Detection Of Internal Tandem Duplications Research Articles

Patient Specific Droplet Digital PCR Targeting FLT3-ITD Allows to Detect Small Clones in Acute Leukemias at Diagnosis and during Follow-up

Approximately 30% of Acute Myeloid Leukemia (AML) patients are characterized by an Internal Tandem Duplication (ITD) in the FLT3 gene that is associated with a worse clinical course, a higher relapse rate, and shorter overall survival. The prognostic significance of measurable residual disease (MRD) positivity after chemotherapy or before hematopoietic stem cell transplantation (HSCT) has been largely demonstrated. Despite this, FLT3-ITD is not used as a marker of MRD because it is reported to be an unstable marker. Moreover, the methods currently used for the detection of FLT3 ITD are characterized by a low Limit of Detection (LoD), therefore small clones (<1%) cannot be identified. For this reason, it is difficult to monitor the persistence or reappearance of a FLT3-positive clone during remission and after HSCT. The possibility of identifying the FLT3-ITD clones as long as they are still very small would allow an early treatment with selective inhibitors. This study aimed 1) to follow up small clones in patients with FLT3 ITD positive at diagnosis and negative after therapy. 2) to verify the presence of small clones at diagnosis in patients who were negative for FLT3-ITD at diagnosis and relapsed as FLT3-ITD positive. We set up a patient-specific approach based on droplet digital PCR (ddPCR). We analyzed 48 samples from 11 AML patients. Seven patients were diagnosed as negative for FLT3-ITD but relapsed with a positive clone (group A), while 4 were identified as FLT3-ITD positive at diagnosis (group B). For each patient, the FLT3-ITD sequence was identified by Sanger sequencing and different patient-specific probes were designed. The LoD of each assay was calculated by mixing the DNA of a wild-type sample with an increasing amount of mutated DNA. Finally, the presence of FLT3-ITD clones was tested in the collected samples by a 2-plex ddPCR, having labeled the patient-specific probes with FAM and the total FLT3 probe with HEX. The target concentration in each sample was expressed as a percentage of FLT3-ITD/FLT3. ddPCR results were compared with the data obtained in the diagnostic routine with LeukoStrat CDx FLT3 mutation assay (Invivoscribe). FLT3-ITD was evaluated at diagnosis and during follow-up in both groups. Regarding group A, ddPCR was able to identify 3 out of 7 patients, evaluated as FLT3 wild-type by the diagnostic test, in which the FLT3-ITD clone was already present at diagnosis, with a percentage of FLT3-ITD/FLT3 of 0.003%, 4.25% and 0.31% for patients 3, 4 and 5. (Fig. 1). In the remaining 4 patients, the absence of an ITD clone at diagnosis was confirmed by ddPCR, but we were able to detect the appearance of a small clone about 9 months before the relapse in 2 of them (pt 1 and 2). In Group B (patients FLT3-ITD positive at diagnosis by routine tests) several time points of follow up were evaluated by ddPCR (Fig.2). In 2 out of 4 patients, FLT3-ITD was negative after treatment and remained negative throughout the follow-up. In patient 8 ddPCR approach was able to identify the presence of a small mutated FLT3-ITD clone (1.43%), which was undetectable by routine test 9 months after diagnosis and 3 months before relapse. In patient 10 ddPCR detected the presence of a small FLT3-ITD clones of 0.004% 0.048% 8 and 3 months before relapse respectively. Our study demonstrates that in FLT3-ITD negative patients a very small clone can be present at diagnosis or can appear soon after the end of chemotherapy. In both cases this clone remains under the limit of detection of 5% for months until the overt relapse. These data are purely cognitive at the moment because the probes are designed on the ITD at relapse, but these data provide the rational for the development of a "universal" ddPCR able to detect the majority of ITD sequences. Finally, our study demonstrates that in patients FLT3-ITD positive at diagnosis, ddPCR allows to detect the persistence or the reappearance of small clones that expand until clinical relapse. The possibility of an early diagnosis of molecular relapse offers a window of time for intervention with selective FLT3 inhibitors in the attempt to prevent or delay relapse. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Non-Canonical FLT3 Mutations (FLT3m) in Patients (Pts) with Newly Diagnosed Acute Myeloid Leukemia (AML) - Outcomes and Prognosis after FLT3 Inhibitor (FLT3i) and Venetoclax Based Regimens

Non-Canonical FLT3 Mutations (FLT3m) in Patients (Pts) with Newly Diagnosed Acute Myeloid Leukemia (AML) - Outcomes and Prognosis after FLT3 Inhibitor (FLT3i) and Venetoclax Based Regimens

