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Gupta R, Jevremovic D, Mathew SJ, Kumar S. Multiparametric Flow Cytometry in the Evaluation of Plasma Cell Proliferative Disorders: Current Paradigms for Clinical Practice. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:e88-e95. [PMID: 38142203 DOI: 10.1016/j.clml.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 12/25/2023]
Abstract
Diagnosis of plasma cell proliferative disorders (PCPDs) is primarily based on the demonstration of monoclonal protein (M-Protein) in blood and/ or urine which often precedes clinical manifestations of the disease. The basic pathophysiology behind the M-protein presence is the proliferation of clonal plasma cells (PCs) in bone marrow or extramedullary sites and is assessed using cytomorphology and immunophenotyping. The role of multiparametric flow cytometry (MFC) for PC identification is technically the most valuable tool in this context as it characterizes as well as quantifies the clonal PCs based on differential expression of various immunophenotypic (IPT) markers. From a diagnostic perspective, MFC is critical in the definite identification of the clonal PCs and delineates benign and borderline entities at one end of the spectrum (MGUS, SMM) with lower clonal PC% and, malignant diseases at the other end (MM and PCL) with higher clonal PC fraction. The role of MFC in assessment of measurable residual disease (MRD) and monitoring of progression in MM and various PCPDs has been validated in multiple clinical studies and is probably one of the most promising tools for predicting treatment outcomes. Furthermore, MFC also plays a crucial role in disease prognostication based on specific IPT profiles. An additional role of MFC in the current clinical scenario is the evaluation of tumor microenvironment based on immune cell repertoire, which is reflecting encouraging results across. Thus, in the current review we concisely describe the role of MFC as a reliable and essential modality in PCPDs, from diagnosis to prediction of treatment outcome and disease monitoring.
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Affiliation(s)
- Ritu Gupta
- Department of Laboratory Oncology, Dr. BRAIRCH, AIIMS, New Delhi, India; Department of Hematology, Mayo Clinic, Rochester, MN.
| | - Dragan Jevremovic
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN
| | | | - Shaji Kumar
- Department of Hematology, Mayo Clinic, Rochester, MN
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2
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Bal S, Schmidt TM, Costa LJ, Callander NS. Clinical implications of measurable residual disease assessment in multiple myeloma in the era of quadruplet therapy. Leuk Lymphoma 2022; 63:3288-3298. [PMID: 36170061 DOI: 10.1080/10428194.2022.2123231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Multiple myeloma is a complex hematological malignancy with substantial heterogeneity in its clinical manifestations, biological processes, and patient outcomes. Although many biomarkers with have been identified to assist with disease monitoring and prognostication, predictive markers that inform treatment decisions remain elusive. As treatments become more effective, assays for measurable residual disease (MRD) below the level of detection of traditional assays have emerged as an essential component of disease assessment with powerful prognostic value for dynamic risk assessment. As its role as a potentially predictive biomarker continues to evolve, it is increasingly clear that MRD assessment has substantial clinical utility in the evaluation of patients with myeloma. In this review, we will summarize the evidence supporting the role of MRD as a prognostic biomarker and highlight the current clinical implications and future applications of MRD assessment in multiple myeloma.
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Affiliation(s)
- Susan Bal
- Division of Hematology and Medical Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Timothy M Schmidt
- Division of Hematology, Medical Oncology and Palliative Care, University of Wisconsin, Madison, WI, USA
| | - Luciano J Costa
- Division of Hematology and Medical Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Natalie S Callander
- Division of Hematology, Medical Oncology and Palliative Care, University of Wisconsin, Madison, WI, USA
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3
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Requirements for operational cure in multiple myeloma. Blood 2021; 138:1406-1411. [PMID: 34324647 DOI: 10.1182/blood.2021012854] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 07/26/2021] [Indexed: 11/20/2022] Open
Abstract
Multiple myeloma is usually considered as an incurable disease. However, with the therapeutic improvement observed in the last few years, achievement of an "operational" cure is increasingly becoming a realistic goal. The advent of novel agents, with or without high-dose chemotherapy and autologous transplantation, uncovered a correlation between the depth of response to treatment and the outcome. Of note, minimal residual disease (MRD) negativity is increasingly shown to be associated with improved progression-free survival (PFS), and MRD status is becoming a well-established and strong prognostic factor. Here, we discuss the impact of MRD negativity on PFS and long-term disease control, as a surrogate for a potential cure in a significant proportion of patients. The MRD value and impact should be examined by focusing on different parameters: (i) sensitivity or lower limit of detection level (method used); (ii) timing of assessment and sustainability (iii) type and duration of treatment; (iv) initial prognostic factors (most importantly, cytogenetics) and (v) patient age. Currently, the highest probability of an operational cure is in younger patients receiving the most active drugs, in combination with autologous transplantation followed by maintenance therapy. Older patients are also likely to achieve operational cure, especially if they are treated upfront with an anti-CD38 antibody-based therapy, but also with novel immunotherapies in future protocols. The incorporation of MRD as a surrogate endpoint in clinical trials, would allow the shortening of these, leading to more personalised management, and achievement of long-term cure.
