scholarly journals Oral azacitidine prolongs survival of patients with AML in remission independent of measurable residual disease status

Blood ◽  
2022 ◽  
Author(s):  
Gail J. Roboz ◽  
Farhad Ravandi ◽  
Andrew H. Wei ◽  
Hervé Dombret ◽  
Felicitas Thol ◽  
...  
Keyword(s):  
Maintenance Therapy ◽  
Residual Disease ◽  
Disease Status ◽  
Prognostic Indicator ◽  
Leukemic Cells ◽  
Multiparameter Flow Cytometry ◽  
Intensive Chemotherapy ◽  
Hematopoietic Stem ◽  
Serial Samples ◽  
Measurable Residual Disease

Measurable residual disease (MRD) in patients with acute myeloid leukemia (AML) in remission after intensive chemotherapy is predictive of early relapse and poor survival. Post-remission maintenance therapy that prolongs MRD negativity or converts MRD positive (MRD+) patients to MRD negative (MRD-) status may delay or prevent relapse and improve overall survival (OS). In the phase 3 QUAZAR AML-001 trial, oral azacitidine (Oral-AZA; formerly CC-486), a hypomethylating agent, significantly prolonged OS and relapse-free survival (RFS) compared with placebo in patients aged ≥55 years with AML in first remission after intensive chemotherapy who were not candidates for hematopoietic stem cell transplantation. In this trial, MRD (≥0.1% leukemic cells in bone marrow) was assessed by multiparameter flow cytometry in serial samples collected at baseline and on day 1 of every 3 cycles. As expected, baseline MRD status was significantly associated with both OS and RFS. Multivariate analyses showed Oral-AZA significantly improved OS and RFS vs. placebo independent of baseline MRD status. Oral-AZA treatment also extended the duration of MRD negativity by 6 months vs. placebo, and resulted in a higher rate of conversion from MRD+ at baseline to MRD- during treatment: 37% vs. 19%, respectively. In the Oral-AZA arm, 24% of MRD responders achieved MRD negativity >6 months after treatment initiation. While presence or absence of MRD was a strong prognostic indicator of OS and RFS, there were added survival benefits with Oral-AZA maintenance therapy compared with placebo, independent of patients' MRD status at baseline. NCT01757535 Clinicaltrials.gov

AMELIORATE: early intensification in FLT3-mutated acute myeloid leukemia based on peripheral blast clearance – MYNERVA-GIMEMA AML1919 trial

2021 ◽  
Author(s):  
Francesco Mannelli ◽  
Giacomo Gianfaldoni ◽  
Paola Guglielmelli ◽  
Francesco Buccisano ◽  
Roberto Caporale ◽  
...  
Keyword(s):  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Residual Disease ◽  
Disease Status ◽  
Phase Iii ◽  
Multiparameter Flow Cytometry ◽  
Current Standard ◽  
Disease Category ◽  
Measurable Residual Disease ◽  
Acute Myeloid

AMELIORATE is a Phase III, randomized trial aiming to personalize treatment intensity in FLT3-mutated acute myeloid leukemia. The current study provides an early appraisal of chemosensitivity based on peripheral blasts clearance, as assessed by multiparameter flow cytometry, from baseline to day 4 of induction. This biomarker was previously demonstrated to predict complete remission achievement and measurable residual disease status. For patients experiencing low peripheral blast cells (i.e., ≤2.0 logs), two major adjustments of treatment as compared with current standard of care are envisioned in the experimental arm: the immediate switch to intensified induction with high-doses cytarabine (1500 mg/m2 b.i.d. on days 5–7 of induction); and the early allocation of the patient to high-risk disease category, to be further refined later based on postinduction measurable residual disease status.

scholarly journals Minimal/measurable residual disease in AML: a consensus document from the European LeukemiaNet MRD Working Party

Blood ◽  
2018 ◽  
Vol 131 (12) ◽  
pp. 1275-1291 ◽  
Author(s):  
Gerrit J. Schuurhuis ◽  
Michael Heuser ◽  
Sylvie Freeman ◽  
Marie-Christine Béné ◽  
Francesco Buccisano ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Medicine ◽  
Residual Disease ◽  
Working Party ◽  
Prognostic Indicator ◽  
The United States ◽  
Molecular Data ◽  
Multiparameter Flow Cytometry ◽  
Consensus Document ◽  
Measurable Residual Disease

