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Bewersdorf JP, Shimony S, Shallis RM, Liu Y, Berton G, Schaefer EJ, Zeidan AM, Goldberg AD, Stein EM, Marcucci G, Bystrom RP, Lindsley RC, Chen EC, Ramos Perez J, Stein A, Pullarkat V, Aldoss I, DeAngelo DJ, Neuberg DS, Stone RM, Garciaz S, Ball B, Stahl M. Intensive induction chemotherapy vs hypomethylating agents in combination with venetoclax in NPM1-mutant AML. Blood Adv 2024; 8:4845-4855. [PMID: 38941537 DOI: 10.1182/bloodadvances.2024012858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 06/11/2024] [Accepted: 06/18/2024] [Indexed: 06/30/2024] Open
Abstract
ABSTRACT Although intensive induction chemotherapy (IC) remains the standard of care for younger patients with acute myeloid leukemia (AML), hypomethylating agents + venetoclax (HMA/VEN) can lead to durable remission among older patients with nucleophosmin 1 (NPM1) mutations. Whether IC or HMA/VEN is superior in patients aged ≥60 years with NPM1-mutant AML is unknown. We performed an international, multicenter retrospective cohort study of 221 patients (147 IC and 74 HMA/VEN) with previously untreated NPM1-mutant AML. Composite complete remission (cCR) (defined as CR + CR with incomplete count recovery) rate was similar for IC and HMA/VEN (cCR, 85% vs 74%; P = .067). Although overall survival (OS) was favorable with IC in unselected patients compared with HMA/VEN (24-month OS, 59% [95% confidence interval (CI), 52-69%] vs 38% [95% CI, 27-55%]; P = .013), it was not statistically different among patients aged 60-75 years (60% [95% CI, 52-70%] vs 44% [95% CI, 29-66%]; P = .069) and patients who received an allogeneic stem cell transplant (70% [95% CI, 58-85%] vs 66% [95% CI, 44-100%]; P = .56). Subgroup analyses suggested that patients with normal cytogenetics (24-month OS, 65% [95% CI, 56-74%] with IC vs 40% [95% CI, 26-60%] with HMA/VEN; P = .009) and without FLT3 internal tandem duplication mutations might benefit from IC compared with HMA/VEN (24-month OS, 68% [95% CI, 59-79%] vs 43% [95% CI, 29-63%]; P = .008). In multivariable analysis, OS was not statistically different between patients treated with IC and HMA/VEN (hazard ratio for death with HMA/VEN vs IC, 0.71; 95% CI, 0.40-1.27; P = .25).
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Affiliation(s)
- Jan Philipp Bewersdorf
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Shai Shimony
- Division of Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Rory M Shallis
- Department of Internal Medicine, Section of Hematology, Yale University and Yale Cancer Center, New Haven, CT
| | - Yiwen Liu
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA
| | - Guillaume Berton
- Département d'hématologie, Institut Paoli-Calmettes, Université d'Aix-Marseille, INSERM U1068, CNRS, Marseille, France
| | - Eva J Schaefer
- Division of Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
- Department of Medical Oncology, National Center for Tumor Diseases, Heidelberg, Germany
| | - Amer M Zeidan
- Department of Internal Medicine, Section of Hematology, Yale University and Yale Cancer Center, New Haven, CT
| | - Aaron D Goldberg
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Eytan M Stein
- Department of Medicine, Leukemia Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Guido Marcucci
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Rebecca P Bystrom
- Division of Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - R Coleman Lindsley
- Division of Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Evan C Chen
- Division of Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Jorge Ramos Perez
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Anthony Stein
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Ibrahim Aldoss
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Daniel J DeAngelo
- Division of Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Donna S Neuberg
- Department of Data Science, Dana Farber Cancer Institute, Boston, MA
| | - Richard M Stone
- Division of Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Sylvain Garciaz
- Département d'hématologie, Institut Paoli-Calmettes, Université d'Aix-Marseille, INSERM U1068, CNRS, Marseille, France
| | - Brian Ball
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA
| | - Maximilian Stahl
- Division of Leukemia, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
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Ruglioni M, Crucitta S, Luculli GI, Tancredi G, Del Giudice ML, Mechelli S, Galimberti S, Danesi R, Del Re M. Understanding mechanisms of resistance to FLT3 inhibitors in adult FLT3-mutated acute myeloid leukemia to guide treatment strategy. Crit Rev Oncol Hematol 2024; 201:104424. [PMID: 38917943 DOI: 10.1016/j.critrevonc.2024.104424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 06/06/2024] [Accepted: 06/16/2024] [Indexed: 06/27/2024] Open
Abstract
The presence of FLT3 mutations, including the most common FLT3-ITD (internal tandem duplications) and FLT3-TKD (tyrosine kinase domain), is associated with an unfavorable prognosis in patients affected by acute myeloid leukemia (AML). In this setting, in recent years, new FLT3 inhibitors have demonstrated efficacy in improving survival and treatment response. Nevertheless, the development of primary and secondary mechanisms of resistance poses a significant obstacle to their efficacy. Understanding these mechanisms is crucial for developing novel therapeutic approaches to overcome resistance and improve the outcomes of patients. In this context, the use of novel FLT3 inhibitors and the combination of different targeted therapies have been studied. This review provides an update on the molecular alterations involved in the resistance to FLT3 inhibitors, and describes how the molecular monitoring may be used to guide treatment strategy in FLT3-mutated AML.
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Affiliation(s)
- Martina Ruglioni
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Stefania Crucitta
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Giovanna Irene Luculli
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Gaspare Tancredi
- Unit of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Maria Livia Del Giudice
- Unit of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Sandra Mechelli
- Unit of Internal Medicine 2, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Sara Galimberti
- Unit of Hematology, Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Romano Danesi
- Department of Oncology and Hemato-Oncology, University of Milan, Italy.
| | - Marzia Del Re
- Unit of Clinical Pharmacology and Pharmacogenetics, Department of Clinical and Experimental Medicine, University of Pisa, Italy
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3
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Bolon YT, Atshan R, Allbee-Johnson M, Estrada-Merly N, Auletta JJ, Broglie L, Cusatis R, Page KM, Phelan R, Sajulga R, Shaw BE, Spahn A, Steinert P, Stewart V, Vierra-Green C, Lee SJ, Spellman SR. Leveraging Hematopoietic Cell Transplant Data and Biorepository Resources at the Center for International Blood and Marrow Transplant Research to Improve Patient Outcomes. Transplant Cell Ther 2024; 30:921.e1-921.e22. [PMID: 38871054 DOI: 10.1016/j.jtct.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 06/06/2024] [Indexed: 06/15/2024]
Abstract
Hematopoietic cell transplantation (HCT) has undergone many advances over the decades. Trends in HCT utilization have been impacted by research based on the data and samples collected by the Center for International Blood and Marrow Transplant Research (CIBMTR). Here, we provide a summary report of the CIBMTR Biorepository resource and describe the biospecimen inventory along with collection and request procedures. The diversity captured in this inventory reflects transplant activity, and these samples can be leveraged for secondary analyses to generate more data and insights to advance the field. We describe how our resources have already impacted HCT practice and elaborate on possibilities for further collaboration and utilization to maximize capabilities and research opportunities. Hematopoietic cell transplant data and biorepository resources at the CIBMTR have been and continue to be leveraged to improve patient outcomes.
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Affiliation(s)
- Yung-Tsi Bolon
- CIBMTR® (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota.
| | - Rasha Atshan
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mariam Allbee-Johnson
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Noel Estrada-Merly
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jeffery J Auletta
- CIBMTR® (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota; Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH
| | - Larisa Broglie
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rachel Cusatis
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kristin M Page
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rachel Phelan
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Pediatric Hematology/Oncology/Blood and Marrow Transplant, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ray Sajulga
- CIBMTR® (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota
| | - Bronwen E Shaw
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ashley Spahn
- CIBMTR® (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota
| | - Patricia Steinert
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Valerie Stewart
- CIBMTR® (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota
| | - Cynthia Vierra-Green
- CIBMTR® (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota
| | - Stephanie J Lee
- CIBMTR® (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota; Fred Hutchinson Cancer Center, Seattle, Washington
| | - Stephen R Spellman
- CIBMTR® (Center for International Blood and Marrow Transplant Research), NMDP, Minneapolis, Minnesota
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4
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Chow RD, Velu P, Deihimi S, Belman J, Youn A, Shah N, Luger SM, Carroll MP, Morrissette J, Bowman RL. Early drivers of clonal hematopoiesis shape the evolutionary trajectories of de novo acute myeloid leukemia. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.08.31.24312756. [PMID: 39252918 PMCID: PMC11383471 DOI: 10.1101/2024.08.31.24312756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Abstract
Mutations commonly found in AML such as DNMT3A, TET2 and ASXL1 can be found in the peripheral blood of otherwise healthy adults - a phenomenon referred to as clonal hematopoiesis (CH). These mutations are thought to represent the earliest genetic events in the evolution of AML. Genomic studies on samples acquired at diagnosis, remission, and at relapse have demonstrated significant stability of CH mutations following induction chemotherapy. Meanwhile, later mutations in genes such as NPM1 and FLT3, have been shown to contract at remission and in the case of FLT3 often are absent at relapse. We sought to understand how early CH mutations influence subsequent evolutionary trajectories throughout remission and relapse in response to induction chemotherapy. Here, we assembled a retrospective cohort of patients diagnosed with de novo AML at our institution that underwent genomic sequencing at diagnosis as well as at the time of remission and/or relapse (total n = 182 patients). Corroborating prior studies, FLT3 and NPM1 mutations were generally eliminated at the time of cytologic complete remission but subsequently reemerged upon relapse, whereas DNMT3A, TET2 and ASXL1 mutations often persisted through remission. Early CH-related mutations exhibited distinct constellations of co-occurring genetic alterations, with NPM1 and FLT3 mutations enriched in DNMT3A mut AML, while CBL and SRSF2 mutations were enriched in TET2 mut and ASXL1 mut AML, respectively. In the case of NPM1 and FLT3 mutations, these differences vanished at the time of complete remission yet readily reemerged upon relapse, indicating the reproducible nature of these genetic interactions. Thus, early CH-associated mutations that precede malignant transformation subsequently shape the evolutionary trajectories of AML through diagnosis, therapy, and relapse.
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Affiliation(s)
- Ryan D Chow
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Priya Velu
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Pathology and Laboratory Medicine, Weill Cornell School of Medicine, Cornell University, New York, NY, USA
| | - Safoora Deihimi
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan Belman
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Angela Youn
- Department of Cancer Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Nisargbhai Shah
- Department of Cancer Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Selina M Luger
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Martin P Carroll
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer Morrissette
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert L Bowman
- Department of Cancer Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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5
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Shen Q, Gong X, Feng Y, Hu Y, Wang T, Yan W, Zhang W, Qi S, Gale RP, Chen J. Measurable residual disease (MRD)-testing in haematological cancers: A giant leap forward or sideways? Blood Rev 2024:101226. [PMID: 39164126 DOI: 10.1016/j.blre.2024.101226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2024] [Revised: 08/07/2024] [Accepted: 08/07/2024] [Indexed: 08/22/2024]
Abstract
Measurable residual disease (MRD)-testing is used in many haematological cancers to estimate relapse risk and to direct therapy. Sometimes MRD-test results are used for regulatory approval. However, some people including regulators wrongfully believe results of MRD-testing are highly accurate and of proven efficacy in directing therapy. We review MRD-testing technologies and evaluate the accuracy of MRD-testing for predicting relapse and the strength of evidence supporting efficacy of MRD-guided therapy. We show that at the individual level MRD-test results are often an inaccurate relapse predictor. Also, no convincing data indicate that increasing therapy-intensity based on a positive MRD-test reduces relapse risk or improves survival. We caution against adjusting therapy-intensity based solely on results of MRD-testing.
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Affiliation(s)
- Qiujin Shen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
| | - Xiaowen Gong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
| | - Yahui Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
| | - Yu Hu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
| | - Tiantian Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
| | - Wen Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
| | - Wei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
| | - Saibing Qi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
| | - Robert Peter Gale
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College of Science, Technology and Medicine, London, UK.
| | - Junren Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China; Tianjin Institutes of Health Science, Tianjin, China.
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6
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Shukla M, Abdul-Hay M, Choi JH. Molecular Features and Treatment Paradigms of Acute Myeloid Leukemia. Biomedicines 2024; 12:1768. [PMID: 39200232 PMCID: PMC11351617 DOI: 10.3390/biomedicines12081768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Revised: 07/26/2024] [Accepted: 07/31/2024] [Indexed: 09/02/2024] Open
Abstract
Acute myeloid leukemia (AML) is a common hematologic malignancy that is considered to be a disease of aging, and traditionally has been treated with induction chemotherapy, followed by consolidation chemotherapy and/or allogenic hematopoietic stem cell transplantation. More recently, with the use of next-generation sequencing and access to molecular information, targeted molecular approaches to the treatment of AML have been adopted. Molecular targeting is gaining prominence, as AML mostly afflicts the elderly population, who often cannot tolerate traditional chemotherapy. Understanding molecular changes at the gene level is also important for accurate disease classification, risk stratification, and prognosis, allowing for more personalized medicine. Some mutations are well studied and have an established gene-specific therapy, including FLT3 and IDH1/2, while others are being investigated in clinical trials. However, data on most known mutations in AML are still minimal and therapeutic studies are in pre-clinical stages, highlighting the importance of further research and elucidation of the pathophysiology involving these genes. In this review, we aim to highlight the key molecular alterations and chromosomal changes that characterize AML, with a focus on pathophysiology, presently available treatment approaches, and future therapeutic options.