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Bal S, Costa LJ. Maintaining the minimal: dynamics of measurable residual disease with continuous lenalidomide therapy. LANCET HAEMATOLOGY 2021; 8:e386-e387. [PMID: 34048675 DOI: 10.1016/s2352-3026(21)00140-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Susan Bal
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Luciano J Costa
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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5
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Maclachlan KH, Came N, Diamond B, Roshal M, Ho C, Thoren K, Mayerhoefer ME, Landgren O, Harrison S. Minimal residual disease in multiple myeloma: defining the role of next generation sequencing and flow cytometry in routine diagnostic use. Pathology 2021; 53:385-399. [PMID: 33674146 DOI: 10.1016/j.pathol.2021.02.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 12/11/2022]
Abstract
For patients diagnosed with multiple myeloma (MM) there have been significant treatment advances over the past decade, reflected in an increasing proportion of patients achieving durable remissions. Clinical trials repeatedly demonstrate that achieving a deep response to therapy, with a bone marrow assessment proving negative for minimal residual disease (MRD), confers a significant survival advantage. To accurately assess for minute quantities of residual cancer requires highly sensitive methods; either multiparameter flow cytometry or next generation sequencing are currently recommended for MM response assessment. Under optimal conditions, these methods can detect one aberrant cell amongst 1,000,000 normal cells (a sensitivity of 10-6). Here, we will review the practical use of MRD assays in MM, including challenges in implementation for the routine diagnostic laboratory, standardisation across laboratories and clinical trials, the clinical integration of MRD status assessment into MM management and future directions for ongoing research.
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Affiliation(s)
- Kylee H Maclachlan
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Haematology Service, Peter MacCallum Cancer Centre, East Melbourne, Vic, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Vic, Australia.
| | - Neil Came
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Vic, Australia; Pathology Department, Peter MacCallum Cancer Centre, East Melbourne, Vic, Australia
| | - Benjamin Diamond
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mikhail Roshal
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Caleb Ho
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katie Thoren
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Marius E Mayerhoefer
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA; Myeloma Program, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Simon Harrison
- Haematology Service, Peter MacCallum Cancer Centre, East Melbourne, Vic, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, Vic, Australia
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Kurtin SE, Taher R. Clinical Trial Design and Drug Approval in Oncology: A Primer for the Advanced Practitioner in Oncology. J Adv Pract Oncol 2021; 11:736-751. [PMID: 33575069 PMCID: PMC7646634 DOI: 10.6004/jadpro.2020.11.7.7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Evidenced-based practice requires timely and accurate integration of scientific advances. This presents a challenge for the oncology clinician given the robust pace of scientific discovery and the increasing number of new drug approvals and expanded indications for previously approved drugs. All currently available antineoplastic therapies have been developed through the clinical trials process. Advanced practitioners (APs) in oncology are often involved in the conduct of clinical trials as primary investigators, sub-investigators, study coordinators, or in the delivery and monitoring of care to patients enrolled in these trials. A prerequisite to evidenced-based practice is understanding how clinical trials are conducted and how to critically analyze published results of studies leading to U.S. Food & Drug Administration approval. Any AP involved in the clinical management and supportive care of patients receiving antineoplastic therapies should be able to critically review published data to glean findings that warrant a change in practice. The goals of this manuscript are to summarize key elements of the clinical trial process for oncology drug development and approval in the United States and to provide a primer for the interpretation of clinical data.
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Affiliation(s)
- Sandra E Kurtin
- The University of Arizona Cancer Center, Tucson, Arizona.,Lifespan Cancer Institute, Providence, Rhode Island
| | - Rashida Taher
- The University of Arizona Cancer Center, Tucson, Arizona.,Lifespan Cancer Institute, Providence, Rhode Island
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Kothari S, Hillengass J, McCarthy PL, Holstein SA. Determination of Minimal Residual Disease in Multiple Myeloma: Does It Matter? Curr Hematol Malig Rep 2020; 14:39-46. [PMID: 30671912 DOI: 10.1007/s11899-019-0497-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW The ability to detect minimal residual disease (MRD) in myeloma has improved due to advances in flow cytometry and sequencing methodologies. Here, we evaluate recent clinical trial data and explore the current and future roles of MRD assessment in the context of clinical trial design and clinical practice. RECENT FINDINGS A review of recent phase III studies reveals that achievement of MRD negativity is associated with improved progression-free survival (PFS) and/or overall survival (OS). Treatment arms that are more effective from a PFS or overall response rate perspective are also associated with superior MRD negativity rates. The current standard MRD methodologies are limited by requiring bone marrow samples and refinement of methodologies that can detect disease outside of the bone marrow is needed. Currently, MRD is a prognostic biomarker and further efforts are required to determine whether it can serve as a surrogate endpoint. The use of MRD status to guide treatment decisions is currently not recommended outside the confines of a clinical trial.
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Affiliation(s)
- Shalin Kothari
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Jens Hillengass
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Sarah A Holstein
- Department of Internal Medicine, University of Nebraska Medical Center, 986840 Nebraska Medical Center, Omaha, NE, 68198, USA.
