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[Cancer Research 61, 7233-7239, October 1, 2001]
© 2001 American Association for Cancer Research


Immunology

Absence of the Wild-Type Allele Predicts Poor Prognosis in Adult de Novo Acute Myeloid Leukemia with Normal Cytogenetics and the Internal Tandem Duplication of FLT3

A Cancer and Leukemia Group B Study1

Susan P. Whitman, Kellie J. Archer, Lan Feng, Claudia Baldus, Brian Becknell, Brian D. Carlson, Andrew J. Carroll, Krzysztof Mrózek, James W. Vardiman, Stephen L. George, Jonathan E. Kolitz, Richard A. Larson, Clara D. Bloomfield and Michael A. Caligiuri2

The Ohio State University, Columbus, Ohio 43210 [S. P. W., K. J. A., L. F., C. B., B. B., B. D. C., K. M., C. D. B., M. A. C.]; The Cancer and Leukemia Group B Statistical Center, Durham, North Carolina 27710 [K. J. A., S. L. G.]; University of Alabama, Birmingham, Alabama 35249 [A. J. C.]; University of Chicago, Chicago, Illinois 60637 [J. W. V., R. A. L.]; and North Shore University Hospital, Manhasset, New York 11030 [J. E. K.]

The FLT3 gene is mutated by an internal tandem duplication (ITD) in 20–25% of adults with acute myeloid leukemia (AML). We studied 82 adults <60 years of age with primary AML and normal cytogenetics, who received uniform high-dose therapy and found FLT3 ITD in 23 (28%) patients. When the 23 FLT3 ITD+ cases were compared with the 59 cases with wild-type (WT) FLT3, disease-free survival (DFS) was inferior (P = 0.03), yet overall survival (OS) was not different (P = 0.14). However, 8 (35%) of 23 FLT3 ITD/+ cases also lacked a FLT3 WT allele (FLT3ITD-R) as determined by PCR and loss of heterozygosity. Thus, three genotypic groups were identified: normal FLT3WT/WT, heterozygous FLT3ITD/WT, and hemizygous FLT3ITD/-. DFS and OS were significantly inferior for patients with FLT3ITD/- (P = 0.0017 and P = 0.0014, respectively). Although DFS and OS for FLT3WT/WT and FLT3ITD/WT groups did not differ (P = 0.32 and P = 0.98, respectively), OS of the FLT3ITD/- group was worse than the FLT3WT/WT (P = 0.0005) and FLT3ITD/WT (P = 0.008) groups. We propose a model in which FLT3ITD/- represents a dominant positive, gain-of-function mutation providing AML cells with a greater growth advantage compared with cells having the FLT3WT/WT or FLT3ITD/WT genotypes. In conclusion, we have identified the FLT3ITD/- genotype as an adverse prognostic factor in de novo AML with normal cytogenetics. A poor prognosis of the relatively young FLT3ITD/- adults (median age, 37 years), despite treatment with current dose-intensive regimens, suggests that new treatment modalities, such as therapy with a FLT3 tyrosine kinase inhibitor, are clearly needed for this group of patients.




