scholarly journals Minimal Residual Disease (MRD) in Myeloma: Independent Outcome Prediction and Sequential Survival Benefits per Log Tumour Reduction

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 3416-3416 ◽  
Author(s):  
Andy C Rawstron ◽  
Walter Gregory ◽  
Ruth M de Tute ◽  
Faith E Davies ◽  
Susan E Bell ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
Clinical Trials ◽  
Minimal Residual Disease ◽  
Research Funding ◽  
Outcome Prediction ◽  
Residual Disease ◽  
Surrogate Endpoint ◽  
Cell Transplant ◽  
Minimal Residual

Abstract Minimal residual disease (MRD), as assessed by flow cytometry is a powerful predictor of outcome in multiple myeloma (MM). We and others have previously demonstrated that such analyses are informative in patients treated with autologous stem cell transplant (ASCT) and non-transplant regimens. It predicts outcome in patients in conventional CR and is applicable to patients with standard and adverse risk cytogenetics. As a consequence MRD assessment is under consideration as a surrogate endpoint for clinical trials. This is urgently needed in MM as >5yrs follow-up is typically required to demonstrate survival differences in trials of upfront therapy. If surrogate end points are to be used in clinical trials it is essential that a reproducible effect is demonstrable using multivariate models. Previous studies have confirmed the effect of MRD on PFS but a consistent effect on OS has been not been definitively shown. This may in part be due to the availability of effective salvage therapy but it is also possible that the traditional threshold of 10-4 for analysis and the categorization of patients as MRD-postive or negative is suboptimal. Flow cytometry does provide a quantitative assessment of residual tumour over a large range and the degree of tumour depletion may be more informative than a positive-negative analysis. 397 patients from the MRC Myeloma IX trial were included in this analysis. Patients were randomly assigned to CTD (cyclophosphamide, thalidomide, and dexamethasone) or CVAD (cyclophosphamide, vincristine, doxorubicin, and dexamethasone) induction for 4-6 cycles followed by standard high-dose melphalan (HDM) ASCT. BM aspirates were obtained at day 100 for MRD analysis. 500,000 cells were evaluated with six-colour antibody combinations including CD138/CD38/CD45/CD19 with CD56/CD27 in all cases and CD81/CD117 in additional cases as required. PFS and OS data analysis was landmarked from the date of the MRD assesment. Of the 397 patients with MRD data available at day 100 after ASCT, 247/397 (62.2%) achieved <0.01% MRD. The level of residual disease varied across four logs in MRD-positive patients (0.01-<0.1% in 49/397, 0.1-<1% in 72/397, 1-<10% in 26/397 and ≥10% in 3/397). The PFS and OS for individuals with ≥1% residual disease was comparable to individuals with a PR/MR/SD confirming that MRD assessment is most relevant in CR. The level of MRD correlated with outcome. The median PFS for patients with ≥10% MRD at day 100 after ASCT was 0.8 years, with 1-<10% MRD was 1.7 years, with 0.1-<1% MRD was 1.9 years, with 0.01-<0.1% MRD was 2.7 years and for patients with <0.01% MRD was 3.1 years (P<0.001). The median OS for these groups was 1 yr, 4 yrs, 5.9 yrs, 6.8 yrs and for patients with <0.01% MRD not reached with >7.5 yrs median follow-up (P<0.001, see figure). A Cox proportional hazards model was used to further evaluate factors influencing outcome. B2M and MRD were log-transformed and along with age were considered as continuous variables. ISS, haemoglobin (<115g/l), platelets (<150x10^9/l) and cytogenetics were used as stratification factors. Cytogenetic groups were classified as unfavourable for patients with gain(1q), del(1p32), t(4;14), t(14;20), t(14;16), and del(17p), or favourable for hyperdiploidy, t(11;14) and t(6;14), or unknown/inevaluable. MRD assessment (χ2 11.8, P=0.0006) and cytogenetics (χ2 35.5, P=<0.0001) were the only factors that retained significance in this multivariate model. Conventional categorical response, ISS and B2M were not predictive of OS (p=0.99, 0.16 and 0.56 respectively). We would conclude that MRD quantitation is more informative than a positive or negative categorization with a 10-4 threshold and independently predicts outcome. In this analysis we were able to demonstrate an approximate 1 year survival benefit per log tumour depletion. A lower cutpoint for predicting improved outcome was not reached and more sensitive assays will likely improve outcome prediction further. This data strongly supports the role of MRD assessment as a surrogate endpoint in clinical trials. Figure 1 Figure 1. Disclosures Rawstron: Celgene: Consultancy; BD Biosciences: Consultancy, Intrasure Patents & Royalties. Gregory:Celgene: Consultancy. Davies:Celgene: Consultancy, Honoraria; Janssen-Cilag: Consultancy, Honoraria; Novartis: Consultancy. Cook:Celgene: Consultancy, Honoraria, Research Funding; Janssen-Cilag: Consultancy, Honoraria. Jackson:Celgene: Honoraria; Janssen-Cilag: Honoraria. Morgan:Celgene: Consultancy, Honoraria, Research Funding; Janssen-Cilag: Consultancy, Honoraria; Merck: Consultancy, Honoraria; Novartis: Consultancy, Honoraria. Owen:Celgene: Consultancy, Honoraria, Research Funding.

