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Verma A, Chi YY, Malvar J, Lamble A, Chaudhury S, Agarwal A, Li HT, Liang G, Leong R, Brown PA, Kaplan J, Schafer ES, Slone T, Pauly M, Chang BH, Stieglitz E, Wayne AS, Hijiya N, Bhojwani D. Nivolumab Plus 5-Azacitidine in Pediatric Relapsed/Refractory Acute Myeloid Leukemia (AML): Phase I/II Trial Results from the Therapeutic Advances in Childhood Leukemia and Lymphoma (TACL) Consortium. Cancers (Basel) 2024; 16:496. [PMID: 38339248 PMCID: PMC10854518 DOI: 10.3390/cancers16030496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/11/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
Improvements in survival have been made over the past two decades for childhood acute myeloid leukemia (AML), but the approximately 40% of patients who relapse continue to have poor outcomes. A combination of checkpoint-inhibitor nivolumab and azacitidine has demonstrated improvements in median survival in adults with AML. This phase I/II study with nivolumab and azacitidine in children with relapsed/refractory AML (NCT03825367) was conducted through the Therapeutic Advances in Childhood Leukemia & Lymphoma consortium. Thirteen patients, median age 13.7 years, were enrolled. Patients had refractory disease with multiple reinduction attempts. Twelve evaluable patients were treated at the recommended phase II dose (established at dose level 1, 3 mg/kg/dose). Four patients (33%) maintained stable disease. This combination was well tolerated, with no dose-limiting toxicities observed. Grade 3-4 adverse events (AEs) were primarily hematological. Febrile neutropenia was the most common AE ≥ grade 3. A trend to improved quality of life was noted. Increases in CD8+ T cells and reductions in CD4+/CD8+ T cells and demethylation were observed. The combination was well tolerated and had an acceptable safety profile in pediatric patients with relapsed/refractory AML. Future studies might explore this combination for the maintenance of remission in children with AML at high risk of relapse.
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Affiliation(s)
- Anupam Verma
- Center for Cancer and Blood Disorders, Pediatric Hematology Oncology Branch, Children’s National Hospital, Washington, DC 20010, USA
- Division of Pediatric Hematology Oncology, Primary Children’s Hospital, University of Utah, Salt Lake City, UT 84113, USA
| | - Yueh-Yun Chi
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA; (Y.-Y.C.); (A.S.W.); (D.B.)
| | - Jemily Malvar
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (J.M.)
| | - Adam Lamble
- Department of Pediatric Hematology Oncology, Seattle Children’s Hospital, Seattle, WA 98105, USA;
| | - Sonali Chaudhury
- Department of Pediatric Hematology Oncology, Ann and Robert Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA;
| | - Archana Agarwal
- Department of Pathology, University of Utah and ARUP Laboratories, Salt Lake City, UT 84108, USA;
| | - Hong-Tao Li
- Department of Urology, University of Southern California, Los Angeles, CA 90033, USA; (H.-T.L.); (G.L.)
| | - Gangning Liang
- Department of Urology, University of Southern California, Los Angeles, CA 90033, USA; (H.-T.L.); (G.L.)
| | - Roy Leong
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Los Angeles, CA 90027, USA; (J.M.)
| | | | - Joel Kaplan
- Department of Pediatric Hematology Oncology, Atrium Health Levine Children’s Hospital, Wake Forrest University, Charlotte, NC 28203, USA;
| | - Eric S. Schafer
- Division of Pediatric Hematology/Oncology, Baylor College of Medicine, Texas Children’s Cancer and Hematology Center, Houston, TX 77030, USA;
| | - Tamra Slone
- Department of Pediatric Hematology Oncology, UT Southwestern, Dallas, TX 75235, USA;
| | - Melinda Pauly
- Department of Pediatric Hematology Oncology, Children’s Healthcare of Atlanta, Atlanta, GA 30322, USA;
| | - Bill H. Chang
- Division of Pediatric Hematology Oncology, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Elliot Stieglitz
- Department of Pediatric Oncology, University of California, San Francisco Benioff Children’s Hospitals, San Francisco, CA 94158, USA;
| | - Alan S. Wayne
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA; (Y.-Y.C.); (A.S.W.); (D.B.)
| | - Nobuko Hijiya
- Division of Pediatric Hematology Oncology and Stem Cell Transplant, Columbia University Medical Center, New York, NY 10032, USA;
| | - Deepa Bhojwani
- Division of Hematology-Oncology, Cancer and Blood Disease Institute, Children’s Hospital Los Angeles, Norris Comprehensive Cancer Center, Keck School of Medicine, University of Southern California, Los Angeles, CA 90027, USA; (Y.-Y.C.); (A.S.W.); (D.B.)
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2
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Roshal M, Gao Q. Flow Cytometry in Diagnosis, Prognostication, and Monitoring of Multiple Myeloma and Related Disorders. Clin Lab Med 2023; 43:363-375. [PMID: 37481317 DOI: 10.1016/j.cll.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
Flow cytometry plays a critical role in the diagnosis, prognostication, therapy response evaluation, and clinical management of plasma cell neoplasms. The review summarizes how flow cytometry is used in the initial evaluation to distinguish primary and secondary clonal plasma cell populations from each other and from reactive plasma cells. We further illustrate the kinds of prognostic information the assessment can provide at diagnosis and disease follow-up of primary plasma cell neoplasms. Technical requirements for MRD assays and their use in therapy efficacy assessment and clinical decision-making in multi-myeloma are discussed.
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Affiliation(s)
- Mikhail Roshal
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center.
| | - Qi Gao
- Department of Pathology and Laboratory Medicine, Memorial Sloan Kettering Cancer Center
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3
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Tan CR, Derkach A, Nemirovsky D, Ciardiello A, Diamond B, Hultcrantz M, Hassoun H, Mailankody S, Shah U, Maclachlan K, Patel D, Lahoud OB, Landau HJ, Chung DJ, Shah GL, Scordo M, Giralt SA, Lesokhin A, Usmani SZ, Landgren O, Korde N. Bortezomib, lenalidomide and dexamethasone (VRd) vs carfilzomib, lenalidomide and dexamethasone (KRd) as induction therapy in newly diagnosed multiple myeloma. Blood Cancer J 2023; 13:112. [PMID: 37491332 PMCID: PMC10368661 DOI: 10.1038/s41408-023-00882-y] [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: 02/21/2023] [Revised: 06/17/2023] [Accepted: 07/11/2023] [Indexed: 07/27/2023] Open
Abstract
Lenalidomide and dexamethasone with bortezomib (VRd) or carfilzomib (KRd) are commonly used induction regimens in the U.S. This single-center, retrospective study evaluated outcomes and safety of VRd and KRd. Primary endpoint was progression-free survival (PFS). Of 389 patients with newly diagnosed multiple myeloma, 198 received VRd and 191 received KRd. Median PFS was not reached (NR) in both groups; 5-year PFS was 56% (95%CI, 48-64%) for VRd and 67% (60-75%) for KRd (P = 0.027). Estimated 5-year EFS was 34% (95%CI, 27-42%) for VRd and 52% (45-60%) for KRd (P < 0.001) with corresponding 5-year OS of 80% (95%CI, 75-87%) and 90% (85-95%), respectively (P = 0.053). For standard-risk patients, 5-year PFS was 68% (95%CI, 60-78%) for VRd and 75% (65-85%) for KRd (P = 0.20) with 5-year OS of 87% (95%CI, 81-94%) and 93% (87-99%), respectively (P = 0.13). For high-risk patients, median PFS was 41 months (95%CI, 32.8-61.1) for VRd and 70.9 months (58.2-NR) for KRd (P = 0.016). Respective 5-year PFS and OS were 35% (95%CI, 24-51%) and 69% (58-82%) for VRd and 58% (47-71%) and 88% (80-97%, P = 0.044) for KRd. Overall, KRd resulted in improved PFS and EFS with a trend toward improved OS compared to VRd with associations primarily driven by improvements in outcome for high-risk patients.
