Post Induction and Post Consolidation Measurable/Minimal Residual Disease Predict Relapse in NPM-1 Positive AML. Outcome of Treatment Relapse. a Single Center Experience

Although the ELN MRD Working Party (Schuurhuis, 2018) recommends that Acute Myeloid Leukemia (AML) patients (pts) with mutated NPM1 (NPM1+) should have molecular assessment of measurable/minimal residual disease (MRD), the most clinically significant timepoints (TPs), the thresholds, the best source of samples, bone marrow (BM) or peripheral blood (PB) and especially the management of molecular relapse, remain controversial. We evaluated the prognostic significance of NPM1 molecular monitoring, its impact on disease recurrence and the outcome of salvage treatment. From Jul 2010 to dec 2018, 83 consecutive NPM1+ AML pts (M/F: 44/39; median age 59 y, 27-74) eligible for intensive chemotherapy (i-T) were treated, according to the NILG-AML00 protocol (ClinicalTrial.gov: NCT00400673): ICE (idarubicine-ARAC-etoposide) as induction, followed by IC consolidation and 3 further consolidation cycles of high-dose ARAC. Allogeneic stem cell transplant (HSCT) was considered at relapse. Quantitative RT-PCR was performed to detect NPM1 mutation (Gorello, 2006) on BM and PB samples at diagnosis (TP0) and at given TPs: at complete remission (CR) (TP1), post-IC (TP2), post-1st ARAC consolidation (TP3) and at the end of treatment (TP4). Serial MRD monitoring during follow-up was made on PB every 3 months (mo) for 5 years (y) or until relapse. Molecular relapse (mR) was defined as the NPM1 level increase at least 1 log in 2 consecutive samples, in absence of hematological relapse (hR). At baseline, karyotype (K) was abnormal in 8 pts (9.6%); 25 (30%) were FLT3-ITD mutated with a median Allelic Ratio (AR) of 0.35 (range: 0.2 to 2.18) (Pratcorona, 2013). During treatment, 608 samples were studied (383 BM and 225 PB), for a median of 8 per patient (range: 3 to 10). At TP1, a higher level of NPM1 unfavorably impacted on relapse (p 0.02) and a cut-off >200 *10^4/ABL was significantly associated with a higher relapse risk (RR) (68.7%) and lower RFS (p 0.006). Moreover, MRD positivity (value >0*10^4 NPM1/ABL) at TP2 on PB was associated to a higher RR (38.8%; p 0. 041) and a level >0.5*10^4/ABL allowed to predict relapse in 75% of pts, also impacting on RFS (p 0.0001) (Figure 1).Molecular NPM1 relapse/progression occurred in 10 pts early during treatment, after a median of 3.5 mo (1.4-6) from diagnosis and in 8 of them simultaneously with hR. In 16 pts mR occurred after a median CR duration of 18.5 mo (10.5-61.5) (late relapse). Hence a mR was more frequent in late than in early relapse (87.5% vs 20%; p 0.001). Median survival was 8.3 mo in early relapsing pts and was not reached in late relapsing pts (p. 0.0002). Age, NPM1 level at TP0, FLT3-ITD mutation, ITD-AR or abnormal K did not impact on type of relapse (mR or hR), but FLT3-ITD was more frequent in early than late relapse (60% vs 18.7%; p 0.04). After a median follow-up of 42 mo (4-108), 5-y relapse-free survival (RFS) and overall survival were 64.2% (+/-6.5% SE) and 71.1% (+/-6.1% SE), respectively. Overall, considering both mR and hR, 26 pts (31.3%) relapsed after a median of 13.5 mo after CR; 24/26 pts received a salvage treatment and 14 (53.8%) (median age 49y, 27-64) could proceed to HSCT after a median of 2.9 mo (5 too old, 7 early progression). Salvage treatment before HSCT was i-T in 7/14 and non-i-T in 7/14 pts (2 ATRA and 5 D-actinomycin, Falini 2015) for a median of 3 cycles (range 2-4). Disease status at HSCT was: mCR in 3 pts, CR with detectable MRD (median NPM1: 125*10^4/ABL, range 17.8-3849) in 9, refractory in 2 pts. Nine/14 HSCT pts (64.2%) are alive and in remission at a median of 29.6 mo (13-49) from HSCT, 2 pts died of sepsis in c-GVDH at 6.2 and 37.5 mo after HSCT, 1 died of VOD and 2 of disease progression. At 3 months after HSCT all MRD positive pts were NPM1 negative. mR occurred in 3 pts at 8, 12 and 15 mo after HSCT and was successfully treated with early pre-emptive donor lymphocyte infusions. With the limits of small numbers, age, type (mR or hR) or timing of relapse (early or late), disease status at HSCT, donor source and conditioning intensity didn't influence survival. Our study shows that PCR monitoring during treatment can identify pts at higher RR according to the transcript levels in BM and PB samples. In NPM1+ AML, molecular monitoring in PB during follow-up is of crucial importance in detecting late molecular relapse allowing to use less toxic molecular-oriented treatments as a bridge to HSCT. Further studies on larger cohorts hopefully will help to confirm its usefulness to guide the treatment approach. Disclosures Rossi: Astellas: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria; Mundipharma: Honoraria; BMS: Honoraria; Sandoz: Honoraria; Janssen: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Amgen: Membership on an entity's Board of Directors or advisory committees; Gilead: Membership on an entity's Board of Directors or advisory committees; Sanofi: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Daiichi-Sankyo: Consultancy; Roche: Membership on an entity's Board of Directors or advisory committees; Jazz: Membership on an entity's Board of Directors or advisory committees. OffLabel Disclosure: D-actinomicin

Download Full-text

Switching to Nilotinib Is Associated with Continued Deeper Molecular Responses in CML-CP Patients with Minimal Residual Disease After ≥ 2 Years On Imatinib: Enestcmr 2-Year Follow-up Results

Blood ◽

10.1182/blood.v120.21.694.694 ◽

2012 ◽

Vol 120 (21) ◽

pp. 694-694 ◽

Cited By ~ 2

Author(s):

Timothy P. Hughes ◽

Jeffrey H. Lipton ◽

Nelson Spector ◽

Brian Leber ◽

Ricardo Pasquini ◽

...

Keyword(s):

