Abstract
The purpose of this study was to investigate the correlation of mutations of the fms-like tyrosine kinase (FLT3) and nucleophosmin (NPM1) genes with the cup-like nuclear morphology of blasts in patients with acute myeloid leukemia (AML). We retrospectively reviewed peripheral blood (PB) and bone marrow (BM) slides of 208 patients prepared at the time of diagnosis of AML based on the results of testing for mutations of both NPM1 exon 12 and FLT3. We investigated the association between this phenotype and hematologic findings, disease markers, and mutations in NPM1 exon 12, FLT3-internal tandem duplication (ITD), and tyrosine kinase domain (TKD) genes. Cup-like nuclei were found in 44 patients (21.2 %) diagnosed with AML. This morphology was associated with high blast counts in the PB and BM; AML type, especially AML M1 (FAB classification); low CD34 expression; and mutation of FLT3-ITD, -TKD, NPM1 regardless of other mutations (p < 0.05 for all). However, FLT3-ITD or TKD mutation alone (nine cases, p = 0.228) was not associated, and NPM1 mutation alone (14 cases, p = 0.036) was weakly associated with cup-like nuclei. Mutation of both NPM1 and FLT3-ITD or TKD (17 cases, p < 0.001) was strongly correlated with the cup-like nuclear morphology. AML with cup-like nuclei is strongly associated with co-occurring mutations of both NPM1 and FLT3-ITD or TKD. Therefore, testing for both mutations is recommended for patients with the cup-like nuclear morphology.
Similar content being viewed by others
References
Bennett JM, Catovsky D, Daniel MT, Flandrin G, Galton DA, Gralnick HR, Willman CL (2000) Hypergranular promyelocytic leukemia: correlation between morphology and chromosomal translocations including t(15;17) and t(11;17). Leukemia 14(7):1197–1200. doi:10.1038/sj.leu.2401795
Orfao A, Chillon MC, Bortoluci AM, Lopez-Berges MC, Garcia-Sanz R, Gonzalez M, Tabernero MD, Garcia-Marcos MA, Rasillo AI, Hernandez-Rivas J, San Miguel JF (1999) The flow cytometric pattern of CD34, CD15 and CD13 expression in acute myeloblastic leukemia is highly characteristic of the presence of PML-RARalpha gene rearrangements. Haematologica 84(5):405–412
Scott AA, Head DR, Kopecky KJ, Appelbaum FR, Theil KS, Grever MR, Chen IM, Whittaker MH, Griffith BB, Licht JD et al (1994) HLA-DR−, CD33+, CD56+, CD16− myeloid/natural killer cell acute leukemia: a previously unrecognized form of acute leukemia potentially misdiagnosed as French-American-British acute myeloid leukemia-M3. Blood 84(1):244–255
Kroschinsky FP, Schakel U, Fischer R, Mohr B, Oelschlaegel U, Repp R, Schaich M, Soucek S, Baretton G, Ehninger G, Thiede C (2008) Cup-like acute myeloid leukemia: new disease or artificial phenomenon? Haematologica 93(2):283–286. doi:10.3324/haematol.11669
Chen W, Konoplev S, Medeiros LJ, Koeppen H, Leventaki V, Vadhan-Raj S, Jones D, Kantarjian HM, Falini B, Bueso-Ramos CE (2009) Cuplike nuclei (prominent nuclear invaginations) in acute myeloid leukemia are highly associated with FLT3 internal tandem duplication and NPM1 mutation. Cancer 115(23):5481–5489. doi:10.1002/cncr.24610
Bennett JM, Pryor J, Laughlin TS, Rothberg PG, Burack WR (2010) Is the association of “cup-like” nuclei with mutation of the NPM1 gene in acute myeloid leukemia clinically useful? Am J Clin Pathol 134(4):648–652. doi:10.1309/AJCPULO8SLW0RKJL
Chen W, Rassidakis GZ, Li J, Routbort M, Jones D, Kantarjian H, Medeiros LJ, Bueso-Ramos CE (2006) High frequency of NPM1 gene mutations in acute myeloid leukemia with prominent nuclear invaginations (“cuplike” nuclei). Blood 108(5):1783–1784. doi:10.1182/blood-2006-03-014340
