Impact of splicing mutations in acute myeloid leukemia treated with hypomethylating agents combined with venetoclax

Spliceosome mutations (SRSF2, SF3B1, U2AF1, ZRSR2), are encountered in;50% of secondary acute myeloid leukemia cases (sAML) and define a molecular subgroup with outcomes similar to sAML in de novo AML patients treated with intensive chemotherapy. Outcomes in patients with spliceosome mutations treated with hypomethylating agents in combination with venetoclax (HMA1VEN) remains unknown. The primary objective was to compare outcomes in patients with spliceosome mutations vs wild-type patients treated with HMA1VEN. Secondary objectives included analysis of the mutational landscape of the spliceosome cohort and assessing the impact of co-occurring mutations. We performed a retrospective cohort analysis of patients treated with HMA1VEN–based regimens at The University of Texas MD Anderson Cancer Center. A total of 119 patients (spliceosome mutated n 5 39 [SRSF2, n 5 24; SF3B1, n 5 8; U2AF1, n 5 7]; wild-type, n 5 80) were included. Similar responses were observed between spliceosome and wild-type cohorts for composite complete response (CRc; 79% vs 75%, P 5 .65), and measurable residual disease–negative CRc (48% vs 60%, P 5 .34). Median overall survival for spliceosome vs wild-type patients was 35 vs 14 months (P 5 .58), and was not reached; 35 months and 8 months for patients with SRSF2, SF3B1, and U2AF1 mutations, respectively. IDH2 mutations were enriched in patients with SRSF2 mutations and associated with favorable outcomes (1- and 2-year overall survival [OS] of 100% and 88%). RAS mutations were enriched in patients with U2AF1 mutations and associated with inferior outcomes (median OS, 8 months). Comparable outcomes were observed between patients with vs without spliceosome mutations treated with HMA1VEN regimens, with specific co-mutation pairs demonstrating favorable outcomes.