MRD in AML : Cause for Action or Just for Concern?

MRD in AML :Cause for Action or Just for Concern?

Richard M. Stone, MDChief of Staff

Dana-Farber Cancer InstituteDirector, Translational Research, Leukemia Division, Department of Medical Oncology

Professor of MedicineHarvard Medical School

Boston, MA

Disclosures- Richard M. Stone, MD

• Consulting relationships past three years:• AbbVie*; Actinium, Agios*; Amgen; Argenix

(DSMB); Arog*; Astellas; AztraZenaca; Biolinerx, Celgene (includes DSMB and steering committee); Fujifilm, Janssen; Juno; Macrogen-ics; Novartis*; Ono; Orsenix; Pfizer; Roche; Stemline, Sumitomo; Takeda (DSMB), Trovagene

• * denotes support to my institution for clinical trials on which I was local PI

• Securities, employment, promotional activities, intellectual property, gifts, grants

• None2

The First Obligate Slide for an MRD talk: The theory

Hourigan & Karp. Nature reviews Clinical oncology. 2013.Kern W, et al. Atlas of Genetics and Cytogenetics in Oncology and Haematology, 2004

Method Sensitivity Target Advantages Disadvantages

Flow cytometry

0.1-0.01%(4 color)

0.01-0.001% (6-10 color)

“LAIP” (leukemia-associatedimmunophenotype)or“DfN” (Difference from normal)

Nearly all AMLs

Rapid, direct

Don’t necessarily need prior sample

Not standardized

Requires expertise

Immunophenotypic shifts

qRT-PCR 0.01-0.001% Fusion transcript or specific mutation (e.g. CBF, NPM1)

High sensitivityStandardized

Not all AMLs

May persist in mature “non-LSCs”

DNA sequencing

Varies by method, as sensitive as 0.0001%

(many in common use are higher ~0.1-1%)

Mutated genes Nearly all AMLs

High sensitivity (e.g., ddPCR)

Discovery potential

Cost/Time

Not all mutationstrack with blasts/LSCs

Not all mutations persist at relapse

The Second Obligate Slide for an AML MRD talk: The Methods

**2017, 2018 ELN AML recommendations suggest MRD monitoring in clinical practice**

MRD: Areas of Agreement

• We are not sure what technique to use and we are not sure when to use it

• We are sure that within any given technique at a given time point the prognosis is better if detectability is not present/present at a lower level than if present/present at a higher level• For example, pre-transplant MRD is worrisome

If you find MRD can the outcome be influenced by allo SCT?

• Walter et al JCO 29:1190, 2011 (FHCRC)• 99 CR1 (incl 11 CRi) younger AML pts undergoing myeloablative

SCT

• Pre-SCT MRD assessed by 10 color MPF

• 24 were MRD +

• The post-SCT relapse rate in MRD += 65% • (v 18%)

• The 2 yr OS rate in MRD+=24%

• (v 75%)

Allogeneic HCT does not seem to attenuate the relapse risk attributed to

pre-transplant MRD (MFC)

CR2

CR2

CR1

CR1

MRD+

MRD-

Walter, et al. Blood 2013; 122:1813

Intensification of BMT conditioning does not reduce risk of relapse in MRD+ setting (via

MFC – deviation from normal approach-but stay tuned)

Walter RB, et al. Leukemia 2015; 29:137

P=NS

Assessment of minimal residual disease using the European LeukemiaNet WT1 assay following induction chemotherapy predicts risk of relapse in acute myeloid leukemia (AML)

Cilloni D et al. JCO 2009;27:5195-5201

©2009 by American Society of Clinical Oncology

Using RT-qPCR to monitor MRD after 2 cycles of chemotherapy

Ivey, et al. NEJM 2016; 374:422

NGS-based detection of MRD also useful

• Jongen-Laurencic, M, et al NEJM 378:1189-1199, 2018 (Hovon-SAKK)

• Age 18-65 AML, NGS at dx and relapse ( N-482, 430 had at least one mutation at dx)

• Persistence of DNMT3A, TET2, ASXL1 (DTA [CHIP-like, see Steensma, D et al, Blood , NEJM]) didn’t carry risk, others did

• MRD ( non DTA) by NGS: 55 v 32% RR, 43 v 66% OS• Flow-based MRD was additive

• If you were pos by both- worst, but either one pos- worse than neither

Rate of Relapse According to Results of Next-Generation Sequencing and Multiparameter Flow Cytometry.

