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Pasquini MC, Wallace PK, Logan B, Kaur M, Tario JD, Howard A, Zhang Y, Brunstein C, Efebera Y, Geller N, Giralt S, Hari P, Horowitz MM, Koreth J, Krishnan A, Landau H, Somlo G, Shah N, Stadtmauer E, Vogl DT, Vesole DH, McCarthy PL, Hahn T. Minimal Residual Disease Status in Multiple Myeloma 1 Year After Autologous Hematopoietic Cell Transplantation and Lenalidomide Maintenance Are Associated With Long-Term Overall Survival. J Clin Oncol 2024:JCO2300934. [PMID: 38701390 DOI: 10.1200/jco.23.00934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 01/31/2024] [Accepted: 03/01/2024] [Indexed: 05/05/2024] Open
Abstract
PURPOSE Prognostic Immunophenotyping in Myeloma Response (PRIMeR) is an ancillary study of minimal residual disease (MRD) assessment for multiple myeloma by next-generation multiparameter flow cytometry (MFC). Patients were enrolled on a three-arm randomized control trial (Blood and Marrow Transplants Clinical Trials Network 0702 Stem Cell Transplant for Myeloma in Combination of Novel Agents [STaMINA]; ClinicalTrials.gov identifier: NCT01109004). METHODS Four hundred and thirty-five patients consented to the MRD panel, which included 10 monoclonal antibodies measured via six-color MFC. MRD was measured at baseline/preautologous hematopoietic cell transplant (BL/preAutoHCT), premaintenance (PM), and 1 year (Y1) after AutoHCT with a sensitivity of 10-5 to 10-6. The primary objective was to assess MRD-negative (MRDneg) at 1 year after AutoHCT and progression-free survival and overall survival (PFS/OS). RESULTS Similar to the STaMINA results, at a median follow-up of 70 months, there was no significant difference in PFS/OS by treatment arm in the PRIMeR patients. MRDneg at all three time points was associated with significantly improved PFS, and MRDneg at Y1 had significantly longer OS. Multivariate analysis of PFS, adjusting for disease risk and treatment arm, demonstrated hazard ratios (HRs) in MRD-positive patients compared with MRDneg patients at BL, PM, and Y1 of 1.55 (P = .0074), 1.83 (P = .0007), and 3.61 (P < .0001), respectively. Corresponding HRs for OS were 1.19 (P = .48), 0.88 (P = .68), and 3.36 (P < .001). Patients with sustained MRDneg or who converted to MRDneg by Y1 had similar PFS/OS. CONCLUSION To our knowledge, this first, prospective US cooperative group, multicenter study demonstrates that MRDneg at Y1 after AutoHCT with lenalidomide maintenance is prognostic for improved 6-year PFS and OS. Serial MRD measurements may direct trials to test how further therapy may improve long-term PFS and OS.
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Affiliation(s)
| | | | | | | | | | - Alan Howard
- National Marrow Donor Program, Minneapolis, MN
| | - Yali Zhang
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | | | - Yvonne Efebera
- OhioHealth, Columbus, OH
- Ohio State University, Columbus, OH
| | - Nancy Geller
- National Heart, Lung and Blood Institute, Bethesda, MD
| | - Sergio Giralt
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | | | | | | | - Nina Shah
- University California San Francisco, San Francisco, CA
| | | | - Dan T Vogl
- University of Pennsylvania, Philadelphia, PA
| | | | | | - Theresa Hahn
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
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Wang YF, Li JL, Lee CC, Wallace PK, Ko BS. Using Artificial Intelligence to Interpret Clinical Flow Cytometry Datasets for Automated Disease Diagnosis and/or Monitoring. Methods Mol Biol 2024; 2779:353-367. [PMID: 38526794 DOI: 10.1007/978-1-0716-3738-8_16] [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] [Indexed: 03/27/2024]
Abstract
Flow cytometry (FC) is routinely used for hematological disease diagnosis and monitoring. Advancement in this technology allows us to measure an increasing number of markers simultaneously, generating complex high-dimensional datasets. However, current analytic software and methods rely on experienced analysts to perform labor-intensive manual inspection and interpretation on a series of 2-dimensional plots via a complex, sequential gating process. With an aggravating shortage of professionals and growing demands, it is very challenging to provide the FC analysis results in a fast, accurate, and reproducible way. Artificial intelligence has been widely used in many sectors to develop automated detection or classification tools. Here we describe a type of machine learning method for developing automated disease classification and residual disease monitoring on clinical flow datasets.
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Affiliation(s)
- Yu-Fen Wang
- AHEAD Medicine Corporation, San Jose, CA, USA.
