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Interactive diagnostics in the indication to allogeneic SCT in AML

Abstract

Owing to the heterogeneity of AML, the indication for allogeneic SCT (allo-SCT) requires an exact definition of the individual subentity and risk category. A comprehensive diagnostic approach is needed, which combines cytomorphology, cytogenetics, FISH, molecular genetics and immunophenotyping. Whereas the categorization in three prognostic karyotype groups is well established, rare recurrent aberrations as the unfavorable t(8;16)(p11;p13), inv(3)(q21q26) and t(6;9)(p23;q34) must also be considered. In normal karyotype, PCR analyses reveal prognostically relevant mutations in >85% of cases, and a molecular data set composed of the FLT3-ITD, MLL-PTD, NPM1 and CEBPA mutations was found able to guide the selection of patients for allo-SCT. Some novel markers as the WT1 mutations might further contribute to risk stratification in normal karyotype. The panel of minimal residual disease parameters is being expanded at this time, for example, by quantitative PCR for the NPM1 mutations. Immunophenotyping allows the definition of leukemia-associated phenotypes in nearly all cases, but its position in the indication to allo-SCT has to be validated. Thus, the optimization of the indication to allo-SCT is an ongoing process that should remain in continuous interaction with the increasing panel of known genetic markers and diagnostic methods.

Introduction

Owing to the heterogeneous profile from clinical, morphological, immunological and genetic aspects, AML is understood as a complex of diverse biologically and prognostically relevant subtypes. A combination of cytomorphology, immunophenotyping, and cytogenetics and molecular genetics only provides the essential parameters for a correct classification of the individual subtype.1 In recent years, especially the diverse FISH and PCR techniques gained importance. The panel of known genetic markers is still increasing,2 and the impact of minimal residual disease (MRD) detection was realized for several AML subtypes.3, 4, 5, 6 Modern therapy concepts aim to restrict the risks of transplant-related morbidity and mortality and of reduced quality of life post transplant7 for those patients with unfavorable outcomes after standard treatment. Thus, the indication to allogeneic SCT (allo-SCT) must now integrate the complete pattern of diagnostic results at diagnosis and during follow-up of AML. Considering the variety of diagnostic parameters and methods that are available for the variety of subtypes, this became a real challenge.

On the basis of the detection of aberrant karyotypes in 55% of AML cases, the categorization in good, intermediate and inferior risk groups has been established in diverse large studies.8, 9, 10 However, less frequent cytogenetic aberrations and the combination of diverse genetic markers—for example, a t(8;21)(q22;q22) combined with a −Y in males,11 or with a cKIT mutation;12, 13 or the t(15;17)/PML-RARA with an FLT3-ITD (internal tandem duplication of the FLT3 gene) or FLT3-TKD (tyrosine kinase domain) mutation14—can complicate decisions.

The detection of recurrent molecular markers in the majority of patients with a normal karyotype15 completely changed understanding of the so-called ‘intermediate prognostic group’. Likewise to the prognostically adverse FLT3-ITD that were identified as adverse prognostic markers in AML less than a decade ago,16, 17 by now the favorable Nucleophosmin (NPM1) mutations in 55% of normal karyotype AML2, 18 have an increasing influence in therapeutic decisions. For some other mutations, for example, FLT3-TKD16, 19, 20 or NRAS,21, 22 the impact on prognosis is still controversial. Mutations of the Wilms’ tumor suppressor gene (WT1)23, 24 and overexpression of the WT125, 26 or BAALC (brain and acute leukemia, cytoplasmic) genes27 were identified as adverse prognostic parameters, but whether they might have a role in the indication to allo-SCT in normal karyotype cases needs additional investigation.

An early evaluation of the response to induction therapy can be performed by a combination of BM cytomorphology,28 multiparameter flow cytometry29 and quantitative PCR (qPCR).5 The measurement of the residual cell load by multiparameter flow cytometry and qPCR allows a more sensitive estimation of persistent disease than cytomorphology and an earlier detection of relapse before the morphological manifestation.3, 4 Although previously molecular MRD diagnostics were available for some reciprocal rearrangements as the t(8;21)/RUNX1-RUNX1T1 only, qPCR is currently being established for a larger spectrum of molecular markers as the NPM1 mutations,30, 31, 32 the FLT3 mutations33, 34, 35 and the MLL-PTD,36 aiming to provide MRD measurement also in normal karyotype cases.

This work gives an overview on the increasing panel of genetic markers, diagnostic techniques and follow-up investigations that became essential for the indication to allo-SCT in AML. In addition, attention is paid to novel markers that might contribute to this complex decision in the future.

Cytomorphology

Cytomorphology still represents one of the basic methods for the indication to allo-SCT in AML. Currently, response to induction therapy is assessed with a day +28 BM aspirate and/or biopsy. However, recent data indicated that early response to induction chemotherapy with a reduction in the day 14 or 16 marrow blasts (‘day 16 blasts’) to <5–10% is associated with a higher likelihood of achieving a CR.28, 37, 38 Indeed, as being demonstrated in a large study of 680 AML patients, CR rates of patients with intermediate karyotype but day 16 blasts <10% were comparable to the cohort with favorable cytogenetics.39 Wells et al.40 demonstrated in 498 pediatric patients that a threshold of 15% BM blasts on day +14 after the start of induction therapy was associated with lower remission rates. Thus, persistence of higher blast percentages once induction is completed should always raise concern whether there might be an indication for allo-SCT.37

Immunophenotyping

Multiparameter flow cytometry is able to detect specific leukemia-associated immunophenotypes (LAIP) in 95% of AML patients at diagnosis.41, 42, 43 These are based on aberrant coexpression of lymphatic Ags (for example, of CD7), asynchronous coexpression of Ags of different maturation stages, aberrant low or bright Ag expression, or Ag loss, for example, loss of HLA-DR in myeloid blasts. Sensitivities of 10−2 to 10−4 are achieved.44 The comparison of the proportions of cells with the respective LAIPs before and after therapy for an early and sensitive evaluation of the response to treatment41, 45 can also be performed when molecular markers for follow-up investigations are not available. Also, the logarithmic difference between LAIP-positive cells on days +1 and +16 after the start of therapy was shown to correlate significantly with the achievement of CR, overall survival (OS) and disease-free survival (DFS).41, 46 Coustan-Smith et al.47 demonstrated that the reduction of aberrant cells to a threshold of 0.1% is a predictor of long-time survival. Another study demonstrated that the reduction of cells carrying the leukemia-specific immunophenotype after induction or consolidation therapy when compared to diagnosis was significantly associated to relapse-free survival. The prognostic impact of flow cytometry was independent of cytogenetics or other prognostically relevant parameters in multivariate analysis.48

In addition, numerous studies demonstrated an increase of LAIP-positive cells before the occurrence of morphological relapse. In a study on 252 pediatric patients with AML, a proportion of >0.5% cells with the aberrant blast phenotype was associated with a threefold increased relapse risk when compared to patients below this threshold.49 Laane et al.6 performed multiparameter flow cytometry analyses in 45 AML patients 60 years of age first at the time of cytomorphological CR and at a second time point after induction/post-remission chemotherapy or before SCT: patients with detectable MRD who did not proceed to allo-SCT had a 5-year DFS of 20–25% only, whereas those receiving an allograft had a similar outcome as MRD-negative patients and did fairly better. Venditti et al.50 determined a threshold of 3.5 × 10−4 aberrant cells being predictive for relapse.

Although these results suggest that an increase of LAIP-positive cells after therapy might be interpreted as possible indication for allo-SCT,6 the final position of multiparameter flow cytometry in the indication to allo-SCT in AML has to be further established.

Cytogenetics

Chromosome banding analyses are obligatory at diagnosis or relapse of AML. Considering the limited sensitivity of chromosome banding and the requirement of 20–25 metaphases for valid results, the combination with diverse molecular FISH techniques thereby became highly important. This can be illustrated by complex karyotypes, which were never fully understood before the introduction of multicolor FISH.

On the basis of cytogenetics, cases are separated into three prognostically relevant groups. In the ‘favorable group’ with the recurrent reciprocal translocations t(15;17)/PML-RARA, t(8;21)/RUNX1-RUNX1T1 and inv(16)/CBFB-MYH11, allo-SCT was removed from the first-line strategies in first CR but still remains an option in case of relapse.51, 52, 53 The coincidence of an FLT3-ITD and a PML-RARA might confer an inferior prognostic impact,14 but this observation is so far based on few studies only. Also, it was suggested that the t(8;21) and the inv(16) core binding factor leukemias have an inferior prognosis when being combined with a loss of Y in males.11 In contrast, the combination of an inv(16)/CBFB-MYH11 with an additional trisomy 22 is prognostically even more favorable when compared an isolated inv(16),11, 15 which demonstrates the relevance of additional aberrations in the CBF leukemias.

