Exploring Relationships of Exposure, Pharmacodynamic Changes and Gene Expression to Clinical Outcome in Adults with Acute Lymphoblastic Leukemia Receiving Inotuzumab Ozogamicin

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 3698-3698
Author(s):  
Luke Fostvedt ◽  
A. Douglas Laird ◽  
Jean-Claude Marshall ◽  
Sherry Li ◽  
Joseph P. Boni
Keyword(s):  
Gene Expression ◽  
Bone Marrow ◽  
Clinical Outcome ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Elimination Rate ◽  
Stock Ownership ◽  
Inotuzumab Ozogamicin ◽  
The Relationship

Abstract Background Inotuzumab ozogamicin (InO) is a targeted antibody-drug conjugate (ADC) under development for treatment of patients with relapsed or refractory CD22-positive acute lymphoblastic leukemia (ALL) and non-Hodgkin's Lymphoma. Correlative analyses from an open-label, Phase 1/2 study (B1931010) included exploring the relationship between InO pharmacokinetic exposure, hematologic measures, and gene expression to treatment response. Methods Patients received 2 to 3 weekly intravenous doses of InO by 1 hour infusion over a 28-day cycle for ≤ 6 cycles (table). Blood samples were drawn during Days 1 and 15 of Cycles 1 and 2 (at 0, 1 and 3 h), and Day 1 of Cycle 4 (at 0 and 1 h) for concentration determination of InO and unconjugated calicheamicin in serum. Samples were analyzed using a validated LC/MS/MS procedure. InO levels were correlated to CD22 protein expression on CD19+ B-lymphocytes in blood and bone marrow, and to minimum residual disease. Lymphocyte regeneration was described using a linear mixed-effects model. To explore the relationship between clinical outcome and expression of genes such as those involved in DNA damage response and apoptosis, optional blood samples for gene expression analysis were collected on Cycle 1 Day 1 and Cycle 1 Day 15 [each at pre- and post-dose time-points]. These samples were assessed for baseline gene expression and gene expression changes using 96-gene TaqMan Low Density Array cards. Results Unconjugated calicheamicin levels were below the limit of quantitation (50 pg/mL) for most patients and time points. Treatment-related decreases in CD22 antigen expression on lymphocytes were rapid but unrelated to InO concentration. Lymphocyte depletion in blood was also rapid, consistently observed regardless of InO dose, and followed by slow regeneration with substantial inter-patient differences in regeneration rate. Percentage of bone marrow blasts was directly related to InO elimination rate. With treatment, as blast percentage decreased, InO elimination rate decreased by approximately 50% by Cycle 4 (ie, after 10 dosing events) compared to the first dose. In bone marrow, lower disease burden at baseline tended to be associated with faster regeneration of lymphocytes during the follow-up period. Patients achieving minimal residual disease (MRD)-negativity tended to have higher peak and trough serum concentrations of InO throughout each cycle compared to patients not achieving MRD-negativity. There was no observed correlation between percentage of blasts at baseline and MRD-negativity. CD22 mRNA levels in blood decreased approximately 10-fold by Day 15 relative to baseline, consistent with selective killing of CD22-positive leukemic blasts by InO. This decrease was more pronounced in subjects who exhibited complete response with/without incomplete platelet count recovery with no evidence of MRD than in subjects who did not exhibit clinical response (p=0.001 using Wilcoxon Rank Sum Test). In addition, multiple other transcripts exhibited decreases following InO administration, including mRNAs encoded by genes regulating proliferation (cyclin-dependent kinase 2), DNA repair (XRCC2), and cell death (death-associated protein kinase 1). Conclusion In patients with ALL receiving InO, CD22 protein expression and lymphocyte count decreased rapidly, followed by slow and variable regeneration, as patients with low disease blast counts at baseline exhibited faster recovery of their counts than those with higher levels. While CD22 expression is not a significant determinant of InO concentration, the number of doses administered did influence drug elimination rate; an effect thought to be associated with target-mediated drug clearance. In related fashion, patients achieving MRD-negativity tended to have higher InO concentrations following InO treatment. Changes in mRNA profiles in blood consistent with the mechanism of action of InO were evident. The extent of reduction in CD22 mRNA was associated with clinical outcome. Study is ongoing for long term follow up. Figure 1. Figure 1. Disclosures Fostvedt: Pfizer Inc: Employment, Other: stock ownership. Laird:Pfizer Inc: Employment, Other: Stock ownership. Marshall:Pfizer Inc: Employment, Other: Stock ownership. Li:Pfizer Inc: Employment, Other: Stock ownership. Boni:Pfizer Inc: Employment, Other: Stock ownership.