Board Of Directors ◽

Minimal Residual Disease ◽

Research Funding ◽

Residual Disease ◽

Molecular Response ◽

Advisory Committees ◽

Molecular Responses ◽

The Difference ◽

Minimal Residual

Abstract Abstract 694 Background: Superior rates of deeper molecular responses were achieved with nilotinib vs imatinib in patients newly diagnosed with Philadelphia chromosome–positive (Ph+) chronic myeloid leukemia in chronic phase (CML-CP) in the Evaluating Nilotinib Efficacy and Safety in Clinical Trials—newly diagnosed patients (ENESTnd) trial. In addition, the 12-month (mo) analysis of the ENEST—complete molecular response (ENESTcmr) study demonstrated that switching to nilotinib after a minimum of 2 years on imatinib led to increased rates of major molecular response (MMR) and deeper molecular responses vs remaining on imatinib. Results from ENESTcmr are presented here with minimum 24 mo of patient follow-up. Methods: Patients with Ph+ CML-CP who had achieved complete cytogenetic responses but still had persistent BCR-ABL positivity by real-time quantitative polymerase chain reaction (RQ-PCR) after ≥ 2 years on imatinib were eligible. Patients (n = 207) were randomized to switch to nilotinib 400 mg twice daily (BID; n = 104) or to continue on the same dose of imatinib (400 or 600 mg once daily [QD]; n = 103). Rates of MMR, MR4 (BCR-ABL ≤ 0.01% according to the International Scale [IS], corresponding to a 4-log reduction), MR4.5 (BCR-ABL ≤ 0.0032%IS, corresponding to 4.5-log reduction), and undetectable BCR-ABL via RQ-PCR with ≥ 4.5-log sensitivity were measured. Results: Among all randomized patients (intent-to-treat population), significantly more patients treated with nilotinib continued to achieve undetectable BCR-ABL by 24 mo (32.7% on nilotinib vs 16.5% on imatinib; P =.005; Table).The difference between the arms in achievement of this endpoint increased between 1 and 2 years (from 12.4% to 16.2%). The median time to MR4.5 and undetectable BCR-ABL was also significantly faster on nilotinib than on imatinib (P = .005 and .003, respectively). Cumulative rates of MR4.5 and undetectable BCR-ABL continued to be higher with nilotinib in patients without those responses at baseline, and the difference between arms appeared to increase over time. The safety profiles for nilotinib and imatinib were consistent with prior studies. By 24 mo, no patients in either arm progressed to accelerated phase/blast crisis. No patients on nilotinib died since the 12-mo analysis; 1 patient on imatinib died from metastatic prostate cancer in follow-up after discontinuation from the study. Conclusions: Switching to nilotinib led to significantly faster, deeper molecular responses in patients with minimal residual disease on long-term imatinib therapy. Since the 12-mo analysis, rates of deep molecular response (MR4.5 and undetectable BCR-ABL) have remained significantly higher in patients who did not have the response at baseline and were switched to nilotinib (vs those remaining on imatinib). In fact, the difference in favor of nilotinib increased between 1 and 2 years. These results suggest that switching to the more potent, selective tyrosine kinase inhibitor nilotinib is beneficial in patients with minimal residual disease after long-term imatinib therapy. Achievement of these deeper molecular responses (MR4.5 and undetectable BCR-ABL) after switching to nilotinib may enable a greater proportion of CML-CP patients to be eligible for future discontinuation studies. Cumulative rates of confirmed undetectable BCR-ABL by 24 mo will be presented as the confirmation assessments for several responders were not available at the time of this analysis. Disclosures: Hughes: Novartis Pharmaceuticals Corp: Consultancy, Honoraria, Research Funding; Bristol Myers Squibb: Consultancy, Honoraria, Research Funding; Ariad: Consultancy; CSL: Research Funding. Lipton:Novartis: Consultancy, Research Funding, Speakers Bureau. Spector:Novarits: Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Consultancy. Leber:Novartis: Advisory Board Other, Honoraria, Speakers Bureau. Schwarer:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees; BMS: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pfizer: Honoraria, Membership on an entity's Board of Directors or advisory committees. Etienne:Novartis: Consultancy, Speakers Bureau; Pfizer: Consultancy; BMS: Consultancy, Speakers Bureau. Branford:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; BMS: Honoraria, Research Funding; Ariad: Research Funding. Purkayastha:Novartis Pharmaceuticals Corp: Employment. Collins:Novartis Pharmaceuticals Corp: Employment. Szczudlo:Novartis Pharmaceuticals Corp: Employment. Cervantes:Novartis: Membership on an entity's Board of Directors or advisory committees; Sanofi-Aventis: Membership on an entity's Board of Directors or advisory committees; BMS: Speakers Bureau; Celgene: Membership on an entity's Board of Directors or advisory committees; Pfizer: Membership on an entity's Board of Directors or advisory committees; Teva Pharmaceuticals: Membership on an entity's Board of Directors or advisory committees.

Download Full-text

Maintenance of Long-Term Undetectable Minimal Residual Disease after Combination of Ibrutinib with Abbreviated Chemotherapy in the Icll-07 Filo Trial

Blood ◽

10.1182/blood-2019-126720 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 3038-3038

Author(s):

Anne-Sophie Michallet ◽

Marie-Sarah Dilhuydy ◽

Fabien Subtil ◽

Valérie Rouille ◽

Beatrice Mahe ◽

...

Keyword(s):

Board Of Directors ◽

Minimal Residual Disease ◽

Research Funding ◽

Residual Disease ◽

Limit Of Detection ◽

Randomised Trial ◽

Primary Objective ◽

Advisory Committees ◽

Minimal Residual

Introduction In previously untreated, medically fit patients with chronic lymphocytic leukaemia (CLL) and no 17p deletion, there is current research interest in improving survival outcomes and potentially sparing some patients from the standard 6 cycles of fludarabine, cyclophosphamide and rituximab (FCR). The phase II ICLL-07 (NCT02666898) trial, conducted by the French Innovative Leukemia Organization (FILO), aimed to explore the efficacy of obinutuzumab and ibrutinib treatment induction for 9 months, followed by a minimal residual disease (MRD)-driven strategy. Methods Following assessment at Month 9, patients in complete response (CR) with bone marrow (BM) MRD <0·01% continued only ibrutinib 420 mg po daily for 6 additional months (I arm). Otherwise, patients received 4x4-weekly cycles of fludarabine/cyclophosphamide (FC) and obinutuzumab 1000 mg iv, alongside continuing ibrutinib for 6 additional months (FCGA+I arm). Beyond Month 16, response was clinically assessed every 3 months and MRD in PB until Month 40 and every 6 months during 36 months. MRD assessment was by 8-colour flow cytometry (limit of detection 10-6). The primary objective was to demonstrate a 30% or higher rate of CR with BM MRD <0·01% at Month 16, by intent-to-treat (ITT) analysis. Progression-free survival (PFS) and overall survival (OS) were secondary endpoints. ResultsBetween 10/2015 and 05/2017, 135 patients were enrolled. At Month 9, only 8% of patients reached CR with BM MRD <0·01%, and thus, in accordance with the MRD-driven strategy, were included in the I arm and continued only ibrutinib for 6 additional months. Most patients were included in the FCGA+I arm and received 4 cycles of FC and obinutuzumab, alongside continuing ibrutinib for 6 additional months. At Month 16, the ITT rate of CR with BM MRD <0·01% was 62% (84/135; 90% confidence interval [CI] 55−69). Of note, the primary objective was exceeded, and this high ITT rate was achieved with no more than 4 cycles of FC and obinutuzumab. The CR rate was 73% by investigator assessment versus 75% by an independent review committee. The PB and BM MRD <0·01% rate was 79%. The most common haematological adverse event (AE) was thrombocytopenia in 45 (34%) of 133 patients at grade 1−2 in Months 1−9 and in 43 (33%) of 130 patients at grade 1−2 in Months 9−15. The most common non-haematological AE were infusion-related reaction in 83 (62%) patients at grade 1−2 in Months 1−9 and gastrointestinal disorders in 62 (48%) patients at grade 1−2 in Months 9−15. A total of 49 serious AE occurred, most frequently infections (10), cardiac events (8) and haematological events (8). No treatment-related deaths occurred. After a median follow-up of 26.3 months, the 2-year PFS rate was 98% (95% CI 95−100) (Figure 1) and the 2-year OS rate was 97.5% (95% CI 96−100). The longitudinal follow-up of PB MRD in the entire cohort showed durability of a deep response, with a PB MRD <0.01% rate of 96% (n=92 evaluable patients) at Month 22 and 91% (n=85 evaluable patients) at Month 28. According to the treatment arm, in the FCGA+I arm, the PB MRD <0.01% rate was 99% at Month 22 and 93% at Month 28; by contrast, in the I arm, 77% of patients had PB MRD <0.01% at each of Months 22 and 28. The strategy achieved deep and durable molecular remission with a high level of undetectable (UD) PB MRD that was maintained over time, as shown in Figure 2. At Month 28, the rate of UD PB MRD was 83% in the FCGA+I arm versus 54% in the I arm. According to the immunoglobulin heavy gene variable (IGHV) mutational status, the PB MRD ≥0.01% rate at Month 28 was 4% for the mutated group versus 23% for the unmutated group (p=0.075, Fisher test). Conclusion These findings from the ICLL-07 trial demonstrated that, in previously untreated, medically fit patients with CLL and no 17p deletion, treatment induction with obinutuzumab and ibrutinib followed by an MRD-driven strategy yielded a high rate of CR with BM and PB MRD <0.01%, together with prolonged PFS and OS. With longer follow-up, including assessing the evolution of PB MRD, the response is maintained. This strategy could be an option in the first-line setting, although randomised trial evidence is needed. Disclosures Salles: Roche, Janssen, Gilead, Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: Educational events; Amgen: Honoraria, Other: Educational events. Leblond:Gilead: Honoraria, Speakers Bureau; Abbvie: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Roche: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Amgen: Honoraria, Speakers Bureau; Astra Zeneca: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau. Cartron:Roche, Celgene: Consultancy; Sanofi, Gilead, Janssen, Roche, Celgene: Honoraria. Cymbalista:Sunesis: Research Funding; Roche: Research Funding; Janssen: Honoraria; Abbvie: Honoraria; AstraZeneca: Honoraria; Gilead: Honoraria. Le Garff-Tavernier:Alexion: Consultancy, Honoraria. Letestu:Alexion: Membership on an entity's Board of Directors or advisory committees, Other: speaker fee, expert contracts; Roche: Membership on an entity's Board of Directors or advisory committees, Other: speaker fee, expert contracts; Janssen: Membership on an entity's Board of Directors or advisory committees, Other: speaker fee, expert contracts; Abbvie: Membership on an entity's Board of Directors or advisory committees, Other: speaker fee, expert contracts. Feugier:janssen: Honoraria, Research Funding, Speakers Bureau; gilead: Honoraria, Research Funding, Speakers Bureau; abbvie: Honoraria, Research Funding, Speakers Bureau; roche: Honoraria, Research Funding, Speakers Bureau.