63. Comparative analysis of testing methods used for the detection of internal tandem duplications in the KMT2A/MLL gene

The Lysine (K)-Specific Methyltransferase 2A (KMT2A) gene (formerly MLL) that resides on human chromosome 11q23 is frequently rearranged in de novo and therapy related leukemia. KMT2A translocations with various partner genes are often easily detected by classic molecular and cytogenetic approaches. However, the detection of small intragenic insertions, the partial tandem duplications of the KMT2A gene (KMT2A-PTD), is challenging. Additional co-occurring alterations, such as Trisomy 11 which alerts one to the PTD, may further hamper the identification of KMT2A-PTD. KMT2A-PTDs occur in 3-10% of adult AML and the presence of a KMT2A-PTD is associated with a poorer AML outcome. As such, accurate detection of KMT2A-PTDs in AML routine clinical diagnostic workup is important. Here we assessed the ability of three orthogonal technologies for KMT2A-PTD analysis:1) an hybridization-capture based Next Generation Sequencing targeting the KMT2A gene region, 2) an MLPA based assay covering exons 4 and 36 of KMT2A and 3) Optical Genome Mapping. We analyzed tumor samples of ten AML patients with KMT2A-PTD and evaluated the relative performance, strengths and weaknesses of these technologies. KMT2A-PTDs are in-frame duplications that typically encompass exons 3 through 9. However, our results revealed the presence of unsuspected variants of KMT2A. Specifically, copy number based approaches, in the absence of structural data, can lead to false positive and negative calls due to genomic alterations, such as unbalanced translocations, involving KMT2A. Therefore, our data suggest that a combined structural and copy number approach are required to accurately detect KMT2A PTDs.

AKT1 internal tandem duplications and point mutations are the genetic hallmarks of sclerosing pneumocytoma.

Sclerosing pneumocytoma is a unique benign neoplasm of the lungs. The molecular alterations in sclerosing pneumocytoma are not well understood. In a previous whole-exome sequencing study, recurrent AKT1 point mutation was observed in about half of the cases of sclerosing pneumocytoma. However, in the remaining half, cancer-related mutations have still not been identified. In this study, we first analyzed the raw sequence data from the previous whole-exome sequencing study (PRJNA297066 cohort). Using Genomon-ITDetector, a special software for detection of internal tandem duplications, we identified recurrent internal tandem duplications in the AKT1 gene in 22 of the 44 tumor samples (50%). All the cases positive for AKT1 internal tandem duplications lacked AKT1 point mutations. Next, we performed targeted next-generation sequencing in an independent cohort of sclerosing pneumocytoma from our hospital (VGH-TPE cohort), and again identified recurrent AKT1 internal tandem duplications in 20 of the 40 (50%) tumor samples analyzed. The internal tandem duplications resulted in duplications of 7 to 16 amino acids in a narrow region of the Pleckstrin homology domain of the AKT1 protein. This region contains the interaction interface between the Pleckstrin homology and kinase domains, which is known to play a critical role in the activation of the AKT1 protein. Moreover, we found that AKT1 internal tandem duplications were mutually exclusive of other forms of AKT1 mutations, including point mutations and short indels. Taking all forms of AKT1 mutations together, we detected AKT1 mutations in almost all the sclerosing pneumocytomas in our study (PRJNA297066 cohort: 41 out of 44 cases, 93%; VGH-TPE cohort: 40 out of 40 cases, 100%). Our results suggest that AKT1 mutation is the genetic hallmark of sclerosing pneumocytoma. These results would help in better understanding of the pathogenesis of sclerosing pneumocytoma.

Next-generation sequencing in the diagnosis and minimal residual disease assessment of acute myeloid leukemia.

Risk-stratification of acute myeloid leukemia (AML) based on recurrent somatic abnormalities has evolved substantially in recent years, as illustrated by the current 2017 European LeukemiaNet (ELN) risk stratification.1 These 2017 ELN AML risk stratification recommendations are based on (cyto)genetic aberrations, including hotspot mutations such as those in NPM1, but also small insertions, deletions and point mutations that occur throughout TP53, RUNX1 and ASXL1, the latter being associated with adverse outcome.1 Next-generation sequencing (NGS) enables reliable detection of patient-specific mutations covering complete genes in molecularly heterogeneous diseases such as AML. NGS should, therefore, be incorporated in the routine work-up of preferably bone marrow specimens for accurate risk stratification in AML. Since risk assessment according to 2017 ELN recommendations only requires knowledge of the status of a handful of well-known driver mutations,1 targeted NGS, easily reaching a sensitivity of 1-2%, is currently the most appropriate and cost-effective approach for routine testing in AML. Targeted NGS using a variety of gene panels has been successfully introduced in routine clinical laboratories; however, several challenges remain. Gene panels A number of commercially available gene panels focusing on genes frequently mutated in myeloid malignancies have been introduced, e.g., the Illumina TruSight Myeloid panel, the Archer VariantPlex Core Myeloid panel, the Human Myeloid Neoplasms QIASeq DNA Panel and the AmpliSeq for Illumina Myeloid panel among many others. As expected, these panels contain all genes relevant for the 2017 ELN classification and show an enormous overlap in additional mutational hotspots and complete coverage of genes frequently mutated in myeloid diseases. In addition to these commercial panels, gene panels can be easily configured to meet local requirements. For instance, if AML patients are classified locally according to 2017 ELN, only NPM1, CEBPA, FLT3, RUNX1, ASXL1, and TP53 need to be included in a small and cost-effective gene panel. These types of NGS-based assays are now emerging.2 Importantly, both commercial NGS-based assays and those developed in-house as well as downstream analyses should be thoroughly validated locally before implementation in daily practice can be considered. Some genes are particularly difficult to sequence with NGS using gene panels. Bi-allelic mutations in CEBPA characteristically confer a favorable outcome in patients with AML.1 CEBPA is a GC-rich gene which is notoriously difficult to amplify by polymerase chain reaction (PCR) and sequence, and should be given special attention when incorporated in a gene panel. Although some commercial NGS gene panel protocols do now successfully include this single exon gene, other NGS approaches, such as capture-based NGS or custom panels for CEBPA mutation detection could be considered. FLT3 internal tandem duplications (ITD) can be reliably determined by fragment-length PCR following standardized protocols;3 however, the size of the FLT3 ITD and the duplication itself make it challenging to sequence the variably-sized amplicons appropriately by NGS and subsequently to analyze the FLT3 ITD by sequence alignment to reference sequences. Moreover, the 2017 ELN recommendations require assessment of the size of the FLT3 ITD clone.1 NPM1-mutant AML cases with high FLT3 ITD/FLT3 wildtype ratios (>0.5) are considered at intermediate risk, whereas NPM1 wildtype AML cases with high FLT3 ITD/FLT3 wildtype ratios are seen as adverse. Standardized NGS-based protocols need to be developed not only for the detection of FLT3 ITD, but also for the quantification of FLT3 ITD/FLT3 wildtype ratios. Examples of sensitive and specific custom-made FLT3 ITD NGS-based mutation detection assays have been published.4,5