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8
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Avet-Loiseau H, Ludwig H, Landgren O, Paiva B, Morris C, Yang H, Zhou K, Ro S, Mateos MV. Minimal Residual Disease Status as a Surrogate Endpoint for Progression-free Survival in Newly Diagnosed Multiple Myeloma Studies: A Meta-analysis. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2019; 20:e30-e37. [PMID: 31780415 DOI: 10.1016/j.clml.2019.09.622] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/05/2019] [Accepted: 09/29/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Therapeutic advances have greatly extended survival times in patients with multiple myeloma, necessitating increasingly lengthy trials when using survival outcomes as primary endpoints. A surrogate endpoint that can more rapidly predict survival could accelerate drug development. We conducted a meta-analysis to evaluate minimal residual disease (MRD) status as a valid progression-free survival (PFS) surrogate in patients with newly diagnosed multiple myeloma (NDMM). MATERIALS AND METHODS We searched abstracts in PubMed, The American Society of Hematology, and the European Hematology Association for "myeloma," "minimal residual disease," and "clinical trial." Because of the need to evaluate the treatment effect on MRD response, only randomized studies for subjects with NDMM were included. Details on the MRD-tested populations were required. The meta-analysis was performed by principles outlined at the 2013 United States Food and Drug Administration workshop on MRD in acute myeloid leukemia.42 For samples that were not measured for MRD and within the subset specified for MRD assessment, their MRD status was imputed from the samples that had known MRD status. Patients that were excluded from planned MRD assessment were considered MRD-positive. RESULTS Six randomized studies, representing 3283 patients and 2208 MRD samples, met analysis inclusion criteria. MRD negativity rates ranged from 0.06 to 0.70. The treatment effect on the odds ratio for MRD-negative response strongly correlated with the hazard ratio for PFS with a coefficient of determination for the weighted regression line of 0.97. Our meta-analysis suggested that MRD status met both the Prentice criteria for PFS surrogacy. CONCLUSIONS These results support the claim that MRD status can be used as a surrogate for PFS in NDMM.
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Affiliation(s)
- Hervé Avet-Loiseau
- Unité de Génomique du Myélome, University of Toulouse, Toulouse, France.
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - Ola Landgren
- Myeloma Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Bruno Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicada (CIMA), Instituto de Investigacion Sanitaria de Navarra (IDISNA), CIBER-ONC number CB16/12/00369, Pamplona, Spain
| | - Chris Morris
- Global Biostatistical Science, Amgen, Inc, Thousand Oaks, CA
| | - Hui Yang
- Global Biostatistical Science, Amgen, Inc, Thousand Oaks, CA
| | - Kefei Zhou
- Global Biostatistical Science, Amgen, Inc, Thousand Oaks, CA
| | - Sunhee Ro
- Global Biostatistical Science, Amgen, Inc, Thousand Oaks, CA
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9
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Soh KT, Wallace PK. Monitoring of Measurable Residual Disease in Multiple Myeloma by Multiparametric Flow Cytometry. ACTA ACUST UNITED AC 2019; 90. [PMID: 31608132 DOI: 10.1002/cpcy.63] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Recent interest in high sensitivity multiple myeloma (MM) measurable residual disease (MRD) testing is a direct consequence of the high-quality responses achieved using novel therapeutic agents and better treatment strategies. Traditional diagnostic measures such as immunohistochemistry and morphology have detection sensitivities of only 10-2 - 10-3, which do not reliably predict progression free survival (PFS) or overall survival (OS) after these treatments. Contemporary monitoring of MM MRD has switched to more sensitive platforms such as quantitative allele-specific oligonucleotide polymerase chain reaction (ASO-qPCR), next-generation sequencing (NGS), and multiparametric flow cytometry (MFC). Though both ASO-qPCR and NGS have excellent detection sensitivities (10-5 - 10-6), both technologies have lower applicability when compared to MFC. Conventional MFC can easily reach a detection sensitivity of 10-4 and when optimized can achieve a sensitivity of 10-5 - 10-6. Current consensus guidelines require a minimum of 2 million and recommend 5 million events be acquired to reach a minimum sensitivity of 10-5. As conventional immunophenotyping protocols are unable to attain these numbers, alternative MFC staining procedures are required. This manuscript describes two high-sensitivity MFC approaches that can be used for MM MRD testing.
