MRD monitoring in Hematological Malignancies: Concepts and Technological Considerations in Lymphoid malignancies (ALL and MCL) Elizabeth Macintyre Onco-Hematology laboratory, Necker-Enfants Malades, Paris, France INSERM 1151 « Normal and Pathological Lymphoid Differentiation » HST & Taiwanese Society of BMT, 13 April 2019
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MRD monitoring in Hematological Malignancies: Concepts and ... fileSpecificity of clonal vs. non-specific amplification of PBL is variable and determines sensititivity and quantitative
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MRD monitoring in Hematological Malignancies: Concepts and Technological Considerations in
Lymphoid malignancies (ALL and MCL)
Elizabeth Macintyre Onco-Hematology laboratory, Necker-Enfants Malades, Paris, France
INSERM 1151 « Normal and Pathological Lymphoid Differentiation »
HST & Taiwanese Society of BMT, 13 April 2019
INDUCTION CONSOLIDATION ( ALLO-SCT)
Hematological CR
Molecular CR
1012
1010
No
mb
re d
e ce
llule
s le
ucé
miq
ues
Temps
108
106
104
102
MAINTENANCE
…
Hematologicalrelapse
MRD1 MRD2 MRD3 MRD4 MRD5 MRD6…..
Therapeuticstratification
Pre-emptive Treatment of molecular relapseEarly detection
of relapse
Diagnostic
Minimal Residual Disease: When, How and Why ?
100%
1% 10E-2
0.01% 10E-4
0.000 10E-6
104
102
Cyt
olo
gyFI
SHFl
ow
Ro
bu
stD
NA
Q-P
CR
RQ
-PC
R
NGS?NGF?ddPCR ?
Kinetics vary with disease, and with disease sub-types
MRD sensitivity• Depends on the number of cells or DNA copies analysed and the number of pathological
events to be identified in order to define MRD positivity
• Flow Cytometry (FC)
– 10-30 cells with a pathological phenotype (universal or patient specific)– If 10 cells,
• Analyse 100 000 cells -> Sensitivity 10E-4 or 0.01% (Acquisition 5-10 mins) = Multiparameter FC or MFC• Analyse 10M cells -> Sensitivity 10E-6 ou 0.0001% (Acquisition >45 mins & requires « bulk lysis ») Next Gen Flow
– Flores-Montero J …. Orfao for the EuroFlow initiative, Leukemia. 2017 Jan 20. doi: 10.1038/leu.2017.29.
• Sensitivity 10E-4 - 10E-5 ou 0.01-0.001% • Depends on backgroud
• There will always be a borderline non-quantifiable gray zone (Poisson distribution)– Positive non-quantifiable (PNQ) ou Positive Below Quantifiable Range (BQR)– Frequency depends on the disease (MCL>ALL)
• It is prudent to take clinical decisions in the Quantifiable Range (QR), at at least 1 log abovethe limit of sensitivity.
– Despite this, the clinical tendency is the opposite ie total negativity.
