Minimal Residual Disease (MRD) Monitoring in NPM1 Mutated Acute Myeloid Leukemia (AML): Impact of Concurrent FLT3-ITD and DNMT3A Mutations on MRD Kinetics and Clinical Outcome

Abstract Introduction In a recent update on MRD monitoring in 407 NPM1 mutated (NPM1mut) AML patients (pts) we could confirm the results from our previous study showing that achievement of RQ-PCR negativity after double induction (DI), after completion of therapy (CT) as well as during the follow-up period (FUP) is significantly associated with a lower cumulative incidence of relapse (CIR) and superior overall survival (OS) [Döhner K, Annals of Hematol; 2013;Suppl.1,92:S39]. In addition, in pts with concurrent FLT3-ITD (FLT3-ITDmut) or DNMT3A (DNMT3Amut) mutations, we also showed that the median NPM1mut transcript levels after each treatment cycle were significantly higher. Aim To evaluate the impact of concurrent FLT3-ITD and DNMT3Amut on MRD kinetics and clinical outcome in NPM1mutAML pts. Methods For this analysis we included all pts enrolled on one of two AMLSG treatment trials [AMLHD98A (NCT00146120) n=46; AMLSG 07-04 (NCT00151242) n=199] for whom the FLT3-ITD and DNMT3A mutation status at the time of diagnosis was determined. MRD levels (ratio NPM1mut/ABL1 transcripts x 104) were detected by NPM1mut specific RQ-PCR using TaqMan technology; the sensitivity of the assays was 10-5 - 10-6. DNMT3A and FLT3-ITD mutation status was assessed by standard PCR-based methods Results In total, 1588 samples [bone marrow n=1564; peripheral blood n=24] from 245 NPM1mut pts were analyzed [at diagnosis, n= 240; during therapy, n= 807; during FUP, n= 541]. FLT3-ITD and DNMT3A mutation status was available in 245/245 (FLT3-ITDmut n=94) and in 234/245 (DNMT3Amut n= 122) pts, respectively. Pre-treatment NPM1mut transcript levels did not correlate with clinical characteristics, DNMT3A or FLT3-ITD mutation status and had no impact on event-free survival, relapse-free survival and OS. Multivariable analyses stratified for FLT3-ITD mutation status after DI and CT revealed RQ-PCR negativity as a significant factor for longer remission duration (hazard ratio (HR) 15.15 and 8.95, respectively) and better OS (HR 6.13 and 4.27, respectively); DNMT3A mutation status had no significant impact in these models. Subgroup analyses showed that the proportion of pts achieving RQ-PCR negativity after DI, after CT and during FUP was significantly lower in DNMT3Amut compared to the DNMT3A wildtype pts (8.6% vs 33.3%, p=<0.001; 36,3% vs 61.9%, p=0.009; 33% vs 51%, p=0.04, respectively) whereas for FLT3-ITDmut pts this effect was only significant after DI (8.3% vs 25%, p=0.022). Based on these findings we further investigated the impact of RQ-PCR negativity in the context of concurrent FLT3-ITD and DNMT3A mutations. After DI, there was no significant difference in CIR and OS for RQ-PCR negative pts with respect to FLT3-ITD or DNMT3A mutation status. After CT, RQ-PCR negative pts with DNMT3Amut had a significantly higher CIR compared to DNMT3A wildtype pts (34% vs 8% at 4 years; p=0.007). This adverse prognostic impact was consistently seen during the FUP (CIR 21% vs 3% at 4 years; p=0.01); there was no difference in CIR rates between pts with and without FLT3-ITD mutations. Conclusions We demonstrate a significant correlation between the DNMT3A mutation status and the achievement of RQ-PCR negativity at all clinically relevant time points i.e. after DI, and CT, and during FUP while this strong correlation was not observed for FLT3-ITDmut. Within the NPM1mut RQ-PCR negative group the presence of DNMT3Amut allows the identification of pts at high risk of relapse. Based on our findings DNMT3A mutation status should be determined in NPM1mut pts to further refine MRD monitoring. The establishment of DNMT3Amut specific MRD assays might provide additional information on MRD status in these pts. Disclosures: Schlegelberger: Celgene: Consultancy. Lübbert:Johnson and Johnson: Advisory Board Other. Kindler:Novartis: Membership on an entity’s Board of Directors or advisory committees. Germing:Celgene: Honoraria, Research Funding. Schlenk:Novartis: Research Funding; Amgen: Research Funding; Pfizer: Honoraria, Research Funding; Chugai: Research Funding; Ambit: Honoraria; Celgene: Honoraria, Research Funding.

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Prognostic Impact of Bone Marrow Erythropoiesis on Newly Diagnosed Plasma Cell Myeloma: A Single Institutional Analyses

Blood ◽

10.1182/blood-2018-99-116619 ◽

2018 ◽

Vol 132 (Supplement 1) ◽

pp. 5579-5579

Author(s):

Daniel E Ezekwudo ◽

Rohit Singh ◽

Bolanle Gbadamosi ◽

Mark Micale ◽

Ishmael Jaiyesimi ◽

...

Keyword(s):

