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Zhang J, Oak J. Challenges of detecting measurable/minimal disease in acute leukemia. Semin Diagn Pathol 2023; 40:216-220. [PMID: 37150656 DOI: 10.1053/j.semdp.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 04/10/2023] [Indexed: 05/09/2023]
Abstract
Measurable/minimal residual disease (MRD) tracking has emerged as a powerful tool for assessing treatment response and predicting outcomes in acute leukemia. However, the clinical and technological challenges associated with MRD tracking must be addressed to improve its utility in routine patient care. This review article aims to provide a summary of the different MRD methodologies used in acute leukemia. It highlights the strengths, diagnostic pitfalls, and clinical utility associated with MRD tracking in this rapidly evolving field.
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Affiliation(s)
- Jingjing Zhang
- Department of Pathology, 300 Pasteur Drive, L235, Stanford, CA 94305, United States
| | - Jean Oak
- Department of Pathology, 300 Pasteur Drive, L235, Stanford, CA 94305, United States.
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Röhnert MA, Kramer M, Schadt J, Ensel P, Thiede C, Krause SW, Bücklein V, Hoffmann J, Jaramillo S, Schlenk RF, Röllig C, Bornhäuser M, McCarthy N, Freeman S, Oelschlägel U, von Bonin M. Reproducible measurable residual disease detection by multiparametric flow cytometry in acute myeloid leukemia. Leukemia 2022; 36:2208-2217. [PMID: 35851154 PMCID: PMC9417981 DOI: 10.1038/s41375-022-01647-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/24/2022] [Accepted: 07/01/2022] [Indexed: 11/08/2022]
Abstract
Measurable residual disease (MRD) detected by multiparametric flow cytometry (MFC) is associated with unfavorable outcome in patients with AML. A simple, broadly applicable eight-color panel was implemented and analyzed utilizing a hierarchical gating strategy with fixed gates to develop a clear-cut LAIP-based DfN approach. In total, 32 subpopulations with aberrant phenotypes with/without expression of markers of immaturity were monitored in 246 AML patients after completion of induction chemotherapy. Reference values were established utilizing 90 leukemia-free controls. Overall, 73% of patients achieved a response by cytomorphology. In responders, the overall survival was shorter for MRDpos patients (HR 3.8, p = 0.006). Overall survival of MRDneg non-responders was comparable to MRDneg responders. The inter-rater-reliability for MRD detection was high with a Krippendorffs α of 0.860. The mean time requirement for MRD analyses at follow-up was very short with 04:31 minutes. The proposed one-tube MFC approach for detection of MRD allows a high level of standardization leading to a promising inter-observer-reliability with a fast turnover. MRD defined by this strategy provides relevant prognostic information and establishes aberrancies outside of cell populations with markers of immaturity as an independent risk feature. Our results imply that this strategy may provide the base for multicentric immunophenotypic MRD assessment.
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Affiliation(s)
- Maximilian A Röhnert
- Department of Medicine I, University Hospital Carl Gustav Carus TU Dresden, Dresden, Germany.
| | - Michael Kramer
- Department of Medicine I, University Hospital Carl Gustav Carus TU Dresden, Dresden, Germany
| | - Jonas Schadt
- Department of Medicine I, University Hospital Carl Gustav Carus TU Dresden, Dresden, Germany
| | - Philipp Ensel
- Department of Medicine I, University Hospital Carl Gustav Carus TU Dresden, Dresden, Germany
| | - Christian Thiede
- Department of Medicine I, University Hospital Carl Gustav Carus TU Dresden, Dresden, Germany
- AgenDix GmbH, Dresden, Germany
| | - Stefan W Krause
- Department of Medicine 5, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Veit Bücklein
- Department of Medicine III, University Hospital LMU Munich, Munich, Germany
- Laboratory for Translational Cancer Immunology, Gene Center, LMU Munich, Munich, Germany
| | - Jörg Hoffmann
- Department of Internal Medicine and Hematology, Oncology and Immunology, Philipps University Marburg and University Hospital Giessen and Marburg, Marburg, Germany
| | - Sonia Jaramillo
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Richard F Schlenk
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
- NCT Trial Center, National Center of Tumor Diseases, German Cancer Research Center, Heidelberg, Germany
| | - Christoph Röllig
- Department of Medicine I, University Hospital Carl Gustav Carus TU Dresden, Dresden, Germany
| | - Martin Bornhäuser
- Department of Medicine I, University Hospital Carl Gustav Carus TU Dresden, Dresden, Germany
- National Center of Tumor Diseases, Dresden, Germany
| | - Nicholas McCarthy
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sylvie Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Uta Oelschlägel
- Department of Medicine I, University Hospital Carl Gustav Carus TU Dresden, Dresden, Germany
| | - Malte von Bonin
- Department of Medicine I, University Hospital Carl Gustav Carus TU Dresden, Dresden, Germany
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Piñero P, Morillas M, Gutierrez N, Barragán E, Such E, Breña J, García-Hernández MC, Gil C, Botella C, González-Navajas JM, Zapater P, Montesinos P, Sempere A, Tarín F. Identification of Leukemia-Associated Immunophenotypes by Databaseguided Flow Cytometry Provides a Highly Sensitive and Reproducible Strategy for the Study of Measurable Residual Disease in Acute Myeloblastic Leukemia. Cancers (Basel) 2022; 14:cancers14164010. [PMID: 36011002 PMCID: PMC9406948 DOI: 10.3390/cancers14164010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 12/26/2022] Open
Abstract
Simple Summary The complete immunophenotypic characterization of acute myeloid leukemia is essential for an accurate diagnosis and follow-up, which is determinant in the course of the disease. In many cases, the only option for the evaluation of minimal residual disease is flow cytometry, so the aim of this study is to develop an automatized multidimensional strategy to identify and characterize LAIPs as well as to detect new emerging aberrances in AML patients during the follow-up. The integrated DFN/LAIP strategy that we propose allows the identification of the most useful markers for minimal residual disease monitoring, improving the sensitivity and specificity of these studies. Furthermore, the use of databases and the automation of the analysis provide the basis for the generation of objective conclusions in minimal residual disease evaluations. Abstract Background: Multiparametric Flow Cytometry (MFC) is an essential tool to study the involved cell lineages, the aberrant differentiation/maturation patterns and the expression of aberrant antigens in acute myeloid leukemia (AML). The characterization of leukemia-associated immunophenotypes (LAIPs) at the moment of diagnosis is critical to establish reproducible strategies for the study of measurable residual disease using MFC (MFC-MRD). Methods: In this study, we identify and characterize LAIPs by comparing the leukemic populations of 145 AML patients, using the EuroFlow AML/ MDS MFC panel, with six databases of normal myeloid progenitors (MPCs). Principal component analysis was used to identify and characterize the LAIPs, which were then used to generate individual profiles for MFC-MRD monitoring. Furthermore, we investigated the relationship between the expression patterns of LAIPs and the different subtypes of AML. The MFC-MRD study was performed by identifying residual AML populations that matched with the LAIPs at diagnosis. To further validate this approach, the presence of MRD was also assessed by qPCR (qPCR-MRD). Finally, we studied the association between MFC-MRD and progression-free survival (PFS). Results: The strategy used in this study allowed us to describe more than 300 different LAIPs and facilitated the association of specific phenotypes with certain subtypes of AML. The MFC-MRD monitoring based on LAIPs with good/strong specificity was applicable to virtually all patients and showed a good correlation with qPCR-MRD and PFS. Conclusions: The described methodology provides an objective method to identify and characterize LAIPs. Furthermore, it provides a theoretical basis to develop highly sensitive MFC-MRD strategies.