- AHEAD Intelligence Ltd, Taipei, Taiwan.
| | - Jeng-Lin Li
- Department of Electrical Engineering, National Tsing Hua University, Hsin-Chu, Taiwan
| | - Chi-Chun Lee
- Department of Electrical Engineering, National Tsing Hua University, Hsin-Chu, Taiwan
| | - Paul K Wallace
- Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Bor-Sheng Ko
- AHEAD Medicine Corporation, San Jose, CA, USA
- AHEAD Intelligence Ltd, Taipei, Taiwan
- Department of Hematological Oncology, National Taiwan University Cancer Center, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- School of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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3
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Cárdenas MC, García-Sanz R, Puig N, Pérez-Surribas D, Flores-Montero J, Ortiz-Espejo M, de la Rubia J, Cruz-Iglesias E. Recommendations for the study of monoclonal gammopathies in the clinical laboratory. A consensus of the Spanish Society of Laboratory Medicine and the Spanish Society of Hematology and Hemotherapy. Part I: Update on laboratory tests for the study of monoclonal gammopathies. Clin Chem Lab Med 2023; 61:2115-2130. [PMID: 37477188 DOI: 10.1515/cclm-2023-0326] [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: 03/30/2023] [Accepted: 05/29/2023] [Indexed: 07/22/2023]
Abstract
Monoclonal gammopathies (MG) are characterized by the proliferation of plasma cells that produce identical abnormal immunoglobulins (intact or some of their subunits). This abnormal immunoglobulin component is called monoclonal protein (M-protein), and is considered a biomarker of proliferative activity. The identification, characterization and measurement of M-protein is essential for the management of MG. We conducted a systematic review of the different tests and measurement methods used in the clinical laboratory for the study of M-protein in serum and urine, the biochemistry and hematology tests necessary for clinical evaluation, and studies in bone marrow, peripheral blood and other tissues. This review included literature published between 2009 and 2022. The paper discusses the main methodological characteristics and limitations, as well as the purpose and clinical value of the different tests used in the diagnosis, prognosis, monitoring and assessment of treatment response in MG. Included are methods for the study of M-protein, namely electrophoresis, measurement of immunoglobulin levels, serum free light chains, immunoglobulin heavy chain/light chain pairs, and mass spectrometry, and for the bone marrow examination, morphological analysis, cytogenetics, molecular techniques, and multiparameter flow cytometry.
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Affiliation(s)
- María C Cárdenas
- Department of Clinical Analysis, Hospital Clinico San Carlos, Madrid, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Ramón García-Sanz
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Noemí Puig
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - David Pérez-Surribas
- Laboratori Pasteur, Andorra La Vella, Andorra
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Juan Flores-Montero
- Hematology Department, University Hospital of Salamanca, Research Biomedical Institute of Salamanca (IBSAL), CIBERONC and Center for Cancer Research-IBMCC (University of Salamanca-CSIC), Salamanca, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - María Ortiz-Espejo
- Department of Clinical Analysis, Hospital Universitario Marqués de Valdecilla, Santander, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
| | - Javier de la Rubia
- Hematology Department, Hospital Universitario y Politécnico La Fe & Universidad Católica de Valencia, Instituto de Investigación Sanitaria La Fe Centro de Investigación Biomédica en Red de Cáncer, CIBERONC CB16/12/00284, Instituto de Salud Carlos III, Valencia, Spain
- Spanish Society of Hematology and Hemotherapy (SEHH), Madrid, Spain
| | - Elena Cruz-Iglesias
- Department of Laboratory Medicine, Osakidetza Basque Health Service, Basurto University Hospital, Bilbao, Spain
- Protein Commission, Spanish Society of Laboratory Medicine (SEQCML), Barcelona, Spain
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4
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Potre C, Borsi E, Potre O, Samfireag M, Costachescu D, Cerbu B, Bratosin F, Secosan C, Negrean RA. Assessing Pretransplant and Posttransplant Therapy Response in Multiple Myeloma Patients. Curr Oncol 2022; 29:8501-8512. [PMID: 36354730 PMCID: PMC9689544 DOI: 10.3390/curroncol29110670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/25/2022] [Accepted: 11/07/2022] [Indexed: 11/11/2022] Open
Abstract
