ETV6::ABL1 fusion: from overlooked minor clone in myeloproliferative neoplasm to major player in leukemic transformation

The ETV6::ABL1 fusion defines a subgroup of myeloid/lymphoid neoplasms with eosinophilia and tyrosine kinase gene fusions. We report a case of extramedullary involvement and leukemic transformation in myeloproliferative neoplasm (MPN), where ETV6::ABL1 was initially overlooked but later detected in the blast phase. ETV6::ABL1 burden was very low during the MPN phase but increased substantially during the blast phase. This correlation between ETV6::ABL1 burden and disease phenotype indicated that an immature leukemic clone is the sole carrier of ETV6::ABL1, suggesting that ETV6::ABL1 is not the primary driver of the MPN phase. Moreover, only the blast phase revealed somatic mutations in RUNX1 and STAG2, or complex karyotype, while the MPN phase revealed no molecular and cytogenetic abnormalities. Therefore, it remains uncertain whether the small clone of ETV6::ABL1 influenced the manifestation of MPN or if another underlying driver was responsible for the MPN phase, necessitating further research.