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 ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 694-694 ◽  
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.

Minimal Residual Disease Monitoring in Childhood Precursor B Lymphoblastic Leukemia with t(12;21)(p13;q22); ETV6-RUNX1: A Comparison Between Quantitative RT-PCR and Flow Cytometry

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 3774-3774
Author(s):  
Sofie J Alm ◽  
Charlotte Engvall ◽  
Julia Asp ◽  
Lars Palmqvist ◽  
Jonas Abrahamsson ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
Minimal Residual Disease ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Fusion Transcript ◽  
Terminal Deoxynucleotidyl Transferase ◽  
Time Points ◽  
Qrt Pcr ◽  
Minimal Residual

Abstract The translocation t(12;21)(p13;q22) resulting in the fusion gene ETV6-RUNX1, is the most frequent gene fusion in childhood precursor B lymphoblastic leukemia (pre-B ALL), affecting about one in four children with pre-B ALL. In the NOPHO ALL-2008 treatment protocol, treatment assignment in pre-B ALL is based on clinical parameters, genetic aberrations, and results from analysis of minimal residual disease (MRD) at day 29 and 79 during treatment (where MRD >0.1% leads to upgrading of treatment). For pre-B ALL, in this protocol MRD analysis is performed using flow cytometry as the method of choice. In this study, we also analyzed MRD in t(12;21)(p13;q22) cases with quantitative reverse transcription-polymerase chain reaction (qRT-PCR) for the fusion transcript ETV6-RUNX1 in parallel with routine MRD analysis with flow cytometry, to determine if qRT-PCR of the ETV6-RUNX1 fusion transcript would be a reliable alternative to FACS. Bone marrow samples were collected at diagnosis and at day 15, 29 and 79 during treatment from 31 children treated according to the NOPHO ALL-2000 (n = 3) and NOPHO ALL-2008 (n = 28) protocols in Gothenburg, Sweden, between 2006 and 2013. Samples were analyzed in parallel with qRT-PCR for ETV6-RUNX1 fusion transcript and with FACS. For qRT-PCR, mRNA was isolated, cDNA synthesized, and qRT-PCR performed with GUSB as reference gene. MRD-qRT-PCR was defined as the ETV6-RUNX1/GUSB ratio at the follow-up time point (day 15/29/79) divided with the ETV6-RUNX1/GUSB ratio at diagnosis (%). MRD analysis with FACS was performed, after lysis of erythrocytes, using antibodies against CD10, CD19, CD20, CD22, CD34, CD38, CD45, CD58, CD66c, CD123, and terminal deoxynucleotidyl transferase, and when applicable also CD13 and CD33. Results of MRD-FACS were expressed as % of all cells. In total, 83 samples were analyzed with both methods in parallel; 31 from day 15 in treatment, 28 from day 29, and 24 from day 79. Overall, MRD-qRT-PCR showed good correlation with MRD-FACS. In total, 31 samples were positive with qRT-PCR and 24 with FACS, with concordant results (positive with both methods or negative with both methods) in 89% of samples, when the limit of decision (positive/negative MRD) was set to 0.1%. The concordance was especially high at the treatment stratifying time points, i.e. day 29 and 79; 89% and 100%, respectively. No samples at these time points were positive with FACS but negative with qRT-PCR. During the follow-up period (6-81 months), one patient relapsed (with negative MRD with both methods at stratifying time points), and two succumbed from therapy-related causes. Our results show that there is a significant relationship between the results of MRD analysis using FACS and MRD analysis using qRT-PCR of ETV6-RUNX1 fusion transcript. The high concordance between the methods indicates that negative MRD using qRT-PCR is as reliable as negative MRD using FACS, and that qRT-PCR could therefore be an alternative to FACS in cases where FACS is not achievable. In comparison to quantitative PCR of TCR/Ig gene rearrangements, which is the current backup MRD method for cases with pre-B ALL in NOPHO ALL-2008, qRT-PCR of ETV6-RUNX1 is much less time and labor consuming, making it appealing in a clinical laboratory setting. Disclosures No relevant conflicts of interest to declare.

scholarly journals Reduced Relapse Risk in Children with Acute Myeloid Leukemia (AML) Who Experience Septic Shock (SS)

Blood ◽  
2019 ◽  
Vol 134 (Supplement_1) ◽  
pp. 3496-3496
Author(s):  
Alix E. Seif ◽  
Yimei Li ◽  
Viviane C. Cahen ◽  
Yuan-Shung V. Huang ◽  
Matt Hall ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Protective Effect ◽  
Research Funding ◽  
Childhood Leukemia ◽  
Residual Disease ◽  
Statistical Significance ◽  
Innate Immune ◽  
Cell Transplant ◽  
Immune Stimulants

