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However, although NPM1 mutations are regarded to be an early event in leukemogenesis, serial analysis of 245 initially NPM1-mutated AML cases revealed a loss of the mutation at relapse in 9% of the cases.
Persistence of DNMT3A was found in five patients who lost the NPM1 mutation at relapse, suggesting that DNMT3A preceded NPM1 mutations (Krönke et al., 2013).
To our knowledge, we describe for the first time a switch of a NPM1 mutation at relapse, compatible with newer models of AML genesis.
Our case also demonstrates the necessity of a broad genetic rescreening at relapse, not only at the onset of leukemia, as monitoring by NPM1 mutation type-specific methods would have missed the newly developed mutation at relapse.
In NPM1-mutated AML, Kronke et al, demonstrated the loss of NPM1 mutation and the persistence on DNMT3A mutation at relapse, suggesting DNMT3A mutation as a founder event in AML pathogenesis [ 55].
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Patient #3 harbored two mutations at relapse.
Furthermore, case #3 had two distinct mutations at relapse (Figure 2b, Table 3).
In these cases, the single clone gained additional mutations at relapse, consistent with a linear pattern of evolution, although minor branching subclones could have been missed.
Here, we describe for the first time a switch of a NPM1 mutation type at relapse having profound impact on AML monitoring strategies.
In AML, there are examples of 'early' mutations lost at relapse and 'late' mutations that are acquired first.
He acquired TP53 mutation at second relapse, 106 months after the initial study at diagnosis and 39.5 months after CR2.
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