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Ma SB, Lin W, Campbell J, Clerici K, White D, Yeung D, Gorniak M, Fleming S, Fong CY, Agarwal R. Laboratory validation and clinical utility of next-generation sequencing-based IGH/TCR clonality testing for the monitoring of measurable residual disease in acute lymphoblastic leukaemia: real-world experience at Austin Pathology. Pathology 2024:S0031-3025(24)00171-5. [PMID: 39025724 DOI: 10.1016/j.pathol.2024.04.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/12/2024] [Accepted: 04/28/2024] [Indexed: 07/20/2024]
Abstract
Measurable residual disease (MRD) testing is an essential aspect of disease prognostication in acute lymphoblastic leukaemia (ALL) and informs clinical decisions. The depth of MRD clearance is highly relevant and requires assays with sufficient sensitivity. Austin Pathology is one of the few laboratories in Australia currently utilising a fully validated and National Association of Testing Authorities (NATA)-accredited ultrasensitive next-generation sequencing (NGS) platform for MRD monitoring in ALL. This technology is based on the detection of clonal rearrangement of immunoglobulin and T cell receptor genes in leukaemic cells, and is capable of achieving a limit of detection at least one to two logs below that of multiparametric flow cytometry (MFC). In this retrospective analysis, we report a clonotype detection rate of up to 85.7% at diagnosis, and a concordance rate of 78.7% in MRD results between NGS and MFC. Of the discordant samples, nearly all were NGS+/MFC-, highlighting the superior sensitivity of NGS. The enhanced sensitivity is clinically relevant, as discordant MRD results often heralded fulminant relapse, and therefore offer clinicians additional lead time and a window of opportunity to initiate pre-emptive therapy. Notwithstanding a small and heterogeneous cohort, our real-world survival data indicate an intermediate relapse risk for NGS+/MFC- patients. In light of recent approval of Medicare rebatable ALL MRD testing, we discuss how NGS can complement other techniques such as MFC in personalising management strategies. We recommend routine clonality testing by NGS at diagnosis and use a multi-modality approach for subsequent MRD monitoring.
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Affiliation(s)
- Stephen B Ma
- Austin Pathology, Heidelberg, Vic, Australia; Austin Health, Heidelberg, Vic, Australia.
| | - Wendi Lin
- Austin Pathology, Heidelberg, Vic, Australia
| | | | | | - Deborah White
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - David Yeung
- South Australian Health and Medical Research Institute, Adelaide, SA, Australia; Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | | | - Shaun Fleming
- Alfred Health, Melbourne, Vic, Australia; Australian Centre for Blood Diseases, Monash University, Melbourne, Vic, Australia
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Pott C, Jurinovic V, Trotman J, Kehden B, Unterhalt M, Herold M, Jagt RVD, Janssens A, Kneba M, Mayer J, Young M, Schmidt C, Knapp A, Nielsen T, Brown H, Spielewoy N, Harbron C, Bottos A, Mundt K, Marcus R, Hiddemann W, Hoster E. Minimal Residual Disease Status Predicts Outcome in Patients With Previously Untreated Follicular Lymphoma: A Prospective Analysis of the Phase III GALLIUM Study. J Clin Oncol 2024; 42:550-561. [PMID: 38096461 DOI: 10.1200/jco.23.00838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 08/23/2023] [Accepted: 10/12/2023] [Indexed: 02/09/2024] Open
Abstract
PURPOSE We report an analysis of minimal residual/detectable disease (MRD) as a predictor of outcome in previously untreated patients with follicular lymphoma (FL) from the randomized, multicenter GALLIUM (ClinicalTrials.gov identifier: NCT01332968) trial. PATIENTS AND METHODS Patients received induction with obinutuzumab (G) or rituximab (R) plus bendamustine, or cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) or cyclophosphamide, vincristine, prednisone (CVP) chemotherapy, followed by maintenance with the same antibody in responders. MRD status was assessed at predefined time points (mid-induction [MI], end of induction [EOI], and at 4-6 monthly intervals during maintenance and