The perfect MRD target
• Universal
• Optimal, uniform Sensitivity/specificity
• Robust
• RapidCompatible with the clinical impact
• Reproducible within and between centres
• Minimal risque of false positive and false negativeresults
• Price compatible with the benefit provided
• Q-PCR, Flow cytometry, ddPCR and IG/TCR NGS
European Study Group on MRD detection
Chairman: B. SchäferFounding Chairman: J.J.M. van Dongen
Supported by Leukaemia & Lymphoma Research, LeukemiaNet, and EuroClonality
www.EuroMRD.org
March 2018
Gold standard since ≈2000: Design of a clone specific IgH VDJ probe in B lineage ALL
FR1-JH1245FR2-JH1245
Clone Specific anti-junctional PCR primers
(ASO)
TGCAACGACTTCCCCGAGGT
DHVH JH
Clone Specific VDJ or DJ amplification with JH specific Taqman
quantification
D N J
Standard curve and ASO selection based on dilution into pooled PBL from
normal donors
Specificity of clonal vs. non-specific amplification of PBL is variableand determines sensititivity and quantitative range (QR)
Sensitivity = lowest level of detectionQuantitative range = lowest level of robust, reproducible, quantifiable detection
Bruggemann et al. Leukemia, 2010 p251, Van der Velden Leukemia 2007 p604
QR 10-4
Nb PCR Cycles
10-1 10-2 10-3 10-4 10-5
Sensitivity 10-5
Acceptable target
10-1 10-2 10-3 10-4 10-5
Sensibilité 10-4
QR 10-3
Threshold Ct Non-specific
signal in
PBL
Unacceptable target
Threshold Ct
20 pediatric studies(11 249 patients)
16 adult studies (2076 patients)
“Minimal residual disease is a “biomarker” of disease in ALLin the powerful sense that MRD IS the disease”
Cave H et al NEJM 1998, van Dongen JJ et al. Lancet 1998 2017, 20 years on…
MRD is an integrative reflexion of many parameters
Hematologic Malignancies: Regulatory Considerations for Use of Minimal Residual Disease in Development of Drug and Biological Products for Treatment
U.S. Department of Health and Human Services - Food and Drug Administration Center for Drug Evaluation and Research (CDER) Center for Biologics Evaluation and Research (CBER)
For new drugs that have a demonstrated durable CR in patients with relapsed or refractory ALL, FDA has accepted MRD of less than 0.01% as supporting evidence of efficacy. As technologies improve and new clinical findings emerge, the level of MRD needed to support an efficacy claim may change.
First FDA approval of a leukemia drug— Blinatumomab (Blincyto; Amgen)—to include patients who are technically in remission but still have measurable residual disease.
October 2018
MRD AS A SURROGATE MARKER FOR EFFICACY ?
Flow cytometry: the first Q-PCR challenger
❖ 598 MRD samples (children + adultes)
❖ Ig/TCR & 4/5C FCM
❖ QualitativeConcordance : 96% ❖if performed in a standardised fashion
Flow cytometry and IG/TCR quantitative PCR for MRD quantitation in acute lymphoblasticleukemia: a French multicenter prospective study on behalf of the FRALLE, EORTC and GRAALL. 238 pts., 598 samples, 4/5 color FlowGarand et al. Leukemia. 2013 Feb;27(2):370-6.
Risk of False positive MRD by qPCR post SCT in pediatric ALLFronkova E, et al. Bone Marrow Transplant 2008; 42: 187–196
Next-generation sequencing indicates false-positive MRD results and better predicts prognosis after SCT in patients with childhood ALLKotrova M et al. Bone Marrow Transplantation volume 52, pages 962–968 (2017)
Oncogenic abnormalities and MRD are independent prognostic factorswhich provide complementary information: GRAALL Adult Ph- ALL
B : Gen : IKZF1 et MLLMRD1 > 10-4MRD1 + distinguishes HR and LR Whatever the oncogenotypeOncogenetic status has no prognosticimpact in MRD- patients
T : Gen : NOTCH1/FBXW7/RAS/PTENMRD1 > 10-4Oncogenetic poor risk defines a poorprognostic group, whatever the MRD status.MRD status has no prognostic impact in oncogenetic low risk patients
Beldjord, Blood 2014
Gen- MRD-Gen+ MRD-Gen- MRD+Gen+ MRD+
Gen- MRD-
Gen+ MRD-
Gen- MRD+
Gen+ MRD+
Integrated use of MRD classification and IKZF1 alt. accurately predicts 79% of relapses in pediatric ALL.
• MRD and IKZF1 in 131 uniformly treated precursor-B-ALL patients • Improvement of risk stratification by combining both?• Results
• strong prognostic significance of MRD classification, independent of IKZF1 alterations• 8 / 11 relapsed cases in the large MRD-M group (n=81; 62%) :IKZF1 alteration+ • integration of both MRD and IKZF1 status
- resulted in a favorable outcome group (n=104; 5 relapses) and a poor outcomegroup (n=27; 19 relapses), - showed a stronger prognostic value than each of the 2 alone (hazard ratio (95%CI): 24.98 (8.29-75.31)).
• MRD and IKZF1 status alone identified only 46 and 54% of the relapses, respectively.•Their integrated use allowed prediction of 79% of all the relapses with 93% specificity.
