MRD in ALL: Optimization and Innovations

PURPOSE OF REVIEW

Measurable residual disease (MRD) is an important monitoring parameter that can help predict survival outcomes in acute lymphoblastic leukemia (ALL). Identifying patients with MRD has the potential to decrease the risk of relapse with the initiation of early salvage therapy and to help guide decision making regarding allogeneic hematopoietic cell transplantation. In this review, we discuss MRD in ALL, focusing on advantages and limitations between MRD testing techniques and how to monitor MRD in specific patient populations.

RECENT FINDINGS

MRD has traditionally been measured through bone marrow samples, but more data for evaluation of MRD via peripheral blood is emerging. Current and developmental testing strategies for MRD include multiparametric flow cytometry (MFC), next-generation sequencing (NGS), quantitative polymerase chain reaction (qPCR), and ClonoSeq. Novel therapies are incorporating MRD as an outcome measure to demonstrate efficacy, including blinatumomab, inotuzumab ozogamicin, and chimeric antigen receptor T (CAR-T) cell therapy. Understanding how to incorporate MRD testing into the management of ALL could improve patient outcomes and predict efficacy of new therapy options.

Psychiatric disorder and outcome in irritable bowel syndrome

A link between irritable bowel syndrome (IBS) and psychiatric illness is well recognized. The authors set out to establish whether a group with a risk of poor outcome IBS could be identified at presentation to a general hospital clinic in a prospective series of 70 subjects. Potential risk factors showed no correlation with IBS outcome at 6-9 months. There was a high rate of persistent mental illness. Clinicians offering specialist care for IBS should consult with psychiatric services to provide assessment irrespective of IBS outcome if major psychopathology is not to be neglected.

Drug treatment of resistant schizophrenia. Limitations and recommendations

Despite the advances achieved since the introduction of chlorpromazine, schizophrenia may respond inadequately to standard drug treatments. The reasons for this include noncompliance, poor tolerance and the development of distressing side effects or the resistance of the illness itself. Treatment-resistant schizophrenia is increasingly the focus of new research developments. The older or classic antipsychotic drugs have a broad spectrum of action on central and peripheral nervous system receptors. Their action on dopamine receptors was an early clue to the pathogenesis of schizophrenia. More recently, multiple subtypes of dopamine receptors have been identified. These, plus serotonin receptors, have been identified in brain structures thought to be implicated in schizophrenic illnesses. Atypical antipsychotic agents whose pharmacological action is either more specific, or which have novel receptor binding profiles show characteristic effects in both animal models and clinically. These drugs may improve symptoms in otherwise resistant illness or where intolerance prevents the use of standard treatments. There are a number of adjunctive somatic treatment strategies using established agents such as lithium and electroconvulsive therapy the use of which is now being explored systematically. The most exciting current development is the re-emergence of clozapine as a highly effective atypical antipsychotic drug which can be used safely if special surveillance is undertaken to monitor for its potentially severe toxic effects. These recent advances offer hope of improvement in the prognosis of people suffering from severe and intractable forms of schizophrenia.