Multiple myeloma (MM) is a hematologic cancer defined by an abnormal development of clonal plasma cells in the bone marrow, releasing vast quantities of immunoglobulins and different proteins. In the majority of patients, MM remains incurable despite decades of medical improvement and a number of treatment breakthroughs. Frontline standard-of-care has little long-term success, with the majority of patients eventually relapsing, although the overall progression-free survival (PFS) has improved significantly in the last ten years. Patients who are eligible for a transplant have the highest PFS rate at 5 years, depending on medication response and other various factors that are yet to be discovered. Therefore, the current study aimed to evaluate the response to VCD (bortezomib, cyclophosphamide, dexamethasone) and VTD (bortezomib, thalidomide, dexamethasone) used as pretransplant regimens, as well as to compare responses between thalidomide and lenalidomide used as maintenance therapy posttransplant. This retrospective study was performed on a group of 105 hospitalized patients in the Hematology Department of the Timisoara Municipal Emergency Clinical Hospital between January 2016 and December 2021. Data was collected from the paper records of patients with MM who were under-followed. The treatment regimens used as induction therapy were either VCD or VTD if cyclophosphamide was contraindicated. Of the 105 patients, 27 became eligible for bone marrow transplantation. Furthermore, they received maintenance therapy which was based on either lenalidomide with dexamethasone or thalidomide with dexamethasone. Of the 62 patients treated with VTD, 17.7% were in complete remission before stem cell transplantation. Of the 43 patients treated with VCD, 37.2% were in complete remission. The 5-year mean progression-free survival (PFS) in the entire cohort was better in the group treated with the VTD regimen (31.6 vs. 27.2 months). However, in the 27 patients undergoing maintenance after ASCT, the PFS with thalidomide was 35.5 months (95% CI = 27-42), while the PFS rate in those receiving maintenance treatment with lenalidomide was 46.1 months (95% CI = 20-73). VCD proved to be superior to VTD in inducing complete pretransplant responses. Regarding maintenance therapy, patients from the lenalidomide group had superior responses compared with those under thalidomide.
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Affiliation(s)
- Cristina Potre
- Department of Internal Medicine, Discipline of Hematology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Ema Borsi
- Department of Internal Medicine, Discipline of Hematology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
- Correspondence:
| | - Ovidiu Potre
- Department of Internal Medicine, Discipline of Hematology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Miruna Samfireag
- Department of Internal Medicine, Discipline of Clinical Practical Skills, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Dan Costachescu
- Discipline of Radiology and Medical Imaging, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Bianca Cerbu
- Methodological and Infectious Diseases Research Center, Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Felix Bratosin
- Methodological and Infectious Diseases Research Center, Department of Infectious Diseases, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
| | - Cristina Secosan
- Department of Obstetrics and Gynecology, “Victor Babes” University of Medicine and Pharmacy, 300041 Timisoara, Romania
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Soh KT, Came N, Otteson GE, Jevremovic D, Shi M, Olteanu H, Natoni A, Lagoo A, Theakston E, Óskarsson JÞ, Gorniak M, Grigoriadis G, Arroz M, Fletcher M, Lin P, Ludwig P, Tembhare P, Matuzeviciene R, Radzevicius M, Kay S, Chen W, Cabrita C, Wallace PK. Evaluation of multiple myeloma measurable residual disease by high sensitivity flow cytometry: An international harmonized approach for data analysis. CYTOMETRY PART B: CLINICAL CYTOMETRY 2022; 102:88-106. [PMID: 35005838 PMCID: PMC10105368 DOI: 10.1002/cyto.b.22053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/15/2021] [Accepted: 12/21/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Multiple myeloma (MM) measurable residual disease (MRD) evaluated by flow cytometry is a surrogate for progression-free and overall survival in clinical trials. However, analysis and reporting between centers lack uniformity. We designed and evaluated a consensus protocol for MM MRD analysis to reduce inter-laboratory variation in MM MRD reporting. METHODS Seventeen participants from 13 countries performed blinded analysis of the same eight de-identified flow cytometry files from patients with/without MRD using their own method (Stage 1). A consensus gating protocol was then designed following survey and discussions, and the data re-analyzed for MRD and other bone marrow cells (Stage 2). Inter-laboratory variation using the consensus strategy was reassessed for another 10 cases and compared with earlier results (Stage 3). RESULTS In Stage 1, participants agreed on MRD+/MRD- status 89% and 68% of the time respectively. Inter-observer variation was high for total numbers of analyzed cells, total and normal plasma cells (PCs), limit of detection, lower limit of quantification, and enumeration of cell populations that determine sample adequacy. The identification of abnormal PCs remained relatively consistent. By consensus method, average agreement on MRD- status improved to 74%. Better consistency enumerating all parameters among operators resulted in near-unanimous agreement on sample adequacy. CONCLUSION Uniform flow cytometry data analysis substantially reduced inter-laboratory variation in reporting multiple components of the MM MRD assay. Adoption of a harmonized approach would meet an important need for conformity in reporting MM MRD for clinical trials, and wider acceptance of MM MRD as a surrogate clinical endpoint.