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Affiliation(s)
- Carlyn Rose Tan
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Andriy Derkach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David Nemirovsky
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Amanda Ciardiello
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Benjamin Diamond
- Myeloma Division, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Malin Hultcrantz
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hani Hassoun
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sham Mailankody
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Urvi Shah
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kylee Maclachlan
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dhwani Patel
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oscar B Lahoud
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heather J Landau
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David J Chung
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexander Lesokhin
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Saad Z Usmani
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ola Landgren
- Myeloma Division, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Neha Korde
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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4
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Tan CR, Derkach A, Nemirovsky D, Ciardiello A, Diamond B, Hultcrantz M, Hassoun H, Mailankody S, Shah U, Maclachlan K, Patel D, Lahoud O, Landau H, Chung D, Shah G, Scordo M, Giralt S, Lesokhin A, Usmani S, Landgren O, Korde N. Bortezomib, Lenalidomide and Dexamethasone (VRd) vs Carfilzomib, Lenalidomide and Dexamethasone (KRd) as Induction Therapy in Newly Diagnosed Multiple Myeloma. RESEARCH SQUARE 2023:rs.3.rs-2583053. [PMID: 36865246 PMCID: PMC9980212 DOI: 10.21203/rs.3.rs-2583053/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
Lenalidomide and dexamethasone with bortezomib (VRd) or carfilzomib (KRd) are commonly used induction regimens in the U.S. This single-center, retrospective study evaluated outcomes and safety of VRd and KRd. Primary endpoint was progression-free survival (PFS). Of 389 patients with newly diagnosed multiple myeloma, 198 received VRd and 191 received KRd. Median PFS was not reached (NR) in both groups; 5-year PFS was 56% (95%CI, 48%-64%) for VRd and 67% (60%-75%) for KRd (P = 0.027). Estimated 5-year EFS was 34% (95%CI, 27%-42%) for VRd and 52% (45%-60%) for KRd (P < 0.001) with corresponding 5-year OS of 80% (95%CI, 75%-87%) and 90% (85%-95%), respectively (P = 0.053). For standard-risk patients, 5-year PFS was 68% (95%CI, 60%-78%) for VRd and 75% (65%-85%) for KRd (P = 0.20) with 5-year OS of 87% (95%CI, 81%-94%) and 93% (87%-99%), respectively (P = 0.13). For high-risk patients, median PFS was 41 months (95%CI, 32.8-61.1) for VRd and 70.9 months (58.2-NR) for KRd (P = 0.016). Respective 5-year PFS and OS were 35% (95%CI, 24%-51%) and 69% (58%-82%) for VRd and 58% (47%-71%) and 88% (80%-97%, P = 0.044) for KRd. Overall, KRd resulted in improved PFS and EFS with a trend toward improved OS compared to VRd with associations primarily driven by improvements in outcome for high-risk patients.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Urvi Shah
- Memorial Sloan Kettering Cancer Center
| | | | | | | | | | | | | | | | | | | | | | - Ola Landgren
- Sylvester Comprehensive Cancer Center, University of Miami
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Broijl A, de Jong ACM, van Duin M, Sonneveld P, Kühnau J, van der Velden VHJ. VS38c and CD38-Multiepitope Antibodies Provide Highly Comparable Minimal Residual Disease Data in Patients With Multiple Myeloma. Am J Clin Pathol 2022; 157:494-497. [PMID: 34643211 PMCID: PMC8973271 DOI: 10.1093/ajcp/aqab163] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/25/2021] [Indexed: 01/03/2023] Open
Abstract
Objectives To compare flow cytometric minimal residual disease (MRD) data obtained using the EuroFlow approach, including the CD38-multiepitope (ME) antibody or the VS38c antibody. Methods We evaluated 29 bone marrow samples from patients with multiple myeloma (MM), of whom 15 had received daratumumab within the past 6 months. We evaluated MRD data and fluorescence intensities. Results Qualitative MRD data were 100% concordant between the 2 approaches. In MRD-positive samples (n = 14), MRD levels showed an excellent correlation (R2 = 0.999). Whereas VS38c staining was strong in both normal plasma cells and MM cells, independent of daratumumab treatment, staining intensities for CD38 were lower in MM cells compared with normal plasma cells, and on both cell types CD38 expression was significantly reduced in daratumumab-treated patients. Conclusions Both CD38-ME and VS38c allow reliable MRD detection in MM patients, but the high expression of VS38c allows easier identification of MM cells, especially in daratumumab-treated patients.
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Affiliation(s)
- Annemiek Broijl
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Augustinus C M de Jong
- Department of Immunology, Laboratory Medical Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mark van Duin
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jesper Kühnau
- Reagent Partnership Division, Diagnostics and Genomics Group, Agilent Technologies, Glostrup, Denmark
| | - Vincent H J van der Velden
- Department of Immunology, Laboratory Medical Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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6
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Ng DP, Miles RR, Andersen EF, Toydemir RM. Flow Cytometry Is More Sensitive Than Fluorescence In Situ Hybridization for Detecting Minimal Residual Disease. Am J Clin Pathol 2021; 156:715-716. [PMID: 34165497 DOI: 10.1093/ajcp/aqab080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Rodney R Miles
- University of Utah and ARUP Laboratories Salt Lake City, UT, USA
| | - Erica F Andersen
- University of Utah and ARUP Laboratories Salt Lake City, UT, USA
| | - Reha M Toydemir
- University of Utah and ARUP Laboratories Salt Lake City, UT, USA
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7
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Riebl V, Dold SM, Wider D, Follo M, Ihorst G, Waldschmidt JM, Jung J, Rassner M, Greil C, Wäsch R, Engelhardt M. Ten Color Multiparameter Flow Cytometry in Bone Marrow and Apheresis Products for Assessment and Outcome Prediction in Multiple Myeloma Patients. Front Oncol 2021; 11:708231. [PMID: 34485145 PMCID: PMC8414971 DOI: 10.3389/fonc.2021.708231] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/19/2021] [Indexed: 11/13/2022] Open
Abstract
Objective In clinical trials (CTs), the assessment of minimal residual disease (MRD) has proven to have prognostic value for multiple myeloma (MM) patients. Multiparameter flow cytometry (MFC) and next-generation sequencing are currently used in CTs as effective tools for outcome prediction. We have previously described 6- and 8-color MFC panels with and without kappa/lambda, which were equally reliable in detecting aberrant plasma cells (aPC) in myeloma bone marrow (BM) specimens. This follow-up study a) established a highly sensitive single-tube 10-color MFC panel for MRD detection in myeloma samples carrying different disease burden (monoclonal gammopathy of unknown significance (MGUS), smoldering multiple myeloma (SMM), MM), b) evaluated additional, rarely used markers included in this panel, and c) assessed MRD levels and the predictive value in apheresis vs. BM samples of MM patients undergoing autologous stem cell transplantation (ASCT). Methods + Results The 10-color MFC was performed in BM and apheresis samples of 128 MM and pre-MM (MGUS/SMM) patients. The markers CD28, CD200, CD19, and CD117 underwent closer examination. The analysis revealed distinct differences in these antigens between MM, MGUS/SMM, and patients under treatment. In apheresis samples, the 10-color panel determined MRD negativity in 44% of patients. Absence of aPC in apheresis corresponded with disease burden, cytogenetics, and response to induction. It also determined MRD negativity in BM samples after ASCT and was associated with improved progression-free survival. Conclusion These results highlight the significance of the evaluation of both BM and apheresis samples with a novel highly sensitive 10-color MFC panel.
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Affiliation(s)
- Veronika Riebl
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Sandra Maria Dold
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Biology, University of Freiburg, Freiburg, Germany
| | - Dagmar Wider
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Marie Follo
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Johannes M Waldschmidt
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Johannes Jung
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Michael Rassner
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Christine Greil
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I Hematology and Oncology, Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg (CCCF), Faculty of Medicine, Medical Center - University of Freiburg, Freiburg, Germany
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8
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Bravo-Pérez C, Sola M, Teruel-Montoya R, García-Malo MD, Ortuño FJ, Vicente V, de Arriba F, Jerez A. Minimal Residual Disease in Multiple Myeloma: Something Old, Something New. Cancers (Basel) 2021; 13:4332. [PMID: 34503142 PMCID: PMC8430644 DOI: 10.3390/cancers13174332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 08/20/2021] [Accepted: 08/23/2021] [Indexed: 12/13/2022] Open
Abstract
The game-changing outcome effect, due to the generalized use of novel agents in MM, has cre-ated a paradigm shift. Achieving frequent deep responses has placed MM among those neoplasms where the rationale for assessing MRD is fulfilled. However, its implementation in MM has raised specific questions: how might we weight standard measures against deep MRD in the emerging CAR-T setting? Which high sensitivity method to choose? Are current response criteria still useful? In this work, we address lessons learned from the use of MRD in other neoplasms, the steps followed for the harmonization of current methods for comprehensively measuring MRD, and the challenges that new therapies and concepts pose in the MM clinical field.