Background: Relapse remains the major clinical risk in children with AML, and persistent minimal residual disease (MRD) poses a particular therapeutic challenge as a presumably chemoresistant cell population. We previously showed innate immune stimulation can generate durable memory immune responses against leukemia cells in preclinical MRD models (Blood 2009 114:2459; Leukemia 2018 32: 539). These treatments mimic the "danger" signal provided by SS and may offer novel immunotherapeutic approaches for patients who fail or are not eligible for targeted immunotherapies. Demonstrating a protective effect of SS against AML relapse would support clinical development of innate immune stimulants. We hypothesized 1) SS is associated with a decreased risk of AML relapse among children who were able to achieve remission after induction, and 2) this effect is most pronounced in children with persistent MRD, who are more likely to have both SS exposures and relapses. Methods: We used a previously assembled cohort of children with de novo AML using Pediatric Health Information System (PHIS) data merged with patients on two clinical trials from the Children's Oncology Group (COG; PLOS One 2015 10:e0143480). We developed and validated a method to detect SS exposures in PHIS using vasopressor billing codes (PBC 2019 10.1002/pbc.27713 #2024) and used COG data for demographics, treatment, and outcomes. SS exposures were captured starting 7 days from first chemotherapy until last day of the last treatment course or 30 days prior to relapse. Follow-up for relapse and non-relapse mortality (NRM) began after the end of Induction II and continued to last contact, off-study date, or until 5 years from diagnosis. Cumulative incidences of relapse (CIR) and NRM (CIN) were estimated treating each other as competing risks. Sub-distribution hazard regression models were used to estimate crude and adjusted sub-hazard ratios (subHR) and associated 95% confidence intervals (CI) of relapse in relation to SS. SS was treated as a time-varying exposure, so each patient became SS-exposed once the first SS occurred. Demographic and clinical characteristics were evaluated as potential confounders of the associations of interest. Results: We identified 569 COG-PHIS patients with AML who achieved complete remission by the end of Induction II. In this cohort, 188 (33%) experienced SS during therapy. Older age, Black non-Hispanic race-ethnicity, Hispanic ethnicity, and receipt of stem cell transplant (SCT) were associated with SS exposure (Table 1). Median follow-up was 1122 days (IQR 413-1745) from the end of Induction II. Relapse occurred in 220 (38.7%) patients and was associated with male sex and genetic risk (Table 1). Positive end-Induction I MRD approached a significant association with relapse. CIRs were similar among SS-exposed and unexposed patients in the overall cohort and in MRD-negative patients (Figs. 1A-B). Among children with persistent MRD, SS-exposed patients had a lower 5-year CIR than unexposed patients (43% vs. 60.1%; Fig. 1C). Adjusted subHR for relapse for the overall cohort was 0.82 (CI: 0.61-1.11); for the MRD-negative subgroup, adjusted subHR was 0.86 (CI: 0.61-1.21); and for the MRD-positive subgroup, 0.57 (CI: 0.31-1.05). These effects were consistently in the protective direction but did not reach statistical significance. In a sensitivity analysis restricting duration of the exposure effect to 12 months, SS exposure in the overall cohort was associated with a risk reduction (adjusted subHR 0.65; CI: 0.45-0.92). NRM occurred in 28 (4.9%) and was associated with high-risk therapy on AAML1031 and with positive MRD, with a near-significant association with SCT (not shown). SS-exposed patients had a higher 5-year CIN (10.4% v. 2.8%; Fig. 1D). Conclusions: Using merged clinical trial and administrative data, we identified a potentially protective effect of exposure to a strong immune stimulus (SS) that was most pronounced in children with persistent MRD. This suggests immune surveillance for low-level AML can be induced and supports investigation of innate immune stimulant therapy for this very poor prognosis childhood leukemia. While NRM is higher among SS-exposed patients, clinical trials of innate immune stimulants would comprise controlled interventions expected to result in markedly less toxicity than unpredictable SS exposures. Repeated dosing may prolong the effect duration beyond 12 months. Disclosures Fisher: Merck: Research Funding; Pfizer: Research Funding; Astellas: Other: Data Safety Monitoring Board Chair for an antifungal study.

Sustained High Rates of Complete Response and Minimal Residual Disease Negativity after 8 Cycles of Carfilzomib (CFZ), Lenalidomide (LEN), and Dexamethasone (DEX) Followed By 2 Years of Lenalidomide Maintenance (CRd-R) in Patients with High-Risk Smoldering Multiple Myeloma: Updated Results of Clinical and Correlative Phase 2 Study

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 3339-3339 ◽  
Author(s):  
Dickran Kazandjian ◽  
Neha S Korde ◽  
Mark Roschewski ◽  
Sham Mailankody ◽  
Candis Morrison ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
Combination Therapy ◽  
Minimal Residual Disease ◽  
Research Funding ◽  
Residual Disease ◽  
Complete Response ◽  
Risk Of Progression ◽  
Minimal Residual