Download Full-text

Improving the Definition of Response Assessment: Prognostic Value of Minimal Residual Disease Combined with PET/CT at Day 100 Post Autologous Stem Cell Transplantation in Multiple Myeloma

Blood ◽

10.1182/blood-2020-142845 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 33-34

Author(s):

Miguel Gonzalez-Velez ◽

Mariano Arribas ◽

Heidi E. Kosiorek ◽

Richard Butterfield ◽

Carlo Guerrero ◽

...

Keyword(s):

Board Of Directors ◽

Prognostic Value ◽

Residual Disease ◽

High Sensitivity ◽

Response Assessment ◽

Advisory Committees ◽

Pet Ct ◽

Definition Of ◽

Minimal Residual

Introduction: Response assessment at day 100 post Autologous Stem Cell Transplant (ASCT) is associated with long-term relapsed free survival (RFS) and overall survival (OS) in multiple myeloma (MM). The International Myeloma Working Group (IMWG) are the preferred criteria to define best response to treatment and define relapse. In the last years, response assessment has incorporated minimal residual disease (MRD) status -associated with improved RFS and OS (Munshi et al); and PET/CT combined with clinical characteristics -also associated with favorable outcomes (Zamagni et al. NCT01910987; MMY3033). The 2016 IMWG MRD criteria, combined imaging (PET/CT) plus next-generation sequencing (NGS) MRD-negative to define complete response (CR). To our knowledge, there is limited data examining the correlation and prognostic value of MRD and FDG-PET/CT at day 100 post ASCT in MM. IN this study, we aimed to determine the prognostic valued of MRD by NGS combined with PET/CT in RFS and OS status after high dose chemotherapy and ASCT in MM. Methods: Patients who underwent ASCT for MM at Mayo Clinic Arizona and had MRD and PET/CT data were included in the study. Clinical data was obtained via retrospective chart review. Cytogenetic risk (CyR) was classified using the mSMART criteria . Disease and ASCT related characteristics were compared by MRD status. MRD was measured by NGS on bone marrow aspirates using the previosly validated clonoSEQ ® Assay (Adaptive Biotechnologies Corporation, Seattle, USA) tracking the IgH, IgK and IgL rearrangements at a minimum sensitivity level of 10-5. MRD was defined by residual clonal cells per million nucleated cells as: negative= 0, borderline= 1-5, positive >5. PET/CT scans were performed locally at baseline and at day 100. Comparisons were performed using the chi-square test for categorical variables, Wilcoxon rank-sum test for continuos variables, McNemar's test and Cohens's Kappa for agreement measures. Results: A total of 103 patients had matched MRD and PET/CT assessment around day 100 (+/-9 days) and were included in the analysis. Median age at diagnosis was 62 years (range, 54-66 years), 71 patients (68.9%) were men. CyR was standard risk in 49 (47.6%), high-risk in 39 (37.9%) and unknown in 15 (14.6%) patients. Most 75 (72.8%) patients were MRD positive, 16 (15.5%) were MRD negative, and 12 (11.7%) borderline. The median main MRD clone detected was 64 (range 0-91,874). 70 patients (68%) and 33 (32%) had a negative and positive PET/CT respectively. The median follow-up time was 18 months (range, 13-31 months). At the time of data analysis, 10 patients (9.7%) had relapsed and only 4 (3.9%) had died. There was a high-correlation between MRD status and PET/CT, 31 patients (93.9%) with positive PET/CT were also MRD positive (p=0.0027). There were no statistical differences between PET/CT and CyR (p=0.95). We analyzed the correlation using the FREQ procedure (McNemars's test); there was a strong association between positive PET/CT and positive MRD in 31/33 patients (93.9%, high sensitivity), and low association for negative PET/CT the negative/borderline MRD in 26/70 (37.1%, low specificity; p<0.001). The agreement measure between the PET/CT and MRD using negative/borderline combined had a kappa of 0.23 (95% CI 0.11, 0.35) indicating a fair agreement beyond chance (Figure 1). PET/CT-CT was a statistically significant predictor of worse RFS (HR 3.53, 95%CI: 1.02-12.24, p<0.0337) and OS (HR 11.38, 95%CI: 1.18-109.56, p<0.0078) (Figure 2-3, respectively). MRD was not predictive of neither RFS (HR 1.72, 95%CI: 0.36-8.14, p<0.49) or OS (p<0.16). Conclusions: In conclusion, we demonstrate that the combination of MRD by NGS (clonoSEQ ®) and PET/CT at day 100 are complementary and have a high sensitivity (true positive rate) and fair correlation of agreement but low specificity (true negative rate). PET/CT was the best most sensitive technique to prognosticate RFS and OS. We did not find prognostic correlation of MRD with RFS and OS. However, our findings might be confounded by the low risk of relapse and death, a longer follow-up may demonstrate clinically important differences. Our results add evidence that MRD plus PET/CT improve the definition of CR in MM patients post ASCT. Prospective studies are needed to elucidate the optimal timing and role of combined MRD, PET/CT with other prognostic markers of clinical outcomes. Disclosures Larsen: Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen Oncology: Honoraria, Membership on an entity's Board of Directors or advisory committees. Fonseca:Juno: Consultancy; Kite: Consultancy; Aduro: Consultancy; OncoTracker: Consultancy, Membership on an entity's Board of Directors or advisory committees; Merck: Consultancy; Bayer: Consultancy; Janssen: Consultancy; Takeda: Consultancy; Novartis: Consultancy; Pharmacyclics: Consultancy; Sanofi: Consultancy; Oncopeptides: Consultancy; GSK: Consultancy; AbbVie: Consultancy; Adaptive Biotechnologies: Membership on an entity's Board of Directors or advisory committees; Amgen: Consultancy; BMS: Consultancy; Celgene: Consultancy.

