1
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Menshawy NE, El-Ghonemy MS, Ebrahim MA, Fahmi MW, Saif M, Denewer M, El-Ashwah S. Aberrant ecotropic viral integration site-1 (EVI-1) and myocyte enhancer factor 2 C gene (MEF2C) in adult acute myeloid leukemia are associated with adverse t (9:22) & 11q23 rearrangements. Ann Hematol 2024; 103:2355-2364. [PMID: 38710877 PMCID: PMC11224084 DOI: 10.1007/s00277-024-05779-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 04/23/2024] [Indexed: 05/08/2024]
Abstract
Acute myeloid leukemia (AML) shows multiple chromosomal translocations & point mutations which can be used to refine risk-adapted therapy in AML patients. Ecotropic viral integration site-1 (EVI-1) & myocyte enhancer factor 2 C gene (MEF2C) are key regulatory transcription factors in hematopoiesis and leukemogenesis & both drive immune escape. This prospective study involved 80 adult de novo AML patients recruited from Oncology Center, Mansoura University, between March 2019 and July 2021. The MEF2C and EVI1 expression were measured using a Taqman probe-based qPCR assay. The results revealed that EVI1 and MEF2C expression were significantly elevated in AML patients as compared to control subjects (p = 0.001. 0.007 respectively). Aberrant expressions of EVI1 and MEF2C showed a significant negative correlation with hemoglobin levels (p = 0.034, 0.025 respectively), & bone marrow blasts (p = 0.007, 0.002 respectively). 11q23 translocation was significantly associated with EVI1 and MEF2C (p = 0.004 and 0.02 respectively). Also, t (9;22) was significantly associated with EVI1 and MEF2C (p = 0.01 and 0.03 respectively), higher expression of EVI1 and MEF2C were significantly associated with inferior outcome after induction therapy (p = 0.001 and 0.018 respectively) and shorter overall survival (p = 0.001, 0.014 respectively). In conclusion, EVI1 & MEF2C were significantly expressed in AML cases. EVI1 & MEF2C overexpression were significantly associated with 11q23 rearrangements and t (9;22) and were indicators for poor outcome in adult AML patients; These results could be a step towards personalized therapy in those patients.
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Affiliation(s)
- Nadia El Menshawy
- Clinical Pathology, Hematology unit, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | - Mohamed S El-Ghonemy
- Clinical Pathology, Hematology unit, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | - Mohamed A Ebrahim
- Medical Oncology Unit, Oncology Center, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | - Maryan Waheeb Fahmi
- Medical Oncology Unit, Oncology Center, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt.
| | - Maha Saif
- Medical Oncology Unit, Oncology Center, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | - May Denewer
- Clinical Hematology Unit, Oncology Center, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
| | - Shaimaa El-Ashwah
- Clinical Hematology Unit, Oncology Center, Faculty of Medicine, Mansoura University, Mansoura, 35516, Egypt
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2
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Ouyang D, Ye N, Jiang Y, Wang Y, Hu L, Chao S, Yarmush M, Tuner M, Li Y, Tang B. Label-free microfluidic chip for segregation and recovery of circulating leukemia cells: clinical applications in acute myeloid leukemia. Biomed Microdevices 2023; 26:3. [PMID: 38085348 DOI: 10.1007/s10544-023-00687-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 12/18/2023]
Abstract
We present a label-free microfluidic chip for the segregation of circulating leukemia cells (CLCs) from blood samples, with a focus on its clinical applications in Acute Myeloid Leukemia (AML). The microfluidic chip achieved an approximate capture efficiency of 92%. The study analyzed a comprehensive set of 66 blood specimens from AML patients in different disease stages, including newly diagnosed and relapsing cases, patients in complete remission, and those in partial remission. The results showed a significant difference in CLC counts between active disease stages and remission stages (p < 0.0001), with a proposed threshold of 5 CLCs to differentiate between the two. The microfluidic chip exhibited a sensitivity of 95.4% and specificity of 100% in predicting disease recurrence. Additionally, the captured CLCs were subjected to downstream molecular analysis using droplet digital PCR, allowing for the identification of genetic mutations associated with AML. Comparative analysis with bone marrow aspirate processing by FACS demonstrated the reliability and accuracy of the microfluidic chip in tracking disease burden, with highly agreement results obtained between the two methods. The non-invasive nature of the microfluidic chip and its ability to provide real-time insights into disease progression make it a promising tool for the proactive monitoring and personalized patient care of AML.
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Affiliation(s)
- Dongfang Ouyang
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA.
- Shriners Hospital for Children, Boston, MA, 02114, USA.
| | - Ningxin Ye
- Department of Biology, University of Ottawa, Ottawa, ON, K1N 6N5, Canada
| | - Yue Jiang
- Medical Imaging Science, University of Manchester, Manchester, M13 9PL, UK
| | - Yiyang Wang
- Department of Microbiology, Immunology and Molecular Genetics, University of Californiain , Los Angeles, Los Angeles, CA, 90095, USA
| | - Lina Hu
- Department of Hematology, Shenzhen People's Hospital, Shenzhen, 518020, Guangdong, China
| | - Shuen Chao
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
- Shriners Hospital for Children, Boston, MA, 02114, USA
| | - Martin Yarmush
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
- Shriners Hospital for Children, Boston, MA, 02114, USA
| | - Memet Tuner
- Center for Engineering in Medicine and Surgery, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, 02129, USA
- Shriners Hospital for Children, Boston, MA, 02114, USA
| | - Yonghua Li
- Department of Hematology, PLA General Hospital of Southern Theater Command, Guangzhou , Guangdong, 510010, China
| | - Bin Tang
- Department of Biomedical Engineering, South University of Science and Technology, Shenzhen , Guangdong, 518055, China.
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3
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Pratz KW, Jonas BA, Pullarkat V, Recher C, Schuh AC, Thirman MJ, Garcia JS, DiNardo CD, Vorobyev V, Fracchiolla NS, Yeh SP, Jang JH, Ozcan M, Yamamoto K, Illes A, Zhou Y, Dail M, Chyla B, Potluri J, Döhner H. Measurable Residual Disease Response and Prognosis in Treatment-Naïve Acute Myeloid Leukemia With Venetoclax and Azacitidine. J Clin Oncol 2022; 40:855-865. [PMID: 34910556 PMCID: PMC8906463 DOI: 10.1200/jco.21.01546] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
PURPOSE There is limited evidence on the clinical utility of monitoring measurable residual disease (MRD) in patients with acute myeloid leukemia treated with lower-intensity therapy. Herein, we explored the outcomes of patients treated with venetoclax and azacitidine who achieved composite complete remission (CRc; complete remission + complete remission with incomplete hematologic recovery) and MRD < 10-3 in the VIALE-A trial. METHODS The patients included in this report were treated with venetoclax and azacitidine. Bone marrow aspirate samples for multiparametric flow cytometry assessments were collected for central analysis at baseline, end of cycle 1, and every three cycles thereafter. MRD-negative response was defined as < 1 residual blast per 1,000 leukocytes (< 10-3 or 0.1%) with an estimated analytic sensitivity of 0.0037%-0.0027%. CRc, duration of remission (DoR), event-free survival (EFS), and overall survival (OS) were assessed. A multivariate Cox regression analysis identified prognostic factors associated with OS. RESULTS One hundred sixty-four of one hundred ninety (86%) patients with CRc were evaluable for MRD. MRD < 10-3 was achieved by 67 of 164 (41%), and 97 of 164 (59%) had MRD ≥ 10-3. The median DoR, EFS, and OS were not reached in patients with CRc and MRD < 10-3, and the 12-month estimates for DoR, EFS, and OS in this group were 81.2%, 83.2%, and 94.0%. Among patients with CRc and MRD ≥ 10-3, the median DoR, EFS, and OS were 9.7, 10.6, and 18.7 months. Multivariate analysis showed that CRc with MRD < 10-3 was a strong predictor of OS (adjusted hazard ratio = 0.285; 95% CI, 0.159 to 0.510; P < .001). CONCLUSION Patients who achieved CRc and MRD < 10-3 with venetoclax and azacitidine had longer DoR, EFS, and OS, than responding patients with MRD ≥ 10-3.
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Affiliation(s)
- Keith W Pratz
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA
| | - Brian A Jonas
- Department of Internal Medicine, Division of Hematology and Oncology, University of California Davis School of Medicine, Sacramento, CA
| | - Vinod Pullarkat
- Department of Hematology and Hematopoietic Cell Transplantation and Gehr Family Center for Leukemia Research, City of Hope Comprehensive Cancer Center, Duarte, CA
| | - Christian Recher
- Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Université de Toulouse 3 Paul Sabatier, Toulouse, France
| | - Andre C Schuh
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Michael J Thirman
- Section of Hematology/Oncology, Department of Medicine, The University of Chicago Medicine, Chicago, IL
| | - Jacqueline S Garcia
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Courtney D DiNardo
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Vladimir Vorobyev
- Department of Hematology, S. P. Botkin City Clinical Hospital, Moscow, Russia
| | - Nicola S Fracchiolla
- UOC Ematologia, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
| | - Su-Peng Yeh
- Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Jun Ho Jang
- Department of Hematology-Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Muhit Ozcan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Kazuhito Yamamoto
- Department of Hematology and Cell Therapy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Arpad Illes
- University of Debrecen, Faculty of Medicine, Department of Hematology, Debrecen, Hungary
| | | | | | | | | | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
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4
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Alshemmari SH, Almazyad M, Ram M, John LM, Alhuraiji A. Epidemiology of de novo Acute Myeloid Leukemia in Kuwait per the 2016 WHO Classification. Med Princ Pract 2022; 31:284-292. [PMID: 35468599 PMCID: PMC9275004 DOI: 10.1159/000524641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 04/12/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Acute myeloid leukemia (AML) is a hematological malignancy that arises from the clonal proliferation of immature myeloid cells. Although the number of AML cases has dramatically increased worldwide, information on its prevalence and incidence in Kuwait is lacking. This study reports the incidence of AML and patient demographics in the country from 2014 to 2020, based on the 2016 WHO classification of AML. SUBJECTS AND METHODS Data on patients with AML, including acute promyelocytic leukemia (APL), were collected from a clinical cohort with 281 cases analyzed in this study. RESULTS The overall median age of the population was 47 years with a 1.1:1 male-to-female ratio. Over the study period, the incidence of AML demonstrated a general increasing trend, with the highest and lowest overall incidence occurring in 2018 and 2015, respectively. The frequency of APL in our cohort was 8.9%. Regarding the 2017 European LeukemiaNet (ELN) risk stratification of patients with AML, 37%, 46%, and 17% of patients had a favorable, intermediate, and adverse risk, respectively. A total of 57% of cases achieved complete remission post-induction, and the median overall survival was 37 months. CONCLUSION Our study may help predict the future trends of AML in Kuwait to help improve clinical management and patient outcomes.