Fludarabine, Cytarabine, Daunoxome Plus Dasatinib Has High Efficacy with an Acceptable Toxicity Profile As Either Consolidation or Salvage Regimen in Adult Philadelphia Positive Acute Lymphoblastic Leukemia Patients

Blood ◽  
2015 ◽  
Vol 126 (23) ◽  
pp. 4908-4908 ◽  
Author(s):  
Giordana Pastori ◽  
Fabio Guolo ◽  
Daniela Guardo ◽  
Paola Minetto ◽  
Marino Clavio ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
The Other ◽  
Consolidation Therapy ◽  
Toxicity Profile ◽  
Newly Diagnosed ◽  
Salvage Regimen ◽  
Minimal Residual

Abstract BACKGROUND AND AIMS The prognosis of Philadelphia positive (Ph+) acute lymphoblastic leukemia (ALL) patients has improved since the introduction of tyrosine kinase inhibitors (TKI). The inclusion of TKIs in standard ALL protocols allows a great increase in complete molecular responses, but at the price of non negligible toxicities and high rates of toxic deaths. On the other and TKI monotherapy as induction treatment allows to rapidly achieve complete hematologic remission (CR) but only a minority of patients achieve a complete molecular response with high risk of relapse. On the other hand, In the last years we tested a combination of Fludarabine, Cytarabine, Daunoxome (FLAD) with or without TKIs (mainly Dasatinib) as salvage regimen in relapsed-refractory ALL, with acceptable toxicity and good efficacy. We decided to apply the same schedule in newly diagnosed Ph+ ALL as consolidation treatment after a two months TKI (Dasatinib) monotherapy induction on a minimal residual disease condition. MATERIALS AND METHODS FLAD regimen consisted with a three-days administration of Fludarabine 30 mg/sqm followed four hours later by Cytarabine 2000 mg/sqm and Daunoxome 100 mg/sqm. TKI were suspended during chemotherapy administration and were re-administrated starting from day 5. G-CSF was given to all patients from day 4 to complete hematological recovery. FLAD was administrated for up to two cycles; all patients with available donor proceeded to allogeneic bone marrow transplantation (allo-BMT) after FLAD. Minimal residual disease (MRD) was evaluated in all patients after each FLAD either by RQ-PCR for VDJ rearrangements, multicolor flow cytometry (MFC) and RQ-PCR for BCR/Abl. Ten Ph+ ALL have been treated with FLAD + TKIs from January 2008 to December 2014: six patients received FLAD as salvage regimen, two of them in post allo-BMT setting, whereas four patients were treated frontline, after hematological CR was obtained with Dasatinib + steroids induction. All frontline patients proceeded to allo-BMT after two FLAD. Median age for frontline patients was 50 years (range 29-58), median follow-up was 20 months. RESULTS As salvage regimen, 5/6 patients achieved hematological CR after FLAD, with three patients achieving also MFC MRD negativity and clearance of VDJ and BCR/Abl transcript. All patients who did not receive subsequent BMT relapsed, whereas of the two transplanted patients one is still in CR after a follow-up of 38 months. In the frontline setting, all patients received 70 days induction of Dasatinib + Steroids and achieved CR with complete hematological recovery. BCR/Abl transcript could be detected in all patients on BM samples on day 33 and on day 70 (Fig. 1), two patientshad MFC MRD positivity both on day 33 and on day 70, whereas two patients achieved MFC MRD negativity on day 33. FLAD was very well tolerated, with negligible non hematological toxicity, with a median duration of ANC <500 and PLT <20000 of 7 and 9 days, respectively, slightly higher in the second course. Median time between the beginning of first and second course was 35 days, whereas median time from second course to allo-BM was 44 days. Two patients achieved BCR/Abl negativity after first FLAD. All patients achieved molecular complete response after the second course (Fig. 1). No patient experienced relapse, whereas one patient died in CR on day +289 after allo-BMT due to myocardial viral infection. CONCLUSIONS FLAD has a very good efficacy in adult Ph+ ALL, with an acceptable toxicity profile. Deep responses have been observed in relapsed patients, and all newly diagnosed patients who received FLAD as consolidation regimen had achieved molecular CR before allo-BMT. Achieving complete hematological response with Dasatinib + steroids allowed us to safely administer two FLAD courses. Figure 1. BCR/abl on bone marrow samples at different timepoints for each of the four patients receiving FLAD as consolidation therapy Figure 1. BCR/abl on bone marrow samples at different timepoints for each of the four patients receiving FLAD as consolidation therapy Disclosures Off Label Use: Use of liposomal daunorubicin in the treatment of ALL.