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Affiliation(s)
- Kah Teong Soh
- Roswell Park Comprehensive Cancer Center, Department of Flow and Image Cytometry, Elm & Carlton Streets, Buffalo, New York 14263
| | - Paul K Wallace
- Roswell Park Comprehensive Cancer Center, Department of Flow and Image Cytometry, Elm & Carlton Streets, Buffalo, New York 14263
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10
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Badea M, Gaman L, Delia C, Ilea A, Leașu F, Henríquez-Hernández LA, Luzardo OP, Rădoi M, Rogozea L. Trends of Lipophilic, Antioxidant and Hematological Parameters Associated with Conventional and Electronic Smoking Habits in Middle-Age Romanians. J Clin Med 2019; 8:E665. [PMID: 31083602 PMCID: PMC6571835 DOI: 10.3390/jcm8050665] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 05/01/2019] [Accepted: 05/09/2019] [Indexed: 01/15/2023] Open
Abstract
It is known that cigarette smoking is correlated with medical associated inquires. New electronic cigarettes are intensively advertised as an alternative to conventional smoking, but only a few studies demonstrate their harmful potential. A cross-sectional study was designed using 150 subjects from Brasov (Romania), divided into three groups: non-smokers (NS = 58), conventional cigarettes smokers (CS = 58) and electronic cigarettes users (ECS = 34). The aim of this study was to determine levels of some plasma lipophilic and hematological components, and the total antioxidant status that could be associated with the smoking status of the subjects. Serum low density lipoproteins (LDL) cholesterol increased significantly for ECS participants versus NS group (18.9% difference) (p < 0.05). Also, the CS group is characterized by an increase of serum LDL cholesterol (7.9% difference vs. NS), but with no significant statistical difference. The variation of median values of serum very low density lipoproteins (VLDL) was in order NS < ECS < CS, with statistical difference between NS and CS groups (34.6% difference; p = 0.023). When comparing the antioxidant status of the three groups, significant differences (p < 0.05) were obtained between NS vs. CS and NS vs. ECS. Similar behavior was identified for CS and ECS. Statistically significant changes (p < 0.0001) for both vitamin A and vitamin E were identified in the blood of NS vs. CS and NS vs. ECS, and also when comparing vitamin A in the blood of the CS group versus the ECS group (p < 0.05). When all groups were compared, the difference in the white blood cell (WBC) was (p = 0.008). A slight increase in the red blood cell (RBC) count was observed, but with no statistical difference between groups. These results indicated that conventional cigarette and e-cigarette usage promotes the production of excess reactive oxygen species, involving different pathways, different antioxidants and bioactive molecules.
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Affiliation(s)
- Mihaela Badea
- Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
| | - Laura Gaman
- "Carol Davila" University of Medicine and Pharmacy, Bucharest 050474, Romania.
| | - Corina Delia
- National Institute for Mother and Child Health "Alessandrescu-Rusescu", Bucharest 20395, Romania.
| | - Anca Ilea
- Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
| | - Florin Leașu
- Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
| | - Luis Alberto Henríquez-Hernández
- Toxicology Unit, Clinical Sciences Department, Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe, s/n, 35019 Las Palmas de Gran Canaria, Spain.
| | - Octavio P Luzardo
- Toxicology Unit, Clinical Sciences Department, Universidad de Las Palmas de Gran Canaria, Paseo Blas Cabrera Felipe, s/n, 35019 Las Palmas de Gran Canaria, Spain.
| | - Mariana Rădoi
- Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
| | - Liliana Rogozea
- Faculty of Medicine, Transilvania University of Brasov, Brasov 500019, Romania.
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Wallace PK. Issue Highlights-May 2018 (94B3). CYTOMETRY PART B-CLINICAL CYTOMETRY 2019; 94:387-391. [PMID: 29734502 DOI: 10.1002/cyto.b.21640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Paul K Wallace
- Department of Flow and Image Cytometry, Roswell Park Cancer Institute, Elm & Carlton Streets, New York, 14263 Buffalo
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12
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Scott SD, Fletcher M, Whitehouse H, Whitby L, Yuan C, Mazzucchelli S, Lin P, de Tute R, Dorwal P, Wallace PK, Tembhare P, Arroz M, Snowden JA, Chantry AD, Barnett D. Assessment of plasma cell myeloma minimal residual disease testing by flow cytometry in an international inter‐laboratory study: Is it ready for primetime use? CYTOMETRY PART B-CLINICAL CYTOMETRY 2018; 96:201-208. [DOI: 10.1002/cyto.b.21754] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 10/26/2018] [Accepted: 11/15/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Stuart D. Scott
- UK NEQAS for Leucocyte ImmunophenotypingSheffield Teaching Hospitals Sheffield UK
- Department of Oncology and Metabolism, Faculty of Medicine, Dentistry and HealthUniversity of Sheffield Sheffield UK
| | - Matthew Fletcher
- UK NEQAS for Leucocyte ImmunophenotypingSheffield Teaching Hospitals Sheffield UK
| | - Helen Whitehouse
- UK NEQAS for Leucocyte ImmunophenotypingSheffield Teaching Hospitals Sheffield UK
| | - Liam Whitby
- UK NEQAS for Leucocyte ImmunophenotypingSheffield Teaching Hospitals Sheffield UK
| | - Constance Yuan
- Clinical Flow Cytometry Laboratory, Laboratory of PathologyCCR, NCI, NIH Bethesda Maryland
| | - Silvia Mazzucchelli
- Department of Haematology and Flow CytometrySynlab Suisse SA Bioggio Switzerland
| | - Pei Lin
- Department of HematopathologyMD Anderson Cancer Center Houston Texas
| | - Ruth de Tute
- HMDS, Department of HaematologySt. James's Institute of Oncology Leeds UK
| | - Pranav Dorwal
- Flow Cytometry LaboratoryWaikato Hospital Hamilton New Zealand
| | - Paul K. Wallace
- Department of Flow and Image CytometryRoswell Park Cancer Institute Buffalo New York
| | - Prashant Tembhare
- Hematopathology LaboratoryTata Memorial Center Mumbai Maharashtra India