Abstract 4522: An optimized NGS workflow for detection of FLT3 internal tandem duplication (ITD) in AML samples

Abstract FLT3 ITD, a prognostic marker and drug target, is present in ~19% of AML patients. FLT3 ITD is a tandem repeat of the entire or partial exon 13-15 region. FLT3 ITDs range in size from 3bp to above 300bp and impact RTK signaling. Recent publications have shown that FLT3 ITD can be detected at single nucleotide resolution by NGS panels. However, detection of large FLT3 ITD and accurate reporting of ITD frequency remain challenging for NGS methods. False negative ITD results or inaccurate mutant/wild type allele ratio measurements could negatively alter treatment decisions for AML patients. The Illumina TruSight Myeloid panel (TMP) is a commercial NGS assay that covers 54 genes involved in myeloid malignancies. Although the TMP assay can detect SBS and small indel, medium to large size FLT3 ITD cannot be detected. Here we present an enhanced workflow to overcome these challenges. Positive controls, dynamic range, accuracy, and inter-run reproducibility were validated for the detection of SBS, indel, and FLT3 ITD using reference standards and DNA extracted from cell lines and AML patient EDTA blood and bone marrow aspirate samples. NGS libraries were prepared following Illumina's standard protocol. 275bp X2 sequencing instead of the standard 150bp X2 was run on MiSeq flowcell v3. Data analysis was performed using a MolecularMD custom pipeline. The analysis of FLT3 ITD was conducted using three methods including two off-the-shelf programs, Pindel and ITDseek, as well as Cigar, a MolecularMD developed ITD detection algorithm. FLT3 ITDs at 126 bp and 21 bp in PL-21 and MOLM-13 cell lines, respectively, were detected by TMP assay using the three algorithms. In contrast to ITDseek which only reports ITD sequence without frequency information, Pindel and Cigar report both ITD sequence and frequency. Compared to Pindel, ITD frequency reported by the custom algorithm is closer to that determined by the fragment analysis. Serial dilution of the 126bp ITD into wild type DNA showed the 0.55% ITD (from fragment analysis) can be reproducibly detected at ~0.6% by the Cigar algorithm. FLT3 ITDs ranging in size from 6bp to 300bp were detected in clinical AML samples using the enhanced TMP workflow and confirmed by a fragment analysis method. Limit of detection, reproducibility and accuracy of SBS and indel detection in other key genes by the TMP assay have also been validated. Low-level mutations, i.e. NRAS G12D at 1.7%, NRAS G13D at 2%, and IDH2 R140Q at 1.4%, were detected by TMP panel from AML samples and further confirmed with an independent assay. A long deletion (52bp) in exon 9 of CALR was also detected by the custom pipeline. In summary, the enhanced TMP workflow allows for accurate detection and reporting of SBS, indel and FLT3 ITDs including large duplications. Optimized detection of FLT3 ITDs will improve AML patient selection for targeted therapy. Citation Format: Xiaodong Wang, Zhenyu Yan, Peng Fang, Weihua Liu, Scott Glynn, Jennifer Biroschak, Chad Galderisi, Cindy Spittle, Jin Li. An optimized NGS workflow for detection of FLT3 internal tandem duplication (ITD) in AML samples [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 4522.

Prevalence of exon 11 internal tandem duplications in the C-KIT proto-oncogene in Australian canine mast cell tumours.

