scholarly journals Treatment-free remission in Chronic Myeloid Leukemia harboring atypical BCR-ABL1 transcripts.

2020 ◽  
Vol 12 (1) ◽  
pp. e2020066 ◽  
Author(s):  
Matteo Dragani ◽  
Jessica Petiti ◽  
Giovanna Rege-Cambrin ◽  
Enrico Gottardi ◽  
Filomena Daraio ◽  
...  
Keyword(s):  
Chronic Myeloid Leukemia ◽  
Tyrosine Kinase ◽  
Minimal Residual Disease ◽  
Myeloid Leukemia ◽  
Kinase Inhibitors ◽  
Residual Disease ◽  
Digital Pcr ◽  
Treatment Free Remission ◽  
Minimal Residual

Discontinuation of tyrosine kinase inhibitors (TKI) is the main goal today in the field of Philadelphia positive chronic myeloid leukemia (Ph + CML) and the criteria to attempt the interruption of therapy are well defined and rely on the possibility to regularly monitor the BCR-ABL1 transcript. Patients harboring atypical transcripts are automatically excluded from protocols due to the absence of a standardized method of quantification of their minimal residual disease (MRD). We report here the outcome of 6 patients with atypical transcripts with a long follow up whose MRD was followed in three cases with digital PCR during their treatment free remission (TFR).

scholarly journals Late molecular recurrences in patients with chronic myeloid leukemia experiencing treatment-free remission

2020 ◽  
Vol 4 (13) ◽  
pp. 3034-3040 ◽  
Author(s):  
Philippe Rousselot ◽  
Clémence Loiseau ◽  
Marc Delord ◽  
Jean Michel Cayuela ◽  
Marc Spentchian
Keyword(s):  
Chronic Myeloid Leukemia ◽  
Tyrosine Kinase ◽  
Myeloid Leukemia ◽  
Kinase Inhibitors ◽  
Kinase Inhibitor ◽  
Residual Disease ◽  
Molecular Response ◽  
Residual Rate ◽  
Treatment Free Remission

Abstract Treatment-free remission (TFR) is an opportunity for patients with chronic myeloid leukemia (CML). Reported cumulative incidence curves of molecular recurrence (MRec) arbor a 2-phase shape with mainly early events, but also some late events (late MRec [LMRec]). Having discontinued our first patient in 2004, we have access to a prolonged follow-up, enabling us to characterize these late events. Over 15 years, 128 patients from our institution were registered in the Stop Imatinib (STIM; A Study for Tyrosine Kinase Inhibitors Discontinuation [A-STIM]) trial. MRec was defined by the loss of major molecular response (BCR-ABL1IS >0.1%). At the first TFR attempt, patients had been taking a tyrosine kinase inhibitor for a median of 7.1 years and in BCR-ABL1IS ≤0.01% (MR4) for a median of 4 years. The median follow-up of patients in TFR was 6.5 years. The TFR rate was estimated to be 45.6% after 7 years. For 9/65 (14%) patients experiencing MRec, recurrence occurred after 2 years in TFR (median, 3.6 years). The residual rate of MRec after 2 years was estimated to be 18%. The probability of remaining in TFR was 65.4% for patients having experienced fluctuations of their minimal residual disease (MRD) (at least 2 consecutive measurements BCR-ABL1IS >0.0032% or loss of MR4), whereas it was 100% for those with stable MRD (P = .003). After 2 years in TFR, we observed an 18% residual rate of LMRec. These late events represent 14% of all MRec and occur in patients with fluctuating MRD measurements. A long-term molecular follow-up therefore remains mandatory for CML patients in TFR. The A-STIM study was registered at www.clinicaltrials.gov as #NCT02897245.

scholarly journals RT-qPCR and RT-Digital PCR: A Comparison of Different Platforms for the Evaluation of Residual Disease in Chronic Myeloid Leukemia

