Dominant and opportunistic leukemic clones: Proposal for a pathogenesis-oriented classification in acute myeloid leukemia

Despite the common clinical, hematological and prognostic features that define acute myeloid leukemia (AML) there is considerable heterogeneity among individual cases, suggesting different pathogenic pathways. Based on a simple theoretical model, according to the vital characteristics of the leukemic clone (proliferative rate and resistance to apoptosis), I propose a classification of AML into two broad categories: (a) high leukemic clone vitality (HLV) AML or “dominant type” AML, corresponding roughly to the World Health Organization (WHO) classification group of entities “AML with recurrent cytogenetic abnormalities” and (b) low leukemic clone vitality (LLV) or “opportunistic type” AML corresponding to the WHO groups “AML with multilineage dysplasia” and “alkylating agent-related AML”. HLV-AML leukemic clones are characterized by rate-limiting genomic mutations capable of conferring proliferation/survival advantage over a normal hematopoietic environment while in LLV-AML, the leukemic clones are not particularly proliferative or apoptosis-resistant, but are nevertheless selected against an impaired, previously damaged hematopoietic environment. Such a pathogenesis-oriented classification might have therapeutic and prognostic implications, providing a theoretical basis for a further adaptation of the current standard treatment strategies to the individual characteristics of the AML patients.