Jongen-Lavrencic M et al. N Engl J Med 2018;378:1189-1199

Case 1: 65 yo M with NK AML, DNMT3A 45%, IDH2 25%, NPM1 38%

• Rec’d 3+7• Achieved CR after 1 cycle c/b diverticular perforation/ underwent

diverting colostomy (MRD neg by Hematologics flow)

• Rec’d modified hidac consolidation x3• Still in CR upon recovery (MRD neg by flow; BRCC 3.5%, DNMT3A

17%)• Underwent colonic re-anastomosis• ? Is this Clonal hematopoiesis and will not effect relapse risk

(Gaidzik, et al Leukemia 2018)• If you transplant this pt… MAC better than RIC ( Hourigan etal ,

JCO 2019)

Key potential uses of MRD monitoring in CR1 AML WHICH WOULD CHANGE THERAPY

• Modify choice of consolidation therapy (allo SCT v chemo) within a given diagnosis-based risk group based on post-induction MRD findings

• Define or Change Therapy based on MRD findings

• Give an ‘MRD eraser’ ( that works differently than chemo)

• Monitor over time ( after chemo or alloSCT) and intervene at time of ‘MRD/molecular relapse’

Bonus Use: Use in Drug development

Survey of 13 major cancer centers on MRD assessment

Flow PCR Comments

CC1 No No What, another hurricane?

CC2 No No “Not convinced results reliable enough to guide retreatment or SCT”

CC3 Yes No

CC4 Yes No “We do flow, but results are confusing”

CC5 No No

CC6 Yes Yes

CC7 Yes Yes

CC8 Yes No “Might be easier to discuss over phone”

CC9 No No “Still no accepted way to do it”

CC10 Yes No “We don’t really know what to do with results”

CC11 No Yes “Only reason I trust flow is because of very experienced, qualified pathologists”

CC12 No Yes (NPM1 only)

CC13 Yes Yes (NPM1 only

Courtesy Jeff Lancet


• ’

Use in Drug development

-Deep Remissions are good

-Therapy A leads to a deeper

remission than therapy B means therapy A

is better

These materials are provided to you solely as an educational resource for your personal use. Any commercial use or distribution of these materials or any portion thereof is strictly prohibited.

OS After Allogeneic HSCT in CR1CALGB 10603 (RATIFY), Phase 3

• Stone RM, et al. N Engl J Med. 2017;377:454-464. 17

Survival Landmarked from Time of Transplant

18

• CPX-351 median OS not reached vs 10.25 months for 7+3

• HR of 0.46 favoring CPX-351 (P=0.0046)

• Cox proportional hazards HR, including transplant as a time-dependent covariate, was 0.51 (95% CI, 0.35–0.75; P=0.0007), favoring CPX-351

Lancet et al, JCO 2018

19

3+7 plus Venetoclax ( DL1: Ven 200 mg d-1 to 10) ( Stone, ASH 2019)

MRD by flow, sens 0.02%

Using it to detect relapse, the best case was in APL based on MRC 15:(Grimwade et al JC0, 2009)

• 30 pts had + transcripts and were candidates for ‘pre-emptive therapy’ with As

• Only 16/30 pts rec’d such therapy • Compliance or poor samples were issues• 10/16 treated pts did not have full blown relapse

• Overall lower rate of relapse c/w hist controls• No dif syndrome when As used preventively

• Overall cost was $5.4K/pt , but was $25.6 K in non-high risk

• We give ATRA and arsenic to everybody now anyway

• In Non-APL, can we really effect outcome by finding out a little earlier than by following CBCs and doing marrow ‘for cause’.