The second ‘intermediate subgroup’ mainly includes normal karyotype and an isolated trisomy 8. However, also all cytogenetic abnormalities with so far unknown impact on prognosis due to their low incidence are included in this category. Whereas trisomy 8 is prognostically not relevant when being found as sole aberration, an unfavorable influence was suggested when the +8 is found in combination with other (noncomplex) abnormalities.10, 54, 55 In contrast, a recent study investigating 131 AML patients with a noncomplex +8 showed no prognostic difference when additional cytogenetic abnormalities were present (excluding the favorable reciprocal rearrangements). Only presence of >80% positive metaphases carrying the +8 was associated with inferior survival.56

With respect to normal karyotype, the optimal post-remission treatment strategy was until recently controversial,57 but current transplantation strategies rather base the indication to allo-SCT on the results of molecular screening (Table 1).58

Table 1 Overview on molecular mutations and aberrant gene expression with prognostic significance in normal karyotype AML

The third ‘unfavorable group’ includes unbalanced karyotypes with numerical or structural gains or losses of chromosomal material (Table 2). Deletions of 5q or 7q and losses of chromosome 7 have major functions. In two-thirds of cases, mutations or deletions of the P53 tumor suppressor gene on 17p13 are observed. Prognosis is dismal also in MLL/11q23 rearrangements (mixed lineage leukemia gene), which are often seen in association with previous application of topoisomerase II inhibitors. In these unfavorable cytogenetic subtypes, relapse rates after standard chemotherapy are up to 80%. Improved outcome was suggested in the subgroup with a t(9;11)(p22;q23)/MLL-AF9 when compared to other MLL/11q23 rearrangements.54, 65 This, however, was not confirmed in another study of 54 patients with MLL/11q23 rearrangements.66 Also in childhood AML the prognostic impact of the t(9;11) remains controversial.67, 68 In the new WHO classification the t(9;11)(p22;q23)/MLL-AF9 defines an own AML subtype.69

Table 2 Selected studies analyzing the prognostic impact of diverse genetic parameters in AML

Especially in complex aberrant karyotypes with the simultaneous occurrence of 3 clonal chromosomal anomalies (being identified in 10–15% of all AML cases), stable remissions are extremely rare after standard chemotherapy.70 Complex aberrant karyotypes are not randomly distributed but frequently involve losses in the 5q14q33, 7q32q35 and 17p13 regions (the latter containing the P53 tumor suppressor gene).71 Recently, Breems et al.72 suggested that a ‘monosomal karyotype’ as defined by the combination of 2 numerical autosomal losses or the combination of an autosomal loss and a structural alteration was a better predictor of an unfavorable prognosis than the traditional definition of complex aberrant karyotypes. However, this aspect needs additional investigation as these data result so far from one study only.

So far, allo-SCT seems the only possibility to achieve stable remissions in the prognostically unfavorable group. In a large EORTC/GIMEMA study in adult AML patients 45 years of age, allo-SCT in first remission improved DFS from <20% to >40% when compared to intensive or high-dose chemotherapy.73 In patients with chromosome 5 or 7 alterations, a 3-year OS of only 25% was reported even when allo-SCT was performed, mainly due to a >80% relapse rate in patients >40 years of age, whereas those 40 years had a better outcome.74

Cytogenetics are predictive for the outcome of therapy also in therapy-associated AML (t-AML). Within the WHO classification, this entity now belongs to the category of therapy-related myeloid neoplasms, which also includes therapy-associated MDS and MDS/MPN (representing cases with overlapping myelodysplastic and myeloproliferative characteristics).69 Armand et al.75 found equal survival in the diverse cytogenetic subgroups independently of a de novo manifestation or an association with previous therapy in 556 patients with MDS or AML undergoing allo-SCT. Nevertheless, karyotypes are differently distributed in de novo and t-AML. First, aberrant karyotypes are more frequent in therapy-associated cases with aberration rates as high as 80% in comparison to 55% in de novo cases. Second, unfavorable karyotypes are found in t-AML with a >45% frequency but in 20% of cases in de novo AML only.76

Likewise, in secondary AML after MDS (s-AML) (or AML with myelodysplasia-related changes according to the new WHO classification)69 prognostically adverse karyotypes are overrepresented.77, 78 Owing to this unfavorable prognostic profile, s-AML is frequently considered to represent an indication to allo-SCT. A retrospective European Group for Blood and Marrow Transplantation study demonstrated a 3-year OS of 31% in patients with advanced MDS or s-AML, however with a high transplant-related mortality (TRM) of 52%79 before the introduction of dose-reduced strategies.

Also at relapse of AML, cytogenetics are highly relevant for the evaluation of prognosis. As the favorable impact of the reciprocal rearrangements from the first WHO hierarchy can also be determined, the karyotype was included in prognostic scores for patients at relapse of AML.80

Rare recurrent cytogenetic aberrations

3q21q26 aberrations

The inv(3)/t(3;3)(q21;q26) is detected in 0.5–1% of all AML patients, but interphase FISH or PCR reveal slightly higher frequencies of cryptic 3q26 breakpoints up to 2%.81 Fusion of EVI1 or the related MDS/EVI1 genes at 3q26 and RPN1 results in increased EVI1 expression, which is significantly associated with worsened OS.81 Allo-SCT was reported to result in a 2-year OS of 62% in 12 inv(3) patients, whereas standard therapy is followed by relapse rates as high as 50%.82

Translocation t(6;9)(q23;q34)

The unfavorable t(6;9)(q23;q34)/DEK-NUP214 rearrangement is found in 0.5–1% of adult AML patients.83 In some of the cases, coincidence with FLT3-ITD might contribute to the adverse prognosis.84 Prognosis seems to be ameliorated by allo-SCT, at least when complete molecular remission is achieved before transplantation: Garcon et al.85 reported DFS of 13–95 months in four patients having achieved molecular CR before allo-SCT, whereas those seven patients remaining MRD positive all developed relapse after SCT.

Translocation t(8;16)(p11;p13)

The rare reciprocal t(8;16)(p11;p13) is characterized by fusion of the MYST3 and CREBBP genes. This results in an aberrant protein—MYST3-CREBBP—which is considered to inhibit RUNX1/AML1-mediated transcription.86 The blasts are characterized by the phenomenon of erythrophagocytosis87 and by the unique combination of positive myeloperoxidase and nonspecific esterase staining in >80% of cells. Similar to the MLL/11q23 rearrangements, there is a close association with previous application of topoisomerase II inhibitors88 with exposure to radiation.89 Further, AML with MYST3 rearrangements was shown to be characterized by an outstanding gene expression profile, which shows parallels to T-cell ALL; thus, targeting of a common T-myeloid progenitor was suggested.90 So far, survival of a few months only was reported in most cases of MYST-rearranged AML,87 and none of four patients reported by Quesnel et al.91 achieved CR after standard chemotherapy. Gervais et al.92 reported a mortality rate of 50% in the so far largest study of 30 cases with MYST3/8p11 rearrangements. Successful allo-SCT was reported in one case by Demuynck et al.93 Although the rare occurrence of the translocation has to be seen, there seems to be a clear indication to allo-SCT in the t(8;16).

Rare numerical trisomies

Numerical gains other than +8 in noncomplex karyotypes are rare in AML and are mainly represented by gains of the chromosomes 11, 13 and 21. They are all associated with a dismal prognosis. In trisomy 11 cases, the frequent coincidence of the prognostically adverse MLL-PTD might contribute to the inferior prognosis.94 In case of trisomy 13, the frequent association with RUNX1/AML1 mutations combined with increased FLT3 gene expression could be relevant for the inferior outcome.95, 96 According to Farag et al.55 who analyzed 101 patients with isolated trisomies, survival was 5% only in standard treated patients in comparison to close to 70% in patients receiving allo-SCT.

Molecular criteria

NPM1 mutations

Mutations of the NPM1 gene are detected in 30% of all AML patients and in 55% of normal karyotype patients. When detected as isolated mutations in normal karyotype, they confer a favorable prognosis. Mostly 4 bp insertions alter the structure of the NPM1 protein, which in consequence is aberrantly localized to the cytoplasm. This is supposed to interfere with the normal participation of the protein within the ARF53 tumor suppressor pathway.18 With respect to the distinct clinical and biological profile, the WHO classification recently categorized NPM1-mutated cases separately as provisional entity.69

Recently, Schlenk et al.58 demonstrated in a retrospective analysis of 872 patients with normal karyotype aged <60 years that in case of isolated NPM1 mutations without an FLT3 mutation, allo-SCT was not able to confer a benefit in first remission, whereas outcome was improved by allo-SCT in case of a concurrent FLT3 mutation or MLL-PTD. The deterioration of prognosis in NPM1-mutated cases by an additional FLT3-ITD has been described before in several larger studies.97, 98, 99, 100 In elderly patients, the favorable impact of NPM1 mutations might be weaker. Scholl et al. investigated 99 elderly patients between 60 and 85 years and found an improved remission rate but no significant survival difference when patients with and without isolated NPM1 mutations were compared.82, 101 Thus, it might be speculated whether elderly patients with isolated NPM1 mutations might still benefit from allo-SCT with dose-reduced conditioning.101

CEBPA mutations

In 9% of AML patients, mutations of the CEBPA gene coding for the respective transcription factor are identified. They are specifically associated to normal karyotype. The CEBPA gene that encodes the CAAT/enhancer-binding-protein-α′ transcription factor is essential for regulation and differentiation of granulopoiesis. CEBPA mutations inhibit the normal function of the CEBPA transcription factor.102 As isolated alterations in AML with normal karyotype, CEBPA mutations predict a favorable prognosis.62, 103 The CEBPA mutations also achieved the status of a provisional entity within the revised WHO classification.69

First-line allo-SCT had no beneficial effect in patients with an isolated CEBPA mutation in the above study of Schlenk et al.58 when compared to standard treatment.