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Affiliation(s)
- Salem H. Alshemmari
- Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait, Kuwait
- Department of Hematology, Kuwait Cancer Center, Kuwait, Kuwait
- *Salem H. Alshemmari,
| | - Mazyad Almazyad
- Department of Medicine, Faculty of Medicine, Kuwait University, Kuwait, Kuwait
| | - Mohan Ram
- Department of Hematology, Kuwait Cancer Center, Kuwait, Kuwait
| | | | - Ahmed Alhuraiji
- Department of Hematology, Kuwait Cancer Center, Kuwait, Kuwait
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5
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Impact of age and induction therapy on outcome of 180 adult patients with acute myeloid leukemia; retrospective analysis and literature review. Leuk Res Rep 2020; 14:100206. [PMID: 32566477 PMCID: PMC7296329 DOI: 10.1016/j.lrr.2020.100206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/17/2020] [Accepted: 06/05/2020] [Indexed: 11/29/2022] Open
Abstract
The prognosis of acute myeloid leukemia (AML) remains poor. Among 180 patients, the median age was 53 (14-88) years. The overall 2-year disease free survival (DFS) was 28.6% (+/- 3.4), 47.7% (+/- 6.6%) for ≤ 40, 23.6% (+/- 5.8%) for 41–60 and 11.7% (+/- 4.2%) for ≥61 (p< 0.0001). The overall 2-year survival (OS) was 45.3% (+/- 3.8%), 78.6% (+/- 5.5%) for ≤40, 43.5% (+/- 6.9%) for 41–60 and 15.8% (+/- 4.8%) for ≥61 (p< 0.0001). Induction outcome of ≥61 was best in high dose chemotherapy (HDC) group (p < 0.0001). Only those ≤40 had durable DFS and OS. HDC appears to improve the outcome of older AML patients.
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6
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Xu X, Zeng Z, Huo L, Liu H, Yu Y, Zhang L, Cen J, Qiu H, Tang X, Fu C, Han Y, Miao M, Jin Z, Ruan C, Wu D, Chen S, Wang Q, Yan L. High expression of myocyte enhancer factor 2C predicts poor prognosis for adult acute myeloid leukaemia with normal karyotype. Br J Haematol 2020; 189:e23-e27. [PMID: 32017034 DOI: 10.1111/bjh.16418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Xiaoyu Xu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China
| | - Zhao Zeng
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Li Huo
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Hong Liu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yan Yu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Ling Zhang
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Jiannong Cen
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China
| | - Huiying Qiu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Xiaowen Tang
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Chengcheng Fu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Yue Han
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Miao Miao
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Zhengming Jin
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Changgeng Ruan
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Depei Wu
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Suning Chen
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Key Laboratory of Thrombosis and Hemostasis of Ministry of Health, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Qinrong Wang
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Lingzhi Yan
- The First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, National Clinical Research Center for Hematologic Diseases, Suzhou, China.,Institute of Blood and Marrow Transplantation, Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
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7
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Sanz MA, Fenaux P, Tallman MS, Estey EH, Löwenberg B, Naoe T, Lengfelder E, Döhner H, Burnett AK, Chen SJ, Mathews V, Iland H, Rego E, Kantarjian H, Adès L, Avvisati G, Montesinos P, Platzbecker U, Ravandi F, Russell NH, Lo-Coco F. Management of acute promyelocytic leukemia: updated recommendations from an expert panel of the European LeukemiaNet. Blood 2019; 133:1630-1643. [PMID: 30803991 PMCID: PMC6509567 DOI: 10.1182/blood-2019-01-894980] [Citation(s) in RCA: 346] [Impact Index Per Article: 69.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 02/20/2019] [Indexed: 12/17/2022] Open
Abstract
Since the comprehensive recommendations for the management of acute promyelocytic leukemia (APL) reported in 2009, several studies have provided important insights, particularly regarding the role of arsenic trioxide (ATO) in frontline therapy. Ten years later, a European LeukemiaNet expert panel has reviewed the recent advances in the management of APL in both frontline and relapse settings in order to develop updated evidence- and expert opinion-based recommendations on the management of this disease. Together with providing current indications on genetic diagnosis, modern risk-adapted frontline therapy, and salvage treatment, the review contains specific recommendations for the identification and management of the most important complications such as the bleeding disorder APL differentiation syndrome, QT prolongation, and other all-trans retinoic acid- and ATO-related toxicities, as well as recommendations for molecular assessment of the response to treatment. Finally, the approach to special situations is also discussed, including management of APL in children, elderly patients, and pregnant women. The most important challenges remaining in APL include early death, which still occurs before and during induction therapy, and optimizing treatment in patients with high-risk disease.
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Affiliation(s)
- Miguel A Sanz
- Departamento de Hematologia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Department of Medicine, University of Valencia, Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Pierre Fenaux
- Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
- Department of Hematology, Université Paris Diderot, Paris, France
| | | | | | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Tomoki Naoe
- National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Eva Lengfelder
- Department of Haematology, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Alan K Burnett
- Department of Haematology, Glasgow University, Glasgow, United Kingdom
| | - Sai-Juan Chen
- State Key Laboratory of Medical Genomics, Shanghai Institute of Hematology, Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Vikram Mathews
- Department of Hematology, Christian Medical College, Vellore, India
| | - Harry Iland
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Eduardo Rego
- Hematology Division and
- Clinical Oncology Division, Department of Internal Medicine, University of Sao Paulo, Ribeirao Preto, Brazil
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lionel Adès
- Hôpital Saint-Louis, Assistance Publique Hôpitaux de Paris, Paris, France
- Department of Hematology, Université Paris Diderot, Paris, France
| | | | - Pau Montesinos
- Departamento de Hematologia, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Centro de Investigación Biomédica en Red de Cáncer, Instituto Carlos III, Madrid, Spain
| | - Uwe Platzbecker
- Medical Clinic and Polyclinic I, Hematology and Cellular Therapy, University Hospital Leipzig, Leipzig, Germany
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Nigel H Russell
- Centre for Clinical Haematology, Department of Haematology, Nottingham University Hospital, Nottingham, United Kingdom; and
| | - Francesco Lo-Coco
- Department of Biomedicine and Prevention, Tor Vergata University of Rome, Rome, Italy
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8
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Schuurhuis GJ, Heuser M, Freeman S, Béné MC, Buccisano F, Cloos J, Grimwade D, Haferlach T, Hills RK, Hourigan CS, Jorgensen JL, Kern W, Lacombe F, Maurillo L, Preudhomme C, van der Reijden BA, Thiede C, Venditti A, Vyas P, Wood BL, Walter RB, Döhner K, Roboz GJ, Ossenkoppele GJ. Minimal/measurable residual disease in AML: a consensus document from the European LeukemiaNet MRD Working Party. Blood 2018; 131:1275-1291. [PMID: 29330221 PMCID: PMC5865231 DOI: 10.1182/blood-2017-09-801498] [Citation(s) in RCA: 757] [Impact Index Per Article: 126.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 01/03/2018] [Indexed: 12/13/2022] Open
Abstract
Measurable residual disease (MRD; previously termed minimal residual disease) is an independent, postdiagnosis, prognostic indicator in acute myeloid leukemia (AML) that is important for risk stratification and treatment planning, in conjunction with other well-established clinical, cytogenetic, and molecular data assessed at diagnosis. MRD can be evaluated using a variety of multiparameter flow cytometry and molecular protocols, but, to date, these approaches have not been qualitatively or quantitatively standardized, making their use in clinical practice challenging. The objective of this work was to identify key clinical and scientific issues in the measurement and application of MRD in AML, to achieve consensus on these issues, and to provide guidelines for the current and future use of MRD in clinical practice. The work was accomplished over 2 years, during 4 meetings by a specially designated MRD Working Party of the European LeukemiaNet. The group included 24 faculty with expertise in AML hematopathology, molecular diagnostics, clinical trials, and clinical medicine, from 19 institutions in Europe and the United States.