Abstract Background: High-risk smoldering multiple myeloma (HR-SMM) is a plasma cell dyscrasia which has a 5-year risk of progression to symptomatic multiple myeloma (MM) of approximately 75% based on current risk models. With the availability of novel therapies, early treatment may decrease the risk of progression and prolong survival as evidenced by the recent QuiRedex study results. More recently, studies have demonstrated that triplet regimens are superior to doublet in MM and whole exome sequencing in HR-SMM is indicative of treatment susceptible biology in early disease; supporting the use of effective combination therapy as early intervention. Expanding on our initial results using modern CRd-R therapy in HR-SMM patients (Korde et al. JAMA Onc 2015) we show unprecedented high rates of obtained and sustained complete response (CR) and minimal residual disease negativity (MRDneg CR) in an expanded cohort of patients with a median follow-up of ~3 years. Methods: Treatment-na•ve patients with HR-SMM (IMWG 2010 criteria; Mayo or PETHEMA models) were treated for 8 cycles (28-day cycles) with CFZ 20/36 mg/m2 IV days 1, 2, 8, 9, 15, 16; LEN 25 mg PO days 1-21, and DEX 20/10 mg IV/PO days 1, 2, 8, 9, 15, 16, 22, 23. Transplant eligible patients underwent stem cell collection after ≥4 cycles of CRd and then continued CRd treatment (i.e. by-default-delayed high-dose melphalan with autologous stem cell transplant; HDM-ASCT). After 8 cycles of combination therapy, patients with SD or better received 2 years of LEN 10 mg PO maintenance. The primary objective was best response (ORR), followed by secondary objectives of progression free survival (PFS) and response duration (DoR) which were assessed after every cycle of induction and every 90 days during maintenance. Correlative studies including assessment of minimal residual disease (MRD) by multi-color flow cytometry (bone marrow aspirate; 10-5 sensitivity) as defined by updated 2016 IMWG response criteria were performed after 8 cycles of induction and 1 and 2 years of maintenance LEN. Results: Eighteen patients meeting eligibility criteria were enrolled (data-lock 7/20/2016). Demographics and disease characteristics are shown in Table 1. Best ORR and >= VGPR rate (n=18) with CRd-R was 100% (Table 2). The proportion of patients who obtained stringent CR/CR after 8 cycles of induction, 1 year of maintenance and 2 years of maintenance was 61%, 89%, and 89%, respectively. Of evaluable patients who achieved at least a CR, the proportion of patients who obtained MRD negativity (MRDneg CR) at the same time-points was 91%, 71%, and 75%, respectively. DoR and PFS at 36 months was 94% and overall survival with a median follow-up duration of 31 months was 100%. Toxicities Grade 3-4 occurring in >1 patient included lymphopenia (39%), neutropenia (28%), anemia (22%), diarrhea (17%), lung infection (17%), hypophosphatemia (11%), and thromboembolic event (11%). Significant serious adverse events included CHF which occurred in one patient. Conclusions: Early treatment of HR-SMM with modern CRd-R combination therapy with by-default-delayed HDM-ASCT resulted in unprecedented high rates of CR and MRDneg CR after 8 cycles of CRd. Following 2 years of additional LEN maintenance therapy, the CR and sustained MRDneg CR rates were 89% and 69%, respectively. Given the significant risk of progression to symptomatic MM and associated life limiting end-organ damage, early intervention for patients with HR-SMM with effective triplet-based therapies may be warranted. This first proof-of-principle study has thus far demonstrated exceptional clinical benefit. Therefore, this study will be re-opened to enrollment and long-term follow up results collected to expand on these promising results. Updated results will be presented at the Annual Meeting. Disclosures Korde: Medscape: Honoraria. Bhutani:Prothena: Research Funding; Takeda Oncology: Research Funding, Speakers Bureau; Bristol-Myers Squibb: Speakers Bureau; Onyx, an Amgen subsidiary: Speakers Bureau. Landgren:BMS: Honoraria; Amgen: Honoraria, Research Funding; Novartis: Honoraria; Celgene: Honoraria, Research Funding; Takeda: Honoraria.

scholarly journals Retrospective Analysis of Minimal Residual Disease Testing By High Throughput Immunosequencing Versus High Sensitivity Flow Cytometry and qPCR in B-Lymphoblastic Leukemia

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 4476-4476
Author(s):  
Omar Fathalla ◽  
Anwar Khan ◽  
Nagehan Pakasticali ◽  
Bijal D. Shah ◽  
Mohammad O Hussaini
Keyword(s):  
Flow Cytometry ◽  
Minimal Residual Disease ◽  
Correlation Coefficient ◽  
High Throughput ◽  
Research Funding ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Cancer Center ◽  
Spearman Correlation ◽  
Minimal Residual