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Affiliation(s)
- Kah Teong Soh
- Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Neil Came
- Peter MacCallum Cancer Centre Melbourne Victoria Australia
| | | | | | - Min Shi
- Mayo Clinic Rochester Minnesota USA
| | | | | | - Anand Lagoo
- Duke University Medical Center Durham North Carolina USA
| | | | | | | | | | - Maria Arroz
- Centro Hospitalar de Lisboa Ocidental Hospital S. Francisco Xavier Lisbon Portugal
| | - Matthew Fletcher
- UK NEQAS for Leucocyte Immunophenotyping, Department of Haematology Royal Hallamshire Hospital Sheffield UK
| | - Pei Lin
- MD Anderson Cancer Center Houston Texas USA
| | | | | | - Reda Matuzeviciene
- Institute of Biomedical Sciences, Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Faculty of Medicine Vilnius University Vilnius Lithuania
- Laboratory Medicine Centre Vilnius University Hospital Santaros Clinics Vilnius Lithuania
| | - Mantas Radzevicius
- Institute of Biomedical Sciences, Department of Physiology, Biochemistry, Microbiology and Laboratory Medicine, Faculty of Medicine Vilnius University Vilnius Lithuania
- Laboratory Medicine Centre Vilnius University Hospital Santaros Clinics Vilnius Lithuania
| | - Sigi Kay
- Tel‐Aviv Sourasky Medical Center Tel‐Aviv Israel
| | - Weina Chen
- University of Texas Southwestern Medical Center Dallas Texas USA
| | | | - Paul K. Wallace
- Roswell Park Comprehensive Cancer Center Buffalo New York USA
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6
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Schmitz A, Brøndum RF, Johnsen HE, Mellqvist UH, Waage A, Gimsing P, op Bruinink DH, van der Velden V, van der Holt B, Hansson M, Andersen NF, Frølund UC, Helleberg C, Schjesvold FH, Ahlberg L, Gulbrandsen N, Andreasson B, Lauri B, Haukas E, Bødker JS, Roug AS, Bøgsted M, Severinsen MT, Gregersen H, Abildgaard N, Sonneveld P, Dybkær K. Longitudinal minimal residual disease assessment in multiple myeloma patients in complete remission – results from the NMSG flow-MRD substudy within the EMN02/HO95 MM trial. BMC Cancer 2022; 22:147. [PMID: 35123422 PMCID: PMC8818194 DOI: 10.1186/s12885-022-09184-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/07/2022] [Indexed: 11/20/2022] Open
Abstract
Background Multiple myeloma remains an incurable disease with multiple relapses due to residual myeloma cells in the bone marrow of patients after therapy. Presence of small number of cancer cells in the body after cancer treatment, called minimal residual disease, has been shown to be prognostic for progression-free and overall survival. However, for multiple myeloma, it is unclear whether patients attaining minimal residual disease negativity may be candidates for treatment discontinuation. We investigated, if longitudinal flow cytometry-based monitoring of minimal residual disease (flow-MRD) may predict disease progression earlier and with higher sensitivity compared to biochemical assessments. Methods Patients from the Nordic countries with newly diagnosed multiple myeloma enrolled in the European-Myeloma-Network-02/Hovon-95 (EMN02/HO95) trial and undergoing bone marrow aspiration confirmation of complete response, were eligible for this Nordic Myeloma Study Group (NMSG) substudy. Longitdudinal flow-MRD assessment of bone marrow samples was performed to identify and enumerate residual malignant plasma cells until observed clinical progression. Results Minimal residual disease dynamics were compared to biochemically assessed changes in serum free light chain and M-component. Among 20 patients, reaching complete response or stringent complete response during the observation period, and with ≥3 sequential flow-MRD assessments analysed over time, increasing levels of minimal residual disease in the bone marrow were observed in six cases, preceding biochemically assessed disease and clinical progression by 5.5 months and 12.6 months (mean values), respectively. Mean malignant plasma cells doubling time for the six patients was 1.8 months (95% CI, 1.4–2.3 months). Minimal malignant plasma cells detection limit was 4 × 10–5. Conclusions Flow-MRD is a sensitive method for longitudinal monitoring of minimal residual disease dynamics in multiple myeloma patients in complete response. Increasing minimal residual disease levels precedes biochemically assessed changes and is an early indicator of subsequent clinical progression. Trial registration NCT01208766 Supplementary Information The online version contains supplementary material available at 10.1186/s12885-022-09184-1.
