Prognostic impact of age and MDS-associated mutations in NPM1 -mutated AML.

Nucleophosmin-1 ( NPM1 ) mutations define a major molecular subtype of acute myeloid leukemia (AML) and is generally associated with favorable prognosis. However, the impact of myelodysplasia-associated mutations (MDSm+) on patient outcomes within this subgroup remains uncertain. We retrospectively analyzed 271 NPM1 -mutated AML patients from three independent cohorts (SWOG, Fred Hutch, and Beat AML) to assess the prognostic significance of MDSm+ and its interaction with age. MDSm+ occurred in 17% of cases, most commonly involving SRSF2 and SF3B1 . Although MDSm+ was associated with inferior overall survival compared to MDSm-in ELN2022 favorable-risk patients (HR 2.0, p =0.008), this effect was largely driven by worse outcomes in older patients ( ≥ 65 years) as older ELN22 favorable-risk patients had poor OS regardless of presence of MDSm+ compared to younger patients. After stratification of patients by age, there was not a significant difference between MDSm+ and MDSm-in either younger patients (HR 0.99, p=0.98) or older patients (HR 1.42, p =0.33). These findings indicate that MDSm+ in NPM1 + AML is not independently associated with adverse risk after adjusting for age and highlight the need for age-adjusted AML risk models.