Minimal Residual Disease Tests Provide an Independent Predictor of Clinical Outcome in Adult Acute Lymphoblastic Leukemia

2002 ◽  
Vol 20 (4) ◽  
pp. 1094-1104 ◽  
Author(s):  
Forida Y. Mortuza ◽  
Mary Papaioannou ◽  
Ilidia M. Moreira ◽  
Luke A. Coyle ◽  
Paula Gameiro ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Acute Lymphoblastic Leukemia ◽  
Clinical Outcome ◽  
Minimal Residual Disease ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Disease Free Survival ◽  
Adult Patients ◽  
Exact Test ◽  
Minimal Residual

PURPOSE: Investigation of minimal residual disease (MRD) in childhood acute lymphoblastic leukemia (ALL) using molecular markers has proven superior to other standard criteria (age, sex, and WBC) in distinguishing patients at high, intermediate, and low risk of relapse. The aim of our study was to determine whether MRD investigation is valuable in predicting outcome in Philadelphia-negative adult patients with ALL. PATIENTS AND METHODS: MRD was assessed in 85 adult patients with B-lineage ALL by semiquantitative immunoglobulin H gene analysis on bone marrow samples collected during four time bands in the first 24 months of treatment. Fifty patients received chemotherapy only and 35 patients received allogeneic (n = 19) or autologous (n = 16) bone marrow transplantation (BMT) in first clinical remission. The relationship between MRD status and clinical outcome was investigated and compared with age, sex, immunophenotype, and presenting WBC count. RESULTS: Fisher’s exact test established a statistically significant concordance between MRD results and clinical outcome at all times. Disease-free survival (DFS) rates for MRD-positive and -negative patients and log-rank testing established that MRD positivity was associated with increased relapse rates at all times (P < .05) but was most significant at 3 to 5 months after induction and beyond. MRD status after allogeneic BMT rather than before was found to be an important predictor of outcome in 19 adult patients with ALL tested. In patients receiving autologous BMT (n = 16), the MRD status before BMT was more significant (P = .005). CONCLUSION: The association of MRD test results and DFS was independent of and greater than other standard predictors of outcome and is therefore important in determining treatment for individual patients.

Achievement of Minimal Residual Disease Negativity By Multiparameter Flow Cytometry Is an Important Therapeutic Endpoint in Patients with Relapsed/Refractory B-Cell Acute Lymphoblastic Leukemia Receiving Salvage Treatment

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 2916-2916 ◽  
Author(s):  
Nicholas J. Short ◽  
Hagop M. Kantarjian ◽  
Jeffrey L. Jorgensen ◽  
Farhad Ravandi ◽  
Musa Yilmaz ◽  
...  
Keyword(s):  
Research Funding ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Advisory Board ◽  
Multiparameter Flow Cytometry ◽  
Inotuzumab Ozogamicin ◽  
Term Survival ◽  
Minimal Residual