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7
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Ciepiela O, Małecka-Giełdowska M, Czyżewska E. Neutrophil Extracellular Traps (NETs) and Hypercoagulability in Plasma Cell Dyscrasias-Is This Phenomenon Worthy of Exploration? J Clin Med 2021; 10:jcm10225243. [PMID: 34830525 PMCID: PMC8624472 DOI: 10.3390/jcm10225243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022] Open
Abstract
Plasma cell dyscrasias (PCDs) are neoplastic diseases derived from plasma cells. Patients suffering from PCDs are at high risk of hypercoagulability and thrombosis. These conditions are associated with disease-related factors, patient-related factors, or the use of immunomodulatory drugs. As PCDs belong to neoplastic diseases, some other factors related to the cancer-associated hypercoagulability state in the course of PCDs are also considered. One of the weakest issues studied in PCDs is the procoagulant activity of neutrophil extracellular traps (NETs). NETs are web-like structures released from neutrophils in response to different stimuli. These structures are made of deoxyribonucleic acid (DNA) and bactericidal proteins, such as histones, myeloperoxidase, neutrophil elastase, and over 300 other proteins, which are primarily stored in neutrophil granules. NETs immobilize, inactivate the pathogens, and expose them to specialized cells of immune response. Despite their pivotal role in innate immunity, they contribute to the development and exacerbation of autoimmune diseases, trigger inflammatory response, or even facilitate the formation of cancer metastases. NETs were also found to induce activity of coagulation and are considered one of the most important factors inducing thrombosis. Here, we summarize how PCDs influence the release of NETs, and hypothesize whether NETs contribute to hypercoagulability in PCDs patients.
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8
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The role of CD44 in the assessment of minimal residual disease of multiple myeloma by flow cytometry. J Hematop 2021. [DOI: 10.1007/s12308-021-00468-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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9
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Soh KT, Wallace PK. Evaluation of measurable residual disease in multiple myeloma by multiparametric flow cytometry: Current paradigm, guidelines, and future applications. Int J Lab Hematol 2021; 43 Suppl 1:43-53. [PMID: 34288449 DOI: 10.1111/ijlh.13562] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/22/2021] [Accepted: 04/07/2021] [Indexed: 12/16/2022]
Abstract
Multiple myeloma (MM) is a heterogeneous group of mature B-cell diseases that are typically characterized by the presence and accumulation of abnormal plasma cells (PCs), which results in the excess production of monoclonal immunoglobulin and/or light chain found in the serum and/or urine. Multiparametric flow cytometry (MFC) is an indispensable tool to supplement the diagnosis, classification and monitoring of the disease due to its high patient applicability, excellent sensitivity and encouraging results from various clinical trials. In this regard, minimal or, more appropriately, measurable residual disease (MRD) negativity by MFC has been recognized as a powerful predictor of favourable long-term outcomes. Before flow cytometry can be effectively implemented in the clinical setting for MM MRD testing, sample preparation, panel configuration, analysis and gating strategies must be optimized to ensure accurate results. This manuscript will discuss the current consensus guidelines for flow cytometric processing of samples and reporting of results for MM MRD testing. We also discuss alternative approaches to detect plasma cells in the presence of daratumumab treatment. Finally, there is a lack of information describing the subclonal distribution of myeloma cells based on their protein expression. The advent of high-dimensional analysis may assist in following the evolution of antigen expression patterns on abnormal plasma cells in patients with relapsed/refractory disease. This in turn can help identify clonal subtypes that are more aggressive for potential informed decision. An analysis using t-SNE to identify the emergence of PCs subclones by MFC, along with the analysis of their immunophenotypic profiles are presented as a future perspective.