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Affiliation(s)
- Carlos Bravo-Pérez
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - María Sola
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - Raúl Teruel-Montoya
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
- CB15/00055-CIBERER, 30003 Murcia, Spain
| | - María Dolores García-Malo
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - Francisco José Ortuño
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - Vicente Vicente
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
- CB15/00055-CIBERER, 30003 Murcia, Spain
| | - Felipe de Arriba
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
| | - Andrés Jerez
- Hematology and Medical Oncology Department, University Hospital Morales Meseguer, IMIB, 30003 Murcia, Spain; (C.B.-P.); (M.S.); (M.D.G.-M.); (F.J.O.); (V.V.); (F.d.A.); (A.J.)
- CB15/00055-CIBERER, 30003 Murcia, Spain
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9
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Ng DP. Flow cytometric myeloma measurable residual disease testing in the era of targeted therapies. Int J Lab Hematol 2021; 43 Suppl 1:71-77. [PMID: 34288444 DOI: 10.1111/ijlh.13587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 11/30/2022]
Abstract
Therapies in myeloma are rapidly advancing with a host of new targeted therapies coming to market. While these drugs offer significant survival benefits and better side-effect profiles compared with conventional chemotherapeutics, they raise significant difficulties in monitoring post-therapy disease status by flow cytometry due to assay interference and/or selection of phenotypically different sub-clones. The principal culprit, anti-CD38 monoclonal antibodies, limits the ability to detect plasma cells based on classical CD38/CD45 gating. Other markers, such as CD138, are known to be suboptimal by flow cytometry. Various techniques have been proposed to overcome this problem. The most promising of these techniques has been the marker VS38c, a monoclonal antibody targeting an endoplasmic reticulum protein which has shown high sensitivity for plasma cells. Alternative techniques for gating plasma cells, while variably effective in the near term are already the subject of several targeted therapies rendering their usefulness limited in the longer term. Likewise, future targets of these therapies may render present aberrancy markers ineffective in MRD testing. These therapies pose challenges that must be overcome with new markers and novel panels in order for flow cytometric MRD testing to remain relevant.
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Affiliation(s)
- David P Ng
- University of Utah, Salt Lake City, UT, USA
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10
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Diamond B, Korde N, Lesokhin AM, Smith EL, Shah U, Mailankody S, Hultcrantz M, Hassoun H, Lu SX, Tan C, Rustad EH, Maura F, Maclachlan K, Peterson T, Derkach A, Devlin S, Landau HJ, Scordo M, Chung DJ, Shah GL, Lahoud O, Thoren K, Murata K, Ramanathan L, Arcila ME, Ho C, Roshal M, Dogan A, Giralt SA, Landgren O. Dynamics of minimal residual disease in patients with multiple myeloma on continuous lenalidomide maintenance: a single-arm, single-centre, phase 2 trial. LANCET HAEMATOLOGY 2021; 8:e422-e432. [PMID: 34048681 DOI: 10.1016/s2352-3026(21)00130-7] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 12/22/2022]
Abstract
Background Lenalidomide maintenance improves progression-free survival for patients with multiple myeloma, although its optimal duration is unknown. Clearance of minimal residual disease (MRD) in the bone marrow results in superior outcomes, although its attainment or sustainment does not alter clinical decision-making. Studies that have evaluated MRD serially are limited in length. We therefore aimed to evaluate longitudinal changes in MRD-status (dynamics) and their association with progression-free survival in patients with multiple myeloma. METHODS In this single-centre, single-arm, phase 2 study, we enrolled patients aged 18 years and older from the Memorial Sloan Kettering Cancer Center (New York, NY, USA) who had newly diagnosed multiple myeloma following unrestricted frontline therapy and an Eastern Cooperative Oncology Group Performance Status of 2 or lower, including patients who started maintenance before study enrolment. All participants received lenalidomide maintenance at 10 mg for 21 days of 28-day cycles until progression or unacceptable toxic effects for up to 5 years on protocol. The primary endpoint was progression-free survival at 60 months per protocol and key secondary endpoints were MRD rates after completion of the 12th, 24th, and 36th cycle of maintenance and the association between progression-free survival and annual measurement of MRD status. MRD was assessed from first-pull bone marrow aspirates at baseline and annually by flow cytometry per International Myeloma Working Group criteria, (limit of detection of at least 1 × 10-5) up to a maximum of 5 years. Patients who completed at least four cycles of treatment were included in the analysis of the primary endpoint, and patients who had completed at least one dose of treatment on protocol were assessable for secondary endpoints. The study was registered at ClinicalTrials.gov, NCT02538198, and is now closed to accrual. FINDINGS Between Sept 8, 2015, and Jan 25, 2019, 108 patients (100 evaluable for the primary endpoint) were enrolled. Median follow-up was 40·7 months (95% CI 38·7-45·0). At 60 months, progression-free survival was 64% (95% CI 52-79). Median progression-free survival was unreached (95% CI unreached-unreached). MRD dynamics were assessed using 340 MRD assessments done over 5 years for 103 evaluable patients. Patients who sustained MRD negativity for 2 years (n=34) had no recorded disease progression at median 19·8 months (95% CI 15·8-22·3) past the 2-year maintenance landmark. By contrast, patients who lost their MRD-negative responses (n=10) were more likely to progress than those with sustained MRD negativity (HR infinite; p<0·0001) and those with persistent MRD positivity (HR 5·88, 95% CI 1·18-33·33; p=0·015) at the 2-year landmark. Haematological and non-haematological serious adverse events occurred in 19 patients (18%). The most common adverse events of grade 3 or worse were decreased lymphocyte count in 48 (44%) patients and decreased neutrophil count in 47 (44%) patients. One death occurred on study due to sepsis and heart failure and was considered unrelated to the study drug. INTERPRETATION Serial measurements of MRD allow for dynamic assessment of risk for disease progression. Early intervention should be investigated for patients with loss of MRD negativity. Sustained MRD positivity is not categorically an unfavourable outcome and might portend prolonged stability of low-level disease. FUNDING Memorial Sloan Kettering and Celgene.
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Affiliation(s)
- Benjamin Diamond
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Neha Korde
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Alexander M Lesokhin
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eric L Smith
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Urvi Shah
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sham Mailankody
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Malin Hultcrantz
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hani Hassoun
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sydney X Lu
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Carlyn Tan
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Even H Rustad
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Francesco Maura
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA
| | - Kylee Maclachlan
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tim Peterson
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andriy Derkach
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sean Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heather J Landau
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Michael Scordo
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - David J Chung
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Oscar Lahoud
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Katie Thoren
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kazunori Murata
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Lakshmi Ramanathan
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Maria E Arcila
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Caleb Ho
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Mikhail Roshal
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ahmet Dogan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ola Landgren
- Myeloma Program, Sylvester Comprehensive Cancer Center, University of Miami, Miami, FL, USA.
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11
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Hupp MM, Bashleben C, Cardinali JL, Dorfman DM, Karlon W, Keeney M, Leith C, Long T, Murphy CE, Pillai V, Rosado FN, Seegmiller AC, Linden MA. Participation in the College of American Pathologists Laboratory Accreditation Program Decreases Variability in B-Lymphoblastic Leukemia and Plasma Cell Myeloma Flow Cytometric Minimal Residual Disease Testing: A Follow-up Survey. Arch Pathol Lab Med 2021; 145:336-342. [PMID: 32886757 DOI: 10.5858/arpa.2019-0493-cp] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Minimal residual disease (MRD) testing by flow cytometry is ubiquitous in hematolymphoid neoplasm monitoring, especially B-lymphoblastic leukemia (B-ALL), for which it provides predictive information and guides management. Major heterogeneity was identified in 2014. Subsequently, new Flow Cytometry Checklist items required documentation of the sensitivity determination method and required lower level of detection (LLOD) inclusion in final reports. This study assesses Laboratory Accreditation Program (LAP) participation and new checklist items' impact on flow cytometry MRD testing. OBJECTIVES.— To survey flow cytometry laboratories about MRD testing for B-ALL and plasma cell myeloma. In particular, enumerate the laboratories performing MRD testing, the proportion performing assays with very low LLODs, and implementation of new checklist items. DESIGN.— Supplemental questions were distributed in the 2017-A mailing to 548 flow cytometry laboratories subscribed to the College of American Pathologists FL3 Proficiency Testing Survey (Flow Cytometry-Immunophenotypic Characterization of Leukemia/Lymphoma). RESULTS.— The percentage of laboratories performing MRD studies has significantly decreased since 2014. Wide ranges of LLOD and collection event numbers were reported for B-ALL and plasma cell myeloma. Most laboratories determine LLOD by using dilutional studies and include it in final reports; a higher proportion of LAP participants used these practices than nonparticipants. CONCLUSIONS.— Several MRD testing aspects vary among laboratories receiving FL3 Proficiency Testing materials. After the survey in 2014, new checklist items were implemented. As compared to 2014, fewer laboratories are performing MRD studies. While LLOD remains heterogeneous, a high proportion of LAP subscribers follow the new checklist requirements and, overall, target LLOD recommendations from disease-specific working groups are met.