To measure the prevalence of internal tandem duplications (ITDs) in exon 11 of the proto-oncogene C-KIT in a sample of Australian cutaneous canine mast cell tumours (MCTs) drawn from general practice and to evaluate relationships between tumour mutation status and prognostic factors including signalment, tumour histological grade, tumour anatomical location and tumour size. C-KIT exon 11 ITDs were detected by PCR in DNA extracted from formalin-fixed, paraffin-embedded canine MCTs sourced from three veterinary diagnostic laboratories in Adelaide and Melbourne. Tumours were graded according to two different systems (Patnaik and Kiupel systems) by board-certified anatomical pathologists blinded to the PCR results. Relationships between tumour mutation status and prognostic factors were evaluated using a generalised binary logistic regression analysis. ITDs were identified in 13 of 74 cutaneous canine MCT samples, giving an overall prevalence of 17.6% (95% confidence interval: 8.9-26.2%). ITDs were detected in 10 of 18 Patnaik grade III MCTs (55.6%) and 11 of 22 Kiupel high-grade MCTs (50%). Wald chi-square analysis revealed that detection of tumour ITDs was significantly associated with both Patnaik's and Kiupel's histologic grading systems (each: P < 0.001). The presence of the ITDs in MCTs was not associated with signalment, tumour anatomical location or tumour size. The prevalence of C-KIT exon 11 ITDs in Australian canine MCTs is similar to the prevalence in overseas canine populations (overall prevalence in Australia approximately 18%). ITDs were more frequently identified in higher grade MCTs.

Comprehensive Detection of Driver Mutations in Acute Myeloid Leukemia Including Internal Tandem Duplications with Anchored Multiplex PCR and Next-Generation Sequencing

IntroductionAcute myeloid leukemia (AML) oncogenesis is thought to require multiple somatic mutations in a "two-hit" process to 1) increase proliferation and 2) prevent maturation of myeloid cells. While FLT3 and KIT mutations are associated with increased proliferation, NPM1, CEBPA and several other mutations can be associated with maturation inhibition. The most common mutations in AML are internal tandem duplications (ITDs) in FLT3, which are detected in more than 20% of pediatric and adult AML cases and are associated with an aggressive phenotype. As FLT3-ITD expressed kinases are sensitive to tyrosine kinase inhibitors, they are of considerable interest for the development of novel AML treatments. Capillary gel electrophoresis can detect ITDs but cannot be easily coupled with assays to detect other mutation types common in AML. Next-generation sequencing (NGS)-based methods enable comprehensive detection of multiple mutation types. However, detection of ITDs by NGS is particularly challenging, in part because of their highly variable nature and the difficulties of mapping repeated sequences to a wild-type reference. Anchored Multiplex PCR (AMP) is a target enrichment strategy for NGS that uses molecular barcoded adaptors and gene-specific primers, permitting open-ended capture of DNA fragments from a single end. We present an approach based on AMP technology and a novel bioinformatics algorithm to detect ITDs in FLT3 as well as other mutation types common in AML.MethodsWe developed a library preparation assay for NGS to detect FLT3-ITDs as well as other mutations relevant in AML from genomic DNA extracted from clinical samples. We designed AMP probes to cover the commonly mutated juxtamembrane domain and tyrosine kinase domain 1. We further developed a novel de novo sequence assembly algorithm based on over 2000 in silico datasets representing a large range of known ITDs.ResultsIn silico datasets enabled optimization of our sequencing data analysis algorithm, resulting in the detection of over 98% of in silico ITDs with no false positives. The AMP library preparation assay in conjunction with the optimized analysis algorithm enabled sensitive NGS-based detection of ITDs in 16 AML-positive blood samples. These results were consistent with results obtained from standard capillary gel electrophoresis. In addition, point mutations in the TKD of FLT3 and insertions in NPM1 exon 11 were detected in 2/7 and 5/7 FLT3-ITD positive blood samples.ConclusionsOur data show that AMP enables accurate NGS-based detection of FLT3-ITDs from clinical DNA samples. As this approach can detect multiple mutation types from a single sample, our AMP library preparation coupled with our NGS analysis algorithm enables simultaneous detection of multiple mutations relevant in AML. DisclosuresVan Deusen:ArcherDX, Inc.: Employment. Bessette:ArcherDX, Inc.: Employment. Johnson:ArcherDX, Inc.: Employment. Berlin:ArcherDX, Inc.: Employment. Banos:ArcherDX, Inc.: Employment. Griffin:ArcherDX, Inc.: Employment. Reckase:ArcherDX, Inc.: Employment. Stahl:ArcherDX, Inc.: Employment. Licon:ArcherDX, Inc.: Employment. Kudlow:ArcherDX, Inc.: Employment.