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Affiliation(s)
- Kah Teong Soh
- Department of Flow and Image Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
| | - Paul K Wallace
- Department of Flow and Image Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, NY, USA
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Soh KT, Tario JD, Hahn T, Hillengass J, McCarthy PL, Wallace PK. CD319
(
SLAMF7
) an alternative marker for detecting plasma cells in the presence of daratumumab or elotuzumab. CYTOMETRY PART B-CLINICAL CYTOMETRY 2020; 100:497-508. [DOI: 10.1002/cyto.b.21961] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 08/27/2020] [Accepted: 09/15/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Kah Teong Soh
- Department of Flow and Image Cytometry Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Joseph D. Tario
- Department of Flow and Image Cytometry Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Theresa Hahn
- Transplant and Cellular Therapy Program Roswell Park Comprehensive Cancer Center Buffalo New York USA
- Department of Medicine Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Jens Hillengass
- Transplant and Cellular Therapy Program Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Philip L. McCarthy
- Transplant and Cellular Therapy Program Roswell Park Comprehensive Cancer Center Buffalo New York USA
- Department of Medicine Roswell Park Comprehensive Cancer Center Buffalo New York USA
| | - Paul K. Wallace
- Department of Flow and Image Cytometry Roswell Park Comprehensive Cancer Center Buffalo New York USA
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11
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Lee LX, Li SC. Hunting down the dominating subclone of cancer stem cells as a potential new therapeutic target in multiple myeloma: An artificial intelligence perspective. World J Stem Cells 2020; 12:706-720. [PMID: 32952853 PMCID: PMC7477658 DOI: 10.4252/wjsc.v12.i8.706] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/08/2020] [Accepted: 08/13/2020] [Indexed: 02/07/2023] Open
Abstract
The development of single-cell subclones, which can rapidly switch from dormant to dominant subclones, occur in the natural pathophysiology of multiple myeloma (MM) but is often "pressed" by the standard treatment of MM. These emerging subclones present a challenge, providing reservoirs for chemoresistant mutations. Technological advancement is required to track MM subclonal changes, as understanding MM's mechanism of evolution at the cellular level can prompt the development of new targeted ways of treating this disease. Current methods to study the evolution of subclones in MM rely on technologies capable of phenotypically and genotypically characterizing plasma cells, which include immunohistochemistry, flow cytometry, or cytogenetics. Still, all of these technologies may be limited by the sensitivity for picking up rare events. In contrast, more incisive methods such as RNA sequencing, comparative genomic hybridization, or whole-genome sequencing are not yet commonly used in clinical practice. Here we introduce the epidemiological diagnosis and prognosis of MM and review current methods for evaluating MM subclone evolution, such as minimal residual disease/multiparametric flow cytometry/next-generation sequencing, and their respective advantages and disadvantages. In addition, we propose our new single-cell method of evaluation to understand MM's mechanism of evolution at the molecular and cellular level and to prompt the development of new targeted ways of treating this disease, which has a broad prospect.
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Affiliation(s)
- Lisa X Lee
- Division of Hematology/Oncology, Department of Medicine, Chao Family Comprehensive Cancer Center, UCI Health, Orange, CA 92868, United States
| | - Shengwen Calvin Li
- Neuro-oncology and Stem Cell Research Laboratory, CHOC Children's Research Institute, Children's Hospital of Orange County, Orange, CA 92868, United States
- Department of Neurology, University of California-Irvine School of Medicine, Orange, CA 92868, United States
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12
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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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13
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Millar JK, Benninger LA, Li Y, Ataya A. A 42-Year-Old Man With Shortness of Breath, Fever, and Pleural Effusions. Chest 2020; 155:e141-e144. [PMID: 31060711 DOI: 10.1016/j.chest.2018.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/19/2018] [Accepted: 10/26/2018] [Indexed: 10/26/2022] Open
Abstract
CASE PRESENTATION A 42-year-old man with a history of progressive multiple myeloma and chronic kidney disease presented with worsening shortness of breath and fever. He was scheduled for a planned admission for chemotherapy on the day of presentation and had developed these symptoms the night before. He had also developed worsening fatigue but denied any new cough, sputum production, or abdominal pain. The patient had been previously admitted 3 weeks prior for neutropenic fever and colitis during his first cycle of chemotherapy.
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Affiliation(s)
| | - Lauryn A Benninger
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL
| | - Ying Li
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, Gainesville, FL
| | - Ali Ataya
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, Gainesville, FL.
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14
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Jacoby E, Shahani SA, Shah NN. Updates on CAR T-cell therapy in B-cell malignancies. Immunol Rev 2020; 290:39-59. [PMID: 31355492 DOI: 10.1111/imr.12774] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Accepted: 05/09/2019] [Indexed: 12/22/2022]
Abstract
By increasing disease-free survival and offering the potential for long-term cure, chimeric antigen receptor (CAR) T-cell therapy has dramatically expanded therapeutic options among those with high-risk B-cell malignancies. As CAR T-cell utilization evolves however, novel challenges are generated. These include determining how to optimally integrate CAR T cells into standard of care and overcoming mechanisms of resistance to CAR T-cell therapy, such as evolutionary stress induced on cancer cells leading to immunophenotypic changes that allow leukemia to evade this targeted therapy. Compounding these challenges are the limited ability to determine differences between various CAR T-cell constructs, understanding the generalizability of trial outcomes from multiple sites utilizing unique CAR manufacturing strategies, and comparing distinct criteria for toxicity grading while defining optimal management. Additionally, as understanding of CAR behavior in humans has developed, strategies have appropriately evolved to proactively mitigate toxicities. These challenges offer complimentary insights and guide next steps to enhance the efficacy of this novel therapeutic modality. With a focus on B-cell malignancies as the paradigm for effective CAR T-cell therapy, this review describes advances in the field as well as current challenges and future directions.