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Affiliation(s)
- Gerrit J Schuurhuis
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Sylvie Freeman
- Department of Clinical Immunology, Institute of Immunology and Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, United Kingdom
| | | | - Francesco Buccisano
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Jacqueline Cloos
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
- Department of Pediatric Oncology, VU University Medical Center, Amsterdam, The Netherlands
| | - David Grimwade
- Division of Genetics & Molecular Medicine, King's College, London, United Kingdom
| | | | - Robert K Hills
- Centre for Trials Research, Cardiff University, Cardiff, United Kingdom
| | | | - Jeffrey L Jorgensen
- Division of Pathology/Laboratory Medicine, Department of Hematopathology, MD Anderson Cancer Center, Houston, TX
| | | | - Francis Lacombe
- Flow Cytometry Platform, University Hospital, Bordeaux, France
| | - Luca Maurillo
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Claude Preudhomme
- Center of Pathology, Laboratory of Hematology, University Hospital of Lille, Lille, France
| | - Bert A van der Reijden
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Christian Thiede
- Universitätsklinikum Carl Gustav Garus an der Technischen Universität Dresden, Dresden, Germany
| | - Adriano Venditti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | - Paresh Vyas
- Medical Research Council Molecular Haematology Unit, Oxford Centre for Haematology, University of Oxford and Oxford University Hospitals National Health Service Trust, Oxford, United Kingdom
| | - Brent L Wood
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Department of Laboratory Medicine and
| | - Roland B Walter
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA
| | - Konstanze Döhner
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany; and
| | - Gail J Roboz
- Weill Cornell Medicine and New York Presbyterian Hospital, New York, NY
| | - Gert J Ossenkoppele
- Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands
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9
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Automated analysis of acute myeloid leukemia minimal residual disease using a support vector machine. Oncotarget 2018; 7:71915-71921. [PMID: 27713120 PMCID: PMC5342132 DOI: 10.18632/oncotarget.12430] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Accepted: 09/29/2016] [Indexed: 11/29/2022] Open
Abstract
We investigated the ability of support vector machines (SVM) to analyze minimal residual disease (MRD) in flow cytometry data from patients with acute myeloid leukemia (AML) automatically, objectively and standardly. The initial disease data and MRD review data in the form of 159 flow cytometry standard 3.0 files from 36 CD7-positive AML patients in whom MRD was detected more than once were exported. SVM was used for training with setting the initial disease data to 1 as the flag and setting 15 healthy persons to set 0 as the flag. Based on the two training groups, parameters were optimized, and a predictive model was built to analyze MRD data from each patient. The automated analysis results from the SVM model were compared to those obtained through conventional analysis to determine reliability. Automated analysis results based on the model did not differ from and were correlated with results obtained through conventional analysis (correlation coefficient c = 0.986, P > 0.05). Thus the SVM model could potentially be used to analyze flow cytometry-based AML MRD data automatically, objectively, and in a standardized manner.
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10
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Jentzsch M, Bill M, Grimm J, Schulz J, Goldmann K, Beinicke S, Häntschel J, Pönisch W, Franke GN, Vucinic V, Behre G, Lange T, Niederwieser D, Schwind S. High BAALC copy numbers in peripheral blood prior to allogeneic transplantation predict early relapse in acute myeloid leukemia patients. Oncotarget 2017; 8:87944-87954. [PMID: 29152132 PMCID: PMC5675684 DOI: 10.18632/oncotarget.21322] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 08/17/2017] [Indexed: 12/15/2022] Open
Abstract
High BAALC expression levels at acute myeloid leukemia diagnosis have been linked to adverse outcomes. Recent data indicate that high BAALC expression levels may also be used as marker for residual disease following acute myeloid leukemia treatment. Allogeneic hematopoietic stem cell transplantation (HSCT) offers a curative treatment for acute myeloid leukemia patients. However, disease recurrence remains a major clinical challenge and identification of high-risk patients prior to HSCT is crucial to improve outcomes. We performed absolute quantification of BAALC copy numbers in peripheral blood prior (median 7 days) to HSCT in complete remission (CR) or CR with incomplete peripheral recovery in 82 acute myeloid leukemia patients using digital droplet PCR (ddPCR) technology. An optimal cut-off of 0.14 BAALC/ABL1 copy numbers was determined and applied to define patients with high or low BAALC/ABL1 copy numbers. High pre-HSCT BAALC/ABL1 copy numbers significantly associated with higher cumulative incidence of relapse and shorter overall survival in univariable and multivariable models. Patients with high pre-HSCT BAALC/ABL1 copy numbers were more likely to experience relapse within 100 days after HSCT. Evaluation of pre-HSCT BAALC/ABL1 copy numbers in peripheral blood by ddPCR represents a feasible and rapid way to identify acute myeloid leukemia patients at high risk of early relapse after HSCT. The prognostic impact was also observed independently of other known clinical, genetic, and molecular prognosticators. In the future, prospective studies should evaluate whether acute myeloid leukemia patients with high pre-HSCT BAALC/ABL1 copy numbers benefit from additional treatment before or early intervention after HSCT.
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Affiliation(s)
- Madlen Jentzsch
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | - Marius Bill
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | - Juliane Grimm
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | - Julia Schulz
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | - Karoline Goldmann
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | - Stefanie Beinicke
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | - Janine Häntschel
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | - Wolfram Pönisch
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | | | - Vladan Vucinic
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | - Gerhard Behre
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | - Thoralf Lange
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
| | | | - Sebastian Schwind
- Department of Hematology and Oncology, University of Leipzig, Leipzig, Germany
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11
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Galluzzi L, Zitvogel L, Kroemer G. Immunological Mechanisms Underneath the Efficacy of Cancer Therapy. Cancer Immunol Res 2016; 4:895-902. [DOI: 10.1158/2326-6066.cir-16-0197] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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12
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Weber S, Haferlach T, Alpermann T, Perglerová K, Schnittger S, Haferlach C, Kern W. Feasibility of BAALC gene expression for detection of minimal residual disease and risk stratification in normal karyotype acute myeloid leukaemia. Br J Haematol 2016; 175:904-916. [PMID: 27662611 DOI: 10.1111/bjh.14343] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 07/31/2016] [Indexed: 12/28/2022]
Abstract
High BAALC gene expression has been associated with poor prognosis in cytogenetically normal acute myeloid leukaemia (CN-AML) and has been suggested as a suitable marker for assessing minimal residual disease (MRD). The purpose of this study was to substantiate these findings by the analysis of a large data set of 632 diagnostic and follow-up samples in 142 intensively treated CN-AML patients. Paired diagnostic/relapse samples of 35 patients revealed stable high BAALC expression in 89%, irrespective of a high proportion of clonal evolution found in 49% of these cases. High BAALC expression, both directly after induction chemotherapy and within 3-6 months after induction chemotherapy, correlated significantly with shorter event-free survival and overall survival. Moreover, 8 of 10 patients displaying high BAALC expression levels after completion of induction therapy as well as 5 of 5 patients exhibiting high BAALC expression levels within 3-6 months after induction chemotherapy experienced relapse with a median of 197 and 101 days, respectively, from sampling to relapse. Thus, BAALC expression-based MRD detection during therapy may be considered a strategy to identify patients at high risk of relapse.
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Affiliation(s)
- Simone Weber
- MLL Munich Leukaemia Laboratory, Munich, Germany
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13
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Pettersson L, Levéen P, Axler O, Dvorakova D, Juliusson G, Ehinger M. Improved minimal residual disease detection by targeted quantitative polymerase chain reaction inNucleophosmin 1type a mutated acute myeloid leukemia. Genes Chromosomes Cancer 2016; 55:750-66. [DOI: 10.1002/gcc.22375] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Revised: 05/12/2016] [Accepted: 05/13/2016] [Indexed: 12/25/2022] Open
Affiliation(s)
| | - Per Levéen
- Department of Pathology; University and Regional Laboratories, Skåne University Hospital; Lund Sweden
| | - Olof Axler
- Department of Pathology; University and Regional Laboratories, Skåne University Hospital; Lund Sweden
| | - Dana Dvorakova
- Department of Internal Medicine-Hematology and Oncology; Center of Molecular Biology and Gene Therapy, Masaryk University and University Hospital Brno; Brno Czech Republic
| | - Gunnar Juliusson
- Department of Hematology; Skåne University Hospital; Lund Sweden
| | - Mats Ehinger
- Department of Pathology; University and Regional Laboratories, Skåne University Hospital; Lund Sweden
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14
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The role of multiparametric flow cytometry in the detection of minimal residual disease in acute leukaemia. Pathology 2015; 47:609-21. [DOI: 10.1097/pat.0000000000000319] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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15
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Ommen HB, Touzart A, MacIntyre E, Kern W, Haferlach T, Haferlach C, Tobal K, Hokland P, Schnittger S. The kinetics of relapse in DEK-NUP214-positive acute myeloid leukemia patients. Eur J Haematol 2015; 95:436-41. [PMID: 25605311 DOI: 10.1111/ejh.12511] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/22/2014] [Indexed: 01/19/2023]
Abstract
Preemptive treatment of relapse of acute myeloid leukemia (AML) holds the promise to improve the prognosis of this currently highly lethal condition. Proposed treatment modalities applicable in preemptive cytoreduction (e.g., demethylating agents or standard chemotherapy) differ substantially in interval from administration to antileukemic effect. The t(6;9) balanced translocation, producing the DEK-NUP214 fusion protein, is seen in only 1% of patients with AML. We hypothesized that in these patients, who relapse with a very high frequency, a more detailed knowledge of leukemic relapse growth kinetics would improve the personalized decision-making regarding re-administration of chemotherapy. Based on standardized quantitative PCR data, we therefore delineated the relapse kinetics in a cohort of 27 relapsing DEK-NUP214-positive patients treated in four different European countries. The prerelapse leukemic burden increased with a median doubling time of 13 d (range: 5-51 d, median: 0.71 logs/month, range: 0.18-1.91 logs/month), with FLT3-ITD-positive patients relapsing significantly faster than FLT3-ITD-negative ones (median: 0.9 vs. 0.6 logs/month, Wilcoxon rank sum test, P = 0.041). Peripheral blood and bone marrow were equally useful for minimal residual disease (MRD) detection, and thus, we found that with sampling intervals of 2 months, 94% of relapses would be detected with a median time from MRD detection to hematological relapse of 64 d. In conclusion, this data provide algorithms for handling the rare patients with DEK-NUP214-positive AML allowing for planning of both MRD follow-up and, upon molecular relapse, the timing of cytoreduction or possibly transplant procedures.