Abstract Background: Minimal residual disease (MRD) assessment by multiparameter flow cytometry (MFC) is prognostic for survival in newly diagnosed patients (pts) with acute lymphoblastic leukemia (ALL). The significance of achieving MRD negativity in the relapsed/refractory setting is less clear. Methods: Between 6/2010 and 5/2015, we identified 130 adult pts with relapsed/refractory B-cell ALL treated at our institution with either inotuzumab ozogamicin (n=75), blinatumomab (n=20) or mini-hyper-CVD plus inotuzumab ozogamicin (HCVD+InO; n=35) in either salvage 1 (S1; n=68) or salvage 2 (S2; n=62). MRD by MFC was assessed on remission bone marrow specimens at the time of achievement of CR/CRp/CRi. The MRD assay used a 15-marker, 6-color panel with a sensitivity of ≤0.01%. Results: Of the initial 130 pts, 78 (60%) achieved morphological response with a median time to response of 30 days (range, 13-99 days) and are the subject of this analysis. Of the 78 responding pts, 41 (53%) received inotuzumab, 11 (14%) blinatumomab, and 26 (33%) HCVD+ino. 46 pts (59%) were in S1 and 32 (41%) in S2. The median number of cycles to best response was 1 (range, 1-3). MRD negativity was achieved in 41 pts (53%). MRD negativity rates for pts in CR, CRp, and CRi were 57%, 53%, and 16%, respectively. Among pts who achieved remission, MRD negativity was achieved in 17 pts (41%) with inotuzumab, 8 (73%) with blinatumomab, and 16 (62%) with HCVD+InO (P=0.10). 26 pts (57%) in S1 and 15 (47%) in S2 became MRD-negative (P=0.40). The median follow-up duration was 27 months (range, 6-55 months). The median event-free survival (EFS) was 12 months in pts who achieved MRD negativity vs. 6 months in those who remained MRD-positive (P=0.09). The median overall survival (OS) was 17 months versus 9 months, respectively (P=0.18). Among pts in S1, achieving MRD negativity was associated with a longer EFS (median 18 months versus 7 months; 2-year EFS rate 46% versus 17%; P=0.06; Figure 1A) and OS (median 27 months versus 9 months; 2-year OS 52% versus 36%; P=0.15; Figure 1B). EFS and OS were similar in S2 regardless of MRD response. As expected, among pts who achieved MRD negativity, those in S1 had longer EFS (median 18 months vs. 5 months; P=0.001) and OS (median 27 months vs. 7 months; P=0.01) compared to those in S2. In contrast, for pts who remained MRD-positive, EFS and OS were similar regardless of salvage status (P=0.41 and P=0.39, respectively). In a 2-month landmark analysis of 64 pts, survival >2 years was observed in all groups of pts regardless of salvage treatment, salvage status or MRD status. 42 (66%) of the pts in this analysis underwent allogeneic stem cell transplantation (alloSCT). EFS and OS did not significantly differ between pts who did or did not undergo alloSCT, although a clear trend for improved long-term survival with alloSCT was observed. Among pts who achieved MRD negativity, the median EFS was 17 months and 12 months, and 2-year EFS rates were 46% and 28% for pts who underwent alloSCT vs. those who did not (P=0.24). The median OS was 24 months and 23 months, and 2-year OS rates were 55% and 46%, respectively (P=0.41). Pts who achieved MRD negativity after S1 treatment and then underwent alloSCT had the best outcomes. Of the 22 pts who achieved MRD negativity after S1 treatment, the median EFS for pts who underwent alloSCT (n=14) compared to those who did not (n=8) was not reached vs. 18 months, and the median OS was not reached vs. 27 months, respectively (P=0.28 for both). Among the 14 pts who achieved MRD negativity after S1 treatment and subsequently underwent alloSCT, 10 (71%) are still alive with a median follow-up of 24 months (range, 5-55 months). Conclusions: In patients with relapsed/refractory ALL, achievement of MRD negativity is associated with improved outcomes. Patients with relapsed/refractory ALL who achieve MRD negativity in S1 can achieve excellent long-term survival, especially if alloSCT is performed. Disclosures O'Brien: Pharmacyclics, LLC, an AbbVie Company: Consultancy, Honoraria, Research Funding; Janssen: Consultancy, Honoraria. Cortes:ARIAD: Consultancy, Research Funding; BMS: Consultancy, Research Funding; Novartis: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Teva: Research Funding. DiNardo:Daiichi Sankyo: Other: advisory board, Research Funding; Novartis: Other: advisory board, Research Funding; Abbvie: Research Funding; Celgene: Research Funding; Agios: Other: advisory board, Research Funding. Jain:Genentech: Research Funding; Incyte: Research Funding; BMS: Research Funding; Celgene: Research Funding; Infinity: Research Funding; Pharmacyclics: Consultancy, Honoraria, Research Funding; Servier: Consultancy, Honoraria; Novartis: Consultancy, Honoraria; Novimmune: Consultancy, Honoraria; Abbvie: Research Funding; Seattle Genetics: Research Funding; ADC Therapeutics: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding. Konopleva:Cellectis: Research Funding; Calithera: Research Funding. Jabbour:ARIAD: Consultancy, Research Funding; Pfizer: Consultancy, Research Funding; Novartis: Research Funding; BMS: Consultancy.

