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Duncavage EJ, Jacoby MA, Chang GS, Miller CA, Edwin N, Shao J, Elliott K, Robinson J, Abel H, Fulton RS, Fronick CC, O'Laughlin M, Heath SE, Brendel K, Saba R, Wartman LD, Christopher MJ, Pusic I, Welch JS, Uy GL, Link DC, DiPersio JF, Westervelt P, Ley TJ, Trinkaus K, Graubert TA, Walter MJ. Mutation Clearance after Transplantation for Myelodysplastic Syndrome. N Engl J Med 2018; 379:1028-1041. [PMID: 30207916 PMCID: PMC6309244 DOI: 10.1056/nejmoa1804714] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Allogeneic hematopoietic stem-cell transplantation is the only curative treatment for patients with myelodysplastic syndrome (MDS). The molecular predictors of disease progression after transplantation are unclear. METHODS We sequenced bone marrow and skin samples from 90 adults with MDS who underwent allogeneic hematopoietic stem-cell transplantation after a myeloablative or reduced-intensity conditioning regimen. We detected mutations before transplantation using enhanced exome sequencing, and we evaluated mutation clearance by using error-corrected sequencing to genotype mutations in bone marrow samples obtained 30 days after transplantation. In this exploratory study, we evaluated the association of a mutation detected after transplantation with disease progression and survival. RESULTS Sequencing identified at least one validated somatic mutation before transplantation in 86 of 90 patients (96%); 32 of these patients (37%) had at least one mutation with a maximum variant allele frequency of at least 0.5% (equivalent to 1 heterozygous mutant cell in 100 cells) 30 days after transplantation. Patients with disease progression had mutations with a higher maximum variant allele frequency at 30 days than those who did not (median maximum variant allele frequency, 0.9% vs. 0%; P<0.001). The presence of at least one mutation with a variant allele frequency of at least 0.5% at day 30 was associated with a higher risk of progression (53.1% vs. 13.0%; conditioning regimen-adjusted hazard ratio, 3.86; 95% confidence interval [CI], 1.96 to 7.62; P<0.001) and a lower 1-year rate of progression-free survival than the absence of such a mutation (31.3% vs. 59.3%; conditioning regimen-adjusted hazard ratio for progression or death, 2.22; 95% CI, 1.32 to 3.73; P=0.005). The rate of progression-free survival was lower among patients who had received a reduced-intensity conditioning regimen and had at least one persistent mutation with a variant allele frequency of at least 0.5% at day 30 than among patients with other combinations of conditioning regimen and mutation status (P≤0.001). Multivariate analysis confirmed that patients who had a mutation with a variant allele frequency of at least 0.5% detected at day 30 had a higher risk of progression (hazard ratio, 4.48; 95% CI, 2.21 to 9.08; P<0.001) and a lower 1-year rate of progression-free survival than those who did not (hazard ratio for progression or death, 2.39; 95% CI, 1.40 to 4.09; P=0.002). CONCLUSIONS The risk of disease progression was higher among patients with MDS in whom persistent disease-associated mutations were detected in the bone marrow 30 days after transplantation than among those in whom these mutations were not detected. (Funded by the Leukemia and Lymphoma Society and others.).
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Affiliation(s)
- Eric J Duncavage
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Meagan A Jacoby
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Gue Su Chang
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Christopher A Miller
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Natasha Edwin
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Jin Shao
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Kevin Elliott
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Joshua Robinson
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Haley Abel
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Robert S Fulton
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Catrina C Fronick
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Michelle O'Laughlin
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Sharon E Heath
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Kimberly Brendel
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Raya Saba
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Lukas D Wartman
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Matthew J Christopher
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Iskra Pusic
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - John S Welch
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Geoffrey L Uy
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Daniel C Link
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - John F DiPersio
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Peter Westervelt
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Timothy J Ley
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Kathryn Trinkaus
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Timothy A Graubert
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
| | - Matthew J Walter
- From the Department of Pathology and Immunology (E.J.D.), the Department of Medicine, Division of Oncology (M.A.J., C.A.M., N.E., J.S., K.E., J.R., S.E.H., K.B., L.D.W., M.J.C., I.P., J.S.W., G.L.U., D.C.L., J.F.D., P.W., T.J.L., M.J.W.), the McDonnell Genome Institute (G.S.C., C.A.M., H.A., R.S.F., C.C.F., M.O.), the Department of Medicine, Division of Hospital Medicine (R.S.), and Siteman Biostatistics Shared Resource, Siteman Cancer Center (K.T.), Washington University School of Medicine in St. Louis, St. Louis; and Massachusetts General Hospital Cancer Center, Boston (T.A.G.)
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