Abstract Introduction: Detection of minimal residual disease (MRD) is one of the most powerful predictors of prognosis in patients with B-Lymphoblastic Leukemia (ALL). Standard methods to detect MRD in ALL include high-resolution flow cytometry (FC) (sensitivity 10 -4 to 10 -5) and qPCR for Ph+ ALL (sensitivity 10 -5 to -6). More recently, high-throughput sequencing (NGS) has been leveraged to detect MRD (sensitivity 10 -6). Retrospective, non-clinical trial based real-world data comparing between these methodologies in the literature is limited to absent. We report our experience at a high-volume cancer center comparing NGS, qPCR, and FC. Methods: All cases of ALL with NGS MRD data at the Moffitt Cancer Center were identified. Corresponding FC, qPCR (p190 and p210) and clinical data were collected electronically and via chart review. 10-color flow cytometry was performed on a Gallios System and analyzed on Kaluza (Beckman Coulter, IN). 750,000 events were collected on all cells. Validated lower limit of detection was at least 0.01%. Antibodies included CD15, CD130, CD10, CD58, CD22, CD33, CD13, CD123, CD19, CD20, CD45, CD38, CD34, CD81, CD200 (BD, Biolegend, Beckman Coulter). Quantidex™ BCR-ABL IS Kit (RT qPCR) was used to quantify BCR-ABL (p190 and p210) and ABL transcripts in total RNA in patients with ALL on Applied Biosystems 7500 Fast Dx Real-Time PCR instrument. The results were expressed by normalized BCR-ABL to ABL (control) ratio. clonoSEQ ® (Adaptive Biotechnologies, Seattle, WA) testing was performed which uses multiplex polymerase chain reaction (PCR) and NGS to identify, characterize, and monitor clonotypes of immunoglobulin (Ig) IgH (V-J), IgH (D-J), IgK, and IgL receptor gene sequences, and translocated BCL1/IgH (J) and BCL2/IgH (J) sequences. Statistical analysis was performed by Spearman correlation coefficient and Kaplan-Meier analysis. Results: 95 samples from 54 unique patients were identified that had both NGS and FC data. A subset of patients had qPCR data (n=31 samples). FC+ values ranged from 0.00004 to 0.75. NGS+ values ranged from 8.25E-08 to 0.49. Spearman correlation coefficient showed moderate concordance between NGS and FC at r=0.62 (p&lt;0.001). Spearman correlation coefficient for qPCR vs Flow was r= 0.08 (p=0.68). Three samples were positive by FC (mean tumor burden (MTB= 0.002) but missed by NGS; whereas 31 samples were detected by NGS (MTB= 0.0016) that were missed by flow cytometry. By FC, 9 samples were equivocal of which 7 were definitively designated as MRD+ by NGS. There were 7 qPCR+/NGS- samples (MTB= 2.5 x 10 -5) and 6 qPCR-/NGS+ cases (MTB= 0.012). Overall survival was worse for MRD+ (by NGS, qPCR, or FC) vs MRD(-) (Figure 1). Conclusion: Our study confirms the importance of MRD detection in ALL and shows the robust utility of NGS for MRD detection in routine hematopathology practice. While qPCR, FC and NGS are complementary given that each can potentially detect MRD missed by another method, the data supports the increased sensitivity of NGS over FC. Figure 1 Figure 1. Disclosures Shah: Servier Genetics: Other; Jazz Pharmaceuticals: Research Funding; Incyte: Research Funding; BeiGene: Consultancy, Honoraria; Acrotech/Spectrum: Honoraria; Pharmacyclics/Janssen: Honoraria, Other: Expenses; Kite, a Gilead Company: Consultancy, Honoraria, Other: Expenses, Research Funding; Precision Biosciences: Consultancy; Amgen: Consultancy; Pfizer: Consultancy, Other: Expenses; Novartis: Consultancy, Other: Expenses; Bristol-Myers Squibb/Celgene: Consultancy, Other: Expenses; Adaptive Biotechnologies: Consultancy. Hussaini: Stemeline Therapeutics: Honoraria.

scholarly journals Retrospective Analysis of Minimal Residual Disease Testing By High Throughput Immunosequencing Versus High Sensitivity Flow Cytometry in Multiple Myeloma

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 1625-1625
Author(s):  
Anwar Khan ◽  
Nagehan Pakasticali ◽  
Omar Fathalla ◽  
Taiga Nishihori ◽  
Mohammad O Hussaini
Keyword(s):  
Multiple Myeloma ◽  
Flow Cytometry ◽  
Minimal Residual Disease ◽  
Correlation Coefficient ◽  
Research Funding ◽  
Residual Disease ◽  
High Sensitivity ◽  
Spearman Correlation ◽  
Color Flow ◽  
Minimal Residual