Download Full-text

Minimal Residual Disease and Outcome Characteristics in Infant KMT2A-Germline Acute Lymphoblastic Leukemia Treated on the Interfant-06 Protocol

Blood ◽

10.1182/blood-2021-145058 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 2383-2383

Author(s):

Janine Stutterheim ◽

Paola De Lorenzo ◽

Inge M. Van Der Sluis ◽

Julia Alten ◽

Philip Ancliffe ◽

...

Keyword(s):

Prognostic Factors ◽

Board Of Directors ◽

Minimal Residual Disease ◽

Residual Disease ◽

Univariate Analysis ◽

Advisory Board ◽

Research Support ◽

Advisory Committees ◽

Free Survival ◽

Minimal Residual

Abstract Background The outcome of infants with KMT2A-germline ALL is much better than of infants with KMT2A-rearranged ALL, but still worse than of non-infant ALL patients. Here, we describe the outcome and prognostic factors for infants with KMT2A-germline ALL treated on Interfant-06 protocol. Methods 167 infants with KMT2A-germline ALL were enrolled in Interfant-06. Univariate analysis on prognostic factors (age, WBC at diagnosis, prednisolone response and CD10 expression) was performed on KMT2A-germline infants in complete remission at the end of induction (EOI) (n=163). Bone marrow minimal residual disease (MRD) was measured in 73 patients, by real-time quantitative PCR of immunoglobulin genes and/or T-cell receptor genes, at various time points (EOI, n= 68, end of consolidation (EOC) n= 56, and before OCTADAD (n=57)). MRD results were classified as negative, intermediate (< 5*10 -4), and high (≥5*10 -4). Genetic data on NUTM1 rearrangements and MRD were available in 53 patients. Results The 6-year event free survival [SE] and overall survival [ SE] was 73.9% (3,6) and 87.2% (2.7). 28 of 31 (90%) relapses occurred early, within 2 years of diagnosis. Treatment related mortality was 3.6%. Age <6 months was a favorable prognostic factor with a 6-year disease-free survival (DFS) [SE] of 91% (9.0) compared to 71.7% (4.2) in infants >6 months of age (p=0.04). Of the MRD timepoints, MRD at end of induction (EOI) was most prognostic for outcome. At EOI, 76.5% (n=52/68) of patients were either MRD negative (41.2%, n=28) or intermediate MRD (35.3%, n=24). 23.5% (n=16) had high EOI MRD, which was associated with significantly lower 6-year DFS (SE), compared to patients with intermediate or negative EOI MRD (61.4% (12.4), 76.4% (11.3) and 87.9% (6.6), respectively; p=0.02, Figure 1a). At EOC, 55.4% (n=31/56) of patients were MRD negative. Outcome by MRD levels at EOC was not significantly different (p=0.24); the 6-year DFS (SE) of negative and intermediate EOC MRD patients was 89.0% (6.0) and 72.7 % (10.6), respectively, while only one of the 5 patients with high EOC MRD relapsed in BM and CNS (Figure 1b). MRD data for both EOI and EOC were available for 55 patients. Of these patients, 18 were MRD negative at EOI and EOC, with a 6-year DFS 93.3% (SE, 6.4). Five patients had negative EOI MRD, but showed intermediate EOC MRD levels; none of these patients relapsed. There were 12 of 55 patients who were MRD positive at EOI and became MRD negative at EOC. These patients had a 6-year DFS of 82.5 % (SE, 11.3). Patients with detectable disease at both timepoints had a 6-year DFS of 68.3% (SE,10.8) (n=20, Figure 1c). At the end of MARMA (TP5), 77.2% (n=44/57) of patients were MRD negative. MRD at TP5 was significantly related to DFS (Figure 1d); the 6-year DFS was 89.6% (SE, 5.0) for MRD negative patients, compared to 65.6% (SE, 14.0) for patients with intermediate MRD levels (p= 0.039). In the current study, NUTM1 status was known in 53 patients with MRD data. Of them, 13 harbored a NUTM1-rearrangement. Seven out of 11 (63.6%) were aged< 6 months and 6 out of 42 (14.3%) were older. None of them relapsed, despite positive EOI MRD detected in 8 cases. Conclusion We conclude that young age at diagnosis and low EOI MRD are favorable prognostic factors in infants with KMT2A-germline ALL. However, the prognostic value of MRD is not as strong as in infants with KMT2A-rearranged ALL or older children with ALL. This can partly be explained by the differences in genetic makeup of infants with KMT2A-germline ALL, thus supporting the hypothesis that in the future a combined MRD- and genetic-based stratification of KMT2A-g infants might be considered Figure 1 Figure 1. Disclosures Biondi: Colmmune: Honoraria; Bluebird: Other: Advisory Board; Novartis: Honoraria; Incyte: Consultancy, Other: Advisory Board; Amgen: Honoraria. Locatelli: Amgen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Miltenyi: Speakers Bureau; Medac: Speakers Bureau; Jazz Pharamceutical: Speakers Bureau; Takeda: Speakers Bureau. Silverman: Takeda, Servier, Syndax, Jazz Pharmaceuticals: Current equity holder in publicly-traded company, Membership on an entity's Board of Directors or advisory committees. Schrappe: Novartis: Honoraria, Other: research support; SigmaTau: Other: research support; Amgen: Other: research support; Servier: Honoraria; Novartis: Honoraria; JazzPharma: Honoraria; JazzPharma: Honoraria, Other: research support; SHIRE: Other: research support; Servier: Honoraria, Other: research support.

Download Full-text

Updated Follow-Up In The CLL2007FMP Trial Supports The Non Superiority Of The Association Fludarabine-Cyclophosphamide (FC) Plus Campath Compared To FC Plus Rituximab and Points Out The Importance Of Minimal Residual Disease, By 6-Color Flow Cytometry Technique, On Progression Free Survival

Blood ◽

10.1182/blood.v122.21.2870.2870 ◽

2013 ◽

Vol 122 (21) ◽

pp. 2870-2870

Author(s):

Pierre Feugier ◽

Remi Letestu ◽

Sylvie Chevret ◽

Thérèse Aurran ◽

Beatrice Mahe ◽

...