follow-up). Patients with evaluable biomarker data at diagnosis were included in the survival analysis. RESULTS MRD positivity was associated with inferior progression-free survival (PFS) at MI (hazard ratio [HR], 3.03 [95% CI, 2.07 to 4.45]; P < .0001) and EOI (HR, 2.25 [95% CI, 1.53 to 3.32]; P < .0001). MRD response was higher after G- versus R-chemotherapy at MI (94.2% v 88.9%; P = .013) and at EOI (93.1% v 86.7%; P = .0077). Late responders (MI-positive/EOI-negative) had a significantly poorer PFS than early responders (MI-negative/EOI-negative; HR, 3.11 [95% CI, 1.75 to 5.52]; P = .00011). The smallest proportion of MRD positivity was observed in patients receiving bendamustine at MI (4.8% v 16.0% in those receiving CHOP; P < .0001). G appeared to compensate for less effective chemotherapy regimens, with similar MRD response rates observed across the G-chemo groups. During the maintenance period, more patients treated with R than with G were MRD-positive (R-CHOP, 20.7% v G-CHOP, 7.0%; R-CVP, 21.7% v G-CVP, 9.4%). Throughout maintenance, MRD positivity was associated with clinical relapse. CONCLUSION MRD status can determine outcome after induction and during maintenance, and MRD negativity is a prerequisite for long-term disease control in FL. The higher MRD responses after G- versus R-based treatment confirm more effective tumor cell clearance.
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Affiliation(s)
| | - Vindi Jurinovic
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Judith Trotman
- Concord Repatriation General Hospital, University of Sydney, Sydney, NSW, Australia
| | - Britta Kehden
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Michael Unterhalt
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | | | | | | | - Michael Kneba
- University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jiri Mayer
- University Hospital and Masaryk University, Brno, Czech Republic
| | - Moya Young
- East Kent Hospital, Canterbury, United Kingdom
| | - Christian Schmidt
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | | | | | - Helen Brown
- Roche Products Ltd, Welwyn Garden City, United Kingdom
| | | | - Chris Harbron
- Roche Products Ltd, Welwyn Garden City, United Kingdom
| | | | | | | | - Wolfgang Hiddemann
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Eva Hoster
- Department of Internal Medicine III, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
- Institute for Medical Information Processing, Biometry, and Epidemiology, Faculty of Medicine, Ludwig-Maximilians-University Munich, Munich, Germany
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Silva W, Rego E. How to Manage Philadelphia-Positive Acute Lymphoblastic Leukemia in Resource-Constrained Settings. Cancers (Basel) 2023; 15:5783. [PMID: 38136329 PMCID: PMC10741425 DOI: 10.3390/cancers15245783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 12/24/2023] Open
Abstract
Recent studies have indicated that more than half of adult patients newly diagnosed with Ph+ ALL can now achieve a cure. However, determining the most suitable protocol for less-resourced settings can be challenging. In these situations, we must consider the potential for treatment toxicity and limited access to newer agents and alloSCT facilities. Currently, it is advisable to use less intensive induction regimens for Ph+ ALL. These regimens can achieve high rates of complete remission while causing fewer induction deaths. For consolidation therapy, chemotherapy should remain relatively intensive, with careful monitoring of the BCR-ABL1 molecular transcript and minimal residual disease. AlloSCT may be considered, especially for patients who do not achieve complete molecular remission or have high-risk genetic abnormalities, such as IKZF1-plus. If there is a loss of molecular response, it is essential to screen patients for ABL mutations and, ideally, change the TKI therapy. The T315I mutation is the most common mechanism for disease resistance, being targetable to ponatinib. Blinatumomab, a bispecific antibody, has shown significant synergy with TKIs in treating this disease. It serves as an excellent salvage therapy, aside from achieving outstanding results when incorporated into the frontline.