MRD Assessment in follow-up: Get you affairs in order

• In patients with a morphologic remission, a rising NPM1 transcript level reliably predicted hematologic relapse. ( Ivey A NEJM 2016)

• MRD flow positivity after rx tantamount to relapse ( Walter et al)

• Huge problems• Lead time between MRD relapse and clinical relapse may be short

• Prove to me that treating MRD relapse is better than treating clinical relapse

• See MRD eraser section

• ? DLI if MRD relapse post SCT?

Ivey A NEJM 2016

Association of Outcomes with Mutation Clearance Determined with the Use of a 40-Gene Panel.

Duncavage EJ et al. N Engl J Med 2018;379:1028-1041


• Define or Change Therapy based on MRD findings

• Give an ‘MRD eraser’ ( that works differently than chemo)

• Blinatumumab in ALL provides the paradigm

Case 2: 67 yo M with t ( 9; 11) AML, FLT3D835Y

• Rec’d 3+7 + midostaurin• Achieved CR after 1 cycle ( 5.7% MRD by Hematologics flow)

• Rec’d modified hidac consolidation• Still in CR upon recovery (1.2% MRD by flow)• Has sibling donor

• Rec’d azacitidine/venetoclax• Still in CR upon recovery ( 0.8% MRD by flow)

• Rec’d related donor RIC allo• 4 months later experience marrow and EM relapse, died soon

thereafter

Is there a way to deal with MRD

(can we change the badness)?

• Is there an a reliable MRD eraser in AML on the

horizon

• Does double umbilical cord transplant erase the

bad prognosis

• Milano et al, NEJM 2016 ( FHCC)

retrospective

SL-401: Novel Targeted Therapy Directed to the IL-3 Receptor (IL-3Rα / CD123)

% v

iab

le

SL-401 (fM)

BPDCN skin biopsy (IHC)

CD123

SL-401 fM IC50

against BPDCN cells

Truncated

diphtheria

toxin IL-3

SL-401

IL-3Rα/CD123Cancer

cell

26

• IL-3Rα/CD123 overexpressed on BPDCN and many other hematologic cancers

• SL-401 = targeted therapy directed to the IL-3Rα/CD123

• SL-401 potent vs BPDCN cells in vitro and in vivo

• Previous Phase 1 study, single cycle of SL-401:

- Major responses in 7/9 patients (78%): 5 CR, 2 PR (Frankel et al. Blood, 2014)

• 65-year old female with AML, achieved CR following daunorubicin + cytarabine induction

• MRD(+) by local analysis -> received 4 cycles of SL-401 (12 μg/kg/day) on trial

• Reduction in marrow aberrant CD123+ population with monocytic markers

• Underwent allogeneic stem cell transplant

Aberrant population(CD45+/CD14+/CD56dim/CD123+/CD33+)

0.6%

0.05%

Screen

End of Cycle 2

CD14

CD

123

CD45 CD14

MRD Decrease in Patient Treated with SL-401

Other potential MRD erasers

• Anti CD33

• Gemtuzumab

• Other anti CD33 ADC

• Anti CD123 other than SL401

• ADC

• Radiolabeled AB

• CART

• Immunological

• Denrtitic cell vaccine

• Low dose chemo ( e.g., aza/venetoclax)

• RELAZA2 trial showed that aza can convert some MRD+ to neg, but will it change LT

outcome ( Platzbecker ,Lancet Oncology 2018)

• Oral Aza! Does it work by reducing MRD? ( Wei a et al , LBA ASH 2019)


• International, multicenter, placebo-controlled, double-blind, randomized, phase III study that enrolled patients from 148 sites in 23 countries (NCT01757535)

QUAZAR AML-001: Study design

PRE-RANDOMIZATION

Screening

Key eligibility criteria:• First CR / CRi with

IC ± consolidation • Age ≥55 years• de novo or secondary AML• ECOG PS score 0-3• Intermediate- or poor-risk

cytogenetics• Ineligible for HSCT• Adequate bone marrow recovery

(ANC ≥0.5 × 109/L, platelet count ≥20× 109/L)

