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Zeijlemaker W, Grob T, Meijer R, Hanekamp D, Kelder A, Carbaat-Ham JC, Oussoren-Brockhoff YJM, Snel AN, Veldhuizen D, Scholten WJ, Maertens J, Breems DA, Pabst T, Manz MG, van der Velden VHJ, Slomp J, Preijers F, Cloos J, van de Loosdrecht AA, Löwenberg B, Valk PJM, Jongen-Lavrencic M, Ossenkoppele GJ, Schuurhuis GJ. CD34 +CD38 - leukemic stem cell frequency to predict outcome in acute myeloid leukemia. Leukemia 2018; 33:1102-1112. [PMID: 30542144 DOI: 10.1038/s41375-018-0326-3] [Citation(s) in RCA: 113] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/07/2018] [Accepted: 10/16/2018] [Indexed: 12/29/2022]
Abstract
Current risk algorithms are primarily based on pre-treatment factors and imperfectly predict outcome in acute myeloid leukemia (AML). We introduce and validate a post-treatment approach of leukemic stem cell (LSC) assessment for prediction of outcome. LSC containing CD34+CD38- fractions were measured using flow cytometry in an add-on study of the HOVON102/SAKK trial. Predefined cut-off levels were prospectively evaluated to assess CD34+CD38-LSC levels at diagnosis (n = 594), and, to identify LSClow/LSChigh (n = 302) and MRDlow/MRDhigh patients (n = 305) in bone marrow in morphological complete remission (CR). In 242 CR patients combined MRD and LSC results were available. At diagnosis the CD34+CD38- LSC frequency independently predicts overall survival (OS). After achieving CR, combining LSC and MRD showed reduced survival in MRDhigh/LSChigh patients (hazard ratio [HR] 3.62 for OS and 5.89 for cumulative incidence of relapse [CIR]) compared to MRDlow/LSChigh, MRDhigh/LSClow, and especially MRDlow/LSClow patients. Moreover, in the NPM1mutant positive sub-group, prognostic value of golden standard NPM1-MRD by qPCR can be improved by addition of flow cytometric approaches. This is the first prospective study demonstrating that LSC strongly improves prognostic impact of MRD detection, identifying a patient subgroup with an almost 100% treatment failure probability, warranting consideration of LSC measurement incorporation in future AML risk schemes.
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Affiliation(s)
- Wendelien Zeijlemaker
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Tim Grob
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rosa Meijer
- Clinical trial Center- HOVON data center, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diana Hanekamp
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Angèle Kelder
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Jannemieke C Carbaat-Ham
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | | | - Alexander N Snel
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Dennis Veldhuizen
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Willemijn J Scholten
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Johan Maertens
- Department of Hematology, University Hospitals Leuven, Campus Gasthuisberg, Leuven, Belgium
| | - Dimitri A Breems
- Department of Hematology, Ziekenhuis Netwerk Antwerpen, Antwerp, Belgium
| | - Thomas Pabst
- Department of Hematology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Markus G Manz
- Department of Hematology, University and University Hospital Zürich, Zürich, Switzerland
| | | | - Jennichjen Slomp
- Department of Clinical Chemistry, Medisch Spectrum Twente/Medlon, Enschede, The Netherlands
| | - Frank Preijers
- Department of Laboratory Medicine - Laboratory for Hematology, Radboud University Nijmegen Medical Center, RUNMC, Nijmegen, The Netherlands
| | - Jacqueline Cloos
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands.,Department of Pediatric Oncology/Hematology, VU University Medical Center, Amsterdam, The Netherlands
| | - Arjan A van de Loosdrecht
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Bob Löwenberg
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Peter J M Valk
- Department of Hematology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Gert J Ossenkoppele
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Gerrit J Schuurhuis
- Department of Hematology, VU University Medical Center, Cancer Center Amsterdam, Amsterdam, The Netherlands.
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Cloos J, Harris JR, Janssen JJWM, Kelder A, Huang F, Sijm G, Vonk M, Snel AN, Scheick JR, Scholten WJ, Carbaat-Ham J, Veldhuizen D, Hanekamp D, Oussoren-Brockhoff YJM, Kaspers GJL, Schuurhuis GJ, Sasser AK, Ossenkoppele G. Comprehensive Protocol to Sample and Process Bone Marrow for Measuring Measurable Residual Disease and Leukemic Stem Cells in Acute Myeloid Leukemia. J Vis Exp 2018. [PMID: 29553571 PMCID: PMC5931431 DOI: 10.3791/56386] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Response criteria in acute myeloid leukemia (AML) has recently been re-established, with morphologic examination utilized to determine whether patients have achieved complete remission (CR). Approximately half of the adult patients who entered CR will relapse within 12 months due to the outgrowth of residual AML cells in the bone marrow. The quantitation of these remaining leukemia cells, known as minimal or measurable residual disease (MRD), can be a robust biomarker for the prediction of these relapses. Moreover, retrospective analysis of several studies has shown that the presence of MRD in the bone marrow of AML patients correlates with poor survival. Not only is the total leukemic population, reflected by cells harboring a leukemia associated immune-phenotype (LAIP), associated with clinical outcome, but so is the immature low frequency subpopulation of leukemia stem cells (LSC), both of which can be monitored through flow cytometry MRD or MRD-like approaches. The availability of sensitive assays that enable detection of residual leukemia (stem) cells on the basis of disease-specific or disease-associated features (abnormal molecular markers or aberrant immunophenotypes) have drastically improved MRD assessment in AML. However, given the inherent heterogeneity and complexity of AML as a disease, methods for sampling bone marrow and performing MRD and LSC analysis should be harmonized when possible. In this manuscript we describe a detailed methodology for adequate bone marrow aspirate sampling, transport, sample processing for optimal multi-color flow cytometry assessment, and gating strategies to assess MRD and LSC to aid in therapeutic decision making for AML patients.
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Affiliation(s)
- Jacqueline Cloos
- Department of Hematology, VU University Medical Center; Pediatric Oncology/Hematology, VU University Medical Center;
| | | | | | - Angele Kelder
- Department of Hematology, VU University Medical Center
| | - F Huang
- Janssen Research & Development, LLC
| | - Gerrit Sijm
- Department of Hematology, VU University Medical Center
| | - Maike Vonk
- Department of Hematology, VU University Medical Center
| | | | | | | | | | | | | | | | - Gertjan J L Kaspers
- Pediatric Oncology/Hematology, VU University Medical Center; Princess Máxima Center for Pediatric Oncology
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