Acute Myeloid Leukemia Subtype-Specific Prognostic Value of NGS in the Setting of Intensive Chemotherapy

We examined the prognostic value of routine NGS data in newly diagnosed acute myeloid leukemia (AML) treated with intensive (7 + 3 backbone) induction, specified by AML subtype. A contemporary (2015-2025) series of 545 Mayo Clinic patients (median age 56 years, females 44%) was considered. Median follow-up was 49 months with 341 (63%) allogeneic hematopoietic stem cell transplantations (AHSCT) recorded. AML subtypes included core-binding factor (CBF; N = 72; 13%), primary non-CBF (N = 403; 74%), post-myelodysplastic syndromes (MDS) or post-myelodysplastic/myeloproliferative neoplasms (post-MDS-MDS/MPN; N = 28; 5%), post-MPN (N = 15; 3%), and therapy-related (t-AML; N = 27; 5%). Corresponding complete remission rates, with/without count recovery (CR/CRi), were 89%, 76%, 64%, 27%, and 78% (p < 0.01) and 5-year transplant-censored survival rates 68%, 57%, 21%, 0%, and 55% (p < 0.01). In multivariable analyses, the prognostic value of specific mutations was mostly limited to primary non-CBF AML where adverse karyotype (OR 1.9; p = 0.04) predicted inferior and FLT3-ITD (OR 0.4; p < 0.01) or NPM1 ^MUT/FLT3 ^WT (OR 0.1; p < 0.01) superior CR/CRi while KRAS ^MUT (HR 8.8; p < 0.01), TP53 ^MUT (HR 5.4; p < 0.01), and TET2 ^MUT (HR 2.3; p = 0.01) predicted inferior and NPM1 ^MUT/FLT3 ^WT (HR 0.3; p = 0.01) superior survival. Prognostication in intensively-treated AML should start with subtype specification and recognition of the limited value of NGS in non-primary AML. Post-MPN AML is particularly associated with dismal outcomes and should be prognostically distinguished from post-MDS-MDS/MPN AML. In primary non-CBF AML, in addition to previously established risk factors, the favorable impact of FLT3-ITD on achieving CR/CRi and the unfavorable impact of KRAS ^MUT and TET2 ^MUT on transplant-censored survival were noted and require confirmation from additional studies.