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Affiliation(s)
- Paula Piñero
- Alicante Institute for Health and Biomedical Research (ISABIAL), 03010 Alicante, Spain
- Correspondence:
| | - Marina Morillas
- Hematology Department, Dr. Balmis General University Hospital, 03010 Alicante, Spain
| | - Natalia Gutierrez
- Hematology Department, Dr. Balmis General University Hospital, 03010 Alicante, Spain
| | - Eva Barragán
- Hematology Department, La Fe University Hospital, 46026 Valencia, Spain
| | - Esperanza Such
- Hematology Department, La Fe University Hospital, 46026 Valencia, Spain
| | - Joaquin Breña
- Hematology Department, La Candelaria General University Hospital, 38010 Santa Cruz de Tenerife, Spain
| | | | - Cristina Gil
- Hematology Department, Dr. Balmis General University Hospital, 03010 Alicante, Spain
| | - Carmen Botella
- Hematology Department, Dr. Balmis General University Hospital, 03010 Alicante, Spain
| | | | - Pedro Zapater
- Pharmacology Department, Dr. Balmis General University Hospital, Miguel Hernández University, 03202 Elche, Spain
| | - Pau Montesinos
- Hematology Department, La Fe University Hospital, 46026 Valencia, Spain
| | - Amparo Sempere
- Hematology Department, La Fe University Hospital, 46026 Valencia, Spain
| | - Fabian Tarín
- Hematology Department, Dr. Balmis General University Hospital, 03010 Alicante, Spain
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Griffioen MS, de Leeuw DC, Janssen JJWM, Smit L. Targeting Acute Myeloid Leukemia with Venetoclax; Biomarkers for Sensitivity and Rationale for Venetoclax-Based Combination Therapies. Cancers (Basel) 2022; 14:cancers14143456. [PMID: 35884517 PMCID: PMC9318140 DOI: 10.3390/cancers14143456] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/12/2022] [Indexed: 11/16/2022] Open
Abstract
Simple Summary Venetoclax has proven to be a promising therapy for newly diagnosed, relapsed and refractory AML patients ineligible for induction chemotherapy. Current ongoing clinical trials are evaluating its effectivity as frontline therapy for all acute myeloid leukemia (AML) patients. However, response rates vary wildly, depending on patient characteristics and mutational profiles. This review elaborates on the efficacy and safety of venetoclax compared to conventional chemotherapy for treatment of AML patients, comparing the response rates, overall survival and adverse events. Moreover, it gives an overview of genetic and epigenetic AML cell characteristics that give enhanced or decreased response to venetoclax and offers insights into the pathogenesis of venetoclax sensitivity and resistance. Additionally, it suggests possible treatment combinations predicted to be successful based on identified mechanisms influencing venetoclax sensitivity of AML cells. Abstract Venetoclax is a BCL-2 inhibitor that effectively improves clinical outcomes in newly diagnosed, relapsed and refractory acute myeloid leukemia (AML) patients, with complete response rates (with and without complete blood count recovery) ranging between 34–90% and 21–33%, respectively. Here, we aim to give an overview of the efficacy of venetoclax-based therapy for AML patients, as compared to standard chemotherapy, and on factors and mechanisms involved in venetoclax sensitivity and resistance in AML (stem) cells, with the aim to obtain a perspective of response biomarkers and combination therapies that could enhance the sensitivity of AML cells to venetoclax. The presence of molecular aberrancies can predict responses to venetoclax, with a higher response in NPM1-, IDH1/2-, TET2- and relapsed or refractory RUNX1-mutated AML. Decreased sensitivity to venetoclax was observed in patients harboring FLT3-ITD, TP53, K/NRAS or PTPN11 mutations. Moreover, resistance to venetoclax was observed in AML with a monocytic phenotype and patients pre-treated with hypomethylating agents. Resistance to venetoclax can arise due to mutations in BCL-2 or pro-apoptotic proteins, an increased dependency on MCL-1, and usage of additional/alternative sources for energy metabolism, such as glycolysis and fatty acid metabolism. Clinical studies are testing combination therapies that may circumvent resistance, including venetoclax combined with FLT3- and MCL-1 inhibitors, to enhance venetoclax-induced cell death. Other treatments that can potentially synergize with venetoclax, including MEK1/2 and mitochondrial complex inhibitors, need to be evaluated in a clinical setting.