Bone Marrow ◽

Clinical Outcome ◽

Plasma Cell ◽

Prognostic Impact ◽

Plasma Cell Myeloma ◽

Newly Diagnosed ◽

Bone Marrow Biopsies ◽

Kaplan Meier ◽

Significant Difference ◽

The Impact

Abstract Introduction: In plasma cell myeloma (PCM), tumor burden and activity plays an important role in diagnosis and prognosis (e.g. circulating plasma cells), however very little attention has been directed to the impact of the non-plasma cell component of the bone marrow. The presence of anemia has been used to distinguish PCM from smoldering myeloma; however this can be a non-specific finding as there are many potential causes of anemia besides PCM. We sought to determine if the level of erythropoiesis in bone marrow biopsies may be a more reliable prognostic factor. In the study herein, we assessed the level of bone marrow erythropoiesis in patients with newly diagnosed PCM, and compared those findings with cytogenetic results (CGs), other prognostic factors and overall clinical outcome. We hypothesized that patients with adequate erythropoiesis (AEp) are likely to have favorable cytogenetics and better outcome compared to those with decreased erythropoiesis (DEp). Methods: We retrospectively reviewed pathology database for bone marrow biopsies in patients with diagnosis of plasma cell myeloma (PCM) at Beaumont Hospital, an academic community center from 2012 and 2014. Biopsy cases without anemia were excluded. A total of 91 patients with plasma cell myeloma and anemia were identified. Each biopsy was re-examined to determine the level of erythropoiesis. The level of erythropoiesis was calculated by multiplying erythroid fraction (obtained from M:E ratio) with non-plasma cell bone marrow cellularity. Cases were separated into AEp and DEp using an erythroid compartment cut-off of 7.5% based on already established data. Kaplan-Meier analysis was used to compare survival between groups. Results: Demographic distribution of studied patients were 46 (50.1%) white, 39 (43%) African Americans and 6 (6.6%) others. Out of 91 cases analyzed, 38 (42%) had AEp whereas 53 (58%) had DEp. Among those with AEp, 23 (62%) had favorable CGs (defined as those without t (4, 14), t (14, 16), t (14, 20) or 17 p deletion); 15 (38%) had unfavorable CGs. Among those with DEp, 14 (26%) had favorable CGs whereas 39 (74%) had unfavorable cytogenetics. The vast majority of patients with favorable CGs were alive whether they had AEp (87%) or DEp (79%), thus CGs remained significant even after controlling for erythroid compartment (p = 0.03). Overall, those with AEp were noted to have significantly lower β-2 microglobulin (AEp median =2.42 mg/dL, DEp median = 4.50 mg/dL, p = 0.02). Kaplan-Meier analysis showed a significant difference in survival curves among the four groups (AEp with favorable CGs, AEp with unfavorable CGs, DEp with favorable CGs, DEp with unfavorable CGs, p<.0001). While the two groups with favorable CGs showed no significant difference (p=.6050), the two groups with unfavorable CGs did (p=.0027). Conclusion: Our findings suggest that patients with PCM and anemia are not a homogenous population. Assessment of the erythroid compartment in these patients reveals a population with AEp that has more favorable CGs and lower β-2 microglobulin than patients with DEp. Despite this finding, patients with favorable CGs had a favorable clinical outcome whether they had AEp or not, indicating that current therapies can overcome differences in erythropoiesis in that group. For patients with unfavorable CGs, however, those with AEp had superior survival outcome compared to those with DEp, indicating that there may be some prognostic or diagnostic utility to assessing erythropoiesis in patients who meet current criteria for PCM, and possibly, incorporating erythropoietic activity into diagnostic/prognostic schema. Disclosures No relevant conflicts of interest to declare.

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Prognostic Impact of Kinase Mutations and Minimal Residual Disease in Core-Binding Factor Leukemia

Blood ◽

10.1182/blood.v126.23.3828.3828 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3828-3828

Author(s):

David Sanford ◽

Jorge E. Cortes ◽

Farhad Ravandi ◽

Wei Qiao ◽

Keyur P. Patel ◽

...

Keyword(s):

Overall Survival ◽

Research Funding ◽

Residual Disease ◽

Univariate Analysis ◽

Prognostic Impact ◽

Rt Pcr ◽

Relapse Free Survival ◽

Free Survival ◽

Log Reduction ◽

Binding Factor

Abstract Background Core-binding factor (CBF) acute myeloid leukemia (AML) is characterized by recurrent cytogenetic abnormalities t(8;21)(q22;q22) or inv(16)(p13q22)/t(16;16)(p13;q22), amenable for minimal residual disease (MRD) monitoring by quantitative reverse transcription polymerase chain reaction (RT-PCR). Kinase mutations (KIT, RAS, FLT3) have been reported to carry adverse prognostic implication. Promising results using FLAG-based treatment (fludarabine/Ara-C/G-CSF) in CBF leukemia in phase 2 [Borthakur G, Am J Hematol, 10, 89 (2014)] and phase 3 [Burnett AK, JCO, 27, 31 (2013)] clinical trials prompted us to review the prognostic impact of MRD evaluation and mutations. Methods The primary aim was to assess the prognostic impact of kinase-activating mutations (KIT, FLT3-TKD, FLT3-ITD, KRAS and NRAS) and MRD in CBF leukemia treated with FLAG-based regimens. Newly diagnosed patients were treated in 2 consecutive phase 2 clinical trials (clinicaltrials.gov identifier: NCT00801489) and received FLAG during induction (1 cycle) and consolidation (up to 6 cycles) in combination with either gemtuzumab (for 3 cycles) or idarubicin (for 2 cycles). Mutation analysis was performed at baseline on bone-marrow aspirates and MRD was measured on serial bone marrow aspirates using RT-PCR to detect RUNX1-RUNX1T1 and CBFB-MYH11 fusion transcripts, normalized to ABL1 transcript. The Kaplan-Meier method was used to estimate unadjusted overall survival (OS) and relapse-free survival (RFS). The Cox-proportional hazards model was used to estimate the association of covariates with OS and RFS. Landmark survival analysis was used to determine the association between OS/RFS and MRD, to account for time-dependent nature of this covariate. Results: One hundred and seven patients were included [t(8;21)=54, inv(16)=53]. Forty-eight were treated with FLAG + gemtuzumab and 59 were treated with FLAG + idarubicin. The 3 year OS and RFS for the cohort was 79% (95% CI, 71-89%) and 82% (95% CI, 74 - 91%) respectively with comparable outcomes with both regimens. The incidence of mutations in KIT, FLT3-ITD, FLT3-TKD and NRAS/KRAS was 13%, 7%, 10% and 38.5% respectively. In univariate analysis, the presence of mutations in KIT, FLT3 and NRAS/KRAS individually or together were not associated with OS or RFS. A 3-log or greater reduction in RT-PCR level at 1 month and 3-4 months was associated with improved RFS. A 3-log or greater reduction in RTPCR level at 6-9 months was also significantly associated with improved OS (HR 0.19, 95% CI 0.03 -1.0, p=0.05) and there was a trend towards improved OS with 3-log reduction at 1 month (HR 0.39, 95% CI 0.14 - 1.06, p=0.06). Conclusion: In contrast to some reports, mutations in KIT, FLT3 and RAS were not prognostic for RFS or OS in our study. Favorable outcomes using FLAG-based therapy in CBF leukemia may abrogate adverse impact of kinase mutations and this hypothesis needs to be clinically tested. The incidence of KIT mutations was slightly lower in our cohort in comparison to most previous reports, which may relate to differences in sensitivity of detection. Significantly, quantitative detection of MRD by PCR early on appears to be a broadly applicable predictor of relapse and may be the most relevant prognostic factor for clinical management of CBF leukemia patients. Table 1. Univariate analysis showing hazard of relapse for all patients HR 95% CI p-value Age 1.00 0.97 - 1.04 0.89 Performance status (ECOG 1,2 vs. 0) 3.59 1.3 - 9.95 0.01 Therapy related (Y vs. N) 0.38 0.05 - 2.93 0.36 CBF Type - [inv(16) vs. t(8;21)] 0.95 0.34 - 2.62 0.92 Treatment (FLAG-ida vs. FLAG-GO) 1.59 0.56 - 4.51 0.38 Mutated KIT (Y vs. N) 1.55 0.35 -6.91 0.56 FLT3-ITD (Y vs. N) 0.7 0.09 - 5.39 0.73 FLT3-TKD (Y vs. N) 2.07 0.46 - 9.32 0.34 RAS - NRAS/KRAS (Y vs. N) 0.79 0.24 - 2.63 0.7 Any mutation -KIT/FLT3/ RAS (Y vs. N) 1.17 0.42 - 3.22 0.76 MRD - 3 log reduction at 1 month (Y vs. N) 0.23 0.06 - 0.81 0.02 MRD - 3 log reduction at 3-4 months (Y vs. N) 0.18 0.05 - 0.61 <0.01 MRD - 3 log reduction at 6-9 months (Y vs. N) 0.29 0.06 - 1.41 0.12 MRD - negative at 6-9 months (Y vs. N) 0.3 0.06 - 1.47 0.13 Figure 1. Outcomes by mutation status (KIT or FLT3 or RAS). (a) Overall survival; (b) Relapse free survival. Figure 1. Outcomes by mutation status (KIT or FLT3 or RAS). (a) Overall survival; (b) Relapse free survival. Disclosures Cortes: Teva: Research Funding; Novartis: Consultancy, Research Funding; BerGenBio AS: Research Funding; Pfizer: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Ariad: Consultancy, Research Funding; Astellas: Consultancy, Research Funding; Ambit: Consultancy, Research Funding; Arog: Research Funding; Celator: Research Funding; Jenssen: Consultancy.