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Affiliation(s)
- Wellington Silva
- Discipline of Hematology, Hospital das Clínicas da Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo 05403-010, Brazil;
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Kovach AE, Wood BL. Updates on lymphoblastic leukemia/lymphoma classification and minimal/measurable residual disease analysis. Semin Diagn Pathol 2023; 40:457-471. [PMID: 37953192 DOI: 10.1053/j.semdp.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 10/18/2023] [Accepted: 10/31/2023] [Indexed: 11/14/2023]
Abstract
Lymphoblastic leukemia/lymphoma (ALL/LBL), especially certain subtypes, continues to confer morbidity and mortality despite significant therapeutic advances. The pathologic classification of ALL/LBL, especially that of B-ALL, has recently substantially expanded with the identification of several distinct and prognostically important genetic drivers. These discoveries are reflected in both current classification systems, the World Health Organization (WHO) 5th edition and the new International Consensus Classification (ICC). In this article, novel subtypes of B-ALL are reviewed, including DUX4, MEF2D and ZNF384-rearranged B-ALL; the rare pediatric entity B-ALL with TLF3::HLF, now added to the classifications, is discussed; updates to the category of B-ALL with BCR::ABL1-like features (Ph-like B-ALL) are summarized; and emerging genetic subtypes of T-ALL are presented. The second half of the article details current approaches to minimal/measurable residual disease (MRD) detection in B-ALL and T-ALL and presents anticipated challenges to current approaches in the burgeoning era of antigen-directed immunotherapy.
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Affiliation(s)
- Alexandra E Kovach
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, United States; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States.
| | - Brent L Wood
- Department of Pathology and Laboratory Medicine, Children's Hospital Los Angeles, Los Angeles, CA, United States; Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
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Darzentas F, Szczepanowski M, Kotrová M, Hartmann A, Beder T, Gökbuget N, Schwartz S, Bastian L, Baldus CD, Pál K, Darzentas N, Brüggemann M. Insights into IGH clonal evolution in BCP-ALL: frequency, mechanisms, associations, and diagnostic implications. Front Immunol 2023; 14:1125017. [PMID: 37143651 PMCID: PMC10151743 DOI: 10.3389/fimmu.2023.1125017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/27/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction The malignant transformation leading to a maturation arrest in B-cell precursor acute lymphoblastic leukemia (BCP-ALL) occurs early in B-cell development, in a pro-B or pre-B cell, when somatic recombination of variable (V), diversity (D), and joining (J) segment immunoglobulin (IG) genes and the B-cell rescue mechanism of VH replacement might be ongoing or fully active, driving clonal evolution. In this study of newly diagnosed BCP-ALL, we sought to understand the mechanistic details of oligoclonal composition of the leukemia at diagnosis, clonal evolution during follow-up, and clonal distribution in different hematopoietic compartments. Methods Utilizing high-throughput sequencing assays and bespoke bioinformatics we identified BCP-ALL-derived clonally-related IGH sequences by their shared 'DNJ-stem'. Results We introduce the concept of 'marker DNJ-stem' to cover the entirety of, even lowly abundant, clonally-related family members. In a cohort of 280 adult patients with BCP-ALL, IGH clonal evolution at diagnosis was identified in one-third of patients. The phenomenon was linked to contemporaneous recombinant and editing activity driven by aberrant ongoing DH/VH-DJH recombination and VH replacement, and we share insights and examples for both. Furthermore, in a subset of 167 patients with molecular subtype allocation, high prevalence and high degree of clonal evolution driven by ongoing DH/VH-DJH recombination were associated with the presence of KMT2A gene rearrangements, while VH replacements occurred more frequently in Ph-like and DUX4 BCP-ALL. Analysis of 46 matched diagnostic bone marrow and peripheral blood samples showed a comparable clonal and clonotypic distribution in both hematopoietic compartments, but the clonotypic composition markedly changed in longitudinal follow-up analysis in select cases. Thus, finally, we present cases where the specific dynamics of clonal evolution have implications for both the initial marker identification and the MRD monitoring in follow-up samples. Discussion Consequently, we suggest to follow the marker DNJ-stem (capturing all family members) rather than specific clonotypes as the MRD target, as well as to follow both VDJH and DJH family members since their respective kinetics are not always parallel. Our study further highlights the intricacy, importance, and present and future challenges of IGH clonal evolution in BCP-ALL.