FLT3 mutations

The most frequent mutations of the FLT3 gene, which codes for the respective receptor class III kinase,104 are represented by internal tandem duplications (FLT3-ITD) in 40% of all patients with a normal karyotype.33, 61 They are localized in the domain that codes for the juxtamembrane domain of the FLT3 receptor.105 Mutations of the TKD are less frequent in 8% of all AML cases. Whereas FLT3-ITD were concordantly shown to contribute a significant unfavorable prognostic impact,16, 17, 61 the influence of the TKD mutations is controversial106 but seems to be weaker and to depend on cooperating mutations.19

In FLT3-ITD, standard chemotherapy is followed by high relapse rates of >80%.51 In previous studies, allo-SCT improved survival from 20–25 to 45–50%.107 Schlenk et al.58 demonstrated the beneficial effects of allo-SCT in first remission for FLT3-ITD and FLT3-TKD. In a study of the Czech Acute Leukemia Clinical Register, median OS of patients with an FLT3-ITD was 42 weeks in comparison to 29 weeks for those receiving standard chemotherapy, and allo-SCT was able to abolish the differences in outcome of FLT3-positive and wild-type patients.108 However, most recommendations on the application of allo-SCT vs conventional therapy in FLT3-mutated AML derive from retrospective studies. Finally, in a large study of 1135 patients performed by Gale et al.,109 the adverse outcome of patients with an FLT3-ITD was not influenced by allo-SCT. Thus, at this time the benefit of an allo-SCT in patients with AML and FLT3-ITD remains unclear.110

MLL-PTD

Partial tandem duplications of the MLL gene (MLL-PTD) are intragenic MLL abnormalities with a specific association to normal karyotype AML (5–10%). They are interpreted as gain-of-function mutations.94 Likewise to interchromosomal MLL alterations they are prognostically unfavorable.63, 66, 111 Also in this subgroup, Schlenk et al.58 found a prognostic benefit in case of an early allo-SCT. In >30% of all MLL-PTD cases, FLT3-ITD are found in coincidence with the MLL-PTD.112, 113 Whether such co-duplication is of clinical relevance when compared to a single mutation has to be determined by additional cases.

Parameters that might become relevant in the future

Mutations of the KIT-tyrosine kinase (another class III receptor tyrosine kinase) are mostly localized in exon 17 of the activation loop.12 They are rare in total AML, but show a >40% frequency in the t(8;21)/RUNX1-RUNX1T1 and inv(16)/CBFB-MYH11 core binding factor leukemias.114, 115 At least in the t(8;21) they confer a unfavorable clinical impact.12 Considering the small population of patients carrying a KIT mutation and a t(8;21)/RUNX1-RUNX1T1 in coincidence, randomized trials will be difficult to perform. Thus, at this time, a final recommendation whether the coincidence of a KIT mutation and the t(8;21)/RUNX1-RUNX1T1 should be considered in the indication to allo-SCT is not possible. Treatment conclusions ultimately have to be based on retrospective analysis of the outcome of chemotherapy vs early intensification/consolidation with an allo-SCT.

For some mutations that are found associated with normal karyotype AML, the prognostic impact still has to be defined, for example, for mutations of the RUNX1 (AML1) gene that encodes the respective transcription factor.84 Mutations of the RAS-oncogenes function by constitutive activation of the RAS pathway.116 NRAS mutations are detected in 10% of all AML cases, but seem to influence prognosis in some cytogenetic and molecular subgroups only.21, 22 Mutations of WT1 were detected in 10% of all AML patients with a specific association to normal karyotype. They seem to be associated with failure to achieve CR,117, 118 and an unfavorable prognosis.23 Their inclusion in a risk-adapted stratification of patients with normal karyotype AML is in discussion.24 Also, overexpression of the respective WT1 gene might become relevant in the future, as this gene is highly expressed in various hematological malignancies and also in AML.119 The same applies to the BAALC gene that is primarily expressed in neuroectoderm-derived tissues and in hematopoietic precursors. High expression correlates in normal karyotype AML with a negative prognosis.64, 120 Also, overexpression of the ERG (ETS-related),121 MN1 (meningioma-related)122 and EVI (ecotropic virus integration-1)81 genes seemed to be associated to a negative prognostic impact in few studies, but data are limited at this time.

Minimal residual disease diagnostics

In the reciprocal gene fusions t(15;17)/PML-RARA, t(8;21)/RUNX1-RUNX1T1 and inv(16)/CBFB-MYH11,3, 4, 5 quantitative real-time PCR achieves sensitivities of 10−5 to 10−6123 and thus is suitable for quantification of the residual leukemic cell load at an early time point after therapy.5 The score of the aberrant gene expression compared after consolidation therapy and at diagnosis was shown to be significantly associated with survival.124 Persistence52 or minor decrease of transcript copy numbers5 predicts an enhanced relapse risk. A threshold of 1% of the initial mutated cell load was determined to correlate with an increased relapse risk in patients with core binding factor leukemias125 and in another study a transcript number of >10 during follow-up was found to correlate with significantly shortened OS in inv(16) cases.126 An increase of the respective fusion transcripts precedes the morphological manifestation of relapse by an interval of 3–6 months and therefore represents a possible indication to allo-SCT.

To reach more AML subgroups and especially patients with a normal karyotype, MRD strategies are being developed for novel markers, for example, the NPM1 mutations. Recent studies performing quantitative real-time PCR demonstrated that the NPM1 mutations represent stable follow-up parameters.30, 31, 127, 128 For patients with an FLT3-ITD, the course of disease can be monitored by semiquantitative PCR,33 whereas exact quantitative measurement requires the labor-intensive design of patient-specific primers due to the heterogeneous mutation profile.34 However, the high instability rates up to 17% in relapsed patients raise doubts on the validity for MRD purposes.129 Others, in contrast, suggested that loss of the mutation occurs in <5% of cases only and that accumulation of the mutation with a higher ratio of mutated to unmutated alleles is associated with an increased relapse risk.33 For FLT3, TKD assays for quantitative monitoring are being developed as well.35 Also in the MLL-PTD, a threshold of a 2log reduction of expression when compared before and after treatment was found to be significantly associated with prognosis.36

Another parameter that might gain importance for follow-up strategies is WT1 expression.119, 123 Overexpression is seen in various leukemia types and especially in AML.119, 130, 131, 132 However, the definite position of WT1 expression for the planning of allo-SCT is not yet determined, and the physiological expression of WT at lower levels in healthy individuals might disturb the interpretation of MRD results. A recent comparison of NPM1 mutations and WT1 expression demonstrated superiority of the NPM1 mutations when quantitative real-time PCR was performed for both parameters.127

Discussion

Meanwhile, the combination of chromosomal and molecular markers allows a categorization of nearly all AML cases in subgroups with distinct clinical profiles69 as a basis for an individualized risk-based indication to allo-SCT (Figure 1).51 Only a comprehensive diagnostic approach combining morphology, immunophenotyping, and diverse cytogenetic and molecular genetic techniques is able to provide the basis for this differentiated risk stratification. One recent major contribution was the definition of a molecular data set composed by the NPM1, FLT3-ITD and -TKD, MLL-PTD and CEBPA mutations, which is able to predict whether patients with a normal karyotype might benefit from an early allo-SCT.58 Trying to define a hierarchy of mutation screening in normal karyotype AML cases, analysis for the NPM1 and the FLT3-ITD mutations should be obligatory, preferentially being combined with analysis for the CEBPA mutations and MLL-PTD. Whether novel molecular markers as the WT1 mutations might contribute to this indication in the future, still has to be defined.117, 118 Also, the panel for the measurement of MRD is continuously expanding. Especially the NPM1 mutations seem to provide very stable and sensitive parameters.30, 31, 127 The combination of immunophenotyping and molecular genetics for MRD detection might be a further step to more safety in the post-treatment period. Measurement of gene expression, for example, of WT1119, 123 or BAALC,64, 120 represents another promising approach for MRD measurement in myeloid malignancies.

Figure 1
figure1

Prognostic subclassification of AML as revealed by the diverse diagnostic techniques in combination with minimal residual disease (MRD) detection (MFC, multiparameter flow cytometry; QR-PCR, quantitative real-time PCR; *, cases with a t(8;21)/RUNX1-RUNX1T1 and additional c-KIT mutations have a worse prognosis; **, uncertain influence on prognosis).

Novel methods, such as gene expression profiling by microarrays that allows the simultaneous measurement of the expression of tens of thousands of genes, might contribute to a more detailed risk stratification for allo-SCT.133 One approach is the definition of diverse prognostic groups within defined genetic subtypes on the basis of distinct gene expression patterns as being shown in normal karyotype AML134, 135 or in core binding factor leukemias.136 Assays to predict the sensitivity to distinct antileukemic compounds as demonstrated by Raponi et al.137 for the farnesyltransferase inhibitor tipifarnib might be helpful to perform selection of patients who probably will have no benefit from pharmacological approaches. Likewise to the progress in molecular risk stratification in normal karyotype,58 these examples indicate that the indication to allo-SCT should remain in continuous interaction with the expansion of diagnostic methods and prognostically relevant markers18 to further optimize this complex decision in the heterogeneous disorder of AML.