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Affiliation(s)
| | | | - Jun H. Choi
- Department of Hematology and Medical Oncology, NYU Langone Health, Perlmutter Cancer Center, New York, NY 10016, USA; (M.S.)
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7
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Dillon LW, Gui G, Ravindra N, Andrew G, Mukherjee D, Wong ZC, Huang Y, Gerhold J, Holman M, D’Angelo J, Miller J, Higgins J, Salk JJ, Auletta JJ, El Chaer F, Devine SM, Jimenez-Jimenez AM, De Lima MJG, Litzow MR, Kebriaei P, Saber W, Spellman SR, Zeger SL, Page KM, Hourigan CS. Measurable Residual FLT3 Internal Tandem Duplication Before Allogeneic Transplant for Acute Myeloid Leukemia. JAMA Oncol 2024; 10:1104-1110. [PMID: 38696205 PMCID: PMC11066770 DOI: 10.1001/jamaoncol.2024.0985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/07/2023] [Indexed: 05/05/2024]
Abstract
Importance Persistence of FLT3 internal tandem duplication (ITD) in adults with acute myeloid leukemia (AML) in first complete remission (CR) prior to allogeneic hematopoietic cell transplant (HCT) is associated with increased relapse and death after transplant, but the association between the level of measurable residual disease (MRD) detected and clinical outcome is unknown. Objective To examine the association between pre-allogeneic HCT MRD level with relapse and death posttransplant in adults with AML in first CR. Design, Setting, and Participants In this cohort study, DNA sequencing was performed on first CR blood from patients with FLT3-ITD AML transplanted from March 2013 to February 2019. Clinical follow-up was through May 2022. Data were analyzed from October 2022 to December 2023. Exposure Centralized DNA sequencing for FLT3-ITD in pre-allogeneic HCT first CR blood using a commercially available kit. Main Outcomes and Measures The primary outcomes were overall survival and cumulative incidence of relapse, with non-relapse-associated mortality as a competing risk post-allogeneic HCT. Kaplan-Meier estimations (log-rank tests), Cox proportional hazards models, and Fine-Gray models were used to estimate the end points. Results Of 537 included patients with FLT3-ITD AML from the Pre-MEASURE study, 296 (55.1%) were female, and the median (IQR) age was 55.6 (42.9-64.1) years. Using the variant allele fraction (VAF) threshold of 0.01% or greater for MRD positivity, the results closely aligned with those previously reported. With no VAF threshold applied (VAF greater than 0%), 263 FLT3-ITD variants (median [range] VAF, 0.005% [0.0002%-44%]), and 177 patients (33.0%) with positive findings were identified. Multivariable analyses showed that residual FLT3-ITD was the variable most associated with relapse and overall survival, with a dose-dependent correlation. Patients receiving reduced-intensity conditioning without melphalan or nonmyeloablative conditioning had increased risk of relapse and death at any given level of MRD compared with those receiving reduced-intensity conditioning with melphalan or myeloablative conditioning. Conclusions and Relevance This study provides generalizable and clinically applicable evidence that the detection of residual FLT3-ITD in the blood of adults in first CR from AML prior to allogeneic HCT is associated with an increased risk of relapse and death, particularly for those with a VAF of 0.01% or greater. While transplant conditioning intensification, an intervention not available to all, may help mitigate some of this risk, alternative approaches will be necessary for this high-risk population of patients who are underserved by the current standard of care.
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MESH Headings
- Humans
- fms-Like Tyrosine Kinase 3/genetics
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/therapy
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/blood
- Female
- Male
- Middle Aged
- Hematopoietic Stem Cell Transplantation/methods
- Adult
- Transplantation, Homologous
- Neoplasm, Residual
- Tandem Repeat Sequences
- Aged
- Gene Duplication
- Cohort Studies
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Affiliation(s)
- Laura W. Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Gege Gui
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Niveditha Ravindra
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Georgia Andrew
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Zoë C. Wong
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | | | | | | | | | - Jesse J. Salk
- TwinStrand Biosciences, Seattle, Washington
- University of Washington School of Medicine, Seattle
| | - Jeffery J. Auletta
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- The Ohio State University College of Medicine, Columbus
| | | | - Steven M. Devine
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
| | | | | | | | | | - Wael Saber
- Medical College of Wisconsin, Milwaukee
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Stephen R. Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- National Marrow Donor Program, Minneapolis, Minnesota
| | - Scott L. Zeger
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kristin M. Page
- Center for International Blood and Marrow Transplant Research, Minneapolis, Minnesota
- Medical College of Wisconsin, Milwaukee
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- Virginia Tech Fralin Biomedical Research Institute Cancer Research Center, Washington, DC
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8
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Wienecke CP, Heida B, Venturini L, Gabdoulline R, Krüger K, Teich K, Büttner K, Wichmann M, Puppe W, Neziri B, Reuter M, Dammann E, Stadler M, Ganser A, Hambach L, Thol F, Heuser M. Clonal relapse dynamics in acute myeloid leukemia following allogeneic hematopoietic cell transplantation. Blood 2024; 144:296-307. [PMID: 38669617 DOI: 10.1182/blood.2023022697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 03/06/2024] [Accepted: 03/29/2024] [Indexed: 04/28/2024] Open
Abstract
ABSTRACT Patients with acute myeloid leukemia (AML) who experience relapse following allogeneic hematopoietic cell transplantation (alloHCT) face unfavorable outcomes regardless of the chosen relapse treatment. Early detection of relapse at the molecular level by measurable residual disease (MRD) assessment enables timely intervention, which may prevent hematological recurrence of the disease. It remains unclear whether molecular MRD assessment can detect MRD before impending relapse and, if so, how long in advance. This study elucidates the molecular architecture and kinetics preceding AML relapse by using error-corrected next-generation sequencing (NGS) in 74 patients with AML relapsing after alloHCT, evaluating 140 samples from peripheral blood collected 0.6 to 14 months before relapse. At least 1 MRD marker became detectable in 10%, 38%, and 64% of patients at 6, 3, and 1 month before relapse, respectively. By translating these proportions into monitoring intervals, 38% of relapses would have been detected through MRD monitoring every 3 months, whereas 64% of relapses would have been detected with monthly intervals. The relapse kinetics after alloHCT are influenced by the functional class of mutations and their stability during molecular progression. Notably, mutations in epigenetic modifier genes exhibited a higher prevalence of MRD positivity and greater stability before relapse, whereas mutations in signaling genes demonstrated a shorter lead time to relapse. Both DTA (DNMT3A, TET2, and ASXL1) and non-DTA mutations displayed similar relapse kinetics during the follow-up period after alloHCT. Our study sets a framework for MRD monitoring after alloHCT by NGS, supporting monthly monitoring from peripheral blood using all variants that are known from diagnosis.
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Affiliation(s)
- Clara Philine Wienecke
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Bennet Heida
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Letizia Venturini
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Razif Gabdoulline
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Katja Krüger
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Katrin Teich
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Konstantin Büttner
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Martin Wichmann
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Wolfram Puppe
- Department of Virology, Hannover Medical School, Hannover, Germany
| | - Blerina Neziri
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Marlene Reuter
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Elke Dammann
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Stadler
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Arnold Ganser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Lothar Hambach
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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9
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Radich J. Transplant, MRD, and predicting relapse in AML. Blood 2024; 144:245-247. [PMID: 39023869 DOI: 10.1182/blood.2024024870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2024] Open
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10
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Hourigan CS. How complete must an AML remission be? Blood 2024; 144:131-132. [PMID: 38990535 DOI: 10.1182/blood.2024024826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2024] Open
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11
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Mukherjee D, Lawal RA, Fitzhugh CD, Hourigan CS, Dillon LW. TP53 mutation screening for patients at risk of myeloid malignancy. Leukemia 2024; 38:1604-1608. [PMID: 38796530 DOI: 10.1038/s41375-024-02283-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/06/2024] [Accepted: 05/08/2024] [Indexed: 05/28/2024]
Affiliation(s)
- Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Rialnat A Lawal
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Courtney D Fitzhugh
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
- Virginia Tech FBRI Cancer Research Center, Washington, DC, USA.
| | - Laura W Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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12
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Scott S, Devonshire A, Dillon R, Thiede C, Cross NCP, White HE, Lo Cascio L, Mokretar K, Potter N, Hourigan CS, Radich J, Corner A, Laloux V, Halliday G, Dilks D, Morrison T, Gilmour K, Cartwright A, Whitby L. Recommendations from the AML molecular MRD expert advisory board. Leukemia 2024; 38:1638-1641. [PMID: 38783160 PMCID: PMC11216975 DOI: 10.1038/s41375-024-02275-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 04/05/2024] [Accepted: 04/30/2024] [Indexed: 05/25/2024]
Affiliation(s)
- Stuart Scott
- UK NEQAS for Leucocyte Immunophenotyping, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK.
| | - Alison Devonshire
- Molecular and Cell Biology, National Measurement Laboratory, LGC, Teddington, UK
| | - Richard Dillon
- Department of Haematology, Guy's International Centre of Excellence in Myeloid Disorders, Guy's and St Thomas NHS Foundation Trust, London, UK
- Department of Medical and Molecular Genetics, King's College, London, UK
| | - Christian Thiede
- University Hospital Carl Gustav Carus, Dresden University of Technology, Dresden, Germany
- AgenDix, Applied Molecular Diagnostics, GmbH, Dresden, Germany
| | - Nicholas C P Cross
- Faculty of Medicine, University of Southampton, Southampton, UK
- Wessex Genomics Laboratory Service, Salisbury District Hospital, Salisbury, UK
| | - Helen E White
- Faculty of Medicine, University of Southampton, Southampton, UK
- Wessex Genomics Laboratory Service, Salisbury District Hospital, Salisbury, UK
| | - Leandro Lo Cascio
- Diagnostics R&D, Medicines and Healthcare Products Regulatory Agency (MHRA), Potters Bar, UK
| | | | - Nicola Potter
- Department of Haematology, Guy's International Centre of Excellence in Myeloid Disorders, Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Jerald Radich
- Translational Science & Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Adam Corner
- Digital Biology Group, Bio-Rad Laboratories, Pleasanton, CA, USA
| | - Véronique Laloux
- Translational Science and Precision Diagnostics, QIAGEN, Courtaboeuf, France
| | - Gemma Halliday
- Horizon Discovery, Diagnostic Reference Standards, Cambridge, UK
| | | | | | - Katelyn Gilmour
- Clinical NGS and Oncology Division, Thermo Fisher, Paisley, UK
| | - Ashley Cartwright
- UK NEQAS for Leucocyte Immunophenotyping, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Liam Whitby
- UK NEQAS for Leucocyte Immunophenotyping, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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13
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Tiong IS, Hiwase DK, Abro E, Bajel A, Palfreyman E, Beligaswatte A, Reynolds J, Anstee N, Nguyen T, Loo S, Chua CC, Ashby M, Wiltshire KM, Fleming S, Fong CY, Teh TC, Blombery P, Dillon R, Ivey A, Wei AH. Targeting Molecular Measurable Residual Disease and Low-Blast Relapse in AML With Venetoclax and Low-Dose Cytarabine: A Prospective Phase II Study (VALDAC). J Clin Oncol 2024; 42:2161-2173. [PMID: 38427924 PMCID: PMC11191043 DOI: 10.1200/jco.23.01599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/21/2023] [Accepted: 12/18/2023] [Indexed: 03/03/2024] Open
Abstract
PURPOSE A prospective phase II study examined the safety and efficacy of venetoclax combined with low-dose cytarabine (LDAC) in AML at first measurable residual disease (MRD) or oligoblastic relapse. METHODS Patients with either MRD (≥1 log10 rise) or oligoblastic relapse (blasts 5%-15%) received venetoclax 600 mg once daily D1-28 plus LDAC once daily D1-10 in 28-day cycles. The primary objective was MRD response in the MRD relapse cohort or complete remission (CR/CRh/CRi) in the oligoblastic relapse cohort. RESULTS Forty-eight adults with either MRD (n = 26) or oligoblastic (n = 22) relapse were enrolled. Median age was 67 years (range, 18-80) and 94% had received previous intensive chemotherapy. Patients received a median of four cycles of therapy; 17% completed ≥12 cycles. Patients with oligoblastic relapse had more grade ≥3 anemia (32% v 4%; P = .02) and infections (36% v 8%; P = .03), whereas grade 4 neutropenia (32 v 23%) or thrombocytopenia (27 v 15%) were comparable with the MRD relapse cohort. Markers of molecular MRD relapse included mutant NPM1 (77%), CBFB::MYH11 (4%), RUNX1::RUNX1T1 (4%), or KMT2A::MLLT3 (4%). Three patients with a log10 rise in IDH1/2 (12%) were included. By cycle 2 in the MRD relapse cohort, a log10 reduction in MRD was observed in 69%; 46% achieved MRD negative remission. In the oligoblastic relapse cohort, 73% achieved CR/CRh/CRi. Overall, 21 (44%) underwent hematopoietic cell transplantation. Median overall survival (OS) was not reached in either cohort. Estimated 2-year OS rate was 67% (95% CI, 50 to 89) in the MRD and 53% (95% CI, 34 to 84) in the oligoblastic relapse cohorts. CONCLUSION For AML in first remission and either MRD or oligoblastic relapse, venetoclax plus LDAC is well tolerated and highly effective.
