IntroductionThe prevalence and significance of several genetic abnormalities in patients with acute myeloid leukemia (AML) have been reported. The most powerful prognostic factor in AML has been the karyotype of the leukemia cells. 1 Three cytogenetic risk groups (favorable, intermediate, and poor) are widely accepted, but there is a practical limitation to the definition of cytogenetic risk, especially in patients falling in the intermediate group. Additional prognostic factors are therefore required. It has been reported that abnormalities in the RAS and p53 genes as well as the FLT3 gene are implicated in the pathogenesis of AML. [2][3][4][5][6][7] Mutations in FLT3, RAS, and p53 have been found in approximately 30%, 20%, and 5% to 10% of adult AML cases, respectively, indicating that mutations in these 3 genes are the most frequent genetic alterations in AML.We and several groups have demonstrated that FLT3 mutations are a strong prognostic factor in AML. [8][9][10][11][12][13][14][15][16][17][18] To date, several large-scale analyses have revealed that FLT3 mutations are essentially found in myeloid-lineage leukemia cells. 16,19,20 However, FLT3 mutations within an activation-loop were found in 5 of 30 acute lymphoblastic leukemia (ALL) cases with mixed-lineage leukemia (MLL) gene-rearranged ALL. 21 It is notable that FLT3 was highly expressed in MLL gene-rearranged ALL, leading to the constitutive activation of wild-type FLT3 kinase, and that primary ALL cells and an ALL cell line SEMK2-M1, which strongly expressed FLT3 but did not carry FLT3 mutations, had the same sensitivity to a potent FLT3 inhibitor as leukemia cells and a cell line with FLT3 mutations. 21,22 FLT3 is preferentially expressed on hematopoietic stem cells as well as in the brain, placenta, and liver. 23,24 The ligand to FLT3 (FL) is expressed as a membrane-bound or soluble form by bone marrow stroma cells and stimulates the stem cells alone or in cooperation with other cytokines. 25-32 FL-FLT3 interaction, therefore, plays an important role in the survival, proliferation, and differentiation of stem cells. In FLT3-expressing leukemia cells, FL stimulation enhances proliferation and reduces apoptosis.Although FLT3 is expressed on the surface of a high proportion of AML cells as well as B-lineage ALL cells, [33][34][35][36][37] little is known about the clinical significance of the FLT3 expression level in acute leukemia. In this study, we analyzed the expression level of the FLT3 transcript quantitatively in comparison with several gene alterations in 181 de novo AML cases. Because the prevalence of the MLL gene rearrangement is lower in adult de novo AML than in therapy-related AML and in infant or childhood acute leukemia, the From the Department of Infectious Diseases and the Department of Hematology, Nagoya University School of Medicine, Japan; the Department of Medicine, Japanese Red Cross Nagoya First Hospital; the Department of Medicine, Saiseikai Maebashi Hospital, Japan; the Research and Development Center for Higher Education, N...