Abstract Introduction: Detection of minimal residual disease (MRD) is one of the strongest predictors of outcome in multiple myeloma (MM). Until recently, the most commonly available method to detect MRD in clinical practice has been high sensitivity flow cytometry (FC) which can detect MRD with at 10 -5 sensitivity. In recent years, next-generation sequencing (NGS) has become a viable method to assess the MRD in MM patients with a 10 -6 sensitivity. NGS appears to have some advantages over HC-FC by circumventing subjectivity of analysis. However, real-world comparison between these two methodologies in the literature is limited and is important to inform daily hematopathology and oncology ordering practices. Methods: We retrospectively identified all cases of MM with NGS MRD data from bone marrow specimens at the Moffitt Cancer Center and collated corresponding flow MRD data and clinical data (OS, patient demographics) electronically and via chart review. 10-color flow cytometry was performed on a Gallios System and analyzed on Kaluza (Beckman Coulter, IN). Two million events were collected on all cells. Validated lower limit of detection was at least 0.01%. Antibodies included CD28, CD81, CD56, CD138, CD319, CD20, CD19, CD117, CD38, CD45, CD27, CD200 (BD, Biolegend, Beckman Coulter). clonoSEQ ® (Adaptive Biotechnologies, Seattle, WA) testing was performed which uses multiplex polymerase chain reaction (PCR) and NGS to identify, characterize, and monitor clonotypes of immunoglobulin (Ig) IgH (V-J), IgH (D-J), IgK, and IgL receptor gene sequences, and translocated BCL1/IgH (J) and BCL2/IgH (J) sequences Statistical analysis was performed by Spearman correlation coefficient and Kaplan-Meier analysis. Results: 192 samples from 122 unique patients were identified that had both NGS and FC data performed on the same sample. FC+ values ranged from 1x10 -7 to 0.39. NGS+ values ranged from 2.3 x 10 -7 to 0.15. Spearman correlation coefficient showed moderate concordance between NGS and FC at r=0.67 (p&lt;0.001). Six samples were positive by FC (mean tumor burden (MTB)= 0.0007) but missed by NGS; whereas 59 samples were positive by NGS (MTB= 0.002) but missed by flow cytometry. Two cases by FC were equivocal and these were both definitively designated as MRD+ by NGS. Overall survival was worse for MRD+ (by NGS or FC) vs MRD(-) (Figure 1). Conclusion: Our study confirms the importance of MRD detection in MM and shows the robust utility of NGS for MRD detection in routine hematopathology practice. While both FC and NGS are complementary given that each can potentially detect MRD missed by another method, the data supports the increased sensitivity of NGS over FC. Figure 1 Figure 1. Disclosures Nishihori: Novartis: Research Funding; Karyopharm: Research Funding. Hussaini: Stemeline Therapeutics: Honoraria.

scholarly journals High Rates of Undetectable Minimal Residual Disease Remissions with Time-Limited Bendamustine, Rituximab, and Venetoclax (BR-VR) in Untreated Chronic Lymphocytic Leukemia (CLL)

Blood ◽  
2021 ◽  
Vol 138 (Supplement 1) ◽  
pp. 1555-1555
Author(s):  
Andrew H. Lipsky ◽  
Brian T. Hill ◽  
Allison M. Winter ◽  
Joseph G. Jurcic ◽  
Mark L. Heaney ◽  
...  
Keyword(s):  
Minimal Residual Disease ◽  
Research Funding ◽  
Residual Disease ◽  
Standard Dose ◽  
Objective Response ◽  
Tumor Lysis Syndrome ◽  
Lymphocytic Leukemia ◽  
Oncology Research ◽  
Minimal Residual