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IGHV-Mutation Status, IGHV-Gene Usage and Chromosomal Aberrations In CLL: Pooled Analysis within First-Line Clinical Trials of the German CLL Study Group (GCLLSG)

Blood ◽

10.1182/blood.v116.21.3609.3609 ◽

2010 ◽

Vol 116 (21) ◽

pp. 3609-3609

Author(s):

Andreas Bühler ◽

Thorsten Zenz ◽

Dirk Winkler ◽

Raymonde Busch ◽

Kirsten Fischer ◽

...

Keyword(s):

Research Funding ◽

Pooled Analysis ◽

P Value ◽

First Line ◽

Mutation Status ◽

Ighv Gene ◽

Significant Difference ◽

Gene Usage ◽

Genomic Aberrations ◽

The Impact

Abstract Abstract 3609 Introduction: IGHV mutation status and genomic aberrations are of independent prognostic importance in CLL. Furthermore IGHV-gene usage showed prognostic value for distinct subgroups (e.g. VH3-21). While the introduction of chemoimmunotherapy (i.e. FCR) has led to remarkable improvement of outcome in CLL, it is unclear which of the known genetic markers retain their prognostic value. We therefore performed a pooled analysis of first-line CLL patients from 3 prospective clinical trials of the GCLLSG namely “CLL2M” (R-Bendamustine) “CLL4” (F vs. FC) and “CLL8” (FC vs. R-FC) to evaluate those genetic markers in a large, well characterized CLL cohort. Material and Methods: Genetic characterization was performed in a central laboratory (Ulm). IGHV data was available for 1063 patients. Genomic aberrations (FISH) were generated for 1053 patients. After pooling genetic data from the outlined GCLLSG first-line trials we investigated the impact of IGHV mutation status and VH gene usage within the hierarchical model of genomic abnormalities (deletion 13q (del(13q)) single (n=353), trisomy 12 (n=115), deletion 11q (del(11q)) (n=229), deletion 17p (del(17p)) (n=73)) concerning, progression free survival (PFS events= PD/death) and overall survival (OS). Median follow-up was 39.1 months. Results: For the del(13q) patients, with 56 % carrying a mutated IGHV gene, we found a significant difference in PFS and OS between the del(13q)/IGHV mutated and the IGHV unmutated subgroup (PFS: p-value 0.002; HR: 1.596; OS: p-value 0.002; HR: 2.15; median PFS mut./70.5 months vs. unmut./41.5 months). In the trisomy 12 subgroup 35 % of patients showed a mutated IGHV whereas 65 % showed an unmutated IGHV. For the trisomy12/IGHV unmutated subgroup we could detect a trend towards a shorter PFS and OS compared to the trisomy12/IGHV mutated group although this was not statistically significant (PFS: p-value 0.059; HR: 1.784; OS: p-value 0.079; HR: 3.05; median PFS not reached vs. 36.8 months). In the del(11q) subgroup 17 % were IGHV mutated, whereas 83 % were unmutated. For none of the clinical endpoints (PFS, OS) a significant difference between the 11q-/IGHV mutated group and the 11q-/IGHV unmutated group could be detected (PFS: p-value 0.451; OS: p-value 0.64; median PFS 32.7 months for both subgroups). Finally among the del(17p) pts. with 23 % IGHV-mutated cases we could not find any difference in PFS or OS among the IGHV-mutated or unmutated subgroup (PFS: p-value 0.995; HR: 0.998; OS: p-value 0.584; HR: 0.80, median PFS 8.8 vs. 9.6 months). In contrast to previous findings we detected no significant difference in clinical behaviour of the mutated VH3-23 subgroup in comparison to all non-VH3-23 mutated cases with regard to PFS and OS within the CLL8 cohort. (median PFS not reached vs. 59.7 months). For unmutated VH1-69 cases no significant differences concerning the clinical endpoints in comparison to all non-VH1-69 unmutated cases were detected. Finally the 66 VH3-21 patients in the pooled data set showed a PFS and OS which was surprisingly more comparable to that of IGHV-mutated cases (PFS: p-value 0.488; OS: p-value 0.467; median PFS 51.9 months for VH3-21 vs. 63.6 months for mutated non-VH3-21). However, stereotyped HCDR3 motifs have not been considered in this analysis. Conclusions: The current data were derived from pooled subgroup analyses based on genomic aberrations among patients enrolled in 1st line treatment trials (i.e. patients requiring treatment). It revealed a differential influence of IGHV-mutation status and gene usage in the different genomic subgroups. This might hint to different biological behaviour apart from postulated mechanisms like B cell receptor mediated antigen drive and could also be reflected by differences in clinical course. The impact of VH3-21 usage and potentially other VH genes appears to be less pronounced in this cohort. The prognostic role of distinct IGHV-genes must be further evaluated in different clinical situations also considering stereotyped B-cell receptors. Disclosures: Bühler: Roche Pharma: Consultancy, Research Funding. Zenz:Roche: Honoraria; Boehringer: Honoraria; GSK: Honoraria; Celgene: Honoraria. Winkler:Roche Pharma AG: Consultancy, Research Funding. Fischer:Roche Pharma AG: Consultancy. Fink:Roche Pharma AG: Consultancy. Wendtner: Celgene, BayerSchering, Roche, Mundipharma: Consultancy, Honoraria. Eichhorst:Roche Pharma AG: Consultancy. Edelmann:Roche Pharma AG: Consultancy, Research Funding. Hallek:Roche Pharma AG: Consultancy. Stilgenbauer:Roche, Bayer, Celgene, GSK, Amgen, Mundipharma: Consultancy, Honoraria, Research Funding.

