Clinical Significance of Dynamic Monitoring of EVI1 Gene Expression in Pediatric Acute Myeloid Leukemia

Clinical Significance of Dynamic Monitoring of EVI1 Gene Expression in Pediatric Acute Myeloid Leukemia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Significance of Dynamic Monitoring of EVI1 Gene Expression in Pediatric Acute Myeloid Leukemia Lan-Nan Zhang, Jian-Xin Li, Zhuo Wang, Li Yang, Zhi Chen, Fang Tao, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4490141/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Dec, 2024 Read the published version in BMC Pediatrics → Version 1 posted 12 You are reading this latest preprint version Abstract Objective To investigate the clinical significance of dynamic monitoring ecotropic virus integration site-1 (EVI1) expression in childhood acute myeloid leukemia (AML). Methods A retrospective analysis was conducted on 113 pediatric AML patients of Wuhan Children's Hospital from 2014 to 2022. The correlation between EVI1 expression levels and clinical indicators including clinical characteristics, first complete remission (CR1), relapse, and overall survival (OS) was analyzed. Receiver operating characteristic (ROC) curve analysis was carried out to comprehend the influence of EVI1 expression on relapse. Results A total of 78 AML children with EVI1 expression at initial diagnosis were eligible, divided into EVI1-positive (EVI1 high ) and EVI1-negative (EVI1 low ) groups. FAB classification (P = 0.047) and abnormal karyotype (P = 0.009) showed significant differences between the two groups. The proportion of EVI1 high in individuals with complex and/or monomeric karyotypes was significantly higher than in other cases (P = 0.032). When completing the first induction therapy, the EVI1high group showed a significantly lower CR1 rate than the EVI1low group (P = 0.015). Among 51 cases with EVI1 expression dynamically monitored, those with EVI1 overexpression more than twice had significantly shorter OS (P < 0.05). Among 19 non-HSCT patients undergoing three EVI1 assessments during induction therapy, those with EVI1 overexpression over once had higher relapse rates (P = 0.045). In addition, EVI1 expression level ≥ 83.38% significantly predicted relapse (AUC = 0.833). Conclusion Aberrantly high expression of EVI1 in pediatric AML was associated with poor prognosis. Continuous and dynamic monitoring of EVI1 expression promotes prognostic evaluation. We add some insights into the impact of EVI1 on the AML patients’ OS and survival. Ecotropic virus integration site-1 Acute myeloid leukemia Relapse Dynamic monitoring Pediatrics Allogeneic hematopoietic stem cell transplantation Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Ecotropic viral integration site-1 (EVI1), an oncogenic zinc finger transcriptional regulator encoded at the MECOM locus in 3q26.2, is essential in the maintenance of hematopoietic stem cell (HSC) function, chromatin remodeling, and development of myeloid neoplastic diseases [ 1 – 2 ] . With its two zinc finger domains ZF1 and ZF2, EVI1 can recognize and bind DNA to function as a transcriptional repressor [ 3 ] . In addition, EVI1 can regulate transcription, signaling, and modifications by interacting with proteins and protein complexes [ 4 ] . Within the hematopoietic system, EVI1 expression is restricted to long-term and short-term HSCs and pivotal for the hematopoietic homeostasis which refers to the differentiation and self-renewal capacity of HSCs [ 5 – 7 ] . Some target genes, such as GATA2, PBX1, PTEN and ERG, might be relevant to EVI1’s oncogenic properties and leukemogenesis [ 8 – 11 ] . EVI1, cooperating with its targets, can pave the way for the leukemic transformation of HSCs and arrest leukemia cells in a stem cell-like state [ 11 ] . Acute myeloid leukemia (AML) is a group of hematological malignancies with high genetic heterogeneity. EVI1 overexpression is present in 8–10% of adult AML and is an independent risk factor of poor prognosis. However, the threshold for high expression of EVI1 and its role in prognosis during childhood AML have not been clearly elucidated [ 2 , 11 – 12 ] . Although allogeneic hematopoietic stem cell transplantation (allo-HSCT) yields a high rate of curability for AML, whether pediatric AML patients with EVI1 overexpression could benefit from HSCT in first complete remission (CR1) calls for further research [ 1 , 12 ] . The purpose of this study is to collect clinical data of AML children who were initially diagnosed in our single center, and to retrospectively analyze the dynamic changes in the expression of EVI1 gene before and after treatment, so as to explore the significance of EVI1 gene in the treatment and prognosis of AML in children. MATERIALS AND METHODS Patients A total of eighty-two newly diagnosed children with AML admitted to the Department of Hematology, Wuhan Children's Hospital from April 2014 to April 2021. All patients were confirmed by morphological, flow cytometric, cytogenetic, and molecular examinations, and complete medical history could be traced. The diagnosis of childhood AML was based on the World Health Organization (2016) classification [ 13 ] . The follow-up cut-off date was December 1, 2021. All the diagnostic methods and chemotherapy regimens conform to the principles outlined in the Declaration of Helsinki. This study was approved for execution by the Ethics Committee of Wuhan Women's and Children's Health Care Center. Informed written consent was obtained from the parents or guardians as appropriate. Inclusion criteria were as follows: performing EVI1 gene expression analysis at initial diagnosis and/or over 6 consecutive times during the course of the disease, and the assessment point for EVI1 expression analysis was the same as the bone marrow puncture time point for evaluating AML, i.e., after each chemotherapy course at initial diagnosis, and before the next chemotherapy course when the bone marrow recovery. The complete treatment flow and bone puncture assessment time points were shown in Fig. 1 . We excluded patients with acute promyelocytic leukemia. The clinical data of the eligible patients were collected, consisting of routine blood and the above-mentioned comprehensive examination data at initial diagnosis, remission during induction therapy phase, treatment modality, as well as the specific time of relapse and survival. Treatment Regimens Chemotherapy All enrolled children were classified as low-, intermediate-, or high-risk according to CCLG-AML-2015/2019 protocol (provided in Supplementary Data) after completing the above-mentioned comprehensive examinations, and the course of disease during treatment was dynamically evaluated based on minimal residual disease (MRD) and genetic testing [ 14 ] . With the informed consent of the parents, children received AML chemotherapy regimen based on "7 + 3" of daurorubicin (40mg/m2 QOD on D1, D3, D5) and cytarabine (100mg/m2 Q12H on D1-7). In addition to the two medicines, etoposide (100mg/m2 QD on D1-5) or homoharringtonine (3mg/m2 QD on D1-5) was randomly adopted in the treatment. Specifically, those admitted in 2014 received the DAE regimen in the first course, while those admitted chemotherapy in 2015 and later received the CCLG-AML-2015 [ 15 ] and CCLG-AML-2019 regimens. In addition, FLAG [ 16 ] , decitabine + venetoclax [ 17 ] were administered for relapsed or refractory cases. Allo-HSCT For children at high-risk of AML, allo-HSCT was feasible after 2–3 courses of chemotherapy if a suitable donor was available. EVI1 Gene Expression Testing The bone marrow samples were evaluated after each chemotherapy course and before the start of the next chemotherapy course, and EVI1 gene expression analysis was performed at each bone marrow evaluation. Children without testing EVI1 expression at initial diagnosis underwent EVI1 gene expression testing at least 6 times during the course of the first treatment. Children with at least 2–3 courses of chemotherapy pre-transplantation would complete 3–4 bone marrow evaluations and EVI1 testing, followed by monthly bone marrow evaluation and EVI1 testing within 6 months post-transplantation. EVI1 gene expression analysis was performed on 2 ml EDTA-sodium anticoagulated bone marrow samples at Wuhan Kindstar Medical Laboratory Co., Ltd. Monocytes of the bone marrow was isolated by the Ficoll method and total RNA was extracted using the Trizol Reagent (Invitrogen, Carlsbad, CA, USA). EVI1 gene expression level was detected by Taqman probe fluorescence real-time quantitative PCR using ABL1 as the internal standard, expressed as a percentage. The EVI1 primers and probe are as follows: EVI1 Forward primer 5'-GTACTTGAGCCAGCTTCCAACA-3', EVI1 Reverse primer 5'-CTTCTTGACTAAAGCCCTTGGA-3', EVI1 Probe 5'-FAM-TCTTAGACGAATTTTACAATGTGAAGTTCTGCATAGATG-BHQ1-3'. Statistical Analysis EVI1 expression level above 75% was defined as EVI1-positive (EVI1 high ) based on literature [ 18 ] , which meant EVI1 overexpression. CR was defined as good myeloproliferation with less than 5% of primitive cells. CR1 was defined as the CR after the first course of induction therapy. Relapse was defined as the reappearance of leukemic cells in the peripheral blood or ≥ 5% of primitive cells in bone marrow (except for other reasons such as bone marrow regeneration after consolidation chemotherapy) or extramedullary leukemic cell infiltration after CR of AML. Overall survival (OS) was defined as the time from diagnosis of AML until death from any cause. All analyses were conducted using SPSS version 20.0. The measured values were expressed as mean ± standard deviation, and the counting data were represented by absolute numbers and percentages. Independent sample t-test was used to compare the continuous variables, and Chi-square test or Fisher's exact test was used to compare the categorical variables. Kaplan-Meier method and Cox regression analysis were used for survival analysis. P < 0.05 was considered to indicate a statistically significant difference. RESULTS Clinical Data of Children Initially Diagnosed with AML Clinical data analysis of different levels of EVI1 gene expression A total of 78 AML children have undergone EVI1 gene expression analysis at initial diagnosis, including 36 males (46.2%) and 42 females (53.8%), with a median age of 4.96 (range 