Keyword(s):

Board Of Directors ◽

Residual Disease ◽

Limit Of Detection ◽

Progression Free Survival ◽

Final Evaluation ◽

Advisory Committees ◽

Color Flow ◽

Free Survival ◽

Minimal Residual

Abstract Introduction CLL2007FMP (fit medically patients) is a Randomized Phase-III Trial conducted by the French Cooperative Group on CLL and WM (FCGCLL/WM) and the “Groupe Ouest-Est d'Etude des Leucémies et Autres Maladies du Sang” (GOELAMS), comparing FC plus Rituximab (FCR) to FC plus Campath (FCCam) in previously untreated fit patients with chronic lymphocytic leukemia (CLL). Early results showed that the FCCam regimen was associated with an unfavourable safety profile limiting significantly its use in this indication (Blood 2012). We present here the results of the extended follow up of the CLLFMP2007 trial, with particular emphasis on survival data, minimal residual disease (MRD) and late adverse events. Methods In this trial, 178 younger (<65) fit patients (pts) (cumulative illness rating scale (CIRS) score of up to 6), were enrolled between November 2007 and January 2009. Cases with del(17p) were excluded. Pts were randomly assigned to receive 6 oral courses of FCR (n=83) or FCCam arm (n=82). The primary endpoint of the study was 3-year progression-free survival (PFS). Secondary endpoints were safety, response to treatment, overall survival (OS) and MRD. MRD evaluation was performed by 6-color flow cytometry in an oligocentric manner. MRD testing was scheduled before therapy initiation and at final evaluation, (i.e. 3 months after completion of immunochemotherapy) where it was to be assessed for all responding patients in both peripheral blood (PB) and bone marrow (BM). Recruitment was interrupted in January 2009 after 165 pts had been randomized due to an excess of mortality in the FCCam arm. Results PFS and OS were not significantly different between the two arms. With a median follow-up of 55.5 months (interquartile range, 50-60), 57 pts in the FCCam arm were free of disease progression compared with 50 in the FCR arm, with a 3-year estimated PFS at 81% in both arms (p=0.80). Fourteen pts died in the FCCam arm (7 from progression and 7 from toxicity) and 9 died in the FCR arm (all from progression), with a 3-year estimated survival at 90% vs. 88% (p=0.85). PFS was significantly impacted by IGHV mutational status (p=0.001), Binet stage (p=0.0002) and MRD level. At final evaluation, MRD was established using the result in PB samples (available for 120 patients) and was determined in 103 pts by combining the results from blood and BM samples. Interpretation was based firstly on the use of the classical 10-4 threshold as reference and secondly on the limit of detection of the technique (0.7x10-5). In MRD-positive patients, the median PFS was 44.7 months (PB) whereas it was not reached in the group with MRD lower than 10-4 (p<0.0001, figure 1) ; similar data were found in MRD-positive PB+BM patients with a median PFS of 46 months whereas it was not reached in the group with MRD lower than 10-4 (p=0.002). No significant difference was found regarding OS but follow-up is still short for this evaluation. Similar results were observed when considering the limit of detection of the MRD technique (data not shown). Late toxicities (occurring after the final evaluation at 3 months after the end of treatment or at the ninth month when treatment was prematurely stopped) included : 1 bile duct cancer, 1 myelodysplastic syndrome, 1 transient ischemic attack, 1 lung adenocarcinoma and one prostate cancer in the FCR arm and 3 febrile neutropenia, 3 pneumonia (1 due to legionella), 1 pneumococcal sepsis, 1 bronchitis, 1 toxoplasma eye infection, 1 pyelonephritis, 2 herpes zoster, 1 acrodermatitis, 1 subdural hematoma, 1 autoimmune thrombocytopenia, 1 agranulocytosis, 1 autoimmune haemolytic anaemia in the FCCam arm. Conclusion Results of this extended follow-up of the CLL2007FMP trial confirm the absence of superiority of the FCCam regimen on OS and PFS. Interestingly, longer follow-up did not reveal a higher rate of late toxicity in FCCam arm, notably in terms of secondary malignancies; Similarly to early toxicity, late was adverse events were mainly infectious. Finally, MRD status determined by 6-color technique in PB and/or BM at post-treatment evaluation was predictive of PFS whatever the treatment arm. This finding is in line with recent reports in other studies pointing out to the powerful value of MRD as prognostic factor, supporting its use as PFS surrogate primary endpoint in clinical trials. Disclosures: Feugier: roche: Honoraria. Cazin:roche: meeting invitation Other, Membership on an entity’s Board of Directors or advisory committees; GSK: meeting invitation, meeting invitation Other, Membership on an entity’s Board of Directors or advisory committees.

Download Full-text

Highly Sensitive Droplet Digital PCR for MYD88L265P Mutation Detection and Minimal Residual Disease Monitoring in Waldenström Macroglobulinemia

Blood ◽

10.1182/blood.v126.23.2645.2645 ◽

2015 ◽

Vol 126 (23) ◽

pp. 2645-2645

Author(s):

Daniela Drandi ◽

Elisa Genuardi ◽

Paola Ghione ◽

Daniele Grimaldi ◽

Barbara Mantoan ◽

...

Keyword(s):

Board Of Directors ◽

Mutation Detection ◽

Residual Disease ◽

Digital Pcr ◽

Droplet Digital Pcr ◽

Advisory Committees ◽

Highly Sensitive ◽

Sensitive Tool ◽

Minimal Residual

Abstract Background. Recently, the somatic MYD88L265P mutation has been found as the hallmark of Waldenström Macroglobulinemia (WM), being detectable in nearly 90% of cases, as well as in up to 50% of IgM MGUS, rarely in other non-Hodgkin lymphomas and never in multiple myeloma (MM). Beyond its potential diagnostic role, this mutation has been associated with tumor growth and therapy resistance. Moreover, MYD88L265P might represent an ideal marker for minimal residual disease (MRD) monitoring in a disease whose therapeutic scenario has been rapidly changing, with many new available and highly effective drugs (nucleoside analogues, proteasome and BTK-inhibitors). However, the current MYD88L265P allele-specific quantitative PCR (ASqPCR) diagnostic tool lacks sensitivity (1.00E-03) and thus is not suitable for MRD. Moreover, is not useful to test peripheral blood (PB), that harbors low concentrations of circulating tumor cells (especially after immunochemotherapy), neither to assess cell-free DNA (cfDNA), usually present at very low amount in plasma. Therefore, our study aims: 1) to assess whether a highly sensitive tool as droplet digital PCR (ddPCR) might be helpful in MYD88L265P screening; 2) to evaluate whether MYD88L265P might be a suitable marker for MRD monitoring in WM. Methods. Bone marrow (BM) and PB samples were collected at diagnosis and during follow-up from a local series of patients affected by WM, IgM MGUS and IgG-secreting lymphoplasmacytic lymphoma (LPL), as well as samples from healthy subjects and MM were used as negative controls. Genomic (gDNA) and cell-free DNA (cfDNA) were extracted as recommended (Qiagen). MYD88L265P was assessed on 100 ng of gDNA by ASqPCR as previously described [Xu 2013] and by ddPCR, using a custom dual labelled probe assay (Bio-Rad). When available, 50 ng of cfDNA were tested for MYD88L265P, only by ddPCR. ddPCR was performed on 20 µl of reaction at 55°C for 40 cycles, run on QX100 droplet reader and analyzed by QuantaSoft v1.6.6 (Bio-Rad). MYD88L265P ASqPCR level was estimated as described [Treon 2012]. ΔCT<8.4 identified a MYD88L265P positive sample. Similarly, MYD88L265P ddPCR cut-off was settled on the highest healthy samples level. IGH rearrangements identification and IGH-based MRD analysis were performed as previously described [van der Velden 2007]. Results. Once the ddPCR assay was optimized, the sensitivity of MYD88L265P ddPCR was compared to ASqPCR on a ten-fold serial dilution standard curves built with a 70% MYD88L265P mutated WM sample, previously identified by Sanger sequencing [Treon 2012]. Whereas ASqPCR confirmed the reported sensitivity of 1.00E−03, ddPCR reached a sensitivity of 5.00E−05. Thereafter, overall 105 samples (48 BM, 57 PB, 52 diagnosis and 53 follow up) from 58 patients (49 WM, 5 IgM MGUS and 4 LPL) as well as 20 controls (15 healthy subjects and 5 MM) were tested by both methods. 32/33 (97%) diagnostic BM scored positive for MYD88L265P by both ddPCR and ASqPCR (being the only one negative a WM), while ddPCR, was able to detect more mutated cases, than ASqPCR, among diagnostic PB samples: 15/19 (79%) vs 9/19 (47%) (Table1). Moreover, to investigate whether the MYD88L265P ddPCR tool could be used for MRD detection we compared it to the standardized IGH-based MRD. An IGH-based MRD marker was found in 40/53 (75%) patients (37 WM and 3 LPL). Five Patients, so far analyzed, with baseline and follow up samples (18 BM, 5 PB) showed highly superimposable results between the two methods. Finally, pivotal results on cfDNA from 10 patients showed higher median levels of MYD88L265P mutation in plasma if compared to PB. Conclusions. We developed a new tool for diagnosis and MRD monitoring in WM, showing that: 1) ddPCR is a highly sensitive tool for MYD88L265P detection, especially useful in low infiltrated samples, like PB; 2) MYD88L265P can be effectively and easily used for MRD monitoring in WM, achieving similar results to standardized IGH-based MRD; 3) cfDNA recovered from plasma might be an attractive alternative for MYD88L265P detection, deserving further investigation. Methodological validation against IgH-based MRD detection and Flow cytometry and correlations with clinical impact are currently ongoing on external samples series. Table 1.PATIENTSWM (45)LPL (2)IgM MGUS (5)TISSUEBMPBBMPBBMPBSAMPLES31141114MYD88L265P ddPCR/ASqPCR30/3011/71/10/01/14/2 TABLE 1. MYD88L265P mutation detection in diagnostic samples: ddPCR vs ASqPCR Disclosures Boccadoro: Sanofi: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Consultancy, Membership on an entity's Board of Directors or advisory committees; Onyx Pharmaceuticals: Consultancy, Membership on an entity's Board of Directors or advisory committees; Janssen-Cilag: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Download Full-text