FOLLOW-UP

• Follow until death, withdrawal of consent, study termination, or loss to follow-up

Randomization (1:1)

Within 4 months (±7 days) of CR/CRi

Stratified by:

• Age: 55–64 / ≥ 65

• Prior MDS/CMML: Y / N

• Cytogenetic risk: Intermediate / Poor

• Consolidation: Y / N

RANDOMIZATION

Continue Treatment

TREATMENT PHASE

(Optional)CC-486/PBO ×21

days

Resp

onse A

ssessment

Every 3 Cycles

> 15% BM Blasts

5%–15% BM Blasts

CR/CRiCC-486 300 mg QD ×14 days

Placebo QD×14 days Stop

TreatmentEnd of Study

28-day cycles

29


• Median follow-up: 41.2 months

• Data cutoff: July 15, 2019• OS was defined as the time from randomization to death by any cause. Kaplan-Meier estimated OS was compared for CC-486 vs. placebo by stratified log-rank test. HRs and 95%CIs were generated using a stratified Cox proportional hazards model.• 95%CI, 95% confidence interval;

Primary endpoint: Overall Survival from randomization

30


• “” Modify choice of consolidation therapy (allo SCT v

chemo) within a given diagnosis-based risk group based

on post-induction MRD findings

• If MRD neg you don’t need transplant; if MRD pos

transplant won’t work”

• Anthony Goldstone, Famous UK transplanter

• Still use pre-rx factors in making decision

• Does MRD neg status adverse biology?

• Does MRD pos status favorable biology?

Having said all that a case can be made to :

• Perform allo in CBF pts or NPM1/FLT3 low or absent who

are transcript or mutation positive after two cycles of

therapy ( what if PCR level is going down, but not UD-

Hadassah Case)

• These are pts we would not normally tx, and transplant

not perfect in MRD+, but better than chemo (Balsat et

al, JCO 2016; Freeman et al JCO 2018)

PB monitoring might be more predictive ( Willekens, et al

Haematologica, 2016)

• And if pre-tx MRD by NGS present do MA conditioning

not RIC ( Hourigan et al JCO 2019)

Proof of Therapeutic Utility of MRD

• UK ( ongoing) : tell half the docs about MRD

results

• GIMEMA (Completed) : Assign FR and INT-

MRD neg to Auto and INT-MRD POS and poor

risk to auto SCT

• US Intergroup: Prove a novel rx erases MRD

and that such ablation improves outcome

MRD has been used to direct therapy in CHILDHOOD AML

• Rubnitz et al, Lancet Oncology 11: 543,2010

• N=232

• Pts got either stnd dose ara-C or hidac in induction

• MRD by MPF used to allocate more or less intensive rx

• Relapse was rare in MRD negative pts (17%)

• But even w intensive rx relapse was still common (40%) in those who were MRD +

• MRD monitoring strategy produced overall results better than historical controls

COG AAML1031

AML <30 yr

MRD assessment end of induction Iby flow

(but also testing molecular and genetic in parallel as pure correlative)

MRD >0.1% = escalate to high risk arm

MRC AML 17/19

Adult AML <60 yr, (and >60 if appropriate for intensive therapy)

MRD amendment: If has a measurable MRD marker (estimate 80% of patients will):

R

Monitor (investigator’s choice what to do with information)

Not monitor

STEP1: Screening protocol Karyotyping, mutation analysis

TIER 1: Separate arms/cassettes/protocols for each risk group (Investigational or SOC)

TIER 2 (after induction) MRD=MRD after 1st cycle

HIDAC x 3

Good risk MRD–ve

V=Venetoclax, HMA: Hypomethylating agents, Ava: Avapritinib, FLT3i: FLT3 inhibitor, *Up to 3 cycles of consolidation