0.5–15.5) years. According to the FAB classification criteria, they were classified as M0 (n = 4; 5.1%), M1 (n = 1; 1.3%), M2 (n = 30; 38.5%), M4 (n = 9; 11.5%), M5 (n = 23; 29.5%), M7 (n = 8; 10.2%), AML (n = 2; 2.6%), as well as myelodysplastic syndrome (MDS)/AML (n = 1; 1.3%). In addition, 4 cases were not tested for EVI1 expression at initial diagnosis but were continuously tested over 6 times during the subsequent disease process (Fig. 2 ), thus included in the analysis. Among the 81 eligible patients, 19 cases (24.35%) of them showed high expression of EVI1. The baseline information was summarized in Table 1 . Table 1 General clinical information and characteristics of 78 children with newly diagnosed AML Characteristics EVI1 high group (n = 19) EVI1 low group (n = 59) t /χ2 P value Age a 5.03 ± 4.48 (0.5-14.08) 4.97 ± 3.98 (0.5–15.5) 0.094 0.95 Gender 0.015 0.859 Male 9 (47.4%) 27 (45.8%) Female 10 (52.6%) 32 (54.2%) FAB classification c 9.663 0.047 M0 3 (15.8%) 1 (1.7%) - 0.043 M1 - 1 (1.7%) - - M2 4 (21.1%) 26 (44.1%) 3.216 0.073 M4 1 (5.3%) 8 (13.6%) 0.327 0.568 M5 8 (42.1%) 15 (25.4%) 1.923 0.165 M7 3 (15.8%) 5 (8.5%) 0.230 0.632 AML - 2 (3.4%) - - MDS-AML - 1 (1.7%) - - Cytogenetics c 10.595 0.009 NK b 6 (31.6%) 19 (32.2%) 0.003 0.960 t(8; 21) 1 (5.3%) 14 (23.7%) 2.078 0.149 CK b or MK b 8 (42.1%) 9 (15.3%) 4.606 0.032 -7 2 (10.5%) - - 0.057 Others 2 (10.5%) 16 (27.1%) 1.392 0.238 Fusion genes c 0.279 0.597 AML1-ETO 1 (5.3%) 14 (23.7%) 2.078 0.149 Negative 11 (57.9% 23 (39.0%) 2.090 0.148 MLL-related 5 (26.3%) 10 (17.0%) 0.321 0.571 Others 2 (10.5%) 12 (20.3%) 0.391 0.532 Gene mutations c 1.772 0.186 NPM1 1/18 (5.55%) 2/57(3.5%) - 0.567 DNMT3A 4/18(22.22%) 1/57(1.7%) - 0.011 FLT3-ITD 1/18(5.55%) 3/57(5.26%) - 1.000 TP53 2/18(11.11%) 1/57(1.75%) - 0.141 a Described as the median ± standard error and range. b MK, monosomal karyotype; CK, complex karyotype; NK, normal karyotype. c All the frequency data were analyzed by Nonparametric Test (Chi-Square test, Fisher’s exact test, and K Independent Samples Test). EVI1 gene expression analysis revealed significant differences in FAB classification ( P = 0.047) and abnormal karyotype ( P = 0.009) between EVI1 high and EVI1 low groups at initial diagnosis. Specifically, compared to EVI1 low group, the EVI1 high group exhibited a higher proportion of M0, M5, and M7, a significantly higher proportion of complex karyotype (CK) or monosomal karyotype (MK) (42.1% vs. 15.0%, P = 0.032), as well as a higher proportion of KMT2A-related abnormalities (26.3% vs. 16.7%). -7 was only found in the EVI1 high group (10.5% vs. 0%). No 3q26-related abnormalities were found in all enrolled patients. Referring to the gene mutations, the incidence of DNMT3A mutation was higher in EVI1 high patients (22.2% vs. 1.7%, P = 0.011). While, NPM1, FLT3-ITD, and TP53 mutations had no relevance to the EVI1 expression. What’s more, no significant differences were observed between the two groups in terms of gender, age at onset, blood cell count at initial diagnosis, and percentage of bone marrow naïve cells, molecular abnormalities, and risk at initial diagnosis (Table 1 ). Based on immunophenotyping analysis, when comparing the surface marker antigen expression, CD56- ( P = 0.006) and CD36+ ( P = 0.002) were found to be predominant in the EVI1 high group in comparison to the EVI1 low group, with statistically significant differences (Table 2 ). Table 2 Correlations of EVI1 expression level with WBC, HGB, PLT, bone marrow blasts, cell markers, CR1 rate, and survive or not after HSCT. Characteristics EVI1 high group (n = 19) EVI1 low group (n = 59) a t /χ2 P value EVI1 expression a 92.68 ± 6.84%(76.99–99.9%) 10.28 ± 14.92%(0.28–70.74%) 23.325 < 0.01 The first B-RT WBC (10 9 /L) a 31.77 ± 41.84 (4.82-186.99) 39.76 ± 55.23(1.31-293.61) − .579 0.565 HGB (g/L) a 83.36 ± 23.77(42.0-130.0) 76.89 ± 25.51 (21.6–128) 0.978 0.331 PLT (10 9 /L) a 4.0-1302.0 (20,103) 1.0-333.0 (27.83) 0.794 0.437 Blasts in BM b 54.19% (20.4–94%) 61.72% (12–95%) -1.317 0.192 Antigen c CD36 6 (31.6%) 2 (3.3%) 9.534 0.002 CD56 4 (21.1%) 34 (56.7%) 7.695 0.006 CR or not after induction 1st 9.432 0.015 Yes 12(63.16%) 43(72.88%) No 2(10.52%) 11(18.64%) Missing or dead 5(26.32%) 5(8.47%) Survive or not after HSCT 0.444 survive 6 20 death 1 1 Overal survival a (45, 876) (295, 1212) 0.338 a Described as the median ± standard error and 95%CI or (lower quartile, upper quartile ). b All the frequency data were analyzed by Nonparametric Test (Chi-Square test, Fisher’s exact test, and K Independent Samples Test). Therapeutic response and prognosis After the first course of induction chemotherapy, in the EVI1 high group, 12 cases achieved CR, 2 cases reached partial response (PR), and 5 cases abandoned treatment, with a CR1 rate of 63.1%. Among them, 7 underwent allo-HSCT treatment (6 survived and 1 died for extramedullary relapse). Until the end of follow-up, a total of 8 patients survived, 6 died, and 5 dropped out, with the quartile of overal survival (OS) (45, 876) days. By comparison, there were 43 cases of CR, 1 of PR, 10 of no response (NR), and 5 of abandonment in the EVI1 low group, with the CR1 rate of 73.3%. 21 of them were treated with allo-HSCT (20 survived and 1 died for bronchiolitis obliterans). There were 36 cases alive, 16 dead, and 7 lost to visit at the last follow-up, with the quartile of OS (295, 1212) days (Table 2 ). After the first course of treatment, the incidence of CR1 in the EVI1 high group was significantly lower than that in the EVI1 low group ( P = 0.015), whereas no significant difference was found in relapse incidence, survival incidence, and OS (Table 2 ). However, multivariate Cox regression analysis was adopted to explore factors which can influence the OS. Between the EVI1 high patients and EVI1 low patients, we found that not EVI1 expression, mutated genes, age, WBC, but MRD1 ( P = 0.001),,cytogenetics ( P = 0.000), and HSCT ( P = 0.004),were the key factors related to OS and survival (Table 3 ). Table 3 Cox regression analysis of the OS for 79 pediatric AML patients Characteristics RR 95%CI for RR P value EVI1 expression 2.559 0.739–9.146 0.137 MRD1 0.001 negative 9.628 2.276–40.729 0.002 positive 0.375 0.093–1.522 0.170 Cytogenetics (CK or MK or not ) 17.430 4.037–75.251 0.000 Fusion genes 0.067 MLL-related 0.151 0.022–1.046 0.056 AML1-ETO 5.769 1.053–31.617 0.043 Other or without fusion genes 4.272 0.793–23.006 0.091 HSCT or not 16.337 2.5-106.770 0.004 Significance of dynamic monitoring of EVI1 expression A total of 51 children with AML were continuously and dynamically tested for EVI1 expression during the course of their disease. 47 were continuously monitored for EVI1 expression at initial diagnosis and throughout their disease courses, and 4 children without EVI1 expression analysis at initial diagnosis received continuously testing for EVI1 expression ≥ 6 times after the first treatment, as mentioned above. Effect of EVI1 expression on AML relapse in the non-HSCT group At the initial diagnosis, after “induction therapy 1” (evaluation of CR1) and “induction therapy 2” (evaluation of CR2) were completed, a total of 3 bone marrow evaluations were conducted, and EVI1 expression analysis was performed 3 consecutive times. There were 11 non-HSCT cases with positive EVI1 expression more than once in the first 3 times, of which 5 relapsed; whereas no relapse occurred in the 8 non-HSCT cases with negative EVI1 expression in the first 3 times, with a significant statistical difference ( P = 0.045) (Table 4 ). Similarly, the 6 non-HSCT cases with positive EVI1 expression more than twice in the first 5 times included 3 relapsed cases, and 2 relapsed among 13 non-HSCT cases with positive EVI1 expression below once in the first 3 times, without a significant difference ( P = 0.262) (Table 4 ). Table 4 Correlations of dynamic monitoring EVI1 expression with relapse rate in the AML patients with no HSCT Total (No.) Relapse (No.) t /χ 2 2 P The first three EVI1 expression levels * 6.742 0.045 EVI1 high ≥ 1 time 11 5 EVI1 high = 0 time 8 0 The first five EVI1 expression levels # 2.421 0.262 EVI1 high ≥ 2 times 6 3 EVI1 high ≤ 1 time 13 2 ROC curve analysis revealed that the EVI1 expression level ≥ 83.38% significantly predicted relapse, with an area under the curve (AUC) of 0.833 (sensitivity, 85.7%; specificity, 83.3%; Youden index, 0.69), as seen in Fig. 3 . Effect of EVI1 gene expression on OS Among the 47 children with AML in whom EVI1 expression analysis was performed at initial diagnosis and during the subsequent course of the disease, with 14 persistent EVI1 low and 33 EVI1 high over once during the course of the disease. Children with ≥ 1 EVI1 high had a shorter OS than those with EVI1 low (χ = 3.81, P = 0.051) (Fig. 4 A ) . In total, 43 children were analyzed for EVI1 expression on three consecutive occasions, including 9 children with EVI1 high more than twice, 12 children with EVI1 high of once, and 22 children with EVI1 low , after a total of three bone marrow evaluations at initial diagnosis and after completion of “induction therapy 1” and “induction therapy 2”. Differences in OS between the three groups were found to be significantly shorter in the EVI1 high ≥ 2 times group than that in the EVI1 low group (χ = 4.852, P = 0.028) (Fig. 4 B ) . A total of 6 bone marrow assessments, performed at initial diagnosis and during the 5 chemotherapy courses of induction plus consolidation therapy, were completed in 36 cases with 6 consecutive EVI1 gene expression assessments, 12 cases with EVI1 high more than twice, and the remaining 24 cases with EVI1 high below once. Comparing the OS of the two groups, it was found that the OS of the EVI1 high ≥ 2 times group was significantly lower than that of the EVI1 high ≤ 1 time group (χ = 5.779, P = 0.016) (Fig. 4 C ) . Children with continuous dynamic monitoring of EVI1 expression during the course of the disease had significantly shorter OS than the EVI1 low group if EVI1 high was present ≥ 2 times and sequentially (χ = 4.098, P = 0.043) (Fig. 4 D). DISCUSSION With advances in technologies such as gene sequencing and flow cytometric analysis, the World Health Organization's precise diagnostic grading and prognostic assessment of AML based on abnormal molecular genetic alterations is updated year by