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Affiliation(s)
- Franziska Darzentas
- Medical Department II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Monika Szczepanowski
- Medical Department II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Michaela Kotrová
- Medical Department II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Alina Hartmann
- Medical Department II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
- University Cancer Center Schleswig-Holstein (UCCSH), University Hospital Schleswig-Holstein, Kiel, Germany
- Clinical Research Unit “CATCH-ALL” (KFO 5010/1), funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation), Bonn, Germany
| | - Thomas Beder
- Medical Department II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
- University Cancer Center Schleswig-Holstein (UCCSH), University Hospital Schleswig-Holstein, Kiel, Germany
| | - Nicola Gökbuget
- Department of Medicine II, Hematology/Oncology, Goethe University Hospital, Frankfurt/M, Germany
| | - Stefan Schwartz
- Department of Hematology, Oncology and Tumor Immunology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Lorenz Bastian
- Medical Department II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
- University Cancer Center Schleswig-Holstein (UCCSH), University Hospital Schleswig-Holstein, Kiel, Germany
- Clinical Research Unit “CATCH-ALL” (KFO 5010/1), funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation), Bonn, Germany
| | - Claudia Dorothea Baldus
- Medical Department II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
- University Cancer Center Schleswig-Holstein (UCCSH), University Hospital Schleswig-Holstein, Kiel, Germany
- Clinical Research Unit “CATCH-ALL” (KFO 5010/1), funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation), Bonn, Germany
| | - Karol Pál
- Central European Institute of Technology, Masaryk University, Brno, Czechia
| | - Nikos Darzentas
- Medical Department II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
- *Correspondence: Nikos Darzentas,
| | - Monika Brüggemann
- Medical Department II, Hematology and Oncology, University Hospital Schleswig-Holstein, Kiel, Germany
- University Cancer Center Schleswig-Holstein (UCCSH), University Hospital Schleswig-Holstein, Kiel, Germany
- Clinical Research Unit “CATCH-ALL” (KFO 5010/1), funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation), Bonn, Germany
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Pierce E, Mautner B, Mort J, Blewett A, Morris A, Keng M, El Chaer F. MRD in ALL: Optimization and Innovations. Curr Hematol Malig Rep 2022; 17:69-81. [PMID: 35616771 DOI: 10.1007/s11899-022-00664-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Measurable residual disease (MRD) is an important monitoring parameter that can help predict survival outcomes in acute lymphoblastic leukemia (ALL). Identifying patients with MRD has the potential to decrease the risk of relapse with the initiation of early salvage therapy and to help guide decision making regarding allogeneic hematopoietic cell transplantation. In this review, we discuss MRD in ALL, focusing on advantages and limitations between MRD testing techniques and how to monitor MRD in specific patient populations. RECENT FINDINGS MRD has traditionally been measured through bone marrow samples, but more data for evaluation of MRD via peripheral blood is emerging. Current and developmental testing strategies for MRD include multiparametric flow cytometry (MFC), next-generation sequencing (NGS), quantitative polymerase chain reaction (qPCR), and ClonoSeq. Novel therapies are incorporating MRD as an outcome measure to demonstrate efficacy, including blinatumomab, inotuzumab ozogamicin, and chimeric antigen receptor T (CAR-T) cell therapy. Understanding how to incorporate MRD testing into the management of ALL could improve patient outcomes and predict efficacy of new therapy options.
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Affiliation(s)
- Eric Pierce
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Benjamin Mautner
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Joseph Mort
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Anastassia Blewett
- Department of Pharmacy Services, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Amy Morris
- Department of Pharmacy Services, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Michael Keng
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA
| | - Firas El Chaer
- Department of Medicine, Division of Hematology and Oncology, University of Virginia Comprehensive Cancer Center, 1300 Jefferson Park Ave, PO Box 800716, Charlottesville, VA, 22908, USA.