References

  1. 1

    Haferlach T, Bacher U, Kern W, Schnittger S, Haferlach C . Diagnostic pathways in acute leukemias: a proposal for a multimodal approach. Ann Hematol 2007; 86: 311–327.

    PubMed  PubMed Central  Google Scholar 

  2. 2

    Falini B, Nicoletti I, Martelli MF, Mecucci C . Acute myeloid leukemia carrying cytoplasmic/mutated nucleophosmin (NPMc+ AML): biologic and clinical features. Blood 2007; 109: 874–885.

    CAS  PubMed  Google Scholar 

  3. 3

    Lo Coco F, Diverio D, Falini B, Biondi A, Nervi C, Pelicci PG . Genetic diagnosis and molecular monitoring in the management of acute promyelocytic leukemia. Blood 1999; 94: 12–22.

    PubMed  Google Scholar 

  4. 4

    Grimwade D, Howe K, Langabeer S, Burnett A, Goldstone A, Solomon E . Minimal residual disease detection in acute promyelocytic leukemia by reverse-transcriptase PCR: evaluation of PML-RAR alpha and RAR alpha-PML assessment in patients who ultimately relapse. Leukemia 1996; 10: 61–66.

    CAS  PubMed  PubMed Central  Google Scholar 

  5. 5

    Schnittger S, Weisser M, Schoch C, Hiddemann W, Haferlach T, Kern W . New score predicting for prognosis in PML-RARA+, AML1-ETO+, or CBFBMYH11+ acute myeloid leukemia based on quantification of fusion transcripts. Blood 2003; 102: 2746–2755.

    CAS  PubMed  PubMed Central  Google Scholar 

  6. 6

    Laane E, Derolf AR, Bjorklund E, Mazur J, Everaus H, Soderhall S et al. The effect of allogeneic stem cell transplantation on outcome in younger acute myeloid leukemia patients with minimal residual disease detected by flow cytometry at the end of post-remission chemotherapy. Haematologica 2006; 91: 833–836.

    PubMed  Google Scholar 

  7. 7

    Messerer D, Engel J, Hasford J, Schaich M, Ehninger G, Sauerland C et al. Impact of different post-remission strategies on quality of life in patients with acute myeloid leukemia. Haematologica 2008; 93: 826–833.

    PubMed  Google Scholar 

  8. 8

    Bloomfield CD, Shuma C, Regal L, Philip PP, Hossfeld DK, Hagemeijer AM et al. Long-term survival of patients with acute myeloid leukemia: a third follow-up of the Fourth International Workshop on Chromosomes in Leukemia. Cancer 1997; 80 (11 Suppl): 2191–2198.

    CAS  PubMed  PubMed Central  Google Scholar 

  9. 9

    Swansbury GJ, Lawler SD, Alimena G, Arthur D, Berger R, Van den BH et al. Long-term survival in acute myelogenous leukemia: a second follow-up of the Fourth International Workshop on Chromosomes in Leukemia. Cancer Genet Cytogenet 1994; 73: 1–7.

    CAS  PubMed  PubMed Central  Google Scholar 

  10. 10

    Grimwade D, Walker H, Oliver F, Wheatley K, Harrison C, Harrison G et al. The importance of diagnostic cytogenetics on outcome in AML: analysis of 1,612 patients entered into the MRC AML 10 trial. The Medical Research Council Adult and Children's Leukaemia Working Parties. Blood 1998; 92: 2322–2333.

    CAS  Google Scholar 

  11. 11

    Schlenk RF, Benner A, Krauter J, Buchner T, Sauerland C, Ehninger G et al. Individual patient data-based meta-analysis of patients aged 16 to 60 years with core binding factor acute myeloid leukemia: a survey of the German Acute Myeloid Leukemia Intergroup. J Clin Oncol 2004; 22: 3741–3750.

    CAS  Google Scholar 

  12. 12

    Cairoli R, Grillo G, Beghini A, Tedeschi A, Ripamonti CB, Larizza L et al. C-Kit point mutations in core binding factor leukemias: correlation with white blood cell count and the white blood cell index. Leukemia 2003; 17: 471–472.

    CAS  PubMed  Google Scholar 

  13. 13

    Cairoli R, Beghini A, Grillo G, Nadali G, Elice F, Ripamonti CB et al. Prognostic impact of c-KIT mutations in core binding factor leukemias: an Italian retrospective study. Blood 2006; 107: 3463–3468.

    CAS  PubMed  Google Scholar 

  14. 14

    Kuchenbauer F, Schoch C, Kern W, Hiddemann W, Haferlach T, Schnittger S . Impact of FLT3 mutations and promyelocytic leukaemia-breakpoint on clinical characteristics and prognosis in acute promyelocytic leukaemia. Br J Haematol 2005; 130: 196–202.

    CAS  PubMed  Google Scholar 

  15. 15

    Marcucci G, Mrozek K, Bloomfield CD . Molecular heterogeneity and prognostic biomarkers in adults with acute myeloid leukemia and normal cytogenetics. Curr Opin Hematol 2005; 12: 68–75.

    CAS  PubMed  PubMed Central  Google Scholar 

  16. 16

    Thiede C, Steudel C, Mohr B, Schaich M, Schakel U, Platzbecker U 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 2002; 99: 4326–4335.

    CAS  PubMed  Google Scholar 

  17. 17

    Schnittger S, Schoch C, Dugas M, Kern W, Staib P, Wuchter C 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 2002; 100: 59–66.

    CAS  PubMed  PubMed Central  Google Scholar 

  18. 18

    Falini B, Mecucci C, Tiacci E, Alcalay M, Rosati R, Pasqualucci L et al. Cytoplasmic nucleophosmin in acute myelogenous leukemia with a normal karyotype. N Engl J Med 2005; 352: 254–266.

    CAS  PubMed  PubMed Central  Google Scholar 

  19. 19

    Bacher U, Haferlach C, Kern W, Haferlach T, Schnittger S . Prognostic relevance of FLT3-TKD mutations in AML: the combination matters—an analysis of 3082 patients. Blood 2008; 111: 2527–2537.

    CAS  PubMed  Google Scholar 

  20. 20

    Yamamoto Y, Kiyoi H, Nakano Y, Suzuki R, Kodera Y, Miyawaki S et al. Activating mutation of D835 within the activation loop of FLT3 in human hematologic malignancies. Blood 2001; 97: 2434–2439.

    CAS  PubMed  Google Scholar 

  21. 21

    Bacher U, Haferlach T, Schoch C, Kern W, Schnittger S . Implications of NRAS mutations in AML: a study of 2502 patients. Blood 2006; 107: 3847–3853.

    CAS  PubMed  Google Scholar 

  22. 22

    Bowen DT, Frew ME, Hills R, Gale RE, Wheatley K, Groves MJ et al. RAS mutation in acute myeloid leukemia is associated with distinct cytogenetic subgroups but does not influence outcome in patients younger than 60 years. Blood 2005; 106: 2113–2119.

    CAS  PubMed  Google Scholar 

  23. 23

    Virappane P, Gale R, Hills R, Kakkas I, Summers K, Stevens J et al. Mutation of the Wilms’ tumor 1 gene is a poor prognostic factor associated with chemotherapy resistance in normal karyotype acute myeloid leukemia: The United Kingdom Medical Research Council Adult Leukaemia Working Party. J Clin Oncol 2008; 26: 5429–5435.

    CAS  PubMed  Google Scholar 

  24. 24

    Paschka P, Marcucci G, Ruppert AS, Whitman SP, Mrozek K, Maharry K et al. Wilms tumor 1 gene mutations independently predict poor outcome in adults with cytogenetically normal acute myeloid leukemia: a Cancer and Leukemia Group B study. J Clin Oncol 2008; 26: 4595–4602.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. 25

    Barragan E, Cervera J, Bolufer P, Ballester S, Martin G, Fernandez P et al. Prognostic implications of Wilms’ tumor gene (WT1) expression in patients with de novo acute myeloid leukemia. Haematologica 2004; 89: 926–933.

    CAS  PubMed  Google Scholar 

  26. 26

    Ommen HB, Nyvold CG, Braendstrup K, Andersen BL, Ommen IB, Hasle H et al. Relapse prediction in acute myeloid leukaemia patients in complete remission using WT1 as a molecular marker: development of a mathematical model to predict time from molecular to clinical relapse and define optimal sampling intervals. Br J Haematol 2008; 141: 782–791.

    CAS  PubMed  Google Scholar 

  27. 27

    Langer C, Radmacher MD, Ruppert AS, Whitman SP, Paschka P, Mrozek K et al. High BAALC expression associates with other molecular prognostic markers, poor outcome, and a distinct gene-expression signature in cytogenetically normal patients younger than 60 years with acute myeloid leukemia: a Cancer and Leukemia Group B (CALGB) study. Blood 2008; 111: 5371–5379.