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Affiliation(s)
- Mila S Griffioen
- Department of Hematology, Amsterdam UMC, Location VUmc, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - David C de Leeuw
- Department of Hematology, Amsterdam UMC, Location VUmc, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Jeroen J W M Janssen
- Department of Hematology, Amsterdam UMC, Location VUmc, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
| | - Linda Smit
- Department of Hematology, Amsterdam UMC, Location VUmc, Cancer Center Amsterdam, 1081 HV Amsterdam, The Netherlands
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Dissecting the Genetic and Non-Genetic Heterogeneity of Acute Myeloid Leukemia Using Next-Generation Sequencing and In Vivo Models. Cancers (Basel) 2022; 14:cancers14092182. [PMID: 35565315 PMCID: PMC9103951 DOI: 10.3390/cancers14092182] [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: 03/29/2022] [Revised: 04/21/2022] [Accepted: 04/25/2022] [Indexed: 02/01/2023] Open
Abstract
Simple Summary Acute myeloid leukemia (AML) is an extremely aggressive form of blood cancer with high rates of treatment failure. AML arises from the stepwise acquisition of genetic aberrations and is a highly heterogeneous disorder. Recent research has shown that individual AML samples often contain several clones that are defined by a distinct combination of genetic lesions, epigenetic patterns and cell surface marker expression profiles. A better understanding of the clonal dynamics of AML is required to develop novel treatment strategies against this disease. In this review, we discuss the recent developments that have further deepened our understanding of clonal evolution and heterogeneity in AML. Abstract Acute myeloid leukemia (AML) is an extremely aggressive and heterogeneous disorder that results from the transformation of hematopoietic stem cells. Although our understanding of the molecular pathology of AML has greatly improved in the last few decades, the overall and relapse free survival rates among AML patients remain quite poor. This is largely due to evolution of the disease and selection of the fittest, treatment-resistant leukemic clones. There is increasing evidence that most AMLs possess a highly complex clonal architecture and individual leukemias are comprised of genetically, phenotypically and epigenetically distinct clones, which are continually evolving. Advances in sequencing technologies as well as studies using murine AML models have provided further insights into the heterogeneity of leukemias. We will review recent advances in the field of genetic and non-genetic heterogeneity in AML.
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Rasheed HM, Donia HM, Nadwan EA, Mourad ZI, Farahat N. Identifying Leukemia-associated Immunophenotypes in Acute Myeloid Leukemia Patients Using Multiparameter Flow Cytometry. Oman Med J 2022; 36:e323. [PMID: 35024173 PMCID: PMC8722324 DOI: 10.5001/omj.2021.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 02/01/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives We sought to identify leukemia-associated immunophenotypes (LAIPs) in 50 acute myeloid leukemia (AML) patients at diagnosis using an eight-color multiparameter flow cytometry (MFC) panel and to detect if they showed any alteration in relapsed/refractory cases. Methods We used the eight-color MFC panel with CD45/side scatter log gating strategy to analyze LAIPs in 50 AML patients presenting to Alexandria University Hospitals, Egypt at diagnosis and relapse and refractory cases. Twenty age and sex matched bone marrow samples from patients performing bone marrow aspirate for non-malignant hematological indications were included as controls. Results LAIPs were observed in 43 (86.0%) cases. Only one aberrant immunophenotype was identified in four cases (9.3%), while two to 12 aberrant immunophenotypes were found in the other 39 (90.7%) cases. Strong LAIPs were obtained by combining CD2, CD4, CD56, with either CD34 or CD117, in contrast to CD19, which has to be combined with CD117. Refractory cases showed the presence of the same LAIPs at both initial diagnosis and persistent disease. One case showed the acquisition of new LAIPs after relapse. Conclusions The good choice of LAIPs depends on their specificity rather than their frequency. The results of this study can help in increasing the sensitivity of LAIPs strategy in minimal residual disease using MFC in AML patients, which is considered an important post-diagnosis parameter associated with prognosis and clinical outcome.
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Affiliation(s)
- Hadeer Mohamed Rasheed
- Clinical Pathology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Hanaa Mahmoud Donia
- Clinical Pathology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Eman Attia Nadwan
- Internal Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Zeinab Ibrahim Mourad
- Clinical Pathology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Nahla Farahat
- Clinical Pathology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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F McGowan P, D Hyter S, Cui W, Plummer RM, Godwin AK, Zhang D. Comparison of flow cytometry and next-generation sequencing in minimal residual disease monitoring of acute myeloid leukemia: One institute's practical clinical experience. Int J Lab Hematol 2021; 44:118-126. [PMID: 34585519 DOI: 10.1111/ijlh.13711] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/19/2021] [Accepted: 09/09/2021] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Monitoring patients with acute myeloid leukemia can be implemented through various techniques such as multiparameter flow cytometry, real-time quantitative polymerase chain reaction, and next-generation sequencing. However, there is scarce studies when comparing the data of next-generation sequencing and flow cytometry for monitoring disease progression, particularly how they might supplement one another when used in tandem. METHODS We investigated 107 patients via retrospective analysis using follow-up MFC and NGS data with a total of 717 MFC and 247 NGS studies to compare these methods in monitoring minimal/measurable residual disease. RESULTS 197 instances were MFC+ /NGS+ , 3 were MFC- /NGS- , 44 were MFC- /NGS+ , and 3 are MFC+ /NGS- . The majority of the MFC- /NGS+ cases occurred within 6 months during the post-treatment phase (64%). Among 44 MFC- /NGS+ instances, 13 had similar NGS profiles to their original day 0 diagnosis. The remaining cases showed preleukemic clonal hematopoiesis mutations, "likely pathogenic mutations," or "variants of uncertain significance." CONCLUSION Our findings show that flow cytometry has its advantages with comparable sensitivity in detecting minimal/measurable residual disease. Next-generation sequencing could be used in an increased and more regular capacity in conjunction with flow cytometry to achieve a more comprehensive surveillance of these patients, resulting in improved outcomes.