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Gökbuget N. MRD in adult Ph/BCR-ABL-negative ALL: how best to eradicate? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:718-725. [PMID: 35158373 PMCID: PMC8824253 DOI: 10.1182/hematology.2021000224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Evaluation of minimal residual disease (MRD) during first-line treatment and after salvage therapy is part of the standard management of acute lymphoblastic leukemia (ALL). Persistent or recurrent MRD is one of the most relevant prognostic factors and identifies a group of patients with resistance to standard chemotherapy. These patients have a high risk of relapse despite continued first-line therapy. Although stem cell transplantation (SCT) is an appropriate strategy, patients with high MRD show an increased relapse rate even after SCT. Approximately one-quarter of adult ALL patients develop an MRD failure, defined as MRD above 0.01% after standard induction and consolidation. The best time point and level of MRD for treatment modification are matters of debate. In order to eradicate MRD and thereby improve chances for a cure, new targeted compounds with different mechanisms of action compared to chemotherapy are being utilized. These compounds include monoclonal antibodies, chimeric antigen receptor T cells, and molecular targeted compounds. Essential factors for decision-making, available compounds, and follow-up therapies are discussed.
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Affiliation(s)
- Nicola Gökbuget
- Department of Medicine II, Hematology/Oncology, Goethe University, Frankfurt, Germany
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Concordance of peripheral blood and bone marrow measurable residual disease in adult acute lymphoblastic leukemia. Blood Adv 2021; 5:3147-3151. [PMID: 34424318 DOI: 10.1182/bloodadvances.2021004234] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/08/2021] [Indexed: 11/20/2022] Open
Abstract
Monitoring of measurable residual disease (MRD) is essential to the management of acute lymphoblastic leukemia (ALL) and is typically performed through repeated bone marrow (BM) assessments. Using a next-generation sequencing (NGS) MRD platform, we performed a prospective observational study evaluating the correlation between peripheral blood (PB) and BM MRD in adults with ALL receiving cellular therapies (hematopoietic cell transplantation [HCT] and chimeric antigen receptor T-cell [CAR-T] therapies). Among the study cohort (N = 69 patients; 126 paired PB/BM samples), we found strong correlation between PB and BM MRD (r = 0.87; P < .001), with a sensitivity and specificity of MRD detection in the PB of 87% and 90%, respectively, relative to MRD in the BM. MRD became detectable in the PB in 100% of patients who subsequently relapsed following HCT, with median time from MRD+ to clinical relapse of 90 days, and in 85% of patients who relapsed following CAR T, with median time from MRD+ to clinical relapse of 60 days. In adult patients with ALL undergoing cellular therapies, we demonstrate strong concordance between NGS-based MRD detected in the PB and BM. Monitoring of ALL MRD in the PB appears to be an adequate alternative to frequent invasive BM evaluations in this clinical setting.
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Consensus Recommendations for MRD Testing in Adult B-Cell Acute Lymphoblastic Leukemia in Ontario. ACTA ACUST UNITED AC 2021; 28:1376-1387. [PMID: 33808300 PMCID: PMC8025812 DOI: 10.3390/curroncol28020131] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/18/2021] [Accepted: 03/29/2021] [Indexed: 11/16/2022]
Abstract
Measurable (minimal) residual disease (MRD) is an established, key prognostic factor in adult B-cell acute lymphoblastic leukemia (B-ALL), and testing for MRD is known to be an important tool to help guide treatment decisions. The clinical value of MRD testing depends on the accuracy and reliability of results. Currently, there are no Canadian provincial or national guidelines for MRD testing in adult B-ALL, and consistent with the absence of such guidelines, there is no uniform Ontario MRD testing consensus. Moreover, there is great variability in Ontario in MRD testing with respect to where, when, and by which technique, MRD testing is performed, as well as in how the results are interpreted. To address these deficiencies, an expert multidisciplinary working group was convened to define consensus recommendations for improving the provision of such testing. The expert panel recommends that MRD testing should be implemented in a centralized manner to ensure expertise and accuracy in testing for this low volume indication, thereby to provide accurate, reliable results to clinicians and patients. All adult patients with B-ALL should receive MRD testing after induction chemotherapy. Philadelphia chromosome (Ph)-positive patients should have ongoing monitoring of MRD during treatment and thereafter, while samples from Ph-negative B-ALL patients should be tested at least once later during treatment, ideally at 12 to 16 weeks after treatment initiation. In Ph-negative adult B-ALL patients, standardized, ideally centralized, protocols must be used for MRD testing, including both flow cytometry and immunoglobulin (Ig) heavy chain and T-cell receptor (TCR) gene rearrangement analysis. For Ph-positive B-ALL patients, MRD testing using a standardized protocol for reverse transcription real-time quantitative PCR (RT-qPCR) for the BCR-ABL1 gene fusion transcript is recommended, with Ig/TCR gene rearrangement analysis done in parallel likely providing additional clinical information.