Safety and Efficacy of Blinatumomab Used in Children with B-Precursor Acute Lymphoblastic Leukemia (ALL) Treated in French Hematological Centers

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 5190-5190
Author(s):  
Anne-Flore Derache ◽  
Fanny Rialland ◽  
Gerard Michel ◽  
Yves Perel ◽  
Virginie Gandemer ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Molecular Remission ◽  
Safety And Efficacy ◽  
Neurological Event ◽  
Grade 3 ◽  
B Lineage ◽  
Time To Relapse

Abstract Blinatumomab is a monoclonal bispecific antibody, combining two binding sites: a CD3 site for T cells and a CD19site for the target B cells. Blinatumomab has demonstrated efficacy and safety in adult relapsed/refractory B-precursor ALL (R/R ALL) populations, but also in the pediatric R/R ALL population as shown by interim results from the Phase 1b/2 study MT103-205 (Gore L et al, ASH 2014). Patients and methods: this retrospective study aims to evaluate safety and efficacy of Blinatumomab in 17 pediatric pts with B-precursor ALL treated in 4 french hematological centers between April 2013 and December 2015 within a compassionate use frame. These 17 pts represent the whole population of French children treated with Blinatumomab outside a clinical trial but under a Temporary Authorization for Use (ATU) given by the French Regulatory Agency (ANSM) within this period. Median age was 6.6 years (8 months - 16.6 years). Results: 1)7 pts (41%) received Blinatumomab at a dose of 15 mcg/m2/day for 28 days/cycle in first or second complete remission for minimal residual disease (MRD) persistence. Six of those 7 pts had a molecular remission (MRD <10-4) after 1 or 2 cycles of Blinatumomab. Those 6 responders could be led to allo-HSCT. One of these died of invasive aspergillosis 131 days after allo-HSCT, without bone marrow relapse. Three pts had no relapse with a median follow-up time of 147 days (142 - 240 days). Time to relapse for the 2 remaining pts was respectively 75 and 86 days after allo-HSCT. One non responder pt was not led to allo-HSCT and died of ALL progression. 2) Ten pts (59%) with R/R ALL received Blinatumomab at a dose of 5-15 mcg/m2/day for 28 days during the first cycle then at a dose of 15 mcg/m2/day for all subsequent cycles; 2 of them being in marrow relapse after allo-HSCT. Four of those 10 pts achieved a molecular remission after 1 or 2 cycles and could receive an allo-HSCT. Two of those 4 pts had a bone marrow relapse respectively 89 and 135 days after allo-HSCT. One patient had an isolated meningeal relapse 141 days after allo-HSCT. Of note no marrow relapse has been observed in this patient with a follow-up of 2.7 years after allo-HSCT. One patient was free of disease with a short follow-up (69 days after allo-HSCT). The 6 pts who did not achieve molecular remission after one or two cycles of Blinatumomab died from ALL progression.3) In total, 10 of 17 pts have achieved a molecular remission after 1 or 2 cycles of Blinatumomab. Four of those 10 pts are alive without any further relapse, with a median follow-up time of 144 days after allo-HSCT (69 - 240 days). The 7 pts who were not in molecular remission after 1 or 2 cycles of Blinatumomab all died of ALL progression.4) Safety: regarding treatment-related adverse events of grade ≥2, 5 of 17 pts (29%) had a cytokine release syndrome of grade ≥ 2 (grade 2= 3, grade 4= 2). Five pts (29%) had an infection: 2 pts had a grade 3 viral infection (HSV oral recurrence, n=1 and herpes zoster, n=1). Two pts had grade 3 sepsis (<i>Enterococcus faecalis<i/>, n=1 and <i>Staphylococcus haemolyticus<i/>, n=1). One patient had a grade 3 soft tissue mucormycosis. Three pts (18%) had hepatic toxicity (≥ grade 3 increased ALAT, n=2). One patient had a grade 4 pericarditis without documented infection. No neurological event was observed. Conclusion: Although our numbers are small 1) Blinatumomab is an effective bridge to HSCT for pts with persisting high MRD after intensive chemotherapy. 2) A 40% MRD response rate has been found for R/R pts but with a dismal final outcome. 3) Toxicity is manageable with a low neurological event rate (none in this study). Blinatumomab should be developed in less advanced B lineage ALL in children. Disclosures Baruchel: Amgen: Consultancy. Brethon:Amgen: Consultancy.