Comparison of FLT3-ITD Detection By High-Throughput Amplicon Sequencing to Routine Diagnostics - a Retrospective Analysis of AMLCG Study Patients

IntroductionIn Acute Myeloid Leukemia (AML) internal tandem duplications (ITD) in the fms-related tyrosine kinase 3 (FLT3) are a frequent event associated with an unfavorable prognosis. At diagnosis, the FLT3-ITD status is routinely assessed by fragment analysis of PCR-amplified cDNA. However, this assay only provides information on the length but not on the position and sequence of the insertion. Therefore, it is attractive to overcome this limitation by the use of high-throughput amplicon sequencing (HTAS) as an alternative strategy for FLT3-ITD detection. To proof the feasibility and accuracy of this approach we performed HTAS on 260 AML patients, of which 250 were FLT3-ITD positive according to routine diagnostics.Patients and MethodsAll samples were obtained from patients treated on the German Acute Myeloid Leukemia Cooperative Group (AMLCG) trials 1999, 2004 and 2008. All patients received intensive induction therapy with curative intent. At diagnosis, patients had a median age of 60 years (range, 18-80 years). Additional molecular marker were screened routinely: NPM1 mutation (62%), KMT2A-PTD (8%), CEBPA mutations (8%). According to the ELN-classification patients clustered into the following groups: ELN intermediate I (70%), intermediate II (21%) or adverse (9%). A normal karyotype was observed in 71%, while 29% had an aberrant karyotpye. All patient samples were analyzed routinely by FLT3 fragment analysis. For HTAS of FLT3 we used custom FLT3 cDNA primers including barcode and adapter-sequences enabling a one-step PCR-protocol. Sequencing was performed (2x250bp paired end) on a MiSeq (Illumina). Per run, up to 96 samples were sequenced, yielding a median of 79,110 reads per amplicon (range: 31,996 - 259,783). As controls, cDNA from FLT3-ITD positive (Molm-13) and negative (HL60) cell lines were used. Sequencing data were aligned to the FLT3 cDNA reference (NM_004119.2) and FLT3-ITDs were called using Pindel software (version 0.2.5a7).ResultsBased on the HTAS results obtained from the FLT3 wild-type control HL60, we set the cut-off for ITD detection at a variant allele frequency (VAF) of 0.5%. Using this threshold, all patients which were assessed to be FLT3-ITD negative in diagnostic routine, were also negative in HTAS. FLT3-ITDs were detected by HTAS in 242 out of 250 (97%) patients who were FLT3-ITD positive patients according to routine fragment analysis. For six out of the 8 remaining patients, no valid ITD was detected by HTAS possibly due to one of the following reasons: a low mutational burden resulting in a VAF below the cut-off level (n=4) or a deletion near the ITD (n=2) potentially interfering with ITD-detection. In total, 308 ITDs were detected in 242 patients by HTAS while in these patients 282 ITDs were detected by routine diagnostics. Of note, HTAS missed 13 subclonal ITDs reported in routine, while 39 additional subclonal ITDs were detected by HTAS only. Overall, HTAS detected a higher number of ITDs per patient (mean: 1.27; range: 1-4) compared to fragment analysis (mean: 1.17; range: 1-3). Patients with more than one ITD according to HTAS showed a trend towards shorter overall and relapse free survival (p=0.105, p=0.104 respectively; Figure 1A). The ITD position (i.e. affected FLT3 domain) based on HTAS did not impact on clinical outcome. There was a significant correlation between the FLT3-ITD levels detected by fragment analysis and HTAS (Pearson, R=0.801, p=0.01; Figure 1B). High FLT3-ITD levels measured by fragment analysis had a significant impact on RFS, whereas this effect was not observed for FLT3-ITD levels measured by HTAS. The quantification of FLT3-ITD by HTAS might be hampered by underestimation of the VAFs of long ITDs that are less likely to be mapped correctly compared to shorter ITDs.ConclusionIn summary, our study demonstrates the feasibility of HTAS for FLT3-ITD detection in AML. In particular, the identification of subclonal ITDs with high sensitivity provides additional information with potential prognostic value. Thus, HTAS may serve as a robust tool that could be implemented in future diagnostic routines. However, bioinformatic algorithms for ITD detection may need further improvement, e.g. to optimize ITD quantification and to facilitate the detection of ITDs in combination with deletions. [Display omitted] DisclosuresHiddemann:Roche: Other: Grants; Genentech: Other: Grants; Roche: Membership on an entity's Board of Directors or advisory committees.

Abstract 3186: Improved sensitive detection method of FLT3 (FMS-like tyrosine kinase) internal tandem duplication (ITD) mutation using next-generation sequencing technology and nested PCR

