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Schwind S, Bischof L, Bill M, Grimm J, Ussmann J, Backhaus D, Brauer D, Thanh TP, Merz M, Franke GN, Metzeler KH, Vucinic V, Herling M, Platzbecker U, Jentzsch M. Quantifying NPM1 MRD in AML patients prior to allogeneic stem cell transplantation: Where to draw the line? Hemasphere 2024; 8:e55. [PMID: 38501048 PMCID: PMC10946283 DOI: 10.1002/hem3.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 01/15/2024] [Accepted: 02/08/2024] [Indexed: 03/20/2024] Open
Affiliation(s)
- Sebastian Schwind
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Lara Bischof
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Marius Bill
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Juliane Grimm
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Jule Ussmann
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Donata Backhaus
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Dominic Brauer
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Tung Pham Thanh
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Maximilian Merz
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Georg-Nikolaus Franke
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Klaus H Metzeler
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Vladan Vucinic
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Marco Herling
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Uwe Platzbecker
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
| | - Madlen Jentzsch
- Medical Clinic and Policlinic 1, Hematology, Cellular Therapy, Hemostaseology, and Infectious Diseases Leipzig University Hospital Leipzig Germany
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2
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Jimenez-Chillon C, Othman J, Taussig D, Jimenez-Vicente C, Martinez-Roca A, Tiong IS, Jain M, Aries J, Cakmak S, Knapper S, Kristensen DT, Murthy V, Galani JZ, Kallmeyer C, Ngu L, Veale D, Bolam S, Orfali N, Parker A, Manson C, Parker J, Erblich T, Richardson D, Mokretar K, Potter N, Overgaard UM, Roug AS, Wei AH, Esteve J, Jädersten M, Russell N, Dillon R. Venetoclax-based low intensity therapy in molecular failure of NPM1-mutated AML. Blood Adv 2024; 8:343-352. [PMID: 38039513 PMCID: PMC10788851 DOI: 10.1182/bloodadvances.2023011106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/26/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023] Open
Abstract
ABSTRACT Molecular failure in NPM1-mutated acute myeloid leukemia (AML) inevitably progresses to frank relapse if untreated. Recently published small case series show that venetoclax combined with low-dose cytarabine or azacitidine can reduce or eliminate measurable residual disease (MRD). Here, we report on an international multicenter cohort of 79 patients treated for molecular failure with venetoclax combinations and report an overall molecular response (≥1-log reduction in MRD) in 66 patients (84%) and MRD negativity in 56 (71%). Eighteen of 79 patients (23%) required hospitalization, and no deaths were reported during treatment. Forty-one patients were bridged to allogeneic transplant with no further therapy, and 25 of 41 were MRD negative assessed by reverse transcription quantitative polymerase chain reaction before transplant. Overall survival (OS) for the whole cohort at 2 years was 67%, event-free survival (EFS) was 45%, and in responding patients, there was no difference in survival in those who received a transplant using time-dependent analysis. Presence of FLT3-ITD mutation was associated with a lower response rate (64 vs 91%; P < .01), worse OS (hazard ratio [HR], 2.50; 95% confidence interval [CI], 1.06-5.86; P = .036), and EFS (HR, 1.87; 95% CI, 1.06-3.28; P = .03). Eighteen of 35 patients who did not undergo transplant became MRD negative and stopped treatment after a median of 10 months, with 2-year molecular relapse free survival of 62% from the end of treatment. Venetoclax-based low intensive chemotherapy is a potentially effective treatment for molecular relapse in NPM1-mutated AML, either as a bridge to transplant or as definitive therapy.
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Affiliation(s)
- Carlos Jimenez-Chillon
- Servicio de Hematología y Hemoterapia, Hospital Universitario Ramón y Cajal, Madrid, Spain
- Department of Medical & Molecular Genetics, King’s College London, London, United Kingdom
| | - Jad Othman
- Department of Medical & Molecular Genetics, King’s College London, London, United Kingdom
- Guy’s and St Thomas Hospital, London, United Kingdom
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
| | - David Taussig
- Department of Haematology, Royal Marsden Hospital, Sutton, United Kingdom
| | | | - Alexandra Martinez-Roca
- Institut d’Investigacions Biomèdiques August Pi i Sunyer, Barcelona, Spain
- Hematology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Ing Soo Tiong
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
- Alfred Hospital and Monash University, Melbourne, VIC, Australia
- Austin Health and Olivia Newton John Cancer Research Institute, Melbourne, VIC, Australia
| | - Manish Jain
- Department of Haematology, Leeds Teaching Hospitals Trust, Leeds, United Kingdom
| | - James Aries
- Department of Haemato-Oncology, St Bartholomew’s Hospital, London, United Kingdom
| | - Seda Cakmak
- Department of Haemato-Oncology, St Bartholomew’s Hospital, London, United Kingdom
| | - Steven Knapper
- Department of Haematology, School of Medicine, Cardiff University, Cardiff, United Kingdom
| | - Daniel Tuyet Kristensen
- Department of Haematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Vidhya Murthy
- Department of Haematology, University Hospitals of Birmingham, Birmingham, United Kingdom
| | | | | | - Loretta Ngu
- Department of Haematology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - David Veale
- Department of Haematology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - Simon Bolam
- Department of Haematology, Taunton and Somerset NHS Foundation Trust, Taunton, United Kingdom
| | - Nina Orfali
- Department of Haematology, St. James's Hospital, Dublin, Ireland
| | - Anne Parker
- Department of Haematology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Cara Manson
- Department of Haematology, Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | - Jane Parker
- Department of Haematology, Northampton General Hospital, Northampton, United Kingdom
| | - Thomas Erblich
- Department of Haematology, The London Clinic, London, United Kingdom
| | - Deborah Richardson
- Department of Haematology, University Hospital Southampton, Southampton, United Kingdom
| | | | - Nicola Potter
- Department of Medical & Molecular Genetics, King’s College London, London, United Kingdom
| | - Ulrik Malthe Overgaard
- Department of Haematology, Rigshospitalet, Copenhagen, Denmark
- Department of Haematology, National Hospital, Copenhagen, Denmark
| | - Anne Stidsholt Roug
- Department of Haematology, Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
- Department of Hematology, Aarhus University Hospital, Aarhus, Denmark
| | - Andrew H. Wei
- Peter MacCallum Cancer Centre, Royal Melbourne Hospital and Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC, Australia
| | - Jordi Esteve
- Hematology Department, Hospital Clínic Barcelona, Barcelona, Spain
| | - Martin Jädersten
- Department of Medicine, Center for Haematology and Regenerative Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | - Nigel Russell
- Guy’s and St Thomas Hospital, London, United Kingdom
| | - Richard Dillon
- Department of Medical & Molecular Genetics, King’s College London, London, United Kingdom
- Guy’s and St Thomas Hospital, London, United Kingdom
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3
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Falini B, Dillon R. Criteria for Diagnosis and Molecular Monitoring of NPM1-Mutated AML. Blood Cancer Discov 2024; 5:8-20. [PMID: 37917833 PMCID: PMC10772525 DOI: 10.1158/2643-3230.bcd-23-0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 09/28/2023] [Accepted: 10/25/2023] [Indexed: 11/04/2023] Open
Abstract
NPM1-mutated acute myeloid leukemia (AML) represents the largest molecular subgroup of adult AML. NPM1-mutated AML is recognizable by molecular techniques and immunohistochemistry, which, when combined, can solve difficult diagnostic problems (including identification of myeloid sarcoma and NPM1 mutations outside exon 12). According to updated 2022 European LeukemiaNet (ELN) guidelines, determining the mutational status of NPM1 (and FLT3) is a mandatory step for the genetic-based risk stratification of AML. Monitoring of measurable residual disease (MRD) by qRT-PCR, combined with ELN risk stratification, can guide therapeutic decisions at the post-remission stage. Here, we review the criteria for appropriate diagnosis and molecular monitoring of NPM1-mutated AML. SIGNIFICANCE NPM1-mutated AML represents a distinct entity in the 2022 International Consensus Classification and 5th edition of World Health Organization classifications of myeloid neoplasms. The correct diagnosis of NPM1-mutated AML and its distinction from other AML entities is extremely important because it has clinical implications for the management of AML patients, such as genetic-based risk stratification according to 2022 ELN. Monitoring of MRD by qRT-PCR, combined with ELN risk stratification, can guide therapeutic decisions at the post-remission stage, e.g., whether or not to perform allogeneic hematopoietic stem cell transplantation.
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Affiliation(s)
- Brunangelo Falini
- Institute of Hematology and Center for Hemato-Oncological Research (CREO), University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
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4
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Deng S, Pan Y, An N, Chen F, Chen H, Wang H, Xu X, Liu R, Yang L, Wang X, Du X, Zhang Q. Downregulation of RCN1 promotes pyroptosis in acute myeloid leukemia cells. Mol Oncol 2023; 17:2584-2602. [PMID: 37746742 DOI: 10.1002/1878-0261.13521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 09/08/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023] Open
Abstract
Reticulocalbin-1 (RCN1) is expressed aberrantly and at a high level in various tumors, including acute myeloid leukemia (AML), yet its impact on AML remains unclear. In this study, we demonstrate that RCN1 knockdown significantly suppresses the viability of bone marrow mononuclear cells (BMMNCs) from AML patients but does not affect the viability of granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood stem cells (PBSCs) from healthy donors in vitro. Downregulation of RCN1 also reduces the viability of AML cell lines. Further studies showed that the RCN1 knockdown upregulates type I interferon (IFN-1) expression and promotes AML cell pyroptosis through caspase-1 and gasdermin D (GSDMD) signaling. Deletion of the mouse Rcn1 gene inhibits the viability of mouse AML cell lines but not the hematopoiesis of mouse bone marrow. In addition, RCN1 downregulation in human AML cells significantly inhibited tumor growth in the NSG mouse xenograft model. Taken together, our results suggest that RCN1 may be a potential target for AML therapy.
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Affiliation(s)
- Sisi Deng
- Shenzhen Bone Marrow Transplantation Public Service Platform, Shenzhen Institute of Hematology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen University Health Sciences Center, China
| | - Yuming Pan
- Shenzhen Bone Marrow Transplantation Public Service Platform, Shenzhen Institute of Hematology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen University Health Sciences Center, China
| | - Na An
- Shenzhen Bone Marrow Transplantation Public Service Platform, Shenzhen Institute of Hematology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen University Health Sciences Center, China
| | - Fengyi Chen
- Shenzhen Bone Marrow Transplantation Public Service Platform, Shenzhen Institute of Hematology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen University Health Sciences Center, China
- Department of Physiology, School of Basic Medical Sciences, International Cancer Center, Shenzhen University Health Sciences Center, China
| | - Huan Chen
- Shenzhen Bone Marrow Transplantation Public Service Platform, Shenzhen Institute of Hematology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen University Health Sciences Center, China
| | - Heng Wang
- Shenzhen Bone Marrow Transplantation Public Service Platform, Shenzhen Institute of Hematology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen University Health Sciences Center, China
- Department of Hematology, Shenzhen Longhua District Central Hospital, China
| | - Xiaojing Xu
- China National GeneBank, BGI-Shenzhen, China
| | - Rui Liu
- China National GeneBank, BGI-Shenzhen, China
| | - Linlin Yang
- Shenzhen Bone Marrow Transplantation Public Service Platform, Shenzhen Institute of Hematology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen University Health Sciences Center, China
| | - Xiaomei Wang
- Department of Physiology, School of Basic Medical Sciences, International Cancer Center, Shenzhen University Health Sciences Center, China
| | - Xin Du
- Shenzhen Bone Marrow Transplantation Public Service Platform, Shenzhen Institute of Hematology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen University Health Sciences Center, China
| | - Qiaoxia Zhang
- Shenzhen Bone Marrow Transplantation Public Service Platform, Shenzhen Institute of Hematology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen University Health Sciences Center, China
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Blackmon AL, Hourigan CS. Test Then Erase? Current Status and Future Opportunities for Measurable Residual Disease Testing in Acute Myeloid Leukemia. Acta Haematol 2023; 147:133-146. [PMID: 38035547 PMCID: PMC10963159 DOI: 10.1159/000535463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/20/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Measurable residual disease (MRD) test positivity during and after treatment in patients with acute myeloid leukemia (AML) has been associated with higher rates of relapse and worse overall survival. Current approaches for MRD testing are not standardized leading to inconsistent results and poor prognostication of disease. Pertinent studies evaluating AML MRD testing at specific times points, with various therapeutics and testing methods are presented. SUMMARY AML is a set of diseases with different molecular and cytogenetic characteristics and is often polyclonal with evolution over time. This genetic diversity poses a great challenge for a single AML MRD testing approach. The current ELN 2021 MRD guidelines recommend MRD testing by quantitative polymerase chain reaction in those with a validated molecular target or multiparameter flow cytometry (MFC) in all other cases. The benefit of MFC is the ability to use this method across disease subsets, at the relative expense of suboptimal sensitivity and specificity. AML MRD detection may be improved with molecular methods. Genetic characterization at AML diagnosis and relapse is now standard of care for appropriate therapeutic assignment, and future initiatives will provide the evidence to support testing in remission to direct clinical interventions. KEY MESSAGES The treatment options for patients with AML have expanded for specific molecular subsets such as FLT3 and IDH1/2 mutated AML, with development of novel agents for NPM1 mutated or KMT2A rearranged AML ongoing, but also due to effective venetoclax-combinations. Evidence regarding highly sensitive molecular MRD detection methods for specific molecular subgroups, in the context of these new treatment approaches, will likely shape the future of AML care.