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10
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Cherian S, Soma LA. How I Diagnose Minimal/Measurable Residual Disease in B Lymphoblastic Leukemia/Lymphoma by Flow Cytometry. Am J Clin Pathol 2021; 155:38-54. [PMID: 33236071 DOI: 10.1093/ajcp/aqaa242] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Assessment for minimal/measurable residual disease (MRD) is a powerful prognostic factor in B lymphoblastic leukemia/lymphoma (B-LL/L) that is quickly becoming standard of care in assessing patients with B-LL/L posttherapy. MRD can be assessed using methodologies including flow cytometry and molecular genetics, with the former being rapid, relatively inexpensive, and widely applicable in many hematopathology/flow cytometry laboratories. METHODS This article presents an approach to MRD detection in B-LL/L by flow cytometry through case presentations with illustration of several potential pitfalls. We review normal maturation patterns, antigens used for assessment, flow panels that can be utilized, considerations to be made during therapy, and clinical impact. The benefits and drawbacks when using the "different from normal" and "leukemia associated phenotype" approaches are considered. RESULTS Evaluation for MRD in B-LL/L by flow cytometry relies on a knowledge of normal immunophenotypic patterns associated with B-cell maturation in states of rest and marrow regeneration so that one can identify patterns of antigen expression that differentiate abnormal, leukemic populations from regenerating hematogones or B-cell precursors. The nature of therapy can affect normal patterns, a phenomenon especially important to take into consideration given the increased use of targeted therapies in the treatment of B-LL/L. CONCLUSIONS Flow cytometry is widely available in many laboratories and is a cost-effective way to evaluate for B-LL/L MRD. However, panel validation and interpreter education are crucial for accurate assessment.
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Affiliation(s)
- Sindhu Cherian
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
| | - Lorinda A Soma
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle
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Bartram J, Patel B, Fielding AK. Monitoring MRD in ALL: Methodologies, technical aspects and optimal time points for measurement. Semin Hematol 2020; 57:142-148. [PMID: 33256904 DOI: 10.1053/j.seminhematol.2020.06.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 06/02/2020] [Indexed: 01/21/2023]
Abstract
The accurate determination of minimal or measurable residual disease (MRD) during the early months of therapy in acute lymphoblastic leukemia is well established as the most important independent prognostic biomarker, predicting response to combination chemotherapy. Stratification based on MRD maximizes treatment effectiveness while minimizing adverse effects. Allele-specific real-time quantitative PCR of clone-defining immunoglobin/T-cell receptor gene rearrangements in the patients' leukemic clones and/or multiparametric flow cytometric tracking of leukemia-associated immunophenotypes are considered standard of care. Following recent advances in high throughput sequencing (HTS; next generation sequencing), much attention has been devoted to the development of HTS-based MRD assays, which can increase sensitivity; theoretically only limited by the number of cells input into the assay. Knowledge of the methods and limitations of each technology, along with awareness of the sensitivity and specificity of MRD at particular treatment time points is important in interpretation of the MRD value. MRD negativity at pre-established protocol-appropriate time points guides continuance with consolidation/maintenance chemotherapy, whereas positivity leads to a change to a biological therapy such as blinatumomab and intensification of therapy to allogeneic stem cell transplant. Positivity after maintenance may herald impending relapse enabling treatment intervention. MRD has been integral to the introduction of novel agents and cellular therapies into clinical trials and standard of care, but the long-term predictive value of MRD on outcome of novel therapies is not yet established. Integration of somatic genetics with MRD may further improve accurate identification of patients with the lowest and highest risk of relapse.
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Affiliation(s)
- Jack Bartram
- Department of Haematology, Great Ormond Street Hospital for Children, London, UK; Cancer Section, DBC Programme, University College London, London, UK.
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