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MESH Headings
- Adolescent
- Adult
- Aged
- Algorithms
- Child
- Child, Preschool
- Chromosomal Proteins, Non-Histone/genetics
- Chromosomal Proteins, Non-Histone/metabolism
- Chromosomes, Human, Pair 6/genetics
- Chromosomes, Human, Pair 6/metabolism
- Chromosomes, Human, Pair 9/genetics
- Chromosomes, Human, Pair 9/metabolism
- Disease-Free Survival
- Female
- Follow-Up Studies
- Humans
- Kinetics
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/therapy
- Male
- Middle Aged
- Models, Biological
- Nuclear Pore Complex Proteins/genetics
- Nuclear Pore Complex Proteins/metabolism
- Oncogene Proteins/genetics
- Oncogene Proteins/metabolism
- Oncogene Proteins, Fusion/genetics
- Oncogene Proteins, Fusion/metabolism
- Poly-ADP-Ribose Binding Proteins
- Recurrence
- Survival Rate
- Translocation, Genetic
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Affiliation(s)
- Hans B Ommen
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | - Aurore Touzart
- Department of Hematology and CNRS UMR 8147, Hôpital Necker-Enfants-Malades, AP-HP, Université Paris 5 Descartes, Paris, France
| | - Elisabeth MacIntyre
- Department of Hematology and CNRS UMR 8147, Hôpital Necker-Enfants-Malades, AP-HP, Université Paris 5 Descartes, Paris, France
| | | | | | | | - Khalid Tobal
- Molecular Oncology Unit, Guy's Hospital, London, UK
| | - Peter Hokland
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
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16
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Buccisano F, Maurillo L, Piciocchi A, Del Principe MI, Sarlo C, Cefalo M, Ditto C, Di Veroli A, De Santis G, Irno Consalvo M, Fraboni D, Panetta P, Palomba P, Attrotto C, Del Poeta G, Sconocchia G, Lo-Coco F, Amadori S, Venditti A. Minimal residual disease negativity in elderly patients with acute myeloid leukemia may indicate different postremission strategies than in younger patients. Ann Hematol 2015; 94:1319-26. [PMID: 25869029 DOI: 10.1007/s00277-015-2364-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 03/22/2015] [Indexed: 11/29/2022]
Abstract
In the present analysis, we evaluated whether in elderly acute myeloid leukemia (AML) patients (>60 years), minimal residual disease (MRD) assessed by flow cytometry may have a role in guiding choice of postremission strategies. We analyzed 149 young and 61 elderly adults who achieved morphological CR after induction course of EORTC/GIMEMA protocols. Elderly patients reached a postconsolidation MRD negative status less frequently than younger ones (11 vs 28 %, p = 0.009). MRD negativity resulted in a longer 5-year disease-free survival (DFS) both in elderly (57 vs 13 %, p = 0.0197) and in younger patients (56 vs 31 %, p = 0.0017). Accordingly, 5-year cumulative incidence of relapse (CIR) of both elderly (83 vs 42 %, p = 0.045) and younger patients (59 vs 24 % p = NS) who were MRD positive doubled that of MRD negative ones. Nevertheless, CIR of MRD negative elderly patients was twofold higher than that of younger MRD negative ones (42 vs 24 %, p = NS). In conclusion, elderly patients in whom chemotherapy yields a MRD negative CR have duration of DFS and rate of CIR significantly better than those who remain MRD positive. Nonetheless, the high CIR rate observed in the elderly suggests that MRD negativity might have different therapeutic implications in this population than in the younger counterpart.
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Affiliation(s)
- F Buccisano
- Ematologia, Dipartimento di Biomedicina e Prevenzione, Università di Roma "Tor Vergata", Roma, Italia,
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17
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Ben Lassoued A, Nivaggioni V, Gabert J. Minimal residual disease testing in hematologic malignancies and solid cancer. Expert Rev Mol Diagn 2015; 14:699-712. [PMID: 24938122 DOI: 10.1586/14737159.2014.927311] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Minimal residual disease (MRD) assays are of a great value to assess treatment efficacy and may provide prognostic information. This is particularly relevant in the era of targeted therapy where the introduction of MRD monitoring has fundamentally transformed the way in which cancer patients are managed. While MRD guidelines are well-established for chronic myeloid leukemia, acute promyelocytic leukemia and acute lymphoblastic leukemia, areas for continuing development are available. High level of standardization and regular external quality control rounds and recommendations for data interpretation remain essential to improve MRD monitoring. In this review, we describe the different applications of MRD assays in most frequent hematologic malignancies and solid cancer and provide an overview of the strengths and potential weaknesses of each method.
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Affiliation(s)
- Amin Ben Lassoued
- Laboratoire de Biochimie et de Biologie Moléculaire, Assistance Publique-Hôpitaux de Marseille (AP-HM), Hôpital NORD, Marseille, France
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18
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Abstract
Abstract
The past 40 years have witnessed major advances in defining the cytogenetic aberrations, mutational landscape, epigenetic profiles, and expression changes underlying hematological malignancies. Although it has become apparent that acute myeloid leukemia (AML) is highly heterogeneous at the molecular level, the standard framework for risk stratification guiding transplant practice in this disease remains largely based on pretreatment assessment of cytogenetics and a limited panel of molecular genetic markers, coupled with morphological assessment of bone marrow (BM) blast percentage after induction. However, application of more objective methodology such as multiparameter flow cytometry (MFC) has highlighted the limitations of morphology for reliable determination of remission status. Moreover, there is a growing body of evidence that detection of subclinical levels of leukemia (ie, minimal residual disease, MRD) using MFC or molecular-based approaches provides powerful independent prognostic information. Consequently, there is increasing interest in the use of MRD detection to provide early end points in clinical trials and to inform patient management. However, implementation of MRD assessment into clinical practice remains a major challenge, hampered by differences in the assays and preferred analytical methods employed between routine laboratories. Although this should be addressed through adoption of standardized assays with external quality control, it is clear that the molecular heterogeneity of AML coupled with increasing understanding of its clonal architecture dictates that a “one size fits all” approach to MRD detection in this disease is not feasible. However, with the range of platforms now available, there is considerable scope to realistically track treatment response in every patient.
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19
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Grimwade D, Freeman SD. Defining minimal residual disease in acute myeloid leukemia: which platforms are ready for "prime time"? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2014; 2014:222-233. [PMID: 25696859 DOI: 10.1182/asheducation-2014.1.222] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The past 40 years have witnessed major advances in defining the cytogenetic aberrations, mutational landscape, epigenetic profiles, and expression changes underlying hematological malignancies. Although it has become apparent that acute myeloid leukemia (AML) is highly heterogeneous at the molecular level, the standard framework for risk stratification guiding transplant practice in this disease remains largely based on pretreatment assessment of cytogenetics and a limited panel of molecular genetic markers, coupled with morphological assessment of bone marrow (BM) blast percentage after induction. However, application of more objective methodology such as multiparameter flow cytometry (MFC) has highlighted the limitations of morphology for reliable determination of remission status. Moreover, there is a growing body of evidence that detection of subclinical levels of leukemia (ie, minimal residual disease, MRD) using MFC or molecular-based approaches provides powerful independent prognostic information. Consequently, there is increasing interest in the use of MRD detection to provide early end points in clinical trials and to inform patient management. However, implementation of MRD assessment into clinical practice remains a major challenge, hampered by differences in the assays and preferred analytical methods employed between routine laboratories. Although this should be addressed through adoption of standardized assays with external quality control, it is clear that the molecular heterogeneity of AML coupled with increasing understanding of its clonal architecture dictates that a "one size fits all" approach to MRD detection in this disease is not feasible. However, with the range of platforms now available, there is considerable scope to realistically track treatment response in every patient.
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Affiliation(s)
- David Grimwade
- Department of Medical & Molecular Genetics, King's College London School of Medicine, London, United Kingdom; and
| | - Sylvie D Freeman
- Department of Clinical Immunology, University of Birmingham Medical School, Edgbaston, Birmingham, United Kingdom
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20
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Detection of minimal residual disease in NPM1-mutated acute myeloid leukemia by next-generation sequencing. Mod Pathol 2014; 27:1438-46. [PMID: 24743218 PMCID: PMC4201902 DOI: 10.1038/modpathol.2014.57] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 02/15/2014] [Accepted: 02/18/2014] [Indexed: 01/08/2023]
Abstract
Detection of minimal residual disease predicts adverse outcome in patients with acute myeloid leukemia. Currently, minimal residual disease may be detected by RQ-PCR or flow cytometry, both of which have practical and diagnostic limitations. Here, we describe a next-generation sequencing assay for minimal residual disease detection in NPM1-mutated acute myeloid leukemia, which encompasses ∼60% of patients with normal karyotype acute myeloid leukemia. Exon 12 of NPM1 was PCR amplified using sequencing adaptor-linked primers and deep sequenced to enable detection of low-prevalence, acute myeloid leukemia-specific activating mutations. We benchmarked our results against flow cytometry, the standard of care for acute myeloid leukemia minimal residual disease diagnosis at our institution. The performance of both approaches was evaluated using defined dilutions of an NPM1 mutation-positive cell line and longitudinal clinical samples from acute myeloid leukemia patients. Using defined control material, we found this assay sensitive to approximately 0.001% mutant cells, outperforming flow cytometry by an order of magnitude. Next-generation sequencing was precise and semiquantitative over four orders of magnitude. In 22 longitudinal samples from six acute myeloid leukemia patients, next-generation sequencing detected minimal residual disease in all samples deemed negative by flow cytometry. Further, in one-third of patients, sequencing detected alternate NPM1 mutations in addition to the patient's index mutation, consistent with tumor heterogeneity. Next-generation sequencing provides information without prior knowledge of NPM1 mutation subtype or validation of allele-specific probes as required for RQ-PCR assays, and without generation and interpretation of complex multidimensional flow cytometry data. This approach may complement current technologies to enhance patient-specific clinical decision-making.