year, which in turn guides the selection of treatment options and improves survival. Structural abnormalities of chromosome 3q26 and the corresponding high expression and functional alterations of EVI1 gene are factors of poor prognosis in AML. The proportions of EVI1 overexpression in pediatric AML patients range from 9–23.5%, and its prognostic significance remains poorly understood [ 1 , 12 , 19 – 23 ] . In this study, we retrospectively analyzed the clinical data of AML children in our center and found that EVI1 expression levels were indicative for the prognosis of AML children, and the percentage of high EVI1 expression at initial diagnosis of AML was about 24.35%, which correlated with lower CR1 rate and poor OS; high EVI1 expression at the induction treatment stage predicted higher incidence of relapse, and continuous dynamic monitoring of EVI1 with multiple high expression or successive. OS was significantly shortened when EVI1 high expression was monitored continuously and dynamically. Abnormally high expression of EVI1 can block granulocytic differentiation of hematopoietic stem cells, resulting in impaired maturation and enhanced proliferation of stem cells leading to leukemia [ 2 ] . The present study showed the significant difference of FAB classification between the EVI1 high and EVI1 low groups at initial diagnosis; subsequently, the proportion of M0 in the EVI1 high group was greater than that in the EVI1 low group, which suggested that the abnormal biological function of EVI1 may be related to the degree of differentiation of AML cells. In addition, EVI1 high may be related to specific karyotypic alterations, especially in MK and/or CK. When using Cox regression analysis to explore the impact factors on OS and survival, we found that not the EVI1 gene expression but the cytogenetic abnormalities (especially CK and/or MK) and HSCT were of great importance. Although we found a significant difference between CD56- and CD36 + in the EVI1 high and EVI1 low groups, their significance in AML is currently unknown. It is reported that CD56 is mainly expressed on the surface of natural killer cells, and its high expression is a sign of poor prognosis in AML [ 24 , 25 ] . Research shows that CD36 may participate in AML cell resistance to cytarabine and tumor microenvironment energy supply to leukemia cells by regulating the lipid metabolism process of leukemic cells [ 26 , 27 ] . Further investigation is needed to determine whether CD56 and CD36 suggest that leukemic cells also undergo "self-interest" regulation in lipid metabolism. Allo-HSCT significantly improves long-term survival expectations for children with high-risk AML, but the optimal timing of transplantation remains a hot topic of current research [ 28 , 29 ] . This study suggested that the incidence of relapse was significantly increased if EVI1 high and children did not underwent HSCT during a total of 3 bone marrow evaluations performed from the initial diagnosis to the end of induction chemotherapy ( P = 0.045); and EVI1 expression ≥ 83.38% had a good predictive value for relapse. OS was significantly shorter ( P < 0.05) in children with AML with ≥ 2 EVI1 high or persistently high EVI1 expression (i.e., ≥ 2 successive high expressions) during induction and/or consolidation phases of treatment. Further monitoring revealed that even high EVI1 expression did not produce a significantly effect on OS after HSCT in children with AML ( P = 0.48), which may be related to the graft-versus-leukemia (GVL) effect of HSCT, which may contribute to the depth and sustained clearance of MRD in AML patients [ 30 ] . Therefore, dynamic monitoring of EVI1 expression during the induction and consolidation phases of treatment in children with AML can help to predict OS, especially the first 3 EVI1 expressions or help to determine the timing of transplantation; secondly, the need to undergo EVI1 testing is significantly reduced in children with AML after HSCT. CONCLUSION In conclusion, childhood AML with EVI1 high expression typically exhibit high-risk karyotypes such as CK, MK, or -7, more commonly in M0, with a low CR1 rate and high risk of relapse, which is necessary to be considered as one of the poor prognostic factors for such patients. Declarations Data Availability ALL source data will be made available by corresponding author upon request. Conflict if interest statement The authors declare that they have no conflict of interest. Ethics statement The studies involving human participants were reviewed and approved by the Wuhan Women's and Children's Health Care Center Ethics Committee. Written informed consent to participate in this study was provided by the participants’ legal guardian. Funding This study was funded by the Natural Science Foundation of Hubei Province in China (No. 2019CFB368 and 2020CFB364), the Applied Basic Frontier Special Project of Wuhan (No. 2020020601012319), and the Wuhan Municipal Commission of Health (Nos. WX21D60, WX21Z4, and WX20D20). References Paredes R, Doleschall N, Connors K, et al. EVI1 protein interaction dynamics: Targetable for therapeutic intervention?[J]. Exp Hematol, 2022. 107: 1-8. Birdwell C, Fiskus W, Kadia TM, et al. EVI1 dysregulation: impact on biology and therapy of myeloid malignancies[J]. Blood Cancer J, 2021, 11(3): 64. Bartholomew C, Kilbey A, Clark AM, et al. The Evi-1 proto-oncogene encodes a transcriptional repressor activity associated with transformation[J]. Oncogene. 1997.14(5):569-577. White DJ, Unwin RD, Bindels E, et al. 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Clinical significance of EVI-1 gene expression and aberrations in patient with de-novo acute myeloid and acute lymphoid leukemia[J]. Leuk Res, 2023 Mar;126:107019. Chen C, Chio CL, Zeng H, et al. High expression of CD56 may be associated with favorable overall survival in intermediate-risk acute myeloid leukemia[J]. Hematology, 2021. 26(1): 210-214. Iriyama N, Hatta Y, Takeuchi J, et al. CD56 expression is an independent prognostic factor for relapse in acute myeloid leukemia with t(8;21)[J]. Leuk Res, 2013. 37(9): 1021-1026. Panda D, Chatterjee G, Sardana R, et al. Utility of CD36 as a novel addition to the immunophenotypic signature of RAM-phenotype acute myeloid leukemia and study of its clinicopathological characteristics[J]. Cytometry B Clin Cytom, 2021. 100(2): 206-217. Hoch REE, Cóser VM, Santos IS, et al. Lymphoid markers predict prognosis of pediatric and adolescent acute myeloid leukemia[J]. Leuk Res, 2021. 107: 106603. Quessada J, Cuccuini W, Saultier P, et al. Cytogenetics of Pediatric Acute Myeloid Leukemia: A Review of the Current Knowledge[J]. Genes (Basel), 2021. 12(6): 924. Reedijk AMJ, Klein K, Coebergh JWW, et al. Improved survival for children and young adolescents with acute myeloid leukemia: a Dutch study on incidence, survival and mortality[J]. Leukemia, 2019. 33(6): 1349-1359. Duan WB, Gong LZ, Jia JS, et al. Clinical features and early treatment effects in intermediate risk and poor risk acute myeloid leukemia with EVI1 positive[J]. Beijing Da Xue Xue Bao Yi Xue Ban, 2017. 49(6): 990-995. Supplementary Data Supplementary Data is not available with this version Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Dec, 2024 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 16 Jul, 2024 Reviews received at journal 14 Jul, 2024 Reviews received at journal 12 Jul, 2024 Reviewers agreed at journal 11 Jul, 2024 Reviewers agreed at journal 09 Jul, 2024 Reviewers agreed at journal 27 Jun, 2024 Reviewers agreed at journal 22 Jun, 2024 Reviewers invited by journal 22 Jun, 2024 Editor invited by journal 21 Jun, 2024 Editor assigned by journal 16 Jun, 2024 Submission checks completed at journal 16 Jun, 2024 First submitted to journal 28 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4490141","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":320842063,"identity":"18963ff9-d460-4bfb-a0fc-7be1a0909652","order_by":0,"name":"Lan-Nan Zhang","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Lan-Nan","middleName":"","lastName":"Zhang","suffix":""},{"id":320842064,"identity":"c263074a-3303-4dec-951a-d271d8b921e9","order_by":1,"name":"Jian-Xin Li","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Jian-Xin","middleName":"","lastName":"Li","suffix":""},{"id":320842065,"identity":"13b24a78-e9af-4d5b-934f-5a011444aa2f","order_by":2,"name":"Zhuo Wang","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Zhuo","middleName":"","lastName":"Wang","suffix":""},{"id":320842066,"identity":"38ecd23f-ad40-44fe-9361-f4584c76efee","order_by":3,"name":"Li Yang","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Yang","suffix":""},{"id":320842067,"identity":"ee0d1c18-6108-4796-9b65-35b48d63c8d8","order_by":4,"name":"Zhi Chen","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Zhi","middleName":"","lastName":"Chen","suffix":""},{"id":320842068,"identity":"5ef7f852-105a-462d-b597-921c7f34207f","order_by":5,"name":"Fang Tao","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Fang","middleName":"","lastName":"Tao","suffix":""},{"id":320842069,"identity":"d510ea12-0c4a-4b27-80b1-188faf0004c5","order_by":6,"name":"Sha Wu","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Sha","middleName":"","lastName":"Wu","suffix":""},{"id":320842070,"identity":"b0f0e333-61d4-4716-a155-4f87e3751ede","order_by":7,"name":"Wen-Jie Lu","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Wen-Jie","middleName":"","lastName":"Lu","suffix":""},{"id":320842071,"identity":"f564ee9e-5439-4e1d-82d1-7cfc168b21ba","order_by":8,"name":"Ming Sun","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Ming","middleName":"","lastName":"Sun","suffix":""},{"id":320842072,"identity":"2b46ea2a-c253-490b-a47b-f12a9ae375e3","order_by":9,"name":"Shan-Shan Qi","email":"","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":false,"prefix":"","firstName":"Shan-Shan","middleName":"","lastName":"Qi","suffix":""},{"id":320842073,"identity":"d3375c19-6f42-4ab1-828a-407550cdd909","order_by":10,"name":"Zhong-Zheng Zheng","email":"","orcid":"","institution":"Shanghai Tissuebank Biotechnology Co., Ltd","correspondingAuthor":false,"prefix":"","firstName":"Zhong-Zheng","middleName":"","lastName":"Zheng","suffix":""},{"id":320842074,"identity":"54492db4-f558-4f92-9af4-d3796732410f","order_by":11,"name":"Hao Xiong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3klEQVRIiWNgGAWjYDACZiBmbGBg4AezbUjRItkAYqcRaxNIi8EBYrUYHGc+9vDrDjs54/PHr0kXJNgw8Ld3J+DVItnMlm4seybZ2OzAmTLpGQlpDBJnzm7Aq4WfmcdMWrKNOXHbwZ6027w/DjMYSOTi18IG0VKfuLmZJ+02T8J/wlpAtkh+bDucuIGN/RhQywHCWoB+SZNmbDtuLHGGh/03T0IyD0G/GJw/fEzyZ1u1HH//8cfGPAl2cvztvfi1gAAzD5jiMQCTBJWDAOMPMMX+gCjVo2AUjIJRMPIAAMAWQdvn54RUAAAAAElFTkSuQmCC","orcid":"","institution":"Children’s Medical Institute of Hematology, Wuhan Children’s Hospital, Huazhong University of Science \u0026 Technology","correspondingAuthor":true,"prefix":"","firstName":"Hao","middleName":"","lastName":"Xiong","suffix":""}],"badges":[],"createdAt":"2024-05-28 10:24:33","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4490141/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4490141/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12887-024-05243-7","type":"published","date":"2024-12-06T15:58:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60338149,"identity":"29fd9324-719f-4e62-b442-26a98324952a","added_by":"auto","created_at":"2024-07-15 17:44:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":280177,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chat of chemotherapy and the time point of bone marrow puncture.