2017 ◽  
Vol 63 (2) ◽  
pp. 525-531 ◽  
Author(s):  
Mary Alikian ◽  
Alexandra S Whale ◽  
Susanna Akiki ◽  
Kim Piechocki ◽  
Celia Torrado ◽  
...  
Keyword(s):  
Chronic Myeloid Leukemia ◽  
Tyrosine Kinase ◽  
Reverse Transcription ◽  
Myeloid Leukemia ◽  
Kinase Inhibitors ◽  
Dynamic Range ◽  
Residual Disease ◽  
Fusion Transcript ◽  
Digital Pcr ◽  
Analytical Sensitivity

Abstract BACKGROUND Tyrosine kinase inhibitors (TKIs) are the cornerstone of successful clinical management of patients with chronic myeloid leukemia (CML). Quantitative monitoring of the percentage of the fusion transcript BCR-ABL1 (breakpoint cluster region–c-abl oncogene 1, non-receptor tyrosine kinase) BCR-ABL1IS (%BCR-ABL1IS) by reverse transcription–quantitative PCR (RT-qPCR) is the gold standard strategy for evaluating patient response to TKIs and classification into prognostic subgroups. However, this approach can be challenging to perform in a reproducible manner. Reverse-transcription digital PCR (RT-dPCR) is an adaptation of this method that could provide the robust and standardized workflow needed for truly standardized patient stratification. METHODS BCR-ABL1 and ABL1 transcript copy numbers were quantified in a total of 102 samples; 70 CML patients undergoing TKI therapy and 32 non-CML individuals. 3 commercially available digital PCR platforms (QS3D, QX200 and Raindrop) were compared with the platform routinely used in the clinic for RT-qPCR using the EAC (Europe Against Cancer) assay. RESULTS Measurements on all instruments correlated well when the %BCR-ABL1IS was ≥0.1%. In patients with residual disease below this level, greater variations were measured both within and between instruments limiting comparable performance to a 4 log dynamic range. CONCLUSIONS RT-dPCR was able to quantify low-level BCR-ABL1 transcript copies but was unable to improve sensitivity below the level of detection achieved by RT-qPCR. However, RT-dPCR was able to perform these sensitive measurements without use of a calibration curve. Adaptions to the protocol to increase the amount of RNA measured are likely to be necessary to improve the analytical sensitivity of BCR-ABL testing on a dPCR platform.

Monitoring Minimal Residual Disease by Quantitative PCR in Chronic Myeloid Leukemia Patients in Complete Cytogenetic Remission

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 4272-4272
Author(s):  
Carolina Pavlovsky ◽  
Isabel Giere ◽  
Virginia Lombardi ◽  
Pedro Negri ◽  
Beatriz Moiraghi ◽  
...  
Keyword(s):  
Chronic Myeloid Leukemia ◽  
Minimal Residual Disease ◽  
Myeloid Leukemia ◽  
Residual Disease ◽  
Cytogenetic Response ◽  
Molecular Response ◽  
Molecular Monitoring ◽  
Transcript Levels ◽  
Minimal Residual

