Oncology Group Study

Blood ◽  
2010 ◽  
Vol 116 (21) ◽  
pp. 2737-2737
Author(s):  
Phoenix A. Ho ◽  
Todd A. Alonzo ◽  
Kenneth J. Kopecky ◽  
Kristen L. Miller ◽  
Julia Kuhn ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Expression Profiling ◽  
Prognostic Significance ◽  
Normal Karyotype ◽  
Prognostic Impact ◽  
Wild Type ◽  
Bone Marrow Blast ◽  
Free Survival ◽  
Cytogenetic Abnormalities ◽  
Pediatric Aml

Abstract Abstract 2737 Synonymous SNPs may directly impact gene function through various translational or post-translational mechanisms. Further, such “silent” SNPs in the mutational hotspots of AML-associated genes have recently been reported to carry prognostic impact. We aimed to determine the prevalence, clinical associations, and prognostic significance of a known SNP in exon 4 of IDH1, near the location of the frequently-mutated R132 codon. Diagnostic marrow specimens from 253 pediatric AML patients (treated on the COG trial AAML03P1) and 274 adult AML patients (treated on SWOG trials S9031, S9333, or S9500) were analyzed for the presence of SNP rs11554137 via direct sequencing. In the pediatric cohort (median age 9.8 years), SNP rs11554137 was present in 27 of 253 (10.7%) patients. SNP+ pediatric patients did not differ significantly from wild-type patients in terms of sex, racial distribution (African American patients accounted for 23% of SNP+ patients vs. 14% of wild-type patients, P=0.24), bone marrow blast percentage, or age distribution, except in patients aged 0–2 years, who accounted for 44% of SNP+ patients vs. 23% of wild- type patients (P=0.013). Recurrent cytogenetic abnormalities occurred with similar frequencies in both the SNP+ and wild-type pediatric populations, as did FLT3/ITD, NPMc, and CEBPA mutations. Miscellaneous cytogenetic abnormalities accounted for 33% of SNP+ patients vs. 14% of wild-type patients, P=0.033. IDH1 SNP status had no prognostic impact on survival in the pediatric cohort, as SNP+ and wild-type patients had similar rates of five-year overall survival (OS, 76% vs. 63%, P=0.50), disease-free survival (DFS, 48% vs. 53%, P=0.97), and relapse rate (RR, 39% vs. 39%, P=0.94). In the adult cohort (median age 63 years), the IDH1 SNP was present in 30 of 274 (10.9%) patients. A slight female predominance for the SNP (63% vs. 37%, P=0.052) occurred among adult patients. The SNP was more prevalent in African American patients, who accounted for 30% of the SNP+ patients vs. 7% of wild-type patients, P=0.0046. SNP+ patients also had somewhat higher diagnostic bone marrow blast percentages (medians 80% vs. 70%, P=0.025). The normal karyotype subset accounted for similar proportions of SNP+ vs. wild-type patients (42% vs. 46%, P=0.83). Notably, SNP rs11554137 was not present in adult core-binding factor AML. Miscellaneous cytogenetic abnormalities were significantly more common in SNP+ patients (46% vs. 22%, P=0.022). SNP status was not significantly associated with FLT3/ITD status when all adult patients were considered (P=0.14). However, within the normal karyotype subset, FLT3/ITD was present in 90% of SNP+ patients vs. 59% of wild-type patients (P=0.0053). SNP+ patients had somewhat poorer 5 year OS (10% vs. 18%, hazard ratio [HR]=1.17) though this difference was not statistically significant (P=0.44). Among the 142 patients who achieved complete remission (CR), however, 5-year relapse-free survival (RFS) was significantly worse for SNP+ patients (0% vs. 25%, HR = 2.89, P=0.0014). Of the 14 SNP+ patients who achieved CR, 13 relapsed and the 14th patient died of sepsis in remission after 61 days. In multivariate analysis, after adjusting for the effects of age and cytogenetic group, SNP rs11554137 retained an independent prognostic effect (P=0.0062) regarding RFS. Notably, when FLT3/ITD status is included in multivariate analysis, SNP positivity loses independent prognostic significance (HR=1.72, P=0.18). Genome-wide expression profiling was performed on 134 pediatric AML specimens in whom IDH1 SNP status was known. By comparing SNP+ patients with wild-type patients, we derived a distinct gene-expression signature for patients with SNP rs11554137. Among the most upregulated probe sets in the SNP+ cohort were those representing PEX6 and NFYA, both of which interact with the TGF-beta/SMAD signaling network; the retinoid × receptor beta gene RXRB; and the FER gene, a tyrosine kinase critical to FLT3 signaling. The IDH1 SNP rs11554137 is present in approximately 11% of pediatric and adult AML patients, and gene expression profiling data suggests that leukemia in SNP+ patients may have unique biologic features. The SNP was an independent predictor of decreased RFS in adult AML in univariate analysis, but not in multivariate analysis when adjusting for FLT3/ITD status. Disclosures: No relevant conflicts of interest to declare.