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4490141/v1/9f9a0b6b4b2f5298ea514729.png"},{"id":60339150,"identity":"c6be74e6-e84b-48fe-b217-cc398dd8bec2","added_by":"auto","created_at":"2024-07-15 17:52:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":283419,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of cases screening.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4490141/v1/e3bf25fa98a304f098d45e4b.png"},{"id":60339560,"identity":"2761aec5-07dc-42a0-a6d3-205d31e27792","added_by":"auto","created_at":"2024-07-15 18:00:57","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":819656,"visible":true,"origin":"","legend":"\u003cp\u003ePredictive value of EVI1 mRNA level to relapse during the induction therapy for pediatric AML patients with EVI1 overexpression ≥1 times using ROC curve analysis.\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-4490141/v1/d7a02f35fc5c73f9f37dc488.png"},{"id":60338151,"identity":"9c0ae246-b96d-4ad1-b251-0242c6b4abdb","added_by":"auto","created_at":"2024-07-15 17:44:57","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":914782,"visible":true,"origin":"","legend":"\u003cp\u003eEffects of EVI1 overexpression on OS of pediatric AML patients at different therapy stages.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(A) \u003c/strong\u003ePediatric AML patients were grouped according to their EVI1 expression level when newly diagnosed. The comparison of OS between EVI1\u003csup\u003e high\u003c/sup\u003e group (group 1) and the persistent EVI1\u003csup\u003elow\u003c/sup\u003e (group 2) one was carried out. “EVI1\u003csup\u003e high\u003c/sup\u003e” refers that the relative EVI1 mRNA level was larger than 75% when newly diagnosed. “Persistent EVI1\u003csup\u003e low\u003c/sup\u003e” means that the relative EVI1 mRNA level was persistent less than or equal to 75% no matter when newly diagnosed or during the subsequent therapy stages. (\u003cstrong\u003eB)\u003c/strong\u003e The difference of OS among those AML patients with EVI1 overexpression ≥2 times (group 1), EVI1 overexpression 1 time (group 3), and persistent EVI1\u003csup\u003e low\u003c/sup\u003e (group 2) during the induction therapy. (\u003cstrong\u003eC)\u003c/strong\u003e The difference of OS between AML patients with EVI1 overexpression ≥2 times (group 1) and persistent EVI1\u003csup\u003e low\u003c/sup\u003e (group 2) during all the therapy stages. (\u003cstrong\u003eD)\u003c/strong\u003e The difference of OS between AML patients with EVI1 overexpression twice successively (group 1) and persistent EVI1\u003csup\u003e low\u003c/sup\u003e (group 2) during all the therapy stages. Kaplan-Meier method and Cox regression analysis were used for the previous conclusions.\u0026nbsp;\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4490141/v1/beef84e7d66401fbcb127b8f.png"},{"id":70964927,"identity":"2d043a5c-4084-4271-8892-5008e0f97092","added_by":"auto","created_at":"2024-12-09 16:17:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4186801,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4490141/v1/b7db36fb-5e09-4856-acec-482840f4f1a1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Significance of Dynamic Monitoring of EVI1 Gene Expression in Pediatric Acute Myeloid Leukemia","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eEcotropic viral integration site-1 (EVI1), an oncogenic zinc finger transcriptional regulator encoded at the MECOM locus in 3q26.2, is essential in the maintenance of hematopoietic stem cell (HSC) function, chromatin remodeling, and development of myeloid neoplastic diseases\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. With its two zinc finger domains ZF1 and ZF2, EVI1 can recognize and bind DNA to function as a transcriptional repressor \u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/sup\u003e. In addition, EVI1 can regulate transcription, signaling, and modifications by interacting with proteins and protein complexes \u003csup\u003e[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. Within the hematopoietic system, EVI1 expression is restricted to long-term and short-term HSCs and pivotal for the hematopoietic homeostasis which refers to the differentiation and self-renewal capacity of HSCs \u003csup\u003e[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. Some target genes, such as GATA2, PBX1, PTEN and ERG, might be relevant to EVI1\u0026rsquo;s oncogenic properties and leukemogenesis \u003csup\u003e[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. EVI1, cooperating with its targets, can pave the way for the leukemic transformation of HSCs and arrest leukemia cells in a stem cell-like state\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAcute myeloid leukemia (AML) is a group of hematological malignancies with high genetic heterogeneity. EVI1 overexpression is present in 8\u0026ndash;10% of adult AML and is an independent risk factor of poor prognosis. However, the threshold for high expression of EVI1 and its role in prognosis during childhood AML have not been clearly elucidated \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. Although allogeneic hematopoietic stem cell transplantation (allo-HSCT) yields a high rate of curability for AML, whether pediatric AML patients with EVI1 overexpression could benefit from HSCT in first complete remission (CR1) calls for further research\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e. The purpose of this study is to collect clinical data of AML children who were initially diagnosed in our single center, and to retrospectively analyze the dynamic changes in the expression of EVI1 gene before and after treatment, so as to explore the significance of EVI1 gene in the treatment and prognosis of AML in children.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eA total of eighty-two newly diagnosed children with AML admitted to the Department of Hematology, Wuhan Children's Hospital from April 2014 to April 2021. All patients were confirmed by morphological, flow cytometric, cytogenetic, and molecular examinations, and complete medical history could be traced. The diagnosis of childhood AML was based on the World Health Organization (2016) classification \u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. The follow-up cut-off date was December 1, 2021. All the diagnostic methods and chemotherapy regimens conform to the principles outlined in the Declaration of Helsinki. This study was approved for execution by the Ethics Committee of Wuhan Women's and Children's Health Care Center. Informed written consent was obtained from the parents or guardians as appropriate.\u003c/p\u003e \u003cp\u003eInclusion criteria were as follows: performing EVI1 gene expression analysis at initial diagnosis and/or over 6 consecutive times during the course of the disease, and the assessment point for EVI1 expression analysis was the same as the bone marrow puncture time point for evaluating AML, i.e., after each chemotherapy course at initial diagnosis, and before the next chemotherapy course when the bone marrow recovery. The complete treatment flow and bone puncture assessment time points were shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. We excluded patients with acute promyelocytic leukemia.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe clinical data of the eligible patients were collected, consisting of routine blood and the above-mentioned comprehensive examination data at initial diagnosis, remission during induction therapy phase, treatment modality, as well as the specific time of relapse and survival.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eTreatment Regimens\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eChemotherapy\u003c/h2\u003e \u003cp\u003eAll enrolled children were classified as low-, intermediate-, or high-risk according to CCLG-AML-2015/2019 protocol (provided in Supplementary Data) after completing the above-mentioned comprehensive examinations, and the course of disease during treatment was dynamically evaluated based on minimal residual disease (MRD) and genetic testing \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e With the informed consent of the parents, children received AML chemotherapy regimen based on \"7\u0026thinsp;+\u0026thinsp;3\" of daurorubicin (40mg/m2 QOD on D1, D3, D5) and cytarabine (100mg/m2 Q12H on D1-7). In addition to the two medicines, etoposide (100mg/m2 QD on D1-5) or homoharringtonine (3mg/m2 QD on D1-5) was randomly adopted in the treatment. Specifically, those admitted in 2014 received the DAE regimen in the first course, while those admitted chemotherapy in 2015 and later received the CCLG-AML-2015 \u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e and CCLG-AML-2019 regimens. In addition, FLAG \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e, decitabine\u0026thinsp;+\u0026thinsp;venetoclax \u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e were administered for relapsed or refractory cases.