Analysis of NPM1 and FLT3 Mutations in Patients with Acute Myeloid Leukemia in Jeddah, Saudi Arabia: A Pilot Study

ORIGINAL ARTICLE
Raed Alserihi, Hameeda Ahmad, Heba Alkhatabi, Talal Qadah, Shahad W. Kattan, Elrashed B. Yasin, Haitham M. H. Qutob, Waleed M. Bawazir, Abeer Fakhr-Eldeen, Manal S. Fawzy, Ahmad S. Barefah

 
International Journal of Biomedicine. 2023;13(1):73-83.
DOI: 10.21103/Article13(1)_OA9
Originally published March 3, 2023

Abstract: 

Background: The outcome of acute myeloid leukemia (AML) is influenced by ethnicity, geographic variations, and the patient’s molecular profile. We aimed to explore the mutation frequencies of the nucleophosmin 1 (NPM1) and the FMS-like tyrosine kinase 3 (FLT3) internal tandem duplication (ITD) or tyrosine kinase domain (TKD) with correlation to the cytogenetic profiles in patients with AML.
Methods and Results: Bone marrow/whole blood samples from 33 patients with AML were screened for NPM1/FLT3-ITD mutations by fragments analysis using a GeneScan analyzer. Depending on the fragment size, the NPM1 and FLT3 wild type (Wt) (170bp and 330bp)  vs. mutated (170/174 bp and 330/351 bp) alleles, respectively, can be distinguished. The allelic ratio of FLT3-ITD⁺ was calculated. FLT3-TKD⁺ mutation was detected by Sanger sequencing. Samples were tested for chromosomal aberrations.
According to the French-American-British (FAB) classification, the predominant type in the present cohort was AML-M5, accounting for 30.3%. NPM1⁺, FLT3-ITD⁺, and double mutations were found in 12.1%, 3.1%, and 6.1% of cases, respectively. The combined NPM1⁺/FLT3-ITD⁺/FLT3-TKD⁺ profile was presented in one patient (3.1%). The dual positivity group (NPM1⁺/FLT3⁺) significantly had a higher WBC count with a median of 81.3×103/µL. A total of 63.6% of patients had abnormal cytogenetics. The NPM1⁺/FLT3-ITD⁺ patients had normal karyotypes. Patients with NPM1-/FLT3- showed complex karyotype (24%) and t(8;21) (8%). The FLT3-ITD⁺ patient had trisomy 8.
Conclusion: The frequency of NPM1/FLT3 mutations in the study cohort showed less rate than in other studies with a distinct pattern. Due to the preliminary nature of the present work, more extensive screening is warranted to evaluate their usefulness as prognostic indicators in this region.

Keywords: 
acute myeloid leukemia • FLT3 • NPM1• sequencing
References: 
  1. Döhner H, Weisdorf DJ, Bloomfield CD. Acute Myeloid Leukemia. N Engl J Med. Sep 17 2015;373(12):1136-52. doi:10.1056/NEJMra1406184
  2. Miranda-Filho A, Piñeros M, Ferlay J, Soerjomataram I, Monnereau A, Bray F. Epidemiological patterns of leukaemia in 184 countries: a population-based study. Lancet Haematol. Jan 2018;5(1):e14-e24. doi:10.1016/S2352-3026(17)30232-6
  3. Dong Y, Shi O, Zeng Q, Lu X, Wang W, Li Y, Wang Q. Leukemia incidence trends at the global, regional, and national level between 1990 and 2017. Exp Hematol Oncol. 2020 Jun 19;9:14. doi: 10.1186/s40164-020-00170-6.
  4. Alahmari B, Alzahrani M, Al Shehry N, Tawfiq O, Alwasaidi T, Alhejazi A, Bakkar M, Al Behainy A, Radwi M, Alaskar A. Management Approach to Acute Myeloid Leukemia Leveraging the Available Resources in View of the Latest Evidence: Consensus of the Saudi Society of Blood and Marrow Transplantation. JCO Glob Oncol. 2021 Jul;7:1220-1232. doi: 10.1200/GO.20.00660.