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Affiliation(s)
- Amanda L. Blackmon
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Christopher S. Hourigan
- Laboratory of Myeloid Malignancies, Hematology Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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6
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Zhao Y, Guo H, Chang Y. MRD-directed and risk-adapted individualized stratified treatment of AML. Chin J Cancer Res 2023; 35:451-469. [PMID: 37969959 PMCID: PMC10643342 DOI: 10.21147/j.issn.1000-9604.2023.05.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/26/2023] [Indexed: 11/17/2023] Open
Abstract
Measurable residual disease (MRD) has been widely recognized as a biomarker for deeply evaluating complete remission (CR), predicting relapse, guiding pre-emptive interventions, and serving as an endpoint surrogate for drug testing. However, despite the emergence of new technologies, there remains a lack of comprehensive understanding regarding the proper techniques, sample materials, and optimal time points for MRD assessment. In this review, we summarized the MRD methods, sample sources, and evaluation frequency according to the risk category of the European Leukemia Net (ELN) 2022. Additionally, we emphasize the importance of properly utilizing and combining these technologies. We have also refined the flowchart outlining each time point for pre-emptive interventions and intervention paths. The evaluation of MRD in acute myeloid leukemia (AML) is sophisticated, clinically applicable, and technology-dependent, and necessitates standardized approaches and further research.
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Affiliation(s)
- Yijing Zhao
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
| | - Hanfei Guo
- Stanford University Medical School, VA Palo Alto Health Care System, Palo Alto 94304, USA
- the First Hospital of Jilin University, Cancer Center, Changchun 133021, China
| | - Yingjun Chang
- Peking University People’s Hospital, Peking University Institute of Hematology, Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing 100044, China
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7
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Falini B. NPM1-mutated acute myeloid leukemia: New pathogenetic and therapeutic insights and open questions. Am J Hematol 2023; 98:1452-1464. [PMID: 37317978 DOI: 10.1002/ajh.26989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 06/02/2023] [Indexed: 06/16/2023]
Abstract
The nucleophosmin (NPM1) gene encodes for a multifunctional chaperone protein that is localized in the nucleolus but continuously shuttles between the nucleus and cytoplasm. NPM1 mutations occur in about one-third of AML, are AML-specific, usually involve exon 12 and are frequently associated with FLT3-ITD, DNMT3A, TET2, and IDH1/2 mutations. Because of its unique molecular and clinico-pathological features, NPM1-mutated AML is regarded as a distinct leukemia entity in both the International Consensus Classification (ICC) and the 5th edition of the World Health Organization (WHO) classification of myeloid neoplasms. All NPM1 mutations generate leukemic mutants that are aberrantly exported in the cytoplasm of the leukemic cells and are relevant to the pathogenesis of the disease. Here, we focus on recently identified functions of the NPM1 mutant at chromatin level and its relevance in driving HOX/MEIS gene expression. We also discuss yet controversial issues of the ICC/WHO classifications, including the biological and clinical significance of therapy-related NPM1-mutated AML and the relevance of blasts percentage in defining NPM1-mutated AML. Finally, we address the impact of new targeted therapies in NPM1-mutated AML with focus on CAR T cells directed against NPM1/HLA neoepitopes, as well as XPO1 and menin inhibitors.
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Affiliation(s)
- Brunangelo Falini
- Institute of Hematology and Center for Hemato-Oncological Research (CREO), University of Perugia and Santa Maria della Misericordia Hospital, Perugia, Italy
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8
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Sartor C, Brunetti L, Audisio E, Cignetti A, Zannoni L, Cristiano G, Nanni J, Ciruolo R, Zingarelli F, Ottaviani E, Patuelli A, Bandini L, Forte D, Sciabolacci S, Cardinali V, Papayannidis C, Cavo M, Martelli MP, Curti A. A venetoclax and azacitidine bridge-to-transplant strategy for NPM1-mutated acute myeloid leukaemia in molecular failure. Br J Haematol 2023; 202:599-607. [PMID: 37226312 DOI: 10.1111/bjh.18887] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/12/2023] [Accepted: 05/16/2023] [Indexed: 05/26/2023]
Abstract
NPM1-mutated acute myeloid leukaemia (NPM1mut AML) represents a mostly favourable/intermediate risk disease that benefits from allogeneic haematopoietic stem cell transplantation (HSCT) in case of measurable residual disease (MRD) relapse or persistence after induction chemotherapy. Although the negative prognostic role of pre-HSCT MRD is established, no recommendations are available for the management of peri-transplant molecular failure (MF). Based on the efficacy data of venetoclax (VEN)-based treatment in NPM1mut AML older patients, we retrospectively analysed the off-label combination of VEN plus azacitidine (AZA) as bridge-to-transplant strategy in 11 NPM1mut MRD-positive fit AML patients. Patients were in MRD-positive complete remission (CRMRDpos ) at the time of treatment: nine in molecular relapse and two in molecular persistence. After a median number of two cycles (range 1-4) of VEN-AZA, 9/11 (81.8%) achieved CRMRD -negative (CRMRDneg ). All 11 patients proceeded to HSCT. With a median follow-up from treatment start of 26 months, and a median post-HSCT follow-up of 19 months, 10/11 patients are alive (1 died from non-relapse mortality), and 9/10 patients are in MRDneg status. This patient series highlights the efficacy and safety of VEN-AZA to prevent overt relapse, achieve deep responses and preserve patient fitness before HSCT, in patients with NPM1mut AML in MF.
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Affiliation(s)
- C Sartor
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - L Brunetti
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti delle Marche, Ancona, Italy
| | - E Audisio
- SC Ematologia, Dipartimento di Ematologia e Oncologia, AO Città della Salute e della Scienza di Torino, Turin, Italy
| | - A Cignetti
- Department of Hematology and Cell Therapy, A.O. Ordine Mauriziano, Turin, Italy
| | - L Zannoni
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - G Cristiano
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - J Nanni
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - R Ciruolo
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - F Zingarelli
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - E Ottaviani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli" Bologna, Bologna, Italy
| | - A Patuelli
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - L Bandini
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - D Forte
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
| | - S Sciabolacci
- Institute of Hematology, Centro Ricerche Emato-Oncologiche, Ospedale S. Maria della Misericordia, University of Perugia, Perugia, Italy
| | - V Cardinali
- Institute of Hematology, Centro Ricerche Emato-Oncologiche, Ospedale S. Maria della Misericordia, University of Perugia, Perugia, Italy
| | - C Papayannidis
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli" Bologna, Bologna, Italy
| | - M Cavo
- Dipartimento di Scienze Mediche e Chirurgiche, Istituto di Ematologia "Seràgnoli", Università degli Studi di Bologna, Bologna, Italy
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli" Bologna, Bologna, Italy
| | - M P Martelli
- Institute of Hematology, Centro Ricerche Emato-Oncologiche, Ospedale S. Maria della Misericordia, University of Perugia, Perugia, Italy
| | - A Curti
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli" Bologna, Bologna, Italy
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9
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Jäger P, Rautenberg C, Kaivers J, Kasprzak A, Geyh S, Baermann BN, Haas R, Germing U, Schroeder T, Kobbe G. Allogeneic hematopoietic stem cell transplantation and pre-transplant strategies in patients with NPM1-mutated acute myeloid leukemia: a single center experience. Sci Rep 2023; 13:10774. [PMID: 37402862 PMCID: PMC10319811 DOI: 10.1038/s41598-023-38037-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/01/2023] [Indexed: 07/06/2023] Open
Abstract
Patients with acute myeloid leukemia (AML) and nucleophosmin 1 gene mutations (NPM1mut) show a favorable prognosis with chemotherapy (CT) in the absence of negative prognostic genetic abnormalities. Between 2008 and 2021 64 patients with NPM1mutAML received alloHSCT because of additional adverse prognostic factors (1st line), inadequate response to or relapse during or after CT (2nd line). To expand the evidence in alloTX in NPM1mut AML, clinical and molecular data were retrospectively analyzed with respect to pre-transplant strategies and outcome. Patients with minimal residual disease negative (MRD-) CR at transplant had better 2-y-PFS and 2-y-OS (77% and 88%) than patients with minimal residual disease positive (MRD+) CR (41% and 71%) or patients with active disease (AD) at transplant (20% and 52%). The 2nd line patients with relapse after completing CT responded well to high dose cytarabine based salvage chemotherapy (salvage CT) in contrast to patients relapsing while still on CT (90% vs 20%, P = 0.0170). 2-y-PFS and 2-y-OS was 86% in patients who achieved a 2nd MRD- CR pre alloHSCT. Outcome in NPM1mutAML depends on disease burden at alloHSCT. Time and type of relapse in relation to CT are predictive for response to salvage CT.
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Affiliation(s)
- Paul Jäger
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany.
| | - Christina Rautenberg
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, Essen, Germany
| | - Jennifer Kaivers
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, Essen, Germany
| | - Annika Kasprzak
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Stefanie Geyh
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Ben-Niklas Baermann
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Rainer Haas
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, Essen, Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology, Heinrich-Heine-University, Medical Faculty, Moorenstr. 5, 40225, Düsseldorf, Germany
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10
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Mill CP, Fiskus W, Das K, Davis JA, Birdwell CE, Kadia TM, DiNardo CD, Daver N, Takahashi K, Sasaki K, McGeehan GM, Ruan X, Su X, Loghavi S, Kantarjian H, Bhalla KN. Causal linkage of presence of mutant NPM1 to efficacy of novel therapeutic agents against AML cells with mutant NPM1. Leukemia 2023:10.1038/s41375-023-01882-4. [PMID: 36977823 DOI: 10.1038/s41375-023-01882-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/13/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023]
Abstract
In AML with NPM1 mutation causing cytoplasmic dislocation of NPM1, treatments with Menin inhibitor (MI) and standard AML chemotherapy yield complete remissions. However, the causal and mechanistic linkage of mtNPM1 to the efficacy of these agents has not been definitively established. Utilizing CRISPR-Cas9 editing to knockout (KO) or knock-in a copy of mtNPM1 in AML cells, present studies demonstrate that KO of mtNPM1 from AML cells abrogates sensitivity to MI, selinexor (exportin-1 inhibitor), and cytarabine. Conversely, the knock-in of a copy of mtNPM1 markedly sensitized AML cells to treatment with MI or cytarabine. Following AML therapy, most elderly patients with AML with mtNPM1 and co-mutations in FLT3 suffer AML relapse with poor outcomes, creating a need for novel effective therapies. Utilizing the RNA-Seq signature of CRISPR-edited AML cells with mtNPM1 KO, we interrogated the LINCS1000-CMap data set and found several pan-HDAC inhibitors and a WEE1 tyrosine kinase inhibitor among the top expression mimickers (EMs). Additionally, treatment with adavosertib (WEE1 inhibitor) or panobinostat (pan-HDAC inhibitor) exhibited synergistic in vitro lethal activity with MI against AML cells with mtNPM1. Treatment with adavosertib or panobinostat also reduced AML burden and improved survival in AML xenograft models sensitive or resistant to MI.
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Affiliation(s)
- Christopher P Mill
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Warren Fiskus
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Kaberi Das
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - John A Davis
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Tapan M Kadia
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Courtney D DiNardo
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Naval Daver
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Koichi Takahashi
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Koji Sasaki
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | | | - Xinjia Ruan
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Xiaoping Su
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Sanam Loghavi
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Hagop Kantarjian
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA
| | - Kapil N Bhalla
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, 77030, USA.
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11
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Kayser S, Levis MJ. The clinical impact of the molecular landscape of acute myeloid leukemia. Haematologica 2023; 108:308-320. [PMID: 36722402 PMCID: PMC9890016 DOI: 10.3324/haematol.2022.280801] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Indexed: 02/02/2023] Open
Abstract
Research into the underlying pathogenic mechanisms of acute myeloid leukemia (AML) has led to remarkable advances in our understanding of the disease. Mutations now allow us to explore the enormous diversity among cytogenetically defined subsets of AML, particularly the large subset of cytogenetically normal AML. Despite the progress in unraveling the tumor genome, only a small number of recurrent mutations have been incorporated into risk-stratification schemes and have been proven to be clinically relevant, targetable lesions. The current World Health Organization Classification of myeloid neoplasms and leukemia includes eight AML categories defined by recurrent genetic abnormalities as well as three categories defined by gene mutations. We here discuss the utility of molecular markers in AML in prognostication and treatment decision-making. New therapies based on targetable markers include IDH inhibitors (ivosidenib, enasidenib), venetoclax-based therapy, FLT3 inhibitors (midostaurin, gilteritinib, and quizartinib), gemtuzumab ozogamicin, magrolimab and menin inhibitors.