| | - Maria Arroz
- Flow Cytometry Laboratory, Department of Clinical PathologyCHLO S. Francisco Xavier Hospital Lisbon Portugal
| | - John A. Snowden
- Department of Oncology and Metabolism, Faculty of Medicine, Dentistry and HealthUniversity of Sheffield Sheffield UK
- Department of HaematologySheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
| | - Andrew D. Chantry
- Department of Oncology and Metabolism, Faculty of Medicine, Dentistry and HealthUniversity of Sheffield Sheffield UK
- Department of HaematologySheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
| | - David Barnett
- UK NEQAS for Leucocyte ImmunophenotypingSheffield Teaching Hospitals Sheffield UK
- Department of Oncology and Metabolism, Faculty of Medicine, Dentistry and HealthUniversity of Sheffield Sheffield UK
- Department of HaematologySheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
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13
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Perrot A, Lauwers-Cances V, Corre J, Robillard N, Hulin C, Chretien ML, Dejoie T, Maheo S, Stoppa AM, Pegourie B, Karlin L, Garderet L, Arnulf B, Doyen C, Meuleman N, Royer B, Eveillard JR, Benboubker L, Dib M, Decaux O, Jaccard A, Belhadj K, Brechignac S, Kolb B, Fohrer C, Mohty M, Macro M, Richardson PG, Carlton V, Moorhead M, Willis T, Faham M, Anderson KC, Harousseau JL, Leleu X, Facon T, Moreau P, Attal M, Avet-Loiseau H, Munshi N. Minimal residual disease negativity using deep sequencing is a major prognostic factor in multiple myeloma. Blood 2018; 132:2456-2464. [PMID: 30249784 PMCID: PMC6284215 DOI: 10.1182/blood-2018-06-858613] [Citation(s) in RCA: 282] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/28/2018] [Indexed: 12/27/2022] Open
Abstract
The introduction of novel agents has led to major improvements in clinical outcomes for patients with multiple myeloma. To shorten evaluation times for new treatments, health agencies are currently examining minimal residual disease (MRD) as a surrogate end point in clinical trials. We assessed the prognostic value of MRD, measured during maintenance therapy by next-generation sequencing (NGS). MRD negativity was defined as the absence of tumor plasma cell within 1 000 000 bone marrow cells (<10-6). Data were analyzed from a recent clinical trial that evaluated the role of transplantation in newly diagnosed myeloma patients treated with lenalidomide, bortezomib, and dexamethasone (RVD). MRD negativity was achieved at least once during maintenance in 127 patients (25%). At the start of maintenance therapy, MRD was a strong prognostic factor for both progression-free survival (adjusted hazard ratio, 0.22; 95% confidence interval, 0.15-0.34; P < .001) and overall survival (adjusted hazard ratio, 0.24; 95% confidence interval, 0.11-0.54; P = .001). Patients who were MRD negative had a higher probability of prolonged progression-free survival than patients with detectable residual disease, regardless of treatment group (RVD vs transplant), cytogenetic risk profile, or International Staging System disease stage at diagnosis. These results were similar after completion of maintenance therapy. Our findings confirm the value of MRD status, as determined by NGS, as a prognostic biomarker in multiple myeloma, and suggest that this approach could be used to adapt treatment strategies in future clinical trials.
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Affiliation(s)
- Aurore Perrot
- Hematology Department, University Hospital, Nancy, France
| | | | - Jill Corre
- Myeloma Genomics Lab University Cancer Institute Toulouse (IUCT)-Oncopole, Cancer Research Center of Toulouse (CRCT), INSERM 1037, Toulouse, France
- Université Paul Sabatier, Toulouse, France
| | | | - Cyrille Hulin
- Hematology Department, University Hospital, Bordeaux, France
| | | | - Thomas Dejoie
- Biochemistry Laboratory, University Hospital, Nantes, France
| | - Sabrina Maheo
- Myeloma Genomics Lab University Cancer Institute Toulouse (IUCT)-Oncopole, Cancer Research Center of Toulouse (CRCT), INSERM 1037, Toulouse, France
- Université Paul Sabatier, Toulouse, France
| | | | | | - Lionel Karlin
- Hematology Department, University Hospital, Lyon, France
| | - Laurent Garderet
- Hematology Department, Saint-Antoine University Hospital, Paris, France
| | - Bertrand Arnulf
- Hematology Department, Saint-Louis University Hospital, Paris, France
| | - Chantal Doyen
- Hematology Department, Centre Hospitalier Universitaire (CHU) Université Catholique de Louvain (UCL) Namur, Yvoir, Belgium
| | - Nathalie Meuleman
- Hematology Department, Institut Jules Bordet (ULB), Brussels, Belgium
| | - Bruno Royer
- Hematology Department, University Hospital, Amiens, France
| | | | | | - Mamoun Dib
- Hematology Department, University Hospital, Angers, France
| | - Olivier Decaux
- Hematology Department, University Hospital, Rennes, France
| | - Arnaud Jaccard
- Hematology Department, University Hospital, Limoges, France
| | - Karim Belhadj
- Hematology Department, University Hospital, Creteil, France
| | | | - Brigitte Kolb
- Hematology Department, University Hospital, Reims, France
| | - Cecile Fohrer
- Hematology Department, University Hospital, Strasbourg, France
| | - Mohamad Mohty
- Hematology Department, Saint-Antoine University Hospital, Paris, France
| | - Margaret Macro
- Hematology Department, University Hospital, Caen, France
| | | | | | | | | | | | | | | | - Xavier Leleu
- Hematology Department, University Hospital, Poitiers, France
| | - Thierry Facon
- Hematology Department, University Hospital, Lille, France
| | - Philippe Moreau
- Hematology Department, University Hospital, Nantes, France; and
| | - Michel Attal
- Hematology Department, University Hospital, Toulouse, France
| | - Hervé Avet-Loiseau
- Myeloma Genomics Lab University Cancer Institute Toulouse (IUCT)-Oncopole, Cancer Research Center of Toulouse (CRCT), INSERM 1037, Toulouse, France
- Université Paul Sabatier, Toulouse, France
| | - Nikhil Munshi
- Hematology Department, Dana-Farber Cancer Institute, Boston, MA
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14