Abstract Measurable residual disease (MRD; previously termed minimal residual disease) is an independent, postdiagnosis, prognostic indicator in acute myeloid leukemia (AML) that is important for risk stratification and treatment planning, in conjunction with other well-established clinical, cytogenetic, and molecular data assessed at diagnosis. MRD can be evaluated using a variety of multiparameter flow cytometry and molecular protocols, but, to date, these approaches have not been qualitatively or quantitatively standardized, making their use in clinical practice challenging. The objective of this work was to identify key clinical and scientific issues in the measurement and application of MRD in AML, to achieve consensus on these issues, and to provide guidelines for the current and future use of MRD in clinical practice. The work was accomplished over 2 years, during 4 meetings by a specially designated MRD Working Party of the European LeukemiaNet. The group included 24 faculty with expertise in AML hematopathology, molecular diagnostics, clinical trials, and clinical medicine, from 19 institutions in Europe and the United States.

Post-remission clonal hematopoiesis; Practical implications for measurable residual disease assessment in acute myeloid leukemia (AML).

2020 ◽  
Vol 38 (15_suppl) ◽  
pp. 7529-7529
Author(s):  
Sanam Loghavi ◽  
Tomoyuki Tanaka ◽  
Ken Furudate ◽  
Sa A Wang ◽  
Koichi Takahashi
Keyword(s):  
Acute Myeloid Leukemia ◽  
Myeloid Leukemia ◽  
Residual Disease ◽  
Disease Status ◽  
Leukemic Cells ◽  
Disease Assessment ◽  
Individual Gene ◽  
Clonal Hematopoiesis ◽  
Measurable Residual Disease ◽  
Acute Myeloid

7529 Background: Clonal Hematopoiesis may persist following complete remission (CR) in patients with acute myeloid leukemia (AML) but does not necessarily indicate residual AML and may represent persistence of pre-leukemic stem cells. Post-remission CH identified by NGS has not been systemically studied in parallel with measurable residual disease (MRD) detection by flow cytometric immunophenotyping (FCI). Methods: We studied bone marrow sample from AML patients at baseline and CR by targeted deep NGS of 295 genes (median 403x depth) and compared the results to FCI. Measurable residual disease (MRD) detection by FCI was performed by comparing the phenotype at CR to baseline and by detection of leukemia associated immunophenotype (LAIP) and derivation from normal (DFN) (sensitivity: 0.1%). Post-CR CH was defined as presence of mutations originally detected in AML with variant allele frequency > 2.5%. FCI results were categorized into 4 groups: a) AML MRD negative by LAIP or DFN b) AML MRD+ (similar to baseline) c) AML MRD+ (different from baseline), d) Negative for AML MRD, but aberrant phenotype suggestive of pre-leukemic cells. We correlated FCI and NGS results. Results: 101 patients were included in the study. 45 (45%) had persistent post-CR clonal hematopoiesis; 23 (51%) had phenotypic alterations detected by FCI including AML MRD+ in 18 (40%) and pre-leukemic cells in 5 (10%). Among patient with no detectable mutations by NGS (n = 56; 55%), 14 (25%) had FCI aberrancies including AML MRD+ in 4 (7%) and pre-leukemic cells in 10 (18%). CH was significantly more common in samples with residual phenotypic aberrancies detected by FCI (p = 0.004). There was no significant correlation between FCI group d and persistent CH (p = 0.4). Persistent ASXL1 (p = 0.024, OR = 7.2 ) and RUNX1 (p = 0.016; OR = 17.3) mutations were significantly associated with FCI abnormalities. The correlation coefficient between FCI abnormalities and RUNX1 mutations inferred from a Bayesian network structure was 0.66. Conclusions: NGS and FCI are complementary in evaluating post treatment disease status in AML. Post CR-CH is associated with phenotypic abnormalities that either represent residual AML or pre-leukemic cells. The latter may not have the same prognostic implications as AML MRD; however, the association with outcome needs to be elucidated. Single cell DNA sequencing technologies may be helpful in more accurately deciphering the association of individual gene mutations and their contribution to phenotypic aberrations.