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21
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Defining minimal residual disease in acute myeloid leukemia: which platforms are ready for "prime time"? Blood 2014; 124:3345-55. [PMID: 25049280 DOI: 10.1182/blood-2014-05-577593] [Citation(s) in RCA: 185] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The past 40 years have witnessed major advances in defining the cytogenetic aberrations, mutational landscape, epigenetic profiles, and expression changes underlying hematological malignancies. Although it has become apparent that acute myeloid leukemia (AML) is highly heterogeneous at the molecular level, the standard framework for risk stratification guiding transplant practice in this disease remains largely based on pretreatment assessment of cytogenetics and a limited panel of molecular genetic markers, coupled with morphological assessment of bone marrow (BM) blast percentage after induction. However, application of more objective methodology such as multiparameter flow cytometry (MFC) has highlighted the limitations of morphology for reliable determination of remission status. Moreover, there is a growing body of evidence that detection of subclinical levels of leukemia (ie, minimal residual disease, MRD) using MFC or molecular-based approaches provides powerful independent prognostic information. Consequently, there is increasing interest in the use of MRD detection to provide early end points in clinical trials and to inform patient management. However, implementation of MRD assessment into clinical practice remains a major challenge, hampered by differences in the assays and preferred analytical methods employed between routine laboratories. Although this should be addressed through adoption of standardized assays with external quality control, it is clear that the molecular heterogeneity of AML coupled with increasing understanding of its clonal architecture dictates that a "one size fits all" approach to MRD detection in this disease is not feasible. However, with the range of platforms now available, there is considerable scope to realistically track treatment response in every patient.
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22
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Jaso JM, Wang SA, Jorgensen JL, Lin P. Multi-color flow cytometric immunophenotyping for detection of minimal residual disease in AML: past, present and future. Bone Marrow Transplant 2014; 49:1129-38. [PMID: 24842529 DOI: 10.1038/bmt.2014.99] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 03/15/2014] [Accepted: 03/21/2014] [Indexed: 01/15/2023]
Abstract
Current chemotherapeutic regimens achieve CR in a large percentage of patients with AML. However, relapse after CR remains a significant problem. The presence of leukemic cells at levels too low to be detected by conventional microscopy, termed minimal residual disease (MRD), has been associated with an increased risk of relapse and shortened survival. Detection of MRD requires the use of highly sensitive ancillary techniques. Multi-color flow cytometric immunophenotyping is a sensitive method for quick and accurate detection of MRD. Use of this method in patient management may result in lower rates of relapse and improved survival, and is an effective means of assessing novel therapeutic agents. This method can be used in the vast majority of patients with AML, regardless of the immunophenotypic, cytogenetic and molecular genetic abnormalities present. Unfortunately, conflicting data regarding optimum methods of measurement and reporting, as well as the expertize required to interpret results have limited broad application of this technique. We provide a broad overview of this technique, including its advantages and limitations, and discuss the methods employed at our institution. We also review several possible areas of future investigation.
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Affiliation(s)
- J M Jaso
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S A Wang
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - J L Jorgensen
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - P Lin
- Department of Hematopathology, University of Texas MD Anderson Cancer Center, Houston, TX, USA
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23
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Rizzari C, Cazzaniga G, Coliva T, De Angelis C, Conter V. Predictive factors of relapse and survival in childhood acute myeloid leukemia: role of minimal residual disease. Expert Rev Anticancer Ther 2014; 11:1391-401. [DOI: 10.1586/era.11.37] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Abstract
SUMMARY Predictive/prognostic factors in acute leukemia continue to be sought, in order to refine treatment strategies. Minimal residual disease (MRD) testing has been shown to be a statistically significant factor by multivariate analysis in both acute lymphoblastic leukemia (ALL) and acute myeloid leukemia. Its utility in guiding therapy has been more extensively studied in pediatric ALL, with some protocols having instituted MRD testing into therapeutic algorithms. The clinical impact of MRD testing in ALL and acute myeloid leukemia will be presented, including both molecular and flow cytometric methodologies, with a more focused discussion of the strategy, methodology and interpretation of MRD testing by multiparametric flow cytometry.
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Affiliation(s)
- Lorinda Soma
- University of Washington, Department of Laboratory Medicine, Division of Hematopathology, Room NW120, Box 357110, 1959 NE Pacific Street, Seattle, WA 98195, USA
| | - Brent Wood
- University of Washington, Department of Laboratory Medicine, Division of Hematopathology, Room NW120, Box 357110, 1959 NE Pacific Street, Seattle, WA 98195, USA
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25
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Freeman SD, Virgo P, Couzens S, Grimwade D, Russell N, Hills RK, Burnett AK. Prognostic relevance of treatment response measured by flow cytometric residual disease detection in older patients with acute myeloid leukemia. J Clin Oncol 2013; 31:4123-31. [PMID: 24062403 DOI: 10.1200/jco.2013.49.1753] [Citation(s) in RCA: 248] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE Older patients with acute myeloid leukemia (AML) have a high relapse rate after standard chemotherapy. We investigated whether measuring chemotherapy sensitivity by multiparameter flow cytometric minimal residual disease (MFC-MRD) detection has prognostic value in patients older than age 60 years or is simply a surrogate for known age-related risk factors. PATIENT AND METHODS Eight hundred ninety-two unselected patients treated intensively in the United Kingdom National Cancer Research Institute AML16 Trial were assessed prospectively for MFC-MRD during treatment. Eight hundred thirty-three patients had leukemia-associated immunophenotypes (LAIPs) identified by pretreatment screening. Four hundred twenty-seven patients entered complete remission (CR) after one or two courses (designated C1 and C2, respectively) and were MFC-MRD assessable by LAIP detection in CR bone marrow for at least one of these time points. MRD positivity was defined as residual disease detectable by LAIP. RESULTS MFC-MRD negativity, which was achieved in 51% of patients after C1 (n = 286) and 64% of patients after C2 (n = 279), conferred significantly better 3-year survival from CR (C1: 42% v 26% in MRD-positive patients, P < .001; C2: 38% v 18%, respectively; P < .001) and reduced relapse (C1: 71% v 83% in MRD-positive patients, P < .001; C2: 79% v 91%, respectively; P < .001), with higher risk of early relapse in MRD-positive patients (median time to relapse, 8.5 v 17.1 months, respectively). In multivariable analysis, MRD status at the post-C1 time point independently predicted survival, identifying a subgroup of intermediate-risk patients with particularly poor outcome. However, survival benefit from gemtuzumab ozogamicin was not associated with MFC-MRD chemotherapy sensitivity. CONCLUSION Early assessment of treatment response using flow cytometry provides powerful independent prognostic information in older adults with AML, lending support to the incorporation of MRD detection to refine risk stratification and inform clinical trial design in this challenging group of patients.
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Affiliation(s)
- Sylvie D Freeman
- Sylvie D. Freeman, University of Birmingham and University Hospitals Birmingham National Health Service (NHS) Trust, Birmingham; Paul Virgo, North Bristol NHS Trust, Bristol; Steve Couzens, University Hospital of Wales; Robert K. Hills and Alan K. Burnett, Cardiff University, Heath Park, Cardiff; David Grimwade, King's College London School of Medicine and Guy's and St Thomas' NHS Foundation Trust, London; and Nigel Russell, Nottingham University Hospital NHS Trust, Nottingham, United Kingdom
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Akiki S, Dyer SA, Grimwade D, Ivey A, Abou-Zeid N, Borrow J, Jeffries S, Caddick J, Newell H, Begum S, Tawana K, Mason J, Velangi M, Griffiths M. NUP98-NSD1 fusion in association with FLT3-ITD mutation identifies a prognostically relevant subgroup of pediatric acute myeloid leukemia patients suitable for monitoring by real time quantitative PCR. Genes Chromosomes Cancer 2013; 52:1053-64. [PMID: 23999921 DOI: 10.1002/gcc.22100] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 07/10/2013] [Indexed: 12/26/2022] Open
Abstract
The cytogenetically cryptic t(5;11)(q35;p15) leading to the NUP98-NSD1 fusion is a rare but recurrent gene rearrangement recently reported to identify a group of young AML patients with poor prognosis. We used reverse transcription polymerase chain reaction (PCR) to screen retrospectively diagnostic samples from 54 unselected pediatric AML patients and designed a real time quantitative PCR assay to track individual patient response to treatment. Four positive cases (7%) were identified; three arising de novo and one therapy related AML. All had intermediate risk cytogenetic markers and a concurrent FLT3-ITD but lacked NPM1 and CEBPA mutations. The patients had a poor response to therapy and all proceeded to hematopoietic stem cell transplant. These data lend support to the adoption of screening for NUP98-NSD1 in pediatric AML without otherwise favorable genetic markers. The role of quantitative PCR is also highlighted as a potential tool for managing NUP98-NSD1 positive patients post-treatment.
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Affiliation(s)
- Susanna Akiki
- West Midlands Regional Genetics Laboratory, Birmingham Women's NHS foundation Trust, Birmingham, UK; School of Cancer Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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27
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Yoon JH, Kim HJ, Shin SH, Yahng SA, Lee SE, Cho BS, Eom KS, Kim YJ, Lee S, Min CK, Cho SG, Kim DW, Lee JW, Min WS, Park CW, Lim JH. BAALC and WT1 expressions from diagnosis to hematopoietic stem cell transplantation: consecutive monitoring in adult patients with core-binding-factor-positive AML. Eur J Haematol 2013; 91:112-21. [PMID: 23672350 DOI: 10.1111/ejh.12142] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2013] [Indexed: 12/22/2022]
Abstract
No consecutive analysis of BAALC and WT1 expressions associated with core-binding factor AML (CBF-AML) from diagnosis to hematopoietic stem cell transplantation (HSCT) has yet been reported. We investigated BAALC and WT1 expressions using a method of real-time quantitative polymerase chain reaction (RQ-PCR) at diagnosis, after induction chemotherapy, at pre-HSCT, and at post-HSCT period in 45 consecutive patients [t(8,21) (n = 28), inv(16) (n = 17)], who received HSCT as a post-remission treatment. BAALC and WT1 RQ-PCR decrement ratio (DR) was also calculated at post-induction chemotherapy, at pre-HSCT, and at post-HSCT compared with the diagnostic level. Higher BAALC expression at diagnosis showed significantly inferior OS (P = 0.031), EFS (P = 0.011), and higher CIR (P = 0.002) rates. At post-HSCT, both higher BAALC and WT1 expressions showed significantly inferior OS (P = 0.005, 0.016), EFS (P = 0.002, 0.006), and higher CIR (P = 0.001, 0.003) rates. A subgroup of t(8;21) showing higher BAALC and WT1 expressions at post-HSCT were also associated with inferior OS (P = 0.018, 0.015) and higher CIR rates (P = 0.019, 0.011). While BAALC DR showed no significant results on outcomes, WT1 DR more than 2-log at post-HSCT showed significantly lower CIR rate (P = 0.028). This study showed that higher post-HSCT BAALC and WT1 expressions in patients with CBF-AML may be good markers of minimal residual disease for the prediction of survival and relapse after HSCT.