Clinical Implications of Minimal Residual Disease Detection in Infants with KMT2A-Rearranged Acute Lymphoblastic Leukemia Treated on the Interfant-06 Protocol

Blood ◽

10.1182/blood-2020-134303 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 41-42

Author(s):

Janine Stutterheim ◽

Inge M. van der Sluis ◽

Paola De Lorenzo ◽

Julia Alten ◽

Philip Ancliff ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Board Of Directors ◽

Minimal Residual Disease ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Disease Free Survival ◽

Cell Receptor ◽

Advisory Committees ◽

Available N ◽

Minimal Residual

Purpose Infant acute lymphoblastic leukemia (ALL) is characterized by KMT2A gene rearrangements and a poor outcome. Therefore, infants are treated with specific protocols. In older children, minimal residual disease (MRD) is used for risk group stratification. In infant ALL, data on MRD are scarce. We evaluated the prognostic value of MRD in a large series of infants with KMT2A rearranged ALL, treated within Interfant-06 in order to establish how to use MRD in these patients. This protocol included a randomization between lymphoid-style consolidation (protocol IB) versus a myeloid-style consolidation (ADE/MAE). Patients and methods MRD was measured in 249 infants with KMT2A-rearranged ALL by DNA-based PCR of rearranged KMT2A, immunoglobulin and/or T-cell receptor genes, at end of induction (EOI) (n=210), end of consolidation (EOC) (n=173) and after MARMA (n=164). MRD results were classified as negative, intermediate (<5x10-4), and high (≥5x10-4). Results In samples with both data on KMT2A MRD PCR and IG/TR MRD targets available (n=223), results were concordant in 94% (n=210/223) of samples. EOI MRD levels predicted outcome with 6-year disease free survival (DFS [SE]) of 60.2% (7.9), 45.0% (5.6), 33.8 % (5.3), for infants with negative, intermediate and high EOI MRD levels, respectively (p=0.0039). Strikingly, when analyzing MRD results according to consolidation treatment given, MRD levels at EOI predicted treatment outcome for patients treated with lymphoid-style consolidation, but not for patients treated with myeloid style consolidation. In patients treated with lymphoid-style consolidation 6-year DFS (SE) was 78.2% (9.8), 47.2% (7.1), 23.2% (7.1) for negative, intermediate and high MRD levels, (figure 1a) respectively (p<0.0001), whilst in myeloid-style treated patients the corresponding figures were 45.0% (10.7), 41.3% (9.4) and 45.9% (8.2) (figure 1b) This implies that patients with low EOI MRD benefit from protocol IB lymphoid consolidation (DFS 78.2% versus 45.0%, figure 1c), while patients with high MRD benefit from ADE/MAE myeloid consolidation (DFS 45.9% versus 23.2%, figure 1d)). In line with these findings, co-expression of myeloid markers was found in a higher percentage of patients with high EOI MRD (81%) versus those with low EOI MRD (50%) (p=0.0186). EOC MRD levels were also predictive of outcome, with 6-year DFS of 68.2 %(5.8), 40.1% (6.2), 11.9% (8.7) for infants with negative, intermediate and high EOC MRD levels respectively (p<0.0001). Patients that had positive EOI MRD and became negative at EOC also had a good outcome (6-DFS (SE) 65.7% (7.8)) Conclusion Induction therapy selects infant ALL patients for the type of subsequent therapy; infants with high EOI MRD benefit from AML-like consolidation, whereas patients with low MRD benefit from ALL-like consolidation. This hypothesis is further supported by the more pronounced expression of myeloid markers in patients with high EOI MRD levels. Patients with positive EOC MRD had dismal outcomes. These findings will be used for treatment interventions in the next Interfant protocol. Disclosures Brethon: Amgen: Other: invitation to meetings, remunerations for oral presentations, advices for the record of Blinatumomab in pediatrics in France. Locatelli:Jazz Pharmaceeutical: Speakers Bureau; Medac: Speakers Bureau; Miltenyi: Speakers Bureau; Bellicum Pharmaceutical: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Amgen: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.

Download Full-text

Heavy and Light Chain Monitoring in High Risk Smoldering Multiple Myeloma Patients Included in the GEM-CESAR Trial: Comparison with Conventional and Minimal Residual Disease IMWG Response Assessment

Blood ◽

10.1182/blood-2019-128655 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 1852-1852

Author(s):

Noemi Puig ◽

Teresa Contreras ◽

Bruno Paiva ◽

María Teresa Cedena ◽

José J Pérez ◽

...