  5. Bawazir A, Al-Zamel N, Amen A, Akiel MA, Alhawiti NM, Alshehri A. The burden of leukemia in the Kingdom of Saudi Arabia: 15 years period (1999-2013). BMC Cancer. Jul 17 2019;19(1):703. doi:10.1186/s12885-019-5897-5
  6. Shallis RM, Wang R, Davidoff A, Ma X, Zeidan AM. Epidemiology of acute myeloid leukemia: Recent progress and enduring challenges. Blood Rev. 07 2019;36:70-87. doi:10.1016/j.blre.2019.04.005
  7. Döhner H, Estey E, Grimwade D, Amadori S, Appelbaum FR, Büchner T, Dombret H, Ebert BL, Fenaux P, Larson RA, Levine RL, Lo-Coco F, Naoe T, Niederwieser D, Ossenkoppele GJ, Sanz M, Sierra J, Tallman MS, Tien HF, Wei AH, Löwenberg B, Bloomfield CD. Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. Blood. 2017 Jan 26;129(4):424-447. doi: 10.1182/blood-2016-08-733196.
  8. Tallman MS, Wang ES, Altman JK, Appelbaum FR, Bhatt VR, Bixby D, Coutre SE, De Lima M, Fathi AT, Fiorella M, Foran JM, Hall AC, Jacoby M, Lancet J, LeBlanc TW, Mannis G, Marcucci G, Martin MG, Mims A, O'Donnell MR, Olin R, Peker D, Perl A, Pollyea DA, Pratz K, Prebet T, Ravandi F, Shami PJ, Stone RM, Strickland SA, Wieduwilt M, Gregory KM; OCN; Hammond L, Ogba N. Acute Myeloid Leukemia, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2019 Jun 1;17(6):721-749. doi: 10.6004/jnccn.2019.0028.
  9. Heuser M, Ofran Y, Boissel N, Brunet Mauri S, Craddock C, Janssen J, Wierzbowska A, Buske C; ESMO Guidelines Committee. Electronic address: clinicalguidelines@esmo.org. Acute myeloid leukaemia in adult patients: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2020 Jun;31(6):697-712. doi: 10.1016/j.annonc.2020.02.018. 
  10. Takahashi S. Current findings for recurring mutations in acute myeloid leukemia. J Hematol Oncol. 2011 Sep 14;4:36. doi: 10.1186/1756-8722-4-36.
  11. Falini B, Nicoletti I, Martelli MF, Mecucci C. Acute myeloid leukemia carrying cytoplasmic/mutated nucleophosmin (NPMc+ AML): biologic and clinical features. Blood. Feb 01 2007;109(3):874-85. doi:10.1182/blood-2006-07-012252
  12. Gregory TK, Wald D, Chen Y, Vermaat JM, Xiong Y, Tse W. Molecular prognostic markers for adult acute myeloid leukemia with normal cytogenetics. J Hematol Oncol. Jun 02 2009;2:23. doi:10.1186/1756-8722-2-23
  13. Catalano G, Niscola P, Banella C, Diverio D, Trawinska MM, Fratoni S, Iazzoni R, De Fabritiis P, Abruzzese E, Noguera NI. NPM1 Mutated, BCR-ABL1 Positive Myeloid Neoplasms: Review of the Literature. Mediterr J Hematol Infect Dis. 2020 Nov 1;12(1):e2020083. doi: 10.4084/MJHID.2020.083. 
  14. Dumbar TS, Gentry GA, Olson MO. Interaction of nucleolar phosphoprotein B23 with nucleic acids. Biochemistry. 1989 Nov 28;28(24):9495-501. doi: 10.1021/bi00450a037.
  15. Cordell JL, Pulford KA, Bigerna B, Roncador G, Banham A, Colombo E, Pelicci PG, Mason DY, Falini B. Detection of normal and chimeric nucleophosmin in human cells. Blood. 1999 Jan 15;93(2):632-42.
  16. Falini B, Brunetti L, Sportoletti P, Martelli MP. NPM1-mutated acute myeloid leukemia: from bench to bedside. Blood. 2020 Oct 8;136(15):1707-1721. doi: 10.1182/blood.2019004226. 
  17. Grimwade D, Ivey A, Huntly BJ. Molecular landscape of acute myeloid leukemia in younger adults and its clinical relevance. Blood. 2016 Jan 7;127(1):29-41. doi: 10.1182/blood-2015-07-604496. 