Abstract Sensitive detection of internal tandem duplication (ITD) mutation of FLT3 is very important in acute myeloid leukemia. To increase detection sensitivity of FLT3-ITD, we developed new detection algorithm using next generation sequencing (NGS) data. We validated results using nested polymerase chain reaction (PCR) methods. We compared results of NGS data, nested PCR and conventional PCR methods. First, using whole exome sequencing data of 83 AML patients, we applied calling algorithm for FLT3-ITD. Briefly, to detect ITDs with NGS data, the reads are aligned to a reference sequence (UCSC hg19), with BWA which is a read aligner allowing soft-clipping. Some reads can be an indication of the occurrence of ITD and BWA aligns those reads as soft-clipped. Second, we deigned two types of primer for Nested PCR. The first primer was targeted wildly for between exon14 and exon15 of FLT3 gene. Nested PCR primer was deigned to target previously reported regions which are frequently occurred ITD mutation. PCR reactions of two steps were performed using the PCR primers sequentially. In these 83 patients, FLT3-ITD was positive only in 7 patients when tested by conventional PCR methods. When NGS detection method was applied, this resulted in positive FLT3-ITD in 11 patients (11/83, 13%). When validation was performed using nested PCR, FLT3-ITD was confirmed in all of 11 patients. Nested PCR detected additional 4 patient positive for FLT3-ITD in this population. For 68 patients, FLT3-ITD was negative by both NGS and nested PCR method. Overall, NGS method improved sensitivity of FLT3-ITD detection by 57% in this population. And the concordance rate of NGS method and nested PCR was 95.2% (79/83). Then we investigated clinical significance of sensitive FLT3-ITD detection. For this, we performed nested PCR and conventional PCR at the same time in 238 AML patients to detect FLT3-ITD. Positive rate for FLT3-ITD was 20% (48/238) and 10% (24/238) by nested PCR and conventional PCR respectively. When survival analysis was performed, among patients with negative FLT3-ITD result by conventional PCR, patients who showed positive for FLT3-ITD by nested PCR had shorter overall survival compared to those who showed negative for FLT3-ITD by nested PCR. (p = 0.03). This implies that sensitive FLT3-ITD detection using nested PCR is clinically meaningful. Diagnosis of FLT3-ITD is very important genetic factor, leading a therapeutic direction for AML patient. Here we report that we have developed alternative more sensitive detection methods for FLT3-ITD based on nested PCR and NGS. Sensitive detection of FLT3-ITD was clinically meaningful, suggesting that these methods should be incorporated in a future clinical practice. Also, we want to note that, NGS method is capable of quantifying FLT3-ITD size and amount in AML patients. Citation Format: Daeyoon Kim, Yoojin Hong, Youngil Koh, Sung-Soo Yoon, Choong-Hyun Sun, Kwang-Sung Ahn, Seungmook Lee, Hongseok Yun, Suyeon Lee. Improved sensitive detection method of FLT3 (FMS-like tyrosine kinase) internal tandem duplication (ITD) mutation using next-generation sequencing technology and nested PCR. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 3186.

Abstract 4856: ITD Assembler: An algorithm for internal tandem duplication discovery from short-read sequencing data

Abstract Tandem duplication of coding sequence is an important mechanism of somatic mutation capable of activating oncogenes such as fms-related tyrosine kinase 3 (FLT3) as well as the potential for underlying constitutional or germline disease. Detection of internal tandem duplication (ITD) in short-read sequencing data remains challenging due to deficiencies in short-read alignment where reads carrying signatures of ITD are often unmapped. Assembly based approaches collapse repetitive sequences, resulting in reduced or lost genomic complexity. The majority of structural variation detection tools are limited to finding insertions that are contained entirely within individual read alignments, and are unable to detect read-spanning duplications. Tools designed to detect large structural variation from paired-end reads that map discordantly based on expected fragment size and orientation do not provide the precision needed to detect ITDs. Only tools that consider the characteristic alignment features that signal the presence of ITDs will be able to detect them; these alignment features include: an excess of reads with unaligned, soft-clipped bases, read pairs where one end is unmapped located near the site of insertion, and read pairs where both ends are unmapped. We introduce ITD Assembler, a novel approach that searches all unmapped reads from exome capture or whole genome sequencing data to identify duplications. From the entire set of unmapped reads plus subset of mapped reads harboring soft-clipped bases, de Bruijn graph assembly is applied to select reads that form cycles, indicative of duplicated sequence structures. Reads from de Bruijn graph cycles are then assembled using an Overlap Layout Consensus (OLC) methodology thereby alleviating the collapse of repeat sequences affecting de Bruijn graph assembly approaches. Resulting OLC assembled contigs are locally aligned to the reference sequence to annotate the position of ITDs. ITD Assembler was run on The Cancer Genome Atlas (TCGA) acute myeloid leukemia (AML) dataset, and FLT3-ITD detection rates were compared against orthogonal algorithms. ITD Assembler identified the highest percentage of TCGA FLT3-ITDs, reported significantly higher allele fractions, and discovered additional ITDs in the KIT, CEBPA and WT1 cancer genes. Citation Format: Oliver A. Hampton, Navin Rustagi, Jie Li, Liu Xi, Richard A. Gibbs, Sharon E. Plon, Marek Kimmel, David A. Wheeler. ITD Assembler: An algorithm for internal tandem duplication discovery from short-read sequencing data. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4856. doi:10.1158/1538-7445.AM2015-4856

Genomon ITDetector: a tool for somatic internal tandem duplication detection from cancer genome sequencing data

Somatic internal tandem duplications (ITDs) are known to play important roles in cancer pathogenesis. Although recent advances in high-throughput sequencing technologies have enabled genome-wide detection of various types of genomic mutations, including single nucleotide variants, indels and structural variations, only a few studies have focused on ITDs. We have developed an analytical tool called 'Genomon ITDetector' for genome-wide detection of somatic ITDs. After evaluating the sensitivity and precision of the proposed approach using synthetic data, we have demonstrated that it can successfully detect not only common ITDs involving FLT3, but also a number of ITDs affecting other putative driver genes in acute myeloid leukemia exome sequencing data. Availability and implementaion: Genomon ITDetector is freely available at https://github.com/ken0-1n/Genomon-ITDetector.