Prognostic Significance of DNA Methyltransferase 3A Mutations in Cytogenetically Normal Acute Myeloid Leukemia: A Study by the Acute Leukemia French Association

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 2506-2506
Author(s):  
Aline Renneville ◽  
Nicolas Boissel ◽  
Olivier Nibourel ◽  
Céline Berthon ◽  
Nathalie Helevaut ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Myeloid Leukemia ◽  
Dna Methyltransferase ◽  
Prognostic Significance ◽  
Gene Mutations ◽  
Wild Type ◽  
Poor Clinical Outcome ◽  
Nucleotide Substitutions ◽  
Dna Methyltransferase 3A ◽  
Wbc Count

Abstract Abstract 2506 Introduction: The development of massively parallel sequencing technologies has led to the identification of somatic DNA methyltransferase 3A (DNMT3A) gene mutations in acute myeloid leukemia (AML), with the highest frequency being found in cytogenetically normal (CN) AML. DNMT3A mutations have been suggested to predict poor clinical outcome in AML, but only few data are available on their prognostic significance within CN-AML. The aim of this study was to determine the frequency, the main associated features, and the prognostic significance of DNMT3A mutations in CN-AML. Patients and methods: This retrospective study was performed in 123 young adult patients (16–60 years) with previously untreated primary CN-AML and enrolled on two concomitant protocols of the Acute French Leukemia Association (ALFA), the ALFA-9801 and ALFA-9802 trials. DNMT3A mutations were screened on genomic DNA by PCR and direct Sanger sequencing. We focused our screening on the 3 conserved domains of DNMT3A (the proline-tryptophane-tryptophane-proline (PWWP) domain, the ADD-type zinc finger domain, and the C5-methyltransferase domain), corresponding to exons 8–9 and 11–23. The patients were also assessed for the presence of FLT3 internal tandem duplication (FLT3-ITD), FLT3 tyrosine kinase domain (FLT3-TKD), NPM1, CEBPA, WT1, IDH1, and IDH2 mutations. Results: Thirty-eight DNMT3A mutations were identified in 36 of the 123 (29%) patients. These alterations consisted of 36 nucleotide substitutions and 2 frameshift deletions. Thirty out of 36 (83%) nucleotide substitutions affected the amino acid residue R882 (R882H, n = 21; R882C, n = 7; R882P, n = 2), 5 represented other missense alterations, and 1 was a nonsense mutation. Two patients exhibited 2 heterozygous missense mutations in different exons, and one patient had a homozygous missense mutation. DNMT3A mutated and wild-type cases did not differ in terms of age, gender, and white blood cell (WBC) count at presentation. DNMT3A mutations were strongly associated with the French-American-British (FAB) subtypes M4/M5 (P =.0002) and the presence of NPM1 mutations (P =.0006), and tended to often co-occur with IDH1R132 mutations (P = .09). In the entire cohort, complete remission rate was found lower in DNMT3A mutated patients than in DNMT3A wild-type patients, but without reaching statistical significance (80% vs 90%, P =.24). DNMT3A mutated patients had a shorter event-free survival (5-year EFS: 13% vs 32%, P =.02) and overall survival (5-year OS: 23% vs 45%, P =.02) compared to DNMT3A wild-type patients. We next performed subgroup analysis according to the NPM1/FLT3-ITD genotypes. In patients with the non-favorable genotypes, that is NPM1 mutated/FLT3-ITD positive, NPM1 wild-type/FLT3-ITD positive, NPM1 wild-type/FLT3-ITD negative (n = 86), 18 (21%) had a concomitant DNMT3A mutation. In this high-risk subgroup of CN-AML, DNMT3A mutations conferred a worse clinical outcome (5-year EFS: 0% vs 23%, P =.02; 5-year OS: 14% vs 37%, P =.06). In patients with the favorable genotype NPM1 mutated/FLT3-ITD negative (n = 37), 18 (49%) were found to display a concomitant DNMT3A mutation. Within this favorable subgroup, patients carrying a DNMT3A mutation had a significantly inferior EFS and OS compared to DNMT3A wild-type patients (5-year EFS: 25% vs 65%, P =.01; 5-year OS: 29% vs 76%, P =.02). Furthermore, in multivariate analysis including age, WBC count, NPM1/FLT3-ITD genotypes, and DNMT3A mutational status, the presence of a DNMT3A mutation remained an independent adverse prognostic factor for EFS (hazard ratio = 2.29; 95% CI, 1.42 to 3.70; P =.0007) and OS (hazard ratio = 2.34; 95% CI, 1.37 to 4.00; P =.002). Conclusion: DNMT3A mutations are one of the most common gene mutations in CN-AML and independently predict poor clinical outcome. Testing for DNMT3A mutations could help further improve risk stratification in CN-AML. Disclosures: No relevant conflicts of interest to declare.