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Soh KT, Tario JD, Wallace PK. Diagnosis of Plasma Cell Dyscrasias and Monitoring of Minimal Residual Disease by Multiparametric Flow Cytometry. Clin Lab Med 2018; 37:821-853. [PMID: 29128071 DOI: 10.1016/j.cll.2017.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Plasma cell dyscrasia (PCD) is a heterogeneous disease that has seen a tremendous change in outcomes due to improved therapies. Over the past few decades, multiparametric flow cytometry has played an important role in the detection and monitoring of PCDs. Flow cytometry is a high-sensitivity assay for early detection of minimal residual disease (MRD) that correlates well with progression-free survival and overall survival. Before flow cytometry can be effectively implemented in the clinical setting, sample preparation, panel configuration, analysis, and gating strategies must be optimized to ensure accurate results. Current consensus methods and reporting guidelines for MRD testing are discussed.
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Affiliation(s)
- Kah Teong Soh
- Department of Flow and Image Cytometry, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
| | - Joseph D Tario
- Department of Flow and Image Cytometry, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - Paul K Wallace
- Department of Flow and Image Cytometry, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
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15
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Raju GK, Gurumurthi K, Domike R, Kazandjian D, Landgren O, Blumenthal GM, Farrell A, Pazdur R, Woodcock J. A Benefit-Risk Analysis Approach to Capture Regulatory Decision-Making: Multiple Myeloma. Clin Pharmacol Ther 2017; 103:67-76. [PMID: 28901535 DOI: 10.1002/cpt.871] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 09/05/2017] [Accepted: 09/10/2017] [Indexed: 12/23/2022]
Abstract
Drug regulators around the world make decisions about drug approvability based on qualitative benefit-risk analysis. In this work, a quantitative benefit-risk analysis approach captures regulatory decision-making about new drugs to treat multiple myeloma (MM). MM assessments have been based on endpoints such as time to progression (TTP), progression-free survival (PFS), and objective response rate (ORR) which are different than benefit-risk analysis based on overall survival (OS). Twenty-three FDA decisions on MM drugs submitted to FDA between 2003 and 2016 were identified and analyzed. The benefits and risks were quantified relative to comparators (typically the control arm of the clinical trial) to estimate whether the median benefit-risk was positive or negative. A sensitivity analysis was demonstrated using ixazomib to explore the magnitude of uncertainty. FDA approval decision outcomes were consistent and logical using this benefit-risk framework.
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Affiliation(s)
- G K Raju
- Light Pharma, Inc., Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Karthik Gurumurthi
- Light Pharma, Inc., Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Reuben Domike
- Light Pharma, Inc., Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Dickran Kazandjian
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, National Cancer Institute, Silver Spring, Maryland, USA
| | - Ola Landgren
- Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Gideon M Blumenthal
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, National Cancer Institute, Silver Spring, Maryland, USA
| | - Ann Farrell
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, National Cancer Institute, Silver Spring, Maryland, USA
| | - Richard Pazdur
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, National Cancer Institute, Silver Spring, Maryland, USA
| | - Janet Woodcock
- U.S. Food and Drug Administration, Center for Drug Evaluation and Research, National Cancer Institute, Silver Spring, Maryland, USA
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16
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Arana P, Paiva B, Cedena MT, Puig N, Cordon L, Vidriales MB, Gutierrez NC, Chiodi F, Burgos L, Anglada LL, Martinez-Lopez J, Hernandez MT, Teruel AI, Gironella M, Echeveste MA, Rosiñol L, Martinez R, Oriol A, De la Rubia J, Orfao A, Blade J, Lahuerta JJ, Mateos MV, San Miguel JF. Prognostic value of antigen expression in multiple myeloma: a PETHEMA/GEM study on 1265 patients enrolled in four consecutive clinical trials. Leukemia 2017; 32:971-978. [PMID: 29099494 DOI: 10.1038/leu.2017.320] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Revised: 10/07/2017] [Accepted: 10/25/2017] [Indexed: 12/21/2022]
Abstract
Persistence of minimal residual disease (MRD) after treatment for myeloma predicts inferior outcomes, but within MRD-positive patients there is great heterogeneity with both early and very late relapses. Among different MRD techniques, flow cytometry provides additional information about antigen expression on tumor cells, which could potentially contribute to stratify MRD-positive patients. We investigated the prognostic value of those antigens required to monitor MRD in 1265 newly diagnosed patients enrolled in the GEM2000, GEM2005MENOS65, GEM2005MAS65 and GEM2010MAS65 protocols. Overall, CD19pos, CD27neg, CD38lo, CD45pos, CD81pos, CD117neg and CD138lo expression predicted inferior outcomes. Through principal component analysis, we found that simultaneous CD38lowCD81posCD117neg expression emerged as the most powerful combination with independent prognostic value for progression-free survival (HR:1.69; P=0.002). This unique phenotypic profile retained prognostic value among MRD-positive patients. We then used next-generation flow to determine antigen stability throughout the course of the disease, and found that the expression of antigens required to monitor MRD is mostly stable from diagnosis to MRD stages, except for CD81 whose expression progressively increased from baseline to chemoresistant tumor cells (14 vs 28%). Altogether, we showed that the phenotypic profile of tumor cells provides additional prognostic information, and could be used to further predict risk of relapse among MRD-positive patients.