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Affiliation(s)
- Jae-Ho Yoon
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, Korea
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28
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Abstract
Technological advances in the laboratory have led to substantial improvements in clinical decision making through the introduction of pretreatment prognostic risk stratification factors in acute myeloid leukaemia (AML). Unfortunately, similar progress has not been made in treatment response criteria, with the definition of 'complete remission' in AML largely unchanged for over half a century. Several clinical trials have demonstrated that high-sensitivity measurements of residual disease burden during or after treatment can be performed, that results are predictive for clinical outcome and can be used to improve outcomes by guiding additional therapeutic intervention to patients in clinical complete remission, but at increased relapse risk. We review these recent trials, the characteristics and challenges of the modalities currently used to detect minimal residual disease (MRD), and outline opportunities to both refine detection and improve clinical use of MRD measurements. MRD measurement is already the standard of care in other myeloid malignancies, such as chronic myelogenous leukaemia and acute promyelocytic leukaemia (APL). It is our belief that response criteria for non-APL AML should be updated to include assessment for molecular complete remission and recommendations for post-consolidation surveillance should include regular monitoring for molecular relapse as standard of care.
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Affiliation(s)
- Christopher S Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, 10 Centre Drive, Bethesda, MD 20892-1583, USA.
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29
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Abstract
Abstract
The achievement of complete hematologic remission (CR) is a prerequisite for cure in acute myeloid leukemia (AML). The conventional definition of CR, based on the morphologic recognition of ≤ 5% of leukemic blasts in the BM, does not provide sufficient insight into the quality of the response. Despite CR rates of 50%-80% (depending on age), the majority of patients with AML relapse within 3-5 years from diagnosis. Therefore, there is great need of more sensitive prognostic factors that can predict relapse. Minimal residual disease (MRD), defined as any measurable disease or leukemia detectable above a certain threshold (defined by the methodology applied), predicts failure to maintain a morphologic CR and affects survival negatively. AML is lagging behind acute lymphoblastic leukemia with respect to the implementation of MRD criteria for guidance during therapy. AML is particularly disadvantaged compared with acute lymphoblastic leukemia in that approximately half of AML patients lack a molecular target suitable for MRD monitoring. The detection of altered antigen (Ag) expression by leukemic myeloblasts is a valid alternative to DNA- or RNA-based MRD assays. Although associated with presenting prognostic factors (eg, cytogenetics and genotype), MRD represents the collective end result of all of the cellular mechanisms that determine a patient's response to a given therapy. Therefore, MRD has 2 potential roles in AML treatment: (1) as a posttherapy prognosticator used to assign patients to optimal postinduction/consolidation therapy, and (2) as an early surrogate end point for the evaluation of therapy efficacy.
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30
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Grimwade D. The changing paradigm of prognostic factors in acute myeloid leukaemia. Best Pract Res Clin Haematol 2012. [DOI: 10.1016/j.beha.2012.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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31
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Minimal residual disease monitoring by quantitative RT-PCR in core binding factor AML allows risk stratification and predicts relapse: results of the United Kingdom MRC AML-15 trial. Blood 2012; 120:2826-35. [PMID: 22875911 DOI: 10.1182/blood-2012-06-435669] [Citation(s) in RCA: 324] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
The clinical value of serial minimal residual disease (MRD) monitoring in core binding factor (CBF) acute myeloid leukemia (AML) by quantitative RT-PCR was prospectively assessed in 278 patients [163 with t(8;21) and 115 with inv(16)] entered in the United Kingdom MRC AML 15 trial. CBF transcripts were normalized to 10(5) ABL copies. At remission, after course 1 induction chemotherapy, a > 3 log reduction in RUNX1-RUNX1T1 transcripts in BM in t(8;21) patients and a > 10 CBFB-MYH11 copy number in peripheral blood (PB) in inv(16) patients were the most useful prognostic variables for relapse risk on multivariate analysis. MRD levels after consolidation (course 3) were also informative. During follow-up, cut-off MRD thresholds in BM and PB associated with a 100% relapse rate were identified: for t(8;21) patients BM > 500 copies, PB > 100 copies; for inv(16) patients, BM > 50 copies and PB > 10 copies. Rising MRD levels on serial monitoring accurately predicted hematologic relapse. During follow-up, PB sampling was equally informative as BM for MRD detection. We conclude that MRD monitoring by quantitative RT-PCR at specific time points in CBF AML allows identification of patients at high risk of relapse and could now be incorporated in clinical trials to evaluate the role of risk directed/preemptive therapy.
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32
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Kühnl A, Grimwade D. Molecular markers in acute myeloid leukaemia. Int J Hematol 2012; 96:153-63. [PMID: 22791509 DOI: 10.1007/s12185-012-1123-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 05/29/2012] [Accepted: 06/07/2012] [Indexed: 12/14/2022]
Abstract
An increasing number of cytogenetic and molecular genetic aberrations have been identified in acute myeloid leukaemia (AML), highlighting the biological heterogeneity of the disease. Moreover, the characterisation of specific molecular abnormalities provides the basis for targeted therapies, such as all trans retinoic acid (ATRA) and arsenic trioxide treatment in acute promyelocytic leukaemia or tyrosine kinase inhibitors in AML with FLT3 mutations. Several cytogenetic and molecular genetic changes have been shown to be prognostically relevant and have been acknowledged in the latest WHO classification of AML as separate entities. A detailed marker assessment at diagnosis is crucial for risk-stratification of AML patients, allowing the identification of those at high risk of relapse, who may benefit from early allogeneic stem cell transplantation. Finally, molecular markers are important for the detection of minimal residual disease after initial therapy and during long-term follow-up, which enables a more tailored treatment approach for individual AML patients.
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Affiliation(s)
- Andrea Kühnl
- Department of Medical and Molecular Genetics, King's College London School of Medicine, London, UK
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33
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Hokland P, Ommen HB, Nyvold CG, Roug AS. Sensitivity of minimal residual disease in acute myeloid leukaemia in first remission - methodologies in relation to their clinical situation. Br J Haematol 2012; 158:569-80. [DOI: 10.1111/j.1365-2141.2012.09203.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Accepted: 05/07/2012] [Indexed: 12/16/2022]
Affiliation(s)
- Peter Hokland
- Department of Haematology; Aarhus University Hospital; Aarhus; Denmark
| | - Hans Beier Ommen
- Department of Haematology; Aarhus University Hospital; Aarhus; Denmark
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34
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Minimal residual disease as a predictive factor for relapse after allogeneic hematopoietic stem cell transplant in adult patients with acute myeloid leukemia in first and second complete remission. Cancers (Basel) 2012; 4:601-17. [PMID: 24213327 PMCID: PMC3712693 DOI: 10.3390/cancers4020601] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Revised: 06/13/2012] [Accepted: 06/14/2012] [Indexed: 11/18/2022] Open
Abstract
Allogeneic hematopoietic stem cell transplantation (allo-SCT) is potentially curative for patients with high-risk leukemia, but disease recurrence remains the leading cause of treatment failure. Our objective was to determine the impact of minimal residual disease (MRD) by any technique in adult patients with acute myeloid leukemia (AML) in morphologic first and second complete remission undergoing allo-SCT. Fifty nine patients were eligible for the study of 160 patients transplanted over ten years. For the MRD assessment we used multiparametric flow cytometry, cytogenetics and fluorescent in situ hybridization; 19 patients (32.2%) were identified as MRD positive. Patients with MRD had a consistently worse outcome over those without MRD, with 3-years leukemia-free survival (LFS) of 15.8% vs. 62.4% and overall survival (OS) of 17.5% vs. 62.3%. Relapse rate was significantly higher in MRD-positive patients; 3 years relapse rate in MRD-positive patients was 57.9% vs. 15.1% in MRD-negative patients. Detection of MRD in complete remission was associated with increased overall mortality (HR = 3.3; 95% CI: 1.45–7.57; p = 0.0044) and relapse (HR = 5.26; 95% CI: 2.0–14.0; p = 0.001), even after controlling for other risk factors. Our study showed that for patients in morphologic complete remission the presence of MRD predicts for significantly increased risk of relapse and reduced LFS and OS.