Wanders E et al., Leukemia 2011
Also true in pediatric T-ALL (MRD, oncogenetics and WBC)
Petit A et al., Blood 2018
O’Connor et al., JCO 2018
MRD should be evaluated indpendently in oncogenic subroupsrequires large patient datasets and sophisticated data management
Blood Cancers
8% of Adult Cancers≈ 50% leukemia, 50% lymphoma
70% Lymphoid, B>>T
45% of Childhood Cancers≈ 70% leukemia, 30% lymphoma
>90% Lymphoid, B>>T
Pediatric
Cancers
Adult
Cancers
MRD in mature lymphoid malignancies
• CLL - Flow• Myeloma - NGS• MCL – Q-PCR, ddPCR, Flow, NGS….• DLBCL, FL and other nodal NHL ….
– Requires development of cfDNA techniques
DNA sources for MRD detection in hematologic malignancies.
Florian Scherer et al. Blood 2017;130:440-452
Q-PCR : the gold standard in MCL MRD
32MRD & MCLMarion Alcantara
• Target• IGH rearrangement
• >90% of patients• t(11;14)
• 25 – 40% of patients• Blood/bone marrow
• Sequencing• Allele-specific primer design• Allele-specific (ASO) RQ-PCR
• Standardized• Sensitive
• Up to 10-5
• Euro-MRD guidelines
• Relative quantification approach• Need a reference standard curve
• Dilutions of the tumor-specific target (diagnostic DNA)
VH4-34(-0)/2N/(-2)DH3-3(-7)/4N/(-5)JH4
ASO
NGS, Vidjil
Too many grey zone values in MCL
PNQ/BQR ≈ 50% of positive results
Retrospective analysis on thawedCryopreserved cells
Being tested prospectivelyin MCLR2 & LYMA101
Kinetics of MRD evolution. Q-PCR (in red) and MFC (in blue) quantification of peripheral blood samples at indicated dates.
Conclusion : Flow cytometry is a more rapid but less sensitive alternative to Q-PCR
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1×10-9
1×10-8
1×10-7
1.0×10-6
1.0×10-5
1.0×10-4
1.0×10-3
1.0×10-2
1.0×10-1
1×100
MALNOU MRD
BM MRD
FMC MRD
RCHOP/RDHAP
BEAM (Feb 2006)
4 R
(Aug 2009-May 2011)
R / 3 months 4 R
(Apr 2014-Apr 2016)
R / 3 months
BQR 2/3 &3/3
BQR 1/3
negative
MCL MRD
Digital Droplet PCR Hybrid technologie between Flow and ASO Q-PCR
Pre-emptive Treatment of molecular relapseEarly detection
of relapse
Diagnostic
Minimal Residual Disease: When, How and Why ?
100%
1% 10E-2
0.01% 10E-4
0.000 10E-6
104
102
Cyt
olo
gyFI
SHFl
ow
Ro
bu
stD
NA
Q-P
CR
RQ
-PC
R
NGS?NGF?ddPCR ?
Kinetics vary with disease, and with disease sub-types
Conclusions
• Q-PCR remains the gold standard for MRD in the EU but not the USA– Flow cytometry can compete if the number of events analysed is increased
to >4M, except in some ALL (and MCL) subtypes– ddPCR is slightly less sensitive than Q-PCR but may be more specific and
merits prospective comparison. • It is very valuable in lymphoma for initial quantification• It is particularly interesting in MCL since there are so many gray zone PNQ/BQR reults
• The relative interests of IG/TR NGS and Q-PCR will be actively evaluatedin the next few years
• The current tendency to require complete MRD negativity encourages the use of techniques with a minimum number of borderline results(ddPCR et NGS cf. qPCR)
• MRD should be evaluated independently in oncogenetic subgroups, atleast in ALL– This requires large patient numbers and encourages international
collaboration
Vahid Asnafi, Nawel Bedjaoui, Jonathan Bond, Chantal Brouzes, Danièle Canioni, Agata Cieslak,
Gaelle Cordonnier, Coralie Derrieux, Charles Dussiaux, Ludovic Lhermitte, Mathieu Simonin, Melania Tesio, Aurore Touzart, Amélie Trinquand, Patrick Villarese and Elizabeth Macintyre
,
M. Alcantara, MH Delfau, M. Callanan, C. Pott, S. Ferrero, O. Hermine……