Analysis Of The Correlation Between The Prognosis And Multi-gene Variation Of Children’s Acute Myelone Leukemia In The C-HUANAN-AML-15 Protocol

ObjectiveTo describe children’s acute myeloid leukemia(AML)gene mutation frequency and mutation distribution.To analyze the relationship between mutant genes and chromosome nucleus,mutant genes and FAB subtypes.To analyze the common and mutually exclusive phenomenon between mutation genes and fusion genes.To explore the impact of multi-gene mutations on the efficacy and prognosis of children’s AML.MethodsA retrospective analysis was conducted on 546 children with de AML(non-APL)admitted from nine hospitals in the South China Cooperative Group from January 2015 to December 2020.All participants were tested for AML-related gene mutations by first or second generation sequencing(NGS).Clinical information was collected including gender,age,date of initial diagnosis,initial peripheral white blood cell count,FAB classification,protocol risk,2017ELN risk,chromosome karyotype,fusion gene,mutation gene,bone marrow morphology after induction chemotherapy,minimal residual disease(MRD).In addition,the long-term follow-up data of patients is also collected,including transplantation,relapse,last follow-up date,survival status,etc.The effect of single gene mutation and multiple gene mutation(≧2)on the prognosis of AML patients was analyzed.The independence risk and protection factors of an incident-free survival rate(EFS)and overall survival rate(OS)were analyzed through the COX regression analysis.Results1.The frequency of AML gene mutation:The frequency of gene mutation in this study is 83.33%(455/546),and the frequency of multi-gene mutation(≧2)is 45.60%(249/546).The incidence of fusion gene and mutation gene was 58.1%and 54.2%,respectively.There are 6 genes with a mutation frequency of more than 10%.Among them,the fusion genes and mutation genes with the highest frequency of mutation are AML1-ETO(26.56%),WT1(21.61%),followed by MLL-rearranged Gene(18.32%),C-Kit(11.17%),ASXL1(10.62%),FLT3-ITD(11.54%).In terms of functional group distribution frequency,the incidence of genetic mutations related to the genetic function group has the highest incidence(27.1%),while the incidence of complex bin genome mutations is the lowest(0.1%).2.The relationship between AML mutant genes and clinical characteristics:(1)In different cell genetic grouping,all NPM1 and CEBPA dual mutations are distributed in the prognosis medium group,and they are accompanied by normal nuclear types;C-KIT mutations are mostly distributed in a good prognostic group,frequently accompanied by T(8;21)or T(16;16);(2)In FAB classification,WT1 is more common in M2 type,c-KIT is more common in M4 type,FLT3-ITD is more common in M5 type,and EVI1 is more common in M7 type.3.The coexistence and mutual exclusion mode between the AML pathogenic genes:In this study,the genes with the most merging types are AML1-ETO(35 species),followed by NRAS(25 species)and WT1(25 species).The spe cific situation of multi-gene mutations:The frequency of coexistence from hig h to low is TET2(83.33%),KRAS(80.00%),AML1-ETO(69.66%),NRAS(67.39%),CBFβ-MYH11(64.86%)ASXL 1(62.07%),NPM1(58.33%),MLL-AF9(52.27%),FLT3-ITD(46.03%),C-KIT(44.26%),EVI1(24.32%).There is a significant coexistence relationship between AML1-ETO and c-KIT mutations(P<0.001),CBFβ-MYH11 and c-KIT mutation(P<0.001),MLL-heavy row and EVI1 mut ation(P<0.001).There is a significant mutual interrogation relationship between AML1-ETO and FLT3-ITD mutations,c-KIT and FLT3-ITD mutations(P=0.041;P=0.032).4.The relationship between single/multigene mutations and prognosis in AML patients:(1)The relationship between single-gene mutations and efficacy and prognosis:AML1-ETO,ASXL1 mutation are the favorable factor for the first induction to relieve success(P=0.001;P=0.021);FLT3-ITD mutation was a negative factor for successful first induced remission(P=0.008),and the gene is also a promotional factor for recurrence(P=0.036).AML1-ETO,CBFβ-MYH11 and C-Kit are the obstacles of recurrence(P=0.002,P=0.022,P=0.006).The OS and EFS of the AML1-ETO positive group in the NON-HSCT group are significantly better than the gene negative group.The OS of the EVI1-positive group is significantly worse than the negative group.The OS and EFS of DEK-NUP214,FLT3-ITD positive group are significantly worse than the negative group.The EFS of the WT1 and CEBPA single-gene positive groups in the HSCT group is significantly worse than the negative group.