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MESH Headings
- Humans
- Aged
- Middle Aged
- Leukemia, Myeloid, Acute/drug therapy
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Neoplasm, Residual
- Cytarabine/administration & dosage
- Sulfonamides/administration & dosage
- Sulfonamides/adverse effects
- Adult
- Female
- Male
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Bridged Bicyclo Compounds, Heterocyclic/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Aged, 80 and over
- Prospective Studies
- Nucleophosmin
- Young Adult
- Adolescent
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Affiliation(s)
- Ing Soo Tiong
- The Alfred Hospital and Monash University, Melbourne, Australia
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
| | - Devendra K. Hiwase
- Royal Adelaide Hospital, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
- South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Emad Abro
- Princess Alexandra Hospital, Queensland, Australia
| | - Ashish Bajel
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
| | | | - Ashanka Beligaswatte
- University of Adelaide, Adelaide, Australia
- Flinders Medical Centre, Bedford Park, Australia
| | - John Reynolds
- The Alfred Hospital and Monash University, Melbourne, Australia
| | - Natasha Anstee
- The University of Melbourne, Melbourne, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Tamia Nguyen
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
| | - Sun Loo
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- The Northern Hospital, Melbourne, Australia
| | - Chong Chyn Chua
- The Alfred Hospital and Monash University, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- The Northern Hospital, Melbourne, Australia
| | - Michael Ashby
- The Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Shaun Fleming
- The Alfred Hospital and Monash University, Melbourne, Australia
| | - Chun Y. Fong
- Austin Health and Olivia Newton John Cancer Research Institute, Melbourne, Australia
| | - Tse-Chieh Teh
- The Alfred Hospital and Monash University, Melbourne, Australia
- Box Hill Hospital, Melbourne, Australia
| | - Piers Blombery
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
- Guy's Hospital, London, United Kingdom
| | - Adam Ivey
- The Alfred Hospital and Monash University, Melbourne, Australia
| | - Andrew H. Wei
- Peter MacCallum Cancer Centre and The Royal Melbourne Hospital, Melbourne, Australia
- The University of Melbourne, Melbourne, Australia
- Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
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14
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Hirsch P, Lambert J, Bucci M, Deswarte C, Boudry A, Lambert J, Fenwarth L, Micol JB, Terré C, Celli-Lebras K, Thomas X, Dombret H, Duployez N, Preudhomme C, Itzykson R, Delhommeau F. Multi-target measurable residual disease assessed by error-corrected sequencing in patients with acute myeloid leukemia: An ALFA study. Blood Cancer J 2024; 14:97. [PMID: 38871702 PMCID: PMC11176326 DOI: 10.1038/s41408-024-01078-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Revised: 05/29/2024] [Accepted: 05/31/2024] [Indexed: 06/15/2024] Open
Abstract
The evaluation of measurable residual disease (MRD) in acute myeloid leukemia (AML) using comprehensive mutation analysis by next-generation sequencing (NGS) has been investigated in several studies. However controversial results exist regarding the detection of persisting mutations in DNMT3A, TET2, and ASXL1 (DTA). Benchmarking of NGS-MRD taking into account other molecular MRD strategies has to be done. Here, we performed error-corrected-NGS-MRD in 189 patients homogeneously treated in the ALFA-0702 study (NCT00932412). Persistence of non-DTA mutations (HR = 2.23 for RFS and 2.26 for OS), and DTA mutations (HR = 2.16 for OS) were associated with poorer prognosis in multivariate analysis. Persistence of at least two mutations in complete remission (CR) was associated with a higher cumulative incidence of relapse (CIR) (HR = 3.71, p < 0.0001), lower RFS (HR = 3.36, p < 0.0001) and OS (HR = 3.81, p = 0.00023) whereas persistence of only one mutation was not. In 100 analyzable patients, WT1-MRD, but not NGS-MRD, was an independent factor for RFS and OS. In the subset of 67 NPM1 mutated patients, both NPM1 mutation detection (p = 0.0059) and NGS-MRD (p = 0.035) status were associated with CIR. We conclude that detectable NGS-MRD including DTA mutations correlates with unfavorable prognosis in AML. Its integration with alternative MRD strategies in AML management warrants further investigations.
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Affiliation(s)
- Pierre Hirsch
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, AP-HP, SIRIC CURAMUS, Hôpital Saint-Antoine, Service d'Hématologie Biologique, 75012, Paris, France.
| | - Jérôme Lambert
- Biostatistics and Medical Information Department, Hôpital Saint Louis, Paris, France
- INSERM U1153 - ECSTRRA Team, Hôpital Saint Louis, Paris, France
| | - Maxime Bucci
- Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Caroline Deswarte
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, AP-HP, SIRIC CURAMUS, Hôpital Saint-Antoine, Service d'Hématologie Biologique, 75012, Paris, France
| | - Augustin Boudry
- Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Juliette Lambert
- Service d'Hématologie Clinique, André Mignot Hospital, Le Chesnay, France
| | - Laurene Fenwarth
- Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | | | - Christine Terré
- Laboratory of Hematology, André Mignot Hospital, Le Chesnay, France
| | | | - Xavier Thomas
- Lyon Sud, University Hospital, 69495 Pierre-Bénite, Lyon, France
| | - Hervé Dombret
- Département Hématologie et Immunologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, F-75010, Paris, France
| | - Nicolas Duployez
- Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Claude Preudhomme
- Univ. Lille, CNRS, Inserm, CHU Lille, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, F-59000, Lille, France
| | - Raphael Itzykson
- Département Hématologie et Immunologie, Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, F-75010, Paris, France
- Université Paris Cité, Génomes, biologie cellulaire et thérapeutique U944, INSERM, CNRS, F-75010, Paris, France
| | - Francois Delhommeau
- Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine, CRSA, AP-HP, SIRIC CURAMUS, Hôpital Saint-Antoine, Service d'Hématologie Biologique, 75012, Paris, France
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15
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Chen J, Gale RP, Hu Y, Yan W, Wang T, Zhang W. Measurable residual disease (MRD)-testing in haematological and solid cancers. Leukemia 2024; 38:1202-1212. [PMID: 38637690 PMCID: PMC11147778 DOI: 10.1038/s41375-024-02252-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/06/2024] [Accepted: 04/09/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Junren Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
- Tianjin Institutes of Health Science, Tianjin, China.
| | - Robert Peter Gale
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College of Science, Technology and Medicine, London, UK
| | - Yu Hu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wen Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Tiantian Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
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16
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Li EW, Tran NYK, McCulloch D, Krigstein M, Catalano A, Othman J, Abadir E, Smith C, Iland H. FLT3-TKD Measurable Residual Disease Detection Using Droplet Digital PCR and Clinical Applications in Acute Myeloid Leukemia. Int J Mol Sci 2024; 25:5771. [PMID: 38891959 PMCID: PMC11171966 DOI: 10.3390/ijms25115771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/18/2024] [Accepted: 05/21/2024] [Indexed: 06/21/2024] Open
Abstract
The tyrosine kinase domain of the FMS-Like tyrosine kinase 3 (FLT3-TKD) is recurrently mutated in acute myeloid leukemia (AML). Common molecular techniques used in its detection include PCR and capillary electrophoresis, Sanger sequencing and next-generation sequencing with recognized sensitivity limitations. This study aims to validate the use of droplet digital PCR (ddPCR) in the detection of measurable residual disease (MRD) involving the common FLT3-TKD mutations (D835Y, D835H, D835V, D835E). Twenty-two diagnostic samples, six donor controls, and a commercial D835Y positive control were tested using a commercial Bio-rad® ddPCR assay. All known variants were identified, and no false positives were detected in the wild-type control (100% specificity and sensitivity). The assays achieved a limit of detection suitable for MRD testing at 0.01% variant allelic fraction. Serial samples from seven intensively-treated patients with FLT3-TKD variants at diagnosis were tested. Five patients demonstrated clearance of FLT3-TKD clones, but two patients had FLT3-TKD persistence in the context of primary refractory disease. In conclusion, ddPCR is suitable for the detection and quantification of FLT3-TKD mutations in the MRD setting; however, the clinical significance and optimal management of MRD positivity require further exploration.
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Affiliation(s)
- Eric Wenlong Li
- Institute of Hematology, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
- Molecular Hematology Laboratory, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
| | - Ngoc Yen Kim Tran
- Molecular Hematology Laboratory, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Derek McCulloch
- Institute of Hematology, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
- Molecular Hematology Laboratory, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
| | - Michael Krigstein
- Department of Hematology, St Vincent’s Hospital, Sydney, NSW 2010, Australia
| | - Alberto Catalano
- Molecular Hematology Laboratory, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Jad Othman
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
- Department of Hematology, Royal North Shore Hospital, Sydney, NSW 2065, Australia
| | - Edward Abadir
- Institute of Hematology, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
| | - Cheryl Smith
- Molecular Hematology Laboratory, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
| | - Harry Iland
- Institute of Hematology, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
- Molecular Hematology Laboratory, Royal Prince Alfred Hospital, Sydney, NSW 2050, Australia
- Faculty of Medicine and Health, The University of Sydney, Sydney, NSW 2050, Australia
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17
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Levis MJ, Hamadani M, Logan B, Jones RJ, Singh AK, Litzow M, Wingard JR, Papadopoulos EB, Perl AE, Soiffer RJ, Ustun C, Ueda Oshima M, Uy GL, Waller EK, Vasu S, Solh M, Mishra A, Muffly L, Kim HJ, Mikesch JH, Najima Y, Onozawa M, Thomson K, Nagler A, Wei AH, Marcucci G, Geller NL, Hasabou N, Delgado D, Rosales M, Hill J, Gill SC, Nuthethi R, King D, Wittsack H, Mendizabal A, Devine SM, Horowitz MM, Chen YB. Gilteritinib as Post-Transplant Maintenance for AML With Internal Tandem Duplication Mutation of FLT3. J Clin Oncol 2024; 42:1766-1775. [PMID: 38471061 PMCID: PMC11095884 DOI: 10.1200/jco.23.02474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 11/29/2023] [Accepted: 12/28/2023] [Indexed: 03/14/2024] Open
Abstract
PURPOSE Allogeneic hematopoietic cell transplantation (HCT) improves outcomes for patients with AML harboring an internal tandem duplication mutation of FLT3 (FLT3-ITD) AML. These patients are routinely treated with a FLT3 inhibitor after HCT, but there is limited evidence to support this. Accordingly, we conducted a randomized trial of post-HCT maintenance with the FLT3 inhibitor gilteritinib (ClinicalTrials.gov identifier: NCT02997202) to determine if all such patients benefit or if detection of measurable residual disease (MRD) could identify those who might benefit. METHODS Adults with FLT3-ITD AML in first remission underwent HCT and were randomly assigned to placebo or 120 mg once daily gilteritinib for 24 months after HCT. The primary end point was relapse-free survival (RFS). Secondary end points included overall survival (OS) and the effect of MRD pre- and post-HCT on RFS and OS. RESULTS Three hundred fifty-six participants were randomly assigned post-HCT to receive gilteritinib or placebo. Although RFS was higher in the gilteritinib arm, the difference was not statistically significant (hazard ratio [HR], 0.679 [95% CI, 0.459 to 1.005]; two-sided P = .0518). However, 50.5% of participants had MRD detectable pre- or post-HCT, and, in a prespecified subgroup analysis, gilteritinib was beneficial in this population (HR, 0.515 [95% CI, 0.316 to 0.838]; P = .0065). Those without detectable MRD showed no benefit (HR, 1.213 [95% CI, 0.616 to 2.387]; P = .575). CONCLUSION Although the overall improvement in RFS was not statistically significant, RFS was higher for participants with detectable FLT3-ITD MRD pre- or post-HCT who received gilteritinib treatment. To our knowledge, these data are among the first to support the effectiveness of MRD-based post-HCT therapy.
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Affiliation(s)
| | | | - Brent Logan
- CIBMTR/Medical College of Wisconsin, Milwaukee, WI
| | | | | | | | | | | | | | | | | | | | | | | | | | - Melhem Solh
- Northside Hospital Cancer Institute, Atlanta, GA
| | | | | | - Hee-Je Kim
- Catholic Hematology Hospital, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | | | - Yuho Najima
- Tokyo Metropolitan Cancer and Infectious Diseases Center, Komagome Hospital, Tokyo, Japan
| | | | | | - Arnon Nagler
- Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Andrew H. Wei
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital, Walter and Eliza Hill Institute of Medical Research and University of Melbourne, Melbourne, Australia
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18
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Loghavi S. SOHO State of the Art Updates and Next Questions-WHO Classification of Acute Myeloid Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00172-1. [PMID: 38866644 DOI: 10.1016/j.clml.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2024] [Revised: 04/30/2024] [Accepted: 05/01/2024] [Indexed: 06/14/2024]
Abstract
The 5th edition of the World Health Organization (WHO) classification of Hematolymphoid tumors provides a hierarchically-driven catalog of hematologic neoplasms and introduces a series of changes to the classification of acute myeloid leukemia (AML). Emphasizing molecular genetic findings, it expands the category of "acute myeloid leukemias with defining genetic abnormalities" while retaining the morphologically defined category of AML for cases that do not harbor disease-defining genetic drivers. The updates to the classification of AML provide refined definitions and diagnostic criteria based on clinicopathologic parameters and molecular genetic findings, emphasizing therapeutically and/or prognostically actionable biomarkers. This review provides an overview of the WHO 5th classification for AML with practical considerations for applying this classification system.