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eAllo-HSCT\u003c/h2\u003e \u003cp\u003eFor children at high-risk of AML, allo-HSCT was feasible after 2\u0026ndash;3 courses of chemotherapy if a suitable donor was available.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eEVI1 Gene Expression Testing\u003c/h2\u003e \u003cp\u003eThe bone marrow samples were evaluated after each chemotherapy course and before the start of the next chemotherapy course, and EVI1 gene expression analysis was performed at each bone marrow evaluation. Children without testing EVI1 expression at initial diagnosis underwent EVI1 gene expression testing at least 6 times during the course of the first treatment. Children with at least 2\u0026ndash;3 courses of chemotherapy pre-transplantation would complete 3\u0026ndash;4 bone marrow evaluations and EVI1 testing, followed by monthly bone marrow evaluation and EVI1 testing within 6 months post-transplantation.\u003c/p\u003e \u003cp\u003eEVI1 gene expression analysis was performed on 2 ml EDTA-sodium anticoagulated bone marrow samples at Wuhan Kindstar Medical Laboratory Co., Ltd. Monocytes of the bone marrow was isolated by the Ficoll method and total RNA was extracted using the Trizol Reagent (Invitrogen, Carlsbad, CA, USA). EVI1 gene expression level was detected by Taqman probe fluorescence real-time quantitative PCR using ABL1 as the internal standard, expressed as a percentage. The EVI1 primers and probe are as follows:\u003c/p\u003e \u003cp\u003eEVI1 Forward primer 5'-GTACTTGAGCCAGCTTCCAACA-3',\u003c/p\u003e \u003cp\u003eEVI1 Reverse primer 5'-CTTCTTGACTAAAGCCCTTGGA-3',\u003c/p\u003e \u003cp\u003eEVI1 Probe 5'-FAM-TCTTAGACGAATTTTACAATGTGAAGTTCTGCATAGATG-BHQ1-3'.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eEVI1 expression level above 75% was defined as EVI1-positive (EVI1 \u003csup\u003ehigh\u003c/sup\u003e) based on literature \u003csup\u003e[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e, which meant EVI1 overexpression. CR was defined as good myeloproliferation with less than 5% of primitive cells. CR1 was defined as the CR after the first course of induction therapy. Relapse was defined as the reappearance of leukemic cells in the peripheral blood or \u0026ge;\u0026thinsp;5% of primitive cells in bone marrow (except for other reasons such as bone marrow regeneration after consolidation chemotherapy) or extramedullary leukemic cell infiltration after CR of AML. Overall survival (OS) was defined as the time from diagnosis of AML until death from any cause.\u003c/p\u003e \u003cp\u003eAll analyses were conducted using SPSS version 20.0. The measured values were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation, and the counting data were represented by absolute numbers and percentages. Independent sample t-test was used to compare the continuous variables, and Chi-square test or Fisher's exact test was used to compare the categorical variables. Kaplan-Meier method and Cox regression analysis were used for survival analysis. \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate a statistically significant difference.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eClinical Data of Children Initially Diagnosed with AML\u003c/h2\u003e \u003cdiv id=\"Sec11\" class=\"Section3\"\u003e \u003ch2\u003eClinical data analysis of different levels of EVI1 gene expression\u003c/h2\u003e \u003cp\u003eA total of 78 AML children have undergone EVI1 gene expression analysis at initial diagnosis, including 36 males (46.2%) and 42 females (53.8%), with a median age of 4.96 (range 0.5\u0026ndash;15.5) years. According to the FAB classification criteria, they were classified as M0 (n\u0026thinsp;=\u0026thinsp;4; 5.1%), M1 (n\u0026thinsp;=\u0026thinsp;1; 1.3%), M2 (n\u0026thinsp;=\u0026thinsp;30; 38.5%), M4 (n\u0026thinsp;=\u0026thinsp;9; 11.5%), M5 (n\u0026thinsp;=\u0026thinsp;23; 29.5%), M7 (n\u0026thinsp;=\u0026thinsp;8; 10.2%), AML (n\u0026thinsp;=\u0026thinsp;2; 2.6%), as well as myelodysplastic syndrome (MDS)/AML (n\u0026thinsp;=\u0026thinsp;1; 1.3%). In addition, 4 cases were not tested for EVI1 expression at initial diagnosis but were continuously tested over 6 times during the subsequent disease process (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), thus included in the analysis. Among the 81 eligible patients, 19 cases (24.35%) of them showed high expression of EVI1. The baseline information was summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eGeneral clinical information and characteristics of 78 children with newly diagnosed AML\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEVI1 \u003csup\u003ehigh\u003c/sup\u003e group (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEVI1\u003csup\u003elow\u003c/sup\u003egroup\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;59)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et /χ2\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.03\u0026thinsp;\u0026plusmn;\u0026thinsp;4.48\u003c/p\u003e \u003cp\u003e(0.5-14.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.97\u0026thinsp;\u0026plusmn;\u0026thinsp;3.98\u003c/p\u003e \u003cp\u003e(0.5\u0026ndash;15.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.859\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (47.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (45.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (52.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32 (54.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFAB classification\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e9.663\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.047\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (44.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.216\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (13.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.327\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.568\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (42.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (25.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.923\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eM7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (15.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (8.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.230\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.632\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAML\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMDS-AML\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCytogenetics\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e10.595\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNK\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (31.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (32.2%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003et(8; 21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (23.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCK\u003csup\u003eb\u003c/sup\u003e or MK\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (42.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (15.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e4.606\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.032\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.057\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (27.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.392\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.238\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFusion genes\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.279\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.597\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAML1-ETO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (5.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14 (23.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.078\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.149\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (57.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (39.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.090\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMLL-related\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (26.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (17.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.321\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.571\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (10.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12 (20.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.532\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGene mutations\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.772\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNPM1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/18 (5.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2/57(3.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.567\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDNMT3A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4/18(22.22%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/57(1.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFLT3-ITD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1/18(5.55%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3/57(5.26%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTP53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2/18(11.11%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1/57(1.75%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.141\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e Described as the median\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error and range. \u003csup\u003eb\u003c/sup\u003e MK, monosomal karyotype; CK, complex karyotype; NK, normal karyotype.\u003csup\u003ec\u003c/sup\u003e All the frequency data were analyzed by Nonparametric Test (Chi-Square test, Fisher\u0026rsquo;s exact test, and K Independent Samples Test).