Abstract The landscape of chronic myeloid leukemia (CML) has radically changed since the introduction of tyrosine kinase inhibitor (TKI), imatinib (IM), now considered as standard therapy. Although excellent cytogenetic responses are obtained, minimal residual disease still persists in a proportion of patients (pts) when measured by serial molecular monitoring by quantitative real-time polymerase chain reaction (RQ-PCR) to measure BCR-ABL transcript levels (Baccarani M et al. Blood2006; 108:1809–20). We monitored BCR-ABL transcript levels by RQ-PCR in 176 chronic phase (CP) –complete cytogenetic response (CCyR) CML pts treated with IM. Median follow-up from start of therapy with IM was 35 (6–80) months. Pts were recruited from 33 centers in Argentina and 2 in Uruguay. Median follow up from the first assessment at our Institution was 18 (6–32) months. Seventy nine patients (45%) had received interferon as 1st line prior to IM and 97/176 (55%) pts received imatinib as 1st line. Eighty eight percent (155/176) pts had received IM 400mg/d and 12% (21/176) 600–800mg at study initiation. Fifty four percent presented with low Sokal score at diagnosis. Peripheral blood samples were tested by RQPCR every 6 months. Major molecular response (MMR) was defined as BCR-ABL/ABL ratio of <0,1% on the Internationale Scale. Rise in transcript levels was immediately reconfirmed. Cytogenetic and mutational analyses were performed if rise in transcripts was confirmed. Overall, 48% had MMR at the initial evaluation (baseline), and this increased to 57% at last follow-up (month 18). No patient with MMR achievement lost CCyR. Only 5 pts lost CCyR, never having achieved MMR (p=0.01). All patients could be divided in 3 groups according to transcript level outcome: 61% decline (at least 1 log reduction of BCR-ABL/ABL ratio), 27% stable (no log variation), 13% rise (increasing 1 log of BCR-ABL/ABL ratio). Among 136 pts with follow up at month 18, we observed (Table 1): Molecular Response At baseline Decline in transcript levels %(pts) Stable transcript levels %(pts) Rise in transcript levels %(pts) Total %(pts) CMR: complete molecular response, U: undetectable CMR ≥ 4 log red <0,01%/U MMR ≥ 3 log red < 0,1% (N:60) 20(12) 63(38) 17(10) 44(60) No MMR > 0,1% (N:76) 47(36) 47(36) 5(4) 56(76) Total 35 (48) 55(74) 10(14) 100(136) From the group of pts with rise in transcript levels, 5 pts lost CCyR, none lost complete hematologic response. Overall, 5%(9/176) pts eventually changed therapy to a 2nd generation TKI: 5 pts with cytogenetic relapse and 4 pts with increase in transcript levels. Our results confirm that molecular responses continue improving over time and a significant number of pts achieve undetectable transcript levels with continued imatinib therapy. Achievement of MMR is associated with sustained cytogenetic response. These results emphasize the validity and feasibility of molecular monitoring in all areas of the world.

scholarly journals Novel Multiplex Droplet Digital PCR Assays to Monitor Minimal Residual Disease in Chronic Myeloid Leukemia Patients Showing Atypical BCR-ABL1 Transcripts

2020 ◽  
Vol 9 (5) ◽  
pp. 1457 ◽  
Author(s):  
Jessica Petiti ◽  
Marco Lo Iacono ◽  
Matteo Dragani ◽  
Lucrezia Pironi ◽  
Cristina Fantino ◽  
...  
Keyword(s):  
Chronic Myeloid Leukemia ◽  
Nested Pcr ◽  
Myeloid Leukemia ◽  
Residual Disease ◽  
Digital Pcr ◽  
Droplet Digital Pcr ◽  
Molecular Response ◽  
Highly Sensitive ◽  
Treatment Free Remission ◽  
Minimal Residual

BCR-ABL1 fusion transcript is the minimal residual disease marker in chronic myeloid leukemia; 2% of patients show unusual breakpoints generating atypical transcripts, not quantifiable by standardized real-time PCR (RT–PCR). Response monitoring is performed by non-quantitative NESTED PCR, useless for evaluating patients’ molecular remission, excluding them from treatment-free-remission protocols. Droplet digital PCR (ddPCR) is highly sensitive technology, allowing an absolute quantification independent of standard curves. Based on this, we have developed assays able to evaluate the molecular response in atypical patients. We designed new ddPCR-based molecular assays able to quantify atypical BCR-ABL1 transcripts, with a detection limit of 0.001%, validated in a cohort of 65 RNA from 11 patients. Fifty samples were identified congruently by ddPCR and NESTED PCR (40 positives and 10 negatives for atypical BCR–ABL1 transcript), while 11 positive samples were detected only by ddPCR. Our results highlight ddPCR usefulness, primarily when the BCR–ABL1/ABL1 level is less than 1.5% and NESTED PCR results are often inaccurate. Furthermore, we identified 3 patients who maintained a deep molecular response for at least one year, who could be considered good candidates for treatment-free remission approaches. Here, we describe a new promising molecular approach, highly sensitive, to monitor atypical BCR–ABL1 patients, paving the foundation to include them in treatment-free remission protocols.