Tier 3 : Maintenance

HIDAC*

MRD –ve

AlloHCT or Observation

V-HIDAC* R

Others

V-7 + 3 7 + 3R

CBF

7 + 3 + GO 7 + 3 + GO + Ava R

Intermediate and High risk non-HCT

Observation Experimental R

FLT 3 ITD/TKD*High risk

V-7 + 37+3CPXR R

V-HMA x 2R

V-HMA x 2R

N=256 N=204

N=268 N=420

V-CPX x 2 HIDAC x 2 V-HIDAC x 2

Allo HCT

V-HMA x 2

ERASE (MRD + ve)

RR R

N=222

Possible US Intergroup Trial

Clinical Use of MRD in AML in 2020

• ELN recommends monitoring

• Should be included in any major clinical trial

• Hard to hang therapeutic decisions on it but

we will

• The perfect is the enemy of the good

• Use as surrogate marker for more rapid

development of new drugs!

Helping us understand MRD in AML

• “Doubt is not a pleasant condition, but certainty

is an absurd one”, Voltaire*

• “The greatest enemy of knowledge is not

ignorance, it is the illusion of knowledge”,

Hawking*

• “When you come to a fork in the road, take it”

Yogi Berra, American Baseball Player

• “A Hungry Dog will even eat Dung”, Talmud*From Othus, M et al BMT, 2019

Acknowledgements• Clinical Team at DFCI:

• Dan DeAngelo, Martha Wadleigh, David Steensma, Jackie Garcia, Goyo Abel , Eric

Winer, Marlise Luskin

• Ilene Galinsky, NP

• Andrian Penicaud, PA, Mary Girard, PA, Sioban Creedon, NP

• BMT Team: Alyea, Antin, Armand, Cutler, Ho, Gooptu, Koreth, Romee, Soiffer

• DFHCC Team: Avigan, Rosenblatt, Amrein, Fathi, Brunner, Hobbs

• Scientific Team at Dana-Farber/Harvard Cancer Center

• Ben Ebert; Andy Lane, Coleman Lindsley,Jim Griffin; Tony Letai, David Weinstock, David

Frank , Kim Stegmeir, Donna Neuberg, Tom Look, S Armstrong, T Graubet. S Tothova, M

Murakami

• Worldwide Collaborators

• Alliance: R Larson, G Marcucci, W Blum, G Uy, G Roboz, S. Mandrekar

• Worldwide:, P Raanani, O Wolach, C Schiffer, T Fischer, H Dohner, K Dohner, C Thiede, R

Schlenk, and others.

How can we quantitate AML?

• Morphologically: 1 in 20• insensitive

• Cytogenetically (metaphase) 1 in 20

• Cytogenetically (interphase) 1 in 100

• Multiparameter flow 1 in 10,000

• PCR based 1 in 10,000

• NGS based 1 in 10,000

RQ-PCR following consolidation completion in RUNX1-RUNX1T1+ AML

– marrow vs blood

Marrow Blood

Willekens, et al. Haematologica 2016; 101:328

Response heterogeneity

B

Morphological treatment response assessment has limited value if MRD-test is obtained

Inaba et al. J Clin Oncol. 2012;30(29):3625-3632

Negative MRD-test Positive MRD-test

<5% blasts by morph ≥5% blasts by morph

Trial Design and Eligibility Criteria (NCT02270463)

Expansion (Stage 2) - Open

• AML in CR

• MRD(+) only

- Centralized analysis of MRD

• SL-401 daily IV infusion for 5 days every 3 weeks

- At highest tested dose in Stage 1 (12

mg/kg/day); MTD not reached

• Secondary endpoints: Change in MRD, survival

Lead-in (Stage 1) - Completed (n=9)

• AML in CR

• Either MRD(+) or MRD(-) if “high-risk”

- Local analysis of MRD

• SL-401 daily IV infusion for 5 days every 3

weeks

- Dose escalation: 7, 9, or 12

mg/kg/day

• Primary endpoint: safety and tolerability

Select inclusion criteria

• AML, achieved first or second CR or CRi within 6 months prior to enrollment

• Not considered immediate candidates for allogeneic SCT

• High-risk disease or MRD+ (Stage 1 / dose escalation); MRD+ (Stage 2 / expansion)