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Affiliation(s)
- P Arana
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicadas (CIMA); Instituto de Investigación Sanitaria de Navarra (IDISNA), CIBERONC, Pamplona, Spain
| | - B Paiva
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicadas (CIMA); Instituto de Investigación Sanitaria de Navarra (IDISNA), CIBERONC, Pamplona, Spain
| | - M-T Cedena
- Hospital 12 de Octubre, CIBERONC, Madrid, Spain
| | - N Puig
- Hospital Universitario de Salamanca, Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC, Salamanca, Spain
| | - L Cordon
- Hospital Universitario y Politécnico La Fe, CIBERONC, Valencia, Spain
| | - M-B Vidriales
- Hospital Universitario de Salamanca, Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC, Salamanca, Spain
| | - N C Gutierrez
- Hospital Universitario de Salamanca, Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC, Salamanca, Spain
| | - F Chiodi
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicadas (CIMA); Instituto de Investigación Sanitaria de Navarra (IDISNA), CIBERONC, Pamplona, Spain
| | - L Burgos
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicadas (CIMA); Instituto de Investigación Sanitaria de Navarra (IDISNA), CIBERONC, Pamplona, Spain
| | - L-L Anglada
- Hospital 12 de Octubre, CIBERONC, Madrid, Spain
| | | | | | - A-I Teruel
- Hospital Clínico de Valencia, Valencia, Spain
| | | | | | - L Rosiñol
- Hospital Clínic, IDIBAPS, Barcelona, Spain
| | - R Martinez
- Hospital Clínico San Carlos, Madrid, Spain
| | - A Oriol
- Institut Català d'Oncologia i Institut Josep Carreras, Hospital Germans Trias i Pujol, Badalona, Spain
| | - J De la Rubia
- Hospital Universitario y Politécnico La Fe, CIBERONC, Valencia, Spain
| | - A Orfao
- Servicio General de Citometría-NUCLEOS, Centro de Investigación del Cancer (IBMCC-USAL, CSIC), IBSAL and Department of Medicine, Universidad de Salamanca, Salamanca, Spain
| | - J Blade
- Hospital Clínic, IDIBAPS, Barcelona, Spain
| | | | - M-V Mateos
- Hospital Universitario de Salamanca, Instituto de Investigacion Biomedica de Salamanca (IBSAL), Centro de Investigación del Cancer (IBMCC-USAL, CSIC), CIBERONC, Salamanca, Spain
| | - J-F San Miguel
- Clinica Universidad de Navarra, Centro de Investigacion Medica Aplicadas (CIMA); Instituto de Investigación Sanitaria de Navarra (IDISNA), CIBERONC, Pamplona, Spain
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17
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Measurement and Clinical Significance of Biomarkers of Oxidative Stress in Humans. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2017; 2017:6501046. [PMID: 28698768 PMCID: PMC5494111 DOI: 10.1155/2017/6501046] [Citation(s) in RCA: 414] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/26/2017] [Accepted: 05/21/2017] [Indexed: 12/11/2022]
Abstract
Oxidative stress is the result of the imbalance between reactive oxygen species (ROS) formation and enzymatic and nonenzymatic antioxidants. Biomarkers of oxidative stress are relevant in the evaluation of the disease status and of the health-enhancing effects of antioxidants. We aim to discuss the major methodological bias of methods used for the evaluation of oxidative stress in humans. There is a lack of consensus concerning the validation, standardization, and reproducibility of methods for the measurement of the following: (1) ROS in leukocytes and platelets by flow cytometry, (2) markers based on ROS-induced modifications of lipids, DNA, and proteins, (3) enzymatic players of redox status, and (4) total antioxidant capacity of human body fluids. It has been suggested that the bias of each method could be overcome by using indexes of oxidative stress that include more than one marker. However, the choice of the markers considered in the global index should be dictated by the aim of the study and its design, as well as by the clinical relevance in the selected subjects. In conclusion, the clinical significance of biomarkers of oxidative stress in humans must come from a critical analysis of the markers that should give an overall index of redox status in particular conditions.