  18. Arber D.A., Brunning R.D., Le Beau M.M., Falini B., Vardiman J.W., Porwit A., Thiele J., Foucar K., Dohner H., Bloomfield C.D. Acute myeloid leukaemia with recurrent genetic abnormalities. In: Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, et al., editors. WHO Classification of Tumors of Hematopoietic and Lymphoid Tissue. International Agency for Research on Cancer; Lyon, France. 2017:141–142. 
  19. Verhaak RG, Goudswaard CS, van Putten W, Bijl MA, Sanders MA, Hugens W, Uitterlinden AG, Erpelinck CA, Delwel R, Löwenberg B, Valk PJ. 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 Dec 1;106(12):3747-54. doi: 10.1182/blood-2005-05-2168. 
  20. Koh Y, Park J, Bae EK, Ahn KS, Kim I, Bang SM, Lee JH, Yoon SS, Lee DS, Lee YY, Park S, Kim BK. Non-A type nucleophosmin 1 gene mutation predicts poor clinical outcome in de novo adult acute myeloid leukemia: differential clinical importance of NPM1 mutation according to subtype. Int J Hematol. 2009 Jul;90(1):1-5. doi: 10.1007/s12185-009-0350-1. 
  21. Haslam K, Chadwick N, Kelly J, Browne P, Vandenberghe E, Flynn C, Conneally E, Langabeer SE. Incidence and significance of FLT3-ITD and NPM1 mutations in patients with normal karyotype acute myeloid leukaemia. Ir J Med Sci. 2010 Dec;179(4):507-10. doi: 10.1007/s11845-010-0567-2. 
  22. Schnittger S, Schoch C, Kern W, Mecucci C, Tschulik C, Martelli MF, Haferlach T, Hiddemann W, Falini B. Nucleophosmin gene mutations are predictors of favorable prognosis in acute myelogenous leukemia with a normal karyotype. Blood. 2005 Dec 1;106(12):3733-9. doi: 10.1182/blood-2005-06-2248
  23. Pazhakh V, Zaker F, Alimoghaddam K, Atashrazm F. Detection of nucleophosmin and FMS-like tyrosine kinase-3 gene mutations in acute myeloid leukemia. Ann Saudi Med. 2011 Jan-Feb;31(1):45-50. doi: 10.4103/0256-4947.75778. 
  24. Park BG, Chi HS, Park SJ, Min SK, Jang S, Park CJ, Kim DY, Lee JH, Lee JH, Lee KH. Clinical implications of non-A-type NPM1 and FLT3 mutations in patients with normal karyotype acute myeloid leukemia. Acta Haematol. 2012;127(2):63-71. doi: 10.1159/000331509.
  25. Grafone T, Palmisano M, Nicci C, Storti S. An overview on the role of FLT3-tyrosine kinase receptor in acute myeloid leukemia: biology and treatment. Oncol Rev. 2012 Apr 17;6(1):e8. doi: 10.4081/oncol.2012.e8. 
  26. Abu-Duhier FM, Goodeve AC, Wilson GA, Gari MA, Peake IR, Rees DC, Vandenberghe EA, Winship PR, Reilly JT. FLT3 internal tandem duplication mutations in adult acute myeloid leukaemia define a high-risk group. Br J Haematol. 2000 Oct;111(1):190-5. doi: 10.1046/j.1365-2141.2000.02317.x. 
  27. Motyckova G, Stone RM. The role of molecular tests in acute myelogenous leukemia treatment decisions. Curr Hematol Malig Rep. 2010 Apr;5(2):109-17. doi: 10.1007/s11899-010-0049-7.
  28. Kindler T, Lipka DB, Fischer T. FLT3 as a therapeutic target in AML: still challenging after all these years. Blood. 2010 Dec 9;116(24):5089-102. doi: 10.1182/blood-2010-04-261867. 
