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Validation of ITD mutations in FLT3 as a therapeutic target in human acute myeloid leukaemia


Effective targeted cancer therapeutic development depends upon distinguishing disease-associated ‘driver’ mutations, which have causative roles in malignancy pathogenesis, from ‘passenger’ mutations, which are dispensable for cancer initiation and maintenance. Translational studies of clinically active targeted therapeutics can definitively discriminate driver from passenger lesions and provide valuable insights into human cancer biology. Activating internal tandem duplication (ITD) mutations in FLT3 (FLT3-ITD) are detected in approximately 20% of acute myeloid leukaemia (AML) patients and are associated with a poor prognosis1. Abundant scientific2 and clinical evidence1,3, including the lack of convincing clinical activity of early FLT3 inhibitors4,5, suggests that FLT3-ITD probably represents a passenger lesion. Here we report point mutations at three residues within the kinase domain of FLT3-ITD that confer substantial in vitro resistance to AC220 (quizartinib), an active investigational inhibitor of FLT3, KIT, PDGFRA, PDGFRB and RET6,7; evolution of AC220-resistant substitutions at two of these amino acid positions was observed in eight of eight FLT3-ITD-positive AML patients with acquired resistance to AC220. Our findings demonstrate that FLT3-ITD can represent a driver lesion and valid therapeutic target in human AML. AC220-resistant FLT3 kinase domain mutants represent high-value targets for future FLT3 inhibitor development efforts.

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Figure 1: Mutation screen of FLT3-ITD reveals secondary kinase domain mutations that cause varying degrees of resistance to AC220.
Figure 2: Modelling of FLT3–AC220 interactions.

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Sequence Read Archive

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SMRT sequencing data is deposited online at http:// under accession number SRA050226.1.


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We thank K. Lin for technical assistance. This work was funded by grants from the Leukemia and Lymphoma Society (to C.C.S. and N.P.S.), the Doris Duke Charitable Foundation (to N.P.S.), NCI Leukemia SPORE P50 CA100632-06 (to M.J.L.), NCI R01 CA12886 (to M.J.L.) and the NIH T-32 Molecular Mechanisms of Cancer (to C.C.S.). C.C.S. would like to acknowledge the EHA/ASH Translational Research Training Institute. N.P.S. would like to thank Art and Alison Kern and the Edward S. Ageno family for their support.

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Authors and Affiliations



C.C.S., Q.W., C.-S.C., K.J.T., A.K., E.E.S. and J.K. designed experiments, performed research, analysed data and wrote the manuscript. N.P.S. designed experiments, analysed data and wrote the manuscript. L.E.D., S.W., J.P.H. and S.S. performed experiments and reviewed the manuscript. P.P.Z. was involved in study design and reviewed the manuscript. A.E.P. and M.J.L. provided reagents, performed research and reviewed the manuscript.

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Correspondence to Neil P. Shah.

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Competing interests

The following authors declare competing financial interests: C.C.S. (consultancy, Astellas Pharma); M.J.L. (consultancy, Ambit Biosciences); J.P.H. and P.P.Z. (employment, Ambit Biosciences) E.E.S. and A.K. (equity ownership and employment, Pacific Biosciences); C.-S.C., K.J.T. and S.W. (employment, Pacific Biosciences).

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Smith, C., Wang, Q., Chin, CS. et al. Validation of ITD mutations in FLT3 as a therapeutic target in human acute myeloid leukaemia. Nature 485, 260–263 (2012).

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