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eEVI1 gene expression analysis revealed significant differences in FAB classification (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.047) and abnormal karyotype (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.009) between EVI1 \u003csup\u003ehigh\u003c/sup\u003e and EVI1\u003csup\u003elow\u003c/sup\u003e groups at initial diagnosis. Specifically, compared to EVI1\u003csup\u003elow\u003c/sup\u003e group, the EVI1 \u003csup\u003ehigh\u003c/sup\u003e group exhibited a higher proportion of M0, M5, and M7, a significantly higher proportion of complex karyotype (CK) or monosomal karyotype (MK) (42.1% vs. 15.0%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.032), as well as a higher proportion of KMT2A-related abnormalities (26.3% vs. 16.7%). -7 was only found in the EVI1 \u003csup\u003ehigh\u003c/sup\u003e group (10.5% vs. 0%). No 3q26-related abnormalities were found in all enrolled patients. Referring to the gene mutations, the incidence of DNMT3A mutation was higher in EVI1\u003csup\u003ehigh\u003c/sup\u003e patients (22.2% vs. 1.7%, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.011). While, NPM1, FLT3-ITD, and TP53 mutations had no relevance to the EVI1 expression. What\u0026rsquo;s more, no significant differences were observed between the two groups in terms of gender, age at onset, blood cell count at initial diagnosis, and percentage of bone marrow na\u0026iuml;ve cells, molecular abnormalities, and risk at initial diagnosis (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eBased on immunophenotyping analysis, when comparing the surface marker antigen expression, CD56- (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006) and CD36+ (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) were found to be predominant in the EVI1 \u003csup\u003ehigh\u003c/sup\u003e group in comparison to the EVI1\u003csup\u003elow\u003c/sup\u003e group, with statistically significant differences (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations of EVI1 expression level with WBC, HGB, PLT, bone marrow blasts, cell markers, CR1 rate, and survive or not after HSCT.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEVI1 \u003csup\u003ehigh\u003c/sup\u003e group (n\u0026thinsp;=\u0026thinsp;19)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEVI1\u003csup\u003elow\u003c/sup\u003e group (n\u0026thinsp;=\u0026thinsp;59)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et /χ2\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEVI1 expression \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.68\u0026thinsp;\u0026plusmn;\u0026thinsp;6.84%(76.99\u0026ndash;99.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.28\u0026thinsp;\u0026plusmn;\u0026thinsp;14.92%(0.28\u0026ndash;70.74%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e23.325\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.01\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe first B-RT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWBC (10\u003csup\u003e9\u003c/sup\u003e/L) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31.77\u0026thinsp;\u0026plusmn;\u0026thinsp;41.84 (4.82-186.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.76\u0026thinsp;\u0026plusmn;\u0026thinsp;55.23(1.31-293.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;.579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.565\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHGB (g/L) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.36\u0026thinsp;\u0026plusmn;\u0026thinsp;23.77(42.0-130.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.89\u0026thinsp;\u0026plusmn;\u0026thinsp;25.51 (21.6\u0026ndash;128)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.978\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.331\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLT (10\u003csup\u003e9\u003c/sup\u003e/L) \u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.0-1302.0 (20,103)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.0-333.0 (27.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlasts in BM \u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54.19% (20.4\u0026ndash;94%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61.72% (12\u0026ndash;95%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-1.317\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.192\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAntigen\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (31.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.3%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e9.534\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCD56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (21.1%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (56.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e7.695\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCR or not after induction 1st\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e9.432\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.015\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12(63.16%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43(72.88%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2(10.52%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11(18.64%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing or dead\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5(26.32%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5(8.47%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvive or not after HSCT\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esurvive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003edeath\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOveral survival\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(45, 876)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(295, 1212)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.338\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003csup\u003ea\u003c/sup\u003e Described as the median\u0026thinsp;\u0026plusmn;\u0026thinsp;standard error and 95%CI or (lower quartile, upper quartile ). \u003csup\u003eb\u003c/sup\u003eAll the frequency data were analyzed by Nonparametric Test (Chi-Square test, Fisher\u0026rsquo;s exact test, and K Independent Samples Test).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eTherapeutic response and prognosis\u003c/h2\u003e \u003cp\u003eAfter the first course of induction chemotherapy, in the EVI1\u003csup\u003ehigh\u003c/sup\u003e group, 12 cases achieved CR, 2 cases reached partial response (PR), and 5 cases abandoned treatment, with a CR1 rate of 63.1%. Among them, 7 underwent allo-HSCT treatment (6 survived and 1 died for extramedullary relapse). Until the end of follow-up, a total of 8 patients survived, 6 died, and 5 dropped out, with the quartile of overal survival (OS) (45, 876) days. By comparison, there were 43 cases of CR, 1 of PR, 10 of no response (NR), and 5 of abandonment in the EVI1\u003csup\u003elow\u003c/sup\u003e group, with the CR1 rate of 73.3%. 21 of them were treated with allo-HSCT (20 survived and 1 died for bronchiolitis obliterans). There were 36 cases alive, 16 dead, and 7 lost to visit at the last follow-up, with the quartile of OS (295, 1212) days (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAfter the first course of treatment, the incidence of CR1 in the EVI1\u003csup\u003ehigh\u003c/sup\u003e group was significantly lower than that in the EVI1\u003csup\u003elow\u003c/sup\u003e group (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.015), whereas no significant difference was found in relapse incidence, survival incidence, and OS (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, multivariate Cox regression analysis was adopted to explore factors which can influence the OS. Between the EVI1\u003csup\u003ehigh\u003c/sup\u003e patients and EVI1\u003csup\u003elow\u003c/sup\u003e patients, we found that not EVI1 expression, mutated genes, age, WBC, but MRD1 (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.001),,cytogenetics (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.000), and HSCT (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004),were the key factors related to OS and survival (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCox regression analysis of the OS for 79 pediatric AML patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95%CI for RR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEVI1 expression\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.559\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.739\u0026ndash;9.146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.137\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRD1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003enegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.628\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.276\u0026ndash;40.729\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.093\u0026ndash;1.522\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCytogenetics (CK or MK or not )\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.430\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.037\u0026ndash;75.251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.000\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFusion genes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.067\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMLL-related\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.022\u0026ndash;1.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAML1-ETO\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.769\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.053\u0026ndash;31.617\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.043\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther or without fusion genes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4.272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.793\u0026ndash;23.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.091\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHSCT or not\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16.337\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.5-106.770\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSignificance of dynamic monitoring of EVI1 expression\u003c/h2\u003e \u003cp\u003eA total of 51 children with AML were continuously and dynamically tested for EVI1 expression during the course of their disease. 