  29. Pourrajab F, Zare-Khormizi MR, Hashemi AS, Hekmatimoghaddam S. Genetic Characterization and Risk Stratification of Acute Myeloid Leukemia. Cancer Manag Res. 2020;12:2231-2253. doi:10.2147/CMAR.S242479
  30. Kassem N, Hamid AA, Attia T, Baathallah S, Mahmoud S, Moemen E, Safwat E, Khalaf M, Shaker O. Novel mutations of the nucleophosmin (NPM-1) gene in Egyptian patients with acute myeloid leukemia: a pilot study. J Egypt Natl Canc Inst. 2011 Jun;23(2):73-8. doi: 10.1016/j.jnci.2011.09.003. Epub 2011 Oct 13. Erratum in: J Egypt Natl Canc Inst. 2012 Jun;24(2):105. 
  31. Slovak ML, Kopecky KJ, Cassileth PA, Harrington DH, Theil KS, Mohamed A, Paietta E, Willman CL, Head DR, Rowe JM, Forman SJ, Appelbaum FR. 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 Dec 15;96(13):4075-83. 
  32. Durney BC, Crihfield CL, Holland LA. Capillary electrophoresis applied to DNA: determining and harnessing sequence and structure to advance bioanalyses (2009-2014). Anal Bioanal Chem. 2015 Sep;407(23):6923-38. doi: 10.1007/s00216-015-8703-5. 
  33. Kristoff CJ, Bwanali L, Veltri LM, Gautam GP, Rutto PK, Newton EO, Holland LA. Challenging Bioanalyses with Capillary Electrophoresis. Anal Chem. 2020 Jan 7;92(1):49-66. doi: 10.1021/acs.analchem.9b04718.
  34. Lyu M, Liao H, Shuai X, Jin Y, Su J, Zheng Q. The prognosis predictive value of FMS-like tyrosine kinase 3-internal tandem duplications mutant allelic ratio (FLT3-ITD MR) in patients with acute myeloid leukemia detected by GeneScan. Gene. 2020 Feb 5;726:144195. doi: 10.1016/j.gene.2019.144195.
  35. Simons A, Shaffer LG, Hastings RJ. Cytogenetic Nomenclature: Changes  in the ISCN 2013 Compared to the 2009  Edition. Cytogenet Genome Res. 2013;141(1):1-6. doi:10.1159/000353118
  36. Renneville A, Roumier C, Biggio V, Nibourel O, Boissel N, Fenaux P, Preudhomme C. Cooperating gene mutations in acute myeloid leukemia: a review of the literature. Leukemia. 2008 May;22(5):915-31. doi: 10.1038/leu.2008.19. 
  37. Coles EC, Colita A, Momanu R, Berbec N, Ivanescu AM, Oprea M, Jardan D, Jardan C, Arghir A, Coriu D, Lupu AR. Importance of assessing cytogenetic and molecular risk factors in acute myeloid leukemia therapy. J Med Life. 2012 Oct-Dec;5(Spec Issue):36-43.
  38. Zhou JR, Zhang X, Zhao YL, Yang JF, Zhang JP, Cao XY, Lu Y, Liu DY, Lyu FY, Ouyang J, Lu PH. [Clinical characteristics and prognosis of 34 cases of acute myeloid leukemia with FLT3 internal tandem duplication and MLL gene rearrangement]. Zhonghua Xue Ye Xue Za Zhi. 2018 Sep 14;39(9):751-756. doi: 10.3760/cma.j.issn.0253-2727.2018.09.010. [Article in Chinese].
  39. Alsobhi E, Farahat F, Daghistani M, Awad K, Al-Zahran O, Al-Saiari A, Koshak F. Overall survival of adult acute myeloid leukemia based on cytogenetic and molecular abnormalities during 5 years in a single center study. Saudi Med J. 2019 Nov;40(11):1171-1176. doi: 10.15537/smj.2019.11.24584.
  40. Alrajeh A, Abalkhail H, Khalil S. Cytogenetics and molecular markers of acute myeloid leukemia from a tertiary care center in Saudi Arabia. Journal of Applied Hematology. 2017;8(2):68-74. doi:10.4103/joah.joah_57_16
  41. Ishfaq M, Malik A, Faiz M, Sheikh I, Asif M, Khan MN, Qureshi MS, Zahid S, Manan A, Arooj M, Qazi MH, Chaudhary A, Alqahtani MH, Rasool M. Molecular characterization of FLT3 mutations in acute leukemia patients in Pakistan. Asian Pac J Cancer Prev. 2012;13(9):4581-5. doi: 10.7314/apjcp.2012.13.9.4581. 
