The aim of this study was to characterize the mutational landscape of patients with FLT3-mutated acute myeloid leukemia (AML) treated within the randomized CALGB 10603/RATIFY trial evaluating intensive chemotherapy plus the multi-kinase inhibitor midostaurin versus placebo. We performed sequencing of 262 genes in 475 patients: mutations occurring concurrently with the FLT3-mutation were most frequent in NPM1 (61%), DNMT3A (39%), WT1 (21%), TET2 (12%), NRAS (11%), RUNX1 (11%), PTPN11 (10%), and ASXL1 (8%) genes. To assess effects of clinical and genetic features and their possible interactions, we fitted random survival forests and interpreted the resulting variable importance. Highest prognostic impact was found for WT1 and NPM1 mutations, followed by white blood cell count, FLT3 mutation type (internal tandem duplications vs. tyrosine kinase domain mutations), treatment (midostaurin vs. placebo), ASXL1 mutation, and ECOG performance status. When evaluating two-fold variable combinations the most striking effects were found for WT1:NPM1 (with NPM1 mutation abrogating the negative effect of WT1 mutation), and for WT1:treatment (with midostaurin exerting a beneficial effect in WT1-mutated AML). This targeted gene sequencing study provides important, novel insights into the genomic background of FLT3-mutated AML including the prognostic impact of co-mutations, specific gene–gene interactions, and possible treatment effects of midostaurin.

本研究的目的是描述在随机 CALGB 10603/RATIFY 试验中接受治疗的FLT3突变急性髓性白血病 (AML) 患者的突变情况，该试验评估了强化化疗加多激酶抑制剂米哚妥林与安慰剂的对比。我们对 475 名患者的 262 个基因进行了测序：与FLT3突变同时发生的突变最常见于NPM1 (61%)、DNMT3A (39%)、WT1 (21%)、TET2 (12%)、NRAS (11% ) )、RUNX1 (11%)、PTPN11 (10%) 和ASXL1(8%) 基因。为了评估临床和遗传特征的影响及其可能的相互作用，我们拟合了随机生存森林并解释了由此产生的变量重要性。WT1和NPM1突变的预后影响最高，其次是白细胞计数、FLT3突变类型（内部串联重复与酪氨酸激酶结构域突变）、治疗（米哚妥林与安慰剂）、ASXL1突变和 ECOG 体能状态。在评估双变量组合时，发现最显着的影响是WT1：NPM1（NPM1突变消除了WT1突变的负面影响），以及WT1 ：治疗（用米哚妥林在WT1突变的AML中发挥有益作用）。这项靶向基因测序研究为FLT3突变 AML的基因组背景提供了重要的、新颖的见解，包括共突变的预后影响、特定基因-基因相互作用以及米哚妥林的可能治疗效果。