    CAS  PubMed  PubMed Central  Google Scholar 

  28. 28

    Kern W, Haferlach T, Schoch C, Loffler H, Gassmann W, Heinecke A et al. Early blast clearance by remission induction therapy is a major independent prognostic factor for both achievement of complete remission and long-term outcome in acute myeloid leukemia: data from the German AML Cooperative Group (AMLCG) 1992 Trial. Blood 2003; 101: 64–70.

    CAS  PubMed  PubMed Central  Google Scholar 

  29. 29

    Kern W, Dannhauser-Riedl S, Ratei R, Schnittger S, Schoch C, Kolb HJ et al. Detection of minimal residual disease in unselected patients with acute myeloid leukemia using multiparameter flow cytometry for definition of leukemia-associated immunophenotypes and determination of their frequencies in normal bone marrow. Haematologica 2003; 88: 646–653.

    PubMed  Google Scholar 

  30. 30

    Chou WC, Tang JL, Wu SJ, Tsay W, Yao M, Huang SY et al. Clinical implications of minimal residual disease monitoring by quantitative polymerase chain reaction in acute myeloid leukemia patients bearing nucleophosmin (NPM1) mutations. Leukemia 2007; 21: 998–1004.

    CAS  PubMed  PubMed Central  Google Scholar 

  31. 31

    Gorello P, Cazzaniga G, Alberti F, Dell’Oro MG, Gottardi E, Specchia G et al. Quantitative assessment of minimal residual disease in acute myeloid leukemia carrying nucleophosmin (NPM1) gene mutations. Leukemia 2006; 20: 1103–1108.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. 32

    Scholl S, Mugge LO, Landt O, Loncarevic IF, Kunert C, Clement JH et al. Rapid screening and sensitive detection of NPM1 (nucleophosmin) exon 12 mutations in acute myeloid leukaemia. Leuk Res 2007; 31: 1205–1211.

    CAS  PubMed  Google Scholar 

  33. 33

    Schnittger S, Schoch C, Kern W, Hiddemann W, Haferlach T . FLT3 length mutations as marker for follow-up studies in acute myeloid leukaemia. Acta Haematol 2004; 112: 68–78.

    CAS  PubMed  PubMed Central  Google Scholar 

  34. 34

    Scholl S, Loncarevic IF, Krause C, Kunert C, Clement JH, Hoffken K . Minimal residual disease based on patient specific Flt3-ITD and -ITT mutations in acute myeloid leukemia. Leuk Res 2005; 29: 849–853.

    CAS  PubMed  PubMed Central  Google Scholar 

  35. 35

    Scholl S, Krause C, Loncarevic IF, Muller R, Kunert C, Wedding U et al. Specific detection of Flt3 point mutations by highly sensitive real-time polymerase chain reaction in acute myeloid leukemia. J Lab Clin Med 2005; 145: 295–304.

    CAS  PubMed  PubMed Central  Google Scholar 

  36. 36

    Weisser M, Kern W, Schoch C, Hiddemann W, Haferlach T, Schnittger S . Risk assessment by monitoring expression levels of partial tandem duplications in the MLL gene in acute myeloid leukemia during therapy. Haematologica 2005; 90: 881–889.

    CAS  PubMed  Google Scholar 

  37. 37

    Preisler HD, Priore R, Azarnia N, Barcos M, Raza A, Rakowski I et al. Prediction of response of patients with acute nonlymphocytic leukaemia to remission induction therapy: use of clinical measurements. Br J Haematol 1986; 63: 625–636.

    CAS  PubMed  PubMed Central  Google Scholar 

  38. 38

    Hussein K, Jahagirdar B, Gupta P, Burns L, Larsen K, Weisdorf D . Day 14 bone marrow biopsy in predicting complete remission and survival in acute myeloid leukemia. Am J Hematol 2008; 83: 446–450.

    PubMed  Google Scholar 

  39. 39

    Haferlach T, Kern W, Schoch C, Schnittger S, Sauerland MC, Heinecke A et al. A new prognostic score for patients with acute myeloid leukemia based on cytogenetics and early blast clearance in trials of the German AML Cooperative Group. Haematologica 2004; 89: 408–418.

    PubMed  Google Scholar 

  40. 40

    Wells RJ, Arthur DC, Srivastava A, Heerema NA, Le BM, Alonzo TA et al. Prognostic variables in newly diagnosed children and adolescents with acute myeloid leukemia: Children's Cancer Group Study 213. Leukemia 2002; 16: 601–607.

    CAS  PubMed  Google Scholar 

  41. 41

    Campana D . Determination of minimal residual disease in leukaemia patients. Br J Haematol 2003; 121: 823–838.

    PubMed  PubMed Central  Google Scholar 

  42. 42

    Griesinger F, Piro-Noack M, Kaib N, Falk M, Renziehausen A, Troff C et al. Leukaemia-associated immunophenotypes (LAIP) are observed in 90% of adult and childhood acute lymphoblastic leukaemia: detection in remission marrow predicts outcome. Br J Haematol 1999; 105: 241–255.

    CAS  PubMed  PubMed Central  Google Scholar 

  43. 43

    Kern W, Haferlach C, Haferlach T, Schnittger S . Monitoring of minimal residual disease in acute myeloid leukemia. Cancer 2008; 112: 4–16.

    CAS  PubMed  PubMed Central  Google Scholar 

  44. 44

    Feller N, van der Pol MA, van SA, Weijers GW, Westra AH, Evertse BW et al. MRD parameters using immunophenotypic detection methods are highly reliable in predicting survival in acute myeloid leukaemia. Leukemia 2004; 18: 1380–1390.

    CAS  PubMed  Google Scholar 

  45. 45

    Cheson BD, Bennett JM, Kopecky KJ, Buchner T, Willman CL, Estey EH 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.

    PubMed  PubMed Central  Google Scholar 

  46. 46

    Kern W, Voskova D, Schoch C, Schnittger S, Hiddemann W, Haferlach T . Prognostic impact of early response to induction therapy as assessed by multiparameter flow cytometry in acute myeloid leukemia. Haematologica 2004; 89: 528–540.

    PubMed  Google Scholar 

  47. 47

    Coustan-Smith E, Ribeiro RC, Rubnitz JE, Razzouk BI, Pui CH, Pounds S et al. Clinical significance of residual disease during treatment in childhood acute myeloid leukaemia. Br J Haematol 2003; 123: 243–252.

    PubMed  PubMed Central  Google Scholar 

  48. 48

    Kern W, Voskova D, Schoch C, Hiddemann W, Schnittger S, Haferlach T . Determination of relapse risk based on assessment of minimal residual disease during complete remission by multiparameter flow cytometry in unselected patients with acute myeloid leukemia. Blood 2004; 104: 3078–3085.

    CAS  PubMed  PubMed Central  Google Scholar 

  49. 49

    Sievers EL, Lange BJ, Alonzo TA, Gerbing RB, Bernstein ID, Smith FO et al. Immunophenotypic evidence of leukemia after induction therapy predicts relapse: results from a prospective Children's Cancer Group study of 252 patients with acute myeloid leukemia. Blood 2003; 101: 3398–3406.

    CAS  PubMed  Google Scholar 

  50. 50

    Venditti A, Buccisano F, Del PG, Maurillo L, Tamburini A, Cox C et al. Level of minimal residual disease after consolidation therapy predicts outcome in acute myeloid leukemia. Blood 2000; 96: 3948–3952.

    CAS  PubMed  Google Scholar 

  51. 51

    de Labarthe A, Pautas C, Thomas X, de Botton S, Bordessoule D, Tilly H et al. Allogeneic stem cell transplantation in second rather than first complete remission in selected patients with good-risk acute myeloid leukemia. Bone Marrow Transplant 2005; 35: 767–773.

    CAS  PubMed  Google Scholar 

  52. 52

    Grimwade D, Jamal R, Goulden N, Kempski H, Mastrangelo S, Veys P . Salvage of patients with acute promyelocytic leukaemia with residual disease following ABMT performed in second CR using all-trans retinoic acid. Br J Haematol 1998; 103: 559–562.

    CAS  PubMed  PubMed Central  Google Scholar 

  53. 53

    Yanada M, Matsuo K, Emi N, Naoe T . Efficacy of allogeneic hematopoietic stem cell transplantation depends on cytogenetic risk for acute myeloid leukemia in first disease remission: a metaanalysis. Cancer 2005; 103: 1652–1658.

    Google Scholar 

  54. 54

    Byrd JC, Mrozek K, Dodge RK, Carroll AJ, Edwards CG, Arthur DC 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 2002; 100: 4325–4336.

    CAS  PubMed  PubMed Central  Google Scholar 

  55. 55

    Farag SS, Archer KJ, Mrozek K, Vardiman JW, Carroll AJ, Pettenati MJ et al. Isolated trisomy of chromosomes 8, 11, 13 and 21 is an adverse prognostic factor in adults with de novo acute myeloid leukemia: results from Cancer and Leukemia Group B 8461. Int J Oncol 2002; 21: 1041–1051.