(2)The relationship between multi-gene mutation and efficacy and prognosis:AML1-ETO(+)ASXL1(+)group has a higher first CR rate than AML1-ETO(-)ASXL1(-)group.AML1-ETO(+)C-Kit(+)group has a higher first CR rate than AML1-ETO(-)C-Kit(-)group.AML1-ETO(+)WT1(+)group has a higher first CR rate than AML1-ETO(-)WT1(-)group.The FLT3-ITD(+)WT1(+)group has a lower CR rate than FLT3-ITD(-)ASXL1(-)group.AML1-ETO(+)C-Kit(+)group has a lower recurrence rate than AML1-ETO(-)C-Kit(-)group.AML1-ETO(+)FLT3-ITD(-)OS and EFS of groups are significantly better than AML1-ETO(+)FLT3-ITD(+)group.The OS and EFS of the MLL Row(+)EVI1(-)group are significantly better than the MLL rear(+)EVI1(+)group.The OS of the MLL-AF9(+)Evil(-)group is significantly better than the MLL-AF9(+)EVI1(+)group.The EFS of the AML1-ETO(+)C-Kit(-)group is obviously inferior to the AML1-ETO(+)C-Kit(+)group.The OS and EFS of the FLT3-ITD(+)WT1(-)group are obviously inferior to the FLT3-ITD(-)WT1(+)group.The OS and EFS of the FLT3-ITD(-)WT1(-)group are significantly better than the FLT3-ITD(+)WT1(-)group.The EFS of the FLT3-ITD(-)WT1(-)group is obviously inferior to the FLT3-ITD(-)WT1(+)group.The OS and EFS of the FLT3-ITD(-)NRAS(-)group are significantly better than the FLT3-ITD(+)NRAS(-)group.The EFS of the FT3-ITD(-)NRAS(+)group is significantly better than the FLT3-ITD(+)NRAS(-)group.OS and EFS of ASXL1(-)WT1(-)group are significantly worse than the ASXL1(-)WT1(+)group.The EFS of ASXL1(-)C-Kit(-)group is significantly worse than the ASXL1(-)C-Kit(+)group.The OS and EFS of the C-Kit(-)NRAS(-)group are significantly worse than the C-Kit(+)NRAS(-)group.The EFS of the C-KIT(-)KRAS(-)group is significantly worse than the C-Kit(+)KRAS(-)group.OS and EFS of the WT1(-)EVI1(+)group are significantly worse than the WT1(+)EVI1(-)group.The OS of the WT1(-)EVI1(-)group is significantly better than the WT1(-)EVI1(+)group.The EFS of the WT1(-)EVI1(-)group is significantly worse than the WT1(+)EVI1(-)group.The OS and EFS of the WT1(-)NRAS(-)group are significantly worse than the WT1(+)NRAS(-)group.The OS and EFS of the WT1(-)KRAS(-)group are significantly worse than the WT1(+)KRAS(-)group.OS and EFS of the WT1(-)CEBPA single(-)group are significantly better than the WT1(+)CEBPPA single(-)group.5.The COX multivariate regression analysis of prognosis in AML patients:Core binding factor(including AML1-ETO and CBFβ-MH11 fusion gene)and WT1 mutation gene are the favorable factor of prognosis.NUP fusion genes and FLT3-ITD mutation genes are the independent risk factor for prognosis.Conclusion(1)83.33%of AML children hava one gene mutation,and 45.60%of AML children had two or more gene mutations.The genes with high mutation frequency were AML1-ETO,WT1,ML-rearrangement,c-KIT,ASXL1 and FLT3-ITD.(2)Genetic mutations in children with AML are correlated with karyotypes and FAB typing.(3)There are significant co-occurrence and mutual exclusion among some gene mutations.(4)Different genetic mutations reveal different clinical efficacy and pre-savings.The AML1-ETO mutation group has higher CR rate,lower recurrence rate,longer OS and EFS.The FLT3-ITD mutant group has lower CR rate,higher recurrence rate,shorter OS and EFS.Transplantation can significantly improve the prognosis of patients with FLT3-ITD mutations.The types and quantities of multi-gene mutations in AML can affect its relief rate,recurrence rate and prognosis.(5)Core binding factor and WT1 gene are the protective factors of prognosis.The NUP fusion gene and FLT3-ITD gene are independent risk factor.