Vardiman JW, Thiele J, Arber DA, Brunning RD, Borowitz MJ, Porwit A, Harris NL, Le Beau MM, Hellstrom-Lindberg E, Tefferi A, Bloomfield CD (2009) The 2008 revision of the World Health Organization (WHO) classification of myeloid neoplasms and acute leukemia: rationale and important changes. Blood 114(5):937–951. doi:10.1182/blood-2009-03-209262
Thiede C, Koch S, Creutzig E, Steudel C, Illmer T, Schaich M, Ehninger G (2006) Prevalence and prognostic impact of NPM1 mutations in 1485 adult patients with acute myeloid leukemia (AML). Blood 107(10):4011–4020. doi:10.1182/blood-2005-08-3167
Thiede C, Steudel C, Mohr B, Schaich M, Schakel U, Platzbecker U, Wermke M, Bornhauser M, Ritter M, Neubauer A, Ehninger G, Illmer T (2002) Analysis of FLT3-activating mutations in 979 patients with acute myelogenous leukemia: association with FAB subtypes and identification of subgroups with poor prognosis. Blood 99(12):4326–4335. doi:10.1182/blood.V99.12.4326
Gale RE, Green C, Allen C, Mead AJ, Burnett AK, Hills RK, Linch DC (2008) The impact of FLT3 internal tandem duplication mutant level, number, size, and interaction with NPM1 mutations in a large cohort of young adult patients with acute myeloid leukemia. Blood 111(5):2776–2784. doi:10.1182/blood-2007-08-109090
McCormick SR, McCormick MJ, Grutkoski PS, Ducker GS, Banerji N, Higgins RR, Mendiola JR, Reinartz JJ (2010) FLT3 mutations at diagnosis and relapse in acute myeloid leukemia: cytogenetic and pathologic correlations, including cuplike blast morphology. Arch Pathol Lab Med 134(8):1143–1151
Oelschlaegel U, Mohr B, Schaich M, Schakel U, Kroschinsky F, Illmer T, Ehninger G, Thiede C (2009) HLA-DRneg patients without acute promyelocytic leukemia show distinct immunophenotypic, genetic, molecular, and cytomorphologic characteristics compared to acute promyelocytic leukemia. Cytometry B Clin Cytom 76(5):321–327. doi:10.1002/cyto.b.20475
Falini B, Mecucci C, Tiacci E, Alcalay M, Rosati R, Pasqualucci L, La Starza R, Diverio D, Colombo E, Santucci A, Bigerna B, Pacini R, Pucciarini A, Liso A, Vignetti M, Fazi P, Meani N, Pettirossi V, Saglio G, Mandelli F, Lo-Coco F, Pelicci PG, Martelli MF (2005) Cytoplasmic nucleophosmin in acute myelogenous leukemia with a normal karyotype. N Engl J Med 352(3):254–266. doi:10.1056/NEJMoa041974
Dohner K, Schlenk RF, Habdank M, Scholl C, Rucker FG, Corbacioglu A, Bullinger L, Frohling S, Dohner H (2005) Mutant nucleophosmin (NPM1) predicts favorable prognosis in younger adults with acute myeloid leukemia and normal cytogenetics: interaction with other gene mutations. Blood 106(12):3740–3746. doi:10.1182/blood-2005-05-2164
Ahmad F, Mandava S, Das BR (2010) Analysis of FLT3-ITD and FLT3-Asp835 mutations in de novo acute myeloid leukemia: evaluation of incidence, distribution pattern, correlation with cytogenetics and characterization of internal tandem duplication from Indian population. Cancer Investig 28(1):63–73. doi:10.3109/07357900903095649
Bacher U, Haferlach C, Kern W, Haferlach T, Schnittger S (2008) Prognostic relevance of FLT3-TKD mutations in AML: the combination matters—an analysis of 3082 patients. Blood 111(5):2527–2537. doi:10.1182/blood-2007-05-091215
Rowley JD, Golomb HM, Dougherty C (1977) 15/17 translocation, a consistent chromosomal change in acute promyelocytic leukaemia. Lancet 1(8010):549–550
Le Beau MM, Larson RA, Bitter MA, Vardiman JW, Golomb HM, Rowley JD (1983) Association of an inversion of chromosome 16 with abnormal marrow eosinophils in acute myelomonocytic leukemia. A unique cytogenetic-clinicopathological association. N Engl J Med 309(11):630–636