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Affiliation(s)
- Meghan M Hupp
- From the Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis (Hupp, Linden)
| | | | - Jolene L Cardinali
- Special Hematology, Hartford Hospital, Hartford, Connecticut (Cardinali)
| | - David M Dorfman
- The Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts (Dorfman)
| | - William Karlon
- The Departments of Pathology and Laboratory Medicine, University of California, San Francisco (Karlon)
| | - Michael Keeney
- London Health Sciences Centre, Lawson Health Research Institute, London, Ontario, Canada (Keeney)
| | - Catherine Leith
- The Department of Pathology and Laboratory Medicine, University of Wisconsin Hospital and Clinics, Madison (Leith)
| | - Thomas Long
- College of American Pathologists, Northfield, Illinois (Bashleben, Long)
| | | | - Vinodh Pillai
- the Department of Pathology and Laboratory Medicine, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania (Pillai)
| | - Flavia N Rosado
- The Department of Pathology and Laboratory Services, University of Texas Southwestern Medical Center, Dallas (Rosado)
| | - Adam C Seegmiller
- The Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee (Seegmiller)
| | - Michael A Linden
- From the Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota Medical Center, Minneapolis (Hupp, Linden)
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12
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Ho C, Syed M, Roshal M, Petrova-Drus K, Moung C, Yao J, Quesada AE, Benhamida J, Vanderbilt C, Liu Y, Zhu M, Yu W, Maciag L, Wang M, Ma Y, Gao Q, Rustad EH, Hultcrantz M, Diamond BT, Zheng-Lin B, Huang Y, Hutt K, Miller JE, Dogan A, Nafa K, Landgren O, Arcila ME. Routine Evaluation of Minimal Residual Disease in Myeloma Using Next-Generation Sequencing Clonality Testing: Feasibility, Challenges, and Direct Comparison with High-Sensitivity Flow Cytometry. J Mol Diagn 2020; 23:181-199. [PMID: 33217553 PMCID: PMC7874334 DOI: 10.1016/j.jmoldx.2020.10.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 09/13/2020] [Accepted: 10/22/2020] [Indexed: 01/12/2023] Open
Abstract
The 2016 International Myeloma Working Group consensus recommendations emphasize high-sensitivity methods for minimal residual disease (MRD) detection, treatment response assessment, and prognostication. Next-generation sequencing (NGS) of IGH gene rearrangements is highly specific and sensitive, but its description in routine clinical practice and performance comparison with high-sensitivity flow cytometry (hsFC) remain limited. In this large, single-institution study including 438 samples from 251 patients, the use of NGS targeting the IGH and IGK genes for clonal characterization and monitoring, with comparison to hsFC, is described. The index clone characterization success rate was 93.6% (235/251), which depended on plasma cell (PC) cellularity, reaching 98% when PC ≥10% and below 80% when PC <5%. A total of 85% of cases were successfully characterized using leader and FR1 primer sets, and most clones showed high somatic hypermutation rates (median, 8.1%). Among monitoring samples from 124 patients, 78.6% (147/187) had detectable disease by NGS. Concordance with hsFC was 92.9% (170/183). Discordant cases encompassed 8 of 124 hsFC MRD+/NGS MRD− patients (6.5%) and 4 of 124 hsFC MRD−/NGS MRD+ patients (3.2%), all with low-level disease near detection limits for both assays. Among concordant hsFC MRD−/NGS MRD− cases, only 5 of 24 patients (20.8%) showed subsequent overt relapse at 3-year follow-up. HsFC and NGS showed similar operational sensitivity, and the choice of test may depend on practical, rather than test performance, considerations.
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Affiliation(s)
- Caleb Ho
- Hematopathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York; Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York.
| | - Mustafa Syed
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Mikhail Roshal
- Hematopathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Kseniya Petrova-Drus
- Hematopathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York; Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Christine Moung
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jinjuan Yao
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Andres E Quesada
- Hematopathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York; Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Jamal Benhamida
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Chad Vanderbilt
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ying Liu
- Hematopathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Menglei Zhu
- Hematopathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Wayne Yu
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Lidia Maciag
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Meiyi Wang
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Yuanyuan Ma
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Qi Gao
- Hematopathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Even H Rustad
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Malin Hultcrantz
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Benjamin T Diamond
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Binbin Zheng-Lin
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ying Huang
- Invivoscribe, Inc., San Diego, California
| | - Kasey Hutt
- Invivoscribe, Inc., San Diego, California
| | | | - Ahmet Dogan
- Hematopathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Khedoudja Nafa
- Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Maria E Arcila
- Hematopathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York; Diagnostic Molecular Pathology Service, Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, New York.
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13
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Dold SM, Riebl V, Wider D, Follo M, Pantic M, Ihorst G, Duyster J, Zeiser R, Wäsch R, Engelhardt M. Validated single-tube multiparameter flow cytometry approach for the assessment of minimal residual disease in multiple myeloma. Haematologica 2020; 105:e523. [PMID: 33054097 PMCID: PMC7556664 DOI: 10.3324/haematol.2019.238394] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sandra Maria Dold
- Department of Medicine I Hematology and Oncology, Medical Center, Faculty of Medicine
- Faculty of Biology
| | - Veronika Riebl
- Department of Medicine I Hematology and Oncology, Medical Center, Faculty of Medicine
| | - Dagmar Wider
- Department of Medicine I Hematology and Oncology, Medical Center, Faculty of Medicine
| | - Marie Follo
- Department of Medicine I Hematology and Oncology, Medical Center, Faculty of Medicine
| | - Milena Pantic
- Department of Medicine I Hematology and Oncology, Medical Center, Faculty of Medicine
| | | | - Justus Duyster
- Department of Medicine I Hematology and Oncology, Medical Center, Faculty of Medicine
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Zeiser
- Department of Medicine I Hematology and Oncology, Medical Center, Faculty of Medicine
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I Hematology and Oncology, Medical Center, Faculty of Medicine
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I Hematology and Oncology, Medical Center, Faculty of Medicine
- Comprehensive Cancer Center Freiburg (CCCF), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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14
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Minimal residual disease negativity in multiple myeloma is associated with intestinal microbiota composition. Blood Adv 2020; 3:2040-2044. [PMID: 31289031 DOI: 10.1182/bloodadvances.2019032276] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/17/2019] [Indexed: 12/24/2022] Open
Abstract
Patients with multiple myeloma (MM) who achieve minimal residual disease (MRD) negativity after upfront treatment have superior outcomes compared with those who remain MRD+ Recently, associations have been shown between specific commensal microbes and development of plasma cell disorders. Here, we report the association between intestinal microbiota composition and treatment outcome in MM. Microbiota composition of fecal samples collected from 34 MM patients after induction therapy and at the time of flow cytometry-based bone marrow MRD testing was determined by 16S ribosomal RNA sequencing. We observed a higher relative abundance of Eubacterium hallii in the 16 MRD- patients relative to the 18 MRD+ patients. No association was observed between microbial relative abundance and autologous stem cell transplantation history or MM paraprotein isotype. No differences in microbiota α diversity were observed between MRD- and MRD+ patients. The potential association of microbiota composition with treatment response in MM patients is an important parameter for additional correlative and clinical investigation.
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15
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Bayly E, Nguyen V, Binek A, Piggin A, Baldwin K, Westerman D, Came N. Validation of a modified pre-lysis sample preparation technique for flow cytometric minimal residual disease assessment in multiple myeloma, chronic lymphocytic leukemia, and B-non Hodgkin lymphoma. CYTOMETRY PART B-CLINICAL CYTOMETRY 2020; 98:385-398. [PMID: 32530574 DOI: 10.1002/cyto.b.21893] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 05/11/2020] [Accepted: 05/13/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Minimal residual disease (MRD) assessment of hematopoietic neoplasia below 10-4 requires more leukocytes than is usually attainable by post-lysis preparation. However, not all laboratories are resourced for consensus Euroflow pre-lysis methodology. Our study aim was to validate a modified pre-lysis protocol against our standard post-lysis method for MRD detection of multiple myeloma (MM), chronic lymphocytic leukemia (CLL), and B-non Hodgkin lymphoma (B-NHL), to meet demand for deeper MRD assessment by flow cytometry. METHOD Clinical samples for MRD assessment of MM, CLL, and B-NHL (50, 30, and 30 cases, respectively) were prepared in parallel by pre and post-lysis methods for the initial validation. Total leukocytes, MRD, and median fluorescence intensity of antigen expression were compared as measures of sensitivity and antigen stability. Lymphocyte and granulocyte composition were compared, assessing relative sample processing stability. Sensitivity of the pre-lysis assay was monitored post validation for a further 18 months. RESULTS Pre-lysis achieved at least 10-4 sensitivity in 85% MM, 81% CLL, and 90% B-NHL samples versus 24%, 48%, and 26% by post-lysis, respectively, with stable antigen expression and leukocyte composition. Post validation over 18 months with technical expertise improving, pre-lysis permitted 10-5 MRD assessment in 69%, 86%, and 82% of the respective patient groups. CONCLUSION This modified pre-lysis procedure provides a sensitive, robust, time efficient, and relatively cost-effective alternative for MRD testing by MFC at 10-5 , facilitating clinically meaningful deeper response assessment for MM, CLL, and B-NHL. This method adaptation may facilitate more widespread adoption of highly sensitive flow cytometry-based MRD assessment.