47 were continuously monitored for EVI1 expression at initial diagnosis and throughout their disease courses, and 4 children without EVI1 expression analysis at initial diagnosis received continuously testing for EVI1 expression\u0026thinsp;\u0026ge;\u0026thinsp;6 times after the first treatment, as mentioned above.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEffect of EVI1 expression on AML relapse in the non-HSCT group\u003c/h2\u003e \u003cp\u003eAt the initial diagnosis, after \u0026ldquo;induction therapy 1\u0026rdquo; (evaluation of CR1) and \u0026ldquo;induction therapy 2\u0026rdquo; (evaluation of CR2) were completed, a total of 3 bone marrow evaluations were conducted, and EVI1 expression analysis was performed 3 consecutive times. There were 11 non-HSCT cases with positive EVI1 expression more than once in the first 3 times, of which 5 relapsed; whereas no relapse occurred in the 8 non-HSCT cases with negative EVI1 expression in the first 3 times, with a significant statistical difference (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Similarly, the 6 non-HSCT cases with positive EVI1 expression more than twice in the first 5 times included 3 relapsed cases, and 2 relapsed among 13 non-HSCT cases with positive EVI1 expression below once in the first 3 times, without a significant difference (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.262) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations of dynamic monitoring EVI1 expression with relapse rate in the AML patients with no \u003cb\u003eHSCT\u003c/b\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (No.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRelapse (No.)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003et /χ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003cem\u003e2 P\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe first three EVI1 expression levels\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e6.742 0.045\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEVI1\u003csup\u003ehigh\u003c/sup\u003e\u0026thinsp;\u0026ge;\u0026thinsp;1 time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEVI1 \u003csup\u003ehigh\u003c/sup\u003e = 0 time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe first five EVI1 expression levels\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e2.421 0.262\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEVI1 \u003csup\u003ehigh\u003c/sup\u003e \u0026ge; 2 times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEVI1 \u003csup\u003ehigh\u003c/sup\u003e \u0026le; 1 time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eROC curve analysis revealed that the EVI1 expression level\u0026thinsp;\u0026ge;\u0026thinsp;83.38% significantly predicted relapse, with an area under the curve (AUC) of 0.833 (sensitivity, 85.7%; specificity, 83.3%; Youden index, 0.69), as seen in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eEffect of EVI1 gene expression on OS\u003c/h2\u003e \u003cp\u003eAmong the 47 children with AML in whom EVI1 expression analysis was performed at initial diagnosis and during the subsequent course of the disease, with 14 persistent EVI1\u003csup\u003elow\u003c/sup\u003e and 33 EVI1\u003csup\u003ehigh\u003c/sup\u003e over once during the course of the disease. Children with \u0026ge;\u0026thinsp;1 EVI1\u003csup\u003ehigh\u003c/sup\u003e had a shorter OS than those with EVI1 \u003csup\u003elow\u003c/sup\u003e (χ\u0026thinsp;=\u0026thinsp;3.81, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.051) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn total, 43 children were analyzed for EVI1 expression on three consecutive occasions, including 9 children with EVI1\u003csup\u003ehigh\u003c/sup\u003e more than twice, 12 children with EVI1 \u003csup\u003ehigh\u003c/sup\u003e of once, and 22 children with EVI1 \u003csup\u003elow\u003c/sup\u003e, after a total of three bone marrow evaluations at initial diagnosis and after completion of \u0026ldquo;induction therapy 1\u0026rdquo; and \u0026ldquo;induction therapy 2\u0026rdquo;. Differences in OS between the three groups were found to be significantly shorter in the EVI1\u003csup\u003ehigh\u003c/sup\u003e\u0026thinsp;\u0026ge;\u0026thinsp;2 times group than that in the EVI1\u003csup\u003elow\u003c/sup\u003e group (χ\u0026thinsp;=\u0026thinsp;4.852, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.028) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eA total of 6 bone marrow assessments, performed at initial diagnosis and during the 5 chemotherapy courses of induction plus consolidation therapy, were completed in 36 cases with 6 consecutive EVI1 gene expression assessments, 12 cases with EVI1\u003csup\u003ehigh\u003c/sup\u003e more than twice, and the remaining 24 cases with EVI1\u003csup\u003ehigh\u003c/sup\u003e below once. Comparing the OS of the two groups, it was found that the OS of the EVI1\u003csup\u003ehigh\u003c/sup\u003e\u0026thinsp;\u0026ge;\u0026thinsp;2 times group was significantly lower than that of the EVI1\u003csup\u003ehigh\u003c/sup\u003e\u0026thinsp;\u0026le;\u0026thinsp;1 time group (χ\u0026thinsp;=\u0026thinsp;5.779, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.016) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eC\u003cb\u003e)\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eChildren with continuous dynamic monitoring of EVI1 expression during the course of the disease had significantly shorter OS than the EVI1\u003csup\u003elow\u003c/sup\u003e group if EVI1\u003csup\u003ehigh\u003c/sup\u003e was present\u0026thinsp;\u0026ge;\u0026thinsp;2 times and sequentially (χ\u0026thinsp;=\u0026thinsp;4.098, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.043) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eD).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eWith advances in technologies such as gene sequencing and flow cytometric analysis, the World Health Organization's precise diagnostic grading and prognostic assessment of AML based on abnormal molecular genetic alterations is updated year by year, which in turn guides the selection of treatment options and improves survival. Structural abnormalities of chromosome 3q26 and the corresponding high expression and functional alterations of EVI1 gene are factors of poor prognosis in AML. The proportions of EVI1 overexpression in pediatric AML patients range from 9\u0026ndash;23.5%, and its prognostic significance remains poorly understood \u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. In this study, we retrospectively analyzed the clinical data of AML children in our center and found that EVI1 expression levels were indicative for the prognosis of AML children, and the percentage of high EVI1 expression at initial diagnosis of AML was about 24.35%, which correlated with lower CR1 rate and poor OS; high EVI1 expression at the induction treatment stage predicted higher incidence of relapse, and continuous dynamic monitoring of EVI1 with multiple high expression or successive. OS was significantly shortened when EVI1 high expression was monitored continuously and dynamically.\u003c/p\u003e \u003cp\u003eAbnormally high expression of EVI1 can block granulocytic differentiation of hematopoietic stem cells, resulting in impaired maturation and enhanced proliferation of stem cells leading to leukemia \u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. The present study showed the significant difference of FAB classification between the EVI1 \u003csup\u003ehigh\u003c/sup\u003e and EVI1\u003csup\u003elow\u003c/sup\u003e groups at initial diagnosis; subsequently, the proportion of M0 in the EVI1 \u003csup\u003ehigh\u003c/sup\u003e group was greater than that in the EVI1\u003csup\u003elow\u003c/sup\u003e group, which suggested that the abnormal biological function of EVI1 may be related to the degree of differentiation of AML cells. In addition, EVI1 \u003csup\u003ehigh\u003c/sup\u003e may be related to specific karyotypic alterations, especially in MK and/or CK. When using Cox regression analysis to explore the impact factors on OS and survival, we found that not the EVI1 gene expression but the cytogenetic abnormalities (especially CK and/or MK) and HSCT were of great importance.\u003c/p\u003e \u003cp\u003eAlthough we found a significant difference between CD56- and CD36\u0026thinsp;+\u0026thinsp;in the EVI1 \u003csup\u003ehigh\u003c/sup\u003e and EVI1\u003csup\u003elow\u003c/sup\u003e groups, their significance in AML is currently unknown. It is reported that CD56 is mainly expressed on the surface of natural killer cells, and its high expression is a sign of poor prognosis in AML \u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e. Research shows that CD36 may participate in AML cell resistance to cytarabine and tumor microenvironment energy supply to leukemia cells by regulating the lipid metabolism process of leukemic cells \u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]\u003c/sup\u003e. Further investigation is needed to determine whether CD56 and CD36 suggest that leukemic cells also undergo \"self-interest\" regulation in lipid metabolism.\u003c/p\u003e \u003cp\u003eAllo-HSCT significantly improves long-term survival expectations for children with high-risk AML, but the optimal timing of transplantation remains a hot topic of current research \u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. This study suggested that the incidence of relapse was significantly increased if EVI1 \u003csup\u003ehigh\u003c/sup\u003e and children did not underwent HSCT during a total of 3 bone marrow evaluations performed from the initial diagnosis to the end of induction chemotherapy (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.045); and EVI1 expression\u0026thinsp;\u0026ge;\u0026thinsp;83.38% had a good predictive value for relapse. OS was significantly shorter (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05) in children with AML with \u0026ge;\u0026thinsp;2 EVI1 \u003csup\u003ehigh\u003c/sup\u003e or persistently high EVI1 expression (i.e., \u0026ge;\u0026thinsp;2 successive high expressions) during induction and/or consolidation phases of treatment. Further monitoring revealed that even high EVI1 expression did not produce a significantly effect on OS after HSCT in children with AML (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.48), which may be related to the graft-versus-leukemia (GVL) effect of HSCT, which may contribute to the depth and sustained clearance of MRD in AML patients\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Therefore, dynamic monitoring of EVI1 expression during the induction and consolidation phases of treatment in children with AML can help to predict OS, especially the first 3 EVI1 expressions or help to determine the timing of transplantation; secondly, the need to undergo EVI1 testing is significantly reduced in children with AML after HSCT.