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Affiliation(s)
- Paul F McGowan
- Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Stephen D Hyter
- Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Wei Cui
- Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Regina M Plummer
- Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Andrew K Godwin
- Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Da Zhang
- Department of Pathology & Laboratory Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
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Hanekamp D, Tettero JM, Ossenkoppele GJ, Kelder A, Cloos J, Schuurhuis GJ. AML/Normal Progenitor Balance Instead of Total Tumor Load (MRD) Accounts for Prognostic Impact of Flowcytometric Residual Disease in AML. Cancers (Basel) 2021; 13:2597. [PMID: 34073205 PMCID: PMC8198261 DOI: 10.3390/cancers13112597] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 12/11/2022] Open
Abstract
Measurable residual disease (MRD) in AML, assessed by multicolor flow cytometry, is an important prognostic factor. Progenitors are key populations in defining MRD, and cases of MRD involving these progenitors are calculated as percentage of WBC and referred to as white blood cell MRD (WBC-MRD). Two main compartments of WBC-MRD can be defined: (1) the AML part of the total primitive/progenitor (CD34+, CD117+, CD133+) compartment (referred to as primitive marker MRD; PM-MRD) and (2) the total progenitor compartment (% of WBC, referred to as PM%), which is the main quantitative determinant of WBC-MRD. Both are related as follows: WBC-MRD = PM-MRD × PM%. We explored the relative contribution of each parameter to the prognostic impact. In the HOVON/SAKK study H102 (300 patients), based on two objectively assessed cut-off points (2.34% and 10%), PM-MRD was found to offer an independent prognostic parameter that was able to identify three patient groups with different prognoses with larger discriminative power than WBC-MRD. In line with this, the PM% parameter itself showed no prognostic impact, implying that the prognostic impact of WBC-MRD results from the PM-MRD parameter it contains. Moreover, the presence of the PM% parameter in WBC-MRD may cause WBC-MRD false positivity and WBC-MRD false negativity. For the latter, at present, it is clinically relevant that PM-MRD ≥ 10% identifies a patient sub-group with a poor prognosis that is currently classified as good prognosis MRDnegative using the European LeukemiaNet 0.1% consensus MRD cut-off value. These observations suggest that residual disease analysis using PM-MRD should be conducted.
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Affiliation(s)
- Diana Hanekamp
- Department of Hematology, Amsterdam University Medical Centers, Cancer Center VU University Medical Center, 1081 HV Amsterdam, The Netherlands; (D.H.); (J.M.T.); (G.J.O.); (A.K.); (J.C.)
- Department of Hematology, Erasmus MC, NL-3000 CA Rotterdam, The Netherlands
| | - Jesse M. Tettero
- Department of Hematology, Amsterdam University Medical Centers, Cancer Center VU University Medical Center, 1081 HV Amsterdam, The Netherlands; (D.H.); (J.M.T.); (G.J.O.); (A.K.); (J.C.)
| | - Gert J. Ossenkoppele
- Department of Hematology, Amsterdam University Medical Centers, Cancer Center VU University Medical Center, 1081 HV Amsterdam, The Netherlands; (D.H.); (J.M.T.); (G.J.O.); (A.K.); (J.C.)
| | - Angèle Kelder
- Department of Hematology, Amsterdam University Medical Centers, Cancer Center VU University Medical Center, 1081 HV Amsterdam, The Netherlands; (D.H.); (J.M.T.); (G.J.O.); (A.K.); (J.C.)
| | - Jacqueline Cloos
- Department of Hematology, Amsterdam University Medical Centers, Cancer Center VU University Medical Center, 1081 HV Amsterdam, The Netherlands; (D.H.); (J.M.T.); (G.J.O.); (A.K.); (J.C.)
| | - Gerrit Jan Schuurhuis
- Department of Hematology, Amsterdam University Medical Centers, Cancer Center VU University Medical Center, 1081 HV Amsterdam, The Netherlands; (D.H.); (J.M.T.); (G.J.O.); (A.K.); (J.C.)
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van Gils N, Denkers F, Smit L. Escape From Treatment; the Different Faces of Leukemic Stem Cells and Therapy Resistance in Acute Myeloid Leukemia. Front Oncol 2021; 11:659253. [PMID: 34012921 PMCID: PMC8126717 DOI: 10.3389/fonc.2021.659253] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/08/2021] [Indexed: 12/26/2022] Open
Abstract
Standard induction chemotherapy, consisting of an anthracycline and cytarabine, has been the first-line therapy for many years to treat acute myeloid leukemia (AML). Although this treatment induces complete remissions in the majority of patients, many face a relapse (adaptive resistance) or have refractory disease (primary resistance). Moreover, older patients are often unfit for cytotoxic-based treatment. AML relapse is due to the survival of therapy-resistant leukemia cells (minimal residual disease, MRD). Leukemia cells with stem cell features, named leukemic stem cells (LSCs), residing within MRD are thought to be at the origin of relapse initiation. It is increasingly recognized that leukemia "persisters" are caused by intra-leukemic heterogeneity and non-genetic factors leading to plasticity in therapy response. The BCL2 inhibitor venetoclax, combined with hypomethylating agents or low dose cytarabine, represents an important new therapy especially for older AML patients. However, often there is also a small population of AML cells refractory to venetoclax treatment. As AML MRD reflects the sum of therapy resistance mechanisms, the different faces of treatment "persisters" and LSCs might be exploited to reach an optimal therapy response and prevent the initiation of relapse. Here, we describe the different epigenetic, transcriptional, and metabolic states of therapy sensitive and resistant AML (stem) cell populations and LSCs, how these cell states are influenced by the microenvironment and affect treatment outcome of AML. Moreover, we discuss potential strategies to target dynamic treatment resistance and LSCs.
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Affiliation(s)
- Noortje van Gils
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Fedor Denkers
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, Netherlands
| | - Linda Smit
- Department of Hematology, Amsterdam UMC, location VUmc, Cancer Center Amsterdam, Amsterdam, Netherlands
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Kolesnikova MA, Sen'kova AV, Pospelova TI, Zenkova MA. Drug responsiveness of leukemic cells detected in vitro at diagnosis correlates with therapy response and survival in patients with acute myeloid leukemia. Cancer Rep (Hoboken) 2021; 4:e1362. [PMID: 33675187 PMCID: PMC8388166 DOI: 10.1002/cnr2.1362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 01/29/2021] [Accepted: 02/17/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Acute myeloid leukemia (AML) is the most common acute leukemia in adults, and chemotherapy remains the most commonly used treatment approach for this group of hematological disorders. Drug resistance is one of the predictors of unfavorable prognosis for leukemia patients. AIM The purpose of this study was to perform a retrospective analysis of the survival rate in AML patients according to age, tumor status, and chemotherapy regimen received and to analyze the therapy response of AML patients depending on the treatment received, initial responsiveness of tumor cells to chemotherapeutic drugs measured in vitro at diagnosis and expression of immunological markers. METHODS The survival of AML patients (n = 127) was analyzed using the Kaplan-Meier method. Drug sensitivity of tumor cells of AML patients (n = 37) and the expression of immunological markers were evaluated by the WST test and flow cytometry, respectively. Correlation analysis was performed using Spearman's rank order correlation coefficient. RESULTS We found the treatment regimen to be the defining factor in the patient survival rate. In addition, the initial responsiveness of tumor cells to chemotherapeutic drugs measured in vitro at diagnosis correlated with the therapy response of AML: patients with high tumor cell sensitivity to particular cytotoxic drugs demonstrated a good response to treatment including these drugs, and patients with initial resistance of tumor cells to a particular chemotherapeutic agents and received it according to the clinical protocols demonstrated a poor response to antitumor therapy. Correlations of drug resistance in leukemic cells with the expression of immature and aberrant immunophenotype markers as established unfavorable prognostic factors confirm our assumption. CONCLUSION The evaluation of the responsiveness of tumor cells to chemotherapy in vitro at diagnosis can be a useful tool for predicting the response of leukemia patients to planned chemotherapy.