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Affiliation(s)
- Emma Bayly
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Clinical Haematology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Vuong Nguyen
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Adrian Binek
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Anna Piggin
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Clinical Haematology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia
| | - Kylie Baldwin
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - David Westerman
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Clinical Haematology, Victorian Comprehensive Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Parkville, Victoria, Australia
| | - Neil Came
- Pathology Department, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, The University of Melbourne, Parkville, Victoria, Australia
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16
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Martins CO, Huet S, Yi SS, Ritorto MS, Landgren O, Dogan A, Chapman JR. Mass Spectrometry-Based Method Targeting Ig Variable Regions for Assessment of Minimal Residual Disease in Multiple Myeloma. J Mol Diagn 2020; 22:901-911. [PMID: 32302778 DOI: 10.1016/j.jmoldx.2020.04.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 03/25/2020] [Accepted: 04/01/2020] [Indexed: 12/11/2022] Open
Abstract
Multiple myeloma is a systemic malignancy of monoclonal plasma cells that accounts for 10% of hematologic cancers. With development of highly effective therapies for multiple myeloma, minimal residual disease (MRD) assessment has emerged as an important end point for management decisions. Currently, serologic assays lack the sensitivity for MRD assessment, and invasive bone marrow sampling with flow cytometry or molecular methods has emerged as the gold standard. We report a sensitive and robust targeted mass spectrometry proteomics method to detect MRD in serum, without the need of invasive, sequential bone marrow aspirates. The method detects Ig-derived clonotypic tryptic peptides predicted by sequencing the clonal plasma cell Ig genes. A heavy isotope-labeled Ig internal standard is added to patient serum at a known concentration, the Ig is enriched in a light chain type specific manner, and proteins are digested and analyzed by targeted mass spectrometry. Peptides from the constant regions of the λ or κ light chains, Ig heavy chains, and clonotypic peptides unique to the patient monoclonal Igs are targeted. This technique is highly sensitive and specific for the patient-specific monoclonal Igs, even in samples negative by multiparametric flow cytometry. Our method can accurately and precisely detect monoclonal protein in serum of patients treated for myeloma and has broad implications for management of hematologic patients.
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Affiliation(s)
- Carlo O Martins
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sarah Huet
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - San S Yi
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Maria S Ritorto
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ahmet Dogan
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jessica R Chapman
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.
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17
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Roshal M. Measurable disease evaluation in patients with myeloma. Best Pract Res Clin Haematol 2020; 33:101154. [PMID: 32139019 DOI: 10.1016/j.beha.2020.101154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Accepted: 01/30/2020] [Indexed: 01/09/2023]
Abstract
Recent years saw significant breakthroughs in treatment of multiple myeloma. Durable remissions are now seen in a significant proportion of patients with the previously uniformly incurable and progressive disease. Yet because of deep suppression of the neoplastic myeloma clones by the newer therapies, older disease monitoring techniques are insufficient to distinguish between the patients at high risk of imminent relapse and those in whom durable remission is expected. This review briefly describes prognostic and therapeutic implications of measurable disease (MRD) evaluation, explains why deep MRD evaluation is needed for patients without morphologic evidence of disease, and reviews the state of the art of evaluation of myeloma MRD by flow cytometry.
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Affiliation(s)
- Mikhail Roshal
- Hematopathology Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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18
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Kunacheewa C, Lee HC, Patel K, Thomas S, Amini B, Srour S, Bashir Q, Nieto Y, Qazilbash MH, Weber DM, Feng L, Orlowski RZ, Lin P, Manasanch EE. Minimal Residual Disease Negativity Does Not Overcome Poor Prognosis in High-Risk Multiple Myeloma: A Single-Center Retrospective Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e221-e238. [PMID: 32037287 DOI: 10.1016/j.clml.2020.01.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 12/28/2019] [Accepted: 01/02/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Minimal residual disease (MRD) is a standard measurement for response assessment in multiple myeloma (MM). Despite new treatments, high-risk MM patients continue to have poor prognosis. We evaluated the effect of MRD negativity in high-risk versus standard-risk patients. PATIENTS AND METHODS We retrospectively evaluated all consecutive MM patients who underwent routine MRD testing by 1-tube 8-color advanced flow cytometry with 2,000,000 events and sensitivity level 10-5 at our center from 2015 to 2018 after initial therapy. Kaplan-Meier and log-rank test were used to assess survival estimates and differences between study groups. RESULTS One hundred thirty-six patients with MRD testing after initial therapy or autologous stem-cell transplantation were identified. At a median follow-up of 14 months (range, 1-36 months), progression-free survival and overall survival were significantly worse in high-risk versus standard-risk patients. During the study period, 50% of high-risk group had experienced disease progression (relapse and/or death) versus 20% in the standard-risk group (P = .0006). No patients with standard-risk died, but 4 (14%) in the high-risk group did (P = .0007). Regardless of MRD status, high-risk patients had statistically significant worse progression-free survival than standard-risk patients. At median follow-up, those with disease 10% standard-risk/MRD negative; 20% standard-risk/MRD positive; 40% high-risk/MRD negative; and 45% high-risk/MRD positive had either experienced relapse or died (P = .0041). MRD status did not significantly affect overall survival in either group (P = .0914); however, longer follow-up is needed to assess survival. CONCLUSION Genetic abnormalities remain a powerful prognostic indicator for MM, regardless of MRD status. For newly diagnosed MM patients treated with novel triple-drug initial therapy and frontline autologous stem-cell transplantation, MRD-negative status did not mitigate the poor-prognosis outcomes of high-risk MM patients.
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Affiliation(s)
- Chutima Kunacheewa
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hans C Lee
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Krina Patel
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Sheeba Thomas
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Behrang Amini
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Samer Srour
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Qaiser Bashir
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Yago Nieto
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Muzzaffar H Qazilbash
- Department of Stem Cell Transplantation, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Donna M Weber
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lei Feng
- Department of Statistics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Robert Z Orlowski
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Pei Lin
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Elisabet E Manasanch
- Department of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX.
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19
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Soh KT, Tario JD, Hahn TE, Hillengass J, McCarthy PL, Wallace PK. Methodological considerations for the high sensitivity detection of multiple myeloma measurable residual disease. CYTOMETRY PART B-CLINICAL CYTOMETRY 2019; 98:161-173. [PMID: 31868315 DOI: 10.1002/cyto.b.21862] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Recent advances in therapeutic interventions have dramatically improved complete response rates in patients with multiple myeloma (MM). The ability to identify residual myeloma cells (e.g., measurable residual disease [MRD]) can provide valuable information pertaining to patient's depth of response to therapy and risk of relapse. Multiparametric flow cytometry is an excellent technique to monitor MRD and has been demonstrated to correlate with patient outcome post-treatment. To achieve the high sensitivity (one abnormal cell in 105 -106 cells) required for MRD evaluation, millions of cells have to be acquired and conventional immunophenotyping protocols are unable to attain these numbers, indicating the needs for alternative flow cytometric staining procedures. A bulk, "Pre-lysis" method is the consensus approach for staining large number of cells, requires two red blood cell lysis steps, and can adversely affect epitope density. In this study, we tested the "Pooled-tube" and "Dextran Sedimentation" staining procedures and correlated them with the "Pre-lysis" method as potential alternative approaches. METHODS A total of 22 bone marrow aspirates from patients with plasma cell (PC) dyscrasia were processed in parallel using the "Pre-lysis," "Pooled-tube," and "Dextran Sedimentation" techniques. Stain indices were calculated and compared to assess their impacts on staining performance for each antibody used in the consensus panel. The recovery of normal and abnormal PCs, mast cells, and B cell precursors was enumerated and compared after their counts were normalized using fluorescent beads. The limit of blank, limit of detection, and lower limit of quantification were established using serial dilution experiments. RESULTS The staining performances of CD19 PECy7, CD27 BV510, CD81 APCH7, and CD138 BV421 were improved using the "Pooled-tube" method when compared to "Pre-lysis." "Pre-lysis" was better at resolving CD56 using clone C5.9 but our results demonstrated similar improvement can also be achieved by "Pooled-tube" when alternative CD56 PE clones were used. "Dextran sedimentation" yielded similar staining results when compared to "Pre-lysis" for all the markers analyzed. The "Pooled-tube" method, when normalized to "Pre-lysis," recovered higher numbers of total PCs (1.2 ± 0.2 times higher; p = .049), normal PCs (1.4 ± 0.26; p = .007), mast cells (1.46 ± 0.27; p = .003), and B cell precursors (1.42 ± 0.3; p = .011), but not abnormal PCs (1.09 ± 0.2; p = .352). There was no evidence that the recovery of cells was different between "Pre-lysis" versus "Dextran Sedimentation." All three flow cytometric assays achieved a minimum sensitivity of 10-5 and approached that of 10-6 for detecting rare events. CONCLUSION Both "Pooled-tube" and "Dextran Sedimentation" staining procedures were comparable to the "Pre-lysis" method and are suitable high sensitivity flow cytometric approaches that can be used to process bone marrow samples for MM MRD testing.