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Affiliation(s)
- Sanam Loghavi
- Department of Hematopathology, MD Anderson Cancer Center, Houston, TX.
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19
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Lucero J, Alhumaid M, Novitzky-Basso I, Capo-Chichi JM, Stockley T, Gupta V, Bankar A, Chan S, Schuh AC, Minden M, Mattsson J, Kumar R, Sibai H, Tierens A, Kim DDH. Flow cytometry-based measurable residual disease (MRD) analysis identifies AML patients who may benefit from allogeneic hematopoietic stem cell transplantation. Ann Hematol 2024; 103:1187-1196. [PMID: 38291275 DOI: 10.1007/s00277-024-05639-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/21/2024] [Indexed: 02/01/2024]
Abstract
Measurable residual disease (MRD) monitoring independently predicts long-term outcomes in patients with acute myeloid leukemia (AML). Of the various modalities available, multiparameter flow cytometry-based MRD analysis is widely used and relevant for patients without molecular targets. In the transplant (HCT) setting, the presence of MRD pre-HCT is associated with adverse outcomes. MRD-negative remission status pre-HCT was also associated with longer overall (OS) and progression-free survival and a lower risk of relapse. We hypothesize that the combination of disease risk and MRD at the time of first complete remission (CR1) could identify patients according to the benefit gained from HCT, especially for intermediate-risk patients. We performed a retrospective analysis comparing the outcomes of HCT versus non-HCT therapies based on MRD status in AML patients who achieved CR1. Time-dependent analysis was applied considering time-to-HCT as a time-dependent covariate and compared HCT versus non-HCT outcomes according to MRD status at CR1. Among 336 patients assessed at CR1, 35.1% were MRD positive (MRDpos) post-induction. MRDpos patients benefitted from HCT with improved OS and relapse-free survival (RFS), while no benefit was observed in MRDneg patients. In adverse-risk patients, HCT improved OS (HR for OS 0.55; p = 0.05). In intermediate-risk patients, HCT benefit was not significant for OS and RFS. Intermediate-risk MRDpos patients were found to have benefit from HCT with improved OS (HR 0.45, p = 0.04), RFS (HR 0.46, p = 0.02), and CIR (HR 0.41, p = 0.02). Our data underscore the benefit of HCT in adverse risk and MRDpos intermediate-risk AML patients.
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Affiliation(s)
- Josephine Lucero
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
| | | | - Igor Novitzky-Basso
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jose-Mario Capo-Chichi
- Advanced Molecular Diagnostics Laboratory, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Tracy Stockley
- Division of Clinical Laboratory Genetics, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
| | - Vikas Gupta
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Aniket Bankar
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Steven Chan
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Andre C Schuh
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Mark Minden
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Jonas Mattsson
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Rajat Kumar
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Hassan Sibai
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Anne Tierens
- Division of Hematology and Transfusion Medicine, Laboratory Medicine Program, University Health Network, Toronto, ON, Canada
| | - Dennis D H Kim
- Division of Medical Oncology & Hematology, Princess Margaret Cancer Centre, Toronto, ON, Canada.
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20
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Reikvam H, Dillon R. Revisiting the role of measurable residual disease in FLT3 mutated acute myelogenous leukemia. Expert Rev Hematol 2024; 17:103-106. [PMID: 38654593 DOI: 10.1080/17474086.2024.2347303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 04/22/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Håkon Reikvam
- K.G. Jebsen Center for Myeloid Blood Cancer, Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, Guy's and St Thomas' NHS Foundation Trust, London, UK
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21
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Tedjaseputra A, Russell N, Dillon R. SOHO State of the Art Updates and Next Questions: Pre-emptive Therapy at Molecular Measurable Residual Disease Failure in Acute Myeloid Leukemia. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00133-2. [PMID: 38734498 DOI: 10.1016/j.clml.2024.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 03/21/2024] [Accepted: 03/22/2024] [Indexed: 05/13/2024]
Abstract
Molecular measurable residual disease (MRD, eg, by real-time quantitative polymerase chain reaction, RT-qPCR), is an integral part of response assessment in acute myeloid leukemia (AML) with established prognostic and evolving therapeutic significance. MRD failure can occur through several pathways (namely MRD persistence at the end of treatment at a high level, MRD progression from a low level or MRD re-emergence during follow up; the latter two constitute MRD relapse as defined by the European Leukemia Net) and is clinically actionable, with survival benefit reported in AML subgroups. Selection of pre-emptive therapy at MRD failure relies upon an integrated clinico-molecular assessment and is subset-specific. In acute promyelocytic leukemia, arsenic trioxide-based regimen for MRD failure following frontline treatment with all-trans-retinoic acid plus chemotherapy represents standard of care, while hypomethylating agents (eg, azacitidine), salvage chemotherapy (eg, FLAG-IDA) and venetoclax-based regimens are effective in NPM1-mutated AML. Specific inhibitors of FLT3 have emerging use in FLT3-mutated AML and are associated with minimal toxicity. Furthermore, immunotherapeutic approaches such as donor lymphocyte infusions and interferon-⍺ are efficacious options in the post-allogeneic-HSCT settings. Enrollment into clinical trials with genomic-guided assignment of pre-emptive therapy at MRD failure should be prioritized. Finally, with the emergence of novel agents (eg, menin inhibitors) and approaches (eg, adoptive cellular and immunological therapy), an exciting future lies ahead where a broad array of highly active pre-emptive therapeutic options will likely be clinically applicable to a wide range of AML subsets.
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Affiliation(s)
- Aditya Tedjaseputra
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK; Cancer Genetics Laboratory, Department of Medical and Molecular Genetics, King's College London, London, UK; Monash Haematology, Melbourne, Australia
| | - Nigel Russell
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Richard Dillon
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK; Cancer Genetics Laboratory, Department of Medical and Molecular Genetics, King's College London, London, UK.
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22
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Murdock HM, Ho VT, Garcia JS. Innovations in conditioning and post-transplant maintenance in AML: genomically informed revelations on the graft-versus-leukemia effect. Front Immunol 2024; 15:1359113. [PMID: 38571944 PMCID: PMC10987864 DOI: 10.3389/fimmu.2024.1359113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/20/2024] [Indexed: 04/05/2024] Open
Abstract
Acute Myeloid Leukemia (AML) is the prototype of cancer genomics as it was the first published cancer genome. Large-scale next generation/massively parallel sequencing efforts have identified recurrent alterations that inform prognosis and have guided the development of targeted therapies. Despite changes in the frontline and relapsed standard of care stemming from the success of small molecules targeting FLT3, IDH1/2, and apoptotic pathways, allogeneic stem cell transplantation (alloHSCT) and the resulting graft-versus-leukemia (GVL) effect remains the only curative path for most patients. Advances in conditioning regimens, graft-vs-host disease prophylaxis, anti-infective agents, and supportive care have made this modality feasible, reducing transplant related mortality even among patients with advanced age or medical comorbidities. As such, relapse has emerged now as the most common cause of transplant failure. Relapse may occur after alloHSCT because residual disease clones persist after transplant, and develop immune escape from GVL, or such clones may proliferate rapidly early after alloHSCT, and outpace donor immune reconstitution, leading to relapse before any GVL effect could set in. To address this issue, genomically informed therapies are increasingly being incorporated into pre-transplant conditioning, or as post-transplant maintenance or pre-emptive therapy in the setting of mixed/falling donor chimerism or persistent detectable measurable residual disease (MRD). There is an urgent need to better understand how these emerging therapies modulate the two sides of the GVHD vs. GVL coin: 1) how molecularly or immunologically targeted therapies affect engraftment, GVHD potential, and function of the donor graft and 2) how these therapies affect the immunogenicity and sensitivity of leukemic clones to the GVL effect. By maximizing the synergistic action of molecularly targeted agents, immunomodulating agents, conventional chemotherapy, and the GVL effect, there is hope for improving outcomes for patients with this often-devastating disease.
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Affiliation(s)
- H. Moses Murdock
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Vincent T. Ho
- Bone Marrow Transplant Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
| | - Jacqueline S. Garcia
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, United States
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23
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Bandyopadhyay S, Duffy M, Ahn KJ, Pang M, Smith D, Duncan G, Sussman J, Zhang I, Huang J, Lin Y, Xiong B, Imtiaz T, Chen CH, Thadi A, Chen C, Xu J, Reichart M, Pillai V, Snaith O, Oldridge D, Bhattacharyya S, Maillard I, Carroll M, Nelson C, Qin L, Tan K. Mapping the Cellular Biogeography of Human Bone Marrow Niches Using Single-Cell Transcriptomics and Proteomic Imaging. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.14.585083. [PMID: 38559168 PMCID: PMC10979999 DOI: 10.1101/2024.03.14.585083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
The bone marrow is the organ responsible for blood production. Diverse non-hematopoietic cells contribute essentially to hematopoiesis. However, these cells and their spatial organization remain largely uncharacterized as they have been technically challenging to study in humans. Here, we used fresh femoral head samples and performed single-cell RNA sequencing (scRNA-Seq) to profile 29,325 enriched non-hematopoietic bone marrow cells and discover nine transcriptionally distinct subtypes. We next employed CO-detection by inDEXing (CODEX) multiplexed imaging of 18 individuals, including both healthy and acute myeloid leukemia (AML) samples, to spatially profile over one million single cells with a novel 53-antibody panel. We discovered a relatively hyperoxygenated arterio-endosteal niche for early myelopoiesis, and an adipocytic, but not endosteal or perivascular, niche for early hematopoietic stem and progenitor cells. We used our atlas to predict cell type labels in new bone marrow images and used these predictions to uncover mesenchymal stromal cell (MSC) expansion and leukemic blast/MSC-enriched spatial neighborhoods in AML patient samples. Our work represents the first comprehensive, spatially-resolved multiomic atlas of human bone marrow and will serve as a reference for future investigation of cellular interactions that drive hematopoiesis.
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Affiliation(s)
- Shovik Bandyopadhyay
- Cellular and Molecular Biology Graduate Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Medical Scientist Training Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael Duffy
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kyung Jin Ahn
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Minxing Pang
- Applied Mathematics & Computational Science Graduate Group, University of Pennsylvania, Philadelphia, PA
| | - David Smith
- Center for Single Cell Biology, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Gwendolyn Duncan
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA
| | - Jonathan Sussman
- Medical Scientist Training Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Genomics and Computational Biology Graduate Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Iris Zhang
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey Huang
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA
| | - Yulieh Lin
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Barbara Xiong
- Medical Scientist Training Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Genomics and Computational Biology Graduate Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tamjid Imtiaz
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA
| | - Chia-Hui Chen
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Anusha Thadi
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Changya Chen
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jason Xu
- Medical Scientist Training Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Genomics and Computational Biology Graduate Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Melissa Reichart
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vinodh Pillai
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Oraine Snaith
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Derek Oldridge
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Siddharth Bhattacharyya
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ivan Maillard
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Martin Carroll
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Charles Nelson
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ling Qin
- Department of Orthopaedic Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kai Tan
- Division of Oncology and Center for Childhood Cancer Research, Children's Hospital of Philadelphia, Philadelphia, PA
- Center for Single Cell Biology, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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24
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Ravindra N, Dillon LW, Gui G, Smith M, Gondek LP, Jones RJ, Corner A, Hourigan CS, Ambinder AJ. Persistent IDH mutations are not associated with increased relapse or death in patients with IDH-mutated acute myeloid leukemia undergoing allogeneic hematopoietic cell transplant with post-transplant cyclophosphamide. Bone Marrow Transplant 2024; 59:428-430. [PMID: 38182672 DOI: 10.1038/s41409-023-02189-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 12/14/2023] [Accepted: 12/15/2023] [Indexed: 01/07/2024]
Affiliation(s)
- Niveditha Ravindra
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Laura W Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Gege Gui
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Matthew Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Lukasz P Gondek
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Richard J Jones
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Adam Corner
- Bio-Rad Laboratories, Digital Biology Group, 5731, W. Las Positias Blvd, Pleasanton, CA, USA
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA.