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18
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Ryherd M, Plassmeyer M, Alexander C, Eugenio I, Kleschenko Y, Badger A, Gupta R, Alpan O, Sønder SU. Improved panels for clinical immune phenotyping: Utilization of the violet laser. CYTOMETRY PART B-CLINICAL CYTOMETRY 2017; 94:671-679. [DOI: 10.1002/cyto.b.21532] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/11/2017] [Accepted: 05/04/2017] [Indexed: 12/13/2022]
Affiliation(s)
| | | | | | | | | | | | - Raavi Gupta
- Amerimmune LLC; Fairfax Virginia
- Department of Pathology; SUNY; New York
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19
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Landgren O. Combination therapy for fit (younger and older) newly diagnosed multiple myeloma patients: Data support carfilzomib, lenalidomide, and dexamethasone independent of cytogenetic risk status. Semin Oncol 2016; 43:703-706. [DOI: 10.1053/j.seminoncol.2016.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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20
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Landgren O, Rajkumar SV. New Developments in Diagnosis, Prognosis, and Assessment of Response in Multiple Myeloma. Clin Cancer Res 2016; 22:5428-5433. [PMID: 28151710 PMCID: PMC5587183 DOI: 10.1158/1078-0432.ccr-16-0866] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 09/21/2016] [Accepted: 09/21/2016] [Indexed: 12/27/2022]
Abstract
Over the past few years, the management of multiple myeloma has changed. We have new guidelines regarding how to set the diagnosis, when to initiate therapy, and how to monitor treatment response. In 2014, the updated International Myeloma Working Group (IMWG) diagnostic criteria changed the definition of multiple myeloma from being a disease defined by symptoms to a disease defined by biomarkers. Today, modern combination therapies have reported up to 60% to 80% of patients reaching a complete response. As a logical and necessary step forward, investigators have explored strategies to detect minimal residual disease (MRD) and its correlation with clinical outcomes. Recent meta-analysis data show that MRD negativity is associated with longer progression-free survival and overall survival. In 2016, the updated IMWG response criteria include MRD as the deepest level of treatment response in multiple myeloma. Simultaneously, we are still quite behind in our understanding of the heterogeneous biology of multiple myeloma and its implications for therapy. Emerging DNA sequencing data show that newly diagnosed multiple myeloma patients have a broad range of mutations, which are distributed unevenly in multiple parallel subclones already present at diagnosis. To move beyond the ill-defined category of "high-risk multiple myeloma," which confers to approximately 25% of all newly diagnosed patients, prospective studies are needed to dissect tumor biology and define multiple myeloma subtypes, and, based on biology, seek to define rational therapies for individual subtypes. This article discusses novel insights and gives perspectives on diagnosis and MRD monitoring and future directions for prognosis and clinical management of multiple myeloma. Clin Cancer Res; 22(22); 5428-33. ©2016 AACR SEE ALL ARTICLES IN THIS CCR FOCUS SECTION, "MULTIPLE MYELOMA MULTIPLYING THERAPIES".
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Affiliation(s)
- Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York.
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21
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Preffer FI, Yuan CM, Lin P, Stetler-Stevenson M, Marti GE. Introduction to multiple myeloma special issue: The flow cytometric detection of minimal residual disease. CYTOMETRY PART B-CLINICAL CYTOMETRY 2016; 90:9-10. [PMID: 26780351 DOI: 10.1002/cyto.b.21342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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22
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Role of MRD status in relation to clinical outcomes in newly diagnosed multiple myeloma patients: a meta-analysis. Bone Marrow Transplant 2016; 51:1565-1568. [PMID: 27595280 PMCID: PMC5571752 DOI: 10.1038/bmt.2016.222] [Citation(s) in RCA: 133] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 06/29/2016] [Accepted: 07/13/2016] [Indexed: 12/19/2022]
Abstract
Driven by access to better drugs, on average, newly diagnosed multiple myeloma patients have over 10 years overall survival. Using modern combination therapies – with or without the addition of high-dose melphalan and autologous stem cell transplantation – up to 80% of patients reach a complete response. As a logical and necessary step forward, clinical studies have explored strategies to detect minimal residual disease (MRD) and its correlation with clinical outcomes. In this context, MRD has been proposed as a regulatory endpoint for drug approval in newly diagnosed multiple myeloma. To better define the role of MRD negativity in relation to clinical outcomes, we undertook a meta-analysis including published clinical trials of newly diagnosed multiple myeloma patients. We applied a random effects model which weighted studies using the inverse-variance method. Studies were combined on the scale of the logarithm of the hazard ratio (HR) and the corresponding standard error. We found that remaining MRD positive was associated with worse progression-free survival (HR=2.85; 95% confidence interval (CI) 2.17–3.74; P<0.001) and overall survival (HR=2.08; 95% CI 1.44–3.01; P<0.001). Our results show that MRD negativity is a strong predictor of clinical outcomes, supportive of MRD becoming a regulatory endpoint for drug approval in newly diagnosed multiple myeloma.
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