scholarly journals The immunologic detection of minimal residual disease in acute leukemia [published erratum appears in Blood 1990 Nov 1;76(7):1901]

Blood ◽  
1990 ◽  
Vol 76 (1) ◽  
pp. 163-171
Author(s):  
D Campana ◽  
E Coustan-Smith ◽  
G Janossy
Keyword(s):  
Bone Marrow ◽  
Residual Disease ◽  
Fetal Liver ◽  
Lymphoblastic Leukemia ◽  
Bone Marrow Examination ◽  
Repeated Testing ◽  
Acute Leukemias ◽  
Minimal Disease ◽  
Systemic Relapse

Certain combinations of differentiation antigens are expressed on leukemia blasts and are absent or extremely rare among normal progenitors in the fetal liver and fetal and regenerating bone marrow. These combinations include cCD3/TdT, a thymic feature retained on thymic-acute lymphoblastic leukemia (T-ALL) blasts outside the thymus, and the coexpression of TdT and myeloid markers (CD13, CD33) on a proportion of ALL and acute myeloid leukemia (AML). Thus, double marker immunofluorescence assays are operationally leukemia-specific and can be applied in 35% of acute leukemias for detecting minimal disease at a less than 10(-4) level; only rare cases, 2 of 35 in our study, switch these relevant features during relapse. The sensitivity and specificity of these assays was tested as follows. First, bone marrow samples taken from patients who had originally presented with blasts expressing the leukemia-associated combinations but were in full morphologic remission were studied, and varying numbers (less than 0.01% to 10% of the mononuclear fraction) of cells with aberrant features were identified in 11.6% of the cases. Second, the outcome of 19 patients with minimal disease identified immunologically while in complete morphologic remission was investigated: all 19 patients have developed systemic relapse within 4 to 25 (median 14.5) weeks. In contrast, 17 of 25 patients also morphologically in complete remission and without residual disease identifiable immunologically after repeated testing are still in morphologic and immunologic remission (follow-up 17 to 114 weeks, median 28 weeks). Only eight patients in this group have relapsed so far: in two patients the relapse was localized in the cerebrospinal fluid, while in six patients a systemic relapse was observed 6 to 51 (median 21.5) weeks after the last negative immunologic bone marrow examination. In conclusion, no false-positive results were detected with these sensitive assays, and the introduction of appropriately planned prospective studies, including the immunologic detection of residual leukemia, is justified on the basis of these observations.

scholarly journals The immunologic detection of minimal residual disease in acute leukemia [published erratum appears in Blood 1990 Nov 1;76(7):1901]

Blood ◽  
1990 ◽  
Vol 76 (1) ◽  
pp. 163-171 ◽  
Author(s):  
D Campana ◽  
E Coustan-Smith ◽  
G Janossy
Keyword(s):  
Bone Marrow ◽  
Residual Disease ◽  
Fetal Liver ◽  
Lymphoblastic Leukemia ◽  
Bone Marrow Examination ◽  
Repeated Testing ◽  
Acute Leukemias ◽  
Minimal Disease ◽  
Systemic Relapse

Abstract Certain combinations of differentiation antigens are expressed on leukemia blasts and are absent or extremely rare among normal progenitors in the fetal liver and fetal and regenerating bone marrow. These combinations include cCD3/TdT, a thymic feature retained on thymic-acute lymphoblastic leukemia (T-ALL) blasts outside the thymus, and the coexpression of TdT and myeloid markers (CD13, CD33) on a proportion of ALL and acute myeloid leukemia (AML). Thus, double marker immunofluorescence assays are operationally leukemia-specific and can be applied in 35% of acute leukemias for detecting minimal disease at a less than 10(-4) level; only rare cases, 2 of 35 in our study, switch these relevant features during relapse. The sensitivity and specificity of these assays was tested as follows. First, bone marrow samples taken from patients who had originally presented with blasts expressing the leukemia-associated combinations but were in full morphologic remission were studied, and varying numbers (less than 0.01% to 10% of the mononuclear fraction) of cells with aberrant features were identified in 11.6% of the cases. Second, the outcome of 19 patients with minimal disease identified immunologically while in complete morphologic remission was investigated: all 19 patients have developed systemic relapse within 4 to 25 (median 14.5) weeks. In contrast, 17 of 25 patients also morphologically in complete remission and without residual disease identifiable immunologically after repeated testing are still in morphologic and immunologic remission (follow-up 17 to 114 weeks, median 28 weeks). Only eight patients in this group have relapsed so far: in two patients the relapse was localized in the cerebrospinal fluid, while in six patients a systemic relapse was observed 6 to 51 (median 21.5) weeks after the last negative immunologic bone marrow examination. In conclusion, no false-positive results were detected with these sensitive assays, and the introduction of appropriately planned prospective studies, including the immunologic detection of residual leukemia, is justified on the basis of these observations.