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Affiliation(s)
- Sabine Kayser
- NCT Trial Center, National Center of Tumor Diseases, German Cancer Research Center (DKFZ), Heidelberg.
| | - Mark J. Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University Baltimore, MD, USA
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12
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Hematopoietic Cell Transplantation in the Treatment of Pediatric Acute Myelogenous Leukemia and Myelodysplastic Syndromes: Guidelines from the American Society of Transplantation and Cellular Therapy. Transplant Cell Ther 2022; 28:530-545. [DOI: 10.1016/j.jtct.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/09/2022] [Indexed: 11/20/2022]
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13
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Falini B. AML risk models: where do we stand ? Am J Hematol 2022; 97:1124-1126. [PMID: 35856388 DOI: 10.1002/ajh.26666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/02/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Brunangelo Falini
- Institute of Hematology and CREO, University and Hospital of Perugia, Perugia, Italy
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14
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Molecular Measurable Residual Disease Assessment before Hematopoietic Stem Cell Transplantation in Pediatric Acute Myeloid Leukemia Patients: A Retrospective Study by the I-BFM Study Group. Biomedicines 2022; 10:biomedicines10071530. [PMID: 35884834 PMCID: PMC9313005 DOI: 10.3390/biomedicines10071530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 06/14/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is a curative post-remission treatment in patients with acute myeloid leukemia (AML), but relapse after transplant is still a challenging event. In recent year, several studies have investigated the molecular minimal residual disease (qPCR-MRD) as a predictor of relapse, but the lack of standardized protocols, cut-offs, and timepoints, especially in the pediatric setting, has prevented its use in several settings, including before HSCT. Here, we propose the first collaborative retrospective I-BFM-AML study assessing qPCR-MRD values in pretransplant bone marrow samples of 112 patients with a diagnosis of AML harboring t(8;21)(q22; q22)RUNX1::RUNX1T1, or inv(16)(p13q22)CBFB::MYH11, or t(9;11)(p21;q23)KMT2A::MLLT3, or FLT3-ITD genetic markers. We calculated an ROC cut-off of 2.1 × 10−4 that revealed significantly increased OS (83.7% versus 57.1%) and EFS (80.2% versus 52.9%) for those patients with lower qPCR-MRD values. Then, we partitioned patients into three qPCR-MRD groups by combining two different thresholds, 2.1 × 10−4 and one lower cut-off of 1 × 10−2, and stratified patients into low-, intermediate-, and high-risk groups. We found that the 5-year OS (83.7%, 68.6%, and 39.2%, respectively) and relapse-free survival (89.2%, 73.9%, and 67.9%, respectively) were significantly different independent of the genetic lesion, conditioning regimen, donor, and stem cell source. These data support the PCR-based approach playing a clinical relevance in AML transplant management.
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15
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Nagler A, Labopin M, Craddock C, Socié G, Yakoub-Agha I, Gedde-Dahl T, Niittyvuopio R, Byrne JL, Cornelissen JJ, Labussière-Wallet H, Arcese W, Milpied N, Esteve J, Canaani J, Mohty M. Cytogenetic risk classification maintains its prognostic significance in transplanted FLT3-ITD mutated acute myeloid leukemia patients: On behalf of the acute leukemia working party/European society of blood and marrow transplantation. Am J Hematol 2022; 97:274-282. [PMID: 34978724 DOI: 10.1002/ajh.26442] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 12/09/2021] [Accepted: 12/15/2021] [Indexed: 11/07/2022]
Abstract
FMS-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) mutational status is a pivotal prognosticator in acute myeloid leukemia (AML) patients and significantly increases the risk of disease relapse. However, it remains unclear whether in FLT3-ITD patients referred for allogeneic stem cell transplantation (allo-SCT), baseline cytogenetics significantly impacts clinical outcome. Using the European Society of Blood and Marrow Transplantation registry, we performed a retrospective analysis of 1631 FLT3-ITD AML patients who underwent allo-SCT with the aim of determining the influence of cytogenetic risk category on patient outcomes. Median patient age was 49 years and median follow-up duration was 36 months. Two-year leukemia-free survival (LFS) and incidence of relapse were 54% and 31.6%, respectively. Non-relapse mortality was experienced by 14.4% with a 2-year overall survival (OS) of 60.1%. On multivariate analysis, LFS was significantly lower in patients with intermediate and adverse risk cytogenetics compared with those with favorable risk cytogenetics, (hazard ratio [HR] = 1.48, 95% confidence interval [CI], 1.06-2.06; p = .02), and (HR = 01.65, 95% CI, 1.13-2.40; p = .009), respectively. OS was significantly lower in patients with adverse risk cytogenetics compared with patients with favorable risk cytogenetics (HR = 1.74, 95% CI, 1.16-2.61; p = .008) with a trend toward lower OS in patients with intermediate risk cytogenetics compared to those with favorable risk cytogenetics (HR = 1.43, 95% CI, 1.00-2.05; p = .052). In addition, adverse risk patients and intermediate risk patients experienced higher relapse rates compared with favorable risk patients (HR = 1.83, 95% CI, 1.13-2.94; p = .013 and HR = 1.82, 95% CI, 1.19-2.77; p = .005). Overall, cytogenetic studies aid in refinement of risk stratification in transplanted FLT3-ITD AML patients.
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Affiliation(s)
- Arnon Nagler
- Hematology Division, Department of Bone Marrow Transplantation, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Charles Craddock
- Centre for Clinical Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Gerard Socié
- Assistance Publique-Hôpitaux de Paris, Hematology Stem Cell Transplantation, Saint Louis Hospital, Paris, France
| | | | - Tobias Gedde-Dahl
- Hematology Department, Section for Stem Cell Transplantation, Oslo University Hospital, Rikshospitalet, Clinic for Cancer Medicine, Oslo, Norway
| | | | | | | | | | - William Arcese
- Stem Cell Transplant Unit, Policlinico Universitario Tor Vergata, University of Rome, Rome, Italy
| | - Noel Milpied
- Hematology and Cell Therapy Department, Bordeaux University Hospital, Bordeaux, France
| | - Jordi Esteve
- Hematology Department, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Jonathan Canaani
- Hematology Division, Department of Hematology, Sheba Medical Center, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mohamad Mohty
- Hôpital Saint-Antoine, EBMT ALWP Office, Paris, France
- Department of Haematology, Saint Antoine Hospital, INSERM UMR 938 and Sorbonne University, Paris, France
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16
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The Role of Nucleophosmin 1 ( NPM1) Mutation in the Diagnosis and Management of Myeloid Neoplasms. LIFE (BASEL, SWITZERLAND) 2022; 12:life12010109. [PMID: 35054502 PMCID: PMC8780493 DOI: 10.3390/life12010109] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 11/17/2022]
Abstract
Nucleophosmin (NPM1) is a multifunctional protein with both proliferative and growth-suppressive roles in the cell. In humans, NPM1 is involved in tumorigenesis via chromosomal translocations, deletions, or mutation. Acute myeloid leukemia (AML) with mutated NPM1, a distinct diagnostic entity by the current WHO Classification of myeloid neoplasm, represents the most common diagnostic subtype in AML and is associated with a favorable prognosis. The persistence of NPM1 mutation in AML at relapse makes this mutation an ideal target for minimal measurable disease (MRD) detection. The clinical implication of this is far-reaching because NPM1-mutated AML is currently classified as being of standard risk, with the best treatment strategy (transplantation versus chemotherapy) yet undefined. Myeloid neoplasms with NPM1 mutations and <20% blasts are characterized by an aggressive clinical course and a rapid progression to AML. The pathological classification of these cases remains controversial. Future studies will determine whether NPM1 gene mutation may be sufficient for diagnosing NPM1-mutated AML independent of the blast count. This review aims to summarize the role of NPM1 in normal cells and in human cancer and discusses its current role in clinical management of AML and related myeloid neoplasms.
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17
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Investigation of measurable residual disease in acute myeloid leukemia by DNA methylation patterns. Leukemia 2022; 36:80-89. [PMID: 34131280 PMCID: PMC8727289 DOI: 10.1038/s41375-021-01316-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 02/05/2023]
Abstract
Assessment of measurable residual disease (MRD) upon treatment of acute myeloid leukemia (AML) remains challenging. It is usually addressed by highly sensitive PCR- or sequencing-based screening of specific mutations, or by multiparametric flow cytometry. However, not all patients have suitable mutations and heterogeneity of surface markers hampers standardization in clinical routine. In this study, we propose an alternative approach to estimate MRD based on AML-associated DNA methylation (DNAm) patterns. We identified four CG dinucleotides (CpGs) that commonly reveal aberrant DNAm in AML and their combination could reliably discern healthy and AML samples. Interestingly, bisulfite amplicon sequencing demonstrated that aberrant DNAm patterns were symmetric on both alleles, indicating that there is epigenetic crosstalk between homologous chromosomes. We trained shallow-learning and deep-learning algorithms to identify anomalous DNAm patterns. The method was then tested on follow-up samples with and without MRD. Notably, even samples that were classified as MRD negative often revealed higher anomaly ratios than healthy controls, which may reflect clonal hematopoiesis. Our results demonstrate that targeted DNAm analysis facilitates reliable discrimination of malignant and healthy samples. However, since healthy samples also comprise few abnormal-classified DNAm reads the approach does not yet reliably discriminate MRD positive and negative samples.
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18
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Yu T, Chi J, Wang L. Clinical values of gene alterations as marker of minimal residual disease in non-M3 acute myeloid leukemia. Hematology 2021; 26:848-859. [PMID: 34674615 DOI: 10.1080/16078454.2021.1990503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Acute myeloid leukemia (AML) is a malignant disease of the hematopoietic system. Residual leukemic cells after treatment are associated with relapse. Thus, detecting minimal residual disease (MRD) is significant. Major techniques for MRD assessment include multiparameter flow cytometry (MFC), polymerase chain reaction (PCR), and next-generation sequencing (NGS). At a molecular level, AML is the consequence of collaboration of several gene alterations. Some of these gene alterations can also be used as MRD markers to evaluate the level of residual leukemic cells by PCR and NGS. However, when as MRD markers, different gene alterations have different clinical values. This paper aims to summarize the characteristics of various MRD markers, so as to better predict the clinical outcome of AML patients and guide the treatment.
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Affiliation(s)
- Tingyu Yu
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
| | - Jianxiang Chi
- Center for the Study of Hematological Malignancies, Nicosia, Cyprus
| | - Li Wang
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, People's Republic of China
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19
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Abstract
Acute myeloid leukemia (AML) is an uncommon but potentially catastrophic diagnosis with historically high mortality rates. The standard of care treatment remained unchanged for decades; however, recent discoveries of molecular drivers of leukemogenesis and disease progression have led to novel therapies for AML. Ongoing research and clinical trials are actively seeking to personalize therapy by identifying molecular targets, discovering patient specific and disease specific risk factors, and identifying effective combinations of modalities and drugs. This review focuses on important updates in diagnostic and disease classifications that reflect new understanding of the biology of AML, its mutational heterogeneity, some important genetic and environmental risk factors, and new treatment options including cytotoxic chemotherapy, novel targeted agents, and cellular therapies.
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Affiliation(s)
- Laura F Newell
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR, USA
| | - Rachel J Cook
- Knight Cancer Institute, Hematology and Medical Oncology, Oregon Health & Science University, Portland, OR, USA
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20
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Aitken MJL, Ravandi F, Patel KP, Short NJ. Prognostic and therapeutic implications of measurable residual disease in acute myeloid leukemia. J Hematol Oncol 2021; 14:137. [PMID: 34479626 PMCID: PMC8417965 DOI: 10.1186/s13045-021-01148-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 08/25/2021] [Indexed: 01/10/2023] Open
Abstract
Quantification of measurable residual disease (MRD) provides critical prognostic information in acute myeloid leukemia (AML). A variety of platforms exist for MRD detection, varying in their sensitivity and applicability to individual patients. MRD detected by quantitative polymerase chain reaction, multiparameter flow cytometry, or next-generation sequencing has prognostic implications in various subsets of AML and at various times throughout treatment. While it is overwhelmingly evident that minute levels of remnant disease confer increased risk of relapse and shortened survival, the therapeutic implications of MRD remain less clear. The use of MRD as a guide to selecting the most optimal post-remission therapy, including hematopoietic stem cell transplant or maintenance therapy with hypomethylating agents, small molecule inhibitors, or immunotherapy is an area of active investigation. In addition, whether there are sufficient data to use MRD negativity as a surrogate endpoint in clinical trial development is controversial. In this review, we will critically examine the methods used to detect MRD, its role as a prognostic biomarker, MRD-directed therapeutics, and its potential role as a study endpoint.