scholarly journals Blast MRD CML 1 Trial: Blockade of PD-1 Added to Standard Therapy to Target Measurable Residual Disease (MRD) in Chronic Myeloid Leukemia (CML)- a Phase II Study of Adding the Anti-PD-1 Pembrolizumab to Tyrosine Kinase Inhibitors in Patients with Chronic Myeloid Leukemia and Persistently Detectable Minimal Residual Disease: A Trial of the ECOG-ACRIN Cancer Research Group (EA9171)

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 1-1
Author(s):  
Amer M. Zeidan ◽  
Victoria Wang ◽  
Jerald P. Radich ◽  
Jan Philipp Bewersdorf ◽  
Vijaya R. Bhatt ◽  
...  
Keyword(s):  
T Cells ◽  
Chronic Myeloid Leukemia ◽  
Tyrosine Kinase ◽  
Myeloid Leukemia ◽  
Research Funding ◽  
Kinase Inhibitors ◽  
Residual Disease ◽  
Third Line ◽  
Tki Discontinuation ◽  
Minimal Residual

Background: Chronic myeloid leukemia (CML) is driven by the activity of the oncogenic BCR-ABL tyrosine kinase, which can be effectively inhibited by tyrosine kinase inhibitors (TKIs) leading to prolonged overall and disease-free survival. Despite their effectiveness, disease can progress on TKI therapy, and lifelong treatment with TKI can have substantial negative effects on quality of life and financial health. Studies assessing the safety of TKI discontinuation in CML patients in molecular remission showed that TKIs can be discontinued in up to 45% of patients without disease recurrence. Programmed death receptor-1 (PD-1) is an inhibitory immune checkpoint receptor expressed by T-cells that can be inhibited by the anti-PD-1 monoclonal antibody pembrolizumab. Preclinical data have shown that PD-1 is highly expressed on CML-specific cytotoxic T-cells and PD-1 ligand (PD-L1) is present on CML cells. In murine CML models, the administration of anti-PD-L1 antibodies prolonged survival. As these studies suggest that disease relapse might be due to PD-1/PD-L1 mediated immune escape by CML cells, we designed the BLAST MRD CML 1 trial to study whether adding pembrolizumab to TKI is safe, increases the rate of conversion to undetectable minimal residual disease (UMRD) and allows a higher rate of TKI discontinuation. Methods: The primary endpoint of this ongoing national, ECOG-sponsored, single-arm pilot phase II clinical trial is to assess the proportion of CML patients on stable-dose TKI who convert to UMRD during or within 2 years of initiating pembrolizumab therapy (NCT#03516279). Secondary endpoints are (I) the proportion of CML patients who maintain UMRD for 6 months and 12 months, (II) the proportion of CML patients who discontinue TKI after achieving UMRD, (III) the proportion of patients who maintain UMRD off TKI at 2 years after first determined UMRD, and (IV) the incidence of grade 3 or 4 immune related adverse events related to pembrolizumab treatment during the first 2 years after registration. UMRD state is defined as an undetectable BCR-ABL using the central RQ-PCR assay with a sensitivity of 4.5 [MR4.5] on 2 consecutive occasions separated by at least 4 weeks with the date of achievement of UMRD constituting the date of first test. Immune related and other adverse events will be assessed according to CTCAE v 5.0 terminology and grading. Adult (≥18 years) patients with pathologically-confirmed CML and who have achieved major molecular response (MR3) but not UMRD at time of screening are eligible. Eligibility was recently expanded to allow third line TKI. Therefore, currently eligible patients must have been on first, second, or third line TKI therapy with either