scholarly journals Clinical Relevance of- Limit of Detection (LOD) - Limit of Quantification (LOQ) - Based Flow Cytometry Approach for Measurable Residual Disease (MRD) Assessment in Acute Myeloid Leukemia (AML)

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 37-38
Author(s):  
Raffaele Palmieri ◽  
Alfonso Piciocchi ◽  
Valentina Arena ◽  
Luca Maurillo ◽  
Maria Ilaria Del Principe ◽  
...  
Keyword(s):  
Health Care ◽  
Myeloid Leukemia ◽  
Residual Disease ◽  
Limit Of Detection ◽  
Leukemic Cells ◽  
For Profit ◽  
Health Care Company ◽  
Measurable Residual Disease ◽  
Acute Myeloid ◽  
Care Company

Background: In Acute Myeloid Leukemia (AML), identification of measurable residual disease (MRD) thresholds with clinical significance is still a matter of debate. For this purpose, multiparametric flow cytometry (MFC) is extensively employed for MRD quantification, due to high sensitivity (down to 1:10-3/10-5 cells) and wide applicability (up to 90% of cases). The identification of 20 clustered residual leukemic cells seems sufficient for the recognition of MRD presence (lower limit of detection [LOD]), whereas a cluster of 50 events may be the minimum threshold for the quantification of a cell population (lower limit of quantitation [LOQ]), provided a sufficient denominator of relevant events (500'000-1'000'000) is acquired. Methods: Using a MFC assay, we assessed the predictive power of a threshold calculated applying the criteria of LOD and LOQ on 261 intensively treated AML patients enrolled in the GIMEMA AML1310 prospective trial.According to the protocol design, patients with a bone marrow residual leukemic cells count (RLCc) equal or above 0.035% of the total no. of mononuclear (MNC) cells qualified as MRDpos,, whileusing LOD and LOQ, we selected the following categories of patients: 1) LODneg if RLCc was below LOD (20x100/total no. of events); 2) LODpos-LOQneg if RLCc was between LOD and LOQ; and 3) LOQpos if RLCc was above LOQ (50x100/total no. of events). Results: The ELN target of 500'000 events was reached in 182/261 (69.6%) patients. Overall, using the predefined AML1310 protocol MRD threshold, 154 (59%) and 107 (41%) were MRDneg and MRDpos, respectively, whereas 74 (28.4%), 43 (16.5%) and 144 (54.4%) patients were classified as LODneg, LODpos-LOQneg and LOQpos, respectively. Two-year overall survival (OS) was 75.4% vs. 79.8% vs. 66.4% for LODneg, LODpos-LOQneg and LODpos, respectively (p=0.1197), and 74.5% vs. 66.4% according to AML1310 protocol 0.035% threshold for MRDneg and MRDpos patients, respectively (p=0.3521). Due to superimposable outcome, LOD-LOQneg and LODpos-LOQneg categories were combined. Accordingly, LODneg/LODpos-LOQneg and LOQpos groups clearly differed in terms of OS (77% vs. 66.4%, p=0.0437) [FIGURE 1A]. Such a figure was challenged in multivariate analysis (p=0.048, HR 0.628, 95% CI 0.396-0.997) that confirmed the independent role of LOD-LOQ approach in influencing OS. To enhance the predictivity of LOD-LOQ estimate, we then focused on samples acquisition of which passed the 500'000 events, according to ELN guidelines. Among 182/261 (69.7%) cases with > 500'000 MNC events as denominator, LODneg/LODpos-LOQneg and LOQpos subgroups were clearly distinct in terms of OS (2-years OS of 83.5% vs. 69.4%, p=0.009). [FIGURE 1B] Similarly, also when selecting those patients (158/261 [60.5%]) whose acquisition passed 500'000 CD45+ events, LODneg/LODpos-LOQneg and LOQpos showed a different behavior with 2-years OS of 86.7% vs. 69.0%, respectively (p=0.004). [FIGURE 1C] Finally, when considering the interaction of the 3 LOD-LOQ categories with possible post-remissional strategies, LODneg/LODpos-LOQneg patients submitted to autologous stem cell transplant showed the best 2-years OS (88.9%) as compared to all the other categories (allogeneic stem cells transplant and no graft-based treatments) (p=0.026). Summary/Conclusion: In conclusion, the use of LOD-LOQ method results in a more sensitive detection of MRD that, in turn, translates in a more accurate recognition of patients with different prognosis. Actually, such an approach allowed to dissect even further the category of patients called MRDneg according to the AML1310 protocol definition, since MRDneg subjects who belonged to a "true negative" LOD-LOQ sub-group [LODneg/LODpos-LOQneg] had a better outcome than the other MRDneg ones. This MRD approach could serve as a useful tool to personalize post-remission strategy in intensively treated AML patients, through selection of high-quality remission patients who may benefit from less intensive post-consolidation therapies. Disclosures Voso: Bristol Myers Squibb: Honoraria, Membership on an entity's Board of Directors or advisory committees, Research Funding. Venditti:Novartis: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company); Pfizer: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company), Speakers Bureau; Amgen: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company); Jazz: Consultancy, Honoraria, Other: TRAVEL, ACCOMMODATIONS, EXPENSES (paid by any for-profit health care company); AbbVie: Consultancy, Honoraria, Other: TRAVEL, ACCOMODATIONS, EXPENSES (paid by any for-profit health care company); Janssen: Consultancy, Honoraria, Other: TRAVEL, ACCOMODATIONS, EXPENSES (paid by any for-profit health care company).