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35
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Nazha A, Cortes J, Faderl S, Pierce S, Daver N, Kadia T, Borthakur G, Luthra R, Kantarjian H, Ravandi F. Activating internal tandem duplication mutations of the fms-like tyrosine kinase-3 (FLT3-ITD) at complete response and relapse in patients with acute myeloid leukemia. Haematologica 2012; 97:1242-5. [PMID: 22532519 DOI: 10.3324/haematol.2012.062638] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
FMS-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutations are among the most frequent molecular aberrations in patients with acute myeloid leukemia. We retrospectively analyzed 324 patients with acute myeloid leukemia treated with front-line induction chemotherapy between October 2004 and March 2010. Fifty-six patients had FLT3-ITD mutation at diagnosis. Fifty-one (91%) patients with FLT3-ITD achieved complete remission. Thirteen patients had FLT3 analysis at complete remission. None had FLT3-ITD. Twenty-five (49%) patients with FLT3-ITD relapsed. Of these, 13 (52%) had FLT3-ITD at relapse (3 negative and 9 not done). Among the 201 patients without FLT3-ITD at diagnosis who achieved complete remission, 77 (38%) relapsed among whom 8 (10%) patients acquired FLT3-ITD clone. We conclude that FLT3-ITD mutations are unstable at follow up and may occur for the first time at relapse. Therefore, FLT3-ITD is not a reliable marker for minimal residual disease in acute myeloid leukemia.
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Affiliation(s)
- Aziz Nazha
- Department of Leukemia, UT-MD Anderson Cancer Center, Houston, TX 77030, USA
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36
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Abstract
The prognostic factors in acute leukemia have undergone a major change over the past decade and are likely to be further refined in the coming years. While age is the single most important prognostic factor in both AML and in ALL, recurring cytogenetic abnormalities and molecular markers have become crucial for the prognosis of patients and for new directions in the development of targeted therapies. No less important is the development of a personalized approach for therapy as determined by the response to therapy using increasingly sensitive technologies. The assessment of MRD is rapidly superseding other prognostic factors in ALL and, somewhat lacking behind, coming into its own in AML. The next decade should see further refinement of response-driven prognostication, to include epigenetics as well as pharmacogenetics and pharmacodynamics of individual drugs used and the responses to them. It is hoped that these refinements and better predictors of response will also lead to a significantly improved overall outcome of patients with both AML and ALL.
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Affiliation(s)
- Chezi Ganzel
- Department of Hematology, Shaare Zedek Medical Center, PO Box 3235, Jerusalem 91031, Israel.
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37
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Gray JX, McMillen L, Mollee P, Paul S, Lane S, Bird R, Gill D, Saal R, Marlton P. WT1 expression as a marker of minimal residual disease predicts outcome in acute myeloid leukemia when measured post-consolidation. Leuk Res 2012; 36:453-8. [DOI: 10.1016/j.leukres.2011.09.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 09/02/2011] [Accepted: 09/06/2011] [Indexed: 02/06/2023]
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38
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Quantification of PML/RARa transcript after induction predicts outcome in children with acute promyelocytic leukemia. Int J Hematol 2012; 95:500-8. [DOI: 10.1007/s12185-012-1034-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 02/17/2012] [Accepted: 02/22/2012] [Indexed: 12/26/2022]
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39
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The minimal residual disease concept coming of age - now for the direct comparison of methodologies. Leuk Res 2012; 36:392-3. [PMID: 22261230 DOI: 10.1016/j.leukres.2011.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 12/28/2011] [Accepted: 12/29/2011] [Indexed: 11/22/2022]
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40
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Prognostic and therapeutic implications of minimal residual disease detection in acute myeloid leukemia. Blood 2011; 119:332-41. [PMID: 22039260 DOI: 10.1182/blood-2011-08-363291] [Citation(s) in RCA: 181] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
The choice of either induction or postremission therapy for adults with acute myeloid leukemia is still largely based on the "one size fits all" principle. Moreover, pretreatment prognostic parameters, especially chromosome and gene abnormalities, may fail in predicting individual patient outcome. Measurement of minimal residual disease (MRD) is nowadays recognized as a potential critical tool to assess the quality of response after chemotherapy and to plan postremission strategies that are, therefore, driven by the individual risk of relapse. PCR and multiparametric flow cytometry have become the most popular methods to investigate MRD because they have been established as sensitive and specific enough to allow MRD to be studied serially. In the present review, we examine the evidence supporting the appropriateness of incorporating MRD detection into the AML risk assessment process. A comprehensive prognostic algorithm, generated by combining pretreatment cytogenetics/genetics and posttreatment MRD determination, should promote advances in development of personalized therapeutic approaches.
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41
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Jovanovic JV, Rennie K, Culligan D, Peniket A, Lennard A, Harrison J, Vyas P, Grimwade D. Development of real-time quantitative polymerase chain reaction assays to track treatment response in retinoid resistant acute promyelocytic leukemia. Front Oncol 2011; 1:35. [PMID: 22655241 PMCID: PMC3356041 DOI: 10.3389/fonc.2011.00035] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Accepted: 09/28/2011] [Indexed: 11/23/2022] Open
Abstract
Molecular detection of minimal residual disease (MRD) has become established to assess remission status and guide therapy in patients with ProMyelocytic Leukemia-RARA+ acute promyelocytic leukemia (APL). However, there are few data on tracking disease response in patients with rarer retinoid resistant subtypes of APL, characterized by PLZF-RARA and STAT5b-RARA. Despite their rarity (<1% of APL) we identified 6 cases (PLZF-RARA, n = 5; STAT5b-RARA, n = 1), established the respective breakpoint junction regions and designed reverse transcription-quantitative real-time polymerase chain reaction (RT-qPCR) assays to detect leukemic transcripts. The relative level of fusion gene expression in diagnostic samples was comparable to that observed in t(15;17) - associated APL, affording assay sensitivities of ∼1 in 10(4)-10(5). Serial samples were available from two PLZF-RARA APL patients. One showed persistent polymerase chain reaction positivity, predicting subsequent relapse, and remains in CR2, ∼11 years post-autograft. The other, achieved molecular remission (CRm) with combination chemotherapy, remaining in CR1 at 6 years. The STAT5b-RARA patient failed to achieve CRm following frontline combination chemotherapy and ultimately proceeded to allogeneic transplant on the basis of a steadily rising fusion transcript level. These data highlight the potential of RT-qPCR detection of MRD to facilitate development of more individualized approaches to the management of rarer molecularly defined subsets of acute leukemia.
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Affiliation(s)
- Jelena V. Jovanovic
- Cancer Genetics Laboratory, Department of Medical and Molecular Genetics, King’s College London School of MedicineLondon, UK
| | | | | | - Andrew Peniket
- Department of Haematology, John Radcliffe HospitalOxford, UK
| | - Anne Lennard
- Department of Haematology, Royal Victoria InfirmaryNewcastle, UK
| | - Justin Harrison
- Department of Haematology, Hemel Hempstead HospitalHemel Hempstead, UK
| | - Paresh Vyas
- Medical Research Council Molecular Haematology Unit, Weatherall Institute of Molecular MedicineOxford, UK
| | - David Grimwade
- Cancer Genetics Laboratory, Department of Medical and Molecular Genetics, King’s College London School of MedicineLondon, UK
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42
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Kristensen T, Møller MB, Friis L, Bergmann OJ, Preiss B. NPM1 mutation is a stable marker for minimal residual disease monitoring in acute myeloid leukaemia patients with increased sensitivity compared to WT1 expression. Eur J Haematol 2011; 87:400-8. [PMID: 21707751 DOI: 10.1111/j.1600-0609.2011.01673.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Mutation in the NPM1 gene occurs in 60% of acute myeloid leukaemia (AML) patients with normal karyotype. NPM1 mutation is potentially a superior minimal residual disease (MRD) marker compared to WT1 gene overexpression by being specific to the malignant clone, although experimental evidence published so far includes very limited numbers of relapsed cases. Also, the stability of the NPM1 mutation has been questioned by reports of the mutation being lost at relapse. In the present study we compared NPM1 mutation and WT1 overexpression as MRD markers in 20 cases of relapsed AML. The 20 patients experienced a total of 28 morphological relapses. Karyotypic evolution was detected in 56% of relapses. All relapses were accompanied by high levels of NPM1 mutation, along with high WT1 mRNA levels, thus demonstrating complete stability of both markers during relapse. Detectable NPM1 mutation following a period of morphological remission was accompanied by a morphological relapse in all cases. In contrast, WT1 expression was detected in 33% of the NPM1 mutation negative samples. This background WT1 expression produced by non-leukaemia cells was highly variable, both between and within patients, and limited the de facto sensitivity of the WT1 expression analysis. The present study therefore provides important experimental evidence demonstrating that NPM1 mutation is superior to WT1 overexpression as marker of MRD in NPM1-mutated AML, even in the presence of extensive karyotypic evolution.
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Affiliation(s)
- Thomas Kristensen
- Department of Pathology, Odense University Hospital, Odense, Denmark
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43
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Chen Y, Cortes J, Estrov Z, Faderl S, Qiao W, Abruzzo L, Garcia-Manero G, Pierce S, Huang X, Kebriaei P, Kadia T, De Lima M, Kantarjian H, Ravandi F. Persistence of cytogenetic abnormalities at complete remission after induction in patients with acute myeloid leukemia: prognostic significance and the potential role of allogeneic stem-cell transplantation. J Clin Oncol 2011; 29:2507-13. [PMID: 21555694 PMCID: PMC4874214 DOI: 10.1200/jco.2010.34.2873] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
PURPOSE To determine the prognostic impact of persistent cytogenetic abnormalities at complete remission (CR) on relapse-free survival (RFS) and overall survival (OS) in patients with acute myeloid leukemia (AML) and to examine the potential role of allogeneic stem-cell transplantation (SCT) in this setting. PATIENTS AND METHODS Data from 254 adult patients with AML (excluding acute promyelocytic leukemia) who achieved CR after induction chemotherapy on various first-line protocols were examined. RESULTS Median follow-up for surviving patients was 43 months. Patients with cytogenetic abnormalities at CR (n = 71) had significantly shorter RFS (P = .001) and OS (P < .001) compared with patients with normal cytogenetics at CR (n = 183); 3-year RFS was 15% and 45%, and 3-year OS was 15% and 56%, respectively. Among the patients with persistent cytogenetic abnormalities at CR, those who underwent SCT in first CR (CR1; n = 15) had better RFS and OS compared to those without SCT (n = 56; P = .04 and .06, respectively). In multivariate analysis, persistent cytogenetic abnormalities at CR was an independent predictor for RFS (P < .001) and OS (P = .001), but among patients with persistent cytogenetic abnormalities at CR, no significant differences in OS (P = .25) was observed between those who did or did not receive SCT with a trend favoring SCT for RFS (P = .08). CONCLUSION Persistent cytogenetically abnormal cells at CR predict a significantly shorter RFS and OS. SCT in CR1 may improve the clinical outcome of patients lacking cytogenetic remission after induction although this depends on patient selection.