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Affiliation(s)
- Elad Jacoby
- Division of Pediatric Hematology, Oncology and BMT, The Edmond and Lily Safra Children's Hospital, Sheba Medical Center and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shilpa A Shahani
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Nirali N Shah
- Pediatric Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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15
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Kunacheewa C, Lee HC, Patel K, Thomas S, Amini B, Srour S, Bashir Q, Nieto Y, Qazilbash MH, Weber DM, Feng L, Orlowski RZ, Lin P, Manasanch EE. Minimal Residual Disease Negativity Does Not Overcome Poor Prognosis in High-Risk Multiple Myeloma: A Single-Center Retrospective Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e221-e238. [PMID: 32037287 DOI: 10.1016/j.clml.2020.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 12/28/2019] [Accepted: 01/02/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Minimal residual disease (MRD) is a standard measurement for response assessment in multiple myeloma (MM). Despite new treatments, high-risk MM patients continue to have poor prognosis. We evaluated the effect of MRD negativity in high-risk versus standard-risk patients. PATIENTS AND METHODS We retrospectively evaluated all consecutive MM patients who underwent routine MRD testing by 1-tube 8-color advanced flow cytometry with 2,000,000 events and sensitivity level 10-5 at our center from 2015 to 2018 after initial therapy. Kaplan-Meier and log-rank test were used to assess survival estimates and differences between study groups. RESULTS One hundred thirty-six patients with MRD testing after initial therapy or autologous stem-cell transplantation were identified. At a median follow-up of 14 months (range, 1-36 months), progression-free survival and overall survival were significantly worse in high-risk versus standard-risk patients. During the study period, 50% of high-risk group had experienced disease progression (relapse and/or death) versus 20% in the standard-risk group (P = .0006). No patients with standard-risk died, but 4 (14%) in the high-risk group did (P = .0007). Regardless of MRD status, high-risk patients had statistically significant worse progression-free survival than standard-risk patients. At median follow-up, those with disease 10% standard-risk/MRD negative; 20% standard-risk/MRD positive; 40% high-risk/MRD negative; and 45% high-risk/MRD positive had either experienced relapse or died (P = .0041). MRD status did not significantly affect overall survival in either group (P = .0914); however, longer follow-up is needed to assess survival. CONCLUSION Genetic abnormalities remain a powerful prognostic indicator for MM, regardless of MRD status. For newly diagnosed MM patients treated with novel triple-drug initial therapy and frontline autologous stem-cell transplantation, MRD-negative status did not mitigate the poor-prognosis outcomes of high-risk MM patients.
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Affiliation(s)
- Chutima Kunacheewa
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hans C Lee
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Krina Patel
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sheeba Thomas
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Behrang Amini
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Samer Srour
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Qaiser Bashir
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yago Nieto
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Muzzaffar H Qazilbash
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Donna M Weber
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lei Feng
- Department of Statistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pei Lin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elisabet E Manasanch
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX.