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Affiliation(s)
- Kah Teong Soh
- Department of Flow and Image Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Joseph D Tario
- Department of Flow and Image Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Theresa E Hahn
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.,Transplant and Cellular Therapy Program, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Jens Hillengass
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Philip L McCarthy
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, New York.,Transplant and Cellular Therapy Program, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Paul K Wallace
- Department of Flow and Image Cytometry, Roswell Park Comprehensive Cancer Center, Buffalo, New York
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20
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Romano A, Palumbo GA, Parrinello NL, Conticello C, Martello M, Terragna C. Minimal Residual Disease Assessment Within the Bone Marrow of Multiple Myeloma: A Review of Caveats, Clinical Significance and Future Perspectives. Front Oncol 2019; 9:699. [PMID: 31482061 PMCID: PMC6710454 DOI: 10.3389/fonc.2019.00699] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/15/2019] [Indexed: 12/11/2022] Open
Abstract
There is an increasing clinical interest in the measure and achievement of minimal residual disease (MRD) negativity in the bone marrow of Multiple Myeloma (MM) patients, as defined equally either by Multicolor Flow Cytometry (MFC) or by Next Generation Sequencing (NGS) technologies. At present, modern technologies allow to detect up to one on 104 or on 105 or even on 106 cells, depending on their throughput. MFC approaches, which have been progressively improved up to the so-called Next Generation Flow (NGF), and NGS, which proved clear advantages over ASO-PCR, can detect very low levels of residual disease in the BM. These methods are actually almost superimposable, in terms of MRD detection power, supporting the lack of unanimous preference for either technique on basis of local availability. However, some technical issues are still open: the optimal assay to use to detect either phenotype (e.g., next generation multidimensional flow cytometry, imaging) or genotype aberrations (e.g., ASO-RQ PCR, digital droplet PCR, NGS) and their standardization, the sample source (BM or peripheral blood, PB) and its pre-processing (red-cell lysis vs. Ficoll, fresh vs. frozen samples, requirement of CD138+ cells enrichment). Overall, MRD negativity is considered as the most powerful predictor of favorable long-term outcomes in MM and is likely to represent the major driver of treatment strategies in the near future. In this manuscript, we reviewed the main pitfalls and caveats of MRD detection within bone marrow in MM patients after front-line therapy, highlighting the improving of the currently employed technology and describing alternative methods for MRD testing in MM, such as liquid biopsy.
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Affiliation(s)
- Alessandra Romano
- Department of Surgery and Medical Specialties, University of Catania, Catania, Italy
| | - Giuseppe Alberto Palumbo
- Division of Hematology, Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele di Catania, Catania, Italy
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie avanzate “G.F. Ingrassia,” University of Catania, Catania, Italy
| | - Nunziatina Laura Parrinello
- Division of Hematology, Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele di Catania, Catania, Italy
- Dipartimento di Scienze Mediche, Chirurgiche e Tecnologie avanzate “G.F. Ingrassia,” University of Catania, Catania, Italy
| | - Concetta Conticello
- Division of Hematology, Azienda Ospedaliero-Universitaria Policlinico Vittorio Emanuele di Catania, Catania, Italy
| | - Marina Martello
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale (DIMES), Università degli Studi di Bologna, Bologna, Italy
| | - Carolina Terragna
- Istituto di Ematologia “L.A.Seràgnoli,” Azienda Ospedaliera Sant'Orsola-Malpighi, Bologna, Italy
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21
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Berger N, Kim-Schulze S, Parekh S. Minimal Residual Disease in Multiple Myeloma: Impact on Response Assessment, Prognosis and Tumor Heterogeneity. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1100:141-159. [PMID: 30411265 DOI: 10.1007/978-3-319-97746-1_9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Multiple Myeloma (MM) therapy has evolved rapidly over the past decade. With current multidrug combinations and autologous transplant, rates of overall response exceed 90% and complete response (CR) more than 50% in some studies. Unfortunately, despite higher rates of CR, relapse rates remain high suggesting that persistent disease may not be measured by current techniques. Traditionally, response rates were defined by urine and serum protein electrophoresis, immunofixation and histopathological absence of clonal plasma cells in the bone marrow. Currently, there are several validated sensitive assays to evaluate for MRD (minimal residual disease); multiparameter flow cytometry (MFC) including nextgeneration flow cytometry (NGF), next-generation sequencing (NGS), and allele specific oligonucleotide quantitative polymerase chain reaction (ASO-qPCR). These methods have provided a means to quantitatively assess residual disease and accurately prognosticate PFS and OS in myeloma. In this chapter, we will discuss the current techniques for MRD detection as well as describe techniques that are emerging for improved characterization of drug resistant residual populations that could be adapted for MRD monitoring in the future. While improved therapies are able to eradicate the dominant clone, resistant sub-clones persist and remain undetectable even by MRD techniques. Characterization of these clones will help design therapies against drug-resistant clones and move us closer to a cure in MM.
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Affiliation(s)
- Natalie Berger
- Hematology/Oncology Fellowship Program, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Seunghee Kim-Schulze
- Department of Oncological Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Samir Parekh
- Division of Hematology and Medical Oncology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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22
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Soh KT, Wallace PK. Monitoring of Measurable Residual Disease in Multiple Myeloma by Multiparametric Flow Cytometry. ACTA ACUST UNITED AC 2019; 90. [PMID: 31608132 DOI: 10.1002/cpcy.63] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Recent interest in high sensitivity multiple myeloma (MM) measurable residual disease (MRD) testing is a direct consequence of the high-quality responses achieved using novel therapeutic agents and better treatment strategies. Traditional diagnostic measures such as immunohistochemistry and morphology have detection sensitivities of only 10-2 - 10-3, which do not reliably predict progression free survival (PFS) or overall survival (OS) after these treatments. Contemporary monitoring of MM MRD has switched to more sensitive platforms such as quantitative allele-specific oligonucleotide polymerase chain reaction (ASO-qPCR), next-generation sequencing (NGS), and multiparametric flow cytometry (MFC). Though both ASO-qPCR and NGS have excellent detection sensitivities (10-5 - 10-6), both technologies have lower applicability when compared to MFC. Conventional MFC can easily reach a detection sensitivity of 10-4 and when optimized can achieve a sensitivity of 10-5 - 10-6. Current consensus guidelines require a minimum of 2 million and recommend 5 million events be acquired to reach a minimum sensitivity of 10-5. As conventional immunophenotyping protocols are unable to attain these numbers, alternative MFC staining procedures are required. This manuscript describes two high-sensitivity MFC approaches that can be used for MM MRD testing.