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Incidence and Prognostic Relevance of ASXL2 Mutations in Adult CBF-AML with t(8;21)(q22;q22): A Study of the German-Austrian AML Study Group (AMLSG)

Blood ◽

10.1182/blood.v126.23.3818.3818 ◽

2015 ◽

Vol 126 (23) ◽

pp. 3818-3818 ◽

Cited By ~ 1

Author(s):

Nikolaus Jahn ◽

Mridul Agrawal ◽

Lars Bullinger ◽

Daniela Weber ◽

Andrea Corbacioglu ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Prognostic Impact ◽

Dependent Manner ◽

Trisomy 8 ◽

Advisory Committees ◽

Mutation Status ◽

Paired Samples ◽

Significant Difference ◽

High Incidence

Abstract Background: The ASXL2 (Additional Sex comb-like 2) gene on chromosome 2p23.3 encodes an epigenetic regulator that is thought to act through histone modification and thereby regulating gene transcription in a context-dependent manner. Recently, ASXL2 mutations (ASXL2mut) were found with a high incidence (~23%) in a cohort of 110 pediatric or adult AML patients (pts) with t(8;21)(q22;q22) (Micol et al., Blood 2014). Aim: We assessed the frequency and prognostic impact of ASXL2mut in the context of other clinical and genetic factors in a large clinically well-defined cohort of intensively treated adults with t(8;21) AML. In addition, the stability of ASXL2 mutation status was analysed in a subset of pts at the time of relapse. Methods: Diagnostic samples from 204 adults with t(8;21);RUNX1/RUNX1T1 -positive AML [median age: 49 years, range: 18-82] were analysed for ASXL2mut in exon 11 and 12 using a combination of PCR-based amplification and subsequent direct DNA-sequencing. Paired samples at diagnosis and relapse were evaluated for the ASXL2 mutation status in a subset of 22 pts. Additional mutation analyses were performed for KIT, FLT3 (ITD and TKD), NRAS, and ASXL1 genes. All pts received intensive treatment either within AMLSG trials (n=155) or according to standard chemotherapy regimens. Results: Thirty four ASXL2mut were identified in 33 (16.2%) of the 204 pts. All mutations (frame-shifts, n=32; non-sense, n=2) created stop codons leading to premature protein truncation with loss of the terminal PHD domain; 27% of the mutations affected codon T740 in exon 12. At diagnosis, there was no significant difference between pts with ASXL2mut and ASXL2 wildtype (ASXL2wt) with respect to sex, WBC, haemoglobin, platelets, LDH serum levels, and circulating or bone marrow blasts. Of note, ASXL2mut were not associated with increasing age, a finding which is commonly observed for ASXL1 mutations in AML. In terms of secondary chromosome aberrations ASXL2mut were frequently associated with del(9q) (P=.006), whereas they never co-occurred with trisomy 8. There was no significant association between ASXL2mut and all other gene mutations analysed. Analysis for ASXL2 mutation status in 22 paired samples obtained at diagnosis and relapse showed a high stability since the mutation was still present in two pts at relapse whereas none of the remaining 20 ASXL2 wildtype cases acquired ASXL2mut. There was no difference in complete remission (CR) rate after double induction between pts with ASXL2mut (88%) and those with ASXL2wt (92%); the same was true when comparing pts with ASXL1 or ASXL2 mutations (ASXL1/2mut) as one group (93%) versus those with ASXL1/2 wildtype. Neither ASXL2mut nor ASXL1/2mut did impact the endpoints event-free-survival, cumulative incidence of relapse, relapse-free and overall survival. Conclusions: Beside KIT and NRAS, ASXL2 is among the most frequently mutated genes in t(8;21) AML. ASXL2mut did not impact achievement of CR or any survival endpoint. Nevertheless, the high incidence (16.2%) of ASXL2mut in t(8;21) AML and the exclusivity to this subgroup of core-binding factor AML implies a peculiar role of ASXL2 in the leukemogenesis of t(8;21) AML providing a basis for further studies. Disclosures Horst: MSD: Research Funding; Pfizer: Research Funding; Amgen: Honoraria, Research Funding; Gilead: Honoraria, Research Funding; Boehringer Ingleheim: Research Funding. Schlenk:Daiichi Sankyo: Membership on an entity's Board of Directors or advisory committees; Novartis: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Janssen: Membership on an entity's Board of Directors or advisory committees; Boehringer-Ingelheim: Honoraria; Arog: Honoraria, Research Funding; Teva: Honoraria, Research Funding.

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Monitoring of Minimal Residual Disease (MRD) of DNMT3A Mutations (DNMT3Amut) in Acute Myeloid Leukemia (AML): A Study of the AML Study Group (AMLSG)

Blood ◽

10.1182/blood.v126.23.226.226 ◽

2015 ◽

Vol 126 (23) ◽

pp. 226-226 ◽

Cited By ~ 2

Author(s):

Verena I. Gaidzik ◽

Daniela Weber ◽

Peter Paschka ◽

Anna Kaumanns ◽

Stefan Krieger ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Continuous Variable ◽