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16
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Soh KT, Tario JD, Hahn TE, Hillengass J, McCarthy PL, Wallace PK. Methodological considerations for the high sensitivity detection of multiple myeloma measurable residual disease. CYTOMETRY PART B-CLINICAL CYTOMETRY 2019; 98:161-173. [PMID: 31868315 DOI: 10.1002/cyto.b.21862] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Recent advances in therapeutic interventions have dramatically improved complete response rates in patients with multiple myeloma (MM). The ability to identify residual myeloma cells (e.g., measurable residual disease [MRD]) can provide valuable information pertaining to patient's depth of response to therapy and risk of relapse. Multiparametric flow cytometry is an excellent technique to monitor MRD and has been demonstrated to correlate with patient outcome post-treatment. To achieve the high sensitivity (one abnormal cell in 105 -106 cells) required for MRD evaluation, millions of cells have to be acquired and conventional immunophenotyping protocols are unable to attain these numbers, indicating the needs for alternative flow cytometric staining procedures. A bulk, "Pre-lysis" method is the consensus approach for staining large number of cells, requires two red blood cell lysis steps, and can adversely affect epitope density. In this study, we tested the "Pooled-tube" and "Dextran Sedimentation" staining procedures and correlated them with the "Pre-lysis" method as potential alternative approaches. METHODS A total of 22 bone marrow aspirates from patients with plasma cell (PC) dyscrasia were processed in parallel using the "Pre-lysis," "Pooled-tube," and "Dextran Sedimentation" techniques. Stain indices were calculated and compared to assess their impacts on staining performance for each antibody used in the consensus panel. The recovery of normal and abnormal PCs, mast cells, and B cell precursors was enumerated and compared after their counts were normalized using fluorescent beads. The limit of blank, limit of detection, and lower limit of quantification were established using serial dilution experiments. RESULTS The staining performances of CD19 PECy7, CD27 BV510, CD81 APCH7, and CD138 BV421 were improved using the "Pooled-tube" method when compared to "Pre-lysis." "Pre-lysis" was better at resolving CD56 using clone C5.9 but our results demonstrated similar improvement can also be achieved by "Pooled-tube" when alternative CD56 PE clones were used. "Dextran sedimentation" yielded similar staining results when compared to "Pre-lysis" for all the markers analyzed. The "Pooled-tube" method, when normalized to "Pre-lysis," recovered higher numbers of total PCs (1.2 ± 0.2 times higher; p = .049), normal PCs (1.4 ± 0.26; p = .007), mast cells (1.46 ± 0.27; p = .003), and B cell precursors (1.42 ± 0.3; p = .011), but not abnormal PCs (1.09 ± 0.2; p = .352). There was no evidence that the recovery of cells was different between "Pre-lysis" versus "Dextran Sedimentation." All three flow cytometric assays achieved a minimum sensitivity of 10-5 and approached that of 10-6 for detecting rare events. CONCLUSION Both "Pooled-tube" and "Dextran Sedimentation" staining procedures were comparable to the "Pre-lysis" method and are suitable high sensitivity flow cytometric approaches that can be used to process bone marrow samples for MM MRD testing.
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Affiliation(s)
- Kah Teong Soh
- Department of Flow and Image Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Joseph D Tario
- Department of Flow and Image Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Theresa E Hahn
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.,Transplant and Cellular Therapy Program, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Jens Hillengass
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.,Transplant and Cellular Therapy Program, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Paul K Wallace
- Department of Flow and Image Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, New York
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17
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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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18
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Holstein SA, Avet-Loiseau H, Hahn T, Ho CM, Lohr JG, Munshi NC, Paiva B, Pasquini MC, Tario JD, Usmani SZ, Wallace PK, Weisel K, McCarthy PL. BMT CTN Myeloma Intergroup Workshop on Minimal Residual Disease and Immune Profiling: Summary and Recommendations from the Organizing Committee. Biol Blood Marrow Transplant 2017; 24:641-648. [PMID: 29242112 DOI: 10.1016/j.bbmt.2017.12.774] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 12/05/2017] [Indexed: 12/21/2022]
Abstract
The Blood and Marrow Transplant Clinical Trials Network Myeloma Intergroup Workshop on Minimal Residual Disease and Immune Profiling was convened on December 1, 2016 at the American Society of Hematology meeting to discuss the emerging data and technologies for minimal residual disease assessment and immune profiling in myeloma. Particular emphasis was placed on developing strategies to incorporate these techniques into clinical trial design. This document reviews the literature, summarizes the topics discussed in the workshop, and provides recommendations for integration of these techniques into future clinical trial design.
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Affiliation(s)
- Sarah A Holstein
- Division of Oncology and Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Hervé Avet-Loiseau
- Centre de Recherches en Cancerologie de Toulouse CRCT, Institut National de la Sante et de la Recherche Medicale, University Cancer Center of Toulouse, Toulouse, France
| | - Theresa Hahn
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
| | - Christine M Ho
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
| | - Jens G Lohr
- Department of Medicine, Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Nikhil C Munshi
- Department of Medicine, Hematologic Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Bruno Paiva
- Centro de Investigación Medica Aplicadas, Instituto de Investigación Sanitaria de Navarra, Centro de Investigacion Biomedica en Red Cancer, Clínica Universidad de Navarra, Pamplona, Spain
| | - Marcelo C Pasquini
- Department of Medicine, Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Milwaukee
| | - Joseph D Tario
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
| | - Saad Z Usmani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Charlotte, North Carolina
| | - Paul K Wallace
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
| | - Katja Weisel
- Department of Hematology and Oncology, Universitatsklinikum Tubingen, Tubingen, Germany
| | - Philip L McCarthy
- Department of Medicine, Blood & Marrow Transplant Center, Roswell Park Cancer Institute, Buffalo, New York
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