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Affiliation(s)
- Marisa J L Aitken
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,McGovern Medical School, UT Health Science Center-Houston, Houston, TX, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Keyur P Patel
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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21
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Abstract
In the past few years research in the underlying pathogenic mechanisms of acute myeloid leukaemia (AML) has led to remarkable advances in our understanding of the disease. Cytogenetic and molecular aberrations are the most important factors in determining response to chemotherapy as well as long-term outcome, but beyond prognostication are potential therapeutic targets. Our increased understanding of the pathogenesis of AML facilitated by next-generation sequencing has spurred the development of new compounds in the treatment of AML, particularly the creation of small molecules that target the disease on a molecular level. Many of the hopeful predictions outlined in our AML review of 2018 are now therapeutic realities: gemtuzumab ozogamicin, venetoclax, FLT3 inhibitors (midostaurin, gilteritinib), IDH inhibitors (ivosidenib, enasidenib), CPX-351, glasdegib, oral decitabine, and oral azacitidine. Others may soon be (quizartinib, APR246 magrolimab, menin inhibitors). The wealth of positive data allows reconsideration of what might soon be new standards of care in younger and older patients with AML. In this review we give an overview of recently approved therapies in AML and address present and future research directions.
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Affiliation(s)
- Sabine Kayser
- Medical Clinic and Policlinic I, Hematology and Cellular Therapy, University Hospital Leipzig, Leipzig, Germany.,NCT Trial Center, National Center of Tumor Diseases, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mark J Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
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22
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Jaramillo S, Schlenk RF. Post-Induction Treatment for Acute Myeloid Leukemia: Something Change? Curr Oncol Rep 2021; 23:109. [PMID: 34272619 PMCID: PMC8285306 DOI: 10.1007/s11912-021-01092-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2021] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Until recently, improvement in terms of survival for patients with acute myeloid leukemia (AML) was achieved mostly in younger patients with dose intensification of conventional chemotherapy and a broadening use of allogeneic hematopoietic cell transplantation (allo-HCT) whereas the results remained dismal and very stable in patients older than 60 years. The current review highlights the recent developments in standard intensive post-remission chemotherapy, evidence for the use of recently approved agents, and discusses the relevance of measurable residual disease (MRD) measurement in treatment adaptation. RECENT FINDINGS Current approvals of midostaurin, venetoclax, gemtuzumab ozogamicin, VYXEOS, ivosidenib, enasidenib, glasdegib, and CC-486 have changed the structure, aim, and schedule of consolidation therapy, and new, well-tolerated agents are being evaluated as maintenance therapies. Furthermore, MRD assessment has been implemented to guide the duration and type of consolidation and maintenance therapy as well as indicate the optimal timing of allo-HCT. Novel therapies have changed the structure and perspective of post-remission therapy in AML for both young and elderly patients. In addition, MRD assessment could guide the type, duration, and intensity of consolidation and maintenance therapy.
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Affiliation(s)
- Sonia Jaramillo
- Department of Hematology, Oncology, and Rheumatology at Heidelberg University Hospital, University of Heidelberg, Heidelberg, Germany
| | - Richard F. Schlenk
- Department of Hematology, Oncology, and Rheumatology at Heidelberg University Hospital, University of Heidelberg, Heidelberg, Germany
- NCT-Trial Center, NCT Heidelberg, DKFZ and Heidelberg University Hospital, Im Neuenheimer Feld 130.3, 69120 Heidelberg, Germany
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23
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Nucleophosmin1 and isocitrate dehydrogenase 1 and 2 as measurable residual disease markers in acute myeloid leukemia. PLoS One 2021; 16:e0253386. [PMID: 34153064 PMCID: PMC8216517 DOI: 10.1371/journal.pone.0253386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 06/03/2021] [Indexed: 11/19/2022] Open
Abstract
Monitoring measurable residual disease (MRD) in acute myeloid leukemia (AML) plays an important role in predicting relapse and outcome. The applicability of the leukemia-initiating nucleophosmin1 (NPM1) gene mutations in MRD detection is well-established, while that of isocitrate dehydrogenase1/2 (IDH1/2) mutations are matter of debate. The aim of this study was to investigate the stability of NPM1 and IDH1/2 mutations at diagnosis and relapse retrospectively in 916 adult AML patients. The prognostic value of MRD was evaluated by droplet digital PCR on the DNA level in a selected subgroup of patients in remission. NPM1 re-emerged at relapse in 91% (72/79), while IDH1/2 in 87% (20/23) of mutation-positive cases at diagnosis. NPM1 mutation did not develop at relapse, on the contrary novel IDH1/2 mutations occurred in 3% (3/93) of previously mutation-negative cases. NPM1 MRD-positivity after induction (n = 116) proved to be an independent, adverse risk factor (MRDpos 24-month OS: 39.3±6.2% versus MRDneg: 58.5±7.5%, p = 0.029; HR: 2.16; 95%CI: 1.25–3.74, p = 0.006). In the favorable subgroup of mutated NPM1 without fms-like tyrosine kinase 3 internal tandem duplication (FLT3-ITD) or with low allelic ratio, NPM1 MRD provides a valuable prognostic biomarker (NPM1 MRDpos versus MRDneg 24-month OS: 42.9±6.7% versus 66.7±8.6%; p = 0.01). IDH1/2 MRD-positivity after induction (n = 62) was also associated with poor survival (MRDpos 24-month OS: 41.3±9.2% versus MRDneg: 62.5±9.0%, p = 0.003; HR 2.81 95%CI 1.09–7.23, p = 0.032). While NPM1 variant allele frequency decreased below 2.5% in remission in all patients, IDH1/2 mutations (typically IDH2 R140Q) persisted in 24% of cases. Our results support that NPM1 MRD even at DNA level is a reliable prognostic factor, while IDH1/2 mutations may represent pre-leukemic, founder or subclonal drivers.
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NPM1-mutated acute myeloid leukemia: from bench to bedside. Blood 2021; 136:1707-1721. [PMID: 32609823 DOI: 10.1182/blood.2019004226] [Citation(s) in RCA: 129] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/24/2020] [Indexed: 12/20/2022] Open
Abstract
The nucleophosmin (NPM1) gene encodes for a multifunctional protein with prominent nucleolar localization that shuttles between nucleus and cytoplasm. NPM1 mutations represent the most common genetic lesion in adult acute myeloid leukemia (AML; about one third of cases), and they act deterministically to cause the aberrant cytoplasmic delocalization of NPM1 mutants. Because of its unique features, NPM1-mutated AML is recognized as a distinct entity in the 2017 World Health Organization (WHO) classification of hematopoietic neoplasms. Here, we focus on recently identified functions of wild-type NPM1 in the nucleolus and address new biological and clinical issues related to NPM1-mutated AML. The relevance of the cooperation between NPM1 and other mutations in driving AML with different outcomes is presented. We also discuss the importance of eradicating NPM1-mutated clones to achieve AML cure and the impact of preleukemic clonal hematopoiesis persistence in predisposing to second AML. The contribution of HOX genes' expression to the development of NPM1-mutated AML is also highlighted. Clinically, yet unsolved diagnostic issues in the 2017 WHO classification of myeloid neoplasms and the importance of NPM1 mutations in defining the framework of European LeukemiaNet genetic-based risk stratification are discussed. Finally, we address the value and limits of NPM1-based measurable residual disease assessment for treatment guidance and present the results of promising preclinical studies with XPO1 and menin-MLL inhibitors.
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Pettersson L, Johansson Alm S, Almstedt A, Chen Y, Orrsjö G, Shah-Barkhordar G, Zhou L, Kotarsky H, Vidovic K, Asp J, Lazarevic V, Saal LH, Fogelstrand L, Ehinger M. Comparison of RNA- and DNA-based methods for measurable residual disease analysis in NPM1-mutated acute myeloid leukemia. Int J Lab Hematol 2021; 43:664-674. [PMID: 34053184 DOI: 10.1111/ijlh.13608] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 05/02/2021] [Accepted: 05/06/2021] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Reverse transcriptase quantitative PCR (RT-qPCR) is considered the method of choice for measurable residual disease (MRD) assessment in NPM1-mutated acute myeloid leukemia (AML). MRD can also be determined with DNA-based methods offering certain advantages. We here compared the DNA-based methods quantitative PCR (qPCR), droplet digital PCR (ddPCR), and targeted deep sequencing (deep seq) with RT-qPCR. METHODS Of 110 follow-up samples from 30 patients with NPM1-mutated AML were analyzed by qPCR, ddPCR, deep seq, and RT-qPCR. To select DNA MRD cutoffs for bone marrow, we performed receiver operating characteristic analyses for each DNA method using prognostically relevant RT-qPCR cutoffs. RESULTS The DNA-based methods showed strong intermethod correlation, but were less sensitive than RT-qPCR. A bone marrow cutoff at 0.1% leukemic DNA for qPCR or 0.05% variant allele frequency for ddPCR and deep seq offered optimal sensitivity and specificity with respect to 3 log10 reduction of NPM1 transcripts and/or 2% mutant NPM1/ABL. With these cutoffs, MRD results agreed in 95% (191/201) of the analyses. Although more sensitive, RT-qPCR failed to detect leukemic signals in 10% of samples with detectable leukemic DNA. CONCLUSION DNA-based MRD techniques may complement RT-qPCR for assessment of residual leukemia. DNA-based methods offer high positive and negative predictive values with respect to residual leukemic NPM1 transcripts at levels of importance for response to treatment. However, moving to DNA-based MRD methods will miss a proportion of patients with residual leukemic RNA, but on the other hand some MRD samples with detectable leukemic DNA can be devoid of measurable leukemic RNA.
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Affiliation(s)
- Louise Pettersson
- Department of Clinical Sciences, Division of Pathology, Lund University, Skane University Hospital, Lund, Sweden.,Department of Pathology, Halland Hospital Halmstad, Region Halland, Halmstad, Sweden
| | - Sofie Johansson Alm
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Alvar Almstedt
- SciLife Clinical Genomics Gothenburg, Gothenburg, Sweden
| | - Yilun Chen
- Department of Clinical Sciences, Division of Oncology, Faculty of Medicine, Lund University, Lund, Sweden
| | - Gustav Orrsjö
- Section for Hematology and Coagulation, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Giti Shah-Barkhordar
- Department of Clinical Genetics and Genomics, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Li Zhou
- Klinisk Patologi, Region Laboratories, Region Skåne, Lund, Sweden
| | - Heike Kotarsky
- Klinisk Patologi, Region Laboratories, Region Skåne, Lund, Sweden
| | - Karina Vidovic
- Department of Clinical Sciences, Division of Pathology, Lund University, Skane University Hospital, Lund, Sweden
| | - Julia Asp
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Vladimir Lazarevic
- Department of Hematology, Oncology and Radiation Physics, Lund University, Skane University Hospital, Lund, Sweden
| | - Lao H Saal
- Department of Clinical Sciences, Division of Oncology, Faculty of Medicine, Lund University, Lund, Sweden.,Lund University Cancer Center, Medicon Village, Lund, Sweden
| | - Linda Fogelstrand
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Ehinger
- Department of Clinical Sciences, Division of Pathology, Lund University, Skane University Hospital, Lund, Sweden.,Klinisk Patologi, Region Laboratories, Region Skåne, Lund, Sweden
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Rautenberg C, Lauseker M, Kaivers J, Jäger P, Fischermanns C, Pechtel S, Haas R, Kobbe G, Germing U, Schroeder T. Prognostic impact of pretransplant measurable residual disease assessed by peripheral blood WT1-mRNA expression in patients with AML and MDS. Eur J Haematol 2021; 107:283-292. [PMID: 33987857 DOI: 10.1111/ejh.13664] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Revised: 05/07/2021] [Accepted: 05/10/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE As peripheral blood (PB) Wilm's Tumor 1 (WT1)-mRNA expression is established as MRD-marker during conventional AML chemotherapy, impact of pretransplant WT1 expression remains unclear. Therefore, we aimed to assess prognostic impact of pretransplant WT1 expression on post-transplant outcome in patients with AML/MDS. METHODS In 64 AML/MDS patients, pretransplant WT1 expression was retrospectively analyzed using a standardized assay offering high sensitivity, specificity, and a validated cut-off. Patients were divided into three groups determined by pretransplant remission and WT1 expression. Post-transplant outcome of these groups was compared regarding cumulative incidence of relapse (CIR), relapse-free (RFS), and overall survival (OS). RESULTS Pretransplant forty-six patients (72%) showed hematologic remission, including 21 (46%) MRD-negative and 25 (54%) MRD-positive patients indicated by WT1 expression, while 18 refractory patients (28%) showed active disease. Two-year estimates of post-transplant CIR, RFS, and OS were similar in MRD-positive (61%, 37%, 54%) and refractory patients (70%, 26%, 56%), but significantly inferior compared with MRD-negative patients (10%, 89%, 90%). After multivariable adjustment, pretransplant MRD negativity measured by WT1 expression retained its prognostic impact on CIR (P = .008), RFS (P = .005), and OS (P = .049). CONCLUSIONS PB WT1 expression represents a useful method to estimate pretransplant MRD, which is highly predictable for post-transplant outcome and may help improving peri-transplant management in AML/MDS patients.