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Affiliation(s)
- Maria A Kolesnikova
- Institute of Chemical Biology and Fundamental Medicine SB RAS, Novosibirsk, Russia.,Novosibirsk Hematology Center, Novosibirsk, Russia
| | | | | | - Marina A Zenkova
- Institute of Chemical Biology and Fundamental Medicine SB RAS, Novosibirsk, Russia
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11
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Pinheiro LHS, Trindade LD, Costa FDO, Silva NDL, Sandes AF, Nunes MAP, Correa CB, Almeida CAC, da Cruz GS, de Lyra Junior DP, Schimieguel DM. Aberrant Phenotypes in Acute Myeloid Leukemia and Its Relationship with Prognosis and Survival: A Systematic Review and Meta-Analysis. Int J Hematol Oncol Stem Cell Res 2020; 14:274-288. [PMID: 33603989 PMCID: PMC7876425 DOI: 10.18502/ijhoscr.v14i4.4484] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 10/14/2020] [Indexed: 01/03/2023] Open
Abstract
Background: The aim of this review was to evaluate the influence of aberrant phenotypes in prognosis and survival in acute myeloid leukemia (AML) patients by multiparametric flow cytometry. Materials and Methods: Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a review of PubMed, Scopus, Science Direct and Web of Science was carried out through 1998 to 2016, conducted by two reviewers independently, evaluating titles, abstracts and full-texts of the selected studies. Results: Ten studies were included on this review, in which the aberrant phenotype expression of 17 markers were detected in AML patients. From these, 11 aberrant phenotypes were associated with prognosis, which eight had shown negative impact on prognosis: CD7, CD56, CD15, CD2, CD3, CD90low, CD123high, CD117high, and three others were associated with good prognosis: CD19, CD98high and CD117+/CD15+. Meta-analysis showed that aberrant expression of CD56 as a poor prognostic marker with unfavorable outcomes is implicated in decreased overall survival in AML patients in 28 months (95% CI: 0.62 to 0.92). Conclusion: This was observed when there was association between CD56 expression and other prognostic factors, influencing on patients' management care and treatment.
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Affiliation(s)
| | - Louise Dantas Trindade
- Department of Pharmacy, Laboratory of Hematology, Federal University of Sergipe, São Cristóvão, Sergipe, Brazil
| | | | - Nathanielly de Lima Silva
- Department of Pharmacy, Laboratory of Hematology, Federal University of Sergipe, São Cristóvão, Sergipe, Brazil
| | - Alex Freire Sandes
- Department of Medicine, Hematology Course, Federal University of São Paulo, São Paulo, São Paulo, Brazil
| | | | - Cristiane Bani Correa
- Department of Morphology, Federal University of Sergipe, São Cristóvão, Sergipe, Brazil
| | | | | | | | - Dulce Marta Schimieguel
- Department of Pharmacy, Laboratory of Hematology, Federal University of Sergipe, São Cristóvão, Sergipe, Brazil
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12
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Wu YY, Huang TC, Ye RH, Fang WH, Lai SW, Chang PY, Liu WN, Kuo TY, Lee CH, Tsai WC, Lin C. A Hematologist-Level Deep Learning Algorithm (BMSNet) for Assessing the Morphologies of Single Nuclear Balls in Bone Marrow Smears: Algorithm Development. JMIR Med Inform 2020; 8:e15963. [PMID: 32267237 PMCID: PMC7177428 DOI: 10.2196/15963] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/11/2019] [Accepted: 12/16/2019] [Indexed: 11/16/2022] Open
Abstract
Background Bone marrow aspiration and biopsy remain the gold standard for the diagnosis of hematological diseases despite the development of flow cytometry (FCM) and molecular and gene analyses. However, the interpretation of the results is laborious and operator dependent. Furthermore, the obtained results exhibit inter- and intravariations among specialists. Therefore, it is important to develop a more objective and automated analysis system. Several deep learning models have been developed and applied in medical image analysis but not in the field of hematological histology, especially for bone marrow smear applications. Objective The aim of this study was to develop a deep learning model (BMSNet) for assisting hematologists in the interpretation of bone marrow smears for faster diagnosis and disease monitoring. Methods From January 1, 2016, to December 31, 2018, 122 bone marrow smears were photographed and divided into a development cohort (N=42), a validation cohort (N=70), and a competition cohort (N=10). The development cohort included 17,319 annotated cells from 291 high-resolution photos. In total, 20 photos were taken for each patient in the validation cohort and the competition cohort. This study included eight annotation categories: erythroid, blasts, myeloid, lymphoid, plasma cells, monocyte, megakaryocyte, and unable to identify. BMSNet is a convolutional neural network with the YOLO v3 architecture, which detects and classifies single cells in a single model. Six visiting staff members participated in a human-machine competition, and the results from the FCM were regarded as the ground truth. Results In the development cohort, according to 6-fold cross-validation, the average precision of the bounding box prediction without consideration of the classification is 67.4%. After removing the bounding box prediction error, the precision and recall of BMSNet were similar to those of the hematologists in most categories. In detecting more than 5% of blasts in the validation cohort, the area under the curve (AUC) of BMSNet (0.948) was higher than the AUC of the hematologists (0.929) but lower than the AUC of the pathologists (0.985). In detecting more than 20% of blasts, the AUCs of the hematologists (0.981) and pathologists (0.980) were similar and were higher than the AUC of BMSNet (0.942). Further analysis showed that the performance difference could be attributed to the myelodysplastic syndrome cases. In the competition cohort, the mean value of the correlations between BMSNet and FCM was 0.960, and the mean values of the correlations between the visiting staff and FCM ranged between 0.952 and 0.990. Conclusions Our deep learning model can assist hematologists in interpreting bone marrow smears by facilitating and accelerating the detection of hematopoietic cells. However, a detailed morphological interpretation still requires trained hematologists.