Keyword(s):

Multiple Myeloma ◽

Bone Marrow ◽

High Risk ◽

Board Of Directors ◽

Research Funding ◽

Residual Disease ◽

Response Assessment ◽

Advisory Committees ◽

Minimal Residual

Introduction: The GEM-CESAR trial is a potentially curative strategy for high-risk smoldering multiple myeloma (HRsMM) patients (pts) in which the primary endpoint is the achievement of bone marrow minimal residual disease (MRD) negativity. However, other methods of disease evaluation in serum such as heavy+light chain (HLC) assessment, with a potential complementary value to the IMWG response criteria, have also been tested. Aim: To evaluate the performance of HLC assay in HRsMM pts at diagnosis and after consolidation, comparing the results with standard serological methods and Next Generation Flow (NGF) for the assessment of bone marrow MRD. Patients and Methods: Ninety HRsMM pts included in the GEM-CESAR trial received six 4-weeks cycles of carfilzomib, lenalidomide and dexamethasone followed by high dose melphalan and 2 further cycles of consolidation with the same regimen. All pts received maintenance treatment with lenalidomide for up to 2 years. SPEP and IFE were performed using standard procedures. Serum IgGk, IgGl, IgAk and IgAl HLC concentrations were measured using Hevylite (The Binding Site Group Ltd, Birmingham, UK) on a SPA PLUS turbidimeter. HLC concentrations and ratios were considered abnormal if they were outside the 95% reference ranges provided by the manufacturer. MRD was analyzed by flow cytometry following EuroFlow recommendations (sensitivity, 2x10-6). Standard response assignment was carried out as per the IMWG guidelines. Hevylite responses were assigned and HLC-pair suppression was defined as in Michalet et al (Leukemia 2018). Results: Out of 90 HRsMM pts, 75 had monoclonal intact immunoglobulin and samples available at diagnosis (50 IgG and 25 IgA). HLC ratio was abnormal in 98% of IgG pts and in 100% of IgA pts. Response assessment by Hevylite and standard IMWG criteria were available in 62 pts post-consolidation (Table 1). A good agreement was found between the two methods (kappa quadratic weighting = 0,6327 (0,4016 - 0,8638)). Among 46 pts with assigned CR as per the IMWG response criteria, there were 3 and 8 pts in PR and VGPR according to the Hevylite method, respectively. In 62 cases, paired Hevylite and MRD assessment data were available. Concordant results were found in 72.5% of cases (45/62; HLC+/NGF+ in 15 and HLC-/NGF- in 30 cases) while in the remaining 27.4% of cases results were discordant (17/62; HLC-/NGF+ in 6 and HLC+/NGF- in 11 cases). Post-consolidation, 24, 25.8 and 42.3% of the 62 samples were positive by SPEP, NGF and Hevylite, respectively. HLC-pair suppression was identified in 13/62 pts; 10 had severe HLC-pair suppression at the end of consolidation. After a median follow-up of 32 months (8-128), 93% of pts remain alive and progression-free. Three patients that have already progressed had their responses assessed post-consolidation. The first pt was assigned VGPR by the standard IMWG criteria and PR by Hevylite and was MRD positive by NGF; the second pt was assigned CR by IMWG criteria and Hevylite but had severe HLC-pair immunosuppression and was MRD positive by NGF; the third pt was in CR by IMWG and HLC criteria and was MRD positive by MFC. Conclusions: Moderate agreement was found between response assessment by Hevylite and the standard IMWG methods as well as between Hevylite and MRD assessment by NGF. Most discordances were a result of Hevylite detecting disease in samples negative by the standard methods, but longer follow-up is needed to ascertain its clinical value. HLC assessment could have anticipated the progression noted in 2 (out of 3) patients. Disclosures Puig: Takeda, Amgen: Consultancy, Honoraria; The Binding Site: Honoraria; Janssen: Consultancy, Honoraria, Research Funding; Celgene: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding, Speakers Bureau. Paiva:Amgen, Bristol-Myers Squibb, Celgene, Janssen, Merck, Novartis, Roche and Sanofi: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene, Janssen, Sanofi and Takeda: Consultancy. Rodriguez Otero:Kite Pharma: Consultancy; Celgene Corporation: Consultancy, Honoraria, Speakers Bureau; BMS: Honoraria; Janssen: Consultancy, Honoraria; Takeda: Consultancy. Oriol:Celgene, Amgen, Takeda, Jansse: Consultancy, Speakers Bureau. Rios:Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees. Alegre:Celgene, Amgen, Janssen, Takeda: Membership on an entity's Board of Directors or advisory committees. de la Rubia:Amgen: Consultancy; Janssen: Consultancy; Celgene: Consultancy; Takeda: Consultancy; AbbVie: Consultancy. De Arriba:Celgene: Consultancy, Honoraria; Janssen: Consultancy, Honoraria; Amgen: Consultancy, Honoraria; Takeda: Honoraria. Ocio:Celgene: Consultancy, Honoraria, Research Funding; Sanofi: Research Funding; BMS: Honoraria; Novartis: Consultancy, Honoraria; Array Pharmaceuticals: Research Funding; Pharmamar: Consultancy; Seattle Genetics: Consultancy; Mundipharma: Research Funding; Amgen: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria; AbbVie: Consultancy; Janssen: Consultancy, Honoraria. Bladé:Janssen, Celgene, Amgen, Takeda: Membership on an entity's Board of Directors or advisory committees; Irctures: Honoraria. Mateos:Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Pharmamar: Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; GSK: Membership on an entity's Board of Directors or advisory committees; Abbvie: Membership on an entity's Board of Directors or advisory committees; EDO: Membership on an entity's Board of Directors or advisory committees; Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees; Adaptive: Honoraria; Takeda: Honoraria, Membership on an entity's Board of Directors or advisory committees.

Download Full-text

Transient Switch to Myeloid Lineage in Acute Lymphoblastic Leukemia during Induction Therapy: The Role of CD371 Expression and Implication for Minimal Residual Disease Detection

Blood ◽

10.1182/blood-2019-127287 ◽

2019 ◽

Vol 134 (Supplement_1) ◽

pp. 377-377

Author(s):

Elena Varotto ◽

Margarita Maurer-Granofszky ◽

Daniela Silvestri ◽

Pamela Scarparo ◽

Ester Mejstrikova ◽

...

Keyword(s):