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Affiliation(s)
- Kah Teong Soh
- Roswell Park Comprehensive Cancer Center, Department of Flow and Image Cytometry, Elm & Carlton Streets, Buffalo, New York 14263
| | - Paul K Wallace
- Roswell Park Comprehensive Cancer Center, Department of Flow and Image Cytometry, Elm & Carlton Streets, Buffalo, New York 14263
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23
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Schouweiler KE, Karandikar NJ, Holman CJ. Immunophenotypic Heterogeneity of Polytypic Plasma Cells and the Impact on Myeloma Minimal Residual Disease Detection by Multiparameter Flow Cytometry. CYTOMETRY PART B-CLINICAL CYTOMETRY 2019; 96:310-318. [DOI: 10.1002/cyto.b.21789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 05/09/2019] [Accepted: 05/15/2019] [Indexed: 11/11/2022]
Affiliation(s)
| | - Nitin J. Karandikar
- Department of PathologyUniversity of Iowa Hospitals and Clinics Iowa City Iowa
| | - Carol J. Holman
- Department of PathologyUniversity of Iowa Hospitals and Clinics Iowa City Iowa
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24
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Gao Q, Yellapantula V, Fenelus M, Pichardo J, Wang L, Landgren O, Dogan A, Roshal M. Tumor suppressor CD99 is downregulated in plasma cell neoplasms lacking CCND1 translocation and distinguishes neoplastic from normal plasma cells and B-cell lymphomas with plasmacytic differentiation from primary plasma cell neoplasms. Mod Pathol 2018; 31:881-889. [PMID: 29403080 PMCID: PMC5998376 DOI: 10.1038/s41379-018-0011-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Accepted: 12/06/2017] [Indexed: 02/07/2023]
Abstract
CD99(MIC2) is a widely expressed cell surface glycoprotein and functions as a tumor suppressor involved in downregulation of SRC family of tyrosine kinase. CD99 expression is tightly regulated through B-cell development. The principal aims of this study were to investigate the clinical utility of CD99 expression (i) in distinguishing normal plasma cells from primary plasma cell neoplasms; (ii) in detection of minimal residual disease in primary plasma cell neoplasms; and (iii) in distinguishing plasma cell component of B-cell lymphomas from primary plasma cell neoplasms. We analyzed expression of CD99 by flow cytometry and immunohistochemistry in lymph nodes, peripheral blood, and bone marrow samples. CD99 showed stage-specific expression with highest expression seen in precursor B and plasma cells. In contrast to the uniform bright expression on normal plasma cells, CD99 expression on neoplastic plasma cells was lost in 39 out of 56 (69.6%) cases. Furthermore, 8 out of 56 samples (14%) showed visibly (>10-fold) reduced CD99 expression. Overall, CD99 expression was informative (absent or visibly dimmer than normal) in 84% of primary plasma cell neoplasm. In the context of minimal residual disease detection, CD99 showed superior utility in separating normal and abnormal plasma cells over currently established antigens CD117, CD81, and CD27 by principal component analysis. Preservation of CD99 expression was strongly associated with cyclin D1 translocation in myeloma (p < 0.05). B-cell lymphomas with plasma cell component could be distinguished from myeloma by CD99 expression. In summary, we established that tumor suppressor CD99 is markedly downregulated in multiple myeloma. The loss is highly specific for identification of abnormal cells in primary plasma cell neoplasms, and can be exploited for diagnostic purposes. The role of CD99 in myeloma pathogenesis requires further investigation.
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Affiliation(s)
- Qi Gao
- Hematopathology Service, Memorial Sloan Kettering Cancer Center
| | - Venkata Yellapantula
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center
| | - Maly Fenelus
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center
| | - Janine Pichardo
- Hematopathology Service, Memorial Sloan Kettering Cancer Center
| | - Lu Wang
- Department of Pathology, Memorial Sloan Kettering Cancer Center
| | - Ola Landgren
- Myeloma Service, Memorial Sloan Kettering Cancer Center
| | - Ahmet Dogan
- Hematopathology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Mikhail Roshal
- Hematopathology Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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25
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Soh KT, Tario JD, Wallace PK. Diagnosis of Plasma Cell Dyscrasias and Monitoring of Minimal Residual Disease by Multiparametric Flow Cytometry. Clin Lab Med 2018; 37:821-853. [PMID: 29128071 DOI: 10.1016/j.cll.2017.08.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Plasma cell dyscrasia (PCD) is a heterogeneous disease that has seen a tremendous change in outcomes due to improved therapies. Over the past few decades, multiparametric flow cytometry has played an important role in the detection and monitoring of PCDs. Flow cytometry is a high-sensitivity assay for early detection of minimal residual disease (MRD) that correlates well with progression-free survival and overall survival. Before flow cytometry can be effectively implemented in the clinical setting, sample preparation, panel configuration, analysis, and gating strategies must be optimized to ensure accurate results. Current consensus methods and reporting guidelines for MRD testing are discussed.
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Affiliation(s)
- Kah Teong Soh
- Department of Flow and Image Cytometry, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA.
| | - Joseph D Tario
- Department of Flow and Image Cytometry, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
| | - Paul K Wallace
- Department of Flow and Image Cytometry, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA
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26
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Landgren O. MRD Testing in Multiple Myeloma: From a Surrogate Marker of Clinical Outcomes to an Every-Day Clinical Tool. Semin Hematol 2018; 55:1-3. [PMID: 29759146 DOI: 10.1053/j.seminhematol.2018.03.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 03/11/2018] [Indexed: 01/23/2023]
Abstract
Minimal residual disease (MRD) testing in multiple myeloma is here to stay. Studies show that MRD negativity is consistently associated with longer progression-free survival (PFS). It is just a matter of time until MRD negativity will become a regulatory endpoint for drug approval. Until that can happen, more analysis will be required to define the exact details of MRD in the regulatory setting. For example, for randomized studies there is need to define the amount of improvement in MRD negativity between the experimental arm and the control arm at a given time-point for a drug to obtain regulatory accelerated approval. Such efforts are underway. For the multiple myeloma field as a whole, important tasks for the (near) coming future are as follows: (1) to conduct or finalize the expanded analysis to define the exact details of MRD in the regulatory setting, (2) to develop new and better MRD assays-both more sensitive MRD assays for bone marrow aspirates and nonbone marrow aspirate-based assays (eg, blood-based and imaging-based MRD assays), and (3) to design novel clinical studies to formally assess the effect of MRD negativity in clinical decision making. The aim with this issue of the Journal is to provide a deep and comprehensive summary of the latest MRD knowledge in the field, and to outline future directions.
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Affiliation(s)
- Ola Landgren
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY.
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27
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Roshal M. Minimal Residual Disease Detection by Flow Cytometry in Multiple Myeloma: Why and How? Semin Hematol 2018; 55:4-12. [PMID: 29759152 DOI: 10.1053/j.seminhematol.2018.02.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 02/27/2018] [Indexed: 11/11/2022]
Abstract
The outlook for myeloma patients has steadily improved with the introduction of newer drug combinations in recent years. Unlike older therapies that largely achieved only modest levels of neoplastic clone reduction, the newer drug combinations have led to deeper suppression of myeloma clones in most patients. Frequently the neoplastic clones become undetectable with traditional disease evaluation approaches. Recent studies using ultrasensitive disease monitoring have demonstrated that patients with disease undetectable by traditional techniques show wide heterogeneity in disease levels varying by several orders of magnitude. Moreover, measurement of the depth of disease suppression even at very low level has emerged as the most powerful prognostication tool in myeloma. Minimal (or measurable) residual disease (MRD) evaluation has also been proposed as a relevant tool in assessment of drug efficacy and in selection of further therapeutic options. In the face of the robust MRD measurement utility data, it has become critical to develop widely applicable disease monitoring techniques that can be applied to more patients in a variety of clinical setting. Both DNA-based and flow cytometry-based approaches have been successfully developed for this purpose achieving sensitivity approaching 1 neoplastic cell in a million. This review article focuses on the theoretical and practical aspects and challenges of deep MRD monitoring in myeloma by flow cytometry. Challenges of flow cytometric disease monitoring in the era of antigen-directed therapy are also discussed.
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Affiliation(s)
- Mikhail Roshal
- Hematopathology Service, Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, NY.
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28
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Abstract
The primary hurdle in the path to curing multiple myeloma (MM) is defining a validated minimal residual disease (MRD) and its utility in the therapeutic decision making. A better definition of MRD will aid in tailoring MM therapy further to address the clonal heterogeneity and genomic instability and overcome patient's ineffective immune surveillance. MRD analysis can define the logical endpoint for maintenance therapy, in addition also aids in providing a better clinical end point for studies comparing novel agents in myeloma. MRD is a surrogate for the survival in MM. Guidelines for global incorporation of MRD in myeloma are fraught with lack of standardization, universal availability and abridged physicians' understanding of MRD modalities. We aimed at addressing some of the frequently asked questions in the MRD assessment and will also place in perspective some arguments in favor of MRD assessment in routine practice and clinical trial scenario.