scholarly journals Expression Pattern and Prognostic Significance of EVI1 Gene in Adult Acute Myeloid Leukemia Patients with Normal Karyotype

2019 ◽  
Vol 36 (2) ◽  
pp. 292-299
Author(s):  
Irena Marjanovic ◽  
Teodora Karan-Djurasevic ◽  
Tatjana Kostic ◽  
Marijana Virijevic ◽  
Nada Suvajdzic-Vukovic ◽  
...  
Keyword(s):  
Acute Myeloid Leukemia ◽  
Expression Pattern ◽  
Myeloid Leukemia ◽  
Prognostic Significance ◽  
Normal Karyotype ◽  
Acute Myeloid

Poor Prognosis of Adult Acute Myeloid Leukemia (AML) with High Level of Evi1 and BAALC Transcript.

Blood ◽  
2004 ◽  
Vol 104 (11) ◽  
pp. 2994-2994
Author(s):  
Valeria Biggio ◽  
Selim Corm ◽  
Hugues Leroy ◽  
Stephane De Botton ◽  
Christophe Roumier ◽  
...  
Keyword(s):  
Overall Survival ◽  
Acute Myeloid Leukemia ◽  
Molecular Markers ◽  
Myeloid Leukemia ◽  
Remission Rate ◽  
Prognostic Significance ◽  
Normal Karyotype ◽  
High Expression ◽  
Fab Classification ◽  
Acute Myeloid

Abstract Cytogenetics remain the most powerful prognostic factor in acute myeloid leukemia (AML). However, 50–60 % of those patients (pts) are included in intermediate or unknown karyotypic risk groups. Molecular markers might improve risk classification and recently, 2 groups have reported that the expression of BAALC and EVI1 might be associated with a poor outcome, especially in pts with normal karyotype (Blood.2003;102:1613; Blood2003;101:837). Thus, we retrospectively analyzed the prognostic significance of the expressions level of these genes, by real time quantitative PCR (RQ-PCR) in AML. Patients and methods: 189 adult pts were analyzed: median age was 49 years (range, 19-65), median WBC counts 19 Giga/L (range, 0-602). FAB classification was: M0=22, M1=41,M2=44,M4=37,M5=26,M6=7,M7=1 and unclassified =11. Karyotype was prognostically favorable (n=28), intermediate (n=115, including 80 normal), unfavorable (n=39) and unknown (n=7). All pts received anthracycline-AraC chemotherapy according to French ALFA group multicenter trials (Castaigne et al, Blood 2004; May 13, Epub ahead of print). Complete remission rate was 83 %, median overall survival: 22 months, range 0.1 to 123. RQ-PCR was performed according to the 2 previous paper recommendations. However the housekeeping gene used in this work was TBP (TF2D). Results were expressed using ΔCt method. High levels of EVI1 were defined by ΔCt lower than 11. BAALC (+) pts and (−) pts were defined by ΔCt value lower or higher than 2.45 (ie the median ΔCt for BAALC expression). Results: 24/189 (13%) pts had high expression of EVI1. By comparison to pts without high EVI1 expression, pretreatment variables other than karyotype (including age, WBC counts, FAB classification) were similar in pts with high EVI1 expression. Patients with high EVI1 expression had significantly worse karyotype: none had favorable karyotype, only 4 (17%) had 3q26 abnormalities ((associated with other adverse abnormalities in 3 cases (i.e. -7/7q-)), 3 had 11q23 abnormalities and 9/24 (37.5%) pts normal karyotype. No significant diferencies between pts with high and low EVI1 expression was found for CR rates and DFS, but high EVI1 expression was associated with poorer overall survival ( median:11.7 months versus 26.9 months; p=0.0372). No pretreatment parameters, including karyotype, differed between BAALC (+) (ie pts with BAALC expression lower than the ΔCt median value) and BAALC (−) pts (ie pts with expression greater than the ΔCt median value). Overall CR rate, DFS, OS were similar in BAALC (+) and BAALC (−) pts. However, in the intermediate cytogenetic subgroup (n=115 pts), BAALC (+) pts had lower median DFS (9.7 months versus 19.8 months; p=0.0316) and EFS (4.1 months versus 11.8 months; p=0.0027) than BAALC (−) pts and a trend for poorer OS:16 months versus 27 months (p=0.07). In conclusion: In adult AML patients, high expression of EVI and BAALC are associated with poorer outcome. Determination at diagnosis of the level of those two genes could be helpful for treatment adjustment, especially in the intermediate cytogenetic subgroup. Correlation between EVI1 and BAALC results and those of other molecular markers (CEBPA, RAS, FLT3) mutations will be presented.