Acute Lymphoblastic Leukemia ◽

Board Of Directors ◽

Minimal Residual Disease ◽

Induction Therapy ◽

Residual Disease ◽

Lymphoblastic Leukemia ◽

Advisory Committees ◽

Aberrant Expression ◽

Flow Network ◽

Minimal Residual

Background Multiparametric flow cytometry (MFC) is critical in the diagnosis and management of pediatric acute lymphoblastic leukemia (ALL), through immunophenotyping (IP), and minimal residual disease (MFC MRD) analysis. The aberrant expression of myeloid markers in B- and T-lineage ALL is a well-known phenomenon. It may be the result of an adaptive mechanism by lineage switch (SW), defined as any variation of blast IP over time. CD371 is a transmembrane glycoprotein usually expressed on normal myeloid cells and most of the myeloid blasts. Aberrant expression of CD371 was observed in DUX4-rearranged B cell precursor ALL (BCP ALL). Aims To investigate the clinical and biological features of CD371 positive (CD371+) pediatric BCP ALL, pointing out its potential implication in MFC MRD monitoring on Day 15. Materials and Methods From June 2014 to January 2017, 862 children with newly diagnosed t(9;22)(q34.1;11.2);BCR-ABL1 negative BCP ALL, were consecutively enrolled in the AIEOP BFM ALL 2009 study by AIEOP centers. Peripheral blood (PB) and bone marrow (BM) samples (SMPs) were processed and analyzed in the Laboratory of Diagnosis and Research of Pediatric Hematology-Oncology, University of Padua, Italy, according to standardized operating protocols designed by the AIEOP BFM Flow Network. At diagnosis, 9 combinations of 8 monoclonal antibodies (MoAbs) were used for IP. MFC MRD (Day 8 on PB, Day 15, 33, and 78 on BM) was performed with 2 combinations of 8 MoAbs from June 2014 to May 2016. Later, a dry 10 colors preformulated tube was adopted for MFC MRD monitoring. Results At diagnosis, CD371 expression was assessed in 823 of 862 (95.5%) SMPs by as many patients (pts; age: 1-17 years; male/female: 446/377). Of those, CD371 was positive in 75 of 823 SMPs (9.1%). CD371 positivity was associated with older age, euploidy, a more immature immunophenotype (B-I as per EGIL classification), and the aberrant expression of CD2 antigen, as well as at least one myeloid marker (Table). CD371+ SMPs showed a stronger expression of CD34, CD45, and CD58 antigens than CD371 negative SMPs (Table). We performed MFC MRD analysis on 207 SMPs of CD371+ BCP ALL (42 on Day 8, 72 on Day 15, 40 on Day 33, and 53 on Day 78). During the first 15 days of Induction therapy, a monocytoid population appeared in 76 SMPs [26 of 42 (61.9%) on Day 8 and 50 of 72 (69.4%) on Day 15]. It was characterized by a strong expression of CD34, CD58 and CD45, reduced expression of CD19, and high SSC. We interpreted that phenomenon as an SW to the myelomonocytic lineage, as previously described in a subtype of BCP ALL expressing CD2 at diagnosis. Myelomonocytic SW displayed 2 different patterns: (a) a single population of blasts with heterogeneous expression of CD19 (strong to dim/negative); (b) 2 distinct populations: the first one with the IP of diagnosis, the second one showing a downregulation of CD19 and CD34, an intensification of CD45, and an increase of SSC (Figure). At the same time points, a clear monocytoid population was visible on May-Grunwald-Giemsa stained smears. The comparison between MFC MRD and PCR MRD data showed a higher concordance when both the populations were included in the final amount of blasts on Day 15 (concordance rate: 89% vs. 82%). SW was transient and disappeared after Day 15, even though chemotherapy was always carried on as per therapeutic ALL protocol. CD371 antigen was an accurate marker of SW in our cohort [sensitivity = 0.93 (95% CI ± 0.06), specificity = 0.98 (95% CI ± 0.005), accuracy = 0.98]. Finally, CD371 positivity was associated with a worse response to Induction therapy, showing a higher proportion of pts enrolled in the high therapeutic risk group of the trial, most frequently due to a slow early response according to PCR MRD on Day 33 and 78 (Table). Conclusions We described a new subtype of pediatric BCP ALL, characterized by the aberrant expression of CD371 and a potential myelomonocytic SW during the first phase of Induction Therapy. Accurate identification of the lineage SW is mandatory to properly assess MFC MRD on Day 15 in these pts, avoiding an underestimation of blast cells. This is particularly important, considering that CD371+ BCP ALL was associated with a poor response to Induction therapy. Even in presence of a prevalent monocytoid population, chemotherapy should be carried on according to a therapeutic protocol for ALL. CD371 antigen should be part of IP diagnosis panel for ALL. A multicenter study of AIEOP BFM Flow Network centers is ongoing. Disclosures Brüggemann: Amgen: Membership on an entity's Board of Directors or advisory committees; Incyte: Membership on an entity's Board of Directors or advisory committees; Roche: Consultancy.

Download Full-text

Minimal Residual Disease Is a Predictor for Progression-Free and Overall Survival in Chronic Lymphocytic Leukemia (CLL) That Is Independent of the Type or Line of Therapy.

Blood ◽

10.1182/blood.v114.22.540.540 ◽

2009 ◽

Vol 114 (22) ◽

pp. 540-540 ◽

Cited By ~ 8

Author(s):

Marwan Kwok ◽

Andy C. Rawstron ◽

Abraham Varghese ◽

Peter Hillmen

Keyword(s):

Overall Survival ◽

Board Of Directors ◽

Minimal Residual Disease ◽

Residual Disease ◽

First Line ◽

Advisory Committees ◽

First Line Therapy ◽

Line Therapy ◽

Line Of Therapy ◽

Minimal Residual

Abstract Abstract 540 The depth of remission in CLL correlates with survival in a large number of trials regardless of the therapy used and the depletion of minimal residual disease (MRD), when reported, is usually associated with improved progression free and overall survival. However it is not clear whether this improved outcome is due to the attainment of MRD negativity or whether MRD eradication is a surrogate for other variables that predict for good response. In order to address the true impact of achieving MRD negativity we present data from 137 patients with CLL who were treated between 1996 and 2007, achieved a good clinical response and had bone marrow examined post-therapy to assess remission status including MRD. The MRD assessment was performed in a single laboratory (HMDS, Leeds, UK) using multicolor flow cytometry capable of detecting minimal residual disease (MRD) to a level of one CLL cell in 10000 leukocytes as recently recommended in the IWCLL Guidelines. Patients were followed for a median duration of 3.1 years (range 0.2 - 12.7) after treatment with chlorambucil (n=13), fludarabine (n=17), fludarabine and cyclophosphamide (n=58), fludarabine and cyclophosphamide with mitoxantrone and/or rituxumab (n=8), alemtuzumab (n=29), autologous stem cell transplantation (n=7) and various other treatments (n=5). Of these, 48 achieved a complete response (CR), 24 achieved a CR with incomplete marrow recovery (CRi), 27 achieved a nodular partial response (nPR) and 38 achieved a partial response (PR). Altogether 58 individuals (42.3%) were MRD negative at the end of treatment, including 28 CR, 20 CRi, 3 nPR and 7 PR patients. Results of the univariate and multivariate analyses are summarized below: Age, number of prior therapies and MRD negativity were independently correlated with overall survival. MRD negativity in the marrow at the end of therapy was independently significant in multi-variate analysis including when analysed against age, stage, prior therapy, IWCLL response assessment and cytopenia. One of the most striking findings was in patients having their first CLL treatment. Of the 58 patients in this series who had achieved a clinical response to first line therapy 24 patients (21 patients following FC, 1 FCR, 1 chlorambucil and 1 fludarabine à autologous SCT) achieved an MRD-negative remission and 34 were MRD-positive. With a median follow-up of 38 months (range 7-153) the 5 year PFS for MRD negative patients was 89% (95% CI 55-97%) compared to 0% for the MRD positive patient (95% CI <1%) and the 5 year OS was 95% (95% C.I. 61-99%) vs 53% (95% C.I. 15-74%) for MRD-negative vs. MRD-positive patients, respectively. Although achieving MRD-negativity with subsequent therapy is relatively beneficial, the greatest differences in outcome were seen in front-line treatment. This data suggests that achieving MRD-negativity after first-line therapy has a profound effect on overall survival. In conclusion, we demonstrate that achieving MRD negativity in CLL is an independent predictor of survival in multivariate even when a variety of different treatment approaches are considered and regardless of the line of therapy.. This is the strongest evidence yet that achieving MRD negativity is the most appropriate aim of therapy in CLL for patients who are fit enough for such an approach. Furthermore patients who achieve MRD negativity after their first therapy have a 5 year PFS of 89% and a 5 year overall survival of 95% suggesting that the optimal time to attempt to achieve MRD negativity is with first line therapy. Disclosures: Hillmen: Roche Pharmaceuticals: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; GlaxoSmithKline: Consultancy, Membership on an entity's Board of Directors or advisory committees.

Download Full-text