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Affiliation(s)
- Christina Rautenberg
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine - University, Duesseldorf, Germany
| | - Michael Lauseker
- Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig-Maximilians-University, Munich, Germany
| | - Jennifer Kaivers
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine - University, Duesseldorf, Germany
| | - Paul Jäger
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine - University, Duesseldorf, Germany
| | - Carolin Fischermanns
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine - University, Duesseldorf, Germany
| | - Sabrina Pechtel
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine - University, Duesseldorf, Germany
| | - Rainer Haas
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine - University, Duesseldorf, Germany
| | - Guido Kobbe
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine - University, Duesseldorf, Germany
| | - Ulrich Germing
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine - University, Duesseldorf, Germany
| | - Thomas Schroeder
- Department of Hematology, Oncology and Clinical Immunology, University Hospital Duesseldorf, Medical Faculty, Heinrich Heine - University, Duesseldorf, Germany.,Department of Hematology and Stem Cell Transplantation, University Hospital Essen, Medical Faculty, University Duisburg-Essen, Essen, Germany
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How I diagnose and treat NPM1-mutated AML. Blood 2021; 137:589-599. [PMID: 33171486 DOI: 10.1182/blood.2020008211] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/30/2020] [Indexed: 12/13/2022] Open
Abstract
Mutations of the nucleophosmin (NPM1) gene, encoding for a nucleolar multifunctional protein, occur in approximately one-third of adult acute myeloid leukemia (AML). NPM1-mutated AML exhibits unique molecular, pathological, and clinical features, which led to its recognition as distinct entity in the 2017 World Health Organization (WHO) classification of myeloid neoplasms. Although WHO criteria for the diagnosis of NPM1-mutated AML are well established, its distinction from other AML entities may be difficult. Moreover, the percentage of blasts required to diagnose NPM1-mutated AML remains controversial. According to the European LeukemiaNet (ELN), determining the mutational status of NPM1 (together with FLT3) is mandatory for accurate relapse-risk assessment. NPM1 mutations are ideal targets for measurable residual disease (MRD) monitoring, since they are AML specific, frequent, very stable at relapse, and do not drive clonal hematopoiesis of undetermined significance. MRD monitoring by quantitative polymerase chain reaction of NPM1-mutant transcripts, possibly combined with ELN genetic-based risk stratification, can guide therapeutic decisions after remission. Furthermore, immunohistochemistry can be very useful in selected situations, such as diagnosis of NPM1-mutated myeloid sarcoma. Herein, we present 4 illustrative cases of NPM1-mutated AML that address important issues surrounding the biology, diagnosis, and therapy of this common form of leukemia.
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Skou AS, Juul-Dam KL, Ommen HB, Hasle H. Peripheral blood molecular measurable residual disease is sufficient to identify patients with acute myeloid leukaemia with imminent clinical relapse. Br J Haematol 2021; 195:310-327. [PMID: 33851435 DOI: 10.1111/bjh.17449] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 01/03/2023]
Abstract
Longitudinal molecular measurable residual disease (MRD) sampling after completion of therapy serves as a refined tool for identification of imminent relapse of acute myeloid leukaemia (AML) among patients in long-term haematological complete remission. Tracking of increasing quantitative polymerase chain reaction MRD before cytomorphological reappearance of blasts may instigate individual management decisions and has paved the way for development of pre-emptive treatment strategies to substantially delay or perhaps even revert leukaemic regrowth. Traditionally, MRD monitoring is performed using repeated bone marrow aspirations, albeit the current European LeukemiaNet MRD recommendations acknowledge the use of peripheral blood as an alternative source for MRD assessment. Persistent MRD positivity in the bone marrow despite continuous morphological remission is frequent in both core binding factor leukaemias and nucleophosmin 1-mutated AML. In contrast, monthly assessment of MRD in peripheral blood superiorly separates patients with imminent haematological relapse from long-term remitters and may allow pre-emptive therapy of AML relapse.
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Affiliation(s)
- Anne-Sofie Skou
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | | | - Hans B Ommen
- Department of Haematology, Aarhus University Hospital, Aarhus, Denmark
| | - Henrik Hasle
- Department of Paediatrics and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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29
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Tiong IS, Dillon R, Ivey A, Teh T, Nguyen P, Cummings N, Taussig DC, Latif A, Potter NE, Runglall M, Russell NH, Raj K, Schwarer AP, Fong CY, Grigg AP, Wei AH. Venetoclax induces rapid elimination of NPM1 mutant measurable residual disease in combination with low-intensity chemotherapy in acute myeloid leukaemia. Br J Haematol 2021; 192:1026-1030. [PMID: 32458446 PMCID: PMC8048658 DOI: 10.1111/bjh.16722] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/28/2020] [Accepted: 04/14/2020] [Indexed: 12/18/2022]
Abstract
Based on promising results in older adults with acute myeloid leukaemia (AML), we treated patients with NPM1mut measurable residual disease (MRD) using off-label venetoclax in combination with low-dose cytarabine or azacitidine. Twelve consecutive patients were retrospectively identified, including five with molecular persistence and seven with molecular relapse/progression. All patients with molecular persistence achieved durable molecular complete remission (CRMRD- ) without transplantation. Six of seven patients with molecular relapse/progression achieved CRMRD- after 1-2 cycles of venetoclax. This paper highlights the promising efficacy of venetoclax-based therapy to reduce the relapse risk in patients with persistent or rising NPM1mut MRD.
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Affiliation(s)
- Ing S. Tiong
- Alfred Hospital and Monash UniversityMelbourneVic.Australia
- Department of Clinical HaematologyAustin Health and Olivia Newton John Cancer Research InstituteMelbourneVic.Australia
| | - Richard Dillon
- Department of Medical and Molecular GeneticsKing's CollegeLondonUK
- Guy's and St Thomas’ HospitalsLondonUK
| | - Adam Ivey
- Alfred Hospital and Monash UniversityMelbourneVic.Australia
| | - Tse‐Chieh Teh
- Alfred Hospital and Monash UniversityMelbourneVic.Australia
| | - Phillip Nguyen
- Alfred Hospital and Monash UniversityMelbourneVic.Australia
| | | | | | | | - Nicola E. Potter
- Department of Medical and Molecular GeneticsKing's CollegeLondonUK
| | - Manohursingh Runglall
- NIHR Comprehensive Biomedical Research Centre at Guy's and St Thomas' NHS Foundation Trust in partnership with King's College London and King's College HospitalLondonUK
| | | | | | | | - Chun Yew Fong
- Department of Clinical HaematologyAustin Health and Olivia Newton John Cancer Research InstituteMelbourneVic.Australia
| | - Andrew P. Grigg
- Department of Clinical HaematologyAustin Health and Olivia Newton John Cancer Research InstituteMelbourneVic.Australia
| | - Andrew H. Wei
- Alfred Hospital and Monash UniversityMelbourneVic.Australia
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Diagnostic and therapeutic pitfalls in NPM1-mutated AML: notes from the field. Leukemia 2021; 35:3113-3126. [PMID: 33879827 PMCID: PMC8056374 DOI: 10.1038/s41375-021-01222-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 02/21/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Abstract
Mutations of Nucleophosmin (NPM1) are the most common genetic abnormalities in adult acute myeloid leukaemia (AML), accounting for about 30% of cases. NPM1-mutated AML has been recognized as distinct entity in the 2017 World Health Organization (WHO) classification of lympho-haematopoietic neoplasms. WHO criteria allow recognition of this leukaemia entity and its distinction from AML with myelodysplasia-related changes, AML with BCR-ABL1 rearrangement and AML with RUNX1 mutations. Nevertheless, controversial issues include the percentage of blasts required for the diagnosis of NPM1-mutated AML and whether cases of NPM1-mutated myelodysplasia and chronic myelomonocytic leukaemia do exist. Evaluation of NPM1 and FLT3 status represents a major pillar of the European LeukemiaNet (ELN) genetic-based risk stratification model. Moreover, NPM1 mutations are particularly suitable for assessing measurable residual disease (MRD) since they are frequent, stable at relapse and do not drive clonal haematopoiesis. Ideally, combining monitoring of MRD with the ELN prognostication model can help to guide therapeutic decisions. Here, we provide examples of instructive cases of NPM1-mutated AML, in order to provide criteria for the appropriate diagnosis and therapy of this frequent leukaemia entity.
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Abstract
PURPOSE OF REVIEW Nucleophosmin (NPM1) mutations are encountered in myeloid neoplasia and are present in ~ 30% of de novo acute myeloid leukemia cases. This review summarizes features of mutant NPM1-related disease, with a particular emphasis on recent discoveries relevant to disease monitoring, prognostication, and therapeutic intervention. RECENT FINDINGS Recent studies have shown that HOX/MEIS gene overexpression is central to the survival of NPM1-mutated cells. Two distinct classes of small molecule drugs, BH3 mimetics and menin-MLL interaction inhibitors, have demonstrated exquisite leukemic cell toxicity in preclinical AML models associated with HOX/MEIS overexpression, and the former of these has shown efficacy in older treatment-naïve NPM1-mutated AML patients. The results of ongoing clinical trials further investigating these compounds will be of particular importance and may alter the clinical management of patients with NPM1-mutated myeloid neoplasms. Significant scientific advancements over the last decade, including improved sequencing and disease monitoring techniques, have fostered a much deeper understanding of mutant NPM1 disease biology, prognostication, and opportunities for therapeutic intervention. These discoveries have led to the development of clinical assays that permit the detection and monitoring of mutant NPM1 and have paved the way for future investigation of targeted therapeutics using emerging cutting-edge techniques.
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Affiliation(s)
- Sanjay S Patel
- Division of Hematopathology, Weill Cornell Medical College, New York, NY, USA
| | - Michael J Kluk
- Division of Hematopathology, Weill Cornell Medical College, New York, NY, USA
| | - Olga K Weinberg
- Department of Pathology, Boston Children's Hospital, 300 Longwood Avenue, Bader 126.2, Boston, MA, 02115, USA.
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Molecular Monitoring in Acute Myeloid Leukemia Patients Undergoing Matched Unrelated Donor - Hematopoietic Stem Cell Transplantation: Single Center Experience. ACTA ACUST UNITED AC 2020; 41:5-12. [PMID: 33500364 DOI: 10.2478/prilozi-2020-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Minimal residual disease (MRD) assessment in acute myeloid leukemia (AML) cases is a complex, multi-modality process and, though much of its clinical implications at different points are extensively studied, it remains even now a challenging area. It is a disease the biology of which governs the modality of MRD assessment; in patients harboring specific molecular targets, high sensitivity techniques can be applied. On the other hand, relapse is considered as the leading cause of treatment failure in AML patients undergoing allogeneic hematopoietic stem cell transplantation (alloHSCT). MATERIALS AND METHODS Since November 2018 until June 2020, 10 AML patients underwent matched unrelated donor (MUD) HSCT at the University Clinic of Hematology-Skopje, Republic of North Macedonia. Molecular markers were identified in a total of 4 patients; 3 patients expressed chimeric fusion transcripts; two RUNX-RUNX1T1 and one for CBFB-MYH11. One patient harbored mutation in the transcription factor CCAAT/enhancer binding protein α (CEBPA). Post-transplant MRD kinetics was evaluated by using quantitative polymerase chain reaction (RT-qPCR) or multiplex fluorescent-PCR every three months during the first two years after the transplantation. RESULTS MRD negativity was achieved in three pre-transplant MRD positive patients by the sixth month of HSCT. They sustained hematological and molecular remission for 19, 9 and 7 months, respectively. The fourth patient died due to transplant-related complications. CONCLUSION According to our experience, when molecularly-defined AML patients undergo HSCT, regular MRD monitoring helps predict impending relapse and direct future treatment strategies.