Prognostic Impact ◽

Advisory Committees ◽

Clinical Endpoints ◽

Clonal Hematopoiesis ◽

Significant Difference ◽

The Impact

Abstract Background: The DNA methyltransferase 3A (DNMT3A) is one of the most frequent mutated genes in AML with a hot spot mutation at codon R882 in 80% of the DNMT3Amut cases. In most of the studies DNMT3Amut predicts for poor overall (OS) and relapse-free survival (RFS). Recently, DNMT3Amut have been associated with age-related clonal hematopoiesis, and they have been identified in early preleukemic stem cells. These findings suggest that DNMT3Amut represents an early event in leukemogenesis and may be part of the leukemia founder clone in most AMLs harboring a DNMT3Amut. We thought to address the question whether MRD monitoring in DNMT3Amut patients (pts) can be used for prognostic classification and risk stratification in these pts. Aims: We monitored MRD for the most common DNMT3Amut (DNMT3Amut -R882H, n=126 and -R882C, n=55) in a large cohort of adult AML pts entered on three AMLSG treatment trials [AML HD98A (n=14; NCT00146120), AMLSG 07-04 (n=86; NCT00151242), AMLSG 09-09 (n=81; NCT00893399)]. Methods: DNMT3Amut MRD monitoring was performed using a cDNA-based RQ-PCR-assay by TaqMan technology with a sensitivity between 10-3 and 10-4. MRD levels are reported as normalized values of DNMT3Amut transcripts per 104ABL1 transcripts (DNMT3Amut/104ABL1). Results: In total, 1,494 samples [bone marrow (BM), n=798; peripheral blood (PB), n=696] from 181 DNMT3Amut pts were analysed [diagnosis, n=287; during therapy, n=840; follow-up, n=367]. Median age of the patients was 50 years (range, 22 to 78); median BM DNMT3Amut transcript level (TL) at the time of diagnosis was 12690 (range, 1396-54280). There was no significant association of TL with presenting clinical characteristics, such as age, white blood cell count, platelet count, BM and PB blasts, lactate dehydrogenase, or with mutations in NPM1, FLT3 [ITD and TKD], CEBPA and cytogenetics. DNMT3Amut TL as log 10 transformed continuous variable and stratified by study did not impact OS (p=0.29), RFS (p=0.17) and EFS (p=0.28). Comparing TL after double induction (DI) did not show a significant difference between 13 patients without complete remission (CR) and 117 in CR (12983 and 12595, respectively; p=0.52). In Cox regression analyses, BM DNMT3Amut TL as log 10 transformed continuous variable during therapy did not impact the clinical endpoints death and relapse. In general, DNMT3Amut TL during therapy (after induction I, induction II, consolidation I and II) were significantly higher in BM than in PB (p=0.01; p=0.05; p=0.004; p=0.008, respectively). We observed the greatest TL reduction (one log) after induction I, whereas subsequent cycles of therapy did not significantly influence TL. To evaluate the impact of DNMT3Amut MRD monitoring with regard to the clinical endpoints OS, cumulative incidence of relapse (CIR) and remission duration (RD) after DI and after end of therapy (ET) we used different statistical approaches; all survival analyses were stratified by study. After DI and ET, only 8/90 and 4/88 BM samples became MRD negative. At these two time-points MRD positivity did not significantly impact OS (p=0.99; p=0.74), CIR (p=0.73; p=0.15) and RD (p=0.83; p=0.16). Next, we investigated the MRD DNMT3Amut log10-reduction (compared to levels at diagnosis) after DI and ET using the median as a cut-off. Again, we could not detect a significant correlation for pts with a higher TL reduction compared with pts with a lower TL reduction for OS and RD after DI and ET (p=0.83; p=0.30; p=0.04; p=0.21, respectively). Lastly, we evaluated the BM DNMT3Amut TL as 4 increasing equally sized intervals according to the quartiles of the distribution. There was no prognostic impact after DI on OS and RD (p=0.53; p=0.89) and ET (p=0.76; p=0.53). When combining PB and BM samples for the analyses we could not find significant changes in the results. Conclusion: In our study most pts had persistent DNMT3Amut TL with only a minority achieving MRD negativity, a finding that supports the presence of persistent clonal hematopoiesis in hematologic remission. Using different explorative approaches, DNMT3Amut TL did not impact clinical outcome neither during therapy nor during follow-up. Disclosures Horst: Gilead: Honoraria, Research Funding; Pfizer: Research Funding; MSD: Research Funding; Boehringer Ingleheim: Research Funding; Amgen: Honoraria, Research Funding. Schlenk:Arog: Honoraria, Research Funding; Boehringer-Ingelheim: Honoraria; Janssen: Membership on an entity's Board of Directors or advisory committees; Teva: Honoraria, Research Funding; Pfizer: Honoraria, Research Funding; Novartis: Honoraria, Research Funding; Daiichi Sankyo: Membership on an entity's Board of Directors or advisory committees.

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Calreticulin Mutation Status Predicts Improved Disease Outcome in Prefibrotic Primary Myelofibrosis but Not in WHO-Defined Essential Thrombocythemia

Blood ◽

10.1182/blood.v124.21.3167.3167 ◽

2014 ◽

Vol 124 (21) ◽

pp. 3167-3167

Author(s):

Heinz Gisslinger ◽

Juergen Thiele ◽

Bettina Gisslinger ◽

Tiina Berg ◽

Martin Schalling ◽

...

Keyword(s):

Overall Survival ◽

Essential Thrombocythemia ◽

Research Funding ◽

Primary Myelofibrosis ◽

Striking Difference ◽

Free Survival ◽

Significant Difference ◽

Calr Mutations ◽

The Impact ◽

Calr Mutation

Abstract The genomic landscape of myeloproliferative neoplasms (MPNs) has altered dramatically due to the recent discovery of somatic mutations of calreticulin (CALR). This discovery enables for the first time molecular information, in addition to JAK2V617F, to be used in the majority of MPN patients as an affirmative variable to discriminate MPNs from reactive myeloid proliferations. The clinical course of essential thrombocythemia (ET) or primary myelofibrosis (PMF) in patients carrying the CALR mutation was reported to be more indolent than in JAK2 positive patients and was associated with increased survival. Our aim was to investigate whether the impact of CALR expression on prognosis and clinical outcome is different in prefibrotic/early PMF (prePMF) compared to WHO-ET. In a cohort of 348 adult patients with the clinical diagnosis of either ET or PMF mutational analysis for CALR was available. Eligibility criteria for the study included: availability of mutation analysis for JAK2, MPL and CALR; availability of representative, treatment-naive bone marrow biopsy (BM); availability of a histological and clinical consensus on the diagnosis; complete long-term documentation of clinical data and outcome. Consenting clinico-pathological findings in our cohort were consistent with 115 cases showing WHO-ET and 85 patients with prePMF. In comparison to WHO-ET, prePMF revealed minor/borderline age- and gender-matched anemia, slight increase in serum LDH level and leukocyte count, minor to slight splenomegaly, and an occasional left shift in granulo- and erythropoiesis with occurrence of a few myelo-and/or erythroblasts (table 1). An accurate differentiation between both MPN entities was shown to exert a significant difference in terms of overall and relative survival and hematologic transformation into overt PMF and AL. The present study revealed a different CALR mutation frequency in ET in contrast to most of the investigations published recently. We observed CALR mutations in 18% of WHO-ET; JAK2, MPL and CALR wildtype (wt) was observed in 13% of WHO-ET. The discrepancy in the frequencies of CALR positivity in our ET cohort to most of the recently published studies may be due to our strict adherence to the WHO criteria for diagnosis of ET. Regarding prePMF, we observed CALR mutations in 39% of the patients. 92% of the JAK2 and MPL wt subgroup carried the CALR mutation, with JAK2, MPL and CALR wt being observed in only 3% of prePMF. The most remarkable differences between WHO-ET and prePMF were seen in the comparison of the overall survival (figure 1). While the CALR mutation did not have any beneficial influence on survival in WHO-ET, it was associated with a superior overall survival in prePMF. Such a striking difference was not seen at the time of transformation into overt myelofibrosis, and there was only a slightly shorter time to progression to fibrosis in CALR wt prePMFs. There was a trend showing that CALR mutated prePMF patients have shorter thrombosis-free survival compared to CALR wt prePMF patients. There was no impact of the CALR mutations on thrombosis-free survival in WHO-ET. The present data confirm that WHO-ET and prePMF are biologically different sub-entities of MPNs. In prePMF, almost 100% of patients are now associated with a known disease-causing mutation. Our data support the classical clinical approach in the diagnosis of thrombocytosis, using BM histology to differentiate WHO-ET from prePMF and to estimate the outcome of the disease more accurately. Table 1:Total cohort (N=200)WHO-ET (N=115)prePMF (N=85)PAge at diagnosis, years0,04median58,8556,460,7range19-8819-8427-88Sex0,587male784335female1227250Hb, g/dL<0,001median14,114,313,5range8,1-17,68,8-17,68,1-16,6WBC, x109/l0,054median9,258,999,6range4,01-24,544,92-22,34,01-24,54Platelets, x109/l0,739median770770794range78-2530414-249078-2530Palpable splenomegaly<0,001No.51 (12 unk, 1 splenectomy)16 (7 unk, 1 splenectomy)35 (5 unk)%25,513,941,2Fibrotic transformations<0,001No.24 (10 unk)6 (1 unk)18 (9 unk)%125,221,2Thrombotic events0,439No.39 (1 unk)22 (1 unk)17%19,51920prev thrombosis0,042No.503416%2530,418,8JAK2 V617F pos0,08No.1207545%6065,252,9CALR pos0,001No.542133%2718,338,8MPL pos0,189No.844%43,54,7JAK2/MPL/CALR wt0,0029No.18153%9133,5 Figure 1 Figure 1. Disclosures Thiele: AOP Orphan Pharmaceuticals: Consultancy, Honoraria; Incyte Corporation: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Shire: Consultancy, Honoraria, Research Funding; Sanofi: Consultancy, Honoraria.

