FLT3-ITD Expression as a Potential Biomarker for the Assessment of Treatment Response in Patients with Acute Myeloid Leukemia

Simple Summary FLT3-internal tandem duplication (ITD) mutation analysis in DNA samples is essential for optimal clinical management in patients with acute myeloid leukemia (AML). However, the utility of FLT3-ITD mutation analysis in cDNA samples and its use as a follow-up biomarker are controversial. In this context, we compared mutation analyses between DNA and cDNA samples and evaluated the use of cDNA analysis for AML monitoring. FLT3-ITD mutation analysis in cDNA samples demonstrated a higher sensitivity than those in DNA samples. In particular, in patients undergoing allogeneic hematopoietic stem cell transplantation, the disease was detected long before they relapsed. In addition, cDNA analysis evaluated the patients' response to FLT3 inhibitors. Therefore, FLT3-ITD cDNA could be a useful additional biomarker in patients with AML, for both the diagnosis and for assessing the treatment response. FLT3-internal tandem duplication (ITD) analysis is not typically performed in cDNA samples and is not considered an appropriate marker for monitoring measurable residual disease (MRD). The aims of this study were to compare FLT3-ITD mutation analysis in DNA and cDNA samples at diagnosis and to demonstrate the usefulness of its expression measurement as an MRD marker after allogeneic stem cell transplantation (allo-HSCT) or FLT3 inhibitor (FLT3i) administration. A total of 46 DNA and cDNA diagnosis samples, 102 DNA and cDNA post-allo-HSCT samples from 34 patients and 37 cDNA samples from 7 patients with refractory/relapse AML treated with FLT3i were assessed for the FLT3-ITD mutation through fragment analysis. In terms of sensitivity, the analysis of cDNA was superior to that of DNA, quantifying higher allelic ratio values in most cases at diagnosis, and thus optimizing the detection of minor clones and prognostic classification. Regarding the last sample before post-HSCT relapse, cDNA analysis anticipated relapse in most cases, unlike DNA analyses. With regard to the post-FLT3i follow-up, FLT3-ITD expression was reduced after the first FLT3i cycle when the treatment was effective, whereas it was not reduced in refractory patients. FLT3-ITD expression could be a useful additional biomarker at diagnosis and for the assessment of MRD after allo-HSCT and FLT3i in AML.

Automated summary

FLT3-ITD cDNA analysis showed higher sensitivity than DNA analysis, detecting disease before relapse in patients undergoing allogeneic hematopoietic stem cell transplantation. It also evaluated the response to FLT3 inhibitors. FLT3-ITD expression could be a useful additional biomarker at diagnosis and for the assessment of measurable residual disease after transplantation and FLT3 inhibitor treatment.