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Freeman SD, Hills RK, Virgo P, Khan N, Couzens S, Dillon R, Gilkes A, Upton L, Nielsen OJ, Cavenagh JD, Jones G, Khwaja A, Cahalin P, Thomas I, Grimwade D, Burnett AK, Russell NH. Measurable Residual Disease at Induction Redefines Partial Response in Acute Myeloid Leukemia and Stratifies Outcomes in Patients at Standard Risk Without NPM1 Mutations. J Clin Oncol 2018; 36:1486-1497. [PMID: 29601212 PMCID: PMC5959196 DOI: 10.1200/jco.2017.76.3425] [Citation(s) in RCA: 136] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Purpose We investigated the effect on outcome of measurable or minimal residual disease (MRD) status after each induction course to evaluate the extent of its predictive value for acute myeloid leukemia (AML) risk groups, including NPM1 wild-type (wt) standard risk, when incorporated with other induction response criteria. Methods As part of the NCRI AML17 trial, 2,450 younger adult patients with AML or high-risk myelodysplastic syndrome had prospective multiparameter flow cytometric MRD (MFC-MRD) assessment. After course 1 (C1), responses were categorized as resistant disease (RD), partial remission (PR), and complete remission (CR) or complete remission with absolute neutrophil count < 1,000/µL or thrombocytopenia < 100,000/μL (CRi) by clinicians, with CR/CRi subdivided by MFC-MRD assay into MRD+ and MRD-. Patients without high-risk factors, including Flt3 internal tandem duplication wt/- NPM1-wt subgroup, received a second daunorubicin/cytosine arabinoside induction; course 2 (C2) was intensified for patients with high-risk factors. Results Survival outcomes from PR and MRD+ responses after C1 were similar, particularly for good- to standard-risk subgroups (5-year overall survival [OS], 27% RD v 46% PR v 51% MRD+ v 70% MRD-; P < .001). Adjusted analyses confirmed significant OS differences between C1 RD versus PR/MRD+ but not PR versus MRD+. CRi after C1 reduced OS in MRD+ (19% CRi v 45% CR; P = .001) patients, with a smaller effect after C2. The prognostic effect of C2 MFC-MRD status (relapse: hazard ratio [HR], 1.88 [95% CI, 1.50 to 2.36], P < .001; survival: HR, 1.77 [95% CI, 1.41 to 2.22], P < .001) remained significant when adjusting for C1 response. MRD positivity appeared less discriminatory in poor-risk patients by stratified analyses. For the NPM1-wt standard-risk subgroup, C2 MRD+ was significantly associated with poorer outcomes (OS, 33% v 63% MRD-, P = .003; relapse incidence, 89% when MRD+ ≥ 0.1%); transplant benefit was more apparent in patients with MRD+ (HR, 0.72; 95% CI, 0.31 to 1.69) than those with MRD- (HR, 1.68 [95% CI, 0.75 to 3.85]; P = .16 for interaction). Conclusion MFC-MRD can improve outcome stratification by extending the definition of partial response after first induction and may help predict NPM1-wt standard-risk patients with poor outcome who benefit from transplant in the first CR.
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Affiliation(s)
- Sylvie D. Freeman
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Robert K. Hills
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Paul Virgo
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Naeem Khan
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Steve Couzens
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Richard Dillon
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Amanda Gilkes
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Laura Upton
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Ove Juul Nielsen
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - James D. Cavenagh
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Gail Jones
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Asim Khwaja
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Paul Cahalin
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Ian Thomas
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - David Grimwade
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Alan K. Burnett
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
| | - Nigel H. Russell
- Sylvie D. Freeman and Naeem Khan, University of Birmingham, Birmingham; Robert K. Hills, Amanda Gilkes, Laura Upton, Ian Thomas, and Alan K. Burnett, Cardiff University; Steve Couzens University Hospital of Wales, Cardiff; Paul Virgo, North Bristol NHS Trust, Bristol; Richard Dillon and David Grimwade, King's College London School of Medicine; James D. Cavenagh, Queen Mary University of London; Asim Khwaja, University College London, London; Gail Jones, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle; Paul Cahalin, Blackpool Teaching Hospital NHS Foundation Trust, Blackpool; Nigel H. Russell, Nottingham University Hospital, Nottingham, United Kingdom; Ove Juul Nielsen, Rigshospitalet, Copenhagen, Denmark
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