Abstract Background: Despite the efficacy of venetoclax (VEN) in frontline CLL, optimal combination regimens and duration of treatment remain unclear. We hypothesized that cytoreduction with bendamustine/rituximab (BR) induction followed by venetoclax/rituximab (VR) consolidation for a fixed 1-year duration would be associated with an increased rate of undetectable minimal residual disease (uMRD) compared to historical controls and a reduction in the risk of tumor lysis syndrome (TLS). Here we report data from an ongoing phase 2 multicenter, US, single-arm, open-label study (NCT03609593) designed to assess the safety and efficacy of BR-VR in previously untreated CLL patients (pts). Methods: Previously untreated CLL/SLL pts ≥ 18 years requiring therapy per iwCLL criteria initially received 3 cycles of bendamustine 50-90 mg/m 2 daily for 2 days and rituximab 375 mg/m 2 every 28 days for 3 cycles. Following BR, VEN was initiated with a standard dose escalation from 20 mg to 400 mg daily over 5 weeks. This was followed by 6 cycles of VR with rituximab given monthly and 5 cycles of VEN alone (12 cycles of VEN in total). Additional eligibility included: ECOG PS ≤ 2, hemoglobin ≥8g/dL, ANC ≥1000/mm 3, and platelets ≥50,000/mm 3. Response was assessed by 2018 iwCLL criteria with uMRD testing by central flow cytometry at a level of &lt;10 -4 in peripheral blood (PB) and bone marrow (BM). The primary endpoint was objective response rate (ORR). Secondary endpoints included uMRD rate, time to uMRD, and adverse events (AEs) assessed by CTCAE v 5.0. Results: As of data cutoff on 30 May 2021, 26 pts were accrued with additional recruitment ongoing. Baseline demographics were as follows: male/female (16/10), median age 60 yrs (range 44-77). Baseline prognostic studies showed unmutated IGHV in 16 (62%) pts, TP53 aberrant (either del(17p) and/or TP53 mutation) in 1 (4%) pt, del(11q) in 3 (12%) pts, and complex karyotype in 4 (15%) pts. TLS risk among 24 evaluable pts at baseline was high (H) in 3 (12.5%), medium (M) in 15 (62.5%), and low (L) in 6 (25%). At a median follow-up of 12.9 mo. (range, 1.9-27.5), 23 pts remain on study. Of 12 pts with at least 15 mo. follow-up (completing all therapy), the ORR was 100% (92% CR/CRi, 8% PR [due to small residual nodes]). 3 pts died on study (2 due to COVID-19 and 1 developed newly metastatic squamous cell carcinoma and taken off study after achieving a CR post-VEN ramp-up). Bendamustine was administered at doses of 50 mg/m 2 in 47%, 70 mg/m 2 in 11%, and 90mg/m 2 in 42% of pts. In 20 evaluable pts, response assessments after cytoreduction with BR demonstrated 15% of pts achieved CR/CRi and 85% achieved PR. For evaluable pts at 16 mo., uMRD (&lt;0.01%) in the PB and BM was observed in 100% (10/10) and 90% (9/10) of pts, respectively. MRD was intermediate (0.01% - &lt;1.0%) in 10% (1 patient) in BM (Figure 1 ORR and MRD). Median time to uMRD was 12 mo. (range 3-15) in PB and 14 mo. (range 5.5-15) in BM. The most common treatment-emergent AEs during BR induction were (any grade/grade ≥3) anemia in 6/2 (21%/7%) pts, nausea in 6/0 (21%/0%), neutropenia in 5/2 (18%/7%), rash in 5/0 (18%/0%), constipation 4/0 (14%/0%), and transaminitis in 3/0 (11%/0%). 2 pts (7%) developed febrile neutropenia during BR. Emergent AEs during VEN treatment included diarrhea in 10/0 (36%/0%) pts, neutropenia in 6/3 (21%/11%), leukopenia in 5/2 (18%/7%), and nausea in 4/0 (14%/0%). TLS risk was substantially reduced after BR lead-in. Of 3 H-risk pts at baseline, none remained H-risk after BR; of 15 M-risk pts, only 1 remained M-risk, with the remainder at L-risk (94% reduction in H- or M- risk TLS). Conclusions: BR-VR is a safe and well-tolerated regimen in untreated CLL pts. BR debulking substantially reduces TLS risk, and this sequential strategy achieves high rates of PB and BM uMRD across all prognostic risk groups. Figure 1 Figure 1. Disclosures Hill: Celgene (BMS): Consultancy, Honoraria, Research Funding; AstraZenica: Consultancy, Honoraria; Pfizer: Consultancy, Honoraria; Gentenech: Consultancy, Honoraria, Research Funding; AbbVie: Consultancy, Honoraria, Research Funding; Kite, a Gilead Company: Consultancy, Honoraria, Other: Travel Support, Research Funding; Karyopharm: Consultancy, Honoraria, Research Funding; Beigene: Consultancy, Honoraria, Research Funding; Epizyme: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Incyte/Morphysis: Consultancy, Honoraria, Research Funding. Jurcic: AbbVie, BMS/Celgene, Novartis: Consultancy; AbbVie, Arog Pharmaceuticals, Astellas, BMS/Celgene, Forma Therapeutics, Genentech, Gilead Sciences, PTC Therapeutics, Syros Pharmaceuticals: Research Funding. Heaney: CTI: Honoraria, Research Funding; Blueprint: Honoraria, Research Funding; Novartis: Honoraria; Sierra Oncology: Research Funding; Cogent: Research Funding; BMS: Research Funding; Kartos: Research Funding. Lamanna: MingSight Pharmaceuticals, Inc.: Research Funding; Gilead Sciences, Inc.: Consultancy; AbbVie: Consultancy, Research Funding; AstraZeneca: Consultancy, Research Funding; Juno Therapeutics, Inc.: Research Funding; Oncternal Therapeutics: Research Funding; Celgene Corporation: Consultancy; Genentech, Inc.: Consultancy, Research Funding; Verastem Oncology: Research Funding; TG Therapeutics, Inc: Research Funding; Janssen Pharmaceuticals, Inc.: Consultancy; BeiGene: Consultancy; Pharmacyclics: Consultancy. OffLabel Disclosure: Venetoclax, Bendamustine, and Rituximab are all FDA approved for use in first-line CLL. The combination of these three agents and dosing schedule utilized in this clinical trial is novel and therefore technically reflects an off-label use.

Assessment of Minimal Residual Disease in Multiple Myeloma patients undergoing Autologous Stem Cell Transplant using Multiparameter Flow Cytometry

QJM ◽  
2021 ◽  
Vol 114 (Supplement_1) ◽  
Author(s):  
NN Mostafa ◽  
WA El-Salakawy ◽  
HM Abdelbary ◽  
RA Radwan ◽  
RK Fathy ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Flow Cytometry ◽  
Minimal Residual Disease ◽  
Residual Disease ◽  
Limit Of Detection ◽  
Multiparameter Flow Cytometry ◽  
P Value ◽  
Cell Transplant ◽  
Post Transplant ◽  
Minimal Residual