scholarly journals Successful Salvage with Inotuzumab Ozogamicin in Relapsed/Refractory Lymphoid Blast Crisis of Chronic Myeloid Leukemia after Failure of Multiple Lines of Therapy Including Blinatumomab

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5452-5452 ◽  
Author(s):  
Alay Mansurov ◽  
Michael Byrne ◽  
Koyamangalath Krishnan
Keyword(s):  
Bone Marrow ◽  
Case Report ◽  
Myeloid Leukemia ◽  
Lymphoblastic Leukemia ◽  
Blast Crisis ◽  
Bone Marrow Aspiration ◽  
Blast Phase ◽  
Inotuzumab Ozogamicin ◽  
Lost To Follow Up

Abstract Background: Lymphoid blast crisis, one of the two major forms of chronic myeloid leukemia (CML) blast crisis (BC), is comprised of lymphoblasts and occurs in about 30% of BC patients. These individuals often respond to the same treatment strategies used in Philadelphia chromosome positive acute lymphoblastic leukemia (Ph+ ALL). Blinatumomab, a bispecific T engager, or BiTE, is an antibody with dual specificity against both CD3 and CD19, and is approved for use in relapsed/refractory ALL. We present the first known case of relapsed/refractory lymphoid blast phase CML, including treatment failure with blinatumomab, who achieved a complete response to inotuzumab ozogamicin. Case report: In 2004, the patient was initially diagnosed with CML and received treatment with hydroxyurea followed by imatinib. He was intermittently compliant, later changed to nilotinib, and was ultimately lost to follow-up. Approximately 11 years after diagnosis, he returned with pancytopenia. Bone marrow aspiration and biopsy showed a hypercellular bone marrow with 10-15% lymphoid blasts that expressed CD34, CD19, cCD79a, HLA-Dr, CD10 and nTdt. Testing for the BCR-ABL translocation (at breakpoint P210) was positive confirming lymphoid blast phase CML. He received hyperCVAD + dasatinib, responded, and was referred for allogeneic hematopoietic cell transplantation (HCT) but deferred for social reasons. He was ultimately lost to follow-up. The patient returned with relapsed disease in February 2017 and bone marrow aspiration and biopsy was consistent with CD19+ lymphoid blast phase CML with BCR-ABL major breakpoint p210 and new F317L mutation of ABL kinase domain. He received salvage therapy with vincristine/prednisone/bosutinib, however, repeat bone marrow testing confirmed persistent CD19+ lymphoid blasts (20%). He was treated with blinatumomab, entered a minimal residual disease (MRD)-positive morphologic remission with 1.9% abnormal B lymphoblasts by flow cytometry. A second cycle of blinatumomab was complicated by bone pain and repeat bone marrow testing showed progressive disease with 50-60% CD19+, CD22+ lymphoblasts. Salvage therapy with fludarabine, cytarabine, and idarubicin (FLAG-Ida) in September 2017 was unsuccessful and palliative treatment with vincristine, prednisone, and methotrexate was initiated. He developed new onset neurologic symptoms in March 2018 and lumbar puncture showed evidence of disease in his central nervous system (CNS) The patient received concurrent intrathecal methotrexate and inotuzumab ozogamicin which led to clearance of CNS disease and a morphologic remission in his marrow. He continues with MRD-positivity with 0.15% B lymphoblasts and is on ponatinib maintenance while allogeneic HCT evaluation is underway. Discussion: This is the first reported patient with lymphoid blast phase CML, refractory to BiTE therapy, that was successfully salvaged with inotuzumab ozogamycin. Recent data from acute lymphoblastic leukemia (ALL) reported that the majority of BiTE failures remained CD19+ and the mechanisms of CD19 immunotherapy failure are poorly understood (Jabbour E, et al, AJH 2017). These patients may be successfully salvaged by CD19-directed chimeric antigen receptor (CAR) T cells or other directed therapies such as inotuzumab ozogamycin. Conclusion: Patients with relapsed/refractory lymphoid blast phase CML should receive directed salvage therapies. This case report demonstrates that failure of one line of directed therapy does not predict for future failures. Disclosures No relevant conflicts of interest to declare.

