Objective: This study aimed to explore the characteristics and clinical value of clonal heterogeneity in acute myeloid leukemia (AML) . Method: A high-throughput sequencing was carried out to detect 68 related genes in 465 AML patients. Clonal heterogeneity was analyzed based on variant allele frequency (VAF) and flow cytometry results combined with clinical data. Results: Gene mutations were discovered in 338 (81.4%) newly diagnosed patients, and 2 or more clones were significantly increased in patients with DNMT3A, NRAS, and RUNX1 mutations (DNMT3A, χ(2)=15.23; P<0.001; NRAS, χ(2)=19.866; P<0.001; RUNX1, χ(2)=23.647; P<0.001) . The number of clones significantly differed between groups at different ages (χ(2)=17.505, P=0.022) . The proportion of carrying 2 and ≥3 clones increased in patients aged more than 60 years old. There was a significant difference in the clonal heterogeneity between newly diagnosed patients and relapsed or secondary patients (χ(2)=11.302, P=0.010) . Moreover, the proportion of patients with clonal heterogeneity gradually increased according to their prognostic risk (χ(2)=17.505, P=0.022) . Based on the clone analysis, the proportion of primary clones of patients with RUNX1 mutation was higher (χ(2)=4.527, P=0.033) . The analysis of clonal heterogeneity and efficacy demonstrated that patients with three or more clones had significantly lower overall survival (OS) and progression-free survival (PFS) compared to other patients (OS, χ(2)=13.533; P=0.004; PFS, χ(2)=9.817; P=0.020) , while in the intermediate-risk group, patients with a significant clonal heterogeneity also exhibited a significant decrease in PFS (χ(2)=10.883, P=0.012) . Cox regression multivariate analysis revealed that carrying three or more clones was an independent factor affecting prognosis, and OS and PFS were significantly lower than those of patients without clones (OS, HR=3.296; 95% CI, 1.568-6.932; P=0.002; PFS, HR=3.241; 95% CI, 1.411-7.440; P=0.006) . Conclusion: Clonal heterogeneity may reflect the biological characteristics of a tumor, suggesting its drug resistance, refractory, and invasiveness, and further evaluate the treatment effect and prognosis of patients.
目的： 探讨急性髓系白血病（AML）的克隆异质性特征及其临床价值。 方法： 采用高通量测序技术靶向检测2016年1月至2019年6月河南省肿瘤医院收治的465例AML患者的68种相关基因，将检出的基因突变位点根据变异等位基因频率（VAF）及同期流式细胞学结果进行克隆异质性分析，并分析其与预后的关系。 结果： 338例（81.4%）初诊患者检出基因突变，其中携带DNMT3A、NRAS和RUNX1突变患者出现2个及以上克隆比例显著增加（DNMT3A：χ(2)=15.231, P<0.001；NRAS：χ(2)=19.866, P<0.001；RUNX1：χ(2)=23.647, P<0.001）。不同年龄组间克隆数差异有统计学意义（χ(2)=17.505, P=0.022），其中>60岁患者携带2个和≥3个克隆的比例增加。初诊患者与复发或继发AML患者间克隆分布差异具有统计学意义（χ(2)=11.302, P=0.010），且患者多克隆的比例随预后危险度增加而逐渐增加（χ(2)=17.505, P=0.022）。而主克隆分析中，RUNX1突变标志的主克隆比例较高（χ(2)=4.527, P=0.033）。克隆异质性与疗效相关分析显示，携带3个及以上克隆患者的总生存（OS）期和无进展生存（PFS）期均远低于其他患者（OS：χ(2)=13.533，P=0.004；PFS：χ(2)=9.817，P=0.020），而在中危组患者中，克隆数目多的患者其PFS期显著缩短（χ(2)=10.883，P=0.012）。Cox回归多因素分析显示，携带3个及以上克隆为影响预后的独立危险因素，其OS期和PFS期显著短于无克隆患者（OS：HR=3.296，95%CI 1.568~6.932，P=0.002；PFS：HR=3.241，95%CI 1.411~7.440，P=0.006）。 结论： 克隆异质性可反映肿瘤的生物学特性，提示其耐药性、难治性及侵袭性，可进一步用来评估疗效和AML中危组患者的预后。.
Keywords: Clonal heterogeneity; Gene mutation; High-throughput sequencing; Leukemia, myeloid, acute.