Utility of mutation-specific immunohistochemical markers for predicting post-induction remission among acute myeloid leukemia patients – A prognostic test accuracy study

Abstract

Objectives: Various prognostically important genetic mutations are associated with acute myeloid leukemia (AML). Studies have found correlation between these mutations and expression of certain abnormal proteins in the tumor cells by immunohistochemistry (IHC). Common genetic mutations are nucleophosmin 1 (NPM1) and FMS like tyrosine kinase 3 (FLT3). This study aimed at studying the prognostic utility of surrogate IHC for these mutations-NPM1 IHC for NPM1 mutation, whereas C-X-C Chemokine Receptor type 4 (CXCR4) and Cluster of Differentiation 123 (CD123) IHC for FLT3 mutation in AML patients. Material and Methods: This was a prognostic test accuracy study done in a tertiary care centre over a period of two years (2018–2020) under two subgroups: who attained remission (remission group) and who failed to achieve remission (not in remission group) after induction therapy. Prognostic IHC markers were performed on the diagnostic bone marrow biopsy. Results: There were 70 cases in remission and 49 cases not in remission with median age of 32 and 31 years, respectively. Median total leucocyte count was significantly more in remission group (P = 0.02). AML subtype and cytogenetics wise, remission group, had significantly more M3 and M4 subtypes and translocations, while not in remission group had more M2 and M1 and more of normal and complex cytogenetics (P = 0.01 and 0.03, respectively). NPM1 and FLT3 mutation did not show significant association with remission status. IHC for NPM1, CXCR4, and CD123 was performed in the diagnostic bone marrow biopsy. Loss of nuclear localization of NPM1 and CXCR4 positivity by IHC was more in remission than not in remission (34.3% vs. 28.6% and 54.3% vs. 44.9%, respectively) which was not statistically significant. The expression of NPM1, CXCR4, and CD123 IHC had low sensitivity (34%, 54%, and 4.3%, respectively) to predict remission status. NPM1 IHC was highly significantly associated with NPM1 mutation and had high sensitivity (89%) and specificity (86%) to predict NPM1 mutation whereas CXCR4 and CD123 had low sensitivity, specificity to predict FLT3 mutation. Conclusion: NPM1 IHC can be used as a surrogate to predict NPM1 mutation whereas CXCR4 and CD123 are not effective surrogates to predict FLT3 mutation.