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD, USA.
| | - Alexander J Ambinder
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
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25
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Schwind S, Bischof L, Bill M, Grimm J, Ussmann J, Backhaus D, Brauer D, Thanh TP, Merz M, Franke GN, Metzeler KH, Vucinic V, Herling M, Platzbecker U, Jentzsch M. Quantifying NPM1 MRD in AML patients prior to allogeneic stem cell transplantation: Where to draw the line? Hemasphere 2024; 8:e55. [PMID: 38501048 PMCID: PMC10946283 DOI: 10.1002/hem3.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/15/2024] [Accepted: 02/08/2024] [Indexed: 03/20/2024] Open
Affiliation(s)
- Sebastian Schwind
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Lara Bischof
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Marius Bill
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Juliane Grimm
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Jule Ussmann
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Donata Backhaus
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Dominic Brauer
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Tung Pham Thanh
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Maximilian Merz
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Georg-Nikolaus Franke
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Klaus H Metzeler
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Vladan Vucinic
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Marco Herling
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Uwe Platzbecker
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Madlen Jentzsch
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
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26
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Mukherjee D, Lawal RA, Fitzhugh CD, Hourigan CS, Dillon LW. TP53 mutation screening for patients at risk of myeloid malignancy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.06.24302401. [PMID: 38410480 PMCID: PMC10896414 DOI: 10.1101/2024.02.06.24302401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
There is increasing recognition of the risk of developing therapy-related myeloid malignancy, including after cellular therapy. While retrospective studies have implicated pre-existing TP53 mutated hematopoietic clones as a common causative mechanism, no prospective screening to identify those patients at greatest risk is currently possible. We demonstrate that ultradeep DNA-sequencing prior to therapy may be used for discovery of TP53 mutations that are subsequently associated with malignancy.
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Affiliation(s)
- Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Rialnat A. Lawal
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Courtney D. Fitzhugh
- Cellular and Molecular Therapeutics Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD
| | - Laura W. Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
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27
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Gangat N, Karrar O, Iftikhar M, McCullough K, Johnson IM, Abdelmagid M, Abdallah M, Al-Kali A, Alkhateeb HB, Begna KH, Mangaonkar A, Saliba AN, Hefazi Torghabeh M, Litzow MR, Hogan W, Shah M, Patnaik MM, Pardanani A, Badar T, Murthy H, Foran J, Palmer J, Sproat L, Khera N, Arana Yi C, Tefferi A. Venetoclax and hypomethylating agent combination therapy in newly diagnosed acute myeloid leukemia: Genotype signatures for response and survival among 301 consecutive patients. Am J Hematol 2024; 99:193-202. [PMID: 38071734 DOI: 10.1002/ajh.27138] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/30/2023] [Accepted: 10/03/2023] [Indexed: 01/21/2024]
Abstract
Venetoclax + hypomethylating agent (Ven-HMA) is currently the standard frontline therapy for older/unfit patients with newly diagnosed acute myeloid leukemia (ND-AML). Our objective in the current retrospective study of 301 adult patients (median age 73 years; 62% de novo) with ND-AML was to identify molecular predictors of treatment response to Ven-HMA and survival; European LeukemiaNet (ELN) genetic risk assignment was favorable 15%, intermediate 16%, and adverse 69%. Complete remission, with (CR) or without (CRi), count recovery, was documented in 182 (60%) patients. In multivariable analysis, inclusive of mutations only, "favorable" predictors of CR/CRi were NPM1 (86% vs. 56%), IDH2 (80% vs. 58%), and DDX41 (100% vs. 58%) and "unfavorable" TP53 (40% vs. 67%), FLT3-ITD (36% vs. 63%), and RUNX1 (44% vs. 64%) mutations; significance was sustained for each mutation after adjustment for age, karyotype, and therapy-related qualification. CR/CRi rates ranged from 36%, in the presence of unfavorable and absence of favorable mutation, to 91%, in the presence of favorable and absence of unfavorable mutation. At median follow-up of 8.5 months, 174 deaths and 41 allogeneic stem cell transplants (ASCT) were recorded. In multivariable analysis, risk factors for inferior survival included failure to achieve CR/CRi (HR 3.4, 95% CI 2.5-4.8), adverse karyotype (1.6, 1.1-2.6), TP53 mutation (1.6, 1.0-2.4), and absence of IDH2 mutation (2.2, 1.0-4.7); these risk factors were subsequently applied to construct an HR-weighted risk model that performed better than the ELN genetic risk model (AIC 1661 vs. 1750): low (n = 130; median survival 28.9 months), intermediate (n = 105; median 9.6 months), and high (n = 66; median 3.1 months; p < .001); survival in each risk category was significantly upgraded by ASCT. The current study identifies genotype signatures for predicting response and proposes a 3-tiered, CR/CRi-based, and genetics-enhanced survival model for AML patients receiving upfront therapy with Ven-HMA.
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Affiliation(s)
- Naseema Gangat
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Omer Karrar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Moazah Iftikhar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Isla M Johnson
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Aref Al-Kali
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Kebede H Begna
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | - Mark R Litzow
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - William Hogan
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mithun Shah
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Talha Badar
- Division of Hematology, Mayo Clinic, Jacksonville, Florida, USA
| | - Hemant Murthy
- Division of Hematology, Mayo Clinic, Jacksonville, Florida, USA
| | - James Foran
- Division of Hematology, Mayo Clinic, Jacksonville, Florida, USA
| | - Jeanne Palmer
- Division of Hematology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Lisa Sproat
- Division of Hematology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Nandita Khera
- Division of Hematology, Mayo Clinic, Scottsdale, Arizona, USA
| | | | - Ayalew Tefferi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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28
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Dillon LW, Higgins J, Nasif H, Othus M, Beppu L, Smith TH, Schmidt E, Valentine Iii CC, Salk JJ, Wood BL, Erba HP, Radich JP, Hourigan CS. Quantification of measurable residual disease using duplex sequencing in adults with acute myeloid leukemia. Haematologica 2024; 109:401-410. [PMID: 37534515 PMCID: PMC10828764 DOI: 10.3324/haematol.2023.283520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/28/2023] [Indexed: 08/04/2023] Open
Abstract
The presence of measurable residual disease (MRD) is strongly associated with treatment outcomes in acute myeloid leukemia (AML). Despite the correlation with clinical outcomes, MRD assessment has yet to be standardized or routinely incorporated into clinical trials and discrepancies have been observed between different techniques for MRD assessment. In 62 patients with AML, aged 18-60 years, in first complete remission after intensive induction therapy on the randomized phase III SWOG-S0106 clinical trial (clinicaltrials gov. Identifier: NCT00085709), MRD detection by centralized, high-quality multiparametric flow cytometry was compared with a 29-gene panel utilizing duplex sequencing (DS), an ultrasensitive next-generation sequencing method that generates double-stranded consensus sequences to reduce false positive errors. MRD as defined by DS was observed in 22 (35%) patients and was strongly associated with higher rates of relapse (68% vs. 13%; hazard ratio [HR] =8.8; 95% confidence interval [CI]: 3.2-24.5; P<0.001) and decreased survival (32% vs. 82%; HR=5.6; 95% CI: 2.3-13.8; P<0.001) at 5 years. DS MRD strongly outperformed multiparametric flow cytometry MRD, which was observed in ten (16%) patients and marginally associated with higher rates of relapse (50% vs. 30%; HR=2.4; 95% CI: 0.9-6.7; P=0.087) and decreased survival (40% vs. 68%; HR=2.5; 95% CI: 1.0-6.3; P=0.059) at 5 years. Furthermore, the prognostic significance of DS MRD status at the time of remission for subsequent relapse was similar on both randomized arms of the trial. These findings suggest that next-generation sequencing-based AML MRD testing is a powerful tool that could be developed for use in patient management and for early anti-leukemic treatment assessment in clinical trials.
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Affiliation(s)
- Laura W Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | - Hassan Nasif
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Megan Othus
- Public Health Sciences Division, Fred Hutchinson Cancer Center, Seattle, WA
| | - Lan Beppu
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
| | | | | | | | | | - Brent L Wood
- Dept. of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | | | - Jerald P Radich
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA; Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD; Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD.
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29
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Sahasrabudhe KD, Mims AS. MRD in AML: who, what, when, where, and how? Blood 2024; 143:296-298. [PMID: 38270942 DOI: 10.1182/blood.2023022226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024] Open
Affiliation(s)
| | - Alice S Mims
- The Ohio State University Comprehensive Cancer Center
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30
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Othman J, Tiong IS, O'Nions J, Dennis M, Mokretar K, Ivey A, Austin M, Latif AL, Amer M, Chan WY, Crawley C, Crolla F, Cross J, Dang R, Elliot J, Fong CY, Galli S, Gallipoli P, Hogan F, Kalkur P, Khan A, Krishnamurthy P, Laurie J, Loo S, Marshall S, Mehta P, Murthy V, Nagumantry S, Pillai S, Potter N, Sellar R, Taylor T, Zhao R, Russell NH, Wei AH, Dillon R. Molecular MRD is strongly prognostic in patients with NPM1-mutated AML receiving venetoclax-based nonintensive therapy. Blood 2024; 143:336-341. [PMID: 37647641 DOI: 10.1182/blood.2023021579] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/27/2023] [Accepted: 08/13/2023] [Indexed: 09/01/2023] Open
Abstract
ABSTRACT Assessment of measurable residual disease (MRD) by quantitative reverse transcription polymerase chain reaction is strongly prognostic in patients with NPM1-mutated acute myeloid leukemia (AML) treated with intensive chemotherapy; however, there are no data regarding its utility in venetoclax-based nonintensive therapy, despite high efficacy in this genotype. We analyzed the prognostic impact of NPM1 MRD in an international real-world cohort of 76 previously untreated patients with NPM1-mutated AML who achieved complete remission (CR)/CR with incomplete hematological recovery following treatment with venetoclax and hypomethylating agents (HMAs) or low-dose cytarabine (LDAC). A total of 44 patients (58%) achieved bone marrow (BM) MRD negativity, and a further 14 (18%) achieved a reduction of ≥4 log10 from baseline as their best response, with no difference between HMAs and LDAC. The cumulative rates of BM MRD negativity by the end of cycles 2, 4, and 6 were 25%, 47%, and 50%, respectively. Patients achieving BM MRD negativity by the end of cycle 4 had 2-year overall of 84% compared with 46% if MRD was positive. On multivariable analyses, MRD negativity was the strongest prognostic factor. A total of 22 patients electively stopped therapy in BM MRD-negative remission after a median of 8 cycles, with 2-year treatment-free remission of 88%. In patients with NPM1-mutated AML attaining remission with venetoclax combination therapies, NPM1 MRD provides valuable prognostic information.
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Affiliation(s)
- Jad Othman
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Ing S Tiong
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
- Alfred Hospital and Monash University, Melbourne, Australia
- Austin Health and Olivia Newton John Cancer Research Institute, Melbourne, Australia
| | - Jenny O'Nions
- Department of Haematology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Mike Dennis
- The Christie NHS Foundation Trust, Manchester, United Kingdom
| | | | - Adam Ivey
- Alfred Hospital and Monash University, Melbourne, Australia
| | - Michael Austin
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | - Anne-Louise Latif
- Department of Haematology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Mariam Amer
- Haematology, University Hospital Southampton, Southampton, United Kingdom
| | - Wei Yee Chan
- Department of Haematology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Charles Crawley
- Department of Haematology, Addenbrooke's Hospital, Cambridge, United Kingdom
| | | | - Joe Cross
- Haematology Department, University Hospital Bristol, Bristol, United Kingdom
| | - Ray Dang
- James Cook University Hospital, Middlesbrough, United Kingdom
| | | | - Chun Y Fong
- Austin Health and Olivia Newton John Cancer Research Institute, Melbourne, Australia
| | - Sofia Galli
- Frimley Park Hospital, London, United Kingdom
| | - Paolo Gallipoli
- Barts Cancer Institute, Queen Mary University of London, London, United Kingdom
| | | | | | - Anjum Khan
- Department of Haematology, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | | | | | - Sun Loo
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Scott Marshall
- City Hospitals Sunderland NHS Trust, Sunderland, United Kingdom
| | - Priyanka Mehta
- Haematology Department, University Hospital Bristol, Bristol, United Kingdom
| | - Vidhya Murthy
- Centre for Clinical Haematology, University Hospitals Birmingham, Birmingham, United Kingdom
| | | | - Srinivas Pillai
- Royal Stoke University Hospital, University Hospital of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Nicola Potter
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
| | - Rob Sellar
- Department of Haematology, University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Tom Taylor
- Nottingham University Hospital, Nottingham, United Kingdom
| | - Rui Zhao
- Torbay Hospital, Torquay, United Kingdom
| | - Nigel H Russell
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Andrew H Wei
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College London, London, United Kingdom
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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31
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Jimenez-Chillon C, Othman J, Taussig D, Jimenez-Vicente C, Martinez-Roca A, Tiong IS, Jain M, Aries J, Cakmak S, Knapper S, Kristensen DT, Murthy V, Galani JZ, Kallmeyer C, Ngu L, Veale D, Bolam S, Orfali N, Parker A, Manson C, Parker J, Erblich T, Richardson D, Mokretar K, Potter N, Overgaard UM, Roug AS, Wei AH, Esteve J, Jädersten M, Russell N, Dillon R. Venetoclax-based low intensity therapy in molecular failure of NPM1-mutated AML. Blood Adv 2024; 8:343-352. [PMID: 38039513 PMCID: PMC10788851 DOI: 10.1182/bloodadvances.2023011106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/26/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023] Open
Abstract
ABSTRACT Molecular failure in NPM1-mutated acute myeloid leukemia (AML) inevitably progresses to frank relapse if untreated. Recently published small case series show that venetoclax combined with low-dose cytarabine or azacitidine can reduce or eliminate measurable residual disease (MRD). Here, we report on an international multicenter cohort of 79 patients treated for molecular failure with venetoclax combinations and report an overall molecular response (≥1-log reduction in MRD) in 66 patients (84%) and MRD negativity in 56 (71%). Eighteen of 79 patients (23%) required hospitalization, and no deaths were reported during treatment. Forty-one patients were bridged to allogeneic transplant with no further therapy, and 25 of 41 were MRD negative assessed by reverse transcription quantitative polymerase chain reaction before transplant. Overall survival (OS) for the whole cohort at 2 years was 67%, event-free survival (EFS) was 45%, and in responding patients, there was no difference in survival in those who received a transplant using time-dependent analysis. Presence of FLT3-ITD mutation was associated with a lower response rate (64 vs 91%; P < .01), worse OS (hazard ratio [HR], 2.50; 95% confidence interval [CI], 1.06-5.86; P = .036), and EFS (HR, 1.87; 95% CI, 1.06-3.28; P = .03). Eighteen of 35 patients who did not undergo transplant became MRD negative and stopped treatment after a median of 10 months, with 2-year molecular relapse free survival of 62% from the end of treatment. Venetoclax-based low intensive chemotherapy is a potentially effective treatment for molecular relapse in NPM1-mutated AML, either as a bridge to transplant or as definitive therapy.