Double, but Not Single, CEBPA mutations Define a Subgroup of Acute Myeloid Leukemia with Favorable Outcome and a Distinct Gene Expression Profile

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 141-141 ◽  
Author(s):  
Bas J. Wouters ◽  
Claudia A.J. Erpelinck-Verschueren ◽  
Bob Lowenberg ◽  
Peter J.M. Valk ◽  
Ruud Delwel
Keyword(s):  
Gene Expression ◽  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Multivariable Analysis ◽  
Favorable Outcome ◽  
Heterozygous Mutation ◽  
Wild Type ◽  
Mutation Status ◽  
Cebpa Mutations ◽  
Acute Myeloid

Abstract Acute myeloid leukemia (AML) is a heterogeneous disease characterized by various cytogenetic and molecular abnormalities, some of which can be used as prognostic markers. Mutations in the transcription factor CCAAT/enhancer binding protein alpha (CEBPA) occur in 5–10% of AML and have consistently been associated with a favorable outcome. Three types of mutations have been described: N-terminal out-of-frame mutations, inframe mutations in the basic leucine zipper (bZIP) region, and a small variable group of remaining aberrations. Most CEBPA mutant AML cases carry two mutations, usually on different alleles (double mutant). However, there are also cases that only express a single heterozygous mutation, and thus retain a wild type allele (single mutant). It is not known whether single and double CEBPA mutations should be considered of equal biological and/or clinical importance. We applied dHPLC WAVE technology in combination with nucleotide sequencing of the entire CEBPA gene in a cohort of 598 cases of adult de novo AML. After exclusion of previously described polymorphisms, we identified 41 cases (6.9%) with at least one mutation. Of these cases, 28 carried double mutations, i.e. two different heterozygous mutations or one homozygous mutation, whereas the remaining cases carried a single heterozygous mutation. To investigate whether CEBPA mutations were associated with specific transcriptional signatures, we examined genome-wide gene expression (GEP) data of 525/598 AMLs, including 38/41 CEBPA mutant cases. Class prediction of total CEBPA mutation status based on GEP data resulted in a relatively large number of false negatives in cross-validation using the PAM algorithm (sensitivity 68%, specificity 99%). Strikingly however, all these missed cases appeared to be of the single mutant group, while the double mutants were recognized with high accuracy. In agreement, unsupervised cluster analysis of the 525 AMLs led to distinct grouping of cases with double mutations, while cases with a single heterozygous mutation did not. These observations suggested that double and single CEBPA mutant AMLs represent distinct biological entities. We next assessed the clinical relevance of this finding. In concordance with previous studies, total CEBPA mutation status associated with favorable overall survival (OS) and event-free survival (EFS) (P=0.023 and P=0.042, log rank test), which was maintained in multivariable Cox’s proportional hazards models with cytogenetic risk group, FLT3-ITD and NPM1 mutation status, age and white blood cell count (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.29–0.77; P=0.002 and HR 0.52, 95% CI 0.33–0.82; P=0.004). Surprisingly, when the double and single CEBPA mutant cases were separately analyzed, only the double mutants showed a highly favorable outcome, while the single mutants could not be distinguished from CEBPA wild type AMLs (P=0.003 versus P=0.51 (OS) and P=0.004 versus P=0.18 (EFS)). In multivariable analysis, CEBPA double mutation status remained associated with favorable outcome (OS HR 0.31, 95% CI 0.16–0.59; P<0.001, and EFS HR 0.34; 95% CI 0.19–0.61; P<0.001), contrasting with the single mutants (HR 1.18, 95% CI 0.58–2.41; P=0.64 and HR 1.65, 95% CI 0.84–3.23; P=0.15). Similarly, in multivariable analysis in the selected normal karyotype subset (n=193), CEBPA double mutations, but not single mutations, were significantly associated with OS (P=0.026 versus P=0.24) and EFS (P=0.013 versus P=0.42). In conclusion, these data demonstrate the existence of distinct transcriptional and clinical characteristics of AML cases with double CEBPA mutations and imply that it is crucial to discriminate them from single mutants to identify those patients with a favorable prognosis.

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