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Minimal Residual Disease (MRD) Monitoring in CBFB-MYH11 Acute Myeloid Leukemia (AML) Is of Prognostic Relevance for Relapse-Free Survival.

Blood ◽

10.1182/blood.v108.11.2298.2298 ◽

2006 ◽

Vol 108 (11) ◽

pp. 2298-2298

Author(s):

Andrea Corbacioglu ◽

Claudia Scholl ◽

Karina Eiwen ◽

Lars Bullinger ◽

Stefan Frohling ◽

...

Keyword(s):

Myeloid Leukemia ◽

Residual Disease ◽

Fusion Transcript ◽

Prognostic Impact ◽

Consolidation Therapy ◽

Relapse Free Survival ◽

Free Survival ◽

Transcript Levels ◽

Minimal Residual

Abstract Detection of minimal residual disease (MRD) in acute myeloid leukemia (AML) associated with specific gene fusions is an important tool for the assessment of response to treatment and the individual risk of relapse. The real-time quantitative RT-PCR (RQ-PCR) method allows the quantification of fusion transcript levels at distinct time points during treatment. While in acute promyelocytic leukemia (APL) MRD monitoring has been clearly shown to be predictive for clinical outcome, the prognostic value of MRD in CBFB-MYH11 AML could not consistently been demonstrated yet. Small patient populations and the availability of bone marrow (BM)/peripheral blood (PB) samples at defined time points mainly hamper most studies. We evaluated the prognostic impact of MRD in a large cohort of CBFB-MYH11 AML by RQ-PCR. A total of 44 patients (16–60 years) were treated within one of the AMLSG treatment trials (AMLHD93 n=4, AMLHD98A n=27, AMLSG07-04 n=13). Patient samples (BM and/or PB) were collected at study entry (n=75), during treatment (n=199), and during follow up (n=140). Following high-dose cytarabine (HiDAC) consolidation therapy, patients received a second course of HiDAC (n=25); autologous stem cell transplantation (SCT) (n=13) or allogeneic SCT from a matched related family donor (n=6) depending on the treatment protocol. Median follow up was 22.5 months. Quantitative CBFB-MYH11 fusion transcript expression was measured by RQ-PCR using TaqMan technology. Primers and probes were chosen according to Europe Against Cancer (EAC) standard protocols. Sensitivities ranged from 10−3 to 10−4.Transcript levels at diagnosis ranged from 6208 to 312987 (median 34293.5). There was no prognostic impact of pretreatment transcript levels on relapse free survival (RFS). The ratio of transcript levels after 2 induction cycles and pretreatment levels ranged from 0 to 0.0049; again, this ratio had no impact on RFS. In contrast, during consolidation therapy 63% of the patients became RQ-PCR negative and RFS was significantly superior (RFS after 2 years 75%) compared to RQ-PCR positive patients (RFS after 2 years 32%) (p=0.03). After consolidation, seven of the RQ-PCR negative patients became positive at least in one BM-sample during follow up. Four patients developed transcript levels above 10 and all relapsed, whereas the three patients with transcript levels remaining below 10 are in continuous remission (p=0.0001). In our study, transcript levels during and after consolidation therapy are significantly associated with clinical outcome in CBFB-MYH11 AML. Risk-adapted therapy may be considered for those patients remaining positive during consolidation therapy. The identification of transcript levels above 10 after consolidation therapy might allow early treatment decisions.

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SF3B1 Mutations and Not TP53 Are Associated with Poor Outcomes in Patients with Del(5q) Myelodysplastic Syndromes (MDS)

Blood ◽

10.1182/blood-2020-141960 ◽

2020 ◽

Vol 136 (Supplement 1) ◽

pp. 25-26

Author(s):

Onyee Chan ◽

Najla Al Ali ◽

David A. Sallman ◽

Eric Padron ◽

Jeffrey E. Lancet ◽

...

Keyword(s):