  42. Adnan-Awad S, Gaber O, Eltokhy SA, Mourad D, Amer M, Kandeel EZ, Eldesouky I. FLT3-ITD Mutations in Egyptian Patients of Acute Myeloid Leukemia: Correlation with Cytogenetic, FAB Subgroups and Prognosis. Clin Lab. 2017 May 1;63(5):1027-1034. doi: 10.7754/Clin.Lab.2017.170121. 
  43. Halahleh K, Taqash A, Abdelkhaleq H, Manasrah M, Marie L, Al-Rabi K. Analysis of FLT3-Activating Mutations in Patients With Acute Myelogenous Leukemia in Jordan: Association With FAB Subtypes and Identification of Subgroups With Poor Prognosis. Clin Lymphoma Myeloma Leuk. 2021 Jul;21(7):e588-e597. doi: 10.1016/j.clml.2021.02.006. 
  44. Di Fiore PP. Playing both sides: nucleophosmin between tumor suppression and oncogenesis. J Cell Biol. 2008 Jul 14;182(1):7-9. doi: 10.1083/jcb.200806069. 
  45. Wang L, Xu WL, Meng HT, Qian WB, Mai WY, Tong HY, Mao LP, Tong Y, Qian JJ, Lou YJ, Chen ZM, Wang YG, Jin J. FLT3 and NPM1 mutations in Chinese patients with acute myeloid leukemia and normal cytogenetics. J Zhejiang Univ Sci B. 2010 Oct;11(10):762-70. doi: 10.1631/jzus.B1000052. 
  46. Haferlach T, Bacher U, Alpermann T, Haferlach C, Kern W, Schnittger S. Amount of bone marrow blasts is strongly correlated to NPM1 and FLT3-ITD mutation rate in AML with normal karyotype. Leuk Res. 2012 Jan;36(1):51-8. doi: 10.1016/j.leukres.2011.04.026. 
  47. Dalal BI, Mansoor S, Manna M, Pi S, Sauro GD, Hogge DE. Detection of CD34, TdT, CD56, CD2, CD4, and CD14 by flow cytometry is associated with NPM1 and FLT3 mutation status in cytogenetically normal acute myeloid leukemia. Clin Lymphoma Myeloma Leuk. 2012 Aug;12(4):274-9. doi: 10.1016/j.clml.2012.01.003. 
  48. Daver N, Liu Dumlao T, Ravandi F, Pierce S, Borthakur G, Pemmaraju N, Nazha A, Faderl S, Jabbour E, Garcia-Manero G, Cortes J, Kantarjian H, Quintás-Cardama A. Effect of NPM1 and FLT3 mutations on the outcomes of elderly patients with acute myeloid leukemia receiving standard chemotherapy. Clin Lymphoma Myeloma Leuk. 2013 Aug;13(4):435-40. doi: 10.1016/j.clml.2013.02.021. 
  49. Chauhan PS, Ihsan R, Singh LC, Gupta DK, Mittal V, Kapur S. Mutation of NPM1 and FLT3 genes in acute myeloid leukemia and their association with clinical and immunophenotypic features. Dis Markers. 2013;35(5):581-8. doi: 10.1155/2013/582569.
  50. Marshall RC, Tlagadi A, Bronze M, Kana V, Naidoo S, Wiggill TM, Carmona SC. Lower frequency of NPM1 and FLT3-ITD mutations in a South African adult de novo AML cohort. Int J Lab Hematol. 2014 Dec;36(6):656-64. doi: 10.1111/ijlh.12204.
  51. Koczkodaj D, Zmorzyński S, Michalak-Wojnowska M, Wąsik-Szczepanek E, Filip AA. Examination of the FLT3 and NPM1 mutational status in patients with acute myeloid leukemia from southeastern Poland. Arch Med Sci. 2016 Feb 1;12(1):120-8. doi: 10.5114/aoms.2015.49811. 