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M. Grever
Pharmacodynamics provide critical insight in drug development
Blood, May 15, 2004; 103(10): 3614 - 3614.
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B. D. Smith, M. Levis, M. Beran, F. Giles, H. Kantarjian, K. Berg, K. M. Murphy, T. Dauses, J. Allebach, and D. Small
Single-agent CEP-701, a novel FLT3 inhibitor, shows biologic and clinical activity in patients with relapsed or refractory acute myeloid leukemia
Blood, May 15, 2004; 103(10): 3669 - 3676.
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K. Bagrintseva, R. Schwab, T. M. Kohl, S. Schnittger, S. Eichenlaub, J. W. Ellwart, W. Hiddemann, and K. Spiekermann
Mutations in the tyrosine kinase domain of FLT3 define a new molecular mechanism of acquired drug resistance to PTK inhibitors in FLT3-ITD-transformed hematopoietic cells
Blood, March 15, 2004; 103(6): 2266 - 2275.
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K. Ozeki, H. Kiyoi, Y. Hirose, M. Iwai, M. Ninomiya, Y. Kodera, S. Miyawaki, K. Kuriyama, C. Shimazaki, H. Akiyama, et al.
Biologic and clinical significance of the FLT3 transcript level in acute myeloid leukemia
Blood, March 1, 2004; 103(5): 1901 - 1908.
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S. Frohling, R. F. Schlenk, I. Stolze, J. Bihlmayr, A. Benner, S. Kreitmeier, K. Tobis, H. Dohner, and K. Dohner
CEBPA Mutations in Younger Adults With Acute Myeloid Leukemia and Normal Cytogenetics: Prognostic Relevance and Analysis of Cooperating Mutations
J. Clin. Oncol., February 15, 2004; 22(4): 624 - 633.
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D. Perrotti, G. Marcucci, and M. A. Caligiuri
Loss of C/EBP{alpha} and Favorable Prognosis of Acute Myeloid Leukemias: A Biological Paradox
J. Clin. Oncol., February 15, 2004; 22(4): 582 - 584.
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L.-Y. Shih, C.-F. Huang, J.-H. Wu, P.-N. Wang, T.-L. Lin, P. Dunn, M.-C. Chou, M.-C. Kuo, and C.-C. Tang
Heterogeneous Patterns of FLT3 Asp835 Mutations in Relapsed de Novo Acute Myeloid Leukemia: A Comparative Analysis of 120 Paired Diagnostic and Relapse Bone Marrow Samples
Clin. Cancer Res., February 15, 2004; 10(4): 1326 - 1332.
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B. D. Cheson, J. M. Bennett, K. J. Kopecky, T. Buchner, C. L. Willman, E. H. Estey, C. A. Schiffer, H. Doehner, M. S. Tallman, T. A. Lister, 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., December 15, 2003; 21(24): 4642 - 4649.
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Y. Minami, K. Yamamoto, H. Kiyoi, R. Ueda, H. Saito, and T. Naoe
Different antiapoptotic pathways between wild-type and mutated FLT3: insights into therapeutic targets in leukemia
Blood, October 15, 2003; 102(8): 2969 - 2975.
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C. M. Zwaan, S. Meshinchi, J. P. Radich, A. J. P. Veerman, D. R. Huismans, L. Munske, M. Podleschny, K. Hahlen, R. Pieters, M. Zimmermann, et al.
FLT3 internal tandem duplication in 234 children with acute myeloid leukemia: prognostic significance and relation to cellular drug resistance
Blood, October 1, 2003; 102(7): 2387 - 2394.
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C. D. Baldus, S. M. Tanner, A. S. Ruppert, S. P. Whitman, K. J. Archer, G. Marcucci, M. A. Caligiuri, A. J. Carroll, J. W. Vardiman, B. L. Powell, et al.
BAALC expression predicts clinical outcome of de novo acute myeloid leukemia patients with normal cytogenetics: a Cancer and Leukemia Group B Study
Blood, September 1, 2003; 102(5): 1613 - 1618.
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K. Spiekermann, K. Bagrintseva, R. Schwab, K. Schmieja, and W. Hiddemann
Overexpression and Constitutive Activation of FLT3 Induces STAT5 Activation in Primary Acute Myeloid Leukemia Blast Cells
Clin. Cancer Res., June 1, 2003; 9(6): 2140 - 2150.
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K. M. Murphy, M. Levis, M. J. Hafez, T. Geiger, L. C. Cooper, B.D. Smith, D. Small, and K. D. Berg
Detection of FLT3 Internal Tandem Duplication and D835 Mutations by a Multiplex Polymerase Chain Reaction and Capillary Electrophoresis Assay
J. Mol. Diagn., May 1, 2003; 5(2): 96 - 102.
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M. Mizuki, J. Schwable, C. Steur, C. Choudhary, S. Agrawal, B. Sargin, B. Steffen, I. Matsumura, Y. Kanakura, F. D. Bohmer, et al.