• Age ≥ 18; ECOG PS 0-2

• Adequate organ function including: LVEF ≥ LLN, creatinine ≤ 1.5mg/dL, albumin ≥ 3.2 g/dL, bilirubin ≤ 1.5

mg/dL, AST/ALT ≤ 2.5x ULN

Limitations of MFC

• Biological• Not all leukemic cells have abnormal phenotype• Immunophenotypic antigen shift between diagnosis and relapse• LAIP-like phenotype representing normal or regenerating marrow,

lowering sensitivity of test• Significant numbers of MRD negative patients still relapse

• Is MRD responsible for relapse?

• Technical• Lack of standardization on measurement and reporting• Variations in fluorescent intensities and instrument performance• Operator-dependent interpretation (expertise needed!)

• Target not identified

PCR for MRD

• Balanced chromosomal rearrangements• PML-RARA/t(15;17), RUNX1-RUNX1T1/t(8;21), CBFB-

MYH11/(inv(16)/t(16;16), DEK-CAN (NUP214)/t(6;9), t(11q23)/MLL fusions, t(5;11)/NUP98-NSD1

• NPM1 mutation

• 60% of AML in children and younger adults

• RNA-based approach: reverse transcription (RT) to generate complementary DNA followed by a quantitative PCR (qPCR) step

• allows a limited panel of optimized standardized assays to be used• Not necessary to characterize translocation breakpoints at the genomic level

Hokland P and Ommen HB Blood 2011

Why RT-PCR?

• RT-qPCR: more reliable and standardizable than conventional RT-PCR

• RT-qPCR platforms - highly reproducible between laboratories

• Rapid turn around time

• Risk of PCR contamination is reduced

• Can quantify an independent housekeeping gene in parallel, enabling suboptimal follow-up samples that could potentially have given rise to false-negative PCR results to be

• Qualitative end-point assays lack the capacity to measure the absolute level of leukemic transcripts or determine if rising or falling

Grimwade and Freeman Blood 2014

Ivey A et al. NEJM 2016; 374:422.

MRC AML17

NPM1mut+ MRD = inferior prognosis346 AML patients age 6-68, with a known NPM1 mutation, MRD measured after induction

(x2) in PB and followed by RT-qPCR (sensitivity ~10-5)

Rising NPM1 RT-qPCR over time also predicted relapse

MRD-test result improves outcome prediction

• Outcome prediction based on pre-treatment information not

very accurate for individual patients1,2

• SWOG S0106: Inclusion of data from MRD-test improves outcome

prediction (modestly)

Model* - MRD data Model* + MRD data

Overall survival 0.68 0.70

Relapse-free survival 0.64 0.68

*Age, gender, performance status, white blood cell count, platelet count, bone marrow blast percentage, cytogenetic risk, NPM1/FLT3-ITD status

1Walter et al. Leukemia. 2015;29(2):312-320; 2Walter et al. Leukemia. 2015;29(10):2104-2107; 3Othus et al. Leukemia. 2016;30(10):2080-2083

OS RFS

LAIP

• Antigens at diagnosis (leukemia-associated immuno phenotypes [LAIPs])

• Present on at least 5-10% of leukemic cells and sufficiently aberrant to be present on less than 0.1 - 0.01% of normal nucleated BM cells

• MRD detection sensitivity threshold of 10-3 to 10-4 can be achieved

• Most sensitive/specific LAIPs identify leukemic cells in “empty spaces”—regions that contain no or very few cells in control BM samples (including regenerating normal marrows).

• Subsequent MFC-MRD tracks these diagnostic LAIPs with a cluster of 20 cell events in the LAIP gate resulting in a maximum

• Sensitivity of between 10-4 and 10-5 w 500 000 nucleated cells

Outline of antibody groups used in panels for identification of AML-aberrant immunophenotypes

(both for LAIP and “different-from-normal” approaches) and subsequent residual disease

monitoring.