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Affiliation(s)
- Yi-Ying Wu
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tzu-Chuan Huang
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ren-Hua Ye
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Hui Fang
- Family Medicine Division, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shiue-Wei Lai
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ping-Ying Chang
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wei-Nung Liu
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Tai-Yu Kuo
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Cho-Hao Lee
- Division of Hematology/Oncology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Wen-Chiuan Tsai
- Department of Pathology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan.,School of Public Health, National Defense Medical Center, Taipei, Taiwan
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13
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Ueda M, Stefan T, Stetson L, Ignatz-Hoover JJ, Tomlinson B, Creger RJ, Cooper B, Lazarus HM, de Lima M, Wald DN, Caimi PF. Phase I Trial of Lithium and Tretinoin for Treatment of Relapsed and Refractory Non-promyelocytic Acute Myeloid Leukemia. Front Oncol 2020; 10:327. [PMID: 32211336 PMCID: PMC7076174 DOI: 10.3389/fonc.2020.00327] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 02/25/2020] [Indexed: 11/13/2022] Open
Abstract
Glycogen synthase kinase-3 (GSK3) inhibitors induce differentiation and growth inhibition of acute myeloid leukemia (AML) cells. Our pre-clinical studies showed GSK3 inhibition leads to sensitization of AML cells to tretinoin-mediated differentiation. We conducted a phase I trial of lithium, a GSK3 inhibitor, plus tretinoin for relapsed, refractory non-promyelocytic AML. Nine patients with median (range) age 65 (42–82) years were enrolled. All subjects had relapsed leukemia after prior therapy, with a median (range) of 3 (1–3) prior therapies. Oral lithium carbonate 300 mg was given 2–3 times daily and adjusted to meet target serum concentration (0.6 to 1.0 mmol/L); tretinoin 22.5 or 45 mg/m2/day (two equally divided doses) was administered orally on days 1–7 and 15–21 of a 28-day cycle. Four patients attained disease stability with no increase in circulating blasts for ≥4 weeks. Median (range) survival was 106 days (60–502). Target serum lithium concentration was achieved in all patients and correlated with GSK3 inhibition in leukemic cells. Immunophenotypic changes associated with myeloid differentiation were observed in five patients. The combination treatment led to a reduction in the CD34+ CD38– AML stem cell population both in vivo and in vitro. The combination of lithium and tretinoin is well-tolerated, induces differentiation of leukemic cells, and may target AML stem cells, but has limited clinical activity in the absence of other antileukemic agents. The results of this clinical trial suggest GSK3 inhibition can result in AML cell differentiation and may be a novel therapeutic strategy in this disease, particularly in combination with other antileukemic agents. Lithium is a weak GSK3 inhibitor and future strategies in AML treatment will probably require more potent agents targeting this pathway or combinations with other antileukemic agents. This trial is registered at ClinicalTrials.gov NCT01820624.
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Affiliation(s)
- Masumi Ueda
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, United States.,Department of Medicine, Division of Medical Oncology, University of Washington, Seattle, WA, United States
| | - Tammy Stefan
- Department of Pathology, Case Western Reserve University, Cleveland, OH, United States
| | - Lindsay Stetson
- Department of Pathology, Case Western Reserve University, Cleveland, OH, United States
| | - James J Ignatz-Hoover
- Department of Pathology, Case Western Reserve University, Cleveland, OH, United States
| | - Benjamin Tomlinson
- Stem Cell Transplant and Hematologic Malignancies Program, University Hospitals Seidman Cancer Center, Cleveland, OH, United States.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Richard J Creger
- Stem Cell Transplant and Hematologic Malignancies Program, University Hospitals Seidman Cancer Center, Cleveland, OH, United States.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Brenda Cooper
- Stem Cell Transplant and Hematologic Malignancies Program, University Hospitals Seidman Cancer Center, Cleveland, OH, United States.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Hillard M Lazarus
- Stem Cell Transplant and Hematologic Malignancies Program, University Hospitals Seidman Cancer Center, Cleveland, OH, United States.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Marcos de Lima
- Stem Cell Transplant and Hematologic Malignancies Program, University Hospitals Seidman Cancer Center, Cleveland, OH, United States.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - David N Wald
- Department of Pathology, Case Western Reserve University, Cleveland, OH, United States.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Paolo F Caimi
- Stem Cell Transplant and Hematologic Malignancies Program, University Hospitals Seidman Cancer Center, Cleveland, OH, United States.,Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
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14
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Rossi G, Giambra V, Minervini MM, De Waure C, Mancinelli S, Ciavarella M, Sinisi NP, Scalzulli PR, Carella AM, Cascavilla N. Leukemia‐associated immunophenotypes subdivided in “categories of specificity” improve the sensitivity of minimal residual disease in predicting relapse in acute myeloid leukemia. CYTOMETRY PART B-CLINICAL CYTOMETRY 2019; 98:216-225. [DOI: 10.1002/cyto.b.21855] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 10/09/2019] [Accepted: 10/22/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Giovanni Rossi
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo Italy
| | - Vincenzo Giambra
- Institute of Stem Cells Biology, Regenerative Medicine and Innovative Therapies (ISBReMIT), Fondazione IRCCS "Casa Sollievo della Sofferenza‐IRCCS" San Giovanni Rotondo Italy
| | - Maria M. Minervini
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo Italy
| | - Chiara De Waure
- Department of Experimental MedicineUniversity of Perugia Perugia Italy
| | - Silvia Mancinelli