Suppression of myeloid transcription factors and induction of STAT response genes by AML-specific Flt3 mutations
Blood, April 15, 2003; 101(8): 3164 - 3173.
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K. Spiekermann, R. J. Dirschinger, R. Schwab, K. Bagrintseva, F. Faber, C. Buske, S. Schnittger, L. M. Kelly, D. G. Gilliland, and W. Hiddemann
The protein tyrosine kinase inhibitor SU5614 inhibits FLT3 and induces growth arrest and apoptosis in AML-derived cell lines expressing a constitutively activated FLT3
Blood, February 15, 2003; 101(4): 1494 - 1504.
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B. Lowenberg, J. D. Griffin, and M. S. Tallman
Acute Myeloid Leukemia and Acute Promyelocytic Leukemia
Hematology, January 1, 2003; 2003(1): 82 - 101.
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J. C. Byrd, K. Mrozek, R. K. Dodge, A. J. Carroll, C. G. Edwards, D. C. Arthur, M. J. Pettenati, S. R. Patil, K. W. Rao, M. S. Watson, et al.
Pretreatment cytogenetic abnormalities are predictive of induction success, cumulative incidence of relapse, and overall survival in adult patients with de novo acute myeloid leukemia: results from Cancer and Leukemia Group B (CALGB 8461)
Blood, December 15, 2002; 100(13): 4325 - 4336.
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S. Frohling, R. F. Schlenk, J. Breitruck, A. Benner, S. Kreitmeier, K. Tobis, H. Dohner, and K. Dohner
Prognostic significance of activating FLT3 mutations in younger adults (16 to 60 years) with acute myeloid leukemia and normal cytogenetics: a study of the AML Study Group Ulm
Blood, December 15, 2002; 100(13): 4372 - 4380.
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K. Spiekermann, K. Bagrintseva, C. Schoch, T. Haferlach, W. Hiddemann, and S. Schnittger
A new and recurrent activating length mutation in exon 20 of the FLT3 gene in acute myeloid leukemia
Blood, October 16, 2002; 100(9): 3423 - 3425.
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K. W. H. Yee, A. M. O'Farrell, B. D. Smolich, J. M. Cherrington, G. McMahon, C. L. Wait, L. S. McGreevey, D. J. Griffith, and M. C. Heinrich
SU5416 and SU5614 inhibit kinase activity of wild-type and mutant FLT3 receptor tyrosine kinase
Blood, September 26, 2002; 100(8): 2941 - 2949.
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L.-Y. Shih, C.-F. Huang, J.-H. Wu, T.-L. Lin, P. Dunn, P.-N. Wang, M.-C. Kuo, C.-L. Lai, and H.-C. Hsu
Internal tandem duplication of FLT3 in relapsed acute myeloid leukemia: a comparative analysis of bone marrow samples from 108 adult patients at diagnosis and relapse
Blood, September 18, 2002; 100(7): 2387 - 2392.
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D. G. Gilliland and J. D. Griffin
The roles of FLT3 in hematopoiesis and leukemia
Blood, August 13, 2002; 100(5): 1532 - 1542.
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S. Schnittger, C. Schoch, M. Dugas, W. Kern, P. Staib, C. Wuchter, H. Loffler, C. M. Sauerland, H. Serve, T. Buchner, et al.
Analysis of FLT3 length mutations in 1003 patients with acute myeloid leukemia: correlation to cytogenetics, FAB subtype, and prognosis in the AMLCG study and usefulness as a marker for the detection of minimal residual disease
Blood, June 17, 2002; 100(1): 59 - 66.
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C. Thiede, C. Steudel, B. Mohr, M. Schaich, U. Schakel, U. Platzbecker, M. Wermke, M. Bornhauser, M. Ritter, A. Neubauer, et al.
Analysis of FLT3-activating mutations in 979 patients with acute myelogenous leukemia: association with FAB subtypes and identification of subgroups with poor prognosis
Blood, May 29, 2002; 99(12): 4326 - 4335.
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R. L. Schilsky, L. M. Dressler, D. Bucci, L. Monovich, S. Jewell, S. Suster, M. A. Caligiuri, P. W. Kantoff, and C. Compton
Cooperative Group Tissue Banks As Research Resources: The Cancer and Leukemia Group B Tissue Repositories
Clin. Cancer Res., May 1, 2002; 8(5): 943 - 948.
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F. J. Giles, A. Keating, A. H. Goldstone, I. Avivi, C. L. Willman, and H. M. Kantarjian
Acute Myeloid Leukemia
Hematology, January 1, 2002; 2002(1): 73 - 110.
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