dasatinib, imatinib, nilotinib, or bosutinib for at least 2 years prior to enrolment. Patients with accelerated or blast phase CML or who have received prior allogeneic hematopoietic stem cell transplant or anti-PD-1/PD-L1 therapy are excluded. Patients will continue a standard dose of TKI therapy and receive pembrolizumab at 200 mg IV every 21 days (Figure 1). MRD status will be assessed centrally every 4 cycles. Patients who achieve UMRD at or prior to cycle 17 will discontinue TKI and pembrolizumab. If MRD remains positive prior to cycle 17, TKI and pembrolizumab will be continued for an additional 18 cycles. If MRD is still detectable after the second year of combined therapy, patients will come off study. If patients are in an UMRD state by the end of year 1 or 2 of pembrolizumab therapy, pembrolizumab will be discontinued. Patients who remain in UMRD status for one year after the first UMRD result will discontinue TKI therapy. Once TKI is discontinued, BCR-ABL will monitored q4 weeks for the first six months post TKI discontinuation, then q8 weeks for the subsequent six months, then q12 weeks for another year. Assuming that the addition of pembrolizumab to TKI will increase the conversion rate to UMRD from 20% to 40%, enrollment of 36 patients (40 patients to allow for 10% drop-out) would give this trial 91% power with a one-sided type-I error of 0.089. The combination therapy will be considered promising if 11 or more patients meet the criteria for TKI discontinuation. Toxicity will be monitored and reviewed every six months. Disclosures Zeidan: Incyte: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Research Funding; Cardinal Health: Consultancy, Honoraria; Leukemia and Lymphoma Society: Other; Epizyme: Consultancy, Honoraria; Ionis: Consultancy, Honoraria; Jazz: Consultancy, Honoraria; Celgene / BMS: Consultancy, Honoraria, Research Funding; Pfizer: Consultancy, Honoraria, Research Funding; Otsuka: Consultancy, Honoraria; Abbvie: Consultancy, Honoraria, Research Funding; Agios: Consultancy, Honoraria; Boehringer-Ingelheim: Consultancy, Honoraria, Research Funding; Cardiff Oncology: Consultancy, Honoraria, Other; Taiho: Consultancy, Honoraria; Novartis: Consultancy, Honoraria, Research Funding; Astellas: Consultancy, Honoraria; Daiichi Sankyo: Consultancy, Honoraria; Acceleron: Consultancy, Honoraria; CCITLA: Other; Astex: Research Funding; MedImmune/Astrazeneca: Research Funding; Trovagene: Consultancy, Honoraria, Research Funding; Aprea: Research Funding; Seattle Genetics: Consultancy, Honoraria; BeyondSpring: Consultancy, Honoraria; ADC Therapeutics: Research Funding. Radich:Amgen: Consultancy; Bristol-Myers Squibb: Consultancy; Jazz: Consultancy; Novartis Pharmaceuticals Corporation: Consultancy, Research Funding. Bhatt:Incyte: Consultancy, Research Funding; Takeda: Consultancy; Omeros: Consultancy; Agios: Consultancy; Rigel: Consultancy; Tolero: Research Funding; Abbvie: Consultancy, Research Funding; Pfizer: Research Funding; Partnership for health analytic research: Consultancy; Jazz: Research Funding; National Marrow Donor Program: Research Funding; Oncoceutics: Other. Gore:Abbvie: Consultancy, Honoraria, Research Funding. Luger:Daiichi-Sankyo: Honoraria; Pfizer: Honoraria; Bristol-Myers Squibb: Honoraria; Acceleron: Honoraria; Agios: Honoraria; Loxo Oncology: Honoraria; Onconova: Research Funding; Kura: Research Funding; Hoffman La Roche: Research Funding; Ariad: Research Funding; Biosight: Research Funding.

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