- Department of Experimental MedicineUniversity of Perugia Perugia Italy
| | - Michele Ciavarella
- Institute of Stem Cells Biology, Regenerative Medicine and Innovative Therapies (ISBReMIT), Fondazione IRCCS "Casa Sollievo della Sofferenza‐IRCCS" San Giovanni Rotondo Italy
| | - Nicola P. Sinisi
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo Italy
| | - Potito R. Scalzulli
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo Italy
| | - Angelo M. Carella
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo Italy
| | - Nicola Cascavilla
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS “Casa Sollievo della Sofferenza” San Giovanni Rotondo Italy
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15
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Kriegsmann K, Löffler H, Eckstein V, Schulz R, Kräker S, Braun U, Luft T, Hegenbart U, Schönland S, Dreger P, Krämer A, Ho AD, Müller-Tidow C, Hundemer M. CD7 is expressed on a subset of normal CD34-positive myeloid precursors. Eur J Haematol 2018; 101:318-325. [PMID: 29797671 DOI: 10.1111/ejh.13100] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To improve monitoring of myeloid neoplasms by flow cytometry-based minimal residual disease (MRD) analysis, we analyzed the significance of leukemia-associated immunophenotype (LAIP) markers in 44 patients. METHODS In a pilot study cohort, peripheral blood or bone marrow samples from 13 patients with myeloid neoplasms and one case of B lymphoblastic leukemia in complete hematologic remission after allogeneic bone marrow or stem cell transplantation were subjected to selection for leukemia-specific phenotypes by fluorescence-activated cell sorting using individual marker combinations, followed by PCR-based chimerism analysis. RESULTS The feasibility of this method could be demonstrated, with selection being successful in 12 cases, including two cases where mixed chimerism was found exclusively in sorted cells. Interestingly, four specimens displayed full donor chimerism in cells expressing the presumably aberrant combination CD34+ /CD7+ . Further analyses, including assessment of an independent cohort of 25 patients not affected by neoplastic bone marrow infiltration, revealed that normal myeloid precursors usually include a population coexpressing CD34, CD13, CD33, and CD7. CONCLUSION We conclude that the combination CD34+ /CD7+ might not be suitable as an LAIP for MRD diagnostics and that a subset of normal myeloid precursors in the bone marrow expresses CD7.
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Affiliation(s)
- Katharina Kriegsmann
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Harald Löffler
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Volker Eckstein
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Renate Schulz
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Sandra Kräker
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Ute Braun
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Thomas Luft
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Ute Hegenbart
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Stefan Schönland
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Peter Dreger
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Alwin Krämer
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Anthony D Ho
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
| | - Michael Hundemer
- Department of Hematology, Oncology and Rheumatology, University of Heidelberg, Heidelberg, Germany
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16
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Coltoff A, Houldsworth J, Keyzner A, Renteria AS, Mascarenhas J. Role of minimal residual disease in the management of acute myeloid leukemia-a case-based discussion. Ann Hematol 2018; 97:1155-1167. [PMID: 29704019 DOI: 10.1007/s00277-018-3330-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 04/04/2018] [Indexed: 01/04/2023]
Abstract
AML is stratified into risk-categories based on cytogenetic and molecular features that prognosticate survival and facilitate treatment algorithms, though there is still significant heterogeneity within risk groupings with regard to risk of relapse and prognosis. The ambiguity regarding prognosis is due in large part to the relatively outdated criteria used to determine response to therapy. Whereas risk assessment has evolved to adopt cytogenetic and molecular profiling, response criteria are still largely determined by bone marrow morphologic assessment and peripheral cell count recovery. Minimal residual disease refers to the detection of a persistent population of leukemic cells below the threshold for morphologic CR determination. MRD assessment represents standard of care for ALL and PML, but concerns over prognostic capability and standardization have limited its use in AML. However, recent advancements in MRD assessment and research supporting the use of MRD assessment in AML require the reconsideration and review of this clinical tool in this disease entity. This review article will first compare and contrast the major modalities used to assess MRD in AML, such as RQ-PCR and flow cytometry, as well as touching upon newer technologies such as next-generation sequencing and digital droplet PCR. The majority of the article will discuss the evidence supporting the use of MRD assessment to prognosticate disease at various time points during treatment, and review the limited number of studies that have incorporated MRD assessment into novel treatment algorithms for AML. The article concludes by discussing the current major limitations to the implementation of MRD assessment in this disease. The manuscript is bookended by a clinical vignette that highlights the need for further research and refinement of this clinical tool.
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Affiliation(s)
- A Coltoff
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - J Houldsworth
- Department of Pathology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A Keyzner
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - A S Renteria
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - John Mascarenhas
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Adult Leukemia Program, Myeloproliferative Disorders Clinical Research Program, Tisch Cancer Institute, Division of Hematology/Oncology, Icahn School of Medicine at Mount Sinai, One Gustave L Levy Place, Box 1079, New York, NY, 10029, USA.