David Grimwade, and Sylvie D. Freeman Blood

2014;124:3345-3355

©2014 by American Society of Hematology

MRD assessment by molecular means will only be useful in certain subgroups; the underlying prognosis matters

Buccisano F et al. Blood 2010;116:2295-2303©2010 by American Society of Hematology

ISSUES WITH NGS MOLECULAR MRD MONITORINGHourigan et al, Leukemia 2017, 31:1482

• Error rates intrinsic to most conventional NGS sequencing techniques allow only for low sensitivity detection of mutated sequencing

• Limitations due to depth of sequencing and algorithms used for mutation calling

• Persistence of genetic mutations in long-term remission

• Somatic mutations (e.g., DNMT3A) can be found in healthy individuals

• Some genes ( e.g. FLT3 mutant) are ‘late’ hits, eradication may not equal deep response

MRD-test positive remission ≈ active disease

• 72 consecutive patients undergoing primarily myeloablative allo-HCT from 1994 – 2012

in 1st/2nd CR or with active disease

• MRD quantified by multigene RT-qPCR

Hourigan et al. J Clin Oncol. 2016;34(21):2557-2558

Emerging technologies: Single Cell RNA-seq

Seq-Well: median 1800 cells/sample, 1000 transcripts/cell

Sequential analysis during induction

reveals transcriptional phenotype shifts

Technological advance: mutation detection within

single cell RNA-seq

• 65-year old female with AML, achieved CR following daunorubicin + cytarabine induction

• MRD(+) by local analysis -> received 4 cycles of SL-401 (12 μg/kg/day) on trial

• Reduction in marrow aberrant CD123+ population with monocytic markers

• Underwent allogeneic stem cell transplant

Aberrant population(CD45+/CD14+/CD56dim/CD123+/CD33+)

0.6%

0.05%

Screen

End of Cycle 2

CD14

CD

123

CD45 CD14

MRD Decrease(?) in a Patient Treated with SL-401y

NPM1 for MRD analysis

• Frameshift mutations in exon 12 of the NPM1 gene are found in ~ 1/3 of AML patients

• Ideal leukemia-specific target for MRD detection by quantitative PCR

• Ivey: followed NPM1, after each cycle of treatment, and quarterly for 24 months following consolidation therapy in 346 patients enrolled on the NCRI AML17 trial.

• RT-qPCR using mutation-specific primers for 3 most common NPM1 mutations.

• Patient-specific primers were designed in patients with rare mutations

• Positivity: amplification in at least 2/3replicates at a cycle-threshold value of 40 or less

• Molecular remission was defined as an absence of detectable NPM1-mutated transcripts by RT-qPCR in a bone marrow sample at a sensitivity of one in 10,000.

• Molecular relapse was defined as the detection of increasing levels of NPM1-mutated transcript in two successive samples.

Grimwade and Freeman Blood 2014Ivey A NEJM 2016

MRD Prediction

• In patients with a morphologic remission, a rising NPM1 transcript level reliably predicted hematologic relapse.

• The persistence of mutated transcripts in peripheral blood following the second chemotherapy cycle was associated with a significantly higher risk of relapse at three years (82% vs. 30%; p<0.001)

• 5-year OS rate for MRD-negative versus MRD-positive patients was 73% versus 24%; p<0.001

Ivey A NEJM 2016

Overall survival of patients with AML according to MRD levels.High risk (MRD: greater than 10−2 LAP+ cells), intermediate risk (MRD: 10−3 to 10−2LAP+ cells), low risk (MRD: fewer than

10−3LAP+ cells); and very low risk (fewer than 10−4 LAP+ cells).

San Miguel J F et al. Blood 2001;98:1746-1751

©2001 by American Society of Hematology

MRD in AML : MPF PREDICTIVE, OS

.

Krauter J et al. JCO 2003;21:4413-4422

©2003 by American Society of Clinical Oncology

DETECTION OF MRD by PCR in CBF AML is

Highly Predictive of Outcome (OS) (Germany)

Documents

MRD in AML : Cause for Action or Just for Concern?