Identification of emerging FLT3 ITD‐positive clones during clinical remission and kinetics of disease relapse in acute myeloid leukaemia with mutated nucleophosmin

FLT3 internal tandem duplication (ITD) mutations are frequently detected at diagnosis in cytogenetically normal acute myeloid leukaemia (CN-AML) and predict unfavourable outcome. FLT3 ITD is an unstable aberration and may be lost or acquired at relapse. Recent whole genome sequencing studies have suggested that FLT3 ITD(+)ve AML relapse may evolve from small subclones undetectable at diagnosis by routine polymerase chain reaction (PCR). We developed a patient-specific real-time quantitative-PCR (RQ-PCR) to implement FLT3 ITD detection in six AML patients whose blasts carried wild-type FLT3 at diagnosis and who relapsed with FLT3 ITD by routine PCR. Patient-specific forward primers were designed after cloning and sequencing the FLT3 ITD in each case. The assay allowed retrospective detection of FLT3 ITD in diagnostic samples of 4/6 cases and to establish the kinetics of clonal evolution preceding relapse. After conventional chemotherapy, all patients had early relapse despite having been classified as NPM1(+)ve/FLT3 ITD(-)ve at presentation, with shorter remissions being observed in four patients re-classified as FLT3 ITD(+)ve by the new assay. Notably, FLT3 ITD clone became detectable by conventional PCR in three patients tested during remission after initial treatment. Our data underscore the need of identifying low FLT3 ITD levels, which are probably associated with relapse in otherwise good prognosis CN-AML.

Detection of internal tandem duplications in the FLT3 gene by different electrophoretic methods

In acute myeloid leukemia (AML), the internal tandem duplication (ITD) in the juxtamembrane domain of the FLT3 (Fms-like tyrosine kinase 3) gene is one of the most frequent genetic alterations associated with poor prognosis. A complex evaluation of the analytical properties of the three most frequently used detection methods--PCR followed by agarose (AGE), polyacrylamide (PAGE) or capillary electrophoresis (CE)--was performed on 95 DNA samples obtained from 73 AML patients. All the three methods verified the presence of a mutant allele in 20 samples from 18 patients. AGE and PAGE could detect the presence of 1%-2% mutant allele, while the detection limit of CE was 0.28%. However, acceptable reproducibility (inter-assay CV <25%) of the mutant allele rate determination was only achievable above 1.5% mutant/total allele rate. The reproducibility of the ITD size determination by CE was much better, but the ITD size calculated by PeakScanner or GeneScan analysis was 7% lower as compared to values obtained by DNA sequencing. The presence of multiple ITD was over-estimated by PAGE and AGE due to the formation of heteroduplexes. This study suggests the use of PCR+CE in the diagnostics and the follow-up of AML patients. The data further supports the importance of proper analytical evaluation of home-made molecular biological diagnostic tests.

Overexpression of BAALC and MN1 Predict Worse Outcome in De Novo AML with Partial Tandem Duplication of MLL.