Research Funding ◽

Somatic Mutations ◽

Univariate Analysis ◽

Molecular Data ◽

Genetic Alterations ◽

Categorical Variables ◽

Prognostic Impact ◽

Tp53 Mutations ◽

Significant Difference ◽

The Impact

Background: Genetic alterations are increasingly being recognized to play an important role in both diagnosis and prognosis of MDS. In general, SF3B1 mutated MDS is known to have favorable outcomes whereas those with mutated TP53 have dismal survivals. However, it is unclear if the impact of these mutations applies to all subtypes of MDS including del(5q), a unique entity that is known for its sensitivity to lenalidomide and better prognosis. A prior study suggests TP53 mutations are associated with worse outcomes in del(5q) MDS (Jadersten et al. 2011), but a more recent study did not find this association and instead they showed SF3B1 mutants (MT) conferred shorter survival compared to wild-type (WT) (Meggendorfer et al. 2017). Herein, we describe our experience of del(5q) MDS patients and assess the prognostic impact of somatic mutations in this population. Methods: We retrospectively reviewed our database of 132 patients with del(5q) MDS who were treated at the Moffitt Cancer Center from 2001 to 2019. Sixty-three patients had molecular data available for analysis. Fisher's exact test of independence was used to determine significance for categorical variables. Univariate and multivariate analyses were conducted using log-rank and Cox regression, respectively. Kaplan-Meier analysis with log-rank test was used to estimate survival outcomes. Results: A total of 132 patients (47M/85F) with a median age of 70 at diagnosis were included in this analysis (Table 1). The majority had isolated del(5q) (86.3%) and the remaining with del(5q) plus other aberration(s) but not meeting criteria as complex cytogenetics. Among patients who received lenalidomide (n=98), 50%, 42.9%, and 7.1% achieved hematologic improvement (HI) or better, no response (NR), and disease progression (DP)/death with a median overall survival (OS) of 93.2, 72.4, and 25.6 months from the time of diagnosis, respectively (p<0.0001) (Figure 1). The median OS of the entire cohort was 73.3 months (median follow-up of 131.3 months), and OS from the time patients stopped lenalidomide was only 26 months. Of the 63 patients with molecular data available, 23.8% were found to have TP53 mutations with a median variant allele frequency (VAF) of 20.4% and 10% SF3B1 MT (median VAF 38.9%). Other common mutations include TET2 (19%) and DNMT3A (17%) as shown in Figure 2. Interestingly, TP53 status did not impact OS (MT 86.4 vs. WT 73.3 months; p=0.72), but those with SF3B1 mutations had a significantly shorter median OS compared to WT (23.9 vs. 83.5 months; p=0.001) (Figure 3). When test for effects of multiple genes had on survival, no combinations were found to be predictive. Univariate analysis showed lenalidomide response significantly impacted OS (HI compared to NR: HR 0.19, 95% CI: 0.05-0.68, p=0.005). Multivariate regression confirmed lenalidomide response and SF3B1 status are independently associated with outcomes. Conclusions: SF3B1 mutations, typically correlate with favorable risk in MDS, are associated with significantly worse prognosis compared to WT in patients with del(5q) MDS. On the contrary, there was no significant difference in OS in patients with TP53 MT vs. TP53 WT. A substantial portion of patients benefited from lenalidomide; however, after lenalidomide failure survivals were limited. Despite the known overall associations between MDS and mutations such as SF3B1 and TP53, our data suggests the del(5q) subset behaves differently which adds to the heterogeneity of the disease. Further studies are needed to clarify the impact of treatments and somatic mutations on outcomes. Disclosures Sallman: Agios, Bristol Myers Squibb, Celyad Oncology, Incyte, Intellia Therapeutics, Kite Pharma, Novartis, Syndax: Consultancy; Celgene, Jazz Pharma: Research Funding. Padron:Novartis: Honoraria; Incyte: Research Funding; Kura: Research Funding; BMS: Research Funding. Lancet:Abbvie: Consultancy; Agios Pharmaceuticals: Consultancy, Honoraria; Astellas Pharma: Consultancy; Celgene: Consultancy, Research Funding; Daiichi Sankyo: Consultancy; ElevateBio Management: Consultancy; Jazz Pharmaceuticals: Consultancy; Pfizer: Consultancy. Komrokji:BMS: Honoraria, Speakers Bureau; Agios: Speakers Bureau; Abbvie: Honoraria; Incyte: Honoraria; Acceleron: Honoraria; Novartis: Honoraria; Jazz: Honoraria, Speakers Bureau; Geron: Honoraria.

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Mutated MYD88 Zygosity and CXCR4 Mutation Status Are Important Determinants of Ibrutinib Response and Progression Free Survival in Waldenstrom's Macroglobulinemia

Blood ◽

10.1182/blood.v128.22.2984.2984 ◽

2016 ◽

Vol 128 (22) ◽

pp. 2984-2984 ◽

Cited By ~ 5

Author(s):

Steven P Treon ◽

Nicholas Tsakmaklis ◽

Kirsten Meid ◽

Guang Yang ◽

Jiaji G Chen ◽

...

Keyword(s):

Copy Number ◽

Research Funding ◽

Somatic Mutations ◽

Progression Free Survival ◽

Amino Acid Position ◽

Wild Type ◽

Mutation Status ◽

Free Survival ◽

Nucleotide Mutation ◽

The Impact

Abstract Activating somatic mutations in MYD88 and CXCR4 are present in 90-95% and 30-40% of untreated WM patients, respectively. Nearly all MYD88 somatic mutations involve a single nucleotide mutation that results in a change from leucine to proline at amino acid position 265, and most are heterozygous. In approximately 10-12% of untreated WM patients, MYD88 L265P is homozygous due to an acquired uniparenteral disomy (aUPD) or copy number alterations (Treon et al, NEJM 2012; Poulain et al, Blood 2013). Over 30 different types of nonsense and frameshift mutations in CXCR4 have been described in WM, and almost always are associated with mutated MYD88 (Hunter et al, Blood 2014). Mutated MYD88 activates BTK, and the BTK inhibitor ibrutinib is highly active in WM (Yang et al, Blood 2013; Treon et al NEJM 2015; Dimopoulos et al, ASH 2015). MYD88 mutations predict for response, while CXCR4 mutations are associated with slower response kinetics and lower response rates among mutated MYD88 WM patients on ibrutinib (Treon et al, NEJM 2015). In this study, we sought to clarify the impact of MYD88 homozygosity on ibrutinib activity in WM. We evaluated 33 previously treated, symptomatic WM patients who received ibrutinib on a clinical trial (NCT01614821), and for whom baseline and serial bone marrow (BM) CD19-selected cells were available for sequencing, copy number (CNA) and aUPD analysis. Mutated MYD88 homozygosity was determined by establishing the ratio of mutant (Mut) versus wild-type (WT) allele expression by Sanger sequencing. CNA status was determined using TaqMan real-time PCR assays. For patients with unaltered copy number, the presence of aUPD was determined by analyzing the tumor/germline allele balance using established TaqMan genotyping assays. At baseline, 9/33 (27.3%) of patients were homozygous for mutated MYD88. Mutated MYD88 homozygosity was confirmed to be due to deletion of the wild-type MYD88 allele by CNA in one patient, and amplification of the mutant MYD88 allele in another patient. TaqMan genotyping assays confirmed the presence of an aUPD in 6 patients that were confined to Chr. 3p. CXCR4 mutations were highly prevalent (8/9; 88.8%) among mutated MYD88 homozygous versus heterozygous (7/24; 29.2%) patients (p=0.014). We next assessed the impact of mutated MYD88 zygosity and CXCR4 mutation status on ibrutinib treatment outcome. The baseline characteristics for patients based on mutated MYD88 zygosity and CXCR4 mutation status are shown in Table 1. Following ibrutinib treatment, serum IgM levels declined by -0.89%, -0.54%, and -0.61% among MYD88Mut/WTCXCR4WT, MYD88Mut/WTCXCR4Mut, and MYD88Mut/Mut patients, respectively. Hemoglobin levels improved by 40.5%, 16.2% and 21.6% among MYD88Mut/WTCXCR4WT, MYD88Mut/WTCXCR4Mut, and MYD88Mut/Mut patients, respectively. Major responses (PR or better) were observed in 100%, 50%, and 89% of MYD88Mut/WTCXCR4WT, MYD88Mut/WTCXCR4Mut, and MYD88Mut/Mut patients, respectively. VGPR occurred in 50% of MYD88Mut/WTCXCR4WT patients, and 16.7% and 22.2% of MYD88Mut/WTCXCR4Mut, and MYD88Mut/Mut patients, respectively. Progression-free survival was also impacted by mutated MYD88 zygosity and CXCR4 mutation status (Figure 1). Median PFS was not reached for patients with MYD88Mut/WTCXCR4WT and MYD88Mut/Mut, and was 25.5 months for those with a MYD88Mut/WTCXCR4Mut mutation status (Log-rank Chi-square: 14.74, p=0.0006). Conclusions: MYD88 homozygosity is strongly associated with activating mutations in CXCR4, and appears to confer a better outcome for WM patients with CXCR4 mutations on ibrutinib therapy. Figure 1 Figure 1. Disclosures Treon: Pharmacyclics: Consultancy, Research Funding; Janssen: Consultancy. Castillo:Pharmacyclics: Honoraria; Abbvie: Research Funding; Otsuka: Consultancy; Biogen: Consultancy; Millennium: Research Funding; Janssen: Honoraria. Palomba:Pharmacyclics: Consultancy.