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Affiliation(s)
- Uday Yanamandra
- a Department of Hematology and Stem Cell Transplant , Army Hospital - Research and Referral , New Delhi , India
| | - Shaji K Kumar
- b Department of Internal Medicine, Division of Hematology , Mayo Clinic , Rochester , MN , USA
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29
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Baughn LB, Linden MA. Standardization of Minimal Residual Disease Testing in Multiple Myeloma. J Appl Lab Med 2017; 2:118-122. [PMID: 33636956 DOI: 10.1373/jalm.2016.020883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/23/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Linda B Baughn
- Department of Laboratory Medicine and Pathology, Division of Laboratory Genetics and Genomics, Mayo Clinic, Rochester, MN
| | - Michael A Linden
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, University of Minnesota, Minneapolis, MN
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Response Assessment in Myeloma: Practical Manual on Consistent Reporting in an Era of Dramatic Therapeutic Advances. Biol Blood Marrow Transplant 2017; 23:1193-1202. [DOI: 10.1016/j.bbmt.2017.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 03/06/2017] [Indexed: 11/23/2022]
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31
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Hassoun H, Roshal M, Sabari J, Nguyen J, Gao Q, Devlin SM, Landau H, Lendvai N, Chung DJ, Lesokhin AM, Korde N, Mailankody S, Dogan A, Giralt SA, Landgren CO. Immunophenotypic evidence for reactive polyclonal marrow plasmacytosis in multiple myeloma patients receiving lenalidomide maintenance. Leuk Lymphoma 2017; 58:2962-2965. [DOI: 10.1080/10428194.2017.1312382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Hani Hassoun
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Mikhail Roshal
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Joshua Sabari
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - James Nguyen
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Qi Gao
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Sean M. Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Heather Landau
- Adult Bone Marrow Transplant Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Nikoletta Lendvai
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - David J. Chung
- Adult Bone Marrow Transplant Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Alexander M. Lesokhin
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Neha Korde
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Sham Mailankody
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Ahmet Dogan
- Department of Pathology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Sergio A. Giralt
- Adult Bone Marrow Transplant Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - C. Ola Landgren
- Myeloma Service, Division of Hematologic Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
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MRD detection in multiple myeloma: comparison between MSKCC 10-color single-tube and EuroFlow 8-color 2-tube methods. Blood Adv 2017; 1:728-732. [PMID: 29296716 DOI: 10.1182/bloodadvances.2016003715] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/22/2017] [Indexed: 11/20/2022] Open
Abstract
In patients with multiple myeloma, obtaining posttreatment minimal residual disease (MRD) negativity is associated with longer progression-free survival and overall survival. Here, we compared the diagnostic performance of a single 10-color tube with that of a EuroFlow 8-color 2-tube panel for MRD testing. Bone marrow samples from 41 multiple myeloma patients were tested in parallel using the 2 approaches. Compared with the sum of the cells from the EuroFlow two 8-color tubes, the Memorial Sloan Kettering Cancer Center (MSKCC) single 10-color tube had a slight reduction in total cell number with a mean ratio of 0.85 (range, 0.57-1.46; P < .05), likely attributable to permeabilization of the cells. Percent of plasma cells showed a high degree of concordance (r2 = 0.97) as did normal plasma cells (r2 = 0.96), consistent with no selective plasma cell loss. Importantly, concordant measurement of residual disease burden was seen with abnormal plasma cells (r2 = 0.97). The overall concordance between the 2 tests was 98%. In 1 case, there was a discrepancy near the limit of detection of both tests in favor of the slightly greater theoretical sensitivity of the EuroFlow 8-color 2-tube panel (analytical sensitivity limit of MSKCC single 10-color tube: 6 cells in 1 million with at least 3 million cell acquisitions; EuroFlow 8-color 2-tube panel: 2 cells in 1 million with the recommended 10 million cell acquisitions).
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Flores-Montero J, Sanoja-Flores L, Paiva B, Puig N, García-Sánchez O, Böttcher S, van der Velden VHJ, Pérez-Morán JJ, Vidriales MB, García-Sanz R, Jimenez C, González M, Martínez-López J, Corral-Mateos A, Grigore GE, Fluxá R, Pontes R, Caetano J, Sedek L, Del Cañizo MC, Bladé J, Lahuerta JJ, Aguilar C, Bárez A, García-Mateo A, Labrador J, Leoz P, Aguilera-Sanz C, San-Miguel J, Mateos MV, Durie B, van Dongen JJM, Orfao A. Next Generation Flow for highly sensitive and standardized detection of minimal residual disease in multiple myeloma. Leukemia 2017; 31:2094-2103. [PMID: 28104919 PMCID: PMC5629369 DOI: 10.1038/leu.2017.29] [Citation(s) in RCA: 417] [Impact Index Per Article: 59.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 12/24/2016] [Accepted: 01/03/2017] [Indexed: 12/20/2022]
Abstract
Flow cytometry has become a highly valuable method to monitor minimal residual disease (MRD) and evaluate the depth of complete response (CR) in bone marrow (BM) of multiple myeloma (MM) after therapy. However, current flow-MRD has lower sensitivity than molecular methods and lacks standardization. Here we report on a novel next generation flow (NGF) approach for highly sensitive and standardized MRD detection in MM. An optimized 2-tube 8-color antibody panel was constructed in five cycles of design-evaluation-redesign. In addition, a bulk-lysis procedure was established for acquisition of ⩾107 cells/sample, and novel software tools were constructed for automatic plasma cell gating. Multicenter evaluation of 110 follow-up BM from MM patients in very good partial response (VGPR) or CR showed a higher sensitivity for NGF-MRD vs conventional 8-color flow-MRD -MRD-positive rate of 47 vs 34% (P=0.003)-. Thus, 25% of patients classified as MRD-negative by conventional 8-color flow were MRD-positive by NGF, translating into a significantly longer progression-free survival for MRD-negative vs MRD-positive CR patients by NGF (75% progression-free survival not reached vs 7 months; P=0.02). This study establishes EuroFlow-based NGF as a highly sensitive, fully standardized approach for MRD detection in MM which overcomes the major limitations of conventional flow-MRD methods and is ready for implementation in routine diagnostics.
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Affiliation(s)
- J Flores-Montero
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - L Sanoja-Flores
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - B Paiva
- Clinica Universidad de Navarra; Applied Medical Research Center (CIMA), IDISNA, Pamplona, Spain (UNAV)
| | - N Puig
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - O García-Sánchez
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - S Böttcher
- Second Department of Medicine, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany (UNIKIEL)
| | - V H J van der Velden
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (EMC)
| | - J-J Pérez-Morán
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - M-B Vidriales
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - R García-Sanz
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - C Jimenez
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - M González
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | | | - A Corral-Mateos
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | | | - R Fluxá
- Cytognos SL, Salamanca, Spain
| | - R Pontes
- Faculty of Medicine, Federal University of Rio de Janeiro and Institute of Pediatrics and Childhood Care, Rio de Janeiro, Brazil
| | - J Caetano
- Department of Hematology, Portuguese Institute of Oncology, Lisbon, Portugal (IPOLFG)
| | - L Sedek
- Department of Pediatric Hematology and Oncology, Medical University of Silesia in Katowice, Zabrze, Poland (SUM)
| | - M-C Del Cañizo
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - J Bladé
- Department of Hematology, Hospital Clinic I Provincial, Barcelona, Spain
| | - J-J Lahuerta
- Department of Hematology, Hospital 12 de Octubre, Madrid, Spain
| | - C Aguilar
- Department of Hematology, Hospital General de Santa Bárbara, Soria, Spain
| | - A Bárez
- Department of Hematology, Complejo Asistencial de Ávila, Ávila, Spain
| | - A García-Mateo
- Department of Hematology, Complejo Asistencial de Segovia, Segovia, Spain
| | - J Labrador
- Hematology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - P Leoz
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
| | - C Aguilera-Sanz
- Department of Hematology, Hospital El Bierzo, Ponferrada, Spain
| | - J San-Miguel
- Clinica Universidad de Navarra; Applied Medical Research Center (CIMA), IDISNA, Pamplona, Spain (UNAV)
| | - M-V Mateos
- Department of Hematology, University Hospital of Salamanca, IBSAL; IBMCC (USAL-CSIC), Salamanca, Spain (HUSAL)
| | - B Durie
- Cedars-Sinai Samuel Oschin Cancer Center, Los Angeles, CA, USA
| | - J J M van Dongen
- Department of Immunology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands (EMC).,Department of Immunohematology and Blood Transfusion, Leiden University Medical Center, Leiden, The Netherlands
| | - A Orfao
- Cancer Research Center (IBMCC-CSIC/USAL-IBSAL); Cytometry Service (NUCLEUS) and Department of Medicine, University of Salamanca, Salamanca, Spain (USAL)
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