Haferlach T, Winkemann M, Loffler H, Schoch R, Gassmann W, Fonatsch C, Schoch C, Poetsch M, Weber-Matthiesen K, Schlegelberger B (1996) The abnormal eosinophils are part of the leukemic cell population in acute myelomonocytic leukemia with abnormal eosinophils (AML M4Eo) and carry the pericentric inversion 16: a combination of May-Grunwald-Giemsa staining and fluorescence in situ hybridization. Blood 87(6):2459–2463
Bloomfield CD, Lawrence D, Byrd JC, Carroll A, Pettenati MJ, Tantravahi R, Patil SR, Davey FR, Berg DT, Schiffer CA, Arthur DC, Mayer RJ (1998) Frequency of prolonged remission duration after high-dose cytarabine intensification in acute myeloid leukemia varies by cytogenetic subtype. Cancer Res 58(18):4173–4179
Fenaux P, Chastang C, Chevret S, Sanz M, Dombret H, Archimbaud E, Fey M, Rayon C, Huguet F, Sotto JJ, Gardin C, Makhoul PC, Travade P, Solary E, Fegueux N, Bordessoule D, Miguel JS, Link H, Desablens B, Stamatoullas A, Deconinck E, Maloisel F, Castaigne S, Preudhomme C, Degos L (1999) A randomized comparison of all transretinoic acid (ATRA) followed by chemotherapy and ATRA plus chemotherapy and the role of maintenance therapy in newly diagnosed acute promyelocytic leukemia. The European APL Group. Blood 94(4):1192–1200
Haferlach T, Schoch C, Loffler H, Gassmann W, Kern W, Schnittger S, Fonatsch C, Ludwig WD, Wuchter C, Schlegelberger B, Staib P, Reichle A, Kubica U, Eimermacher H, Balleisen L, Gruneisen A, Haase D, Aul C, Karow J, Lengfelder E, Wormann B, Heinecke A, Sauerland MC, Buchner T, Hiddemann W (2003) Morphologic dysplasia in de novo acute myeloid leukemia (AML) is related to unfavorable cytogenetics but has no independent prognostic relevance under the conditions of intensive induction therapy: results of a multiparameter analysis from the German AML Cooperative Group studies. J Clin Oncol 21(2):256–265. doi:10.1200/JCO.2003.08.005
Yoshida K, Sanada M, Shiraishi Y, Nowak D, Nagata Y, Yamamoto R, Sato Y, Sato-Otsubo A, Kon A, Nagasaki M, Chalkidis G, Suzuki Y, Shiosaka M, Kawahata R, Yamaguchi T, Otsu M, Obara N, Sakata-Yanagimoto M, Ishiyama K, Mori H, Nolte F, Hofmann WK, Miyawaki S, Sugano S, Haferlach C, Koeffler HP, Shih LY, Haferlach T, Chiba S, Nakauchi H, Miyano S, Ogawa S (2011) Frequent pathway mutations of splicing machinery in myelodysplasia. Nature 478(7367):64–69. doi:10.1038/nature10496
Christopeit M, Ocheni S, Haferlach T, Miersch K, Zabelina T, Klyuchnikov E, Binder M, Ayuk F, Schafhausen P, Zander AR, Bokemeyer C, Kroger N, Bacher U (2012) Evaluation of BM cytomorphology after allo-SCT in patients with MDS. Bone Marrow Transplant. doi:10.1038/bmt.2012.161
Bacher U, Schnittger S, Macijewski K, Grossmann V, Kohlmann A, Alpermann T, Kowarsch A, Nadarajah N, Kern W, Haferlach C, Haferlach T (2012) Multilineage dysplasia does not influence prognosis in CEBPA-mutated AML, supporting the WHO proposal to classify these patients as a unique entity. Blood 20:4719–4722. doi:10.1182/blood-2011-12-395574
Kussick SJ, Stirewalt DL, Yi HS, Sheets KM, Pogosova-Agadjanyan E, Braswell S, Norwood TH, Radich JP, Wood BL (2004) A distinctive nuclear morphology in acute myeloid leukemia is strongly associated with loss of HLA-DR expression and FLT3 internal tandem duplication. Leukemia 18(10):1591–1598. doi:10.1038/sj.leu.2403458
Conflict of interest
The authors declare that they have no conflict of interest.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Park, B.G., Chi, HS., Jang, S. et al. Association of cup-like nuclei in blasts with FLT3 and NPM1 mutations in acute myeloid leukemia. Ann Hematol 92, 451–457 (2013). https://doi.org/10.1007/s00277-012-1645-5
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00277-012-1645-5