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TP53 and MYD88 Mutations As Detected By Liquid Biopsy in the Prediction of Progression-Free Survival in Patients with Diffuse Large B-Cell Lymphoma

Blood ◽

10.1182/blood-2021-148122 ◽

2021 ◽

Vol 138 (Supplement 1) ◽

pp. 4480-4480

Author(s):

Maher Albitar ◽

Andrew Ip ◽

Hong Zhang ◽

Andrew L. Pecora ◽

Jeffrey Justin Estella ◽

...

Keyword(s):

Board Of Directors ◽

Research Funding ◽

Residual Disease ◽

Progression Free Survival ◽

B Cell Lymphoma ◽

Leadership Role ◽

Advisory Committees ◽

Free Survival ◽

Large B Cell Lymphoma ◽

Significant Difference

Abstract Introduction: Liquid biopsy has been reported to be useful in predicting residual disease in patients with diffuse large B-cell lymphoma (DLBCL). Most of the studies focused on quantifying the level of circulating lymphoma-specific DNA. We explored the clinical relevance of the specific mutated genes in predicting progression in patients with DLBCL. Method: Peripheral blood samples were collected from patients with DLBCL based on their visit to clinic without other specific selection. Median age of patients is 69 (range 28-91), with 51% of the patients being male. These patients were treated on multiple protocols including R-CHOP, R-EPOCH, Magrath, HCVAD, CAR-T (#2 patients), and others. cfDNA was extracted and sequenced by next generation sequencing using 177 gene panel. The panel uses single primer extension (SPE) approach with UMI. Sequencing depth is increased to more than 2000X after removing duplicates. Low level mutations are confirmed by inspecting BAM file. Results: A total of 86 sample from 61 patients were collected post clinical remission at different time points (median 28 weeks, range: 1-994 weeks). Of these samples, 56 (65%) from 46 patients (75%) were positive. However, 6 of these samples from 4 patients had germline mutations or mutations in TET2, ASXL1, or DNMT3A that are consistent with CHIP (clonal hematopoiesis of indeterminate potential). The remaining 50 positive samples from 42 patients had 8 repeats on the same patients collected at different time points. Comparing the 19 negative patients with the 42 positive patients post-remission, patients with residual molecular disease were significantly older than patients without residual disease (P=0.01). However, there was no significant difference between the two groups in gender, ethnic background, LDH, cell of origin classification, or TP53 positivity by IHC. Patients with residual disease showed tendency for short progression-free survival (P=0.08). Focusing on patients with specific mutations detected in the cfDNA showed that 14 (23%) patients had mutations either in TP53 or MYD88. There was no significant difference in age between these two groups or any of the other clinical variables. However, patients with TP53/MYD88 mutations had significantly shorter survival (P=0.04). Conclusion: Post-remission residual disease as measured by circulating cfDNA is an independent predictor of potential relapse in patients with DLBCL. However, presence of it is important to determine the aggressiveness of the residual circulating clone. Residual circulating lymphoma DNA with TP53 or MYD88 mutations is a strong predictor of earlier relapse. Figure 1 Figure 1. Disclosures Pecora: Genetic testing cooperative: Other: equity investor; Genetic testing cooperative: Membership on an entity's Board of Directors or advisory committees. Feldman: Alexion, AstraZeneca Rare Disease: Honoraria, Other: Study investigator. Goy: Bristol Meyers Squibb: Membership on an entity's Board of Directors or advisory committees; AstraZeneca: Membership on an entity's Board of Directors or advisory committees; MorphoSys: Honoraria, Other; AbbVie/Pharmacyclics: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; AstraZeneca: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Novartis: Consultancy, Honoraria; Acerta: Consultancy, Research Funding; Elsevier's Practice Update Oncology, Intellisphere, LLC(Targeted Oncology): Consultancy; Celgene: Consultancy, Honoraria, Research Funding; Michael J Hennessey Associates INC: Consultancy; Elsevier PracticeUpdate: Oncology: Consultancy, Honoraria; Janssen: Membership on an entity's Board of Directors or advisory committees; Bristol Meyers Squibb: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; Kite, a Gilead Company: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Medscape: Consultancy; Gilead: Membership on an entity's Board of Directors or advisory committees; Genentech/Hoffman la Roche: Research Funding; AbbVie/Pharmacyclics: Membership on an entity's Board of Directors or advisory committees; OncLive Peer Exchange: Honoraria; Janssen: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding; Xcenda: Consultancy, Honoraria; Vincerx pharma: Membership on an entity's Board of Directors or advisory committees; Rosewell Park: Consultancy; LLC(Targeted Oncology): Consultancy; Genomic Testing Cooperative: Current holder of stock options in a privately-held company, Membership on an entity's Board of Directors or advisory committees, Other: Leadership role; Xcenda: Consultancy; Hoffman la Roche: Consultancy; Incyte: Honoraria; Kite Pharma: Membership on an entity's Board of Directors or advisory committees; Infinity/Verastem: Research Funding; Janssen: Research Funding; Karyopharm: Research Funding; Vincerx: Honoraria, Membership on an entity's Board of Directors or advisory committees; Physicians' Education Resource: Consultancy, Other: Meeting/travel support; COTA (Cancer Outcome Tracking Analysis): Current holder of stock options in a privately-held company, Membership on an entity's Board of Directors or advisory committees, Other: Leadership role; Phamacyclics: Research Funding; Constellation: Research Funding; Hackensack Meridian Health, Regional Cancer Care Associates/OMI: Current Employment.

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