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Affiliation(s)
- Yiming Chen
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jorge Cortes
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Zeev Estrov
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Stefan Faderl
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wei Qiao
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lynne Abruzzo
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - Sherry Pierce
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Xuelin Huang
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Partow Kebriaei
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Tapan Kadia
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Marcos De Lima
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hagop Kantarjian
- From the University of Texas MD Anderson Cancer Center, Houston, TX
| | - Farhad Ravandi
- From the University of Texas MD Anderson Cancer Center, Houston, TX.,Corresponding author: Farhad Ravandi, MD, Department of Leukemia, Unit 428, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030; e-mail:
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44
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Riera L, Lasorsa E, Bonello L, Sismondi F, Tondat F, Di Bello C, Di Celle PF, Chiarle R, Godio L, Pich A, Facchetti F, Ponzoni M, Marmont F, Zanon C, Bardelli A, Inghirami G. Description of a novel Janus kinase 3 P132A mutation in acute megakaryoblastic leukemia and demonstration of previously reported Janus kinase 3 mutations in normal subjects. Leuk Lymphoma 2011; 52:1742-50. [DOI: 10.3109/10428194.2011.574757] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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45
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Krönke J, Schlenk RF, Jensen KO, Tschürtz F, Corbacioglu A, Gaidzik VI, Paschka P, Onken S, Eiwen K, Habdank M, Späth D, Lübbert M, Wattad M, Kindler T, Salih HR, Held G, Nachbaur D, von Lilienfeld-Toal M, Germing U, Haase D, Mergenthaler HG, Krauter J, Ganser A, Göhring G, Schlegelberger B, Döhner H, Döhner K. Monitoring of minimal residual disease in NPM1-mutated acute myeloid leukemia: a study from the German-Austrian acute myeloid leukemia study group. J Clin Oncol 2011; 29:2709-16. [PMID: 21555683 DOI: 10.1200/jco.2011.35.0371] [Citation(s) in RCA: 298] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To evaluate the prognostic value of minimal residual disease (MRD) in patients with acute myeloid leukemia (AML) with NPM1 mutation (NPM1(mut)). PATIENTS AND METHOD RNA-based real-time quantitative polymerase chain reaction (RQ-PCR) specific for the detection of six different NPM1(mut) types was applied to 1,682 samples (bone marrow, n = 1,272; blood, n = 410) serially obtained from 245 intensively treated younger adult patients who were 16 to 60 years old. RESULTS NPM1(mut) transcript levels as a continuous variable were significantly associated with prognosis after each treatment cycle. Achievement of RQ-PCR negativity after double induction therapy identified patients with a low cumulative incidence of relapse (CIR; 6.5% after 4 years) compared with RQ-PCR-positive patients (53.0%; P < .001); this translated into significant differences in overall survival (90% v 51%, respectively; P = .001). After completion of therapy, CIR was 15.7% in RQ-PCR-negative patients compared with 66.5% in RQ-PCR-positive patients (P < .001). Multivariable analyses after double induction and after completion of consolidation therapy revealed higher NPM1(mut) transcript levels as a significant factor for a higher risk of relapse and death. Serial post-treatment assessment of MRD allowed early detection of relapse in patients exceeding more than 200 NPM1(mut)/10(4) ABL copies. CONCLUSION We defined clinically relevant time points for NPM1(mut) MRD assessment that allow for the identification of patients with AML who are at high risk of relapse. Monitoring of NPM1(mut) transcript levels should be incorporated in future clinical trials to guide therapeutic decisions.
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Affiliation(s)
- Jan Krönke
- Department of Internal Medicine III, University Hospital of Ulm, Ulm, Germany
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Østergaard M, Nyvold CG, Jovanovic JV, Andersen MT, Kairisto V, Morgan YG, Tobal K, Pallisgaard N, Özbek U, Pfeifer H, Schnittger S, Grubach L, Larsen JK, Grimwade D, Hokland P. Development of standardized approaches to reporting of minimal residual disease data using a reporting software package designed within the European LeukemiaNet. Leukemia 2011; 25:1168-73. [DOI: 10.1038/leu.2011.69] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Prospective separation of normal and leukemic stem cells based on differential expression of TIM3, a human acute myeloid leukemia stem cell marker. Proc Natl Acad Sci U S A 2011; 108:5009-14. [PMID: 21383193 DOI: 10.1073/pnas.1100551108] [Citation(s) in RCA: 213] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Hematopoietic tissues in acute myeloid leukemia (AML) patients contain both leukemia stem cells (LSC) and residual normal hematopoietic stem cells (HSC). The ability to prospectively separate residual HSC from LSC would enable important scientific and clinical investigation including the possibility of purged autologous hematopoietic cell transplants. We report here the identification of TIM3 as an AML stem cell surface marker more highly expressed on multiple specimens of AML LSC than on normal bone marrow HSC. TIM3 expression was detected in all cytogenetic subgroups of AML, but was significantly higher in AML-associated with core binding factor translocations or mutations in CEBPA. By assessing engraftment in NOD/SCID/IL2Rγ-null mice, we determined that HSC function resides predominantly in the TIM3-negative fraction of normal bone marrow, whereas LSC function from multiple AML specimens resides predominantly in the TIM3-positive compartment. Significantly, differential TIM3 expression enabled the prospective separation of HSC from LSC in the majority of AML specimens with detectable residual HSC function.
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Abstract
Abstract
An increasing body of data has demonstrated that the traditional concept of morphologic complete remission in acute myeloid leukemia, in which less than 5% myeloblasts is regarded as a sufficient response criterion, is not biologically sound. Fortunately, the quantitative reverse-transcribed polymerase chain reaction (RT-PCR) method seems to be a promising alternative because of its high degree of preclinical standardization and extreme sensitivity on the background of an accurate day-to-day estimate of sample quality. Widespread implementation of this has, however, to some extent been hampered by the lack of knowledge of how and when to measure minimal residual disease levels and, even more importantly, how to react preemptively on a molecular relapse defined by a PCR reversal. Thus, only few prospective studies have been published to date to clinically validate this assay. Here, we discuss outstanding issues in the clinical implementation of RT-PCR for fusion transcripts, mutated and overexpressed genes in acute myeloid leukemia patients in complete remission, and propose a set of guidelines, which can be used when designing prospective trials aimed at validating the use of RT-PCR as well as for following these patients based on mathematical models for disease recurrence recently developed in our laboratory.
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Corbacioglu A, Scholl C, Schlenk RF, Eiwen K, Du J, Bullinger L, Fröhling S, Reimer P, Rummel M, Derigs HG, Nachbaur D, Krauter J, Ganser A, Döhner H, Döhner K. Prognostic Impact of Minimal Residual Disease inCBFB-MYH11–Positive Acute Myeloid Leukemia. J Clin Oncol 2010; 28:3724-9. [DOI: 10.1200/jco.2010.28.6468] [Citation(s) in RCA: 112] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeTo evaluate the prognostic impact of minimal residual disease (MRD) in patients with acute myeloid leukemia (AML) expressing the CBFB-MYH11 fusion transcript.Patients and MethodsQuantitative reverse transcriptase polymerase chain reaction (PCR) was performed on 684 bone marrow (BM; n = 331) and/or peripheral blood (PB; n = 353) samples (median, 13 samples per patient) from 53 younger adult (16 to 60 years old) patients with AML treated in prospective German-Austrian AML Study Group treatment trials. Samples were obtained at diagnosis (BM, n = 45; PB, n = 48), during treatment course (BM, n = 153; PB, n = 122), and at follow-up (BM, n = 133; PB, n = 183). To evaluate the applicability of PB for MRD detection, 198 paired BM and PB samples obtained at identical time points were analyzed.ResultsThe following three clinically relevant checkpoints were identified during consolidation and early follow-up that predicted relapse: achievement of PCR negativity in at least one BM sample during consolidation therapy (2-year relapse-free survival [RFS], 79% v 54% for PCR positivity; P = .035); achievement of PCR negativity in at least two BM or PB samples during consolidation therapy and early follow-up (≤ 3 months; 2-year RFS, P = .001; overall survival, P = .01); and conversion from PCR negativity to PCR positivity with copy ratios of more than 10 after consolidation therapy. Analysis of paired BM and PB samples revealed BM samples to be more sensitive during the course of therapy, whereas for follow-up, PB samples were equally informative.ConclusionWe defined clinically relevant MRD checkpoints that allow for the identification of patients with CBFB-MYH11–positive AML who are at high risk of relapse. Monitoring of CBFB-MYH11 transcript levels should be incorporated into future clinical trials to guide therapeutic decisions.
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Affiliation(s)
- Andrea Corbacioglu
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Claudia Scholl
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Richard F. Schlenk
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Karina Eiwen
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Juan Du
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Lars Bullinger
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Stefan Fröhling
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Peter Reimer
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Mathias Rummel
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Hans-Günter Derigs
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - David Nachbaur
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Jürgen Krauter
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Arnold Ganser
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Hartmut Döhner
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
| | - Konstanze Döhner
- From the University Hospital of Ulm, Ulm; Kliniken Essen Süd, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen; University Hospital of Giessen, Medizinische Klinik and Polikinik IV, Giessen; Städtische Kliniken Frankfurt am Main-Höchst, Frankfurt; Hannover Medical School, Hannover, Germany; and University Hospital of Innsbruck, Innsbruck, Austria
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