  52. Peterlin P, Renneville A, Ben Abdelali R, Nibourel O, Thomas X, Pautas C, de Botton S, Raffoux E, Cayuela JM, Boissel N, Terré C, Celli-Lebras K, Castaigne S, Preudhomme C, Gardin C, Dombret H. Impact of additional genetic alterations on the outcome of patients with NPM1-mutated cytogenetically normal acute myeloid leukemia. Haematologica. 2015 May;100(5):e196-9. doi: 10.3324/haematol.2014.115576.
  53. DiNardo CD, Cortes JE. Mutations in AML: prognostic and therapeutic implications. Hematology Am Soc Hematol Educ Program. 2016 Dec 2;2016(1):348-355. doi: 10.1182/asheducation-2016.1.348. 
  54. Kiyoi H, Yanada M, Ozekia K. Clinical significance of FLT3 in leukemia. Int J Hematol. 2005 Aug;82(2):85-92. doi: 10.1532/IJH97.05066. 
  55. Markovic A, MacKenzie KL, Lock RB. FLT-3: a new focus in the understanding of acute leukemia. Int J Biochem Cell Biol. 2005 Jun;37(6):1168-72. doi: 10.1016/j.biocel.2004.12.005.
  56. Choudhary C, Müller-Tidow C, Berdel WE, Serve H. Signal transduction of oncogenic Flt3. Int J Hematol. 2005 Aug;82(2):93-9. doi: 10.1532/IJH97.05090.
  57. El Fakih R, Rasheed W, Hawsawi Y, Alsermani M, Hassanein M. Targeting FLT3 Mutations in Acute Myeloid Leukemia. Cells. 2018 Jan 8;7(1):4. doi: 10.3390/cells7010004.
  58. Abou Dalle I, Ghorab A, Patel K, Wang X, Hwang H, Cortes J, Issa GC, Yalniz F, Sasaki K, Chihara D, Price A, Kadia T, Pemmaraju N, Daver N, DiNardo C, Ravandi F, Kantarjian HM, Borthakur G. Impact of numerical variation, allele burden, mutation length and co-occurring mutations on the efficacy of tyrosine kinase inhibitors in newly diagnosed FLT3- mutant acute myeloid leukemia. Blood Cancer J. 2020 May 4;10(5):48. doi: 10.1038/s41408-020-0318-1.
  59. Döhner K, Schlenk RF, Habdank M, Scholl C, Rücker FG, Corbacioglu A, Bullinger L, Fröhling S, Döhner H. Mutant nucleophosmin (NPM1) predicts favorable prognosis in younger adults with acute myeloid leukemia and normal cytogenetics: interaction with other gene mutations. Blood. 2005 Dec 1;106(12):3740-6. doi: 10.1182/blood-2005-05-2164. 
  60. Thiede C, Koch S, Creutzig E, Steudel C, Illmer T, Schaich M, Ehninger G. Prevalence and prognostic impact of NPM1 mutations in 1485 adult patients with acute myeloid leukemia (AML). Blood. 2006 May 15;107(10):4011-20. doi: 10.1182/blood-2005-08-3167. 
  61. Gari M, Abuzenadah A, Chaudhary A, Al-Qahtani M, Banni H, Ahmad W, Al-Sayes F, Lary S, Damanhouri G. Detection of FLT3 oncogene mutations in acute myeloid leukemia using conformation sensitive gel electrophoresis. Int J Mol Sci. 2008 Nov;9(11):2194-2204. doi: 10.3390/ijms9112194. 
  62. Jastaniah W, Al Ghemlas I, Al Daama S, Ballourah W, Bayoumy M, Al-Anzi F, Al Shareef O, Alsultan A, Abrar MB, Al Sudairy R. Clinical characteristics and outcome of childhood de novo acute myeloid leukemia in Saudi Arabia: A multicenter SAPHOS leukemia group study. Leuk Res. 2016 Oct;49:66-72. doi: 10.1016/j.leukres.2016.08.009. 
  63. Zaker F, Mohammadzadeh M, Mohammadi M. Detection of KIT and FLT3 mutations in acute myeloid leukemia with different subtypes. Arch Iran Med. 2010 Jan;13(1):21-5. 
  64. Stirewalt DL, Kopecky KJ, Meshinchi S, Appelbaum FR, Slovak ML, Willman CL, Radich JP. FLT3, RAS, and TP53 mutations in elderly patients with acute myeloid leukemia. Blood. 2001 Jun 1;97(11):3589-95. doi: 10.1182/blood.v97.11.3589. Erratum in: Blood 2001 Aug 15;98(4):924.