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Affiliation(s)
- Carlos Jimenez-Chillon
- Servicio de Hematología y Hemoterapia, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Medical & Molecular Genetics, King’s College London, London, United Kingdom
| | - Jad Othman
- Department of Medical & Molecular Genetics, King’s College London, London, United Kingdom
- Guy’s and St Thomas Hospital, London, United Kingdom
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - David Taussig
- Department of Haematology, Royal Marsden Hospital, Sutton, United Kingdom
| | | | - Alexandra Martinez-Roca
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Hematology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Ing Soo Tiong
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Alfred Hospital and Monash University, Melbourne, VIC, Australia
- Austin Health and Olivia Newton John Cancer Research Institute, Melbourne, VIC, Australia
| | - Manish Jain
- Department of Haematology, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - James Aries
- Department of Haemato-Oncology, St Bartholomew’s Hospital, London, United Kingdom
| | - Seda Cakmak
- Department of Haemato-Oncology, St Bartholomew’s Hospital, London, United Kingdom
| | - Steven Knapper
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Daniel Tuyet Kristensen
- Department of Haematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Vidhya Murthy
- Department of Haematology, University Hospitals of Birmingham, Birmingham, United Kingdom
| | | | | | - Loretta Ngu
- Department of Haematology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - David Veale
- Department of Haematology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - Simon Bolam
- Department of Haematology, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | - Nina Orfali
- Department of Haematology, St. James's Hospital, Dublin, Ireland
| | - Anne Parker
- Department of Haematology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Cara Manson
- Department of Haematology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Jane Parker
- Department of Haematology, Northampton General Hospital, Northampton, United Kingdom
| | - Thomas Erblich
- Department of Haematology, The London Clinic, London, United Kingdom
| | - Deborah Richardson
- Department of Haematology, University Hospital Southampton, Southampton, United Kingdom
| | | | - Nicola Potter
- Department of Medical & Molecular Genetics, King’s College London, London, United Kingdom
| | - Ulrik Malthe Overgaard
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
- Department of Haematology, National Hospital, Copenhagen, Denmark
| | - Anne Stidsholt Roug
- Department of Haematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | - Andrew H. Wei
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Jordi Esteve
- Hematology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Martin Jädersten
- Department of Medicine, Center for Haematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Nigel Russell
- Guy’s and St Thomas Hospital, London, United Kingdom
| | - Richard Dillon
- Department of Medical & Molecular Genetics, King’s College London, London, United Kingdom
- Guy’s and St Thomas Hospital, London, United Kingdom
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32
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Falini B, Dillon R. Criteria for Diagnosis and Molecular Monitoring of NPM1-Mutated AML. Blood Cancer Discov 2024; 5:8-20. [PMID: 37917833 PMCID: PMC10772525 DOI: 10.1158/2643-3230.bcd-23-0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/28/2023] [Accepted: 10/25/2023] [Indexed: 11/04/2023] Open
Abstract
NPM1-mutated acute myeloid leukemia (AML) represents the largest molecular subgroup of adult AML. NPM1-mutated AML is recognizable by molecular techniques and immunohistochemistry, which, when combined, can solve difficult diagnostic problems (including identification of myeloid sarcoma and NPM1 mutations outside exon 12). According to updated 2022 European LeukemiaNet (ELN) guidelines, determining the mutational status of NPM1 (and FLT3) is a mandatory step for the genetic-based risk stratification of AML. Monitoring of measurable residual disease (MRD) by qRT-PCR, combined with ELN risk stratification, can guide therapeutic decisions at the post-remission stage. Here, we review the criteria for appropriate diagnosis and molecular monitoring of NPM1-mutated AML. SIGNIFICANCE NPM1-mutated AML represents a distinct entity in the 2022 International Consensus Classification and 5th edition of World Health Organization classifications of myeloid neoplasms. The correct diagnosis of NPM1-mutated AML and its distinction from other AML entities is extremely important because it has clinical implications for the management of AML patients, such as genetic-based risk stratification according to 2022 ELN. Monitoring of MRD by qRT-PCR, combined with ELN risk stratification, can guide therapeutic decisions at the post-remission stage, e.g., whether or not to perform allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Brunangelo Falini
- Institute of Hematology and Center for Hemato-Oncological Research (CREO), University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
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33
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Gaut D, Oliai C, Boiarsky J, Zhang S, Salhotra A, Azenkot T, Kennedy VE, Khanna V, Olmedo Gutierrez K, Shukla N, Moskoff B, Park G, Afkhami M, Patel A, Jeyakumar D, Mannis G, Logan AC, Jonas BA, Schiller G. Measurable residual disease conversion rate with consolidation chemotherapy in acute myeloid leukemia. Leuk Lymphoma 2024; 65:69-77. [PMID: 37801340 DOI: 10.1080/10428194.2023.2264426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/20/2023] [Indexed: 10/07/2023]
Abstract
The rate of MRD clearance in AML with standard consolidation chemotherapy is not well defined. A multi-institution retrospective analysis was performed on 107 consecutively treated AML patients in morphologic complete remission with detectable MRD post-induction therapy who received standard chemotherapy consolidation. In response to standard intermediate/high-dose cytarabine consolidation therapy, 26 of 60 patients (43.3%) with MRD threshold of detection of at least 0.1% converted to MRD-negative status (undetectable with assay used), and 6 of 47 patients (12.8%) with MRD threshold of detection > 0.1% converted to MRD-negative status. Multivariable logistic regression for patients with MRD threshold of detection of at least 0.1% showed that, when controlling for age, ELN risk category, dose of cytarabine, and use of a combination agent, treatment with 1 cycle of consolidation cytarabine versus ≥2 cycles decreased the odds of conversion of AML to MRD-negative (OR = 0.24, 95% CI 0.07-0.85, p = 0.03).
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Affiliation(s)
- Daria Gaut
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Caspian Oliai
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Jonathan Boiarsky
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Shiliang Zhang
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, California, USA
| | - Tali Azenkot
- Division of Hematology/Oncology, Department of Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Vanessa E Kennedy
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Vishesh Khanna
- Division of Hematology, Department of Medicine, Stanford Cancer Institute, Stanford, California, USA
| | - Karla Olmedo Gutierrez
- Division of Hematology/Oncology, Department of Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | - Navika Shukla
- Divison of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Benjamin Moskoff
- Division of Hematology/Oncology, Department of Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Gabriel Park
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, California, USA
| | - Michelle Afkhami
- Department of Hematology and Hematopoietic Cell Transplant, City of Hope, Duarte, California, USA
| | - Anand Patel
- Divison of Hematology/Oncology, Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Deepa Jeyakumar
- Division of Hematology/Oncology, Department of Medicine, University of California Irvine School of Medicine, Orange, California, USA
| | - Gabriel Mannis
- Division of Hematology, Department of Medicine, Stanford Cancer Institute, Stanford, California, USA
| | - Aaron C Logan
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Brian A Jonas
- Division of Hematology/Oncology, Department of Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Gary Schiller
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, USA
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34
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Ofran Y. Is it time for age and clinically adjusted minimal residual disease interpretation in acute myeloid leukemia? Haematologica 2024; 109:6-7. [PMID: 37534509 PMCID: PMC10772512 DOI: 10.3324/haematol.2023.283693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 07/26/2023] [Indexed: 08/04/2023] Open
Abstract
Not available.
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Affiliation(s)
- Yishai Ofran
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem.
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35
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Walter RB. Perspective on measurable residual disease testing in acute myeloid leukemia. Leukemia 2024; 38:10-13. [PMID: 37973819 DOI: 10.1038/s41375-023-02084-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 10/24/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Affiliation(s)
- Roland B Walter
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
- Department of Medicine, Division of Hematology and Oncology, University of Washington, Seattle, WA, USA.
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, USA.
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36
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Kennedy VE, Smith CC. FLT3 targeting in the modern era: from clonal selection to combination therapies. Int J Hematol 2023:10.1007/s12185-023-03681-0. [PMID: 38112995 DOI: 10.1007/s12185-023-03681-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 10/14/2023] [Accepted: 11/14/2023] [Indexed: 12/21/2023]
Abstract
Fms-like tyrosine kinase 3 (FLT3) is the most frequently mutated gene in acute myeloid leukemia (AML). Modern targeting of FLT3 with inhibitors has improved clinical outcomes and FLT3 inhibitors have been incorporated into the treatment of AML in all phases of the disease, including the upfront, relapsed/refractory and maintenance settings. This review will discuss the current understanding of FLT3 biology, the clinical use of FLT3 inhibitors, resistance mechanisms and emerging combination treatment strategies.
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Affiliation(s)
- Vanessa E Kennedy
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, 505 Parnassus Ave, Box 1270, San Francisco, CA, 94143, USA
| | - Catherine C Smith
- Division of Hematology/Oncology, Department of Medicine, University of California San Francisco, 505 Parnassus Ave, Box 1270, San Francisco, CA, 94143, USA.
- Helen Diller Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA, USA.
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Cloos J. Understanding differential technologies for detection of MRD and how to incorporate into clinical practice. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:682-690. [PMID: 38066915 PMCID: PMC10727023 DOI: 10.1182/hematology.2023000454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Patient- and leukemia-specific factors assessed at diagnosis classify patients with acute myeloid leukemia (AML) in risk categories that are prognostic for outcome. The induction phase with intensive chemotherapy in fit patients aims to reach a complete remission (CR) of less than 5% blasts in bone marrow by morphology. To deepen and sustain the response, induction is followed by consolidation treatment. This postremission treatment of patients with AML is graduated in intensity based on this favorable, intermediate, or adverse risk group classification as defined in the European Leukemia Network (ELN) 2022 recommendations. The increment of evidence that measurable residual disease (MRD) after induction can be superimposed on risk group at diagnosis is instrumental in tailoring further treatment accordingly. Several techniques are applied to detect MRD such as multiparameter flow cytometry (MFC), quantitative (digital) polymerase chain reaction (PCR), and next-generation sequencing. The clinical implementation of MRD and the technique used differ among institutes, leading to the accumulation of a wide range of data, and therefore harmonization is warranted. Currently, evidence for MRD guidance is limited to the time point after induction using MFC or quantitative PCR for NPM1 and core binding factor abnormalities in intermediate-risk patients. The role of MRD in targeted or nonintensive therapies needs to be clarified, although some data show improved survival in patients achieving CR-MRD negativity. Potential application of MRD for selection of conditioning before stem cell transplantation, monitoring after consolidation, and use as an intermediate end point in clinical trials need further evaluation.
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Affiliation(s)
- Jacqueline Cloos
- Department of Hematology, Cancer Center Amsterdam, Amsterdam UMC, location VUMC, Amsterdam, the Netherlands
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Ravandi F, Cloos J, Buccisano F, Dillon R, Döhner K, Freeman SD, Hourigan CS, Ossenkoppele GJ, Roboz GJ, Subklewe M, Thiede C, Arnhardt I, Valk PJM, Venditti A, Wei AH, Walter RB, Heuser M. Measurable residual disease monitoring in patients with acute myeloid leukemia treated with lower-intensity therapy: Roadmap from an ELN-DAVID expert panel. Am J Hematol 2023; 98:1847-1855. [PMID: 37671649 PMCID: PMC10841357 DOI: 10.1002/ajh.27087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 09/07/2023]
Abstract
With the availability of effective targeted agents, significant changes have occurred in the management of patients with acute myeloid leukemia (AML) over the past several years, particularly for those considered unfit for intensive chemotherapy. While testing for measurable residual disease (MRD) is now routinely performed in patients treated with intensive chemotherapy to refine prognosis and, possibly, inform treatment decision-making, its value in the context of lower-intensity regimens is unclear. As such regimens have gained in popularity and can be associated with higher response rates, the need to better define the role of MRD assessment and the appropriate time points and assays used for this purpose has increased. This report outlines a roadmap for MRD testing in patients with AML treated with lower-intensity regimens. Experts from the European LeukemiaNet (ELN)-DAVID AML MRD working group reviewed all available data to propose a framework for MRD testing in future trials and clinical practice. A Delphi poll served to optimize consensus. Establishment of uniform standards for MRD assessments in lower-intensity regimens used in treating patients with AML is clinically relevant and important for optimizing testing and, ultimately, improving treatment outcomes of these patients.