    CAS  PubMed  Google Scholar 

  56. 56

    Schaich M, Schlenk RF, Al-Ali HK, Dohner H, Ganser A, Heil G et al. Prognosis of acute myeloid leukemia patients up to 60 years of age exhibiting trisomy 8 within a non-complex karyotype: individual patient data-based meta-analysis of the German Acute Myeloid Leukemia Intergroup. Haematologica 2007; 92: 763–770.

    PubMed  Google Scholar 

  57. 57

    Farag SS, Ruppert AS, Mrozek K, Mayer RJ, Stone RM, Carroll AJ et al. Outcome of induction and postremission therapy in younger adults with acute myeloid leukemia with normal karyotype: a Cancer and Leukemia Group B study. J Clin Oncol 2005; 23: 482–493.

    CAS  PubMed  Google Scholar 

  58. 58

    Schlenk RF, Dohner K, Krauter J, Frohling S, Corbacioglu A, Bullinger L et al. Mutations and treatment outcome in cytogenetically normal acute myeloid leukemia. N Engl J Med 2008; 358: 1909–1918.

    CAS  PubMed  Google Scholar 

  59. 59

    Slovak ML, Kopecky KJ, Cassileth PA, Harrington DH, Theil KS, Mohamed A et al. Karyotypic analysis predicts outcome of preremission and postremission therapy in adult acute myeloid leukemia: a Southwest Oncology Group/Eastern Cooperative Oncology Group Study. Blood 2000; 96: 4075–4083.

    CAS  PubMed  PubMed Central  Google Scholar 

  60. 60

    Haferlach T, Schoch C, Loffler H, Gassmann W, Kern W, Schnittger S et al. Morphologic dysplasia in de novo acute myeloid leukemia (AML) is related to unfavorable cytogenetics but has no independent prognostic relevance under the conditions of intensive induction therapy: results of a multiparameter analysis from the German AML Cooperative Group studies. J Clin Oncol 2003; 21: 256–265.

    PubMed  PubMed Central  Google Scholar 

  61. 61

    Yanada M, Matsuo K, Suzuki T, Kiyoi H, Naoe T . Prognostic significance of FLT3 internal tandem duplication and tyrosine kinase domain mutations for acute myeloid leukemia: a meta-analysis. Leukemia 2005; 19: 1345–1349.

    CAS  PubMed  PubMed Central  Google Scholar 

  62. 62

    Preudhomme C, Sagot C, Boissel N, Cayuela JM, Tigaud I, de BS et al. Favorable prognostic significance of CEBPA mutations in patients with de novo acute myeloid leukemia: a study from the Acute Leukemia French Association (ALFA). Blood 2002; 100: 2717–2723.

    CAS  PubMed  Google Scholar 

  63. 63

    Dohner K, Tobis K, Ulrich R, Frohling S, Benner A, Schlenk RF et al. Prognostic significance of partial tandem duplications of the MLL gene in adult patients 16 to 60 years old with acute myeloid leukemia and normal cytogenetics: a study of the Acute Myeloid Leukemia Study Group Ulm. J Clin Oncol 2002; 20: 3254–3261.

    PubMed  Google Scholar 

  64. 64

    Baldus CD, Tanner SM, Ruppert AS, Whitman SP, Archer KJ, Marcucci G 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 2003; 102: 1613–1618.

    CAS  PubMed  Google Scholar 

  65. 65

    Mrozek K, Heinonen K, Lawrence D, Carroll AJ, Koduru PR, Rao KW et al. Adult patients with de novo acute myeloid leukemia and t(9; 11)(p22; q23) have a superior outcome to patients with other translocations involving band 11q23: a Cancer and Leukemia Group B study. Blood 1997; 90: 4532–4538.

    CAS  PubMed  Google Scholar 

  66. 66

    Schoch C, Schnittger S, Klaus M, Kern W, Hiddemann W, Haferlach T . AML with 11q23/MLL abnormalities as defined by the WHO classification: incidence, partner chromosomes, FAB subtype, age distribution, and prognostic impact in an unselected series of 1897 cytogenetically analyzed AML cases. Blood 2003; 102: 2395–2402.

    CAS  PubMed  Google Scholar 

  67. 67

    Rubnitz JE, Raimondi SC, Tong X, Srivastava DK, Razzouk BI, Shurtleff SA et al. Favorable impact of the t(9;11) in childhood acute myeloid leukemia. J Clin Oncol 2002; 20: 2302–2309.

    CAS  PubMed  Google Scholar 

  68. 68

    Lo Nigro L, Bottino D, Panarello C, Morerio C, Mirabile E, Rapella AM et al. Prognostic impact of t(9;11) in childhood acute myeloid leukemia (AML). Leukemia 2003; 17: 636.

    PubMed  Google Scholar 

  69. 69

    Jaffe ES, Harris NL, Stein H, Vardiman JW . World Health Organization Classification of Tumours: Pathology and Genetics of Tumours of Haematopoietic and Lymphoid Tissues. IARC Press: Lyon, 2008.

    Google Scholar 

  70. 70

    Buchner T, Hiddemann W, Berdel WE, Wormann B, Schoch C, Fonatsch C et al. Subgroup specific therapy effects in AML: AMLCG data. Ann Hematol 2004; 83 (Suppl 1): S100–S101.

    PubMed  Google Scholar 

  71. 71

    Schoch C, Kern W, Kohlmann A, Hiddemann W, Schnittger S, Haferlach T . Acute myeloid leukemia with a complex aberrant karyotype is a distinct biological entity characterized by genomic imbalances and a specific gene expression profile. Genes Chromosomes Cancer 2005; 43: 227–238.

    CAS  PubMed  Google Scholar 

  72. 72

    Breems DA, Van Putten WL, De Greef GE, Van Zelderen-Bhola SL, Gerssen-Schoorl KB, Mellink CH et al. Monosomal karyotype in acute myeloid leukemia: a better indicator of poor prognosis than a complex karyotype. J Clin Oncol 2008; 26: 4791–4797.

    PubMed  Google Scholar 

  73. 73

    Suciu S, Mandelli F, de Witte T, Zittoun R, Gallo E, Labar B et al. Allogeneic compared with autologous stem cell transplantation in the treatment of patients younger than 46 years with acute myeloid leukemia (AML) in first complete remission (CR1): an intention-to-treat analysis of the EORTC/GIMEMAAML-10 trial. Blood 2003; 102: 1232–1240.

    CAS  PubMed  PubMed Central  Google Scholar 

  74. 74

    van der Straaten HM, van BA, Brand R, Schattenberg AV, Egeler RM, Barge RM et al. Allogeneic stem cell transplantation for patients with acute myeloid leukemia or myelodysplastic syndrome who have chromosome 5 and/or 7 abnormalities. Haematologica 2005; 90: 1339–1345.

    PubMed  Google Scholar 

  75. 75

    Armand P, Kim HT, DeAngelo DJ, Ho VT, Cutler CS, Stone RM et al. Impact of cytogenetics on outcome of de novo and therapy-related AML and MDS after allogeneic transplantation. Biol Blood Marrow Transplant 2007; 13: 655–664.

    CAS  PubMed  PubMed Central  Google Scholar 

  76. 76

    Schoch C, Kern W, Schnittger S, Hiddemann W, Haferlach T . Karyotype is an independent prognostic parameter in therapy-related acute myeloid leukemia (t-AML): an analysis of 93 patients with t-AML in comparison to 1091 patients with de novo AML. Leukemia 2004; 18: 120–125.

    CAS  Google Scholar 

  77. 77

    Messner HA . How good is allogeneic transplantation for high-risk patients with AML? Best Pract Res Clin Haematol 2006; 19: 329–332.

    PubMed  Google Scholar 

  78. 78

    Larson RA . Is secondary leukemia an independent poor prognostic factor in acute myeloid leukemia? Best Pract Res Clin Haematol 2007; 20: 29–37.

    PubMed  Google Scholar 

  79. 79

    de Witte T, Hermans J, Vossen J, Bacigalupo A, Meloni G, Jacobsen N et al. Haematopoietic stem cell transplantation for patients with myelo-dysplastic syndromes and secondary acute myeloid leukaemias: a report on behalf of the Chronic Leukaemia Working Party of the European Group for Blood and Marrow Transplantation (EBMT). Br J Haematol 2000; 110: 620–630.

    CAS  PubMed  Google Scholar 

  80. 80

    Breems DA, Van Putten WL, Huijgens PC, Ossenkoppele GJ, Verhoef GE, Verdonck LF et al. Prognostic index for adult patients with acute myeloid leukemia in first relapse. J Clin Oncol 2005; 23: 1969–1978.

    PubMed  Google Scholar 

  81. 81

    Lugthart S, van Drunen E, van NY, van HA, Erpelinck CA, Valk PJ et al. High EVI1 levels predict adverse outcome in acute myeloid leukemia: prevalence of EVI1 overexpression and chromosome 3q26 abnormalities underestimated. Blood 2008; 111: 4329–4337.

    CAS  PubMed  Google Scholar 

  82. 82

    Weisser M, Haferlach C, Haferlach T, Schnittger S . Advanced age and high initial WBC influence the outcome of inv(3) (q21q26)/t(3;3) (q21;q26) positive AML. Leuk Lymphoma 2007; 48: 2145–2151.