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17
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Martínez-Losada C, Serrano-López J, Serrano-López J, Noguera NI, Garza E, Piredda L, Lavorgna S, Consalvo MAI, Ottone T, Alfonso V, Peinado JR, Garcia-Ortiz MV, Morales-Ruiz T, Jérez A, Hurtado AM, Montesinos P, Cervera J, Such E, Ibañez M, Sempere A, Sanz MÁ, Lo-Coco F, Sánchez-García J. Clonal genetic evolution at relapse of favorable-risk acute myeloid leukemia with NPM1 mutation is associated with phenotypic changes and worse outcomes. Haematologica 2018; 103:e400-e403. [PMID: 29622659 DOI: 10.3324/haematol.2018.188433] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Carmen Martínez-Losada
- Hematology Department, Reina Sofía University Hospital/Maimonides Biomedical Research Institute of Córdoba (IMIBIC)/University of Córdoba, Spain
| | - Juana Serrano-López
- Hematology Department, Reina Sofía University Hospital/Maimonides Biomedical Research Institute of Córdoba (IMIBIC)/University of Córdoba, Spain
| | - Josefina Serrano-López
- Hematology Department, Reina Sofía University Hospital/Maimonides Biomedical Research Institute of Córdoba (IMIBIC)/University of Córdoba, Spain
| | - Nelida I Noguera
- Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy.,Laboratory of Neuro-Oncohematology, Santa Lucia Foundation, Rome, Italy
| | | | - Liliana Piredda
- Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | - Serena Lavorgna
- Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | | | - Tiziana Ottone
- Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | - Valentina Alfonso
- Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy
| | - Juan Ramón Peinado
- Medical Sciences Department, Faculty of Medicine/University of Ciudad Real (UCLM), Spain
| | - María Victoria Garcia-Ortiz
- Maimónides Biomedical Research Institute of Córdoba (IMIBIC)/University of Córdoba/Reina Sofia University Hospital, Spain
| | - Teresa Morales-Ruiz
- Maimónides Biomedical Research Institute of Córdoba (IMIBIC)/University of Córdoba/Reina Sofia University Hospital, Spain
| | - Andrés Jérez
- Hematology Department University Hospital Morales Meseguer-IMIB, Spain
| | - Ana María Hurtado
- Hematology Department University Hospital Morales Meseguer-IMIB, Spain
| | - Pau Montesinos
- Hematology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - José Cervera
- Hematology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Esperanza Such
- Hematology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Marian Ibañez
- Hematology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Amparo Sempere
- Hematology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Miguel Ángel Sanz
- Hematology Department, Hospital Universitari I Politècnic La Fe, Valencia, Spain
| | - Francesco Lo-Coco
- Department of Biomedicine and Prevention, "Tor Vergata" University, Rome, Italy.,Laboratory of Neuro-Oncohematology, Santa Lucia Foundation, Rome, Italy
| | - Joaquín Sánchez-García
- Hematology Department, Reina Sofía University Hospital/Maimonides Biomedical Research Institute of Córdoba (IMIBIC)/University of Córdoba, Spain
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18
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Gomez-Arteaga A, Guzman ML. Minimal Residual Disease in Acute Myeloid Leukemia. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1100:111-125. [PMID: 30411263 DOI: 10.1007/978-3-319-97746-1_7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Monitoring measurable (minimal) residual disease (MRD) in acute myeloid leukemia (AML) has greatly increased our ability to assess chemosensisitivity to treatment as well as the duration of treatment responses. There is strong evidence to support its prognostic value for long-term outcomes at different time points and across assays and targets. It's role as a surrogate endpoint to define risk-adapted strategies is still under evaluation. In this chapter, we will discuss the definition of MRD in AML, the potential contribution of leukemia stem cells (LSCs) to MRD and we will review all the current approaches to assess residual disease including the 2018 European Leukemia Network (ELN) working group recommendations for MRD standardization in AML. In addition, a summary of MRD studies associated to prognosis will be described.
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Affiliation(s)
- Alexandra Gomez-Arteaga
- Department of Medicine, Division of Hematology and Oncology, Weill Cornell Medicine - New York Presbyterian Hospital, New York, NY, USA
| | - Monica L Guzman
- Department of Medicine, Division of Hematology and Oncology, Weill Cornell Medicine - New York Presbyterian Hospital, New York, NY, USA.
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19
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[Clinical and biological prognostic factors in relapsed acute myeloid leukemia patients]. Med Clin (Barc) 2016; 147:185-191. [PMID: 27374030 DOI: 10.1016/j.medcli.2016.05.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Revised: 05/17/2016] [Accepted: 05/19/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Acute myeloid leukemia (AML) is the most frequent type of acute leukemia in adults. Despite recent advances in the characterization of pathogenesis of AML, the cure rates are under 40%, being leukemia relapse the most common cause of treatment failure. Leukaemia relapse occurs due to clonal evolution or clonal escape. In this study, we aimed to analyze the clinical and biological factors influencing outcomes in patients with AML relapse. PATIENTS AND METHODS We included a total of 75 AML patients who experienced leukaemia relapse after achieving complete remission. We performed complete immunophenotyping and conventional karyotyping in bone marrow aspirates obtained at diagnosis and at leukemia relapse. RESULTS Overall survival (OS) of the series was 3.7%±2.3, leukaemia progression being the most common cause of death. Patients relapsing before 12 months and those with adverse cytogenetic-molecular risk had statistically significant worse outcomes. A percentage of 52.5 of patients showed phenotypic changes and 50% cytogenetic changes at relapse. We did not find significant clinical factors predicting clonal evolution. The presence of clonal evolution at relapse did not have a significant impact on outcome. CONCLUSIONS Patients with relapsed AML have a dismal prognosis, especially those with early relapse and adverse cytogenetic-molecular risk. Clonal evolution with phenotypic and cytogenetic changes occurred in half of the patients without predictive clinical factors or impact on outcome.
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20
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Hokland P, Ommen HB, Mulé MP, Hourigan CS. Advancing the Minimal Residual Disease Concept in Acute Myeloid Leukemia. Semin Hematol 2015; 52:184-92. [PMID: 26111465 DOI: 10.1053/j.seminhematol.2015.04.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The criteria to evaluate response to treatment in acute myeloid leukemia (AML) have changed little in the past 60 years. It is now possible to use higher sensitivity tools to measure residual disease burden in AML. Such minimal or measurable residual disease (MRD) measurements provide a deeper understanding of current patient status and allow stratification for risk of subsequent clinical relapse. Despite these obvious advantages, and after over a decade of laboratory investigation and preclinical validation, MRD measurements are not currently routinely used for clinical decision-making or drug development in non-acute promyelocytic leukemia (non-APL) AML. We review here some potential constraints that may have delayed adoption, including a natural hesitancy of end users, economic impact concerns, misperceptions regarding the meaning of and need for assay sensitivity, the lack of one single MRD solution for all AML patients, and finally the need to involve patients in decision-making based on such correlates. It is our opinion that none of these issues represent insurmountable barriers and our hope is that by providing potential solutions we can help map a path forward to a future where our patients will be offered personalized treatment plans based on the amount of AML they have left remaining to treat.
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Affiliation(s)
- Peter Hokland
- Department of Hematology, Aarhus University Hospital, Denmark
| | - Hans B Ommen
- Department of Hematology, Aarhus University Hospital, Denmark
| | - Matthew P Mulé
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Christopher S Hourigan
- Myeloid Malignancies Section, Hematology Branch, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD.
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