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Gaut D, Mead M. Measurable residual disease in hematopoietic stem cell transplantation-eligible patients with acute myeloid leukemia: clinical significance and promising therapeutic strategies. Leuk Lymphoma 2020; 62:8-31. [DOI: 10.1080/10428194.2020.1827251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Daria Gaut
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Monica Mead
- Division of Hematology/Oncology, Department of Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
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Nagler A, Labopin M, Canaani J, Niittyvuopio R, Socié G, Kröger N, Itäla-Remes M, Yakoub-Agha I, Labussière-Wallet H, Gallego-Hernanz MP, Deconinck E, Chevallier P, Finke J, Esteve J, Mohty M. Cytogenetic risk score maintains its prognostic significance in AML patients with detectable measurable residual disease undergoing transplantation in remission: On behalf of the acute leukemia working party of the European society for blood and marrow transplantation. Am J Hematol 2020; 95:1135-1141. [PMID: 32530520 DOI: 10.1002/ajh.25905] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 06/03/2020] [Accepted: 06/09/2020] [Indexed: 12/22/2022]
Abstract
While evidence for measurable residual disease (MRD) is a harbinger of inferior outcome in acute myeloid leukemia (AML) patients referred for allogeneic stem cell transplantation (allo-SCT), the exact clinical trajectory of specific patient subsets in this clinical setting is undefined. Using a recently published prognostic cytogenetic model (Canaani et al. Leukemia 2019) we evaluated whether this model applied also to studies of patients with positive MRD. The analysis comprised MRD+ patients in first complete remission undergoing allo-SCT from a matched sibling donor or unrelated donor. Seven hundred and seventy-five patients were evaluated with a median follow-up duration of 22 months. Cytogenetic risk score was favorable, intermediate/FLT3wt intermediate/FLT3-ITD3, and adverse in 15%, 28.3%, 37% and 19.7% of the patients, respectively. Favorable and intermediate/FLT3wt risk patients had 2-year leukemia-free survival rates of 78% and 61%, respectively, compared with only 50% and 37% for intermediate/FLT3-ITD3 and adverse risk patients, respectively (P < .001). In multivariate analysis adverse and intermediate/FLT3-ITD3 risk patients were more likely to experience disease relapse compared with favorable risk patients [hazard ratio (HR) = 3.9, 95% confidence interval (CI), 2.1-7.3; P < .001, and HR = 4.4, CI 95%, 2.4-7.8; P < .001, respectively]. The European society for blood and marrow transplantation cytogenetic risk score is a valuable adjunct for risk stratification of MRD+ AML patients.
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Affiliation(s)
- Arnon Nagler
- Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
- EBMT ALWP office, Saint Antoine Hospital, Paris, France
| | - Myriam Labopin
- Department of Haematology and EBMT Paris study office / CEREST-TC, Saint Antoine Hospital, Paris, France
| | - Jonathan Canaani
- Chaim Sheba Medical Center, Tel Aviv University, Tel-Hashomer, Ramat Gan, Israel
| | - Riitta Niittyvuopio
- HUCH Comprehensive Cancer Center, Stem Cell Transplantation Unit, Helsinki, Finland
| | - Gerard Socié
- Department of Hematology - BMT, Hopital St. Louis, Paris, France
| | - Nicolaus Kröger
- Bone Marrow Transplantation Centre, University Hospital Eppendorf, Hamburg, Germany
| | - Maija Itäla-Remes
- TD7 (Stem Cell Transplant Unit), Turku University Hospital, Turku, Finland
| | | | | | | | - Eric Deconinck
- Hopital Jean Minjoz, Service d'Hématologie, Besancon, France
| | | | - Jürgen Finke
- Department of Medicine -Hematology, Oncology, University of Freiburg, Freiburg, Germany
| | - Jordi Esteve
- Hematology Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Mohamad Mohty
- Department of Haematology and EBMT Paris study office / CEREST-TC, Saint Antoine Hospital, INSERM UMR 938 and Université Pierre et Marie Curie, Paris, France
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Fenwarth L, Fournier E, Cheok M, Boyer T, Gonzales F, Castaigne S, Boissel N, Lambert J, Dombret H, Preudhomme C, Duployez N. Biomarkers of Gemtuzumab Ozogamicin Response for Acute Myeloid Leukemia Treatment. Int J Mol Sci 2020; 21:E5626. [PMID: 32781546 PMCID: PMC7460695 DOI: 10.3390/ijms21165626] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/03/2020] [Indexed: 11/27/2022] Open
Abstract
Gemtuzumab ozogamicin (GO, Mylotarg®) consists of a humanized CD33-targeted antibody-drug conjugated to a calicheamicin derivative. Growing evidence of GO efficacy in acute myeloid leukemia (AML), demonstrated by improved outcomes in CD33-positive AML patients across phase I to III clinical trials, led to the Food and Drug Administration (FDA) approval on 1 September 2017 in CD33-positive AML patients aged 2 years and older. Discrepancies in GO recipients outcome have raised significant efforts to characterize biomarkers predictive of GO response and have refined the subset of patients that may strongly benefit from GO. Among them, CD33 expression levels, favorable cytogenetics (t(8;21), inv(16)/t(16;16), t(15;17)) and molecular alterations, such as NPM1, FLT3-internal tandem duplications and other signaling mutations, represent well-known candidates. Additionally, in depth analyses including minimal residual disease monitoring, stemness expression (LSC17 score), mutations or single nucleotide polymorphisms in GO pathway genes (CD33, ABCB1) and molecular-derived scores, such as the recently set up CD33_PGx6_Score, represent promising markers to enhance GO response prediction and improve patient management.
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Affiliation(s)
- Laurène Fenwarth
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Elise Fournier
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Meyling Cheok
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Thomas Boyer
- Laboratory of Hematology, CHU Amiens, F-80054 Amiens, France;
| | - Fanny Gonzales
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Sylvie Castaigne
- Department of Hematology, CH Versailles, F-78157 Le Chesnay, France; (S.C.); (J.L.)
| | - Nicolas Boissel
- Adolescent and Young Adult Hematology Unit, Hôpital Saint-Louis, AP-HP, Université de Paris, F-75010 Paris, France;
| | - Juliette Lambert
- Department of Hematology, CH Versailles, F-78157 Le Chesnay, France; (S.C.); (J.L.)
| | - Hervé Dombret
- Department of Hematology, Hôpital Saint-Louis, AP-HP, Université de Paris, F-75010 Paris, France;
| | - Claude Preudhomme
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
| | - Nicolas Duployez
- UMR 9020–UMR-S 1277–Canther–Cancer Heterogeneity, Plasticity and Resistance to Therapies, Institut de Recherche contre le Cancer de Lille, University Lille, CNRS, Inserm, CHU Lille, F-59000 Lille, France; (E.F.); (M.C.); (F.G.); (C.P.); (N.D.)
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Ball B, Stein EM. Which are the most promising targets for minimal residual disease-directed therapy in acute myeloid leukemia prior to allogeneic stem cell transplant? Haematologica 2020; 104:1521-1531. [PMID: 31366466 PMCID: PMC6669154 DOI: 10.3324/haematol.2018.208587] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/01/2019] [Indexed: 12/19/2022] Open
Abstract
Minimal residual disease has emerged as an important prognostic factor for relapse and survival in acute myeloid leukemia. Eradication of minimal residual disease may increase the number of patients with long-term survival; however, to date, strategies that specifically target minimal residual disease are limited. Consensus guidelines on minimal residual disease detection by immunophenotypic and molecular methods are an essential initial step for clinical trials evaluating minimal residual disease. Here, we review promising targets of minimal residual disease prior to allogeneic stem cell transplantation. Specifically, the focus of this review is on the rationale and clinical development of therapies targeting: oncogenic driver mutations, apoptosis, methylation, and leukemic immune targets. We review the progress made in the clinical development of therapies against each target and the challenges that lie ahead.
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Affiliation(s)
- Brian Ball
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Eytan M Stein
- Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Detection and management of acute myeloid leukemia measurable residual disease: is it standard of care? Curr Opin Hematol 2020; 27:81-87. [PMID: 31895104 DOI: 10.1097/moh.0000000000000566] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW In the present manuscript, we will review the current approaches to investigate measurable residual disease (MRD) and its clinical applications in AML management. RECENT FINDINGS Over the last decades, several methods have been developed to trace MRD, with flow cytometry and polymerase chain reaction (PCR) being the most reliable. However, new technologies, such as digital PCR and Next-Generation Sequencing are emerging as particularly useful in AML. The 2017 European LeukemiaNet (ELN) recommendations have incorporated MRD assessment to define the response criteria to therapy, and more recently, the ELN MRD Working Party has published guidelines for the use of MRD in clinical practice. SUMMARY Morphologic complete remission (mCR) after induction therapy, has been consistently shown not only to have a critical prognostic role but also to fail in predicting relapse on an individual basis. Major attempts to improve our prediction capability have been made by measuring the residual levels of leukemic cells that persist in the bone marrow after chemotherapy. This number of cells, also called MRD, harbors in the bone marrow below the threshold of morphology and is responsible for leukemia recurrence. Therefore, the detection of MRD promises to help predict the risk of relapse, allowing a more proper patients' risk-stratification and the use of risk-tailored therapeutic strategy.
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The prognostic impact of FLT3-ITD, NPM1 and CEBPa in cytogenetically intermediate-risk AML after first relapse. Int J Hematol 2020; 112:200-209. [PMID: 32495317 DOI: 10.1007/s12185-020-02894-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 03/30/2020] [Accepted: 05/22/2020] [Indexed: 12/19/2022]
Abstract
We evaluated the impact of FLT3-ITD, NPM1 mutations, and double mutant CEBPa (dmCEBPa) on overall survival (OS) after relapse in patients with cytogenetically intermediate-risk acute myeloid leukemia (AML) who were treated with chemotherapy alone in the first remission (CR1). Patients aged 16-65 years diagnosed with cytogenetically intermediate-risk AML, and who achieved CR1 were included. We retrospectively analyzed FLT3-ITD, NPM1 mutations and CEBPa using samples obtained at diagnosis, which therefore did not affect the therapeutic decisions. Among 235 patients who had achieved CR1, 152 relapsed, and 52% of them achieved second CR. The rate of achieving second CR was significantly higher (85%) in those with dmCEBPa. Patients with FLT3-ITD had significantly worse OS after relapse than those without (19% vs 41%, p = 0.002), while OS was comparable between patients with and without NPM1 mutations (37% vs 34%, p = 0.309). Patients with dmCEBPa had improved OS than those without (61% vs 32%, p = 0.006). By multivariate analysis, FLT3-ITD was independently associated with worse OS after relapse [hazard ratio (HR) 1.99, 95% CI 1.27-3.12, p = 0.003], and dmCEBPa with improved OS (HR 0.40, 95% CI 0.17-0.93, p = 0.033). Our data show that screening for these mutations at diagnosis is useful for facilitating effective therapeutic decision-making even after relapse.
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Bazarbachi A, Bug G, Baron F, Brissot E, Ciceri F, Dalle IA, Döhner H, Esteve J, Floisand Y, Giebel S, Gilleece M, Gorin NC, Jabbour E, Aljurf M, Kantarjian H, Kharfan-Dabaja M, Labopin M, Lanza F, Malard F, Peric Z, Prebet T, Ravandi F, Ruggeri A, Sanz J, Schmid C, Shouval R, Spyridonidis A, Versluis J, Vey N, Savani BN, Nagler A, Mohty M. Clinical practice recommendation on hematopoietic stem cell transplantation for acute myeloid leukemia patients with FLT3-internal tandem duplication: a position statement from the Acute Leukemia Working Party of the European Society for Blood and Marrow Transplantation. Haematologica 2020; 105:1507-1516. [PMID: 32241850 PMCID: PMC7271578 DOI: 10.3324/haematol.2019.243410] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 03/19/2020] [Indexed: 12/13/2022] Open
Abstract
The FMS-like tyrosine kinase 3 (FLT3) gene is mutated in 25-30% of patients with acute myeloid leukemia (AML). Because of the poor prognosis associated with FLT3-internal tandem duplication mutated AML, allogeneic hematopoietic stem-cell transplantation (SCT) was commonly performed in first complete remission. Remarkable progress has been made in frontline treatments with the incorporation of FLT3 inhibitors and the development of highly sensitive minimal/measurable residual disease assays. Similarly, recent progress in allogeneic hematopoietic SCT includes improvement of transplant techniques, the use of haploidentical donors in patients lacking an HLA matched donor, and the introduction of FLT3 inhibitors as post-transplant maintenance therapy. Nevertheless, current transplant strategies vary between centers and differ in terms of transplant indications based on the internal tandem duplication allelic ratio and concomitant nucleophos-min-1 mutation, as well as in terms of post-transplant maintenance/consolidation. This review generated by international leukemia or transplant experts, mostly from the European Society for Blood and Marrow Transplantation, attempts to develop a position statement on best approaches for allogeneic hematopoietic SCT for AML with FLT3-internal tandem duplication including indications for and modalities of such transplants and on the potential optimization of post-transplant maintenance with FLT inhibitors.