    CAS  PubMed  Google Scholar 

  83. 83

    Visani G, Bernasconi P, Boni M, Castoldi GL, Ciolli S, Clavio M et al. The prognostic value of cytogenetics is reinforced by the kind of induction/consolidation therapy in influencing the outcome of acute myeloid leukemia—analysis of 848 patients. Leukemia 2001; 15: 903–909.

    CAS  PubMed  Google Scholar 

  84. 84

    Dohner K, Dohner H . Molecular characterization of acute myeloid leukemia. Haematologica 2008; 93: 976–982.

    PubMed  Google Scholar 

  85. 85

    Garcon L, Libura M, Delabesse E, Valensi F, Asnafi V, Berger C et al. DEK-CAN molecular monitoring of myeloid malignancies could aid therapeutic stratification. Leukemia 2005; 19: 1338–1344.

    CAS  PubMed  Google Scholar 

  86. 86

    Jacobson S, Pillus L . Modifying chromatin and concepts of cancer. Curr Opin Genet Dev 1999; 9: 175–184.

    CAS  PubMed  Google Scholar 

  87. 87

    Velloso ER, Mecucci C, Michaux L, Van OA, Stul M, Boogaerts M et al. Translocation t(8;16)(p11;p13) in acute non-lymphocytic leukemia: report on two new cases and review of the literature. Leuk Lymphoma 1996; 21: 137–142.

    CAS  PubMed  Google Scholar 

  88. 88

    Bernasconi P, Orlandi E, Cavigliano P, Calatroni S, Boni M, Astori C et al. Translocation (8;16) in a patient with acute myelomonocytic leukemia, occurring after treatment with fludarabine for a low-grade non-Hodgkin's lymphoma. Haematologica 2000; 85: 1087–1091.

    CAS  PubMed  Google Scholar 

  89. 89

    Savasan S, Mohamed AN, Lucas DR, Dugan MC, Ryan JR, Ravindranath Y . Acute myeloid leukaemia with t(8;16)(p11;p13) in a child after intrauterine X-ray exposure. Br J Haematol 1996; 94: 702–704.

    CAS  PubMed  Google Scholar 

  90. 90

    Murati A, Gervais C, Carbuccia N, Finetti P, Cervera N, Adelaide J et al. Genome profiling of acute myelomonocytic leukemia: alteration of the MYB locus in MYST3-linked cases. Leukemia 2009; 23: 85–94.

    CAS  PubMed  Google Scholar 

  91. 91

    Quesnel B, Kantarjian H, Bjergaard JP, Brault P, Estey E, Lai JL et al. Therapy-related acute myeloid leukemia with t(8;21), inv(16), and t(8;16): a report on 25 cases and review of the literature. J Clin Oncol 1993; 11: 2370–2379.

    CAS  PubMed  Google Scholar 

  92. 92

    Gervais C, Murati A, Helias C, Struski S, Eischen A, Lippert E et al. Acute myeloid leukaemia with 8p11 (MYST3) rearrangement: an integrated cytologic, cytogenetic and molecular study by the groupe francophone de cytogenetique hematologique. Leukemia 2008; 22: 1567–1575.

    CAS  PubMed  Google Scholar 

  93. 93

    Demuynck H, Verhoef GE, Zachee P, Vandenberghe P, Van OA, Paridaens R et al. Therapy-related acute myeloid leukemia with t(8;16)(p11;p13) following anthracycline-based therapy for nonmetastatic osteosarcoma. Cancer Genet Cytogenet 1995; 82: 103–105.

    CAS  PubMed  Google Scholar 

  94. 94

    Schichman SA, Caligiuri MA, Strout MP, Carter SL, Gu Y, Canaani E et al. ALL-1 tandem duplication in acute myeloid leukemia with a normal karyotype involves homologous recombination between Alu elements. Cancer Res 1994; 54: 4277–4280.

    CAS  PubMed  Google Scholar 

  95. 95

    Silva FP, Lind A, Brouwer-Mandema G, Valk PJ, Giphart-Gassler M . Trisomy 13 correlates with RUNX1 mutation and increased FLT3 expression in AML-M0 patients. Haematologica 2007; 92: 1123–1126.

    CAS  PubMed  Google Scholar 

  96. 96

    Dicker F, Haferlach C, Kern W, Haferlach T, Schnittger S . Trisomy 13 is strongly associated with AML1/RUNX1 mutations and increased FLT3 expression in acute myeloid leukemia. Blood 2007; 110: 1308–1316.

    CAS  PubMed  Google Scholar 

  97. 97

    Schnittger S, Schoch C, Kern W, Mecucci C, Tschulik C, Martelli MF et al. Nucleophosmin gene mutations are predictors of favorable prognosis in acute myelogenous leukemia with a normal karyotype. Blood 2005; 106: 3733–3739.

    CAS  PubMed  PubMed Central  Google Scholar 

  98. 98

    Dohner K, Schlenk RF, Habdank M, Scholl C, Rucker FG, Corbacioglu A et al. Mutant nucleophosmin (NPM1) predicts favorable prognosis in younger adults with acute myeloid leukemia and normal cytogenetics: interaction with other gene mutations. Blood 2005; 106: 3740–3746.

    PubMed  PubMed Central  Google Scholar 

  99. 99

    Verhaak RG, Goudswaard CS, van PW, Bijl MA, Sanders MA, Hugens W et al. Mutations in nucleophosmin (NPM1) in acute myeloid leukemia (AML): association with other gene abnormalities and previously established gene expression signatures and their favorable prognostic significance. Blood 2005; 106: 3747–3754.

    CAS  PubMed  PubMed Central  Google Scholar 

  100. 100

    Thiede C, Koch S, Creutzig E, Steudel C, Illmer T, Schaich M et al. Prevalence and prognostic impact of NPM1 mutations in 1485 adult patients with acute myeloid leukemia (AML). Blood 2006; 107: 4011–4020.

    CAS  PubMed  PubMed Central  Google Scholar 

  101. 101

    Scholl S, Theuer C, Scheble V, Kunert C, Heller A, Mugge LO et al. Clinical impact of nucleophosmin mutations and Flt3 internal tandem duplications in patients older than 60 years with acute myeloid leukemia. Eur J Haematol 2008; 80: 208–215.

    CAS  PubMed  Google Scholar 

  102. 102

    Pabst T, Mueller BU, Zhang P, Radomska HS, Narravula S, Schnittger S et al. Dominant-negative mutations of CEBPA, encoding CCAAT/enhancer binding protein-alpha (C/EBPalpha), in acute myeloid leukemia. Nat Genet 2001; 27: 263–270.

    CAS  PubMed  Google Scholar 

  103. 103

    Frohling S, Schlenk RF, Stolze I, Bihlmayr J, Benner A, Kreitmeier S et al. CEBPA mutations in younger adults with acute myeloid leukemia and normal cytogenetics: prognostic relevance and analysis of cooperating mutations. J Clin Oncol 2004; 22: 624–633.

    PubMed  Google Scholar 

  104. 104

    Gilliland DG, Griffin JD . Role of FLT3 in leukemia. Curr Opin Hematol 2002; 9: 274–281.

    PubMed  Google Scholar 

  105. 105

    Kiyoi H, Towatari M, Yokota S, Hamaguchi M, Ohno R, Saito H et al. Internal tandem duplication of the FLT3 gene is a novel modality of elongation mutation which causes constitutive activation of the product. Leukemia 1998; 12: 1333–1337.

    CAS  Google Scholar 

  106. 106

    Whitman SP, Ruppert AS, Radmacher MD, Mrozek K, Paschka P, Langer C et al. FLT3 D835/I836 mutations are associated with poor disease-free survival and a distinct gene-expression signature among younger adults with de novo cytogenetically normal acute myeloid leukemia lacking FLT3 internal tandem duplications. Blood 2008; 111: 1552–1559.

    CAS  PubMed  PubMed Central  Google Scholar 

  107. 107

    Bornhauser M, Illmer T, Schaich M, Soucek S, Ehninger G, Thiede C . Improved outcome after stem-cell transplantation in FLT3/ITD-positive AML. Blood 2007; 109: 2264–2265.

    PubMed  Google Scholar 

  108. 108

    Doubek M, Muzik J, Szotkowski T, Koza V, Cetkovsky P, Kozak T et al. Is FLT3 internal tandem duplication significant indicator for allogeneic transplantation in acute myeloid leukemia? An analysis of patients from the Czech Acute Leukemia Clinical Register (ALERT). Neoplasma 2007; 54: 89–94.

    CAS  PubMed  Google Scholar 

  109. 109

    Gale RE, Hills R, Kottaridis PD, Srirangan S, Wheatley K, Burnett AK et al. No evidence that FLT3 status should be considered as an indicator for transplantation in acute myeloid leukemia (AML): an analysis of 1135 patients, excluding acute promyelocytic leukemia, from the UK MRC AML10 and 12 trials. Blood 2005; 106: 3658–3665.

    CAS  PubMed  Google Scholar 

  110. 110

    Meijer E, Cornelissen JJ . Allogeneic stem cell transplantation in acute myeloid leukemia in first or subsequent remission: weighing prognostic markers predicting relapse and risk factors for non-relapse mortality. Semin Oncol 2008; 35: 449–457.