  65. Rubio P, Campos B, Digiorge JA, Gallego MS, Medina A, Rossi JG, Felice MS, Alonso CN. NPM1, FLT3 and CEBPA mutations in pediatric patients with AML from Argentina: incidence and prognostic value. Int J Hematol. 2016 Nov;104(5):582-590. doi: 10.1007/s12185-016-2064-5.
  66. Kumsaen P, Fucharoen G, Sirijerachai C, Chainansamit SO, Wisanuyothin N, Kuwatjanakul P, Wiangnon S. FLT3-ITD Mutations in Acute Myeloid Leukemia Patients in Northeast Thailand. Asian Pac J Cancer Prev. 2016;17(9):4395-4399. 
  67. Perry M, Bertoli S, Rocher C, Hayette S, Ducastelle S, Barraco F, Labussière-Wallet H, Salles G, Recher C, Thomas X, Paubelle E. FLT3-TKD Mutations Associated With NPM1 Mutations Define a Favorable-risk Group in Patients With Acute Myeloid Leukemia. Clin Lymphoma Myeloma Leuk. 2018 Dec;18(12):e545-e550. doi: 10.1016/j.clml.2018.06.006. 
  68. Kandeel EZ, El Sayed G, Elsharkawy N, Eldin DN, Nassar HR, Ibrahiem D, Amin R, Hanafi M, Khalil M, Kamel A. Impact of FLT3 Receptor (CD135) Detection by Flow Cytometry on Clinical Outcome of Adult Acute Myeloid Leukemia Patients. Clin Lymphoma Myeloma Leuk. 2018 Aug;18(8):541-547. doi: 10.1016/j.clml.2018.05.014. 
  69. Sakaguchi M, Yamaguchi H, Najima Y, Usuki K, Ueki T, Oh I, Mori S, Kawata E, Uoshima N, Kobayashi Y, Kako S, Tajika K, Gomi S, Shono K, Kayamori K, Hagihara M, Kanda J, Uchiyama H, Kuroda J, Uchida N, Kubota Y, Kimura S, Kurosawa S, Nakajima N, Marumo A, Omori I, Fujiwara Y, Yui S, Wakita S, Arai K, Kitano T, Kakihana K, Kanda Y, Ohashi K, Fukuda T, Inokuchi K. Prognostic impact of low allelic ratio FLT3-ITD and NPM1 mutation in acute myeloid leukemia. Blood Adv. 2018 Oct 23;2(20):2744-2754. doi: 10.1182/bloodadvances.2018020305. 
  70. Boddu P, Kantarjian H, Borthakur G, Kadia T, Daver N, Pierce S, Andreeff M, Ravandi F, Cortes J, Kornblau SM. Co-occurrence of FLT3-TKD and NPM1 mutations defines a highly favorable prognostic AML group. Blood Adv. 2017 Aug 17;1(19):1546-1550. doi: 10.1182/bloodadvances.2017009019. 
  71. FM A-D, Rashid Mir R, Javid J, Sharaf  F, Burrow N.  Optimization of allele specific PCR (AS-PCR) for the early detection of FLT3 (D835Y) mutation in Acute Myeloid Leukemia patients at Tabuk, Saudi Arabia. International Journal of Advanced Research (IJAR). 2017;5(1):817–822. doi:10.21474/ijar01/2819
  72. Fröhling S, Schlenk RF, Breitruck J, Benner A, Kreitmeier S, Tobis K, Döhner H, Döhner K; AML Study Group Ulm. Acute myeloid leukemia. 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. 2002 Dec 15;100(13):4372-80. doi: 10.1182/blood-2002-05-1440. 
  73. 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 Mar 1;111(5):2527-37. doi: 10.1182/blood-2007-05-091215. 
  74. Yohe S. Molecular Genetic Markers in Acute Myeloid Leukemia. J Clin Med. 2015 Mar 12;4(3):460-78. doi: 10.3390/jcm4030460. 

Download Article
Received December 13, 2022.
Accepted January 24, 2023.
©2023 International Medical Research and Development Corporation.