Abstract BACKGROUND Multiple Myeloma (MM) is still considered an incurable relapsing disease, despite major advances in multidrug combinations, incorporation of autologous transplant and achieving higher rates of CR. This suggests persistent presence of residual disease, not detected by current techniques. Minimal residual disease (MRD) monitoring by multiparameter flow cytometry (MFC) is a powerful tool to quantitatively measure residual disease and allow tailoring of the management plan on individual basis. AIM To assess the value of MRD by MFC in determining the efficacy of treatment, monitoring depth of remission and predicting impending relapse. PATIENTS AND METHODS We included 33MM patients, who were candidates for ASCT in this prospective study. MFC (with a 0.01% limit of detection) on a BM aspirate obtained before transplant and at day 100 post-transplant, was used to measure MRD for all patients. Patients were then later assessed for progression 1-year post-transplant. RESULTS MRD status at 100 days post-transplant was strongly related to the risk of 1-year post-transplant progression (p-value 0.001), and by using a ROC curve, we found that MRD (%) at 100 days post-transplant can predict progression after 1 year with a best cutoff value ≥ 0.04 achieving a 75% sensitivity and 81.2% specificity. On dividing the patients according to their MRD status before and after transplant, group 3 who were MRD positive pre- and post-transplant, had a high risk of progression 1year post-transplant (p-value 0.003). The use of bortezomib-based regimens resulted in a deeper response and a more negative MRD pre-transplant (p-value 0.01), that was maintained post-transplant. Also, ASCT resulted in the development of deeper remission (p-value 0.004) and more MRD negativity (p-value 0.02). CONCLUSION we recommend the use of MRD by MFC as a powerful prognostic tool that should be incorporated in routine myeloma workup.

Prognostic Value of DNA Ploidy By Flow Cytometry for Pediatric B-Cell Acute Lymphoblastic Leukemia: A Peruvian Cohort Study

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 4-5
Author(s):  
Elizabeth Cervantes ◽  
Daniel J Enriquez ◽  
Judith Vidal ◽  
Rosario Retamozo ◽  
Arturo Zapata ◽  
...  
Keyword(s):  
Flow Cytometry ◽  
Clinical Trials ◽  
Acute Lymphoblastic Leukemia ◽  
Prognostic Value ◽  
Dna Ploidy ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Cell Acute Lymphoblastic Leukemia ◽  
Minimal Residual

Background: B-cell Acute Lymphoblastic Leukemia (B-ALL) represents an aggressive malignancy but highly curable in children. Currently, pediatric collaborative clinical trials have reported survival rates that exceed 90%, and DNA ploidy by flow cytometry (FC) has been pointed for risk stratification and prognosis in these clinical trials. However, its generalized use remains controversial as few studies reported no impact in real-world populations. We aimed to evaluate prognostic value of DNA ploidy measured by FC in a large cohort of Peruvian children with B-ALL. Methods: We evaluated prospectively DNA-ploidy by FC in bone marrow diagnostic samples from newly diagnosed children (&lt;15 years) with B-ALL treated at Instituto Nacional de Enfermedades Neoplasicas (Lima-Peru) between 2017-2019. DNA-ploidy was evaluated using Propidium Iodide and calculated as the mean ratio between fluorescence of pathologic B blasts and normal marrow cells. Ploidy categories were established based on previous reports of DNA-index(DI): Diploid + Low-Hyperdiploidy (DLH; DI: 0.95 - 1.15), hypo-diploid (HD; DI&lt;0.95) and High-hyperdiploidy (HH; DI&gt;1.15), and recalculated using maximally selected rank statistics. Samples were analyzed in a FacsCanto II flow cytometer (BD) and Infinicyt software (Cytognos). All patients received BFM-2009 protocol and had minimal residual disease evaluation at the end of IA and IB induction. Minimal residual disease (MRD) was evaluated with FC using a detection threshold of 0.0025% and considering positive ≥0.01%. Survival curves (event-free and overall survival) were estimated using the Kaplan-Meier method and compared with the Log-rank test. Results: A total of 192 children were included (2 HD, 141 DLH and 49 HH cases according to DNA ploidy by FC). Clinical characteristics and outcomes are shown in Table 1. Median age at diagnosis was 5 years (Range:1-14), 10 years for HD, 6 and 3 years for DLH and HH, respectively (p=0.002). F/M ratio was 1:1.3 for all cases, but 1:2 in HH group. Most karyotypes (62%) had unsatisfactory or poor-quality result, 29% were considered normal, and only 9 hyperdiploidy and 2 hypodiploidy cases were detected by conventional karyotyping. Regarding genetics, 21 TEL/AML, 19 E2A/PBX1 and 9 BCR/ABL cases were detected by multiplex-PCR and most balanced alterations had DLH subtype and only one HD case had TEL/AML. MRD positivity after Induction IA was 35% without difference between groups (50% HD, 36% DLH and 31% HH, p=0.77), however after Induction IB, MRD was positive in 50% of HD, 12% of DLH and 5% of HH (p=0.048). At eight-teen months of follow-up, one relapse was seen in HD cases, and 11% DLH and 10% in HH. Median EFS and OS was not reached, however one-year EFS and OS were 86% for both without significant differences between groups. Multivariate analysis showed that MRD positivity remains as the principal independent prognostic factor and ploidy by DNA did not show any impact in terms of MRD, EFS and OS. Conclusion: High-Hyperdiploidy by DNA ploidy was associated to better MRD negativity rate after induction IB but without impact in short-term EFS and OS. DNA ploidy did not represent a prognostic factor in our study cohort, however long-term follow-up is warranted. Additionally, a better genetic risk stratification is necessary to improve outcomes in Latino high-risk population. Disclosures No relevant conflicts of interest to declare.

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