scholarly journals Gene-edited stem cells enable CD33-directed immune therapy for myeloid malignancies

2019 ◽  
pp. 201819992 ◽  
Author(s):  
Florence Borot ◽  
Hui Wang ◽  
Yan Ma ◽  
Toghrul Jafarov ◽  
Azra Raza ◽  
...  
Keyword(s):  
Stem Cells ◽  
T Cells ◽  
Residual Disease ◽  
Immune Therapy ◽  
Leukemic Cells ◽  
Sequencing Analysis ◽  
Hematopoietic Stem ◽  
Genetic Ablation ◽  
Targeted Immunotherapy

Antigen-directed immunotherapies for acute myeloid leukemia (AML), such as chimeric antigen receptor T cells (CAR-Ts) or antibody-drug conjugates (ADCs), are associated with severe toxicities due to the lack of unique targetable antigens that can distinguish leukemic cells from normal myeloid cells or myeloid progenitors. Here, we present an approach to treat AML by targeting the lineage-specific myeloid antigen CD33. Our approach combines CD33-targeted CAR-T cells, or the ADC Gemtuzumab Ozogamicin with the transplantation of hematopoietic stem cells that have been engineered to ablate CD33 expression using genomic engineering methods. We show highly efficient genetic ablation of CD33 antigen using CRISPR/Cas9 technology in human stem/progenitor cells (HSPC) and provide evidence that the deletion of CD33 in HSPC doesn’t impair their ability to engraft and to repopulate a functional multilineage hematopoietic system in vivo. Whole-genome sequencing and RNA sequencing analysis revealed no detectable off-target mutagenesis and no loss of functional p53 pathways. Using a human AML cell line (HL-60), we modeled a postremission marrow with minimal residual disease and showed that the transplantation of CD33-ablated HSPCs with CD33-targeted immunotherapy leads to leukemia clearance, without myelosuppression, as demonstrated by the engraftment and recovery of multilineage descendants of CD33-ablated HSPCs. Our study thus contributes to the advancement of targeted immunotherapy and could be replicated in other malignancies.

Precursor T Cell Acute Lymphoblastic Leukemia (T-ALL) Blasts Lose Expression of Markers of Immaturity during Chemotherapy: Implications for the Detection of Minimal Residual Disease.