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Affiliation(s)
- Farhad Ravandi
- Department of Leukemia, The University of Texas - MD Anderson Cancer Center, Houston
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Francesco Buccisano
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King’s College, London, United Kingdom
| | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
| | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancy, Hematology Branch, National Heart, Lung, and Blood Institute, Bethesda
| | - Gerrit J Ossenkoppele
- Department of Hematology, Amsterdam University Medical Center (UMC), Vrije Universiteit Amsterdam, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gail J Roboz
- Department of Medicine, Division of Hematology and Oncology, Weill Cornell Medicine, New York
| | - Marion Subklewe
- Department of Medicine III, University Hospital, Ludwig Maximilian University Munich, Germany
| | - Christian Thiede
- Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Isabell Arnhardt
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Peter J M Valk
- Department of Hematology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Adriano Venditti
- Department of Biomedicine and Prevention, Hematology, University Tor Vergata, Rome, Italy
| | - Andrew H Wei
- Department of Haematology, Peter MacCallum Cancer Centre, Royal Melbourne Hospital, University of Melbourne and Walter and Eliza Hall Institute of Medical Research, Melbourne, Australia
| | - Roland B Walter
- Translational Science and Therapeutics Division, Fred Hutchinson Cancer Center, Seattle
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
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Blackmon AL, Hourigan CS. Test Then Erase? Current Status and Future Opportunities for Measurable Residual Disease Testing in Acute Myeloid Leukemia. Acta Haematol 2023; 147:133-146. [PMID: 38035547 PMCID: PMC10963159 DOI: 10.1159/000535463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Measurable residual disease (MRD) test positivity during and after treatment in patients with acute myeloid leukemia (AML) has been associated with higher rates of relapse and worse overall survival. Current approaches for MRD testing are not standardized leading to inconsistent results and poor prognostication of disease. Pertinent studies evaluating AML MRD testing at specific times points, with various therapeutics and testing methods are presented. SUMMARY AML is a set of diseases with different molecular and cytogenetic characteristics and is often polyclonal with evolution over time. This genetic diversity poses a great challenge for a single AML MRD testing approach. The current ELN 2021 MRD guidelines recommend MRD testing by quantitative polymerase chain reaction in those with a validated molecular target or multiparameter flow cytometry (MFC) in all other cases. The benefit of MFC is the ability to use this method across disease subsets, at the relative expense of suboptimal sensitivity and specificity. AML MRD detection may be improved with molecular methods. Genetic characterization at AML diagnosis and relapse is now standard of care for appropriate therapeutic assignment, and future initiatives will provide the evidence to support testing in remission to direct clinical interventions. KEY MESSAGES The treatment options for patients with AML have expanded for specific molecular subsets such as FLT3 and IDH1/2 mutated AML, with development of novel agents for NPM1 mutated or KMT2A rearranged AML ongoing, but also due to effective venetoclax-combinations. Evidence regarding highly sensitive molecular MRD detection methods for specific molecular subgroups, in the context of these new treatment approaches, will likely shape the future of AML care.
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Affiliation(s)
- Amanda L. Blackmon
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Jimenez-Chillon C, Dillon R, Russell N. Optimal Post-Remission Consolidation Therapy in Patients with AML. Acta Haematol 2023; 147:147-158. [PMID: 38008085 PMCID: PMC10997264 DOI: 10.1159/000535457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/20/2023] [Indexed: 11/28/2023]
Abstract
BACKGROUND Despite recent advances, 40-85% of patients with acute myeloid leukaemia (AML) achieve complete remission after intensive chemotherapy. However, without optimal treatment after remission, the risk of relapse remains high. SUMMARY A variable number of consolidation cycles consisting of intermediate doses of cytarabine are the most commonly used regimens in low-intermediate-risk AML, while patients at higher risk of relapse should consolidate response by proceeding to HSCT. Different post-consolidation (maintenance therapies) have demonstrated their benefit in prolonging relapse-free survival, and others are still under investigation. Careful consideration should be given to which patients benefit most from each of these interventions, considering that the risk of relapse is dynamic. KEY MESSAGES Patients consolidated with chemotherapy should receive either 2 courses of HDAC or no more than 3-4 cycles of IDAC with dose reduction in patients over 60 years. Patients with mutated FLT3 AML benefit from post-consolidation maintenance with FLT3 inhibitors, and selected patients not fit for adequate consolidation may benefit from CC-468 maintenance. Patients at higher risk of relapse should proceed to allogeneic SCT as soon as possible, opting for a more intensive conditioning in patients younger than 55 years. However, autologous HSCT may still have role in favourable-risk MRD-negative AML. Multiple treatment options targeting MRD are emerging, either as definitive treatment or as a bridge to allogeneic transplantation, and are likely to become increasingly relevant.
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Affiliation(s)
- Carlos Jimenez-Chillon
- Servicio de Hematologia y Hemoterapia, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Medical and Molecular Genetics, King’s College, London, UK
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King’s College, London, UK
- Guy’s and St Thomas Hospital, London, UK
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Feng Y, Qi S, Liu X, Zhang L, Hu Y, Shen Q, Gong X, Zhang W, Wang J, Yan W, Wang T, Wang H, Song Z, Zhu X, Gale RP, Chen J. Have we been qualifying measurable residual disease correctly? Leukemia 2023; 37:2168-2172. [PMID: 37704711 PMCID: PMC10624632 DOI: 10.1038/s41375-023-02026-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 08/30/2023] [Accepted: 09/05/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Yahui Feng
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Saibing Qi
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xueou Liu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Li Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Yu Hu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Qiujin Shen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaowen Gong
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wei Zhang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Junxia Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Wen Yan
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Tiantian Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Huijun Wang
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Zhen Song
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China
- Tianjin Institutes of Health Science, Tianjin, China
| | - Xiaofan Zhu
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
- Tianjin Institutes of Health Science, Tianjin, China.
| | - Robert Peter Gale
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College of Science, Technology and Medicine, London, UK
| | - Junren Chen
- State Key Laboratory of Experimental Hematology, National Clinical Research Center for Blood Diseases, Haihe Laboratory of Cell Ecosystem, Institute of Hematology & Blood Diseases Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, China.
- Tianjin Institutes of Health Science, Tianjin, China.
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Zhao Y, Guo H, Chang Y. MRD-directed and risk-adapted individualized stratified treatment of AML. Chin J Cancer Res 2023; 35:451-469. [PMID: 37969959 PMCID: PMC10643342 DOI: 10.21147/j.issn.1000-9604.2023.05.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/26/2023] [Indexed: 11/17/2023] Open
Abstract
Measurable residual disease (MRD) has been widely recognized as a biomarker for deeply evaluating complete remission (CR), predicting relapse, guiding pre-emptive interventions, and serving as an endpoint surrogate for drug testing. However, despite the emergence of new technologies, there remains a lack of comprehensive understanding regarding the proper techniques, sample materials, and optimal time points for MRD assessment. In this review, we summarized the MRD methods, sample sources, and evaluation frequency according to the risk category of the European Leukemia Net (ELN) 2022. Additionally, we emphasize the importance of properly utilizing and combining these technologies. We have also refined the flowchart outlining each time point for pre-emptive interventions and intervention paths. The evaluation of MRD in acute myeloid leukemia (AML) is sophisticated, clinically applicable, and technology-dependent, and necessitates standardized approaches and further research.
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Affiliation(s)
- Yijing Zhao
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Hanfei Guo
- Stanford University Medical School, VA Palo Alto Health Care System, Palo Alto 94304, USA
- the First Hospital of Jilin University, Cancer Center, Changchun 133021, China
| | - Yingjun Chang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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DeWolf S, Tallman MS, Rowe JM, Salman MY. What Influences the Decision to Proceed to Transplant for Patients With AML in First Remission? J Clin Oncol 2023; 41:4693-4703. [PMID: 37611216 PMCID: PMC10564290 DOI: 10.1200/jco.22.02868] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 05/12/2023] [Accepted: 06/14/2023] [Indexed: 08/25/2023] Open
Abstract
Although allogeneic hematopoietic cell transplantation (allo-HCT) remains the backbone of curative treatment for the majority of fit adults diagnosed with AML, there is indeed a subset of patients for whom long-term remission may be achieved without transplantation. Remarkable changes in our knowledge of AML biology in recent years has transformed the landscape of diagnosis, management, and treatment of AML. Specifically, markedly increased understanding of molecular characteristics of AML, the expanded application of minimal/measurable residual diseases testing, and an increased armamentarium of leukemia-directed therapeutic agents have created a new paradigm for the medical care of patients with AML. An attempt is herein made to decipher the decision to proceed to transplant for patients with AML in first complete remission on the basis of the current best available evidence. The focus is on factors affecting the biology and treatment of AML itself, rather than on variables related to allo-HCT, an area characterized by significant advancements that have reduced overall therapy-related complications. This review seeks to focus on areas of particular complexity, while simultaneously providing clarity on how our current knowledge and treatment strategies may, or may not, influence the decision to pursue allo-HCT in patients with AML.
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Affiliation(s)
- Susan DeWolf
- Leukemia Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Martin S. Tallman
- Division of Hematology and Oncology Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jacob M. Rowe
- Rambam Health Care Campus and Technion, Israel Institute of Technology, Haifa, Israel
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
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Othman J, Potter N, Mokretar K, Taussig D, Khan A, Krishnamurthy P, Latif AL, Cahalin P, Aries J, Amer M, Belsham E, Conneally E, Craddock C, Culligan D, Dennis M, Duncan C, Freeman SD, Furness C, Gilkes A, Gkreka P, Hodgson K, Ingram W, Jain M, King A, Knapper S, Kottaridis P, McMullin MF, Mohite U, Ngu L, O'Nions J, Patrick K, Rider T, Roberts W, Severinsen MT, Storrar N, Taylor T, Russell NH, Dillon R. FLT3 inhibitors as MRD-guided salvage treatment for molecular failure in FLT3 mutated AML. Leukemia 2023; 37:2066-2072. [PMID: 37558736 PMCID: PMC10539160 DOI: 10.1038/s41375-023-01994-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 07/17/2023] [Accepted: 08/02/2023] [Indexed: 08/11/2023]
Abstract
Patients with FLT3-mutated AML have a high relapse rate and suboptimal outcomes. Many have co-mutations suitable for measurable residual disease (MRD) monitoring by RT-qPCR and those destined to relapse can be identified by high or rising levels of MRD, called molecular failure. This provides a window for pre-emptive intervention, but there is little evidence to guide treatment. The use of FLT3 inhibitors (FLT3i) appears attractive but their use has not yet been evaluated. We identified 56 patients treated with FLT3i at molecular failure. The FLT3 mutation was an ITD in 52, TKD in 7 and both in 3. Over half of patients had previously received midostaurin. Molecular failure occurred at a median 9.2 months from diagnosis and was treated with gilteritinib (n = 38), quizartinib (n = 7) or sorafenib (n = 11). 60% achieved a molecular response, with 45% reaching MRD negativity. Haematological toxicity was low, and 22 patients were bridged directly to allogeneic transplant with another 6 to donor lymphocyte infusion. 2-year overall survival was 80% (95%CI 69-93) and molecular event-free survival 56% (95%CI 44-72). High-sensitivity next-generation sequencing for FLT3-ITD at molecular failure identified patients more likely to benefit. FLT3i monotherapy for molecular failure is a promising strategy which merits evaluation in prospective studies.
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Affiliation(s)
- Jad Othman
- Department of Medical and Molecular Genetics, King's College London, London, England, UK
- Guy's and St Thomas' NHS Foundation Trust, London, England, UK
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Nicola Potter
- Department of Medical and Molecular Genetics, King's College London, London, England, UK
| | | | - David Taussig
- The Royal Marsden NHS Foundation Trust, London, England, UK
| | - Anjum Khan
- Leeds Teaching Hospitals NHS Trust, Leeds, England, UK
| | | | | | - Paul Cahalin
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, England, UK
| | - James Aries
- Barts Cancer Institute, Queen Mary University of London, London, England, UK
| | - Mariam Amer
- University Hospital Southampton, Southampton, England, UK
| | | | | | | | | | - Mike Dennis
- The Christie NHS Foundation Trust, Manchester, England, UK
| | | | - Sylvie D Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, Scotland, UK
| | | | - Amanda Gilkes
- Department of Haematology, Cardiff University, Cardiff, Wales, UK
| | | | | | | | - Manish Jain
- Leeds Teaching Hospitals NHS Trust, Leeds, England, UK
| | - Andrew King
- Addenbrooke's Hospital, Cambridge, England, UK
| | - Steven Knapper
- School of Medicine, Cardiff University, Cardiff, Wales, UK
| | | | | | | | - Loretta Ngu
- Royal Devon & Exeter NHS Foundation Trust, Exeter, England, UK
| | - Jenny O'Nions
- University College London Hospital NHS Foundation Trust, London, England, UK
| | | | - Tom Rider
- The Royal Sussex County Hospital, Brighton and Hove, England, UK
| | - Wing Roberts
- Great North Children's Hospital, Newcastle upon Tyne, England, UK
| | - Marianne Tang Severinsen
- Department of Hematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | | | - Tom Taylor
- Nottingham University Hospital, Nottingham, England, UK
| | - Nigel H Russell
- Guy's and St Thomas' NHS Foundation Trust, London, England, UK
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College London, London, England, UK.