scholarly journals Deep Sequencing Approach for Minimal Residual Disease Detection in Acute Lymphoblastic Leukemia

Blood ◽  
2012 ◽  
Vol 120 (21) ◽  
pp. 1388-1388
Author(s):  
Malek Faham ◽  
Jianbiao Zheng ◽  
Martin Moorhead ◽  
Victoria Carlton ◽  
Patricia Lee Stow ◽  
...  
Keyword(s):  
Bone Marrow ◽  
Flow Cytometry ◽  
Research Funding ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Clonal Evolution ◽  
Employment Equity ◽  
Equity Ownership ◽  
Minimal Residual

Abstract Abstract 1388 Background: The clinical management of patients with acute lymphoblastic leukemia (ALL) relies on accurate prediction of relapse hazard to determine the intensity of therapy and avoid over- or under-treatment.1 The measurement of minimal residual disease (MRD) during therapy has now emerged as the most important predictor of outcome in ALL.2 We developed the LymphoSIGHT platform, a high-throughput sequencing method, which universally amplifies antigen-receptor gene segments and can identify all leukemia-specific sequences at diagnosis, allowing monitoring of disease progression and clonal evolution during therapy. In this study, we determined the sensitivity and specificity of this method, delineated the extent of clonal evolution present at diagnosis, and compared its capacity to measure MRD to that of flow cytometry and allele-specific oligonucleotide PCR (ASO-PCR) in follow-up samples from >100 patients with ALL. Methods: Using the sequencing assay, we analyzed diagnostic bone marrow samples from 100 ALL patients for clonal rearrangements of immunoglobulin (IgH@) and T cell receptor (TRB@, TRD@, TRG@) genes, as well as the extent of clonal evolution present at diagnosis. We assessed the capacity of the sequencing assay to detect MRD using diagnostic samples from 12 ALL patients carrying 13 leukemic IgH clonal rearrangements. Serial dilutions were prepared in normal peripheral blood mononucleated cells, at a range between <1 in 1 million to >1 in 1,000 cells. We also assessed MRD in follow-up samples from 106 ALL patients and analyzed concordance between MRD results obtained by the sequencing assay, flow cytometry and ASO-PCR. Results: In diagnostic bone marrow samples, we detected the presence of a high-frequency clonal rearrangement of at least one receptor (“calibrating receptor”) in all the 100 ALL samples; 94 samples had at least 2 calibrating receptors at diagnosis, with 51 having 3 or more. We also detected a variable degree of clonal evolution: the number of evolved clones in each sample ranged from 0 to 6933, with 39 (37%) samples having 1–50 evolved clones and 17 (16%) >50 (Figure 1). In experiments with mixtures of normal and leukemic cells, the sequencing assay unequivocally and accurately detected leukemic signatures in all dilutions up to a concentration of at least one leukemic cell in 1 million leukocytes. In direct comparisons with established MRD assays performed on follow-up samples from patients with B-ALL, sequencing detected MRD in all 28 samples positive by flow cytometry, and in 35 of the 36 positive by ASO-PCR; it also revealed MRD in 10 and 3 additional samples that were negative by flow cytometry and ASO-PCR, respectively (Figure 2). Conclusions: The sequencing assay is precise, quantitative, and can detect MRD at levels below 1 in 1 million leukocytes (0.0001%), i.e., represents sensitivity 1–2 orders of magnitude higher than standard flow cytometric and ASO-PCR methods. Our assay also allows monitoring of all leukemic rearrangements regardless of their prevalence at diagnosis, which abrogates the risk of false-negative MRD results due to clonal evolution. Finally, the sequencing assay utilizes a set of universal primers and does not require development of patient-specific reagents. These data, together with the results of our comparison with standard MRD assays in clinical samples, strongly support the use of the sequencing assay as a next-generation MRD test for ALL. Disclosures: Faham: Sequenta: Employment, Equity Ownership, Research Funding. Zheng:Sequenta: Employment, Equity Ownership, Research Funding. Moorhead:Sequenta: Employment, Equity Ownership, Research Funding. Carlton:Sequenta: Employment, Equity Ownership, Research Funding.

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