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Affiliation(s)
- Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
- Department of Anatomy, Cell Biology, and Physiological Sciences, American University of Beirut, Beirut, Lebanon
| | - Gesine Bug
- Department of Medicine 2, Hematology and Oncology, University Hospital, Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | - Eolia Brissot
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | - Fabio Ciceri
- Vita-Salute San Raffaele University of Milan, Milan, ItalyHematology and Bone Marrow Transplantation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hartmut Döhner
- Department of Internal Medicine III, Ulm University Hospital, Ulm, Germany
| | - Jordi Esteve
- Hematology Department, Hospital Clínic of Barcelona, IDIBAPS, University of Barcelona, Barcellona, Spain
| | - Yngvar Floisand
- Department of Hematology, Oslo University Hospital - Rikshospitalet, Oslo, Norway
- Center for Cancer Cell Reprogramming, Institute for Cancer Research, Oslo University Hospital, Montebello, Oslo, Norway
| | - Sebastian Giebel
- Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie Institute - Oncology Center, Gliwice Branch, Gliwice, Poland
| | - Maria Gilleece
- Department of Haematology, Leeds Teaching Hospitals Trust, Leeds, UK
| | - Norbert-Claude Gorin
- Department of Hematology and Cell Therapy, European Society for Blood and Marrow Transplantation, Paris Office, Hopital Saint-Antoine, Paris, France
| | - Elias Jabbour
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mahmoud Aljurf
- Department of Hematology King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Hagop Kantarjian
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mohamed Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation and Cellular Therapies Program, Mayo Clinic, Jacksonville, FL, USA
| | - Myriam Labopin
- Acute Leukemia Working Party, Paris Study Office, European Society for Blood and Marrow Transplantation, Paris, France
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | | | - Florent Malard
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
| | - Zinaida Peric
- University Hospital Center Zagreb, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Thomas Prebet
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Annalisa Ruggeri
- Department of Pediatric Hematology and Oncology, IRCCS Bambino Gesù Children's Hospital, Roma, ItalyEurocord, Hôpital Saint Louis, Paris, France
| | - Jaime Sanz
- Hematology Department, Hospital Universitari i Politecnic La Fe. Instituto de Investigación Sanitaria La Fe, Valencia, CIBERONC, Instituto Carlos III, Madrid, Spain
| | - Christoph Schmid
- Department of Hematology and Oncology, Augsburg University Hospital, Augsburg, Germany
| | - Roni Shouval
- Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - Jurjen Versluis
- Erasmus University Medical Center Cancer Institute, Rotterdam, the Netherlands
| | - Norbert Vey
- Department of Hematology, Institut Paoli-Calmettes, Marseille, France
| | - Bipin N Savani
- Department of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Arnon Nagler
- Hematology and Bone Marrow Transplantation Division, Chaim Sheba Medical Center, Tel-Hashomer, Sackler School of Medicine, Tel Aviv University, Israel
| | - Mohamad Mohty
- Sorbonne Universités, UPMC University of Paris 06, INSERM, Centre de Recherche Saint-Antoine (CRSA), Hematology Department, AP-HP, Saint Antoine Hospital, Paris, France
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Yanada M, Takami A, Yamasaki S, Arai Y, Konuma T, Uchida N, Najima Y, Fukuda T, Tanaka M, Ozawa Y, Ikegame K, Takanashi M, Ichinohe T, Okamoto S, Atsuta Y, Yano S. Allogeneic hematopoietic cell transplantation for adults with acute myeloid leukemia conducted in Japan during the past quarter century. Ann Hematol 2020; 99:1351-1360. [DOI: 10.1007/s00277-020-04051-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 04/20/2020] [Indexed: 12/12/2022]
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Dillon R, Hills R, Freeman S, Potter N, Jovanovic J, Ivey A, Kanda AS, Runglall M, Foot N, Valganon M, Khwaja A, Cavenagh J, Smith M, Ommen HB, Overgaard UM, Dennis M, Knapper S, Kaur H, Taussig D, Mehta P, Raj K, Novitzky-Basso I, Nikolousis E, Danby R, Krishnamurthy P, Hill K, Finnegan D, Alimam S, Hurst E, Johnson P, Khan A, Salim R, Craddock C, Spearing R, Gilkes A, Gale R, Burnett A, Russell NH, Grimwade D. Molecular MRD status and outcome after transplantation in NPM1-mutated AML. Blood 2020; 135:680-688. [PMID: 31932839 PMCID: PMC7059484 DOI: 10.1182/blood.2019002959] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/11/2019] [Indexed: 12/15/2022] Open
Abstract
Relapse remains the most common cause of treatment failure for patients with acute myeloid leukemia (AML) who undergo allogeneic stem cell transplantation (alloSCT), and carries a grave prognosis. Multiple studies have identified the presence of measurable residual disease (MRD) assessed by flow cytometry before alloSCT as a strong predictor of relapse, but it is not clear how these findings apply to patients who test positive in molecular MRD assays, which have far greater sensitivity. We analyzed pretransplant blood and bone marrow samples by reverse-transcription polymerase chain reaction in 107 patients with NPM1-mutant AML enrolled in the UK National Cancer Research Institute AML17 study. After a median follow-up of 4.9 years, patients with negative, low (<200 copies per 105ABL in the peripheral blood and <1000 copies in the bone marrow aspirate), and high levels of MRD had an estimated 2-year overall survival (2y-OS) of 83%, 63%, and 13%, respectively (P < .0001). Focusing on patients with low-level MRD before alloSCT, those with FLT3 internal tandem duplications(ITDs) had significantly poorer outcome (hazard ratio [HR], 6.14; P = .01). Combining these variables was highly prognostic, dividing patients into 2 groups with 2y-OS of 17% and 82% (HR, 13.2; P < .0001). T-depletion was associated with significantly reduced survival both in the entire cohort (2y-OS, 56% vs 96%; HR, 3.24; P = .0005) and in MRD-positive patients (2y-OS, 34% vs 100%; HR, 3.78; P = .003), but there was no significant effect of either conditioning regimen or donor source on outcome. Registered at ISRCTN (http://www.isrctn.com/ISRCTN55675535).
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MESH Headings
- Adolescent
- Adult
- Aged
- Female
- Hematopoietic Stem Cell Transplantation/mortality
- Humans
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/therapy
- Male
- Middle Aged
- Neoplasm Recurrence, Local/genetics
- Neoplasm Recurrence, Local/mortality
- Neoplasm, Residual/diagnosis
- Neoplasm, Residual/genetics
- Nuclear Proteins/genetics
- Nucleophosmin
- Recurrence
- Young Adult
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Affiliation(s)
- Richard Dillon
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
- Cancer Genetics Service, Viapath, Guy's Hospital, London, United Kingdom
- Department of Haematology, Guy's Hospital, London, United Kingdom
| | - Robert Hills
- Nuffield Department of Population Health, University of Oxford, United Kingdom
| | - Sylvie Freeman
- Institute of Immunology and Immunotherapy, University of Birmingham, United Kingdom
| | - Nicola Potter
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
- Cancer Genetics Service, Viapath, Guy's Hospital, London, United Kingdom
| | - Jelena Jovanovic
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
| | - Adam Ivey
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
| | - Anju Shankar Kanda
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
| | - Manohursingh Runglall
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
| | - Nicola Foot
- Cancer Genetics Service, Viapath, Guy's Hospital, London, United Kingdom
| | - Mikel Valganon
- Cancer Genetics Service, Viapath, Guy's Hospital, London, United Kingdom
| | - Asim Khwaja
- Department of Haematology, University College, London, United Kingdom
| | | | | | | | | | - Mike Dennis
- Christie Hospital, Manchester, United Kingdom
| | - Steven Knapper
- Department of Haematology, Cardiff University, Cardiff, United Kingdom
| | - Harpreet Kaur
- Royal Hallamshire Hospital, Sheffield, United Kingdom
| | | | - Priyanka Mehta
- Bristol Haematology and Oncology Centre, Bristol, United Kingdom
| | - Kavita Raj
- Department of Haematology, Guy's Hospital, London, United Kingdom
| | | | | | | | | | - Kate Hill
- University Hospital, Southampton, United Kingdom
| | | | - Samah Alimam
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
- Department of Haematology, Guy's Hospital, London, United Kingdom
| | - Erin Hurst
- Royal Victoria Infirmary, Newcastle, United Kingdom
| | | | - Anjum Khan
- St James' Hospital, Leeds, United Kingdom
| | - Rahuman Salim
- Clatterbridge Cancer Centre, Liverpool, United Kingdom
| | | | | | - Amanda Gilkes
- Department of Haematology, Cardiff University, Cardiff, United Kingdom
| | - Rosemary Gale
- Department of Haematology, University College, London, United Kingdom
| | - Alan Burnett
- Blackwaterfoot, Isle of Arran, United Kingdom; and
| | - Nigel H Russell
- Department of Haematology, Guy's Hospital, London, United Kingdom
- Nottingham University Hospital, Nottingham, United Kingdom
| | - David Grimwade
- Department of Medical and Molecular Genetics, King's College, London, United Kingdom
- Department of Haematology, Guy's Hospital, London, United Kingdom
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Andreani G, Cilloni D. Strategies for minimal residual disease detection: current perspectives. BLOOD AND LYMPHATIC CANCER-TARGETS AND THERAPY 2019; 9:1-8. [PMID: 31807111 PMCID: PMC6855617 DOI: 10.2147/blctt.s172693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 12/13/2018] [Indexed: 11/25/2022]
Abstract
Currently, the post-remission treatment in acute leukemia is based on the genetic profile of leukemic cells at diagnosis (ie, FLT3 ITD positivity) and on the level of measurable residual disease (MRD) after induction and consolidation chemotherapy. Two methods are currently preferred for MRD evaluation in many centers: multiparameter flow cytometry and real-time quantitative PCR. Additional methods such as next-generation sequencing and digital PCR are under investigation, in an attempt to increase the sensitivity and thus allowing the detection of small clones. Many studies suggest that MRD positivity after chemotherapy is associated with negative prognosis, and the reappearance of MRD during follow-up allows impending relapse to be identified and consequently enables early intervention. Finally, MRD positivity before hematopoietic stem cell transplantation is predictive of the outcome. Although the significance of MRD in acute leukemia has been widely explored, the assessment of molecular MRD is not yet a routine practice. In this review, we describe the significance of MRD in different settings and the main markers and methods used for MRD detection.
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Affiliation(s)
- Giacomo Andreani
- Department of Clinical and Biological Sciences, University of Turin, Turin,Italy
| | - Daniela Cilloni
- Department of Clinical and Biological Sciences, University of Turin, Turin,Italy
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43
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Jentzsch M, Schwind S, Bach E, Stasik S, Thiede C, Platzbecker U. Clinical Challenges and Consequences of Measurable Residual Disease in Non-APL Acute Myeloid Leukemia. Cancers (Basel) 2019; 11:E1625. [PMID: 31652787 PMCID: PMC6893483 DOI: 10.3390/cancers11111625] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/18/2019] [Accepted: 10/21/2019] [Indexed: 12/19/2022] Open
Abstract
The ability to detect residual levels of leukemic blasts (measurable residual disease, MRD) has already been integrated in the daily routine for treatment of patients with chronic myeloid and acute lymphoblastic leukemia. In acute myeloid leukemia (AML), a variety of mostly retrospective studies have shown that individuals in AML remission who tested positive for MRD at specific time-points or had increasing MRD levels are at significantly higher risk of relapse and death compared to MRD-negative patients. However, these studies differ with respect to the "MRD-target", time-point of MRD determination, material analyzed, and method applied. How this probably very valuable MRD information in individual patients may be adapted in the daily clinical routine, e.g., to separate patients who need more aggressive therapies from those who may be spared additional-potentially toxic-therapies is still a work-in-progress. With the exception of MRD assessment in acute promyelocytic leukemia (APL), the lack of randomized, prospective trials renders MRD-based decisions and clinical implications in AML a difficult task. As of today, we still do not have proof that early intervention in MRD-positive AML patients would improve outcomes, although this is very likely. In this article, we review the current knowledge on non-APL AML MRD assessment and possible clinical consequences.
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Affiliation(s)
- Madlen Jentzsch
- Medical Clinic and Policlinic 1, Hematology and Cellular Therapy, Leipzig University Hospital, 04103 Leipzig, Germany.
| | - Sebastian Schwind
- Medical Clinic and Policlinic 1, Hematology and Cellular Therapy, Leipzig University Hospital, 04103 Leipzig, Germany.
| | - Enrica Bach
- Medical Clinic and Policlinic 1, Hematology and Cellular Therapy, Leipzig University Hospital, 04103 Leipzig, Germany.
| | - Sebastian Stasik
- Medical Department I, University Hospital and Faculty of Medicine, TU Dresden, 01307 Dresden, Germany.
| | - Christian Thiede
- Medical Department I, University Hospital and Faculty of Medicine, TU Dresden, 01307 Dresden, Germany.
| | - Uwe Platzbecker
- Medical Clinic and Policlinic 1, Hematology and Cellular Therapy, Leipzig University Hospital, 04103 Leipzig, Germany.