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, childhood AML with EVI1 high expression typically exhibit high-risk karyotypes such as CK, MK, or -7, more commonly in M0, with a low CR1 rate and high risk of relapse, which is necessary to be considered as one of the poor prognostic factors for such patients.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eALL source data will be made available by corresponding author upon request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eConflict if interest statement\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eEthics statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe studies involving human participants were reviewed and approved by the Wuhan Women\u0026apos;s and Children\u0026apos;s Health Care Center Ethics Committee. Written informed consent to participate in this study was provided by the participants\u0026rsquo; legal guardian.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by the Natural Science Foundation of Hubei Province in China (No. 2019CFB368 and 2020CFB364), the Applied Basic Frontier Special Project of Wuhan (No. 2020020601012319), and the Wuhan Municipal Commission of Health (Nos. WX21D60, WX21Z4, and WX20D20). \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eParedes R, Doleschall N, Connors K, et al. EVI1 protein interaction dynamics: Targetable for therapeutic intervention?[J]. Exp Hematol, 2022. 107: 1-8.\u003c/li\u003e\n\u003cli\u003eBirdwell C, Fiskus W, Kadia TM, et al. EVI1 dysregulation: impact on biology and therapy of myeloid malignancies[J]. Blood Cancer J, 2021, 11(3): 64.\u003c/li\u003e\n\u003cli\u003eBartholomew C, Kilbey A, Clark AM, et al. The Evi-1 proto-oncogene encodes a transcriptional repressor activity associated with transformation[J]. Oncogene. 1997.14(5):569-577.\u003c/li\u003e\n\u003cli\u003eWhite DJ, Unwin RD, Bindels E, et al. Phosphorylation of the leukemic oncoprotein EVI1 on serine 196 modulates DNA binding, transcriptional repression and transforming ability[J]. PLoS One. 2013.8(6):e66510.\u003c/li\u003e\n\u003cli\u003eKataoka K, Sato T, Yoshimi A, et al. Evi1 is essential for hematopoietic stem cell self-renewal, and its expression marks hematopoietic cells with long-term multilineage repopulating activity[J]. J Exp Med. 2011.208(12):2403-2416.\u003c/li\u003e\n\u003cli\u003eZhang Y, Stehling-Sun S, Lezon-Geyda K, et al. PR-domain-containing Mds1-Evi1 is critical for long-term hematopoietic stem cell function[J]. 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The role of EVI1 gene quantification in AML patients with 11q23/MLL rearrangement after allogeneic hematopoietic stem cell transplantation[J]. Bone Marrow Transplant, 2021. 56(2): 470-480.\u003c/li\u003e\n\u003cli\u003eWu X, Wang H, Deng J, et al. Prognostic significance of the EVI1 gene expression in patients with acute myeloid leukemia: a meta-analysis[J]. Ann Hematol, 2019. 98(11): 2485-2496.\u003c/li\u003e\n\u003cli\u003eBalgobind BV, Lugthart S, Hollink IH, et al. EVI1 overexpression in distinct subtypes of pediatric acute myeloid leukemia[J]. Leukemia, 2010. 24(5): 942-949.\u003c/li\u003e\n\u003cli\u003eElsherif M, Hammad M, Hafez H, et al. MECOM gene overexpression in pediatric patients with acute myeloid leukemia[J]. Acta Oncol, 2022. 61(4): 516-522.\u003c/li\u003e\n\u003cli\u003eNabil R, Abdellateif MS, Gamal H, et al. Clinical significance of EVI-1 gene expression and aberrations in patient with de-novo acute myeloid and acute lymphoid leukemia[J]. Leuk Res, 2023 Mar;126:107019.\u003c/li\u003e\n\u003cli\u003eChen C, Chio CL, Zeng H, et al. High expression of CD56 may be associated with favorable overall survival in intermediate-risk acute myeloid leukemia[J]. Hematology, 2021. 26(1): 210-214.\u003c/li\u003e\n\u003cli\u003eIriyama N, Hatta Y, Takeuchi J, et al. CD56 expression is an independent prognostic factor for relapse in acute myeloid leukemia with t(8;21)[J]. Leuk Res, 2013. 37(9): 1021-1026.\u003c/li\u003e\n\u003cli\u003ePanda D, Chatterjee G, Sardana R, et al. Utility of CD36 as a novel addition to the immunophenotypic signature of RAM-phenotype acute myeloid leukemia and study of its clinicopathological characteristics[J]. Cytometry B Clin Cytom, 2021. 100(2): 206-217.\u003c/li\u003e\n\u003cli\u003eHoch REE, C\u0026oacute;ser VM, Santos IS, et al. Lymphoid markers predict prognosis of pediatric and adolescent acute myeloid leukemia[J]. Leuk Res, 2021. 107: 106603.\u003c/li\u003e\n\u003cli\u003eQuessada J, Cuccuini W, Saultier P, et al. Cytogenetics of Pediatric Acute Myeloid Leukemia: A Review of the Current Knowledge[J]. Genes (Basel), 2021. 12(6): 924.\u003c/li\u003e\n\u003cli\u003eReedijk AMJ, Klein K, Coebergh JWW, et al. Improved survival for children and young adolescents with acute myeloid leukemia: a Dutch study on incidence, survival and mortality[J]. Leukemia, 2019. 33(6): 1349-1359.\u003c/li\u003e\n\u003cli\u003eDuan WB, Gong LZ, Jia JS, et al. Clinical features and early treatment effects in intermediate risk and poor risk acute myeloid leukemia with EVI1 positive[J]. Beijing Da Xue Xue Bao Yi Xue Ban, 2017. 49(6): 990-995.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Supplementary Data","content":"\u003cp\u003eSupplementary Data is not available with this version\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Ecotropic virus integration site-1, Acute myeloid leukemia, Relapse, Dynamic monitoring, Pediatrics, Allogeneic hematopoietic stem cell transplantation","lastPublishedDoi":"10.21203/rs.3.rs-4490141/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4490141/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo investigate the clinical significance of dynamic monitoring ecotropic virus integration site-1 (EVI1) expression in childhood acute myeloid leukemia (AML).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective analysis was conducted on 113 pediatric AML patients of Wuhan Children's Hospital from 2014 to 2022. The correlation between EVI1 expression levels and clinical indicators including clinical characteristics, first complete remission (CR1), relapse, and overall survival (OS) was analyzed. Receiver operating characteristic (ROC) curve analysis was carried out to comprehend the influence of EVI1 expression on relapse.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 78 AML children with EVI1 expression at initial diagnosis were eligible, divided into EVI1-positive (EVI1\u003csup\u003ehigh\u003c/sup\u003e) and EVI1-negative (EVI1\u003csup\u003elow\u003c/sup\u003e) groups. FAB classification (P\u0026thinsp;=\u0026thinsp;0.047) and abnormal karyotype (P\u0026thinsp;=\u0026thinsp;0.009) showed significant differences between the two groups. The proportion of EVI1 high in individuals with complex and/or monomeric karyotypes was significantly higher than in other cases (P\u0026thinsp;=\u0026thinsp;0.032). When completing the first induction therapy, the EVI1high group showed a significantly lower CR1 rate than the EVI1low group (P\u0026thinsp;=\u0026thinsp;0.015). Among 51 cases with EVI1 expression dynamically monitored, those with EVI1 overexpression more than twice had significantly shorter OS (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Among 19 non-HSCT patients undergoing three EVI1 assessments during induction therapy, those with EVI1 overexpression over once had higher relapse rates (P\u0026thinsp;=\u0026thinsp;0.045). In addition, EVI1 expression level\u0026thinsp;\u0026ge;\u0026thinsp;83.38% significantly predicted relapse (AUC\u0026thinsp;=\u0026thinsp;0.833).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAberrantly high expression of EVI1 in pediatric AML was associated with poor prognosis. Continuous and dynamic monitoring of EVI1 expression promotes prognostic evaluation. We add some insights into the impact of EVI1 on the AML patients\u0026rsquo; OS and survival.\u003c/p\u003e","manuscriptTitle":"Clinical Significance of Dynamic Monitoring of EVI1 Gene Expression in Pediatric Acute Myeloid Leukemia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-15 17:44:53","doi":"10.21203/rs.3.rs-4490141/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-16T05:43:32+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-14T20:54:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-07-12T13:04:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"5514255125081963129224239489357394944","date":"2024-07-11T06:39:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"33837073207958249571398785998573913609","date":"2024-07-09T14:40:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"156045095857351657272890220035393972042","date":"2024-06-27T16:21:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91845511668049502023215560215290417545","date":"2024-06-22T16:52:59+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-22T08:59:03+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-21T07:17:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-16T12:33:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-16T12:32:46+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-05-28T10:23:10+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4801dc91-68ca-4d70-b5a9-782d05121c56","owner":[],"postedDate":"July 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-09T16:08:00+00:00","versionOfRecord":{"articleIdentity":"rs-4490141","link":"https://doi.org/10.1186/s12887-024-05243-7","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2024-12-06 15:58:12","publishedOnDateReadable":"December 6th, 2024"},"versionCreatedAt":"2024-07-15 17:44:53","video":"","vorDoi":"10.1186/s12887-024-05243-7","vorDoiUrl":"https://doi.org/10.1186/s12887-024-05243-7","workflowStages":[]},"version":"v1","identity":"rs-4490141","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4490141","identity":"rs-4490141","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}