Acute myeloid leukemia (AML) has a poor prognosis and a heterogeneous mutation landscape. Although common mutations are well-studied, little research has characterized how the sequence of mutations relates to clinical features. Using published, single-cell DNA sequencing data from three institutions, we compared clonal evolution patterns in AML to patient characteristics, disease phenotype, and outcomes. Mutation trees, which represent the order of select mutations, were created for 207 patients from targeted panel sequencing data using 1 639 162 cells, 823 mutations, and 275 samples. In 224 distinct orderings of mutated genes, mutations related to DNA methylation typically preceded those related to cell signaling, but signaling-first cases did occur, and had higher peripheral cell counts, increased signaling mutation homozygosity, and younger patient age. Serial sample analysis suggested that NPM1 and DNA methylation mutations provide an advantage to signaling mutations in AML. Interestingly, WT1 mutation evolution shared features with signaling mutations, such as WT1-early being proliferative and occurring in younger individuals, trends that remained in multivariable regression. Some mutation orderings had a worse prognosis, but this was mediated by unfavorable mutations, not mutation order. These findings add a dimension to the mutation landscape of AML, identifying uncommon patterns of leukemogenesis and shedding light on heterogeneous phenotypes.

急性髓系白血病 (AML) 预后不良且突变情况异质。尽管常见突变已得到充分研究，但很少有研究描述突变序列与临床特征的关系。利用来自三个机构的已发表的单细胞 DNA 测序数据，我们将 AML 的克隆进化模式与患者特征、疾病表型和结果进行了比较。使用 1 639 162 个细胞、823 个突变和 275 个样本，根据目标组测序数据为 207 名患者创建了代表选定突变顺序的突变树。在 224 个不同的突变基因排序中，与 DNA 甲基化相关的突变通常先于与细胞信号传导相关的突变，但信号传导优先的病例确实发生，并且具有更高的外周细胞计数、增加的信号传导突变纯合性和更年轻的患者年龄。连续样本分析表明，NPM1和 DNA 甲基化突变为 AML 中的信号突变提供了优势。有趣的是，WT1突变进化与信号突变具有共同的特征，例如WT1 - 早期增殖并发生在较年轻的个体中，这一趋势在多变量回归中仍然存在。一些突变顺序的预后较差，但这是由不利突变介导的，而不是突变顺序。这些发现为 AML 的突变景观增添了一个维度，识别了罕见的白血病发生模式并揭示了异质表型。