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Molecular Detection of Minimal Residual Disease before Allogeneic Stem Cell Transplantation Predicts a High Incidence of Early Relapse in Adult Patients with NPM1 Positive Acute Myeloid Leukemia. Cancers (Basel) 2019; 11:cancers11101455. [PMID: 31569375 PMCID: PMC6826431 DOI: 10.3390/cancers11101455] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 01/07/2023] Open
Abstract
We analyzed the impact of alloHSCT in a single center cohort of 89 newly diagnosed NPM1mut AML patients, consecutively treated according to the Northern Italy Leukemia Group protocol 02/06 [NCT00495287]. After two consolidation cycles, the detection of measurable residual disease (MRD) by RQ-PCR was strongly associated with an inferior three-year overall survival (OS, 45% versus 84%, p = 0.001) and disease-free survival (DFS, 44% versus 76%, p = 0.006). In MRD-negative patients, post-remissional consolidation with alloHSCT did not provide a significant additional benefit over a conventional chemotherapy in terms of overall survival [OS, 89% (95% CI 71–100%) versus 81% (95% CI 64–100%), p = 0.59] and disease-free survival [DFS, 80% (95% CI 59–100%) versus 75% (95% CI 56–99%), p = 0.87]. On the contrary, in patients with persistent MRD positivity, the three-year OS and DFS were improved in patients receiving an alloHSCT compared to those allocated to conventional chemotherapy (OS, 52% versus 31%, p = 0.45 and DFS, 50% versus 17%, p = 0.31, respectively). However, in this group of patients, the benefit of alloHSCT was still hampered by a high incidence of leukemia relapse during the first year after transplantation (43%, 95% CI 25–60%). Consolidative alloHSCT improves outcomes compared to standard chemotherapy in patients with persistent NPM1mut MRD positivity, but in these high-risk patients, the significant incidence of leukemia relapse must be tackled by post-transplant preemptive treatments.
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Patel SS, Pinkus GS, Ritterhouse LL, Segal JP, Dal Cin P, Restrepo T, Harris MH, Stone RM, Hasserjian RP, Weinberg OK. High NPM1 mutant allele burden at diagnosis correlates with minimal residual disease at first remission in de novo acute myeloid leukemia. Am J Hematol 2019; 94:921-928. [PMID: 31148220 DOI: 10.1002/ajh.25544] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 05/21/2019] [Accepted: 05/28/2019] [Indexed: 12/28/2022]
Abstract
Acute myeloid leukemia (AML) with mutated NPM1 is a newly recognized separate entity in the revised 2016 WHO classification, and is associated with a favorable prognosis. While previous studies have evaluated NPM1 in a binary fashion, we recently demonstrated a significant independent negative prognostic effect of high NPM1 mutant allele burden (VAF) at diagnosis in a cohort of de novo AML patients. Although the importance of minimal residual disease (MRD) monitoring in NPM1-mutated AML has been well characterized, the potential relationship between diagnostic allele burden and MRD is unknown. We retrospectively evaluated for MRD at first remission (CR1). We used either next-generation sequencing (NGS) [n = 71], and/or immunohistochemistry (IHC) for mutant NPM1 (NPM1c) [n = 60], in a subset of patients from our recently examined cohort. We identified a statistically significant positive correlation between the VAF at diagnosis, and at CR1 (Spearman r = 0.4, P = .006), and enrichment for MRD in high diagnostic VAF patients (P = .05), as previously defined. IHC-positivity also correlated significantly with a higher median diagnostic NPM1 VAF (0.42 vs 0.39, P = .02), and with the VAF at CR1 (Spearman r = 0.7, P = .003). In multivariable analyses, both high diagnostic VAF (P = .003) and MRD (P = .02) were independent predictors of shorter event-free survival (EFS). Our findings suggest a relationship between the NPM1 mutant allele burden at diagnosis, and the presence of MRD at first remission. Our findings support IHC as a potentially useful adjunctive tool for disease monitoring.
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Affiliation(s)
- Sanjay S. Patel
- Department of PathologyBrigham and Women's Hospital Boston Massachusetts
| | | | | | - Jeremy P. Segal
- Division of Genomic and Molecular PathologyUniversity of Chicago Chicago Illinois
| | - Paola Dal Cin
- Department of PathologyBrigham and Women's Hospital Boston Massachusetts
| | - Tamara Restrepo
- Department of PathologyBoston Children's Hospital Boston Massachusetts
| | - Marian H. Harris
- Department of PathologyBoston Children's Hospital Boston Massachusetts
| | - Richard M. Stone
- Department of Medical OncologyDana‐Farber Cancer Institute Boston Massachusetts
| | | | - Olga K. Weinberg
- Department of PathologyBrigham and Women's Hospital Boston Massachusetts
- Department of PathologyBoston Children's Hospital Boston Massachusetts
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Cheng Z, Dai Y, Pang Y, Jiao Y, Liu Y, Cui L, Qian T, Quan L, Cui W, Pan Y, Ye X, Shi J, Fu L. High EGFL7 expression may predict poor prognosis in acute myeloid leukemia patients undergoing allogeneic hematopoietic stem cell transplantation. Cancer Biol Ther 2019; 20:1314-1318. [PMID: 31306053 DOI: 10.1080/15384047.2019.1638663] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Epithelial growth factor-like 7 (EGFL7) is a secretory protein with a well-characterized role in angiogenesis and the oncogenesis of certain solid tumors. Overexpression of EGFL7 is associated with adverse prognosis in patients with cytogenetically normal acute myeloid leukemia (CN-AML). However, whether this association persists after allogeneic hematopoietic stem cell transplantation (allo-HSCT) remains unclear. To further clarify the prognostic role of EGFL7, seventy-one AML patients with EGFL7 expression data who underwent allo-HSCT from The Cancer Genome Atlas database were included and divided into either EGFL7high or EGFL7low group based on the median EGFL7 expression level. Two groups had similar clinical and molecular characteristics except that the EGFL7high group had less frequent NPM1 mutations (P= .001). Kaplan-Meier survival curves showed that high EGFL7 expressers had shorter OS than the low expressers (P= .040). Univariate analysis showed that high EGFL7 expression, MLL-PTD, RUNX1 and TP53 mutations were associated with short OS (all P< .05). Multivariate analysis indicated that high EGFL7 expression, FLT3-ITD, RUNX1 and TP53 mutations were independent risk factors for OS (all P< .05). Collectively, our study suggested that EGFL7, like the other widely-used risk stratification factors, could serve as a prognostic tool and therapeutic target in AML, even after allo-HCST.
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Affiliation(s)
- Zhiheng Cheng
- Department of Hematology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China.,Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen , Groningen , Netherlands.,Translational Medicine Center, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China.,Translational Medicine Center, Huaihe Hospital of Henan University , Kaifeng , China
| | - Yifeng Dai
- Immunoendocrinology, Division of Medical Biology, Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen , Groningen , Netherlands
| | - Yifan Pang
- Department of Medicine, William Beaumont Hospital , Royal Oak , MI , USA
| | - Yang Jiao
- Life Sciences Institute and Innovation Center for Cell Signaling Network, Zhejiang University , Hangzhou , China
| | - Yan Liu
- Translational Medicine Center, Huaihe Hospital of Henan University , Kaifeng , China
| | - Longzhen Cui
- Translational Medicine Center, Huaihe Hospital of Henan University , Kaifeng , China
| | - Tingting Qian
- Translational Medicine Center, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China
| | - Liang Quan
- Translational Medicine Center, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China
| | - Wei Cui
- Department of Clinical Laboratory, Beijing Haidian Hospital, Beijing Haidian Section of Peking University Third Hospital , Beijing , China
| | - Yue Pan
- Department of Clinical Laboratory, Beijing Haidian Hospital, Beijing Haidian Section of Peking University Third Hospital , Beijing , China
| | - Xu Ye
- Department of Hematology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China
| | - Jinlong Shi
- Department of Biomedical Engineering, Chinese PLA General Hospital , Beijing , China
| | - Lin Fu
- Department of Hematology, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China.,Translational Medicine Center, The Second Affiliated Hospital of Guangzhou Medical University , Guangzhou , China.,Department of Hematology, Huaihe Hospital of Henan University , Kaifeng , China
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Short NJ, Ravandi F. How close are we to incorporating measurable residual disease into clinical practice for acute myeloid leukemia? Haematologica 2019; 104:1532-1541. [PMID: 31273094 PMCID: PMC6669140 DOI: 10.3324/haematol.2018.208454] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/05/2019] [Indexed: 12/22/2022] Open
Abstract
Assessment of measurable residual disease, also called “minimal residual disease,” in patients with acute myeloid leukemia in morphological remission provides powerful prognostic information and complements pretreatment factors such as cytogenetics and genomic alterations. Based on data that low levels of persistent or recurrent residual leukemia are consistently associated with an increased risk of relapse and worse long-term outcomes, its routine assessment has been recommended by some experts and consensus guidelines. In addition to providing important prognostic information, the detection of measurable residual disease may also theoretically help to determine the optimal post-remission strategy for an individual patient. However, the full therapeutic implications of measurable residual disease are uncertain and thus controversy exists as to whether it should be routinely incorporated into clinical practice. While some evidence supports the use of allogeneic stem cell transplantation or hypomethylating agents for some subgroups of patients in morphological remission but with detectable residual leukemia, the appropriate use of this information in making clinical decisions remains largely speculative at present. To resolve this pressing clinical issue, several ongoing studies are evaluating measurable residual disease-directed treatments in acute myeloid leukemia and may lead to new, effective strategies for patients in these circumstances. This review examines the common technologies used in clinical practice and in the research setting to detect residual leukemia, the major clinical studies establishing the prognostic impact of measurable residual disease in acute myeloid leukemia, and the potential ways, both now and in the future, that such testing may rationally guide therapeutic decision-making.
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Affiliation(s)
- Nicholas J Short
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Farhad Ravandi
- Department of Leukemia, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Heuser M, Mina A, Stein EM, Altman JK. How Precision Medicine Is Changing Acute Myeloid Leukemia Therapy. Am Soc Clin Oncol Educ Book 2019; 39:411-420. [PMID: 31099617 DOI: 10.1200/edbk_238687] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Pretreatment somatic mutations influence acute myeloid leukemia (AML) pathogenesis and responses to chemotherapy. Integration of cytogenetic abnormalities and molecular mutations, co-occurring and in isolation, have resulted in a more refined prognostic assessment. In addition, research performed over the last few years has led to the development of novel therapies and new drug approvals in patients with both newly diagnosed and relapsed/refractory (R/R) AML. Here we discuss the use of these newly approved therapies. Advances in AML have also occurred through development of better tools to assess response to treatment. Both multiparameter flow cytometry and polymerase chain reaction can be used to assess for the presence or absence of measurable residual disease (MRD) and increase the sensitivity of response assessment. The role of MRD assessment is gaining relevance and its integration in clinical trials and treatment decision making will be explored in the second half of this article.
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Affiliation(s)
| | | | - Eytan M Stein
- 3 Memorial Sloan-Kettering Cancer Center and Weil Cornell Medical College, New York, NY
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49
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Minimal/Measurable Residual Disease Monitoring in NPM1-Mutated Acute Myeloid Leukemia: A Clinical Viewpoint and Perspectives. Int J Mol Sci 2018; 19:ijms19113492. [PMID: 30404199 PMCID: PMC6274702 DOI: 10.3390/ijms19113492] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/02/2018] [Accepted: 11/03/2018] [Indexed: 02/06/2023] Open
Abstract
Acute myeloid leukemia (AML) with NPM1 gene mutations is currently recognized as a distinct entity, due to its unique biological and clinical features. We summarize here the results of published studies investigating the clinical application of minimal/measurable residual disease (MRD) in patients with NPM1-mutated AML, receiving either intensive chemotherapy or hematopoietic stem cell transplantation. Several clinical trials have so far demonstrated a significant independent prognostic impact of molecular MRD monitoring in NPM1-mutated AML and, accordingly, the Consensus Document from the European Leukemia Net MRD Working Party has recently recommended that NPM1-mutated AML patients have MRD assessment at informative clinical timepoints during treatment and follow-up. However, several controversies remain, mainly with regard to the most clinically significant timepoints and the MRD thresholds to be considered, but also with respect to the optimal source to be analyzed, namely bone marrow or peripheral blood samples, and the correlation of MRD with other known prognostic indicators. Moreover, we discuss potential advantages, as well as drawbacks, of newer molecular technologies such as digital droplet PCR and next-generation sequencing in comparison to conventional RQ-PCR to quantify NPM1-mutated MRD. In conclusion, further prospective clinical trials are warranted to standardize MRD monitoring strategies and to optimize MRD-guided therapeutic interventions in NPM1-mutated AML patients.
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50
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Kayser S, Levis MJ. Clinical implications of molecular markers in acute myeloid leukemia. Eur J Haematol 2018; 102:20-35. [PMID: 30203623 DOI: 10.1111/ejh.13172] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 12/16/2022]
Abstract
The recently updated World Health Organization (WHO) Classification of myeloid neoplasms and leukemia reflects the fact that research in the underlying pathogenic mechanisms of acute myeloid leukemia (AML) has led to remarkable advances in our understanding of the disease. Gene mutations now allow us to explore the enormous diversity among cytogenetically defined subsets of AML, particularly the large subset of cytogenetically normal AML. Despite the progress in unraveling the tumor genome, only a small number of recurrent mutations have been incorporated into risk-stratification schemes and have been proven to be clinically relevant, targetable lesions. We here discuss the utility of molecular markers in AML in prognostication and treatment decision making, specifically highlighting the aberrations included in the current WHO classification.
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Affiliation(s)
- Sabine Kayser
- Department of Internal Medicine V, University Hospital of Heidelberg, Heidelberg, Germany.,Clinical Cooperation Unit Molecular Hematology/Oncology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Mark J Levis
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
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