    CAS  PubMed  Google Scholar 

  111. 111

    Schnittger S, Kinkelin U, Schoch C, Heinecke A, Haase D, Haferlach T et al. Screening for MLL tandem duplication in 387 unselected patients with AML identify a prognostically unfavorable subset of AML. Leukemia 2000; 14: 796–804.

    CAS  PubMed  Google Scholar 

  112. 112

    Libura M, Asnafi V, Tu A, Delabesse E, Tigaud I, Cymbalista F et al. FLT3 and MLL intragenic abnormalities in AML reflect a common category of genotoxic stress. Blood 2003; 102: 2198–2204.

    CAS  PubMed  Google Scholar 

  113. 113

    Olesen LH, Nyvold CG, Aggerholm A, Norgaard JM, Guldberg P, Hokland P . Delineation and molecular characterization of acute myeloid leukemia patients with coduplication of FLT3 and MLL. Eur J Haematol 2005; 75: 185–192.

    CAS  PubMed  Google Scholar 

  114. 114

    Paschka P, Marcucci G, Ruppert AS, Mrozek K, Chen H, Kittles RA et al. Adverse prognostic significance of KIT mutations in adult acute myeloid leukemia with inv(16) and t(8;21): a Cancer and Leukemia Group B study. J Clin Oncol 2006; 24: 3904–3911.

    CAS  PubMed  Google Scholar 

  115. 115

    Schnittger S, Kohl TM, Haferlach T, Kern W, Hiddemann W, Spiekermann K et al. KIT-D816 mutations in AML1-ETO-positive AML are associated with impaired event-free and overall survival. Blood 2006; 107: 1791–1799.

    CAS  PubMed  Google Scholar 

  116. 116

    Stirewalt DL, Kopecky KJ, Meshinchi S, Appelbaum FR, Slovak ML, Willman CL et al. FLT3, RAS, and TP53 mutations in elderly patients with acute myeloid leukemia. Blood 2001; 97: 3589–3595.

    CAS  PubMed  Google Scholar 

  117. 117

    King-Underwood L, Pritchard-Jones K . Wilms’ tumor (WT1) gene mutations occur mainly in acute myeloid leukemia and may confer drug resistance. Blood 1998; 91: 2961–2968.

    CAS  PubMed  Google Scholar 

  118. 118

    Summers K, Stevens J, Kakkas I, Smith M, Smith LL, Macdougall F et al. Wilms’ tumour 1 mutations are associated with FLT3-ITD and failure of standard induction chemotherapy in patients with normal karyotype AML. Leukemia 2007; 21: 550–551.

    CAS  PubMed  Google Scholar 

  119. 119

    Weisser M, Kern W, Rauhut S, Schoch C, Hiddemann W, Haferlach T et al. Prognostic impact of RT-PCR-based quantification of WT1 gene expression during MRD monitoring of acute myeloid leukemia. Leukemia 2005; 19: 1416–1423.

    CAS  PubMed  PubMed Central  Google Scholar 

  120. 120

    Bienz M, Ludwig M, Leibundgut EO, Mueller BU, Ratschiller D, Solenthaler M et al. Risk assessment in patients with acute myeloid leukemia and a normal karyotype. Clin Cancer Res 2005; 11: 1416–1424.

    CAS  PubMed  Google Scholar 

  121. 121

    Marcucci G, Maharry K, Whitman SP, Vukosavljevic T, Paschka P, Langer C et al. High expression levels of the ETS-related gene, ERG, predict adverse outcome and improve molecular risk-based classification of cytogenetically normal acute myeloid leukemia: a Cancer and Leukemia Group B study. J Clin Oncol 2007; 25: 3337–3343.

    CAS  PubMed  Google Scholar 

  122. 122

    Heuser M, Beutel G, Krauter J, Dohner K, von NN, Schlegelberger B et al. High meningioma 1 (MN1) expression as a predictor for poor outcome in acute myeloid leukemia with normal cytogenetics. Blood 2006; 108: 3898–3905.

    CAS  PubMed  Google Scholar 

  123. 123

    Shimoni A, Nagler A . Clinical implications of minimal residual disease monitoring for stem cell transplantation after reduced intensity and nonmyeloablative conditioning. Acta Haematol 2004; 112: 93–104.

    PubMed  PubMed Central  Google Scholar 

  124. 124

    Leroy H, de BS, Grardel-Duflos N, Darre S, Leleu X, Roumier C et al. Prognostic value of real-time quantitative PCR (RQ-PCR) in AML with t(8;21). Leukemia 2005; 19: 367–372.

    CAS  PubMed  PubMed Central  Google Scholar 

  125. 125

    Krauter J, Gorlich K, Ottmann O, Lubbert M, Dohner H, Heit W et al. Prognostic value of minimal residual disease quantification by real-time reverse transcriptase polymerase chain reaction in patients with core binding factor leukemias. J Clin Oncol 2003; 21: 4413–4422.

    CAS  PubMed  PubMed Central  Google Scholar 

  126. 126

    Marcucci G, Caligiuri MA, Dohner H, Archer KJ, Schlenk RF, Dohner K et al. Quantification of CBFbeta/MYH11 fusion transcript by real time RT-PCR in patients with inv(16) acute myeloid leukemia. Leukemia 2001; 15: 1072–1080.

    CAS  PubMed  PubMed Central  Google Scholar 

  127. 127

    Barragan E, Pajuelo JC, Ballester S, Fuster O, Cervera J, Moscardo F et al. Minimal residual disease detection in acute myeloid leukemia by mutant nucleophosmin (NPM1): comparison with WT1 gene expression. Clin Chim Acta 2008; 395: 120–123.

    CAS  PubMed  Google Scholar 

  128. 128

    Bacher U, Badbaran A, Fehse B, Zabelina T, Zander A, Kroger N . Quantitative monitoring of NPM1 mutations provides a valid minimal residual disease parameter following allogeneic stem cell transplantation. J Exp Hematol 2009; 37: 135–142.

    CAS  Google Scholar 

  129. 129

    Cloos J, Goemans BF, Hess CJ, van Oostveen JW, Waisfisz Q, Corthals S et al. Stability and prognostic influence of FLT3 mutations in paired initial and relapsed AML samples. Leukemia 2006; 20: 1217–1220.

    CAS  PubMed  PubMed Central  Google Scholar 

  130. 130

    Ellisen LW, Carlesso N, Cheng T, Scadden DT, Haber DA . The Wilms tumor suppressor WT1 directs stage-specific quiescence and differentiation of human hematopoietic progenitor cells. EMBO J 2001; 20: 1897–1909.

    CAS  PubMed  PubMed Central  Google Scholar 

  131. 131

    Keilholz U, Menssen HD, Gaiger A, Menke A, Oji Y, Oka Y et al. Wilms’ tumour gene 1 (WT1) in human neoplasia. Leukemia 2005; 19: 1318–1323.

    CAS  PubMed  Google Scholar 

  132. 132

    Cilloni D, Gottardi E, De Micheli D, Serra A, Volpe G, Messa F et al. Quantitative assessment of WT1 expression by real time quantitative PCR may be a useful tool for monitoring minimal residual disease in acute leukemia patients. Leukemia 2002; 16: 2115–2121.

    CAS  PubMed  Google Scholar 

  133. 133

    Haferlach T, Kohlmann A, Kern W, Hiddemann W, Schnittger S, Schoch C . Gene expression profiling as a tool for the diagnosis of acute leukemias. Semin Hematol 2003; 40: 281–295.

    CAS  PubMed  Google Scholar 

  134. 134

    Bullinger L, Dohner K, Bair E, Frohling S, Schlenk RF, Tibshirani R et al. Use of gene-expression profiling to identify prognostic subclasses in adult acute myeloid leukaemia. N Engl J Med 2004; 350: 1605–1616.

    CAS  PubMed  Google Scholar 

  135. 135

    Radmacher MD, Marcucci G, Ruppert AS, Mrozek K, Whitman SP, Vardiman JW et al. Independent confirmation of a prognostic gene-expression signature in adult acute myeloid leukemia with a normal karyotype: a Cancer and Leukemia Group B study. Blood 2006; 108: 1677–1683.

    CAS  PubMed  PubMed Central  Google Scholar 

  136. 136

    Bullinger L, Rucker FG, Kurz S, Du J, Scholl C, Sander S et al. Gene-expression profiling identifies distinct subclasses of core binding factor acute myeloid leukemia. Blood 2007; 110: 1291–1300.

    CAS  PubMed  Google Scholar 

  137. 137

    Raponi M, Lancet JE, Fan H, Dossey L, Lee G, Gojo I et al. A 2-gene classifier for predicting response to the farnesyltransferase inhibitor tipifarnib in acute myeloid leukemia. Blood 2008; 111: 2589–2596.

    CAS  PubMed  Google Scholar 

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Bacher, U., Haferlach, C., Schnittger, S. et al. Interactive diagnostics in the indication to allogeneic SCT in AML. Bone Marrow Transplant 43, 745–756 (2009). https://doi.org/10.1038/bmt.2009.54

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Keywords

  • AML
  • allogeneic SCT
  • indication
  • molecular markers
  • minimal residual disease

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