Abstract 1002Poster Board I-24 Background and purpose:Overexpression of BAALC, MN1, or ERG gene has been described to have adverse impact on the outcome of acute myeloid leukemia (AML) with normal karyotype. The majority of patients with partial tandem duplication of MLL gene (MLL-PTD) had normal karyotypes. The prognostic relevance of overexpression of these genes in MLL-PTD AML was not clear. Aims:We aimed to (1) measure the mRNA expression levels of FLT3, BAALC, FHIT, MN1, and ERG genes in AML patients with MLL-PTD (2) compare the expression levels of these genes with normal controls, and (3) determine their prognostic significance. Patients and methods:Bone marrow samples from 93 de novo AML patients with MLL-PTD at diagnosis were analyzed. MLL-PTD was screened by Southern blot analysis or reverse transcriptase polymerase chain reaction (RT-PCR) then confirmed by real-time quantitative PCR (RQ-PCR). RQ-PCR assay with TaqMan probe was performed to measure the expression of FLT3, BAALC, FHIT, MN1, and ERG genes in MLL-PTD AML as well as in 34 normal controls for comparison. The expression levels of target genes were calculated as the copy number of each gene normalized to the copy number of ABL control gene (NCN). Positive and negative controls as well as standard curve constructs were included in each assay. Mutational analysis was performed by DNA/cDNA PCR followed by GeneScan analysis for detection of internal tandem duplication of FLT3 gene (FLT3/ITD). The expression levels of each target genes were dichotomized at the median value to low and high expression groups. The event-free and overall survivals (EFS and OS) were compared between the 2 groups. Results:The expression levels of mRNAs for FLT3, BAALC, FHIT, MN1, and ERG genes at diagnosis in MLL-PTD AML and 34 normal controls are shown in Table.GeneMLL-PTDNCN/100 ABL(Mean±SE)ControlsNCN/100 ABL(Mean±SE)PFLT3703.4±59.663.6±6.9<0.001BAALC377.2±81.927.2±4.8<0.001FHIT36.5±4.426.9±3.50.089MN122.5±2.95.3±0.8<0.001ERG251.1±23.6147.2±22.90.012MLL-PTD patients had significantly higher expression levels of FLT3, BAALC, MN1, and ERG compared to normal controls. The expression of FHIT was also higher than that of controls, but did not reach statistic significance. FLT3/ITD was present in 26 of 52 patients (50%). The expression levels of the above genes were not different between patients with FLT3/ITD and those without. The median age of the entire cohort was 56 years. The median EFS and OS of the 52 patients who received standard induction chemotherapy were 5.8 and 11.4 months, respectively. The complete remission (CR) rate was higher in the low expression group than that of high expression group for BAALC (P = 0.011). The CR rate was not significantly different between low and high expression groups for FLT3, FHIT, MN1, or ERG, and between FLT3/ITD(+) and (-) groups. There were no significant difference in EFS or OS between patients with FLT3/ITD and those without. Patients with high expression of BAALC had a significantly shorter survival than those with low expression group; the median EFS was 10.3 mons (95% CI: 5.9-14.7 mons) vs. 0 mon, P = 0.044 and the median OS was 16.4 mons (95% CI: 8.3-25.5 mons) vs. 10.9 mons (95% CI: 6.5-15.3 mons), P = 0.031. Patients with high expression of MN1 also had a poor outcome compared with low expression group; the median EFS was 10.9 mons (95% CI: 0-28.3 mons) vs. 4.1 mons (95% CI: 0-11.7mons), P = 0.002 and the median OS was 29.7 mons (95% CI: 0-70.7mons) vs.11.0 mons (95% CI: 10.7-11.3 mons), P = 0.024. The EFS and OS were not significantly different between low and high expression groups for FLT3, BAALC, FHIT, and ERG. Conclusions:Our results showed that MLL-PTD was associated with overexpression of FLT3, BAALC, MN1, and ERG. The patients with lower expression level of BAALC had a higher CR rate and patients with overexpression of BAALC or MN1 had poor EFS and OS. FLT3/ITD had no prognostic impact.Supported by grants NSC97-2314-B-182 -011-MY3, NSC96-2314-B-195-006-MY3, and MMH-E-96009. Disclosures:No relevant conflicts of interest to declare.

Rapid and sensitive detection of internal tandem duplication and activating loop mutations of FLT3

Mutations of the FLT3 gene, a receptor tyrosine kinase, are the most frequent genetic alteration reported in acute myeloid leukaemia, with internal tandem duplications (ITD) or mutations within the activating loop (AL) reported at a frequency of around 24% and 6%, respectively. ITD mutations have associated with a poor prognosis. In this study we have used polymerase chain reaction (PCR), combined with restriction enzyme digestion for the detection of AL mutations, with the DNA products separated on the Agilent 2100 Bioanalyser using a DNA-500 kit. This analysis enabled the rapid identification of mutations in FLT3, approximate sizing of the ITD, an estimate of the proportion of mutant RNA and in some cases, specific heteroduplex patterns associated with triplet deletions. Our data shows that approximately 16% of the patients examined had an ITD mutation and over 13% had a mutation in the AL including triplet deletions involving codons 835/836 and point mutations in codon D839. Based on the sensitivity and speed of the bioanalyser, we suggest that this method is invaluable and provides an improvement to the current use of agarose gels for the analysis of FLT3 PCR products.

High-Resolution Melting Analysis for Detection of Internal Tandem Duplications

High-resolution melting analysis (HRMA) is a recently introduced closed-tube fluorescence-based method for rapid mutation screening and detection. However, all of the targets by which this technique has been validated thus far have had single-base substitutions, deletions, or similarly small mutational deviations from the wild-type sequence. In the current study, we sought to determine the feasibility of utilization of HRMA for the detection of larger sequence aberrations, using internal tandem duplications (ITD) in the juxtamembrane domain of the FLT3 gene as a model system. This gene is important in the growth and differentiation of hematopoietic progenitors and ITDs in this gene have been identified in a subset of poor-prognosis acute myelogenous leukemias (AML). DNA extracted from 62 AML samples was analyzed on a prototype high-resolution melting instrument. The samples interrogated for the FLT3 ITDs were subjected to post-amplification denaturation with frequent and regular fluorescence acquisition. The fluorescence versus temperature melting graphs generated were analyzed for deviation from the profiles reproducibly obtained for the wild-type samples. Results by HRMA were compared to results obtained using capillary electrophoresis-based fragment analysis, temperature gradient capillary electrophoresis detection, and sequencing of ITDs. FLT3 ITDs were detected in 13 of 62 AML samples with 100% concordance between the detection methods. This study demonstrates the utility of HRMA to rapidly and accurately screen samples for the presence of large sequence aberrations including FLT3 ITDs.