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 1521-1521 ◽  
Author(s):  
Mikhail Roshal ◽  
Jonathan Fromm ◽  
Stuart Winter ◽  
Kimberly Dunsmore ◽  
Brent Wood
Keyword(s):  
T Cells ◽  
Minimal Residual Disease ◽  
Residual Disease ◽  
Lymphoblastic Leukemia ◽  
Positive Sample ◽  
High Expression ◽  
Leukemic Cells ◽  
Rank Test ◽  
Multiparameter Flow Cytometry ◽  
Minimal Residual

Abstract Immunophenotyping has become a primary modality in detection of minimal residual disease (MRD) in acute leukemia. Detection and enumeration of leukemic blasts relies on the recognition of the aberrancies in the immunophenotype of the abnormal population. Antigens associated with immature phenotype are thought to represent particularly good markers for identification of leukemic cells. In particular the expression of terminal deoxynucleotide transferase (TdT) on the T-lineage blasts outside the thymus and aberrantly high expression CD99 have been shown to be present in virtually all cases of T-ALL at diagnosis. CD34 and CD10 have also been used as markers of immaturity and aberrancy in MRD. Upon therapy precursor B cell ALL blasts have been shown to lose markers associated with immaturity complicating the detection of MRD. Immunophenotypic changes in T-ALL have not been well characterized. We studied the utility of these markers in the detection of MRD in pediatric patients undergoing chemotherapy under the Children’s Oncology Group (COG) research protocol for treatment of T-ALL. Per protocol (COG-AALL0434) patients received cytarabine intrathecally (IT) on day 1; vincristine IV and daunorubicin hydrochloride IV on days 1, 8, 15, and 22; prednisone IV or orally twice daily on days 1–28; pegaspargase intramuscularly (IM) on day 4, 5, or 6; and methotrexate (MTX) IT on days 8 and 29. Blood and bone marrow samples from 74 consecutive patients enrolled in the protocol between 05/2007 and 04/2008 and who had at least one positive sample (>0.1% blasts of total white cells) at days 8, 15 or 29 post first day of induction were analyzed at diagnosis and in the setting of MRD detection for abnormal expression of TdT, CD99, CD34 and CD10 by multiparameter flow cytometry. Expression of individual antigens was assessed both by percentage of the leukemic blasts with levels of expression above those of normal mature T cells in the samples and by mean fluorescence quotient relative to normal T cells. Consistent with prior reports, nearly all patient samples demonstrated expression of TdT (96%, MFQ=1.35(central 95%=1.01–1.74)) and high expression of CD99 (96%, MFQ=1.34(1.01–1.59)) on at least 20% of abnormal cells at diagnosis. Moreover, TdT and CD99 could be used for blast enumeration with 88% of cases showing greater than 50% positivity for each marker. Expression of these markers began to decline by day 8 and continued to decrease through day 29. Thus only a minority of positive cases showed expression of TdT (24%, MFQ=1.08(0.9–1.62), p<0.001, by Wilcoxon signed-rank test) or CD99 (44%, MFQ=1.14 (0.88–1.51) p<0.001) and in yet smaller proportion of cases could these markers be used for blast enumeration (11% and 26% respectively) by day 29. Median decline for CD99 positivity on the abnormal blasts was 24%, 26% and 62% at day 8, 15 and 29 respectively. Similarly, the differences for TdT were 30%, 44% and 60% respectively. CD34 and CD10 were expressed on a minority of pre-treatment cases (41% and 28% respectively) and expressed similar but less dramatic decline. At day 29, 25.9% of cases expressed CD34 and 16.2% of cases expressed CD10. Median change was 16% for CD34 and 17% for CD10 for cases that expressed those antigens before treatment. Figure 1 demonstrates the declines in both “high positive” with abnormal blasts showing greater than 50% positivity for a marker and of “low positive” cases showing between 20–50% positivity. We conclude that expression of common T-ALL markers of immaturity dramatically declines in the setting of chemotherapy, reducing their value for immunophenotypic detection of MRD. We speculate that this change is due to either chemotherapy induced partial maturation or selective survival of more mature aberrant cells. These results suggest the need for expansion of immunophenotyping panels to decrease reliance on individual markers of immaturity for T-ALL detection in order to achieve a more accurate evaluation of MRD. Figure 1: Loss of markers of immaturity in T-ALL Figure 1:. Loss of markers of immaturity in T-ALL

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