- Guy's and St Thomas' NHS Foundation Trust, London, England, UK.
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45
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Versluis J, Saber W, Tsai HK, Gibson CJ, Dillon LW, Mishra A, McGuirk J, Maziarz RT, Westervelt P, Hegde P, Mukherjee D, Martens MJ, Logan B, Horowitz M, Hourigan CS, Nakamura R, Cutler C, Lindsley RC. Allogeneic Hematopoietic Cell Transplantation Improves Outcome in Myelodysplastic Syndrome Across High-Risk Genetic Subgroups: Genetic Analysis of the Blood and Marrow Transplant Clinical Trials Network 1102 Study. J Clin Oncol 2023; 41:4497-4510. [PMID: 37607457 PMCID: PMC10552956 DOI: 10.1200/jco.23.00866] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/30/2023] [Accepted: 06/30/2023] [Indexed: 08/24/2023] Open
Abstract
PURPOSE Allogeneic hematopoietic cell transplantation (HCT) in patients with myelodysplastic syndrome (MDS) improves overall survival (OS). We evaluated the impact of MDS genetics on the benefit of HCT in a biological assignment (donor v no donor) study. METHODS We performed targeted sequencing in 309 patients age 50-75 years with International Prognostic Scoring System (IPSS) intermediate-2 or high-risk MDS, enrolled in the Blood and Marrow Transplant Clinical Trials Network 1102 study and assessed the association of gene mutations with OS. Patients with TP53 mutations were classified as TP53multihit if two alleles were altered (via point mutation, deletion, or copy-neutral loss of heterozygosity). RESULTS The distribution of gene mutations was similar in the donor and no donor arms, with TP53 (28% v 29%; P = .89), ASXL1 (23% v 29%; P = .37), and SRSF2 (16% v 16%; P = .99) being most common. OS in patients with a TP53 mutation was worse compared with patients without TP53 mutation (21% ± 5% [SE] v 52% ± 4% at 3 years; P < .001). Among those with a TP53 mutation, OS was similar between TP53single versus TP53multihit (22% ± 8% v 20% ± 6% at 3 years; P = .31). Considering HCT as a time-dependent covariate, patients with a TP53 mutation who underwent HCT had improved OS compared with non-HCT treatment (OS at 3 years: 23% ± 7% v 11% ± 7%; P = .04), associated with a hazard ratio of 3.89; 95% CI, 1.87 to 8.12; P < .001 after adjustment for covariates. OS among patients with molecular IPSS (IPSS-M) very high risk without a TP53 mutation was significantly improved if they had a donor (68% ± 10% v 0% ± 12% at 3 years; P = .001). CONCLUSION HCT improved OS compared with non-HCT treatment in patients with TP53 mutations irrespective of TP53 allelic status. Patients with IPSS-M very high risk without a TP53 mutation had favorable outcomes when a donor was available.
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Affiliation(s)
- Jurjen Versluis
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
- Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Wael Saber
- Medical College of Wisconsin, Milwaukee, WI
| | - Harrison K. Tsai
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | | | - Laura W. Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | | | | | | | - Pranay Hegde
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | | | | | | | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD
| | | | - Corey Cutler
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Swaminathan M, Ravandi F. Can measurable residual disease assessment be reliably used to defer allogeneic stem cell transplant in patients with intermediate-risk acute myeloid leukemia? Haematologica 2023; 108:2561-2563. [PMID: 37345488 PMCID: PMC10543186 DOI: 10.3324/haematol.2023.283120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 06/16/2023] [Indexed: 06/23/2023] Open
Affiliation(s)
- Mahesh Swaminathan
- The University of Texas, MD Anderson Cancer Center, Department of Leukemia, Texas
| | - Farhad Ravandi
- The University of Texas, MD Anderson Cancer Center, Department of Leukemia, Texas.
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Salhotra A, Yuan S, Ali H. Fifty years of BMT: risk stratification, donor matching, and stem cell collection for transplantation. Front Oncol 2023; 13:1196564. [PMID: 37700828 PMCID: PMC10493308 DOI: 10.3389/fonc.2023.1196564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/07/2023] [Indexed: 09/14/2023] Open
Abstract
In this review, we discuss recipient risk assessment for allo-HCT regarding comorbidities present at baseline to predict non relapse mortality. We further reviewed the incorporation of remission status and cytogenetic risk prior to allograft transplantation to predict relapse rates for hematologic malignancies. HCT-CI and DRI are tools available to physicians to assess the risk-benefit of allo-HCT in patients referred for transplantation. Next, we discuss our algorithm for donor selection and criteria for donor selection in case matched donors are not available. Finally, we discuss our approach for stem cell mobilization, especially in donors failing G-CSF, and our approach for the use of plerixafor and data supporting its use.
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Affiliation(s)
- Amandeep Salhotra
- Department of Hematology and Hematopoietic Cell Transplantation (HCT), City of Hope National Medical Center, Duarte, CA, United States
| | - Shan Yuan
- Division of Transfusion Medicine, Department of Pathology and Laboratory Medicine, City of Hope National Medical Center, Duarte, CA, United States
| | - Haris Ali
- Department of Hematology and Hematopoietic Cell Transplantation (HCT), City of Hope National Medical Center, Duarte, CA, United States
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Pasca S, Guo MZ, Wang S, Stokvis K, Shedeck A, Pallavajjala A, Shams C, Pallavajjala R, DeZern AE, Varadhan R, Gocke CD, Jones RJ, Gondek LP. Cell-free DNA measurable residual disease as a predictor of postallogeneic hematopoietic cell transplant outcomes. Blood Adv 2023; 7:4660-4670. [PMID: 37276081 PMCID: PMC10448421 DOI: 10.1182/bloodadvances.2023010416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 05/25/2023] [Accepted: 05/25/2023] [Indexed: 06/07/2023] Open
Abstract
The measurable residual disease (MRD) assessment provides an attractive predictor of allogeneic hematopoietic cell transplnat (alloHCT) outcomes. Cell-free DNA (cfDNA) has been applied to diagnosis, early detection, and disease burden monitoring in various tumors, but its utility as an MRD test in myeloid malignancies has not been systematically evaluated. We sought to determine the differential sensitivity between bone marrow (BM) and cfDNA MRD and to assess the effect of cfDNA MRD on alloHCT outcomes. The technical and clinical validation cohorts, including 82 patients participating in clinical trials (Bone Marrow Transplant Clinical Trials Network-0201 and 0402), were used. Ultradeep error-corrected targeted sequencing was performed on plasma and BM-derived DNA. We demonstrated that 94.6% (range, 93.9-95.3) of cfDNA was derived from hematopoietic tissue. The mutant allele fraction was congruent between BM and cfDNA (rho = 0.8; P < .0001); however, cfDNA seemed to be more sensitive in detecting clones with a variant allele frequency (VAF) of <0.26%. cfDNA-MRD clearance by day 90 after alloHCT (D90) was associated with improved relapse-free survival (RFS, median survival not reached vs 5.5 months; P < .0001) and overall survival (OS, median survival not reached vs 7.3 months; P < .0001) when compared with patients with persistent MRD. Irrespective of pre-alloHCT MRD, D90 cfDNA MRD was associated with inferior 2-year OS (16.7% vs 84.8%; P < .0001) and RFS (16.7% vs 80.7%; P < .0001). cfDNA seems to be an accurate, minimally invasive alternative to BM aspirates in MRD assessment and confers important prognostic implications in patients with myeloid malignancies undergoing alloHCT.
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Affiliation(s)
- Sergiu Pasca
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Matthew Z. Guo
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Shiyu Wang
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Kristin Stokvis
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Audra Shedeck
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Aparna Pallavajjala
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Cynthia Shams
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Roshni Pallavajjala
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Amy E. DeZern
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Ravi Varadhan
- Division of Biostatistics, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher D. Gocke
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Richard J. Jones
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Lukasz P. Gondek
- Division of Hematological Malignancies, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
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Ravindra N, Dillon LW, Gui G, Smith M, Gondek LP, Jones RJ, Corner A, Hourigan CS, Ambinder AJ. Persistent IDH mutations are not associated with increased relapse or death in patients with IDH-mutated acute myeloid leukemia undergoing allogeneic hematopoietic cell transplant with post-transplant cyclophosphamide. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.14.23294087. [PMID: 37662423 PMCID: PMC10473775 DOI: 10.1101/2023.08.14.23294087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
The presence of measurable residual disease (MRD) prior to an allogeneic hematopoietic transplant (alloHCT) in Acute Myeloid Leukemia (AML) has been shown to be associated with an increased risk of post-transplant relapse. Since the Isocitrate Dehydrogenase genes (IDH1/2) are mutated in a considerable proportion of patients with AML, we studied if these mutations would serve as useful targets for MRD. Fifty-five IDH-mutated AML patients undergoing non-myeloablative alloHCT with post-transplant cyclophosphamide at a single center were sequenced at baseline using a multi-gene panel followed by targeted testing for persistent IDH mutations at the pre- and post-alloHCT timepoints by digital droplet PCR or error-corrected next generation sequencing. The cohort included patients who had been treated with IDH inhibitors pre- and post-transplant (20% and 17% for IDH1 and 38% and 28% for IDH2). Overall, 55% of patients analyzed had detectable IDH mutations during complete remission prior to alloHCT. However, there were no statistically significant differences in overall survival (OS), relapse-free survival (RFS), and cumulative incidence of relapse (CIR) at 3 years between patients who tested positive or negative for a persistent IDH mutation during remission (OS: IDH1 p=1, IDH2 p=0.87; RFS: IDH1 p=0.71, IDH2 p= 0.78; CIR: IDH1 p=0.92, IDH2 p=0.97). There was also no difference in the prevalence of persistent IDH mutation between patients who did and did not receive an IDH inhibitor (p=0.59). Mutational profiling of available relapse samples showed that 8 out of 9 patients still exhibited the original IDH mutation, indicating that the IDH mutations remained stable through the course of the disease. This study demonstrates that persistent IDH mutations during remission is not associated with inferior clinical outcomes after alloHCT in patients with AML.
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Affiliation(s)
- Niveditha Ravindra
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Laura W. Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Gege Gui
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Matthew Smith
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Lukasz P. Gondek
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Richard J. Jones
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Adam Corner
- Bio-Rad Laboratories, Digital Biology Group, 5731, W. Las Positias Blvd, Pleasanton, CA
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD
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50
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Gui G, Dillon LW, Ravindra N, Hegde PS, Andrew G, Mukherjee D, Wong Z, Auletta J, El Chaer F, Chen E, Chen YB, Corner A, Devine SM, Iyer S, Jimenez Jimenez AM, De Lima MJG, Litzow MR, Kebriaei P, Spellman SR, Zeger SL, Page KM, Hourigan CS. Measurable Residual IDH1 before Allogeneic Transplant for Acute Myeloid Leukemia. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.07.28.23293166. [PMID: 37577695 PMCID: PMC10418565 DOI: 10.1101/2023.07.28.23293166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Measurable residual disease (MRD) in adults with acute myeloid leukemia (AML) in complete remission is an important prognostic marker, but detection methodology requires optimization. The persistence of mutated NPM1 or FLT3-ITD in the blood of adult patients with AML in first complete remission (CR1) prior to allogeneic hematopoetic cell transplant (alloHCT) has been established as associated with increased relapse and death after transplant. The prognostic implications of persistence of other common AML-associated mutations, such as IDH1, at this treatment landmark however remains incompletely defined. We performed testing for residual IDH1 variants (IDH1m) in pre-transplant CR1 blood of 148 adult patients undergoing alloHCT for IDH1-mutated AML at a CIBMTR site between 2013-2019. No post-transplant differences were observed between those testing IDH1m positive (n=53, 36%) and negative pre-transplant (overall survival: p = 0.4; relapse: p = 0.5). For patients with IDH1 mutated AML co-mutated with NPM1 and/or FLT3-ITD, only detection of persistent mutated NPM1 and/or FLT3-ITD was associated with significantly higher rates of relapse (p = 0.01). These data, from the largest study to date, do not support the detection of IDH1 mutation in CR1 blood prior to alloHCT as evidence of AML MRD or increased post-transplant relapse risk.
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Affiliation(s)
- Gege Gui
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Laura W Dillon
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Niveditha Ravindra
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Pranay S Hegde
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Georgia Andrew
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Devdeep Mukherjee
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Zoë Wong
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Jeffery Auletta
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
- The Ohio State University College of Medicine, Columbus, OH
| | | | - Evan Chen
- Dana-Farber Cancer Institute, Boston, MA
| | | | | | - Steven M Devine
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
| | - Sunil Iyer
- Columbia University Irving Medical Center, New York, NY
| | | | | | | | - Partow Kebriaei
- The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stephen R Spellman
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
- National Marrow Donor Program, Minneapolis, MN
| | - Scott L Zeger
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Kristin M Page
- Center for International Blood and Marrow Transplant Research, Minneapolis, MN
- Medical College of Wisconsin, Milwaukee, WI
| | - Christopher S Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
- Myeloid Malignancies Program, National Institutes of Health, Bethesda, MD
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